preventive medicine:

the science and practice of HEALTH protection

April – June 2008

Perspective 1

MG Russell J. Czerw

Chemical Defense Against Blood-Feeding Arthropods 4

by Disruption of Biting Behavior

COL Mustapha Debboun, MS, USA; Jerome A. Klun, PhD

The Deployed Warfighter Protection Research Program: 9

Finding New Methods to Vanquish Old Foes

CAPT Stanton E. Cope, MSC, USN; COL (Ret) Daniel A. Strickman, MS, USA; Graham B. White, PhD

Support of Far-Forward Disease Surveillance Operations with Deployable, 21

Real-Time Vector-Borne Disease Agent Analytic Capability

Col James A. Swaby, BSC, USAF; James C. McAvin

Level III Preventive Medicine in a Counterinsurgency Environment 25

MAJ Derek J. Licina, MS, USA

Preparing the Force for the Chemical, Biological, Radiological, and 36

High Yield Explosives Battlefield; Today and Tomorrow

LTC Gary Matcek, MS, USA; Scott Crail, MS; SFC Courtney Moore, USA; James Bernardo

The Army Preventive Medicine Specialist in the 40

Medical Education and Training Campus Era

LTC Dennis B. Kilian, MS, USA; SFC Roye L. Patton, USA; HMCS William Adams, USN

Malaria Risk Assessment for the Republic of Korea 46

Based on Models of Mosquito Distribution

Desmond H. Foley, PhD; et al

The US Air Force Aerial Spray Unit: A History of 54

Large Area Disease Vector Control Operations, WWII Through Katrina

Maj Mark Breidenbaugh, BSC, USAFR; Maj Karl Haagsma, BSC, USAFR

Evolution of the Army Hearing Program 62

MAJ Scott McIlwain, MS, USA; et al

Perspectives of Malaria and Japanese Encephalitis in the Republic of Korea 67

LTC William J. Sames, MS, USA; Heung-Chul Kim, PhD; COL (Ret) Terry A. Klein, MS, USA

Health Implications of Occupational Environmental Health Sampling 74

Coleen Weese, MD, MPH
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

April – June 2008 The Army Medical Department Center & School PB 8-08-4/5/6

0809205

GEORGE W. CASEY, JR

General, United States Army

Chief of Staff

DISTRIBUTION: Special

Administrative Assistant to the

Secretary of the Army

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JOYCE E. MORROW

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April – June 2008 1

The Department of Defense defines the term force

multiplier as

A capability that, when added to and employed by a

combat force, significantly increases the combat

potential of that force and thus enhances the probability

of successful mission accomplishment.1

Military planners, strategists, and analysts generally

use the term as related to factors such as technology,

intelligence, training, tactics, terrain, etc. However,

over the last century, the science and practice of

preventive medicine in the military has itself become

an increasingly significant force multiplier.

Nonetheless, the contributions of preventive medicine

are often not recognized as such following successful

military campaigns. On the other hand, the absence of

effective measures are immediately apparent, for all

the wrong reasons. In early 1943, following the

extremely difficult and costly opening campaigns

against the Japanese in Paupau New Guinea, General

MacArthur was told that 72% of the combined Allied

force was sick, 60% with malaria. His brief response

clearly captures the indisputable value of preventive

medicine as a force multiplier:

Doctor, this will be a long war if for every division I

have facing the enemy, I must count on a second

division in hospital with malaria and a third division

convalescing from this debilitating disease.2

General MacArthur’s remarks were indicative of the

increasing awareness among top level commanders of

preventive medicine’s vital role in combat operations.

Over time, that evolving realization has resulted in

top-down emphasis, policies, and regulations to

institutionalize preventive medicine as an integral part

of the planning and execution of training and

operational deployments.3

Fortunately, increasing awareness of preventive

medicine’s role in the improvement of human health

has not been limited to the military. Governments at all

levels have established policies and regulatory

frameworks, committed resources, and conducted

public awareness programs targeted at the improvement of the overall health of their populations.

As with most areas of medical science, the practice of

preventive medicine transcends the military-civilian

boundary. In this regard, military medicine is very

fortunate to have been both beneficiary of and

contributor to its progress over the years. This issue of

the AMEDD Journal focuses on the science and

practice of preventive medicine from a military

perspective, while featuring articles that reflect the

mutual benefits to both sides from the overlap of

knowledge, practices, and purpose.

COL Mustapha Debboun and Dr Jerome Klun open

this issue with a stimulating article exploring the

background and current science of synthetic organic

chemical arthropod repellents. As related in their

article, the world’s first truly effective insect repellent

was developed in a collaborative effort of the US

Army and the Department of Agriculture, which began

during World War II. They detail the chemistry of

what are currently the 3 most effective compounds and

the experiments that explore the mechanism of their

repellency. This research is a prime example of the

type of partnerships between military and civilian that

are so effective in the science of preventive medicine.

The importance of such collaboration to the military is

demonstrated in the next article. CAPT Stanton Cope,

USN, and his coauthors describe the Deployed

Warfighter Protection research program (DWFP), an

innovative, forward-thinking DoD effort to tap into

nonmilitary talent and resources in the search for new

ways of protecting our deployed personnel from

Perspective

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

vector-borne diseases. The DWFP provides funding to

both government and nongovernment research projects

which are exploring new and better ways of troop

protection. Although the DWFP is a recent initiative,

the results have been an ever-increasing level of

knowledge in the sciences involved, with attendant

improved sophistication in techniques and procedures,

as well as a number of products created specifically for

dealing with the insect threat.

Knowledge of the specific disease threats in a

deployment area is critical in determining the type of

preventive medicine measures which are required for

force protection. Current data may or may not be

available, or accurate, and obtaining such information

has always been a time-consuming, multifaceted

undertaking. Col James Swaby, USAF, and James

McAvin have been involved in the development of a

system that will allow forward deployed units to assess

the local threat of vector-borne diseases in real-time,

without dependence on far-away laboratories. Their

article details the Vector Surveillance Analytic

System, a vitally important advancement in our arsenal

of weapons to protect the health of our Warriors.

Since the end of combat in Korea in 1953, the

character of military conflict has evolved from the

classic model of conventional warfare between armies

into operations against shadowy, low-tech, loosely

organized insurgencies. MAJ Derek Licina has

contributed a profound, well-researched article that

spotlights how counterinsurgency operations are rarely

won with overwhelming firepower alone, but with

other operations targeting the conditions which

provide the base of support for those insurgents.

Preventive medicine can and should be a major

component of such operations. This important article is

developed using the history of such conflicts combined

with extensive experience with current counterinsurgency operations in the middle east. MAJ Licina

proposes thoughtful changes in doctrine, organization,

and training of Army preventive medicine designed to

significantly improve its capability to directly

contribute to long-term counterinsurgency operations.

The principles and science of preventive medicine may

indeed be the “secret weapon” that will effect a

favorable shift in both the physical and ideological

environments of modern military conflict.

An ironic reality of the shift in the character of military

operations to the fluid, ill-defined, counterinsurgency

environment is the increased potential for the use of

unconventional weapons, at almost any time or place.

Insurgents have no political, moral, or ethical

limitations to their actions, and are not concerned

about repercussions. Their lack of sophistication

increases the potential danger that chemical,

biological, radiological, or high yield explosives

(CBRNE) could be used in almost any scenario,

including accidentally during transport or storage.

LTC Gary Matcek and his team from the CBRNE

Sciences Branch have contributed an article describing

both the training of medical personnel to cope with the

evolving threats, and the development of new tools

and protocols to enhance their capabilities. The danger

represented by CBRNE weapons is not limited to the

battlefield or military installation. The importance of

this component of preventive health science cannot be

overemphasized.

One of the many changes stemming from the latest

round of the Base Closure and Realignment

Committee activity is the consolidation of a significant

portion of Army, Navy, and Air Force medical enlisted

training at Fort Sam Houston. The Medical Education

and Training Campus is a result of that initiative. LTC

Dennis Kilian and his coauthors describe in detail the

meticulous collaborative process that resulted in the

plan for consolidated training of enlisted preventive

medicine personnel. Their article provides insight into

the plans for both the academic syllabus changes and

the personnel and physical infrastructure requirements

necessary to make the concept a reality.

Even after years of intensive research and

countermeasures, malaria remains one of the most

persistent, and deadly, vector-borne health threats in

the world today. Assessment of the risk of malaria in a

given geographic region is the first step in planning to

address its threat. Since malaria is transmitted solely

by several species of the Anopheles mosquito, identification of the actual and potential distribution of those

species in a geographic area could be a valuable tool in

the development of the risk assessment. Dr Desmond

Foley and his coauthors present a new approach they

developed to model the distribution of malaria vectors,

using the US military installations on the Korean

peninsula as the areas of interest. Their detailed and

clearly presented article demonstrates the

immeasurable value of the symbiotic relationship of

military and civilian resources and talent in the war

against vector-borne disease. The increase in the

number and capabilities of data-gathering sources,

Perspective
April – June 2008 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

combined with increasingly sophisticated analysis and

modeling techniques are powerful weapons in the

hands of dedicated professionals such as Dr Foley and

his team. Innovative work such as this will continue to

evolve, to the benefit of everyone, everywhere.

In 1918, an airplane was used to distribute insecticide

for the first time.4Since then, aerial application of

pesticides has been an invaluable tool for both

agriculture and preventive medicine. USAFR Maj

Mark Breidenbaugh and Maj Karl Haagsma have

written an excellent article about one of today’s US

military aerial spray capabilities, the USAF Aerial

Spray Unit (AFASU). Their article traces the long

history of this versatile unit, and describes its multiple

roles in responding to both military and civilian

requirements throughout the United States and

overseas. The article focuses on large area insect

problems, especially mosquitoes, which become very

serious in the aftermath of hurricanes. The AFASU’s

response to Hurricane Katrina in Louisiana is detailed

as an illustration of the extensive planning and close

cooperation between the military and civilian

preventive medicine authorities that is required to

ensure a timely and effective response. The article

provides an informative overview of this unique

capability, and the high level of professionalism of

those who perform the vitally important missions.

Hearing is something that most of us take for granted,

yet it is one of the most important, and most

vulnerable, of our senses in a survival situation,

including combat. Not surprisingly, some loss of

hearing is one of the most common conditions among

military veterans. Extremely loud noise is an

unavoidable part of military operations, but hearing

loss in not inevitable. In their informative article, MAJ

Scott McIlwain and his coauthors provide an overview

of the conditions that contribute to hearing loss, and

statistics that demonstrate the surprising extent of that

loss among military members today. They detail the

various research, techniques, and equipment used to

address this hazard, which has resulted in the Army

Hearing Program, the current structure designed to

provide effective loss prevention services at all

locations, including forward deployed areas. This

article contains important information which should be

of interest to everyone, military or civilian.

Despite all of our efforts since the Korean War,

malaria and Japanese encephalitis remain valid threats

in Korea. LTC William Sames and his coauthors have

contributed an important article describing the

situation faced by our Warriors and their families, as

well as the Korean population as a whole, and the

ongoing efforts to control the threat posed by the two

diseases. The article is packed with information about

the cycles of infection and transmission for each

disease, the hosts that harbor the pathogens, and the

cooperative relationships between the US military

preventive medicine specialists and the various Korean

agencies in actions to address these threats. As clearly

illustrated throughout the articles in this issue, there

are no boundaries to preventive medicine’s importance

to health, whether civilian, military, or national.

At first look, evaluation of the health of Soldiers

returning from deployment would seem

straightforward—a physical examination focused on

injuries and whatever illnesses the Soldier may have

incurred during the deployment period. However, the

extent of follow-on illnesses that are a result of

deployments has been recognized only relatively

recently. Dr Colleen Weese’s article is an eye-opening

look at the complexities involved in quantifying the

problem of environmental hazards, and the measures

implemented to address those hazards for our

deploying Warriors. The results include a program that

collects and catalogues worldwide environmental data

for area assessments, a system that maintains the

exposure history of military personnel throughout their

lifetime, and formalized requirements for the sampling

and evaluation of air, water, and soil from the

deployment area. Most importantly, significant

exposures must now be documented in the individual

medical record. Dr Weese’s article demonstrates the

responsiveness of the military medical system, and the

extent of our efforts to protect the health of our

dedicated Warriors, whether immediate or long-term.

REFERENCES

1. Joint Publication 1-02: DoD Dictionary of Military

and Associated Terms. Washington, DC: Joint Staff,

US Dept of Defense; March 4, 2008. Available at:

http:// www.d tic.mil/do ctrine/jel/ne w_p ubs/

jp1_02.pdf.

2. Coates JB. Communicable Diseases: Malaria.

Washington, DC: US Dept of the Army; 1963.

Preventive Medicine in World War II; vol 6:2.

3. Gates MB. Prevention is the best way to health. Army

Med Dept J. April-June 2006:3-6.

4. http://entweb.clemson.edu/pesticid/history.htm
4 www.cs.amedd.army.mil/references_publications.aspx

In military operations, vector-borne diseases and

associated discomfort caused by biting arthropods can

be largely prevented with proper use of personal

protective measures, particularly arthropod repellents.

When appropriately applied, such repellents are the

first line of defense against a wide range of arthropodborne pathogens and will preserve the fighting strength

of the troops. The bites of arthropods transmit many of

the disease-causing agents that cause our military the

most trouble. These diseases can take Soldiers out of

the action, make them miserably sick, or even kill

them. In addition, the diseases and the arthropods that

transmit them are as much of a threat during routine

field training exercises or humanitarian/disaster

assistance operations as during actual combat.

Arthropod repellents provide military commanders

with a quick and inexpensive measure to protect the

force in any military situation, no matter how quickly

the unit is involved in action. They can be applied

effectively to prevent any arthropod-borne disease,

whether or not surveillance has identified the

pathogen. Arthropod repellents are often the only

means of protection against arthropodborne diseases in combat environments

when vector control measures are not

possible, or when the speed of military

developments prevents the use of

chemoprophylaxis or vaccines. In addition,

commanders will be able to minimize

incidence of any vector-borne disease,

providing a tactical advantage against an

unprotected enemy force which does not

have the benefit of an effective, longlasting arthropod repellent.

The Department of Defense (DoD) Insect

Repellent System is available for use by all

military personnel to prevent arthropodborne pathogens that cause diseases such

as malaria, leishmaniasis, trypanosomiasis,

scrub typhus, West Nile fever, and Lyme

disease. As shown in Figure 1, the repellent system

consists of 3 components: permethrin on uniforms

(and bed nets), deet on exposed skin, and proper wear

of the uniform. When used properly, this system will

prevent disease, pain, and the annoyance caused by

bites of insects such as mosquitoes, sand flies, ticks,

and chiggers. The repellent system is critical to the

Army Medical Regiment’s motto to “Conserve the

Fighting Strength,” and is a mission essential task

contained in Soldier Training Publication 21-1.

1

Further, DoD policy mandates that every Soldier,

Sailor, Airman, and Marine must strictly follow the

guidelines and methods of the repellent system. Details

are found in the Armed Forces Pest Management

Board Technical Guide 36 2and in the US Army

Center for Health Promotion and Preventive Medicine

fact sheet on the DoD Insect Repellent System3and at

the US Army Medical Department Center and School

deployment training portal website.4

DoD operates the Walter Reed Army Institute of

Research and 5 other US overseas laboratories: Armed

Forces Research Institute of Medical Sciences,

Chemical Defense Against Blood-Feeding

Arthropods by Disruption of Biting Behavior

COL Mustapha Debboun, MS, USA

Jerome A. Klun, PhD

Permethrin

on

Uniform

Deet on

Exposed

Skin

Properly

Worn

Uniform

A Basic

Training

Task

DoD Policy

Critical

For Your

Health

Figure 1. The DoD Insect Repellent System
April – June 2008 5

Bangkok, Thailand; US Army Medical Research UnitKenya, Nairobi; Naval Medical Research Center

Detachment, Lima, Peru; Naval Medical

Research Unit-2, Jakarta, Indonesia; and the

Naval Medical Research Unit 3, Cairo,

Egypt. These resources, combined with

collaborations with the US Department of

Agriculture, Agricultural Research Services

and the Australian Army Malaria Institute,

place the US military in an outstanding

position to test and evaluate repellents in

the laboratory and in the field against

vectors of many disease-causing pathogens.

All haematophagous arthropod pests such

as female mosquitoes, sand flies, mites,

black flies, and ticks require a blood meal to

produce eggs and complete their life cycles.

Males do not blood feed. Thus, thankfully,

only half of the population of such

arthropod species are biters and bloodfeeders. The biting activity of females is

complex and they may preferably feed only

on specific hosts such as reptiles or birds. In

some species, the females may have

multiple hosts which often include humans.

It is these arthropod species of bloodfeeders that are simply annoying, or

represent vectors of dangerous pathogenic

diseases that can injure or kill. The diseases

vectored are many and include malaria,

leishmaniasis, dengue, yellow fever, West

Nile fever, Lyme borreliosis, and spotted

fevers. Throughout history, humans have

struggled against the blood-feeding

arthropods, and the struggle continues today

in full force.

Synthetic organic chemicals have proven effective in

interfering with arthropod blood-feeding behavior, and

can offer personal protection against the bites of

nuisance pests and disease vectors by topical

application to skin or clothing.5,6 Several notably

effective synthetic repellent compounds, the structures

of which are shown in Figure 2, are: N,N-diethyl-3-

methylbenzamide (deet) (structure 1), 2-(2-

hydroxyethyl)-1-piperidinecarboxylic acid 1-

methylpropylester (variously known as KBR3023,

Bayrepel, Picaridin or Icaridin) (structure 2), and (1S,

2’S)-methylpiperidinyl-3-cyclohexene-1-carboxamide

(SS220) (structure 3). Each of these repellent

compounds has an interesting developmental history,

and each is known to interfere with arthropod bloodfeeding behavior.

Deet was developed in 1954 as an outgrowth of an

intensive systematic chemical search for synthetic

personal-protection chemicals that began during World

War II with a collaborative effort involving the US

Department of the Army and the Department of

Agriculture (USDA), Bureau of Entomology and Plant

Quarantine.7,8 In the years following its development,

deet became the standard personal protection repellent

product of choice for use by the general public and

military organizations worldwide. The use of deet was

so universal that it became an anthropogenic organic

chemical pollutant in many bodies of surface waters

ranging from the Tama River in Japan and the Rhine

River in Germany, to the waters of the North Sea.9

N

O

CH3

N CH3

O

H

N CH3

H O

N

O

CH3

H H

N

O

CH3

HO N

O

O H

1S, 2'S 1R, 2'S

1S, 2'R 1R, 2'R

1

2

1

3

2

4

5 6

1

2

3 4

5 6

Figure 2. Chemical structure of Deet, KBR3023, and the diastereoisomers of AI3-37220.
6 www.cs.amedd.army.mil/references_publications.aspx

In 1996, the discovery of KBR 3023 was announced,10

and the racemic compound was subsequently

commercialized worldwide by Bayer. This compound

contains 2 asymmetric centers as indicated in Figure 2,

structure 2, and, therefore, the racemic compound is

composed of 4 diastereoisomers. Preliminary work

with the yellow fever mosquito, Aedes aegypti,

indicated that the 1R, 2’S diastereoisomer of KBR

3023 (RS-KBR 3023) was the most effective in

deterring mosquito biting.11 The KBR 3023 efficacy

might be improved by using the most biologically

active form of its 4 stereoisomers. Independent field

and laboratory bioassays with the racemic KBR 3023

generally show that it effectively reduced bites of

mosquitoes, sand flies, noseeums, and ticks, and

effectiveness of the compound was often equivalent to

deet.12-18 In human volunteer laboratory bioassays with

Ae. aegypti, we found that deet and SS220 were

equally effective and more effective, respectively, than

KBR 3023 in suppressing its biting.19 The 3 repellent

compounds were equally effective against Anopheles

stephensi. Internet searches indicate that Lanxess and

S.C. Johnson, respectively, are actively involved in

marketing this compound.*

The racemic 2-methylpiperidinyl-3-cyclohexene-1-

carboxamide was first identified as an insect repellent

by McGovern et al,20 and the USDA assigned the

compound the code number AI3-37220. Like KBR

3023, AI3-37220 contained 2 asymmetric centers, and

achiral synthesis yielded a racemic mixture of 1S, 2'S,

1R, 2’S, 1S, 2’R and 1R, 2’R diastereoisomers (Figure

2, structures 3, 4, 5, and 6). The racemic mixture

proved to be effective against the biting behavior of a

wide variety of blood-feeding arthropods.21-29

A study of the stereoisomers of AI-37220 showed that

the 1S, 2'S stereoisomer (SS220) was the most

effective isomer of the four in reducing bites by Ae.

aegypti,

30 and it is surmised that enhanced repellent

effects can be realized through specific formulation of

this most active stereoisomer. Toxicological tests

indicate that SS220 is biologically pacific and

amenable to dermal application to defend humans

against many blood-feeding arthropods.

Deet, KBR 3023, and SS220 are among the most

effective synthetic repellent compounds for protection

against nuisance and blood-feeding arthropods that

vector human diseases. Despite the widespread

knowledge of the protective qualities of these repellent

compounds,17,19,31 there was, until recently, little

information available on how the compounds

mechanistically affect whole organism behavior and

thereby suppresses the biting. A series of behavioral

tests32 with Ae. aegypti, An. stephensi mosquitoes and

the sand fly, Phlebotomus papatasi in the presence of

deet, SS220, and KBR 3023 topically applied to the

skin of human volunteers showed that the insects were

deterred from feeding on and repelled from surfaces

emanating the compounds. When offered a 12 cm2or

24 cm2area of skin, one half treated with compound

and one half untreated, the insects fed almost

exclusively on untreated skin. The sand flies and

mosquitoes did not at any time physically contact

chemically-treated surfaces. When treated and

untreated skin areas were covered with cloth, insects

landed and bit only through cloth covering untreated

skin. These observations provided evidence that the

chemicals deterred feeding and repelled insects from

treated surfaces primarily as a result of olfactory

sensing. When cloth, one half untreated and the other

half treated with chemical, was placed over untreated

skin, insects only touched and specifically bit through

the untreated cloth. This showed that the activity of the

chemicals does not involve a chemical skin interaction. In the presence of any of the 3 repellent

compounds, no matter how presented to the insects,

overall population biting activity was reduced by about

one-half relative to the controls. The research indicates

that the protection afforded by deet, SS220, and KBR

3023 against the insect feeding upon humans is

mechanistically a combined consequence of feeding

deterrent and repellent effects of the compounds.

The behavioral studies clearly showed that all 3

compounds were perceived by olfactory sensing, and it

was curious that these man-made and structurally

different compounds profoundly influenced the bloodfeeding behavior of Ae. aegypti, An. stephensi, and P.

papatasi in similar ways. Natarajan et al 11 conducted

computer-assisted stereochemical structure-activity

relationship and molecular overlay studies of SS220,

KBR 3023, and deet to show that forms of compounds

possessing the highest levels of repellent and feeding

deterrent activity each have similar three-dimensional

structural motifs. This suggests that the

biomacromolecule(s) responsible for the olfactory

*Websites: http://www.bayrepel.com/bre/en/index.php

http://www.autan.com/nqcontent.cfm?a_id=1

Chemical Defense Against Blood-Feeding Arthropods by Disruption of Biting Behavior
April – June 2008 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

recognition of the compounds in the insects is (are)

specifically sensitive to the active space-matching

qualities of SS220, RS-KBR 3023, and deet. The

development of new behaviorally-active chemical

tools for protection of humans against blood-feeding

disease vectors will ultimately depend upon the extent

to which the fundamental nature of this process is

understood.

REFERENCES

1. Soldier Training Publication 21-1, Soldier’s Manual

of Common Tasks, Level 1. Washington, DC: US

Dept of the Army; 14 December 2007.

2. AFPMB Technical Guide No. 36: Personal Protective

Measures Against Insects And Other Arthropods Of

Military Significance. Washington, DC: Armed

Forces Pest Management Board, US Dept of Defense;

April 18, 2002. Available at: http://www.afpmb.org/

coweb/guidance_targets/ppms/TG36/TG36.pdf.

3. USACHPPM Fact Sheet: DoD Insect Repellent

System. Aberdeen Proving Ground, MD: US Army

Center for Health Promotion and Preventive

Medicine. June 2007. Available at: http://chppmw w w . a p g e a . a r m y . m i l / d o c u m e n t s / F A C T /

D O D I n s e c t R e p e l l e n t S y s t e m J u s t h e F a c t sJune2007.pdf.

4. DoD Insect Repellent System. Deployment Relevant

Training. US Army Medical Department Center and

School Deployment Portal website. Available at:

http://www.cs.amedd.army.mil/deployment2.aspx#.

5. Philip CB, Paul JR, Sabin AB. Dimethyl phthalate as

a repellent in control of Phlebotomus pappataci or

sand fly fever. War Medicine. 1944;6:27-33.

6. Strickman D, Miller ME, Lee KW, et al. Successful

entomological intervention against Anopheles

sinensis, limiting transmission of Plasmodium vivax

to American Soldiers in the Republic of Korea. Kor J

Entomol. 2001;31:189-195.

7. McCabe ET, Barthel WF, Gertler SI, Hall SD. Insect

Repellents. III. N, N-diethylamides. J Org Chem.

1954;19:493-498.

8. Cushing EC. History of Entomology in World War II.

Baltimore, MD: The Lord Baltimore Press Inc; 1957.

9. Knepper TP. Analysis and mass spectrometric

characterization of the insect repellent Bayrepel and

its main metabolite Bayrepel-acid. J Chromatogr.

2004;1046(1-2):159-166.

10. Boeckh J, Breer H, Geier M, et al. Acylated 1,3-

aminopropanols as repellents against bloodsucking

arthropods. Pestic Sci. 1996;48(4):359-373.

11. Natarajan R, Basak SC, Balaban AT, Klun JA,

Schmidt WF. Chirality index, molecular overlay and

biological activity of diastereoisomeric mosquito

repellents. Pest Manag Sci. 2005;61(12):1193-1201.

12. Badolo A, Ouédraogo AP, Ilboudo-Sanogo E,

Costantini C. Evaluation of the sensitivity of Aedes

aegypti and Anopheles gambiae complex mosquitoes

to two insect repellents: DEET and KBR 3023. Trop

Med Int Health. 2004;9(3):330-334.

13. Carpenter S, Eyres K, McEndrick I, et al. Repellent

efficiency of BayRepel against Culicoides

impunctatus (Diptera: Ceratopogonidae). Parasitol

Res. 2005;95(6):427-429.

14. Costantini C, Badolo A, Ilboudo-Sanogo E. Field

evaluation of the efficacy and persistence of insect

repellents deet, IR3535, and KBR 3023 against

Anopheles gambiae complex and other Afrotropical

vector mosquitoes. Trans R Soc Trop Med Hyg.

2004;98(11):644-652.

15. Perrotey S, Madulo-Leblond G, Pesson B. Laboratory

testing of the insect repellent KBR 3023 against

Phlebotomus duboscqi (Diptera: Psychodidae).

Parasitol Res. 2002;88(7):712-713.

16. Yap HH, Jahangir K, Zairi J. Field efficacy of four

insect repellent products against vector mosquitoes in

a tropical environment. J Am Mosq Control Assoc.

2000;16(3):241-244.

17. Frances SP, Cooper RD, Waterson DGE, Beebe NW.

Field evaluation of repellent formulations containing

deet and picaridin against mosquitoes in Northern

Territory, Australia. J Med Entomol. 2004;41(3):414-

417.

18. Pretorius A-M, Jensenius M, Clarke F, Ringertz SH.

Repellent efficacy of deet and KBR 3023 against

Amblyomma hebraeum (Acari: Ixodidae). J Med

Entomol. 2003;40(2):245-248.

19. Klun JA, Khrimian A, Margaryan A, Kramer M,

Debboun M. Synthesis and repellent efficacy of a

new Chiral Piperidine analog: comparison with deet

and BayRepel activity in human-volunteer laboratory

assays against Aedes aegypti and Anopheles

stephensi. J Med Entomol. 2003;40(3):293-299.

20. McGovern TP, Schreck CE, Jackson J. Mosquito

repellents: alicyclic amides as repellents for Aedes

aegypti and Anopheles quadrimaculatus. Mosq News.

1978;38:346-349.
8 www.cs.amedd.army.mil/references_publications.aspx

21. Carroll JF, Solberg VB, Debboun M, Klun JA,

Kramer M. Comparative activity of deet and AI3-

37220 repellents against the ticks Ixodes scapularis

and Amblyomma americanum (Acari: Ixodidae) in

laboratory bioassays. J Med Entomol. 2004;41

(2):249-254.

22. Debboun M, Strickman D, Glass JA, et al. Laboratory

evaluation of AI3-37220, AI3-35765, CIC-4, and deet

repellents against three species of mosquitoes. J Am

Mosq Control Assoc. 1999;15(3):342-347.

23. Debboun M, Strickman D, Solberg VB, et al. Field

evaluation of deet and a piperidine repellent against

Aedes communis (Diptera: Culicidae) and Simulium

venustum (Diptera: Simuliidae) in the Adirondack

mountains of New York. J Med Entomol. 2000;37

(6):919-923.

24. Frances SP, Cooper RD, Popat S, Beebe NW. Field

evaluation of repellents containing deet and AI3-

37220 against Anopheles koliensis in Papua New

Guinea. J Am Mosq Control Assoc. 2001;17(1):42-

44.

25. Frances SP, Cooper RD, Sweeney AW. Laboratory

and field evaluation of the repellents deet, CIC-4, and

AI3-37220 against Anopheles farauti (Diptera:

Culicidae) in Australia. J Med Entomol. 1998;35

(5):690-693.

26. Frances SP, Cooper RD, Sweeney AW, Popat S.

Field evaluation of the repellents deet, CIC-4, and

AI3-37220 against Anopheles in Lae, Papua New

Guinea. J Am Mosq Control Assoc. 1999;15(3):339-

341.

27. Solberg VB, Klein TA, McPherson KR, Bradford

BA, Burge JR, Wirtz RA. Field evaluation of deet

and a piperidine repellent (AI3-37220) against

Amblyomma americanum (Acari: Ixodidae). J Med

Entomol. 1995;32(6):870-875.

28. Robert LL, Coleman RE, Lapointe DA, Martin PJ,

Kelly R, Edman JD. Laboratory and field evaluation

of five repellents against the black flies Prosimulium

mixtum and P. fuscum (Diptera: Simuliidae). J Med

Entomol. 1992;29(2):267-272.

29. Walker TW, Robert LL, Copeland RA, et al. Field

evaluation of arthropod repellents, deet and a

piperidine compound, AI3-37220, against Anopheles

funestus and Anopheles arabiensis in western Kenya.

J Am Mosq Control Assoc. 1996;12(2 PART 1):172-

176.

30. Klun JA, Schmidt WF, Debboun M. Stereochemical

effects in an insect repellent. J Med Entomol. 2001;38

(6):809-812.

31. Carroll JF, Klun JA, Debboun M. Repellency of deet

and SS220 applied to skin involves olfactory sensing

by two species of ticks. Med Vet Entomol. 2005;19

(1):101-106.

32. Klun JA, Khrimian A, Debboun M. Repellent and

deterrent effects of SS220, picaridin, and deet

suppress human blood feeding by Aedes aegypti,

Anopheles stephensi, and Phlebotomus papatasi. J

Med Entomol. 2006;43(1):34-39.

Chemical Defense Against Blood-Feeding Arthropods by Disruption of Biting Behavior

AUTHORS

COL Debboun is the Chief, Medical Zoology Branch at the Department of Preventive Health Services, Academy of

Health Sciences, US Army Medical Department Center & School, Fort Sam Houston, Texas.

Dr. Klun is a Research Entomologist at the Invasive Insect Biocontrol and Behavior Laboratory, United States

Department of Agriculture, ARS Beltsville Agricultural Research Center, Beltsville, Maryland.
April – June 2008 9

The Deployed Warfighter Protection

Research Program: Finding New

Methods to Vanquish Old Foes

CAPT Stanton E. Cope, MSC, USN

COL (Ret) Daniel A. Strickman, MS, USA

Graham B. White, PhD

*Detailed information on the DWFP can be found at

http://www.afpmb.org/dwfpresearch.htm.

INTRODUCTION

The Deployed Warfighter Protection research program

(DWFP) is an initiative to develop and validate novel

methods to protect United States military deployed

abroad from threats posed by disease-carrying insects.1

Vector-borne diseases such as malaria, dengue,

leishmaniasis, and chikungunya are among the most

important health risks facing deployed troops. There

are no vaccines for many diseases transmitted by

biting insects, so methods in insect management and

control, as well as personal protection, are the primary

tools available to protect troops.2-5

During and following World War II, scientists from

the US Department of Agriculture (USDA) were

regularly funded by the Department of Defense (DoD)

to develop new methods and materials for controlling

biting insects, particularly those that transmit diseases

to humans. This highly successful collaboration

produced tools that are still part of our insect-control

arsenal today. Examples include:

 Deet (N,N-diethyl-3-methyl-benzamide), the

primary ingredient in the majority of insect

repellents available today.

 Ultra low volume application of insecticides, a

methodology that distributes a limited amount of

chemical per acre by optimizing the dispersion and

concentration of size-limited droplets, now the

standard method used by spray trucks deployed to

protect neighborhoods against mosquitoes.

 Permethrin-impregnated fabrics for personal

protection against the bites of ticks, mosquitoes,

and other blood-feeding flying insects. Permethrin

is a synthetic pyrethroid insect repellent that is

used to treat uniforms, bed nets, tentage, and other

fabrics.

On a global basis, many diseases transmitted by

insects are increasing and spreading (eg, chikungunya,

dengue, West Nile fever) or remain widespread and

prevalent (eg, malaria, leishmaniases,

trypanosomiases) despite variable vector control

efforts. This situation is demonstrated in Table 1. Also,

increasing numbers of species of medically important

insects are developing resistance to insecticides

commonly used today. For strategic reasons, therefore,

there is a critical need in the DoD for the types of

products USDA is uniquely able to provide. The

DWFP is designed to not only encourage the rapid

development of such products, but also to improve the

capability of USDA to provide long-term, innovative

support to military preventive medicine. In short, it is

the intent of the DoD, through the DWFP, to provide

funding to the USDA Agricultural Research Service

(ARS) to reinvigorate this mutually beneficial working

relationship between DoD and USDA, particularly as

it pertains to DWFP, as defined in 2 written

agreements.7,8

ADMINISTRATION AND AREAS OF EMPHASIS

OF THE PROGRAM

The DWFP is administered by the Research Liaison

Officer of the Armed Forces Pest Management Board.

The program, which was started in Fiscal Year 04, is

funded at $5 million per year. It consists of a

noncompetitive funding process for USDA ARS-based

research, and a competitive grants process open to

non-USDA ARS scientists. Up to $3 million per year

is given to USDA ARS, specifically to National

Program 104, dealing with Veterinary, Urban, and

Medical Entomology. The funds are then distributed to

various laboratories within the USDA system as

described below.

Up to $1.4 million is awarded each year in new

competitive grants. The amount available for new
10 www.cs.amedd.army.mil/references_publications.aspx

starts each year depends on how many projects are

carried over from previous years. Grants are awarded

for up to $250,000 per year, for up to 3 years. The call

for preproposals generally goes out around September.

These are then reviewed by a DWFP Technical

Committee, consisting of 8 to 10 members, civilian

and military, representing the Army, Navy, and Air

Force. Based on preproposal reviews, investigators

may be asked to submit a full proposal. In November,

the DWFP Committee convenes for a 2-day review of

the USDA research and to determine which new

competitive grants will be awarded. Final competitive

award winners are usually notified in December.

The DWFP research portfolio is concentrated in 3

specific areas: novel insecticide chemistries/

formulations, application technology, and personal

protective systems. The first area includes discovery of

new active ingredients, tests of existing insecticides on

pests and vectors of public health importance,

especially mosquitoes and sand flies, and

reformulation of existing insecticides to improve

efficacy or delivery.

INVOLVEMENT OF THE US DEPARTMENT OF

AGRICULTURE

The USDA ARS has been a partner in DWFP since

2004, but cooperation between the nation’s

agricultural research and the military goes back many

decades. World War II was a unique moment in this

relationship. American forces were faced with the

usual disease challenges of warfare, but, for the first

time, scientific understanding and industrial capacity

combined to offer hope of preventing those diseases

caused by vector-borne pathogens. The USDA Bureau

of Entomology and Plant Quarantine laboratory in

Orlando9targeted the flea vectors of plague, the louse

vectors of typhus, the chigger vectors of scrub typhus,

mosquitoes including vectors of malaria and yellow

fever,10 as well as bedbugs, cockroaches, flies, and

ticks.11 In just a few years, the laboratory refined the

uses of DDT* as a control agent for public health pests

and of repellent chemicals (ethyl hexanediol, dimethyl

phthalate, dimethyl carbate, indalone, and benzyl

benzoate) as topical and clothing repellents. Workers

at the Beltsville Center invented the insecticidal

*1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane or Dichloro-diphenyl-trichloroethane

Vectors Diseases Incidence,

Prevalence

Mosquitoes

Malaria Warm regions—deaths in excess of

one million per year

Lymphatic filariasis Warm regions—infections in excess

of 200 million

Arboviruses (chikungunya, dengue,

Japanese encephalitis, Rift Valley fever,

West Nile virus, yellow fever, etc)

Spreading—epidemics increasing

Flies and roaches Dysentery Global and repetitive

Sand flies Leishmaniases Focal—approximately 6 million

infections a year

Fleas Plague Widespread—occasional outbreaks

Blackflies Onchocerciasis (River Blindness) Africa and Americas: focal—less

than 10 million cases

Tsetse African trypanosomiases (Sleeping Sickness) Africa: focal—less than 5 million

cases

Reduviid bugs Chagas disease Americas: 24 million cases across

15 countries

Ticks and mites Borrelioses, ehrlichias etc Widespread

Table 1. Major Global Vector-borne Diseases6

Snails Schistosomiasis Warm regions—Approximately 200

million cases

The Deployed Warfighter Protection Research Program:

Finding New Methods to Vanquish Old Foes
April – June 2008 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

aerosol bomb12 (precursor of all spray cans) for

military use during WWII, and collaborated with the

Orlando Lab to invent the repellent deet13 in 1947.

The USDA continued to collaborate with the military

through the 1970s and 1980s, most notably working

out the means for permethrin treatment of military

uniforms.14-16 Concentration on military problems

slowed, eventually reduced to the development of

repellent active ingredients and improved trapping

systems. The DWFP effort brought greater focus in 3

ways. First, it provided significant funds ($3 million

per year) to the USDA ARS for research. Second, it

defined the subject areas of most interest to the

military, namely new toxicants for public health pests,

new application equipment for pesticides, and new

personal protection system. Finally, the DWFP

established mechanisms of communication between

the military and the USDA ARS that have kept both

sides engaged in the conversation on the direction of

research required to produce products for the

protection of military personnel from arthropods that

transmit pathogens.

During the last 3 years we have conceived and

executed the concept of a “virtual laboratory” that

takes advantage of the core strengths of the USDA

ARS at each of the laboratories to establish a smooth

flow for development of new vector control products.

Chemical discovery proceeds from several strategies

that are, for the most part, based on basic science

rather than bulk screening. Promising candidates

emerge from bioassays, leading to more

comprehensive evaluation against target insects. Once

we have what we think is a useful chemical, we

consider how best to use it against target insects in an

integrated pest and disease management program.

With those goals in mind, we have in the past

approached individual private companies in order to

form a partnership for further development. In that

case, it is up to the company to formulate the active

ingredient. Recently, we have been performing

research on formulation, reasoning that a preparation

closer to product status may be more attractive for

industrial development. We are also working on

regulatory issues by funding a position on public

health pesticides with IR-4*, the USDA-funded entity

that supports registration of pesticides for use on

specialty crops.17

Some USDA ARS laboratories and investigators have

had only a temporary involvement with DWFP,

depending mainly on whether the core agricultural

mission of their unit effectively synergized the military

mission of the funds. Currently, there are 5

laboratories that receive DWFP funding. The

following sections discuss some of the work underway

in those laboratories.

Invasive Insect Biocontrol and Behavior

Laboratory

The Invasive Insect Biocontrol and Behavior

Laboratory in Beltsville, Maryland, is the laboratory

that first patented deet13 the dominant active ingredient

in American insect repellents. It continues to be wellequipped to perform any level of synthetic and

analytical chemistry, an obvious advantage for a

laboratory attempting to discover new toxicants and

repellents. Chauhan and colleagues18 have been

involved in the discovery of promising new repellent

active ingredients, mosquito larvicides, and exciting

new insecticidal chemistries. He takes advantage of a

small Aedes aegypti colony on site and performs

simple, screening bioassays to guide his work. Another

research team is at the cutting edge of research on how

mosquitoes detect hosts.19 Using molecular biology

and electrophysiology, they will develop tools that

dissect biting behavior into its component,

physiological parts. Combined with the synthetic

chemistry of the laboratory, this work will provide

very precise pathways for discovering entirely new

behavior-altering chemicals. Potential products could

be chemicals that selectively repel infected

mosquitoes, chemicals that induce mosquitoes to bite

nonhuman hosts, and powerful attractants that could be

combined with toxicants.

Mosquito and Fly Research Unit

Scientists at the Mosquito and Fly Research Unit

(MFRU) in Gainesville, Florida, are experts on many

aspects of the biology and control of mosquitoes and

flies. Their work includes the following:

*Interregional Research Project No 4 (IR-4), the Minor Crop Pest Management Program, is the principal public effort supporting the

registration of crop protection products and biological pest control agents for approximately $40 billion minor crop industry.

Source: USDA Cooperative State Research, Education, and Extension Service, http://www.csrees.usda.gov/nea/pest/in_focus/

ipm_if_minor.html
12 www.cs.amedd.army.mil/references_publications.aspx

 Toxicant discovery by Pridgeon et al20 includes

tests of registered toxicants that have not yet been

applied for public health pests. They also work

with industry to explore the effectiveness of new

compounds that have not been used as

insecticides. Promising chemicals have also been

extracted from native plants.

 Pridgeon and associates21 have invented an

entirely new class of “molecular pesticides” that

promise to combine great safety, flexibility, and

specificity.22,23

 Bernier and colleagues have extended fundamental

work to the production of inhibitors for

mosquitoes (patent pending) and powerful

attractants for flies24 and mosquitoes.25

Collaborators at the University of Florida are using

computational chemistry (QSAR/QSPR*) to

reanalyze pesticide bioassay data generated over

50 years at the Orlando and Gainesville

laboratories, resulting in synthesis of repellents

with 3-fold longer repellency than deet.26

 Researchers Cooperband and Allen27 have also

explored the effects of sublethal dosages of

pesticides on mosquito behavior using quantitative

interpretation of videos, extending our knowledge

of how best to apply residual insecticides.

 Research is underway on fly control, including

trapping and toxicants, at field sites in the United

States and middle eastern locations.

 The Center for Medical, Agricultural, and

Veterinary Entomology, which includes the

MFRU, has been very active in developing field

tests sites, including Thailand; Kenya; Camp

Blanding, Florida; and the Coachella Valley,

California. The MFRU works closely with the

Navy Entomology Center of Excellence at the US

Naval Air Station, Jacksonville, Florida, especially

for field testing and evaluation of application

equipment.

Biological Control of Pests Research Unit

At the Biological Control of Pests Research Unit

(BCPRU) in Stoneville, Mississippi, Lyn and Streett28

collaborate with scientists at the MFRU and industry

to develop formulations of public health pesticides.

Also, the BCPRU has facilities for pilot production of

biopesticides.

Natural Products Utilization Research Unit

The Natural Products Utilization Research Unit in

Oxford, Mississippi, has a history of working in

partnership with the University of Mississippi School

of Pharmacy on the discovery of natural sources of

bioactive compounds. The unit goes beyond simple

extracts to complex analysis of families of chemicals

and optimization through synthesis of series of

compounds. Thanks to DWFP funding, USDA was

able to leverage the effort by transferring funds to the

University of Mississippi for insecticide development.

Cantrell and colleagues29,30 have already been involved

in discovery and patent of repellents and toxicants.

The products of their research will be screened on site

using a new and very simple bioassay developed by

Becnel and Pridgeon31 at the MFRU. Promising

candidates will be evaluated in more detail by the

MFRU.

Areawide Pest Management Research Unit

Hoffmann and associates32,33 at the Areawide Pest

Management Research Unit (APMRU) in College

Station, Texas, have worked closely with the MFRU

and the Navy Entomology Center of Excellence to

systematically evaluate the droplet spectra of a wide

range of application equipment. The data have already

informed the military on the best equipment for its

purposes. Also, Nachman’s34 completed work on

neuropeptides of public health pests, including

mosquitoes, ticks, and flies, has established an entirely

new potential mechanism for insecticidal mode of

action.

COMPETITIVE AWARD HIGHLIGHTS

Publicly posted on the federal government’s website†

announcing grant availability, DWFP requests for

preproposals have yielded an average of 38

submissions annually, from academics, military

entomologists, industry, and others around the world.

More than one-third of these have been invited to

prepare full proposals, from which 34 projects, shown

in Table 2, have been selected for grant funding during

the first 5 years of the program. The range of topics

and the quality of many proposals have been

impressive. Indeed, many of the intended products

could find wider applications for public health and

veterinary pest control. So far, the smallest grant value

was $22,552 over 2 years, while some grants have

*Quantitative structure-activity relationship/quantitative

structure-property relationship † http://www.grants.gov/

The Deployed Warfighter Protection Research Program:

Finding New Methods to Vanquish Old Foes
April – June 2008 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

Award Recipient Purpose Org* Highlights

2004 (n=8)

CDR Claborn (Dr Walker) Sprayer diesel conversion M 2 prototypes & NSN†

LTC Coleman Sand Fly control--Iraq M Improved field operations

LCDR Hoffman Mosquito control with UAV‡ M Passed to USAF

Prof Phil Koehler Filth & Biting Fly control A 1 NSN† & 2 deployed citations

Dr Bob Peterson Comparative risk analyses A Publications & public appreciation

Dr Steve Presley Hollow fiber impregnated fabric A Novel technology

Dr Bill Reifenrath Repellent synergy D Cancelled

Dr Ed Rowton Sand Fly control--laboratory M Essential collaborations

2005 (n=7)

Prof Chas Apperson Dengue vector ovitrap A Duty under instruction student

Prof Lane Foil Targeted sand fly control A WRAIR§

collaboration

LT Haagsma Mosquito control with UAV‡ M Passed to USDA ARS APMRU

Dr Que Lan Novel mosquito insect growth regulator A Product licensed

Dr Mike Scharf Low molecular weight insecticides A Industry support

LT Stancil (LCDR Florin) Dengue vector larval control M EPA¶

registration in preparation

Prof Alon Warburg Sand Fly control military camps A WRAIR§

collaboration

2006 (n=6)

Bruce Dorendorf Diesel backpack D NECE** collaboration

Bruce Dorendorf Ultra lowvolume nozzle D NECE** collaboration

Dave Malone New ultra low volume adulticide etofenprox D EPA¶

registration in progress

Dr Phil Kaufman Novel compounds A Duty under instruction student

Dr Bob Peterson Comparative risk analyses A Strategic appreciation

Dr Gaby Zollner Novel vapor repellent M Delayed

2007 (n=3)

Dr Ed Rowton Sand Fly control—WRAIR§

laboratory M Essential collaborations

MAJ Richardson Sand Fly insectary, USAMRU-K

†† M Pioneering service

Dr Dolan & Dr McAllister Natural product pesticides G CDC-NCZVED‡‡ collaborations

2008 (n=10)

Bruce Dorendorf Ultra low volume backpack diesel system D

Prof Lane Foil Sand Fly larval control A

MAJ Stephen Frances Australia field repellent fabrics M

Philipp Kirsch Adulticides targeting Sand Flies D

Prof Phil Koehler Military protections vs Filth Flies A

Richard Poche Host-target insecticides vs Sand Flies D

LT Richardson Novel tools & strategies vs Ae.aegypti M

Prof Masoud Salyani Spray methods vs Sand Flies A

Prof Alon Warburg Phlebotomine control A

Dr Mike Willis Formulate UW4015 larvicide D

Table 2. Deployed Warfighter Protection Research Program Competitive Project Grants

*Type of organization:

A – Academia (n=14) D – Industry (n=8)

M – Military (n=11) G – Other government (n=1)

†National Stock Number

‡Unmanned aerial vehicle

§Walter Reed Army Institute of Research

¶US Environmental Protection Agency

**Navy Entomology Center of Excellence

††US Army Medical Research Unit, Kenya

‡‡US Centers for Disease Control and Prevention–National Center for Zoonotic, Vector-Borne, and Enteric Diseases
14 www.cs.amedd.army.mil/references_publications.aspx

exceeded $200,000 per year for 3 years. Awardees are

encouraged to seek patents and find licensees for their

products, several of which are already nearing

commercialization.

For example, in 2005 a grant was awarded to

ADAPCO (Sanford, Florida) to develop etofenprox35

for use as mosquito ultra low volume (ULV)

adulticide. This chemical, a nonester pyrethroid

manufactured by the Mitsui Group in Japan and

licensed to Central Life Sciences (Schaumburg,

Illinois) for US registration for public health

applications, is far less toxic to humans, animals, and

birds than most other insecticides currently used for

mosquito control.36 It is expected to receive EPA

approval for marketing this year.

Although the DWFP program prioritizes the discovery

and development of agents for use against bloodfeeding adult mosquitoes and biting flies that would

afflict deployed military personnel, some research

grants have been awarded for development of

chemicals with new modes of action against mosquito

developmental stages in water. At the University of

Wisconsin, Madison, Lan and colleagues37-41 had the

idea to block sterol carrier proteins that are

metabolically essential for the nutrition and growth of

mosquito larvae. After screening tens of thousands of

candidate compounds, they discovered several with the

power to block mosquito sterols, effectively serving as

growth inhibitors. The most appropriate compound has

been licensed by a commercial company where it is

being formulated for applied use. Both phases of the

work have been supported by DWFP grants.

Among DWFP grants awarded to scientifically

qualified military officers, the first was for adapting an

unmanned aerial vehicle, shown in Figure 1, to carry

application equipment for delivery of larvicidal

granules or ULV adulticide. This project originated

with the Disease Vector Ecology and Control Center

(now the Navy Entomology Center of Excellence) at

the Jacksonville Naval Air Station, where capabilities

were demonstrated, then adopted by the USAF Aerial

Spray Unit*at Youngstown, Ohio. To further develop

this application technology with an unmanned aerial

vehicle platform made in the United States, the project

has been transferred to the Application Technology

Laboratory of the USDA ARS at the APMRU. This

relay of progressive research and development steps

has been facilitated by DWFP funds and objectives to

meet one of the strategic DoD goals of fielding

unmanned vehicles.

Also by collaboration with the Navy Entomology

Center of Excellence, a series of DWFP grants have

enabled Dorendorf Advanced Technologies, Inc

(Winnebago, Minnesota) to design and build new

sprayers using military fuels instead of gasoline. The

first backpack system, shown in Figure 2, operates

almost silently with compressed air from cylinders

charged by a diesel-fuelled compressor which also

drives a truck-mounted ULV sprayer, the

TerminatorTM. In addition to the strategic advantages

of silent spraying, a unique ULV nozzle is being

created for the backpack system. Altogether, this

Figure 1. Yamaha RMax unmanned aerial vehicle fitted

with ULV spray nozzles (top) and with twin hopper

(bottom) for application of granular larvicide to control

mosquitoes.

*See related article on page 54.

The Deployed Warfighter Protection Research Program:

Finding New Methods to Vanquish Old Foes
April – June 2008 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

purpose-built, diesel-fuelled spray

equipment will allow troops to be

deployed with battlefield-ready

spray equipment for vector

control.

From diverse proposals for better

insect repellency of fabrics to

protect military personnel, one

DWFP grant was awarded to

researchers at the Institute of

Environmental and Human Health,

Texas Tech University, Lubbock,

Texas. That ingenious project

developed a new type of

permethrin-impregnated hollow

fiber capable of being integrated

with many textiles. This durable

microcapillary can serve as a

convenient carrier fiber for weaving the repellent and

insecticidal powers of permethrin into any fabrics used

for making clothes, curtains, tents, and other protective

layers.*

Two DWFP projects have employed pyriproxyfen, the

most powerful insect growth regulator (IGR), against

dengue vector mosquitoes. In the Peruvian Amazon

community at Iquitos, Stancil42 (Naval Medical

Research Center Detachment, Peru)

received a grant to optimize

strategies for preventing the breeding

of Aedes aegypti mosquitoes in

containers of water. The project ran

for 3 years, and involved

collaboration with Peruvian scientists

and researchers from the University

of California and Rothamsted

Research, United Kingdom. In

addition to simply stopping the

breeding of mosquitoes in treated

habitats, effective quantities of

pyriproxyfen IGR are transferred from one container

to another by mosquito females as they go from site to

site laying their eggs, thus impacting more habitats

than were treated directly. Mosquito population

suppression across whole suburbs of the city has

effectively prevented dengue transmission without the

need to spray adulticides. Building on that

achievement, researchers at the Armed Forces

Research Institute of Medical Sciences, Bangkok,43 in

conjunction with local military

personnel in Thailand, are now

evaluating several devices treated

with pyriproxyfen IGR for

protecting military camps against

Aedes aegypti and the arboviruses

transmitted by this widespread

domestic mosquito (see Table 1).

The biggest emphasis of DWFP

projects has been to find ways to

combat Phlebotomus sand flies

(Figure 3) which are problematic

in many parts of the Middle East.

These small hairy flies transmit

Leishmania parasites that cause

disfiguring sores (Figure 4) which

fester for many months and require

long-term medication. Some forms

of the infection go to the liver and can be fatal. More

than a thousand US personnel have contracted

leishmaniasis during ongoing Operations Enduring

Freedom and Iraqi Freedom.44 Unfortunately, the types

of insecticide sprays that normally control mosquitoes

are generally ineffective against sand flies. To address

this threat, DWFP grants were channeled, by

competitive award, via the Entomology Division at the

Walter Reed Army Institute of Research to facilitate

intensive field studies of sand fly

behavior and control. Although a

series of research papers by Coleman,

Burkett, and colleagues45-47 have

resulted, the sand fly biting problem

has not been resolved. Consequently,

efforts to understand how to improve

the delivery of more effective

insecticidal sprays are being

reemphasized. Also, Warburg and

colleagues48 at the Kuvin Center of

the Hadassah Medical School,

Jerusalem, received a DWFP grant to

develop measures to protect outposts against sand

flies. These projects have revealed that sand flies often

emerge from the soil beneath tents and camps. In an

effort to prevent sand flies breeding in rodent burrows,

the Genesis Company (Wellington, Colorado) won an

award for producing insecticidal baits that would pass

through specific rodent reservoir hosts of leishmaniasis

to prevent breeding of sand fly larvae in their burrows.

This approach is being developed with other feedthrough treatments by Mascari et al49-51 at Louisiana

Figure 2. The first backpack ULV

sprayer system developed under

DWFP grants operates almost silently

with compressed air from cylinders.

Figure 3. Phlebotomus sand fly

(Photo courtesy of Ed Rowton, PhD)

*Project results unpublished to date
16 www.cs.amedd.army.mil/references_publications.aspx

State University for field testing against sand flies in

Turkey.

Control of filth flies and house flies is best achieved by

good sanitation, but this cannot always be ensured in

deployment situations. One competitive DWFP award

enabled Koehler52 and military students in the Urban

Entomology Unit of the Department of Entomology

and Nematology at the University of Florida,

Gainesville, to optimize some old countermeasures for

fly control. For example, one student evaluated

pesticides for residual treatments of various types of

string and rope on which flies like to rest. He

determined which combination of insecticide and

string fiber would be most effective for use against

flies in tented camps. Another student continues this

line of experimentation by devising ways to drape

loops of treated string over attractant traps to which

flies are lured and killed. These masters level graduate

students were supported by the US Navy’s Medical

Service Corps Inservice Procurement Program.53

Another development from Koehler’s team, invisible

imidacloprid paint bait with attractant for killing flies

quickly, was the first DWFP product to receive a

National Stock Number from the Armed Forces Pest

Management Board.

As the DWFP competitive grants program has grown,

awardees have included entomologists at the US

Centers for Disease Control, Division of Vector-Borne

and Zoonotic Diseases, for development of natural

pesticides extracted from agricultural waste. Other

plant products that have insect repellent properties are

under evaluation for insecticidal potency against flies,

mosquitoes, and sand flies, while Scharf and Song54,55

are exploring low molecular weight compounds that

could serve as volatile repellents and insecticides for

potential limitation of biting insects over a wide area.

Although the public perception of pesticides can be

unfavorable, the facts are that the use of pesticides can

be extremely effective against all sorts of pests and

disease vectors. In an effort to investigate this

dichotomy, one of the most original lines of inquiry

funded by DWFP competitive grants has allowed

Peterson and colleagues56-61 at Montana State

University, Bozeman, to undertake comparative risk

analyses of the impact of pesticides. For a series of

model scenarios involving vector-borne diseases such

as malaria, West Nile fever, and plague, they carefully

quantified the likely benefits of vector control by

means of appropriate insecticide applications, versus

possible disadvantages to the health of people and

environmental impact. One particular study by Macedo

et al62 weighed the potential health benefits of vector

control against the adverse consequences of likely

exposure of deployed military personnel to pesticides

used on clothing and bed nets, and sprayed around the

camp. In all cases, the risk to humans was found to be

minimal compared with the health benefits of avoiding

vector-borne diseases.

UPGRADING DEFENSE AGAINST DISEASES

TRANSMITTED BY INSECT BITES

While many useful products from DWFP research are

already on the way towards production and supply for

the public as well as deployed troops, the examples

described above are far from sufficient to cover all our

needs. Apart from combating mosquitoes and the

various types of flies that transmit debilitating

Figure 4. Examples of dermal leishmaniasis contracted

in Iraq during Operation Iraqi Freedom. Note in the top

photo that the area of the arm covered by the shirt

sleeve is free of bites, demonstrating the value of simple

measures in the prevention of insect bites.

(Photos courtesy of COL Russell Coleman, MS, USA)

The Deployed Warfighter Protection Research Program:

Finding New Methods to Vanquish Old Foes
April – June 2008 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

infections such as malaria, leishmaniasis, dengue, and

other arboviruses, there are many other noxious types

of biting insects (bedbugs, fleas, lice, etc) and other

arthropods (ticks, mites, scorpions, etc) that merit our

concern. With nearly 5 years of progress in the DWFP

program, however, our focus remains on the most

dangerous flying vectors, particularly certain species

of mosquitoes and sand flies. That focus is necessary

until we have greatly improved methods and materials

to protect our forces deployed to forward situations in

all regions of the world from the threats of

inconspicuous insect foes. This will allow those forces

to more effectively deal with the challenges presented

by the more obvious human enemies.

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27. Cooperband MF, Allan SA. Behavioral definitions,

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39. Kim MS, Wessely V, Lan Q. Identification of

mosquito sterol carrier protein-2 inhibitors. J Lipid

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activity of sterol carrier protein-2 inhibitor in four

species of mosquitoes. J Med Entomol. 2008;45

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GJ. Potential use of pyriproxyfen for control of Aedes

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program. J Med Entomol. 2006;43(4):647-662.

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distribution of sand flies. J Med Entomol. 2007;44

(1):29-41.

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Peterson RKD. Equine risk assessment for

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Hum Ecol Risk Assess. 2008;14:392-407.

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Environmental concentrations, fate, and risk

assessment of pyrethrins and piperonyl butoxide after

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2008;27:1063-1068.
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61. Schleier JJ, Macedo PA, Davis RS, Shama LM,

Peterson RKD. A two-dimensional probabilistic acute

human-health risk assessment of insecticide exposure

after adult mosquito management. Stoch Environ Res

Risk Assess. 2008; 22, doi:10.1007/s00477-008-0227-5.

62. Macedo PA, Peterson RK, Davis RS. Risk

assessments for exposure of deployed military

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Toxicol Environ Health. 2007;70(20):1758-1771.

The Deployed Warfighter Protection Research Program:

Finding New Methods to Vanquish Old Foes

AUTHORS

CAPT Cope is the Research Liaison Officer of the Armed Forces Pest Management Board, Washington, DC.

COL (Ret) Strickman is the National Program Leader, Program 104: Veterinary, Medical, and Urban Entomology at

the US Dept of Agriculture, Agricultural Research Service, Beltsville, Maryland.

Dr White is Technical Consultant for the Deployed Warfighter Protection Research Program, based at the Mosquito

and Fly Research Unit, Center for Medical, Agricultural, and Veterinary Entomology, USDA Agricultural Research

Service, Gainesville, Florida.

COL DUNEMN JOINS THE AMEDD JOURNAL EDITORIAL REVIEW BOARD

The AMEDD Journal welcomes COL Kathleen N. Dunemn, AN,

USA, as a member of the Editorial Review Board. COL Dunemn is

Chief, Department of Nursing Science, Academy of Health Sciences,

AMEDD Center and School, Fort Sam Houston, Texas, and the

Nursing Education/Enlisted Training Consultant to the Office of The

Surgeon General.

COL Dunemn joins the board replacing COL Patricia Patrician, AN,

USA. COL Patrician has been a member of the Board since October,

2004. We thank COL Patrician for her dedication to the high

standards and professional quality of this publication, and her years of

service and support to our mission.

The Editors
April – June 2008 21

The Vector Surveillance Analytic System (VSAS) is a

portable, field-durable, field-sustainable, real-time,

arthropod-borne agent detection platform used to

support disease surveillance operations at far forward

locations. The VSAS was originally developed to

establish a DoD deployable methodology for dengue

virus detection, but focus on system capability was

redirected to Leishmania detection and deployed in

August 2003 to support the Leishmaniasis Control

Program (LCP) of the 520th Theater Army Medical

Laboratory, Tallil Air Base (AB), Iraq.1 The mobility

of the VSAS allowed direct support to US Army

Preventive Medicine and US Air Force Public Health

Leishmania surveillance operations throughout the

LCP area of responsibility. Force health protection

support was provided at Camp Victory; Baghdad

International Airport AB; Balad AB; and Kirkuk AB,

Iraq; and Kabul, Afghanistan, from February to

October of 2004.

The VSAS operates as a standalone field surveillance

activity or as an extension of other deployable assets,

such as the US Army Area Medical Laboratory or the

Air Force Biological Augmentation Team. The field

utility of the VSAS is clearly proven in diverse

operational applications and environmental conditions;

Leishmania surveillance Southwest Asia,2dengue

surveillance at Joint Task Force Bravo, Honduras,3,4

and with the Armed Forces Research Institute of

Medical Sciences, Bangkok, Thailand.5It has also

been adapted for use in the Arctic by NASA* in the

development of genomics-based identification

methodologies for the Haughton-Mars Project†on

Devon Island in the Territory of Nunavut, Canada.

The VSAS addresses a requirement established by the

Joint Program Executive Office (JPEO) for Chemical

and Biological Defense for the development of

deployable identification technologies for disease

agents of operational significance.6 The JPEO has

designated Leishmania and dengue virus as threat

agents (Block 1, Tier 2). To address that threat, testing

is underway to incrementally establish VSAS

technologies as subcomponents of the Joint Biological

Agent Identification and Diagnostic System (JBAIDS),

a JPEO/DoD accepted analytic system.

The VSAS is composed of:

1. Thermally-stable, hydrolytic enzyme resistant,

freeze-dried, dual-fluorogenic, polymerase chain

reaction (PCR) and reverse transcription-PCR

(RT-PCR) assays and positive control template,

genomic DNA and Armored-RNA®(Asuragen,

Incorporated, Austin, Texas).7,8

2. Preformatted sample stabilization and processing

materials.

3. Two-man transportable, field-durable, real-time

PCR instrumentation: the Ruggedized Advanced

Pathogen Identification Device (RAPID®)

(Idaho Technology Incorporated [ITI], Salt Lake

City, Utah).

Assay primer and probe oligonucleotides are designed

de novo, and freeze-dried PCR reagents are

manufactured by ITI.2,3 Assays are prepared using an

ITI proprietary formulation that is formatted to

standardized PCR and RT-PCR thermal cycling

protocols. The ITI vector surveillance reagent kit is

preformatted with color coding to simplify

preparation. Freeze-dried assays only require hydration

and addition of sample template prior to analysis. The

thermal-stable property of the assays eliminate the

Support of Far-Forward Disease Surveillance

Operations with Deployable, Real-Time

Vector-Borne Disease Agent Analytic

Capability

Col James A. Swaby, BSC, USAF

James C. McAvin

*National Aeronautics and Space Administration

†Information on the research project available at:

http://www.marsonearth.org/
22 www.cs.amedd.army.mil/references_publications.aspx

need for a -20°C cold chain that is typically required

for PCR reagents, thus vastly enhancing the mobility

of the system. It also eliminates cold storage and

resupply requirements that are unacceptable under farforward deployed conditions.

Arthropod nucleic acid extracts are prepared with a

commercially available, off-the-shelf, thermally stable,

preformatted, guanidinium thiocyanate based total

nucleic acid (DNA and RNA)

purification kit, QIAamp Viral

RNA Mini Kit (QIAGEN,

27220 Turnberry Lane,

Valencia, California 91355).

Extract is prepared following

the manufacturer’s spin

protocol with the exception that

the carrier RNA step is not

implemented, thus eliminating

the need for a 4°C cold chain.

Also, centrifugation steps are

adapted to the RAPID mini

centrifuge, eliminating the need

for a tabletop centrifuge. This

kit has been adopted because of

its field-worthiness and its

capability to extract total

nucleic acid in a standardized,

single protocol which is

applicable to organisms harboring either RNA or DNA

genomes. Two other advantages of the kit are the lysis

buffer, “Anschlagpuffer Virus Lysis” (AVL), which

has been shown to inactivate infectious agents,9thus

providing an additional level of safety when

processing samples, and the genomic RNA template,

which has been shown to remain stable in AVL at

ambient temperatures (25oC to 37oC) for days to

weeks. The kit efficiently purifies nucleic acid from

diverse matrices, to include mammalian body fluids

and tissues and arthropod homogenate.

The RAPID PCR thermocycler, is a real-time fluorimeter with a closed capillary design and 32-sample

capacity.10,11 The thermocycler is operated by a laptop

computer with programmable PCR cycling conditions.

Data management is automated. The RAPID mini

centrifuge is used for sample preparation and capillary

loading. The RAPID thermocycler is the

commercialized version of the JBAIDS thermocycler.

Since the technologies of these thermocyclers are

essentially identical, assays can be readily transitioned

from one instrument to the other.

The VSAS, including several hundred assays and

sample processing materials, are transported in 2

hardened, waterproof cases (63  49.2  35.2 cm).

The VSAS is routinely transported as personal

equipment on military helicopters or fixed-wing

aircraft, or transported on commercial airlines as

baggage. Ground transportation

is by light vehicle or carried

manually. The small footprint of

the VSAS allows configuration

on a truck tailgate with the

system powered by a 110V or

220V source, usually an electric

generator, or, if necessary, the

12V battery of a vehicle with

the engine running. The

efficiency of preformatted

reagent and sample preparation

kits, along with the closed

capillary design of the RAPID,

permit sample processing and

master mix preparation to be

conducted without a biological

containment hood or spatial

separation. However, in order to

tailor protective measures to the

surveillance requirements, appropriate operator

personnel protective equipment must be provided and

personnel made aware of which vector(s) will be

recovered. System configuration requires about 10

minutes, and sample processing and analysis less than

2 hours.

The VSAS provides deployable analytic capability for

real-time vector-borne disease risk assessment. This is

paramount in affecting time-critical and focused

disease prevention and control measures. This is

especially relevant to leishmaniasis and dengue fever

because, in the absence of a vaccine or prophylactic

drug, the only means of protecting deployed military

personnel is the prevention of bites by infected

arthropods. Prevention and control of transmission is

most effectively achieved through heightened

awareness of the need for personal protective

measures, and by reduction in vector populations.

Focused application of insecticides and elimination of

breeding habitat in areas where the risk is greatest—

The Ruggedized Advanced Pathogen

Identification Device.

Support of Far-Forward Disease Surveillance Operations with Deployable,

Real-Time Vector-Borne Disease Agent Analytic Capability
April – June 2008 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

where infected vectors and breeding populations are

found—are the most effective uses of vector control

resources to reduce transmission.1,2

The Armed Forces Pest Management Board (AFPMB)

has approved Leishmania genus (LEIS) and visceral

genotype (LVL) PCR assays as DoD accepted

methodologies for Leishmania vector surveillance. The

VSAS dengue RT-PCR assay (DU-JCM) was

submitted to AFPMB in February 2008. The LEIS,

LVL, and DU-JCM assays will be submitted

concurrently to the JPEO for approval as candidates

for clearance by the US Food and Drug Administration

on the JBAIDS. Additional assays of operational

significance are in development.

The VSAS is a joint US Air Force, Army, and Navy

product developed through a Cooperative Research

and Development Agreement with ITI, the JPEO

primary contractor.

ACKNOWLEDGEMENT

The authors thank MAJ Jason Richardson, MS, USA, for his comments and suggestions in reviewing this article.

The VSAS development was funded in part by the US Air Force Protection Battle Lab, Lackland Air Force

Base, San Antonio, Texas, and the Directorate of Modernization in the Office of the Air Force Surgeon General,

Falls Church, Virginia.

The Vector Surveillance Analytic System operating in the field environment in Thailand

during August 2007.
24 www.cs.amedd.army.mil/references_publications.aspx

REFERENCES

1. Coleman RE, Burkett DA, Putnam JL, et al. Impact

of Phlebotomine sand flies on US military operations

at Tallil Air Base, Iraq: background, military

situation, and development of a “Leishmaniasis

Control Program”. J Med Entomol. 2006;43:647-662.

2. McAvin JC, Coleman RE, Hochberg LP, et al.

Detection of Leishmania parasites and visceral

leishmaniasis genotype identification in sand flies by

field-deployable, real-time polymerase chain

reaction. J Med Entomol. In press.

3. McAvin JC, Escamilla EM, Blow JA, et al. Rapid

identification of dengue virus by RT-PCR using

field-deployable instrumentation. Mil Med. 2005;170

(12):1053-1059.

4. McAvin JC, Bowles DE, Swaby JA, et al.

Identification of Aedes aegypti and its respective life

stages by real-time PCR. Mil Med. 2005;170

(12):1060-1065.

5. McAvin JC, Powers MD, Blow JA, Putman JL, Huff

WB, Swaby JA. Deployable, field-sustainable RTPCR assays for rapid screening and serotype

identification of dengue virus in mosquitoes. Mil

Med. 2007;172:329-334.

6. Niemeyer DM, Wilson S, et al. Enhanced laboratory

capabilities: the joint biological agent identification

and diagnostic system. Society Scope [Society of

Armed Forces Medical Laboratory Scientists serial

online]. 2003;6(3). Available at: http://

www.safmls.org/Scopes/Scope%20-%202003%

20Fall.pdf.

7. Pasloske BL, Walkerpeach CR, Obermoeller RD,

Winkler M, DuBois DB. Armored RNA technology

for production of ribonuclease resistant viral RNA

controls and standards. J Clin Micro. 1998;36:3590-

3594.

8. Walkerpeach CR., Winkler M, DuBois DB, Pasloske

BL. Ribonuclease-resistant RNA controls (armored

RNA) for reverse transcription-PCR, branched DNA,

and genotyping assays for hepatitis C virus. Clin

Chem. 1999;45:2079-2085.

9. Blow JA, Dohm DJ, Negley DL, Mores CN. Virus

inactivation by nucleic acid extraction reagents. J

Virol Meth. 2004;119:195-198.

10. Wittwer CT, Ririe KM, Andre RV, David DA,

Gundry RA, Balis UJ. The lightcycler: a

microvolume multisample fluorimeter with rapid

temperature control. Bioechniques. 1997;22:176-181.

11. Wittwer CT, Herrmann MG, Moss AA, Rasmussen

RP. Continuous fluorescence monitoring of rapid

cycle DNA amplification. Biotechniques.

1997;22:130-138.

AUTHORS

Col Swaby is Chief, 59th Clinical Research Training

Division, 59th Medical Wing, and Principle Investigator,

Vector-borne Disease Surveillance, 59th Medical Wing/

SGR, Lackland Air Force Base, Texas. He is also

Associate Biomedical Sciences Corps Chief for Medical

Entomology, and Consultant to the USAF Surgeon

General for Entomology.

James McAvin is a Molecular Biologist with the 59th

Clinical Research Training Division, 59th Medical

Wing, Lackland Air Force Base, Texas.

Support of Far-Forward Disease Surveillance Operations with Deployable,

Real-Time Vector-Borne Disease Agent Analytic Capability
April – June 2008 25

BACKGROUND

“What kind of war do you prepare for when you

cannot prepare for them all?” Andrew Krepinevich

poses the question in his analysis of the US Army

before, during, and after a counterinsurgency in

Vietnam.1 The question has resurfaced as the Army

again finds itself operating in a counterinsurgency in

Iraq. Has the Army as an institution learned and

implemented change based on experiences in the

Philippines during the early 20th century, or Vietnam,

Lebanon, and El Salvador in the latter part of the same

century? Are we trained and equipped to contribute

toward an overarching US government strategy

addressing underlying factors of an insurgency?

Although the broader questions have been debated and

recommendations published, the role of preventive

medicine (PM) in support of counterinsurgency

operations has not.

Counterinsurgency is, by definition, “Those military,

paramilitary, political, economic, psychological, and

civic actions taken by a government to defeat an

insurgency.”2 The recently published Army Field

Manual 3-24: Counterinsurgency3emphasizes

political, social, and economic programs as more

valuable than kinetic force in addressing the root cause

of an insurgency. In the absence of legitimate

governments providing for the population, insurgents

deliver essential services such as water, electricity,

sanitation, and medical care. Hezbollah exemplifies

this characterization in the care and services they

provide for the Lebanese population in exchange for

individuals to fill their militia ranks. This pattern

replicated itself in the streets of Baghdad, as observed

by then MG Peter Chiarelli.4 He found “...anticoalition and antigovernment religious rhetoric

originated from those areas of Baghdad characterized

by low electrical distribution, sewage running raw

through the streets, little to no potable water

distribution, and no solid waste pickup....a direct

correlation existed between the level of local

infrastructure status, unemployment figures, and

attacks on US Soldiers.” MG Chiarelli studied these

underlying factors and achieved success by focusing

reconstruction and employment efforts on sewage,

water, electricity, and trash removal—what he called

“SWET.” Three of these 4 services make up core

competencies of Army PM personnel. Is PM currently

being leveraged in Iraq, Afghanistan, and the Horn of

Africa to contribute toward the overall strategic effort?

That is debatable. Are they formally trained in

counterinsurgencies and doctrinally established to

meet the demand? Not really.

APPLICATION OF CURRENT DOCTRINE

Doctrine for Level III PM detachments is driven by

multiple Department of Defense (DoD) Directives and

Instructions, Army Regulations, Department of the

Level III Preventive Medicine in a

Counterinsurgency Environment

MAJ Derek J. Licina, MS, USA

ABSTRACT

As the Department of Defense moves forward to secure Baghdad, military forces are being strategically

dispersed in very austere environments. These forces live and work side-by-side with their Iraqi counterparts in

an effort to clear, hold, and reconstruct the city block by block, and further separate the insurgents from the

general population. Level II preventive medicine (PM) personnel directly support these forces and keep them in

the fight by reducing acute illness and disease and nonbattle injuries. Level III PM is performing the traditional

PM mission of reducing both acute and chronic illness while conducting Deployment Occupational

Environmental Health Surveillance and supporting Level II PM. However, the doctrinal basis of Level III

allocation and priorities of core competencies have shifted. Are we meeting the need? This article attempts to

answer the question based on experience as a Level III PM detachment commander in Baghdad, and provide

recommendations for change across the spectrum of the Army’s structure of doctrine, organizations, training,

materiel, leadership, education, personnel, and facilities.
26 www.cs.amedd.army.mil/references_publications.aspx

Army Pamphlets, and myriad Field Manuals. The most

robust description of duties and responsibilities is

found in Field Manual 4.02-17, Preventive Medicine

Services,

5 which was last updated in August 2000. It

highlights Level III support in the areas of medical

threat analysis, health hazard assessment, disease and

nonbattle injury (DNBI) surveillance, health physics

surveys, disease-vector identification, environmental

health assessments, and field sanitation team training,

among other operational capabilities. These areas are

relevant in both permissive and nonpermissive

environments, though their overall priority may shift.

PM services in stability, support, and civil-military

operations are discussed in Field Manual 4.02-17 and

more accurately describe what contributions PM can

make in a counterinsurgency.

During the 2007 surge in operations in Baghdad, the

61st Medical Detachment provided Level III support

to the multinational divisions in Baghdad and central

Iraq which were engulfed in a counterinsurgency. Over

70,000 US, Coalition, contractor, and third country

nationals supported operations in this nefarious battle

space. Doctrinally established to support 17,000

personnel, the 61st Medical Detachment in reality

performed the mission of 4 detachments. They

provided support in an area over 80,000 km2, including

20 forward operation bases (FOBs), 70 joint security

stations (JSSs) and combat outposts (COPs), and the

Victory Base Complex, which is equivalent to a

midsize municipality in the United States. Doctrine

states that Level III PM is 100% mobile, however,

during the counterinsurgency in Iraq, this has only

been true on the FOBs to which they were assigned.

Moving between FOBs requires external support such

as uparmored* vehicles, helicopters, and stalwart

security. The criteria for this doctrinal basis of

allocation should be further explored. New criteria

such as the number of Level II PM assets supported, or

type of conflict (counterinsurgency, peacekeeping, or

disaster response/humanitarian assistance) could be

added and weighted to determine operational needs on

the ground.

During the Operation Iraqi Freedom (OIF) 06-08

rotation, the 61st Medical Detachment executed a

majority of these doctrinal tasks. Prior to deployment,

a medical threat profile based on hazards in the area of

operation was developed. Not considered during this

analysis were diseases that could be brought into

theater by Coalition forces and contract partners who

may not require stringent predeployment health

screening. Round worm infections and bed bug

infestations among employed third country nationals

providing services to Coalition personnel were not

uncommon.

Health hazard assessments were conducted to

characterize exposure to the omnipresent dust, smoke

from burning solid waste, and diverse chemicals. As

the war spiraled into a counterinsurgency, Coalition

forces moved into urban environments in and around

Baghdad to establish JSSs and COPs. These locations

were based among existing infrastructure where

running water was intermittent and solid waste

disposal nonexistent. This posed increased risk to

Coalition personnel performing personal hygiene using

local water, defecating in improvised containers, and

living next to solid waste burn pits used to eliminate

trash and decrease the rodent and vector populations.

Level II PM provided direct support to these austere

sites which rapidly grew in number. Occupational

Environmental Health Surveillance at these locations

was limited due to time, the daily enemy threat, and

competing acute health priorities.

Doctrinally, surveillance for disease and nonbattle

injury (DNBI) is the responsibility of Level III PM.

Unfortunately, or fortunately depending upon

perspective, the 61st Medical Detachment did not

monitor DNBIs. An excellent rapport was established

with the Theater Medical Command PM physician

who monitored DNBIs and notified the 61st Medical

Detachment of patterns or trends within their area of

operation. This allowed Level III PM to focus energy

on prevention while knowing any spike in illness

would be identified and collaboratively addressed in a

timely manner. Unfortunately, this method builds

dependency and reduces recognition and assessment

skills that could be employed in a counterinsurgency

environment when working with host nation security

forces or the local civilian population.

MEETING THE NEED IN A

COUNTERINSURGENCY

These are just a few examples of how Level III PM

addressed doctrinal tasks during a counterinsurgency.

*Military vehicles which have been reinforced with additional

armor to counter the affects of roadside and buried bombs,

and improved penetrating direct fire munitions.

Level III Preventive Medicine in a Counterinsurgency Environment
April – June 2008 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

There are other examples where the Army could learn

from Level III successes and failures to drive change.

The Army uses “doctrine, organizations, training,

materiel, leadership, education, personnel, and

facilities (DOTMLPF)” as “a problem-solving

construct for assessing capabilities and managing

change.”6 Recent experience in Iraq and a reflection on

previous counterinsurgency operations provide

justification to stimulate change within the PM field

using the DOTMLPF construct.

Doctrine

The global shift of populations toward urban areas and

the inability of governments to provide basic services

fuels insurgent efforts to exploit the disenfranchised.4

Counterinsurgencies are built to address these groups

and underlying factors. Such operations are “a long,

slow process that requires the integration of all

elements of national power...to accomplish the tasks

of creating and supporting legitimate host governments

that can then defeat the insurgency.”7 The Viet Cong

understood the power of PM and employed sanitation

extensively in their civic action and propaganda

efforts. They used slogans such as “Prevention of

Disease is Patriotism” and “Prevention of Disease is

Fighting the Americans.”8 Dr Richard Carmona, the

US Surgeon General, reflected on his time as a Special

Forces medic during the war in Vietnam: “PM is

probably the most important thing I learned...not only

was I responsible for the health care of my team, but

for an entire village as well!”9 Both sides realized

interactions between Soldiers and indigenous

populations provided opportunities to make positive

impressions and obtain support from the population.10

In the current situation, the shortage of international

and nongovernmental organizations in Iraq means that

military forces possess the only readily available

capability to support the needs of the population.

Current civil-military operations (CMO) doctrine

mentions building host nation capacity and local

sufficiency in the areas of health education, water

supply, and waste disposal.5 These areas are ripe for

intervention by Level III PM working through, by, and

with host nation counterparts to fill the void in

essential services, provide legitimacy to the

government, and stimulate the economy through job

creation. Understanding these capabilities, the 61st

Medical Detachment and the Multinational Corps-Iraq

Force Health Protection Officer reached out to the

Corps CMO staff. Discussions acknowledged that

Provincial Reconstruction Teams (PRTs) and Civil

Affairs (CA) units have no organic PM equipment and

should coordinate with PM detachments for

support.5,11 Offers were made to have the 61st Medical

Detachment advise, coordinate, and evaluate public

health resources within their respective areas of

operation to advance host nation services provided to

the population.12 Conceptual agreement was achieved

and laudatory comments made, however, strategic

support was not provided. They requested that the

subject be revisited in the future, but short term tactical

needs dictated that Level III PM pursue other avenues

of support. As of this writing, the 61st Medical

Detachment is working with the 1st Calvary Division

G9 CMO staff to address the significant void in public

health and sanitation. Progress is slow. The

omnipresent challenges of PM units engaging PRT and

CA personnel may be rooted in CA and PM

indoctrination courses, which is explored later in this

article.

Organizations

The history of PM efforts highlight different, yet

synergistic capabilities between veterinary and

preventive medicine personnel, which could be

employed in Iraq and future counterinsurgencies. For

example, when millions of Pakistanis were displaced

from their homes, a major relief effort was mounted by

PM physicians, a PM company, and 42 enlisted personnel.13 This was not the 2005 earthquake disaster

response in Pakistan, rather the relief effort following

the flooding of the Brahmaputra River in 1954. In

1963, a team of 4 physicians, 3 sanitary engineers, an

entomologist, and 8 PM technicians administered

41,000 doses of typhoid fever vaccine, deloused 9,000

people, and treated 75 wells following intense flooding

in Morocco.14 Army Veterinary Corps officers actively

participated in the Medical Civic Action program in

Vietnam where they prevented zoonotic diseases and

provided treatment and care to domestic animals.15

Unfortunately, current organizational structure within

veterinary and PM communities does not leverage

capabilities; rather, the structure fosters competition in

accomplishing similar goals.

In an effort to reduce perceived and actual food and

water inspection overlap, serious consideration should

be given to merging the Veterinary Food Inspection

Specialist (military occupational specialty (MOS)
28 www.cs.amedd.army.mil/references_publications.aspx

68R) and PM Specialist (MOS 68S). Title the new

specialty “68RS, Public Health Specialist” and

establish doctrine and training to meet the future need.

Experts in both fields have vacillated over this concept

for years. Unfortunately, to date there has been little

recognition of the immediate and future application of

creating a more dynamic Soldier to meet tactical and

operational needs in counterinsurgency missions.

Building upon the public health synergy of the new

68RS MOS, the organizational structure of Level III

PM could be changed to enhance the efficiency and

effectiveness of their efforts. The current Modified

Table of Organization and Equipment* (MTOE)

assigns 13 personnel to the detachment as shown in

Figure 1. Increasing the MTOE to 14 assigned with 3

additional designated personnel to be added during

deployment (similar to the function of the Professional

Officer Filler Information System16) as shown in

Figure 2, could greatly enhance the detachment’s

capabilities in a counterinsurgency.

Veterinary medical care is provided to Coalition

military and contract working dogs in Iraq, however,

minimal engagement with indigenous animal

populations is occurring. Team 4 of this conceptual

medical detachment could address host nation food

production, provide animal husbandry training, and

support vaccination and zoonotic disease surveillance

programs. One can argue that these missions are part

of existing veterinary doctrine, but they are not being

performed in Iraq.17 Colocating PM and veterinary

medicine assets on the same forward operating base

may facilitate coordination, but assigning both specialties to a PM detachment would synchronize these

capabilities toward a common goal. Conversely, this

concept could be applied to a veterinary detachment by

adding an Environmental Science/Engineer Officer

(MOS 72D/E) and Public Health Specialists (MOS

68RS) to their MTOE.

Additionally, the Medical Laboratory Specialist (MOS

68K10) would bring a comprehensive laboratory

capability for the analysis of food, water, tissue, blood,

and body fluid. Based on the experiences with

legionella, Methicillin Resistant Staphylococcus

Aureus, tuberculosis, Q-fever, and suspected cases of

leishmaniasis, histoplasmosis, salmonella, E. Coli, and

other illnesses during the OIF 06-08 rotation, the

Medical Laboratory Specialist must be qualified to test

for some of these and other infectious agents found in

austere environments. The Medical Logistics

*Defines the structure and equipment of a military organization or unit.

HEADQUARTERS

Commander (Major, MOS 72D/B*)

Executive Officer (Captain, MOS 72B/D*)

First Sergeant (MOS 68S40*)

Mechanic (MOS 63B10*)

PUBLIC HEALTH TEAM 1

3 Preventive Medicine Specialists:

MOS 68S30

MOS 68S20

MOS 68S10

PUBLIC HEALTH TEAM 2

3 Preventive Medicine Specialists:

MOS 68S30

MOS 68S20

MOS 68S10

PUBLIC HEALTH TEAM 3

3 Preventive Medicine Specialists:

MOS 68S30

MOS 68S20

MOS 68S10

Figure 1. Current US Army Modified Table of Organization and Equipment personnel allocation for

the Level III Preventive Medicine Detachment.

*MOS (military occupational specialty) glossary:

72B Entomologist

72D Environmental Science Officer

68S Preventive Medicine Specialist

63B Light-Wheel Vehicle Mechanic

Level III Preventive Medicine in a Counterinsurgency Environment
April – June 2008 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

Specialist (MOS 68J10) could manage all classes of

supply for this new detachment. A PM Specialist

currently performs logistics duties which draws time

and effort away from the PM mission. Assignment of a

Medical Logistics Specialist to the MTOE to manage

unit logistics would liberate the Public Health

Specialists to perform their public health mission.

Collectively, these changes would eliminate

redundancy, increase efficiency, and assist host nations

in meeting public health needs.

Training

Four years into the Iraq counterinsurgency, the PM

community continues to focus support internally on

Coalition assets rather than externally on the civilian

population and Iraqi Security Forces. This lack of

public health integration exists for many reasons, some

within and others outside of DoD’s control.

Institutional training provides fertile ground to

increase this capacity.

HEADQUARTERS

Commander (Major, MOS 72B/D/E*)

Executive Officer (Captain, MOS 72B/D/E*)

First Sergeant (MOS 68RS40*)

Mechanic (MOS 63B10*)

Medical Supply Specialist (MOS 68J10*)

PUBLIC HEALTH TEAM 1

3 Preventive Medicine Specialists:

†MOS 68RS30

MOS 68RS20

MOS 68RS10

PUBLIC HEALTH TEAM 2

3 Preventive Medicine Specialists:

†MOS 68RS30

MOS 68RS20

MOS 68RS10

PUBLIC HEALTH TEAM 3

3 Preventive Medicine Specialists:

†MOS 68RS30

MOS 68RS20

MOS 68RS10

‡PUBLIC HEALTH TEAM 4

Veterinary Officer (Captain, MOS 64B)

Veterinary Technician (MOS 68T10)

Medical Laboratory Technician (MOS 68K10)

Figure 2. Current US Army Modified Table of Organization and Equipment§ personnel allocation

for the Level III Preventive Medicine Detachment.

*MOS (military occupational specialty) glossary:

72B Entomologist

72D/E Environmental Science/Engineer Officer

68S Preventive Medicine Specialist

63B Light-Wheel Vehicle Mechanic

†The conceptual 68RS MOS would be created as a merger of existing MOSs 68R, Veterinary Food Inspection Specialist, and

68S, Preventive Medicine Specialist.

‡Team 4 is envisioned as Army Medical Department Professional Officer Filler System (PROFIS) staffing billets. PROFIS

predesignates qualified Active Duty health professionals serving in Table of Distribution and Allowance** units to fill Active

Duty and early deploying and forward deployed units of Forces Command, Western Command, and the medical commands

outside of the continental United States upon mobilization or upon the execution of a contingency operation.16

§Defines the structure and equipment for a military organization or unit.

**Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to

perform a specific mission for which there is no appropriate table of organization and equipment.
30 www.cs.amedd.army.mil/references_publications.aspx

All Army PM officers attend the Principles of Military

Preventive Medicine indoctrination course. The

program of instruction (POI) consists of 585.4 hours of

common core, clinical, and science track instruction.18

A review of the common core and science track

courses which are completed by nonclinicians reveals

that only 11 hours (3%) are focused on material

directly or indirectly related to counterinsurgencies

(Table 1).

Although other classes, such as water quality analysis,

develop competencies which can be applied in

counterinsurgencies, these classes do not draw

correlation between the two. Further analysis revealed

14 hours of instruction (Table 2) provided during the

clinical track relate to counterinsurgencies. These

classes should be incorporated into the common core

track to increase the capabilities of all PM officers.

Serious consideration should be given to adding

courses highlighting root causes of counterinsurgencies and effective employment of Army PM in

support of civil-military operations.

Concurrent with changes in training delivered within

the AMEDD POIs, further development of external

training must also be addressed. As previously

indicated, aggressive efforts were made by the 61st

Medical Detachment to engage CA personnel, with

little return on investment. This limited success was

certainly not due to a lack of effort, rather, the

difficulties were a result of what was routinely

observed as a lack of education. CA officers in theater

understood the significant impact water and sanitation

have during a counterinsurgency. Unfortunately,

discussions with both seasoned and new CA Officers

revealed that they had received minimal training on

how to leverage PM in bridging public health gaps.

CA doctrine discusses PM, but what emphasis is

placed on this battle operating system during initial

training is unknown to the author.12 A comprehensive

analysis of their course POI could identify where

training deviates from doctrine, and how Army PM

could provide training assistance. Cross-training CA

and PM personnel could create a symbiotic

relationship yielding substantial dividends during

counterinsurgencies.

Recent experiences in Iraq continue to identify

profound shortfalls in the Army Field Sanitation Team

(FST) program.19 The program is conceptually accepted by all levels of command, but implementation

is lacking. Many perceive the FST course as nothing

more than an avenue to obtain enlisted promotion

points. Team members are assigned on paper but lose

currency or complete the task only if time permits.

Most unit commanders do not procure FST equipment

due to high costs, other priorities, and time. The

establishment of a single National Stock Number to

streamline the FST kit would reduce the time spent

tracking numerous line items found in the current kit

and increase commander compliance. Army medics

adopted the FST responsibility in Iraq with direct

support from Level II PM personnel. Is it more

practical to add FST classes to the Army medic POI

Level III Preventive Medicine in a Counterinsurgency Environment

Title Hours

Army HIV Program 1

Introduction to Humanitarian Assistance

Operations 1

Malaria Prevention 1

Preventive Medicine Support for Disasters 1

Population Health 1

Disaster Relief Practical Exercises 2

Nutrition Concerns in Disaster Relief 2

Preventive Medicine Aspects of Detainee

Operations 2

Table 1. Common core/science track counterinsurgency related classes taught in US Army Course

6AF5 - Principles of Military Preventive Medicine.

Table 2. Clinical track counterinsurgency related

classes taught in US Army Course 6AF5 - Principles

of Military Preventive Medicine.

Title Hours

Rapid Health Assessment 1

Public Health Assessment 1

Civil Affairs and Foreign Government Liaison 2

Implications of Emerging Infectious Diseases 2

Preventive Medicine Support in Contingency

Operations 8
April – June 2008 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

and have them assume the mission? This may be a

desirable situation upon which the Army should

capitalize.

A net gain in FST training was made by the 61st

Medical Detachment during OIF 06-08. The decision

to shift training from Coalition members to the Iraqi

Security Forces was made upon arrival, and consensus

was reached at the strategic level to replicate this effort

throughout theater. Training host nation military and

civilian populations in PM is essential to sustain their

fighting force and build basic sanitation capacity.

Cultural implementation of these newly acquired skills

will not occur overnight, but they are essential in

meeting short and long term needs of the population.

Materiel

Coalition personnel in Iraq are working alongside the

ISF and operating out of austere joint security stations.

Level III PM is supplying some of those stations and

Army-led Military Transition Teams with basic FST

equipment to meet urgent needs in controlling vectors

and purifying water. Despite the regulation

requirement for supplies, they do not have the

resources on hand for many reasons.20 It should be

assumed that similar scenarios will exist in future

counterinsurgencies and Level III PM must be

equipped with additional kits to support those in need.

Insurgents will continue to pursue the use of toxic

industrial chemicals and weapons of mass destruction.

Increasing the Level III detachment’s direct chemical

reading capability to measure contaminant levels is a

critical requirement. The INFICON (Two Technology

Place, East Syracuse, New York 13057) HAPSITE®

gas chromatograph/mass spectrometer, and Smiths

(Smiths Detection, 21 Commerce Drive, Danbury, CT

06810) HazMatIDTM portable chemical identifier used

by the Army Area Medical Laboratory and Navy

Forward-Deployed Preventive Medicine Unit provide

this much needed capability. Neither of these Level IV

PM units were in theater during OIF 06-08, which

placed higher expectations upon Level III PM to

execute missions they were ill-equipped to perform.

Leadership

The current Army PM leadership was shaped by

experiences during the first Gulf War (1991) and the

Balkan deployments—a conventional war and peace

keeping operations. Much of their work led to the

development and implementation of the Occupational

Environmental Health Surveillance (OEHS) program

which is easily implemented in a linear battlefield and

semipermissive environment.21-23 This program

captures data to analyze acute, chronic, and delayed

health effects, primarily through air, soil, and water

sampling.23

Recent events in Iraq led to reprioritizing the acute

public health needs over the OEHS sampling mission.

OEHS results from the US Army Center for Health

Promotion and Preventive Medicine (CHPPM) were

provided to the 61st Medical Detachment, on average,

91 days after sample shipment for air, 52 days for soil,

and 59 days for water. Level II PM experienced

similar turnaround times resulting in a de-emphasis on

OEHS sampling in lieu of addressing acute needs

using real time analysis equipment. This was

counterintuitive for some Level II PM officers who

perceived OEHS air, soil, and water sample collection

as their primary mission and lifeline to definitive

answers. The PM community and leadership must

address the OEHS sampling and documentation

requirement in a counterinsurgency environment with

resources currently available. It may be more realistic

to have Level II and III PM personnel conduct initial

base camp OEHS sampling within their areas of

operation and Level IV PM conduct routine and base

camp closure OEHS sampling in conjunction with the

Army Corps of Engineers. Serious discussion must

also address this requirement and how PM measures

effectiveness. One could argue that OEHS sampling

does not tie directly to DNBI statistics which is the

current default measure of PM success or failure.

The effectiveness of Level III PM detachments in the

field is directly dependent on Soldiers that the Army

recruits, develops and places in positions of leadership

and command. In the final analysis, without dedicated,

intelligent, well-trained, professional leadership, none

of the other factors discussed herein will matter in the

performance of these detachments. Leaders in higher

command positions must have the full spectrum of

insight and understanding as to the capabilities and

ultimate, long-term strategic value represented by the

Level III PM resource. Only then will the assets be

intelligently applied and adequately supported. That

command perspective comes from education and

training in the strategic considerations of

counterinsurgency operations, combined with the

insights and understanding that only result from actual
32 www.cs.amedd.army.mil/references_publications.aspx

experience developing and employing the Level III

PM resources.

Over the next 5 to 10 years, leaders within the PM

community will draw upon observations and lessons

learned during the Balkan deployments and initial

phases of OEF and OIF. Over the long term, Level II

PM personnel currently serving in Iraq will assume

leadership roles. Their counterinsurgency experience

will likely drive changes in core competencies, with an

emphasis on acute and general public health

intervention, to meet what is perceived by many as the

conflict of the future.7,24,25

Personnel Recruitment

Level III PM detachments are commanded by field

grade Entomologist (MOS 72B) and Environmental

Science/Engineer (MOS 72D/E) officers, which make

these 2 specialties of particular interest in assessing

recruitment and retention. The Army objective force

for these officers is 346, with a current strength of 335

(97% fill). From 2004 to 2006, the objective force for

these professions was 72 officers, of whom 61 (85%)

are commissioned.26 They joined through direct

commissions following graduate school, college

Reserve Officer Training Corps, or the US Military

Academy. Some, like the author, convert to PM after

serving as a Health Care Administrative Assistant

(MOS 70B). Assuming that not all of the 61

commissioned officers will serve a career in the

military could justify pursuing other recruitment

avenues. A study assessing conversion trends from

MOS 70B to the MOS 72 series may justify a

marketing campaign to recruit these officers coming

out of multiple OIF rotations. They would bring a first

hand understanding of how PM can support the

warfighter during a counterinsurgency.

Supporting the field grade Level III PM detachment

commanders are company grade executive officers

serving in these specialty areas. A review of active

duty Army company grade Environmental Science/

Engineer officer authorizations revealed that half were

in garrison assignments.27 Forty-six percent of

lieutenants and 53% of captains were assigned to field

units, 26% and 25% respectively to CHPPM, and 28%

and 22% respectively to Army medical centers or other

organizations. In the perspective of an Army at war,

this appears disproportionate to the current and future

requirements. In 2006, the Army PM Consultant posed

a salient question in the Army Medical Department

Journal: “Should some MEDDAC ESO [medical

department activity environmental science officer]

positions be converted under current military-tocivilian initiatives in order to provide better

developmental opportunities for junior officers

elsewhere?”28 It could be argued there is no better

place to apply and develop skills than during combat

deployments by conserving the fighting strength of

those in harm’s way. Reducing garrison positions

could shift personnel to meet current PM shortages in

deployable multifunctional medical battalions, and

afford growth in areas such as newly activated civil

affairs battalions and each regional special operations

command. Experience in these assignments would

generate skills necessary to effectively serve as both a

Level III PM detachment executive officer and

commander in a counterinsurgency environment.

Similar analysis should be completed to assess the

proposed merger of the Veterinary Food Inspection

Specialist (MOS 68R) and Preventive Medicine

Specialist (MOS 68S) in the enlisted force structure.

Ultimately, they will serve as Level III PM detachment

members, NCOs, and detachment sergeants who

execute the unit mission. It is imperative to solicit

feedback from both recently returned and currently

deployed PM and veterinary personnel, as they

understand the current operational requirements. A

comprehensive review of the manning document for

the existing MOSs is necessary to shape future

authorizations for the proposed Public Health

Specialists (MOS 68RS). Other proposed changes,

such as replacing the current MOS 68S level 10

(Private First Class through Specialist) at each Army

brigade with a MOS 68S level 30 (Staff Sergeant),

must be considered, since these positions will drive

manning requirements.29

Personnel Retention

Numerous media outlets discuss the potential impact

of high operational demands on retention. According

to the DoD, “Army, Navy, Marine Corps, and Air

Force met or exceeded overall retention missions.”30

What is not clear are retention rates in the PM

community. Unlike most officers who enter Army PM

with a degree related to their chosen field, and with the

intention of directly applying that education, enlisted

PM personnel are selected and trained by the Army in

various skill sets necessary for their MOS. At specific

points in the enlisted career path, the Army offers

additional training of increasing sophistication to

Level III Preventive Medicine in a Counterinsurgency Environment
April – June 2008 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

support their respective specialties. However, the

Army also regularly offers opportunities and

incentives for Soldiers to change to another MOS

specialty altogether, depending on staffing priorities

and shortfalls at the time. Any Soldier considering a

long-term career in PM will evaluate opportunities in

their field against those opportunities represented in

another MOS or civilian life, and make a rational

decision. With low promotion rates to Sergeant First

Class (grade E7) and above, due in part to the scarcity

of senior PM level positions, this weighs heavily in the

minds of Staff Sergeants (grade E6). These NCOs

typically have 10 years in service and debate whether

to continue their profession, reclassify, or leave the

military. Unless the PM enlisted authorizations are

adjusted to support and encourage the pursuit of

careers by our enlisted Soldiers, the effectiveness and

manning of Level III PM will be less than optimum.

Increasing senior level enlisted PM authorizations

allowing for professional growth commensurate with

time invested could make a difference. Adding Master

Sergeant (grade E8) positions to combatant and other

strategic commands where Environmental Science/

Engineer officers currently serve would be a force

multiplier, allow for professional growth and

promotion, and positively impact retention rates.

Additionally, investing in the long term education of

both may provide an impetus to serve a career in

uniform.

The Army PM leadership took the initiative in 2004

and crafted an education and training program by

sending Environmental Science officers to the

Uniformed Services University of the Health Sciences

to complete a one-year Master of Public Health degree

followed by a one-year utilization tour in Washington,

DC. These officers can specialize in areas such as

international health which has applicability in both

disaster response and counterinsurgency operations.

Upon graduation, the officer could work at DoD or

military service headquarters levels, or other

governmental agencies, such as the Department of

State or US Agency for International Development,

applying their skills to real world requirements.

Assignments in other agencies broaden their

understanding of interagency operations and meet the

intent of DoD Directive 3000.05, Military Support for

Stability, Security, Transition, and Reconstruction

Operations31 and the Quadrennial Defense Review.

25

Facilities

Proposed consolidation of all services’ enlisted

medical training at Fort Sam Houston, Texas as part of

the Base Realignment and Closure process is

commended and should be replicated among other

medical specialties. Consolidation of training efforts

could reduce duplication in facilities, operations and

maintenance costs, and personnel required to conduct

similar training programs at 3 different service

institutions while increasing productivity and

developing a joint PM service member. Experience in

Iraq highlights similarities in capability between Air

Force, Army, and Navy professionals performing PM

tasks. Current doctrine drives requirements for each

service where the Navy traditionally focused on

maritime operations, the Air Force on wing support,

and the Army on the foot Soldier. In the

counterinsurgency environment of Iraq, Navy

Environmental Health officers are collocated on

forward operating bases with Army Soldiers. Air Force

Public Health and Bio Environmental Engineer

officers/technicians are working shoulder to shoulder

with Army personnel on large air bases. The 61st

Medical Detachment provided general area PM

support to all service personnel within multinational

divisions in Baghdad and central Iraq during the OIF

06-08 rotation. Additionally, all 3 services received

OEHS equipment and laboratory support from the US

Army Center for Health Promotion and Preventive

Medicine for the OEHS mission while deployed in

Iraq. It is imperative that leaders within each service

recognize the similarities in capabilities and

requirements to develop a common set of knowledge,

attitudes, and beliefs for a joint service PM training

platform. This platform should be institutionalized at a

consolidated PM training facility at Fort Sam Houston.

CONCLUSION

The 2006 DoD Quadrennial Defense Review states:

...the ability to wage irregular and unconventional warfare and the skills needed for counterinsurgency,

stabilization and reconstruction, military diplomacy,

and complex interagency coalition operations are

essential.25

Adoption and implementation of the aforementioned

DOTMLPF changes could facilitate transformation

within the PM community to meet these current and

future demands, and directly support overarching US

government efforts in rebuilding essential services in
34 www.cs.amedd.army.mil/references_publications.aspx

fragile societies. As recently observed in Iraq, and

highlighted by the National Security Strategy signed

by President George W. Bush:

Military involvement may be necessary to stop a bloody

conflict, but peace and stability will last only if followon efforts to restore order and rebuild are successful.32

Preventive Medicine can support both undertakings.

REFERENCES

1. Krepinevich AF Jr. The Army and Vietnam.

Baltimore, MD: Johns Hopkins University Press;

1986:6.

2. Joint Publication 1-02: DoD Dictionary of Military

and Associated Terms. Washington, DC: Joint Staff,

US Dept of Defense; July 12, 2007. Available at:

http://www.dtic.mil/doctrine/jel/new_pubs/

jp1_02.pdf.

3. Field Manual 3-24: Counterinsurgency. Washington,

DC: US Dept of the Army; 15 December 2006:1-1,2-

13.

4. Chiarelli PW, Michaelis PR: Winning the peace: the

requirement for full-spectrum operations. Mil Rev.

2005;4:4-17.

5. Field Manual 4-02.17: Preventive Medicine Services.

Washington, DC: US Dept of the Army; 28 August

2000:4-1,4-10.

6. Field Manual 1: The Army. Washington, DC: US

Dept of the Army; June 2005:4-3,4-4.

7. Nagl JA. A better war in Iraq. Armed Forces J.

A u g u s t 2 0 0 6 . Av a i l a b l e a t : h t t p : / /

www.armedforcesjournal.com/2006/08/1931298.

8. Ahearn AM. Viet Cong medicine. Mil Med.

1966;131:219-221.

9. Carmona RH. Presentation to the National Disabled

Veterans Winter Sports Clinic. Aspen, CO: 2003.

10. Field Manual-Interim 3-07.22: Counterinsurgency.

Washington, DC: US Dept of the Army; 1 October

2004. Replaced by FM 3-24, 2006.

11. US Dept of State. Fact Sheet on Provincial

Reconstruction Teams. Baghdad, Iraq: Embassy of

the United States; 2006.

12. Field Manual 4-02.43: Force Health Protection

Support for Army Special Operations Forces.

Washington, DC: US Depart of the Army; 27

November 2006:4-11,4-12.

13. Erickson RL. Military Preventive Medicine:

Mobilization and Deployment. Vol 1. Washington,

DC: Borden Institute, Office of the Surgeon General,

US Dept of the Army; 2003:81-98.

14. Keating PJ. Moroccan flood relief: a personal report.

Med Bull US Army Eur. 1963;20(4):96-99.

15. Webb CR Jr. Medical considerations in internal

defense and development. Mil Med. 1968;133:391-

396.

16. Medical Corps Professional Development Guide.

Fort Sam Houston, TX: US Army Medical

Department Center and School; March 2002:27.

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

Techniques, and Procedures. Washington, DC: US

Dept of the Army; 30 December 2004:1-1,4-7.

18. US Army Medical Dept. Principles of Military

Preventive Medicine Program of Instruction. Fort

Sam Houston, TX: US Army Medical Dept Center

and School; 2003.

19. Field Manual 4-25.12: Unit Field Sanitation Team.

Washington, DC: US Dept of the Army; 25 January

2002:1-1,2-75.

20. Army Regulation 40-5: Preventive Medicine.

Washington, DC: US Dept of the Army; 25 May

2007:1-19.

21. Department of Defense Directive 6490.2:

Comprehensive Health Surveillance. Washington,

DC: US Dept of Defense; 21 October 2004:1-6.

22. Department of Defense Instruction 6490.03:

Deployment Health. Washington, DC: US Dept of

Defense; 11 August 2006:5-13.

23. Army Regulation 11-35: Deployment Occupational

and Environmental Health Risk Management.

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

2007:1-9.

24. Hammes TX. The Sling and The Stone.. St. Paul,

MN: Zenith Press; 2004:xiii-xiv,224-291.

25. Office of the Secretary of Defense. Quadrennial

Defense Review Report. Washington, DC: US Dept of

Defense; February 6, 2006.

26. Army Medical Service Corps. Career Management

Histograms. Alexandria, VA: US Dept of the Army;

December 2006.

27. Army Medical Service Corps: MOS 67C Roster.

Alexandria, VA: US Dept of the Army; February

2007.

28. Ciesla JJ. The evolving role of Environmental

Science Officers and Environmental Engineers in the

Medical Service Corp. Army Med Dept J. April-June

2006:19.

29. Sames WJ, Delk TC, Lyons PJ: Field preventive

medicine: challenges for the future. Army Med Dept

J. April-June 2006:43.

Level III Preventive Medicine in a Counterinsurgency Environment
April – June 2008 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

30. DoD Announces Recruitment and Retention Numbers

for June [press release]. Washington, DC: Office of

the Assistant Secretary of Defense (Public Affairs),

US Dept of Defense:2007.

31. Department of Defense Directive 3000.05: Military

Support For Stability, Security, Transition, And

Reconstruction (SSTR) Operations. Washington, DC:

US Dept of Defense; November 28, 2005:1-11.

32. The National Security Strategy of the United States of

America 2006. Washington, DC: The National

Security Council, The White House; March 2006:16.

Available at: http://www.whitehouse.gov/nsc/

nss/2006/nss2006.pdf.

AUTHOR

MAJ Licina is Commander, 61st Medical Detachment,

86th Combat Support Hospital (CSH), Fort Campbell,

Kentucky. The 86th CSH is a part of the 44th Medical

Command at Fort Bragg, North Carolina.

86th Combat Support Hospital

44th Medical Command
36 www.cs.amedd.army.mil/references_publications.aspx

The Chemical, Biological, Radiological, and High

Yield Explosives (CBRNE) Sciences Branch*

provides training to a diverse group of students,

including members of the various US military services,

foreign students, and civilians on medical operations

on the nuclear, biological, chemical, or directed energy

battlefield; as well as the safe use of radiation and

radioactive materials. In 2007, the CBRNE Sciences

Branch taught the 5-day Tactical Radiological

Operations (TRO) Course at the Idaho National

Laboratory, Idaho Falls, ID. The TRO course was

developed and has evolved in response to lessons

learned after 4 years of deployments in support of

Operation Enduring Freedom (OEF) and Operation

Iraqi Freedom (OIF). The gap analysis suggested that

traditional health physics training designed for hospital

and garrison environments did not provide the

instruction and focus that Nuclear Medical Science

Officers need when dealing with radiological hazards

in nonmature theaters of operation.

The regulatory constraints on the use of licensed

radioactive material limit the ability of the Army

Medical Department Center and School

(AMEDDC&S) to provide real world situations where

health physics training would more closely replicate

deployment and homeland defense scenarios. At the

Idaho National Laboratory, the Department of Energy

was able to provide, at one location, access to a unique

combination of facilities, radioactive materials, and

trained professional staff that cannot be duplicated at

any Department of Defense facility. In order to bridge

training gaps, the CBRNE Sciences Branch and the US

Army Chemical School coordinated with the Idaho

National Laboratory to accommodate OEF and OIF

scenario-driven environmental health physics training

for military personnel. The TRO course consists of

didactic health physics training, radiation detection/

identification equipment training, high energy

radioactive source identification and quantification,

and radiological dispersal device training that

culminated with a field training exercise incorporating

basic military skills and team technical skills. It is also

designed to facilitate small team training and

interaction with training scenarios to provide

opportunities for both individual leadership

development and team problem solving.

Across the Army manpower structure, there are many

different military occupational skills that have similar

military knowledge requirements. This is true for

radiological operations for some medical, chemical

corps, and engineering disciplines. In order to broaden

the availability of quality subject matter experts to

address multiple mission requirements for such

specialists, the TRO course is offered for Environmental Science and Engineering Officers and Chemical Operations Specialists.

The 2007 scenarios included:

 Tactical movement of a survey team into a

location to conduct a base camp assessment for

radiological hazards

 High energy radioactive source identification and

mitigation to include exposure guidance for

personnel

 Decontamination of personnel exposed to weapons

grade or other nuclear materiel

 Encounters with media personnel regarding

potential radioactive contamination to military and

host nation personnel

Preparing the Force for the Chemical,

Biological, Radiological, and High Yield

Explosives Battlefield; Today and Tomorrow

LTC Gary Matcek, MS, USA

Scott Crail, MS

SFC Courtney Moore, USA

James Bernardo

*Department of Preventive Health Services, AMEDD Center and

School
April – June 2008 37

The critical tasks accomplished were:

 Selection of the proper radiation detection/

identification equipment for a given mission.

 Proper operation of radiation detection/

identification equipment for a given mission.

 Design radiological survey using Technical Guide

236A; Basic Radiological Dose Estimation – A

Field Guide,

1

and then brief the brigade

commander.

 Conduct radiological survey of area to include

soil, air, and water sampling.

TESTING AND FIELDING NEW EQUIPMENT

Recently, the CBRNE Sciences Branch participated in

several meetings about the development of the new

XM-329 Joint Chemical, Biological and

Radiological Agent Water Monitoring System

(JCBRAWM). The system is under

development by the US Chemical Corps to

augment the M272 Water Test Kit in response

to the Army’s identification of the need to

expand the M272 capability to include the full

spectrum of CBRNE threats. The requirement

for expansion in capabilities is the result of

recent threats in the areas of homeland

security and homeland defense. The

JCBRAWM consists of the AN/PDR-77

Radiac Detector Set which tests water for

possible radiological contamination, the Hand

Held Assay for possible biological

contamination, and the standard M272 Water

Test Kit for chemical contamination.

As the Nuclear Medical Science Officers and

Preventive Medicine Specialists execute their wartime

mission of base camp assessment, the enhanced

capability provided by the JCBRAWM will further

improve the safety and survivability of all Soldiers on

the battlefield by ensuring that water sources are at an

acceptable level of cleanliness and purification for

consumption. In addition, it will increase the capability

of the US Chemical Corps to identify which natural or

manmade water sources should or should not be used

for personal or equipment decontamination.

As a further complement to the type of equipment that

will be used to sample and test water, the US Chemical

Corps has enhanced the immediate personnel

decontamination capability of the Army by developing

the Reactive Skin Decontamination Lotion (RSDL).

The new lotion provides a Soldier with the capability

to perform on-the-spot decontamination without the

necessity of the full spectrum decontamination line—a

manpower intensive process. Through the use of the

JCBRAWM and the RSDL, the Preventive Medicine

Specialist will now have the ability to conduct on-thespot chemical, biological, and radiological testing,

with the added capability for personal and equipment

decontamination.

Both AMEDD and the Chemical Corps will benefit

from these recent new equipment developments. Even

though JCBRAWM development testing is not

complete, the CBRNE Sciences Branch will continue

to represent the Army Medical Command in advising

the developmental team to ensure optimum usability

by Preventive Medicine Specialists.

A STANDARD OF PROFICIENCY FOR FIXED

MEDICAL TREATMENT FACILITIES IN ALLHAZARDS RESPONSE

A hazardous material incident involving CBRNE

hazards or other threats, whether accidental or

intentional, has the potential to produce catastrophic

loss of life or property, or strike terror in the affected

population. An incident may occur in the US or

overseas. The Army Training and Evaluation Plan–

Mission Training Plan for US Army fixed installation

medical treatment facilities (MTF) provides hospital

and clinic commanders and staff with a descriptive,

mission oriented program to train the facility staff to

perform its critical operations during such an event.

Joint Chemical, Biological, and Radiological Agent Water

Monitoring System (JCBRAWM)
38 www.cs.amedd.army.mil/references_publications.aspx

While US Army Medical Command directives,

national healthcare standards, and local conditions and

procedures dictate unique training requirements and

performance standards, the Mission Training Plan

describes many of the tasks that any staff of a hospital

or clinic may be called upon to execute with a high

level of proficiency. The commander of each facility is

not expected to train on every single task in the

Mission Training Plan; rather, tasks are selected and

prioritized based on an assessment of an MTF’s

strengths and weaknesses, and on those tasks that

focus on training deficiencies that impact on the

MTF’s ability to perform its first receiver mission.

The CBRNE Science Branch was assigned the task to

develop an Army Training and Evaluation Plan

containing individual, collective, and leader tasks for

fixed military MTFs to support installation protection

missions and plans for CBRNE and all other hazards.

The training documents traditionally have a unit/

activity doctrinal manual to provide operating

principles and techniques that allow the training

developer to analyze and enumerate collective tasks

for the entity. In this case, there was no baseline

publication for fixed installation MTFs, thus, the team

relied on an extensive literature review to help develop

the tasks.

The unit, leader, and individual training syllabi support

the accomplishment of both Homeland Security

missions and traditional full spectrum military

operations. Therefore, current doctrinal manuals,

Army Training and Evaluation Plan–Mission Training

Plans, and federal government response guidelines

offer a wealth of information on training tasks that can

be adapted for installation MTFs. According to the

Army Training and Doctrine Command Regulation

350-70,

2

a revision of tasks rather than a full-scale

developmental effort is preferred for training similar

missions in a different environment or setting. By

identifying tasks from current documentation, the team

can build a basic outline from which to further analyze

and refine required CBRNE tasks for a fixed MTF.

Once candidate tasks have been defined, a mission/job

analysis must still be conducted to identify critical

collective tasks. This is a key step, since the collective

tasks performed to accomplish a unit or MTF mission

will drive the development or revision of individual

and leader tasks that directly support the mission.

Mission analysis identifies unit organizational and

functional structure before development of unit

training products.

Armed with baseline collective, leader, and individual

tasks, members of the team and a government

representative will conduct site visits to MTFs. This is

required to receive input from the MTF commander

and staff and to analyze candidate tasks within the

context of existing installation plans and standard

operating procedures.

As a result of site visits and continuing analysis and

development, a list of proposed collective, leader, and

individual tasks are presented for review. An example

of proposed tasks in support of CBRNE events are:

 Perform public health emergency officer functions

 Conduct termination planning

 Conduct interagency coordination

 Review and update CBRNE incident response plan

A task validation board or some other proponent

mechanism will then be convened for further review

and selection to approve the proposed tasks. Once that

approval is received, the training developers will enter

the tasks into the Automated Systems Approach to

Training.

The trainers/evaluators will develop and present a

training evaluation plan based on the approved

collective, leader, and individual tasks. Training

evaluation is the process used to identify task

performance and deficiencies in unit and individual

training, and to obtain recommendations for

improvement of training, or the products that support

training. There is no specific procedure prescribed for

Army Training and Doctrine Command proponents in

the development or conduct of unit training evaluation.

The procedures selected are dependent upon a variety

of factors, including, in this case, the MTF real-world

workload, whether the unit can be visited by external

evaluators, whether actual training execution can be

observed, and how many unit personnel are available

to participate in an exercise or other evaluation

vehicle. By its very nature, CBRNE response exercises

in a Homeland Security scenario require enormous

amounts of coordination and resources from local,

state, and federal agencies and role players to provide

Preparing the Force for the Chemical, Biological, Radiological, and

High Yield Explosives Battlefield; Today and Tomorrow
April – June 2008 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

the proper test conditions. Therefore, standard Army

and AMEDD evaluation regimens may yield to the

Department of Homeland Security and/or state

emergency management evaluation schedules and

requirements. Individual and leader task evaluations

can be done in the schoolhouse or at the MTFs by use

of student performance measurement and testing,

including practical exercise, and therefore lend

themselves to a regular assessment schedule without

the need for a large commitment of resources. The

evaluators will take these factors and AMEDD

guidance into account in development of the

evaluation plan.

Training and evaluation exercises for a fixed MTF are

inherently difficult for the commander for a variety of

reasons. Most notably, the hospital or clinic must

perform real-world missions, resulting in severe time

and resource constraints for training missions, which

impact personnel availability issues. Despite the need

to perform day-to-day operations, the facility must

train and undergo periodic evaluations in accordance

with directives, not only from higher command, but

from civilian agencies such as the Joint Commission

on Accreditation of Healthcare Organizations and the

Department of Homeland Security. The strategy

selected by the commander for training MTF

departments must include various methods of training

individuals, designated staff, leaders, and the

department and facility staffs as a whole.

ACKNOWLEDGEMENT

The authors gratefully acknowledge the assistance of

Eric Bodenhausen, Jose Perez, and Doug Hanson for

their editorial review and comments.

REFERENCES

1. Technical Guide 236A, Basic Radiological Dose

Estimation – A Field Guide. Aberdeen Proving

Ground, MD: US Army Center for Health Promotion

and Preventive Medicine; August 15, 2001. Available

at: http://chppm-www.apgea.army.mil/documents/tg/

techguid/tg236a.pdf.

2. TRADOC Regulation 350-70: Systems Approach to

Training Management, Processes, and Products. Fort

Monroe, VA: US Army Training and Doctrine

Command; March 9, 1999:chap II-11. Available at:

http://www-tradoc.army.mil/tpubs/regs/r350-70/

350_70_ii_11.htm.

AUTHORS

LTC Matcek is the Officer in Charge, CBRNE Sciences Branch, Department of Preventive Health Services, AMEDD

Center and School, Fort Sam Houston, Texas.

Scott Crail is a Senior Radiological CBRNE Instructor, CBRNE Sciences Branch, Department of Preventive Health

Services, AMEDD Center and School, Fort Sam Houston, Texas.

SFC Moore is the Noncommissioned Officer in Charge, CBRNE Sciences Branch, Department of Preventive Health

Services, AMEDD Center and School, Fort Sam Houston, Texas.

Mr Bernardo is a Project Manager, Training Developer, and Instructor, CBRNE Sciences Branch, Department of

Preventive Health Services, AMEDD Center and School, Fort Sam Houston, Texas.
40 www.cs.amedd.army.mil/references_publications.aspx

OVERVIEW

On 15 September 2005, President Bush endorsed the

Department of Defense (DoD) Base Closure and

Realignment Commission’s (BRAC) report and

forwarded it to Congress. The congress had 45

legislative days, until November 9, 2005, to accept or

reject the report in its entirety. However, it was not

authorized to make any changes to the final report.1

Since the congress took no action before the deadline,

the BRAC recommendations became law. By statute,

DoD had until September 15, 2007, to initiate closing

and realigning the installations specified in the report.

Additionally, the process must be completed by

September 15, 2011.2

Included in the BRAC recommendations was

Commission Recommendation 172, San Antonio

Regional Medical Center, Texas.3It is within this

recommendation that the concept of the Medical

Education and Training Campus (originally submitted

under BRAC as the Medical Enlisted Training Center)

was established. The recommendation specifically was

to relocate “...all (except Aerospace Medicine)

medical basic and specialty enlisted training at Fort

Sam Houston, Texas, with the potential of

transitioning to a joint training effort.”4In response to

the requirement for the Medical Education and

Training Campus, the Army Medical Department

Center and School (AMEDDC&S) directed its

subordinate teaching departments to coordinate with

the Interservice Training Review Organization

(ITRO). The ITRO then conducted meetings among

the services to determine if courses would collocate or

integrate. The specified construct was:

 Quick Look Group

 Detailed Analysis Group

 Resources Required Analysis

While this process is uniform for all, the remainder of

this article will focus on its application to Preventive

Medicine.

QUICK LOOK GROUP

The Preventive Medicine Quick Look Group,

composed of the Army 68S10* Program Manager,

Class Advisor, and Instructional Systems Specialist;

and the Navy Program Manager, Service Lead, and

Instructional Systems Specialist; along with various

ITRO staff, met from September 12-14, 2006. This 3-

day initial study revealed sufficient commonality

existing between the US Army Preventive Medicine

Specialist Course†and the US Navy Preventive

Medicine Technician Course‡to propose consolidating

a majority of the training and recommend continuing

the ITRO process. The members of this Quick Look

Group agreed to future meetings to develop a

consolidated curriculum and identify computer based

training opportunities. It was agreed that membership

of these studies should include the current participants.

The Quick Look Group made the following specific

recommendations:

 Ensure a joint services curriculum and required

support facilities will be in compliance with

current certification/accreditation requirements.

 Coordinate proposed facilities plans with service

subject matter experts.

 Due to shipboard and Fleet Marine Force training

requirements, Navy students must have phase II,

Navy specific sites (ie, shipboard training).

 Phase II sites will require dedicated instructor

staff.5(p6)

The Army Preventive Medicine Specialist

in the Medical Education and Training

Campus Era

LTC Dennis B. Kilian, MS, USA

SFC Roye L. Patton, USA

HMCS William Adams, USN

*Army Military Occupational Specialty 68S10, Preventive

Medicine Specialist

†Army Training Course 322-68S10

‡Navy Training Course HM 8432
April – June 2008 41

Since the US Air Force enlisted preventive medicine

personnel are considered part of the aerospace

medicine community, their training will relocate from

Brooks City Base, San Antonio, TX, to Wright-Patterson Air Force Base, Dayton, OH. Consequently, the

Air Force is not part of the BRAC-driven preventive

medicine training review and reorganization.

DETAILED ANALYSIS GROUP

The meeting of the Preventive Medicine Detailed

Analysis Group was held March 6-8, 2007. The

military training personnel who were previously part

of the Quick Look Group conducted an in-depth

analysis of the 2 programs of instruction (POI)

conducted in the training of service specific preventive

medicine personnel.

The Army trains Preventive Medicine Specialists

(Military Occupational Specialty 68S10) for 15 weeks

(75 academic days) at the AMEDDC&S, Fort Sam

Houston, Texas. For planning factors, the Army

training requirement for Fiscal Year (FY) 2010 is 209

students. The basic course* consists of 532 hours of

didactic/laboratory/practical training, and 110 hours of

field training exercises and situational training

exercises—a total of 642 academic hours. At the time

of review by the Detailed Analysis Group, there were

7 class iterations per year, with a maximum class

population of 32 students, minimum of 12 students,

and an average of 21. The enrollment pay grade for

Active Army Soldiers is E4 or below, E6 or below for

members of the Reserve Component. As a part of the

POI, students must pass specified areas of the DoD

Pest Management Certification exam. Additionally,

they are offered the opportunity to take the ServSafe®

certification examination.†

The Navy trains Preventive Medicine Technicians

(PMT) for 26 weeks (130 academic days) at the Naval

School of Health Sciences, San Diego, California. The

Navy training requirement for FY 2010 is 160

students. The Navy uses multiple clinical and field

training sites, including ships, fixed facilities, and local

civilian facilities. The PMT basic course consists of

844 hours of didactic/laboratory/practical training

(including a 160-hour course: Medical Entomology

and Pest Management Technology for PMTs), and 64

hours of other required training and activities. The

training totals 1,040 hours. At the time of review by

the Detailed Analysis Group, there were 4 class

iterations per year, with a maximum class population

of 40 students, minimum of 20 students, and an

average of 40. The enrollment pay grade for active

duty Navy is E3 through E7. This course is open to

Navy Reserve and Coast Guard personnel. As a part of

the POI, students are required to pass specified pest

management categories of the DoD Pest Management

Certification exam. Students may take the Certified

Environmental Health Technician exam from the

National Environmental Health Association.5(p6)

During the Detailed Analysis Group working sessions,

the Army and Navy representatives presented several

concerns for further examination:

Army

 AMEDDC&S will be able to continue to invite

international students to attend preventive

medicine training.

 Ensure that food service sanitation remains in the

curriculum to enable Army students to

successfully pass the ServSafe Exam.5(p5)

Navy

 Scope of practice – a concern because Navy PMTs

operate clinically, unlike Army preventive

medicine personnel.

 Course content – considered an opportunity since

Joint Occupational and Environmental Health

Surveillance is largely undocumented in the Navy

POI5(p5) (current requirements driven by a DoD

Directive,6a DoD Instruction,7and a

memorandum from the Chairman of the Joint

Chiefs of Staff 8).

 Requirement for a Phase II clinical site – since

there are no shipboard environment training

facilities at Fort Sam Houston, teaching shipboard

practices would be problematic.

 Accreditation/certifications – maintaining accreditation/certifications was viewed as a critical

requirement, which is consistent with other

programs relocating and integrating into the

Medical Education and Training Campus concept.

*Army Training Course 322-68S10

†The ServSafe Food Safety Certification is a risk management

program of the National Restaurant Association Educational

Foundation. ServSafe is the most widely accepted food safety

program among local, state, and federal health departments.

Information available at http://www.nraef.org.
42 www.cs.amedd.army.mil/references_publications.aspx

As a result of the work of the Preventive Medicine

Detailed Analysis Group, a recommendation for the

core consolidation of approximately 449 hours of

instruction was submitted. The resultant total Army

course length will be 642 hours, the Navy course

length will be 1,120 hours. Within each syllabus, 449

hours of instruction will be presented in a joint

format.5(p7)

RESOURCE REQUIREMENTS ANALYSIS

The Preventive Medicine Resources Required

Analysis was conducted at the AMEDDC&S, August

14-16, 2007. The following were the areas of focus

during the sessions:

Manpower analysts identified instructor, average daily

student load, and student man-year requirements. The

representatives reviewed the course model data

developed during the Detailed Analysis Group. The

group consensus was a consolidated lecture ratio of

2:56 (later amended to 2:61). The discussion focused

on the requirement to divide students into groups with

a ratio of 1 instructor for every 6 students during the

majority of the consolidated laboratory exercises.

Service instructors expressed concerns that instructor/

student ratios should be preserved. This concern was

due to the fact that proper instructor/student ratios

were not initially being maintained during overlapping

iterations (overlapping iterations drive requirements to

21 instructors, without regard to service). The

manpower cost model initially authorized 17

instructors (8 Navy, 9 Army). After further analysis,

21 instructors (10 Navy, 11 Army) were authorized,

thereby resolving concerns about instructor/student

ratios. The initial class size was 56 students (36 Army,

20 Navy) with 6 projected class iterations.9 These

numbers were revised at the design charrette* for the

Medical Education and Training Campus buildings 3

and 4, raising class size to 61 students (35Army, 26

Navy).

Facilities analysts did an in-depth review to identify all

requirements needed to support training. The analysts

used FY 2010 year of execution data and service

student numbers for all studies. The analysts, in

conjunction with service subject matter experts,

determined the consolidated and integrated enlisted

preventive medicine instructional facility would have 4

laboratories: microbiology/water analysis (Figure 1),

industrial hygiene (Figure 2), medical entomology,

which would have an associated small multifunction

lab primarily used by the Navy for clinical aspects of

public health (Figure 3). In addition, 4 student lecture

classrooms were designed: one for 61 students in a

joint lecture environment, one for 36 students for

Army specific lecture, and 2 classrooms, each seating

26 students for Navy specific lectures.

Resources Required Analysis attendees met with the

Medical Education and Training Campus/Transition

Integration Office (METC/TIO) staff to determine

equipment requirements, manpower overhead, and the

concept of operations.

The METC/TIO staff also discussed academic

concerns regarding curriculum development, clinical

sites, and accreditation and certification issues.9(p3)

The Navy representatives expressed several concerns

relative to academics and associated accreditation and

certification. For example, the Program Director must

be a credentialed (grade O5) Environmental Health

Officer or Army equivalent Environmental Science

*A final, intensive effort to finish a project before a dead-line.

Source: Random House Unabridged Dictionary. New York, NY:

Random House, Inc; 2006.

Figure 1. Planned preventive medicine microbiology/

water analysis laboratory classroom (61 students,

1,661 sq ft) for the consolidated and integrated enlisted

preventive medicine instructional facility at Fort Sam

Houston, Texas.

The Army Preventive Medicine Specialist in the

Medical Education and Training Campus Era
April – June 2008 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

Figure 3. Planned preventive medicine medical entomology laboratory classroom (2,548 sq ft)

for the consolidated and integrated enlisted preventive medicine instructional facility at Fort

Sam Houston, Texas.

Figure 2. Planned preventive medicine industrial hygiene laboratory classroom (2,905 sq ft) for

the consolidated and integrated enlisted preventive medicine instructional facility at Fort Sam

Houston, Texas.
44 www.cs.amedd.army.mil/references_publications.aspx

and Engineering Officer (ESEO) to meet requirements

which allow Navy students to sit for certification

exams. As previously discussed, Navy PMTs are

currently eligible for the National Environmental

Health Association professional certification*as a

Certified Environmental Health Technician (CEHT).

The Navy PMTs take the CEHT examination at the

end of the entire curriculum (including clinical

training) prior to transfer to their next duty station.

Navy PMTs are eligible for the examination based on

the current Navy curriculum which allows the student

to earn 48 to 60 semester hours of credit towards the

Bachelor of Science (Health Sciences) degree

completion program at selected colleges and

universities.10 Since the Army requires credential

certification of all field grade ESEOs,11 the Navy

agreed to the rotation of the directorship of this

program.

DESIGN CHARRETTE

After the Resources Required Analysis, the METC

leadership team held a series of design charrettes,

which included AMEDDC&S preventive medicine

representatives, to address each of the Medical

Instructional Facilities (MIF) (preventive medicine is

assigned to MIF-4). It is within this process that

detailed requirements for laboratories, classrooms,

white boards, smart podiums, etc, were documented.

The results of this effort yielded a formal request for

proposal, which, at the time this article was written,

had not been released.

CONCLUSION

The US Army has invested heavily in the future of

preventive medicine. They have driven detailed

analyses of time, programs of instruction, and

equipment and facilities required to produce the

Soldiers of tomorrow. Make no mistake, the future of

the Army Preventive Medicine Specialist is bright.

From Initial Entry Training/Advanced Individual

Training, our Soldiers will have the benefit of working

and learning in a joint services environment. While the

initiative for a unified medical command was not

adopted because of the significant differences in

organization, responsibilities, and operations of US Air

Force preventive medicine assets relative to the Army

and Navy, the Services have been directed by the

Deputy Secretary of Defense into a “new governance

plan.”12 This plan focuses on medical research,

medical education and training, health care delivery in

major markets, and shared support services. While this

does not include battlefield health care, the primary

and most crucial reason for considering a unified

medical command, the Army Preventive Medicine

Specialist and Navy Preventive Medicine Technician

will reap the benefits of BRAC 2005 Recommendation

172.3 This is because both Army and Navy preventive

medicine personnel serve in infantry units—the Army

brigade combat team and the Navy in the Marine

Corps infantry battalion. Currently, in Iraq and

Afghanistan there are countless examples of Army and

Navy preventive medicine units working both

interoperably and interchangeably, furthering DoD’s

Force Health Protection requirements. By starting this

orientation of our Soldiers at the earliest point in their

Army career, the Army and Navy will only improve

this requirement.

REFERENCES

1. Gilmore GJ. President sends BRAC commission

report to Congress [Dept of Defense information

website]. September 16, 2005. Available at: http://

www.defenselink.mil/news/newsarticle.aspx?

id=17278. Accessed January 17, 2008.

2. Miles D. BRAC deadline expires; DoD to begin

closures, realignments [Dept of Defense information

website]. November 9, 2008. Available at: http://

www.defenselink.mil/news/newsarticle.aspx?

id=18352. Accessed January 17, 2008.

3. US Dept of Defense. 2005 Base Closure and

Realignment Commission Report. Vol 1. Arlington,

Virginia: Defense Base Closure and Realignment

Commission; September 8, 2005:262. Available at:

http://www.brac.gov/docs/final/Volume1BRAC

Report.pdf. Accessed April 17, 2008.

4. Medical Joint Cross Service Group. Annex. X:

Medical Joint Cross Service Group Report for BRAC

2005. Arlington, Virginia: Defense Base Closure and

Realignment Commission, Medical Joint Cross

Service Group; May 9, 2005:43. Available at: http://

www.defenselink.mil/brac/pdf/VolX_Medical-o.pdf.

Accessed January 17, 2008.

5. Health Care Interservice Training Office. Detailed

Analysis Group Report: 6-8 March 2007. San Diego,

California; Naval School of Health Sciences; 2007:3.

6. Department of Defense Directive 6490.02E;

Comprehensive Health Surveillance. Washington,

DC: US Dept of Defense; October 21, 2004.

The Army Preventive Medicine Specialist in the

Medical Education and Training Campus Era

*Information available at: http://www.neha.org/credential/
April – June 2008 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

7. Department of Defense Instruction 6490.03;

Deployment Health. Washington, DC: US Dept of

Defense; August 11, 2006.

8. Office of the Chairman, Joint Chiefs of Staff.

Memorandum MCM 0028-07, Procedures for

Deployment Health Surveillance. Washington DC:

US Dept of Defense; November 2, 2007. Available

at: http://amsa.army.mil/Documents/JCS_PDFs/

MCM-0028-07.pdf.

9. Health Care Interservice Training Office. Resource

Requirements Analysis Summary Report: JuneSeptember 2007. Fort Sam Houston, Texas; US Army

Medical Dept Center and School; 2007:3.

10. Health Care Interservice Training Office. Preventive

Medicine Specialist: Preventive Medicine

Technician: Resource Requirements Analysis Report:

14-16 August 2007. Fort Sam Houston, Texas; US

Army Medical Dept Center and School; 2007:4.

11. Army Pamphlet 600-4; Army Medical Department

Officer Development and Career Management.

Washington, DC: US Dept of the Army; June 27,

2007:78.

12. Philpott T. Rejected medical command [Military.com

website]. December 16, 2006. Available at: http://

www.military.com/features/0,15240,120543,00.html.

Accessed January 27, 2008.

AUTHORS

LTC Kilian is Chief, Environmental Quality Branch,

and Program Manager for 68S10, Department of

Preventive Health Services, AMEDDC&S, Fort Sam

Houston, Texas.

SFC Patton is the Noncommissioned Officer in Charge,

Environmental Quality Branch, and Class Advisor for

68S10, Department of Preventive Health Services,

AMEDDC&S, Fort Sam Houston, Texas.

At the time this article was written, HMCS Adams was

the Service Lead, Preventive Medicine Technician

Course, Naval School of Health Sciences, San Diego,

California. He is currently the Command Master Chief,

USS Reuben James (FFG-57).

The US Army Medical Department Center and School, Fort Sam Houston, Texas
46 www.cs.amedd.army.mil/references_publications.aspx

INTRODUCTION

Arthropod-borne pathogens that cause diseases, such

as malaria, yellow fever, and dengue, are major health

threats to the military. For example, losses to malaria

and other preventable diseases among Allied forces

operating in the China-Burma-India theater during

World War II far exceeded the number of casualties

inflicted by enemy action.1 Malaria was second only to

combat injury as the reason for hospitalization among

American troops in Vietnam, and the number one

reason for troops deployed to Somalia.2 A significant

proportion of Joint Task Force personnel inserted into

Liberia in August 2003 (80 out of 290 who had been

ashore) experienced symptoms of malaria.3Infected

troops returning to the United States increase the rate

of imported malaria.4

Anopheles mosquito species are solely responsible for

global malaria cases. Over 450 species of Anopheles

are known, but only a fraction are malaria vectors.

More precise information on the actual and potential

geographic distribution of the species responsible for

malaria could assist a host of health-related actions,

including predeployment counselling for prophylaxis;

the choice of health messages during deployment;

decisions as to the locations of refugee camps,

hospitals, and bases; postdeployment evaluation of

health risk exposures; selection of the type and extent

of vector control; the choice of vector identification

tools; identification of the likely vector for a region;

and management or quarantine of invasive vector and

parasite species.

Recently, computer programs have become available

that combine climate information with data on where

organisms have been collected to produce maps of the

potential distribution of these organisms.5,6 A variety

of mosquito species have been modeled in this way.7,8

The output from these models, usually the suitability

for occurrence of a particular species, can be extended

to a resolution of one km2or less.

The zone where humans, parasites and vectors cooccur constitutes a geographic area of malaria risk that

we dub the “mal-area” (see Figure 1). The mal-area

can be regarded as the ecological niche or potential

spatial extent of this disease.9 A subset of the

ecological niche is the mal-area of current

transmission, which expands and contracts according

to the level of mosquito survival and abundance,

human-vector contact, and case detection and

Malaria Risk Assessment for the

Republic of Korea Based on

Models of Mosquito Distribution

Desmond H. Foley, PhD

COL (Ret) Terry A. Klein, MS, USA

Heung Chul Kim, PhD

Richard C. Wilkerson, PhD

Leopoldo M. Rueda, PhD

ABSTRACT

Data on climate, environment, and adult and larval mosquito collection sites throughout the Republic of Korea

(ROK) were used to model the potential distribution of the 8 anopheline species known to occur there. These

models were overlaid on predicted areas of malaria suitability to better define the distribution of malaria risk in

the ROK. The concept of the “mal-area”— an area of co-occurrence of humans, parasites and vectors, where

malaria transmission is possible—is explained. Quantification of the mal-area in the vicinity of 5 military

installations in the north of the country suggested that they had very different malaria risks, depending on what

the vector species were, and the method of calculation. An online mal-area calculator for malaria risk assessment

(currently under development) is discussed.
April – June 2008 47

treatment, among a myriad of other factors. Because

the Plasmodium parasite is normally dependent on a

human or mosquito host, the mal-area should

approximate the spatial extent of the parasite. The

phenomenon of “anophelism without malaria”

describes the area where vectors and humans, but not

parasites, co-occur, eg, many populated parts of the

United States have malaria vectors but the disease was

eradicated there.

Until recently, detailed intelligence on the distribution

of vectors was not available for malaria risk models.

The Malaria Atlas Project10 (MAP) models the limits

of actual malaria transmission using information on

international travel-health guidelines and estimates of

vector occurrence, from altitude and degree of

urbanization data.11

Fine-tuning such maps of global malaria suitability by

incorporating detailed mosquito species distribution

models could provide a clearer picture of areas of

heightened malaria risk. The resulting mal-area extent

could be used as a simple index to compare malaria

risk between locations of interest (Figure 1).

Specifically, mal-area mapping could improve force

health protection in areas of operation such as the

Republic of Korea (ROK) that have a history of

malaria transmission.

Prior to the 1950s, Plasmodium vivax malaria was

endemic and widespread in the ROK,12 suggesting that

the potential mal-area is extensive in that country.

Malaria was eradicated in the 1970s but reemerged in

1993 and reached a peak of 4142 cases in 2000 before

falling to 774 cases in 2004.13 Most malaria cases

appear to have been contracted near the Demilitarized

Zone (DMZ) that separates North and South Korea.13

This is reflected in the northerly location of the area of

current malaria suitability, as determined by the MAP

models (see Figure 2). The anopheline fauna of South

Korea (ie, the ROK) is relatively well resolved

taxonomically,14-16 and ongoing mosquito surveillance

makes this country an ideal location to test the malarea approach to assessing malaria risk. The

anopheline fauna of the ROK includes 8 species:

Anopheles sinensis sensu stricto (s.s.) Wiedemann

An. pullus M. Yamada (=An. yatsushiroensis)

An. lesteri Baisas & Hu (=An. anthropophagus)

An. sineroides S. Yamada

An. kleini Rueda

An. belenrae Rueda

An. lindesayi japonicus S. Yamada

An. koreicus S. Yamada & Watanabe

These species are not all identifiable based on

morphology, but a polymerase chain reaction (PCR)

technique has been developed for species

identification.

15 Historically, An. sinensis was

considered the primary vector. However, the discovery

of additional species and results from field and

laboratory parasite studies have combined to point to

An. kleini, An. pullus, and An. sinensis as the likely

vectors around the DMZ.13 Logically, since further

mosquito and parasite sampling is required, all species

could be regarded as potential vectors.

Figure 1. Illustration of the concept of the mal-area as it

applies to malaria risk assessment in geographic space.

Presence/absence of humans (H), areas of suitability for

Plasmodium species (P), and predicted distribution of

malaria vectors (V) are shown, as well as the mal-area

(VPH); the area of overlap where malaria transmission is

possible. Histogram shows the percentage of the sampled

area that these parameters cover. The value for VPH

could be used as a simplified index of malaria risk to

compare different areas.
48 www.cs.amedd.army.mil/references_publications.aspx

We used climate and adult and larval mosquito

collection data from sites throughout the ROK to

model the distribution of all 8 anopheline species. To

better understand the distribution of malaria risk in the

ROK, especially around military installations in the

north of the country, the resulting models of potential

species distributions were compared with areas of

malaria suitability. An online mal-area calculator for

malaria risk assessment that is

under development is discussed

later in this article.

MATERIALS AND

METHODS

Adult mosquito surveillance

was conducted at selected US

military installations using New

Jersey light traps (John W.

Hock Co, Gainesville, FL) and

M o s q u i t o M a g n e t s ®

(Woodstream Corporation,

Lititz, PA) (Figure 3), and

larval collections were made

throughout the ROK. Adults

and larvae were identified to

species by comparison of DNA

products produced by PCR.15

We used the Genetic Algorithm for Rule-set Prediction

(GARP)5,17 and a maximum entropy approach, known

as Maxent,6,18 for distribution modelling. GARP uses

an iterative process of rule selection, evaluation,

testing, and incorporation or rejection. The genetic

algorithm in GARP allows the rules to “evolve” to

maximize predictive accuracy. A rule is selected and is

applied to half the points (training data) and models

assessed with the other half of the points (testing data).

The change in predictivity between iterations is used to

evaluate whether a particular rule should be

incorporated into the model. Maxent is based on the

idea that the best explanation for unknown phenomena

will maximize the entropy of the probability

distribution, subject to the constraint of the

environmental conditions where species have been

detected. Output was predicted probability of presence.

The methodology and results of this modelling will be

reported in greater detail in a forthcoming paper.

We obtained

 altitude and a selection of climate grid layers for

1980 through 1990 from Worldclim,19

 five layers summarizing aspects of topography and

landform (topographic index, slope, aspect, flow

direction, and flow accumulation) from the US

Geological Survey’s HYDRO-1K Elevation

Derivative Database,20

 data layers summarizing the “greenness index”—

termed the Normalized Difference Vegetation

Index21—from the Advanced

V e r y H i g h R e s o l u t i o n

Radiometer satellite data

presenting percentage tree cover

for 1992-1993,

 thirteen classes of land-use/

land-cover from the Global

Land Cover Facility,22

 soil taxonomy suborders of

the world from the US

Department of Agriculture

National Soils Conservation

Service,23 and

 data on areas equipped for

irrigation from the Aquastat site

of the Food and Agriculture

Organization of the United

Nations.24

Figure 2. Locations of mosquito collection points in the

ROK used in species distribution modelling. Also depicted

is the extent of the area predicted active for malaria.

(Data derived from the Malaria Atlas Project.10 Data from

the boxed area was used for mal-area calculations.

Figure 3. The Mosquito Magnet uses propane

to produce CO2 and heat to attract insect

vectors which are caught in the vacuum and

deposited in the collection bag.

Malaria Risk Assessment for the Republic of Korea

Based on Models of Mosquito Distribution
April – June 2008 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

In all, 79 one-km2environmental data layers were

available, which we reduced to 15 by principal

components analysis (PCA) in Minitab 15.1.1.0

(Minitab Inc, State College PA) prior to mosquito

distribution modelling. The 15 PC layers explained

more than 95% of the overall variation in the 79

environmental parameters. We imported data

into ArcView 3.3 (ESRI, Redlands, CA) for

image analysis.

The current spatial limits of P. vivax in the

ROK were taken from the MAP website10 and

resampled for one-km2resolution to match

that of the mosquito distribution models (see

Figure 2). We assumed that human population

density throughout the areas of interest was

sufficient for malaria transmission. We applied

a 10-km radius buffer around 5 selected US

military installations in the northeast of the

ROK. Using ArcView 3.3, we conducted map

queries for 3 scenarios for possible areas of

coincidence of vectors and malaria within the

buffers, where false= 0 and true= 1. We also

conducted a map calculation for a fourth

scenario where no coincidence of vectors and

malaria= 0, one vector species coinciding with

malaria = 1, two species coinciding = 2, and

three species coinciding with malaria = 3. In

scenario 1, only one species, An. sinensis, is

considered a vector, as had been assumed by

workers in the past. Scenario 2 assumes that

any of the 8 anopheline species occurring in

the ROK can transmit malaria if they co-occur

with the spatial limits of parasites. This is the

most conservative scenario. Scenario 3

assumes An. kleini, An. pullus, and An.

sinensis are vectors, as has been suggested in

the literature.13 In this scenario the cooccurrence of any or all of these species with

the malaria suitable area is scored as true (= 1)

for the purposes of the mal-area calculation.

Scenario 4 assumes An. kleini, An. pullus, and

An. sinensis are vectors, but that the risk

increases if more than one species co-occurs

with the malaria suitable area. These species

were equally weighted, as definitive

information on their relative vectorial

importance is lacking. The total number of

one-km2pixels scored true for the first 3

scenarios, and the sum of values for these

pixels for the fourth scenario were calculated

for the buffered areas surrounding the 5

installations.

Figure 4. Examples of Maxent models of the potential distribution

for 2 anopheline species in the ROK, based on mosquito

collection data and environmental data layers. Darker shading

indicates greater predicted suitability of that area for the

occurrence of that species.
50 www.cs.amedd.army.mil/references_publications.aspx

RESULTS

Mosquitoes were identified to species from a total of

174 collection locations in the ROK from collections

from 1998 through 2006 (see Figure 2). Some of these

data were reported previously.25 Distribution models

revealed that An. sinensis, An. kleini, An. pullus, and

An. belenrae were predicted to occur widely, whereas

An. lesteri is predicted to occur only in northwest areas

of the ROK (Figure 4). Examples of output from

Maxent models for An. kleini and An. lesteri are

presented in Figure 4. Collection data and distribution

maps will be available from the MosquitoMap

website* and in a future publication. All species are

predicted to occur in the north of the ROK where

malaria has been most common since it first

reappeared in 1993.

Mal-area calculations for the 4 scenarios are shown in

Figure 5. In all scenarios, Camp Humphreys has no

malaria transmission risk due to it falling outside the

predicted spatial limits of malaria as given on the

MAP website.10 Comparison of the mal-area scores

(Figure 6) reveals that Camp Humphreys and

Kwangsa-ri have the lowest values. The scores for

scenario 4 are higher than for the other scenarios,

reflecting the cumulative effect of vector species’

occurrences on malaria risk. In these examples, the

rank of the malaria risk of the 5 installations does not

change markedly with the different scenarios, except

that Colbern has a higher score for the An. sinensisonly scenario.

DISCUSSION

Arthropod-borne infectious diseases are a major health

threat to our combat troops. We cannot afford to

ignore this health threat nor repeat the mistakes of

previous conflicts where many Soldiers were

debilitated or killed by preventable infectious diseases.

Knowledge of the identity and occurrence of the major

vectors is a prime requirement to determine the threat

posed by vector-borne diseases. Predicting where the

vectors are likely to be found could be a valuable

addition to health risk assessment and disease control

strategies.

As standardized and accessible techniques for

modelling the distribution of disease vectors are recent

developments, the approach given here is new.

Application of models of vector distribution to disease

risk assessment is a logical next step. We have shown

that a simple index of the area where disease *http://www.mosquitomap.org

Figure 5. Four scenarios of the extent of the mal-area for malaria within 10 km of 5 US military installations in the

ROK (one-km2pixel resolution), based on vector distribution models and the areas predicted suitable for malaria, from

the Malaria Atlas Project.10 Darker areas indicate greater risk of malaria.

Legend:

A. Anopheles sinensis is the only vector.

B. Any of the 8 Anopheles species known from the ROK are present.

C. Any of 3 species (An. kleini, An. sinensis and An. pullus) is present.

Malaria Risk Assessment for the Republic of Korea

Based on Models of Mosquito Distribution
April – June 2008 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

transmission is possible, the mal-area, can be used to

assess disease risk for a 10 km radius buffer around

US military installations in the ROK. Although any

size area can be considered, a 10-km buffer is

appropriate to calculate the health risk arising from the

local environment, or the amount of vector control

needed within a barrier zone around these points.

We have shown that the method of calculating the

mal-area is an important variable. Identification of the

vector species, and the weight attached to these species

in terms of vectorial importance is also critical.

However, the accuracy, scale, and precision of models

of vector and parasite distribution is of fundamental

importance. It should be noted that little information is

available for malaria in North Korea11 and so the

malarious area may extend further north than shown

here. The World Health Organization reported that a

malaria epidemic occurred in North Korea shortly after

the first case of malaria reemerged along the DMZ in

1993, suggesting a parallel outbreak occurred in both

countries.26 The mal-area calculations shown here do

not yet take into account seasonality, use of insecticide

bed nets, human movement, socio-economic level, or

many other variables that modify the prevalence and

incidence of malaria. In addition, vector distribution

models predict general habitat suitability, but factors

not included in these models include historical,

physical, climatological, and biotic constraints that

may play a role in limiting potential distribution.

Evaluating and improving vector model accuracy is an

ongoing task, but better models can be easily

incorporated as they become available.

Despite the simplified assumptions of the mal-area

method of risk assessment shown here, the approach is

potentially very quick and can be used for any area of

interest in the world, even where medical intelligence

is sketchy. One can see the location of the mal-area

within the area of interest, or the mal-area can be

Figure 6. Mal-area calculations in number of one-km2pixels for malaria within 10 km of 5 US military installations in the

ROK, based on vector distribution models and the areas predicted suitable for malaria, from the Malaria Atlas Project.
52 www.cs.amedd.army.mil/references_publications.aspx

reduced to a single figure to compare risk between

areas. In the absence of other intelligence, the mal-area

approach has potential as a first approximation of risk.

Alternatively, vector and mal-area maps can be used as

base layers in more complex epidemiological GIS

disease risk models. A generic mal-area tool could

conceivably be used to measure any risk factor,

including other vector-borne diseases, where spatial

models of the risk components are available. Such a

tool would have great value for medical intelligence

estimates, particularly when forces are deployed to

hostile locations for the first time.

We are constructing high resolution maps of potential

geographical distribution of a selection of mosquito

vectors of disease which will soon be available via the

MosquitoMap website, an online clearinghouse for

georeferenced mosquito collection records, and species

distribution models derived from those records.

MosquitoMap uses ArcGIS Server 9.2 to enable the

query and mapping of georeferenced mosquito

collection records as points or country-level

aggregations. Data come from records held by

museums, scientific literature, and private collections.

Currently there are 65,000 records, mainly for

Australasia and the Neotropics.

An application within MosquitoMap, the mal-area

calculator, is designed to provide a fast, easy, and

intuitive interface for rapidly assessing relative malaria

risk. The intention is for the user to define a location or

area anywhere on the face of the earth and the

calculator combines models of disease distribution

with predicted distribution of major disease vectors.

Based on the location or area defined, an HTML and/

or PDF chart will be rendered that graphs statistics for

grid layers of various combinations of the VPH

variables. These statistics will consist of the

percentage of cells that contain a certain value for the

user defined area. MosquitoMap and the mal-area

calculator rely on distribution models for all vector

species, but these are currently lacking. However,

these applications provide a framework to host and

analyze future vector and disease models as they

become available.

ACKNOWLEDGEMENT

Funding for this project was provided by the

Department of Defense Global Emerging Infections

Surveillance and Response System, Silver Spring, MD

(project No. G00018_08_WR). We thank A.

Townsend Peterson for advice regarding distribution

modelling. We thank LCDR Jean-Paul Chretien for

advice and support. This research was performed

under a Memorandum of Understanding between the

Walter Reed Army Institute of Research and the

Smithsonian Institution, with institutional support

provided by both organizations.

REFERENCES

1. Stone JH, ed. Crisis Fleeting. Washington, DC:

Office of The Surgeon General, US Dept of the

Army; 1969.

2. Malaria Foundation International. FAQs. Available

at: http://www.malaria.org/travelhealth.html.

3. Smith AM, Hooper C. The mosquito can be more

dangerous than the mortar round. The obligations of

command. Nav War Coll Rev. 2005;58(1):77-87.

Available at: http://www.nwc.navy.mil/press/review/

documents/NWCRW05.pdf.

4. Barrett O. Malaria: epidemiology. In: Ognibene AJ,

Barrett O, eds. Internal Medicine in Vietnam. Volume

II, General Medicine and Infectious Diseases.

Washington, DC: Office of The Surgeon General, US

Dept of the Army; 1982:279-291.

5. Pereira RS. Desktop GARP. 2002. Available at:

http://www.lifemapper.org/desktopgarp/.

6. Phillips SJ. Maxent software for species habitat

modeling, ver. 2.2.0. 2006. Available at: http://

www.cs.princeton.edu/~shapire/maxent/.

7. Levine RS, Peterson AT, Benedict MQ. Geographic

and ecologic distributions of the Anopheles gambiae

Complex predicted using a genetic algorithm. Am J

Trop Med Hyg. 2004;70:105–109.

8. Moffett A, Shackelford N, Sarkar S. Malaria in

Africa: vector species’ niche models and relative risk

maps. PloS ONE. 2007;2(9):e824. doi:10.1371/

journal.pone.0000824.

9. Peterson AT. Ecological niche modelling and

understanding the geography of disease transmission.

Vet Italiana. 2007;43:393-400.

10. Malaria Atlas Project website. Available at: http://

www.map.ox.ac.uk/MAP_overview.html.

11. Guerra CA, Snow RW, Hay SI. Defining the global

spatial limits of malaria transmission. Advances in

Parasitol. 2006;62:157-179.

12. Ree H-IL. Unstable vivax malaria in Korea. Korean J

Parasitol. 2000;38:119-138.

Malaria Risk Assessment for the Republic of Korea

Based on Models of Mosquito Distribution
April – June 2008 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

13. Lee W-J, Klein TA, Kim H-C, Choi Y-M, Yoon S-H,

Chang K-S, Chong S-T, Lee I-Y, Jones JW, Jacobs

JS, Sattabongkot J, Park J-S. Anopheles kleini,

Anopheles pullus, and Anopheles sinensis: potential

vectors of Plasmodium vivax in the Republic of

Korea. J Med Entomol. 2007;44(6):1086-1090.

14. Wilkerson RC, Li C, Rueda LM, Kim HC, Klein TA,

Song GH, Strickman D. Molecular confirmation of

Anopheles (Anopheles) lesteri from the Republic of

South Korea and its genetic identity with An. (Ano.)

anthropophagus from China (Diptera: Culicidae).

Zootaxa. 2003;378:1-14.

15. Li C, Lee JS, Groebner JL, Kim H-C, Klein TA,

O’Guinn ML, Wilkerson RC. A newly recognized

species in the Anopheles Hyrcanus Group and

molecular identification of related species from the

Republic of South Korea (Diptera: Culicidae).

Zootaxa. 2005;939:1-8.

16. Rueda LM. Two new species of Anopheles

(Anopheles) Hyrcanus Group (Diptera: Culicidae)

from the Republic of South Korea. Zootaxa.

2005;941:1-26.

17. Stockwell DRB, Noble IR. Induction of sets of rules

from animal distribution data: a robust and

informative method of analysis. Math Comput Simul.

1992;33:385-390.

18. Phillips SJ, Anderson RP, Schapire RE. Maximum

entropy modeling of species geographic distributions.

Ecol. Modell. 2006;190:231-259.

19. Hijmans RJ, Cameron S, Parra J. WorldClim [database online]. Available at http://www.worldclim.org/.

20. HYDRO1k home page. US Geological Survey

website. Available at: http://edc.usgs.gov/products/

elevation/gtopo30/hydro/.

21. MODIS Normalized Difference Vegetation Index

page. University of Maryland Global Land Cover

Facility website. Available at: http://

glcf.umiacs.umd.edu/data/ndvi/.

22. Land Cover Classification page. University of Maryland Global Land Cover Facility website. Available

at: http://glcf.umiacs.umd.edu/data/landcover/.

23. Global Soils Region Map. US Dept of Agriculture

National Resources Conservation Service website.

Available at: http://soils.usda.gov/use/worldsoils/

mapindex/order.html.

24. AQUASTAT resources page. Food and Agriculture

Organization of the United Nations website.

Available at: http://www.fao.org/nr/water/aquastat/

main/index.stm.

25. Rueda LM, Kim H-C, Klein TA, Pecor JE, Li C,

Sithiprasasna R, Debboun M, Wilkerson RC.

Distribution and larval habitat characteristics of

Anopheles Hyrcanus Group and related mosquito

species (Diptera: Culicidae) in South Korea. J Vector

Ecol. 2006;31:198-205.

26. Han ET, Lee DH, Park KD, Seok WS, Kim YS,

Tsuboi T, Shin EH, Chai JY. Reemerging vivax

malaria: changing patterns of annual incidence and

control programs in the Republic of Korea. Korean J

Parasitol. 2006;44:285-294.

AUTHORS

Dr Foley is a Research Entomologist at the Walter Reed Biosystematics Unit of the Division of Entomology, Walter

Reed Army Institute of Research, based at the Smithsonian Institution Museum Support Center, Suitland, Maryland.

COL (Ret) Klein is a consultant with Force Health Protection, 18th Medical Command, Unit 15281, Yongsan Garrison,

Seoul, Republic of Korea.

Dr Kim is a Research Entomologist with the 5th Medical Detachment, 168th Medical Battalion (AS), 18th Medical

Command, Unit 15247, Yongsan Garrison, Seoul, Republic of Korea.

Dr Wilkerson is a Research Entomologist and Manager at the Walter Reed Biosystematics Unit of the Division of

Entomology, Walter Reed Army Institute of Research, based at the Smithsonian Institution Museum Support Center,

Suitland, Maryland.

Dr Rueda is a Research Entomologist at the Walter Reed Biosystematics Unit of the Division of Entomology, Walter

Reed Army Institute of Research, based at the Smithsonian Institution Museum Support Center, Suitland, Maryland.
54 www.cs.amedd.army.mil/references_publications.aspx

ABSTRACT

The US Air Force has had a long history of aerial

applications of pesticides to fulfill a variety of

missions, the most important being the protection of

troops through the minimization of arthropod vectors

capable of disease transmission. Beginning in World

War II, aerial application of pesticides by the military

has effectively controlled vector and nuisance pest

populations in a variety of environments. Currently,

the military aerial spray capability resides in the US

Air Force Reserve (USAFR), which operates and

maintains C-130 airplanes capable of a variety of

missions, including ultra low volume applications for

vector and nuisance pests, as well as higher volume

aerial applications of herbicides and oil-spill

dispersants. The USAFR aerial spray assets are the

only such fixed-wing aerial spray assets within the

Department of Defense. In addition to troop

protection, the USAFR Aerial Spray Unit has

participated in a number of humanitarian/relief

missions, most recently in the response to the 2005

Hurricanes Katrina and Rita, which heavily damaged

the Gulf Coasts of Louisiana, Mississippi, and Texas.

This article provides historical background on the Air

Force Aerial Spray Unit and describes the operations

in Louisiana in the aftermath of Hurricane Katrina.

INTRODUCTION

Human health has long been at risk from arthropodborne diseases. Malaria, dengue, West Nile virus, and

others continue to cause human health problems and

create media attention. Military entomologists are

acutely aware of the disease threat to deployed troops

from insect pests, and have remained an integral part

of the Department of Defense (DoD) since they were

employed with excellent results to combat malaria in

the South Pacific during World War II.1In that

conflict, military entomologists quickly developed

effective strategies to control mosquitoes and maintain

troop health. One such method was the application of

insecticides from aircraft to areas with high mosquito

activity. Aerial applications of pesticides are an

effective way of rapidly reducing numbers of potential

insect vectors across large areas and in a relatively

short period of time.2-5 Unlike truck-mounted spray

units or backpack sprayers, aircraft can access

developed and undeveloped areas which are prone to

arthropod outbreaks.

The Air Force has the mission to provide a fixed-wing,

large-area, aerial pesticide application capability to

control disease vectors, pest organisms, and

undesirable/invasive vegetation, as well as treat oil

spills in combat areas, on DoD installations, or in

response to declared emergencies. In addition, DoD

requires the Air Force to provide training to air crews

and ground support personnel in the principles and

practices of aerial pesticide application.

The Air Force Aerial Spray Unit (AFASU) traces its

history back to early aerial applications of DDT during

the later stages of World War II. After the end of the

war, the Special DDT Flight was created in 1946, but

was soon transformed to the Special Aerial Spray

Flight (SASF) in 1947 when the Air Force became a

separate armed service.6 Eventually, as US military

operations in Vietnam were reduced in the early

1970s, active duty Air Force assets were moved to

reserve status, including spray planes returning from

Operation Ranch Hand defoliation flights in Vietnam.7

After more than 25 years at Langley Air Force Base,

Virginia, the SASF was transferred from the active Air

Force to the Air Force Reserve in 1973. Prior to this

transfer, the SASF had sprayed for mosquitoes,

Japanese beetles, and fire ants in various locations at

the request of the Army, Navy, and other federal

agencies. The move to the Air Force Reserve resulted

in a change of location and designation. Relocated to

Rickenbacker Air Force Base, Ohio, the unit was

The US Air Force Aerial Spray Unit:

A History of Large Area Disease Vector

Control Operations, WWII Through Katrina

Maj Mark Breidenbaugh, BSC, USAFR

Maj Karl Haagsma, BSC, USAFR
April – June 2008 55

referred to as the Spray Branch of the 907th Tactical

Airlift Wing. In 1986, the Spray Branch began to

transition from C-123 airplanes to C-130A airplanes

and developed the modular aerial spray system for use

in C-130E and H airplanes. The aerial spray mission

was assigned to the 910th Airlift Wing at the

Youngstown Air Reserve Station, Ohio, in 1991.

Nonmilitary emergency aerial spray responses (and the

targeted health threat) by Air Force aerial spray assets

as part of the Air Force Reserve are shown in Table 1.

The AFASU trains for a primary wartime mission of

protecting deployed troops from arthropod-borne

illness by participating in ongoing mosquito control

programs at different locations throughout the United

States. By training in various geographic regions, the

AFASU gains experience controlling different vector

and nuisance species under diverse geographical and

environmental conditions. The same measures are

employed for herbicide applications. Some missions

are designed for soil sterilization, such as at the Utah

Test and Training Range, where large targets need to

remain free of vegetation so that unexploded ordinance

can be safely recovered. Other herbicide missions

concentrate on habitat restoration, by lowering the

dominance of invasive plant species, allowing native

plants to recover and lowering the threat of wildfires.

The AFASU has been involved with prairie restoration

on the Saylor Creek Range, Idaho, combating the

growth of cheatgrass (Bromus tectorum L.), and at

Smoky Hill Air National Guard Range, Kansas, for the

control of musk thistle (Carduus nutans L.). Table 2

lists the AFASU’s current standing domestic

operational commitments and the dates of inception

for each.

As mentioned earlier, a modular aerial spray system

(MASS) was developed for use with the C-130H

airplane. The MASS, which has a maximum 2,000-

gallon capacity for liquid materials, can be

rolled on or off the airplane in approximately

one-half hour. Functional in a variety of

configurations, the MASS is useful for such

applications as ultra low volume adult

mosquito sprays (adulticiding), mosquito

liquid larvicide sprays, herbicide applications,

and oil dispersants for emergency cleanup of

oil spills.

Ultra low volume sprays create an aerosol

cloud of small discrete droplets that drift

through the air. This type of application is

referred to as a space spray since the goal is to

drift droplets through a particular space

resulting in contact with flying insects.5For

this reason, the flight period of the target pests

is one of the most important planning factors

for missions using the ultra low volume

configuration to control mosquitoes and

nuisance flies.8 Current methodologies for

AFASU mosquito adulticiding use the MASS

with booms placed through the fuselage doors.

Those booms are fitted with flat fan nozzles

positioned perpendicular to the slipstream of the

aircraft for maximum shear and atomization of the

sprayed liquid. This is especially important since the

diameter of a droplet that effectively adheres to a

mosquito is 10 μm to 25 μm.9

In contrast to space spray applications, deposition

spray missions produce large drops which are intended

to drop quickly onto a surface (eg, mosquito larvicide

or herbicide application).

HURRICANES AND MOSQUITOES

In response to requests from state public health

agencies, the AFASU has been tasked to control

mosquitoes threatening human health or creating an

unacceptable nuisance level in the aftermath of

hurricanes (see Table 1).10 However, following some

Year Location Health Threat Coverage

(acres)

1973 Panama Equine encephalitis 37,600

1975 Guam Dengue fever 157,530

1978 Azores Japanese beetles 8,700

1983 Minnesota Equine encephalitis 525,000

1985 Idaho Grasshoppers 718,100

1987 Puerto Rico Dengue fever 177,000

1989 South Carolina Hurricane Hugo

mosquito control

855,500

1992 Florida Hurricane Andrew

mosquito control

279,170

1999 North Carolina,

Virginia

Hurricane Floyd

mosquito control

1,700,000

2005 Louisiana,

Texas

Hurricanes Katrina and

Rita mosquito control

2,880,000

Table 1. Nonmilitary emergency deployments by the

AFASU after transition to the US Air Force Reserve.
56 www.cs.amedd.army.mil/references_publications.aspx

of these events, federal authorities, unfamiliar

with mosquito biology, have questioned the

local public health officials’ requests for

mosquito control, apparently unaware of a

relationship between hurricanes and increased

mosquito activity. Since the presence of

mosquitoes following storms may surprise

some, perhaps there is a valid question: do

hurricanes create abnormally large mosquito

populations? And, by extension, do hurricanes

increase the risk of mosquito-borne illnesses

such as encephalitides, dengue, and malaria?

Since mosquito larvae develop in water, it is

not difficult to extrapolate that a significant

increase in potential breeding sites as a result

of flooding from hurricanes would lead to a

significant increase in mosquito populations.

It is this premise that leads mosquito control

personnel and vector ecologists to anticipate

increased mosquito numbers following major

storms. Logically, the presence of high

densities of mosquitoes increases the potential for

transmission of mosquito-borne disease. It is, however,

important to define parameters for making such

statements. Accordingly, we must identify the

mosquito species capable of vectoring disease and

determine if the pathogen is present in the resident

mosquito population or enzootic hosts.

The destructive power of hurricanes creates a scenario

in which mosquito populations are increasing at the

same time many people are displaced or have had their

primary shelters compromised. Exposure to

mosquitoes is increased by the concentration of those

displaced by the storm into temporary shelters, and by

their activities as they search for food, construction

materials, medical care, etc. Under such conditions,

individuals may face maximum exposure to nuisance

mosquito bites and mosquito vectors.

Mason and Cavalie11 analyzed a malaria epidemic in

Haiti following Hurricane Flora in 1963, observing an

explosive increase in mosquito breeding brought on by

heavy rainfall and extensive flooding. In this case, the

researchers also tied an increased incidence of malaria

to Hurricane Flora because all disease factors were

present, including a heavy reservoir of gametocyte

carriers, mosquitoes, and an exposed population (eg,

people displaced and residual insecticide treatments

negated by hurricane damage).

More recently, Gagnon et al12 reviewed the incidence

of malaria in El Niño years—which always include

significant flooding conditions—in South America and

found a significant relationship between flooding and

malaria epidemics in northern Peru.

By contrast, in Honduras, Hurricane Mitch killed

6,546 people and displaced another 1.1 million from

excessive rainfall and flooding.13 Obviously this

population was very exposed as a result of the

displacement, but Campanella and Tarantini14 found

only a small increase in malaria cases between time

periods preceding the arrival of Hurricane Mitch

(statistically significant compared to 1997 but not to

1998). Likewise, O’Leary et al 15 did not find an

increase in dengue in Federal Emergency Management

Agency (FEMA) relief workers in Puerto Rico after

Hurricane Georges in 1998. These researchers relate

that 82% of the workers reported mosquito bites, but

unfortunately they do not comment on the overall

mosquito density during the study.

Experts are often questioned by the popular press and

in some cases opinions on the hurricane-mosquito

disease issue can differ markedly. For example, the

New Orleans Times-Picayune quoted the State

Epidemiologist of Louisiana as saying that heavy

rainfall from hurricane Katrina actually killed adult

mosquitoes, washed away larvae, and killed or

Table 2. Current AFASU domestic operational commitments.

Location or Agency Purpose Year

initiated

Langley Air Force Base, VA Mosquito control 1973

Marine Corps Recruit

Depot, Parris Island, SC

Biting midges and

mosquito control

1983

Hill Air Force Base, Utah

Test and Training Range

Clearing bombing

range undergrowth

1983

US Coast Guard Oil spill dispersants 1992

Smoky Hill Air National

Guard Range, KS

Musk thistle control 1995

Mountain Home

Air Force Base, ID

Cheat grass control 2000

Grand Forks

Air Force Base, ND

Mosquito control 2001

Minot Air Force Base, ND Mosquito control 2005

The US Air Force Aerial Spray Unit:

A History of Large Area Disease Vector Control Operations
April – June 2008 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

dispersed the birds that carry West Nile virus.16

Without quoting a source, in 2006 Lauran Neergaard

of the Associated Press stated somewhat

contradictorily that “...recent research shows:...

Hurricanes don't spur West Nile [virus mosquito

vectors]. Instead, heavy rains temporarily flush out the

tiny pools where mosquitoes have laid eggs. Yet the

CDC [Centers for Disease Control and Prevention]

fears that New Orleans and the Gulf Coast are ripe for

a surge in West Nile this summer because of the rubble

left by Hurricane Katrina last year, full of watercollecting crevices that make perfect mosquito

breeding grounds.”17 Other news articles made

contrasting statements. The director of the University

of Minnesota Center for Infectious Disease Research

and Policy warned that following Hurricane Katrina,

rural areas could expect dramatic increases in

mosquito numbers within 2 weeks, especially those

areas where the storm left many pools of stagnant

water.18 Similarly, in October 2005, the Houston

Chronicle [online] reports that, according to Texas

A&M University entomology professor Jim Olson,

floodwater mosquitoes take advantage of a direct hit

from a storm in unique ways. They are able to hide in

grass and avoid being blown away by wind. But when

the storm surge hits, they ride it inland like surfers,

into new territory. Further, Professor Olson says, “The

hurricane actually concentrates them, it exacerbates

the problem.”19 In comments to The Rocky Mountain

News in September 2005, Dr Janet McAllister of the

CDC described the mosquito problem 2 weeks after

Hurricane Katrina as having reached “biblical

proportions.”20 However, in the online discussions

on the ProMED website, other contributors in the

field suggested the opposite.21

In summarizing the above information, it appears

that immediately following the landfall of a major

hurricane, the mosquito problem may actually

disappear or be minimized by intense wind, rainfall,

and flooding. However, it is generally agreed that

additional developmental habitat is created by such

storms and, depending on environmental factors

(temperature, rainfall, contamination, topography,

etc), large numbers of vector and/or nuisance biting

mosquitoes can be present in a period as short as 2

weeks.22

The American Mosquito Control Association and

the CDC, along with a host of federal, state, and

county level public health agencies, have worked

diligently to convince FEMA to anticipate major

mosquito outbreaks following hurricanes and other

flood producing events and to develop strategic

responses to such events. Developing a dialogue

between federal and state public health agencies was

one reason that the vector control aspects of the

response to Hurricane Katrina were quick and

decisive.

HURRICANE KATRINA

On September 8, 2005, the AFASU deployed to

conduct aerial spray operations for mosquito and filth

fly control in support of the FEMA Hurricane Katrina

relief effort and were officially assigned to Joint Task

Force Katrina on September 9, 2005. Two spray

aircraft, a spare aircraft, and 3 crews set up at Duke

Field, Florida, near Eglin AFB on the Florida

panhandle. Duke Field was chosen because it was the

closest fully-functioning military base with the

logistical capability of supporting the C-130H spray

aircraft. A total of 53 personnel were involved with the

flying, entomology, maintenance, administrative,

communication and life support issues relating to the

AFASU response.

The extent of the damage caused by Hurricane Katrina

is well known.23 High winds downed trees and

destroyed homes, while heavy rain caused extensive

The pilot of an Air Force Aerial Spray Unit C-130H airplane

aligns the airplane onto the next flight line during an aerial

spray mission over New Orleans, Louisiana, during postKatrina operations in September 2005.
58 www.cs.amedd.army.mil/references_publications.aspx

flooding. Storm-induced breeches in the New Orleans

levee system resulted in the catastrophic flooding of

approximately 80% of the city. Prehurricane

evacuations had been incomplete in New Orleans and

subsequent flooding exacerbated the problem by

significantly increasing the difficulty of relief efforts.

In early September, the full-scope of damage and level

of human suffering was still unknown. News agencies

reported potential human fatalities as high as 10,000

inside New Orleans, incidents of gunfire aimed at

rescue aircraft,24 and that EPA water tests showed E.

coli levels were 10 times above safe levels.25 Rapid

mosquito and fly development was projected as

temperatures reached 90°F during the day, and only

cooled into the upper 70s (°F) at night. Filth flies,

which have the potential to develop quickly in the type

of habitat created in flooded New Orleans (eg, fecal

contamination, muck, trash, animal carcasses) and

move between unhygienic substrates and human food,

potentially transferring harmful bacteria in the process,

were considered to be the immediate insect vector

public health threat by public health officials. Apart

from filth flies, an additional concern for vector

ecologists was that Louisiana already had a

background of West Nile virus (WNV) circulating in

mosquito pools and birds. By August 30, 2005, 40

cases of WNV had been reported in Louisiana,

including 4 deaths. That was already more cases in

Louisiana than in all of 2004.26 By all accounts,

Hurricane Katrina created enough damage to expose

the population to potential vector and

nuisance mosquito feeding. In particular, the

absence of electricity, physical damage to

living structures, and the use of temporary

shelters by 200,000 displaced people

combined to make these individuals

vulnerable to mosquito bites and potential

disease transmission. Similarly, intense

mosquito exposure to rescue, cleanup, and

utility repair crews, as well as law

enforcement personnel was also projected.

Thus, mosquito and fly control was

considered a high priority in the strategy to

protect public health.

The major crisis of the storm was the

flooding of New Orleans. The recovery effort

included a combined force from the military

services, as well as other federal, state, and

local agencies. The mission of the AFASU

was to provide a stopgap measure to control

mosquitoes until local mosquito control programs

could resume operations. Hurricane Katrina had

completely disabled normal mosquito control

operations within the entire region south of Lake

Pontchartrain. The damage ranged from various levels

of equipment damage to the destruction of entire

facilities. In one unusual example, spray trucks from

Orleans Parish were pressed into service by an Army

National Guard Unit. Further, employees of local

Mosquito Control Districts (MCD) were themselves

displaced by the storm. Air Force spray assets

provided aerial vector control until MCDs could regain

their normal operations or contracts could be

established with private applicators. An additional

complicating factor for nonmilitary aerial applicators

was that the region had been designated as military

controlled airspace, making spray activities by private

applicators impossible at times.

The performance of aerial spray operations in and

around New Orleans was complicated. The AFASU

previously conducted spray operations during federally

declared disasters but the situation in New Orleans was

particularly challenging. To determine the vector

threat, entomologists from the Louisiana Department

of Health, CDC, and Air Force visited areas in and

around New Orleans, conducted mosquito landing

counts, surveys for filth flies, and directly consulted

with bivouacking Army and Navy Preventive

An Air Force Aerial Spray Unit C-130H airplane during a vector

control mission over New Orleans, Louisiana, September 2005.

The US Air Force Aerial Spray Unit:

A History of Large Area Disease Vector Control Operations
April – June 2008 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

Medicine Troops. This was the most effective means

of evaluating the insect vector potential because the

storm had severely limited communication between

organizations conducting vector surveillance.

Telephone and email service was erratic and troops

continued to move around. In some cases, troops had

deployed with insect surveillance equipment but had

no time to put it to use because of higher priority tasks.

Driving in New Orleans was difficult since many roads

were still flooded or obstructed by debris. Also,

military and police checkpoints were frequent. The

few vehicles on the roads were limited to first

responders—military, police, rescue, and utility repair.

This was actually fortunate since few intersections had

functioning traffic lights and general disrepair existed

throughout the area. By driving to forward locations,

surveillance data was gathered from Army and Air

Force personnel from the Louis Armstrong Airport and

Navy personnel from the Naval Air Station.

FLY CONTROL IN NEW ORLEANS

Timing insecticide applications with the period of

maximum exposure of the target pest is a critical

component of any pest control operation. Fly control

began 3 hours before sunset to correspond with the

diurnal activity of flies but avoid the warmest part of

the day. Fuselage booms were equipped with 6

stainless steel flat fan TeeJet nozzles (size 8008)

(TeeJet® Technologies, Wheaton, Illinois. 630-665-

5000). Delivered by C-130H airplanes from a height of

150 feet above ground level using 1,000 foot wide lane

separations (swath width), the organophosphate

insecticide Dibrom Concentrate®(AMVAC Chemical

Corporation, 4100 E Washington Blvd, Los Angeles,

California, 90023) was applied at a rate of 1.0 fl oz per

acre, as requested by the State of Louisiana Office of

Public Health. Applications were made in Orleans

Parish on 13 and 14 September, and again on 21 and

27 September, 2005.

Fly populations were monitored at 6 locations in

Orleans Parish prior to the aerial spray mission on 21

September by the use of sticky fly paper outdoors for

approximately 24 hours. Unfortunately, post-spray

surveillance was not possible because military support

for this activity had been evacuated in advance of

Hurricane Rita. Nonetheless, entomologists on the

ground in the New Orleans French Quarter observed

heavy mortality in flies (sarcophagids, muscids,

calliphorids, etc) within 15 minutes following the

spray application. Flies that were resting on the sides

of buildings or especially in trees near garbage piles

were more impacted by the application than those flies

under canopies or crawling around under the trash

bags/piles. Environmental parameters were recorded as

partly cloudy skies, light steady wind, 3 to 6 knots

from the south and south-southwest, and temperatures

ranging from 88°F to 82°F with no inversion layers.

Such conditions are generally considered excellent for

an aerial application. Preseley et al27 found low

numbers of muscid flies and mosquitoes in Orleans

Parish during samples taken from 16 to 18 September,

which may be testament to the success of these sprays.

Aerial applications of Dibrom have been utilized

against flies following hurricanes since 1961.28 After

Hurricane Camille, Dubose29 reported mortalities in

caged flies between 49% and 95%, where the lower

range represents cages in protected locations versus

higher mortalities from cages in exposed areas. It is

assumed similar mortality rates occurred during these

applications in Orleans Parish.

MOSQUITO SPRAYS BEYOND NEW ORLEANS

Mosquito sprays were also highly successful outside of

the greater New Orleans area. In these cases, Dibrom

was used at 0.5 to 0.75 fl oz/acre, depending on

mosquito population densities. Flat fan nozzles (TeeJet

8005) were used on airplanes flying a lane separation

of 2,500 feet. Lane separation was dropped to 1,500

feet in low wind conditions (<5 mph). Release altitude

was 150 feet above ground level for all applications.

In Acadia Parish (September 29) the primary pest

mosquitoes were Psorophora columbiae (Fabr.) and

Ps. ciliata (Dyar & Knab) as determined by Acadia

Parish Mosquito Control personnel who measured

landing rates of these vicious biters at an average of 49

per minute (range 10 to 200, 22 sites). Wind was from

the north at 6 to 8 knots, temperature was 84°F, and

relative humidity was 60%. The spray application

began 2 hours prior to sunset. A total of 169,764 acres

were sprayed. An 88% reduction in mosquito landing

rates was observed at these same locations the

following day. This level of reduction was considered

to be a borderline success since landing rates were still

noticeable. In parish areas not sprayed, average

landing rates were higher than the previous day (91 per

minute; range 30 to 200, 22 sites). In response to

increasing mosquito densities and the incomplete

control from the September 29 spray mission, the
60 www.cs.amedd.army.mil/references_publications.aspx

application rate was increased from 0.5 fl oz/acre to

0.75 fl oz/acre on 30 September. Environmental

conditions were nearly the same as the previous night,

northerly wind at 4 to 6 knots, temperature 84°F,

relative humidity 60%. Again, spraying commenced 2

hours prior to sunset and a total of 139,156 acres were

sprayed. Excellent control was achieved from the

September 30 spray mission, and post-application

landing counts were reduced on average by 99%

(range of percent reduction 95% to 100%).

In all, a total of 1,942,607 acres in the following 12

Louisiana parishes were sprayed for vector and

nuisance mosquitoes by the AFASU:

Increasing availability of private contractors,

restoration of electrical power, and the assumption of

normal mosquito control activities by MCDs led the

Louisiana State Office of Public Health to release the

AFASU on October 10, 2005. Additional AFASU

spray missions continued in the state of Texas, where a

total of 938,015 acres were treated.30 As shown in

Table 1, the combined total of 2,880,622 acres was the

largest area treated since the AFASU was transferred

to the Air Force Reserves.

CONCLUSION

The AFASU response to Hurricanes Katrina and Rita

effectively illustrates why the unit was formed—to

effectively minimize the occurrence of vectors and

nuisance pests by treating large areas where such

populations exist. This activity also demonstrates the

need for military aerial spray assets in domestic

situations where local vector control agencies were

incapacitated or overwhelmed, and use of contract

aerial spray assets was unfeasible because of severe

airspace restrictions.

This deployment of assets was not done in a void.

Without the assistance of state and federal agencies

and their personnel, the deployment would have been

extremely difficult, if not impossible. In fact, MCDs,

state health agencies, and aerial spray contractors bore

the brunt of public health and vector control activities

following the AFASU’s stand down and

redeployment. However, this event demonstrates the

AFASU’s ability to fill a “stopgap” role in domestic

emergencies such as that which followed Hurricanes

Katrina and Rita, and its importance in civilian and

military contingencies.

ACKNOWLEDGEMENT

The authors thank the Acadia Parish Mosquito Control

agency which provided landing counts for Acadia

Parish before and after aerial spray missions, and CPT

Kurt Kresta, MS, USA, for his efforts in the sampling

of filth fly densities. We also extend a special thank

you to the AFASU aircrew members and maintenance

and support personnel for their unwavering

professionalism and dedication to ensuring the success

of these very important missions.

REFERENCES

1. Hays CW. The United States Army and malaria

control in World War II. Parassitologia. 2000;42:47-

52.

2. Parrish DW, Hodapp CJ. Biological evaluation of the

C-47 aerial spray system for adult mosquito control.

Mosq News. 1962;22:36-37.

3. Knapp FW, Pass BC. Low-volume aerial sprays for

mosquito control. Mosq News. 1966;26:22-25.

4. Service MW. 2000. Medical Entomology for

Students, 2nd Ed. Cambridge UK: University of

Cambridge Press.

5. World Health Organization. Space spray application

of insecticides for vector and public health pest

control: A practitioner’s guide. Geneva, Switzerland:

World Health Organization; 2003.

6. Dowell F. An examination of United States Air Force

aerial spray operations. Mosq News. 1965;25:209-

216.

7. Scheer CJ. Aerial spraying...Air Force style. World

Agric Aviat. 1975;2:12-13,23-30.

8. Wright RE, Knight KL. Effect of environmental

factors on biting activity of Aedes vexans (Meigen)

and Aedes trivittatus (Coquillett). Mosq News

1966;26:565-578.

9. Mount GA. Optimum droplet size for adult mosquito

control with space sprays or aerosols of insecticides.

Mosq News. 1970;30:70-75.

Acadia

Ascension

Beauregard

Calcasieu

Jefferson

Orleans

Plaquemines

Saint Bernard

Tangipahoa

Vermilion

Vernon

Washington

The US Air Force Aerial Spray Unit:

A History of Large Area Disease Vector Control Operations
April – June 2008 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

10. Breidenbaugh M, Olson S, Spears B, Teig D. Emergency mosquito control after Hurricane Floyd. Wing

Beats Fla Mosq Control Assoc. 2000;11(3):36-38.

11. Mason J, Cavalie P. Malaria epidemic in Haiti

following a hurricane. J Trop Med Hygen.

1965;14:533-539.

12. Gagnon AS, Smoyer-Tomic KE, Bush ABG. The El

Niño southern oscillation and malaria epidemics in

South America. Int J Biometeorol 2002;46:81–89.

13. Balluz L, Moll D, Diaz Martinez MG, Merida

Colindres JE, Malilay J. Environmental pesticide

exposure in Honduras following Hurricane Mitch.

Bull WHO. 2001;79:288-295.

14. Campanella N, Tarantini F. Incidence of some

infectious diseases in an area of Nicaragua seriously

affected by Hurricane Mitch. Ig Mod. 2000;113:209-

223.

15. O'Leary DR, Rigau-Pe ́Rez JG, Hayes EB, Vorndam

AV, Clark GG, Gubler. DJ.. Assessment of Dengue

Risk in Relief Workers in Puerto Rico after Hurricane

Georges, 1998. Am J Trop Med Hyg. 2002;66:35–39.

16. United Press International. Hurricanes help stop West

Nile virus. Physorg.com [serial online] January 23,

2006. Available at: http://www.physorg.com/

news10152.html. Accessed July 2, 2006.

17. Neergaard L. West Nile beginning its summer

assault. Las Vegas Sun. June 26, 2006. Available at:

http://www.lasvegassun.com/sunbin/stories/

thrive/2006/jun/26/062602005.html.

18. Roos R. Hurricane Katrina sparks fears of disease

outbreaks. CIDRAP News [serial online]. September

2, 2005. Available at: http://www.cidrap.umn.edu/

c i d r a p / c o n t e n t / f s / f o o d - d i s e a s e / n e w s /

sep0205hurricane.html. Accessed July 2, 2006.

19. Hopper L. Rita's pesky offspring are here and they're

hungry. 2005. Available at: http://www.chron.com/

disp/story.mpl/special/05/rita/3384381.html.

Accessed July 2, 2006.

20. Erickson J. Mosquito numbers explode due to

hurricane flooding. Rocky Mountain News.

September 13, 2005. Available at: http://www.

promedmail.org/pls/promed/f?p=2400:1202:

9066594965860822079::no::f2400_p1202_check_dis

play,f2400_p1202_pub_mail_id:x,30431.

21. ProMED-mail. Mosquitoes, post hurricane, USA

(07). Archive 20050918.2756: September 18, 2005.

Available at: http://www.promedmail.org/pls/promed

/f?p=2400:1202:9066594965860822079::no::

f2400_p1202_check_display,f2400_p1202_pub_mail

_id:x,30431. Accessed 8 July 2006.

22. Watson JT, Gayer M, Connolly, MA. Epidemics after

natural disasters. Emerging Infect Dis. 2007;13:1-5.

23. Manuel J. In Katrina’s wake. Environ Health

Perspect. 2006;114:A32–A39.

24. Associated Press. New Orleans mayor: 10,000 feared

dead. Foxnews.com [serial online]. 2005. Available

at: http://www.foxnews.com/story/0,2933,

168489,00.html. Accessed July 2, 2006.

25. Fox News. Bacteria in waters 10x safe levels.

Foxnews.com [serial online]. 2005. Available at:

http://www.foxnews.com/story/0,2933,168790,

00.html. Accessed July 2, 2006.

26. Centers for Disease Control and Prevention. Update:

West Nile virus activity – United States, 2005.

MMWR. 2005;54:851-852.

27. Presley SM, Rainwater TR, Austin GP, Platt SG, Zak

JC, Cobb GP, Marsland EJ, Tian K, Zhang B,

Anderson TA, et al. Assessment of pathogens and

toxicants in New Orleans, LA following Hurricane

Katrina. J Environ Sci Tech. 2006;40:468-474.

28. Davis NA, Whipp AA, Warner WW. Control of

house flies with aerial sprays containing Dibrom.

Proceedings of the 32nd Annual Meeting of the

Florida Anti-mosquito Association. 1961:31-33.

29. Dubose W. Aerial spray tests with caged filth flies.

Mosq News. 1970;30:266-267.

30. Breidenbaugh M, Haagsma K, Olson S, Teig D,

Spears B, McHugh C, Walker W, Sanders D. Air

Force aerial spray operation to control adult mosquitoes following Hurricanes Katrina and Rita. Wing

Beats Fla Mosq Control Assoc. 2006;17(2):7-15.

AUTHORS

Maj Breidenbaugh is Chief Entomologist, Air Force

Aerial Spray Unit, 757 Airlift Squadron, 910th Airlift

Wing, USAFR, at the Youngstown Air Reserve Station,

Vienna, Ohio.

Maj Haagsma is Research Entomologist, Air Force

Aerial Spray Unit, 757 Airlift Squadron, 910th Airlift

Wing, USAFR, at the Youngstown Air Reserve Station,

Vienna, Ohio.
62 www.cs.amedd.army.mil/references_publications.aspx

POLICY DEVELOPMENT

Noise-induced hearing loss appears in literature as

early as the 16th century when a French surgeon

named Ambroise Paré described acoustic trauma in

detail when he wrote of the treatment of injuries

sustained by firearms.1 Even so, the protection of

hearing would not be addressed for 3 more centuries

until the jet engine was invented, bringing long

overdue attention and a flurry of policy development

addressing the prevention of hearing loss.

In 1976, the General Accounting Office, now the

Government Accountability Office, issued an

investigative report.2 This

report identified over half of

US government employees,

including the Department of

Defense (DoD), as working

in environments with

inadequate procedures for

identifying and rectifying

occupational health hazards.

Further, the report requested

that the US Congress amend

the Occupational Safety and

Health Act3to bring federal

a g e n c i e s u n d e r t h e

inspection control of the

Department of Labor. As a

result, in 1978, military

audiologists and other

government employees

achieved standardization in

m i l i t a r y h e a r i n g

conservation with the

publication of DoD

I n s t r u c t i o n ( D O D I )

6055.12,

4 which provides

guidance and requirements

for hearing conservation

implementation.

To implement DODI 6055.12, the Army published a

technical bulletin (TB MED 501, Hearing

Conservation, now discontinued) in 1980. DODI

6055.12 was updated in 1987 to implement new

requirements established by the 1983 Federal Noise

Amendment.5 The new policy identified specific role

responsibilities within a hearing conservation program

and thereby paved the way for the first enforceable

regulation to be published on the subject. The new,

and current, implementing guidance is Department of

the Army Pamphlet 40-501, Hearing Conservation

Program.

6 This multifaceted approach to prevention

has enjoyed many years of success until Operations

Enduring Freedom and Iraqi Freedom, as illustrated in

Figure 1. The large scale

c o m b a t o p e r a t i o n s

challenged this garrisonoriented prevention strategy.

Figure 2 demonstrates that

the majority of hearing loss

in the Army is concentrated

among those Soldiers

involved in combat. Data

about the percentage of

Soldiers who returned from

a combat deployment with

significant hearing problems

in 2004 are presented in

Table 1. These hearing losses are the direct result of

their noise exposure, and

emphasize the importance of

hearing protection for combat and combat training.

Annual data from the

Department of Veterans

Affairs (VA) evidenced the

immediacy for implementing

change by showing hearing

as a primary disability.12-14

In 2006, the VA awarded

55,864 new cases for hearing

Evolution of the Army Hearing Program

MAJ D. Scott McIlwain, MS, USA

CPT Kara Cave, MS, USA

COL Kathy Gates, MS, USA

COL (Ret) Don Ciliax, MS, USA

Figure 1. Percentage of US Army Forces Command

Soldiers classified with H3 hearing profile* or

greater, displayed by year to demonstrate the

marked increase shown since the beginnings of

Operations Enduring Freedom (October 2001) and

Iraqi Freedom (March 2003).†

*H3 hearing profile is defined by the US Army Standards of

Medical Fitness7as “speech reception threshold in best

ear not greater than 30 dB HL, measured with or without

hearing aid; or acute or chronic ear disease.”

†Chart is a compilation of data from 3 studies.8-

10 (Source:

http://chppm-www.apgea.army.mil/hcp// figures

tables.aspx) and the Defense Occupational and

Environmental Health Readiness System Data Repository,

Comprehensive Hearing Threshold Database for the Dept

of Defense, 2008. (Source://doehrswww.apgea.army.mil/

doehrsdr/).

0

10

20

30

40

50

60

34.3

16.6 16.2

51.8

1974 1989 1994 2007

Percentage
April – June 2008 63

loss alone. Between the starts of Operations Enduring

Freedom and Iraqi Freedom, compensation payments

for hearing loss increased by 319%. Hearing loss is the

second most common new disability award by the VA,

surpassed only by tinnitus. In 2007, hearing loss

compensation reached over 1 billion dollars for a

predominantly preventable injury. These figures do not

account for service members who remain on active

duty with hearing loss or those who may lose

hearing in the future as a result of current

hazardous noise exposure. Furthermore, the data

presented are for primary disability only and do not

include Veterans who have another primary

disability rating, such as an amputated limb, in

combination with hearing loss or tinnitus as a

secondary disability.

ACCEPTING CHANGE

Whether in peacetime or wartime, hazardous noise

exists as one of the primary occupational hazards

in the Army. The risk of noise-induced hearing loss

in Soldiers has reached the highest rate in over 30

years. This trend resulted from current combat

operations, increased numbers of combat arms

Soldiers, extended periods of weapons training, and

deployment of new and more powerful noise sources

from weapons systems, vehicles, and aircraft. US

forces in Iraq and Afghanistan experienced a

substantial number of blast injuries from improvised

explosive devices, rocket-propelled grenades, and

mortar rounds. These types of explosions remain the

Table 1. Clinically diagnosed noise-induced hearing loss

incidence rates among Soldiers, April 1, 2003, through March

31, 2004.*

Condition Diagnosed†

Postdeployment

Related Diagnosis

(n=806)

Nondeployment

Related Diagnosis

(n=141,050)

Acoustic trauma

Permanent threshold shift

Tinnitus

Eardrum perforation

H3 or H4 hearing profile

45

236

248

13

127

(5.6%)

(29.3%)

(30.8%)

(1.6%)

(15.8%)

78

639

2101

88

3140

(0.1%)

(0.5%)

(1.5%)

(0.1%)

(2.2%)

Any of the above 553 (68.6%) 5668 (4.0%)

*Data are from Helfer et al.11

†Diagnoses as coded in accordance with the International Classification of

Diseases, 9th Revision, Clinical Modification (US Public Health Service).

CENTCOM†0.40%

FORSCOM* 61.57%

CENTCOM†1.94%

FORSCOM* 51.98%

2007 2006

Figure 2. Percentage of Soldiers in FORSCOM* and CENTCOM† who tested at H2‡and H3§or greater hearing

threshold levels in 2006 and 2007.** Overall, a much larger percentage of FORSCOM Soldiers are involved in

combat operations, and the corresponding impact on hearing loss is clearly reflected in the data.

*Army Forces Command

†Army Central Command

‡Audiometer average level for each ear at 500, 1000, 2000 Hz, or not more than 30 dB, with no individual level greater than 35 dB at

these frequencies, and level not more than 55 dB at 4000 Hz; or audiometer level 30 dB at 500 Hz, 25 dB at 1000 and 2000 Hz,

and 35 dB at 4000 Hz in better ear. (Poorer ear may be deaf).

§H3 hearing profile is defined by the US Army Standards of Medical Fitness7as “speech reception threshold in best ear not greater

than 30 dB HL, measured with or without hearing aid; or acute or chronic ear disease.”

**Chart is a compilation of data from 3 studies.8-

10 (Source: http://chppm-www.apgea.army.mil/hcp//figurestables.aspx) and the

Defense Occupational and Environmental Health Readiness System Data Repository, Comprehensive Hearing Threshold Database for

the Dept of Defense, 2008. (Source://doehrswww.apgea.army.mil/doehrsdr/).
64 www.cs.amedd.army.mil/references_publications.aspx

single largest cause of injury from Operation Iraqi

Freedom and comprise 47% of all medical

evacuations.15 As a result, developments in protecting

Soldiers from these types of hazards are paramount.

The Combat Arms Earplug (CAE) is a nonlinear

earplug that allows effective communication and

situational awareness while

providing protection from

hazardous impulse noises.

Introduced to the military by the

start of Operation Enduring

Freedom, Soldiers shunned them

f o r o p e r a t i o n a l u s e .

Astonishingly, they were also

considered cost prohibitive by the

units at approximately $6 per pair.

With units’ strengths decreasing

because of hearing loss, in 2004

the military began issuing CAEs

to all deploying Soldiers and

Marines. In fact, the Marine

Corps was so convinced of the

concept that they ordered over

20,000 pairs in 2004, temporarily

depleting the entire national stock of CAEs. Anecdotal

information from audiologists who served in Iraq

indicated that no Soldier seen at a combat support

hospital who reported that he or she was wearing the

CAE when exposed to an explosion had ruptured

eardrums.16 The CAE is now a rapid fielding issue

item for deploying Soldiers. The CAE allows most

speech information to pass

through with minimal attenuation,

while protecting against noise

associated with combat events.

The CAE will soon become a

standard issue item for all initial

entry Soldiers, allowing them to

train with the CAE prior to using

them in combat.15

Army Audiologists have been

serving with combat support

hospitals in Iraq since January

2004. Providing these reactive

services in theater was logical, but

the concept was not wholly sound

because it neglected the need for

prevention and maintenance of

The Combat Arms Earplug

(Image courtesy of Aearo Technologies, 5457

W. 79th Street, Indianapolis, IN 46268)

Tactical Communication and Protective System

The obstacle of protecting hearing while enhancing a Soldier’s communication ability and situational

awareness is being addressed by a new generation of hearing protection. This new category of equipment is

known as the tactical communications and protective system (TCAPS). TCAPS introduced a new category of

electronic hearing protection that utilizes active noise reduction to soften noise, thus enhancing speech

discrimination, while at the same time providing a noise reduction rate of up to 40 dB. In addition to being

light and rugged, TCAPS devices provide protection and allow Soldiers to monitor environmental sounds,

communicate, accurately gauge auditory distance, and localize sound sources without hindrance. Furthermore,

some of these devices allow processing of military specific radio connections without signal interruption

while reducing environmental sounds. QUIETPRO®(Nacre US Inc, 106 Bud Place, Aberdeen, North Carolina

28375), one of the TCAPS devices, is a rapid equipping force

item. It allows both hearing enhancement and protection. The

response from Soldiers has been extremely favorable, in fact,

anecdotal information indicates that they do not want to deploy

without them.

Also, Soldiers of the 4th Infantry Division, 3rd Brigade Combat

Team are receiving QUIETPRO devices to use during their

impending Operation Iraqi Freedom deployment. Audiologists

are working closely with the 3rd BCT leadership to ensure that

the devices are properly fitted to Soldiers, and they are trained

on the devices. In addition, all Soldiers are provided

predeployment hearing services, which include a predeployment

audiogram, earplug fitting, and a health education briefing. Quietpro® TCAPS Device

(Photo courtesy of Nacre US, Inc.)

Evolution of the Army Hearing Program
April – June 2008 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

Soldier hearing readiness while in a forward

deployed environment. The paradigm of what

composed a comprehensive hearing conservation

program in the past has shifted, and now

considers the Soldiers’ environment on the

battlefield. Operational hazardous noise situations

that involved large military-unique equipment,

lengthy work days, and immature infrastructure of

base camps are addressed. Urban terrain—such as

the streets of Baghdad—is a particular hazard for

Soldiers because it is wrought with obstacles such

as buildings, alley ways, and ditches. To

compound the importance of good hearing,

civilian inhabitants must be distinguished from

actual combatants in an often chaotic

environment.

A study was conducted by the US Army Human

Engineering Laboratory in 1990 to investigate the

effects of communications on performance.17 The

experiment, involving 30 experienced tank crews,

required crews to conduct gunnery scenarios under

communication conditions ranging from very good to

extremely poor. Performance measures were recorded

in different levels of speech intelligibility for each

scenario, based on the modified rhyme test (a

standardized intelligibility test). Five levels of speech

intelligibility were used: 100%, 75%, 50%, 25%, and

0% intelligible. The specific measures used to evaluate

performance as a function of speech intelligibility

were mission time, mission completion, mission

errors, and gunner accuracy. The scenarios consisted

of 10 missions, each requiring the commander to

instruct the gunner to shoot at up to 3 targets (21

targets per scenario). Four targets (tank, truck,

helicopter, or troops) appeared during each mission.

As is the standard operating procedure for armor

operations, it was the commander’s task to instruct the

gunner to shoot at the appropriate target with the

appropriate weapon. The results, displayed in Table 2,

are compelling for the argument that the

multidimensional sense of hearing provides an

indispensable amount of information and could mean

the difference between life and death on the battlefield.

THE ARMY HEARING PROGRAM

The Army had to develop the means to prevent noiseinduced hearing loss in Soldiers while ensuring their

maximum combat effectiveness in training and during

deployments. As a result, a contemporary model called

the Army Hearing Program (AHP) was established.

The AHP provides prevention services in a more fluid

environment than that experienced in garrison.

As the Army transforms, the AHP will better meet the

needs of Army civilians and Soldiers in all

environments, especially those where the traditional

hearing conservation approach does not. The AHP, an

operational approach, provides hearing services to

Soldiers in their training and operational

environments. The AHP consists of 4 major elements:

hearing readiness, clinical hearing services,

operational hearing services, and hearing conservation.

This combination of services promotes and increases

Soldier awareness of hearing, and the importance of

maintaining normal hearing for good situational

awareness and voice communication in any

environment, including combat. Due to current combat

operations, the risk of Soldiers incurring noise-induced

hearing loss is greater now than it has been in 30 years.

Hazardous noise is one of the primary occupational

hazards in the Army. As a result, AMEDD added

authorizations for 10 badly needed Army Audiologists

in 2007. These positions will have a positive impact on

the Army Hearing Program, but will still place the

inventory at a point that is one-third lower than it was

in 1990.

Hearing services continue in the combat support

hospital in support of Operation Iraqi Freedom. The

prevalence of acoustic trauma is high in the combat

theater, and commanders cannot afford to lose Soldiers

to a medical evacuation for several weeks to determine

their hearing status. In order to ensure hearing-injured

Soldiers are provided immediate care, hearing sites

have been established at all major forward operating

bases in Iraq. Soldiers receive immediate hearing care

Function Good Word

Intelligibility

Poor Word

Intelligibility

Time Required to Identify Target 40 Seconds 90 Seconds

Incorrect Command Heard 1% 37%

Correct Target Identification 98% 68%

Correct Targets Engaged 94% 41%

Incorrect Target Engaged 0% 8%

Table 2. Results of the US Army Human Engineering Laboratory

study of communication on performance of tank crews under

simulated battlefield conditions (1990).

Data from Garinther and Peters.16
66 www.cs.amedd.army.mil/references_publications.aspx

and follow-up services in-theater, and are quickly

returned to duty.

CONCLUSION

Army-wide implementation of the AHP requires

additional hearing resources to ensure both clinical and

nonclinical hearing services are provided to Soldiers.

In September 2006, hearing readiness was included in

the Readiness Module of the Medical Protection

System. Commanders and medical leaders can now

monitor individual and unit compliance. Hearing

readiness compliance for active duty Soldiers is

currently 74%, a 15% increase since September

2006.15 Funding is projected to fully implement AHP

to bring hearing conservation into the 21st century,

meeting the challenges of today’s battlefield and that

of the foreseeable future. The Army will no longer

accept hearing loss as an inevitable byproduct of

military service.

REFERENCES

1. Nuland S. Doctors: The Biography of Medicine. New

York; Vintage Books: 1988.

2. US General Accounting Office. Hazardous Working

Conditions in Seven Federal Agencies. Washington,

DC: US General Accounting Office; 1976;

Publication HRD-76-144: 1-104.

3. Occupational Safety and Health Act of 1970, Pub L

No. 91-596, 84 STAT. 1590 (1970).

4. Department of Defense Instruction 6055.12: DoD

Hearing Conservation Program (HCP). Washington,

DC: US Dept of Defense; March 5, 2004.

5. Occupational Noise Exposure; Hearing Conservation

Amendment; Final Rule. Fed. Reg. 48:9738-9785,

Mar. 8, 1983.

6. DA Pamphlet 40-501: Hearing Conservation

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

December 10, 1998.

7. Army Regulation 40-501: Standards of Medical

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

December 14, 2007: 80.

8. Walden BB, Prosek RA, Worthington DW. The

Prevalence of Hearing Loss Within Selected U.S.

Army Branches. Washington, DC: US Army Medical

Research and Development Command, US Dept of

the Army; August 31, 1975:1-49.

9. Ohlin D, Aspinall KB, Monk WH. Hearing

conservation in the U.S. Army. Army Med Dept J.

Fall 1994:38-42.

10. Ohlin D. U.S. Army hearing conservation program

yields cost avoidance from reduced veterans hearing

loss disability. USACHPPM Today. 1995;2(2).

11. Helfer T, Jordan N, Lee R. Postdeployment hearing

loss in US Army Soldiers seen at audiology clinics

from April 1, 2003, through March 31, 2004. Am J

Audiol. 2005;14(2):161-168.

12. US Army Center for Health Promotion and

Preventive Medicine. Veterans’ compensation

reports. 2007. Available at: http://chppmwww.ap gea.army.mil/hcp//reso urces/2006_

veterans_compensationchart.ppt. Accessed

September 6, 2007.

13. US Army Center for Health Promotion and

Preventive Medicine. Veterans Administration

Disability Report. 2007. Available at: http://chppmwww.ap gea.army.mil/hcp//reso urces/2006_

vadisabilityReport.ppt. Accessed September 6, 2007.

14. US Army Center for Health Promotion and

Preventive Medicine. Cost effectiveness of hearing

conservation programs. 2007. Available at: http://

chppm-www.apgea.army.mil/hcp//costeffective.aspx.

Accessed September 6, 2007.

15. Gates K. Operational hearing services. Military

Audiology Short Course presented at: Annual

Meeting of Military Audiology Association; April 18,

2007; Denver, CO.

16. McIlwain DS. Audiology in Operation Iraqi

Freedom. Audiol Today. 2004;16(5):24-25.

17. Garinther GR, Peters LJ. Impact of communications

on armor crew performance. Army Res Dev Acquis

Bull. January-February 1990:1-5.

AUTHORS

MAJ McIlwain is an instructor and course writer in the

Department of Preventive Health Services at the Army

Medical Department Center and School, Fort Sam

Houston, Texas.

CPT Cave is Chief of the Fort Bliss Hearing Program at

the William Beaumont Army Medical Center, Fort

Bliss, Texas.

COL Gates is the Audiology and Hearing Program

Consultant to The Army Surgeon General. She is also

the Proponency Officer for Preventive Medicine, Office

of The Surgeon General, Falls Church, Virginia.

COL (Ret) Ciliax is an Army Hearing Program

Consultant at the Center for Health Promotion and

Preventive Medicine, Aberdeen Proving Ground,

Maryland.

Evolution of the Army Hearing Program
April – June 2008 67

An important aspect of vector-borne disease

prevention is an understanding of how to defeat the

host–reservoir–pathogen-vector cycle through vector

surveillance. Surveillance may lead to new or

improved vector identification information, revised

vector checklists and distributions, new information

about vector bionomics, or useful aspects of hostreservoir-pathogen-vector interactions. Over the past

decade, Army entomologists and their Korean

collaborators have significantly increased surveillance

studies to update knowledge and answer questions

about vector-borne disease impacts on potential

military operations in the Republic of Korea (ROK).

The studies have attempted to increase our knowledge

of pathogen-vector-host-reservoir relationships,

primarily in terms of vector identification and

bionomics, host behavior, geographical and seasonal

distributions, and potential control or mitigation

solutions. Vector surveillance is further augmented by

human epidemiological investigations that identify

human populations at risk, and disease distributions

that can be correlated with relative vector importance.

Country-specific knowledge was acquired through

these studies to explain the human side of disease

acquisition. Portions of this article condense the results

of selected vector surveillance programs of the 18th

Medical Command (MEDCOM), Yongsan, Korea,

but, more importantly, focus on understanding Koreaspecific disease issues.

MALARIA

During the Korean War, annual malaria rates ranged

from 8.3 to 39.2 per 1,000 Soldiers.1In 1979, after

years of eradication efforts, the World Health

Organization (WHO) declared the ROK to be malaria

free.2 However, in 1993, a Korean soldier based near

the demilitarized zone (DMZ) who had no recent

travel history was diagnosed with vivax malaria.3 This

case was identified as autochthonous transmission that

rapidly spread throughout the ROK troops stationed

along the DMZ, and subsequently to local civilian

communities. Based on WHO reports, North Korea

experienced a similar resurgence of malaria, especially

along the DMZ. While it was thought malaria in the

ROK originated from North Korea, it soon became

evident that malaria was again endemic in the ROK.3-5

The Table presents the number of malaria cases

reported annually in the ROK since 1993.

While malaria remains concentrated along the DMZ in

northern Gyeonggi Province, other areas of the ROK

are being affected as ROK veterans return to their

homes and develop malaria resulting from latent liver

stages.6-8 Consequently, malaria spreads throughout

the peninsula. In similar fashion, Koreans visiting

northern Gyeonggi Province may acquire the disease,

and then return to their home, elsewhere in Korea,

after which the disease is expressed.6-8If the infective

person (demonstrating fevers and chills) waits several

days before seeking medical attention and is fed upon

by vector mosquitoes, a focal point for malaria may

have been created, and it may or may not survive for

successive transmission or seasons.

In order to determine where malaria occurs, especially

in military or transient populations, one must

determine where the infective mosquito fed upon the

affected person. Since it takes from 12 days to a year

for vivax malaria to express disease (blood stage

parasites), the locations of where the disease was

expressed and where it was acquired are often

completely different, especially among Soldiers who

train along the DMZ, then return to their home base or

are redeployed to the US or other countries. Therefore,

detailed patient interviews by preventive medicine

personnel trained in conducting epidemiological

investigations/interviews are essential for quality data

collection and determination of the site of

transmission/infection. To achieve this, selected

personnel in the Force Health Protection staff, 18th

MEDCOM, conduct interviews and record and analyze

Perspectives of Malaria and Japanese

Encephalitis in the Republic of Korea

LTC William J. Sames, MS, USA

Heung-Chul Kim, PhD

COL (Ret) Terry A. Klein, MS, USA
68 www.cs.amedd.army.mil/references_publications.aspx

these data for all US military malaria

cases diagnosed in the ROK.

Personnel who do not regularly work

malaria issues may assume the area of

disease expression is where the disease

was acquired. This has lead to the

implementation of corrective actions in

the wrong area. For example, vector

control actions may be implemented in

areas with few vectors, and warnings

may be given to bases or communities

where malaria is very low risk. In other

instances, unit leaders may think that

they had a successful training event

because no one contracted malaria

during the event. However, they do not

associate future disease expression as the

result of inadequate protection, which

many times can be traced back to the

lack of command emphasis on personal

protective measures (PPM) during their

training event. The delay in the onset of

symptoms blurs the direct causeconsequence relationship. Therefore,

most people fail to associate their

failures in protective actions with the

consequences of contracting the disease.

Anopheles mosquitoes overwinter as

eggs or nulliparous females (unfed

females without eggs), which do not become infected

until they feed on a person with circulating parasites.

Therefore, the annual vivax malaria cycle is only

maintained by a pool of latent malaria cases and

asymptomatic carriers. As the temperature warms in

late April to early May, the overwintering female

mosquito takes a blood meal and lays eggs 3 to 5 days

later with resultant increasing vector populations.

These noninfected vector mosquitoes bite persons

expressing the latent form of malaria, or untreated

individuals who no longer demonstrate symptoms but

harbor infective parasites, which in turn infect the new

uninfected vectors. The vector population continues to

increase throughout the summer and interactions with

infective reservoirs and susceptible hosts assure that

some of the parasites will be acquired and transmitted

by the vector.

In rural areas along the DMZ, the probability of

acquiring malaria in April or May is low, but steadily

increases with peak transmission times occurring in

late July and throughout August. During the peak

period, the vector population is generally at its highest.

Because there has been sufficient time during this

period for vector-reservoir interaction, it is the older

mosquito that is the dangerous mosquito (the period

from ingestion of the parasite to transmission is a

minimum of 9 days at optimal temperatures). Drainage

of the rice paddies for harvest marks the downturn of

malaria vector populations and results in a significant

decrease in the number of malaria cases, which

typically stop presenting in October or early

November.

A number of factors, including droughts (reduction of

breeding sites), heavy rain from monsoons and

cyclones (mosquitoes washed downstream and older

adult mosquitoes killed), pesticide/herbicide usage in

the rice paddies (overhanging grasses along the banks

provide habitat) affect population levels and the mean

Number of Plasmodium vivax malaria cases reported in

the Republic of Korea (ROK) by year since 1993.

Year US Forces

Korea

ROK

Military

ROK

Veterans

ROK

Civilians Total

1993 1 1 0 0 2

1994 3 18 1 2 24

1995 1 88 12 7 108

1996 14 285 25 46 370

1997 33 1,156 207 361 1,757

1998 42 1,657 1,127 1,148 3,974

1999 58 1,084 996 1,541 3,679

2000 48 1,289 1,273 1,580 4,190

2001 30 673 748 1,067 2,518

2002 48 406 472 885 1,811

2003 30 273 274 560 1,137

2004 22 158 244 424 848

2005 17 233 322 769 1,341

2006 24 311 432 1,278 2,045

2007 34 447 462 1,271 2,214

Total 405* 8,079 6,595 10,939 26,018

*Distribution: US military - 361; Korean Army augmentees to the US Army - 43;

DoD civilian - 1

Sources of data: Korea Center for Disease Control and Prevention, Seoul, ROK;

Force Health Protection, 18th Medical Command, Yongsan Garrison, ROK.

Perspectives of Malaria and Japanese Encephalitis in the Republic of Korea
April – June 2008 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

age of the population that directly impacts on

transmission levels. As many of these conditions are

variable, they affect the number of malaria cases for

any given year. For example, a very late autumn

during 2006 resulted in a spike of malaria cases at the

end of the malaria season and contributed to an

increased number of latent cases the following year.

Only certain Anopheles species vector malaria. They

feed sometime between dusk and dawn, and are often

classified as primary or secondary vectors depending

on their relative susceptibility to acquire salivary gland

infections and interaction with human hosts, as some

are zoophilic and prefer to feed on large animals such

as cows.9,10 Until 2005, An. sinensis was considered

the primary malaria vector in Korea, and it was

thought to be distinguished from other Anopheles

species by morphological characters.

In 1999, while rearing progeny broods for the Walter

Reed Biosystematics Unit (WRBU), two of the

authors, COL Klein and Dr Kim, discovered that

members of one sample demonstrated characteristics

of 2 or more species. Subsequently, more progeny

broods from wild-caught blood fed females were

reared, and a selected fragment of the ITS2 gene was

sequenced by polymerase chain reaction by a WRBU

team and a researcher from the US Army Medical

Research Institute for Infectious Disease to determine

species and subsequently determine if morphological

characters could be applied for their identification. In

2005, these teams of Army and Korean entomologists

determined that Anopheles sinensis and closely related

species consisted of at least 5 species: An. sinensis, An.

pullus, An. lesteri, plus 2 new species: An. belenrae,

and An. kleini, and further demonstrated that these

species could not be reliably identified by

morphological characters.11

These same entomologists, working with the Armed

Forces Research Institute of Medical Sciences and the

Korea National Institute of Health (KNIH), implicated

An. pullus and An. kleini as the primary vectors of

malaria, with An. sinensis having a lesser role.10

Therefore, areas with relatively large populations of

An. pullus and An. kleini should correlate with areas

for the highest risk of malaria. Preliminary

investigations, human-based surveillance, and larval

and adult surveillance studies suggest that there is a

valid correlation between the numbers of malaria cases

and these primary vector populations. These studies

are also working to determine if there is a separation of

the larval habitat between these species, so control

efforts can focus on selected habitats of greater

importance rather than on large scale areas, which do

not support large vector populations.*

JAPANESE ENCEPHALITIS

Japanese encephalitis (JE) is a viral mosquito-borne

disease that can affect the human central nervous

system, and may be fatal or leave people with mild to

severe brain damage (neurological deficiencies). It is

vectored by Culex tritaeniorhynchus in Korea and

poses a greater threat south of Seoul where very large

vector populations occur. Large water birds are the

primary reservoir and swine function as amplifying

hosts. Humans are considered to be dead-end hosts as

they rarely develop sufficient viremia to infect

mosquitoes. The disease is prevalent where wetland

rice farming occurs, with population densities of

vector mosquitoes peaking near the end of summer and

early fall (August to early October).

Japanese encephalitis was first identified from an

American Soldier at Inchon in 1946.12 In 1949, JE

became a notifiable disease and 5616 cases resulting in

2729 deaths (49%) were reported. After 1950,

outbreaks of several thousand cases were reported

periodically every 2 to 3 years. The largest outbreak

occurred in 1958 with 6,897 cases. Since 1958, there

were between 2000 to 3000 cases reported annually

until 1968.13

In the mid to late 1960s, the Korean government

instituted a massive JE immunization program for

school-aged children which significantly changed the

epidemiology of JE in Korea, but not the threat. Since

the inception of the program, the number of JE cases

dropped significantly, and for most years only a few

sporadic cases (0 to 7 cases annually) have occurred

over the past decade. In addition to the immunization

program, a vast improvement of the environment,

sanitation, and a higher standard of living contributed

to the reduction of JE cases.

The relative proportion of symptomatic to

asymptomatic (or mild unreported) cases is 1/25 to

1/1000 (and perhaps less in healthy young men), while

*See related article on page 46.
70 www.cs.amedd.army.mil/references_publications.aspx

JE infections may result in severe morbidity with 10%

to 30% mortality among those that demonstrate

symptoms.14,15 Researchers at the Department of

Defense (DoD) Global Emerging Infections System

and the Walter Reed Army Institute of Research are

coordinating to evaluate pre- and postdeployment

blood samples from Soldiers previously deployed to

Korea to determine relative rates of transmission in

lieu of no symptomatic cases reported among US

Soldiers over the past 2 decades. Currently, the US

protocol in Korea for JE vaccine categorizes

inoculation as voluntary upon request by the

individual.

Japanese encephalitis is maintained in the environment

through a mosquito–large wading bird–mosquito

cycle. The principal vectors prefer to feed on birds, but

will feed on alternate hosts when birds are not

available or when the alternate hosts enter the

mosquitoes’ habitat.16 Pigs serve to amplify the

transmission cycle, producing extremely high viremias

that infect large numbers of the blood-feeding vector

mosquitoes.17 Japanese encephalitis infection causes

spontaneous abortion in sows about to litter. For this

reason, breeder sows are often immunized. However,

because of the costs and the absence of effect on

production, young pigs raised for slaughter are not

immunized since virus infections do not affect their

health or weight gain. When military personnel reside

or train near vector mosquito habitats, such as rice

paddies where large wading birds are present and

especially near pig farms when JE is circulating, they

are at high risk for infection. Therefore, risk

assessments conducted for JE should consider the

seasonality and proximity of swine farms to US

military installations and training sites.

The KNIH conducts mosquito surveillance. When JE

vector populations exceed 50% of the collected

mosquitoes, the KNIH issues public JE alerts, reminds

citizens to use all means to protect themselves from

mosquito bites, and encourages high risk groups to

obtain vaccinations. However, the areas where the

Korean workforce conducts sampling are often not the

same areas of interest as those of the US armed forces.

Additionally, the KNIH conducts sero-surveillance for

the presence of JE antibodies/infection from

slaughtered pigs at selected sentinel sites. The KNIH

again reports the results in public news releases, which

emphasize vaccination and PPM. However, these data

do not reflect the focal infections since:

 sentinel sites are limited;

 only data from slaughterhouses are reported, not

the pig farm sites where the transmission

occurred; and

 pig farms are isolated and not evenly distributed.

While these data are limited, they serve as an early

warning system. For example, prior to the

immunization program, it was observed that

approximately 2 weeks after the pigs were

serologically positive for JE, mosquito samples were

identified as positive, and shortly thereafter, focal

outbreaks of JE in human populations resulted.

As the structure, distribution, and concentration of US

military forces change in Korea in response to

transformation and base closures, vector-borne

diseases must be considered, for example, the

movement of forces currently deployed north of Seoul

to Camp Humphreys (near Pyeongtaek), which is

programmed to become the primary US Army

installation on the Korean peninsula. Currently, much

of Camp Humphreys is surrounded by rice paddies—

surveillance in 2005 and 2006 demonstrated large

populations of Culex tritaeniorhynchus occurred from

August through early October. The demographics of

this installation will change from a Soldier based

community to a Soldier and family member based

community, placing family members, including young

children, at risk in an area were they may be exposed

to large populations of potentially infected vectors. In

addition, 2 of 7 JE cases reported in the highly

vaccinated Korean population during 2007 resided

near Pyeongtaek, suggesting that implementation of a

JE vaccination program is necessary to protect the

susceptible and growing US population at Camp

Humphreys. Thus, constant surveillance of mosquito

populations, their infection rates, and coordination

with the KNIH and Korea Center for Disease Control

and Prevention is necessary to delineate the risks and

reduce the threat of Japanese encephalitis to US

populations.

MALARIA AND JAPANESE ENCEPHALITIS

PREVENTION AND CONTROL STRATEGIES

Readiness is a key issue with US military personnel in

the ROK. The proximity and uncertainty of a rapidly

Perspectives of Malaria and Japanese Encephalitis in the Republic of Korea
April – June 2008 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

escalating enemy threat dictate that commanders and

their Soldiers must be prepared for hostile actions and

“train as they fight.” This includes the prevention of

disease and nonbattle injuries, especially those due to

preventable diseases. Command emphasis and routine

implementation of PPM is essential. It not only

decreases the potential for malaria and JE

transmission, but also decreases the probability of

contracting scrub typhus and multiple tick-borne

diseases. It also serves as an alert to commanders for

other diseases (ie, Hantaan virus), where PPM and/or

other strategies must be employed.

The prevention of mosquito-borne disease in endemic

high-risk areas of the ROK requires strict adherence to

the DoD Insect Repellent System, to include the

mandatory use of bed nets during overnight field

training events. In 2007, the Eighth Army purchased

bed nets for use by military personnel who conducted

overnight events in malaria high-risk areas near the

DMZ. Barracks also replaced the tent village at

Warrior Base and were thought to have an additional

benefit of preventing vectorSoldier interactions. It

was later observed that Soldiers would gather outside

during off-duty hours and at night in shorts and t-shirts

to socialize. Thus, their behavior exposed them to

potentially infected mosquitoes, even though they all

had the means to prevent mosquitoes from biting them

and getting malaria or other diseases. Therefore,

human behaviors continue to serve as major risk

factors and cannot be overlooked.

Chemoprophylaxis (chloroquine with terminal

primaquine) may be used to reduce the risks of

acquiring malaria.18 While it does not prevent

transmission or infection, it does reduce the reservoir

population (infective humans) required for the

transmission of malaria to ROK civilians and US

military personnel living or deployed in close

proximity to ROK bases near the DMZ. However, an

effective chemoprophylaxis program requires strict

adherence to policy and observed compliance.19,20 As a

result of increasing malaria rates observed in US and

ROK populations in 1998, the Eighth US Army placed

all US Soldiers training near the DMZ on

chemoprophylaxis. Commanders apparently did not

understand the program as there were many variations

(event and situational dependent), including

noncompliance with terminal primaquine (15 mg

daily for 14 days after the malaria season or when

departing malaria high-risk areas). This resulted in an

increased proportion of US diagnosed malaria cases

being attributed to exposure in Korea.

Based on recommendations from the Preventive

Medicine and Entomology Consultants, Force Health

Protection, 18th MEDCOM, after 1999 the

chemoprophylaxis policy was changed:

 Only those Soldiers residing in malaria high-risk

areas (Camp Bonifas-Joint Security Area at

Panmunjom and Camp Greaves) are placed on

chemoprophylaxis.

 Command emphasis is placed on prevention using

PPM that includes proper wear of the uniform,

impregnating uniforms with permethrin, and using

the standard military topical insect repellents while

in field environments near the DMZ.

Efforts to combat mosquitoes with ultra low volume

(ULV) or thermal foggers present several issues for

US military forces in Korea. First, for various reasons,

training areas are not treated, so PPM and other

mitigation strategies must be employed in those areas.

Second, US bases where mosquito-borne diseases are a

threat are usually surrounded by rice paddies and as

such are basically “islands” in a sea of mosquito

habitat. Third, adulticides applied by ULV are

effective over a short time and distance but do not

significantly slow the migration of mosquitoes from

the surrounding rice paddies. Fourth, pesticide

resistance is a continual concern as some populations

of mosquitoes are resistant to at least one of the

pesticides used by the Korean health officials. Thus,

health departments have resorted to a “cocktail” of

insecticides rather than one specific type. However, it

is thought that most mosquito populations are

susceptible to pesticides currently used by the US

military, although there have been no studies to

confirm this supposition.

On bases, Soldiers tend to escape the affects of vectorborne disease because they are normally inside from

dusk to dawn, the primary mosquito feeding times.

Some bases are still located in urban areas where

vector populations are low, further suggesting that the

greatest risk for mosquito-borne disease is during

overnight field training events. Planting vegetative

borders along the perimeter of installations that are

surrounded by rice paddies, then treating the
72 www.cs.amedd.army.mil/references_publications.aspx

vegetation with semipersistent chemicals may reduce

vector populations to acceptable levels. This reduction

would occur as mosquitoes are killed when they come

into contact with the pesticide while resting on the

vegetation during their movement from off-post to

areas where the Soldiers reside. Currently, none of the

US installations or field training sites have perimeter

vegetation that meet the requirements for barrier spray

application and control, and, of course, the efficacy of

this control strategy should be tested before full

implementation.

Additionally, larval surveillance that identifies sources

of vector populations on or near US installations must

be conducted. On US installations, these sites must be

identified on detailed maps to ensure control

techniques are implemented (eg, drainage of water

sources and application of larvicides) to reduce vector

populations. If larvicides are applied to water sources,

they must be surveyed periodically to ensure that they

are effective. Pre- and postsurveillance must also be

conducted when pesticides are applied to control adult

populations, especially since preliminary observations

of ULV application indicate that it is effective for less

than one hour after application.

New Jersey light traps (NJLT) have been used for

mosquito collection since the end of the Korean War.

These traps use light as an attractant and therefore

require light security where they are employed. Also,

due to security at US military installations, there are

few places where lights which interfere with the

collections of mosquitoes are not present. Because

light is used as an attractant, all insects attracted to

lights (ie, moths, flies, beetles) are collected, which

results in damaged mosquito specimens that cannot be

identified. Furthermore, a killing agent is placed in the

collection chamber that rapidly kills mosquitoes,

rendering them useless for virus isolation. However,

newer innovative mosquito traps have been evaluated

that do not depend upon light security, collect larger

numbers of mosquitoes, and collect mosquitoes alive

so that virus infection rates can be determined.

For example, the Mosquito Magnet®, uses CO2 and

heat as attractants and selectively collects mosquitoes.

Octenol can be added as an attractant and acts to

attract more of some species, but repels others (eg,

Culex pipiens and Culex orientalis). In general, more

Anopheles mosquitoes are captured in the Mosquito

Magnets using octenol than in other mosquito traps,

but the increased attraction/repellency has not been

determined for each species. While these traps provide

many advantages—portable, can be used in areas

without electricity such as field training sites, collect

large numbers of mosquitoes, live-capture mosquitoes

in relatively good condition so they can more easily be

identified and used for virus isolations—over the

stationary NJLT, they require propane (an explosive

gas) and must be secured. Results of the use of

Mosquito Magnets demonstrated their utility in the

identification of JE infection rates in mosquitoes as

high as 3.3/1,000 and 0.3/1,000 at Warrior Base;

thereby identifying the focal transmission and

epidemic potential of this virus.

CONCLUSION

Vivax malaria and Japanese encephalitis remain valid

threats to military populations in Korea. The primary

threat of malaria is north of Seoul and along the DMZ.

Travel history within Korea is important in

understanding Korean malaria issues, and leaders must

remember to determine the site of transmission and not

the site of diagnosis when implementing prevention

and control measures. Recent studies have provided

new information on the acute and latent forms of

Korean malaria, the identification of new Anopheles

species, and the incrimination of potential malaria

vectors and their habitats.

Japanese encephalitis continues to circulate in avian

and swine populations. Korean vaccination programs

have significantly reduced Japanese encephalitis

expression in humans. However, with the movement

of US military dependent populations to Camp

Humphreys, the US military Japanese encephalitis

vaccination and prevention policies for this susceptible

population must be reevaluated. Studies are needed to

determine practical control strategies for "island

populations" of susceptible hosts, such as are found on

some US military installations in Korea.

Finally, military organizations performing vector

surveillance studies in the ROK should coordinate

their visit with the Force Health Protection staff at the

18th MEDCOM and the 5th Medical Detachment.

These organizations currently have resources and

collaborations for in-country support on the

identification of vectors, rearing immature vectors to

Perspectives of Malaria and Japanese Encephalitis in the Republic of Korea
April – June 2008 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

the adult stage, information regarding malaria

interviews, and collaborative support with Korean

health organizations and universities.

REFERENCES

1. Marshall IH. Malaria in Korea. In: Recent Advances

in Medicine and Surgery Based on Professional

Medical Experiences in Japan and Korea 1950-1953

[professional education course, 19-30 April, 1954].

Vol. 2. Medical Science Publication No. 4.

Washington, DC: US Army Medical Service

Graduate School, Walter Reed Army Medical Center;

1954:270-283. Available at: http://history.amedd.

army.mil/booksdocs/korea/recad2/ch6-2.htm.

2. World Health Organization. Synopsis of the world

malaria situation, 1979. Wkly Epidemiol Rec. 1981;

56:145-149.

3. Feighner BH, Pak SI, Novakoski WL, Kelsey LL,

Strickman D. Reemergence of Plasmodium vivax in

the Republic of Korea. Emerg Infect Dis. 1998;4:295-

297.

4. Chai IH, Lim GI, Yoon SN, Oh WI, Kim SJK, Chai

JY. Occurrence of tertian malaria in male patients

who have never been abroad [in Hangul]. Korean J

Parasitol. 1994;32:195-200.

5. Cho SY, Kong Y, Park SM, et al. Two vivax malaria

cases detected in Korea. Korean J Parasitol. 1994;

32:281-284.

6. Ree HI. Unstable vivax malaria in Korea. Korean J

Parasitol. 2000;38:119-138.

7. Park JW, Klein TA, Lee HC, et al. Vivax malaria: a

continuing health threat to the Republic of Korea. Am

J Trop Med Hyg. 2003;69:159-167.

8. Han ET, Lee DH, Park KD, et al. Reemerging vivax

malaria: changing patterns of annual incidence and

control programs in the Republic of Korea. Korean J

Parasitol. 2006;44:285-294.

9. Service MW. Mosquitoes (Culicidae). In: Lane RP,

Grosskey RW, eds. Medical Insects and Arachnids.

London, UK: Chapman & Hall; 1993:120-240.

10. Lee WJ, Klein TA, Kim HC, et al. Anopheles kleini,

An. pullus, and An. sinensis: potential vectors of

plasmodium vivax in the Republic of Korea. J Med

Entomol. 2007;44:1086-1090.

11. Rueda LM,. Two new species of Anopheles

(Anopheles) Hyrcanus Group (Diptera: Culicidae)

from the Republic of South Korea. Zootaxa.

2005;941:1-26.

12. Sabin AB, Schlesinger RW, Ginder WR, Matsumoto

M. Japanese B encephalitis in an American Soldier in

Korea. Am J Hyg. 1947;46:356-375.

13. Sohn YM. Japanese encephalitis immunization in

South Korea: past, present, and future. Emerg Infect

Dis. 2000;6:17-24.

14. Halstead SB, Grosz CR. Subclinical Japanese

encephalitis. I. Infection of Americans with limited

residence in Korea. Am J Hyg. 1962;75:190-201.

15. Huang CH. Studies of Japanese encephalitis in China.

Adv Virus Res. 1982;27:71-101.

16. Pant CP. Control of vectors of Japanese encephalitis.

Geneva: World Health Organization; 1979. Available

on request [WHO/VBC/79.733] from Division of

Control of Tropical Diseases, World Health

Organization, 1211 Geneva 27, Switzerland.

17. Burns KF, Tigertt WD, Matumoto M. Japanese

equine encephalomyelitis: 1947 epizootic. II.

Serological and etiological studies. Am J Hyg 1949;

50:27-45.

18. Park JW, Klein TA, Lee HC, et al, Vivax malaria: a

continuing health threat to the Republic of Korea. Am

J Trop Med Hyg. 2003;69:159-167.

19. Gambel JM, Brundage JF, Burge RJ, DeFraites RF,

Smoak BL, Wirtz RA. Survey of US Army Soldiers’

knowledge, attitudes, and practices regarding

personal protective measures to prevent arthropodrelated disease and nuisance bites. Mil Med.

1998;163:695-701.

20. Gambel JM, Brundage JF, Kuschner RA, Kelley PW.

Deployed US Army Soldiers' knowledge and use of

personal protection measures to prevent arthropodrelated casualties. J Trav Med 1998;5:217-220.

AUTHORS

LTC Sames is assigned to the Defense Logistics

Agency, Fort Belvoir, Virginia. Previously he was the

entomology consultant to the 18th Medical Command,

Yongsan Garrison, Seoul, South Korea.

COL (Ret) Klein is a consultant to the 18th Medical

Command, Yongsan Garrison, Seoul, South Korea.

Dr Kim is the Entomology Laboratory leader, 5th

Medical Detachment, Yongsan Garrison, Seoul, South

Korea.
74 www.cs.amedd.army.mil/references_publications.aspx

One of the legacies of the military campaign in the

Persian Gulf is the realization that the public health

toll of a conflict is not truly known at the time the

deployment ends. Concerns regarding delayed health

effects may extend the medical mission for years. In a

January 2003 Washington Post article, David Brown1

described a “new system to keep health syndromes at

bay.” He noted that “the agonizing investigation of

what came to be known as Gulf War syndrome eroded

trust in the military, cost hundreds of millions of

dollars and consumed thousands of years of human

labor.” Brown acknowledged that the inability of the

military to provide answers to questions relating to

exposures, troop location, false chemical alarms, and

predeployment health status among other concerns

fueled a belief that

...horrible things may have occurred during the war....

military health officials and most civilian researchers

who studied the subject do not believe anything unusual

or undiscovered occurred in the Gulf War to cause

chronic illness. This time, the military is determined to

begin and conclude the conflict with much better

information.

Brown also addressed the information that is being

collected to characterize occupational and

environmental exposures, and its potential uses.

THE EVOLUTION OF THE OCCUPATIONAL AND

ENVIRONMENTAL HEALTH ASSESSMENT

Efforts to characterize occupational and environmental

health (OEH) exposures in deployed settings have

matured substantially. During the deployment to the

Balkans, health surveillance policy stressed a need to

identify health threats in theater, routinely and

uniformly collect and analyze information relevant to

troop health, and disseminate this information in a

timely manner. US Army preventive medicine

personnel collected air, water, and soil samples from a

variety of locations, largely out of concern about

industrial contamination. The ambient air was

monitored for volatile organic compounds,

semivolatile organic compounds, particulate matter

less than 10 μm in diameter (PM 10), and associated

metals. The main source of particulate was coal-fired

power plants. Sampling indicated intermittent

detections of volatile components of fuel at

concentrations that were not sufficient to produce

acute health effects, and, the potential for chronic

health effects was considered minimal due to

intermittent exposures at varied locations. At one

location near a lead smelter, ambient sampling

indicated elevated levels of lead. Blood lead testing

was performed to assess exposure of the Kosovo

Peacekeeping Forces. Fortunately, the smelter

ultimately closed. Nearly 600 PM 10 samples were

taken and compared to US Environmental Protection

Agency (EPA) Air Quality Index levels. Sixty percent

of the samples were in the good category, where no

health effects are expected. Another 38% were in the

moderate category, with less than 2% categorized as

unhealthy for sensitive groups or unhealthy in

general.2 These categories and corresponding levels

are used in the US to alert the population and sensitive

subgroups such as elderly, children, and those with

heart and lung disease when outdoor activity could be

hazardous to their health.

Limited environmental regulations allowed pollution

of surface waters with raw sewage and industrial

wastes. While US forces drank bottled water, water for

cooking, laundry, and showers was produced locally

by reverse osmosis water purification units and treated

municipal supplies. Finished water did not exceed any

of the US Environmental Protection Agency (EPA)

primary drinking water standards. Soil sampling was

also performed and compared to the EPA risk-based

guidelines, and, given the limited duration of exposure,

no concerns were noted.

ANTICIPATION AND HAZARD RECOGNITION

The current OEH assessment process focuses on

hazard anticipation as well as recognition. Prior to the

location of a site, planners can request a preliminary

hazard or Phase I assessment from the Global Threat

Health Implications of Occupational

Environmental Health Sampling

Coleen Weese, MD, MPH
April – June 2008 75

Assessment Program.* This process identifies industry

and other relevant features of a location, past use and

practices, as well as available intelligence. This can be

used to guide in the selection of a location, and to

focus the Occupational and Environmental Health Site

Assessment (OEHSA). One of the initial actions taken

by preventive medicine personnel upon arrival at a site

is the OEHSA. This is an overview of the location that

surveys potential health risks, samples soil and water,

and investigates focal concerns such as stained soil

that might indicate a fuel spill, stored or discarded

toxic material containers, or problems from local

industry or operations. These findings are summarized

and serve as a starting point for periodic base camp

assessments. While the actual sampling frequency and

extent may vary with the size of the camp, the

location, or its population, a typical analysis includes

soil and water samples which are analyzed for

pesticides, volatile and semivolatile compounds, and

metals. Current technology analyzes for presence of

compounds, identifies those present, and quantifies the

amount. Typically, ambient air sampling, noise, and

entomological and radiation surveys are also

conducted. The results are stored in the Defense

Occupational and Environmental Health Readiness

System†(DOEHRS) data portal, maintained and

operated by the US Army Center for Health Promotion

and Preventive Medicine (USACHPPM).‡

USACHPPM’S ROLE IN OCCUPATIONAL AND

ENVIRONMENTAL HEALTH SURVEILLANCE

AND SUPPORT

The USACHPPM provides consultative assistance,

equipment, and analytical support to deployed

preventive medicine units. Standardized guidance

documents and decision criteria provide a framework

for hazard identification, exposure monitoring, and

operational risk assessment. USACHPPM also

provides training on the use of technical guidance and

environmental monitoring equipment. OEH hazard

data is archived along with the geographic location.

Since 2005, ambient sampling data linked to a base

location can be matched with a roster of the base camp

population to identify a population at risk. Presently,

the USACHPPM data archives holds tens of thousands

of sample results. These may exist as spreadsheets of

data consisting of various concentrations of unfamiliar

compounds tied to a location, without a clear

connection to a defined population at risk or known

exposure durations. Clearly, interpretation must occur

before this information is useful for any consideration

of impact to health.

During the 1990s, the USACHPPM attempted to

identify existing exposure guidelines to use for

comparative purposes. Occupational exposure values

exist for many compounds, for example, the Threshold

Limit Values, or TLV’s, which

...refer to airborne concentrations of substances and

represent conditions under which it is believed that

nearly all workers may be repeatedly exposed day after

day without adverse health effects.

4

Some are near-effect levels based on studies of

workers, in settings where monitoring of industrial

hygiene documented exposures. Others are based on

scarce toxicological data and extrapolations. As a

whole, the quantity and quality of data on which they

are based varies, resulting in differing levels of

uncertainty. These occupational guidelines are

typically used to determine when a worker should be

enrolled in medical surveillance. They are also used by

industrial hygienists to determine if exposure reduction

is needed, and if controls, including personal

protective equipment, should be implemented. Another

source was those guidelines created for use in

environmental assessment and cleanup. These often

assume a 24-hour, daily, lifetime exposure, and are

typically derived to protect children, pregnant women,

and other sensitive populations. These are not effect

levels, but conservative guidelines which include

safety factors that can serve as “clean-up goals” before

locations are considered acceptable for unrestricted

access, or use as a home site or park. Additionally,

short term exposure guidelines exist for acute events

such as a chemical release. None of the guidelines

entirely address the deployment exposure scenario—a

*The Global Threat Assessment Program, a function of USACHPPM, identifies and assesses deployment OEH hazards and threats

for worldwide priority deployment areas, both existing and planned. These assessments are used by the OEH surveillance

activities that support the intelligence preparation of the environment during operational planning.3

†Defense Occupational and Environmental Health Readiness System is an integrated environmental, safety, and occupational

health application supporting Department of Defense initiatives to capture, store, and analyze the exposure history of militaryrelated personnel throughout their life. Source: DoD Health Affairs. Available at: http://www.ha.osd.mil/peo/ritpo/ritpo_01.asp

‡Available at: https://doehsportal.apgea.army.mil/doehrs-oehs/ Authorized users only.
76 www.cs.amedd.army.mil/references_publications.aspx

relatively fit, healthy force, potentially exposed 24

hours per day for a roughly 12 to 15 month period or

less. Additionally, sampling indicates a point

exposure, but any one individual is unlikely to be at

any spot on a base camp for 24 hours per day.

Therefore, existing guidelines were modified to derive

the Military Exposure Guidelines.

FROM CONCENTRATIONS TO CONCLUSIONS

Military Exposure Guidelines (MEGs), are screening

levels for specified exposure durations, for hundreds of

chemicals in air, water, and soil. These screening

levels are found in the USACHPPM Technical Guide

230 5and were derived from existing levels established

by other organizations, such as the EPA, or

occupational standards, as discussed above, modified

to fit the deployed population and time frame. As with

any guideline, its use necessitates an understanding of

whether it represents a screening level or an action

level. For example, when exceeded, some occupational

levels necessitate a specific action on the part of an

employer which might be to control or reduce the

exposure and potentially initiate a medical action. In

contrast, screening values, such as those used by the

EPA in environmental assessment, are conservative

and thus an exceedance is an indication that further

evaluation may be necessary, that some remediation

should occur, etc. However, an exceedance is not

likely to indicate a specific medical action for any

individual or population. Other values that have been

derived for emergency planning purposes also have

some safety factors built in, but the uncertainty is

usually less, so exceedances may be associated with

specific actions. The MEGs are screening values, not

action levels, and were reviewed by the Committee on

Toxicology of the National Academy of Sciences as

part of the Department of Defense (DoD) approach to

OEH assessment. The Committee considered them

appropriate force protective screening values, useful to

provide information to a commander and to guide

further actions. On the other hand, the Committee

agreed that MEGs were not casualty estimates and that

exceedances did not indicate that a health effect was

likely in the exposed population .

6 This point is often

missed or misunderstood, particularly in the context of

medical actions, documentation, and potentially longterm surveillance and compensation.

So what is the appropriate use of a Military Exposure

Guideline in OEH assessment? When a contaminant is

measured above the MEG appropriate for the

presumed duration of exposure—there are short-term

and long-term MEGS—there is some “space” for

evaluation. This is done by looking at potential health

effects associated with measured levels. Given that the

screening guidelines have some built-in safety factors,

there may be no health effects. This step identifies the

health severity. The next step is to examine the

likelihood of exposures and probability (number of

samples, etc). Once a health threat has been identified

and its health severity and probability determined, the

risk is compared to others in the process of operational

risk management, a process for identifying, assessing,

and controlling risks from operational hazards,

including OEH hazards.7 Risk is determined by

estimating the probability and severity of a potential

adverse impact that may result from hazards due to the

presence of an adversary or some other hazardous

condition (ie, environmental contamination). Risks

range from low through extremely high. For example,

the Army’s OEH hazard operational risk management

(ORM) assessments for 2005 are presented in Table 1.

Leaders seek to mitigate risk by evaluating hazards

and implementing ORM options during operational

planning. When applied by medical personnel, the

ORM process allows planners to include the

assessment of the severity of hazards, characterize the

risks in the context of the proposed operation, and then

effectively communicate the risk assessments and

appropriate control measure options to the

commander. Commanders then make informed

decisions by balancing the OEH risks and other

operational risks with mission requirements. Given

that ORM is intended to focus on operational risk to a

mission, OEH exposures with acute effects and impact

are weighted more heavily.

ACUTE VERSUS DELAYED HEALTH RISKS

Typically, acute exposures are characterized as high

enough to cause an effect immediately, or in the short

term (hours or days). While they are easier to measure,

and easier to interpret and relate to a health effect, it

may be less likely that monitoring information exists

because they are often unanticipated. Examples might

include a fuel spill impacting water, a release of metals

or other chemicals due to a fire or burning of

materials, or an emission from industry due to less

stringent controls or diminishing infrastructure.

Hazards associated with acute effects may impact

Health Implications of Occupational Environmental Health Sampling
April – June 2008 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

operations, and as such are given a higher operational

risk than hazards with delayed effects. However, a

memorandum issued by the Joint Chiefs of Staff in

November 2007,8introduced new hazard severity

categories for use in ORM that address both acute and

chronic effects. Those severity categories are

presented in Table 2.

8(pB-9) The intent was to inform

commanders of the potential effects that might not

impact the operation, but which might be force health

protection considerations. This supports the DoD

requirement to document exposures that can cause

latent health effects and, when indicated, conduct

long-term medical surveillance.9It is quite difficult to

meet this requirement if a provider does not have

access to the data or the interpretation.

Lower levels of hazards which may pose a chronic

risk, or contribute to or cause a delayed health effect

are substantially more complicated to evaluate. It is

more likely that routine, nonincident conditions

generate levels that are relatively low, but may on

occasion reach levels that, if sustained, could pose a

chronic risk. However, this requires relatively constant

exposure to these levels. Levels that are not high

enough to pose an acute risk, but high enough to be of

concern for chronic exposure may or may not be

typical or sustained. Additionally, defining the

population who would experience a sustained exposure

is difficult since people move, exposure conditions are

more likely to be variable then constant, and sampling

is most often intermittent. However, long term MEGs

US Unified Command

Country Involved

Number of

ORM

Assessments

Low Risk Moderate Risk High Risk

Central Command

Afghanistan 60 50 8 Ambient air based on PM10*

2 Treated water quality

Djibouti, Egypt, Kenya, Ethiopia,

Kyrgyzstan, Uzbekistan, United Arab

Emirates, Yemen, Saudia Arabia

31 24 2 Ambient air based on PM10*

2 Treated water quality

Iraq 195 125 57 PM10* and metals

9 Treated water quality

2 Raw water quality

2 PM10* and lead

Kuwait 37 20 16 Ambient air based on PM10* 1 Treated water quality

Qatar 11 9 2 Ambient air based on PM10*

European Command

Bosnia, Georgia, Kosovo (Serbia),

Morocco

5 4 1 Raw water quality

Southern Command

Antigua, Belize, Dominican Republic,

Columbia, Grenada, Guatemala,

Haiti, Honduras, Netherlands

Antilles, Nicaragua, Panama

17 12 1 Water quality

1 Bottled water

2 Ambient air based on PM10*

Northern Command,

Joint Task Force, Katrina

United States 136 133 2 Ambient air based on PM10*

1 Treated water quality

Totals 492 378 92 Ambient air

19 Water quality

2 Ambient air

1 Water quality

*Particulate matter less than 10 μm in diameter

Table 1. US Army Occupational and Environmental Health Operational Risk Management (ORM)

Assessments Performed During Calendar Year 2005.
78 www.cs.amedd.army.mil/references_publications.aspx

Table 2. O

p

erational Hazard Se

v

erity

Ranking for Occupational and Environm

ental H

ealth Hazards During Military

D

e

plo

y

m

ents.

Description of T

ypes

of Health EffectsDrivers for SeverityCategory*

O

p

eratio

n

al S

e

v

erity

R

a

n

k

N

one Negligible Marginal Critical Catastrophic

A

c

ute

Effe

cts

†

No effects areanticipated

Few exposed personnel (ifany) are expected to havenoticeable acute healtheffects during mission.Exposed personnel areexpected to be able toeffectively conduct allbasic functions duringmis s ion operations .Minimal to no degradationof abilities to conductcomplex tasks areexpected.

Few exposed personnel (if any) areexpected to have noticeable acutehealth effects during mission.Exposed personnel are expected to beable to effectively conduct all basicfunctions during mission operations.Minimal to no degradation of abilitiesto conduct complex tasks areexpected.

Many personnel are expected to haveacute disabling/incapacitating healtheffects that require im

mediate

medical treatment or support (eg, areconsidered casualties.) There may belimited numbers of fatalities.Personnel not experiencing thesemore serious acute effects areexpected to have at least noticeable,but not disabling, health effects. Manypersonnel will have limited ability toconduct basic tasks, though complexskills may be significantly degraded.

Many casualties with severea c u t e d i s a b l i n g /incapacitating effectsrequiring im

mediate and

significant medical attentionand/or additional supportfor survival. Increasingnumber of deaths. Exposedpersonnel unable to performbasic physical and/ormental functions.

and/or and/or and/or and/or not a driver

C

hro

nic

Effe

cts

‡

No effects areanticipated

Few exposed personnel (ifany) are expected todevelop delayed onset,irreversible effects.

Many exposed personnel are plausiblyexpected to develop delayed onset,irreversible effects. While this may notaffect the im

mediate physiological

c a p a b i l it i e s o f i n d i v i d u a l s ,com

manders must consider long term

implications and appropriatelycom

municate the resulting risks.

Psychological implications mayadver sel y impact operationsparticularly over extended operationalperiods.

Majority to all exposed personnel areplausibly expected to develop delayedonset, irreversible effects due to thespecified exposure.

§ While this may

not affect the im

mediate physiological

c a p a b i l it i e s o f i n d i v i d u a l s ,com

manders must consider long term

implications and appropriatelycom

municate the resulting risks.

Psychological implications mayadversely impact operations,particularly over extended operationalperiods.

This level of hazard severityis reserved for the mostserious of conditions whereim

mediate survivability

against acute effects is thepriority. Those that surviveexposures may be atincreased risk for certainchronic hazards.

*Effects associated with a chemical are typically either acute or chronic, but in some cases may be both. In general, short term single exposures are primarily associated with acute

effects, while repeated long term exposures are associated with chronic effects. The ORM risk assessment process requires decisions to be based on the most operationallysignificant risk which is generally due to acute health effects. However there are certain circumstances where a chronic irreversible health effect may drive the ORM decisionmaking.

†Acute effects: Have relatively im

mediate onset (seconds to hours). While acute effects caused by a hazard are typically reversible, chronic effects may occur secondarily depending

on type of hazard and severity of acute effect.

Examples:

Noticeable but not disabling eye/upper respiratory irritation, cough, mild gastrointestinal upset, general malaiseDisabling/incapacitating- difficulty breathing, severe nausea/diarrhea, impaired vision; Severe - pulmonary edema, seizures, coma

‡Chronic effects: Typically have a delayed onset (months to years) and are generally considered irreversible. Examples: cancer, chronic lung or liver disease, neurological damage.§Particularly since there is substantial variability/uncertainty with the scientific evidence between certain occupational/environmental exposures and chronic health effects, the severity

ranking must factor in the scientific weight of evidence supporting the link between the specified hazard exposure and the specific irreversible effect/disease.

Health Implications of Occupational Environmental Health Sampling
April – June 2008 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

are screening values for more chronic effects and the

measured exposure would need to be sustained for

long periods. Therefore, actions can be taken to reduce

or mitigate the exposure. Typically, follow-up

sampling indicates that the exposure is not likely to be

sustained, and the long term MEG is not exceeded on a

long-term basis. In the event of a significant risk for a

delayed health effect, efforts to identify the exposed

population at risk and conduct medical surveillance or

epidemiological studies could be initiated.

DOCUMENTATION OF EXPOSURE AND ACCESS

TO OEH EXPOSURE INFORMATION

Documentation of “significant OEH exposures” in the

individual medical record has been required by

DoD9(p8) for some time. In reality, although data

collection has occurred, the content and method of

such documentation has been a subject of some debate.

“Significant” is not defined in the document, although

one line states that exposures “...that result in an acute

illness or that have potential to cause latent illness will

be included in the patient records of those individuals

affected or possibly exposed.” 9(p12) The

aforementioned Joint Chiefs of Staff memorandum

specifies the need to document “significant

occupational and environmental exposures,” and

defines those exposures as “...exposures that will

plausibly result in clinically relevant adverse health

outcomes to exposed individuals.”8(pA-3) While it is

likely that individuals who seek care for an acute

illness will have documentation in their medical

records, it is possible that no sampling was available

for the incident. The requirement to include OEH

exposure data related to potential delayed effects

necessitates the assembly and summarization of longterm sampling data. OEH data files are large and do

not lend themselves to inclusion like a lab slip or

industrial hygiene sample. Additionally, many

providers believe that long-term, ambient, populationlevel data, as opposed to individual or personal

samples, do not belong in a medical record, but are

more appropriate for epidemiological studies. Finally,

many providers are unfamiliar with the compounds

and the basis of screening guidelines and would not

necessarily be able to use the information to take

specific actions.

US Air Forces Central* created Environmental/

Occupational Health Workplace Exposure data forms

that are prepared by bioenvironmental engineers and

reviewed by medical personnel. As Army and Air

Force units are often collocated, Army personnel have

sometimes requested documentation, and the Army

preventive medicine units in the field have generated

Standard Form (SF) 600s†for some sites. An example

of one such SF 600 for a location in Iraq is provided

on page 80. A subgroup of the Joint Environmental

Surveillance Working Group,‡ working with the US

Central Command Surgeon’s office and preventive

medicine organizations in theater, identified the types

of entries in the SF 600 made by the military services

to date, and is identifying the format and data elements

to promote consistency. USACHPPM has initiated a

parallel procedure to create site summaries from the

ORM reports completed for base camps that are

shorter and can be used by a physician who desires

information about a base camp, an interested Soldier,

the US Department of Veterans Affairs, or deployed

preventive medicine units that are creating the SF

600s. Additionally, full ORM reports, sample results

by location, and other information are still accessible

to anyone with a desire or need to know through the

DOEHRS. These efforts to distill and layer

information for archiving should make the information

manageable and useful for those who need only a

summary with the identification of any concerns.

Throughout the process, the identification of potential

long-term concerns can be documented and archived

for current or future use. As these efforts continue and

progress, providers will become familiar with the types

of OEH health risks evaluated in theatre, and can use

this information for communication with patients, and

in the evaluation of individual patients. Requests for

assistance and consultation can be obtained from the

Environmental Medicine Program at USACHPPM

(http://chppm-apgea.army.mil).

*The US Air Force component of US Central Command

†Chronological Record of Medical Care

‡The Joint Environmental Surveillance Working Group was established in 1997 by the Assistant Secretary of Defense (Health

Affairs). It serves as a coordinating body to develop and make recommendations for DoD-wide OEHS policy. The working group

includes representatives from the Army, Navy, and Air Force OEHS health surveillance centers, the Joint Staff, other DoD entities,

and VA.
80 www.cs.amedd.army.mil/references_publications.aspx

REFERENCES

1. Brown D. U.S. acts to stem a Gulf War legacy –

military hopes new system keeps health syndrome at

bay. Washington Post. January 21, 2003:A1.

2. Environmental Surveillance Assessment No. 47-EM2638-00, Environmental Surveillance of Kosovo,

Mitrovica, Serbia, 17-20 June 2000. Aberdeen

Proving Ground, MD: US Army Center for Health

Promotion and Preventive Medicine. Available at:

http://chppm-www.apgea.army.mil/contactus.asp.

3. Kirkpatrick JS. Global threat assessment program.

Army Med Dept J. April-June 2006:51-54.

4. 2007 TLVs and BEIs. Cincinnati, Ohio: The

American Conference of Governmental Industrial

Hygienists; 2007:3.

5. Technical Guide 230, Guide for

Deployed Preventive Medicine

Personnel on Health Risk Assessment.

Version 1.3. Aberdeen Proving

Ground, MD: US Army Center for

Health Promotion and Preventive

Medicine. 2003. Available at: http://

c h p p m- w w w . a p g e a . a r m y . m i l /

documents/tg/techguid/tg230.pdf.

6. National Research Council. Review of

the Army's Technical Guides on

Assessing and Managing Chemical

Hazards to Deployed Personnel.

Washington, DC: National Academies

Press; 2004:12,76-77.

7. Field Manual 3-100.12: Risk Management. Fort

Monroe, VA: US Army Training and Doctrine

Command; February, 2001.

8. Office of the Chairman, Joint Chiefs of Staff.

Memorandum MCM 0028-07, Procedures for

Deployment Health Surveillance. Washington DC:

US Dept of Defense; November 2, 2007.

9. Department of Defense Instruction 6490.03:

Deployment Health. Washington, DC: US Dept of

Defense; August 11, 2006.

AUTHOR

Dr Weese is Program Manager for Environmental

Medicine, USACHPPM, Aberdeen Proving Ground,

Maryland.

An example of an environmental/occupational health workplace exposure

data form completed for a forward deployed location in Iraq.

Health Implications of Occupational Environmental Health Sampling

THE US ARMY CENTER FOR

HEALTH PROMOTION AND

PREVENTIVE MEDICINE
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:

EDITOR, AMEDD JOURNAL

ATTN: MCCS DT

2423 FSH-HOOD ST

FORT SAM HOUSTON, TX 78234-5078

DSN 471-6301

Comm 210-221-6301

Email: amedd.journal@amedd.army.mil