The United States Army Veterinary Corps

January – March 2009

Perspective 1

MG Russell J. Czerw

A Corps Challenged, Capable, and Committed 5

BG Timothy K. Adams

Food and Water Risk Assessment: A Decision Tool for the Tactical Commander 7

CW3 Chris Heryford, VC, USA

Quality Assurance, Networking, and Collaboration Actions by the 12

DoD Veterinary Food Analysis and Diagnostic Laboratory

LTC Roger W. Parker, VC, USA

Food and Waterborne Disease Threats 15

COL Marc E. Mattix, VC, USA

A Veterinary Service Squad Deployment in Support of Operation Iraqi Freedom 21

CPT Marla Brunell, VC, USA

Veterinary Civil Action Programs in Afghanistan: Pros, Cons, and How 25

MAJ Jessica McCoy, VC, USAR

Overview of Combat Trauma in Military Working Dogs in Iraq and Afghanistan 33

MAJ Janice L. Baker, VC, USAR; et al

Military Working Animal Chemical, Biological, Radiological, and Nuclear 38

Protection and Medical Countermeasures

MAJ Kelley L. Evans, VC, USA

Validation and Operational Application of a Rapid Method for Rabies Antigen Detection 42

LTC Greg A. Saturday, VC, USA; LTC Robin King, VC, USA; Leslie Fuhrmann, MS

B Virus (Cercopithecine Herpesvirus 1) Therapy and Prevention Recommendations 46

LTC Christopher E. Keller, VC, USA

Directed Energy (Laser) Induced Retinal Injury: 51

Current Status of Safety, Triage, and Treatment Research

LTC Deborah L. Whitmer, VC, USA; Bruce E. Stuck, ScD, MS

Opportunities for Military Medical Officers: The Epidemic Intelligence Service 57

at the Centers for Disease Control and Prevention

CPT Kristina McElroy, VC, USAR

The 3rd Army Rescue of the Lipizzaners 59

MAJ Boris Brglez, VC, USA

ALSO IN THIS ISSUE

Fresh Frozen Plasma 64

LTC Clayton D. Simon, MC, USA; et al

Total Intravenous Anesthesia on the Battlefield 68

LTC Paul Barras, AN, USA; et al

Should We Teach Every Soldier How to Start Intravenous Fluids? 73

MAJ Robert L. Mabry, MC, USA; MAJ Peter J. Cuenca, MC, USA

Abstracts from the US Army-Baylor Doctoral Program in Physical Therapy 76
LTG Eric B. Schoomaker

The Surgeon General

Commander, US Army Medical Command

MG Russell J. Czerw

Commanding General

US Army Medical Department Center and School

January – March 2009 The Army Medical Department Center & School PB 8-09-1/2/3

0835304

GEORGE W. CASEY, JR

General, United States Army

Chief of Staff

DISTRIBUTION: Special

Administrative Assistant to the

Secretary of the Army

By Order of the Secretary of the Army:

Official:

JOYCE E. MORROW

Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/references_publications.aspx

A Professional Publication

of the AMEDD Community

The Army Medical Department Journal [ISSN 1524-0436] is published quarterly for

The Surgeon General by the US Army Medical Department Center & School, ATTN:

MCCS-HSA Ste 135, 1750 Greeley Road, Fort Sam Houston, TX 78234-5078.

CORRESPONDENCE: Manuscripts, photographs, official unit requests to receive

copies, and unit address changes or deletions should be sent to the Journal at the

above address. Telephone: (210) 221-6301, DSN 471-6301

DISCLAIMER: The Journal presents clinical and nonclinical professional information

to expand knowledge of domestic & international military medical issues and

technological advances; promote collaborative partnerships among Services,

components, Corps, and specialties; convey clinical and health service support

information; and provide a peer-reviewed, high quality, print medium to encourage

dialogue concerning healthcare initiatives.

Views expressed are those of the author(s) and do not necessarily reflect official US

Army or US Army Medical Department positions, nor does the content change or

supersede information in other Army Publications. The Journal reserves the right to edit

all material submitted for publication (see inside back cover).

CONTENT: Content of this publication is not copyright protected. Material may be

reprinted if credit is given to the author(s).

OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical

Department units and organizations, and other members of the medical community

worldwide.
January – March 2009 1

The focus of this issue of the AMEDD Journal is the

US Army Veterinary Corps, a small component of the

Army Medical Department, but one that plays an

indispensable role in safeguarding the health and wellbeing of Soldiers, Marines, Sailors, and Airmen

throughout the world. Moreover, in this increasingly

dangerous environment of potential threats from many

sources, large and small, the Veterinary Corps has

become a vital resource of homeland defense

capabilities, lending their expertise in epidemiology,

biohazard control, and especially in the protection of

the food and water supply. Articles in this issue reflect

the broad range of responsibilities and activities of

Army veterinary professionals, from directed energy

injury research to the care and rehabilitation of

severely injured military working dogs. Army

veterinary professionals do it all, and I am happy for

this opportunity to showcase their expertise and

capabilities.

The AMEDD Journal welcomes BG Timothy Adams,

the Chief of the Army Veterinary Corps, to this issue

with an excellent overview of the evolving

responsibilities and challenges of the Corps, and the

philosophical and organizational approaches which are

necessary to deal with them. His observations articulate the sense of dedication, responsibility, and loyalty

that is the hallmark of today’s Army, and reflected

every day in the performance and achievements of our

Army healthcare professionals.

Department of Defense Directive 6400.4 1dictates the

missions for the Army Veterinary Corps. The first

policy of the DoD Veterinary Service Program is

“Ensure food ingredients and food products are safe,

wholesome, and meet quality standards.”1(p2) This

responsibility is featured in 3 articles. First, CW3

Chris Heryford describes a valuable capability offered

by the Veterinary Command to assist commanders of

units scheduled for short-term deployments into

foreign countries, whether for infrastructure rebuilding, humanitarian assistance, or military training.

Quite often these deployments are into areas with little

or no regulation or standards of food handling, storage,

preparation, or delivery, and limited knowledge of

available potable water sources. The commander can

request a food and water risk assessment prior to

deployment. Veterinary or preventive medicine

specialists will go to the area and evaluate the potential

sources of food and water as to the level of risk each

poses, and make recommendations towards mitigation

of those risks. This information provides the

deployment commander with the knowledge needed to

make crucial decisions regarding providing food and

water to the troops. CW3 Heryford provides a detailed,

clearly articulated description of what is involved in

such assessments, and how the information should be

used by those responsible for the health of deploying

troops. Next, LTC Roger Parker, the Director of the

DoD Veterinary Food Analysis and Diagnostic

Laboratory here at Fort Sam Houston, has contributed

a very informative article describing the roles and

responsibilities of the laboratory, and the detailed

control measures to ensure quality assurance.

Additionally, he describes the extensive systems of

collaboration among testing laboratories nationwide,

including military and other federal agencies, as well

as local, state, and university resources. Finally, COL

Marc Mattix presents an excellent article which is a

primer on existing threats to the food and water

supplies of developed countries, and how such threats

are addressed and countered. The Army Veterinary

Perspective

Major General Russell J. Czerw
2 www.cs.amedd.army.mil/references_publications.aspx

Corps is front and center in this effort, and COL

Mattix makes the importance of that role very clear.

Veterinary units have been deploying in support of

Operations Iraqi Freedom and Enduring Freedom since

the beginning of the Global War on Terror. The next 2

articles focus on such deployments to the respective

theaters, presenting different perspectives on the

mission requirements and the challenges faced in

accomplishing them. CPT Marla Brunell’s article

details the various categories of support provided

during the 64th Medical Detachment (VS) deployment

to southwest Asia and northeast Africa. The veterinary

personnel were organized into small squads at various

locations, each of which was responsible for the entire

spectrum of veterinary support: food inspections, both

receipt and storage; medical support for the assigned

military working dogs; stray animal control; and

examination of local animals brought into the base

compound. This article provides a clear look at the

extent of the important work that small numbers of our

veterinary professionals perform on a daily basis to

ensure the health of all of our deployed Soldiers. MAJ

Jessica McCoy’s article presents a different aspect of

the missions of veterinary Soldiers, the veterinary civil

action program (VETCAP). While the VETCAP has

been a part of military operational deployments for

many years, their use in Afghanistan came into question because of the alleged detrimental effect on the

domestic veterinary infrastructure. Therefore, a detailed study was designed and conducted to evaluate the

local impact against the military value, and attempt to

quantify the tradeoffs. This is an excellent depiction of

the “big picture” roles that Army veterinary personnel

play in support of the military mission in a theater of

operations.

Dogs have long been an important component of the

military. Moreover, our understanding of their

capabilities and our ability to train and use them

continues to expand. Today, military working dogs are

more vital than ever in the counterinsurgency

environment of both combat theaters. However, the

very nature of that environment has resulted in a much

larger incidence of serious trauma injuries among

those dogs than seen in earlier conflicts. MAJ Janice

Baker and her coauthors have contributed a well

written, informative article describing how Army

veterinary professionals have adapted to the situation,

both in staffing adjustments and, more importantly, in

how such trauma is handled in the field. As is usually

the case in the Army where doctrine and standing

procedures do not fit the situation at hand, time and

again our skilled and dedicated medical and veterinary

professionals have adapted, cooperated, and found

ways to save the lives of these valuable resources.

MAJ Baker et al also present carefully developed

recommendations as to doctrine, training, and organization based on real world experience and success. In

that the current environments are probably the

template for future conflicts, this article is a must read

for those planning for the future employment and care

of military working dogs.

MAJ Kelley Evans’ article discusses another aspect of

care which must be considered for military working

animals. The dangers to Soldiers represented by the

chemical, biological, radiological, and nuclear threats

are understood and addressed by doctrine, training,

and equipment. However, those same threats apply to

the animals that accompany us into harm’s way. MAJ

Evans presents a historical background of the military

veterinarians’ efforts to address the various unconventional threats, the first of which was the use of

poison gas in World War I. He describes the various

measures developed and used, including a variety of

gas masks for both draft animals and dogs, and special

containers for the smaller animals. He also discusses

the current efforts to provide both protection and

treatment capability for the military dog which reflect

the current threat environment. This is an interesting

read which provides insight into an aspect of US military history that is not well known.

Rabies is a zoonotic viral disease which has plagued

humans throughout history. It is present on every populated continent except Australia, and continues to kill

thousands of people every year. Rabies has always

been a threat to US military personnel as they deploy

around the world, and military health providers are

often not able to obtain data on the prevalence of

rabies in a given area of operations. As LTC Greg Saturday and his coauthors point out in their informative

article about rabies in Iraq and Afghanistan, the first

indication to US medical personnel of the actual

presence of rabies is usually the result of an incident

involving a military member. An animal bite sets off a

chain of events in which the animal is captured, a

sample of brain tissue is sent to the Veterinary

Laboratory Europe (VLE) at Landstuhl, Germany, and

Perspective
January – March 2009 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

the Soldier begins treatment. Test results are obtained

within hours once the sample arrives at the laboratory.

However, these individual tests following bite

incidents have been the only data available about the

presence of rabies in the area. Obviously, this limited

sample is of marginal value in understanding the extent of rabies infections. In their article, LTC Saturday

et al discuss use of a test procedure developed by the

Centers for Disease Control and Prevention that allows

in-theater testing of animals by deployed veterinary

personnel, as well as local civilian veterinarian

resources. The test is relatively simple and cost

effective, requiring minimal resources and no special

facilities to perform. The test was deployed by the

VLE into both theaters in the summer of 2008, and

data collection began almost immediately. This is

another example of the initiative and professionalism

of our skilled professionals to identify a problem, and

then implement a solution. In this situation, as is so

often the case, the solution benefits not only our Soldiers, but the local civilian populace as well.

As we have pointed out in this and previous issues of

the AMEDD Journal, US Army veterinary professionals are working in many areas of medical science

outside of those defined as missions of the Veterinary

Corps. The article by LTC Deborah Whitmer and Dr

Bruce Stuck is an excellent example of another one of

those critically important areas of research. Directed

energy, predominately in the form of lasers, is a growing threat to unprotected eyes, especially on the

modern battlefield. Laser beams are now almost ubiquitous, whether as range finders, target designators,

aiming devices, or used intentionally as blinding or

burning weapons. Often the injury is sustained without

the Soldier’s knowledge of the cause. LTC Whitmer

and Dr Stuck present a very informative, well-illustrated, clinical description of the potential threat, the

mechanism of damages inflicted on the eyes, and

current research on methods of examination and

treatment. This article should be a must-read for all

medical personnel involved in patient examination and

evaluation, as it provides a basis for inquiry about eye

injury and follow-on examination and treatment.

Rabies is the best known zoonotic disease in that it is,

unfortunately, a common threat to (and from) the animals that live among us. However, there are others that

our troops encounter as they deploy around the world.

LTC Christopher Keller presents a well-researched,

informative analysis of a viral disease that is endemic

among a specific genus of monkey, commonly called

macaques, that are indigenous throughout Asia and

Africa. The B virus, a form of herpesvirus, has a high

fatality rate in documented human infections. Although most of those cases involve biomedical research personnel working with the animals, they serve

as a warning as to the serious nature of the disease

which can, of course, be contracted through encounters

in the wild. LTC Keller’s thorough presentation of the

clinical aspects of the disease, its diagnosis, and

treatment should be considered an important resource

for both medical planners and those conducting

predeployment training for those areas within which

macaques are found.

CPT Kristina McElroy has provided information about

an important postgraduate educational and practical

application opportunity for medical and veterinary

professionals interested in epidemiology. The Epidemic Intelligence Service is a 2-year, postdoctorallevel fellowship program of the CDC that conducts

epidemiologic investigations, research, and public

health surveillance nationally and internationally for

all types of epidemics, including chronic disease and

injuries. Selectees get first hand experience in

detection, identification, analysis, and response for

actual and potential large-scale health threats. The

training and experience they receive is unique and

increasingly important, especially in this era of the

increasing threat of bioterrorism. CPT McElroy’s

article is an excellent introduction to this opportunity,

and she has provided complete information for anyone

who may be interested. Anyone who has any interest

in the practice of epidemiology should investigate this

program.

Army veterinarians usually work in the background,

providing continuous support while performing vital

functions that are not known to the majority of people.

Occasionally, a veterinarian steps to the front and becomes the “point” in events that are not only very

important at the time, but also may have historical

significance. In fairness, this applies not only to US

Army veterinarians, but also those of other militaries,

even our adversaries. MAJ Boris Brglez’s fascinating

article presents one of those unique situations from late

in World War II, when US and German Army veterinarians joined together to ensure that the legendary

line of Lipizzaner horses would be preserved for future

generations. The successful operation to seize and

move the herds of horses intact has been saved from
4 www.cs.amedd.army.mil/references_publications.aspx

Perspective

obscurity by its association with General George

Patton, because it was units of his 3rd Army that

accomplished it, with his approval. However, as MAJ

Brglez makes clear, it was the recognition of the

significance of the horses by the leaders on the front

lines, many of whom were actually veterans of horse

cavalry units, that inspired the bold, almost flawlessly

planned and executed operation. Unfortunately, lost in

most depictions of this operation is the fact that it

almost assuredly would not have occurred without the

initiative and cooperation of 2 military veterinarians

from opposing sides of the battlefield. This article

clearly provides that important perspective.

I am pleased that we have the opportunity to include 3

additional articles in this issue dealing with aspects of

combat medicine. Each of these articles, albeit brief,

contain information which is timely and important to

Army medicine’s most important mission—saving the

lives of our wounded Warriors. First, LTC Clayton

Simon and his coauthors have contributed an overview

of fresh frozen plasma (FFP) and its use in damage

control surgery. They examine the properties of FFP

and provide information about its storage and use.

Also, they present clinical data from its use in combat

damage control at a combat support hospital. This

article is packed with well-documented, clearly

presented information which should be considered as

we review and revise our doctrines for combat medical

care for future conflicts.

Next, LTC Paul Barras and his coauthors present a

proposal for a different approach to administering

anesthesia in the battlefield environment. In their

clearly presented, extensively documented article, they

make a solid case for total intravenous anesthesia

(TIVA) as the standard method of anesthesia at every

level of combat damage control, beginning with the

forward surgical team. LTC Barras et al explain that

TIVA is safer for the patient, requires much less

equipment than inhalant anesthetics, is easier to

control, and can be administered continuously

throughout the intensive care period if necessary. Their

article is another example of the initiative and high

levels of medical skill and knowledge that are common

characteristics of Army medical professionals.

MAJs Robert Mabry and Peter Cuenca have the final

article in this issue. They present a proposal to change

the current combat lifesaver (CLS) training for all

Soldiers that is mandated by the Army Training and

Doctrine Command. They advocate elimination of the

requirement to train Soldiers in the placement of

intravenous (IV) lines and the administration of IV

fluids. Their article is a logical, well-considered

presentation of the factors that argue against using

already limited training time to train a skill that, in

application, may be detrimental to both the injured

Soldier and that Soldier attempting to provide first aid.

First, they discuss the extreme difficulty of training an

individual to correctly and safely administer an IV,

even in the most benign environments. More

importantly, they present the current clinical evidence

that IV fluid administration early in the trauma care

cycle is rarely helpful to the injured, and is often

counterproductive. Rather, the authors contend that

hemorrhage control should be the primary concern for

the initial caregivers, and detailed training in

application of tourniquets would be of much greater

value in saving the lives of severely wounded

Warriors. The information in this article should be

carefully considered by those charged with defining

our Soldiers’ necessary skills, syllabus design, and

planning to meet the training requirements.

Finally, I am proud to present a collection of research

abstracts prepared by the 2009 class of doctoral

students of the US Army-Baylor University Doctoral

Program in Physical Therapy. The 5 abstracts report

the results of the students’ research projects which

were conducted as part of their curriculum and in

support of the Neuromusculoskeletal Injury Prevention

and Rehabilitation Research Program. The projects

were collaborations of the military students and

physical therapy experts from the TRUE Foundation

and universities. These abstracts are another clear

indication of the high levels of professional knowledge

and skills found in the Army Medical Department, as

well as the outstanding opportunities available for our

dedicated medical professionals.

REFERENCE

1. Department of Defense Instruction 6400.4: DoD

Veterinary Services Program. Washington, DC: US

Dept of Defense; August 22, 2003.
January – March 2009 5

The United States Army Veterinary Corps existed for

the better part of the last century, and continues to be

an integral part of the Army Medical Department and

the Department of Defense, as well as serving

interagency responsibilities across the federal

government. The Army Veterinary Corps is essential

and contributes to a comprehensive approach to both

animal and human health. However, never have we

been as challenged as we are today. As we look for

answers and ways to achieve our constantly expanding

mission, we must continue to be flexible and adaptive.

Operating in two combat areas of responsibility and

around the world on other fronts, we are covering

missions from care of military working dogs, to class I

food safety and quality assurance, support of

provincial reconstruction teams, research and

development, and much more.

We are a small Corps with a huge mission that is

expanding, and we are being spread thinner and

thinner. As Corps Chief, I look for signals of change

and avenues and connections to effectively and

efficiently enhance and contribute to health and global

security—one health, combining both human and

animal medicine and preventive medicine as they

relate to the health of our warriors, national public, and

international partners. As a Corps, we must continue

the exceptional service and support provided and look

for efficiencies and ways to optimize our resources.

The Active Army and our Reserves are performing

with amazing tenacity and professionalism, however,

this cannot be sustained without adjustments and a

rebalancing of our entire force. This rebalancing effort

is underway and we are a part of it.

Though many challenges lie ahead, the Corps will

adjust to assist in the rebalancing of the force. Stability

operations, humanitarian assistance, food defense, and

civil support are areas of new, heightened focus. We

are currently on track in the Total Army Analysis for

approval of four new veterinary service medical

detachments (two active and two reserve) in this effort

to rebalance and cover down on current and

anticipated missions. Retention and leadership

development are high priority initiatives, and

significant progress has been made with pay incentives

and continuing education. Our Corps must look within

to muster the determination and motivation to serve in

a capacity commensurate with sacrifices already made.

Personal benefit can only be defined and measured by

the individual, however, Corps mission success will be

measured by the overall success and security of the

nation. Never have times required more sustained

selfless service and sacrifice, and never has there been

more potential for these attributes to impact on our

future. In his inaugural address, the Commander-inChief said:

[The] values upon which our success depends—hard

work and honesty, courage and fair play, tolerance and

curiosity, loyalty, and patriotism—these things are...

true... What is demanded then is a return to these

truths. What is required of us now is a new era of

responsibility—a recognition...that we have duties to

A Corps Challenged, Capable, and

Committed

Brigadier General Timothy K. Adams

BG Adams is Chief of the US Army Veterinary

Corp and the Assistant Surgeon General, Force

Projection.
6 www.cs.amedd.army.mil/references_publications.aspx

ourselves, our nation, and the world, duties that we do

not grudgingly accept but rather seize gladly, firm in

the knowledge that there is nothing so satisfying...than

giving our all to a difficult task.

These are relevant words for the challenges

confronting us, and the United States Army Veterinary

Corps gets it!

Veterinarians and veterinary personnel—enlisted,

commissioned, or civilian—have a unique ability to

relate, translate, and adapt to a variety of situations and

challenges. We know this, and I am confident that we

will continue to rise to the challenges that lie ahead

while leading on all fronts. As we undergo the

impending transformation of our military, and as the

operational climate and global landscape change, we

must not only be adaptive, but resilient to its impact on

our responsibilities.

As part of the Army Medical Department team, the

Veterinary Corps will continue to lead, and the Corps

will respond effectively. We all have an opportunity

and obligation to be a part of this which transcends

individual achievement and interests.

Never have we been so globally challenged, but never

have we been so capable to meet these challenges. I

am confident, I am proud and I remain ever committed

to the success of the world’s finest military veterinary

organization and its future successes.

A Corps Challenged, Capable, and Committed
January – March 2009 7

BACKGROUND

Scenarios such as that described above are occurring

more frequently. Globalization, due to many factors

including the end of the Cold War and the inception of

the Global War on Terrorism, stimulated avenues and

opened doors into many countries. The joint concept

initiated by DoD increased the opportunities for

various exercises with foreign militaries, not to

mention the vast array of humanitarian missions and

infrastructure rebuilding around the world.

Additionally, the National Guard Security and State

Partnership Program* links US states with partner

countries with goals for evolving international affairs

missions for the National Guard using the unique civilmilitary nature of the Guard to interact with both

active and reserve forces of foreign countries.

Currently, US military exercises occur on a regular

basis in diverse areas throughout the world with no

end in sight.

What does this mean from a food safety perspective?

Commanders on the ground, particularly in developing

countries, must find a way to safely feed their troops

without government approved sources. Depending on

the country, eating local food in an exotic foreign land

can be exciting yet unsafe due to insufficient sanitation

standards and environmental public health issues. In

the past, food establishments/suppliers chosen in a

local area for an exercise were either “passed” or

“failed.” This approach left no options for a

commander if every food establishment failed, which,

historically, was the case most of the time. In contrast,

a food and water risk assessment is the process of

assessing all identified hazards and risks involved in a

commander’s troop feeding plan and providing sound

recommendations that will reduce the overall risk to

the Soldier. The assessment, initial risk levels, and

potential mitigation steps to achieve reduced risks are

provided as a recommendation to the supported unit’s

commander as a decision tool for possible actions and/

or changes to the projected troop feeding plan. After

an assessment is conducted, selection of food sources

becomes the discretion of the commander based on

accepted risks.

US Army Veterinary Command (VETCOM) food

safety programs historically provided minimal support

to short-term exercises due to a lack of knowledge

concerning their existence and capabilities. The food

safety support for smaller exercises was inconsistent

and sporadic, as field commanders simply did not

know the support existed. Marketing the availability of

FWRA service to all branches of the US military

increases the awareness and decreases risk of food and

Food and Water Risk Assessment:

A Decision Tool for the Tactical Commander

CW3 Chris Heryford, VC, USA

SCENARIO

A unit consisting of 200 US Navy Construction Battalion personnel are tasked to execute a 30-day nation

building initiative in a country with little to no infrastructure. The mission encompasses design and construction

of a local school in cooperative efforts with the local government. Food sources approved by the US Department

of Defense (DoD) are not available in the country, and transportation of government-owned food or military

rations into theater is not an option. Where do the troops eat? The only viable option remaining is for troops to

subsist on the local economy for the duration of the exercise. During advance party and reconnaissance

operations, exercise planners identified and generated a list of potential food caterers and/or food suppliers in the

local area. US Army Veterinary personnel, who are responsible for food safety, were contacted and traveled to

the area of the exercise, months in advance. They conducted food and water risk assessments (FWRA) of all

local food producers and suppliers identified by the exercise planners. Risk levels and recommendations were

determined for each food establishment and presented to the combatant commander who then decided on the

safest actions regarding the troop feeding plan. Decreasing the possibility of food and waterborne diseases

during the exercise was obviously the ultimate goal.

*http://www.ngb.army.mil/ia/Tab2.aspx
8 www.cs.amedd.army.mil/references_publications.aspx

water-borne disease outbreaks (diarrhea and vomiting)

during exercises. The VETCOM maintains an

aggressive stance for supporting the Warfighter during

exercises throughout the world using FWRA. In

recognition of the value of providing options to the

commander, exercise support is at the top of the list for

mission priorities. FWRA, provides diverse options,

consultation, and recommendations which offer

command flexibility to future troop feeding plans.

RECEIVING THE MISSION

A Veterinary Corps officer (VCO) is the most likely

candidate to be an assessor for conducting a FWRA.

However, Preventive Medicine officers could be

selected in the absence of a VCO. Whichever the case,

once a support mission is received, procrastination is

not an option. The process of supporting certain

exercises can be extremely fluid at times, so proactive

execution promotes success. A majority of the support

is provided prior to the actual exercise, preferably

occurring during the initial planning phase for a unit’s

deployment. Preparation and coordination inevitably

consume more time than actual time on the ground in

the country. General exercise intelligence should be

gathered about the number of troops involved, duration

of the exercise, and location. Modifying a feeding plan

late in the process, just before or during an exercise, is

nearly impossible. Exercise planners must have a

general idea of where they want to procure their food

well in advance. A list of food preparation facilities,

caterers, hotel restaurants, and/or other facilities must

be provided to the appropriate VETCOM headquarters

in theater by the unit conducting the exercise. The list

of possible food sources by location is absolutely

crucial in order to initiate an assessment.

There are a number of additional potential

impediments that cannot be overlooked, to include:

country clearances, visas, travel coordination,

immunizations, and points of contact. Proper preparation greatly reduces the possibility of being halted at

an airport and ultimately forced to return home before

ever getting started. If assigned to a mission, never

assume that someone else is taking care of the aforementioned requirements. Establishing contact with key

players for an exercise is rather challenging and

frustrating at times, especially for joint exercises.

People change positions, go on leave, or are transferred. Telephone numbers and email addresses might

be incorrect or not work at all, so attempting to speak

to the right person could result in the classic, endless

cycle of telephone pursuit. Perseverance builds

character. An initial point of contact list should contain

several individuals, and not be limited to the exercise

planner(s), operations staff or commander of the unit

conducting the exercise, the military coordinator and/

or the Bilateral Affairs Officer in the country’s US

embassy, the local Ministry of Public Health or

equivalent position, and the food establishment

managers. Usually, support missions comprise of one

or 2 assessors, and do not coincide with the supported

unit’s movement. Thus, those with whom you gain

contact become imperative elements in successful

support.

Become aware of the country’s public health stance.

Begin by surfing the world-wide web. The final risk

determination is dependent upon the collection of

significant environmental health information prior to

entering a country. Knowledge of prevalent zoonotic

diseases, local sanitation standards, and public water

conditions should be the background for recommendations the assessor will provide the supported

unit. Particular health risks from an animal and food

standpoint mirror a country’s unique infrastructure

development. A quick history lesson on the social and

political paths of a country leading to the present

situation provides insight into what may be expected

concerning potential risks from the food defense and

security standpoint. The World Health Organization,

Centers for Disease Control and Prevention, and the

Armed Forces Medical Intelligence Center are worthy

sources of information on the internet. An internet

search for a country’s history seems too simple, yet it

is an effective tool for developing general expectations. A well-rounded picture of the country is the

goal.

Anyone assigned to an FWRA should prepare a

packing list of equipment and references. As a

minimum, the most recent versions of Army Military

Standard 3006 1and Army Technical Bulletin MED

530 2should be readily accessible. Surface swabbing

becomes a valuable means for the identification of

improper cleaning and sanitation procedures, so bring

a Novalum®(Charm Sciences, Inc, Lawrence, MA

01843) with an adequate number of shelf-stable

surface swabs. Acidity/alkalinity and chlorine test

strips are small, light, easy to pack, and effective for

determining adequate sanitation concentrations during

Food and Water Risk Assessment: A Decision Tool for the Tactical Commander
January – March 2009 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

production and cleaning. A quick-reading digital

thermometer with alcohol swabs for temperature

verifications and an ultraviolet “black” light to reveal

possible rodent activity should be on the list as well.

The suggested equipment, shown in the Figure, is not

all-inclusive and should be altered to meet the

assessor’s needs to obtain the best objective evidence

within the limits of the available assets. The tools and

references shape the mission for meaningful data

collection and ensuring the assessor is able to

adequately evaluate the situation.

EXECUTE THE MISSION

The VCO should arrive in the exercise area months

before the unit to allow the exercise commander to

adjust plans if needed. There are 3 main actions that

should occur:

1. Conduct FWRAs of all caterers, restaurants, and/

or food preparation facilities involved in the

troop feeding plan.

2. Conduct interviews with local public health

officials to determine common zoonotic and

food/waterborne disease statistics and data in the

country.

3. Draw bottle and source (tap) water samples for

laboratory testing. All objective evidence

gathered throughout the process influences the

initial risk assessment of each food

establishment.

The assessment is similar to an initial commercial

sanitary audit outlined in Military Standard 3006 1

without the availability of any prearranged production

details. Consequently, facts and details are discovered

while an assessor is in the food establishment, so the

assessor should remain flexible, observant, and

receptive. While assessing a food establishment, a

number of concerns should be verified, to include

origin of raw ingredients, water potability, sanitation

and cleaning programs, sanitation training program,

pest control program, food processing operations,

storage, cooking, and holding times and temperatures

(HACCP Plan), general infrastructure conditions and

equipment, and food defense. An accurate record of

significant food safety and security deficiencies, as

well as plotting product flow should be recorded. It is

extremely important to take good notes.

Laboratory testing of the source water for each

establishment serves as additional data for influencing

the risk assessment. Onsite preventive medicine (PM)

water testing assets provide the perfect solution;

however, PM resources are not always available. If

PM is not in theater, the VCO creates alternate

avenues for testing by bringing Colilert vessels or

sterile urine specimen cups. As a last resort, purchase

the most predominantly consumed brand name bottled

water in the area, and use the bottles for sample

collection. Pour out the bottled water, rinse the bottle

5-6 times with the source water in question, and collect

the sample. In most situations, samples will have to be

brought back in your check-in luggage due to limited

or questionable shipping providers, therefore taping

the caps and triple bagging with zip lock bags is

recommended. Samples should then be submitted to

the nearest DoD Veterinary Laboratory after the VCO

returns. At a minimum, all water samples will be

tested for routine microbiological parameters, with

further chemical and radiological testing if adequate

sample volumes are available. Final test results

influence the initial risk level.

Interviews with local public health officials provide

additional data for supporting initial risk decisions.

Coordinating and executing interviews often reveal

exclusive data not discoverable through internet resources or text references. Ask simple questions:

What diseases are endemic to this area?

What is the overall water quality in the area?

Recommended minimum test kit equipment for member

of FWRA team.
10 www.cs.amedd.army.mil/references_publications.aspx

What are some of the government controls in place

for sanitation standards?

Are there laboratories in the area?

What are the public health capabilities?

Even better, obtain any available statistical data. It

is amazing how a few questions will gain

information of tangible value. A list of questions

should be prepared and answered, yet allow a free

flowing conversation supported by good listening

skills.

Although determination of the overall initial risk is

subjective, it is supported by observations of food

handling practices (both unsafe and satisfactory),

potential hazards based on food science knowledge

and tests, and VCO experience. Focus on critical food

safety issues, the absence or presence of critical

control points, data from laboratory results of source

water tests, and answers obtained during public health

interviews.

The combination of discoveries assist the

determination of the probability and severity of each

identified hazard, and ultimately an initial risk level, as

shown in the Table, which is comparable to the

concepts in Army Technical Guide 248.

3

Initial risk

levels are categorized as extremely high, high,

moderate, or low.

The initial risk level is the amount of risk of possible

health hazards in a feeding plan to which Soldiers are

exposed before recommended food safety controls are

identified and applied. Once that initial risk level is

established, appropriate recommendations and control

measures are compiled. The assessor generates recommendations that will reduce critical microbiological,

chemical, and physical hazards found during the

assessment. Some general examples are:

 Avoid particular food products

 Do not drink from any available tap water sources

 Verify temperature prior to consumption

 Immediate consumption upon receipt

 Sanitation and hazard analysis and critical control

point* training for personnel preparing food

 Additional laboratory testing

 Use single service disposable plates and utensils

REPORTING

There are 2 documents submitted at the end of the

evaluation, the FWRA report for the exercise

commander and the after-action report, both prepared

in general memorandum format. Once the tap water

laboratory results are complete, each food service

establishment will have a separate risk level assigned,

to include the detailed deficiencies discovered during

each visit. When feasible, the VCO will personally

brief the tactical commander. Normally, the tactical

commander will not be in the country during the

FWRA, so email and telephone may be the only means

of communication. Attempt to remove any misconception about the assessments by emphasizing that

food establishments are neither approved nor disapproved. Keep the information and guidance concise

and to the point. At a minimum, the recommendations

and residual risk levels should be discussed. The afteraction report is filtered through the chain of command

and the Defense Occupational and Environmental

Health Readiness System.†

CONCLUSION

The FWRA program is actually an old concept with a

new approach and a new name. The Army Veterinary

Command provided similar services in the past with

less standardization and visibility. On June 1, 2008,

the Veterinary Command released a supplement to

Technical Guide 248 3entitled “Food and Water Risk

Assessment.” It is the first comprehensive standard for

conducting FWRA. The goal of the program is to

provide improved customer service to the tactical

commanders and their Soldiers. Approaching food

safety concerns with FWRA broadens the perspective

of the commander’s decision process, and removes the

“go/no go” mentality for designation of food sources.

Commanders are educated about their troop feeding

plan and are therefore able to formulate decisions

based on solid information and risk analysis.

Food and Water Risk Assessment: A Decision Tool for the Tactical Commander

*A management system, also known as HACCP, by which food safety is addressed through the analysis and control of

biological, chemical, and physical hazards from raw material production, procurement, and handling, to manufacturing,

distribution, and consumption of the finished product, namely the “farm-to-table-continuum.” Source: http://

www.afdo.org/afdo/HACCP/

†https://doehsportal.apgea.army.mil/doehrs-oehs/
January – March 2009 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

The determined probability of a given hazard mapped against that hazard’s severity

defines the corresponding risk estimate for that combination of factors.

Hazard Probability

Hazard Severity

Frequent (A) Likely (B) Occasional (C) Seldom (D) Unlikely (E)

[Corresponding Risk Estimate]

Catastrophic (I) Extremely

High

Extremely

High High High Moderate

Critical (II) Extremely

High High High Moderate Low

Marginal (III) High Moderate Moderate Low Low

Negligible (IV) Moderate Low Low Low Low

REFERENCES

1. Mil-Std-3006: Sanitation Requirements for Food Establishments. Washington, DC: Office of The Surgeon General,

US Dept of the Army; June 1, 2008.

2. Technical Bulletin MED 530: Occupational and Environmental Health Food Sanitation. Washington DC: US Dept

of the Army; October 30, 2002.

3. Technical Guide 248: Guide for Deployed Preventive Medicine Personnel on Health Risk Assessment. Aberdeen

Proving Ground, MD: US Army Center for Health Promotion and Preventive Medicine. August 2001. Available at:

http://chppm-www.apgea.army.mil/documents/tg/techguid/tg248.pdf.

AUTHOR

CW3 Heryford is Food Safety Officer for the Southern Europe District Veterinary Command, Caserme Ederle,

Vicenza, Italy.
12 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

The Department of Defense (DoD) Veterinary Food

Analysis and Diagnostic Laboratory (FADL) at Fort

Sam Houston, Texas, is the definitive DoD veterinary

laboratory resource providing force health protection

in support of US Armed Forces around the globe. A

priority mission of this 50-person agency is food

safety, defense, and quality assurance supporting food

supplies purchased and distributed for consumption by

all of the US military services. Another priority

mission is diagnostic testing for prevention and control

of zoonotic and animal diseases concerning

government-owned animals and privately-owned

animals of authorized personnel within military

communities. Finally, the FADL provides technical

consultation on the integration of laboratory testing

into science-based food audit and inspection systems

of the US Army Veterinary Service.

Food microbiology capabilities include verification

testing of food vendor quality assurance programs,

operational ration pathogen screening, foodborne

illness sample testing, food/water surveillance testing,

and pathogen/toxin identification. Microbiology

methods incorporate conventional microbiology using

agar plates and advanced, rapid techniques, such as

real-time polymerase chain reaction. Food chemistry

capabilities include quantifying pesticides, antimicrobials, and toxic residues; identifying heavy metals;

confirming quality packaging indices; and performing

routine chemistry testing for moisture, protein, fat, and

solids. Chemistry methods range from simple

extractions for percent fat, single-analyte instrumental

analysis such as mercury and cyanide, and very

complex tests such as gas chromatographic mass

spectrometry (GC-MS) for pesticides or inductively

coupled mass spectrometry (ICP-MS) for heavy

metals. Techniques such as infrared spectrometry and

microscopy are used to identify foreign object

contamination of foods. Diagnostics capabilities

include serology (eg, equine infectious anemia, brucellosis, toxoplasmosis, Lyme disease, Rocky Mountain spotted fever, ehrlichiosis, and babesiosis); rabies

testing (suspect animals involved with human exposure, rabies serology of animals destined for international movement); and infectious disease surveys

(eg, leptospirosis). Diagnostic methods include

immunoassays, rapid screening tests, and virus neutralization or propagation using cell culture.

QUALITY ASSURANCE

Most testing is performed according to approved

official methods as promulgated by the following

recognized methods standardization bodies: AOAC*

International, US Department of Agriculture, US Food

and Drug Administration, American Public Health

Association, US Centers for Disease Control and

Prevention, US Environmental Protection Agency

(EPA), and World Health Organization.

Quality control of procedures is a priority

responsibility of all FADL personnel with formal

oversight by a section of quality assurance scientists

and specialists. FADL has been accredited by the

American Association for Laboratory Accreditation

(A2LA) since 2001. Independent auditors from A2LA

conduct on-site, 3-day comprehensive systems audits

of the FADL on a biennial basis. During intervening

years, A2LA conducts formal off-site reviews of

FADL quality systems documents. Laboratory accreditation from A2LA is based on ISO/IEC 17025:2005,

1

the internationally accepted criteria for competence.

The FADL complies with the ISO/IEC 17025

requirement to have “quality control procedures for

monitoring the validity of tests and calibrations

undertaken.”1(p20) Quality control procedures include

the regular use of certified reference materials and/or

internal quality control using secondary reference

Quality Assurance, Networking, and

Collaboration Actions by the DoD Veterinary

Food Analysis and Diagnostic Laboratory

LTC Roger W. Parker, VC, USA

*Association of Analytical Communities. Information available at: http://www.aoac.org/. Accessed Jan 23, 2009.
January – March 2009 13

materials, and replication of tests or calibrations using

the same or different methods. The FADL conducts its

own internal audits, method reviews, and quality

control checks on a continuous basis to maintain the

highest level of quality. In addition to internal

performance-based quality control, the FADL

participates in proficiency testing, usually by

contracting with an external provider who assesses

laboratory performance by interlaboratory comparison.

LABORATORY NETWORKING AND COLLABORATIONS

The FADL participates in the following laboratory

networks and collaborations:

 The Directory of DoD Public Health Laboratory

Services2is a central database compilation of

information which allows medical personnel to

determine the locations of appropriate laboratories

where specimens of public health concern can be

tested, to obtain contact information and

information related to sampling and sample

handling, to improve reporting and surveillance of

emerging pathogens, and to help protect force

readiness. In the event of a large or suspected

outbreak, the Directory’s list of points-of-contact

should help ensure notification of proper

personnel, and efficient use of DoD’s extensive

laboratory resources.

 The DoD Joint Occupational and Environmental

Surveillance Laboratory Compendium3is a

database of environmental testing laboratories.

The database was created to assist DoD, EPA, and

other personnel who respond to emergency

situations in the identification of qualified and

appropriate laboratory capabilities and capacities

to analyze chemical and biological analytes, as

well as chemical warfare, bioterrorism, and

radiochemical agents.

 The FADL actively collaborates with the US

Army Center for Health Promotion and Preventive

Medicine (USACHPPM) and USACHPPM-South

(Fort Sam Houston, Texas) in some overlapping

environmental surveillance missions (eg, vectorborne diseases and operational water safety).

 As part of the Global War on Terrorism, the

FADL’s mission now incorporates the need for

rapid detection of biowarfare/bioterrorism agents

in food and water. To further develop this

capability, the FADL has established a

memorandum of understanding with the US Army

Medical Research Institute of Infectious Diseases*

(USAMRIID). There are critical support

requirements in the area of food defense which can

most readily be filled using the expertise and

experience at USAMRIID.

The Food Emergency Response Network†(FERN)

integrates the nation's food-testing laboratories at the

local, state, and federal levels into a network that is

able to respond to emergencies involving biological,

chemical, or radiological contamination of food. The

FERN plays a number of critical roles related to food

safety and defense, including:

Provides a national surveillance program that

offers an early means for the detection of threat

agents in the American food supply.

Prepares the nation's laboratories to respond to

food-related emergencies.

Provides significant surge capacity to strengthen

the nation's response towards widespread complex

emergencies (intentional or inadvertent) related to

agents in food.

Enhances the ability of the nation to restore

confidence in the food supply following a threat or

an actual emergency targeting that food supply.

The FADL gains additional benefit by sending

laboratory scientists to FERN-provided training

workshops involving advanced methods. As part of

FERN’s food surveillance program, the FADL uploads

food pathogen testing results into eLEXNET©‡, a

secure, internet-based system that centralizes food

safety laboratory data to allow multiple government

agencies to compare, communicate, and coordinate

analytical findings.

For highly pathogenic avian influenza diagnostics, the

FADL participates in the National Animal Health

Laboratory Network§(NAHLN). The network is part

*Information available at: http://www.usamriid.army.mil/

†Information available at: http://www.fernlab.org/

‡Electronic Laboratory Exchange Network (US Dept of Agriculture and the Food and Drug Administration). Information

available at: http://www.boozallen.com/consulting/industries_article/658975. Accessed January 23, 2009.

§US Dept of Agriculture, Animal and Plant Health Inspection Service. Information available at: http://www.aphis.usda.

gov/animal_health/nahln/. Accessed January 23, 2009.
14 www.cs.amedd.army.mil/references_publications.aspx

of a national strategy to coordinate and link the

diagnostic testing capacities of the federal veterinary

diagnostic laboratories with the extensive infrastructure of state and university veterinary diagnostic

laboratories. The NAHLN enhances the nation’s early

detection of, response to, and recovery from animal

health emergencies, including bioterrorist events,

newly emerging diseases, and foreign animal disease

agents that threaten the nation’s food supply and

public health.

CONCLUSION

As part of its continuous quality improvement

processes, the FADL strives to maintain strategic and

operational networking, collaboration, and technical

sharing among relevant public health partners

including military, federal, state, and private agencies.

Quality Assurance, Networking, and Collaboration Actions by the

DoD Veterinary Food Analysis and Diagnostic Laboratory

REFERENCES

1. American Society for Quality. ANSI/ISO/IEC 17025-2005 American National Standard: General Requirements for

the Competence of Testing and Calibration Laboratories. Milwaukee, WI: Quality Press; 2005.

2. Armed Forces Institute of Pathology. Directory of DoD Public Health Laboratory Services. Available at: https://afipgeis.afip.osd.mil. Accessed January 23, 2009.

3. Armed Forces Institute of Pathology. DoD Joint Occupational and Environmental Surveillance Laboratory

Compendium. Available at: https://labcomp.afip.osd.mil/. Accessed January 23, 2009.

AUTHOR

LTC Parker is Director of the DoD Veterinary Food Analysis and Diagnostic Laboratory, Fort Sam Houston, Texas.
January – March 2009 15

The developed world enjoys the most varied,

affordable, safe, wholesome and affordable food

supply in the history of civilization. This is not by

accident; the safety of the food chain is ensured

through a complex, integrated network of local,

county, state, federal, and Department of Defense

organizations dedicated to mitigating the threat of

unintentional contamination of our food supply from

production through transportation and distribution to

the consumer (Figure 1). From local and county health

departments through federal agencies, including the

Food and Drug Administration and the US Department

of Agriculture Food Safety and Inspection Service and

Veterinary Services, each link along the food chain is

monitored and regulated with the goal of achieving

healthy herds, flocks, crops, and communities, and a

safe food supply. Yet even with this system in place,

food and waterborne disease continues to be a significant health risk in populations throughout the

world, including the United States.1 A majority of the

foodborne disease agents are zoonotic, that is, maintained in vertebrate animal reservoirs and incidentally

infective to humans. We are intimately connected to

animal populations through shared, or zoonotic

diseases, the food chain, and the human-animal

bond—our innate desire to surround ourselves with

animals. In an era where many US citizens believe

steak comes from the local supermarket, it is essential

to remember that it is impossible to separate

agriculture from food, and it is equally inadvisable to

separate animal health from human health.2

The resurgence of the One Health Concept* has fueled

improved connectivity in integrated surveillance and

reporting for humans and animal diseases both within

the United States and abroad. The risk for food and

waterborne disease is greatest in regions with fractured

public health and veterinary infrastructure, lack of a

functioning national health surveillance system, and

unknown incidence of endemic disease, factors present

in many locations around the world where the US

military is deployed. The risk of foodborne disease is

further increased in concentrated military populations

composed of immunologically naïve Soldiers largely

unaware of the host of disease agents present in local

fare. Protecting our deployed Soldiers, Marines,

Sailors, and Airmen from food and waterborne disease

is the primary focus of the US Army Veterinary

Service.

It is impossible to overstate the importance of a safe

and secure food supply, not only to the individual but

also to nations. Public confidence in the food chain is

essential; a loss of public trust carries significant

social, economic, and political weight. Even the

perception of an unsafe food supply creates serious

social and economic consequences (Figure 2). The

1999 dioxin contamination of the Belgian poultry,

meat, and dairy industries caused $1.5 billion in lost

revenues and was directly responsible for the peaceful

ouster of the Belgian coalition government in general

elections 6 weeks following release of the discovery.

The full effects of potential chronic disorders such as

teratogenesis, carcinogenesis, immunosuppression, and

Food and Waterborne Disease Threats

COL Marc E. Mattix, VC, USAR

*The One Health Concept, first articulated by early

scientists such as Rudolph Virchow, recognizes the intimate

relationship between human health, animal health and the

environment, and calls for an integrative, collaborative

approach to health by encouraging the collaboration

between experts of diverse fields of study.3

Retail/Serving

The Consumer

Transportation

Distribution

Preparation

Production

Processing

Figure 1. The food chain consists of interconnected steps

from farm to fork, each with its own unique array of vulnerabilities to unintentional or deliberate adulteration.
16 www.cs.amedd.army.mil/references_publications.aspx

liver or kidney failure is yet to be seen.4 One positive

effect of the Belgian dioxin scare was that the removal

of poultry products from the shelves resulted in an

astounding 40% decrease in the incidence of

Campylobacter infections, a bacterial agent ubiquitous

in the poultry industry.5 The cause of dioxin

contamination was determined to be intentional,

criminal contamination of recycled cooking oil

destined for animal feed. The use of dioxin in

subsistence as an intentional politically motivated

attack surfaced in 2004 with the alleged poisoning of

Viktor Yushchenko, the Ukrainian opposition

presidential candidate.

The agriculture-food industry is a highly complex,

integrated, just-in-time system of massive concentrated

production, transportation, processing, national and

international distribution

and retail. There are

numerous critical control

points uniquely susceptible to unintentional adulteration throughout the

food chain. Similarly, the

industry is an open “soft”

target for intentional

contamination for social,

political, economic, or

religious motivations. The

January 2001 Department

o f Defense report,

Proliferation: Threat and

Response,

6 was the first official document which

identified that attacks on US food supplies could affect

the economic stability of the country and erode

military readiness. As outgoing Secretary of Health

and Human Services, Tommy Thompson said in a

2004 interview that he worries “every single night”

about “food poisoning” on a massive scale. He

continued, “I for the life of me cannot understand why

the terrorists have not attacked our food supply,

because it is so easy to do.”7 Ensuring the safety of the

food chain from intentional adulteration, termed food

defense, is an emerging role of the US Army

Veterinary Service.

Food and waterborne disease due to unintentional

contamination remains a significant health threat, even

in the United States. We are no further away from the

great endemic diseases of the underdeveloped world

than an air transport of fresh vegetables destined for

our grocery stores and restaurants. A typical restaurant

meal contains ingredients from 30 countries and is

handled by food service workers from no fewer than 4

countries. US citizens believe food safety is the

responsibility of the vendor and regulatory agencies. In

stark contrast, the entire developing world believes the

responsibility for food safety lies with the consumer—

caveat emptor. With this perception in the US, perhaps

it is not surprising that 74% of US households failed to

meet minimum sanitary standards in a recent Audits

International survey.8 The risk lies not just with meats,

but equally with fresh fruits and vegetables. For the

first time, the incidence of foodborne disease due to

consumption of produce equaled that due to

contaminated meat, poultry, eggs, and seafood in

2000. Reports of large-scale outbreaks traced to

spinach or lettuce have

become as commonplace

as ground beef recalls.9

Food and waterborne

disease is responsible for

an estimated 76 million

cases of gastroenteritis

annually in the United

States alone, with

325,000 hospitalized

patients and 5,000 deaths.

Worldwide, food and

wate rbo rne diseases

represent the most

commonly reported outbreaks to the World Health

Organization. This is a staggering fact given the extent

of infectious diseases abroad such as malaria,

leishmaniasis, and tuberculosis. No doubt the

incidence has always been high in the underdeveloped

world. The increase in recognized outbreaks likely

represents improved surveillance and reporting.10

The primary route of exposure is fecal-oral

contamination of food and water due to poor food

handler hygiene and the use of contaminated water and

ice in processing. Raw and undercooked meat, poultry,

eggs, dairy products, shellfish, and produce are the

highest risk food items commonly consumed.

Unpasteurized milk was responsible for 45 outbreaks

in the United States from 1998 through 2005. Other

means of infection are person-to-person via

asymptomatic carriers and episodes of public

Figure 2. Loss of consumer confidence in the safety of the

food chain carries significant social, economic, and political implications. Even the perception of unsafe food can

potentially cause large-scale perturbations in global

markets.

Food and Waterborne Disease Threats
January – March 2009 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

vomiting, through fomites or aerosolization. A review

of 348 outbreaks of acute gastroenteritis reported to

the Centers for Disease Control and Prevention

revealed 39% were foodborne, 12% were person-toperson, 3% were due to contaminated water, and 46%

were from undetermined sources.11 Control of disease

outbreaks is usually restricted to the identification and

removal of the point source, and minimizing personto-person transmission. Critical to the process is rapid,

sensitive, and specific diagnostics. Agent detection in

food and water systems poses unique diagnostic

challenges. Water detection requires a large sample

size and sophisticated concentration technologies.

Many food items contain enzymatic inhibitors that

reduce the effectiveness of assays. Development of

new validated detection assays is an ongoing focus in

the food and water diagnostic community.12

Many kinds of infectious agents are responsible for

causing food and waterborne diseases, including

viruses like Norovirus and Rotavirus, bacteria

including Salmonella, Campylobacter and Shigella,

metazoan parasites like trichinosis, and protozoal

infections such as cryptosporidiosis. Many outbreaks

are multifactoral, further complicating the diagnosis

and tracing the origin of outbreaks. The majority of

cases present as acute gastroenteritis: nausea and

vomiting, cramps, fever, diarrhea, headache, and

myalgia. Many diverse disease agents present with

similar signs and symptoms, although the presence of

blood in the stool should always raise concerns about a

bacterial agent and inspire the attending health care

worker to collect stool specimens for culture. Of

interest, less than 60% of cases of acute gastroenteritis

presented to physicians in the US are actually cultured

for disease agents. While most cases of acute

gastroenteritis resolve within a matter of days, a low

percentage of cases develop serious complications,

including hemolytic-uremic syndrome, thrombotic

thrombocytopenic purpura, Reiter’s Syndrome

(consisting of arthritis, urethritis, and conjunctivitis),

septicemia, dehydration, and electrolyte and acid-base

derangement, shock and death.13,14

SHIGA-TOXIN PRODUCING ESCHERICIA COLI

The enteric coliform organism, E. coli, is ubiquitous in

animals and farm environments. Most strains exist as

innocuous intestinal flora and serve as a useful

indicator of fecal contamination. Some strains

including O157:H7 and 0153 produce a Shiga-like

toxin and are capable of causing severe gastroenteritis.

The primary source is the mammalian intestinal tract.

While many mammals carry this organism, human

exposure is primarily from ruminants and

contaminated environments. Products at greatest risk

include raw milk, fresh produce, water sources,

unpasteurized cider, and undercooked ground beef.

The incidence of disease in the US is 2.8 per 100,000,

with an estimated 73,000 cases per year. Disease

outbreaks are commonly associated with large-scale

recalls of regionally, nationally, or internationally

distributed ground beef. Following a 2- to 5-day

incubation period, affected patients develop a 6 to 10

day course of severe cramps, fever, and watery

diarrhea that becomes bloody with time. Many recovered patients become silent carriers, capable of

shedding organisms for protracted periods. Up to 4%

of infected juveniles develop hemolytic-uremic

syndrome, while a smaller proportion of adults

develop thrombotic thrombocytopenic purpura. The

cardinal signs of cramping and blood diarrhea always

warrant a stool culture and strain typing. A typical

isolation media is Sorbitol-McConkey agar. Shiga-like

toxin is detected using a verotoxin assay. Treatment

consists of supportive fluid and electrolyte therapy.

Antibiotics appear to predispose for hemolytic-uremic

syndrome. Antidiarrheal products like Imodium are

contraindicated. Shiga-like E. coli is a reportable

disease.15,16

NOROVIRUS

Norovirus is a nonenveloped, single-strand RNA virus

of the family Caliciviridae. It is resistant to drying,

freezing, steam, and chlorination, and is the number

one cause of acute gastroenteritis, responsible for over

50% of outbreaks in the United States. Detection was

restricted to a few specialized research laboratories

until recently, thus explaining the large proportion of

historic foodborne disease outbreaks with

undetermined etiology. This is a disease of highdensity encampments, including everything from

Naval vessels and cruise ships to military and youth

training camps, and even a recent outbreak at a

marathon dance contest. Oysters in contaminated

waters filter and concentrate the virus in high titers.

Transmission is primarily through contaminated food

and water supplies, although the hardy nature of this

virus explains many cases of person-to-person

transmission and exposure via aerosolization following

episodes of public vomiting. Diagnosis is made by
18 www.cs.amedd.army.mil/references_publications.aspx

reverse transcriptase polymerase chain reaction

technology.17

The symptoms are that of a typical case of

gastroenteritis, with up to 30% of recovered patients

becoming asymptomatic shedding carriers of the

disease. A notable exception was the Norovirus

outbreak in the British field hospital in Afghanistan in

2002. Twenty-nine patients and staff were affected by

an unusually severe, acute disease characterized by

headache, stiff neck, photophobia, listlessness,

disseminated intravascular coagulation, and mild

gastrointestinal symptoms. The disease presentation

resembled a hemorrhagic viral disease like Rift Valley

Fever more than a typical intestinal agent. Diagnosis

was delayed for several days, resulting in a palpable

operational paralysis in the sector.18 This outbreak

speaks loudly for the need for forward-deployed,

rapid, sensitive, and specific diagnostics to support

military operations.

CRYPTOCOCCUS NEOFORMANS

Cryptococcus neoformans, the etiology of

cryptosporidioisis is a minute, intracellular

apicomplexan protozoal parasite (Figure 3). Reservoirs

include humans, ruminants (especially calves), and

even birds. Transmission is fecal-oral, and can be

human-to-human, animal-to-human, foodborne, or

waterborne. The most common source of outbreaks is

a failure of solid waste management. The disease is

self-limiting in the immunocompetent patient, with

nausea, cramps, and an explosive

watery diarrhea of 3 to 4 days

duration following a 1- to 12-day

incubation period. In immunosuppressed patients, cryptosporidiosis

becomes a chronic diarrhea with

persistent shedding of myriad

organisms. Up to 20% of acquired

immunodeficiency syndrome

patients are affected by chronic

cryptosporidiosis.19 While some

outbreaks are truly due to a

zoonotic strain spread from

livestock to humans, the majority

of cases are actually caused by

genotype I, a strictly anthroponotic

variant. Outbreaks have been

reported from swimming pools and water parks and

from the food service industry, including an interesting

case in Spokane, Washington, traced to contaminated

green onions.20 The most spectacular outbreaks are due

to solid waste failures. The 1993 outbreak in

Milwaukee, Wisconsin, affected 403,000 residents,

and stands today as the largest public health outbreak

in US history.21 At the time, diary farms located along

2 rivers upstream from Milwaukee were blamed.

However subsequent study of the causative organism

revealed its nonzoonotic nature, thus implicating

human fecal contamination of the drinking water

supply as the likely source of infection.22

Control and prevention must thus follow a 2-pronged

approach, both directed at limiting the ingestion of

food and water contaminated by ruminant fecal

material, but also aimed at prevention and early

detection of large-scale community waste management

failures.

TRICHINOSIS

Trichinosis is cause by the nematode parasite,

Trichinella spiralis, a member of the Class

Adenophorea. Transmission is entirely from ingesting

raw or undercooked meat. This nematode parasite is

unique in that the infected human or animal serves as

both the intermediate and definitive host. Reservoirs

include rats, pigs, dogs and cats, horses, wildlife, and

even marine mammals. The US commercial swine

industry is likely free of the disease, however,

backyard and foreign pork products should be

considered contaminated.23

After 5 to 15 days incubation, the

patient presents with a triad of

signs: myalgia, fever and fatigue,

edema of the upper eyelids, and a

stunning peripheral eosinophilia.

Diagnosis is made via history of

exposure, clinical examination,

hematology, assays to detect

elevated muscle enzymes such as

lactate dehydrogenase and creatine

phosphokinase, and muscle biopsy.

Biopsies reveal coiled nonencapsulated nematode larvae eliciting

minimal local tissue reaction

(Figure 4). Suspect animal muscle

tissue can be evaluated by

histopathology or a larvae per gram (LPG) digestion

assay.24

Figure 3. An electron micrograph of

Cryptosporidium parvum organisms

within an enterocyte.

Food and Waterborne Disease Threats
January – March 2009 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

Outbreaks in the United States are most often due to

ingestion of wild game jerky, including cougar and

bear. A Montana outbreak was

traced to bear jerky prepared

following 6 months of freezing.

The LPG assay revealed 212 larvae

per gram!23 Outbreaks in France

and Belgium have been traced to

consumption of raw horse flesh,

and outbreaks throughout Germany

are typically due to smoked pork

sausage. A 2007 outbreak in

Pomerania affected over 200

people, and was traced to raw pork

from a single producer. Other

outbreaks around the world were

caused by ingestion of barbequed

badger (Russia and Korea); dog

meat (Russia, Kaza khstan,

Slovakia, Thailand, and China);

fox sausage (Italy); and barbequed

leg of jackal (Algeria).25,26

Prevention requires cooking all

meat to 160o, or until it turns from

pink to brown. Historically, freezeresistant strains were restricted to

the Arctic; however, the past 2 decades have seen

increasing numbers of freeze-resistant strains

responsible for outbreaks in the lower 48 states.27

Judicious rodent control on farming operations is

essential, as is sanitary disposal of garbage.

Food and waterborne diseases are

easily preventable by following

basic hygiene practices and having

complete knowledge of the

p r o c e s si n g a n d p r o d u ct s

consumed. The US Army

Veterinary Service maintains a

worldwide directory of sanitarily

approved food sources28 to ensure

that our Soldiers, Marines, Sailors,

and Airmen are protected against

incursions of food and waterborne

disease. Food safety spans the

entire food chain, from farm

production through consumption in

the dining facility. Unfortunately,

the finest food safety network can

be rendered ineffective through

poor hygiene and high risk

behavior. As Field-Marshall Sir

William Slim wrote in his memoirs

of command of the 14th Army in

Burma in 1942,

Good doctors are no use without good discipline. More

than half the battle against disease is fought, not by the

doctors, but by the regimental officers.29

Figure 4. A photomicrograph of muscle

tissue from a bear, demonstrating

profiles of Trichinella spiralis larvae.

REFERENCES

1. Mead P, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis. 1999;5

(5):607-625.

2. Marano N, Pappaioanou M. Historical, new, and reemerging links between human and animal health. Emerg Infect

Dis. 2004;10(12):2065-2066.

3. King LJ, Anderson LR, Blackmore CG, et al. Executive summary of the AVMA One Health Initiative Task Force

report. J Am Vet Med Assoc. 2008;233(2):259-261.

4. Bernard A, Fierens S. The Belgian PCB/dioxin incident: a critical review of health risks evaluations. Int J Toxicol.

2002;21(5):333-340.

5. Vellinga A, Van Looke F. The dioxin crisis as experiment to determine poultry-related Campylobacter enteritis.

Emerg Infect Dis. 2002;8(1):19-22.

6. Proliferation: Threat and Response. Washington, DC: US Dept of Defense; January 2001.

7. Allen M. Rumsfeld To Remain At Pentagon, Thompson Quits at HHS, Warns of Vulnerabilities. Washington Post.

December 4, 2004;A01. Available at: http://www.washingtonpost.com/ac2/wp-dyn/A33767-2004Dec3?

language=printer. Accessed January 6, 2009.

8. Saelens M. Results of 1999 home food safety survey by Audits International to be announced. PR Newswire, 1999.

9. DeWaal C, Barlow K. Outbreak alert! Closing the gaps in our Federal food-safety net. Washington, DC: Center for

Science in the Public Interest; 2002.
20 www.cs.amedd.army.mil/references_publications.aspx

10. Grein T, Kamara K, Rodier G, et al. Rumors of disease in the global village: outbreak verification. Emerg Infect Dis.

2000;6(2):97-102.

11. Lynch M, Painter J, Woodruff R, Braden C. Surveillance for foodborne-disease outbreaks - United States, 1998-

2002. MMWR. Morb Mortal Wkly Rep. 2006;55(SS10):1-34.

12. Jaykus L. Epidemiology and detection as options for control of viral and parasitic foodborne disease. Emerg Infect

Dis. 1997;3(4):529-539.

13. Petersen K, James W. Agents, vehicles, and causal inference in bacterial foodborne disease outbreaks: 82 reports

(1986-1995). J Amer Vet Med Assoc. 1998;212(12):1874-1881.

14. LeBaron C, Furutan N, Lew J, et al. Viral agents of gastroenteritis public health importance and outbreak

management. MMWR. Morb Mortal Wkly Rep. 1990;39(RR-5):1-24.

15. Rangel J, Sparling P, Crowe C, Griffin P, Swerdlow D. Epidemiology of Escherichia coli O157:H7 outbreaks, United

States, 1982-2002. Emerg Infect Dis. 2005;11(4):603-609.

16. Solomon E, Yaron S, Matthews K. Transmission of Escherichia coli O157:H7 from contaminated manure irrigation

water to lettuce tissue and its subsequent internalization. Appl Environ Microbiol. 2002;68(1):397-400.

17. Widdowson M, Sulka A, Bulens S, et al. Norovirus and foodborne disease, United States, 1991-2000. Emerg Infect

Dis. 2005;11(1):95-102.

18. Brown D, Gray J, MacDonald P, Green A, Morgan D. Outbreak of acute gastroenteritis associated with Norwalk-like

viruses among British military personnel - Afghanistan, May 2002. MMWR. Morb Mortal Wkly Rep. 2002;51

(22):477-479.

19. Yoder J, Beach M. Cryptosporidiosis surveillance - United States, 2003-2005. MMWR. 2007;56(SS-7):1-10.

20. Foodborne Outbreak of Cryptosporidiosis–Spokane, Washington, 1997. MMWR Morb Mortal Wkly Rep.

1998;47:565-567.

21. Mackenzie WR, Hoxie NJ, Proctor ME, et al. A massive outbreak in Milwaukee of cryptosporidium infection

transmitted through the public water supply. New Eng J Med. 1994;331:161-167.

22. Peng M, Xiao L, Freeman A, Arrowood M, Escalante A, Weltman A. Genetic polymorphism among

Cryptosporidium parvum isolates: evidence of two distinct human transmission cycles. Emerg Infect Dis. 1997;3

(4):567-573.

23. Roy S, Lopez A, Schantz P. Trichinellosis surveillance - United States, 1997-2001. MMWR. Morb Mortal Wkly Rep.

2003;52(SS-6):1-8.

24. Clausen M, Meyer C, Krantz T, et al. Trichinella infection and clinical disease. QJM. 1996;89(8):631-636.

25. Laurichesse H, et al. Outbreak of trichinosis in France associated with eating horse meat. Commun Dis Rep CDR Rev.

1997;7(5):R69-R73.

26. Trichinellosis Outbreaks- Northrhine- Westfalia, Germany, 1998-1999. MMWR. Morb Mortal Wkly Rep. 1999;48:488-

492.

27. Worley D, Seesee F, Espinosa B, Sterner M. Survival of sylvatic Trichinella spiralis isolates in frozen tissue and

processed meat products. J Amer Vet Med Assoc. 1986;189(9):1047-1049.

28. Worldwide Directory of Sanitarily Approved Food Establishments for Armed Forces Procurement. Fort Sam

Houston, Texas: US Army Veterinary Command; June 4, 2008. Available at: http://vets.amedd

.army.mil/VETSVCS/approved.nsf/a33b0b8376c838 f586256 f82007b f7b7/a981a3522 fa3217e86256 f

960052191f?OpenDocument.

29. Slim W. Defeat Into Victory. 2nd ed. London: Cassell and Company LTD; 1956:180.

AUTHOR

COL Mattix is Assistant Chief, US Army Veterinary Corps for Mobilization and Reserve Affairs, Falls Church,

Virginia.

Food and Waterborne Disease Threats
January – March 2009 21

INTRODUCTION

The 64th Medical Detachment (VS) deployed to

southwest Asia and northeast Africa from January

2005 to January 2006 in support of Operation Iraqi

Freedom. The unit was divided into squads providing

veterinary services in 3 countries: Kuwait; Qatar; and

Djibouti, Africa. A squad typically consists of a

Veterinary Corps Officer, an animal technician (MOS*

68T), and one to 4 food inspectors (MOS 68R). The

mission at each location consisted of food inspection,

assistance with stray animal control, and medical care

of military working dogs (MWDs).1

The deployment offered Soldiers the experience of

working in all 3 countries. Each location had a busy

food mission. On a frequent basis, food inspectors

recommended rejection of food delivered onto base

due to decreased quality and condition. Stray animal

control by euthanasia was routine work in all 3

locations as well. This is an unpopular task among

Soldiers and difficult for veterinary services personnel,

but it is absolutely necessary to protect Soldiers from

zoonotic diseases. Many challenges were routinely

faced while attempting to provide adequate care to

MWDs. The treatment space and equipment at each

location varied and was usually inadequate. This was

largely overcome by coordination with human medical

facilities. In fact, 3 MWD surgeries were performed at

medical facilities on base.

FOOD MISSION

There are a variety of food facilities on a forward

deployed base, for example, dining facilities, fast food

establishments (Burger King, Subway, Pizza Hut),

AAFES†exchange, operational ration storage, and

prime vendor warehouses.

The food inspectors typically inspected from 200,000

lbs to 300,000 lbs of subsistence per month at each

location. Support provided by food inspectors

included: receipt inspections, military-wide and local

recalls, product shelf-life extension at the AAFES

exchange and prime vendor warehouse, operational

ration inspections, monitoring temperatures and

expiration dates at the AAFES exchange, verification

of approved sources, guidance on refrigeration

failures, and attendance at monthly menu board

meetings.2

Receipt Inspections

The majority of food inspection work consisted of

receipt inspections. As trucks arrived at the base with

food, the food inspectors checked the seals on truck

doors; looked for evidence of tampering; measured the

temperature inside; checked for approved sources; and

inspected the quality and condition of food. Our squad

found a substantial amount of food from unapproved

sources as well as problems with the condition of food

arriving on base. As a result of our initial findings, we

implemented 100% receipt inspection, out of

necessity, to ensure that only safe food entered the

base.2

Food Trends. There were 3 common problems found

with food arriving on base:

Unapproved Sources. The Worldwide Directory of

Sanitarily Approved Food Establishments for

Armed Forces Procurement3provides a list of

acceptable manufacturing plants that may be used

to obtain food sources for the military. In our

experience, lack of compliance existed from the

prime vendor. Products typically can be acquired

more quickly and less expensively by the prime

vendor from surrounding countries rather than by

shipment from Europe or the United States.

However, without evaluation of the sanitary

practices and security of these plants, the products

could pose a health risk to military personnel.

Insect Infestation (Figures 1 and 2). Infestation

occurred mostly in the pasta or flour which was

stored for too long at higher temperatures,

A Veterinary Service Squad Deployment In

Support of Operation Iraqi Freedom

CPT Marla Brunell, VC, USA

*Military occupational specialty

†Army and Air Force Exchange Service
22 www.cs.amedd.army.mil/references_publications.aspx

allowing insect eggs in these

products to hatch.

Temperature Abuse (Figures 3,

4, and 5). The quality and

condition of subsistence was

frequently diminished due to

improper temperature while in

storage, during delivery, or at

the search pit*.

ANIMAL MISSION

Military Working Dogs

Depending on the location, a squad was typically

responsible for 10 to 20 MWDs:

 Preventive Medicine. Dogs at home stations and

those deployed are provided parasite prevention

and routine vaccinations. MWDs deployed to

southeast Asia, southwest Asia, and the Balkans

are additionally provided doxycycline or

tetracycline daily as prophylaxis against rickettsia

and babesia infection.4(p33)

 Physical Examinations. At a minimum, military

veterinarians perform semiannual physical examinations of MWDs to detect and address problems

or changes in the health of the animals.4(p26)

 Sick Call/Emergency/Surgical Care.

Military veterinarians and animal

technicians are on-call 24 hours

per day to care for MWDs. As

mentioned earlier, each location

varied, but most were inadequate

for MWD treatment due to lack of

equipment and/or space. Kuwait

had an acceptable facility which

included a designated veterinary

trailer with a storage area, as well

as a treatment room/laboratory

with a sink and microscope. In

addition, a surgery suite with

a nesthetic ca pabilities wa s

provided. Upon the team’s arrival

in Qatar, the designated veterinary treatment room

doubled as the dog food storage area. The room

was too small to set up an exam table and be able

to move around and treat an animal.

We usually worked where space

could be found, offices, hallways or

outside. An anesthesia machine and

microscope was available, however,

no de ntal, ra di og ra phic, o r

sophisticated laboratory equipment

(ie, blood analysis) was available at

either the Qatar or Kuwait locations.

On a regular basis, radiographic and

laboratory equipment was used at the

medical facilities on base. There was no veterinary

treatment room and only sparse medical

equipment was available in Djibouti. There was a

very small number of MWDs in Djibouti, therefore, extensive equipment was not feasible. If a

dog required further diagnosis or treatment, it

could be flown to Qatar, and, depending on the

case, to Germany if necessary. If an emergency

arose, a civilian veterinarian off-base could be

used.

Four MWDs required surgery during the

deployment. Two aural hematoma repairs, an

extraction of an abscessed tooth, and a root canal

on a fractured canine tooth were completed. In 3

of the cases, we did not have the proper room or

necessary equipment (ie, dental drill) to perform

surgery. The medical personnel on base

were cooperative and allowed us to use

their facilities and equipment to

s u c c e s s f ull y a c c o m p li s h t h e

procedures. When necessary, we had

the option to fly dogs to the 51st

Medical Detachment, our referral

center in Germany, for treatment.

However, if the opportunity existed to

treat dogs in-theater, it was best to get

the dog back to duty as soon as

possible. Understandably, time was

always a concern to the kennel masters

who had a severe scheduling problem if

they were short a dog team on the gate.

The availability of base funding was

explored to address the need for more efficient

treatment. We were very proud that the necessary

funding was secured after 8 months, and we broke

ground to build a treatment room/surgical suite

with veterinary equipment for the dogs in Qatar.

The room was built as an addition onto the dog

*A secure area outside and away from the entrance gate

of a base where guards and bomb dogs search vehicles

for explosives before allowing them to enter.

Figure 1. Beetles in pasta.

A Veterinary Service Squad Deployment, Operation Iraqi Freedom

Figure 2. Insect in unopened,

sealed bottle of water.
January – March 2009 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

kennel and contained an isolation kennel and an

area for food inspection. Equipment purchased

included a surgery table/dental sink, centrifuge,

surgery light, dental unit, and

an autoclave.

 Medical Evacuation. As

mentioned above, we had the

option to coordinate with

human medical facilities to fly

an MWD to Germany for care

if the dog required emergency

care beyond our capabilities.

However, that is more easily

said than done. Patience is

required as there is always

much coordination with

aeromedical assets as flight

times can change frequently.

Also, personnel rotate often

so you must keep your points

of contact roster current.

Another factor to consider is

the requirement to keep the

patient stable until the flight,

and then en route. The

handler accompanies the

MW D , h o w e v e r , t h e

veterinary unit must decide if

the handler can adequately

monitor and treat the dog

during travel, or if an animal

technician is required to

accompany the patient.

 Kennel Inspections. Kennel

i n s p e c t i o n s w e r e

performed on a monthly

basis to ensure MWD

housing was adequate,

clean, and safe. The

kennels at the different

sites also varied in size and

quality, from very well

built concrete structures

with well -landscaped

training yards and new

obstacles, to dog crates

stored in a tent with old

worn obstacles in a dirt

yard.5

 Handler Training. Training was offered to the dog

handlers on various topics such as heat injury

prevention, ear cleaning, first aid, bandaging,

subcutaneous and intravenous fluid

administration, and intravenous

catheter placement.

MWD Trends. The 3 most common problems encountered with

MWDs:

Otitis externa. The dogs work in

hot and dirty conditions, which

provides an environment that favors

bacterial and/or yeast infections and

subsequent inflammation of the

external ear canal. A complication

of otitis externa is development

of an aural hematoma. Dogs will

head shake and scratch to try to

gain relief from irritated ears. The

result can be fracture of the cartilage and a hematoma originating from the auricular artery

within the fractured cartilage.

Our squad ensured that the handlers understood the importance

ofchecking MWDs on a weekly

basis and cleaning their ears, if

needed, to help prevent infections.

Figure 3. Beef with freezer burn. Some

packages were broken exposing raw

meat.

Figure 4. Thawed and refrozen chicken.

Evidence of “purge,” frozen blood and

juices outside the chicken.

Figure 5. Refrigeration unit failed in the truck transporting frozen meat en route

(left). The outside air temperature was 120°F. Blood from thawed meat flowed from

the truck when inspectors opened the doors (right).
24 www.cs.amedd.army.mil/references_publications.aspx

Lameness. MWDs work long, hard hours jumping

in and out of tall trucks in the search pit.

Orthopedic examinations of lame dogs were

usually unremarkable. Typically, there would be a

grade I/IV lameness but a specific lesion could not

be localized. Again, medical personnel from the

clinic were very cooperative and allowed us use of

their radiographic equipment, which enabled us to

rule out orthopedic injuries such as fractures.

Muscle injuries were presumed and 3 days cage

rest with nonsteroidal anti-inflammatory drugs

were curative in most cases.

Dental disease. Two dental surgeries were

performed. The first was extraction of a carnassial

tooth, which had developed a root abscess. The

second was a root canal on a canine tooth that was

fractured at the gum line during training.

Stray Animal Control/ Rabies Bite Control Program

Excessive numbers of stray animals (mostly dogs and

cats) come onto bases looking for food. Strays can

carry disease and parasites to the human population.

Rabies virus is transmitted in saliva via a bite to

humans and is fatal unless treated with post exposure

antibodies. The Department of Public Works had the

responsibility of trapping stray animals on base and

bringing them to veterinary services for euthanasia.

Unfortunately, this was an almost everyday occurrence

and was difficult at times for the veterinarian and

technician to euthanize so many animals. There were

several instances of Soldiers bitten while handling

stray animals. These Soldiers were given post

exposure antibody treatment as a precaution. The

animals were captured, decapitated, and specimens

sent to Veterinary Lab Europe in Landstuhl, Germany,

for rabies testing. In all of our cases, the specimens

were negative for rabies. It was important to obtain

this information so the Soldiers who were bitten could

discontinue the post exposure treatment.

Health Checks on Local Animals

Periodically, camels or falcons were brought on base

to entertain Soldiers. Our squad did health checks on

the animals prior to Soldiers handling them to look for

any obvious signs of disease that could potentially be

zoonotic.

CONCLUSION

Several trends in both the food and animal missions

were noted. The 3 most common problems with food

were temperature abuse, unapproved sources, and

insect infestation. These were mostly due to lack of

compliance to US standards by the prime vendor. By

vigilant inspection and recommending rejection of

food to facility managers, the prime vendor began

complying and the food quality improved

dramatically. The 3 most common reasons our squad

saw MWDs were otitis externa, lameness, and dental

problems. These were mostly related to the

environment and working conditions the MWDs were

experiencing. In Qatar, the treatment room was almost

complete when we rotated from theater. While we did

not get to use the facility ourselves, our successors

benefited from it. Our experiences, challenges, and

accomplishments are typical and similar to other

Veterinary Service units deployed in support of

Operations Iraqi Freedom and Enduring Freedom.

REFERENCES

1. Army Regulation 40-905: Veterinary Health Services.

Washington, DC: US Dept of the Army; August 16,

2004.

2. Army Regulation 40-657: Veterinary/Medical Food

Inspection and Laboratory Service. Washington, DC:

US Dept of the Army; November 6, 1997.

3. Worldwide Directory of Sanitarily Approved Food

Establishments for Armed Forces Procurement. Fort

Sam Houston, Texas: US Army Veterinary

Command; June 4, 2008. Available at: http://vets.

a m e d d . a r m y . mil/ V E T S VC S/ a p p r o v e d . n s f/

a33b0b8376c838f586256f82007bf7b7/a981a3522fa3

217e86256f960052191f?OpenDocument.

4. The Handbook of Veterinary Care and Management

of the Military Working Dog. Lackland AFB, Texas:

Dept of Defense Military Working Dog Veterinary

Service; March 5, 2004.

5. Army Pamphlet 190-12: Military Working Dog

Program. Washington, DC: US Dept of the Army;

September 30, 1992.

AUTHOR

CPT Brunell is Chief, Wiesbaden Branch, Northern

Europe District Veterinary Command, Wiesbaden,

Germany.

A Veterinary Service Squad Deployment, Operation Iraqi Freedom
January – March 2009 25

INTRODUCTION

The cooperative medical assistance (CMA) team is a

small team composed of a doctor, medics, and

physicians assistants, and may include a veterinarian,

dentist, and/or optometrist. The purpose of this team is

to provide social or political quick impact projects in

the form of medical assistance to areas in countries

without a well-developed medical, dental, or veterinary infrastructure. The team includes translators,

and, in Afghanistan, male and female medical

personnel as well. In Afghanistan, the team is on-call

to provide single day clinics, usually in remote areas,

at the request of the resident military or provincial

reconstruction team (PRT) leaders. These short-term

clinics are referred to as civil action programs (CAPs),

or, more specifically, MEDCAPs (medical),

VETCAPs (veterinary), and DENCAPs (dental),

according to the services offered. The CMA team is

hosted, protected, and supported by the military unit.

The requesting unit determines the site, and performs

all preparation for the event, to include advertising.

Often, the resident unit augments the team with their

own medical assets, although the CMA team has the

discretion to determine the medical, veterinary, and

dental procedures provided. Since the military unit or

PRT is the entity with a long-term interest in the area,

they are responsible for measuring the impact of the

clinic on the local people.

Nongovernmental organizations, and even at times the

requesting units, are often confused over the purpose

of the CMA team. It is not a substitute for local

medical assets. It is not meant to replace the local

veterinarian, doctor, or dentist. It is not meant to

provide medical care for underserved communities. It

is not meant to respond to disease outbreaks or become

involved in control measures. Requests for such

services are routinely denied by the CMA team leader.

Although all those involved in the process hope that

the VETCAP/MEDCAP adds to the health and wellbeing of the local community, that is not the primary

function of their mission. It is, rather, a tool utilized by

the combatant commander or the head of the PRT to

gain access into the local community, or to provide

recompense for perceived hardship borne by the

community due to military operations. It is also a

method by which military units may gain favor with

the civilian population, who then may be more willing

and able to provide information on local insurgents. It

may occasionally be used as a show of force within

areas that are closely controlled by insurgents, to show

that the coalition forces are unafraid and able to

provide aid despite the danger. It has also been used as

a reward for good behavior when a community has

been active in fighting the insurgency on their own.

Therefore, while it may appear that the CMA team is

only conducting humanitarian operations, that is an

adjunct benefit to the accomplishment of military

goals.

It is clear from follow-up interviews with military and

PRT members that a successfully conducted

MEDCAP/VETCAP generates goodwill within the

Veterinary Civil Action Programs in

Afghanistan: Pros, Cons, and How

MAJ Jessica McCoy, VC, USAR

ABSTRACT

Veterinary civic action programs (VETCAPs) are short-term clinics that are conducted by military

veterinarians to treat the local livestock. They are used successfully by military commanders and provincial

reconstruction team leaders to prepare the battlefield for further engagements. Hundreds of VETCAPs have

been conducted in Afghanistan since 2001. However, veterinary-focused, nongovernmental organizations

working in Afghanistan contend that these programs decrease the sustainability of the veterinary infrastructure

throughout the country. This paper presents a study conducted from March 2006 through February 2007 which

seeks to quantify the effect of veterinary civic action programs on the local veterinary infrastructure in

Afghanistan, and determine ways in which the military objective may be obtained while causing least damage

to the veterinary infrastructure.
26 www.cs.amedd.army.mil/references_publications.aspx

community. VETCAPs in particular create a bond

between Afghan herdsmen and military units. Afghans

are extremely appreciative when they see military

personnel willing to wrestle sheep and risk kicks and

bites in order to treat their animals. The operation itself

also creates a mild chaos which is entertaining for the

community, and a crowd always develops at the

VETCAP site. This crowd and chaos provide an

environment in which people may speak to Soldiers

without raising undue suspicion. Lastly, the VETCAP

provides a visible example of outreach which the

locals will be talking about for a long time. Because of

the lack of basic veterinary care, the vaccination and

deworming of herdsmen's animals has an immediate

beneficial impact on village health. This benefit

extends beyond the direct benefit to the herdsmen.

Animals are intimately associated with the economic

and social well-being of the Afghan people. Legal

agriculture makes up 38% of the gross domestic

product.1 However, the impact of animals on the

economic well-being of villagers is not fully

demonstrated by this statistic. Animals are not just

used for their meat, milk, and hides. They are used for

transportation of goods along roads which are

inaccessible to vehicles. Oxen are used for plowing

and threshing grain. Horses are essential to the

maintenance of the social fabric between tribes. How

can it be detrimental if the vaccination or deworming

of a herdsman's animals allows them to survive

another year or reproduce one more offspring?

However, these operations have the potential to

compete with the nascent veterinary service growing

in Afghanistan. For many years, the government

attempted to provide veterinary care for free.

However, the system was poorly resourced, medications were rarely available, and veterinary training

was poor. There was no incentive for veterinarians to

do a good job, since their services were free. The

modern government of Afghanistan, however, has

realized that that the old government-supported

veterinary services were ineffective. They cannot

afford to support all veterinary care throughout this

agrarian country. Therefore, the majority of veterinarians today in Afghanistan work on a fee-forservice basis. This model has been generally

successful, and as of 2006 there were 587 veterinary

field units (VFU), each associated with one of 7

international nongovernmental organizations. These

VFUs employ over 800 veterinary professionals. As

shown in Figure 1, the veterinary field units are

moderately well distributed throughout the country,

although some places are truly underserved. However,

they represent a “new” model for veterinary services in

Afghanistan, and the number of VFUs and their

coverage across the country continues to grow.

In areas in which there is a veterinarian, the provision

of free service is understandably detrimental to their

business. Aside from the immediate competition,

delivery of free veterinary service encourages the local

inhabitants to seek free veterinary care, and to

continue to regard free veterinary care as a right.

Services provided for free to one group of people will

spark complaints of herdsmen to veterinarians in other

areas asking them why they charge for their services.

The nongovernmental organizations are fighting

against this mindset in order to create a sustainable

fee-for-service veterinary infrastructure. If our actions

disrupt this fight, we risk the end of sustainable

veterinary services. This will have an enormous detrimental long-term impact. For this reason, we must be

very careful in the performance of VETCAPs to ensure

that we do not endanger the long-term viability of the

local veterinarians. This research was conducted in

order to determine the extent of impact our operations

have on local veterinary infrastructure, and to

investigate ways of fulfilling the military intent of the

operation with minimal negative impact on the local

veterinarians.

METHODOLOGY

This study was devised after extensive interviews with

all the nongovernmental organizations known to be

working in the veterinary field in Afghanistan. Prior to

arrival at the VETCAP site, the location was checked

against a list of known veterinarians which was

provided by the nongovernmental organization

working in the area. If security allowed, the local

veterinarian was contacted prior to the VETCAP in

order to inform him of the activities and ask if he

would like to participate. On nearly every occasion,

where this was possible, the veterinarian agreed to

work with us. In these instances, the veterinarian was

also interviewed to establish, from his perspective, the

willingness of the local people to use his services. He

was asked about his prices, and whether or not he was

able to work full time as a veterinarian. He was also

Veterinary Civil Action Programs in Afghanistan: Pros, Cons, and How
January – March 2009 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

asked to estimate the percentage of animals in his area

that he had vaccinated.

On every mission, interviews were conducted of all

herdsmen who brought their animals to the VETCAP

site. They were asked from where they brought their

animals, whether they had vaccinated their animals

before, and if they knew of any local veterinarian.

Note was made of the species and herd size of animals

that they brought, and any outstanding illnesses or

complaints.

RESULTS

Interviews were conducted at every VETCAP mission

by the cooperative medical assistance team over a

period of 7 months. Nearly 1,600 herdsmen were

interviewed in 7 provinces over 30 mission-days.

During this time, over 8,800 animals were seen. Ten

local veterinary professionals and 5 veterinary students

were also interviewed. Data was discarded from 2

missions, one in Kabul and the other in Ghazni, where

the principle investigator was absent. However, in both

areas there was a general denial of the presence of a

veterinary field unit (even though there was a large

veterinary hospital very close by the site in Kabul),

and vaccination rates were reported to be none (Kabul)

or negligible (Ghazni). In Gardez, I was forced to use a

translator from the local unit, whom I discovered at the

end of the day had not understood the directions for

interviewing properly. Therefore that interview data

was discarded. The consolidated data is presented in

the Table.

Herd sizes ranged from one to 230 animals. The

majority of these were sheep and goats, although the

species distribution was very site-specific. Cows were

the next most prevalent, followed by equids, dogs,

camels, and birds. Sheep and goats were often run in

mixed herds and their numbers were not differentiated

in this study. Approximately 10% of the herdsmen that

brought their animals to the VETCAP said their

animals had been vaccinated at least once previously.

With the exception of horses, herdsmen would not

Figure 1. Veterinary Field Units in Afghanistan. (Source: Afghan Veterinary Association)
28 www.cs.amedd.army.mil/references_publications.aspx

bring their animals more than 7

km to get vaccinated or

dewormed. The majority of

animals seen were healthy.

There appeared to be an inverse

proportion of goats and sheep

that were thin in any given

area. This implies that mixed

herd foraging areas have either

good graze or browse but not

both. Such herds would benefit

from species separation, or

elimination, but there may have

been a time component

associated with running sheep

and goats together, in that one

does better at certain times of

year or under certain weather

conditions.

A small percentage of animals coming to the VETCAP

would be unwell. These were rarely due to disease, but

rather due to mismanagement. Traumatic injuries,

wounds (Figure 2), bloat (Figure 3), and “slipper

feet” (Figure 4), presumably due to chronic laminitis,

were the most common problems seen. Overloading

pack animals and not allowing them to rest post-injury

were the primary inciting causes.

The veterinarians interviewed were all from central

and northern provinces. Of the ones interviewed, only

two had a strong opinion of military VETCAPs. One

disliked them, and thought they should stop, the other

thought they acted as an enticement for future

veterinary activity and wanted more of them. Both

veterinarians were located in the Panjshir Province,

where nearly a third of the VETCAPs were performed.

The veterinary students in Nangarhar were simply

pleased to have animals to work on, and the other

veterinarians were happy to have us in their area of

operations and did not appear to appreciate the

potential conflict of loss of their business. The private

veterinarians agreed that vaccination rates were low in

their areas, while the provincial veterinarians in

Gardez and Panjshir thought that vaccination rates

were quite good. This contradicted our data from the

VETCAPs.

DISCUSSION

Biases in Data Collection

It is important to note that the population interviewed

was not randomly selected. They were all herdsmen,

and they all brought their animals to the VETCAP site

for vaccination or treatment. Since we did not make

“house calls,” all animals had to be able to make the

journey. Therefore we saw very few severely ill

animals (although 2 animals subsequently collapsed

upon arrival at the site). Sometimes we were able to

inform the population prior to our arrival that we were

coming, but sometimes not, and this had a strong

Numbers of animals seen at VETCAPs in Afghanistan, August 2006 through February

2007 (minus those in Kabul & Ghazni*).

Province

Balkh Bamian Gardez Kapisa Nangarhar Panjshir Kandarhar

Cattle 79 147 284 61 69 1210 51

Sheep/Goats 188 1690 759 312 29 2460 96

Donkeys 20 337 33 26 2 129 3

Horses 3 58 1 19 0 40 0

Dogs 2 0 14 5 4 9 5

Camels 0 0 0 0 45 0 0

% Access to VFU 0% 0.75%

Data

Unreliable

66% 100% 21%

Vaccination

Rate† 4% 20% 13% 7% 4%

*The principle investigator was absent at those VETCAPs.

†Percent of herdsmen who reported their animals had ever been vaccinated.

No Data

Figure 2. Pack horse with open wound caused by poorlyfitted pack and poor body condition (Nangarhar). Owner

complained that the local veterinarian was ineffective

because he “couldn’t fix the wound” while allowing the

animal to continue to work. “If I don’t take goods over the

pass every day with my horse, my family doesn’t eat,” was

his reply when I asked him to rest the horse.

Veterinary Civil Action Programs in Afghanistan: Pros, Cons, and How
January – March 2009 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

effect on what types of animals we saw. If we were

unable to give forewarning, we saw significantly fewer

small ruminants, as they would be already in the

grazing areas which were distant from the villages

where the VETCAPs were performed. Lastly, data on

prevalence of vaccination and knowledge of access to

a local veterinarian were collected by interview. This

data is always subject to some skepticism, particularly

knowledge of a local veterinarian. There was a

suspicion on the part of the Afghan villagers that

VETCAPs would not be performed if the coalition

forces knew that there was a local veterinarian

available. This often led to confusion when the

military unit or provincial reconstruction team did

their initial assessment. However, as stated earlier, the

reasons for performing the VETCAP had little to do

with providing veterinary service per se, but rather to

gain influence or information. Asking the same

question during the VETCAP itself, however, should

give more reliable results, since it is clear that we were

not going to close up the VETCAP for receiving a

positive response. However, there were several

instances when I knew there was a local veterinarian

within a few kilometers, and yet the local people

appeared unaware. It is unclear whether this response

was due to ignorance, politics, or a sense that this

could damage one’s chances to get another VETCAP

later.* However, I believe more confidence may be

placed in these onsite answers than would be prudent

for answers obtained prior to the VETCAP. This

indicates a need for better advertising on the part of

some of the veterinarians, so that people become

aware of the services they offer.

General State of Veterinary Services in Afghanistan

When this study was done in 2006, there were 587

veterinary field units (VFUs) registered in

Afghanistan. While not completely covering the

country, some areas had quite good coverage.

Although many veterinarians were provided with

motorcycles, they did not appear to use them to do

farm-calls, but rather simply to get resupplies for their

pharmacy. This may have been due to unwillingness of

the veterinarian to pay for the needed fuel, or to the

herdsmen themselves being unwilling to walk long

distances to inform the veterinarian that his services

were needed.† The location of a VETCAP, as

previously stated, was unrelated to the presence of a

local VFU, so places visited could be well or

underserved. These veterinarians work on a fee-forservice basis, and are required to recover their costs in

Figure 3: Bloat was surprisingly common. The locals in the

small village in Gardez Province have discovered a cure.

One downer cow also presented at this site in which the

herdsman had put a knife through the omasum and into the

lungs.

*Over the 3 years for which data was available, with the exception of Panjshir Province, the CMA team revisited an area

near a previous site only once. During 2006, there were 3 missions to Panjshir, more than any other province, and there

was some potential overlap in area of effect. This was done at the insistence of the provincial governor. However, there

were virtually no visits prior to 2006. As long as site visits to the same areas do not repeat in subsequent years, the

effect will be negligible.

†There was generally no cell phone or taxi service in the areas in which we worked.

Figure 4. Chronic laminitis (photo taken in Gardez) may

have caused “slipper feet” in cows. This was a common

finding in Kandahar as well.
30 www.cs.amedd.army.mil/references_publications.aspx

order to replenish their medications. The veterinarians

may be weighing the cost of procuring the medication,

to include fuel for the motorcycle and possibly for the

refrigerator, and hold off going into the capital to

procure more drugs until there is additional reason to

go.

Presumptive Competition

When the veterinary nongovernmental organizations

heard of the military providing veterinary care free of

charge, they were quite concerned about the level of

competition this would pose for the free market

veterinarians. Not only is there direct competition,

where the VETCAP “steals” the business of the local

veterinarian, but there is also a more subtle effect. The

locals already have a sense of veterinary entitlement

that remains from the Soviet era, and the VETCAPs

serve to promote the idea that veterinary care “should”

be free. Herders leave with the notion that the Afghan

veterinarians are charging them for something which,

in the developed world, as evidenced by the coalitionprovided VETCAP, is normally free. This causes

resentment, and makes it even more difficult for

veterinarians to receive payment for their services.

Therefore it is imperative that the unit requesting the

VETCAP be very aware of the potential downsides to

their actions, and the potential impact on long-term

sustainability of veterinarians in the area.

What are the goals of VETCAPs? As stated

previously, VETCAPs are not primarily about

providing veterinary care, but rather about community

access and good will. It is a highly visible form of

local aid and its somewhat chaotic nature can be a

useful distractor. According to commanders informally

interviewed several weeks after each mission, the

VETCAP was extremely effective in producing a more

open and friendly community attitude toward the

coalition forces. Therefore, asking these commanders

to remove VETCAPs from their “toolbox” is unlikely

to meet with success. However, there are ways to

achieve the military objectives without sacrificing the

local veterinarians or veterinary infrastructure.

Ways to Meet the Goals Without Sacrificing the

Veterinary Community

In order to limit the negative effects of performing a

VETCAP while still retaining the military objectives,

the following standard operating procedure was

developed based on this study:

Distance of VETCAP site from a veterinarian. The

study showed that herdsmen were unwilling to

bring their animals more than 7 km in order to be

vaccinated or dewormed. Therefore, if there is no

veterinarian within 14 km, then there is no overlap

between the coalition and local veterinarian’s

sphere of influence. A veterinarian within 10 km

of the VETCAP site would experience only very

minor competition. Therefore, if there is a VFU

within 10 km of the site, the local veterinarian

should be requested to join the VETCAP. Due to

security concerns, this sometimes has to be done

on the morning of the operation. If he accepts, then

he should be brought to the VETCAP site,

provided with all the supplies needed, and perform

the majority of the treatments. While coalition

forces do mostly prophylactic treatments, sick

animals are taken to the veterinarian. The

VETCAP then becomes a focal point to show

support for the local veterinarian.

If there is a local veterinarian within 10 km and he

is unwilling to join the operation, or, more likely,

the military unit is unable to find him, then we

must downgrade our operation to deworming only.

All herdsmen are then advised to take their

animals to the local veterinarian for vaccination

(since the veterinarians uniformly identified

vaccination as their primary source of income),

and any sick animals should be referred to him for

treatment as well. In this way, we cause minimal

interference with the economic potential of the

veterinarian despite working in “his space.”

If there is no veterinarian within 10 km of the

VETCAP site, then the site may be designated as

underserved, and we provide full-service

veterinary care.

Fliers were distributed at every VETCAP, which

explained that this event was a one-time gift of the

Coalition Forces, and explained that further

treatment and guidance was available from the

local veterinarian. These fliers were very popular,

and sometimes goaded kids into finding an extra

animal just so they could get one.

Very often, herdsmen request extra medication for

their herds “just over the hill.” One must not grant

this request. If one grants this request, then not

only do you run out of medication much sooner

Veterinary Civil Action Programs in Afghanistan: Pros, Cons, and How
January – March 2009 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

than expected, but, more importantly, you have now

destroyed the 7 km “zone of

influence.” The 7 km limit is

determined by how far herdsmen are willing to push, drag, or

otherwise herd their animals to

get to you. Treating animals

beyond this zone does nothing to

advance your mission of

improving local relations, and

can impact long-term veterinary

care for everyone in the area. Do

not do it.

OTHER WAYS TO ASSIST

There are other ways to assist and

provide visible outreach to the community, thereby

completing the military objective without impinging

on the local veterinary infrastructure. Provision of a

storage facility for grains is a cost-effective way in

which to assist the local farmers and herdsmen. Much

of the grain harvested every year is spoiled by insects

or weather. The Kuchis, a nomadic sheep-herding tribe

similar to the Bedouin, particularly complained of

having no way to store feed along their migratory

routes pending their return. One can build a silo and

paint “a gift from the American public” in large letters

on the side, and it will be more permanently

appreciated within the community

than any one-day VETCAP.

Another way to assist is through

literacy programs. Although 64% of

adults were noted as “literate” by

UNESCO* in 2000,2the majority

of farmers with whom I worked

were unable to read and write. This

ma ke s rec o rd -kee ping ve r y

difficult, and, consequently, herd

improvement programs are almost

impossible to implement. Again,

this will have a longer-lasting effect

on the animal health in the area than

a VETCAP, and education

generally serves the cause of the

moderates, which is also a strategic

objective in Afghanistan. Lastly, it was noted

throughout the year that there were far more problems

related to poor husbandry practices than to contagious

diseases. Wounds due to poorly fitted tack and packs,

white-line abscesses (Figure 5) that festered until they

burst out the top of the hoof (Figure 6), bloat and

chronic laminitis, poor forage selection, ignorance of

pasture rotation or management, and even limiting

access to water are far more serious to the entire

animal industry (and compound any potential disease

threat) than contagious diseases and parasites.

Teaching herdsmen the principles behind good

husbandry practices will allow them to modify their

procedures to get more and healthier animals. Another

concept which is foreign to many Afghans is that it

may be better to have fewer, healthy animals than

many not-so-well-fed ones. However, an economic

study should be done prior to recommending this

course of action.† Other ways to assist herdsmen with

their animals that will be appreciated can be easily

devised, and many will be specific to the site of

implementation. It requires thought and preparation,

but is ultimately more beneficial to both herdsmen and

coalition partners, as well as the veterinarians, than

conducting another VETCAP.

CONCLUSION

The VETCAP is performed for the purposes of gaining

favor within a community. It has been extremely

effective in producing the desired results in

Figure 6. Horse with hoof abscess which has extended into

coronet area (Nangarhar).

Figure 5. White line abscess in a pack

horse on the Afghanistan-Pakistan

border.

*United Nations Education, Scientific, and Cultural Organization

†In studies conducted among the migrating herdsmen in Africa, the economic benefit of keeping a thin animal that could

later be fattened outweighed the potential benefit of increased offspring due to more or better forage per animal.3
32 www.cs.amedd.army.mil/references_publications.aspx

Afghanistan, as well as other countries that have a

strong agrarian economy and poorly developed

veterinary infrastructure. Therefore it is difficult to

convince the military commanders to stop performing

VETCAPs. However, by following the rules outlined

in this paper, the negative impact of the VETCAP can

be lessened, while still achieving the desired military

result. The gold standard option, of course, is to

perform some other service which can have the same

effect. These effects are often more resilient, and

appreciated for a longer period of time, than the oneday VETCAP. Each area is unique in its attributes, and

determination of the appropriate project will depend

on the time horizon and resources available to the

combatant or provincial reconstruction team

commander.

REFERENCES

1. The World Factbook. Afghanistan. Central Intelligence Agency web site. Available at: https://www.cia.gov/library/

publications/the-world-factbook/geos/af.html. Accessed January 13, 2008.

2. UIS Statistics in Brief. Education in Afghanistan. UNESCO Institute for Statistics web site. Available at: http://

s t a t s . u i s . u n e s c o . o r g / u n e s c o / T a b l e V i e w e r / d o c u m e n t . a s p x ? R e p o r t I d = 1 2 1 & I F _ L a n g u a g e =

eng&BR_Country=40&BR_Region=40535. Accessed December 17, 2008.

3. Bekure S, de Leeuw PN, Grandin BE, Neate PJH, eds. Maasai herding: An analysis of the livestock production

system of Maasai pastoralists in eastern Kajiado District, Kenya. ILCA Systems Study 4. Addis Ababa, Ethiopia:

International Livestock Centre for Africa; 1991. Available at: http://www.ilri.org/InfoServ/Webpub/Fulldocs/

X5552e/x5552e00.htm. Accessed February 10, 2009.

AUTHOR

MAJ McCoy is currently the Ministerial Advisor for Animal Health and Food Safety, US Dept of Agriculture, Foreign

Agricultural Service, Baghdad, Iraq. When this article was written, she was the Senior Veterinarian, 405th Civil Affairs

Battalion, Bagram Air Base, Afghanistan.

Veterinary Civil Action Programs in Afghanistan: Pros, Cons, and How
January – March 2009 33

INTRODUCTION

Military working dogs face the same dangers in

combat as human service members, and serious

traumatic injuries are not uncommon in these dogs.

Ballistic, explosive, and blunt trauma has occurred in

many dogs and veterinarians in combat zones must be

prepared to manage these cases. Even before reaching

veterinary care, dog handlers, medics, and other

human medical providers are faced with providing

lifesaving treatment on canine service members at the

point of injury.

DEPLOYED VETERINARY PERSONNEL

Historically, veterinary teams in deployed units tasked

with caring for working dogs have not been trained,

staffed, or equipped to manage major trauma, focusing

instead on day-to-day care and medical management

of working dogs in their respective theater of

operations.1 The majority of their work in theater

actually focuses on food safety, which, overall, is the

largest portion of their daily duties. Occasional serious

injury or illness was considered the exception rather

than the rule, to be dealt with when it occurs. Training

given to Army Veterinary Corps officers and enlisted

animal care specialists (veterinary technicians) to

ensure proficiency in managing these cases was

proportional to the likelihood of it actually occurring,

which was considered unlikely. With occasional

exceptions, veterinarians assigned to these units are

usually veterinary field officers (AOC*64A), often

junior captains who usually have no formal clinical

training after graduation from veterinary school. In

rare cases, they entered the military after internship or

residency training. Internship or residency training is

not a requirement to practice veterinary medicine, and

only a small percentage of graduate veterinarians

pursue this advanced post-graduate training. The

Veterinary Corps has an extensive program which

allows veterinarians to complete clinical residency

training, but there are no assigned positions within the

deployable units for residency-trained clinical

specialists. Veterinarians preparing to deploy often

complete the Army’s Veterinary Clinical Proficiency

Course, an intense 2-week classroom and hands-on

review of common emergency and surgical treatments,

along with certain diagnostic methods.

In both Operations Iraqi Freedom and Enduring

Freedom, there are only a handful of veterinary

treatment facilities among the extensive number of

bases which house working dogs, and transport time to

veterinary care may be anywhere from hours to days,

depending on the situation. Human medical providers

such as medics, physicians’ assistants, and physicians

are often faced with providing lifesaving care to

injured working dogs until they can be transported to a

location with a veterinary treatment facility in-theater.

Since 2005, a veterinary clinical medicine officer

(AOC 64F), either a surgeon or internal medicine

specialist, has been assigned to the deployed veterinary

unit in Iraq to augment the existing veterinary capabilities. This has proven very helpful with serious

medical and surgical cases, although some serious

trauma cases still present to the veterinary field officers at remote forward operating bases throughout the

theater. Thus, the veterinary field officer may be the

only veterinarian in the area and is responsible for

managing major canine trauma. A veterinary clinical

specialist has not been specifically assigned to the

Afghanistan theater. However, the Army Reserve has

provided veterinary coverage in that theater. Many

Army Reserve veterinarians are practicing clinical

veterinarians in civilian life and therefore come to

theater with extensive clinical experience.

The current conflicts in Iraq and Afghanistan have

defied doctrine and the “status quo” of deployed

veterinary operations. The likelihood of seeing a

critically wounded military working dog increased

Overview of Combat Trauma in Military

Working Dogs in Iraq and Afghanistan

MAJ Janice L. Baker, VC, USAR

CPT Christina A. Truesdale, VC, USA

CPT(P) Justin R. Schlanser, VC, USA

*Area of concentration
34 www.cs.amedd.army.mil/references_publications.aspx

profoundly with the rise of the insurgency. Veterinary

officers and enlisted animal care specialists deploying

with deployable veterinary units must be prepared for

this occurrence. Despite the limitations in equipment,

staff, and training, deployed veterinarians have

adapted to the challenge and done an excellent job in

managing these cases.

INJURIES AND WOUND DISTRIBUTION

There is currently no standardized database to capture

injury data in working dogs, such as the Joint Theater

Trauma Registry for injuries in human service

members. Studies to analyze canine injuries or illness

in theater have relied on massive data calls, word-ofmouth reporting, or screening records of deceased

working dogs once the medical record is sent for

archiving at the Department of Defense Working Dog

Center at Lackland Air Force Base. Although several

studies are currently underway, and a few have been

presented as preliminary data, apparently none have

been published since the beginning of Operations Iraqi

Freedom and Enduring Freedom.

Preliminary data in a study of gunshot wounds in US

military working dogs shows a survival rate of 33% in

21 dogs. Of the surviving dogs, there is a return to

duty rate of 71%, with the remaining 29% undergoing

continued care and expected to eventually return to full

duty. This data also

shows that 5 of the 7

dogs that survived their

injuries were considered

in critical condition at

some point in following

their injuries, requiring

advanced lifesaving care

by medics in the field or

by veterinarians at the

deployed veterinary

treatment facilities.2

Currently there is no

standa rdized injury

severity score methodology for dogs as there is

for human trauma

victims. However, classification of canine casualties for these studies is

modeled as closely as

possible to human

studies. The terms killed in action (KIA), died of

wounds (DOW), wounded in action (WIA), and

disease, nonbattle injury (DNBI) are defined to allow

comparison to human morbidity and mortality studies.

A dog is considered KIA if it dies prior to reaching

care of a veterinarian in a facility capable of

resuscitative treatment or surgery. A dog is considered

DOW if it arrives at veterinary care as defined above,

but subsequently dies of the wounds, or are euthanized

because death is imminent. The term WIA indicates

the dog ultimately survived its wounds, and DNBI is

used for cases of injury or illness not caused by

combat action. According to the preliminary ballistic

wound data, none of the injured dogs were categorized

as DOW; they either died instantly from catastrophic

trauma or survived to return to their home station.2

One study of human combat casualties showed

approximately 12% of patients died with injuries

which were determined to be potentially survivable.3

That is, they suffered injuries from which, with proper

identification and treatment of those injuries, they

could possibly have survived. No canine casualties in

the ballistic wound study have been identified in this

category.

Wound distribution for these cases does not appear to

mirror wound distribution for human combat

casualties. For example, wounds to the thorax from

An animal care specialist

provides postoperative

physical therapy to a working dog who had received a

gunshot wound to the shoulder. The dog underwent

extended physical therapy

at the DoD Dog Center at

Lackland, Air Force Base,

Texas, and returned to full

duty.

This military working dog incurred a gunshot wound to the

head. Following intensive care and treatment for skull

fracture, detached retina, and traumatic brain injury, he

recovered fully and returned to duty 4 months after the

injury.

Overview of Combat Trauma in Military Working Dogs in Iraq and Afghanistan
January – March 2009 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

any cause (ballistic, explosive, blunt trauma) appear to

be more common in canines than in human service

members.3,4 This is probably due to several factors,

including the four-footed, head-forward stance of dogs

rather than the upright stance of humans, as well as the

fact that dogs generally do not wear body armor.

While it is commercially available, it is quite heavy,

does not carry the same ballistic rating as human body

armor, and is thought to contribute to fatigue and heat

injury in dogs. The practicality of its use is limited.

The US military does not issue body armor to its

working dogs, although some improvised or

commercially-acquired types have been used in

theater.

Explosive injuries and blunt trauma make up the

majority of other major combat trauma in dogs.5

Improvised explosive devices and mortar and rocket

attacks have caused injuries in dogs as well, and,

anecdotally, such events appear more likely to result in

a combined mass casualty event where both human

and canine casualties occur.

INTEGRATION OF VETERINARY CARE INTO THE HUMAN

MEDICAL ASSETS IN THEATER

As mentioned above, deployed veterinary teams are

not specifically equipped, staffed, or trained to manage

serious canine trauma cases. Most locations lack

diagnostic imaging and comprehensive laboratory

equipment, and are minimally staffed with skilled

veterinary providers. Integration with human medical

resources such as a combat support hospital, Air Force

theater hospital, or other human medical facilities is

vital to providing advanced veterinary care to critically

injured dogs.

In one notable case, a working dog and several human

service members were seriously injured when an

improvised explosive device caused a building to

collapse, trapping the service members and the dog

under the rubble. The dog was placed on the

evacuation helicopter along with the injured humans,

and taken to the Air Force theater hospital in Balad

where they were treated side-by-side in the emergency

department. Emergency department personnel were

assigned to assist the veterinarian with emergency care

of the dog until he could be stabilized and transferred

to the veterinary treatment facility adjacent to the

hospital. Separating the dog from the handler to go

straight to the veterinary treatment facility, while the

handler was sent to the hospital, would have caused

confusion with medical operations within the medical

evacuation system, and would have required additional

personnel to triage and transport the dog to a separate

location. They treated the dog as another combat

casualty, and brought the veterinarian into the

emergency department as the veterinary provider. This

allowed a smoother and more efficient flow in

treatment of all of the casualties. In addition, proximity

of the dog to an injured handler is important to morale

of the team, and calmness of a potentially aggressive

working dog.

In another case, a dog suffered multiple fragmentary

wounds following a suicide bombing in close

proximity to the dog and handler. The dog and handler

were taken back to the forward operating base, where

they were immediately separated. The handler was

taken to the combat support hospital, while the dog

was taken straight to the veterinary treatment facility.

The veterinary field officer quickly recognized signs

of shock and the need for emergency exploratory

surgery which she felt was beyond her capabilities and

that of her staff in their facility. She immediately

transferred the dog back to the hospital where she

performed lifesaving splenectomy and intestinal

resection and anastamosis with the assistance of

human trauma surgeons, a certified registered nurse

anesthetist, and other surgical staff. This action

effectively turned Level I veterinary capability into

Level III capability at that location without costly

addition to veterinary equipment or manpower.

Those are just 2 cases illustrating how the deployed

veterinary teams are adapting to their situation to

provide excellent care to dogs with combat trauma.

Integration with human medical resources is vital and

perhaps should be made doctrinal. Several individual

cases have been reported of medical facility

commanders refusing to allow dogs treatment in their

facilities. An unwarranted and unscientific fear of

contamination seems to be the driving cause of this. In

reality, there are very few infectious or zoonotic

diseases that can be transmitted from dogs to humans,

and many of these are mitigated through prophylactic

vaccinations (ie, rabies) and strict prophylactic

antibiotic regimens that working dogs undergo while

deployed.6 There has been no formal study in the

military sector to support this, but it is likely that

working dogs pose no more of a health threat to

humans in the medical facility than other humans in

that same facility. As long as routine body substance

isolation and local decontamination measures are
36 www.cs.amedd.army.mil/references_publications.aspx

followed, medical facility commanders should not use

this as a reason to refuse dogs emergency care in their

facilities.

TACTICAL CANINE COMBAT CASUALTY CARE:

STANDARDS BASED ON EVIDENCE AND COMBAT

DATA

Tactical combat casualty care for human casualties has

well-defined standards of care, as does advanced

trauma management, damage control surgery, and

critical care. Standards exist for everything from use of

tourniquets to use of fluids, blood, and blood products

in resuscitation.7 These standards are based on casualty

data and multiple formal studies on actual combat

casualties and trauma management in the civilian

sector.8,9 Since there has been no casualty database

from which to compile and analyze data for canines,

veterinarians in deployed environments have been left

to manage these cases based on their own individual

experience, “gut feeling,” or other available resources.

Similarly, until recently there was no

standardized canine first aid training for

working dog handlers, and no known

formal military training available for

human medical personnel who may be

responsible for caring for dogs at the

point of injury. Dog handlers and human

medical personnel who requested this

training from their area’s military

veterinarian received training based on

the comfort level and experience of that

individual veterinarian. The reality,

unfortunately, was that few veterinarians

had been deployed and even fewer had

experience with combat trauma. Virtually

none had experience with point-of-injury,

prehospital care, but were asked to train

battle-experienced medics and human

medical providers in this area. Add to that

the fact that they were training these

providers on guidelines that were neither

evidence-based nor standardized, and the

guidance was often conflicting.

Veterinarians were understandably

reluctant to train nonveterinarians on lifesaving procedures, such as needle

thoracotomy, that they themselves had

never performed on an actual patient.

However, lessons learned from combat

have shown that human medical

personnel will improvise when faced with a critically

injured dog far from veterinary care, extrapolating

from their medical skills. There are multiple cases in

which they have performed these lifesaving procedures

on injured dogs with good success.2 Because they will

proceed with this care regardless of whether they have

received training or not, a new thought is emerging

about this training. It may be time to develop

evidence-based standards of care that can be used by

veterinary personnel as well as the human medical

providers who provide prehospital canine care on the

battlefield. Recently, Vogelsang’s excellent article10

summarized the basics of military working dog care

for human medical providers who may be faced with

this situation in deployed locations. This was the only

article we could find in the literature to address this

concept and it is likely the first of its type, a situation

that only emphasizes the need for this type of training

and information.

Overview of Combat Trauma in Military Working Dogs in Iraq and Afghanistan

A Veterinarian and human trauma team join forces to perform lifesaving surgery on a working dog injured by an explosion.
January – March 2009 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

THE WAY AHEAD

The increase in severe combat trauma in dogs has lead

to a different way of thinking in the Army Veterinary

Corps, and also with human medical providers and

units employing dogs on the battlefield. Work is

underway to develop a canine injury database similar

to the Joint Theater Trauma Registry. Clinical training

of junior veterinary officers and enlisted animal care

specialists has increased immensely over the last few

years, with new interest and focus on management of

trauma and critical care transport. Special operations

and flight medic students are given introductory

instruction on managing canine emergencies. Several

studies are underway regarding combat injuries,

morbidity, and mortality of dogs in combat theaters,

and of medical evacuation and en route care of

working dogs from theater.

Recommendations for continued advancement in this

area include creation of doctrine that specifies human

medical facilities can be used in treatment of canine

casualties, continued recording of canine morbidity

and mortality statistics, and integration of brief

standardized blocks of instruction for canine casualties

in combat medic, flight medic, and other medical

provider courses. In addition, prior to deployment,

veterinary officers and animal care specialists should

be required to gain hands-on training and experience in

civilian veterinary emergency and critical care

facilities through formal arrangements with veterinary

teaching hospitals and veterinary specialty centers.

The area of canine combat trauma management lags

behind its human counterpart in resources,

standardization, and training, but certainly not in

motivation or resourcefulness. Deployed veterinarians

have done a fantastic job in adapting to their situation

and providing excellent care to injured canine service

members.

REFERENCES

1. Tofolli CA, Rolfe DS. Challenges to military working

dog management and care in the Kuwait theater of

operation. Mil Med. 2006;171:1002-1005.

2. Baker JL, Truesdale CA, Schlanser J, Lacy WA,

Miller LA. Gunshot wounds in military working dogs

in OIF and OEF, 2003-2008. Paper presented at:

2008 Force Health Protection Conference; August 13,

2008; Santa Fe, NM.

3. Holcomb JB, McMullin NR, Pease L, Caruso J,

Wade CE, Oetjen-Gerdes MA, Champion, HR,

Lawnick M, Farr W Rodriguez S, Butler F. Causes of

death in US Special Operations Forces in the Global

War on Terrorism, 2001-2004. Ann Surg. 2007;245:

986-991.

4. Kelly JF, Ritenour AE, McLaughlin DF, et al. Injury

severity and causes of death from Operation Iraqi

Freedom and Operation Enduring Freedom: 2003-

2004 vs 2006. J Trauma. 2008;64:S21-S27.

5. Foster A. Current veterinary operations in Afghanistan. Paper presented at: 2008 Force Health Protection Conference; August 14, 2008; Santa Fe, NM.

6. Deployment Guidelines for Military Working Dogs.

Falls Church, VA: US Dept of Defense Veterinary

Service Activity; 2004. Memorandum DODVSA 17

May 2004.

7. US Army Institute of Surgical Research. Joint Theater Trauma System clinical practice guidelines for

damage control resuscitation at level IIb and III.

Updated April 2008. Available at: http://www.usaisr.

amed d.a rmy.mil/cp gs/2 00 8%2 00 4%2 0CPG%

20Damage%20Control%20Resuscitation%20for%

20Level%20IIb-III.pdf. Accessed January 13, 2009.

8. Johnson JW, Gracias VH, Schwab W, et al. Evolution

in damage control for exsanguinating penetrating

abdominal injury. J Trauma. 2001;51:261-271.

9. Shapiro MB, Jenkins DH, Schwab W, Rotondo MD.

Damage control: a collective review. J Trauma. 2000;

49:969-978.

10. Vogelsang R. Care of the military working dog by

medical providers. J Spec Oper Med. 2007;7(2):33-

47. Available at: https://jsoupublic.socom.mil/publica

tions/jsom/jsomq107.pdf. Accessed January 12, 2009.

AUTHORS

At the time this article was written, MAJ Baker was

Command Veterinarian, Joint Special Operations

Command, Fort Bragg, North Carolina.

CPT Truesdale is Command Veterinarian, Joint Special

Operations Command, Fort Bragg, North Carolina.

CPT(P) Schlanser is Regimental Veterinary Surgeon,

75th Ranger Regiment, Fort Benning, Georgia.
38 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

Protection for animals used by the military is part of

history. A prime example is the development and use

of armor for horses in the 15th century. But it was not

until World War I when chemical protection for

service members was developed that chemical

protection for military working animals (MWAs) was

also addressed. For the US military, that consisted of

bags or containers for pigeons and masks for horses

and dogs. The idea then, and now, is to provide

MWAs with the same level of chemical, biological,

radiological, and nuclear (CBRN) protection as is

provided for US service members. For pigeons and

dogs the basic concept was the same; protection of the

animal during the CBRN attack or incident so that it

could go back to work after the “all clear” was

sounded, or moved out of the threat or contaminated

area. Horses could continue to work through a CBRN

attack or incident if necessary. Masks only provided

respiratory protection for dogs and horses, leggings

provided lower leg protection for horses, eye and ear

protection was included for dogs, and no protection

was provided for skin. For medical countermeasures,

the same drugs available for service members have

been used. Unfortunately, little research has been done

to prove what dose is effective. Other countries such as

the United Kingdom, Germany, Czech Republic, and

Israel had CBRN protection and medical

countermeasures for their MWAs, and there is limited

work continuing in some countries.

PIGEONS

Since Roman times, pigeons have been used to deliver

messages over long distances. In 1917, the US Army

Signal Corps established a pigeon service. As the

needs of the Signal Corps changed for the number of

pigeons and employment, so did the designs for

chemical protection. The Army Signal Corps worked

with the Army Chemical Corps on the design and

testing of various boxes and bags that would protect 2

to 4 pigeons and 12 to 20 pigeons. A small hand

bellows (operated by the pigeoneers) and canister were

part of the design to help force filtered air at specified

time intervals into the bag or box (Figure 1). As

communication technology advanced, the need for

pigeons declined. The pigeon service was disbanded in

1957.1

HORSES AND MULES

In almost any conceivable theater of operations,

situations arise where the presence of horse

cavalry, in a ratio of a division to an army, will be

of vital moment.

General George Patton2

In contemplated operations in mountainous terrain,

plans should include facilities for supply by pack

train.

General Omar Bradley2

Horses and mules have, of course, been used

throughout history as work animals, both in agriculture

and normal transport, and on the battlefield. The

earliest recorded use of horses in warfare occurred in

Eurasia (modern day Ukraine, Hungary, and Romania)

in the era 4000-3000 BC. The versatility and

adaptability of horses and mules for transportation of

Military Working Animal Chemical,

Biological, Radiological, and Nuclear

Protection and Medical Countermeasures

MAJ Kelley L. Evans, VC, USA

Figure 1. Pigeon Bag, M4 (E7R2), with PG 103 carrier,

1949. Note the hand-operated bellows with filters.
January – March 2009 39

people, equipment, and supplies over

various terrains is well known. Because

of these qualities, US forces have used

horses and mules in the Afghanistan

theater of the war on terror. Horses are

still routinely used by city and state

police forces for crowd control and

daily law enforcement activities.

The first horse gas mask was developed

during World War I. The technology of

the day used several layers of

cheesecloth following the same line of

thinking as that which had Soldiers

cover their nose with a handkerchief.

However, covering only the nose left

the horse’s eyes, legs, and skin

vulnerable to chemical agents. It was believed at the

time that eye protection was not needed for chemical

agents (lachrymal gases). The design and material of

the US M1–M3 series horse gas mask closely

resembled the feed bags used for grain for horses and

mules (Figure 2), thus many horses chewed holes in

their gas masks. By World War II, the design had been

changed and 2 different types of horse mask were

manufactured, one for cavalry and one for the pack

and artillery horses and mules. The difference between

the designs was that the cavalry horse had 2 canisters

on the right side of the neck (to balance the weight of

the rifle on the left shoulder), and the pack and

artillery version had one canister on each shoulder

(Figure 3). Eye protection and lower leg

protection were also added during this

time. Motorized, mechanized, and

aviation advances began replacing horse

cavalry, pack, and artillery units. The

horse gas mask program was almost

canceled in 1943. However, as the war

continued and horses and mules were

transported by air into the China-BurmaIndia theater, the requirement to provide

oxygen to animals in unpressurized

airplanes became a major concern. In

1950, the Army determined that there

was indeed a requirement for animal

oxygen masks. As a result, in 1951, the

Army modified the horse gas mask to

function as an interim solution for an

oxygen mask for flights in unpressurized airplanes.3In

the same year as the pigeon service was disbanded

(1957), all horse units were deactivated, and the horse

gas mask program cancelled.

DOGS

Dogs are man’s best friend at home, and in battle.

Unlike pigeons, horses, and other land animals used by

the US military in the past, the military working dog

(MWD) remains a vital part of the US armed forces.

The first record of a dog in battle is from the Stone

Age, a type of mastiff used in Tibet.4Since then,

various breeds and sizes have served a variety of

functions from detection (explosives, narcotics,

mines), patrol, sentries, messengers, casualty finders

(search and rescue), and trackers to suicide bombers

and even cigarette delivery dogs in World War I. As

with the other 4-legged military working animals (ie,

horses), CBRN protection for dogs was first developed

during World War I. Lessons learned during development of the horse gas mask helped pave the way for

the first dog gas mask with a few differences in design,

in particular provisions for eye and ear protection

(Figure 4). As with the horse gas mask program, not

much work was done between World Wars I and II.

After 2 years of development, the M6 (Figure 5) was

ordered in 1944 for all dogs going into theater. After

World War II, the M6 was not produced. In the mid

1960s, the Army Provost Marshall General validated

the requirement for MWD chemical protection and

requested the restart of M6 manufacturing or

development of a suitable replacement item. This

request included the investigation of collective (whole

body) protection rather than only a mask (individual

Figure 2. Horse Gas Mask,

Flannelette Type, M1, 1919.

Figure 3. Horse Gas Mask, Pack/Artillery, M4, with eye protection, 1940.
40 www.cs.amedd.army.mil/references_publications.aspx

protection). However, in 1969 the

dog mask program was declared

obsolete, despite the nonconcurrence

of the Army Provost Marshall

General.

PRESENT DAY

Over the past 90 years, MWA CBRN

protection development has only

occurred when the threat dictated

changes for service member CBRN

protection. Presently, no CBRN protection for MWDs

is available in the DoD system. The late 1960s concept

that collective (whole body) protection is the best way

to provide MWD CBRN protection is the main focus

of today’s protection development programs.

Great Britain has developed a 2-dog overpressurized

protective shelter called FIDOS (Field Inflatable DogKennel Operational Shelter), the specifications of

which are proprietary to the British Secretary of

Defence. The FIDOS was deployed to Iraq at the

beginning of Operation Iraqi Freedom.

The Defense Threat Reduction

Agency funded 2 small business

innovative research projects in 2008

specifically for developing MWD

CBRN collective protection. This is

the first time in recent years that a

US agency has specifically funded

research and development for MWD

CBRN protection. In a separate

effort, the US Army Natick Soldier

Center is working with a fabric for

passive CBRN filtration. The

advantage of passive CBRN

filtration is the requirement for little

or no power for CBRN protection, unlike the current

US systems that require overpressure, special filters,

and increased power. The collaboration of Natick, the

industry partners, Army and civilian veterinarians, and

US MWD handlers developed 2 prototypes using this

technology. One prototype fits over an extra large varikennel, and the other is fold-out/popup prototype

designed to be used during patrol or when away from

other immediate protection. These prototypes are still

in early development and require physiological

parameter simulation and testing before the next stage

of development. A CBRN collectively protected tent

or shelter is required for the provision

of veterinary medical care to MWDs

in a CBRN environment. The Joint

Expeditionary Collective Protection

(JECP) capabilities development document was approved in July 2008. It

has specific language regarding the

requirement to treat MWD casualties

in a CBRN protected environment.

The JECP program is in the test and

evaluation stage of development.

Although torso/body protection from projectiles/

explosives has long been standard for Soldiers, neither

the DoD MWD Program Manager nor the DoD MWD

Veterinary Service approves the use of ballistic vests

or any type of body armor for MWDs in today’s

operating environment. This is because of the resulting

increased heat stress and decreased mobility.

MEDICAL COUNTERMEASURES

The provision of MWA medical treatment in a CBRN

incident has been focused on the questions of what

was humane for the animal, and would the animal be

able to work after decontamination and treatment. As

with CBRN protection, new CBRN drugs were

developed when the threat to service members

changed. Dr Jonathan Fradkin, a retired US Army

Veterinary Corps officer, headed a group of veterinary

toxicologists and internal medicine, critical, and

emergency care specialists to determine the dosage of

drugs available for US service members to use for

MWD nerve agent treatment:

 Antidote Treatment, Nerve Agent Autoinjector

(ATNAA)—atropine and 2 pralidoxime chloride

Military Working Animal Chemical, Biological, Radiological, and

Nuclear Protection and Medical Countermeasures

Figure 4. Dog Gas Mask, Flannelette Type, M1, 1918.

Figure 5. Dog Gas Mask, M6, 1944.
January – March 2009 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

in one autoinjector (replaces the MARK I Antidote

Treatment Kit, Nerve Agent)

 Atropen (atropine)

 Convulsant Antidote for Nerve Agent (CANA)—

diazepam

The group’s recommendations, incorporated into

Army Field Manual 4-02.18,

5

are based on

extrapolations from human data rather than animal

data. No research has been funded to prove or disprove

the recommendations or evaluate a MWD’s ability and

effectiveness to work after CBRN treatment. In 2007,

Army Supply Bulletin SB 8-75-S7 6included MWD

initial issue requirements for ATNAA, Atropen,

CANA, Skin Exposure Reduction Paste Against

Chemical Warfare Agents, Reactive Skin

Decontamination Lotion, doxcycline, and

ciprofloxacin. In conjunction with the inclusion of the

MWD issue list in SB 8-75-S7, a MWD handler’s

guide for using medical chemical defense material

should be available in March 2009 (National Stock

Number: 7610-01-564-2341).

CONCLUSION

Approximately 30 years passed between the

development of the M1 horse and dog gas masks and

the M4 horse and M6 dog gas masks. Over 40 years

ago, both programs were declared obsolete. Although

CBRN protection has come a long way from the days

of handkerchiefs and layered cheese cloth for both

service members and MWAs, much remains to be

done to protect, decontaminate, and treat if necessary,

and address other MWA unique issues. New threats

such as toxic industrial materials make CBRN

protection, decontamination, and treatment items even

more essential to have in the field, but also more

challenging to develop. Part of the challenge is to

ensure that DoD senior leadership recognizes the

importance and continued relevance of MWAs in

today’s noncontiguous battlefield* environment as

vital force multipliers and force protection assets. The

requirement for CBRN protection, decontamination,

and treatment has been documented in several CBRN

defense functional analyses at the DoD level.

However, specific funding to address these gaps is not

a priority, nor is evaluation of which current treatment

and decontamination recommendations; or use of

equipment, drugs, or protocols developed for service

members could be used for MWAs, with or without

modifications. Discussions of this topic among

academia, federal and state veterinarians, and other

MWA stakeholders have produced agreement that the

start of development of working dog CBRN

equipment, drugs, and protocols will pave the way for

the development of similar CBRN materiel and

protocols for other animal species.

ACKNOWLEDGEMENTS

I thank Dr Jonathan Fradkin, DVM (MAJ (Ret), VC,

USA) for his expertise and vision.

World War I and World War II photos are courtesy of

the US Army Chemical Corps and the US Army

Medical Research Institute of Chemical Defense

historians.

REFERENCES

1. Razes J. Pigeons of war. America in WWII. August

2007. Available at: http://www.americainwwii.com/

stories/pigeons.html. Accessed January 15, 2009.

2. Waller AL. Horses and Mules and National Defense

[Office of the US Army Quartermaster General].

1958. Army Quartermaster Foundation web site.

Available at: http://www.qmfound.com/horse.htm.

Accessed December 12, 2008.

3. Walker RD. Military masks animals in chemical

warfare [Gas mask museum web site]. Available at:

http://www.gasmasklexikon.com/page/USA-MilAnimals.htm. Accessed December 12, 2008.

4. Lemish MG. War Dogs: A History of Loyalty and

Heroism. Dulles, VA: Potomac Books Inc; 1996.

5. Field Manual 4-02.18: Veterinary Service Tactics,

Techniques, and Procedures. Washington, DC: US

Dept of the Army; December 2004:chptr 5.

6. Department of the Army Supply Bulletin SB 8-75-S7.

Washington, DC: US Dept of the Army; 20 July

2008:p5-3.

7. Field Manual 3-0: Operations. Washington, DC: US

Dept of the Army; February 2008:chap5,p5-14.

AUTHOR

MAJ Evans is Chief, South Texas Branch Veterinary

Services, Fort Sam Houston, Texas.

*Noncontiguous areas of combat operations do not share a

common boundary.7
42 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

Reports of “vicious” or “mad” dogs first appeared in

legal documents in Mesopotamia (modern day Iraq)

about 2,300 BC.

1 Over 4,000 years later, this

preventable disease is still killing people at an

alarming rate. According to the World Health

Organization (WHO), rabies is present on every

continent except Australia and Antarctica as shown in

Figure 1. Human deaths worldwide from rabies are

estimated by WHO to number over 55,000 per year,

predominately in Africa and Asia.2 Rabies is

transmitted by the bite of an infected animal, the

majority of which are dog bites.

Rabies is a zoonotic viral infection

that results in encephalomyelitis,

severe destruction of the central

nervous system, and death. Once

clinical symptoms are noticed, the

disease is essentially 100% fatal.

Current worldwide deployment of

US forces into the endemic rabies

regions of Iraq, Afghanistan, and

Africa pose an additional risk from

this deadly, bullet-shaped Rhabdovirus. The Veterinary Laboratory

Europe (VLE) in Landstuhl,

Germany, is currently the only

laboratory that provides diagnostic

capabilities of potential rabies

exposure to US service members and civilians within

the US Central Command, the European Command,

and the African Command areas of operation.

Veterinary Corps officers and technicians on the

ground are the front line of defense for exposed

individuals. Once a bite is reported, veterinary units

are contacted, the animal is located, brain tissue is

collected, and samples are submitted to VLE. Prior to

shipment of suspect samples, immediate wound care of

the exposed individual is performed by medical

personnel, rabies immune globulin is infiltrated at the

site of the bite, and a series of parenteral cell culture

vaccines are begun. Once the sample arrives at VLE,

Validation and Operational Application of a

Rapid Method for Rabies Antigen Detection

LTC Greg A. Saturday, VC, USA

LTC Robin King, VC, USA

Leslie Fuhrmann, MS

ABSTRACT

The Veterinary Laboratory Europe (VLE) deployed a direct, rapid immunohistochemical test (DRIT), developed by the

Centers for Disease Control and Prevention (CDC), to the US military veterinary units in Iraq and Afghanistan. The test

detects rabies virus antigen in fresh and frozen brainstem samples from various animal species. The goal was to conduct

surveillance in 2 countries without current rabies diagnostic capabilities and little historical data on rabies prevalence.

During the deployment the DRIT was evaluated, and Veterinary Corps officers and technicians were trained to operate the

test. Civilian veterinarians from both Iraq and Afghanistan were organized for a lecture forum on rabies, a sample

collection lab, and familiarization with the DRIT. Samples collected in Iraq and Afghanistan were tested in the field with

the DRIT, and compared to the traditional laboratory standard utilizing direct fluorescent antibody testing at VLE and the

CDC with 100% agreement.

Figure 1. The presence of rabies worldwide. Source: World Health Organization. Available at: http://www.who.int/rabies/rabies_maps/en/index.html
January – March 2009 43

the gold standard diagnostic test of direct fluorescent

antibody assay (DFA) is performed. Within 4 hours, a

result is generated to guide further treatment decisions.

An additional confirmation test by cell culture is run

via murine neuroblastoma (MNA) cell line with a final

report in 4 to 5 days. With expedited shipping and

timely results from VLE, the amount of unnecessarily

administered post exposure vaccine and potential side

effects, as well as the cost of this valuable and limited

vaccine, are decreased substantially.

RABIES DIAGNOSTICS AT THE VETERINARY

LABORATORY EUROPE

Since the initiation of military operations in

Afghanistan and Iraq, submission of samples to VLE

for evaluation of rabies has resulted in 16 positive

samples from a total of 285 submissions to date, each

case often affecting more than one person. These

results, however, are likely to be only the tip of the

iceberg for rabies prevalence in these countries, as

these are only cases where an animal has bitten a US

service member. The incidences of rabies in Iraq and

Afghanistan are truly unknown, as the infrastructure

and ability to test and report rabies by other than

clinical symptoms are severely limited. Table 1

presents the total number of positive samples

identified at VLE from Iraq and Afghanistan with the

use of fluorescent antibody identification.

EVOLUTION OF THE DIRECT, RAPID

IMMUNOHISTOCHEMICAL TEST

In February 2006, Lembo et al3outlined and reported a

preliminary study to compare the results of the direct

rapid immunohistochemical test (DRIT) performed in

the field in Tanzania, and the gold standard DFA

performed at the CDC. The DRIT showed a sensitivity

and specificity equivalent to those of the DFA, which

approaches 100%.

The standard operating procedure for the DRIT

outlines the steps used during the procedure.4 The test

begins by making a touch impression of the brainstem

on a glass slide. The slide is then processed through 10

dipping wells, as shown in Figure 2, containing

various chemicals and incubation times. The test’s

core component is a cocktail of highly concentrated

and biotinylated antinucleocapsid monoclonal

antibodies that recognizes all genotype 1 variants of

rabies virus (RABV) antigen.3 After one hour of

processing through the wells, positive rabies antigen is

identified as magenta inclusions within the impression

smear using a standard light microscope. An example

is shown in Figure 3.

Given the results cited by Lembo et al3and the fact

that this is a relatively simple and fast test requiring

little infrastructure, VLE decided to deploy and utilize

the DRIT to capture rabies data on animals not

involved in human exposure cases. This test will

enable the US military veterinary units as well as

civilian veterinarians in Iraq and Afghanistan to

conduct surveillance and support the “One Health”*

initiative. As stated by Lembo et al:

First, this technique could greatly enhance epidemicologic surveillance in remote areas where rabies incidence data are difficult to obtain. Second, the test could

improve the ability to respond to outbreaks with

effective management decisions. Third, it could be extremely valuable in guiding decisions regarding rational

use of rabies PEP [post exposure prophylaxis].3(p312)

In February 2007, VLE invited experts from the CDC

to train the diagnostic division and staff on this new

test, as well as to test known positive cases banked at

VLE. Preparations were made to deploy the DRIT to

selected US Army Veterinary Units in Iraq and

Afghanistan. During the subsequent year, all samples

submitted to VLE for rabies diagnostics were tested

with the DRIT along with the standard DFA and MNA

testing with 100% agreement. Development of positive

and negative controls from known DFA tested samples

Table 1. Total number of samples from Iraq and

Afghanistan testing positive for rabies which were

identified at the Veterinary Laboratory Europe using

fluorescent antibody identification, from 2004 through

October 2008.

IRAQ AFGHANISTAN

Year Species Positive

Test

Year Species Positive

Test

2005 Canine 1 2004 Canine 1

2007 Canine 3 2005 Canine 5

2007 Mongoose 1 2005 Pig 1

2006 Canine 3

2008 Canine 1

Total 5 Total 11

*The One Health Concept, first articulated by early

scientists such as Rudolph Virchow, recognizes the

intimate relationship between human health, animal

health, and the environment, and calls for an integrative,

collaborative approach to health by encouraging the

collaboration between experts of diverse fields of study.5
44 www.cs.amedd.army.mil/references_publications.aspx

were added that were fixed in 10% buffered formalin,

and stored in phosphate buffered saline.

PREDEPLOYMENT

Prior to deployment, PowerPoint instructional aids and

collection material were forwarded to designated

Veterinary Corps officers in Iraq and Afghanistan to

instruct personnel on how to properly obtain the

section of brainstem needed for testing, as well as

detailing the storage of all samples to be tested.

Predeployment collection of samples allowed for

numerous samples to be stockpiled and available for

testing during the training timeframe. All supplies and

testing equipment were then packaged in a deployable

ruggedized forward test kit that provided enough

testing for 500 samples, with ongoing resupply

provided by VLE.

DEPLOYMENT

In March and June of 2008, VLE deployed a

veterinary pathologist to Iraq and Afghanistan

respectively to field the DRIT, conduct rabies

surveillance, and provide training to selected

individuals. The goals of each deployment were:

Evaluate the DRIT in the field.

Train selected US Army veterinary units on the

testing procedures

Familiarize key civilian

veterinarians to this new

potential asset.

Provide a link to the CDC

through key governmental

organizations for potential

ongoing civilian veterinary

surveillance.

After initial training of military

personnel was completed and

stockpiled samples were tested,

respective military units organized

a rabies forum with local key

civilian veterinarians. During the

forum, a rabies lecture was

provided, and a hands -on

collection and testing laboratory

was conducted utilizing the DRIT,

as well as microscopic evaluation.

Furthermore, an exchange of ideas and information

between US military and their civilian counterparts

was made, linking their common interest and future

coordination regarding rabies surveillance in Iraq and

Afghanistan.

RESULTS

Table 2 presents the breakdown of animals collected

and tested in Iraq and Afghanistan during the period

February through June 2008. The chart simply

represents a snapshot of the rabies prevalence during

that period in selective locations within Iraq and

Afghanistan. Data continues to be collected from both

Figure 3. Results of a direct rapid immunohistochemical test. Left: Negative

brain touch impression. Right: Positive reaction. Rabies virus antigen appears as

magenta inclusions against a neuronal hematoxylin counterstain

Figure 2. A representation of the direct rapid immunohistochemical test with 10 unknown samples and a positive

and a negative control slide.

Validation and Operational Application of a Rapid Method for Rabies Antigen Detection
January – March 2009 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

of these countries by US veterinary units, along with

ongoing analysis by VLE and the CDC.

CONCLUSION

Veterinarians are the first line of defense in the

education, prevention, and diagnosis of this fatal

zoonotic disease, and a critical link to the appropriate

treatment of exposed individuals. Surveillance is only

the first piece to a much broader approach toward

control of rabies that will likely involve education,

animal control, and mass parenteral and oral

vaccination. Much of the developed world has held

rabies at bay through this type of multifactorial

approach toward elimination of this deadly disease.

Infrastructure, stability, and funding within Iraq and

Afghanistan are significant obstacles to overcome

before rabies can be managed appropriately. However,

with the advent of this cost effective and relatively

simple test, much needed surveillance information can

be gathered and managed by the military and the

respective governments of Iraq and Afghanistan to

help the global initiative to eradicate this preventable

and costly disease.

REFERENCES

1. Baer JM. The history of rabies. In: Jackson AC,

Wunner WH, eds. Rabies. 2nd ed. San Diego, CA:

Academic Press; 2007:1.

2. World Health Organization. Human and animal

rabies. Available at: http://www.who.int/rabies/en/.

Accessed February 13, 2009.

3. Lembo T, Niezgoda M, Velasco-Villa A, Cleaveland

S, Ernest E, Rupprecht CE. Evaluation of a direct,

rapid immunohistochemical test for rabies diagnosis.

Emerg Infect Dis. 2006;12(2):310-313. Available at:

http://www.cdc.gov/ncidod/eid/vol12no02/05-

0812.htm. Accessed February 13, 2009.

4. Niezgoda M, Rupprecht CE. Standard operating

procedure for the direct rapid immunohistochemistry

test for the detection of rabies virus antigen. National

Laboratory Training Network Course. Atlanta: US

Dept of Health and Human Services, Centers for

Disease Control and Prevention; 2006:1–16.

5. King LJ, Anderson LR, Blackmore CG, et al.

Executive summary of the AVMA One Health

Initiative Task Force report. J Am Vet Med Assoc.

2008;233(2):259-261.

AUTHORS

LTC Saturday is Chief, Diagnostics Division, Veterinary Laboratory Europe, Landstuhl, Germany.

LTC King is Commander, Veterinary Laboratory

Europe.

Mrs Fuhrmann is Quality Assurance Officer, Veterinary

Laboratory Europe.

Table 2. Animals tested for rabies in Afghanistan and

Iraq using the direct rapid immunohistochemical test,

February through June 2008.

IRAQ AFGHANISTAN

Specimen Total

Tests

Positive Specimen Total

Tests

Positive

Cat 147 0 Cat 49 0

Dog 62 1 Dog 52 1

Fox 17 0 Jackal 8 0

Jackal 36 1 Monkey 3 0

Rabbit 2 0 Total 112 1

Cow 4 4

Total 268 6
46 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

There are many herpesviruses of nonhuman primates

and other animal species, but B virus stands alone as a

documented zoonotic hazard. B virus, also known as

Cercopithecine herpesvirus 1 (CHV-1), Herpesvirus

simiae, Herpes simiae, or Simian B disease, is

considered endemic among monkeys of the genus

Macaca.1(p747) B virus is a large, double-stranded DNA

α-herpesvirus that has a predilection to invade the

central nervous system causing fatal encephalomyelitis

in humans.2 The historical fatality rate of untreated

human infections is 70% to 80% if not treated

promptly.3 There are approximately 40 known deaths,4

most, if not all, occurring among biomedical research

personnel working with captive monkeys or their

tissues. Cercopithecine herpesvirus produces a mild

clinical disease in monkeys similar to human herpes

simplex viruses (HSV-1 and HSV-2). Animals can

shed the virus through oral, ocular, and genital

secretions with or without visible lesions or open skin

lesions.3 Macaques are the most common monkey used

in biomedical research and are found in more climates

and habitats than any other primate except humans.5

This disease is important to physicians and veterinarians who provide medical care during deployments

as well as those who provide occupational medical

oversight in biomedical research facilities. Many of the

recommendations that follow in this article are from

the 2002 report of the B Virus Working Group:

Recommendations for Prevention of and Therapy for

Exposure to B Virus (Cercopithecine Herpesvirus 1).2

Readers are highly encouraged to read the report as it

is the definitive, most current source of information on

this virus.

RESERVOIR AND INCIDENCE OF DISEASE IN MONKEYS

There are 16 to 19 species of Macaca monkeys5,6

which are part of a larger group of primates

taxonomically classified as Catarrhini in reference to

their elongate muzzle with a narrow, turned-down nose

(similar to humans). They are indigenous to Africa,

Asia, and extreme southern Europe (introduced to

Gibraltar) and some possess ischial callosities for

sitting.1(p680) Several of the more common species

found in Asia are shown in Figures 1 through 5.

B virus is ubiquitous in macaques which experience an

age-related increase during adolescence with the

incidence of disease approaching 100% by the end of

the first breeding season. Latency is established in the

ganglia of the sensory nerves serving the region in

which the virus was introduced.7 Once there, the virus

remains in the sensory neurons for the life of the host

and results in a persistent, subclinical infection.

Periodically, the virus can reactivate due to stress from

social challenges, transportation, immunosuppression,

breeding, illness, or new housing; travel down the

neuronal axon to the mucosal epithelium; replicate;

and be shed.3Infected monkeys often have no or very

mild symptoms.8 The frequency of active viral

shedding appears to be low at 2% to 3%.3 Virus

infection in humans is rare.2 Macaques with primary

infection may develop lingual or labial vesicles or

ulcers (Figure 6) which heal in 1 to 2 weeks.7,9

Keratoconjunctivitis or corneal ulcers might also be

noted.7,9

MODE OF TRANSMISSION

The transmission of B Virus to humans from monkeys

primarily occurs by exposure to contaminated saliva

through bites and scratches from animals.9 Exposures

to B Virus can also occur from contaminated tissues or

fluids, needles, scalpel blades, or scratches from

contaminated cages or objects in a biomedical research

environment. There is one documented case of humanto-human transmission from an infected animal

handler and spouse who applied hydrocortisone cream

to his skin lesions and subsequently applied the cream

to an area of contact dermatitis under a ring on her

finger.10 One fatal case of a female worker at a primate

center occurred after an ocular exposure to biologic

material (possibly fecal) from a rhesus macaque.11

B Virus (Cercopithecine Herpesvirus 1 )

Therapy and Prevention Recommendations

LTC Christopher E. Keller, VC, USA
January – March 2009 47

CLINICAL SIGNS IN HUMANS

The incubation period for B virus is reported to be

from 2 days to 5 weeks after exposure. Most welldocumented cases present 5 to 21 days after exposure.2

With its varied onset of incubation and clinical signs,

the description in assorted references of clinical signs

of B virus is varied as well, as shown in the following

examples:

After exposure to B virus, humans might develop a

herpetiform lesion at the site of inoculation. Early

clinical signs and symptoms include myalgia,

fever, headache, and fatigue followed by

progressive neurological disease with numbness,

hyperesthesia, paresthesia, diplopia, ataxia,

confusion, urinary retention, convulsions,

dysphagia, and an ascending flaccid paralysis.7

Some patients present with a progression of

symptoms that first appear near the site of

exposure (vesicular rash, tingling, itching, pain, or

numbness at the site). Some patients may develop

lymphadenopathy proximal to the site of

inoculation. However, many patients have no

symptoms at the site of infection. Others present

with symptoms limited to the peripheral nervous

system or central nervous system. Within the first

3 weeks after exposure, paresthesia may develop

and proceed proximally along the affected

extremity. Associated symptoms can include fever,

myalgias, weakness of the affected extremity,

abdominal pain, sinusitis, and conjunctivitis. Other

organs, including lung and liver, may be involved.

The virus spreads along the nerves of the

peripheral nervous system to the spinal cord and

the brain. Symptoms can include meningismus,

nausea, vomiting, persistent headache, confusion,

diplopia, dysphagia, dizziness, dysarthria, cranial

nerve palsies, and ataxia. Seizures, hemiplegia,

hemiparesis, ascending paralysis, respiratory

failure, and coma occur later in the course of

infection. The presentation of late stage disease is

that of brain stem encephalomyelitis evolving into

a diffuse encephalomyelitis during its terminal

stages. A third presentation involves flu-like

illness with fever, chills, myalgias, and other

nonspecific symptoms, no focal findings, later

followed by an abrupt onset of central nervous

system signs.2

Symptoms include “vesicular skin lesions at or

near the exposure site; aching; chills and other flulike symptoms; persistent fever; nausea; lethargy;

chest pain and difficult breathing; and neurological

Figure 1. Rhesus macaque (M. mulatta)* Figure 2. Japanese macaque (M. fuscata)*

Figure 3. Cynomolgus macaque (M. fascicularis)* Figure 4. Stump-tailed macaque (M. arctoides)*

Figure 5. Pig-tailed macaque (M. nemestrina)*

*Photos and geographic distribution maps courtesy of the National Primate Research Center’s Primate Info Net. Available

at: http://pin.primate.wisc.edu/factsheets
48 www.cs.amedd.army.mil/references_publications.aspx

symptoms such as itching or tingling at or near the

exposure site, numbness, dizziness, double vision,

difficult swallowing and confusion.” Other

symptoms may occur as well. Treatment is critical,

as coma, respiratory failure and death quickly

result otherwise.12

The various possibilities for presentation could be

problematic for medical practitioners if they are

unfamiliar with recognition of the symptoms and

disease in humans before the central nervous system is

i n f e ct e d . Al s o , m e di c al

practitioners must recognize that

deep puncture wounds which are

difficult to clean; inadequately

cleansed wounds; and wounds

sustained on the face (especially

the eye), neck, or thorax pose

greater risks of infection.

Inoculation of those sites with the

virus allows little time for

treatment before the virus ascends

to the central nervous system by

the infected axon.2 Many persons

surviving B virus infection have

residual neurologic sequelae, and

progressive neurologic deterioration can also occur.3

DIAGNOSTIC CHALLENGES

Research with B virus is limited, given the rarity of

human infections, the lack of federal funding, and the

biosafety levels 3 or 4 containment requirements13 to

work with the virus. Currently only 2 human diagnostic laboratories exist, one in the state of Georgia

and the other in England.2 No true B virus specific

serologic assays are available at this time as diagnosis

of human infection is difficult for a number of reasons.

First, while serologic tests are the mainstay, they are

unable to detect antiviral antibodies until 7 to 10 days

after infection. Also, in most adults infected with

HSV-1/HSV-2, anti-HSV antibodies will react with B

virus antigen due to an anamnestic response of their

immune system.2 Another problem is that if a

suspected exposure occurs and is treated prophylactically, the treatment with antiviral drugs could

impede B Virus replication or lessen the development

of an immune response in the patient. PCR

(polymerase chain reaction) tests are not useful at this

time due to the infrequent and intermittent viral

shedding.2Furthermore, as there are different

genotypes of B virus and the average amino acid

sequence of homologous B virus and HSV proteins is

62.5% (range 26.5% to 87.5%),14 the exquisite

sensitivity of PCR testing becomes its limitation in

identifying B virus.

INITIAL TREATMENT

Both adequacy and timeliness of wound or mucosa

cleansing are the most important factors for reducing

the risk of B Virus infection after

a known or suspect exposure. First

aid consists of washing the bite,

scratch, or exposure to any

secretion for at least 15 minutes

w i t h p o v i d o n e - i o d i n e ,

chlorhexidine, or detergent soap

within 5 minutes of exposure.2

Pote ntial e ye o r muc ou s

membrane exposure should be

irrigated immediately with sterile

saline or water for 15 minutes

immediately after exposure. After

that, a qualified health care

provider should carefully examine

the exposed area to determine the

likelihood that an exposure

occurred and the exposed area

should be cleansed again.2For

each primate exposure, the health care provider needs

to assess 4 variables2:

 The source of the exposure should be determined.

Macaques are the only primates known to transmit

B virus.

 The timeliness and adequacy of first aid for the

wound should be assessed. Was the wound

cleansed within 5 minutes of exposure and was the

duration of cleansing a full 15 minutes?

 The type of wound or exposure, the depth of the

wound, and the location of the wound should be

determined. Deep punctures are likely to result in

inadequately cleansed wounds and pose a higher

risk of infection; superficial wounds and scratches

that are easily cleansed are therefore usually

considered low risk.

 Was there an exposure to materials that have come

in contact with macaques, such as needles,

scalpels, or cages?

Figure 6. Macaque monkey with a lingual

vesicle due to B virus.

(Photo courtesy of Dr J. K. Hilliard, Viral Immunology Center, Georgia State University,

Atlanta, GA)

B Virus (Cercopithecine Herpesvirus 1 ) Therapy and Prevention Recommendations
January – March 2009 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

Incising or biopsy of the wound is not recommended

as it could lead to further infection of the site. The

wound or exposure site should be cultured for B virus

after cleansing. While cultures of the wound or site of

exposure are usually negative, a positive wound

culture does indicate an exposure occurred and that

antiviral treatment is indicated.2Some experts debate

the value of serum blood testing. If performed, enough

blood must be collected to ensure that there is enough

serum for serial testing. Lastly, safely examine the

monkey if possible. While this is not likely outside a

research environment, within a research facility it is

possible for the veterinarian and staff to perform a

physical examination for active herpetic ulcers and to

culture mucocutaneous membranes. Also, testing for B

virus is usually performed on a scheduled basis within

the facility and the B virus status of the macaque might

be known. If the monkey is positive and is actively

shedding as evidenced by lesions or culture, antiviral

treatment should be initiated.

Antiviral therapy should be started within hours of the

exposure if used for prophylactic treatment. While

there are pros and cons of their use as described in the

2002 Clinical Infectious Diseases report,2the drug of

choice would be valacyclovir (1 g orally 3 times a day

for 14 days).2 An alternative drug would be acyclovir

(800 mg orally 5 times a day for 14 days).2 The most

frequently reported adverse effects of oral acyclovir

use are nausea, headache, diarrhea, and rash.

Neurologic complications of confusion and dizziness

have occasionally been reported with acyclovir use.2

Ganciclovir is poorly absorbed orally and should not

be used for prophylactic treatment. A suggested

schedule for follow up appointments is 1, 2, and 4

weeks after exposure, or anytime there is a change in

clinical status.2Further, if serologic testing is

considered or performed, it is recommended 3 to 6

weeks after initial exposure and at later points (eg, 3

months) to check for rising titers. Additionally, culture

of materials obtained from the conjunctivae,

oropharynx, and any unhealed skin lesions might be

performed 1 to 2 weeks after discontinuation of

antiviral medication to detect viral shedding.2

TREATMENT OF VIRAL DISEASE

Treatment with intravenous (IV) antiviral therapy for

B virus should be initiated with the presence of any

signs or symptoms of B virus, or a positive culture

other than the initial postcleansing wound culture. If

central nervous system symptoms are absent, treatment

with acyclovir (12.5 to 15 mg/kg IV every 8 hours) or

alternatively with ganciclovir (5 mg/kg IV every 12

hours) should be used.2 With peripheral nervous

system or central nervous system involvement,

ganciclovir is the recommended treatment (5 mg/kg IV

every 12 hours). Proper hydration must be ensured and

acyclovir must be administered slowly to avoid

precipitation in renal tubules and renal insufficiency.2

Serum levels of creatinine must also be monitored in

patients receiving high doses of acyclovir and adjusted

accordingly. The increased toxicity (myelosuppression) with ganciclovir must be balanced against the

potential benefit of the drug. The dose of ganciclovir

should be adjusted accordingly for renal insufficiency,

and white blood cell and platelet counts should be

monitored closely.2Intravenous therapy should be

continued until symptoms resolve and 2 or more sets

of cultures yield negative results after having been

held for 10 to 14 days.2Some experts believe patients

should then be switched to oral prophylactic treatment.

Other experts believe that lifelong suppressive therapy

is needed, while others recommend treatment be

discontinued at some point.2In reality, no good data

exist to aid in the determination of when or whether

treatment should be discontinued, and antiviral therapy

generally has not been effective in patients with

advanced encephalomyelitis. Standard blood and body

fluid precautions should be used in the care of patients

undergoing treatment for B virus or those otherwise

known or suspected to be shedding virus.2

CONCLUSION

B virus stands alone as a documented zoonotic hazard

and all macaques should be considered positive for B

virus until proven otherwise. B virus produces a mild

clinical disease similar to human herpes simplex in

monkeys but produces a life threatening disease in

humans that has resulted in several deaths. The

transmission of B virus to humans from monkeys

primarily occurs by exposure to contaminated saliva

through bites and scratches. Following exposure,

humans may develop a herpetiform vesicle at the site

of inoculation followed by a disseminated viral

infection leading to ascending paralysis, encephalitis,

and death in about 70% to 80% of cases. Given the

prevalence of disease within the natural reservoir and

the public health aspects of this disease, physicians

and veterinarians should be well versed to recognize

and provide initial treatment. The wound, if any,
50 www.cs.amedd.army.mil/references_publications.aspx

should be thoroughly cleansed as first aid is most

critical for the prevention of B virus. Serum samples

and cultures should be considered for serology and

viral isolation. Initiation of antiviral therapy with

valacyclovir, acyclovir, or ganciclovir may be

warranted if the history and/or symptoms are

compatible with B virus infection.

Of the 16 to 19 species of Macaca monkeys, the vast

majority are found in the Asia Pacific region. This

presents unique public health aspects for medical

planners with the increasing deployment of military

personnel into the Asia Pacific region. To protect

deploying personnel, medical planners should be

aware of this zoonotic disease and consider it in their

force protection planning or survey estimate. Planners

must understand that macaques are to be avoided as B

virus is an ubiquitous disease, often with no overt

clinical signs, and macaques have a wide geographical

distribution. Education of deploying personnel and

medical staff of signs, symptoms, and treatment of this

disease should be planned and presented prior to

deployment and appropriate antiviral prophylactic

medications should be stocked in medical kits. The

best preventive measure would be to educate all

deploying members on the virus, and to leave all

animals alone while deployed. Lastly, it is

recommended that medical providers and veterinarians

read the 2002 Clinical Infectious Diseases report,2and

check the Centers for Disease Control and Prevention

and B virus laboratory web sites for the most current

information.

REFERENCES

1. Bernacky BJ, Gibson SV, Keeling ME, Abee CR.

Nonhuman primates. In: Fox JG, Anderson LC, Loew

FM, Quimby FW, eds. Laboratory Animal Medicine.

2nd ed. San Diego, CA: Academic Press; 2002.

2. Cohen JI, Davenport DS, Stewart JA, Deitchman S,

Hilliard JK, Chapman LE, for the B Virus Working

Group. Recommendations for prevention of and

therapy for exposure to B virus (Cercopithecine

Herpesvirus 1). Clin Inf Dis. 2002;35:1191-1203.

3. Elmore D, Eberle R. Monkey B virus (Cercopithecine

herpesvirus 1). Comp Med. 2008;58:11-22.

4. National Institute for Occupational Safety and Health.

Cercopithecine herpesvirus 1 (B virus) infection

resulting from ocular exposure. Available at: http://

www.cdc.gov/niosh/hid5.html.

5. Rowe N. The Pictorial Guide to the Living Primates.

Charlestown, RI: Pogonias Press; 1996:120.

6. Ostrowski SR, Leslie MJ, Parrott T, Abelt S, Piercy

PE. B-virus from pet macaque monkeys: an emerging

threat in the United States?. Emerg Infect Dis.

1998;4:117-120.

7. Barkley WE, Bascom R, Bush RK, et al, for the

Committee on Occupational Safety and Health in

Research Animal Facilities. Occupational Health and

Safety in the Care and Use of Research Animals.

Washington, DC: National Academy Press; 1997:66-

68.

8. National Center for Infectious Diseases, Centers for

Disease Control and Prevention Website. B virus

(Cercopithecine Herpesvirus 1) infection. Available

at: http://www.cdc.gov/ncidod/diseases/bvirus.htm.

9. Fox JG, Newcomer CE, Rozmiarek H. Selected

zoonoses. In: Fox JG, Anderson LC, Loew FM,

Quimby FW, eds. Laboratory Animal Medicine. 2nd

ed. San Diego, CA: Academic Press; 2002:1068.

10. Centers for Disease Control and Prevention.

Epidemiologic notes and reports B-virus infection in

humans – Pensacola, Florida. Morb Mortal Wkly Rep.

1987;36(19):289-290.

11. Centers for Disease Control and Prevention. Fatal

cercopithecine herpesvirus 1 (B virus) infection

following a mucocutaneous exposure and interim

recommendations for worker protection. Morb

Mortal Wkly Rep. 1998;47(49):1073-1076.

12. Bennett BT, Abbee CR, Henrickson R, eds.

Nonhuman Primates in Biomedical Research:

Biology and Management. San Diego, CA: Academic

Press; 1995:395.

13. Chosewood LC, Wilson DE, eds. Biosafety in

Microbiological and Biomedical Laboratories, 5th

ed. Washington, DC: US Dept of Health and Human

Services; 2007. Available at: http://www.cdc.gov/

OD/ohs/biosfty/bmbl5/BMBL_5th_Edition.pdf.

Accessed December 18, 2008.

14. Perelygina I, Zhu I, Zurkuhlen H, Mills R,

Borodovsky M, Hilliard JK. Complete sequence and

comparative analysis of the genome of herpes B virus

(Cercopithecine Herpesvirus 1) from a rhesus

monkey. J Virol. 2003;77:6167-6177.

AUTHOR

LTC Keller is Chief, Animal Research Section,

Department of Clinical Investigation, Tripler Army

Medical Center, Honolulu, Hawaii.

B Virus (Cercopithecine Herpesvirus 1 ) Therapy and Prevention Recommendations
January – March 2009 51

INTRODUCTION

Directed Energy (DE) in the form of electromagnetic

radiation refers to the application of electromagnetic

energy at a single or a band of wavelengths (or

frequencies) on a target. Sources of DE such as a

common flashlight, a laser, or a high powered

microwave transmitter can emit electromagnetic

radiation at single wavelength (or frequency) or at

multiple wavelengths with emission powers from

nanowatt to megawatts, and emission durations from

femtoseconds to continuous wave. Military uses of DE

sources include lasers and high powered microwave or

radio frequency radiation. The word laser is actually

an acronym for light amplification by stimulated

emission of radiation, a process that facilitates the

production of a collimated beam of radiation that is

easily directed toward a target. Military applications of

DE include range finders, target designators, live-fire

training devices, illuminators, and battlefield

contaminate detection systems. Nonlethal weapons/

deterrent applications of directed energy include the

millimeter wave active denial systems or

visible laser dazzlers. For some time now,

medical specialties have used lasers or

“directed energy devices” to cut, heat, ablate,

or produce photochemical/phototoxic

reactions to produce a desire effect on

biological tissues. Medical applications also

include numerous diagnostic applications

such as pulsed oximeters, otic thermometers,

and advanced retinal imaging technologies

including scanning laser ophthalmoscopes

and optical coherence tomography imaging.

The use of lasers on the modern battlefield

has become common in recent years,

particularly to assist in the accuracy of target

identification and fire control systems. With

the maturation of DE technology, additional

military applications will emerge (eg, the use

of high energy lasers to produce adverse

target effects) and DE systems will continue to be an

integral part of US military technology.

The most important biological sensor on the modern

battlefield, the human eye, is extremely vulnerable to

injury from military lasers.1In an instant, and without

any sound or warning, temporary or permanent visual

impairment can be produced at tactical ranges and

beyond. Specifically, the retina is extremely

susceptible to injury from common military lasers that

operate in the retinal hazard wavelength region (400

nm – 1400 nm) where direct exposures can produce

temporary or permanent visual impairment including

blindness. Common military laser rangefinders and

designators operating near 1064 nm can produce a

vitreous hemorrhage in the unaided eye at a range of

several hundred meters and minimal retinal lesions out

to nearly 2 km (Figure 1). Optical aids (ie, binoculars,

targeting scopes with magnification) in use at the time

of the exposure increase the range at which the eye is

susceptible to injury. Visible and near infrared laser

illuminators are used in Iraq and Afghanistan to

Directed Energy (Laser) Induced Retinal

Injury: Current Status of Safety, Triage, and

Treatment Research

LTC Deborah L. Whitmer, VC, USA

Bruce E. Stuck, ScD, MS

Figure 1. Ocular hazard distances for common military lasers

extend to tactically significant distances. The top row images (left

to right) show the approximate effect (visual or resulting retinal

injury) to distance relationship for the GLLD. The fourth image

indicates that the collimated laser energy is focused to a small

spot on the sensory retina due to imaging properties of the eye.

Ocular exams by an ophthalmologist are indicated in symptomatic

exposure patients even though the patient may not have any

concurrent overt physical trauma.
52 www.cs.amedd.army.mil/references_publications.aspx

illuminate or “point out” specific

targets in much the same way a

laser pointer is used in a lecture

hall. Visible laser illuminators

a re also used to wa rn

noncombatants and deter

suspected combatants from

approaching fixed positions such

as a checkpoint or the end of a

convoy (Figure 2). Persistence in

approach might then imply

malicious intent and warrant the

use of more lethal force. Most

laser illuminator ocular hazard

distances are between 50 m and

100 m, however, intrabeam exposure beyond those distances appears extremely

bright and may result in a flash effect or after-image

that persists for a few minutes, but will not result in an

injury. The “bright light exposure” causes the exposed

to wonder if he/she were injured and triggers self

vision checks or a request to see an eye care specialist.

On the other hand, intrabeam exposure to these

illuminators within a few feet can result in significant

retinal pathology and visual dysfunction.

The general lack of familiarity with the actual ocular

hazards of lasers leads to patient apprehension of

actual or potential visual impairment which can

seriously degrade force effectiveness. Most laser

exposures are accidental and caused by misuse of the

system or neglect of safety guidance. Predictably, the

large number of devices currently deployed has

resulted in a number of inadvertent and even intentional exposures. Therefore a rapid, accurate

assessment is important to minimize false positive claims while

assuring the ocular health of the

unit.

Diagnosis of potential laser

incidents in a deployed setting is

challenging since some laser

injuries cause minimally visible

(via ophthalmoscope) retinal

lesions and require tertiary level

diagnostic capabilities such as

fluorescein angiography and

optical coherent tomography. Location of a very small

retinal lesion within the fovea can cause noticeable

dysfunction, whereas a lesion outside the macula may

go unnoticed. More severe laser-induced retinal injury

(eg, retinal or vitreous hemorrhage) can result in a

dramatic psychological effect with the immediate

onset of visual dysfunction. Secondary effects (with

later onset) to laser-induced retinal injury such as

retinal hole formation, retinal traction and scar

formation, nerve fiber layer loss remote from the

lesion site, intraretinal scar concomitant with multiple

lesions in proximity, and choroidal neovascularization

have been observed in human laser accident cases1

(Figure 3). Presently there is no consensus on

treatment of laser-induced retinal injuries. However

the mission of the US Army Medical Research

Detachment of the Walter Reed Army Institute of

Figure 2. A GHOST green handheld optical

surveillance and targeting device is shown

mounted on a machine gun. Laser illuminators are deployed to Afghanistan and

Iraq for both target designation and

nonlethal deterrent applications.

Figure 3. Accidental ocular laser exposure case. Left image: Four days post injury in the right eye of a patient self

exposed to a military pulsed laser. The two black arrows indicate two large areas of lesions. Right image: Two

months post injury of the same patient. The black arrow indicates bridging of scar formation between discrete lesions

within the fovea.

Directed Energy (Laser) Induced Retinal Injury: Current Status of

Safety, Triage, and Treatment Research
January – March 2009 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

Research is to conduct research that establishes safety

threshold guidelines for Department of Defense (DoD)

lasers and optical systems; as well as pursuit of

effective triage capabilities and treatment

countermeasures for laser induced retinal injuries.

LASER INJURY MECHANISMS

The biological effect produced by exposure to laser

radiation is basically determined by the amount of

energy per unit area delivered to and absorbed by the

target tissue for a given exposure duration. Hence, a

beam’s power (watts), exposure duration (seconds),

and irradiance diameter or spot size (in cm2) must be

known to determine the exposure dose or radiant

exposure (Joules/cm2). The irradiance or the rate of

energy delivery to the tissue per unit area is given in

watts/cm2. The radiant exposure is simply the

irradiance times the exposure duration. This exposure

dose or radiant exposure coupled with the relative

absorption of the target tissue determines the

magnitude and lateral extent of tissue temperature rise

of an applied laser beam.1,2 The eye is more

susceptible to injury from the energy in the laser beam

than to direct exposure of the dermis or skin primarily

because of the focusing of energy onto the retina and

to some extent the relative absorption and transmission

of specific laser wavelength by the outer ocular

media.3-6 For visible wavelengths or wavelengths in

the retinal hazard region (400 nm to 1400 nm), the

cornea and lens focus light to a fine spot on the retina.

For short pulse lasers, typical in lasers used in firecontrol devices (laser rangefinders and designators),

the beam is transmitted through the outer ocular media

(cornea, aqueous humor, lens, vitreous humor) to a

small spot on the retina, resulting in a localized,

intense temperature elevation or even a plasma

formation that can disrupt membranes and produce a

small hemorrahage.2If one is looking directly into and

toward the laser, the fovea, (the center of the visual

field where one has high acuity and color vision) can

be injured. Cornea and lens refraction of laser beams

produce retinal irradiances that are up to 105times

greater than the corneal irradiances.6 This results in the

retina being highly susceptible to injury.

Laser radiation can damage the eye by

photodisruptive, photothermal, or photochemical

mechanisms.6-8 Photochemical injury results usually

from ultraviolet or visible light and results from

chemical bonds being broken by the laser energy. This

usually results in opacities of the cornea or lens.

Photothermal injury on the retina is due to the small,

spot-sized focusing effect which results in a rapid 10°

C to 20°C rise in tissue temperature, which denatures

the tissue protein. Photodisruption results from

formation of a plasma and shock wave that disrupts the

site and surrounding tissue. Tissue is fragmented,

perforated, or distorted immediately by a

photodisruptive injury.1,9 It is useful to differentiate

between these mechanisms, but more than one effect

may be involved in any particular injury. Secondary to

the actual injury, inflammatory and ischemic pathways

are activated that lead to further tissue injury and

death.

CURRENT ARMY RESEARCH ON SAFETY, TRIAGE, AND

TREATMENTS

Research at the Army Medical Research Detachment

(USAMRD) is directed towards both defining and

understanding thoroughly the mechanisms of laserinduced retinal injury, retinal injury thresholds, and the

implication of laser exposure on the visual system, as

well as exploring effective triage and treatment

options. The establishment of the science base to

develop exposure limits or guidelines for a next

generation of laser exposure conditions inherent to

military use and operations is necessary for the safe

Figure 4. Fundus photo of multiple experimentally

induced laser retinal lesions demonstrating variable

visible injury. Left to right: Significant foveal lesion with

overt hemorrhage into the vitreous; middle lesion with

red rim and white center is indicative of retinal hemorrhage; upper right circular white lesion indicative of a

minimal visible lesion. Injury variability is a function of

the exposure dose and its location on retina, as well as

the variables of the laser, including wavelength, pulse

duration, retinal irradiance diameter and pulse repetition frequency.
54 www.cs.amedd.army.mil/references_publications.aspx

use of directed energy systems in both training and

operational scenarios. This research also enables the

development of new, effective systems that pose

reduced risks of injury to the Soldiers who use them.

Laser-induced injury threshold doses are determined

predominately in animal models as a function of laser

wavelength(s), exposure duration, irradiance diameter

at the target tissue, and the additive effects of

Directed Energy (Laser) Induced Retinal Injury: Current Status of

Safety, Triage, and Treatment Research

Figure 5. Diagnostic imaging: Scanning laser ophthalmoscope (SLO) and optical coherence tomography (OCT) images

of experimentally induced Argon laser injury. The top panel indicates normal noninjured SLO/OCT scan with the

vertical arrow on the SLO (left) image indicating section scanned to generate the OCT image to the right of it. The

white arrow on the OCT image indicates the normal depression of the foveal pit. The bottom panel shows same area

of the retina scanned after multiple lesions were created. The 2 white arrows indicate 2 lesions within the retina on

either side of the foveal pit that are disruptions of the photoreceptor and retinal pigment epithelial layers.
January – March 2009 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

repetitive pulse exposure or repeated exposure10

(Figure 4). Biophysical models or cellular models are

used to characterize the interaction of the radiation

with the target tissue.11 From these data and theoretical

considerations, maximum permissible exposure doses

or limits are established and adopted by ANSI

Z136.1.

12 Historical and recent research at the

USAMRD, in collaboration with the Air Force

Research Laboratory, has established a robust

biological effects data base which is assessed to set the

exposure guidelines. Recently, such collaboration has

focused on determining the ocular and skin effects for

infrared radiation,13 resulting in a recommendation to

adjust the exposure guideline to assure the safe testing

and use of the advanced laser systems designed for use

in selected DoD high energy laser systems.

One tool developed at the USAMRD for clinical

evaluation/triage of potential and actual laser induced

retinal injury patients is the Aidman Vision Screener*

and Amsler Grid†card. This field triage aid allows

combat medics and other forward deployed medical

personnel to perform a preliminary vision function

screening to assess an injury that may only be obvious

to the patient because overt external injury may be

absent. Ongoing research is investigating retinal tissue

biomarkers for early identification of retinal injuries

that have minimal or no initial visual acuity

dysfunction (outside of fovea).

Several research approaches are being investigated to

evaluate multiple therapy approaches to laser related

retinal injury. Ongoing protocols are assessing new

pharmacological agents for treatment and prophylaxis

of laser retinal injury, including advanced neuroprotectants to prevent retinal and nerve fiber cell

injury/death. Drug delivery techniques are being

developed to research treatment approaches for first

responder field administration as well as for specialist

level care14 (Figure 5). Cell and molecular approaches

are being explored to identify principal protein

markers of retinal cell injury for potential prognostic

applications.

The spectrum of treatment modalities being

investigated is designed to establish immediate and

long term treatment recommendations. Currently, there

is no specific universally accepted/recommended

therapy for laser induced retinal injuries. Historically,

anecdotal therapeutic approaches that have been used

to treat patients with ocular laser injuries have

typically included systemic nonsteroidal and steroid

regimens.15 The responses were variable and not

consistent with clinical expectations. Based on the

accumulative research at USAMRD in a nonhuman

primate model, response to therapy differs based on

the type of laser involved and the exact area(s) of the

retinal structures that are injured, and the dosage of

medications varies as a function of these variables.

Specifically, recent research indicates that

nonhemorrhagic retinal injuries created by Nd:YAG

lasers respond to a moderate dose of steroid, while

hemorrhagic lesions respond better to indomethacin.16

This degree of variability no doubt has lead to the

mixed clinical responses in some of the historical

cases.1

RELEVANCE FOR PATIENT CARE

The Army Medical Research Detachment evaluates

potential laser incident patients as requested for

follow-up to assist in differentiating actual laser retinal

injuries from other causes of visual acuity loss. Based

on the history and clinical findings of several recently

evaluated patients from both Afghanistan and Iraq, it is

apparent that in spite of training and warnings to the

contrary, occasional intentional illumination occurs. It

is important for primary care providers to realize that a

patient with solely a laser retinal injury will otherwise

appear uninjured and initially may have subtle visual

disturbances. Army Field Manual 8-50 17 provides

guidance and a decision tree for the assessment of

laser-induced injury.

CONCLUSION

Lasers and other directed energy devices are being

deployed extensively on the modern battlefield.

Military lasers do pose a significant ocular hazard if

inadvertent or intentional exposure occurs. The extent

of injury and duration of effect are dependent upon the

type of laser, the distance from the source, and other

factors (ie, binoculars) that affect the amount of energy

deposited on the retina. Presently there is no

universally accepted therapeutic treatment regimen in

the medical community for confirmed retinal laser

lesions. Responses to anecdotal therapy in the past

have been variable due to the multiple factors that

*Information available from the Defense Technical Information Center: http://oai.dtic.mil/oai/oai?verb=getRecord&

metadataPrefix=html&identifier=ADA232777

†http://eyecareamerica.org/eyecare/conditions/macular-degeneration/amsler.cfm
56 www.cs.amedd.army.mil/references_publications.aspx

affect the extent and type of retinal injury. Research is

ongoing at the US Army Medical Research Detachment of the Walter Reed Institute of Research to

provide evidence-based medical and as-needed

surgical therapeutic treatment recommendations.

Clinical therapeutic approaches under evaluation

include first responder and tertiary treatment options.

Further basic research is in progress to find therapy

modalities utilizing cell based neuroprotection

treatment options that will potentially be of use in the

future. Additionally, research is ongoing to evaluate

potential diagnostic capabilities such as retinal specific

biomarkers that will improve the detection of early and

subtle laser induced retinal injuries. This could

enhance forward-deployed diagnostic capabilities,

allowing early initiation of therapy and minimize

evacuation for specialist level diagnostics.

REFERENCES

1. Mainster MA, Stuck BE, Brown J. Assessment of

alleged retinal laser injuries. Arch Ophthalmol.

2004;122:1210-1217.

2. Mainster MA, White TJ, Allen RG. Spectral

dependence of retinal damage produced by intense

light sources. J Opt Soc Am. 1970;60:848-855.

3. Lund DJ, Edsall P, Stuck BE, Schulmeister K.

Variation of laser-induced retinal injury thresholds

with retinal irradiated area: 0.1-s duration, 514 nm

exposures. J Biomed Opt. 2007:12(2):024023.

4. Sliney DH, Wolbarsht ML. Safety With Lasers and

Other Optical Sources: A Comprehensive Handbook.

New York, NY: Plenum Press; 1980.

5. Boettner EA, Wolter JR. Transmission of the ocular

media. Invest Ophthalmol Vis Sci. 1962;1:776-783.

6. Mellerio J. Light effects on the retina. In: Albert DM,

Jakobiec FA, eds. Principles and Practice of

Ophthalmology. Vol 1. Philadelphia, PA: WB

Saunders Co; 1994:1326-1345.

7. Mainster MA, Turner PL. Photic retinal injury and

safety. In: Ryan SJ, Ogden TE, Hinton DR, Schachat

AP, eds. Retina. Vol 2. 3rd ed. St Louis, MO: Mosby

Inc; 2001:1797-1809.

8. Mainster MA, Ham WT Jr, Delori FC. Potential

retinal hazards: instrument and environmental light

sources. Ophthalmology. 1983;90:927-932.

9. Hacker HD, Brown J, Cheramie RD, Stuck BE. New

approaches to the diagnosis and management of laser

eye injury. In: Manns F, Soderberg PG, Ho A, Stuck

BE, Belkin M, eds. Proceedings of SPIE–Opthalmic

Technologies XVII, SPIE 642623-1-11. The

International Society for Optical Engineering; 2007.

10. Lund BJ, Lund DJ, Edsall PR. Laser-induced retinal

damage threshold measurements with wavefront

correction. J Biomed Opt. 2008;13(5):064011-1-10.

11. Schulmeister K, Husinsky J, Seiser B, Edthofer F,

Fekete B, Farmer L, Lund DJ. Ex vivo and computer

model study on retinal thermal laser-induced damage

in the visible wavelength range. J Biomed Opt.

2008;13(5):054038-1-13.

12. ANSI Z136.1: American National Standard for Safe

Use of Lasers. Washington DC: American National

Standards Institute; 2007.

13. Schulmeister K, Sliney DH, Mellerio J, Lund DJ,

Stuck BE, Zuclich JA. Review of exposure limits and

experimental data for corneal and lenticular damage

from short pulsed UV and IR laser radiation. J Laser

Appl. 2008;20(2):98-195.

14. Whitmer D, Lund DJ, Hacker HD, Brown J, Pitman

M, Palmer F, Jenkins K, Stuck BE. Topical drug

therapies for laser induced retinal injury. Invest

Ophthalmol Vis Sci. 2008;49:E-Abstract 4666.

15. Brown J, Hacker HD, Schuschereba ST, H. Zwick,

Lund DJ, Stuck BE. Steroidal and nonsteroidal antiinflammatory medicals can improve photoreceptor

survival after laser retinal photocoagulation.

Ophthalmology. 2007;114:1876-1883.

16. Zuclich JA, Lund DJ, Stuck BE. Wavelength

dependence of ocular damage thresholds in the nearIR to far-IR transition region: proposed revisions of

MPEs. Health Phys. 2007;92(1):15-23.

17. Field Manual 8-50: Prevention and Medical

Management of Laser Injuries. Washington, DC: US

Dept of the Army; August 8, 1990.

AUTHORS

LTC Whitmer is Chief of the Analytical Toxicology

Division at the US Army Medical Research Institute of

Chemical Defense, Aberdeen Proving Ground,

Maryland.

Dr Stuck is Director, US Army Medical Research

Detachment, Walter Reed Army Institute of Research,

located at Brooks City-Base, San Antonio, Texas.

Directed Energy (Laser) Induced Retinal Injury: Current Status of

Safety, Triage, and Treatment Research
January – March 2009 57

The Epidemic Intelligence Service (EIS) was

established in 1951 at what is today the Centers for

Disease Control and Prevention (CDC) in Atlanta,

Georgia. The EIS is a unique, 2-year post-graduate

training program of service and on-the-job learning for

health professionals interested in the practice of

epidemiology. The EIS program is primarily a

postdoctoral-level fellowship, with most officers*

holding PhDs or doctoral degrees in medicine,

veterinary science, or dentistry. The program accepts a

small number of nondoctoral candidates with a master

of public health (eg, nurses, physician assistants) and

doctor of pharmacy degrees. Each year, approximately

80 officers complete the EIS program, and 70% to

75% of graduating officers remain in the field of

public health.

From its initial purpose as an early warning system

against biological warfare and man-made epidemics,

the mission of the EIS has expanded into a

surveillance and response unit for all types of

epidemics, including chronic disease and injuries. EIS

officers serve on the epidemiologic frontlines,

conducting epidemiologic investigations, research, and

public health surveillance nationally and

internationally. Over the past 57 years, nearly 3,000

EIS officers have responded to requests for

epidemiologic assistance within the United States and

throughout the world. EIS officers have played pivotal

roles in combating the root causes of major epidemics

such as smallpox eradication, polio, and HIV-AIDS.

EIS officers were directly involved in the emergency

response for hurricanes Katrina and Rita, establishing

active medical surveillance programs for infectious

diseases. More recently, EIS officers have responded

internationally to outbreaks of Ebola and Marburg

fever, and investigated whether domestic disease

outbreaks were in any way related to bioterrorism.

One example of a topic that is important to the global

operations of the Department of Defense (DoD) is the

emergence of H5N1 avian influenza in southeast Asia.

The concern is that this avian strain may spread to

humans and cause a global pandemic. EIS officers

have been actively engaged in planning and

emergency preparedness for pandemic influenza. They

are also performing influenza surveillance by

monitoring rates of respiratory and influenza infection.

Additionally, the CDC is closely watching the

currently circulating strains of seasonal influenza for

drug resistance to the antiviral medications oseltamivir

(Tamiflu) and zanamivir (Relenza). While Tamiflu and

Relenza are used to treat seasonal influenza, they have

also been stockpiled by many countries for use in a

pandemic. EIS officers are working behind the scenes

to analyze the rates of antiviral resistance. The recent

discovery that influenza is showing signs of resistance

to Tamiflu may have an adverse impact on the DoD’s

Tamiflu stockpile for pandemic influenza.

Modeled after a traditional medical residency program

where the bulk of the education occurs through

experiential learning, the EIS program provides

valuable training to the officers and a vital service to

CDC and the agency’s public health partners.

Throughout the 2-year program, EIS officers are

required to complete 8 core tasks. They evaluate a

public health surveillance system, conduct an analytic

epidemiology project, make an oral scientific

presentation to a local or national meeting, write a

scientific paper for a peer-reviewed journal, and write

an article for the weekly Morbidity Mortality Weekly

Report published by the CDC. EIS officers must

participate in an acute public health response and

investigation called an Epi-Aid.1In addition, EIS

officers are required to respond to public inquiries.

These 8 tasks are supplemented by training in applied

Opportunities for Military Medical Officers:

The Epidemic Intelligence Service at the

Centers for Disease Control and Prevention

CPT Kristina McElroy, VC, USAR

*The CDC uses the term “officer” to designate a participant in the EIS (Source: http://www.cdc.gov/eis/about/

factsheet.htm). Consequently, in this article, appearance of the term officer does not refer to military personnel

unless it is used as such directly in context. The Editor
58 www.cs.amedd.army.mil/references_publications.aspx

epidemiology, surveillance, communications,

pandemic flu preparedness, and other topics. EIS

officers train in all major subject areas of public health

science at the CDC.

The EIS program has partnerships with several federal

agencies such as the Department of Agriculture, the

Food Safety and Inspection Service, and DoD. The

agencies select participants from applicants. The

selectees are assigned to the EIS program for 2 years,

returning to their sponsoring agency upon completion

of the fellowship. Since 1994, the Air Force has sent

14 Biomedical Science Corps* officers and 2

physicians, the Army has sent 2 veterinarians and 1

physician, and the Navy has sent 2 physicians. While

military nurses and environmental officers with a

master of public health degree are eligible to apply to

the program, thus far, only physicians and

veterinarians have participated in the DoD

sponsorship. Active duty personnel have follow-on

assignments to the Air Force Institute for Occupational

Health, Walter Reed Army Institute of Research,

Armed Forces Medical Intelligence Center, and the

DoD Global Emerging Infections System. In addition,

there are several DoD-CDC liaison positions available.

In addition to active duty medical personnel

participating in EIS, eligible US Army and Air Force

Reserve and National Guard officers have also

completed EIS training, benefiting their civilian

employers as well as the DoD. Those participants

apply for the EIS program with their civilian

credentials.

Anyone interested in the EIS program may obtain

more information at http://www.cdc.gov/EIS/, or

EIS Program

Centers for Disease Control and Prevention

Mailstop E-92

1600 Clifton Road NE

Atlanta, GA 30333

(404) 498-6110 eisepo@cdc.gov

The application for active duty personnel differs

among the military services. US Air Force officers

apply for EIS through the Air Force Institute of

Technology. Interested Army Medical Department

(AMEDD) officers must apply for EIS through the

Long Term Health Education Training program.

AMEDD officers should contact both the Army

Personnel Management Directorate and their Corpsspecific branch proponency office located at Fort Sam

Houston, Texas.

The Epidemic Intelligence Service benefits global

health and the DoD. Military medical officers who

participate in the program strengthen the collaboration

between the CDC and the DoD. Graduates of the

program are trained epidemiologists who can analyze a

population and apply the statistical results to

prevention, treatment and management of chronic and

infectious diseases, as well as occupational and

environmental health. From surveillance of

communicable diseases to injury prevention to

bioterrorism response, military EIS alumni directly

influence health promotion, disease prevention, and

force health protection. Ultimately, EIS alumni,

whether Active Duty or Reserve, provide a ready force

of qualified public health professionals and

epidemiologists who can meet the demands of the

current operational tempo, while enhancing and

increasing the DoD’s capacity to respond to public

health emergencies.

REFERENCE

1. Centers for Disease Control and Prevention. Proposed

Data Collections Submitted for Public Comment and

Recommendations. Federal Register. 2006;71(147):43

487. Available at: http://www.fda.gov/ohrms/DOCK

ETS/98fr/E6-12269.pdf. Accessed January 28, 2009.

AUTHOR

CPT McElroy, a member of the 358th Medical

Detachment (Veterinary Service) in Tuskegee,

Alabama, is currently a Fellow in the EIS postgraduate

program. She is assigned to the Rickettsial Zoonoses

Branch of the Division of Viral and Rickettsial

Diseases, National Center for Zoonotic, Vector-borne,

and Enteric Diseases, CDC, Atlanta, Georgia.

*The Air Force Veterinary Corps was disbanded in 1980 and the 272 veterinarians were transferred to the Biomedical

Science Corps. The veterinary career field was eliminated in fiscal year 1983. (Source: http://airforcemedicine.afms

.mil/sg_newswire/jan_05/BiomedicalSciencesCorpsCelebrates.htm)

Opportunities for Military Medical Officers: The Epidemic Intelligence Service at the

Centers for Disease Control and Prevention
January – March 2009 59

Nation building activities and stability operations

conducted by the United States military are essential to

the success of newly established democracies such as

Iraq and Afghanistan. US Army Civil Affairs units

spearhead the rebuilding of countries by developing

engineering projects, force protection and public

health programs, and agricultural development. US

Army veterinarians, in conjunction with various US

governmental agencies and host nation equivalents,

establish vaccination programs to prevent the spread of

zoonotic diseases, develop livestock husbandry

programs to stimulate the economy, and educate the

local populace in animal and public health issues to

improve the overall health of the country.

Currently, the US is fighting religious extremism and

fundamentalism in the middle and far east. In the past,

the US fought against the spread of Nazism, fascism,

and communism. In order for democracies to flourish,

it is essential the US and its allies prevent the

destruction of irreplaceable national resources, such as

healthy populations, cultural treasures, historical monuments, agriculture, and heavy industry. One such historical example of cultural preservation is the seizure

and protection of the great Lipizzaner breed of horses

by US military intervention late in World War II.

In April 1945, General George Patton’s 3rd Army was

leading the American advance into Bavaria, Germany

to combat German Field Marshall Ferdinand

Schoerner’s 7th Army. The 11th Panzer Division was

the 7th Army's largest and most effective remaining

combat unit, responsible for defending western

Czechoslovakia from the advancing Russians and

Bavaria from the approaching Americans. Unknown to

the advancing Allies, at the geographic center of the

upcoming battlefield was Europe’s finest collection of

horses, the Lipizzaners, a majority of which belonged

to the Spanish Riding Schools in Austria, Slovenia,

and Italy, but were then under the control of the

German Army.

The German Army had been breeding and training

horses in Czechoslavakia for assignment to German

cavalry regiments in Hostoun (Hostau),

Czechoslovakia, since October 1938. Unlike the

Americans, the German Army continued to use horses

to move troops and equipment, and in combat

operations. In 1943, about 800 German veterinarians

were responsible for the supply and management of

500,000 to 1,000,000 horses.1Since the US Army was

primarily mechanized, as few as 170 US Army veterinarians were involved in the European conflict.2 However, veterinarians were needed to prevent the loss of

animals and to ensure the safety of meat, dairy, and

eggs essential to feed the malnourished survivors freed

from Nazi concentration camps, impoverished German

citizens, and fatigued US troops.

The presence of the Lipizzaners in Czechoslovakia led

to the collaboration of former enemies to save the

herd.3 Two German Army veterinarians, Captains

Rudolph Lessing and Wolfgang Kroll, managed the

irreplaceable herd of breeding and performance horses

in Hostau. On April 26, 1945, Captain Lessing, from

the 11th Panzer Division, riding a Lipizzaner and

leading an Arabian, risked his life to negotiate a

surrender to the 2nd Cavalry Group. Captain Lessing

had volunteered to contact the Americans without the

approval of Lieutenant Colonel Hubert Rudolfsky, the

German commander of the breeding/training facility in

Hostau.

Captain Lessing, and Captain Thomas Stewart, a US

Army intelligence officer in the 42nd Squadron of the

2nd Cavalry Group, developed a plan on April 26,

1945, to rescue the horses. Colonel Charles Hancock

Reed, commander of 2nd Cavalry Group

(Mechanized) and an old cavalry officer and rider,

supervised the planning of “Operation Cowboy.” The

goal of the operation was to return the Lipizzaners to

their rightful owners, Austria, Slovenia, and Italy.

Colonel Reed had become aware of the presence of the

Lipizzaners, and a number of prisoners of war (POWs)

who tended the herd in Hostau, from captured

documents and the interrogation of a recently captured

Luftwaffe officer, Walter H. Oberst.

The 3rd Army Rescue of the Lipizzaners

MAJ Boris Brglez, VC, USA
60 www.cs.amedd.army.mil/references_publications.aspx

Operation Cowboy required the

authorization of General Patton,

whose approval to allow US Army

operations in Czechoslovakia

represented a substantial military and

political risk. At the Yalta Conference

in February 1945, Soviet Premier

Josef Stalin, US President Franklin

Roosevelt, and British Prime Minister

Winston Churchill agreed that Russia

would occupy western Czechoslovakia upon defeat of the Germans.

It was not until 0730 on May 4, 1945,

t hat Ge ne ral Oma r B ra dle y,

commander of the 12th Army Group

which included the 3rd Army, gave

General Patton the green light to

attack Czechoslovakia.

Colonel Reed agreed to allow Captain Stewart to

accompany Captain Lessing to Hostau, hoping to

negotiate a peaceful surrender with the Germans, as

well as obtaining the release and evacuation of the

POWs who were caring for the herds.

On the evening of 26 April, beneath a full moon,

Captains Stewart and Lessing crossed the CzechGerman border on horseback. Captain Stewart had

ridden horses in his native Tennessee prior to the war

and managed to keep up with Captain Lessing in their

ride across the countryside, including jumping

obstacles on the journey. After a short night’s sleep,

Captains Stewart and Lessing were able to negotiate

the peaceful surrender of Hostau, despite Lieutenant

Colonel Rudolfsky’s initial intent to fight the

advancing Americans. On the evening of 27 April,

Captain Lessing accompanied Captain Stewart to the

American lines.

Task Force Reed, commanded by Major Robert P.

Andrews, was formed from the 42nd Squadron, 2nd

Cavalry Group, and consisted of infantry, tanks, and

assault guns to facilitate Operation Cowboy. Task

Force Reed crossed the Czech-German border on the

morning of 28 April. Most of the German troops

surrendered without a fight, however, a group of

Schutzstaffel (SS) troops posted near Hostau refused

to surrender and challenged Task Force Reed.

Miraculously, the Americans suffered only 2 seriously

wounded casualties, Sergeant Owen Sutton and Private

Raymond Manz. Both died from their wounds soon

afterwards. Private Manz was awarded

the Distinguished Service Cross

posthumously. The significance of this

operation and their sacrifice was

memorialized on September 16, 2006,

when the Czech citizens of Bělá nad

Radbuzou, a small town near Hostau,

erected monuments to Sergeant Sutton

and Private Manz in memory of their

heroic acts during the operation.5

By midafternoon of 28 April, US

troops occupied Hostau, liberating

about 400 American, British,

Yugoslavian, French, and Polish

POWs. The Americans seized a

numbe r o f ho rse s, i ncl udi ng

approximately 300 Lipizzaners, over

100 Arabians, 200 thoroughbred and trotting horses,

and 600 Cossack horses. The Austrian Lipizzaner herd

had been divided, the majority of the mares were in the

breeding farm in Hostau, while the stallions were

located at St. Martin, Austria. A contingent of Task

Force Reed departed on 29 April to rejoin the 2nd

Cavalry Group for other missions. Captain Stewart

remained in command of the defense of Hostau,

commanding German troops, Cossacks (white

Russians), and Polish prisoners to assist in its defense.

On 30 April, the remaining SS troops in the area

attacked Hostau and were defeated by the end of the

day. Germany surrendered to the Allies on 7 May.

Within days of the surrender, senior Russian officers

visited Hostau, making inquiries regarding the horses.

COL Charles Hancock Reed.

(Photo courtesy of the Lipizzan

Association of North America4)

A Lipizzaner mare in front of the stables at Hostau,

Czechoslovakia, 1945. (Photo courtesy of the Lipizzan Association of North America4)

The 3rd Army Rescue of the Lipizzaners
January – March 2009 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

On 7 May, Austrian Colonel Alois Podhajsky,

Commandant of the Spanish Riding School in Vienna,

asked General Patton for the responsibility to protect

all displaced Lippizzaner herds. He was granted this

honor and privilege. On 12 May, under Patton’s

orders, all horses were moved from Hostau to

Schwarzenburg in Bavaria. Mares and foals were

transported in trucks, and the remainder of the herd

traveled on the hoof.6 On 18 May and 25May, more

than 200 horses, predominantly Lipizzaners of the

Piber (Austria) herd, were

returned to St. Martin,

Austria, and placed under the

direct supervision of Colonel

Podhajsky.7(p127)

The remaining 700 horses,

consisting of Arabians,

Sl ove nia n Li pi zzane r s,

t ho r oughb red s, t r otting

horses, and some Cossack

horses, were transferred to a

large German breeding

establishment at a Remount

Depot in Mansbach, Germany. All of the horses were

war “booty” belonging to the

US Army and were eventually shipped to the United States for use

by the US Army Remount Service.

Descriptions of this legendary rescue has

been recorded in various documents, such

as Colonel Reed’s 1970 memoirs,3

documented discussions with Captain

Stewart, and in Captain Lessing’s

biography,8 which discussed his

employment by the US Army for one year

after World War II. Captain Lessing took

care of the horses in US Army’s custody,

including the transport of the horses to the

port of Bremerhaven, Germany, for

shipment to the United States. Colonel

Podhajsky’s memoir states that the horses

were accompanied on the ship bound for

the US by a US Army Veterinary Corps

officer.7(p132) Although historically

inaccurate, the 1963 movie entitled

“Miracle of the White Stallions” was

loosely based on Colonel Podhajsky’s

book. The movie succeeded in capturing

the daring and spirit of the rescue, as well as the

cultural significance of the horses and the appreciation

of the local populace for the rescue operation.

General Patton certainly deserves the credit he

received for his foresight in authorizing the risky

rescue and protection of the Lipizzaners and other

horses held by the Germans. However, he apparently

never publicly discussed Colonel Reed’s successful

execution of the mission. In his autobiography,9his

onl y me nti on o f the

Lipizzaner horses is his

description of an exhibition

he attended with Under

Secretary of War Robert P.

Patterson on May 7, 1945 in

St. Martin, Austria, during a

trip to the headquarters of

General Walton Walker’s

XXth Corps. He describes the

maneuvers taught to the

horses and their military

significance, such as the

courbette (half rear) and volte

(leap in the air). Patton

concluded that the Imperial

Spanish Riding Academy and

t h e t r ai ni n g o f t h e

US Army Soldiers loading Lipizzaner mares and foals onto trucks for

transport from Hostau, Czechoslovakia to Schwarzenburg, Germany,

May 12, 1945. (Photo courtesy of the Lipizzan Association of North

America4)

Lipizzaner horses in transport to Schwarzenburg,

Germany, May 12, 1945. (Photo courtesy of the

Lipizzan Association of North America4)
62 www.cs.amedd.army.mil/references_publications.aspx

Lipizzaners, which was established in the 16th century

during the reign of King Charles V, was an art form

which should not be allowed to perish, no matter how

esoteric.9

The history of the Lipizzaner rescue and the high

survival rate of the horses, avoiding disease and

physical injury, is testimony to the role military

veterinarians play in preserving people’s culture and

agricultural resources liberated from tyranny and

oppression by the US military and its allies. Veterinary

vigilance prevented outbreaks of zoonotic diseases

such as glanders, encephalitis, rabies, and Q fever

spreading to people, horses and other livestock. The

significant role that military veterinarians play in the

preservation of cultural assets, the promotion of

security and public health, and assistance in the

rebuilding of economies in ruins is fundamental to the

ability of newly established democracies to thrive and

eventually stand on their own, becoming productive

and contributing members of the global community.

REFERENCES

1. Zieger W. Das deutsche Heeresveterinarwesen im

Zweiten Weltkrieg [German Military Veterinary

Services in the Second World War]. Freiburg,

Germany: Rombach & Co; 1973.

2. Miller EB. United States Army Veterinary Service in

World War II. Washington, DC: Office of The

Surgeon General, US Dept of the Army; 1961:272.

3. Reed C. Personal Memoirs: Account of the Rescue of

the Lipizzans, 4 November 1970. Appended to

Charles H. Reed to William S. Biddle, 14 February

1973. Richmond, Virginia, 113th Calvary Group

Correspondence and papers concerning WWII

service, history folder, box 22, Biddle Papers, MHI.

4. WWII photos page. Lipizzan Association of North

America Web site. http://www.lipizzan.org/

photogallery/wwii_photos/, An Historic Moment:

Colonel Podhajsky before General Patton in St

Martin, Austria, 1945.

5. Commemorative foundation website. Dedication of

memorial in 2006 to US Soldiers killed and wounded

in Operation Cowboy, April 1945. Available at:

www.gjt.cz/includes/military/BNB/BNB3.htm.

Accessed January 28, 2009.

6. Glueckstein F. Gen George S Patton Jr and the

Lipizzaners. Army. 2006;56(6). Available at: http://

findarticles.com/p/articles/mi_qa3723/is_200606/

ai_n17177005?tag=content;col1. Accessed January

29, 2009.

One of the groups of Lipizzaner and other horses moving

under US Army control from Hostau, Czechoslovakia, to

Schwarzenburg, Germany, May 12, 1945. (Photo courtesy

of the Lipizzan Association of North America4)

General Patton riding the Lipizzaner stallion Favory Afrika

in Salzburg, Austria, in 1945. The horse had been selected

by Adolph Hitler himself to be a gift to his Axis ally,

Emperor Hirohito of Japan.6(Photo courtesy of the Patton

Museum)

The 3rd Army Rescue of the Lipizzaners
January – March 2009 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

7. Podhajsky A. My Dancing White Horses. HogarthGaute F, trans. New York, NY: Holt Rinehart, and

Winston, Inc; 1965.

8. Dietbert A. Gesprache mit einem Pferdemann, Dr.

Rudolf Lessing [Conversations with a Horseman, Dr

Rudolf Lessing]. Bremen, Germany: PferdesportVerlag Rolf Ehlers GmbH; 1995:19.

9. Patton GS. War as I knew it. New York, NY:

Houghton Mifflin Harcourt; 1995:328-329.

AUTHOR

MAJ Brglez is Staff Veterinarian, Directorate of

Combat And Doctrine Development, US Army Medical

Department Center and School, Fort Sam Houston,

Texas.

General Patton and Colonel Alois Podhajsky, Commandant of the Spanish Riding School,

May 7, 1945, in St. Martin, Austria.6(Photo courtesy of the Lipizzan Association of North

America4)
64 www.cs.amedd.army.mil/references_publications.aspx

Fresh Frozen Plasma

LTC Clayton D. Simon, MC, USA

MAJ(P) Jeremy Perkins, MC, USA

LTC Paul Barras, AN, USA

COL Brian Eastridge, MC, USA

COL Lorne H. Blackbourne, MC, USA

INTRODUCTION

For years, much has been said and written concerning

the transfusion practices in the massively bleeding

patient. It makes intuitive sense to transfuse whole

blood in the massively bleeding patient since that is

exactly what the patient is losing. However, since

whole blood is not a product that is available for

common hospital use, crystalloids and packed cells are

commonly infused to treat the massively bleeding.

Infusing a crystalloid solution (normal saline or

lactated Ringer’s solution) or stored packed red blood

cells without clotting factors into a hemorrhaging

patient will dilute the clotting factors and can actually

make the patient more coagulopathic.1-6 Clearly, the

severely injured patient does not bleed crystalloid.

There have been a lot of recent discussions on the

benefits of fresh frozen plasma (FFP) in combat

wounded. This paper provides some basic information

on FFP.

WHAT IS FRESH FROZEN PLASMA?

When a donor gives a unit of whole blood, the blood is

separated into several components

parts. The major components are

packed red blood cells (pRBC), FFP,

and sometimes platelets. The FFP

can be further separated into

cryoprecipitate and what is known as

“cryo-poor plasma,” a product rarely

used for therapeutic means. Plasma

is the liquid, noncellular portion of

bl ood, a nd contai ns wate r,

electrolytes, and proteins. The

proteins in plasma include the major

clotting factors and intrinsic

anticoagulants. The plasma is

separated from whole blood after

donation and then frozen. To be

considered “fresh,” the plasma must be placed into the

freezer within 8 hours of collection and stored at

minus 18°C or lower, otherwise it is just frozen plasma

(another product rarely used for therapeutic means).

FFP can be prepared either by separation from whole

blood or collection via plasmapheresis.

Fresh frozen plasma contains the majority of all known

coagulation factors, but essentially no cells (eg, red

blood cells or white blood cells) nor platelets. In

addition to the coagulation factors, FFP also contains

approximately 500 mg of fibrinogen. Of note, the

fibrinogen in 1 unit of FFP is approximately equal to

the amount of fibrinogen found in 2 units of

cryoprecipitate.7 These clotting factors and fibrinogen

are critical for normal hemostasis.

COAGULOPATHY AND DAMAGE CONTROL SURGERY

Damage control surgery is the method of treating

severely wounded patients in the combat zone. It

applies the principles of an abbreviated operation to

stop bleeding without completely restoring anatomy

and returning the patient to the intensive care unit for

re s u s citati on, wa rmi n g, a nd

correction of coagulopathy (inability

to form clot) before returning to the

operating room.8-10 The civilian data

on damage control patients reveals a

c l e a r c o r r e l a t i o n b e t w e e n

coagulopathy and mortality. Macleod

et al demonstrated an increased

mortality (19% mortality) if a trauma

patient has a documented elevation in

their prothrombin time (PT) versus

those patients with a normal PT (5%

mortality) on admission to the

e m e r g e n c y d e p a r t m e n t . 1 1

Furthermore, if a patient returns to

the intensive care unit after the Fresh Frozen Plasma
January – March 2009 65

abbreviated damage control operation and is

coagulopathic, the probability of death is much higher

and correlates with the degree of coagulopathy.12

COMBAT DATA

Combat wounded patients have severe soft tissue

injuries and amputations not often seen in civilian

trauma; and the coagulopathy seen in trauma patients

may be even more of a consequence in these patients.

Retrospective analysis from a combat support hospital

has revealed a mortality benefit associated with

infusing FFP to pRBCs in a 1:1.4 ratio (clinically, in

the chaos of treating a hemorrhaging trauma patient

this is transfused in a 1:1 ratio) in severely injured

patients.13 In this study, mortality for each of the

FFP:pRBCs ratios increased as more pRBCs were

transfused for fewer units of FFP. With an FFP:pRBC

ratio of 1:8, the mortality was 65%. The mortality was

34% for the FFP:pRBC ratio of 1:2.5, but the high

FFP:pRBC ratio of 1:1.4 resulted in a mortality of

19%.13 The data is presented in the Figure. From these

retrospective data, it appears evident that the severely

injured, coagulopathic patient needs not only oxygen

carrying capacity and volume from packed red blood

cells, but also clotting factors from FFP in a high ratio

approaching a 1:1 ratio.

FFP STORAGE AND PREPARATION

When frozen FFP is maintained at -18°C, it is good for

12 months. Food and Drug Administration regulations

require that FFP be stored at a temperature no higher

than -18°C, and according to the standards published

by the American Association of Blood Banks, “Fresh

Frozen Plasma shall be prepared from a whole blood

or apheresis collection and frozen at less than or equal

to -18°C.”14 Most commercially available small

freezer units can easily maintain temperatures of -20°

C, making FFP available for extended storage at all far

forward medical facilities.

Thawing FFP is a simple process. It is the widely

accepted practice to place the desired units in a warm

water bath of 30oC to 37oC for 20 to 30 minutes with

gentle agitation. Von Heymann, et al evaluated the

effects of 2 commercially available thawing devices

and running warm water (43oC) on the activity of

clotting factors, inhibitors, and activation markers in

fresh-frozen plasma. From 1 hour to 6 hours after

thawing, no significant differences in the activity of

the investigated coagulation markers dependent on the

thawing procedure were found.15 If the thawed FFP is

immediately transfused, it remains rich in clotting

factors. This product can be rapidly infused

intravenously through a warming device set at 37oC to

40oC. If the thawed FFP is not infused immediately it

can be maintained at room temperature for up to 4

hours, or stored for up to 5 days at 1oC to 6oC.

THAWED PLASMA

If thawed FFP is not transfused within 24 hours, it is

considered a distinct product termed “thawed plasma.”

While most clotting factors are stable in thawed

plasma, some factors including V and VIII (termed

labile factors) degrade over time and this degradation

accelerates while plasma is stored in the liquid state.

The advantage of having thawed plasma on hand is

that it is immediately available for infusion to the

severely injured patient. Many stateside blood banks

have adopted this policy of maintaining thawed plasma

for immediate release. In an effort to decrease requestto-infusion times, some larger trauma centers even

maintain thawed plasma at 1oC to 6oC in the operating

room.

UNIVERSAL FRESH FROZEN PLASMA DONOR

While it is common knowledge that O- is the universal

donor for pRBCs, the same cannot be said for FFP.

The A and B antigens of the blood are found on the red

cells themselves. The type O individual is devoid of

these proteins on the red cells. Plasma, on the other

hand, contains the antibodies to the corresponding

65%

34%

19%

0

10

20

30

40

50

60

70

FFP:pRBC Ratio

Mortality (%)

Mortality by FFP:pRBC Ratio. A high ratio of 1:1.4

was associated with a lower mortality rate

compared to medium (1:2.5) and low ratios (1:8)

(P <0.001).13
66 www.cs.amedd.army.mil/references_publications.aspx

absent protein. For example, a blood type A individual

has Anti-B antibodies in his blood. Type O plasma has

both Anti-A and Anti-B antibodies and is incompatible

with about 55% of the population. However, an

individual with type AB blood has neither Anti-A nor

Anti-B antibodies. This makes the AB plasma ideal for

universal use when the blood type of the patient is

unknown. The Rh status is irrelevant because any

plasma with Anti-D (the D protein is commonly

referred to as Rh) is destroyed at the manufacturing

stage. Considering the fact that only 4% of the

population is blood type AB (and thus, the donor pool

for the universal donor is very small) the best FFP to

transfuse is blood type “compatible” based on the

blood type determined in the blood bank and should

replace the universal donor as soon as possible.

FUTURE

The future direction for combat damage control

resuscitation will likely include synthetic hemoglobin

as a replacement for pRBCs, especially in far forward

environments. In the canine model this product is

already available in the form of Oxyglobin®(Biopure

Corporation, Cambridge, MA) and is actually used by

veterinarians during canine trauma surgery today.16

This “synthetic blood product” consists of chemically

stabilized hemoglobin in a balanced salt solution.

When administered intravenously, this stabilized

hemoglobin immediately circulates in the plasma and

delivers oxygen to the body's tissues and organs. It is

only a matter of time before this type of product is

available for human use. Freeze-dried clotting factors

or a combination of recombinant clotting factors like

NovoSeven®(Novo Nordisk, Inc, Princeton, NJ), a

recombinant factor VII, will possibly replace FFP (or

act in synergy with FFP). Freeze dried or cryopreserved (frozen) platelets may someday replace our

current platelets (platelets currently have a 5 day shelf

life!). All of these components will need a long shelf

life and preferably be heat stable to provide the full

benefit of blood and blood product support for

severely injured service members far forward in an

austere combat environment.

CONCLUSIONS

Coagulopathy clearly correlates with mortality in

severely injured damage control patients. Combat

injured casualties represent a unique subset of these

patients often with massive tissue injury. While

administering packed red blood cells replaces oxygen

carrying capacity, it is deficient in coagulation factors.

Whole blood administration accomplishes both red cell

and plasma replacement, but is both labor and time

intensive. Aggressively replacing the lost clotting

factors approaching a 1:1 ratio of FFP to pRBCs

should be a goal in all abbreviated damage control

operations and intensive care unit resuscitation of all

severely injured patients undergoing a massive blood

transfusion (>10 units of pRBCs in 24 hours) in the

combat zone. This is accomplished by assuring FFP is

readily available and pushing FFP far forward to

surgical facilities on the battlefield.

REFERENCES

1. Tieu BH, Holcomb JB, Schreiber MA. Coagulopathy:

its pathophysiology and treatment in the injured

patient. World J Surg. 2007;31(5):1055-1065.

2. Murray DJ, Pennell BJ, Weinstein SL, Olson JD.

Packed red cells in acute blood loss: dilutional

coagulopathy as a cause of surgical bleeding. Anesth

Analg. 1995;80(2):336-342.

3. Hewson JR, Neame PB, Kumar N, Ayrton A, Gregor

P, Davis C, Shragge BW. Coagulopathy related to

dilution and hypotension during massive transfusion.

Crit Care Med. 1985;13(5):387-391.

4. Murray DJ, Olson J, Strauss R, Tinker JH.

Coagulation changes during packed red cell

replacement of major blood loss. Anesthesiology.

1988;69(6):839-845.

5. Leslie SD, Toy PT. Laboratory hemostatic

abnormalities in massively transfused patients given

red blood cells and crystalloid. Am J Clin Pathol.

1991;96(6):770-773.

6. Ho AM, Karmakar MK, Dion PW. Are we giving

enough coagulation factors during major trauma

resuscitation? Am J Surg. 2005;190(3):479-484.

7. Hoffman M, Jenner P. Variability in fibrinogen and

Von Willebrand factor content of cryoprecipitate.

Brief Sci Rep. 1990;93(5):694-697.

8. Shapiro M, Jenkins D, Schwab CW, et al. Damage

control: collective review. J Trauma. 2000;49:969-

978.

9. Lee JC, Peitzman AB. Damage-control laparotomy.

Curr Opin Crit Care. 2006;12(4):346-350.

10. Phelan HA, Patterson SG, Hassan MO, Gonzalez RP,

Rodning CB. Thoracic damage control operation:

principles, techniques, and definitive repair. J Am

Coll Surg. 2006;203(6):933-941.

Fresh Frozen Plasma
January – March 2009 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

11. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J

Trauma. 2003;55(1):39-44.

12. Gonzalez EA, Moore FA, Holcomb JB, et al. Fresh frozen plasma should be given earlier to patients requiring

massive transfusion. J Trauma. 2007;62(1):112-119.

13. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients

receiving massive transfusions at a combat support hospital. J Trauma. 2007;63(4):805-813.

14. Standards for Blood Banks and Transfusion Services. 25th ed. Bethesda, Maryland: American Association of Blood

Banks; 2007:sect 5.7.5.9.

15. Von Heymann C, Pruss A, Sander M, et al. Thawing procedures and the time course of clotting factor activity in

fresh frozen plasma: a controlled laboratory investigation. Anesth Analg. 2006;103:969-974.

16. Freedom of Information Summary. Oxyglobin. US Food and Drug Administration, Center for Veterinary Medicine.

January 12, 1998. NADA 141-067.

AUTHORS

LTC Simon is Director of Blood Services, Brooke Army Medical Center, Fort Sam Houston, Texas.

MAJ(P) Perkins is Deputy Director, Military Casualty Research Division, and Chief, Department of Blood Research,

Walter Reed Army Institute of Research, Bethesda, Maryland.

LTC Barras is Assistant Chief Nurse Anesthetist, Womack Army Medical Center, Fort Bragg, North Carolina.

COL Eastridge is Surgical Director, Surgical Intensive Care Unit, Brooke Army Medical Center, Fort Sam Houston,

Texas.

COL Blackbourne is Commander, Institute of Surgical Research, Brooke Army Medical Center, Fort Sam Houston,

Texas.
68 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

The current conflicts in Afghanistan and Iraq have

demonstrated the impressive advancements in

warfighting technology at the military’s disposal. The

US military in the 21st century is an awesome

warfighting machine that is continually looking to

improve its capabilities. The military medical system

has also displayed its robust capabilities, though there

is still room for improvement. Surprisingly, the

delivery of anesthesia on the battlefield is still

accomplished with fairly simple gas delivery systems.

Is there a better, smarter, and safer way to deliver

anesthesia to our wounded warriors? Total intravenous

anesthesia (TIVA) has particular application in combat

medicine because it accomplishes the goal of general

anesthesia while it decreases the equipment necessary

to provide inhalation anesthetics. The focus of this

article is to review historical milestones in combat

anesthesia, develop the basic concepts of TIVA,

explore some of the purported benefits, particularly in

combat trauma, and briefly describe some future trends

in intravenous anesthesia. The goal is to demonstrate

the safety, simplicity, scientific principles, and small

logistical footprint of TIVA.

COMBAT ANESTHESIA: HISTORICAL PERSPECTIVE

Throughout history, attempts have been made to allay

the suffering of injured Soldiers on the battlefield. In

the Middle Ages, people sought pain relief in herbs,

roots, seeds, flowers, opium, mandrake, hemlock, the

mulberry tree, and even the garden lettuce, among

other remedies.1 A sea sponge saturated with the juices

of soporific plants became the major analgesic of the

time. By the middle of the 17th century, whiskey, gin,

and rum had replaced most drugs, considered unsafe

since there was no way to standardize the dose,

although occasionally physicians used opium.1

Colonial surgeons relied on speed and medications

such as opium, rum, or cider vinegar when available.2

In the mid 1800s, the inhalation of ether anesthesia

was recommended for military use. The first combat

use of ether was by American forces in Buena Vista,

Mexico, early in 1847, and then again at Vera Cruz.3

In the US Civil War, the Army Medical Service

reported employing surgical anesthesia in no fewer

than 80,000 cases. Surgeons preferred chloroform

most of the time, although a mixture of ether and

chloroform was also described, as well as alcohol and

opiates.1 Throughout WWI and WWII, continuous

advances were made to provide gas anesthetic agents

to the austere conditions of the battlefield. Ether

continued to be the anesthetic of choice although

intravenous Thiopental gained popularity during

WWII.1 However, Thiopental fell from favor after the

attack on Pearl Harbor where surgeons noted that

many Soldiers who were in hemorrhagic shock died

after receiving the anesthetic. New vaporizers, airway

equipment, and blood transfusions for treatment of

shock were other battlefield advances made during

WWII.1 Anesthetists in the Korean War exercised the

added benefit of intravenous muscle relaxation with

the introduction of succinylcholine and tubocurarine.

In Vietnam, intravenous barbiturates (pentobarbital,

secobarbital) and morphine with atropine or

scopolamine were used preoperatively.1 The induction

agent of choice was sodium thiopental used with a

relaxant. The most common gas anesthetic agents

included diethyl ether, halothane, methoxyflurane, and

nitrous oxide—oxygen in conjunction with narcotics

such as morphine and meperidine.1 The common

problem faced throughout all of these historical

conflicts remains today. Front line surgeries are

performed in austere environments within the

constraints of logistical supply trains. While

attempting to provide the safest anesthetic as far

forward as possible, providers are still hampered by

the same question, “What do we bring to war and how

do we carry it there?”

Total Intravenous Anesthesia on the

Battlefield

LTC Paul Barras, AN, USA

MAJ Joel McMasters, MC, USA

LTC(P) Kurt Grathwohl, MC, USA

COL Lorne H. Blackbourne, MC, USA
January – March 2009 69

TOTAL INTRAVENOUS ANESTHESIA VS GENERAL

Total intravenous anesthesia is the method of

providing general anesthesia without the use of

volatile anesthetic gases. General anesthesia, whether

intravenous or inhalational, is recognized as analgesia,

amnesia, absence of movement and autonomic

stability. With the intravenous anesthetics available

today, combat trauma patients can be safely induced

and maintained without the use of volatile anesthetic

gases. The avoidance of inhalational agents adds a

significant degree of safety on the battlefield, as

intravenous anesthetics do not trigger malignant

hyperthermia, whereas the inhaled gases do. Furthermore, the pharmacokinetic and pharmacodynamic

properties of most modern drugs makes them very

titratable and suitable for continuous infusion, even in

the most austere environments. Drugs like ketamine,

propofol, midazolam, and newer synthetic, short acting

opioids allow for predictable pharmacokinetic

modeling, making TIVA an attractive alternative on

the battlefield.4

Physiologic advantages of TIVA include improved

maintenance of hemodynamic stability and

temperature conservation, particularly with ketamine.

Intravenous ketamine provides dissociative anesthesia,

which provides amnesia and excellent analgesia. The

ketamine-induced rise in blood pressure and heart rate

seen in the normotensive patient can be beneficial in

the trauma patient by attenuating further hemodynamic

compromise. Furthermore, the peripheral

vasoconstriction caused by ketamine can decrease core

to periphery heat loss.5 Total intravenous anesthesia

may also be beneficial in patients who have

experienced a traumatic brain injury. In July 2005, an

article in the American Society of Anesthesiologists

newsletter reported that TIVA was provided to over

100 patients requiring craniotomy or craniectomy.6

Further, the article also indicated that a decrease in

mortality of 50% was reported when compared to

similar neurotrauma patients receiving volatile gas

anesthetics. A related study reported that the hemodynamic stimulation induced by ketamine may

improve cerebral perfusion and that ketamine does not

increase intracranial pressure when used under

conditions of controlled ventilation and coadministration of a benzodiazepine.7

Compared to inhalational anesthesia, TIVA has also

been shown to attenuate the body’s stress response to

surgery. Analyzing the complete intraoperative period

at 7 event-related time points, it was demonstrated that

larger plasma concentrations of stress hormones

occurred in an inhalation regimen than in a TIVA

regimen.8Propofol administration may inhibit lipid

peroxidation and restore antioxidant enzyme levels in

extremity surgery requiring tourniquet application.9

Perhaps the most documented benefits of TIVA are a

reduced recovery time and reduction in the incidence

of nausea and vomiting. Propofol TIVA resulted in a

clinically relevant reduction of postoperative nausea

and vomiting compared with isoflurane-nitrous oxide

anesthesia.10 Ozkose et al11 reported a reduced

recovery time in TIVA patients and a significantly

reduced incidence in nausea, vomiting, and pain. They

also concluded that TIVA patients required fewer

additional drugs and showed the lowest additional

costs in the post-anesthesia care unit. Hofer et al12

demonstrated similar TIVA improvement in early

postoperative patient well-being and reduced incidence

in postoperative nausea and vomiting. The highquality emergence usually seen with TIVA results in

fewer interventions in the postoperative period, thus

serving as a force multiplier.

WHY TIVA IN COMBAT

Even in the most austere conditions, most providers

would never compromise on the monitors necessary

(electrocardiogram, pulse oximetry, capnography,

blood pressure monitors) to provide an anesthetic.

However, space, superfluous equipment, and electricity can become issues. Furthermore, logistical resupply and disposal of waste gases are also major issues.

In the current theaters of both Iraq and Afghanistan,

TIVA has become a reliable alternative to general

anesthesia with volatile agents. With TIVA, there is

less dependency on anesthetic machines and

electricity. Currently, the military fields the Narkomed

M anesthesia workstation (Dräger Medical Inc,

Telford, Pennsylvania) and Ohmeda PAC draw-over

vaporizers (Datex-Ohmeda Inc, Madison, Wisconsin)

for delivery of inhalation anesthetics in the combat

zone. Both are reliable for delivery of inhalation

anesthetics, but there are significant drawbacks to

each. The Narkomed M is supplied in 2 containers

weighing 75 kg and is rather large and bulky (see

Figure 1). It requires electricity (battery back-up less

than 3 hours) and compressed oxygen for continuous

operation. The Ohmeda PAC vaporizer, although

small, has a one-way circuit that prevents the

absorption of CO2 and recirculation of anesthetic
70 www.cs.amedd.army.mil/references_publications.aspx

gases, resulting in an increased use of volatile agent.

Both the Narkomed M and the Ohmeda PAC require

some sort of scavenging system to remove waste

gases, and both are dependent on the availability of

volatile agents (isoflurane and sevoflurane) from

supply channels.

On the other hand, TIVA requires very little

equipment to administer a general anesthetic. Whether

using a bolus technique or a continuous infusion

through a pump, TIVA can be employed without the

use of an anesthesia machine. Basically a TIVA

technique uses the same intravenous medications used

for anesthetic induction continued throughout the

maintenance phase of the anesthetic. Several syringe

infusion pumps available on the market, (eg, Alaris

(CardinalHealth Inc, Dublin, Ohio), Baxter (Baxter

Inc, Deerfield, Illinois) (shown in Figure 2), Bard

(C.R. Bard, Inc, Deerfield, Massachusetts)) are quick

to set up, and simple to operate. Most run reliably on

batteries for several hours and are easily packed in the

pocket of a rucksack. Induction medications such as

ketamine, propofol, and etomidate can be titrated or

continuously infused throughout the maintenance

phase of the anesthetic. Adjuncts such as narcotics and

muscle relaxants can also be easily titrated or

continuously infused. Given preemptively, scopolamine and midazolam provide sedation and amnesia

with little hemodynamic compromise.13

Battlefield trauma patients often require multiple

surgical interventions with intermittent intensive care

stabilization. Another important benefit of TIVA over

inhalation agents is that battlefield trauma patients can

be maintained on the same intravenous medications,

although at decreased doses, throughout the intensive

care unit period. Multiple trauma patients often remain

endotrachealy intubated following damage control

surgery, through the resuscitation period, and often

through transport to a higher echelon of care. Utilizing

a continuous infusion of amnestics, hypnotics,

narcotics, and muscle relaxants, patients can be

transported with minimal equipment while maintaining

enroute hemodynamic stability and comfort. The

above advantages of TIVA in the combat setting can

be summarized as the “Four Ss”: simple, safe,

scientific, and a small logistical footprint.

FUTURE DIRECTION

Military anesthesia educational programs have

Figure 1. Narkomed M anesthesia workstation at the 399th recognized the importance and increasing role of

Combat Support Hospital in Iraq.

Figure 2. A Baxter syringe infusion pump.

Total Intravenous Anesthesia on the Battlefield
January – March 2009 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

TIVA on the battlefield. In the past few years,

programs for both nurse anesthetists and

anesthesiologists have integrated TIVA as part of their

residency training. This effort to increase the use of

TIVA on the battlefield was led by the Triservice

Research Group Initiative on TIVA, or TARGIT

Center. The TARGIT Center has delivered thousands

of total intravenous anesthetics over the past 5 years,

and have shared their expertise with the global

anesthesia community. The reply from the US military

anesthesia community to the TARGIT Center’s

admirable efforts has been impressive. In 2006, the

program director of the US Army Graduate Program in

Anesthesia Nursing (LTC Thomas Ceremuga, oral

communication, March 2008) conducted an informal

survey of 105 Army and Air Force combat

experienced certified registered nurse anesthetists

regarding anesthesia techniques and skills. They

identified TIVA as one of the top 10 areas of critical

importance in the education of nurse anesthetists at the

AMEDD Center and School. An article in the

American Society of Anesthesiologists March 2007

newsletter reported that

...military programs make it a requirement that all

graduating residents understand the use of TIVA in

both minor and major elective surgical cases during

their residency, along with didactic training on the use

of TIVA techniques in a combat setting.14

As TIVA becomes more popular, innovations in

infusion pumps and delivery systems make

intravenous anesthesia more practical in combat.

Ongoing developments in advanced biomedical

technology result in pumps that are smaller, lighter,

and have extended battery life. Perhaps the most

exciting innovation in TIVA administration is the

target controlled infusion system currently being used

in Europe (not yet approved by the US Food and Drug

Administration for use domestically). It is a

microprocessor-controlled syringe pump that

automatically and variably controls the rate of infusion

of a drug to attain a defined target medication level in

the patient.4It is analogous to using an inhalational gas

analyzer to measure delivery of volatile gas agents, but

has shown a greater degree of precision and accuracy.

Current infusion pumps simply deliver a

preprogrammed amount and do not automatically

adjust to maintain steady state anesthetic drug levels in

the bloodstream. Target controlled infusers are light,

compact, and show great promise for use in treating

combat trauma patients. There are exciting new

initiatives underway in the US military. The previously

mentioned TARGIT Center was created to develop

techniques and strategies that will lead to the

advancement, research, education, and implementation

of total intravenous anesthesia on the battlefield and in

austere environments.15

CONCLUSIONS

The field of anesthesia has evolved tremendously from

the days of ether and chloroform. Anesthetic

administration on the battlefield has also evolved, with

continuous efforts to minimize equipment and

compensate for the effect of extremely austere

environments. Many of the concerns and obstacles

faced by early anesthesia providers continue to exist

today. The needs for safety, rapid set up, mobility, and

availability of logistical resupply are all concerns for

military anesthesia providers. Intravenous general

anesthesia decreases dependency on an anesthesia

machine and minimizes equipment, compressed gas,

and electricity requirements. Total intravenous

anesthesia has emerged as a practical, reliable method

of delivering anesthesia to patients injured in battle in

any location. Given the safety, simplicity, scientific

nature, and small logistical footprint of TIVA, the

Department of Defense would be wise to consider

TIVA as the battlefield anesthetic of the future.

REFERENCES

1. Condon-Rall ME. A Brief History of Military

Anesthesia: Anesthesia and Perioperative Care of the

Combat Casualty. Washington, DC: The Borden

Institute, Office of the Surgeon General, US Dept of

the Army; 2000:855-896.

2. Buckenmaier CC. The history of pain treatment in

war times: progress and pitfalls, from morphine to

regional anesthesia. [American Pain Foundation

website]. November 28, 2005. Available at: http://

w w w . p a i n f o u n d a t i o n . o r g / p a g e . a s p ?

file=ManageYourPain/Chats/Veterans112805.htm.

Accessed March 4, 2008.

3. Houghton IT. Some observations on early military

anaesthesia. Anaesth Intensive Care. 2006;34(suppl

1):6-15.

4. Campbell L, Engbers F, Kenny G. Total intravenous

anaesthesia. CPD Anaesthesia. 2001;3(3):109-119.
72 www.cs.amedd.army.mil/references_publications.aspx

5. Ikeda T, Kazama T Sessler DI, et al. Induction of

anesthesia with ketamine reduces the magnitude of

redistribution hypothermia. Anesth Analg.

2001;93:934-938. Available at: www.anesthesiaanalgesia.org/cgi/reprint/93/4/934.pdf.

6. Mongan P, Grathwohl KW, Buckenmaier CC, et al.

On the front: Army anesthesiologists in Operation

Iraqi Freedom–perioperative consultants making a

difference on the battlefield. ASA Newsletter [serial

online]. July 2005;69(8). Available at: http://

w w w . a s a h q . o r g/ N e w s l e t t e r s / 2 0 0 5 / 0 7 - 0 5 /

mongan07_05.html.

7. Himmelseher S, Durieux ME. Revising a dogma:

ketamine for patients with neurological injury?

Anesth Analg. 2005;101:524-534.

8. Ledowski T, Bein B, Hanss R, et al. Neuroendocrine

stress response and heart rate variability: a

comparison of total intravenous versus balanced

anesthesia. Anesth Analg. 2005;101:1700-1705.

9. Turan R, Yagmurdur H, Kavutcu M. Propofol and

tourniquet induced ischemia reperfusion injury in

lower extremity operations. Eur J Anaesthesiol.

2007;24(2):185-189.

10. Visser K, Hassink EA, Bonsel GJ, et al. Randomized

controlled trial of total intravenous anesthesia with

propofol versus inhalation anesthesia with isofluranenitrous oxide: postoperative nausea with vomiting

and economic analysis. Anesthesiology. 2001;95

(3):616-626.

11. Ozkose Z, Ercan B, Unal Y, et al. Inhalation versus

total intravenous anesthesia for lumbar disc

herniation: comparison of hemodynamic effects,

recovery characteristics, and cost. J Neurosurg

Anesthesiol. 2001;13(4):296-302.

12. Hofer CK, Zollinger A, S. Büchi S, et al. Patient wellbeing after general anaesthesia: a prospective,

randomized, controlled multi-centre trial comparing

intravenous and inhalation anaesthesia. Br Journal

Anaesth. 2003;91(5):631-637.

13. Reynolds SF, Heffner J. Airway management of the

critically ill patient: rapid-sequence intubation. Chest.

2005;127:1397-1412.

14. Mongan PD, Darin KV. Training the combat

anesthesiologist of tomorrow. ASA Newsletter [serial

online]. March 2007;71(3). Available at: http://

w w w . a s a h q . o r g/ N e w s l e t t e r s / 2 0 0 7 / 0 3 - 0 7 /

mongan03_07.html.

15. Chisholm P. Knock me out. Mil Med Tech. 2004;8

(6). Available at: http://www.military-medicaltechnology.com/article.cfm?DocID=659.

AUTHORS

LTC Barras is Assistant Chief Nurse Anesthetist,

Womack Army Medical Center, Fort Bragg, North

Carolina.

MAJ McMasters is Assistant Chief of Anesthesia,

Brooke Army Medical Center, Fort Sam Houston,

Texas.

LTC(P) Grathwohl is Chief of Anesthesia Critical Care,

and Director, Anesthesiology/Critical Care Medicine,

San Antonio Uniformed Services Health Education

Consortium. He is also Critical Care Consultant to The

Surgeon General of the Army.

COL Blackbourne is Commander, Institute of Surgical

Research, Brooke Army Medical Center, Fort Sam

Houston, Texas.

Total Intravenous Anesthesia on the Battlefield
January – March 2009 73

The recent mandate by the US Army Training and

Doctrine Command requiring all Soldiers entering

Basic Combat Training after October 1, 2007, to be

combat lifesaver (CLS) certified is an outstanding step

to improve training across the Army in lifesaving firstaid skills.1 However, the requirement for all Soldiers to

be competent in placing an intravenous (IV) line and

initiating treatment with IV fluids, per the current CLS

standards, may not be the best use of precious training

resources in the light of the most recent medical

research and battlefield experience.

The outcome of a battle casualty will often be

determined by whoever provides initial care. In most

cases this will be a fellow Soldier, not a medic. The

CLS course was developed to bridge the gap between

self-aid or buddy-aid until care could provided by the

platoon combat medic (military occupational specialty

68W).2 The CLS concept has been further refined over

the last decade to reflect the concepts of Tactical

Combat Casualty Care (TC3), which focuses on

treating the leading causes of preventable battlefield

death while minimizing the risk to first-aid providers

and the tactical mission.3 The TC3 concept is possibly

the most significant advance in point of injury care

since the distribution of the individual field dressing in

the late 1800s.4

The most important battlefield first-aid skill is

controlling hemorrhage, by far the leading and most

preventable cause of battlefield death in modern

warfare. Bellamy showed 9% of those killed in action

during the Vietnam conflict died of potentially

preventable extremity hemorrhage.5 A similar fatality

rate from compressible extremity hemorrhage in Iraq

was demonstrated by Cuadrado et al.6Proper

tourniquet application is the most important method in

the control of severe hemorrhage in the tactical setting.

Other lifesaving skills emphasized in the TC3 include

needle decompression of a tension pneumothorax and

airway management, the second and third leading

causes of preventable battle field deaths, causing 4%

and 1% of all fatal injuries respectively.5-10

The main purpose of performing IV catheterization in

the setting of trauma is to administer fluids or blood

products to treat hemorrhagic shock. Seven percent of

patients on the battlefield require aggressive

resuscitation.11 Current transfusion protocols emphasize fresh whole blood and procoagulants rather than

crystalloids to restore organ perfusion, prevent the

dilution of clotting factors, and avoid hypothermia.11

For patients in significant hemorrhagic shock,

aggressive hemorrhage control at the point of

wounding, followed by expeditious transport to

surgical care, is most important. Evacuation and

subsequent surgical management of noncompressible

truncal hemorrhage should not be delayed by attempts

to place an IV.

In the management of shock, the traditional strategy of

early fluid resuscitation beginning in the field and

continuing into the operating room has been

challenged, specifically in the context of penetrating

thoracic trauma. In 1994, a prospective trial by Bickell

et al12 compared immediate versus delayed fluid

resuscitation in hypotensive patients with penetrating

torso injuries. They reported that patients in whom

fluids were restricted until arrival in the operating

room had lower mortality, fewer postoperative

complications, and shorter hospital length of stay. In a

follow-up prospective trial, patients were divided into

either restrictive resuscitation (goal systolic blood

pressure (SBP) greater than 80 mm Hg) versus liberal

resuscitation (goal SBP greater than 100 mm Hg).

There was not a significant difference in mortality

between groups, but hemorrhage did take longer to

control in the group with the liberal fluid strategy.13

These studies were largely responsible for significant

changes in the management of injured Soldiers on the

battlefield and were adopted by US military and Israeli

Defense Forces.14-18 In 2003, Holcomb14 introduced

the term “hypotensive resuscitation” in his article

about lessons learned in Somalia. Current military

prehospital doctrine now emphasizes the restriction of

IV fluids in casualties who have controlled

hemorrhage, normal mental status, and stable vital

Should We Teach Every Soldier How to Start

Intravenous Fluids?

MAJ Robert L. Mabry, MC, USA

MAJ Peter J. Cuenca, MC, USA
74 www.cs.amedd.army.mil/references_publications.aspx

signs or even mild hypotension (systolic blood

pressure greater than 90). A relatively small

percentage of all combat casualties are likely to benefit

from IV fluid resuscitation on the battlefield. These

include patients with significant hypotension resulting

from severe hemorrhage that has been controlled; and

those with hypotension or severe hemorrhage and a

head injury. All other casualties with uncontrolled

hemorrhage and signs of shock may be challenged

with a very limited amount of IV fluid (1000 mL of

Hextend). Further fluid administration is likely to be

detrimental. The practice of permissive hypotension is

designed to prevent “popping the clot” off an injured

vessel, as well as the dilution of clotting factors with

massive amounts of crystalloid fluid.

IV placement is a skill that requires significant time to

train. In the current CLS course, the IV portion is the

longest, most resource and instructor intensive block

of training. This is precious training time that could be

used for tactical casualty scenarios and practicing

sustainable, life-saving skills, such as hemorrhage

control techniques. In the civilian sector, Basic

Emergency Medical Technicians (EMT-B) are not

taught IV insertion. The first level of civilian EMT to

have IV placement in their scope of practice is EMTIntermediates. The national standard curriculum for

EMT-I requires 300 to 400 hours of classroom and

field instruction after EMT-B certification. EMT-I

students are required to place a minimum of 25 IVs on

live patients of various age groups under instructor

supervision to be considered competent in this skill.19

The current AMEDD CLS Course Instructor Guide20

does not specify the number of successful IV

catheterizations required to certify a CLS in this skill.

It is left to the unit’s medical officer. Certification as a

CLS will not mean that these Soldiers are competent at

placing IVs. At best, it will mean they are familiar

with the procedure.

Casualties presenting in overt shock typically have

difficult intravenous access. They are often extremely

diaphoretic and their peripheral vasculature is

constricted. Placement of an IV in a trauma patient in a

moving ambulance by an experienced EMT-I or higher

level provider takes 10 to 12 minutes and has a 10% to

40% failure rate.21 Paradoxically, starting an IV in

those patients who would most benefit from limited

fluid resuscitation will be extremely difficult for even

the most skilled medical provider. During a hostile

tactical situation combined with darkness, fatigue, and

fear, it will be very unlikely that a Soldier without

significant medical experience will be able to place an

IV under battlefield conditions. For this reason, TC3

guidelines emphasize sternal intraosseous catheter

placement for fluid resuscitation.22

Insertion of an IV catheter is not without risks.

Complications include local and systemic infections,

thrombophlebitis, catheter embolism, and injury to

associated nerves, tendons, and arteries.23-25 Complications are inversely related to the skill and

experience of the medical provider.

Based on the available literature and the lessons being

learned from both Iraq and Afghanistan, it is clear that

IV placement is not a critical life-saving skill, while

hemorrhage control is. Training all Soldiers to start

IVs without the requisite understanding of the

indications, contraindications, risks, and benefits of

who would benefit from IV fluids and who could be

harmed could result in many receiving unneeded or

detrimental care on the battlefield. If Soldiers spend

the vast majority of their first-aid training time

learning IV placement, the most time-consuming skill

in the CLS course, yet one that does not save lives,

which tool will they reach for under the stress of

combat? Will Soldiers be killed by snipers as they

waste precious minutes starting IVs? Will evacuation

be delayed while attempts to “get the IV” are made?

Will proper tourniquet and dressing application be

neglected while focusing on the more “technical” and

“high-speed” IV insertion?

While most Soldiers will not benefit from IV training,

it may have a place in some units. Units operating far

forward with little or no organic medical support, such

as Special Operations Forces, may benefit from this

training. These units are often small and have the time

and resources to train to a high standard in advanced

first-aid skills.

Many line commanders likely participated in “IV

training” led by their unit medical officers during their

formative years. Insertion of an IV on the “first stick”

is considered by many as the quintessential battlefield

medical skill. It is not. Rapid hemorrhage control is.

Additional medical training for all Soldiers is much

needed. The Training and Doctrine Command has

taken an excellent first step. Our battlefield

commanders want robust first-aid training for our

Warriors. We must continue to synthesize the tactical

and medical lessons from the present conflicts to guide

our training. It is the duty of the Army Medical

Should We Teach Every Soldier How to Start Intravenous Fluids?
January – March 2009 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

Department and military health care providers to

develop best practices of battlefield care and advise

our combat commanders how to implement them.

Together we can save lives on the battlefield and

accomplish the Army mission.

REFERENCES

1. Glasch MA. IV injections added to BCT

requirements. US Army Training & Doctrine

Command News Service. September 14, 2007.

Available at: http://www.tradoc.army.mil/pao/

TNSarchives/September%2007/091407-1.html.

2. Field Manual 4-02: Force Health Protection in a

Global Environment. Washington, DC: US Dept of

the Army; 13 February 2003: Appendix C.

3. Butler F. Tactical combat casualty care: combining

good medicine with good tactics. J Trauma. 2003;54

(suppl):S2-S3.

4. Mabry RL, McManus JG. Prehospital advances in the

management of severe penetrating trauma. Crit Care

Med. 2008;36(7)(suppl):S258-S266.

5. Bellamy RF. The causes of death in conventional

land warfare: implications for combat casualty care

research. Mil Med. 1984;149(2):55-62.

6. Cuadrado D, Arthurs Z, Sebesta J, et al. Cause of

death analysis at the 31st Combat Support Hospital

during Operation Iraqi Freedom. Paper presented at:

28th Annual Gary P. Wratten Army Surgical

Symposium; May 2006; Walter Reed Army Institute

of Research; Silver Spring, Maryland.

7. Mabry RL. Tourniquet use on the battlefield. Mil

Med. 2006;171:352-356.

8. Little R. Modern combat lacking in old medical

supply. Baltimore Sun. March 6, 2005.

9. Beekley A, Sebesta J, Blackbourne L, et al.

Prehospital tourniquet use in Operation Iraqi

Freedom: effect on hemorrhage control and

outcomes. Presented at the 36th Annual Scientific

Meeting of the Western Trauma Association. Big

Sky, Montana. March 2006.

10. McPherson JJ, Feigin DS, Bellamy RF. Prevalence of

tension pneumothorax in fatally wounded combat

casualties. J Trauma. 2006;60:573-578.

11. Beekley AC, Starnes BW, Sebesta JA. Lessons

learned from modern military surgery. Surg Clin

North Am. 2007;87(1):157-184.

12. Bickell W, Wall M, Pepe P, et al. Immediate versus

delayed fluid resuscitation for hypotensive patients

with penetrating torso injuries. New Engl J Med.

1994;331(17):1105-1109.

13. Dutton R, Mackenzie C, Scalea T. Hypotensive

resuscitation during active hemorrhage: impact on inhospital mortality. J Trauma. 2002;52(6):1141-1146.

14. Holcomb J. Fluid resuscitation in modern combat

casualty care: lessons learned from Somalia. J

Trauma. 2003;54(suppl 5):S46-S51.

15. Champion H. Combat fluid resuscitation:

introduction and overview of conferences. J Trauma.

2003;54(suppl 5):S7-S12.

16. Butler F, Hagmann J, Richards D. Tactical

management of urban warfare casualties in special

operations. Mil Med. 2000;165(suppl 4):1-48.

17. Krausz M. Fluid resuscitation strategies in the Israeli

army. J Trauma. 2003;54(suppl 5):S39-S42.

18. Rhee P, Koustova E, Alam H. Searching for the

optimal resuscitation method: recommendations for

the initial fluid resuscitation of combat casualties. J

Trauma. 2003;54(suppl 5):S52-S62.

19. National Highway Traffic Safety Administration.

Contents of 1998 emergency medical technicianintermediate: national standard curriculum. Available

at: http://www.nhtsa.dot.gov/people/injury/ems/

EMT-I/index.html. Accessed February 26, 2009.

20. Subcourse IS0873, Combat Lifesaver Course:

Instructor Guide. B ed. Newport News, VA: US

Army Institute of Professional Development; 2006.

21. Lewis F. Prehospital intravenous fluid therapy:

physiologic computer modeling. J Trauma. 1986;26

(9):804-811.

22. Butler FK, Holcomb JB, Giebner SD, McSwain NE,

Bagian D. Tactical combat casualty care 2007:

evolving concepts and battlefield experience. Mil

Med. 2007;172(suppl 1):S1-S19.

23. Bregenzer T, Conen D, Sakmann P, Widmer A. Is

routine replacement of peripheral intravenous

catheters necessary?. Arch Int Med. 1998;158:151-

156.

24. Levine R, Spaite D, Valenzuela T, Criss E, Wright A,

Meislin H. Comparison of clinically significant

infection rates among prehospital-versus in-hospitalinitiated IV lines. Ann Emerg Med. 1995;25:502-506.

25. Elliot T, Faroqui M. Infections and intravascular

devices. Br J Hosp Med. 1992;48:496-503.

AUTHORS

MAJ Mabry is Medical Director for Academics, Dept

of Combat Medic Training, AMEDD Center & School,

Fort Sam Houston, Texas.

MAJ Cuenca is Staff Emergency Physician, Dept of

Emergency Medicine, Brooke Army Medical Center,

Fort Sam Houston, Texas.
76 www.cs.amedd.army.mil/references_publications.aspx

The Influence of Sex, Height, and Weight on Trunk Muscle Thickness and Endurance

(NCT00373009)

Deydre S. Teyhen* John D. Childs* Nicole M. Hall*

Sonrie C. Gervacio* Joseph A. Lopez* Jason R. Mitchler*

Alison C. Wright†Jessica L. Dugan†Steven Z. George‡

Purpose/Hypothesis: Trunk muscle endurance may have an important role in the prevention and treatment of low back

pain (LBP). Direct assessment of trunk muscle function is not feasible. Therefore, muscle morphometry has been used as

an indirect measure. The purpose was to describe how sex, height, weight, and body mass index (BMI) influence trunk

muscle thickness and endurance times and to provide reference data for trunk morphometry in Soldiers.

Subjects: Soldiers (144 male, 46 female, 21.6 ± 4.0 years; 24.7 ± 2.9 kg/m2) attending combat medic training without a

history of LBP were enrolled.

Materials/Methods: Ultrasound images were obtained bilaterally at rest for the following trunk muscles: rectus

abdominis, transversus abdominis (TrA), internal oblique, and external oblique, and lumbar multifidis at L4-L5. The

following 4 endurance tests were assessed: supine flexor endurance test, prone extensor endurance test, and right and left

horizontal side support. Independent t-tests were performed to determine if muscle thickness, muscle symmetry, or

endurance times differed based on sex. Pearson product moment correlations were performed to determine the

associations between height, weight, and BMI with muscle thickness values. Sex and weight were included in regression

analysis to determine their contribution to the variance in trunk muscle thickness. Finally, sex, weight, and muscle

thickness values were included in a regression analysis to determine their contribution to the variance in endurance times.

Results: Muscle thickness was greater in males than females (p<0.006). However, the TrA accounted for 10% of total

abdominal muscle thickness regardless of sex. Muscle symmetry ranged from 6.6%-19.8% but did not differ based on sex

(p>0.34). Asymmetry was > 12% for the lateral abdominal muscles. Weight had a stronger correlation (r = 0.28 to 0.54)

to muscle thickness as compared with height and BMI (p<0.001). Weight and sex were able to account for 23-30% of the

variance in muscle thickness values while they only accounted for 6% of the variance in endurance test times. Males were

able to hold the 4 endurance test postures about a minute longer than females (p<0.002). However, there was no

difference in trunk extensor endurance time between the sexes (p>0.20). Relationship between endurance time with sex,

height, BMI, and muscle thickness were low (r<0.20).

Abstracts from the US Army-Baylor Doctoral

Program in Physical Therapy

The following research abstracts were presented on June 6, 2008, as part of US Army-Baylor University Doctoral

Program in Physical Therapy Research Day at Fort Sam Houston, Texas. The research abstracts were prepared as part of a

capstone event for the doctoral student class of 2009 that highlights their involvement in faculty directed research.

The research projects support the mission of the Neuromusculoskeletal Injury Prevention and Rehabilitation Research

Program (NIPRRP):

Promote Warrior readiness and human performance through systematic research and

the advancement of evidence-based practice related to neuromusculoskeletal conditions.

The NIPRRP focuses on optimal prevention, diagnostic, and intervention strategies associated with neuromusculoskeletal

conditions. NIPRRP accomplishes this mission by integrating the results of clinical and applied research to help achieve

the ultimate goal of minimizing disability and maximizing performance for beneficiaries of the military healthcare system

and the overall population. Target populations include healthy individuals and patients with a broad range of

neuromusculoskeletal conditions such as extremity overuse injuries, low back and neck pain, and neuropathic conditions.

*US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas

†TRUE Research Foundation, San Antonio, Texas

‡Brooks Center for Rehabilitation Studies, Department of Physical Therapy, University of Florida, Gainesville, Florida
January – March 2009 77

Conclusion: Muscle thickness and symmetry values were consistent with findings of prior researchers. Sex and weight

were significantly associated with muscle thickness, thus their possible confounding effects should be examined and their

potential role as covariates considered in future research. Sex, height, weight, BMI, and muscle thickness values were

poorly related to endurance hold times.

Military/Clinical Relevance: Asymmetry of muscle thickness values was found in individuals without a history of LBP;

its use as a clinical indicator or predictor for LBP requires further inquiry. This study also provides normative data for

trunk muscle size and symmetry, which could be used for comparison studies in a similar population with LBP.

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program

Acknowledgement: The research reported in this abstract was supported by a grant from the DoD Peer Reviewed Medical

Research Program #W81XWH-06-1-0564.

The Effects of Traditional Sit-Up Training Versus Core Stabilization Exercises on Sit-Up

Performance in US Army Soldiers: A Cluster Randomized Trial (NCT00373009)

John D. Childs* Steven Z. George† Alison C. Wright‡Jessie L. Dugan‡

Timothy Benedict* Andrew Fortenberry* Jamie Bush* Janice Preston*

Rene McQueen* Deydre S. Teyhen*

Purpose/Hypothesis: Despite the longstanding tradition of performing sit-ups in the US Army, it has been postulated that

this exercise increases lumbar spine loading, potentially increasing the risk of injury and development of low back pain

(LBP). To address these concerns, health professionals commonly recommend “core stabilization” exercises, based on

evidence it improves abdominal and trunk muscle strength and performance without excessive spine loading and may

decrease the incidence of LBP. However, core stabilization exercise programs (CSEP) have not been widely adopted in

the US Army because of the perceived deleterious impact on sit-up performance on the Army Physical Fitness Test

(APFT). Therefore, the purpose of this study was to determine whether performing CSEP in lieu of traditional sit-ups has

detrimental effects on APFT sit-up and push-up performance and pass rates.

Subjects: Participants included healthy Soldiers between 18-35 years of age participating in Advanced Individual

Training (N=2616). Soldiers with a previous history of LBP or other serious condition that precluded participation in

physical training were excluded.

Materials/Methods: Companies of Soldiers were cluster randomized to receive traditional exercise program (TEP) or

CSEP. TEP consisted of exercises that target the rectus abdominus, oblique abdominals, and hip flexor musculature.

CSEP was comprised of exercises that target the transverus abdominus and multifidi musculature. Soldiers completed

their exercise program during unit physical training 4 times per week for 12 weeks. Performance on the AFPT was

assessed at baseline and 12 weeks. Descriptive statistics were calculated to summarize the data. Independent variables

were Group, Quartile, and Time. Dependent measures were scores and pass rates for sit-up, push-up, and overall APFT. A

2×4×2 repeated-measures ANOVA with pairwise comparisons using the Bonferroni inequality was performed to examine

differences in the overall and sit-up scores. Differences in pass rates were assessed with a chi-square.

Results: The mean age of subjects was 21.9 ± 4.3 years of age. Both groups performed sit-ups outside of unit physical

training at equal rates (TEP: 69.5% and CSEP: 65%, P=0.067). Both groups demonstrated significant improvements in

their overall and sit-up score and pass rates over time (P<0.05). There were no significant between group differences in

overall scores (P=0.142) or sit-up performance (P=0.543) on the APFT after 12 weeks of training. CSEP and TEP

improved their sit-up pass rates by 5.6% and 3.9%, respectively (P<0.05). The NNT for CSEP was 56.

Conclusion: CSEP did not have a detrimental impact on APFT scores or pass rates. There was actually a small but

significantly greater increase in sit-up pass rate in the CSEP (5.6%) versus the TEP (3.9%). Therefore, incorporating

CSEP into Army physical training does not increase the risk of suboptimal performance on the APFT.

Military/Clinical Relevance: A company with 400 Soldiers performing CSEP would actually result in 7 additional

Soldiers progressing from a failure to a pass on the sit-up component of the APFT compared to TEP.

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program

Acknowledgement: The research reported in this abstract was supported by a grant from the DoD Peer Reviewed Medical

Research Program #W81XWH-06-1-0564.

*US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas

†Brooks Center for Rehabilitation Studies, Department of Physical Therapy, University of Florida, Gainesville, Florida

‡TRUE Research Foundation, San Antonio, Texas
78 www.cs.amedd.army.mil/references_publications.aspx

Median and Ulnar Neuropathies in US Army Dental Assistants (MOS* 68e)

Pre- And Posttraining as Preventive Dental Specialists (MOS 68e-X2)

David G. Greathouse† Tiffany L. Mason† Carla R. Carrillo† Chelsea L. Jordan†

Bryan B. Pickens† Thomas G. Sutlive†Scott W. Shaffer†Josef H. Moore†

Purpose/Hypothesis: Dentists and dental hygienists have been reported as having a high prevalence of upper-extremity

musculoskeletal disorders, including carpal tunnel syndrome (CTS). Unfortunately, previous research has not involved

dental assistants or the impact of dental training. Therefore, the purpose of this study was to determine the presence of

median and ulnar neuropathies in US Army dental assistants pre- and post-training as preventive dental specialists.

Subjects: Forty-two US Army dental assistants, enrolled in the preventive dental specialist course, volunteered to

participate in the study. Thirty-five preventive dental specialist students (mean age 23.3 ± 5.8 yrs; 11 male, 24 female)

completed both the pre- and posttraining data collections.

Materials/Methods: Subjects were evaluated during the first and last weeks of their 12-week 68E-X2 course. Subjects

completed a history form, were interviewed, and underwent a physical examination. Nerve conduction status of the

median and ulnar nerves of both upper extremities were obtained by performing motor, sensory, and F-wave nerve

conduction studies (NCS). Descriptive statistics for subject demographics and nerve conduction study variables and Chi

square analysis for NCS comparison studies were calculated.

Results: Twelve of the 35 subjects (34%) presented with abnormal electrophysiologic values suggestive of median

mononeuropathy at or distal to the wrist. Eight subjects had findings pre- and posttraining, 3 subjects had findings pretraining only, and one subject had findings post-training only. Four of these 12 subjects had clinical examination findings

(special tests) consistent with the electrophysiological findings. The ulnar nerve electrophysiologic assessment was

normal in all subjects sampled. Additionally, there was no statistically significant shift in the prevalence of median

neuropathies following the 12-week training program (Chi-square, 0.280; p = 0.60).

Conclusions: The prevalence of median mononeuropathies in this sample of US Army dental assistants closely mirrors

the prevalence reported for other dental professionals. This study demonstrates that for this sample, the 12-week training

program did not appear to affect the electrophysiologic status of the median or ulnar nerves.

Military/Clinical Relevance: A high prevalence of musculoskeletal disorders including median neuropathy at or distal to

the wrist or carpal tunnel syndrome have been reported in dental personnel including dentists and dental hygienists. The

presence of median neuropathy at or distal to the wrist is also prevalent in this sample of dental assistants; however, the

12-week 68E-X2 training program did not appear to affect the electrophysiologic status of the median or ulnar nerves.

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program

*Military occupational specialty

†US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas

Dynamic Plantar Pressure Parameters Predictive Of Static Foot Posture

Deydre S. Teyhen‡ Brian E. Stoltenberg‡ Timothy G. Eckard‡Peter M. Doyle‡

David M. Boland‡Jess J. Feldtmann‡Joseph M. Molloy‡Stephen L Goffar‡

Douglas S. Christie‡ Thomas McPoil§

Purpose/Hypothesis: The Foot Posture Index (FPI-6) is a static assessment of foot posture based upon 6 observations.

Extreme FPI-6 scores have been associated with increased risk for overuse injury. However limited knowledge exists

about the relationship between static FPI-6 scores and dynamic plantar pressure distributions during gait. This study was

conducted to explore which dynamic plantar pressure measurements are associated with FPI-6 classifications. A

secondary purpose was to describe normative data regarding FPI-6 scores.

Subjects: Participants were (n = 1,000, 566 males, 434 females) predominately active adults (30.6 ± 8.0 years, 26.2 ± 3.7

kg/m2) who ran 3.1 ± 1.4 days/week.

Abstracts from the US Army-Baylor Doctoral Program in Physical Therapy
January – March 2009 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

Materials/Methods: FPI-6 (scored from -12 to +12) was assessed during bilateral stance and was categorized based on

established cut-off values. Additionally, subjects walked across a capacitance-based pressure platform, with an average of

5 steps representing the dynamic pressure pattern. Descriptive statistics relating to FPI-6 total and subscale scores were

calculated. The plantar pressure system sampled a total of 246 variables describing the dynamic foot. A significant

Pearson product moment correlation (r > 0.2 and p <0.01) was used to narrow the number of variables of interest. A

hierarchical stepwise backwards regression analysis was then performed to determine the most parsimonious set of

variables associated with total FPI-6 score.

Results: The mean FPI-6 score was 3.4 ± 2.9 (range: -6.0 to 11.0); resulting in the following classifications: 13 highly

pronated, 220 pronated, 669 normal, 93 supinated, and 5 highly supinated feet. Very few subjects (n = 31) scored a -2 on

any of the FPI-6 subscales. Pearson product moment correlations yielded 45 variables with an r-value > 0.2. Regression

analysis resulted in 15 variables of interest. Seven variables were removed from the model based on multicollinearity. The

resulting 8 variable model (R = 0.59, R2 = 0.35) had an average residual between the predicted and measured FPI-6

scores of 0.0 ± 2.3 on the 25 point scale.

Conclusions: The range of FPI-6 scores was limited, with only 2% of subjects being classified as having an extreme foot

posture. Mathematically based cut-off values based (i.e., > 1.5 SD from mean to define highly pronated and supinated)

would result in a more normal distribution of scores (74 highly pronated, 158 pronated, 527 normal, 143 supinated, and

98 highly supinated). A multivariate model generated using dynamic plantar foot parameters was able to predict total FPI6 scores. The difference between measured and predicted FPI-6 values was just slightly larger than the interrater standard

error of the measurement (1.7 points).

Military/Clinical Relevance: The multivariate model predictive of FPI-6 scores consisted of variables that appear to be

biomechanically plausible and informs the association between static foot posture and foot posture during gait. Future

researchers should assess the ability of FPI-6 scores and the newly proposed cut-off values to identify individuals at risk

for lower extremity overuse injuries.

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program

Acknowledgement: The research reported in this abstract was funded through National Defense Center for Energy and

Environment (Office of the Assistant Secretary of the Army (Installations and Environment)) under contract W74V8H04-D-0005 Task 0427.

‡US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas

§Department of Physical Therapy, Northern Arizona University, Flagstaff, Arizona

Dynamic Plantar Pressure Parameters Predictive of Static Arch Height Index

Deydre S. Teyhen** Brian E. Stoltenberg** Keith M. Collinsworth** Crystal L. Giesel**

Drew G. Williams** Cyrus H. Kardouni** Joseph M. Molloy** Stephen L Goffar**

Douglas S. Christie** Thomas McPoil††

Purpose/Hypothesis: Although extreme values of arch height have been associated with increased risk for overuse

injury, knowledge is limited regarding the association between arch height and plantar pressure distributions during gait.

The purpose of this study was to determine if a multivariate model from plantar pressure parameters during gait could be

used to predict dorsal arch height and arch height index (AHI).

Subjects: Participants (n=1,000; 566 male, 434 female) were predominately active adults (30.6 ± 8.0 years, 26.2 ± 3.7 kg/

m

2

) who ran 3.1 ± 1.4 days/week.

Materials/Methods: Dorsal arch height at 50% foot length divided by foot (toe-to-heel) length was used to calculate AHI

in bilateral stance. Dynamic plantar pressure measurements were obtained using a capacitance based pressure platform.

The plantar pressure system sampled a total of 246 variables describing the average of 5 steps from the right foot during

gait. A significant Pearson product moment correlation (r > 0.3 and p <0.01) was used to narrow the number of variables

of interest. A hierarchical stepwise backwards regression analysis was then performed to determine the most

parsimonious set of variables associated with arch height. The plantar pressure parameters predictive of arch height and

**US Army-Baylor Doctoral Program in Physical Therapy, San Antonio, Texas

††Department of Physical Therapy, Northern Arizona University, Flagstaff, Arizona
80 www.cs.amedd.army.mil/references_publications.aspx

foot length were used to define a dynamic AHI. Correlation and residual analysis were performed to assess the association

between statically and dynamically determined arch height indices.

Results: Pearson product moment correlations (r > 0.3) yielded 39 variables. The regression analysis resulted in 19

variables of interest; 14 were removed from the model based on multicollinearity. The resulting 5-variable model (F =

296.6; P < 0.001) was able to predict static arch height (R = 0.77 [95% CI = 0.75 to 0.80] ), with a mean residual of 0.00 ±

0.39 cm. Variables in the final model indicated an association between a higher arch and an increase in area between the

foot axis and gait line, an increase in forefoot width, larger force-time integral (impulse) values for the lateral hindfoot

and 1st metatarsal region, and greater mean pressure in the lateral forefoot. The correlation between the static and

dynamically determined arch height indices was r = 0.60 (95% CI = 0.53, 0.63), with a mean residual of 0.000 ± 0.015.

Conclusions: The results of this study provide a biomechanically plausible multivariate model predictive of arch height

based on plantar pressure parameters and inform the association between static arch height and dynamic foot posture.

Specifically, plantar pressure parameters were useful in predicting static arch height, foot length, and AHI based solely on

these kinetic and geometric measures of the foot obtained during gait.

Military/Clinical Relevance: Future researchers should assess the association between these variables and lower extremity

overuse injuries. The multivariate model developed in this study helps to provide the clinician with a topographical map

of the foot which may be useful in designing orthoses that account for both the shape and plantar pressure parameters of

the foot.

Supports: Neuromusculoskeletal Injury Prevention & Rehabilitation Research Program

Acknowledgement: The research reported in this abstract was funded through National Defense Center for Energy and

Environment (Office of the Assistant Secretary of the Army (Installations and Environment)) under contract W74V8H04-D-0005 Task 0427.

Dynamic Plantar Pressure Parameters Predictive Of Static Foot Posture (continued)

Abstracts from the US Army-Baylor Doctoral Program in Physical Therapy
SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international

military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps,

and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewed

print medium to encourage dialogue concerning health care issues and initiatives.

REVIEW POLICY

All manuscripts will be reviewed by the AMEDD Journal’s Editorial Review Board and, if required, forwarded to the appropriate

subject matter expert for further review and assessment.

IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST

1. Related to individual authors’ commitments: Each author is responsible for the full disclosure of all financial and personal

relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state

explicitly whether potential conflicts do or do not exist. Authors should do so in the manuscript on a conflict-of-interest

notification section on the title page, providing additional detail, if necessary, in a cover letter that accompanies the

manuscript.

2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this

assistance, if any.

3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done

so in the manuscript.

4. Related to project support: Authors should describe the role of the study sponsor, if any, in study design; collection, analysis,

and interpretation of data; writing the report; and the decision to submit the report for publication. If the supporting source

had no such involvement, the authors should so state.

PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH

When reporting experiments on human subjects, authors must indicate whether the procedures followed were in accordance with

the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki

Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki

Declaration, the authors must explain the rationale for their approach and demonstrate that the institutional review body

explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether the

institutional and national guide for the care and use of laboratory animals was followed.

GUIDELINES FOR MANUSCRIPT SUBMISSIONS

1. Articles should be submitted in digital format, preferably an MS Word document, either as an email attachment (with

illustrations, etc), or by mail on CD or floppy disk accompanied by one printed copy of the manuscript. Ideally, a manuscript

should be no longer than 24 double-spaced pages. However, exceptions will always be considered on a case-by-case basis. In

general, 4 double-spaced MS Word pages produce a single page of 2 column text in the AMEDD Journal production format.

2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles

should conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible.

Inclusion of a list of article acronyms and abbreviations can be very helpful in the review process and is strongly encouraged.

3. A complete list of references cited in the article must be provided with the manuscript. The following is a synopsis of the

American Medical Association reference format:

 Reference citations of published articles must include the authors’ surnames and initials, article title, publication title,

year of publication, volume, and page numbers.

 Reference citations of books must include the authors’ surnames and initials, book title, volume and/or edition if

appropriate, place of publication, publisher, year of copyright, and specific page numbers if cited.

 Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying

information as possible (location, dates, presenters, sponsors, titles).

4. Either color or black and white photographs may be submitted with the manuscript. Color produces the best print reproduction

quality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, GIF, BMP) and MS Word

photo files are preferred. Prints of photographs are acceptable. Please do not send photos embedded in PowerPoint. Images

submitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of each

photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and

photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript.

5. The authors’ names, ranks or academic/certification credentials, titles or positions, current unit of assignment, and contact

information must be included on the title page of the manuscript.

6. Submit manuscripts to:

US ARMY MEDICAL DEPARTMENT CENTER & SCHOOL

ATTN: MCCS HSA STE 135

1750 GREELEY ROAD

FORT SAM HOUSTON, TX 78234-5078

DSN 471-6301

Comm 210-221-6301

Fax: DSN 471-2226 Comm 210-221-2226

Email: amedd.journal@amedd.army.mil