J

The

OURNAL

 Multidisciplinary Aspects of Public Health

THE UNITED STATES ARMY

MEDICAL DEPARTMENT

January-June 2018

First Record of Aedes (Stegomyia) malayensis Colless (Diptera: Culicidae) in the Lao People’s

Democratic Republic, Based on Morphological Diagnosis and Molecular Analysis 1

Maysa T. Motoki, PhD; Elliott F. Miot, MS; Leopoldo M. Rueda, PhD; et al

Mosquito Surveillance Conducted by US Military Personnel in the Aftermath of the

Nuclear Explosion at Nagasaki, Japan, 1945 8

David B. Pecor, BS; Desmond H. Foley, PhD; Alexander Potter

Georgia’s Collaborative Approach to Expanding Mosquito Surveillance in Response to

Zika Virus: Year Two . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

Thuy-Vi Nguyen, PhD, MPH; Rosmarie Kelly, PhD, MPH; et al

An Excel Spreadsheet Tool for Exploring the Seasonality of Aedes Vector Hazard for

User-Specified Administrative Regions of Brazil . . . . . . . . . . . . . . . . . . . . . . . .22

Desmond H. Foley, PhD; David B. Pecor, BS

Surveillance for Scrub Typhus, Rickettsial Diseases, and Leptospirosis in US and

Multinational Military Training Exercise Cobra Gold Sites in Thailand . . . . . . . . . . . . . . .29

Piyada Linsuwanon, PhD; Panadda Krairojananan, PhD; COL Wuttikon Rodkvamtook, PhD, RTA; et al

Risk Assessment Mapping for Zoonoses, Bioagent Pathogens, and Vectors at

Edgewood Area, Aberdeen Proving Ground, Maryland 40

Thomas M. Kollars, Jr, PhD; Jason W. Kollars

Optimizing Mission-Specific Medical Threat Readiness and Preventive

Medicine for Service Members 49

COL Caroline A. Toffoli, VC, USAR

Public Health Response to Imported Mumps Cases–Fort Campbell, Kentucky, 2018 55

LTC John W. Downs, MC, USA

Developing Medical Surveillance Examination Guidance for New Occupational Hazards:

The IMX-101 Experience 60

W. Scott Monks, MPAS, PA-C

Missed Opportunities in Human Papillomavirus Vaccination Uptake Among

US Air Force Recruits, 2009-2015 67

COL Paul O. Kwon, MC, USA; Jenny Lay, MPH; David Hrncir, MD, MPH; Lynn Levin, PhD, MPH

Barriers to Physical Activity Among Military Hospital Employees 76

Darren Hearn, DPT, MPH; Anna Schuh-Renner, PhD; Michelle Canham-Chervak, PhD, MPH; et al

Hydration Strategies for the Female Tactical Athlete . . . . . . . . . . . . . . . . . . . . . .83

Capt Taylor K. Zak, USAF, MC; MAJ Christina M. Hylden, MC, USA; COL Anthony E. Johnson, MC, USA

Spurgeon Neel Annual Writing Award Top Essays

America’s Guerilla Hospitals in the Vietnam War: the CIDG Experience 91

Justin Barr, MD

Ambiguous Duty: Red Cross Nurses and the First World War 99

CPT Denis L. Alfin, USA

The Figures of Experience: A Brief History of Risk and Planning Within

the Army Medical Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

MAJ Michael H. Mobbs, USA
JOURNAL

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US Army Medical Department Journal
January – June 2018 1

The Nakai Nam Theun National Protected Area (NNT 

NPA), known as the Watershed Management and Protection Authority area bordering Vietnam, is located 

in Nakai District, Khammuane Province, Lao People’s 

Democratic Republic (PDR). It is an important Southeast Asian biodiversity area, containing mammals, birds, 

reptiles, amphibians,1 and insects, including mosquitoes. 

It is also the home of a number of rare or newly discovered species of animals.2-5

Rueda et al 6 reported a total of 101 species from Laos, 

including newly recorded Aedes (Stegomyia) species 

collected from Khammuane province, ie Aedes (Stegomyia) albopictus (Skuse) and Ae. (Stg.) pseudoscutellaris (Theobald), and those reported in the literature, 

ie, Ae. (Stg.) aegypti (Linnaeus), Ae. gardnerii imitator

(Leicester), Ae. (Stg.) seatoi Huang, Ae. (Stg.) annandalei (Theobald), Ae. (Stg.) craggi (Barraud), Ae. (Stg.) malikuli Huang, Ae. (Stg.) perplexus (Leicester), Ae. (Stg.)

desmotes (Giles), Ae. (Stg.) pseudalbopictus (Borel).7-9

All voucher specimens of these newly recorded species, 

as reported by Rueda et al,6 were deposited in the Smithsonian Institution, National Museum of Natural History, 

Washington, DC, and in the Entomology Laboratory, Institut Pasteur Laos. Tangena et al 10 added an additional 

51 species to the list of Lao mosquito fauna. However, 

all voucher specimens from that report were, unfortunately, damaged or lost, and we were not able to conduct 

any further morphological examinations or DNA analysis of those specimens from this study.

The subgenus Stegomyia of genus Aedes has 128 valid 

species worldwide,11 with 24 species found in the Greater Mekong subregion of Asia (Cambodia, China, Laos, 

Myammar, Thailand, and Vietnam), including 12 species from Lao PDR. Several species of subgenus Stegomyia are major vectors of various organisms that cause 

human infectious diseases such as dengue, yellow fever, 

chikungunya, Zika viruses, and filariasis.12-14

Aedes aegypti is the primary vector of dengue throughout the tropical and subtropical regions of the world.15

Aedes albopictus is also an important vector in dengue 

epidemics.16-18 Aedes malayensis Colless is widely distributed in many parts of Asia,19 particularly Cambodia, 

India, Malaysia, Singapore, Taiwan, Thailand, and Vietnam.11 A recent study showed a high susceptibility of Ae. 

malayensis and its vectorial capacity for both dengue serotype 2 and chikungunya.20 This species is recorded for 

the first time in the Lao PDR. In this study, we confirmed 

the identification of Ae. malayensis from Laos based on 

the cytochrome c oxidase subunit I (COI) mitochondrial 

gene and the morphological diagnostic characteristics of 

adults, and compared them with Ae. albopictus.

Materials and Methods

Specimen Collection

Larvae of mosquitoes were collected from aquatic 

habitats along the Nam Noy River (17.768548°N, 

105.381989°E), Lao PDR (Figure 1) in March 2017, using 

standard larval dippers (350 ml, 13 cm diam ( BioQuip, 

First Record of Aedes (Stegomyia) malayensis

 Colless (Diptera: Culicidae) in the Lao

 People’s Democratic Republic, Based on

 Morphological Diagnosis and Molecular

 Analysis

Maysa T. Motoki, PhD Khamsing Vongphayloth, MD Mustapha Debboun, PhD

Elliott F. Miot, MS Nothasine Phommavanh, BS LCDR Jeffrey C. Hertz, USN

Leopoldo M. Rueda, PhD Khaithong Lakeomany, BS Paul T. Brey, PhD

Abstract

This is the first confirmed record of Aedes (Stegomyia) malayensis Colless from the Lao People’s Democratic 

Republic. Its larvae were collected from rock pools and rock holes along the Nam Noy River in the Nakai Nam 

Theun National Protected Area, Khammuane Province. Larvae were reared in the laboratory and emerged 

adults were identified based on morphological characters and mitochondrial DNA analysis, using data from the 

mitochondrial cytochrome c oxidase subunit I. Detailed photographs of the morphological diagnostic characters and information on the bionomics of Ae. malayensis are included.
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

Rancho Dominguez, CA, USA). They were carefully 

transferred into a WhirlPak plastic bag (BioQuip) using 

pipettes, and transported to the laboratory of Institut 

Pasteur du Laos.

Morphological Identification

Emerged adults were pinned on paper points, each given a unique collection number, properly labeled, and 

identified using a stereomicroscope (Olympus SZX7, 

Tokyo, Japan) following the morphological keys of Rattanarithikul et al.21 Voucher specimens were deposited 

in the Entomology Collection, Institut Pasteur du Laos, 

Vientiane, Lao PDR, and the National Mosquito Collections of the Smithsonian Institution, National Museum 

of Natural History, Washington, DC. Diagnostic characters of Ae. malayensis adults were photographed.

DNA Extraction and Sequencing

Total genomic DNA was extracted from a single whole 

mosquito using Macherey-Nagel NucleoSpin Tissue 

(GmbH & Co KG, Duren, Germany) according to manufacturer’s instructions. The fragment of mitochondrial 

cytochrome c oxidase subunit I (mtDNA COI) gene was 

amplified using the polymerase chain reaction (PCR) 

Master Mix 2X (Promega Corporation, Madison, WI, 

USA) utilizing LCO1490 and HCO2198 primers.22 The 

PCR protocol consisted of a one minute denaturation at 

94°C and 5 cycles at 94°C for 40 seconds, 45°C for 40 

seconds and 72°C for one minute, followed by 30 cycles at 94°C for 40 seconds, 49°C for 40 seconds and 

72°C for one minute, and a 5-minute extension at 72°C. 

The PCR amplicons were electrophoresed in 1.5% TAE 

agarose gels stained with GelRed Nucleic Acid Gel 

Stain (Biotium Inc, Hayward, CA, USA), and the PCR 

products were then cleaned by adding ExosapIT (USB Co, Cleveland, 

OH, USA). Samples were placed in 

the thermocycler and ran at 37°C for 

30 minutes, followed by 80°C for 15 

minutes.

All sequencing reactions were conducted in both directions using the 

original primers and the Big Dye Terminator Kit v.3.1 (PE Applied Biosystems, Warrington, UK), analyzed 

on an ABI Prism 3500xL - Avant Genetic Analyzer (Applied Biosystems, 

Foster City, CA, USA). Sequences 

were edited in Sequencher v.5.4.6 

(Genes Codes Co, Ann Arbor, MI, 

USA), and aligned using Geneious 

9.1.6.23 A bootstrapped24 Neighbor 

Joining tree 25 was used based on 

1,000 replicates. The evolutionary distances were calculated using the Kimura-2 parameters method26 conducted in MEGA v.7.27 All 658 base pair (bp) of the barcode 

fragment were included in pairwise comparisons. Two 

sequences of Ae. albopictus were used as an outgroup.

Results

Morphological Diagnosis

The adult Ae. malayensis is very similar to Ae. albopictus, 

except for the diagnostic characters given below21:

1. A supraalar area of thorax with a patch of pale 

scales extended toward the scutellum in Ae.

malayensis, and a supraalar area of thorax with 

spot of pale scales not extended toward the scutellum in Ae. albopictus (Figure 2);

2. Abdominal terga IV-VI with dorsal white 

bands connected to lateral pale patches in Ae. 

malayensis, and abdominal terga IV-VI with 

dorsal white bands separated from lateral spots 

in Ae. albopictus (Figure 3).

Furthermore, the adults of Ae. malayensis are very similar to adults of Ae. alcasidi Huang, Ae. riversi Bohart 

and Ingram, and Ae. scutellaris (Walker) and share the 

following diagnostic characters19:

1. Midfemur without median white line on anterior 

surface;

2. Wing with minute basal spot of white scales on 

costa; and

3. Hindtarsomere 5 entirely white.19 Unfortunately, 

we did not have samples of Ae. alcasidi, Ae. riversi,

FIRST RECORD OF AEDES (STEGOMYIA) MALAYENSIS COLLESS (DIPTERA: CULICIDAE) IN THE LAO

PEOPLE’S DEMOCRATIC REPUBLIC, BASED ON MORPHOLOGICAL DIAGNOSIS AND MOLECULAR ANALYSIS

AU - Attapeu HO - Houaphan OU - Oudomsouk VI - Vientiane (VC - Vientiane Capital)

BO - Bokeo KH - Khammuane PH - Phongsaly XA - Xayabury

BL - Borikhamxay LO - Louangnamtha SA - Saravane XE - Sekong

CH - Champasak LP - Luang Prabang SV - Savannakhet XI - Xieng Khouang

Figure 1. Sampling location of Ae. malayensis in the Lao PDR.
January – June 2018 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

or Ae. scutellaris to compare, but we present the 

photographs of those diagnostic characters of Ae. 

malayensis from the Lao PDR (Figure 4).

Bionomics

Larvae (n=31) of Ae. malayensis were collected in the 

NNT NPA from rock holes and rock pools along the 

edges of the Nam Noy River, in an open area between 

the river and the forest. The habitats were not completely shaded, but some of them were naturally shaded by 

the rocks with fresh, clean, and cool water, and 

without vegetation (Figure 5). Larvae of Ae. albopictus were also collected from the same habitats in association with Ae. malayensis. Adults 

(n=17) of Ae. malayensis were collected using 

sweep nets near larval habitats. Adult females 

were attracted to humans and fed on their blood.

Molecular Characterization

The fragment of COI was sequenced for 4 

specimens of Ae. malayensis, and 2 specimens 

of Ae. albopictus were used as an outgroup 

(GenBank numbers: MG921172-MG921178). 

We compared them with the DNA barcode 

sequences of our samples with those published 

previously (KY420809, KY420810, KY420811; 

KR349280, KR349282).20 The amplicon length 

of the barcode sequence of Ae. malayensis was 

consistent at 658 bp (without primers). The base 

compositions were similar for all specimens, 

14.31% G, 15.98% C, 29.22% A, and 40.49% 

T. The bootstrap consensus tree confirmed the 

differences observed in the morphology of the 

Ae. malayensis female adult compared with Ae. 

albopictus (Figure 6).

Comment

Larvae of Ae. malayensis have been found in tree holes 

in Singapore and Taiwan, and in coconut shells in Vietnam. In Thailand, they were found in rock holes, rock 

pools, water jars, and bamboo cups, while in Malaysia 

they were collected from rock pools, bamboo stumps, a 

coconut shell, and artificial containers.19 In the Lao PDR, 

Ae. malayensis was found in rock pools (Figure 5) and 

rock holes together with Ae. albopictus. This sympatry 

A B

Figure 2. Morphological comparison of the thorax.

(A) Ae. malayensis - a supraalar area of thorax with a patch of pale scales extended upward toward 

the scutellum.

(B) Ae. albopictus - a supraalar area of thorax with spot of pale scales not extended toward the scutellum.

A

B

Figure 3. Morphological comparison of the abdominal terga IV-VI.

(A) Ae. malayensis - dorsal white bands connected to lateral pale

patches.

(B) Ae. albopictus - dorsal white bands separated from lateral spots.
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

was also observed in Singapore, Malaysia, Thailand, 

and Taiwan.19,28 The larval habitat along the Nam Noy 

River is approximately 40 km from the nearest urban 

center of Oudomsouk (17.710971°N, 105.15086°E), and 

could only be accessed by a 3-hour boat trip.

Larvae of Ae. malayensis are morphologically similar 

to Ae. albopictus and are very difficult to separate from 

each other.28 The body ornamentations of the adults 

and larvae are highly variable.28 Despite the fact that 

Ae. albopictus is very similar to Ae. malayensis, the 

combination of some distinct morphological characters 

differentiate these 2 species 21 (Figures 2 and 3). Likewise, 

the adults of Ae. malayensis are very similar to adults of 

Ae. alcasidi, Ae. riversi, and Ae. scutellaris,

19 particularly 

the wings, midfemur, and hindtarsomere 5 (Figure 4). 

Overall, Ae. malayensis can be especially recognized by 

its abdominal ornamentation (Figure 3).

DNA barcoding of the mitochondrial COI has been an 

efficient and useful marker for mosquito identification 

and confirmation of new species.29-31 Herein, the observed morphological differences are corroborated with 

the COI sequences. The COI sequences of Ae. malayensis from Lao PDR were clustered with the COI sequences of the Singapore samples, and distinguished from the 

Ae. albopictus, thereby confirming the existence of Ae. 

malayensis in the Lao PDR (Figure 6).

Dengue, chikungunya, Zika, and yellow fever viruses 

are the most important pathogens associated with the 

species of subgenus Stegomyia.

14,32 Because of the important role of Aedes (Stegomyia) species in arbovirus 

transmission, Huang28 described for the first time the 

larvae and pupae, and redescribed both adult sexes of 

Ae. malayensis from samples collected from the type

locality in Pulau Hantu, Singapore.

Even though the medical importance of Ae. malayensis

was not well known at the time, it was found to have 

strong anthropophilic behavior in Bo-Pia, Prachuap 

Khiri Khan, Thailand,19 and India,33 as well as our 

recent observations in Nakai, along the Nam Noy River. 

In addition, Rosen et al 34 reported that Ae. malayensis

was susceptible to all 4 serotypes of dengue virus after 

oral infection, but the presence of virus in the mosquito 

saliva was not determined. Moreover, Mendenhall et al 20

compared the vector competence of Ae. albopictus and 

Ae. malayensis with Ae. aegypti from Singapore after 

oral infection with dengue serotype 2 and chikungunya 

viruses and observed the high susceptibility of Ae. 

malayensis and Ae. albopictus to both arboviruses. 

FIRST RECORD OF AEDES (STEGOMYIA) MALAYENSIS COLLESS (DIPTERA: CULICIDAE) IN THE LAO

PEOPLE’S DEMOCRATIC REPUBLIC, BASED ON MORPHOLOGICAL DIAGNOSIS AND MOLECULAR ANALYSIS

A B C

Figure 4. Morphological characters of Ae. malayensis that are similar to Ae. alcasidi, Ae. riversi, and Ae. scutellaris:

(A) Midfemur without median white line on anterior surface.

(B) Hindtarsomere 5 entirely white.

(C) Wing with minute basal spot of white scales on costa.
January – June 2018 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

Importantly, the saliva of infected Ae. malayensis

contained infectious particles for both viruses. This 

provided the evidence that Ae. malayensis and Ae. 

albopictus from Singapore possess all the necessary 

traits to transmit these arboviruses.

Aedes malayensis remains an understudied species of 

Stegomyia, although it is found in Singapore, Malaysia, 

Thailand, Cambodia, Vietnam, Taiwan, China (Hainan),19,29,35 India,33 and now in the Lao PDR. Because of 

the wide distribution of Ae. malayensis in many parts 

of Asia,19 its high vector competence,20,34 and its anthropophilic behavior,19,33 more studies are warranted on the 

significance of this Stegomyia species as an arbovirus 

vector in the Lao PDR.

Acknowledgments

We are grateful to the staff of the Watershed Management and Protection Authority (WMPA) area who authorized 

our research in the WMPA area and 

provided technical support during the 

fieldwork; the staff of the Public Health 

Office, Nakai District, Khammuane 

Province for cooperation and field assistance; and the Institut Pasteur du Laos 

staff for their support throughout this 

study. Special thanks go to Dr Sandra 

Nagaki for reviewing this manuscript 

and for her valuable comments. We 

also appreciate the input of Louis Lambrechts of the Insect-Virus Interaction 

group of the Institut Pasteur de Paris.

This study was partially supported by 

the US Naval Medical Research Unit 

Two, work unit number D1428, in support of the Military Infectious Diseases 

Research Program and Institut Pasteur 

du Laos.

References

1. Wildlife Conservation Society.

Nakai Nam Theun National 

Protected Area [internet]. 2017. 

Available at: https://laos.wcs.org/

Saving-Wild-Places/Nakai-Nam-Theun-NPA.aspx.

Accessed December 12, 2017.

2. Musser GG, Smith AL, Robinson MF, Lunde DP. 

Description of a new genus and species of rodent 

(Murinae, Muridae, Rodentia) from the Khammouan Limestone National Biodiversity Conservation Area in Lao PDR. Am Mus Novitates. 

2005;3497:1-31.

3. Luu VQ, Truong QN, Thomas C, et al. New country records of reptiles from Laos. Biodivers Data J. 

2013;1:e1015.

4. Luu VQ, Nguyen TQ, Le MD, Bonkowski 

M, Ziegler T. A new species of karst-dwelling 

bent-toed gecko (Squamata: Gekkonidae) from 

Khammouane Province, central Laos. Zootaxa. 

2016;4079(1):87-102.

Figure 5. Larval habitats (rock holes) of Ae. malayensis in the 

Nakai District.

Figure 6. Bootstrapped NJ tree using COI sequences of Ae. malayensis (MG921172-

MG921176 = Lao PDR; KY420809-KY420811=Singapore20) based on 1,000 replicates 

of Tamura-Nei algorithm. Bootstrap values less than 50% are not shown. Scale bar 

represents sequence (%) divergence between samples. Ae. albopictus (MG921177-

MG921178) was used as an outgroup.

MG921178 Ae. albopictus

MG921177 Ae. albopictus

MG921173 Ae. malayensis

MG921174 Ae. malayensis

MG921175 Ae. malayensis

MG921176 Ae. malayensis

KY420811 Ae. malayensis

KY420809 Ae. malayensis

KY420810 Ae. malayensis

0.0100

100

99

82
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

5. Luu VQ, Nguyen TQ, Le MD, Bonkowski 

M, Ziegler T. A new karst dwelling species 

of the Gekko japonicus group (Squamata: 

Gekkonidae) from central Laos. Zootaxa. 2017;4263(1):179-193.

6. Rueda LM, Vongphayloth K, Pecor JE, et al. Mosquito fauna of Lao People’s Democratic Republic, 

with special emphasis on the adult and larval surveillance at Nakai District, Khammuane Province. 

US Army Med Dep J. July-September 2014;25-32.

7. Apiwathnasorn C, ed. A List of Mosquito Species 

in Southeast Asia. Bangkok, Thailand: SEAMEOTROPMED, National Centre of Thailand, Mahidol 

University; 1985.

8. Tsuda Y, Kobayashi J, Nambanya S, et al. An ecological survey of dengue vectors in Central Lao 

PDR. Southeast Asian J Trop Med Public Health. 2002;33:63-67.

9. Vythilingam I, Sidavong B, Thim CS, Phonemixay

T, Prompida S, Jeffrey J. Species composition of 

mosquitoes of Attapeu Province, Lao’s People 

Democratic Republic. J Am Mosq Control Assoc.

2006;22:140-143.

10. Tangena JAA, Thammavong P, Malaithong N, et 

al. Diversity of mosquitoes (Diptera: Culicidae) 

attracted to human subjects in rubber plantations, 

secondary forests, and villages in Luang Prabang 

Province, Northern Lao PDR. J Med Entomol.

2017;1-16.

11. Walter Reed Biosystematics Unit. Systematic catalog of Culicidae (database on line). Suitland, MD: 

Walter Reed Biosystematics Unit, Smithsonian

Institution; 2015. Available at: http://www.mosqui

tocatalog.org. Accessed January 3, 2018.

12. Peters W. A Colour Atlas of Arthropods in Clinical Medicine. London, UK: Wolfe Publishing Ltd; 

1992.

13. Huang Y-M. The subgenus Stegomyia of Aedes in 

the Afrotropical Region with keys to the species 

(Diptera: Culicidae). Zootaxa. 2004;700:1-120.

14. Huang Y-M. Medical entomology studies-XI. The 

subgenus Stegomyia of Aedes in the Oriental Region with keys to the species (Diptera: Culicidae). 

Contr Am Entomol Inst. 1979;165(6):1-79.

15. Chow VTK, Chan YC, Yong R, et al. Monitoring of 

dengue viruses in field-caught Aedes aegypti and 

Aedes albopictus mosquitoes by a type-specific 

polymerase chain reaction and cycle sequencing. 

Am J Trop Med Hyg. 1998;58:578-586.

16. Paupy C, Ollomo B, Kamgang B, et al. Comparative role of Aedes albopictus and Aedes aegypti in the emergence of dengue and chikungunya in central Africa. Vector Borne Zoonotic Dis. 

2010;10(3):259-266.

17. Tomasello D, Schlagenhauf P. Chikungunya and 

dengue autochthonous cases in Europe, 2007-2012. 

Travel Med Infect Dis. 2013;11(5):274-284.

18. Lai S, Huang Z, Zhou H, et al. The changing epidemiology of dengue in China, 1990-2014: a descriptive analysis of 25 years of nationwide surveillance 

data. BMC Med. 2015;13(1):1-12.

19. Huang Y-M. Contributions to the mosquito fauna 

of Southeast Asia. XIV. The subgenus Stegomyia

of Aedes in Southeast Asia. I-The scutellaris group 

of species. Contr Am Entomol Inst. 1972;9(1):1-109.

20. Mendenhall IH, Manuel M, Moorthy M, et al. Peridomestic Aedes malayensis and Aedes albopictus

are capable vectors of arboviruses in cities. PLoS 

Negl Trop Dis. 2017;11(6):e0005667.

21. Rattanarithikul R, Harbach RE, Harrison BA, 

Panthusiri P, Coleman RE, Richardson JH. Illustrated keys to the mosquitoes of Thailand VI. Tribe 

Aedini. Southeast Asian J Trop Med Pub Health.

2010;41(suppl 1):1-225.

22. Folmer O, Black M, Hoeh W, Lutz R, Vrijenhoek 

R. DNA primers for amplification of mitochondrial cytochrome c oxidase subunit I from diverse 

metazoan invertebrates. Mol Mar Biol Biotechnol. 

1994;3:294-299.

23. Kearse M, Moir R, Wilson A, et al. Geneious Basis: an integrated and extendable desktop software 

platform for the organization and analysis of sequence data. Bioinformatics. 2012;28:1647-1649.

24. Felsenstein J. Confidence limits on phylogenies: An approach using the bootstrap. Evolution. 

1985;39:783-791.

25. Saitou N, Nei M. The neighbor-joining method: a 

new method for reconstructing phylogenetic trees. 

Mol Biol Evol. 1987;4:406-425.

26. Kimura M. A simple method for estimating evolutionary rate of base substitution through comparative studies of nucleotide sequences. J Mol Evol. 

1980;16:111-120.

27. Kumar S, Stecher G, Tamura K. MEGA7: molecular Evolutionary Genetics Analysis version 7.0 for 

bigger datasets. Mol Biol Evol. 2016;33:1870-1874.

28. Huang Y-M. A redescription of Aedes (Stegomyia) scutellaris malayensis Colless and the differentiation of the larva from that of Aedes (S.) 

albopictus (Skuse). Proc Entomol Soc Washington. 

1971;73(1):1-8.

29. Wang G, Li C, Guo X, et al. Identifying the main 

mosquito species in China based on DNA barcoding. PLoS One. 2012;7(10):e47051.

30. Linton YM, Pecor JE, Porter CH, et al. Mosquitoes of eastern Amazonian Ecuador: biodiversity, 

bionomics and barcodes. Mem Inst Oswaldo Cruz. 

2013;108(I):100-109.

FIRST RECORD OF AEDES (STEGOMYIA) MALAYENSIS COLLESS (DIPTERA: CULICIDAE) IN THE LAO

PEOPLE’S DEMOCRATIC REPUBLIC, BASED ON MORPHOLOGICAL DIAGNOSIS AND MOLECULAR ANALYSIS
January – June 2018 7

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31. Chan A, Chiang LP, Hapuarachchi HC, et al. DNA 

barcoding: complementing morphological identification of mosquito species in Singapore. Paras 

Vect. 2014;7:569.

32. Huang Y-M. The subgenus Stegomyia of Aedes in 

the Afrotropical Region. I. The africanus group of 

species (Diptera: Culicidae). Contr Am Entomol 

Inst. 1990;26(1):1-90. Available at: www.dtic.mil/

get-tr-doc/pdf?AD=ADA511785. Accessed June 14, 

2018.

33. Tewari S, Hiriyan J, Reuben R. Epidemiology of 

subperiodic Wuchereria bancrofti infection in the 

Nicobar Islands, India. Trans R Soc Trop Med Hyg.

1995;89(2):163-166.

34. Rosen L, Rozemboom LE, Gubler DJ, Lien JC, 

Chaniotis BN. Comparative susceptibility of mosquito species and strains to oral and parental infection with dengue and Japanese encephalitis viruses. 

Am J Trop Med Hyg. 1985;34(3):603-615.

35. Colless DH. Notes on the taxonomy of the Aedes 

scutellaris Group, and new records of A. paullusi

and A. albopictus (Diptera: Culicidae). Proc Linn 

Soc N S W. 1962;312-315. Available at: https://ar

chive.org/details/biostor-86217. Accessed June 14, 

2018.

Authors

Dr Motoki and Mr Miot share lead author responsibility 

for this report.

Dr Motoki is a Research Entomologist of Institut Pasteur 

du Laos, Vientiane, Lao PDR, and formerly was Postdoctoral Entomologist of the Department of Entomology, 

Smithsonian Institution, Museum Support Center, Suitland, Maryland.

Authors (continued)

Mr Miot is a PhD candidate at the Université Pierre et 

Marie Curie (UPMC), Cellule Pasteur UPMC, Paris, 

France, working at the Institut Pasteur du Laos, Vientiane, Lao PDR. He is affiliated with the Insect-Virus Interactions Group, Department of Genomes and Genetics, 

Institut Pasteur, Paris, France, and the Centre National 

de la Recherche Scientifique, Unité Mixte de Recherche 

2000, Paris, France.

Dr Rueda is an Adjunct Scientist of the Smithsonian

Institution and formerly was Research Entomologist and 

Chief of the Walter Reed Biosystematics Unit, Entomology Branch, Walter Reed Army Institute of Research 

located at the Smithsonian Institution Museum Support 

Center, Suitland, Maryland.

Dr Vongphayloth is a Medical Doctor and Entomologist 

of Institut Pasteur du Laos, Vientiane, Lao PDR.

Mr Phommavanh is an Assistant Technical Entomologist 

of Institut Pasteur du Laos, Vientiane, Lao PDR.

Mr Lakeomany is an Assistant Technical Entomologist 

of Institut Pasteur du Laos, Vientiane, Lao PDR.

Dr Debboun is Director of the Mosquito and Vector 

Control Division, Harris County Public Health, Houston, 

Texas.

LCDR Hertz is Chief of Entomological Sciences, US Naval Medical Research Center - Asia, located at the US 

Navy Region Center, Sembawang, Singapore.

Dr Brey is a Research Entomologist and Director of

Institut Pasteur du Laos, Vientiane, Lao PDR.

Articles published in the Army Medical Department Journal are indexed in MEDLINE, 

the National Library of Medicine’s bibliographic database of life sciences and biomedical 

information. Inclusion in the MEDLINE database ensures that citations to AMEDD 

Journal content will be identified to researchers during searches for relevant information 

using any of several bibliographic search tools, including the National Library of 

Medicine’s PubMed service.
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

On August 9, 1945, the United States military detonated 

a nuclear bomb over the city of Nagasaki, Japan, marking only the second (and last) time a nuclear weapon was 

ever used in combat. Five days later, Japan officially surrendered to Allied forces, ending World War II (WWII). 

On this day, now known as V-J Day (Victory over Japan) President Harry Truman selected General Douglas A. MacArthur to supervise the Allied occupation of 

Japan. During this occupation in the months after the 

end of WWII, US military entomologists were tasked 

with developing and implementing a mosquito control 

plan for Japan.1 Challenges related to mosquito control 

abounded in postwar Japan, many of which had been 

building during the years leading up to the end of the 

war. In 1942, there was a Dengue fever outbreak reported from Nagasaki, however, with the destruction of cities 

and the displacement of populations, information about 

Dengue fever incidence before American occupation is 

limited.2 According to La Casse,1 Japanese informants 

claimed that Dengue fever was completely unheard of 

in Japan before 1942,1 but approximately 13,000 Dengue 

fever cases were reported in that year. It is important to 

note that many houses in Japan were required to keep 

concrete tanks holding water for fire suppression during 

wartime and these containers were perfect habitat for 

container-breeding mosquitoes such as Aedes albopictus Skuse.2

 One of the first directives by US military 

authorities was to fill with dirt, overturn, or destroy 

these containers.2 Other important container-breeding 

sites included cemeteries, particularly for Ae. albopictus and Ae. togoi (Theobald). Although each gravesite 

may only have provided habitat for a few larvae, large 

number of these breeding sites meant large populations 

of mosquitoes in cities like Nagasaki.2 Gray articulated 

this challenge eloquently, while commenting generally 

on this challenge impacting people across the world: “It 

is a strange commentary on human intelligence that the 

graves of the dead are permitted to bring death, disease 

and discomfort to the living.” 2 Mosquitoes collected 

from “foul-water,” including liquid manure tanks, posed 

another significant challenge. These tanks were present 

in most agriculture fields and were productive breeding 

sites for species such as Culex quinquefasciatus Say, Cx. 

pipiens Linnaeus, and Armigeres species.2 Finally, rice 

paddies are of particular concern for the malaria vector, Anopheles sinensis Wiedemann sensu lato in and 

around Nagasaki. Mosquitoes that breed in containers, 

polluted water, and rice paddies were the primary concerns for Nagasaki under Allied occupation. In a 1947 

report prepared by the Commanding Officer of the US 

Army 207th Malaria Survey Detachment (MSD), CPT 

Walter La Casse, noted that there was great concern in 

early 1946 that an epidemic of Japanese encephalitis 

(JEV) was a major threat to American forces occupying mainland Japan.1

 Thus, a plan was developed to collect as much bionomics data as possible to help develop 

mosquito abatement plans. The 207th MSD stationed in 

Kyoto, Japan, conducted mosquito surveys from 1946-

1949.3 Mosquito taxonomy in Japan was not well established before WWII. Until 1945, only 12 mosquito species were described from the islands; however, by 1959, 

the total number of species known from Japan was 45.3

In this article, we present digitized records and data of 

mosquito specimens housed within the US National 

mosquito collection that are associated with US military 

surveillance in the city of Nagasaki during Allied occupation of Japan. The specimens of interest were donated 

Mosquito Surveillance Conducted by US

 Military Personnel in the Aftermath of the

 Nuclear Explosion at Nagasaki, Japan, 1945

David B. Pecor, BS

Desmond H. Foley, PhD

Alexander Potter

Abstract

Mosquito surveillance data can be used to develop bionomic profiles of vector species to inform abatement 

plans. Thus, surveillance was conducted in the months following Allied occupation of Japan at the conclusion 

of World War II. Mosquito surveillance in Nagasaki, Japan, began one month after the nuclear bomb destroyed 

much of the city. The resulting specimens housed within the US National mosquito collection are documented 

here for the first time. Specimen labels were digitized and specimens were photographed to record specimen 

condition as part of the process for making them readily available to researchers.
January – June 2018 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

to the United States National Museum (USNM) collection by Charles A. Triplehorn in November 1973, and 

are part of the personal collection of Dr Donald J. Borror who is most famous for his work using bioacoustics 

to track bird distributions. However, in 1945, Dr Borror 

was a US Navy entomologist deployed to Japan.4 In correspondence with the South East Asia Mosquito Project 

(later redesignated as the Walter Reed Biosystematics 

Unit (WRBU)) staff, Dr Borror mentioned documented 

paper records by Triplehorn containing detailed collection data. An exhaustive search of the WRBU archives 

did not discover these records. In 1974, there was at least 

one attempt to contact Dr Borror to request additional 

information regarding these collection data, but with 

no response. This article describes how specimen label 

data related to these collections were digitized and photographed, and all specimens cataloged and accessioned 

into the USNM inventory.

Materials and Methods

The National mosquito collection is comprised of approximately 1.5 million specimens and is managed by the 

WRBU. Digitization is continuous, however, generally 

focused on gathering specimen data related to ongoing 

vector-borne disease outbreaks or taxonomic revisions. 

The Nagasaki specimens were due for accession but had 

a low priority for digitization and had remained unnoticed for decades. Upon rediscovering these specimens 

during a routine search for species distribution updates, 

their historical importance was immediately recognized 

and the rest of the collection was systematically inspected for other specimens collected in post-WWII Japan.

Specimen labels were digitized by entering verbatim label data into a standard USNM entomology EMu (electronic museum) data entry form. All specimens were assigned a unique USNM catalog number to be officially 

accessioned into the collection. Although all specimens 

were assigned new catalog numbers, each record retains 

every associated original specimen number within the 

individual records. Each specimen received a unique 

number and all associated preparations (eg, slides) were 

also assigned the same catalog number so that all objects 

associated with each specimen can be tracked using the 

same catalog number. The 2D matrix barcode labels 

with these catalog numbers were affixed to each specimen. Barcode labels for pinned specimens were added 

under existing labels and can be read by a barcode scanner when the specimen is inverted, while barcodes were 

affixed directly to slide preparations (Figure 1). Specimen labels were photographed to allow verbatim data 

to be independently verified and address possible errors 

in interpretation. Specimens were photographed using a 

Dino-Lite Edge handheld digital microscope (Dino-Lite 

US, Torrance, CA) with extended depth of field capability for vertical imaging to document their current condition. Each specimen was examined and recorded to document its current condition, sex, and if remounting was 

required. Figures 1, 2, and 3 show 3 specimen records 

including photographs, digitized label data, and notes.

In order to map these localities, each specimen was georeferenced using the point-radius method5

 which investigates text descriptions of localities on specimen labels 

as well as any information relevant to the description 

of the collection site provided in original descriptions. 

This allows assignment of the most precise gazetteer 

entry as possible to serve as a centroid of a collection 

event.6 To account for the uncertainty of the exact locality, an uncertainty measurement was assigned using 

the Mammal Networked Information System Georeferencing Calculator (http://maniset.org).5

 This method accounts for errors and missing information including coordinate datum, extent of the named place, and precision 

of the coordinates assigned. All specimen label data that 

could be used to characterize the collecting events were 

captured and retained.7 This approach has been applied 

in the past to specimens of the USNM Psychodidae collection.8,9 As details about the exact collection sites are 

not available, specimens within the WWII Japan collection were generally assigned a centroid for the city of 

Nagasaki and an uncertainty measurement encompassing the entire city.

Results

A total of 452 specimens representing 16 unique taxa 

with a summary list of habitat descriptions (bionomics) reported for each mosquito species are shown in 

the Table. Although some specimens showed signs of 

damage, eg, rubbed setae, broken antennae and/or legs, 

wings, etc, most were in fair shape with labels that could 

be read clearly. Nearly all specimens in this investigation were found to have been collected in Nagasaki, Japan, in September and October, 1945. Smaller subsets of 

specimens from the 207th MSD were collected in Nagasaki, Kyoto, and Isahaya-shi between 1947 and 1950. 

Of the 16 taxa found in this collection, 8 are known to 

vector pathogens, including Plasmodium sp. (An. sinensis), Japanese encephalitis virus (Ae. togoi, Cx. tritaeniorhynchus Giles, Cx. vishnui Theobald) and Dengue 

fever virus (Ae. albopictus). In addition, the Table includes the vector status for each taxon.

Comment

When considering the time and place of these collections, 

it is natural to wonder whether these specimens show any 

signs of radiation exposure that can be measured today. 

However intriguing, it is not likely that these specimens 
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

will have any recordable radiation. One 

reason is that after the initial explosion 

over Nagasaki, only low levels of radiation were recorded from areas outside of 

a 1.5 km radius from ground zero.10 Additionally, nuclear fallout is expected to 

affect invertebrates differently depending on their life history; insects that used 

topsoil would be more adversely affected 

than those, such as mosquitoes, that use 

water that is frequently flushed or diluted 

with rainfall. Fuller et al 11 suggested resilience of aquatic invertebrate populations 

to radionuclides.

Since data characterizing the risk to 

insects after a nuclear explosion are 

rare, studies examining the impact of 

radiation exposure due to nuclear reactor meltdowns may be more appropriate. 

Williams et al 12 investigated the effects 

of the Chernobyl nuclear disaster on local populations of Chironomidae species 

and found morphological deformities in 

60% of field-collected larvae. Although 

a significant finding, radiation from uncontained nuclear waste was pervasive in 

this location and had been affecting the 

Figure 1.

Specimen information

Catalog Number: USNMENT01240053

Scientific Name: Aedes (Stg.) albopictus (Skuse, 1894)

Sex/Lifestage: Female, Adult

Preparation: Pin mounted

Notes: Specimen is in good condition with diagnostic characters clearly visible. Some setae appear rubbed on scutum. Specimen has some dust/debris covering exterior. Glue affixing specimen to pin is stable.

Collection data

Locality: Nagasaki, Japan Collection Date: 9 October 1945

Collector: Borror, D.J. Verbatim Scientific Name: Ae. albopictus

Additional Information: #8

Figure 2.

Specimen Information

Catalog Number: USNMENT01240364 Scientific Name: Aedes (Stg.) albopictus (Skuse, 1894)

Sex/Lifestage: Whole larva Preparation: Slide mounted

Notes: Specimen is in good condition with diagnostic characters clearly visible. Mounting medium appears to be 

Canada Balsam and has darkened slightly.

Collection Data

Locality: Iron kettle, bombed area, Nagasaki, Japan Collection Date: 11 October 1945

Collector: Borror, D.J. Verbatim Scientific Name: Ae. albopictus

Additional Information: #18C

MOSQUITO SURVEILLANCE CONDUCTED BY US MILITARY PERSONNEL

IN THE AFTERMATH OF THE NUCLEAR EXPLOSION AT NAGASAKI, JAPAN, 1945
January – June 2018 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

ecosystem for years after the disaster. 

A study investigating the possible impact of the Fukushima Dai-ichi Nuclear 

Power Plant meltdown of 2011 on local 

populations of the pale grass blue butterfly (Zizeeria maha) found some evidence 

of morphological abnormalities attributed to radiation exposure.13 However, this 

site also had persistent radiation exposure risk. Biological asymmetry, known 

as fluctuating asymmetry (FA) can be 

used as a measure of developmental stability. A study14 on stag beetles (Lucanus 

cervus) in Chernobyl found that males 

in highly contaminated sites had significantly elevated levels of FA in secondary sexual characters compared to males 

from control sites. A detailed study of FA 

in mosquito samples from Nagasaki may 

or may not reveal the physical effects of 

radiation but data on mating success are 

no longer possible.

The specimens examined during this 

study represent a lasting and permanent 

record for the invaluable work done to 

characterize and combat the mosquitoborne disease threats during the Allied 

forces occupation of Japan. Military entomologists and other medical officers 

during that time made systematic collections to develop bionomic profiles 

for vector species to inform mosquito 

abatements plans. Although it has been 

nearly 75 years since these collections 

were made, the specimens form a lasting 

legacy that can be used in taxonomic revisions and to accurately predict species 

distributions and biology.

Acknowledgements

This study was made possible by a FY2017 grant 

(P0091_17_WR_1.3.1.) from the Armed Forces Health 

Surveillance Branch and its Global Emerging Infections 

Surveillance Section.

This research was performed under a Memorandum of 

Understanding between the Walter Reed Army Institute 

of Research and the Smithsonian Institution’s National 

Museum of Natural History, with institutional support 

provided by both organizations.

References

1. La Casse WJ. Mosquito Survey Data on Japan 

and Their Application in the Control of MosquitoBorne Diseases. Office of the Surgeon, HQ Corps, 

APO 301; 1947.

2. Gray HF. Mosquito control problems in Japan. 

Mosq News. 1947;7(1):7-11.

3. Tanaka K, Mizusawa K, Saugstad E. A revision of 

the adult and larval mosquitoes of Japan (including 

Ryukyu archipelago and the Ogasawara islands) 

and Korea (Diptera: Culicidae). Contrib Am Entomol Inst. 1979;16.

Figure 3.

Specimen information

Catalog Number: USNMENT01240280

Scientific Name: Culex (Ocu.) bitaeniorhynchus (Giles, 1901)

Sex/Lifestage: Male, Adult

Preparation: Pin mounted adult with slide mounted genitalia

Notes: Specimen is in fair condition with diagnostic characters clearly visible. 

Glue affixing specimen to pin is stable. Slide mounting medium appears to 

be Euparal and remains clear. 

Collection data

Locality: Nagasaki, Japan

Collector: Borror, D.J.

Collection Date: 15 November 1945

Verbatim Scientific Name: Culex (Culex) bitaeniorhynchus

Identified by: S.S. 1973

Additional Information: SEAMP ACC No. PREP 69/1396; #1E
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

4. Gaunt SL. In memoriam: Donald J. Borror. The 

Auk. 1989;106:321-323. Available at: https://sora.

unm.edu/sites/default/files/journals/auk/v106n02/

p0321-p0323.pdf. Accessed July 9, 2018.

5. Wieczorek J, Hijmans R, Guo Q. Point-radius 

method for georeferencing locality descriptions 

and calculating associated uncertainty. Int J Geogr 

Inf Sci. 2004;18(8):745-767.

6. GeoNames Website. Available from: http://www.

geonames.org/. Accessed March 2018.

7. Foley DH, Wilkerson RC, LM Rueda. Importance 

of the “what,” “when,” and “where” of mosquito collection events. J Med Entomol. 2009;46(4):717-722.

8. Rueda L, Foley D, Pecor D, Wolkoff M. Records 

and distribution of New World Phlebotomine sand 

Flies (Psychodidae: Diptera), with special emphasis on primary types and species diversity. US 

Army Med Dep J. July-September 2015:33-46.

9. Rueda L, Pecor J, Wolkoff M, Pecor D, Benyamin S, 

Bousses P, Debboun M. New records, distribution, 

and updated checklists of old world Phlebotomine 

sand flies, with emphasis on Africa, Southwest 

Asia, and Central Asia. US Army Med Dep J. January-June 2017:65-85.

10. World Nuclear Association. Hiroshima, Nagasaki, 

and Subsequent Weapons Testing [internet]. Updated March 2016. Available at: http://www.world-nuclear.org/information-library/safety-and-security/

radiation-and-health/hiroshima,-nagasaki,-andsubsequent-weapons-testin.aspx. Accessed March 

2018.

11. Fuller N, Smith JT, Nagorskaya GL. Does Chernobyl-derived radiation impact the developmental 

stability of Asellus aquaticus 30 years on?. Sci Total Environ. 2017;576:242-250.

A summary of the mosquito specimens considered within this study. Species names are presented along with the total number 

of specimens associated with each taxon, each species vector status and the collection site description used to inform species 

bionomics profiles.

Species Name Specimen

Count

Vector Status Collection Site Description

Aedes (Hul.) japonicus

(Theobald, 1901) 13 WNV Fire tub, cemetery urn, rock hole

Aedes (Stg.) albopictus

(Skuse, 1894) 127 DENV, CHIKV, ZIKV Bamboo stump, bamboo vase, concrete tub, creek, pan, iron kettle bombed area, cemetery urn, wooden tub

Aedes (Tan.) togoi

(Theobald, 1907) 149 JEV Bamboo stump, bucket, cement tank, ditch, fire tub, rock hole, tank in bombed area, wooden barrel

Anopheles (Ano.) koreicus

Yamada and Watanabe, 1918 15 Cement tank, seepage pool

Anopheles (Ano.) sinensis s.l. 31 Brugia malayi and secondary 

vector of Plasmodium sp. Ditch, grassy pool, nightsoil pool, pond, rice paddy

Armigeres (Arm.) subalbatus

(Coquillett, 1898) 22 Wuchereria bancrofti Crack, nightsoil pool

Culex (Cui.) pallidothorax

Theobald, 1905 21 Cave pool, creek in bombed area

Culex (Cux.) quinquefasciatus

Say, 1823 6 Wuchereria bancrofti Concrete tank, stone pool

Culex (Cux.) tritaeniorhynchus

Giles, 1901 23 JEV Cement tank, fire tub, nightsoil pool, pond, rice paddy

Culex (Cux.) vagans

Wiedemann, 1828 7 No data

Culex (Cux.) vishnui

Theobald, 1901 1 JEV Artificial pond

Culex (Eum.) hayashi

Yamada, 1917 14 Air raid shelter, cement tank, lily pond, ground pool

Culex (Lop.) infantulus

Edwards, 1922 9 Cave pool

Culex (Ocu.) bitaeniorhynchus

Giles, 1901 5 No data

Tripteroides (Trp.) bambusa

(Yamada, 1917) 8 Bamboo stump

Uranotaenia (Ura.) bimaculiala

(Leicester, 1908) 1 No data

WNV indicates West Nile virus; DENV, Dengue virus; CHIKV, chikungunya virus; ZIKV, Zika virus; JEV, Japanese encephalitis virus.

MOSQUITO SURVEILLANCE CONDUCTED BY US MILITARY PERSONNEL

IN THE AFTERMATH OF THE NUCLEAR EXPLOSION AT NAGASAKI, JAPAN, 1945
January – June 2018 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

12. Williams DD, Nesterovitch AI, Tavares AF, Muzzatti EG. Morphological deformities occurring 

in Belarusian chironomids (Diptera: Chironomidae) subsequent to the Chernobyl nuclear disaster. 

Freshw Biol. 2001; 46(4):503-512. Available at: 

https://onlinelibrary.wiley.com/doi/full/10.1046/

j.1365-2427.2001.00699.x. Accessed July 9, 2018.

13. Hiyama A, Nohara C, Kinjo S, Taira W, Gima S, 

Tanahara A, Otaki, JM. The biological impacts 

of the Fukushima nuclear accident on the pale 

grass blue butterfly. Sci Rep. 2012;2(570). Available at: http://www.nature.com/articles/srep00570.

Accessed July 9, 2018.

14. Møller AP. Developmental instability and sexual 

selection in stag beetles from Chernobyl and a control area. Ethology. 2002;108:193-204. Available at: 

https://doi.org/10.1046/j.1439-0310.2002.00758.x. 

Accessed July 9, 2018.

Authors

Mr Pecor is a Research Technician with the Walter Reed 

Biosystematics Unit, Entomology Branch, Walter Reed 

Army Institute of Research, located at the Smithsonian 

Institution, Museum Support Center, Suitland, Maryland.

Dr Foley is a Research Entomologist at the Walter Reed 

Biosystematics Unit, Entomology Branch, Walter Reed 

Army Institute of Research, and a Research Associate 

of the Entomology Department within the National Museum of Natural History, located at the Smithsonian Institution, Museum Support Center, Suitland, Maryland.

Mr Potter is a student at Kalamazoo College, Michigan. 

He completed a Walter Reed Army Institute of Research 

College Qualified Leaders internship with the Walter 

Reed Biosystematics Unit in Summer 2017.
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

Georgia’s exposure to emerging mosquito-borne diseases is increasing due to international travel, immigration to Georgia, and out of state residents relocating to 

Georgia. The Department of Public Health (DPH) maintained its mission to prevent and respond to Zika virus 

(ZIKV) transmission and used its current funding to 

prepare for future public health emergencies.

The prevention or reduction of transmission of mosquito-borne diseases is completely dependent on the control of mosquito vectors and limiting person-mosquito 

contact. Mosquito surveillance is a key component of 

any local integrated vector management program. The 

goal of mosquito‐based surveillance is to quantify human risk by determining local vector presence and 

abundance. Historically, the DPH was tasked with dealing with nuisance mosquito complaints with limited 

funding for mosquito control, not to mention mosquito 

surveillance. Not until the introduction of West Nile virus (WNV) in 2001 was sufficient funding provided to 

begin dealing with mosquito vector species.

Unfortunately, WNV funding diminished over the next 

several years and most mosquito control programs were 

either eliminated or downsized. By 2005, only 55 counties in Georgia conducted sporadic mosquito surveillance, and by 2015, the number of counties was reduced 

to 13. Further, the availability of known mosquito control was limited to 6 counties. However, with the declaration by the World Health Organization in 2016 that 

the ZIKV threat constituted a public health emergency, 

funding was provided to increase mosquito surveillance 

and emergency mosquito control.1

Integrated Mosquito Management

Mosquito control is integral to protect the public health. 

In Georgia, there are ≈60 different mosquito species. 

Each mosquito species has a different flight range, host 

preference, larval habitat, and potential for carrying and 

transmitting infectious diseases.

Although nuisance mosquitoes can already be considered a health problem in Georgia, mosquitoes that carry 

infectious diseases like WNV, La Crosse encephalitis 

(LAC), and eastern equine encephalitis (EEE), as well 

as those that can transmit new and emerging viruses 

such as chikungunya and ZIKV are especially considered a public health concern.

Georgia’s Collaborative Approach to

 Expanding Mosquito Surveillance in

 Response to Zika Virus: Year Two

Thuy-Vi Nguyen, PhD, MPH

Rosmarie Kelly, PhD, MPH

Shawna Stuck, MPH

R. Christopher Rustin, DrPH, MT, REHS

Abstract

With the continued increase in international travel and immigration to Georgia, the Department of Public 

Health (DPH) continued its mission to prevent and respond to Zika virus (ZIKV) transmission.

Methods: We analyzed surveillance data from the DPH to compare the geographical distribution of counties 

conducting surveillance, total number, and overall percentage of mosquito species collected in 2016 and 2017. 

Mosquito surveillance in 2017 was mapped by county and species using ArcMap 10.2.0.

Results: From 2016 and 2017, mosquito surveillance increased from 60 to 159 counties (165% increase). A total 

of 145,346 mosquitoes were trapped and identified in 2016 compared to 152,593 in 2017 (5.43% increase). There 

was a difference in the type of mosquito species found by year. Some species collected in previous years were 

not collected in 2017, while other species found in 2017 were not previously collected during mosquito surveillance. Also, certain mosquito species were found outside of their expected geographical range.

Conclusion: The continued collaborative response to ZIKV by the DPH allowed a continued increase in its surveillance program. Existing and new partnerships continued to develop with military and local health departments to expand and share data. This additional surveillance data allowed DPH to make sound public health 

decisions regarding mosquito-borne disease risks and close gaps in data related to vector distribution.
January – June 2018 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

One of the practices to control the mosquitoes to reduce 

the nuisance factor and protect public health is the use of 

a wide variety of control methods known as Integrated 

Mosquito Management (IMM). The first part of IMM is 

trapping and surveillance, which quantifies the numbers, 

species, and location of mosquitoes.

The Importance of Mosquito Surveillance

A scientifically driven surveillance program is the backbone of every mosquito control operation. Surveillance 

for native and exotic mosquito species should be part of 

mosquito control, regardless of the immediate threat of 

disease outbreaks. It should be developed proactively to 

justify mosquito control funding requirements and risk 

for arboviral disease transmission.

The primary purpose of mosquito surveillance is to determine the species composition, abundance, and spatial distribution within the geographic area of interest 

through collection of eggs, larvae, and adult mosquitoes. 

Surveillance is valuable for determining changes in the 

geographic distribution and abundance of mosquito species, evaluating control efforts by comparing presurveillance and postsurveillance data, obtaining relative measurements of the vector populations over time, accumulating a historical database, pesticide resistance studies, 

and facilitating appropriate and timely decisions regarding interventions.

Methods

Mosquito surveillance trapping data 

provided by the DPH and that collected in collaboration with DPH were analyzed. The geographical distribution 

of counties conducting surveillance, 

total number, and overall percentage 

of mosquito species collected in 2016 

were compared to 2017 data. Mosquito surveillance in 2017 was mapped 

by county and species using ArcMap 

10.2.0 (Esri, Inc, Redlands, CA). Human and livestock case data were also 

compared to surveillance data to detect disease patterns.

Results

In 2017, mosquito surveillance was 

performed in all 159 Georgia counties (Figure 1). This is compared to 

surveillance conducted in 60 counties in 2016, and only 13 counties in 

2015 (Table 1). This is the first time 

surveillance data was collected in 

every county in Georgia, and while 

surveillance was limited in many counties, these data 

can serve as an initial baseline.

The focus of mosquito surveillance 

has traditionally been on WNV, LAC, 

and EEE vectors, thus data reported to 

the DPH from other sources is incomplete, consisting only of those specific 

vectors sent for arboviral testing. Similar to previous years, including 2016, 

Culex quinquefasciatus (Say) was 

captured at the highest percentage of 

mosquitoes collected overall in 2017 

(62.5% /56%) (Table 2). Trapping was 

prioritized in urban and suburban areas to target container-breeding Aedes aegypti (L.) and Ae. albopictus 

(Skuse), and the shift in surveillance 

focus was demonstrated in the gradual increase in Ae. albopictus (3.7% 

to 4.0%) from 2016 to 2017 (Table 2). 

Although the restriction of limited surveillance was not a problem in 2017 

with surveillance being performed in 

all counties in Georgia, Ae. aegypti

was found only in Muscogee County, 

March

January

February

April

May

June

July

August

September

November

December

October

40

Miles

0

N

Figure 1. The month in which mosquito surveillance was performed in each county in 2017. Surveillance was performed 

during several months in some counties.

Table 1. Number and percentage of 

counties with mosquito surveillance 

performed per year, 2001-2017.

Year No. of Counties 

Conducting 

Surveillance

Percentage 

of Counties

(N=159)

2001 2 1.3%

2002 11 6.9%

2003 26 16.4%

2004 56 35.2%

2005 55 34.6%

2006 28 17.6%

2007 28 17.6%

2008 28 17.6%

2009 26 16.4%

2010 22 13.8%

2011 19 11.9%

2012 12 7.5%

2013 13 8.2%

2014 15 9.4%

2015 13 8.2%

2016 60 37.7%

2017 159 100.0%
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

Table 2. Mosquito species collected per year, 2015-2017.

Species 2015 Totals from 

13 Counties

Percentage of 

Total Collection 

from 13 Counties 

2016 Totals 

from 60

Counties 

Percentage of 

Total Collection 

from 60 Counties

2017 Totals 

from 159

Counties

Percentage of

Total Collection

from 159 Counties

Ae. aegypti 82 0.108% 26 0.018% 32 0.021%

Ae. albopictus 1,141 1.500% 5375 3.698% 6,175 4.047%

Ae. cinereus 0 0.000% 4 0.003% 143 0.094%

Ae. vexans 162 0.213% 6,583 4.529% 3,295 2.159%

Aedes/Ochlerotatus spp. 6 0.008% 120 0.083% 243 0.159%

An. barberi 0 0.000% 1 0.001% 0 0.000%

An. crucians 25 0.033% 1,879 1.293% 1,230 0.806%

An. punctipennis 26 0.034% 494 0.340% 1,100 0.721%

An. quadrimaculatus 61 0.080% 268 0.184% 74 0.048%

Anopheles spp. 5 0.007% 135 0.093% 214 0.140%

Cq. perturbans 1,265 1.663% 5,975 4.111% 1,820 1.193%

Cs. inornata 130 0.171% 14 0.010% 12 0.008%

Cs. melanura 906 1.191% 996 0.688% 2,139 1.402%

Culex spp. 4,996 6.569% 10,876 7.483% 9,401 6.161%

Culiseta spp. 0 0.000% 0 0.000% 12 0.008%

Cx. coronator 262 0.345% 629 0.433% 542 0.355%

Cx. erraticus 300 0.394% 2,425 1.676% 2,211 1.449%

Cx. nigripalpus 5,657 7.438% 11,101 7.638% 26,599 17.431%

Cx. peccator 0 0.000% 12 0.008% 0 0.000%

Cx. quinquefasciatus 60,423 79.450% 90,709 62.409% 85,357 55.938%

Cx. restuans 100 0.131% 389 0.268% 460 0.301%

Cx. salinarius 350 0.460% 2,962 2.038% 7,954 5.213%

Cx. territans 1 0.001% 34 0.023% 70 0.046%

Ma. dyari 0 0.000% 0 0.000% 3 0.002%

Ma. titillans 0 0.000% 98 0.068% 244 0.160%

Oc. atlanticus 1 0.001% 758 0.522% 298 0.195%

Oc. canadensis 0 0.000% 117 0.081% 1 0.001%

Oc. fulvus pallens 0 0.000% 1 0.001% 39 0.026%

Oc. infirmatus 2 0.003% 45 0.031% 74 0.048%

Oc. japonicus 8 0.011% 53 0.037% 376 0.246%

Oc. mitchellae 0 0.000% 9 0.006% 8 0.005%

Oc. sollicitans 0 0.000% 0 0.000% 30 0.020%

Oc. sticticus 0 0.000% 31 0.021% 36 0.024%

Oc. taeniorhynchus 0 0.000% 5 0.003% 488 0.320%

Oc. thibaulti 0 0.000% 0 0.000% 2 0.001%

Oc. triseriatus 25 0.033% 71 0.049% 74 0.048%

Oc. trivittatus 0 0.000% 7 0.005% 499 0.327%

Or. signifera 3 0.004% 23 0.016% 117 0.077%

Ps. ciliata 0 0.000% 25 0.017% 46 0.030%

Ps. columbiae 88 0.116% 332 0.229% 225 0.147%

Ps. cyanescens 2 0.003% 30 0.021% 100 0.066%

Ps. discolor 0 0.000% 0 0.000% 5 0.003%

Ps. ferox 10 0.013% 106 0.073% 326 0.214%

Ps. howardii 3 0.004% 34 0.023% 9 0.006%

Ps. mathesoni 0 0.000% 0 0.000% 9 0.006%

Psorophora spp. 6 0.008% 0 0.000% 9 0.006%

Tx. rutilus 1 0.001% 52 0.036% 21 0.014%

Ur. iowii 0 0.000% 13 0.009% 2 0.001%

Ur. sapphirina 2 0.003% 118 0.081% 43 0.028%

unknown 3 0.004% 2,411 1.659% 426 0.279%

Total 76,052 145,346 152,593

GEORGIA’S COLLABORATIVE APPROACH TO EXPANDING

MOSQUITO SURVEILLANCE IN RESPONSE TO ZIKA VIRUS: YEAR TWO
January – June 2018 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

again at low numbers (n=32) similar to 2016 (n=26) (Table 2). The statewide results suggest that Ae. albopictus

has outcompeted this species, an occurrence reported 

previously in current literature.2 We continue to explore 

why this small pocket of Ae. aegypti persists in Muscogee County.

The expected continuing increase of ZIKV throughout 

the years was actually not observed in 2017. The first 

travel-associated case of ZIKV was reported in Georgia 

in December 2015. In 2016, there were 113 travel-associated cases reported in Georgia. In 2017, there were a total of 6 travel-associated cases. To date, there have been 

no locally transmitted (mosquito to human) cases of 

Zika in Georgia. For travel-associated cases, a response 

protocol was developed and followed where vector surveillance coordinators (VSC) performed adult mosquito 

surveillance around the residence of each case, as well 

as applying larvicide once mosquito breeding sites were 

identified. Barrier spraying with adulticide was also performed if the residence was in a high risk area.

West Nile Virus

The WNV is a mosquito-borne disease of birds. Humans 

are occasionally infected with WNV through mosquito 

bites. Approximately, 1 in 5 people infected with WNV 

develop symptoms of “West Nile fever,” often characterized by fever, headache, fatigue, and muscle pain or 

weakness.3 Less than 1% of people infected with WNV 

develop neurologic disease such as meningitis, encephalitis, or flaccid paralysis.3

As shown in Figure 2, West Nile virus was first documented in Georgia in July 2001. Six human cases of 

WNV encephalitis were reported in Georgia that year, 

including one death. Cases have been reported each year 

since, with varying numbers of human deaths. To improve identification of Georgians infected with WNV, 

surveillance for WNV illness in humans was expanded 

for the 2003 transmission season to include all acute infections of WNV. In addition, routine screening of the 

national blood supply began in 2003, resulting in the 

identification of individuals infected with WNV prior 

to the development of symptoms (some WNV infections are asymptomatic). While the majority of human 

infections with arboviruses have resulted from bites by 

infected mosquitoes, other rare modes of transmission 

have been identified, including blood transfusion and 

organ transplantation. The increase in WNV among 

mosquitoes, humans, and birds represents the importance of mosquito surveillance to monitor disease patterns, facilitating rapid response to disease outbreaks.

Figure 2. The number of counties conducting annual mosquito surveillance, 2001-2017; the number of counties 

detecting WNV each year; the percentage of the annual collection testing positive for WNV.

Note: *indicates 6 counties conducted testing; **indicates 5 counties conducted testing.

% WNV Positive

Number of Counties

10

40

0

50

30

60

80

20

70

90

150

160

170

140

130

120

110

100

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

*2013

*2014

*2015

*2016

**2017

7%

6%

5%

4%

3%

2%

1%

0%

Counties Performing Surveillance Counties with Positive WNV Results % of Collection WNV Positive
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

In 2017, the number of WNV cases increased significantly, making it the state’s second most active year 

after 2012. Georgia reported 48 cases of WNV and 15 

WNV presumptive viremic blood donors (PVD), with 

7 deaths in 2017. The PVDs were asymptomatic at the 

time of blood donation, but tested positive for the presence of select arboviruses.

Forty-three (87.5%) of the 48 cases experienced WNV 

neurologic illness (altered mental status, paralysis, encephalitis, Guillain-Barré syndrome and/or meningitis) 

and 5 (10.4%) were diagnosed with WNV fever. The 

average age of the 48 case population was 61.4 years 

(range 17-87). The average age of those with WNV neurologic illness (n=5) was 64.6 years (range 26-87). Forty 

(83%) of the 48 cases were male. The majority of cases 

were reported in July, August, and September, with the 

peak in August.

California serogroup (CS) viruses, including California 

encephalitis, Keystone, La Crosse encephalitis (LAC), 

Jamestown Canyon, snowshoe hare, and trivittatus, are 

all mosquito-borne arboviral infections. In the United 

States, LAC is the most common of the California serogroup viruses. There were 2 cases of LAC reported in 

Georgia in 2017 and zero cases of LAC in 2016. 

In 2017, two confirmed cases of EEE and one of PVD 

were reported in Georgia, compared to one case of EEE 

in 2016.

Invasive Mosquito Species

One of the benefits of mosquito surveillance is determining where mosquito species are found, as well as 

monitoring a change in species range. This is especially 

important for vector species and for invasive species, 

which may become involved in arboviral disease cycles.

Culex coronator (Dyar and Knab) was first detected in 

Georgia in 2006. It was found initially in counties below 

the Fall line (Figure 3), a geological boundary dividing 

Georgia’s Coastal Plain from its Piedmont region.4 Mosquito surveillance conducted in 2017 showed that this 

species can now be found in most regions of Georgia 

(Figure 4). It is important to monitor Cx. coronator as 

it has the potential to be involved in the WNV transmission cycle.

Ochlerotatus japonicus (Theobald) was first detected 

in Georgia in 2002. Since this species lays its eggs in 

rock pools, it was initially found only above the Fall line 

(Figure 5). Mosquito surveillance conducted in 2017 

showed that this species can now be found in most regions of Georgia (Figure 6). Similar to Cx. coronator, it 

Figure 4. Counties where specimens of Culex coronator species were collected in 2017.

No Data

Less than 10

More than 10

Count of Culex coronator 

species collected in 2017

40

Miles

0 N

Figure 3. Counties where specimens of Culex coronator species were collected in 2009.

Counties

Culex coronator 2009

40

Miles

0

N

GEORGIA’S COLLABORATIVE APPROACH TO EXPANDING

MOSQUITO SURVEILLANCE IN RESPONSE TO ZIKA VIRUS: YEAR TWO
January – June 2018 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

is important to monitor Oc. japonicus because it also 

has the potential to be involved in the WNV transmission cycle.

Comprehensive statewide surveillance allowed DPH to 

observe the geographic distribution of these important 

species and for the first time document their distribution 

to areas of the state where they had not been found before.

Comment

Resources and Preparedness

Prior to 1970, adequate infrastructure, funding, and 

public support to fight mosquito-borne diseases such as 

yellow fever, dengue, and malaria were generally available. However, once these diseases were eradicated in 

the United States, public health policy decisions greatly 

decreased the resources for surveillance, prevention, 

and control of vector-borne diseases. This was understandable because control programs had reduced the 

public health threat from these diseases, thus lowering 

the priority for allocation of resources. Those decisions, 

notwithstanding the technical problems of insecticide, 

drug resistance, and excessive emphasis on insecticide 

sprays to kill adult mosquitoes, contributed greatly to 

the resurgence of diseases such as malaria and dengue, 

and the introduction and rapid spread of diseases such 

as WNV. Decreased resources for vector-borne diseases 

in general resulted in the discontinuation or merger of 

many programs, and ultimately to the deterioration of 

the public health infrastructure necessary to deal with 

those diseases. Moreover, training programs in vectorborne diseases decreased dramatically after 1970. Thus, 

the DPH was faced with a critical shortage of specialists trained to respond effectively to the resurgence of 

vector-borne diseases, such as Zika virus.

The likely consequence to Georgia of a continued lack 

of good vector surveillance and control programs is the 

knowledge gap as to which mosquitoes and which diseases were present in specific areas of the state. The inability to provide accurate information regarding risk of 

disease, the detection of new arboviruses that were being introduced to Georgia, and which new diseases were 

competently vectored would also be of great concern. 

Since arboviral pathogens could not be detected early, 

before they infected humans, Georgia experienced cases 

of arboviral disease that could have been prevented, and, 

because some of those pathogens are singularly lethal, 

the state also experienced unnecessary morbidity and 

mortality. Georgia recognized this challenge and, with 

additional Zika funding from the Centers for Disease 

Control and Prevention (CDC), began building a team of 

vector surveillance and control staff that could respond 

to the threat of Zika virus.

Ochlerotatus japonicus 2009 Counties

40

Miles

0

N

Figure 5. Counties where specimens of Ochlerotatus japonicus species were collected in 2009.

Figure 6. Counties where specimens of Ochlerotatus japonicus species were collected in 2017.

No Data

Less than 100

10-100

More than 100

Count of Ochlerotatus Japonicus 

species collected in 2017

N

40

Miles

0
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

Vector Surveillance Coordinator Districts

The establishment of 4 regional VSC districts has begun 

to rebuild Georgia’s capacity to detect and respond to 

both existing and newly introduced vector-borne diseases. The vector-borne disease prevention program from 

2016 has been strengthened with the hiring of additional 

staff for 2017, providing the ability to conduct further 

mosquito surveillance in more counties around the state.

Nine of 18 health districts were assigned a VSC, whose 

responsibility is to conduct and improve mosquito surveillance for arborviral diseases such as WNV, EEE, 

LAC, Zika and other mosquito-borne diseases. Due to 

limited funding, not all health districts were assigned a 

VSC to assist with mosquito surveillance; these districts 

were assigned to the state entomologists. However, some 

of the districts already had mosquito surveillance programs, and some had an environmental health director 

or environmental health specialists (EHSs) who had an 

interest in conducting mosquito surveillance within their 

district or county, and a sound collaboration was formed.

The VSCs were placed in areas of potential higher risk 

and regions with little to no mosquito control in most of 

the included counties to provide more thorough surveillance in the designated districts. Additional and more 

comprehensive training was provided to the VSCs to 

strengthen their knowledge based on both larval and 

adult mosquito identification.

The DPH established a goal for the 2017 mosquito season 

to conduct surveillance in all 159 counties. Surveillance 

started in May 2017, and together with EHSs and mosquito control, surveillance was conducted in every county in Georgia, accomplishing our goal. To better prepare 

for the next mosquito‐borne virus to emerge, mosquito 

surveillance equipment and training in mosquito surveillance, identification, and control was arranged for all 

interested people in every health district. In response to 

the threat of possible Zika transmission, the DPH set up 

10 additional trailers (total of 11) with mosquito-borne 

disease threat response equipment, a moveable laboratory with both surveillance and identification equipment, 

and emergency control supplies and equipment.

The Future

Any vector control should be guided by robust mosquito 

surveillance to evaluate the effectiveness of interventions. Surveys performed by the CDC found an increase 

in the number of US counties with Ae. aegypti and Ae. 

albopictus mosquitoes that are competent Zika‐transmitting vectors.5

 On June 20, 2017, the CDC released a 

statement on the survey findings that show an increase 

in the number of counties in the southern United States 

reporting the presence of Ae. aegypti and Ae. albopictus

as compared to a previous report.5 This demonstrates a 

continued risk of mosquito-borne diseases and the importance of statewide surveillance.

Conclusion

The small increase in overall mosquito prevalence in 

2017 could be due to low numbers in rural areas where 

breeding sites for anthropophilic mosquito species are 

not as prevalent. The data support the decisions made 

for previous mosquito surveillance programs where surveillance was only performed in high risk suburban areas when limited funding was provided.

In Georgia, statewide mosquito surveillance was conducted in all 159 counties in 2017. The goal of vector 

control was to suppress Ae. aegypti and Ae. albopictus

mosquito populations in a coordinated and effective 

manner to prevent or interrupt Zika virus transmission. 

The CDC developed guidelines on their surveillance 

and control in the United States. The magnitude of activities used in a vector control response depends on the 

extent of mosquito-borne transmission, as measured by 

the number of Zika cases and their geographic and temporal distribution. The increase in Zika vector species 

collected in 2017 compared to previous years represents 

the progress and success of rebuilding the vector surveillance program in Georgia.

References

1. World Health Organization. Zika virus and complications [internet]. 2017. Available at: http://www.

who.int/emergencies/zika-virus/en/. Accessed February 2, 2017.

2. Champion SR, Vitek CJ. Aedes aegypti and Aedes 

albopictus habitat preferences in south Texas, USA. 

EHI. 2014;8(suppl 2):35-42.

3. Centers for Disease Control and Prevention. West 

Nile virus [internet]. 2018. Available at: https://

www.cdc.gov/westnile/index.html. Accessed 

March 14, 2018.

4. Duncan MS. Fall Line. New Georgia Encyclopedia 

[internet]. 2016. Available at: http://www.georgia

encyclopedia.org/articles/geography-environment/

fall-line. Accessed February 22, 2018.

5. Hahn MB, Eisen L, McAllister J, Savage HM, 

Eisen RJ. Updated Reported Distribution of Aedes 

(Stegomyia) aegypti and Aedes (Stegomyia) albopictus (Diptera: Culicidae) in the United States, 

1995-2016. J Med Entomol. 2017;54(5):1420-1424.

GEORGIA’S COLLABORATIVE APPROACH TO EXPANDING

MOSQUITO SURVEILLANCE IN RESPONSE TO ZIKA VIRUS: YEAR TWO
January – June 2018 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

Authors

Dr Nguyen is a Public Health Entomologist with the 

Vector-Borne & Zoonotic Diseases Team, Environmental Health Section, Georgia Department of Public Health, 

Atlanta, Georgia.

Dr Kelly is a Public Health Entomologist with the Vector-Borne & Zoonotic Diseases Team, Environmental 

Health Section, Georgia Department of Public Health, 

Atlanta, Georgia.

Ms Stuck is a Vectorborne Disease Epidemiologist with 

the Acute Disease Epidemiology Section, Georgia Department of Public Health, Atlanta, Georgia.

Dr Rustin is the Director of Environmetal Health and 

Deputy Director of the Division of Health Protection, 

Georgia Department of Public Health, Atlanta, Georgia.

Borden Institute Invites New Publication Ideas

The Borden Institute, an agency of the US Army Medical Department Center & School, Health Readiness Center 

of Excellence, invites the submission of topics for publication. All subjects and perspectives associated with the art 

and science of military medicine are welcome. This includes textbooks, monographs, specialty books, and history 

publications. This call for submissions is open from August 10, 2018, through November 10, 2018. 

Although the Borden Institute has numerous book projects in production, we encourage the submission of new 

topics for future publication consideration. Please see our website, www.cs.amedd.army.mil/borden, for information 

about the Borden Institute, a complete publication list, and author guidelines.

Publication proposals should be 3 to 10 pages in length and include the following information:

1. Your complete contact information: name, address, e-mail address, telephone number, and fax numbers; 

also clearly indicate the corresponding author or editor if there is more than one associated with the proposal.

2. Title of proposed book.

3. Proposed table of contents.

4. Main topic of book.

5. Specific topics/themes to be discussed.

6. Timeline for completion of the manuscript.

7. Please explain the following: Why and/or how does your manuscript fit within the Borden Institute’s book 

series? How does your book uniquely contribute to military medicine?

8. Submit files as email attachments (MS Word or PDF format).

Submissions will be reviewed by the Borden Institute Publication Board and all potential authors and editors will 

be notified no later than January 31, 2019 regarding the status of their manuscript proposal.

Send proposals to:

Borden Institute

c/o Mr. Ernest Barner

3630 Stanley Rd. Bldg. 2841, Rm. 1326

JBSA Fort Sam Houston, TX 78234

Or email: ernest.j.barner.civ@mail.mil

Please feel free to contact the Borden Institute with questions or for further help with the submission process: 

210-221-0760; http://www. cs.amedd.army.mil/borden.
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

The risks to military personnel deployed to the US 

Southern Command (SOUTHCOM) countries from 

Aedes vectored viruses such as chikungunya (CHIKV), 

dengue (DENV), yellow fever (YFV), and Zika (ZIKV) 

should not be underestimated. A recent study1 found 

active-duty travelers and those visiting friends and 

relatives among US Department of Defense (DoD) beneficiaries travelling to chikungunya-outbreak regions in 

the Americas had a composite attack rate for CHIKV, 

and DENV infection of 3.7%. The authors point out the 

risk of returning travelers with subclinical infections 

causing secondary transmissions in nonendemic regions (contiguous United States), and the importance of 

pretravel counseling to ZIKV-outbreak regions due to 

the shared vector, Aedes aegypti (L.) of CHIKV, DENV, 

YFV and ZIKV. Although Ae. albopictus (Skuse) is 

thought to be a competent vector of ZIKV,2 Ae. aegypti 

has been implicated as the primary transmitter of the 

virus in human populations in the recent outbreak in the 

Americas.3,4

In response to the 2016 World Health Organization declaration of a public health emergency of international 

concern over ZIKV linked disease, the Walter Reed 

Biosystematic Unit produced MS Excel tools (http://vec

tormap.si.edu/Project_ESWG_ExcelZika.htm) that use 

published average yearly habitat suitability models and 

average monthly temperature data to predict the timing 

of Aedes vector hazards for contiguous United States 

(CONUS) military facilities.5 Excel-based tools were 

constructed to assist entomologists and other health 

personnel understand whether ZIKV transmission is 

likely to occur at a location and when they should conduct vector surveillance and control. Foley and Pecor5

concentrated on DoD facilities but emphasized that 

the approach could be used with any habitat suitability 

models and for any area of interest. The ability to incorporate near real-time and forecast temperature data 

improved accuracy in the short term compared to the 

use of average monthly temperature data, which were 

more suited for longer term planning.

For tropical areas compared to temperate ones, temperature is less dominant among climatic drivers of intraannual changes in mosquito suitability, which limits 

the applicability of the approach of Foley and Pecor5 for 

many areas of SOUTHCOM. However, the availability 

of recently published global monthly habitat suitability 

models for Ae. aegypti and Ae. albopictus 6 presents an 

opportunity to extend to new areas our approach for 

providing vector hazard seasonality data.

Bugoch et al6 used monthly climatic suitability models 

for autochthonous transmission of ZIKV around the 

world, conditional on the predicted occurrence of competent Aedes mosquito vectors. To account for seasonal 

variation in the geographical range of ZIKV suitability, 

they produced maps for each month of the year. They 

used mosquito species distribution models for Ae. aegypti and Ae. albopictus7

 (originally fitted to annual 

data and covariates) to make monthly predictions by use 

of new monthly covariates for temperature-persistence 

An Excel Spreadsheet Tool for Exploring

 the Seasonality of Aedes Vector Hazard

 for User-Specified Administrative Regions

 of Brazil

Desmond H. Foley, PhD

David B. Pecor, BS

Abstract

Aedes-vectored viruses are a major concern for active-duty military personnel working in South and Central 

America at certain times of the year. Knowledge about the seasonal changes of vector activity is important as 

it informs time-sensitive vector control, prophylaxis, and travel decisions. To assist in-country and extralimital efforts to anticipate when vector hazards and the risks of transmission are highest, we developed an Excel 

spreadsheet tool that uses published monthly habitat suitability models to display various aspects of average 

Aedes seasonality for user-defined second order administrative areas of Brazil. This tool expands on those 

previously developed by the authors for the contiguous United States, with the aim of translating global habitat 

suitability models into user-friendly formats to provide actionable intelligence for areas of interest.
January – June 2018 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

suitability,8 relative humidity, and precipitation. They 

refined these seasonal maps by scaling their values so 

that the sum of all monthly maps equaled the annual 

mean map of Kraemer et al.9 Final global monthly vector maps show predictions of areas with high likelihood 

for observation or detection of mosquito populations, 

which were assumed to be sufficiently abundant to enable transmission of vector-borne diseases to humans.

The extended Figure 6 in the article by Faria et al 10

shows the 12-monthly suitability maps for ZIKV transmission of Bugoch et al6

 for the Americas. Faria et al10

used linear regression to find that, for each Brazilian 

region, there was a strong association between estimated climatic suitability and weekly Zika notified cases 

(adjusted R2>0.84, P<.001). They also found that, similar to previous findings from DENV outbreaks, notified ZIKV cases lag climatic suitability by about 4 to 6 

weeks in all regions, except northeast Brazil, where no 

time lag was evident.

In this article, we demonstrate the potential utility of 

global monthly habitat suitability models to explore Aedes seasonality for administrative areas of Brazil. Building on our experience with the Excel user interface developed for CONUS military facilities, we designed a 

tool that shows the intensity of Aedes hazard at any time 

point throughout the year.

Materials and Methods

Twelve monthly raster layers of 0.04166665 degrees 

resolution were obtained for Ae. aegypti habitat 

suitability.6,9,10

We used the Global Administrative Areas (GADM) v 

2.8* Administrative regions 2nd order administrative 

level polygons for Brazil, but some editing of the file 

was necessary before use. Some names were used multiple times so it was necessary to create a field in ArcMap 10.4 (Environmental Systems Research Institute, 

Redmond, CA) that concatenated Admin 1 (State) and 

2 (District) so that each row in the feature table had a 

unique name combination. Of a total of 5,505 polygons, 

8 were outlying islands (Espírito Santo_Ilha Trindade, 

Espírito Santo_Ilhas de Martim Vaz), and others incompletely overlapped the raster coverage (Bahia_Madre de 

deus, Minas Gerais_Santa Cruz de Minas, Rio Grande 

do Norte_Fernando de Noronha, Rio Grande do Sul_

Capela de Santana, Santa Catarina_Floriniapolis, São 

Paulo_Suzanápolis). These were not considered further 

in the analysis. Santa Catarina_Florianópolis, which is 

comprised of a peninsula and nearby island are present 

in GADM as 2 polygons; the island (Florianopolis) and 

the mainland portion (Floriniapolis [note difference in 

spelling]).

We created a point layer from the polygon layer by using Data Management Tools > Features > Feature to 

Point tool and added longitude and latitude to the points 

by using Data Management Tools > Features >Add XY 

Coordinates. For the XY coordinates of centroids, the 

island row was selected and the mainland XY was deleted. However, for the population analysis (LandScan) 

data from the 2 polygons were combined. Other issues 

involved the need to aggregate some polygons and correct the names of several others. Extraction of all administrative area centroid raster values (ie, average 

values) was first obtained for polygons using the Zonal 

statistics as Table tool and, where needed, the Extract 

values to points tool. This approach was needed because 

smaller polygons would not produce results using the 

Zonal statistics as Table tool, which necessitated using 

the raster data associated with the points for these facilities administrative areas. We used the human population density according to LandScan 2011.† This was 

accomplished using the summary output in the Zonal 

Statistics as Table tools in ArcMap.

Seasonality: Ranking

Seasonality can be presented as a graph of the 12-month 

pattern of habitat suitability, abundance, etc. Interpretation and comparison of the pattern in one area to other 

areas can be subject to human error, due to variation 

in the y-axis, which may mask the underlying pattern. 

For this reason, we explored the use of rank and related 

metrics to define important aspects of seasonality for 

use in semiautomated calculations of vector hazard. For 

sites that exhibit a seasonal pattern in Ae. aegypti habitat suitability, monthly data were standardized by ranking (1 to 12) in Excel (RANK.EQ) to allow comparison 

within and among areas of interest, both in terms of the 

relative suitability and the direction (rise=1, fall= -1) of 

change in suitability with the next time period. Ideally, 

metrics automatically derived from the rank should inform the user that for the month in question, suitability 

scores are near the annual peak or lowest point, scores 

are set to increase or decrease, or scores are moving in 

*http://www.gadm.org/

†LandScan 2011. People/1 sq km. This product was made using 

the LandScan (2011) High Resolution Global Population Data Set, 

the copyright to which is held by UT-Battelle, LLC, which operates the Oak Ridge National Laboratory under contract to the US 

Department of Energy. The US Government has certain rights in 

the data set. Neither UT-Battelle, LLC, nor the US Department of 

Energy, nor any of their employees, makes any warranty, express 

or implied, or assumes any legal liability or responsibility for the 

accuracy, completeness, or usefulness of the data set. Information about LandScan is available from the Oak Ridge National 

Laboratory at: http://www.ornl.gov/sci/landscan/.
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

a certain direction. Scores derived for one location can 

readily be contrasted with those from another.

Average habitat suitability values were calculated for 2 

consecutive months to create finer temporal resolution 

(2 weeks) that were ranked (1 to 24). In addition to rank 

(1 to 24) and rise/fall (1, -1), we constructed metrics that 

measured accumulated rise/fall values, to show the duration of the rise and fall extending into the future (future 

trend or forecast) and the past (past trend or hind cast). 

We scored a rise as 1 and a no rise as -1, and considered 

that if change in rank was unidirectional, the rise/fall 

value would be the same as the preceding rise/fall value.

Instances where a plateau or trough was present can be 

disguised by the ranking process, due to the exaggeration of minor differences in values. One solution was to 

round up suitability values to three decimal places to 

tie the ranks of similar scores. Equal Rank ascending 

in Excel sometimes resulted in the maximum being less 

than 24 due to tied ranks. To address this, we calculated 

the maximum rank in a separate column and changed 

the highest rank values to 24. This had the effect of exaggerating the jump in rank to the maximum of 24 in 

a minority of cases, but simplified the identification of 

peaks and troughs. Figure 1 displays an idealized seasonal pattern of rank values with 6 important points in a 

typical seasonal cycle and the output for various metrics.

Seasonality: Multivariate Analysis

To help visualize seasonality spatially, we created Interpolated surfaces (Spatial Analyst 

Tools>Interpolation>Kriging) for the rank of each 

month (12 months) using the point shapefile for each 

second order administrative area, and then created a mask around each point of 100 km (Analysis 

Tools>Proximity>Buffer), with all buffers dissolved 

together. Then we clipped interpolated surfaces by the 

mask (Spatial Analyst Tools>Extraction>Extract by 

Mask), and created a 3-band (red, green, blue) principle 

component layer summarizing the 12 interpolated surfaces to give a summary of the yearly seasonal pattern 

(Spatial Analyst Tools>Multivariate>Principle Components). We also developed iso clusters (Spatial Analyst 

Tools>Multivariate>Iso Cluster Unsupervised Classification) based on 2 and 6 classes for the 12 interpolated 

surfaces, then conducted zonal statistics for these iso 

clusters on the original 12 monthly habitat suitability 

models. The overlay map show the 5 regions described 

in Faria et al,10 the outlines of the states, and the colorcoded Aedes seasonality map for Brazil. The graphics 

capabilities are discussed further in the Seasonality 

Graphics Presentations section on page 25.

Results

An Excel tool was constructed (Figure 2) with the following components:

User Controlled Inputs

These comprise drop-down lists and dependent dropdown lists:

Select State

Select District

Select Date

Automatically Generated Values

Aedes hazard this date: The more red that extends to 

the right, the higher the Aedes hazard at that location 

during the user-defined time period. The sum of the 

12-month values equals the yearly hazard value. Bars 

indicate the probability of mosquito occurrence (0-1.0).

Annual Aedes hazard this place: The more red that extends to the right, the higher the Aedes hazard at that 

location across the whole year. Bars indicate the probability of mosquito occurrence (0-1.0).

Rank this date (1 low, 24 high): The rank from the lowest Ae. aegypti probability (=1) to the highest (=24) for 

each of 24 two-week periods for the particular location 

selected.

Maximum rank this location: The maximum rank over 

24 two-week periods for the particular location selected. 

Note that maximum rank can be less than 24 due to tied 

scores.

Future trend (rising 1, falling -1): Is the Ae. aegypti

probability going to rise (1) or fall (-1) in the next 2-week 

period? Stationary values do not change the prevailing 

score.

Past trend (hind cast): Ascending number of consecutive times that the probability of Ae. aegypti has risen 

(positive) or fallen (negative) as time advances, eg, “12” 

means that the following period will be the 12th successive time that values have increased, and -2 means that 

the following period will be the second successive time 

that values have decreased. Flat (zero trend) periods are 

counted as a continuation of the prevailing trend.

Future trend (forecast): Descending number of consecutive times that the probability of Ae. aegypti is predicted to rise (positive) or fall (negative) as time advances, 

eg, “1” means that 1 successive period of rising values is 

predicted to occur, -12 means that 12 successive periods 

of falling values are predicted to occur. Flat (zero trend) 

EXCEL TOOL FOR AEDES VECTOR SEASONALITY
January – June 2018 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

periods are counted as a continuation of the prevailing trend.

Vector Hazard score (0 -1.0):

(Rank)/(Maximum rank) × (Annual Aedes hazard for the district 

chosen)

In theory, this scale could range 

from 0 to 1.0 based on the highest rank of vector distribution and 

activity throughout the year at the 

location of interest. Users should 

not rely solely on this metric to 

assess hazard.

Area (sq km): Area of the second 

order administrative region.

Number of people: Estimated 

number of people within the second order administrative region 

according to Landscan.

Average density of people (sq 

km): Average density of the second order administrative region 

derived from Landscan.

Control advice: A text description of where in the seasonal 

cycle of Aedes hazard this time 

and place represents. Warning: 

text advice is based on changes 

in rank, which can result in unexpected results. For example, 

although probability may change over time in a minor 

way, as in the off-season, this will be translated to different ranks, which can exaggerate the perception of 

change and lead to spurious advice. The user is advised 

to always consult the accompanying graph to gauge the 

veracity of the automated advice. Advice for each position of the cycle can be tailored by editing contents of 

cells EJ17:EJ24.

Possible advisory warnings that could be triggered for 

the 6 time periods shown in Figure 1 include:

1. Aedes hazard is at the highest expected level for 

this location. Maximize vector control and community education.

2. Aedes hazard is high for this location but falling. 

Maintain vector control and community education.

3. Aedes hazard is near a low point (could be more 

than one) for this location. Minimize vector 

control and community education. Be aware that 

peak in cases can lag peak in vectors.

4. Aedes hazard is the lowest for this location. Prepare for scaling up vector control.

5. Aedes hazard is starting to rise for this location. 

Initiate vector control and community education.

6. Aedes hazard is near a high point for this location. Maximize vector control and community 

education.

Further refinement of these advisory warnings should 

include consultation with vector control and public 

health personnel.

Seasonality Graphics Presentations

In addition, Figure 2 presents a graph which displays the 

seasonal pattern in Aedes suitability (blue line) and the 

time period selected (red line), and a map of Brazil with 

A

B

Figure 1. Typical seasonal pattern of modelled Aedes probability over a year divided into 2 

week periods for Espírito Santo-Alfredo Chaves, Brazil. Section A: Boxed numbers indicate 

important date points in this seasonal pattern, as described in the text. Section B: Outputs 

for various metrics for the 6 date points shown in section A.
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

the location of the administrative region selected. Figure 

3 shows the results of clustering Aedes seasonality into 2 

and 6 clusters and according to the first 3 principal components (PCs). With 2 iso clusters, Brazil is divided into 

a northern cluster and a geographically larger southern 

cluster. The northern cluster shows a peak in March to 

April and a trough in July to December, while the southern cluster peaks in December to March and exhibits 

a pronounced trough in May to September. With 6 iso 

clusters, the northeastern region shows a more complicated pattern for Brazil. Mean monthly values for each 

cluster are shown in Figure 3. The continuous PC map 

shows the most complicated pattern.

The Excel file for Brazil is freely available via the VectorMap website, http://vectormap.si.edu/.

Comment

Knowledge of vector seasonality is powerful intelligence about when vector to human contact is expected, 

thereby providing clarity on the timing of vector hazard 

and disease transmission risk. In this article, we demonstrate the potential utility of global habitat suitability models to predict Aedes (Ae. aegypti) seasonality 

for administrative areas of Brazil. We created a simple 

Excel spreadsheet interface that calculates metrics and 

displays various aspects of seasonality for hazard and 

risk assessment for Ae. aegypti vectored diseases such 

as dengue, chikungunya, yellow fever, and Zika. We 

believe that this approach adds value to monthly habitat suitability models by allowing a wide variety of users to explore seasonal patterns for any area of interest. 

Knowledge about the seasonal changes in vector hazard 

is important as it informs time-sensitive vector control, 

prophylaxis, and travel decisions.

Faria et al 10 found that, for each Brazilian region, there 

was a strong association between estimated climatic 

suitability and weekly Zika notified cases and that notified ZIKV cases lag climatic suitability by about 4-6 

weeks in all regions, except northeast Brazil, where 

no time lag was evident. The observation that Aedes

seasonality iso clusters (Figure 3) are most diverse in 

northeast Brazil may account for the absence of lag, for 

example, if transmission occurred in iso clusters 3, 5 or 

6 that experience earlier suitability for Aedes, cases may 

appear around the time of peak suitability for the other 

iso cluster areas.

This tool could be extended for other areas of interest 

where a polygon or point feature delimiting the area is 

available. The authors are currently exploring extending this tool to other countries such as Colombia, Puerto 

Rico, and Thailand. If monthly models of habitat suitability or abundance for Ae. aegypti or other vector species become available, these can be used with the current Excel interface.

There are a number of limitations with our approach, a 

few of which are discussed herein: As the primary outputs of the zonal statistics used here were mean values, 

areas of interest should not be too large, or cover topologically diverse areas, as the range of values can show 

high diversity not adequately captured in the mean. Ideally, areas should show a clear seasonal pattern, as areas 

that are not suitable for the vector or have uniformly low 

Figure 2. Output sheet for the Brazil Aedes/Zika Excel tool showing (left) inputs for location and date and outputs; (center) 

output line chart; and (right) map of Brazil with location.

EXCEL TOOL FOR AEDES VECTOR SEASONALITY
January – June 2018 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

or high suitability will give spurious results for the metrics that rely on ranking used here. The use of ranks can 

introduce a false sense of seasonal change and should 

always be considered alongside the actual values; the 

graph of change in habitat suitability values in the tool 

is provided for this purpose. Auto generated textualized 

suggestions regarding response to the position in the 

annual seasonal cycle of vector hazard is an aspect of 

this tool under development and the user should show 

caution in following these suggestions. The seasonal 

predictions are only as good as the model underpinning 

this tool; the current model may not accurately show 

what happens in future years. The relationship of vector 

habitat suitability to disease risk is not always obvious 

and appears to vary depending on the region. In addition, consideration of lag and congenital Zika syndrome 

should take into consideration the full 9 months of pregnancy. Users of this Excel tool are advised to adjust the 

date backward an appropriate amount to gauge how past 

Aedes hazard relates to current Zika case numbers. Finally, ZIKV can be imported and spread by nonvector 

transmission routes (eg, sexual transmission13 ), so a 

level of caution is recommended when trying to relate 

vector hazard with disease risk.

Our aim was to create an easy to use interface between 

monthly vector habitat suitability models and areas of 

interest for those lacking the time and skills to use learn 

and deploy GIS software. Ideally, this platform would 

be made available via a web-based interface. However, 

many users need to access this tool in austere environments where internet connectivity is unreliable or completely unavailable. The MS Excel-based platform can 

be downloaded before deployment and run on any laptop or desktop computer without the need for an internet 

connection. The Excel tool we developed is an accessible and adaptable platform for entomological decisionmaking that makes use of readily available data and 

models. As a new model becomes available, it can be 

easily incorporated into this tool. Validation of the output from this tool using mosquito surveillance results, 

and obtaining user feedback, would be useful goals for 

future research.

Acknowledgments

We thank Dr Moritz Kraemer and collaborators for access to the models of Aedes suitability. We also thank 

MAJ Wes McCardle (Chief, Walter Reed Biosystematic Unit) for his support during the development of this 

tool. This study was made possible from a FY2017 grant 

(P0091_17_WR_1.3.1.) from the Armed Forces Health 

Surveillance Branch and its Global Emerging Infections 

Surveillance Section.

References

1. Lindholm DA, Myers T, Widjaja S, et al. Mosquito exposure and Chikungunya and Dengue infection among travelers during the Chikungunya 

outbreak in the Americas. Am J Trop Med Hyg. 

2017;96(4):903-912.

Figure 3. Aedes aegypti seasonality for second order 

administrative regions of Brazil reduced to 2 iso clusters, 6 iso clusters, and 3 (red, green, blue) principal 

components. Note the mean seasonality (probability per 

month) as graph for each iso cluster.
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Grard G, Caron M, Mombo IM, et al. Zika virus in Gabon (Central Africa)-2007: a new threat 

from Aedes albopictus?. PLoS Negl Trop Dis. 

2014;8(2):e2681.

3. Guerbois M, Fernandez-Salas I, Azar SR, et al. 

Outbreak of Zika virus infection, Chiapas State, 

Mexico, 2015, and first confirmed transmission by 

Aedes aegypti mosquitoes in the Americas. J Infect 

Dis. 2016;214(9):1349-1356. Available at: https://doi.

org/10.1093/infdis/jiw302. Accessed June 18, 2018.

4. Ferreira-de-Brito A, Ribeiro IP, Miranda RM, Fernandes RS, Campos SS, Silva KA, et al. First detection of natural infection of Aedes aegypti with 

Zika virus in Brazil and throughout South America. 

Mem Inst Oswaldo Cruz. 2016;111(10):655-658. doi: 

10.1590/0074-02760160332.

5. Foley DH, Pecor DB. A location-specific spreadsheet for estimating Zika risk and timing for Zika 

vector surveillance, using US military facilities as 

an example. US Army Med Dep J. January-June 

2017:34-46.

6. Bogoch II, Brady OJ, Kraemer MU, et al. Potential for Zika virus introduction and transmission 

in resource-limited countries in Africa and the 

Asia-Pacific region: a modelling study. Lancet 

Infect Dis. 2016;16(11):1237-1245. doi: 10.1016/

S1473-3099(16)30270-5.

7. Brady OJ, Golding N, Pigott DM, et al. Global 

temperature constraints on Aedes aegypti and Ae 

albopictus persistence and competence for dengue 

virus transmission. Parasit Vectors. 2014;7:338.

8. Lambrechts L, Paaijmans KP, Fansiri T, et al. Impact of daily temperature fluctuations on dengue 

virus transmission by Aedes aegypti. Proc Natl 

Acad Sci U S A. 2011;108(18):7460-7465.

9. Kraemer MU, Sinka ME, Duda KA, Mylne AQ, 

Shearer FM, Barker CM, et al. The global distribution of the arbovirus vectors Aedes aegypti and 

Ae. albopictus. ELife. 2015;4:e08347. DOI: 10.7554/

eLife.08347.

10. Faria NR, Quick J, Claro IM, Thézé J, de Jesus 

JG, Giovanetti M. et al. Establishment and cryptic transmission of Zika virus in Brazil and the 

Americas. Nature. 2017; 546:406-410. doi:10.1038/

nature22401

11. Foy BD, Kobylinski KC, Chilson Foy JL, Blitvich 

BJ, Travassos da Rosa A, Haddow AD. et al Probable non-vector-borne transmission of Zika virus, 

Colorado, USA. Emerg Infect Dis. 2011;17:880-882.

Authors

Dr Foley is a Research Entomologist at the Walter Reed 

Biosystematics Unit, Entomology Branch, Walter Reed 

Army Institute of Research, and a Research Associate 

of the Entomology Department within the National Museum of Natural History, located at the Smithsonian Institution, Museum Support Center, Suitland, Maryland.

Mr Pecor is a Research Technician at the Walter Reed 

Biosystematics Unit, Entomology Branch, Walter Reed 

Army Institute of Research, located at the Smithsonian 

Institution, Museum Support Center, Suitland, Maryland.

EXCEL TOOL FOR AEDES VECTOR SEASONALITY

Aedes albopictus (courtesy of the CDC)

Aedes aegypti (courtesy of the CDC)
January – June 2018 29

Thailand serves as a center for a multinational AsiaUnited States military exercise named Cobra Gold 

(CBG) that brings together military personnel from the 

United States and the Asia-Pacific region. It is the largest multinational military exercise hosted by Thailand 

and the United States. During this exercise, training 

activities include humanitarian missions such as construction of schools or multipurpose buildings for the 

community as well as various field-training exercises

including survival in new and challenging battlefield environments. In each year since 1982, more than 13,000 

troops from the United States and 35 partner countries 

have participated in the exercises that are held in many 

regions of Thailand. The training usually occurs between January and March, within the hot and dry season 

that occurs from October to April, which may alter the 

distribution of wild animals, rodents, arthropod vectors, 

and hence pathogen transmission.1,2 The CBG training 

sites are usually in rural or semirural areas making them 

potential habitats for various vector-borne and zoonotic 

diseases posing risks to the training troops. To address 

these concerns, the US Army Medical Directorate of the 

Armed Forces Research Institute of Medical Sciences 

(USAMD-AFRIMS) in Bangkok, Thailand, initiated 

a vector-borne and rodent-borne disease surveillance 

program in 2017 in support of CBG training exercises. 

The aim of this surveillance was to evaluate potential 

risk of vector-borne and rodent-borne disease infections 

and hence establish a more accurate risk assessment for 

these diseases. Such information is particularly useful 

to regional and combatant commanders for timely and 

focused implementation of personal protective measures 

and disease prevention and control programs.

Some of the major vector-borne diseases of public health 

importance in this region include scrub typhus, rickettsioses,3,4 and leptospirosis; all associated with small 

mammals and their ectoparasites, especially rodents 

in rural and semirural settings. Most common clinical 

signs and symptoms of rickettsial diseases and leptospirosis are reminiscent of other infectious diseases such 

as malaria, typhoid fever, and dengue fever, which are 

characterized by high fever and headaches, making differential diagnosis from various other febrile illnesses 

difficult. Thus, the true burden and risk factors associated with these diseases still remain largely unknown.

Among arthropod-borne diseases, scrub typhus was a 

major cause of morbidity and mortality in military operations in Asia-Pacific region during World War II.5

 It 

Surveillance for Scrub Typhus, Rickettsial

 Diseases, and Leptospirosis in US and

 Multinational Military Training Exercise

 Cobra Gold Sites in Thailand

Piyada Linsuwanon, PhD Surachai Leepitakrat, MS

Panadda Krairojananan, PhD MAJ Silas Davidson, MS, USA

COL Wuttikon Rodkvamtook, PhD, RTA MAJ Elizabeth Wanja, MS, USA

Abstract

We report findings of field surveillance for disease vectors and the prevalence of Orientia tsutsugamushi, the 

causative agent for scrub typhus, and other Rickettsial species that cause murine typhus and spotted fever 

group rickettsioses, in chigger mites and small rodents; and Leptospira in rodent kidney, urine, and environmental water samples. The study sites included various Royal Thai Army military installations and other training sites, and surrounding areas where the multinational military training exercise Cobra Gold was conducted 

in Thailand in 2017 and 2018. The overall prevalence of O. tsutsugamushi and Rickettsia infection in chiggers 

was 1.3% (20/1,594) and 7.5% (119/1,594), respectively. Serum samples of the captured rodents indicated previous exposure to O. tsutsugamushi infection with a seropositive rate of 12.2%. Leptospira species were isolated 

from rodent kidneys and water samples collected from catchment areas as well as tap water used for hand washing. Findings from this surveillance are important in determining the potential for scrub typhus, rickettsioses, 

and leptospirosis risk to military and US government personnel, as well as for informing regional and combatant commanders for prevention, correct diagnosis, prompt treatment, and timely and focused implementation 

of vector control and personal protective measures.
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

is caused by the infection of Orientia bacteria which is 

transmitted to humans through the bite of infected trombiculid larval mites, commonly referred to as chiggers, 

which serve as vectors and main reservoirs of this pathogenic bacterium.1

 The chiggers primarily feed on rodents 

but occasionally on humans, presenting an opportunity 

to transmit the Orientia bacteria. Scrub typhus is predominantly endemic in the Asia-Pacific region, an area 

commonly referred to as the “Tsutsugamushi Triangle” 

that extends from northeastern Japan to Pakistan and 

Afghanistan in the west and northern Australia in the 

south, although there have been recent reports of scrub 

typhus outside this region. Approximately one million 

cases occur in the endemic areas each year and more 

than a billion people are at risk worldwide.6 Typically, 

patients with scrub typhus respond well to doxycycline, 

ceftriaxone, and azithromycin treatment. However, 

evidence of potential doxycycline-refractory Orientia 

tsutsugamushi (Tamura) strain have been reported in 

northern Thailand,7 raising concerns about efficacy of 

antibiotic treatment and the growing level of drug-resistant bacteria. Currently, there is no effective vaccine to 

prevent this disease. The current prevention method is 

mainly vector control and avoidance of exposure.

Murine typhus is one of the typhus group rickettsiosis. 

It is a flea-borne disease that is endemic in tropical and 

subtropical areas of the world.8 The rat flea, Xenopsylla 

cheopis (Rothschild), has been considered the main vector. Murine typhus is caused by infection with Rickettsia typhi which is present in flea feces. The pathogens 

enter the body through the bite site during feeding of 

infected flea on host skin, or by accidentally rubbing 

contaminated feces into the bite site during scratching 

by the host. Spotted fever group rickettsiosis is a tickborne or flea-borne infectious disease caused by groups 

of bacteria in the genus Rickettsia, such as R. honei 

(Hone), R. felis (Bouyeret), R. japonica (Uchida), and R. 

helvetica (Beati). The disease is endemic throughout the 

world although the prevalence varies from region to region. Information on spotted fever rickettsiosis has only 

rarely been documented in Thailand,9-11 although many 

regions have suitable environment for arthropod vectors 

and pathogens. The actual burden of murine typhus and 

spotted fever rickettsiosis in Thailand is still underestimated and not well understood.

Leptospirosis is a worldwide bacterial zoonotic disease 

that affects humans. Pathogenic Leptospira species 

are the causative agents of leptospirosis, being spread 

in nature and reflecting maintenance in the kidneys of 

many wild and domestic reservoir hosts.12,13 Its transmission occurs when animals are exposed to Leptospira

pathogens excreted from colonized renal tubules of infected reservoir hosts via urine into the environment.14

Generally, humans are accidental hosts and acquire the 

disease by indirect contact with water or soil contaminated with urine of infected animals or by direct exposure to infected animal tissue or urine.13,14 Infections 

vary in severity from mild, self-limiting febrile illnesses 

to more serious life-threatening conditions. Numerous 

cases of leptospirosis have been reported within the US 

military personnel in the Asia-Pacific region as recently 

as 2014, when more than 81 US service members became infected during an obstacle course at the Jungle 

Warfare Training Center, Camp Gonsalves in northern 

Okinawa.15

In Thailand, leptospirosis is a reportable disease to the 

Bureau of Epidemiology, Department of Disease Control, and Ministry of Public Health. Most infections 

are reported from agricultural workers, primarily rice 

farmers, due to their tendency to work bare-footed in the 

fields.16 The incidence of leptospirosis is underestimated 

because only clinically diagnosed cases are reported 

and symptoms often resembles other febrile illnesses 

leading to misdiagnosis.13 An overview of the national 

surveillance system for leptospirosis in Thailand indicates that there is no clear case definition for the disease, 

laboratory confirmation is infrequently used, and there 

is an inability to link clinical, epidemiologic, and laboratory data.17 A lack of knowledge in naturally circulating 

Leptospira compounds the difficulty in linking human 

host to disease in the rodents. Understanding this relationship is critical to deciphering disease epidemiology 

and is also useful for risk communication.

Small rodents are widespread and are considered as important reservoir hosts for zoonotic diseases. They also 

play an important role in the survival and ecology of 

various ectoparasites including chiggers, ticks, fleas, and 

lice. Conducting activities in close proximity to rodents’ 

habitats may lead to an increased risk of disease transmission. In this study, we investigated the occurrence of 

disease vectors and prevalence of scrub typhus, rickettsioses, and leptospirosis in small rodents, chiggers and 

water samples collected from the CBG exercise areas of 

Thailand during the 2017 and 2018 training periods.

Materials and Methods

Study Sites

The study sites included select sites where CBG training 

exercise took place. In 2017, surveillance was conducted in 5 different provinces including Chaiyaphum, Buri 

Rum, Khon Kaen, Chanthaburi, and Rayong. In 2018, 

the selected CBG surveillance sites were in Nakhon 

SURVEILLANCE FOR SCRUB TYPHUS, RICKETTSIAL DISEASES, AND LEPTOSPIROSIS IN US

AND MULTINATIONAL MILITARY TRAINING EXERCISE COBRA GOLD SITES IN THAILAND
January – June 2018 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

Ratchasima, Chachoengsao, Lopburi, Chanthaburi, and 

Rayong. Small rodents and ectoparasites were collected 

from the actual training sites and surrounding areas to 

cover as many habitats as possible. Also, water samples 

were collected from water bodies in the vicinity of the 

training sites as well as from taps used for cleaning and 

hand washing at students’ dining halls and toilet facilities. Summaries of study site, survey period, number of 

rodents captured and rodent infestation rate per site is 

presented in Table 1 and Figure 1.

Collection of Small Rodents and Water Samples

All procedures involving animals were conducted in 

compliance with the animal use protocol (PN15-06: 

Field sampling of small mammal populations to support 

zoonotic disease surveillance and ectoparasite collection) approved by the Institutional Animal Care and Use 

Committee of USAMD-AFRIMS. Locally made wirelive traps measuring 14 cm x14 cm x 28 cm were used. 

Rodents were baited with bananas, potatoes, palm seeds, 

or other types of food that are commonly found in the 

trapping areas or were recommended by local hunters. 

A total of 60 to 80 traps were set per night in each site 

before sunset (around 4 pm) and collected the following 

morning before 8 am. Locations of the surveillance sites 

were recorded using handheld GPS trackers (Garmin 

Ltd, Olathe, Kansas).

Rodent Processing and Sample Collection

The captured rodents were euthanized with carbon dioxide. Blood samples were collected by postmortem cardiocentesis and aliquoted into serum separator tubes. To 

prevent potential loss of ectoparasites that might drop off 

the rodents due to the decrease in body temperature, the 

carcasses were immediately placed in zip-locked plastic bags and fumigated using ether for 5 minutes. Ectoparasites that fell off in the plastic bags were carefully 

collected using paint brushes. Carcasses were inspected 

and the fur of each rodent was thoroughly examined using fine-toothed flea comb to dislodge any ectoparasite 

into plastic trays. Ectoparasites were stored in collection tubes containing 70% ethanol. Clusters of chiggers 

on rodent ears, bodies, or genital areas were collected 

together with the thin layers of skin to prevent damage 

and preserved in 70% ethanol.

Rodents were identified to species following taxonomic key of small mammals of southeast Asia. For tissue 

sample collection, the surface of the rodent abdomen was 

cleaned with 70% ethanol before necropsy. Rodents were 

dissected and internal organs including lung, liver, kidney, and spleen were harvested. Serum and tissue samples were stored in dry-ice containers and transported to 

the USAMD-AFRIMS laboratory in Bangkok, where the 

samples were later stored at -80°C until further analysis.

Table 1. Diversity of small rodents captured from study sites, load of chigger infestations, seropositivity, and Orientia

and Rickettsia sp. positivity rates by rodent species.

Order Family Species

(No. rodents caught)

Seropositivity

(No. seropositive rodents)

Pathogen 

Detection in 

Rodent Hosts

Chigger

STG MT SFG STG RT Infestation Total Chigger

Rodentia Muridae Bandicota indica (57) 11.1 (5) 5.3 (3)

a 64.9 (37)b 2,441 (1-328)c

Bandicota savilei (51) 8.9 (4) 76.5 (39) 3,831 (2-338)

Berylmys berdmorei (3) 4.4 (25) 100 (3) 18 (4-9)

Mus caroli (4) NA NA NA

Mus cervicolor (6) NA NA NA 16.7 (1) 30 (30)

Niviventer fulvescens (1) NA NA NA 100 (1) 43 (43)

Rattus berdmorei (25) 2.2 (1)

Rattus exulans (78) 15.6 (7) 25 (1) 1.3 (1) 5.1 (4)

Rattus norvegicus (4) 4.4 (25)

Rattus tanezumi (189) 53.3 (24) 75 (3) 100 (25) 1.1 (25) 1.1 (25) 65.6 (124) 12,592 (4-595)

Sciuridae Menetes berdmorei (16) NA NA NA 12.5 (25) 341 (5-236)

Insectivora Tupaiiae Tupaia belangeri (3) NA NA NA

Tupaia glis (25) NA NA NA

2 Orders 3 Families 13 Species 12.2 (29) 1.3 (3) 0.8 (25) 1.2 (3) 2.3 (6) 64.1 (207) 19,296

STG indicates scrub typhus group; MT, murine typhus; SFG, spotted fever group; RT, Rickettsia species.

Notes concerning numbers in parentheses:

a. Number of rodents with active infection of the target pathogen.

b. Number of rodent host with trombiculid chigger.

c. Range of chiggers collected per hour.
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

SURVEILLANCE FOR SCRUB TYPHUS, RICKETTSIAL DISEASES, AND LEPTOSPIROSIS IN US

AND MULTINATIONAL MILITARY TRAINING EXERCISE COBRA GOLD SITES IN THAILAND

Figure 1. Distribution map showing (A) locations of the cobra gold training exercise during the training period of 2017 and 2018 together with average of incidence of scrub typhus cases between 2016 and 2018; (B) Orientia (OT) and Rickettsia (RT) positivity in trombiculid chiggers; (C) Seropositivity of antibodies to scrub typhus (STG), murine typhus (MT) and spotted fever rickettsiosis (STG) among rodent population trapped in the training sites.
January – June 2018 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

Morphological Identification of Chigger Mites

Approximately 10% of chiggers from each rodent were 

sampled for identification using the standard taxonomic 

keys previously described by Nadchatram et al 18 and 

other published taxonomic keys. Slide-mounted chiggers were examined under a dissecting microscope at 

400x magnification (Carl Zeiss AG, Oberkochen, Germany) and identified to genus and species level. The remaining chiggers were transferred to 95% ethanol for 

better preservation of nucleic acid and further pathogen 

testing.

Detection of Antibodies Reaction against

O. tsutsugamushi and Rickettsia spp. in Rodents

Serum samples were tested for the presence of specific 

antibodies to the causative agents of scrub typhus, murine typhus, and spotted fever group rickettsioses using indirect immunofluorescent staining assays (IFA).19

Types of whole cell antigens used for IFA included a 

mixture of O. tsutsugamushi genotype Karp, Kato, and 

Gilliam for scrub typhus group antibody assessment, R. 

typhi isolate Wilmington for murine typhus assessment, 

and R. honei isolate TT112 for spotted fever group rickettsiosis. Rodent sera were initially screened at the dilution of 1:50 (seropositivity cutoff). Any positive sample 

was serially diluted to a final concentration of 1:12,800 

and tested for antibody titer.

Leptospira Cultures

Isolation of Leptospira was performed using 5-fluorouracil-containing Ellinghausen-McCullough-Johnson-Harris (EMJH) medium (Becton, Dickinson and 

Company, Franklin Lakes, New Jersey) with 5% rabbit 

serum (Thermo Fisher Scientific Inc, Waltham, Massachusetts). At the field site, sterile environment was 

maintained by the use of a Bunsen burner containing 

95% alcohol. Urine specimens were collected using sterile syringes and needles and dropped in 3 mL of 0.1% 

semisolid EMJH medium. A section of the cortex from 

one kidney of each rodent was homogenized using syringe homogenization method. The homogenates were 

suspended in 5 mL culture EMJH media and debris 

tissue allowed to precipitate. After 24 hours, 500 μL 

of the culture was pipetted and subcultured into 3 mL 

semisolid EMJH medium and stored at room temperature until transported back to USAMD-AFRIMS. For 

water samples, EMJH medium was inoculated with 

500 μL of the collected water and the bacterial cultures 

were subpassaged as described earlier. The culture vials 

were incubated at 30°C for 16 weeks with biweekly dark 

field microscopic observations to verify the presence of 

Leptospira.

Pathogen Detections by PCR

Detection of O. tsutsugamushi and Rickettsial Species

in Rodents and Chiggers

Nucleic acid was individually extracted from 3 or 4 

types of rodent tissues including liver, lung, spleen, and/ 

or kidneys and chigger samples using MagAttract 96 cador pathogen kit (Qiagen Bioinformatics, Hilden, Germany) following manufacturer protocol. The presence 

of O. tsutsugamushi and Rickettsia DNA were evaluated 

using quantitative real-time PCR (qPCR) assay targeting 

47-kDa high temperature transmembrane protein (HtrA) 

gene and 17-kDa genus-specific gene following previous described protocols as shown in Table 2. The qPCR 

analysis was performed in triplicated reactions and carried out using CFX96 Real-Time PCR Detection System 

(Bio-Rad Laboratories, Inc, Hercules, California).

Detection of Leptospira DNA in Trapped Rodents

and Water Samples

The kidney specimens were subjected to genomic DNA 

extraction using the QIAmp DNA Mini kit (Qiagen) according to the manufacturer’s instructions. Two different qPCR assays were used for Leptospira DNA detection. The lipL32 qPCR was used to detect the Leptospira 

DNA in the rodent’s kidney specimens,22 while the qPCR 

assay targeting 16s rRNA gene (rrs) gene was used to 

detect the Leptospira DNA in the water samples (Table 

2).23 For collected water evaluation, 50 mL of water was 

centrifuged at 3,000×g for 30 minutes to concentrate 

the bacterial cells. The pellet was resuspended in 140 

μL sterile water, and nucleic acid was extracted from 

the suspension using the QIAamp Viral RNA Mini Kit 

(Qiagen) following the manufacturer’s protocol. Positive 

controls included DNA samples prepared from reference 

L. interrogans culture, Leptospira-infected rodent kidney tissues, and Leptospira

positive water samples collected during previous surveillance studies. The DNA 

prepared from nonpathogenic L. biflexa culture and 

from noninfected rodent’s 

tissue was used as negative 

controls.

Table 2. Summary of pathogen detections by PCR.

Pathogen Target

Gene

Detection 

Method

Type of Samples Reference

Protocol

Orientia tsutsugamushi 47-kDa HtrA qPCR Rodent tissue, chigger Jiang et al20

Rickettsial sp. 17-kDa qPCR Rodent tissue, chigger Wright et al21

Leptospira spp. lipL32 qPCR Rodent tissue McAvin et al22

16s rRNA qPCR Water sample Smythe et al23

16s rRNA nPCR Leptospira culture medium Boonsilp et al24

16s rRNA nPCR Leptospira qPCR positive sample Boonsilp et al24
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

The nested single tube PCR assay targeting partial rRNA 

gene was performed on positive lipL32 and rrs qPCR 

assay samples as previous described.24 Amplicons were 

determined using 1.5% gel electrophoresis followed by 

staining with GelStar (Lonza Rockland Inc, Rockland, 

Maine). Positive PCR samples were purified by GeneJET 

PCR Purification Kit (Thermo Fisher). After purification, 

PCR products were sent to Macrogen, Inc (Seoul, South 

Korea) for sequencing. The DNA sequences of partial rrs 

amplicons were analyzed using Sequencher v 5.0 software (Gene Codes Corporation, Ann Arbor, Michigan) 

and trimmed to the 433 base pair length fragments. For 

molecular identification of Leptospira species, the DNA 

fragments were compared to available Leptospira sequences in the GenBank database using the Basic Local 

Alignment Search Tool (BLASTn) algorithm.

Identification of Recovered Leptospira Isolates

Using 16S Rrna Gene Amplification

The isolated Leptospira was regrown in liquid EMJH at 

30°C for 7 days and total genomic DNA extracted from 

the cultures using the GeneJET Genomic DNA Purification kit (Thermo Fisher) according to manufacturer’s instructions. The nested single tube PCR assay and analysis were performed as described earlier.

Data Management and Statistical Analysis

Digital map for seropositive rodents and ectoparasites 

infected with Orientia and Rickettsia pathogens were 

created using qGis v 2.18.16 (https://qgis.org/en/site/). 

The epidemiological parameters and indices were calculated according to the guidelines recommended by the 

World Health Organization.25,26 The parameters included 

rodent infestation rate (number of captured rodents from 

number of traps), mean abundance (number of chiggers 

collected per number of examined rodents), chigger infestation rate (percentage of rodents infested with chiggers from the total number of captured rodents), specific 

chigger index (number of chiggers of specific genus recovered from specific rodent host species per number of 

individual hosts), and overall chigger index (total number of chiggers collected [regardless of species] per total 

SURVEILLANCE FOR SCRUB TYPHUS, RICKETTSIAL DISEASES, AND LEPTOSPIROSIS IN US

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Table 3. Overall percentage infestations of rodents and trombiculid chiggers, and seropositivity and pathogen positivity by collection sites.

CBG Collection Site

(No. rodents 

caught)

Collection 

Periods

Rodent Chigger Seropositivity

(No. of assayed)

Pathogen

Positivity

Infestation 

Rate* ChiggerInfestation†

No.

Chiggers

Chigger

Index

STG MT SFG STG RT

2017 Buri Ram (125) 2017: April,

October

23.6

(125/530)

33.6

(42/125)

7,974 189.9 8.1

(10/123)

2.4

(3/125)

4

(5/125)

Chaiyaphum (48) 2017: January,

March, July

11.4

(48/420)

75

(36/48)

1,763 49.3 13.6

(6/44)

Chanthaburi (23) 2017: January,

September

1.3

(6/480)

21.7

(5/23)

20 4.0 15

(3/20)

4.3

(1/23)

Khon Kaen (62) 2017: January,

March, July

13.8

(62/450)

21

(13/62)

1,132 87.1 20

(10/50)

6

(3/50)

4

(2/50)

Rayong (3) January 2017 1

(2/200)

Total: 261 36.8

(96/261)

10,889 113.5 12.2

(29/237)

1.3

(3/237)

0.8

(2/237)

1.2

(3/261)

2.3

(6/261)

2018 Chachoeng

Sao (9)

December 2017 44.4

(4/9)

111 27.8

Chanthaburi (51) January 2018 22.4

(51/228)

72.5

(37/51)

3,110 84.1 25.5

(13/51)

Lopburi (54) December 2017 15.4

(54/350)

77.8

(42/54)

3,804 91.9 1.8

(1/54)

3.7

(2/54)

Nakhon

Ratchasima (18)

November 2017 44.4

(8/18)

97 12.1

Rayong (23) January 2018 17.3

(23/133)

87

(20/23)

1,285 64.3 13

(3/23)

4.3

(1/23)

Total: 155 71.6

(111/155)

8,407 76.3 10.8

(16/148)

0.7

(1/148)

1.9

(3/155)

Grand Total: 416 49.8

(207/416)

19,296 93.2 0.72

(3/416)

2.2

(9/416)

0.72

(3/416)

0.72

(3/416)

2.2

(9/416)

CBG indicates Cobra Gold; STG, scrub typhus group; MT, murine typhus; SFG, spotted fever group; RT, Rickettsia species.

Notes concerning numbers in parentheses:

*number of captured rodents/number of traps deployed

†number of rodents infested with chiggers/total number of captured rodents
January – June 2018 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

number of infested hosts). The index was multiplied by 

100 to give the percentage index. Correlation analysis 

was performed to determine association between seropositivity, prevalence of chigger infestation on the rodent, chigger index, and qPCR positivity rate of target 

pathogen in chiggers.

Results

Abundance of Rodents and Chigger Mites Were Found 

in CBG Training Exercise Sites

In total, 416 small rodents including rats, mice, and 

tree-shrews representing 7 genera and 13 species were 

collected (Table 1). A total of 261 rodents (62.7%) were 

collected in 2017 (CBG 2017) and 155 rodents (32.3%) 

trapped in 2018 (CBG 2018) (Table 3). Rodent and ectoparasite populations were surveyed for 37 trap nights 

at 39 sites covering most of the CBG training exercises 

sites and surrounding areas (Figure 1). Rodents were 

successfully trapped from all of the training sites with 

variations in infestation rates among sites. The CBG 

2017 training site located at Buriram and areas adjacent 

to the training sites were heavily infested with rats with 

the overall infestation rate of 23.6%. For CBG 2018, the 

rate of rodent infestation was highest in Chanthaburi 

(22.4%) and Rayong (17.3%). The Asian house rat, Rattus tanezumi (Kloss), considered the main reservoir host 

of many zoonotic diseases, was the most abundant rodent species trapped (45.4%, 189/416). Of the collected 

rodents, 207 were infested with chiggers which corresponded to 49.7% prevalence of chigger infestation. 

These findings suggested that all of the training sites 

should be considered as areas at high or moderate risk 

for rodent-borne and ectoparasite-borne diseases.

Diversity of Chigger Population

Chiggers were found in all study sites, except the CBG 

2017 Rayong site. Seven of 13 rodent species were infested with chiggers. The main reservoir hosts of trombiculid chiggers included Berylmys berdmorei (Blyth), 

Bandicota savilei (Thomas), R. tanezumi (Temminck), 

and B. indica (Bechstein). The overall chigger index indicated that chiggers were most abundant in the CBG 

2017 Buriram site (189.9), followed by CBG 2018 Lopburi site (91.9), and CBG 2017 Khon Kaen site (87.1).

A total of 19,296 chiggers belonging to 7 genera were 

recovered from the rodent hosts (Table 3). Out of 207 

chigger infested rodents, 158 

(76.3%) rodents were infested 

with trombiculid chiggers from 

a single genus, while 43 (20.8%) 

and 6 (2.9%) rodents harbored 

chiggers from 2 and 3 genera, respectively. On average, 

rodents hosted 1.27±0.5 genera (mean±SEM) of chiggers. 

The most abundant chiggers 

belonged to the Walchai species (26.9%) followed by chiggers from Ascoschoengastia

sp (33.3%), Leptotrombidium 

sp (21.7%), and Scheogastia sp 

(13.5%). Chiggers from Helenicula sp (1.4%), Blankaartia sp (1%) and Trombiculindus sp (0.5%) were found in 

only few rodents (Table 4).

Prevalence of O. tsutsugamushi and Rickettsia DNA in 

Trombiculid Chiggers

A total of 1,594 nucleic acid samples extracted from 

3,489 chiggers were tested. The sample set consisted 

of 1,297 samples extracted from individual chiggers 

and 297 samples extracted from pools of 2,192 chiggers (5 to 10 chiggers per pool). Orientia positivity 

rate in chiggers was 1.3% (20/1,594) (Table 5). The 

mean of Orientia pathogenic bacteria load detected in 

individual chiggers ranged from 13.8 to 2,251.6 copies/μl. The positive chiggers were recovered from 18 

Table 5. Numbers of trombiculid chiggers positive for Orientia

and Rickettsia by genus.

Genera Number of

Positive

Samples

Study Site

RT STG

Ascoshoengastia - 4 Chaiyaphum, Khon Kaen

Gahrliepia 70 6 Chaiyaphum, Buriram, *Chanthaburi,

Lopburi, †Rayong, Chachoeng Sao 

Helenicula 1 2 Khon Kaen

Leptotrombidium 39 5 Chaiyaphum, †Chanthaburi, Khon 

Kaen, †Rayong

Scheongastia 9 3 Buriram

Total 119 20

RT indicates Rickettsia species; STG, scrub typhus group.

*Cobra Gold 2017 †Cobra Gold 2018

Table 4. Chigger genus composition among small rodent species.

Rodent Species

(No. of rodents caught)

Genus of Chigger

(No. of rodents infested with the specific genus of chigger)

Lepto Scheo Ascos Walch Blank Helen Trombi

Bandicota indica (57) 194 (7) 70 (1) 12 (3) 2,162 (36) 3 (1)

Bandicota savilei (51) 154 (4) 3,677 (39)

Berylmys berdmorei (3) 18 (3)

Menetes berdmorei (16) 336 (1) 5 (1)

Mus cervicolor (6) 30 (1)

Niviventer fulvescens (1) 43 (1)

Rattus tanezumi (189) 1,006 (32) 4,706 (26) 5,164 (66) 1,614 (41) 2 (1) 98 (3) 2(1)

Total: 323 1,733 (45) 4,781 (28) 5,176 (69) 7,501 (120) 5 (25) 98 (3) 2(1)

Lepto indicates Leptotrombidium; Scheo, Scheogastia; Ascos, Ascoschoengastia; Walch, Walchia; Balnk, 

Blankaartia; Helen, Helenicula; trombi, trombiculindus.
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

individual rodents. 66.6% (12/18) rodents were 

caught in the training exercise sites, indicating 

that there may be a high risk of scrub typhus 

disease transmission. The rodent species with 

positive chiggers were R. tanezumi (72.2%, 

13/18); B. savilei (22.2%, 4/18); and B. indica

(5.6%, 1/18), respectively. Rattus tanezumi was 

the only species complex that showed correlation between seropositivity to O. tsutsugamushi, 

load of chigger, and its prevalence infection in 

chiggers. A significant finding during this surveillance is the first time detection of Rickettsia

DNA in trombiculid chigger samples in Thailand. Rickettsial pathogens were detected in 119 

(7.5%) samples with an average bacterial load 

between 16.4 and 425.4 copies/μl. One pool of 

Ascoshoengustia sp. chiggers had Orientia and 

Rickettsia bacteria coinfection.

Seroprevalence of O. tsutsugamushi and 

Rickettsia Infection in Wild Rodents

Secondary antibodies for some of rodent species such as Tupia species are not commercially 

available, hence 7.4% of the rodents were excluded from serological assay. Of the 385 rodents examined, 45 rodents (11.7%) captured 

from 6 of 10 CBG training exercise sites were 

seropositive for antibodies to O. tsutsugamushi-antigen group (Table 1). The highest seroprevalance to O. tsutsugamushi was the CBG 

2018 Chanthaburi site with (25.5%), followed by 

the CBG 2017 Khon Kean (20%), Chanthaburi 

(15%), and Chaiyaphum (13.6%) sites, the CBG 

2018 Rayong site, and the CBG 2017 Buriram 

site (8.1%). Seropositive rodents against O. tsutsugamushi antigens were detected in 7 rodent 

species: R. berdmorei (50%, 1/2), R. norvegicus

(50%, 1/2), B. berdmorei (66.7%, 2/3), R. tanezumi (12.7%, 24/189), R. exulas (9%, 7/78), B. 

indica (8.8%, 5/57), and B. savilei (7.8%, 4/51). 

Seropositivity differed significantly among 

rodent species, but not among the study sites. 

Correlation between chigger and seropositivity was only found in 3 rodent species; R. tanezumi, B. indica, and B. savilei (P<.0001, 95% 

CI) (Figure 2). Only 1.6% of the rodents were 

seropositive to rickettsial pathogens with 1% of 

R. typhi 4 and 0.5% of R. honei.

27 Almost all of 

the seropositive rodents were caught from the 

training site in Khon Kaen, except one rodent 

that was seropositive to R. typhi which was collected from the Lopburi training site. Mixed 

infections of 2 different types of bacteria were 

found in rodents captured from the Khon Kaen 

SURVEILLANCE FOR SCRUB TYPHUS, RICKETTSIAL DISEASES, AND LEPTOSPIROSIS IN US

AND MULTINATIONAL MILITARY TRAINING EXERCISE COBRA GOLD SITES IN THAILAND

Figure 2. Genus composition of chigger population recovered from specific rodent hosts.

Total no. trombiculid chiggers

Scheogastia

Gahrilepia (Walchia)

Trombiculindus

Helenicula

Blankaartia

Ascoschoengastia

Leptotrombidium

0.1 1 10 100 1000

Bandicota savilei

Rattus tanezumi

Total no. trombiculid chiggers

0.1 1 10 100 1000

Scheogastia

Gahrilepia (Walchia)

Trombiculindus

Helenicula

Blankaartia

Ascoschoengastia

Leptotrombidium

Total no. trombiculid chiggers

Bandicota indica

Scheogastia

Gahrilepia (Walchia)

Trombiculindus

Helenicula

Blankaartia

Ascoschoengastia

Leptotrombidium

0.1 1 10 100 1000
January – June 2018 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

site, where one rodent had specific antibodies to O. tsutsugamushi and R. honei, 

while another rodent had antibodies to R. 

typhi and R. honei.

The presence of Orientia and Rickettsia DNA in rodents was examined. The 

efficiency of qPCR assay for detection 

of 47-kDa HtrA gene and 17-kDa gene 

was 97% and 101.3%, respectively. R2

of the standard curve was 99.4 for both 

of 47-kDa HtrA and the 17-kDa genes. 

Orientia species DNA was detected 

only in lung samples of 3 rodents (0.7%, 

3/416). Only 2 rodent species, R. tanezumi (1.1%, 2/189) and R. exulans (1.3%, 

1/78) were positive. All of the Orientia

positive rodents were caught from the 

training areas in Buriram province. A total of 9 rodents 

had active rickettsial pathogens infections (2.2%, 9/416). 

All Rickettsia positive rodents were collected from traps 

from villages and plantations near the training sites of 

Buriram, Chanthaburi, Lopburi, and Rayong (Table 

3). Rickettsia DNA was found in many organs with the 

highest prevalence in lung (66.7%, 6/9), followed by kidney (22.2%,2/9) and liver (11.1%, 1/9), respectively from 

3 rodent species, including R. exulans,

4 B. indica,3

 and 

R. tanezumi.

27

Detection of Leptospira spp. in Rodent Tissue and 

Water Samples

During the 2017 surveillance, all of the rodents were 

shown to be Leptospira negative by the qPCR assay 

targeting the lipL32 gene. Of the 36 water samples 

collected from puddles, rivers, canals, and tap water 

around the training sites and tested for Leptospira by 

qPCR assay targeting rrs gene, none of the samples was 

positive for Leptospira. However, 3 samples were positives in the EMJH media culture (Table 6). Two of these 

samples were recovered from the pond in the school 

and water source in the village around training site in 

Chaiyaphum. The other isolate was recovered from the 

paddy field water samples in Khon Kaen. The partial rrs

gene was amplified from the 3 positive water cultures. 

Results obtained from BLASTn search and phylogenetic 

analysis of rrs gene sequences confirmed bacteria as the 

intermediate L. licerasiae.

During the 2018 surveillance period, a total of 155 

rodents and 105 water samples were determined for 

Leptospira DNA. Two rodents (1.3%), Mus cervicolor

(Hodgson) from Nakhon Ratchasima and R. tanezumi

from Chanthaburi, were positive for Leptospira infection. Thirty-three of 105 (31%) water samples from 5 

areas were positive for Leptospira by rrs real-time PCR 

detection. Three of the positive water samples were collected from Nakhon Ratchasima, 2 from Chachoengsao, 5 from Lopburi, 6 from Chanthaburi, and 17 from 

Rayong. Eight isolates of Leptospira were successfully 

recovered from culture. Two isolates from the site in Nakhon Ratchasima were recovered from tap water near 

the construction site and another one from a canteen in 

the school. The positive culture sample from Chachoengsao and Lopburi were collected from the ponds near 

the school. Two isolates from Chanthaburi were recovered from 2 tap water samples from a canteen. The last 

2 isolates were the tap water samples collected from the 

CBG construction site in Rayong.

Comment

In this study, rodent trapping and collection of ectoparasites were used instead of the conventional black plate 

technique to cover larger areas where exposure to vector and pathogen might occur. In addition, due to the 

military operations, the movement of service members 

throughout large training areas made it difficult for the 

black plate method to be used to conduct surveillance in 

all potential risk areas. By using the rodent collection 

method, we successfully collected high numbers of trombiculid chiggers as well as mange mites, ticks, and fleas 

with 49.8% of collected rodents having ectoparasites.

Trombiculid chiggers were recovered from almost all 

training sites, except the CBG 2017 Rayong site because 

only few rodents were caught (n=3). A relatively high 

diversity of chiggers was also found. Our findings indicated that certain rodent species appeared to host more 

chigger species than others. However, the correlation 

between these 2 matrices could not be analyzed because 

the prevalence of chigger load in rodent hosts was not 

Table 6. Summary of Leptospira positive samples.

CBG Province Rodents Environmental Water 

Samples

No.

Trapped

Rodents

lipL32 qPCR

Positive

No.

Samples

rrs

qPCR

Positive

Positive

Culture

2017 Chaiyaphum 13 0 9 0 2

Chantaburi 6 0 10 0 0

Khon Khan 14 0 7 0 1

Rayong 3 0 10 0 0

Total 36 0 36 0 3

2018 Nakhon Ratchasima 18 1 22 3 2

Chachoengsao 9 0 22 2 1

Lopburi 54 0 21 5 1

Chantaburi 51 1 20 6 2

Rayong 23 0 20 17 2

Total 155 2 105 33 8

CBG indicates Cobra Gold.
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

distributed evenly. One of the metrics recommended by 

the WHO is the determination of “arthropod index,” 25 or 

“chigger index” as analyzed in our study. Multiple studies have demonstrated abundant trombiculid chiggers in 

various locations in Thailand, although information of 

chigger indices in different geographic regions is currently lacking. To compare our findings with previous 

reported data, we reanalyzed the overall chigger indices 

from the available data previously reported from Thailand. By recalculating the data reported by Coleman et 

al,28 we found that the chigger index was 59.5 (153,899 

chiggers/2,587 infested hosts). Even though Coleman 

and colleagues conducted extensive rodent and chigger surveillance studies in many regions in Thailand, 

most of the rodents (88%) were caught from Chiangrai 

province. Therefore, the overall chigger index seemed 

to mainly represent data from specific areas only. Other 

studies conducted in neighboring province of Chiangmai also showed a relatively similar high chigger index 

(50.6, 2,277/45).29 In our study, a higher chigger index 

was observed (93.2, 19,296/207). Of all the CBG training sites, the CBG 2017 Buriram site showed the highest chigger index (189.9) which was significantly higher 

than the other sites. This suggested that Buriram site 

may be considered an area with a high risk of chiggerborne disease transmission to service members.

Many species of trombiculid mites are important vectors of Orientia pathogen. Of the trombiculid chiggers 

collected, 5 genera: Walchai, Leptotrombidium, Ascoschoengastia, Helenicula, and Scheogastia were positive 

for Orientia. Rickettsia sp. infection in a large number 

of trombiculid chiggers in Thailand was reported for the 

first time in our study. All of the Orientia and Rickettsia

infected chiggers were recovered from rodents caught 

approximately 1 to 2 months before the CBG training 

exercise started.

Based on our serosurveillance study, seropositivity of 

small rodents to O. tsutsugamushi infection was high in 

many training sites, with the highest seropositive rate in 

the CBG 2018 Chanthaburi site. Data for scrub typhus 

seropositivity in the rodent population were analyzed together with data of scrub typhus patient obtained from 

the Thai Ministry of Public Health. Scrub typhus infection rate in Thailand over a 4-year surveillance period 

between 2014 and 2017 was high with a total of 31,199 

cases reported. The number of scrub typhus cases varied within seasons and regions. The vast majority of the 

confirmed cases was reported from the northern regions 

of Thailand, followed by northeastern, southern, and 

central parts. According to the most recent annual reports in 2016 and 2017, scrub typhus cases were found 

in all provinces where CBG took place.

The finding and isolation of Leptospira pathogens in rodent tissue and water samples may be an indication that 

activities associated with water, both ground and piped 

water, may be of concern especially to individuals with 

wounds or any break in the skin. Human infections occur when they come into contact with the contaminated 

environment and when the organism penetrates through 

broken skin or mucosa. A recent report from Dierk et 

al 15 investigated the association between training activities and the largest record of leptospirosis cases within 

the US military in 2014. This report indicated that the 

relationship of water exposure in areas with high leptospirosis levels increased the risk of symptomatic disease 

for US Marines training in Okinawa, Japan. Rodents 

are well-known reservoirs of Leptospira and are often 

implicated as the source of human leptospirosis in Thailand. Environmental contamination by Leptospira is a 

more effective route of infection than direct contact, and 

rodents play an important role as efficient disseminators 

of Leptospira in the environment. Therefore, the prevalence of infected rodents may serve as an indicator of 

Leptospira transmission throughout the environment.

Findings from our surveillance indicate that scrub typhus, rickettsial diseases, and leptospirosis that are 

widely distributed throughout Thailand pose a more 

significant threat to military personnel than previously 

realized. This information is important in determining 

the potential risk for scrub typhus, other rickettsial diseases, and leptospirosis to military and US government 

personnel, and for informing regional and combatant 

commanders for timely diagnosis, treatment and prevention including focused implementation of personal 

protective measures and vector control in training areas. Continuous surveillance on the ecology, entomology, and epidemiology of these public health important 

vector-borne diseases is warranted to provide a more 

accurate risk assessment and determine “hot spots” for 

these diseases to assist site selection and planning for 

future CBG training exercises.

Acknowledgments

The authors thank Sirima Wongwairot, Nutthanun 

Auysawasdi, Chawin Limsuwan, Taweesak Monkanna, 

Opas Thachin, Kasima Wasuworawong, and the staff of 

USAMD-AFRIMS and the Research Division of Royal 

Thai Army-AFRIMS for their assistance in the field IFA 

assay. This research was supported by the Global Emerging Infections Surveillance and Response System, a division of the Armed Forces Health Surveillance Branch 

of the Department of Entomology, USAMD-AFRIMS 

under proposal ID 17_AF_1.5.2 for fiscal year 2017 and 

P0081_18_AF_05 for fiscal year 2018.

SURVEILLANCE FOR SCRUB TYPHUS, RICKETTSIAL DISEASES, AND LEPTOSPIROSIS IN US

AND MULTINATIONAL MILITARY TRAINING EXERCISE COBRA GOLD SITES IN THAILAND
January – June 2018 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

References

1. Lerdthusnee K, Nigro J, Monkanna T, et al. Surveys of 

rodent-borne disease in Thailand with a focus on scrub 

typhus assessment. Integr Zool. 2008;3(4):267-273.

2. Wongkoon S, Jaroensutasinee M, Jaroensutasinee K. 

Distribution, seasonal variation & dengue transmission prediction in Sisaket, Thailand. Indian J Med Res. 

2013;138(3):347-353.

3. Jones KE, Patel NG, Levy MA, et al. Global 

trends in emerging infectious diseases. Nature. 

2008;451(7181):990-993.

4. Xu G, Walker DH, Jupiter D, Melby PC, Arcari CM. 

A review of the global epidemiology of scrub typhus. 

PLoS Negl Trop Dis. 2017;11(11):e0006062.

5. Kelly DJ, Richards AL, Temenak J, Strickman D, 

Dasch GA. The past and present threat of rickettsial 

diseases to military medicine and international public 

health. Clin Infect Dis. 2002;34(suppl 4):S145-S169.

6. Watt G, Parola P. Scrub typhus and tropical rickettsioses. Curr Opin Infect Dis. 2003;16(5):429-436.

7. Watt G, Chouriyagune C, Ruangweerayud R, et al. 

Scrub typhus infections poorly responsive to antibiotics in northern Thailand. Lancet. 1996;348(9020):86-89.

8. Bitam I, Dittmar K, Parola P, Whiting MF, Raoult 

D. Fleas and flea-borne diseases. Int J Infect Dis. 

2010;14(8):e667-e676.

9. Strickman D, Tanskul P, Eamsila C, Kelly DJ. Prevalence of antibodies to rickettsiae in the human population of suburban Bangkok. Am J Trop Med Hyg. 

1994;51(2):149-153.

10. Jiang J, Sangkasuwan V, Lerdthusnee K, et al. Human 

infection with Rickettsia honei, Thailand. Emerg Infect 

Dis. 2005;11(9):1473-1475.

11. Takada N, Fujita H, Yano Y, Huang WH, Khamboonruang C. Serosurveys of spotted fever and murine typhus in local residents of Taiwan and Thailand compared with Japan. Southeast Asian J Trop Med Public 

Health. 1993;24(2):354-356.

12. Bharti AR, Nally JE, Ricaldi JN, et al. Leptospirosis: 

a zoonotic disease of global importance. Lancet Infect 

Dis. 2003;3(12):757-771.

13. Faine S Adler B, Bolin C, Perolat P, eds. Leptospira 

and Leptospirosis. Armadale, Australia: MediSci. 1999.

14. Ko AI, Goarant C, Picardeau M. Leptospira: the dawn 

of the molecular genetics era for an emerging zoonotic 

pathogen. Nat Revs Microbiol. 2009;7(10):736-747.

15. Dierks J, Servies T, Do T. A study on the leptospirosis 

outbreakamong US Marine Trainees in Okinawa, Japan. Mil Med. 2018;183(3-4):e208-e212.

16. Tangkanakul W, Smits HL, Jatanasen S, Ashford 

DA. Leptospirosis: an emerging health problem in 

Thailand. Southeast Asian J Trop Med Public Health. 

2005;36(2):281-288.

17. Sejvar J, Tangkanakul W, Ratanasang P, et al. An outbreak of leptospirosis, Thailand--the importance of the 

laboratory. Southeast Asian J Trop Med Public Health. 

2005;36(2):289-295.

18. Nadchatram M, Dohany AL. A Pictorial Key to the 

Subfamilies, Genera and Subgenera of Southeast Asian 

Chiggers (Acari, Prostigmata, Trombiculidae). Kuala 

Lumpur, Malaysia: Institute for Medical Research; 

1974.

19. Rodkvamtook W, Ruang-Areerate T, Gaywee J, et al. 

Isolation and characterization of Orientia tsutsugamushi from rodents captured following a scrub typhus 

outbreak at a military training base, Bothong district, 

Chonburi province, central Thailand. Am J Trop Med 

Hyg. 2011;84(4):599-607.

20. Jiang J, Chan TC, Temenak JJ, Dasch GA, Ching WM, 

Richards AL. Development of a quantitative real-time 

polymerase chain reaction assay specific for Orientia 

tsutsugamushi. Am J Trop Med Hyg. 2004;70(4):351-356.

21. Wright CL, Nadolny RM, Jiang J, et al. Rickettsia 

parkeri in gulf coast ticks, southeastern Virginia, USA. 

Emerg Infect Dis. 2011;17(5):896-898.

22. McAvin JC, Kengluecha A, Takhampunya R, Richardson JH. A field-expedient method for detection of leptospirosis causative agents in rodents. US Army Med 

Dep J. July-September 2012:22-28.

23. Smythe LD, Smith IL, Smith GA, et al. A quantitative 

PCR (TaqMan) assay for pathogenic Leptospira spp. 

BMC Infect Dis. 2002 Jul 08;2:13.

24. Boonsilp S, Thaipadungpanit J, Amornchai P, et al. 

Molecular detection and speciation of pathogenic Leptospira spp. in blood from patients with culture-negative leptospirosis. BMC Infect Dis. 2011 Dec 13;11:338.

25. Division of Communicable Diseases. Plague Manual: 

Epidemiology, Distribution, Surveillance and Control. Geneva, Switzerland: World Health Organization; 

1999.

26. WHO. Human Leptospirosis: Guidance for Diagnosis, Surveillance, and Control. Geneva, Switzerland: 

World Health Organization; 2003.

27. Healy GR, Ruebush TK 2nd. Morphology of Babesia microti in human blood smears. Am J Clin Pathol. 

1980;73(1):107-109.

28. Coleman RE, Monkanna T, Linthicum KJ, et al. Occurrence of Orientia tsutsugamushi in small mammals 

from Thailand. Am J Trop Med Hyg. 2003;69(5):519-524.

29. Rodkvamtook W, Gaywee J, Kanjanavanit S, et al. 

Scrub typhus outbreak, northern Thailand, 2006-2007. 

Emerg Infect Dis. 2013;19(5):774-777.

Authors

The following authors are with the Department of Entomology, USAMD-AFRIMS, Bangkok, Thailand:

Dr Linsuwanon is the head, Scrub Typhus Section;

Dr Krairojananan is the head, Leptospirosis Section;

Mr Leepitakrat is the head, Mite and Rodent Section;

MAJ Davidson is the Chief, Department of Entomology;

MAJ Wanja is the Deputy Chief, Department of Entomology.

COL Rodkvamtook is the Deputy Chief, Research Division, 

Royal Thai Army-AFRIMS, Bangkok, Thailand.
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

Throughout history, epidemics of infectious diseases 

have had tremendous effects on the fighting strength 

of armies, causing delay and cancellation of military 

operations. From its founding, the US military has employed preventive medicine for force protection in order 

to conserve its fighting strength. Prior to World War I, 

the ratio of deaths due to disease versus battle injury 

was approximately 10:1, which decreased to 1:1 during 

World War I and 0.01:1 during the Gulf War.1 During the 

American Revolution, the Continental Army was greatly 

affected by typhus and smallpox. Dr Bodo Otto, Brigade 

Surgeon for General Washington, and ancestor of this 

paper’s authors, was the first to inoculate the Continental Army against smallpox.2

 Today, the mission of the 

US Army Public Health Center is to “Enhance Army 

readiness by identifying and assessing current and 

emerging health threats, developing and communicating public health solutions, and assuring the quality and 

effectiveness of the Army’s Public Health Enterprise.”3

Most emerging and reemerging disease threats to humans are zoonotic.4

 In 2014, zoonotic diseases comprised 7.4% of all reportable medical events, excluding 

sexually transmitted diseases, with tick-borne diseases 

being the most frequently reported.5 Mosquito-borne 

diseases, such as West Nile virus (WNV) and Zika virus, also pose a risk to military personnel and their families. For example, in 2015, 6% of Culex species pools 

collected from military installations in the United States 

were positive for WNV.6 Influenza and other zoonotic 

diseases continue to pose a risk to military personnel 

and their families, particularly where crowding or other 

unique stressors exist.7

Biological agents are a threat to military installations 

through use of weapons, surreptitious attack, or criminal release. Bioagent databases have been developed for 

rapid detection and identification of the biological agents 

during natural outbreaks and criminal/terrorist release, 

for example, Select Agents List in the United States and 

the Biological Agents Database in Poland. The accuracy 

and applicability of these lists/databases can vary depending on whether the application is military or civilian.8,9 The Hazard Prediction and Assessment Capability 

(HPAC) is used by the Department of Defense for training, planning, and tactical operations, and has satisfactorily met the criteria for dispersion modeling.10 The Bioagent Transport and Environmental Modeling System 

(BioTEMS) has been used to supplement HPAC to provide greater resolution should a weapon of mass destruction be released, and to fill the gap in HPAC criminal release as well as low volume/low altitude/surreptitious release. For example, vertical resolution can be improved 

in HPAC for heights of 10 m or less.11 In a collaborative 

study between the Defense Threat Reduction Agency 

(DTRA); the Consequence Management Unit, 415th 

Chemical Brigade; and the South Carolina Department 

of Health and Environmental Control, BioTEMS accurately predicted environmental survival and transport 

of a simulated release, whereas HPAC underestimated 

environmental survival and transport by 300%.*

The BioTEMS consists of a set of algorithms and models 

that have been used as a standalone system for risk assessments of bioagents, infectious diseases, vectors, and 

to supplement HPAC. The BioTEMS has been used to 

produce bioagent risk assessments for an overseas naval installation, Fort Detrick, national and international 

training exercises, national political conventions, and to 

assist the DTRA during a presidential inauguration in 

analyzing risk of selected agents and to optimize placement of Biological Integrated Detection Systems (BIDS) 

units. Risk assessments have also been developed with 

BioTEMS for several infectious and zoonotic diseases 

and to distribution of vectors, eg, arboviruses, Ebola, 

Rocky Mountain spotted fever, avian influenza, plague, 

Shigella, tularemia, mosquitoes, ticks, and mites. It has 

been used to produce risk assessments in several countries, including Bangladesh, Brazil, Cameroon, China, 

India, Iran, Libya, Georgia, Turkey, United Arab Emirates, Sierra Leone, and several cities in the United States. 

Risk Assessment Mapping for Zoonoses,

 Bioagent Pathogens, and Vectors at

 Edgewood Area, Aberdeen Proving Ground,

 Maryland

Thomas M. Kollars, Jr, PhD

Jason W. Kollars

*Limited access documents not available to the general public.
January – June 2018 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

Recently, BioTEMS was used to identify free-living 

pathogenic amoebae as the most likely cryptic reservoirs for Ebola virus (P>93%), identify high risk areas 

within 15 m, and to determine where to place ProVector devices with antimicrobials.12 The BioTEMS Ebola 

model and ProVector anti-Ebola formulation have the 

potential to reduce the risk of Ebola virus for deployed 

military forces.

Military personnel and their families can be at risk from 

vector-borne diseases and release of bioagents on military installations. For example, high risk areas for Yersinia pestis, the etiologic agent of bubonic plague, were 

identified at the US Air Force Academy installation, 

with some high risk sites adjacent to family housing on 

the base.13 Lyme borreliosis poses a significant risk to 

military personnel and their families where competent 

vectors are present. In 2015, over 1,000 ticks tested by 

the Army Public Health Command were positive for B. 

burgdorferi, 21% of I. scapularis ticks were positive.14

The Edgewood Area, Aberdeen Proving Ground (APG), 

Harford County, Maryland, is at risk for several zoonotic/vector borne diseases and the release of a bioagent. Through routine sampling of mosquito populations, 

the US Army Kirk Medical Clinic Preventive Medicine 

unit at APG detected WNV positive mosquitoes and followed up with mosquito control in 2014.

15 Over 1,100 

cases of Lyme disease were confirmed in Harford County from 2000 to 2015.16 Preliminary modeling of I. scapularis populations was accurate to within one square 

meter at the Edgewood Area.17 Because of the potential 

risk at the Edgewood Area from zoonotic pathogens and 

bioagents, BioTEMS risk assessments were conducted 

for H5N1 avian influenza, eastern equine encephalitis 

(EEE), WNV, Zika virus (ZIKAV), unnamed Bioagent 

X, the lone star tick (Amblyomma americanum), and the 

black-legged tick (I. scapularis).

Methods and Results

There are approximately 1,000 people living on Edgewood Area, with nearly 15,000 people working in both 

areas of APG. Nearly 20,000 retirees and their families use the recreational facilities at Edgewood.18 ArcGIS geospatial analysis software, Statistica statistical software, and the BioTEMS were used to analyze 

geographic information and conduct data analysis. The 

BioTEMS uses up to several hundred abiotic and biotic 

factors to produce risk and vulnerability assessments 

for biological agents and infectious diseases. Examples 

of biotic and abiotic factors include pathogen strain, 

vector/host relationship, vectorial capacity, host/vector 

physiology, colonization ability, population dynamics 

of hosts and vectors, soil, and weather conditions, such 

as wind, temperature, precipitation, and shade. The 

BioTEMS analysis includes mechanistic and empirical methods, for example, artificial intelligence, fuzzy 

logic, niche analysis, random forests, general additive 

regression, and parametric and nonparametric statistics. The BioTEMS is capable of identifying direction 

of movement of pathogens/vectors, areas for mitigation 

and management, time for optimal medical countermeasures, and sites for environmental sampling and optimization for placement of BIDS. The BioTEMS TIGER 

model was used to model ZIKAV. The TIGER acronym 

represents the 6 stages in the invasion of a mosquito species or haplotype:

• Transport - identifies the point of origin, method, 

and rate of transport to a locality.

• Introduction - the point or area of initial introduction/immigration of species or haplotypes and preliminary spread into a locality.

• Gap - determines the area where vector/pathogen 

infiltrates and initially spreads once it has gained 

a foothold.

• Escalade - incorporates abiotic and biotic factors as 

possible resistance to invasion.

• Residence and recruitment - incorporates factors and areas where vector/pathogen adds to genetic diversity or becomes endemic and recruits 

conspecifics/haplotypes.

BioTEMS risk assessment maps (RAMs) were developed for Edgewood for the following infectious diseases 

and vectors: H5N1 avian influenza, EEE, WNV, ZIKAV, 

unnamed Bioagent X, lone star tick (Amblyomma americanum), and black-legged tick (Ixodes scapularis). Both 

HPAC and BioTEMS were used to model the simulated 

release of the unnamed bioagent. The BioTEMS risk assessment, based upon abiotic and biotic factors, is given 

in percentage, and output is visualized in Google Earth.

The BioTEMS risk assessment identified ticks and tickborne illnesses as the most significant threat to personnel at the Edgewood Area, with I. scapularis posing an 

18% risk and A. americanum a 14% risk, for a combined 

risk assessment of 32%. The risk assessment of mosquito-borne diseases at the Edgewood Area ranked WNV 

highest at 1.1% and EEE at 0.2%. The expected direction 

of movement of ZIKAV introduced through the airport 

is 349°. The BioTEMS risk assessment for H5N1 Avian 

influenza was 0.3%. The risk assessment for environmental transport for Bioagent X released into the Edgewood Area from 3 points was 4.2%. Optimal sites were 

identified for conducting surveillance and control for tick 

and mosquito-borne pathogens and H5N1 avian influenza. The area of Bioagent X deposition was identified 

by HPAC which estimated its time to degradation at 24 
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

8 km

Figure 4. BioTEMS risk assessment map: eastern equine encephalitis virus at the Edgewood Area. Red polygons indicate 

optimal sites for surveillance and integrated vector management.

N

5 km

Figure 3. BioTEMS risk assessment map: West Nile virus at the 

Edgewood Area. Red polygons indicate optimal sites for surveillance and integrated vector management.

N

8 km

Figure 2. BioTEMS risk assessment map: lone star tick (Amblyomma americanum) at the Edgewood Area. Red polygons indicate optimal sites for surveillance.

N

Figure 1. BioTEMS risk assessment map: black-legged tick (Ixodes scapularis) at the Edgewood Area. Red polygons indicate 

optimal sites for surveillance.

8 km

N

RISK ASSESSMENT MAPPING FOR ZOONOSES, BIOAGENT PATHOGENS, AND VECTORS

AT EDGEWOOD AREA, ABERDEEN PROVING GROUND, MARYLAND
January – June 2018 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

hours. The BioTEMS predicted the bioagent would last 

a minimum of 30 days in the environment and spread 

beyond the initial area of deposition. It also predicted 

the bioagent could replicate over 10,000 times the initial 

release amount, resulting in the environmental transport 

of Bioagent X beyond the initial area of deposition. The 

BioTEMS identified optimal sites for surveillance and 

sampling for the vectors and pathogens (Figures 1-7).

Comment

Tick-borne Pathogens

The following is a summary of several tick-borne pathogens detected in I. scapularis and A. americanum from 

North America as reported by the Centers for Disease 

Control and Prevention in 201819:

Anaplasmosis is transmitted to humans by tick bites primarily from the blacklegged tick (I. scapularis) in the 

northeastern and upper midwestern United States. Babesia microti, the etiologic agent of babesiosis in the United States is transmitted by the blacklegged tick (I. scapularis) and is found primarily in the northeast and upper 

midwest. Borrelia mayonii, which also causes Lyme 

borreliosis, has been found in I. scapularis in the upper 

midwestern United States. Borrelia miyamotoi, transmitted by I. scapularis, is suspected of causing illness 

in the United States. Bourbon virus has been identified 

in a few patients in the midwest and southern United 

States and has been detected in A. americanum; its distribution in the United States is unknown. Ehrlichiosis 

is transmitted by A. americanum and Heartland virus 

found in the midwest and the south is most likely transmitted by A. americanum. Lyme disease is transmitted 

by I. scapularis in the eastern and upper midwestern 

United States. Lyme borreliosis, transmitted by Ixodes

species, is the most commonly reported vector-borne 

disease in the United States with about 30,000 cases reported annually, with case reports in Maryland ranking 

consistently among the top 10%.15 Southern-tick associated rash illness is transmitted by A. americanum. Tularemia is transmitted by the Dermacentor variabilis, D. 

andersoni, and A. americanum. Powassan disease, most 

cases of which have been reported from the northeast 

and Great Lakes region, is transmitted by I. scapularis

and the groundhog tick (I. cookei). Rocky Mountain 

spotted fever (RMSF) is transmitted by (D. variabilis), 8 km

N

Figure 5. BioTEMS risk assessment map: Zika virus if introduced 

through the airport located at Edgewood Area. Red polygon 

indicates high risk area for immediate integrated vector management and surveillance to reduce likelihood of introduction, 

yellow polygon indicates surveillance areas and control should 

Zika virus be detected, purple arrow indicates most likely direction of spread of Zika virus in mosquito population.

8 km

N

Figure 6. BioTEMS risk assessment map: H5N1 avian influenza 

at the Edgewood Area. Red polygons indicate optimal sites for 

environmental testing and surveillance in waterfowl.
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

D. andersoni, and the brown dog tick Rhipicephalus 

sanguineous. Spotted-fever group Rickettsia have been 

isolated from A. americanum, a species that is capable 

of transmitting RMSF in the lab, although its role in 

RMSF transmission is not well understood.20 Also, an 

emerging illness, delayed anaphylaxis to red meat, is associated with A. americanum.

21 In the November 2017 

Vector-borne Disease Report,22 the Army Public Health 

Center reported 71 cases of Lyme disease in active duty 

Army beneficiaries compared to 111 cases during the 

same time period in 2016. Of 270 ticks tested by the 

DoD Human Tick Testing Kit Program for B. burgdorferi, 25% were positive; 7 of these ticks also tested positive for Babesia microti and 9 tested positive for Anaplasma phagocytophilum.

22 Evidence from other studies indicate high risk from these 2 species in Maryland. 

Twenty-six percent of I. scapularis in Carroll, Harford, 

and Howard counties tested positive for B. burgdorferi, 

and E. chaffeensis, and B. lonestari have been isolated 

from A. americanum at Aberdeen Proving Ground.23-25

West Nile Virus

West Nile virus, family Flaviviridae, was first identified in the United States in 1999.26 West Nile virus is 

an arbovirus, principally transmitted by mosquitoes 

in the genus Culex, with passerine birds serving as the 

natural reservoir. Transmission to humans, horses, and 

other mammal species occurs through a bridge mosquito species, such as Cx. salinarius, Cx. pipiens, and Cx. 

restuans, the primary vectors in the northeastern United States.27 Over the next decade WNV spread across 

North America and is now endemic. The first case of 

WNV in Maryland was reported in 2001, and from 2001 

and 2016 there were 334 reported cases.28 In addition to 

Culex species, Ochlerotatus japonicas, an invasive species in Maryland, is capable of transmitting WNV.29 In 

addition to Culex species, monitoring for and testing of 

Oc. japonicas and Ae. albopictus should be conducted 

at the Edgewood Area. The BioTEMS predicted the risk 

of EEE to be low at the Edgewood Area. From 2007-

2016 there were no reported cases of EEE in humans in 

Maryland; however, there have been EEE cases reported in horses and in mosquitoes, for example, Culiseta 

melanura and Culex salinarius.30,31 The BioTEMS has 

been used to predict EEE in other states and is capable 

of predicting the risk of EEE geographically to within 

30 m.32 Surveillance of EEE at Edgewood Area should 

be conducted when testing for arboviruses in other mosquito species, such as WNV C. pipiens, or when EEE is 

reported in other parts of Maryland.

Zika Virus

Zika virus was first isolated in 1947 from a rhesus macaque monkey and in 1948 from Aedes africanus from 

cages placed on a tower in the Zika Forest near Lake 

Victoria, Uganda.33 The Zika Forest is a tropical forest, 

now surrounded by pastures and with small hamlets 

where research continues on vector-borne diseases, even 

using the same tower (Figure 8). However, ZIKAV is 

no longer restricted to transmission of Ae. africanus in 

the tropical forest ecosystem in Africa. Several Aedes

species have now been implicated in transmission of ZIKAV to humans in urban habitats where the poor are 

particularly at risk and the disease is spreading globally.34 Establishing patterns of invasion of vectors and vector-borne diseases into new geographic areas is critical 

for protecting the public health and naïve human populations. For example, the predictive map developed for Ae. 

aegypti and Ae. albopictus globally has a resolution of 5 

km.35 The principle factor responsible for the introduction of disease vectors is air and ship transport.36,37 Edgewood Area has a small airport, and aircraft travelling 

from areas within the North America or other regions 

could introduce infected Aedes species infected with 

ZIKAV. Once introduced into an area, the invasive mosquito species can spread rapidly across regions through 

ground transport.38,39 In addition to the import of infected mosquitoes, introduction of ZIKAV into the a new 

4 km

Figure 7. BioTEMS risk assessment map: Bioagent X if released 

at Edgewood Area. Red polygons indicate optimal sites for surveillance and environmental transport and a yellow ellipse indicates HPAC deposition model of Bioagent X.

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RISK ASSESSMENT MAPPING FOR ZOONOSES, BIOAGENT PATHOGENS, AND VECTORS

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January – June 2018 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

geographic area can occur when local mosquitoes bite infected travelers and become infected 

or when people become infected through sex or 

contaminated blood.40,41 The BioTEMS TIGER 

model has been used and validated to identify 

areas at high risk for invasive mosquito species 

and mosquito-borne diseases, and identify surveillance and integrated vector management in 

several countries. It is able to predict direction 

of movement to within 4° or less.42 From 2016 

through May 2017, nearly 4,000 cases with 

laboratory evidence of recent possible Zika infection were reported in the US territories.43 As 

frequent travelers, military personnel and their 

families are at risk for arbovirus infection and 

transporting infected mosquitoes or introducing infection to local mosquitoes upon return. 

Pre-travel counseling should be provided to 

travelers to ZIKAV-outbreak regions.44

H5N1 Avian Influenza

Although BioTEMS identified the risk of H5N1 

avian influenza as low at the Edgewood Area. 

There are several sites where the virus could be 

maintained and serve as a source of an outbreak 

should it be introduced. Environmental transmission can provide a mechanism for the persistence mechanism of avian influenza even where 

epidemics cannot be sustained.45 In a study of 

avian influenza in Maryland, the risk to backyard poultry was positively associated with exposure to waterfowl and location, particularly in 

northern Maryland.46 Edgewood Area lies on a peninsula 

and is part of the eastern flyway for waterfowl. The possibility of introduction of avian influenza through infected 

waterfowl should be of concern. Environmental samples 

and waterfowl should be tested for avian influenza virus 

at the Edgewood Area. Because of the large area suitable 

for waterfowl, identifying areas at highest risk for the 

introduction and survival of H5N1 avian influenza using 

BioTEMS can optimize surveillance efforts.

Bioagent X

The threat of biological warfare and bioterrorism is significant. Small quantities of lethal biological agents can 

be easily concealed, transported, and released into susceptible populations. Military and civilian populations 

are vulnerable to biological weapons and it is difficult to 

provide adequate protection.47 The BioTEMS was used 

in conjunction with HPAC to model a computer simulated release of Bioagent X, enhancing the capability of 

HPAC to accurately predict the environmental survival 

and transport of the bioagent. For example, HPAC predicted Bioagent X would survive 24 hours and would be 

restricted in area, whereas BioTEMS predicted the bioagent would survive a minimum of 30 days and would 

spread outside the affected zone identified using HPAC. 

The BioTEMS can also be used to identify where environmental samples can be collected for both measuring 

naturally occurring strains of bioagents and sampling 

post-release. This capability can assist in consequence 

management and providing forensic information for law 

enforcement.

Conclusion

Identifying the risk of vector-borne diseases and implementing integrated vector management at the Edgewood 

Area is of significant public health value. The BioTEMS 

RAMs can be used to assist public health officials identify and mitigate the risk of zoonotic/infectious diseases 

and bioagents. Once the risk of an infectious disease 

is determined, medical and preventive measures can 

be taken to reduce the threat to military personnel and 

their families. For example, several high risk sites were 

adjacent to base family housing located in the northeast 

portion. Particular effort should be conducted in vector 

Figure 8. Research tower in the Zika forest and surrounding landscape 

near Lake Victoria, Uganda. A mosquito vector for the Zika virus, Aedes 

africanus, was first identified in this location in 1948.
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

management in and around this family housing area, 

including education, surveillance, testing, vegetation 

management, and, if needed, application of pesticides. 

To reduce time and cost of surveillance, sites for surveillance that overlap can be chosen. Although not utilized in the current project, the BioTEMS can be used 

to identify where biological sensors should be placed at 

Edgewood to optimize detection and mitigate environmental survival. Additional BioTEMS RAMs are being 

developed for other military installations and cities in 

the United States and abroad.

References

1. Smallman-Raynor MR, Cliff AD. Impact of infectious diseases on war. Infect Dis Clin North Am. 

2004;18:341-368.

2. Gibson J. Dr. Bodo Otto and the Medical Background of the American Revolution. Baltimore, 

MD: Charles C. Thomas; 1937.

3. US Army Public Health Center. Mission [internet]. Available at: https://www.army.mil/info/organization/unitsandcommands/commandstructure/

usaphc#org-about. Accessed February 26, 2018.

4. Dorjee S, Poljak Z, Revie CW, Bridgland J, McNab 

B, Leger E, Sanchez J. a review of simulation modelling approaches used for the spread of zoonotic 

influenza viruses. animal and human populations. 

Zoonoses Public Health. 2013;60(6):383-411.

5. US Army Public Health Center. Zoonotic Disease: 

Vol 5, 1 January-31 December 2014:2. Available 

at: https://phc.amedd.army.mil/Periodical%20Li

brary/ZoonoticDiseaseSummary_Vol5_2015.pdf. 

Accessed June 7, 2018.

6. US Army Public Health Center. Zoonotic Disease: 

Vol 6, 1 January-31 December 2015:2. Available at: 

https://phc.amedd.army.mil/Periodical%20Library

/ZDR_CY2015_v2.pdf. Accessed June 7, 2018.

7. Gray GC, Callahan JD, Hawksworth AW, Fisher 

CA, Gaydos JC. Respiratory diseases among U.S. 

military personnel: countering emerging threats. 

Emerg Infect Dis. 1999;5:379-385.

8. Niemcewicz M, Kocik J, Bielecka A, Wierciski 

M. Biological agents database in the armed forces. 

Arch Immunol Ther Exp (Warsz). 2014;62:357-361.

9. Cieslak TJ, Kortepeter MG, Wojtyk RJ, JansenHJ, 

Reyes RA, Smith JO. Beyond the dirty dozen: a 

proposed methodology for assessing future bioweapon threats. Mil Med. 2018;183:E59-E65.

10. Chang JC, Hanna SR Boybeyi Z, Franzese P. Use 

of Salt Lake City URBAN 2000 Field Data to evaluate the Urban Hazard Prediction Assessment Capability (HPAC) Dispersion Model. J App Meteorol. 2005;44:495-501. Available at: https://journals.

ametsoc.org/doi/full/10.1175/JAM2205.1. Accessed 

June 6, 2018.

11. Hanna SR, Reen B, Hendrick E, et al. Comparison of observed, MM5 and WRF-NMM modelsimulated, and HPAC-assumed boundary-layer 

meteorological variables for 3 days during the 

IHOP field experiment. Boundary-Layer Meteorol. 2010;134(2):285-306. Available at: https://link.

springer.com/article/10.1007/s10546-009-9446-7. 

Accessed June 6, 2018.

12. Kollars TM Jr, Senessie C, Sunderland G. Identifying and modeling the cryptic reservoirs of 

Ebola virus using artificial intelligence. Afr J Clin 

Exp Microbiol. 2018;19(3):229-237. Available 

at: https://www.ajol.info/index.php/ajcem/article/

view/172666/162067. Accessed June 29, 2018.

13. Kollars TM, Kollars E, Kollars PG. United States 

Air Force Academy: identifying areas at risk for the 

persistence of plague using the Bioagent Transport 

and Environmental Modeling System (BioTEMS). 

J Microbiol Modern Techniques. 2017;3(1):1-3. 

Available at: http://www.annexpublishers.co/arti

cles/JMC/3101-United-States-Air-Force-AcademyIdentifying-Areas-at-Risk-for-the-Persistence-ofPlague-using-the-Bioagent-Transport-and-Envi

ronmental-Modeling-System-BioTEMS.pdf. Accessed June 7, 2018.

14. US Army Public Health Center. Army VectorBorne Disease Report; 9 September 2015. Available at: https://phc.amedd.army.mil/Periodical%20

Library/Vector-borneDisease9SEP2015.pdf. Accessed June 7, 2018.

15. Rominiecki A. APG continues mosquito testing for 

West Nile virus. September 11, 2014. APG News. 

Aberdeen Proving Ground, Maryland.

16. Centers for Disease Control and Prevention. Lyme 

Disease [internet]. 2018. Available at: https://www.

cdc.gov/lyme/index.html. Accessed June 7, 2018.

17. Kollars TM. Habitat modeling of the black-legged 

tick: reducing the risk of lyme disease at a military installation in the United States. Curr Trends 

Bioeng Biomed Sci. 2018;12(2):1-2. Available at: 

https://juniperpublishers.com/ctbeb/pdf/CTBEB.

MS.ID.555834.pdf. Accessed June 7, 2018.

18. Agency for Toxic Substances and Disease Registry. Public Health Assessment for US Army Aberdeen Proving Ground, Edgewood Area Aberdeen, 

Harford County, Maryland. US Department of 

Health and Human Services. May 20, 2008. Available at: https://www.atsdr.cdc.gov/hac/pha/aber

deenprovingground/aberdeenprovinggroundfinal

pha052008.pdf. Accessed June 7, 2018.

19. Centers for Disease Control and Prevention. Tickborne Diseases of the United States [internet]. 2018. 

Available at: https://www.cdc.gov/ticks/diseases/

index.html. Accessed June 7, 2018.

20. Parker RR, Philip CB, Jellison WL. Rocky Mountain Spotted Fever: potentialities of tick transmission in relation to geographical occurrence in the 

United States. Am J Trop Med Hyg. 1933;13:341-378.

RISK ASSESSMENT MAPPING FOR ZOONOSES, BIOAGENT PATHOGENS, AND VECTORS

AT EDGEWOOD AREA, ABERDEEN PROVING GROUND, MARYLAND
January – June 2018 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

21. Commins SP, Platts-Mills TAE. Delayed anaphylaxis to red meat in patients with IgE Specific for 

Galactose alpha-1,3-Galactose (alpha-gal). Curr 

Allergy Asthma Rep. 2013;13(1):72-77. Available 

at: https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC3545071/. Accessed June 7, 2018.

22. US Army Public Health Center (2017). Army 

Vector Borne Disease Report; 20 November 2017. 

Available at: https://phc.amedd.army.mil/Periodi

cal%20Library/Vector-borneDisease20NOV2017.

pdf. Accessed June 5, 2018.

23. Feldman KA, Connally NP, Hojgaard A, Jones EH, 

White JL, Hinckley AF. Abundance and infection 

rates of Ixodes scapularis nymphs collected from 

residential properties in Lyme disease-endemic 

areas of Connecticut, Maryland, and New York. J 

Vector Ecol. 2015;40:198-201.

24. Stromdahl EY, Randolph MP, O’Brien JJ, Gutierrez AG. Ehrlichia chaffeensis (Rickettsiales: Ehrlichieae) infection in Amblyomma americanum 

(Acari: Ixodidae) at Aberdeen Proving Ground, 

Maryland. J Med Entomol. 2000;37:349-356.

25. Stromdahl EY, Williamson PC, Kollars TM Jr, 

Evans SR, Barry RK, Vince MA, Dobbs NA. Evidence of Borrelia lonestari DNA in Amblyomma 

americanum (Acari: Ixodidae) removed from humans. J Clin Microbiol. 2003;41:5557-5562.

26. Centers for Disease Control and Prevention. 

Outbreak of West Nile viral encephalitis--New 

York, 1999. MMWR Morb Mortal Wkly Rep. 

1999;48(38):845-849.

27. Molaei G, Andreadis TG, Armstrong PM, Anderson JF, Vossbrinck CR. Host feeding patterns of 

Culex mosquitoes and West Nile virus transmission, northeastern United States. Emerg Infect Dis. 

2006;12:468-474.

28. Centers for Disease Control and Prevention. West 

Nile virus disease cases reported to CDC by state 

of residence, 1999-2016 [internet]. 2017. Available 

at: https://www.cdc.gov/westnile/resources/pdfs/

data/West-Nile-virus-disease-cases-reported-toCDC-by-state_1999-2016_09292017.pdf. Accessed 

June 7, 2018.

29. Sardelis MR, Turrell MJ. Ochlerotatus j. japonicas 

in Frederick County Maryland: discovery, distribution, and vector competence for West Nile virus. J 

Am Mosq Control Assoc. 2001;17(2):137-141.

30. Maryland Department of Health (2013). Eastern 

Equine Encephalitis Confirmed in Maryland Horse 

[internet]. August 16, 2013. Available at: https://

health.maryland.gov/newsroom/Pages/EasternEquine-Encephalitis-Confirmed-in-MarylandHorse.aspx. Accessed June 7, 2018.

31. Muul I, Johnson BK, Harrison BA. Ecological 

Studies of Culiseta melanura (Diptera: Culicidae) 

in relation to eastern and western equine encephalomyelitis viruses on the eastern shore of Maryland. 

J Med Entomol. 1975;11:739-748.

32. Kollars TM. Identification of arbovirus surveillance sites at maritime and airports to reduce the 

risk of export of eastern equine encephalitis and 

import of Zika viruses into coastal Georgia. IOSR 

J Dent Med Sci. 2016;15:87-90.

33. Dick GW, Kitchen SF, Haddow AJ. Zika virus. I. 

Isolations and serological specificity. Trans R Soc 

Trop Med Hyg. 1952;46:509-520.

34. Atif M, Azeem M, Sarwar MR, Bashir A. Zika virus disease: a current review of the literature. Infection. 2016;44(6):695-705.

35. Kraemer MU, Sinka ME, Duda KA, et al. The global distribution of the arbovirus vectors Aedes aegypti and Ae albopictus. ELife. 2015;4. DOI10.7554/

eLife.08347.

36. Tatem AJ, Hay SI, Rogers DJ. Global traffic and 

disease vector dispersal. Proc Natl Acad Sci U S A. 

2006;103(16):6242-6247.

37. Meyerson L, Mooney H. Invasive alien species in an era of globalization. Front Ecol Env.

2007;5:199-208.

38. Lindsay MD, Jardine A, Giele C, et al. Investigation of the first case of dengue virus infection 

acquired in Western Australia in seven decades: 

evidence of importation of infected mosquitoes?. 

PLoS Negl Trop Dis. 2015; 9(9): e0004114.

39. Medlock JM, Hansford KM, Schaffner F, Versteirt 

V, Hendrickx G, Zeller H, Van Bortel W. A review 

of the invasive mosquitoes in Europe: ecology, public health risks, and control options. Vector Borne 

Zoonotic Dis. 2012;12(6):435-447.

40. Hills SL, Russell K, Hennessey M, Williams C, 

Oster AM, Fischer M, Mead P. Transmission of 

Zika virus through sexual contact with travelers 

to areas of ongoing transmission-continental United States, 2016. MMWR Morb Mortal Wkly Rep.

2016;65(8):215-216.

41. Musso D, Stramer SL. Zika virus: a new challenge 

for blood transfusion. Lancet. 2016;387:1993-1994

42. Kollars TM. Potential for the invasive species Aedes albopictus and arboviral transmission through 

the Chabahar Port in Iran. Iranian J Med Sci. 

2017;S.1.

43. Centers for Disease Control and Prevention. Pregnancy outcomes after maternal Zika virus infection during pregnancy - U.S. territories, January 

1, 2016-April 25, 2017. MMWR Morb Mortal Wkly 

Rep. 2017;66(23);615-621.
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

44. Lindholm DA, Myers T, Widjaja S, et al. Travelers 

are at risk for arbovirus infection; pretravel counseling should be provided to travelers to ZIKV-outbreak regions. Am J Trop Med Hyg. 2017;96:903-912.

45. Breban R, Drake JM, Stallknecht DE, Rohani P. 

The role of environmental transmission in recurrent avian influenza epidemics. PLoS Comput Biol. 

2009;5(4):e1000346.

46. Madsen JM, Zimmermann NG, Timmons J, 

Tablante NL. Avian influenza seroprevalence and 

biosecurity risk factors in Maryland backyard 

pou...ltry: a cross-sectional study. PLoS ONE. 

2013;8(2):e56851.

47. Atlas RM. Combating the threat of biowarfare 

and bioterrorism: defending against biological 

weapons is critical to global security. BioScience.1999;49(6):465-477. Available at: https://aca

demic.oup.com/bioscience/article/49/6/465/229529. 

Accessed June 7, 2018.

Authors

Dr Thomas Kollars is with the College of Health Sciences, Liberty University, Lynchburg, Virginia. He is a 

former Brigade Surgeon of the 415th Chemical Brigade 

in the US Army Reserve.

Mr Jason Kollars is a senior in the College of Engineering and Computing, Georgia Southern University, 

Statesboro, Georgia.

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January – June 2018 49

There are various, disparate resources of information 

available for consultation regarding potential biological 

risks associated with various parts of the world; however, there is not a consolidated resource of information 

that identifies not only the risks, but also the appropriate 

preventive measures and diagnostic tests that should be 

performed to identify overt as well as subclinical infection. This article in intended to provide a consolidated 

resource of information to facilitate the identification, 

diagnostic testing, and prevention of diseases that pose 

a risk to military service members. The information is 

presented to assist medical providers with accessing 

information needed to best determine pre- and postdeployment medical assessment for preventive medicine 

and veterinary personnel, and other service members 

who are at risk for exposure to endemic, zoonotic, and 

vector-borne diseases.

This article is a resource document providing identification and descriptions of many resources that provide 

valuable insight into country-specific biological threats, 

along with specific information on where to submit samples and specimens of concern for identification and diagnosis. Additionally, resources to inform medical readiness and prepare the medical threat brief are provided.

The following fictional scenario illustrates the challenges faced by an Army Reserve unit in achieving missionspecific medical readiness for an impending deployment.

Scenario: Mission-Specific Medical Threat

Readiness Considerations

DET 22 is preparing for deployment to Eritrea. The 

DET Commander, a physician, has requested her Preventive Medicine Officer (PMO) to prepare a medical 

threat brief outlining the known and potential biological threats that may be encountered during deployment. 

The Deputy Commander is a Veterinary Corps officer 

who provides assistance with preparation of the medical 

readiness plan. The briefing must include information 

on theater-specific biological threats, resources for diagnostics beyond the scope of what can be supported in 

theater, and individual medical readiness including:

` required immunizations,

` personal protective measures,

` serology testing,

` vector identification.

In preparing for the deployment, the PMO faces some 

challenges in ensuring the information is as current and 

complete as possible. First, she must determine if there 

is current information available on the known and potential biological threats in Eritrea. Does the Army Public 

Health Center have a prepared Entomological and Zoonotic Operational Risk Assessment (EZORA) for Eritrea, 

or do they have the ability to prepare an EZORA within 

the next 6 weeks? Also, whom should she contact for assistance with providing the specific information needed 

for the medical threat brief core and redeployment slides?

Optimizing Mission-Specific Medical Threat

 Readiness and Preventive Medicine for

 Service Members

COL Caroline A. Toffoli, VC, USAR

Abstract

Deployments and mobilizations of Army Soldiers have been continuing processes and will be sustainable requirements for the foreseeable future. Global deployments often position service members in austere environments that can include exposure to biological threats that can significantly affect their health and medical readiness. Unit commanders and operations personnel bear the responsibility for researching and disseminating 

up-to-date information on potential biological threats including vector-borne diseases and zoonotic diseases.

It has been a significant challenge to inform and prepare service members for the potential threats in Army 

Reserve units and units that do not have access to preventive medicine advisors. With the expanding list of 

known pathogens and the discovery and surveillance of emerging threats, it is extremely important for leaders 

and providers to have readily-available access to information about current, mission-specific biological threats.

This article discusses the resources that are available to leaders, providers, and service members, and provides 

an organized resource for obtaining current and complete information on global biological threats that could 

affect combat readiness.
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

The detachment will require the ability to integrate resources available that provide global biosurveillance, 

medical readiness, diagnostics, and preventive medicine 

information.

Is there a way the PMO can find the pieces of information needed and compile them into one resource to 

provide to the command? The health of the service 

members depends on the availability of accurate, current information.

The PMO is concerned about how to adequately address 

the information needed by the Soldiers and leaders during this deployment preparation, especially since many 

of the Soldiers will venture into austere environments, 

and may work routinely with potential vectors of disease. Does the information adequately deliver/provide 

the Soldiers and medical providers with information 

that will support the mission?

Problem Statement

How do those responsible for medical readiness of deploying Army units obtain current information on biological threats across the range of military operations, 

with the variety of exposure to pathogens and in the austere environments in which they serve?

What is Adequate Medical Readiness

for Deployment?

Many resources are available for consultation by Soldiers who are deploying to areas of operation that pose 

medical risks. The evolution of known and emerging 

pathogens warrants the availability of a contemporaneous resource of information for deploying troops who 

have the potential to be exposed to pathogens that have 

vector transmission or zoonotic potential.

Organisms may change their resistance patterns by a variety of natural and induced processes. Additional variation can also occur through migration from other populations of a pathogen, or through a range of cytological 

and molecular changes. These processes warrant constant vigilance and surveillance of known and emerging 

pathogens.

Preventive Medicine (PM) and Veterinary Corps (VC) 

Soldiers bear the risk of exposure to vectors and pathogens that are otherwise of little concern to military service members. The interaction with foreign food sources, animals, and austere environments are a frequent 

occurrence for PM and VC Soldiers, and exposes them 

to significant risks for infection with parasites, bacteria, 

viruses, fungi, molds and protozoans.

Information Sources

World Health Organization

The World Health Organization produces fact sheets 

on international travel and health, global vector-borne 

diseases, and information concerning disease outbreak 

and neglected zoonotic diseases. There are also disease 

distribution maps. This information is available at http://

www.who.int/en/.

US Army Public Health Center

The US Army Public Health Center (APHC) strives to 

be a world-class provider of public health services across 

the US Army and the Department of Defense (DoD). 

Its mission is to enhance Army readiness by identifying and assessing current and emerging health threats, 

developing and communicating public health solutions, 

and assuring the quality and effectiveness of the Army’s 

public health enterprise.

The APHC is an exceptional resource for information 

that includes major disciplines of concern to deploying 

service members. These include:

• animal medicine,

• deployment and environmental health,

• diseases and conditions,

• health surveillance and evaluation,

• laboratory sciences and toxicology, and

• region-specific public health information.

The APHC website is a primary site for information on 

global threats and best practices to promote health and 

prevent disease. The website is available at https://phc.

amedd.army.mil.

National Center for Medical Intelligence

The National Center for Medical Intelligence (NCMI) 

is a component of the Defense Intelligence Agency. Its 

mission is to monitor, track, and assess a full range of 

global health events that could negatively affect the 

health of US military and civilian populations. Before 

troops are deployed to foreign areas for combat, peacekeeping, or humanitarian operations, NCMI’s assessment of potential health risks and foreign health care 

capabilities assists medical providers in planning for the 

proper medical countermeasures, health care support, 

and medical personnel support.

The NCMI support to US forces includes:

 Environmental health: identify and assess envi- ronmental risks that can degrade force health or 

effectiveness.

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January – June 2018 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

 Infectious disease: identify, assess, and report on 

infectious disease risks that can degrade mission 

effectiveness of deployed forces and/or cause longterm health implications, and support national security and homeland defense by reporting foreign 

disease outbreaks that may be naturally occurring 

or intentional.

 Life sciences and biotechnology: assess foreign biotechnological developments and medical advances.

 Medical capabilities: assess foreign emergency and 

disaster response capabilities, and maintain and 

update an integrated database on all medical treatment, training, pharmaceutical, and research and 

production facilities.

 Medical intelligence products.

The NCMI resources are available at https://www.ncmi.

detrick.army.mil/index.php.

Specific Resources

Entomological and Zoonotic Operational

Risk Assessments

Entomological and zoonotic operational risk assessments (EZORAs) are prepared jointly by the APHC 

Entomological Sciences Program and the Veterinary 

Services Portfolio to assist public health and military 

medical planners with predeployment planning and deployments to a country of concern. In addition to vector-borne disease risk, an EZORA also covers zoonotic 

risks to military personnel and military working dogs.

The EZORA website provides in-depth information 

on global site-specific diseases and vectors of concern, 

as well as health risk communication consultation and 

training. It is available at https://phc.amedd.army.mil/

topics/envirohealth/epm/Pages/EZORA.aspx.

Epidemiology and Surveillance

Global Emerging Infections Surveillance

and Response System

The Defense Health Agency (DHA) Armed Forces 

Health Surveillance Branch (AFHSB) plays a critical 

role in force health protection. As the central epidemiologic resource for the US Armed forces, AFHSB conducts medical surveillance to protect all those who serve 

our nation in uniform and allies who are critical to our 

national security interests. The AFHSB collects data 

about service members and populations of our global 

partners. The Global Emerging Infections Surveillance 

and Response System (GEIS) has become a respected 

authority in surveillance and research about emerging 

infectious disease and endemic diseases throughout the 

world. The AFHSB-GEIS provides direction, funding, 

and oversight to a network of more than 70 partners 

based in all regions of the world. Working in conjunction with their host nations, these partners conduct disease surveillance and rapid outbreak response, encourage research and innovation, and build capacity. The 

GEIS partner network enhances global public health 

capacity by providing support to:

 Improve DoD and international partners’ capacity to detect and respond to outbreaks of relevant 

emerging infectious disease.

 Promote the establishment of electronic surveillance systems that support comprehensive emerging infectious disease surveillance and/or syndromic-based surveillance systems such as the Suite for 

Automated Global Electronic bioSurveillance.

 Conduct scientifically valid evaluations of existing 

and new surveillance and outbreak response systems.

 Support applied research and development of laboratory diagnostic technologies to rapidly detect potential emerging infectious disease threats (eg, diagnostics, computers and/or laboratory-based systems).

 Enhance the host nation public health research, 

clinical investigation and laboratory capacity.

The AFHSB can access epidemiologic information and 

service member exposure data, and it produces monthly 

and annual reports on disease occurrence and outcomes. 

The resources of the AFHSB are available at https://

www.afhsc.mil/Home/About.

Disease Reporting System Internet

The Disease Reporting System Internet (DRSi) is an internet-based resource used to report and keep a historical record of reportable medical events (RME), and a 

resource for acquiring specific epidemiological data on 

the incidence of any disease of interest. The DRSi was 

launched by the Navy and Marine Corps Public Health 

Center in 2008 and is the system now used by both the 

Navy and Army for reportable diseases. It uses guidelines and case definitions developed by the AFHSB. 

Medical assets based in the United States and those deployed are required to use DRSi to report RMEs. The 

Army Disease Reporting System Internet is the Army’s 

branch of DRSi. Access is restricted to medical professionals who have been granted access in order to 

perform disease reporting or surveillance. Reportable 

medical event case definitions and information concerning the DRSi access request process are available at the 

Public Health Center’s website, https://phc.amedd.army.

mil/topics/healthsurv/de/Pages/DRSiResources.aspx.

Global Biosurveillance Portal

The Global Biosurveillance Portal (G-BSP) was developed by the DoD Joint Program Executive Office for 
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

Chemical and Biological Defense to meet requirements 

for biosurveillance situational awareness and collaboration capability to support strategic, operational, and 

tactical users. The G-BSP is an unclassified, web-based 

enterprise environment that facilitates collaboration, 

communication, and information sharing in support 

of the detection, management, and mitigation of manmade and naturally occurring hazards. The web portal:

 Provides a set of tools and capabilities to enhance 

the situational awareness of all hazards from the 

tactical to the strategic level.

 Facilitates the fusion of multiple unclassified information sources. Hundreds of data sources can be 

displayed as layers on a map, enabling users to research a specific area of responsibility for both current and historical hazards.

 Provides a “one stop shop” to access information on 

specific human, vector, and animal threats; medical 

countermeasures; facilities capable of providing interventions; and local infrastructure and resourcing.

This resource is accessible by establishing an account at 

https://www.biosurveillanceportal.org.

APHC Entomological Sciences Branch

Located within the US Army Public Health Center Regional Commands, The Entomological Sciences Branch 

maintains the expertise to address vector-borne, emerging diseases that potentially affect force health and 

readiness.

Services include:

 Vector and reservoir surveillance: assists units with 

setting up surveillance programs for insects and 

arthropods capable of transmitting disease, and 

assess pathogen levels in large and small mammal 

populations on military installations.

 Identification services: identifies submitted ticks, 

insects, rodents, reptiles, birds, nuisance plants, or 

any other unknown specimen.

 Pathogen diagnostics: coordinates the testing of insects, arthropods, animal blood, and tissue, as well 

as environmental samples for a wide range of disease causing organisms.

 Environmental science engineering officers (ESEO) 

assistance visits: Provides specialized, on-site support to orient newly assigned ESEOs as well as specialized field training for preventive medicine staff 

to address region-specific pest problems.

 Installation medical entomology and public health 

support: reviews/creates documents and program 

activities to bring pest management programs 

into compliance with regulatory requirements and 

sound integrated pest management practices.

 Health risk communication: provides briefings and 

other educational material on operational and institutional risk management of vector-borne and zoonotic disease.

 Deployment training: provides training on entomological issues of preventive medicine for units preparing to deploy.

 Special consultations and tailored training: subject 

matter experts who can perform quick-response 

investigations and training on entomology-related 

procedures, practices, or perceived issues.

The resources offered by the APHC Entomological Sciences Branch are available at https://phc.amedd.army.

mil/topics/envirohealth/epm/Pages/Deployment-PestManagement.aspx. There are also external resource 

documents that identify specific threats, such as arachnids and venomous snakes, which are prevalent in the 

areas of operation where service members are frequently deployed.

Diagnostics

US Army Medical Research Institute

of Infectious Diseases

The US Army Medical Research Institute of Infectious 

Diseases (USAMRIID) serves as the DoD lead laboratory for medical biological defense research. It serves as 

a national resource for the isolation and identification of 

infectious disease agents and is a DoD reference center 

for information related to arthropod-borne and hemorrhagic fever viruses. While their core mission is to protect the warfighter from biological threats, they also investigate disease outbreaks and threats to public health. 

Research conducted at USAMRIID leads to medical 

solutions—therapeutics, vaccines, diagnostics, and information—that benefit both military personnel and civilians. The core competencies of USAMRIID include:

 Development, testing and evaluation of medical 

countermeasures.

 Providing world-class expertise in medical biologi- cal defense.

 Rapid identification of biological agents.

 Training and educating the force.

 Maintaining biosafety, biosurety and biosecurity 

standards.

 Preparing for technological uncertainty.

The capabilities of USAMRIID include a special pathogens laboratory where clinical or environmental samples can be submitted for identification. The Specimen 

Collection and Submission Manual provides specific 

guidelines on sample submission. More information is 

available at http://www.usamriid.army.mil/index.htm.

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AND PREVENTIVE MEDICINE FOR SERVICE MEMBERS
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THE ARMY MEDICAL DEPARTMENT JOURNAL

Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) 

Division of Vector-Borne Diseases maintains The International Catalog of Arboviruses. The Catalog is meant 

primarily for the description of those viruses biologically transmitted by arthropods in nature and actually 

or potentially infectious for humans or domestic animals. The Catalog lists, describes, and provides technical information for hundreds of viruses, including the 

epidemiology and geographic distribution, and provides 

specific information on specimens required for testing 

through state health departments. Instructions for submitting specimens to CDC Diagnostic Laboratories for 

detection of arboviral diseases, bacterial zoonoses, and 

rickettsial zoonoses are available at http://www.cdc.gov/

ncezid/dvbd/specimensub/index.html.

EZORA Website

The EZORA website discussed earlier provides information about environmental sample submission, availability of Arthropod Vector Rapid Detection kits, food 

and bottled water analysis, toxicology assessments, and 

other evaluations.

Prevention

Centers for Disease Control and Prevention

The CDC maintains a website on global travelers’ health 

that includes information for clinicians regarding medicines and vaccinations that should be administered prior 

to travel, as well as posttravel evaluation guidance. The 

CDC Health Information for International Travel (commonly called the Yellow Book) is published every 2 years 

as a reference for those who advise international travelers about health risks. This reference is available at http://

wwwnc.cdc.gov/travel/page/yellowbook-home-2014.

Immunizations and Chemoprophylaxis

Army Regulation 40-5621 identifies mandatory vaccinations for military personnel by category, along with 

guidance on pre-exposure rabies prophylaxis for at-risk 

populations. Chemoprophylaxis for diseases that have 

been shown to be of military significance is also discussed. These include anthrax, influenza, meningococcal disease, leptospirosis, plague, scrub typhus, smallpox, traveler’s diarrhea, and malaria. Consulting for current information and guidance for appropriate drugs and 

dosing regimens is essential (for example, the CDC Advisory Committee on Immunizations Practices (ACIP ), 

the NCMI, and the Control of Communicable Diseases 

Manual 2). Note that the recommendation to consult with 

the appropriate preventive medicine authority has been 

omitted from the current (2013) version of Army Regulation 40-562.

DHA Immunization Healthcare Branch

The DHA Immunization Healthcare Branch supports 

all DoD immunization programs and provides clinical 

consultative services, educational support, and training resources. Its resources are available at https://

health.mil/Military-Health-Topics/Health-Readiness/

Immunization-Healthcare/Vaccine-Recommendations/

Vaccine-Recommendations-by-AOR.

Rabies Prophylaxis

Specific guidelines on rabies prophylaxis for veterinarians and animal care providers are found in the Compendium of Veterinary Standard Precautions for Zoonotic 

Disease Prevention in Veterinary Personnel,

3

 The document addresses pre- and postexposure prophylaxis as 

well as titers, and promotes its guidelines in accordance 

with the CDC ACIP. http://www.cdc.gov/vaccines/acip/

about.html.

Regulatory Guidance

Army Personnel Policy

The Department of the Army Personnel Policy Guidance 

for Overseas Contingency Operations 4 requires that all 

personnel deploying to an area of operations are current 

with theater-specific immunizations which are provided 

in a table format. Further, the policy mandates that in 

accordance with ASD(HA) Memorandum dated March 

14, 2006,5 predeployment serum specimens for medical 

examinations will routinely be collected within one year 

of deployment. However, if an individual’s health status 

has recently changed or has had an alteration in occupational exposures that increases health risks, a healthcare 

provider may choose to have a specimen drawn closer 

to the actual date of deployment. Postdeployment serum 

specimens for medical examinations should be collected no later than 30 days after arrival at the demobilization site, home station, or inpatient medical treatment 

facility.

Active duty military activities with medical facilities 

are usually able to perform some diagnostic testing including immunology; however, specialized tests are often referred to approved laboratories or other military 

installations.

Geographic Combatant Command

Medical Entry Standards

Uniformed service members must meet service standards of fitness according to service regulations and 

policies. Additionally, to deploy to a given combatant 

command area of responsibility, additional standards 

may apply based upon operational conditions of the 

deployed location. For example, Modification 13 to US 
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

Central Command Individual Protection and Individual/

Unit Deployment Policy* defines the standards of fitness for the US Central Command area of responsibility. 

Each combatant command develops its own standards 

of fitness for deployment which are available from that 

command. Leaders of deploying service members must 

contact the individual combatant command for the fitness policies that pertain to its area of responsibility.

Medical Threat Briefing

The purpose of medical threat briefings, deployment 

health guides, and deployment health cards is to help 

reduce the risk of disease and nonbattle injury during 

deployment. Per the Army Personnel Policy Guidance,4

all personnel will receive health threat briefings prior to 

deployment. Health threat briefings and products should 

be administered and distributed by preventive medicine 

personnel.

A medical threat briefing (MTB) contains information 

on health threats and countermeasures while deployed. 

A MTB resources website is hosted on Army Knowledge Online (restricted access), available at https://www.

us.army.mil/suite/files/35828267. Health professionals 

should use the core slides as a starting point to customize and assemble their own MTB. Use the provided resources list to research specific geographic areas.

Conclusion

Although we will continue to face known and emerging biological threats globally, the Army is able to meet 

the future challenges of health promotion and medical 

readiness. With the vast array of resources available for 

consultation, the challenges of surveillance, diagnostics, 

prevention, and treatment are manageable. The difficulty 

of operating in austere environments while maintaining 

health is lessened through the flow of information and 

exchange of updated methodologies that support advancements in disease awareness, vector identification, 

and personnel protection.

References

1. Army Regulation 40-562 (BUMEDINST 6230.15B, 

AFI 48–110_IP, CG COMDTINST M6230.4G) Immunizations and Chemoprophylaxis. Washington, 

DC: Departments of the Army, Navy, Air Force, 

and Coast Guard; 2013. Available at: https://army

pubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/

r40_562.pdf.

2. Heyman DL, ed. Control of Communicable Diseases Manual. 20th ed. Washington, DC: American 

Public Health Association Press; 2014.

3. Williams CJ, Scheftel JM, Elchos BL, Hopkins SG, 

Levine JF. Compendium of Veterinary Standard 

Precautions for Zoonotic Disease Prevention in 

Veterinary Personnel: National Association of State 

Public Health Veterinarians: Veterinary Infection 

Control Committee 2015. J Am Vet Med Assoc. 

2015;247(11):1252-1277. Available at: https://avma

journals.avma.org/doi/10.2460/javma.247.11.1252.

4. Department of the Army Personnel Policy Guidance for Overseas Contingency Operations. Washington, DC: US Department of the Army; 2013.

5. Assistant Secretary of Defense (Health Affairs). 

Memorandum: Policy for Pre- and Post-deployment Serum Collection. Washington, DC: US Department of Defense; March 14, 2006. Available at: 

http://www.armyg1.army.mil/MilitaryPersonnel/

Hyperlinks/Adobe%20Files/OSD%20Memo%20

dtd%2020060314.pdf.

Author

COL Toffoli is Chief Veterinarian, 804th Medical Brigade, Devens, Massachusetts.

OPTIMIZING MISSION-SPECIFIC MEDICAL THREAT READINESS

AND PREVENTIVE MEDICINE FOR SERVICE MEMBERS

*Internal military document not readily accessible by the general 

public.
January – June 2018 55

Mumps is an acute viral disease caused by a paramyxovirus that presents with fever and swelling of one 

or more of the salivary glands: parotid, sublingual, or 

submandibular.1 Mumps is usually a self-limited, mild 

disease. However, in some cases, it can develop more severe complications such as meningoencephalitis, or orchitis that results in male sterility.2

 Severe complications 

are typically more associated with patients who develop 

disease as adolescents or adults.2 Mumps had become 

relatively rare in the post-vaccine era.3 However, focal 

outbreaks have become increasingly common, particularly among the unimmunized and students in colleges 

and universities.3 Mumps has an incubation period of 12 

to 25 days following exposure, and can be transmitted 

to another person from roughly 2 days prior to symptom onset until about 5 days after symptom onset.4

 The 

measles, mumps, and rubella (MMR) vaccine is only 

approximately 78% effective for mumps prevention after one dose, and approximately 90% effective after the 

standard 2-dose series.3 However, it is well-described 

that outbreaks have occurred even among populations 

where more than 85% of those at risk had received 2 

doses of MMR vaccine previously.3 In October 2017, 

the Centers for Disease Control and Prevention (CDC) 

advised that a 3rd “booster” dose of MMR vaccine be 

provided to a “group or population at increased risk 

for acquiring mumps because of an outbreak.”5 However, MMR vaccine has not been shown to be effective 

for postexposure prophylaxis, and in at least one small 

study, a 3rd dose given as postexposure prophylaxis was 

not shown to significantly reduce the mumps attack rate 

when compared to those exposed individuals who had 

previously received 2 doses of MMR vaccine.6

Background

In spring 2018, the Fort Campbell Department of Preventive Medicine (FTCKY DPM) was notified of 3 

suspected mumps cases who presented to the medical 

activity (MEDDAC) emergency department (ED) on 

a Friday afternoon (Day 0). The 3 suspected cases involved an active duty Soldier (father, 29 years old), his 

spouse (mother, 29 years old), and their daughter (5 

years old). The Soldier and his spouse reported the onset of fever and left facial swelling within the 24 hours 

prior to presentation to the ED (Day -1). The child had 

no overt facial swelling, but complained of jaw pain and 

tenderness. The Soldier reported that his family had 

recently traveled to an area of the United States with 

an active mumps outbreak, staying from about 5 weeks 

prior to presentation to 2 weeks prior to presentation. 

The location to which the Soldier and his family traveled 

is not provided here due to privacy concerns. The Soldier reported that his family stayed with members of his 

spouse’s family, and that all 4 members of his spouse’s 

family with whom they resided had become confirmed 

cases of mumps while the Soldier’s family was present. 

The Soldier stated that, in fact, he had moved his family 

to another house in an attempt to prevent transmission 

of mumps to his family. The Soldier initially felt that he 

and his family had “gotten lucky” as it had been over 2 

weeks since their last contact with a known mumps case, 

and they had not yet developed symptoms.

A review of available records found that the Soldier had 

received 2 doses of MMR vaccine at the time of his accession into the Army. His spouse had no evidence of 

Public Health Response to Imported Mumps

 Cases–Fort Campbell, Kentucky, 2018

LTC John W. Downs, MC, USA

Abstract

Mumps is an acute viral disease caused by a paramyxovirus that presents with fever and swelling of one or 

more of the salivary glands. Although not generally considered a disease of military importance, mumps has 

been associated with outbreaks among young adults in close living quarters, potentially placing Soldiers at 

risk for transmission of mumps when living in congregated settings. This article reports a recent public health 

response to 3 imported mumps cases occurring at Fort Campbell, Kentucky, that resulted in a contact investigation for 109 close contacts across varied settings. No secondary mumps cases were identified. This report 

highlights the need for continuous preparation for public health emergency response, and the need to develop 

and maintain strong working relationships with local civilian public health assets, as well as with installation 

organizations, such as schools, child care centers, and public affairs resources.
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

MMR vaccine or mumps titer in her military electronic 

health record. The daughter had received a single dose 

of MMR vaccine, approximately one year prior. With 

further questioning, the Soldier revealed that he had 

returned from a 7-day field exercise on the evening 

(Day -1) prior to presentation, and that he slept in a 

communal tent with roughly 20 other Soldiers during 

this exercise. He also reported that his daughter attended an on-post elementary school for the 4 days prior to 

presentation. On the basis of symptoms consistent with 

mumps, and reported epidemiologic linkage to known 

cases of mumps associated with a well-reported mumps 

outbreak, a contact investigation was initiated.

Investigation

The investigation began with a call to local civilian public health authorities to request assistance with obtaining 

buccal swab mumps polymerase chain reaction (PCR) 

testing for confirmation through the Tennessee Department of Health (TNDOH) Laboratory. Civilian public 

health authorities were very receptive to this request 

for assistance and immediately began coordination for 

testing. Buccal swab samples were obtained from the 

family on Day 1 for processing at the TNDOH Laboratory. The samples were obtained in accordance with 

published CDC guidance.7 These samples were collected by TNDOH officials and processed on Day 3. Prior 

buccal swab samples for mumps viral culture had been 

obtained during the family’s ED visit for processing at 

a commercial laboratory. However, the presumed turnaround time was excessive, and we could not be certain 

that the samples had been properly obtained.

On Day 4, laboratory testing conducted by the TNDOH 

Laboratory confirmed a positive buccal swab mumps 

PCR in both the Soldier and his spouse. Mumps PCR 

was negative for the child; however, a serum mumps 

IgM returned positive for the child later on Day 6. Serum mumps IgM is known to result in both false-positive and false-negative results in previously vaccinated 

individuals.4 Thus, this positive mumps IgM may have 

been secondary to the child having received one dose 

of MMR vaccine previously. However, given the child’s 

repeated exposures to known mumps cases among her 

family, and the risk of initially overlooking any secondary cases among other exposed children if we assumed 

the child to not be infected and therefore cease any further investigation of the child’s contacts, FTCKY DPM 

made the decision to continue the contact investigation 

as if the child represented a probable case, in accordance 

with case definitions as discussed later.

For the purposes of this investigation, a confirmed case 

was defined as a positive mumps laboratory confirmation 

via PCR or viral culture in a patient with an acute illness 

consistent with mumps. A probable case was defined as 

acute parotitis or other salivary gland swelling lasting 

at least 2 days in a person with an epidemiologic linkage to another probable or confirmed case, or a person 

with a positive mumps serum IgM.3,4 For the purposes 

of this investigation, presumptive evidence of mumps 

immunity was defined as either valid documentation of 

2 doses of MMR vaccine for contacts over age 4 years, 

or laboratory evidence of immunity by positive mumps 

IgG serology, referred to hereafter as “mumps titer.”3

All individuals involved in this investigation were born 

after 1957; thus, presumptive immunity based on age 

was not a consideration.

Specific recommendations were tailored to each setting 

(children and educators, healthcare workers, and other 

Soldiers). However, our contact and containment plan 

was generally consistent with the following recommendations for each setting: (1) those contacts for whom 

evidence of presumptive immunity was available could 

continue attending work and school without interruption; (2) those contacts who had only received one dose 

of MMR should receive the second dose as soon as possible, provided the first dose was at least 28 days prior; 

and (3) those contacts for whom no evidence of immunity could be found were to be excluded from work and/

or school from postexposure day 12 through postexposure day 25. Understanding that the MMR vaccine does 

not provide complete immunity to all even after 2 doses, 

all contacts were reassessed for symptoms by questionnaire or interview on days 15, 20, and 26 following their 

respective exposure.

Soldiers who had slept in the communal tent with the 

case-Soldier were considered close contacts. A list of 

these contacts was obtained through the case-Soldier’s 

company commander. An immunization review was 

conducted of these contacts. Of the 27 total contacts 

identified here (average age 24 years, range 20-37 years), 

only 4 Soldiers had presumptive evidence of immunity 

available in the electronic medical record. This was in 

part due to the realization that in the Army Medical Protection System (MEDPROS), mumps immunity is assumed to be present based on positive testing of measles 

and rubella titers drawn upon a Soldier’s accession into 

the Army.8,9 This assumption then transfers to the electronic medical record as the Soldier being “up to date” 

on MMR vaccine. However, this assumption was not 

consistent with published guidance for contact investigations.3,4 Thus, as only measles and rubella titers were 

available for review, but not mumps titers, we initially 

assumed that 23 of the 27 (85%) of the exposed Soldiers 

did not have evidence of immunity to mumps.

PUBLIC HEALTH RESPONSE TO IMPORTED MUMPS CASES – FORT CAMPBELL, KENTUCKY, 2018
January – June 2018 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

Under the assumption that these 23 Soldiers had very 

likely received MMR vaccine previously, but simply 

had no documented evidence of mumps immunity per 

Army policy as described, we opted to send these 23 

Soldiers for mumps IgG serology right away in order to 

clearly document evidence of mumps immunity. We assumed that any significant presence of mumps IgG less 

than 5 days after exposure would have to be secondary 

to previously established immunity. Furthermore, if the 

Soldiers showed evidence of immunity to both measles 

and rubella, given their young age, it was most likely 

due to a history of having received at least one dose of 

MMR vaccine. Of those 23 Soldiers, 18 (78%) had positive mumps titers results. In this manner, we were able 

to establish presumptive immunity for 22 (81%) of the 

27 total Soldier contacts. The remaining 5 Soldiers for 

which presumptive immunity to mumps could not be established were housed in a separate barracks area, and 

excluded from contact with other Soldiers for postexposure days 12 to 25. Follow-up symptom interviews were 

conducted by Army Public Health Nurses (APHNs) on 

postexposure days 15, 20, and 26. No symptoms consistent with secondary cases were identified.

Six healthcare workers (HCW) were potentially exposed to mumps during the care of the index cases. Fortunately, the need for isolation and droplet precautions 

was identified immediately upon the family’s arrival at 

the MEDDAC ED, and this likely limited the number of 

exposed HCWs. Of these 6 HCW contacts, only 3 (50%) 

initially had presumptive evidence of immunity available in the electronic health record. This was likely due 

to the fact that the HCWs were hired prior to 2015 when 

a more rigorous pre-employment vaccination review 

was implemented at this facility to achieve more consistency with guidance in Army Regulation (AR) 40-562,

10

and the 2011 CDC recommendations for the immunization of HCWs.11 These 3 HCWs were also sent for immediate mumps IgG serology, and all 3 resulted in positive 

mumps titers. The HCWs were counseled on the signs 

and symptoms of mumps, and to stay home should they 

develop any signs or symptoms suggestive of mumps, 

but were allowed to continue working after presumptive 

immunity had been established.

The child’s school was the source of the majority of 

contacts identified to investigate. The child attended 

prekindergarten in a setting where children and staff 

moved in and out of several different classrooms. This 

resulted in a total of 62 child contacts (age range 3 to 5 

years), and 14 educator contacts. Notification of this potential exposure to a probable mumps case was provided 

to parents of the other prekindergarten children via a 

memorandum drafted by FTCKY DPM and a mumps 

fact sheet sent home with the students on Day 4 of the 

investigation. Of the child contacts, 55 (89%) had received at least one dose of MMR vaccine, and 47 (76%) 

had evidence of 2 doses of MMR vaccine available for 

review. Seven child contacts were initially identified as 

having no evidence of presumptive immunity to mumps, 

and were recommended for exclusion from school for 

postexposure days 12 through 25. When their parents 

were presented with this recommendation, evidence of 

at least one prior MMR vaccination was provided to the 

APHNs for an additional 5 children. This brought the 

total with at least one prior MMR vaccination to 60 of 

62 (97%) children. Two children were excluded from 

school at the recommendation of FTCKY DPM for postexposure days 12 through 25. Follow-up mumps symptom interviews were conducted by APHNs on postexposure days 15, 20, and 26. No secondary mumps cases 

were identified.

Of the 14 educator contacts, only 3 (21%) had presumptive evidence of immunity immediately available for 

review. Upon notification from their employer, the Department of Defense Educational Activity (DoDEA), 

directed that they would be excluded from work and 

placed on sick leave for postexposure days 12 through 

25 unless they were able to provide evidence of presumptive immunity to mumps, an additional 7 educators provided sufficient documentation of presumptive 

immunity to remain working in the school. Four educators (28% of total educator contacts) were excluded 

from work as they were unable to provide any evidence 

of presumptive immunity to mumps. As with the other 

contacts, follow-up mumps symptom interviews were 

conducted by APHNs on postexposure days 15, 20, and 

26. No secondary mumps cases were identified.

We were fortunate that no secondary cases developed 

during this contact investigation. Heightened awareness and surveillance for additional cases continued 

until 50 days after the initial case presentations (two 25-

day incubation periods) with no additional cases being 

identified.

Comment

A number of lessons can be learned from this contact 

investigation for other Army public health professionals to consider in future communicable disease contact 

investigations on their installation. First, a strong relationship with local civilian public health officials (at 

least at the local and regional level, and as necessary, at 

the state level) is absolutely key to success. Fort Campbell has the unique situation of lying astride the state 

border between Tennessee and Kentucky. This requires 

working with public health professionals in both states, 
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

and maintaining relationships with these professionals 

through regular contact and interaction. For example, 

just one month prior to this event, FTCKY DPM had 

hosted a joint public health emergency preparedness 

tabletop exercise, which was attended by local public 

health professionals from several nearby counties in 

both Tennessee and Kentucky. Fortuitously, nursing staff 

from Fort Campbell DoDEA schools and Fort Campbell 

Child and Youth Services also attended. The relationships formed as a result of this event and prior meetings 

were critical in ensuring that confirmatory testing was 

readily available, and that local public health professionals were prepared to react had the contact investigation 

extended to their jurisdictions.

Engaging public affairs professionals early in the process helped to ensure that timely and correct information 

about the investigation was disseminated to the public. 

The Fort Campbell MEDDAC Public Affairs office was 

very effective in translating information about mumps 

and the investigation into a timely press release to local 

media that was transmitted through social media almost 

simultaneously with the letters sent by the school to parents notifying them of potential exposure to mumps. Of 

note, a press release posted on the Fort Campbell MEDDAC public Facebook page received over 350 shares and 

nearly 100 comments within the first 18 hours. A press 

release to a local newspaper was posted on the newspaper’s Facebook page and received a similar volume of 

shares and comments within the first 18 hours. Comments were generally supportive of efforts to prevent 

additional disease spread. This effort to ensure that accurate information was provided to the Fort Campbell 

community in an expedient manner likely helped to prevent the development of rumors and inaccuracies that 

can occur when information flow is less than timely.

A separate notification message was sent to all Fort 

Campbell clinical providers and nurses through an 

email distribution list shortly following the press release. 

This message provided additional, clinically-relevant information about the index cases, and when and where 

potential exposures would have occurred. It also included a mumps fact sheet, and specific information about 

incubation periods and when secondary cases could 

potentially be seen.4 This information helped clinicians 

and nurses to appropriately respond to calls from patients and concerned parents who had read the press release and were concerned that they had been exposed 

and/or that they were currently experiencing mumps 

symptoms. This was particularly important as the public response, via social media and the MEDDAC call 

center, generally occurred within the first 48 hours after 

the press release, almost a week prior to when secondary 

cases would have been expected to appear based on incubation period. The FTCKY DPM leadership also met 

with MEDDAC department chiefs to review signs and 

symptoms of mumps, and to ensure that incubation periods and exposure locations were understood.

Some areas for improvement were identified as well. As 

noted previously, the Army does not routinely check 

mumps titers on Soldiers at initial entry training. As 

such, presumptive immunity could not immediately be 

established for most Soldiers. However, some practitioners were unfamiliar with this discrepancy and initially 

declared presumptive immunity based on an “up to date” 

MEDPROS immunization report. Army Regulation 40-

562 states “Immunity against mumps is not necessary as 

a military requirement, but may be appropriate in exceptional clinical circumstances such as outbreaks.”10(p15) To 

this point, the investigation also reiterated that installation occupational health clinics should not use MEDPROS as a reliable means of establishing presumptive 

immunity for active duty HCWs. The MEDPROS is a 

system of record for maintaining Soldier readiness, and 

does not delineate HCWs as having different vaccine 

recommendations. Clear documentation of a completed 

MMR vaccine 2-dose series or positive serology is necessary for HCWs in accordance with AR 40-562.

10(p15)

This standard meets and exceeds recommendations for 

HCW vaccination created by the CDC.

In the future, better relationships should be established with local DoDEA leadership. Army Public 

Health Nurses work frequently with installation Child 

and Youth Services to ensure a safe and healthy child 

care environment; however, relationships with DoDEA 

schools may not be as strong. At Fort Campbell, DoDEA 

educators did not visit installation occupational health 

for pre-employment examination, and did not meet with 

installation occupational health as part of their initial 

arrival process. As such, Fort Campbell occupational 

health had no immunization records for these employees, nor did Fort Campbell DoDEA nurses. As on-post 

educators should be appropriately vaccinated for their 

work, a better solution may be for these employees to inprocess installation occupational health for an immunization review as part of their onboarding process. Army 

Regulation 40-56210 is the DoD standard for immunization practices with applicability to all DoD uniformed 

personnel and select civilian employee, as well as the 

US Coast Guard. Although AR 40-562 indicates that “as 

a condition of employment,” DoD schoolteachers will 

be administered Advisory Committee on Immunization 

Practices recommended adult immunizations unless already immune,10(p12) we found that DoDEA may not routinely enforce this requirement within the contiguous 

PUBLIC HEALTH RESPONSE TO IMPORTED MUMPS CASES – FORT CAMPBELL, KENTUCKY, 2018
January – June 2018 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

United States. Efforts to introduce and familiarize installation public health and occupational health assets to 

local DoDEA officials before an event such as this occurs may allow for greater cooperation in the future and 

prevent the delay in establishing evidence of presumptive immunity that was noted during this investigation.

Conclusion

Mumps may not be considered a disease of military 

importance; however, Soldiers may travel of their own 

accord or be deployed to locations where mumps outbreaks are occurring. Understanding that the MMR vaccine does not provide 100% immunity against mumps, 

Soldiers have the potential to develop acute mumps, and 

may be at greater risk of its complications as adults. Military public health professionals should prepare themselves to respond to mumps cases to prevent the spread 

of disease, and should be sure to include colleagues in 

local civilian public health in their planning. This investigation clearly illustrates that the magnitude of a 

contact investigation can quickly increase, particularly 

when Soldiers are living in close quarters, and when 

consolidated child care settings are involved. Thus, continuous preparation for the possibility of these events 

through public health emergency response exercises is 

essential so that even if additional cases appear and investigations expand, military public health professionals 

will have an organized framework for response, and can 

depend on previously developed collegial relationships 

to assist in resolving the problem.

Acknowledgements

The author acknowledges the efforts of Army Public 

Health Nurses MAJ Simone Edwards, CPT Courtney 

Buchwald, and Ms Jennifer Williams who were essential 

in conducting and completing this investigation.

References

1. Rubin SA, Carbone KM. Mumps. In: Kasper DL, 

Hauser SL, Jameson JL, Fauci AS, Longo DL, 

Loscalzo J, eds. Harrison’s Principles of Internal 

Medicine. 19th ed. New York: McGraw Hill Education; 2015: chap 231e.

2. D’Epiro J. Mumps–It’s Back!. Clinician Rev. 

2015;25(4):24-31.

3. Fiebelkorn AP, Barskey A, Hichman C, Bellini W. 

Chapter 9: Mumps. In: Roush SW, Baldy LM, Hall 

MAK, eds. Manual for the Surveillance of Vaccine-Preventable Diseases. 6th ed. Atlanta, GA: 

Centers for Disease Control and Prevention; 2013. 

Available at: https://www.cdc.gov/vaccines/pubs/

surv-manual/chpt09-mumps.html. Accessed July 

24, 2018.

4. Kansas Department of Health and Environment. 

Mumps Investigation Guideline [internet]. 2018. 

Available at: http://www.kdheks.gov/epi/Investigation_Guidelines/Mumps_Disease_Investigation_

Guideline.pdf. Accessed July 24, 2018.

5. Marin M, Marlow M, Moore KL, Patel M. Recommendation of the Advisory Committee on Immunization Practices for Use of a Third Dose of Mumps 

Virus-Containing Vaccine in Persons at Increased 

Risk for Mumps During an Outbreak. MMWR 

Morb Mortal Wkly Rep. 2018;67(1):33-38.

6. Fiebelkorn AP, Lawler J, Curns AT, Brandeburg 

C, Wallace GS. Mumps postexposure prophylaxis 

with a third dose of measles-mumps-rubella vaccine, Orange County, New York, USA. Emerg Infect Dis. 2013;19(9):1411-1417.

7. Centers for Disease Control and Prevention. Illustration of Parotid Gland and Instructions for 

Collection of Buccal Fluid [internet]. 2010. Available at: https://www.cdc.gov/mumps/lab/detectionmumps.html. Accessed June 29, 2018.

8. Department of the Army. ALARACT 255/2014 

Implementation of Measles, Mumps, and Rubella 

(MMR), Polio, and Varicella Vaccine Requirement 

into the Army Routine Adult Immunization Profile. 

2014.

9. Department of the Army. ALARACT 081/2006 The 

Accession Screening and Immunization Program 

(ASIP). 2006.

10. Army Regulation 40-562, Immunizations and Chemoprophylaxis for the Prevention of Infectious 

Diseases. Washington, DC: US Department of the 

Army; October 7, 2013.

11. Centers for Disease Control and Prevention. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 

2011;60(RR-7):1-45.

Author

LTC Downs is with the Department of Preventive 

Medicine, Blanchfield Army Community Hospital, Fort 

Campbell, Kentucky.
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

Developing Medical Surveillance for New

Occupational Hazards

When new substances are introduced to the workplace, 

the potential health risks to exposed workers must be 

known. If a gap in knowledge exists, an investigation 

of these health risks must be completed. If the hazard 

cannot be fully managed using engineering, administrative, and/or personal protective controls, a medical surveillance program must be developed and implemented. 

This publication will focus on the medical surveillance 

aspect of an overall occupational surveillance program 

when new substances are introduced to the workplace.

To begin developing a medical surveillance program, 

occupational health providers must first conduct a thorough literature search for studies and information related to the substance in question. Toxicologic data, safety 

data sheets, clinical outcome studies, research and development data, peer-reviewed journal studies or articles, and even popular medicine articles are good places 

to start gathering information. Included in this step is 

soliciting help from experts with knowledge of the substance, obtaining information on how the substance will 

be used (eg, manufacturing and handling), and gathering knowledge of how humans have the potential for developing morbidity related to the substance in question. 

This step helps to identify what is known and what is not 

known about the new substance. It also identifies gaps in 

knowledge that can be filled by requesting new toxicology studies that enlighten occupational health providers 

about the potential human health effects.

The second step is to solicit assistance from the toxicology and scientific communities. Requesting studies 

on the new substance that help to determine potential 

health effects to humans is essential. The focus of these 

studies should be in areas where there is little knowledge that address the most likely route(s) of exposure, 

and that explore the health effects of most concern. A 

medical surveillance program that uses this information 

will be able to successfully monitor the health of potentially exposed workers, especially if it employs biomarker testing as part of the exam protocol. Examples of 

Army resources that may be helpful at this step include 

the US Army Public Health Center Toxicology Directorate, the Army Research Laboratory, and Edgewood 

Chemical Biological Center.

The third step is to consult with industrial hygiene (IH) 

and safety personnel at the installation to determine the 

type of controls that are needed to protect workers who 

may be exposed to the new substance. If engineering 

and/or administrative controls are not enough to protect 

workers from exposure, a recommendation for personal 

protective equipment (PPE) should be given by IH and 

implemented by the employer. An exposure monitoring 

plan should also be developed among industrial hygiene, 

safety, and medical personnel to address the needs for 

quantitative data to assess actual worker exposure, validate the selection and use of appropriate PPE (eg, respirators), and compare toxicological information with 

medical observations and expectations.

Developing Medical Surveillance Examination

 Guidance for New Occupational Hazards:

 The IMX-101 Experience

W. Scott Monks, MPAS, PA-C

Abstract

New materials are constantly being created to address the operational needs of the US Army. These materials 

provide challenges to occupational health practitioners by presenting unknown health risks and possible effects 

to workers they evaluate. The responsibility for developing a medical surveillance exam, as part of a comprehensive workplace surveillance program, may become the responsibility of the provider working in a clinic on 

a military installation where manufacturing, testing, and/or use of the material is being conducted. Insensitive 

munitions explosive (IMX) has presented such an opportunity for Army occupational medicine providers 

within the last few years. This article describes the course of action taken by the occupational health clinics, 

personnel of Army ammunition plants producing IMX-101, and the US Army Public Health Center-Army Institute of Public Health to address the situation of developing a medical surveillance examination during a time 

when little to no information existed about the components of this new explosive compound.
January – June 2018 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

Occupational exposure limits should be identified from 

federal and consensus organizations including, but not 

limited to: American Conference of Governmental Industrial Hygienists (ACGIH) Threshold Limit Values, 

Occupational Safety & Health Administration (OSHA) 

Permissible Exposure Limits, Occupational Alliance for 

Risk Science (OARS) Workplace Environmental Exposure Limits (WEELs), and National Institute for Occupational Safety and Health Recommended Exposure 

Limits. Many chemical substance exposure values are 

published but many have yet to be developed. Army occupational health professionals typically follow the most 

stringent of the OSHA or ACGIH surveillance values.

If IH or safety personnel have initially determined that 

engineering controls are not enough to reduce the exposure (thus requiring that workers wear PPE), it is recommended that they, along with the employer, work to 

improve existing engineering controls or to develop a 

new type of engineering control to reduce or eliminate 

exposure. The ultimate goal is the reduction or elimination of PPE, if feasible.

Once all preliminary steps are implemented and it is determined that medical surveillance is still required, the 

last step is to attempt to develop a biological exposure 

index (BEI) for the substance in question. The reference 

for this process can be found on the ACGIH website 

(www.acgih.org). A BEI helps to focus the medical surveillance program towards the health issues that would 

most concern an occupational health provider. These biologic tests need to have as high a level of sensitivity and 

specificity as possible. A proper medical surveillance 

program should be established for workers who have a 

potential exposure, including those over the exposure 

limit regardless of PPE use, maintenance workers who 

may have short duration but very high exposures, and as 

required to document effectiveness of engineering and 

PPE control practices.

All of these steps should provide enough information for 

the medical authority to develop a medical surveillance 

exam that includes the following:

` appropriate questions for the subjective portion of 

the exam,

` appropriate physical exam focus and lab/diagnostic testing strategy for the objective portion of the 

exam, and

` assessment and plan parameters that include frequency of evaluation (eg, annual, biannual, every 5 

years), what to do when abnormal results are found, 

and criteria for limited duty, medical removal, etc.

Case Study: The Evolution of the IMX-101 Medical

Surveillance Examination

Insensitive munitions are “munitions which reliably fulfill their performance, readiness and operational requirements on demand, and which minimize the probability of 

inadvertent initiation and severity of subsequent collateral damage to weapon platforms, logistic systems, and 

personnel when subjected to unplanned stimuli.”1 The 

Department of Defense (DoD) recently launched an initiative to improve the safety of its munitions. IMX-101 

(BAE Systems, Inc, Arlington, VA) is one formulation 

approved by the US Army for use in several weapons 

systems, including the M795 155 mm artillery projectile.2

The components of IMX-101 are 3-nitro-1,2,4-triazol5-one (NTO), 2,4-dinitroanisole (DNAN), and nitroguanidine (NQ). Army ammunition plants began producing IMX-101 in 2011. The Army also started medical 

and work environment surveillance at these plants the 

same year. At that time, there were limited toxicological 

studies using animal and in vitro models that described 

the health effects of each individual component. These 

studies gave insight into potential effects in humans 

but did not fully explain all possible human health outcomes. Because this was a novel compound, previous 

medical surveillance data was nonexistent. What was 

known, however, was that certain components were 

chemically very similar to other explosive compounds 

(for instance DNAN and 2,4,6-trinitrotoluene (TNT)). It 

was reasonably assumed that similar compounds would 

have similar health effects to humans (which later would 

be confirmed by toxicological studies and literature review). When deciding how to proceed with performing 

medical surveillance examinations, the occupational 

health providers at the plants producing IMX-101 were 

placed in a unique situation.

The First Medical Surveillance Examination

Guidelines for IMX-101

Concerns about the health effects and toxicity of IMX101 components were voiced by Army ammunition plant 

workers and occupational health personnel at the same 

time the Army obtained certification to produce the 

rounds. Although toxicity clearances on all substances 

had been performed as a part of this process, medical 

surveillance examinations (MSE) of workers and industrial hygiene survey methods were not well defined after 

the acquisitions process.

When the first MSE guidelines were developed and 

implemented at active ammunition plants in 2011, there 

were few studies or toxicologic data (other than the 
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

toxicity clearance data) that answered questions about 

the human health effects of IMX-101 or its components. 

The approach in this early stage was to monitor multiple 

organ systems that were suspected to be targets of this 

new compound. The Joint Munitions Command asked 

the US Army Public Health Center-Army Institute of 

Public Health (USAPHC-AIPH) Toxicology Portfolio to 

conduct additional studies and toxicologic assessments 

of all IMX-101 compounds to further define the health 

hazards and help refine the MSE guidelines. Based on 

findings from these studies, the original set of MSE 

guidelines appeared to exceed what was clinically necessary. Monk and Mirza outline and discuss the original 

MSE guidelines in a 2014 USAPHC-AIPH white paper.3

Review of Early Medical Surveillance Data

Production of IMX-101 began within months of qualification at Army ammunition plants. As a part of the 

contract between the manufacturer of IMX-101 and the 

Holston Army Ammunition Plant, the USAPHC-AIPH 

received the first set of medical surveillance records on 

workers for analysis in June 2014. The surveillance time 

period evaluated was from April 2013 through December 2013. Baseline surveillance exams were completed 

on workers between April and July 2013, and the first 

follow-up exam was completed in September 2013. Two 

additional monthly exams were completed, the first in 

October, and another in the November-to-December 

timeframe.

A multispecialty team from the USAPHC-AIPH, including occupational medicine physicians, physician assistants, nurses, and industrial hygienists, analyzed the 

MSE data. The group was looking for any evidence that 

the original MSE protocol was able to detect an occupationally-acquired adverse health outcome. Parameters 

including the workers’ exposure length and magnitude 

based on industrial hygiene workplace surveillance data 

were also used. This task proved difficult because of its 

multifaceted nature.

At the conclusion of the evaluation, the USAPHC-AIPH 

determined that the primary focus should be on developing and implementing engineering controls that control 

exposures to IMX-101 and its components. Industrial 

hygiene workplace surveillance data during this time 

period showed workers were being exposed to NTO over 

the USAPHC-AIPH occupational exposure limit (OEL) 

at the time (OEL: 8-hr TWA 0.09 mg/m3); workers were 

also exposed, although less frequently, to DNAN (OEL: 

8-hr TWA 1.6 mg/m3). There were no exam, lab, or diagnostic test data collected during this time period, suggesting there were health effects to workers in the areas 

of primary concern related to the known or suspected 

toxicological effects of all IMX-101 components (hematologic/hepatic/metabolic for DNAN, male (rodent) reproductive for NTO). Abnormal lab findings discovered 

during this review were not significantly different from 

findings found in similar conditions and compared to the 

general US population. The original PPE recommended 

(Tyvek or cotton ammunition plant coveralls with antistatic treatment, nitrile gloves, full-face respirators with 

organic material fillers (for certain operations), and antistatic, grounding footwear) appeared to be protecting 

workers. The panel recommended continued efforts to 

find reliable biomarkers for use during MSEs and more 

studies to determine long-term, occupationally proportional exposure effects to human health. The USAPHCAIPH panel’s final determination was that the MSE protocol that was originally implemented likely exceeded 

what was clinically important to monitor workers appropriately and that the guidelines should be updated.

During this review, efforts had already begun to retrofit existing plants and rebuild/overhaul plants with 

improved engineering controls to manage potential exposures. Production rates (quantity) of IMX compound 

and IMX-containing munitions vary based on demand. 

Engineering controls for existing, new, and retrofit operations include local exhaust (eg, point source) and 

canopy hood ventilation systems.

Work continues today on developing monitoring methods for the IMX-101 mixture and its individual compounds. As the occupational health community develops their understanding regarding the routes of entry 

into a worker’s body, the techniques that industrial hygienists use will be refined to reflect the environmental 

situation. Currently, air sampling is done at the plants 

to evaluate the potential for inhalation exposure. Wipe 

sampling has been conducted to evaluate skin exposure 

to IMX, DNAN, and NTO. Other sampling methods not 

currently employed may be available in the future.

The PPE for workers exposed to IMX-101 that is currently used at most plants includes vapor and liquid 

impervious/barrier-type coveralls, full-face respirator 

masks with air purifying filter cartridges, and nitrile 

gloves. Some plants still use cotton coveralls and gloves 

which do not offer as much direct protection from dermal exposure. To date, USAPHC-AIPH is not tracking 

any cases of adverse health effects believed to be directly caused by IMX-101 or its components in workers 

who are using any form of PPE.

Although we are lacking studies that can produce BEIs 

for DNAN, NTO, NQ, or IMX-101, we do have toxicology information, OELs for DNAN and NTO developed 

DEVELOPING MEDICAL SURVEILLANCE EXAMINATION GUIDANCE FOR NEW OCCUPATIONAL HAZARDS:

THE IMX-101 EXPERIENCE
January – June 2018 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

by USAPHC-AIPH, WEELs for DNAN, NTO, and NQ 

developed by OARS, and past surveillance practices 

with similar compounds (eg, TNT) that can be used to 

monitor the health of workers until further research is 

conducted.

Updated IMX-101 Toxicology Data

The most up-to-date resource for the toxicologic assessment of IMX-101 and its components was published 

by the USAPHC-AIPH in December 2014.4 The report 

summarizes the data from multiple studies completed 

by the USAPHC Toxicology Portfolio. It also mentions 

findings from other, nongovernment investigators.

According to the report, DNAN is the main component 

in the IMX-101 mixture. It has similar health effects to 

that of TNT; the primary target for both is the hematopoietic system. The secondary targets of DNAN include 

the hepatic system as well as disruption to the metabolic 

process caused by the metabolite dinitrophenol (DNP).4

NTO primarily targets the reproductive system (at high 

oral doses, specifically males in rat studies); however, 

adverse health consequences to humans are not expected 

given current exposure levels. NTO was demonstrated 

to affect spermatogenic tissues. Tests investigating the 

endocrine disruptive potential of NTO were negative, 

suggesting NTO acts directly on sperm production.4

NQ does not appear to have significant health effects. 

However, one study using mice did associate NQ with 

a possible diuretic effect. There are also concerns regarding aquatic breakdown products of NQ, and further 

study is recommended.4

Oral and dermal toxicity data are currently the only data 

available for the IMX-101 mixture. In the subacute oral 

exposure studies (14-day, repeated oral dose), the mixture displayed the characteristics of the individual components. The hematologic effects (eg, splenomegaly) 

observed were “likely due to the DNAN component of 

the IMX-101 mixture; the adverse events occur[ing] at 

the concentrations similar to those of DNAN alone.” 4(p29)

NTO was noted as the cause for adverse testicular effects 

(decreased testis and epididymis size, decreased sperm 

count in rat studies). However, due to the presence of 

DNAN and NQ in the IMX-101 mixture, the testicular 

effects of NTO were decreased 10-fold when compared 

to NTO alone. The in vitro, frozen human cadaver, dermal penetration study showed an increased dermal absorption with NTO (0.4 times greater) and NQ (7 times 

greater) as the IMX-101 mixture as opposed to NTO 

and NQ alone. This suggests potential enhanced toxicity, possibly due to synergistic, toxicokinetic mixture 

effects. In vivo effects of dermal exposure to IMX-101 

have not been studied to date.4

Proposed Revisions to the First Medical

Surveillance Guidelines

As noted earlier, the medical surveillance approach originally used at facilities that produce IMX-101 exceeded 

what would generally be considered as an appropriate 

balance between cumulative sensitivity and cumulative specificity. That is, the current regimen carries an 

excessive risk of detecting false positive health effects 

that would be presumed to be an outcome from IMX-101 

exposure. Like false negatives, false positives may be 

harmful to individuals so an artful balance and minimization of both is desirable.

Based on the new toxicology knowledge described 

above and in response to calls from stakeholders to 

modify the surveillance, the USAPHC-AIPH published 

a revised guideline for IMX-101 medical surveillance.3

While recognizing the still-present knowledge gaps regarding the potential human health effects of IMX-101 

on exposed workers, the new guidelines attempt to reconcile laboratory and diagnostic tests that have no applicable biological monitoring capability with ones that 

have evidence-based studies to support their use.

The revised surveillance guideline focuses on the potential for hematologic and liver effects of DNAN and 

the metabolic effects of the DNAN metabolite DNP, the 

potential reproductive effects of NTO, and monitoring 

the renal system for potential NQ effects.

The differences between the elements of the original 

IMX-101 medical surveillance guidelines and the proposed revisions to these guidelines are shown in the 

Table.

Explaining the Changes to IMX-101 Medical

Surveillance

As mentioned earlier, DNAN and TNT have similar effects on human health. Monks and Mirza 3

 suggest use of 

an approach similar to TNT surveillance by monitoring 

a complete blood count (CBC) primarily focusing on red 

blood cells (RBCs), glucose-6-phosphate dehydrogenase deficiency status, and liver function tests (LFTs) as 

advised in Technical Bulletin (Medical) 297.5 Due to the 

possible metabolic effects of DNP, a complete metabolic 

panel was advised. Finally, NQ displayed the potential 

to affect the renal system in toxicology studies; therefore, a dipstick urinalysis was recommended.

Frequency of testing was another consideration when 

designing the surveillance guidelines. Hematologic 
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

metrics require the most frequent evaluation. The original guidelines recommended monthly blood tests. When 

evaluating CBC results, however, it would be unlikely to 

see rapid changes in the RBCs (especially the hemoglobin (Hgb) and red cell indices) that are clinically significant and specific enough for DNAN or IMX-101 exposure. A 90-day follow-up after the baseline examination 

is more in line with the normal RBC lifecycle and early 

enough to detect a significant drop in Hgb, a change in 

LFTs related to chemical exposure, or subclinical signs 

of health changes before a worker becomes symptomatic.

If a worker presents symptomatically sooner than 90 days 

in the initial 90 days of employment and/or exposure to 

IMX-101 components, the evaluation should proceed as if 

it were the 90-day evaluation. Subsequently, semiannual 

exams should be conducted to include the 90-day exam 

elements with the addition of regular haptoglobin (Hp) 

and a reticulocyte count (RC). Optional serum lactate 

dehydrogenase (LDH) or peripheral blood smear evaluation further strengthens the surveillance regimen of tests 

to monitor any potential hematological changes with as 

much specificity, and in the most likely timeframe of occurrence, for hemolytic anemia as possible. The purpose 

of watching for a decrease in the Hgb levels (as defined) 

and Hp levels below the laboratory reference range during the semiannual exam is to detect an exposed worker 

with the potential for hemolytic anemia. The addition of 

a serum LDH level to the Hp level has a 90% specificity 

for hemolysis (a normal value for both of these tests has a 

92% sensitivity for ruling out hemolysis).6,7 If hemolysis 

is confirmed, coupled with findings for anemia on the 

CBC, an increase in the RC, and abnormalities on the 

peripheral blood smear (eg, schistocytes, bite cells, spur 

cells), the anemia is likely of the hemolytic type. The 

worker’s history and physical exam findings, along with 

the occupational health provider’s clinical acumen, are 

what will then determine if an IMX exposure is the real 

cause of the described exam abnormalities. In the case of 

an accidental, gross exposure to IMX-101 components, 

the postaccident exam should follow the elements of a 

semiannual exam, with follow-up examinations as determined by the occupational medicine provider (likely 

every 90 days for 2 or more consecutive cycles).

Proposed Revisions to IMX-101 Medical Surveillance Laboratory 

and Diagnostic Testing Guidelines

Baseline Examination

History and physical (with modified questionnaires)

CBC with manual differential

Comprehensive metabolic panel (including AST, ALT, and ALP)

Dipstick urinalysis

Gamma-glutamyltransferase (GGT)

Glucose-6-phosphate dehydrogenase (G6PD)

90-day Examination

Same as Baseline exam but WITHOUT G6PD

Semiannual Examination

Same as 90-day exam with the addition of:

Haptoglobin (Hp)

Reticulocyte count (RC)

Optional Tests

Lactate dehydrogenase (LDH)

Peripheral blood smear

Other tests at provider’s discretion as needed

Termination Examination

Same as Semiannual exam

Additional Surveillance Examination Elements

Pulmonary function test (spirometry)

Original IMX-101 Medical Surveillance Laboratory and Diagnostic 

Testing Guidelines (used during April-December 2013 data review)

ALL Examinations

CBC with manual differential

Comprehensive metabolic panel

Lipid panel

Thyroid panel–thyroid stimulating hormone (TSH), free T4, T3

Thyroid peroxidase antibody (TPO antibody) 

Thyroglobulin antibody (TG antibody)

Follicle stimulating hormone (FSH)

Luteinizing hormone (LH)

Testosterone (total and free)

Prolactin

Sex hormone binding globulin (SHBG)

Men–sperm count (offered but none collected)

Women–If of childbearing age (if desired): estradiol, 3-day

anti-Mullerian hormone (AMH)

Baseline Examination ONLY

History and physical

Aspartate aminotransferase (AST)

Alanine aminotransferase (ALT)

Alkaline phosphatase (ALP)

Electrocardiogram (EKG)

Chest X-ray

Low testosterone questionnaire (men)

Obstetrics / gynecological history (women)

Thyroid questionnaire

Additional Surveillance Examination Elements

Pulmonary function test (spirometry; baseline results only)

Comparison of the IMX-101 Medical Surveillance Guidelines.3

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THE IMX-101 EXPERIENCE
January – June 2018 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

Addressing the suspected reproductive system effects of 

NTO, the USAPHC-AIPH conducted a literature review 

of infertility and abnormal endocrine findings related to 

reproduction in the general US population. According 

to a recent CDC study discussing infertility rates among 

the general US population, 12% of women and 9% of 

men aged from 15 to 44 years have sought medical help 

to have a baby (conceive or prevent miscarriage).8 Testing for changes in both male and female sexual hormones 

to date has not shown any adverse effects to exposed 

workers. Optional sperm count testing was offered to 

male workers as part of the original surveillance protocol but no samples were collected. It would be difficult 

for occupational health providers to distinguish IMXrelated infertility when compared to the “background 

infertility” of the general US population. Because there 

is no long-term safety data regarding any of the IMX101 compounds and to monitor the unlikely but still possible effects of NTO on reproductive health, Monks and 

Mirza 3 developed a model questionnaire that could be 

used to evaluate workers’ reproductive health.

The potential for a rapidly changing plant operations 

schedule affecting the timing of surveillance exams and 

changes in exposure profiles in the newly proposed guidance is an issue that poses a challenge. For example, a 

worker (or segment of workers) in a plant may produce 

IMX-101 for only 3 months. Once this production cycle 

is over, they may work in an area that has a different hazard exposure profile. Constantly altering the medical surveillance (or even the need for surveillance) can be difficult from the occupational health perspective. This issue 

has been identified and will require further investigation.

While it is true that the above testing regime has the 

potential to detect non-IMX-101 related medical issues, 

it is believed that this method is more focused on the 

important and most likely IMX-related health effects. 

There is also enough confirmatory testing built into the 

scheme to detect these issues with fair certainty. The 

goal is to detect IMX-related adverse health issues in the 

absence of BEIs. If the evaluation focuses on the known 

(or most likely) health effects without interference of 

non-evidence-based testing, then the surveillance is 

achieving its goal until a better method is developed.

One final item that is important to mention was the effort that was placed into producing a clearly written 

health risk management message explaining why the 

USAPHC-AIPH was recommending changes to the 

medical surveillance. It is essential to explain to occupational health clinic providers and workers why their testing regimen would be changing in a way that they can 

understand and accept the reasoning behind the decision.

Summary

This IMX case study represents the difficult situation of 

retroactively trying to develop a medical surveillance 

program to address potential exposure to new compounds. Attempting to accomplish all of the necessary 

steps as discussed in this article to build an evidencebased approach for medical surveillance is made more 

challenging after production has started and workers are 

potentially exposed. This approach has potential health 

risk implications for the workers involved. It appears 

that no adverse effects related to IMX-101 or its individual compounds have occurred to date. It is possible 

that we are currently monitoring workers with the most 

sensitive and specific biologic tests available for IMX101, but lack the studies to prove that this is the case.

We are in a better position today in defining the health 

risks of IMX-101 and refining the methods to protect 

workers than we were a few years ago. There are still 

knowledge gaps that must be explored before it can be 

said that there is a “best-case scenario.” That scenario 

includes industrial hygiene monitoring that is technically reliable and accurately defines the exposure levels, engineering controls that reduce exposures as much 

possible, the use of PPE (as appropriate) based on the 

remaining exposure risk, and an evidence-based medical surveillance program that evaluates and detects the 

biologic effect on humans with specificity and sensitivity. The Army and all stakeholders remain dedicated to 

improving their portion of this program and ultimately 

will focus on what is best to protect the worker.

Acknowledgements

I thank Dr Raul Mirza, Dr Pearline McKenzie-Garner, 

Ms Renita Shoffner, Dr Mark Johnson and his team in 

the Toxicology Directorate at the APHC, Ms Lindsey 

Kneten, LTC Joseph Llanos, COL William Rice, and Dr 

Pete Matos for their contributions to this article.

References

1. Beyard M. US insensitive munitions policy update. 

Paper presented at: National Defense Industrial Association Insensitive Munitions & Energetic Materials Technology Symposium; 2007; Miami, FL.

2. Fung V. Process improvement and optimization of 

insensitive explosive IMX-101. National Defense 

Industrial Association Insensitive Munitions & 

Energetic Material Technology Symposium; 2012; 

Las Vegas, NV.

3. Monks WS, Mirza RA. Medical Surveillance Examination for Workers Exposed to IMX-101 and 

Its Components [white paper]. Aberdeen Proving 

Ground, MD: US Army Public Health Command; 

2014.
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

4. Williams L, Johnson M, Eck WS. Toxicology Report No. S.0024589-15. Toxicology Assessment of 

IMX-101-Update. Aberdeen Proving Ground, MD: 

US Army Public Health Command; December 

2014.

5. Department of the Army. Technical Bulletin Medical 297. Guidelines for Exposure Prevention, Medical Surveillance and Evaluation of Workers with 

the Potential for Exposure to 2,4,6-Trinitrotoluene 

(TNT).Washington, DC: US Department of the 

Army; 2010.

6. Marchand A, Galen RS, Van Lente F. The predictive value of serum haptoglobin in hemolytic disease. JAMA. 1980;243(19):1909-1911.

7. Galen RS. Application of the predictive value model in the analysis of test effectiveness. Clin Lab 

Med. 1982;2(4):685-699.

8. Chandra A, Copen CE, Stephen EH. Infertility Service Use in the United States: Data From the National Survey of Family Growth, 1982-2010. Natl 

Health Stat Report. 2014;22(73):1-21.

Author

Mr Monks is a Physician Assistant, Occupational Medicine Division, US Army Public Health Center, Aberdeen 

Proving Ground, Maryland.

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THE IMX-101 EXPERIENCE
January – June 2018 67

Background

Globally, approximately 2 million new incident cancer 

cases are caused by infectious diseases every year, and 

600,000 of these cases are caused by the Human Papillomavirus (HPV).1

 Interestingly, HPV is also the most 

common sexually transmitted infection (STI) in the 

United States with an estimated 14 million new genital HPV infections yearly, half of which are diagnosed 

among individuals 15 to 24 years of age.2 From 2003 to 

2006, HPV prevalence was as high as 42.5% among females aged 14 to 59 years,3

 the majority of whom (53.8%) 

were aged 20 to 24 years.4 Further, studies have demonstrated that HPV seroprevalence is actually low (1% to 

8%) in late adolescence but increases with age, reaching 

up to 15% to 35% by age 40 years.5 However, HPV acquisition may be accelerated in highly sexually active 

populations, such as military personnel.6,7 For example, 

HPV seroprevalence was reported to be as high as 45% 

to 51% among active duty (AD) women.7 Another study 

found that incident infections of HPV were common 

with more than one-third of male AD service members 

seroconverting to one or more of the HPV serotypes.5 In 

fact, HPV is also the most common STI among the US 

military,8 although HPV vaccination coverage remains 

consistently low.9 During the years 2000 to 2012, there 

were an estimated 304,021 incident cases of HPV (17.5 

per 100,000 person-years) among AD service members.10 To put these data in perspective, the number of 

healthcare visits due to HPV alone was greater than 

gonorrhea and chlamydia combined.5 More recently, a 

study among female AD service members revealed only 

22.5% vaccination uptake of one dose or more.9

Although most HPV infections are self-limited and

asymptomatic,11 persistent infection with high-risk HPV 

types can cause cancers of the cervix, vagina, vulva, 

penis, anus, rectum, and oropharynx.12-14 Specifically, 

HPV 16 and HPV 18 are high-risk types that are more 

likely to persist and progress to cancer.15,16 Whereas, 

low-risk HPV types 6 and 11 typically cause anogenital 

warts and respiratory papillomatosis.17 Thus, cancer prevention and treatment requires public health interventions and early detection.

One primary prevention tool is immunization. Vaccines 

have been one of the greatest success stories in public health. The Food and Drug Administration has approved 2 cancer preventive vaccines, one for Hepatitis 

B virus18 that is a leading cause of liver cancer, the other 

for HPV. In 2006, a 3-dose HPV quadrivalent vaccine 

(4vHPV) (Gardasil; Merck & Co, Inc, Whitehouse Station, NJ) was licensed in the United States, protecting 

against several HPV strains (types 6, 11, 16, 18) that are 

responsible for about 70% of cervical cancers and 80% 

of genital warts.9 The Advisory Committee on Immunization Practices (ACIP) and the US Centers for Disease 

Control and Prevention (CDC) recommended its use in 

females aged 11-12 years, and catch-up vaccination for 

females aged 13 to 26 years who have not been previously vaccinated.19 A bivalent HPV vaccine (2vHPV) (Cervarix; GlaxoSmithKline plc, Brentford, London, UK) 

was licensed in 2009.20 The ACIP also expanded their 

recommendation in 2009 to include vaccination with 

the 4vHPV for males between ages 9 and 26 years.21

In 2014, a 9-valent HPV vaccine (9vHPV) (Gardasil 9; 

Merck & Co, Inc) became available.22 The ACIP recommended that any of these 3 vaccines be used for routine 

vaccinations of females, while only 2 vaccines (4vHPV 

and 9vHPV) were indicated for males.23 In 2016, ACIP 

updated their recommendations regarding dosing schedules and administration of the 9vHPV vaccine.24,25 The 

notable change from prior ACIP reports22,23 was the reduction to a 2-dose schedule for males and females who 

Missed Opportunities in Human

 Papillomavirus Vaccination Uptake

 Among US Air Force Recruits, 2009-2015

COL Paul O. Kwon, MC, USA

Jenny Lay, MPH

David Hrncir, MD, MPH

Lynn Levin, PhD, MPH

The material contained in this study was reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation 

and/or publication. The investigators have adhered to the policies for protection of human subjects as prescribed in Army Regulation 70-

25: Use of Volunteers as Subjects of Research, 1990.
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

start the series at ages 9 to 14 years. For young adults 

between the ages of 15 to 26 years, the dosing schedule 

remained unchanged at 3 doses.24,25

The 5 additional types included in 9vHPV vaccine contained oncogenic types 31, 33, 45, 52, and 58 which 

added primary protection against cervical cancer and 

cervical pre-cancers, including cervical intraepithelial 

neoplasia grade 2 or 3 and adenocarcinoma in situ.23,26

In late 2016, when the 9vHPV vaccine was widely distributed in the United States,24 the CDC estimated an 

average of 30,700 HPV-related cancers diagnosed yearly, 

of which approximately 92% were attributed to these 

specific HPV types.15,27 Among females, this translates 

to prevention of approximately 81% of cervical, 73% 

of vaginal, and 63% of vulvar cancers.15 Among males, 

57% of penile cancer could be prevented. Among males 

and females combined, an estimated 88% of anal and 

66% of oropharyngeal cancers would be preventable.15

Overall, an estimated total of 28,500 cancers would be 

prevented per year with full vaccine coverage with the 

9vHPV vaccine and 100% vaccine efficacy.27,28 Additionally, close to 90% of all anogenital warts would be 

prevented along with most cases of recurrent respiratory papillomatosis.17 Even though these vaccines are 

available, one study revealed an increased incidence of 

HPV-associated cancers occurring in 11.7 per 100,000 

population from 2008 to 2012, compared with the rate 

of 10.8 per 100,000 population from 2004 to 2009.27,29

Although HPV vaccination uptake has increased in both 

females and males since a licensed HPV vaccine was 

first made available for each sex,22 low coverage among 

adolescent populations continues to exist.30 During the 

period 2014-2015, the 1 dose or more coverage was only 

62.8% for females and 49.8% for males among the age 

group 13 to 17 years. Comparatively, the 1 dose or more 

coverage (56.1%) for females and males combined was 

less than the coverage for the 1 dose or more (81.3%) 

of meningococcal 4-valent conjugate vaccine and the 

coverage for the 1 dose or more (86.4%) of tetanusdiphtheria-acellular pertussis vaccine. This disparity 

underscores the extent of the HPV vaccination uptake 

deficiencies among these younger age groups.30 Thus, 

catch-up vaccination recommendations herald an opportunity for increased awareness and public health efforts to increase HPV immunization uptake rates.

Several factors support the ACIP recommendation to 

vaccinate males and females in the catch-up age range. 

These include studies showing high HPV vaccine efficacy in sexually active women aged 15 to 26 years 

with prior HPV exposure,31 reports on the prevalence 

of HPV infection in US women,3 lack of exposure to 

high-risk HPV types included in the 9vHPV vaccine,32

and cost-effectiveness analyses on catch-up vaccination 

within this older population.33,34 Less is known, however, 

about HPV vaccine uptake in the catch-up group of older teens and young adults as the National Health Interview Survey only began collecting data in 2013 on age 

at first HPV dose among female and males aged 15 to 

26 years.35 In one study, HPV vaccination uptake among 

adults aged 19 to 26 years who reported ever receiving one dose or more of an HPV vaccine was quite low. 

Among women aged 19 to 26 years, approximately 12% 

reported receiving their first ever dose of HPV vaccine 

as catch-up sometime between ages 19 to 26 years, compared to only 2% of men within similar age groups.36

Following the ACIP recommendations,22 the Department 

of Defense (DoD) made the 9vHPV vaccine available to 

service members aged 17 to 26 years.37,38 In 2013, the 

President’s Cancer Panel developed a strategy to accelerate vaccine coverage.1

 As part of this national effort, the 

DoD created a set of instructions39 in order to promote 

these goals. Additionally, the US Department of Health 

and Human Service’s Healthy People 2020 goals were 

updated to reach higher HPV vaccination coverage in 

specific age groups.40 More recently, the National Cancer 

Institute issued a joint statement to focus on the low coverage rates of HPV vaccinations and the missed opportunities to prevent vaccine preventable cancer. Placing HPV 

vaccination as a global health priority, the US National 

Cancer Program has focused on a vaccination campaign 

against avoidable cancers. The campaign addresses one 

of the primary and most effective goals to combat preventable cancer: reduce missed clinical opportunities to

recommend and administer HPV vaccines.

41

Despite these efforts, low vaccination uptake rates persist for both the adolescent and catch-up age groups of 

older teens and young adults. The main goal of this study 

was to characterize the missed opportunities and past 

HPV vaccine uptake rates among AD Air Force (AF) 

recruits (some of whom have prior doses of HPV vaccination documented in their historical electronic DoD 

immunization records) across a 6-year period (2009-

2015) in order to highlight the importance of continued 

surveillance and catch-up immunization campaigns 

within the US military. As electronic vaccination and 

medical records are centralized for the US AF AD and 

beneficiary populations, our objectives were to determine HPV vaccine uptake by HPV vaccine dose and to 

quantify missed opportunities for HPV vaccination during basic training among this population in the catch-up 

age group, aged 17 to 26 years.

MISSED OPPORTUNITIES IN HUMAN PAPILLOMAVIRUS VACCINATION UPTAKE

AMONG US AIR FORCE RECRUITS, 2009-2015
January – June 2018 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

Methods

A retrospective descriptive analysis of electronic records was performed to determine vaccine uptake and 

the percent of missed opportunities for HPV vaccination among AD AF recruits. The study population was 

identified using administrative data from the Basic Military Training System and included all AD AF recruits 

attending basic training at Joint Base San AntonioLackland from October 1, 2009, to September 30, 2015. 

Vaccination codes and other medical encounter data 

were obtained from the Aeromedical Services Information Management System (ASIMS) and the Air Force 

Medical Operations Agency (AFMOA). Demographic 

and military service data, including birth year, age, sex, 

marital status, race/ethnicity, and military beneficiary 

status prior to the beginning of basic training, were obtained from the Defense Enrollment Eligibility Reporting System and confirmed using military personnel data. 

Recruits who were younger than 17 years, older than 26 

years, or did not complete basic training were excluded from the analysis.

HPV vaccination uptake among recruits for the period prior to entry 

into military service and during basic 

training was calculated using ASIMS 

data. Vaccine uptake rates were determined according to sex, age group, 

birth year, race/ethnicity, marital status, year of entry into basic military 

training, and prior military beneficiary status, stratified by the number of 

HPV doses. Any recruit with a record 

of receiving 3 or more HPV doses was 

considered to have completed the dose 

series.

A missed opportunity for HPV vaccination was defined as a well-care outpatient encounter (non-HPV infection 

related) occurring on or after initial 

intake within a recruit’s basic training 

dates when he or she was eligible for 

HPV vaccination and the vaccine was 

not administered. The number and 

percentage of missed opportunities 

to initiate HPV vaccination during 

basic training by demographic and 

service-related characteristics were 

calculated using ASIMS and AFMOA 

data for recruits who never received 

one dose of HPV vaccine prior to 

entry or during basic training. Statistical methods included computing 

means and proportions to describe vaccine uptake rates 

and missed opportunities in the study population. Data 

were analyzed using SAS version 9.4 (SAS Institute 

Inc, Carey, NC). Approval to conduct the study was obtained from the Institutional Review Boards of Walter 

Reed Army Institute of Research and Joint Base San 

Antonio-Lackland.

Results

The study population included a total of 198,888 AD AF 

recruits aged 17 to 26 years who had completed basic 

training between October 1, 2009, and September 30, 

2015. The mean age of the recruits was 20.16 years (SD 

2.16 years), with the majority comprised of males (79%), 

non-Hispanic whites (67%), and single marital status 

(69%) (Table 1). Among all recruits in this predominately 

male population, 0.44% received one HPV dose, 0.30% 

received 2 doses, and 0.83% had 3 or more doses (Table 

2). Female recruits had much higher vaccine coverage 

than males (one or more dose(s) was 

5.7% for women and 0.47% for men). 

Coverage for one or more HPV dose(s) 

was highest in the youngest catch-up 

age group 17-20 (1.7%) and then decreased somewhat with increasing age 

(Table 2). A pattern of increasing vaccine uptake with each subsequent birth 

cohort also was observed. Among 

race/ethnic groupings, non-Hispanic 

whites (1.2%) had the lowest vaccine 

uptake at each vaccine dose (Table 2). 

Single recruits also had slightly lower 

vaccine uptake for one or more HPV 

dose(s) (1.5%) compared with married recruits (1.8%) (Table 2). In addition, vaccine uptake among recruits 

increased with each year of entry into 

basic training during the study period, 

2009-2015 (Table 2).

Among the subset of 22,720 recruits 

with prior TRICARE beneficiary 

status, patterns of vaccine uptake 

by demographic and service-related 

characteristics were similar to those 

found for all recruits; however, HPV 

coverage was much higher compared 

with recruits without prior TRICARE 

beneficiary status. Overall, vaccine 

uptake for one or more HPV dose(s) 

among women who were prior beneficiaries was 25.2%, but only 3.8% 

among men with prior beneficiary 

status (Table 3).

Table 1. Demographic Characteristics 

of US Air Force Recruits, 2009-2015

(N=198,888).

Demographic Category n (%N)

Sex

Male 157,129 (79%)

Female 41,759 (21%)

Age Group, years

17-20 129,696 (65%)

21-23 49,222 (25%)

24-26 19,970 (10%)

Cohort Year*

1983-1986 10,786 (5%)

1987-1990 57,171 (29%)

1991-1994 102,038 (51%)

1995-1998 28,863 (15%)

Race/Ethnicity

White, non-Hispanic 133,015 (67%)

Black, non-Hispanic 31,135 (16%)

Hispanic 19,372 (10%)

Asian/Pacific Islander 7,770 (4%)

Other 7,596 (4%)

Marital Status

Married 59,867 (30%)

Single 137,789 (69%)

Other 1,223 (1%)

Year of Entry

2009 10,504 (5%)

2010 33,486 (17%)

2011 35,100 (18%)

2012 35,272 (18%)

2013 31,627 (16%)

2014 29,692 (15%)

2015 23,207 (12%)

*Cohort year not determined for 6 recruits.
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

Table 4 presents the results of missed opportunities for the first dose of HPV vaccine among 

AD AF recruits for whom the data showed 

that they were never vaccinated against HPV. 

Of the 195,744 recruits who had not initiated 

the HPV vaccination, 99.9% had one or more 

missed opportunities, 95.3% had 2 or more 

missed opportunities, and 76% had 3 or more 

missed opportunities to receive the first HPV 

dose.

Comment

In this study, we determined HPV vaccine uptake and missed opportunities to initiate the 

HPV vaccination series among a population 

of AD AF recruits between the ages of 17 to 

26 years, a catch-up age group for routine HPV 

vaccination recommended by the ACIP among 

those who have not been previously vaccinated. Male recruits comprised 79% of this 

study population. The particularly low vaccine 

uptake of 5.7% for women with one or more 

dose(s) and 0.47% for men with one or more 

dose(s) was likely due to the inadequate capture of nonmandated HPV vaccine information 

in a recruit’s ASIMS record. In addition, the 

observed low coverage among males may be 

the result of ACIP recommendations for HPV 

vaccination for males in the catch-up age range 

during the study period.21-23 As of 2016, ACIP 

recommends routine HPV vaccination among 

males up to age 21 if they were not previously 

vaccinated or had not completed the 3-dose series. However, ACIP states that the HPV vaccine may be offered to males aged 22-26 years.23

Other studies that have examined HPV vaccine 

uptake in military populations have conducted 

female only studies. In a relatively large study 

of 270, 257 age-eligible service women in the 

Army, Air Force, Navy, Marine Corps, and 

Coast Guard, 22.5% received at least one HPV 

dose during the study period, 2006-2011.9 In a 

smaller study conducted at an Army medical 

center, 14.8% of eligible AD service women 

aged 18 to 26 years received one or more HPV 

vaccine doses during the period 2007-2010,42

while another study conducted at a Navy medical center and its affiliated clinics found that beneficiaries had higher vaccination coverage than AD service 

women.43 While we also found higher vaccine uptake 

among recruits with prior beneficiary status where electronic records were available, the vaccine coverage was 

only 25.2% for women and 3.8% for men, an alarmingly 

low uptake among a population that has full access to 

healthcare.

There were numerous well-care medical encounters 

during basic training among this population of AD AF 

recruits which underscores the importance of offering 

MISSED OPPORTUNITIES IN HUMAN PAPILLOMAVIRUS VACCINATION UPTAKE

AMONG US AIR FORCE RECRUITS, 2009-2015

Table 2. HPV Vaccination Uptake Among US Air Force Recruits, 2009-2015. 

Demographic

Category

Number

in Category

n

Number of HPV Vaccinations

1 Dose

n1 (%n)

2 Doses

n2 (%n)

3 Doses

n3 (%n)

Study Population Total 198,888 881 (0.4%) 605 (0.3%) 1,658 (0.8%)

Sex

Male 157,129 315 (0.2%) 176 (0.1%) 253 (0.1%)

Female 41,759 566 (1.4%) 429 (1.0%) 1,405 (3.4%)

Age Group, years

17-20 129,696 598 (0.5%) 421 (0.3%) 1,143 (0.9%)

21-23 49,222 208 (0.4%) 135 (0.3%) 373 (0.8%)

24-26 19,970 75 (0.4%) 49 (0.2%) 142 (0.7%)

Cohort Year*

1983 642 5 (0.8%) 1 (0.2%) 2 (0.3%)

1984 1,715 6 (0.3%) 1 (0.1%) 6 (0.3%)

1985 3,314 11 (0.3%) 8 (0.2%) 11 (0.3%)

1986 5,115 14 (0.3%) 11 (0.2%) 34 (0.7%)

1987 7,848 28 (0.4%) 9 (0.1%) 34 (0.4%)

1988 11,126 42 (0.4%) 26 (0.2%) 72 (0.6%)

1989 15,785 62 (0.4%) 37 (0.2%) 92 (0.6%)

1990 22,412 79 (0.4%) 57 (0.3%) 155 (0.7%)

1991 27,876 102 (0.4%) 78 (0.3%) 207 (0.7%)

1992 27,524 99 (0.4%) 71 (0.3%) 184 (0.7%)

1993 25,120 129 (0.5%) 79 (0.3%) 230 (0.9%)

1994 21,518 133 (0.6%) 92 (0.4%) 262 (1.2%)

1995 16,300 83 (0.5%) 63 (0.4%) 210 (1.3%)

1996 9,843 66 (0.7%) 51 (0.5%) 120 (1.2%)

1997 2,710 21 (0.8%) 21 (0.8%) 39 (1.4%)

1998 10 1 (10%) 0 (0%) 0 (0%)

Race/Ethnicity

White, non-Hispanic 133,015 403 (0.3%) 301 (0.2%) 946 (0.7%)

Black, non-Hispanic 31,135 221 (0.7%) 115 (0.4%) 243 (0.8%)

Hispanic 19,372 101 (0.5%) 87 (0.4%) 208 (1.1%)

Asian/Pacific Islander 7,770 71 (0.9%) 45 (0.6%) 87 (1.1%)

Other 7,596 85 (1.1%) 57 (0.8%) 174 (2.3%)

Marital Status

Married 59,867 275 (0.5%) 217 (0.4%) 572 (1.0%)

Single 137,789 584 (0.4%) 381 (0.3%) 1,069 (0.8%)

Other 1,223 85 (7.0%) 57 (4.7%) 174 (14.2%)

Year of Entry

2009 10,504 51 (0.5%) 23 (0.2%) 60 (0.6%)

2010 33,486 90 (0.3%) 58 (0.2%) 155 (0.5%)

2011 35,100 127 (0.4%) 80 (0.2%) 238 (0.7%)

2012 35,272 151 (0.4%) 86 (0.2%) 280 (0.8%)

2013 31,627 164 (0.5%) 119 (0.4%) 284 (0.9%)

2014 29,692 142 (0.5%) 129 (0.4%) 327 (1.1%)

2015 23,207 156 (0.7%) 110 (0.5%) 314 (1.4%)

*Cohort year not determined for 6 recruits.
January – June 2018 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

HPV vaccination in this catch-up age group. Of note, 

99% of recruits had one or more missed opportunities

to initiate the vaccination series. A study of women with 

private insurance also reported that a large percentage 

(97.1%) of unvaccinated women in the catch-up age 

range had at least one missed opportunity to receive the 

first dose of the HPV vaccine.44 It is important to note 

that an opportunity for HPV vaccination can be considered an opportunity to reduce risk of several HPVassociated cancers including carcinomas of the cervix 

and squamous cell cancers of the vagina, vulva, penis, 

anus, rectum, and oropharynx.13-15

A major strength of the current evidence-based study is 

the inclusion of all AD AF recruits during the period 

October 1, 2009 to September 30, 2015. This allowed for 

standard and comprehensive data collection, utilizing 

a centralized electronic database, in order to compute 

HPV uptake and trends. This study is also one of few45

that describes vaccine uptake and missed opportunities 

among males in the catch-up age range, an age group 

that is considered an important component of the US 

HPV vaccination campaign. Some limitations, however, 

should also be considered. Information on prior history 

of HPV vaccination can be captured in ASIMS among 

recruits who were prior beneficiaries. However, since 

HPV vaccination is not mandatory for AD AF recruits, 

this information is provided on a voluntary basis for the 

majority of recruits. Thus, HPV vaccine uptake rates 

may be grossly underestimated among recruits that 

have no prior TRICARE beneficiary status and thus 

no available documentation of HPV vaccination from 

Table 3. HPV Vaccination Uptake Among US Air Force Recruits by Prior TRICARE Beneficiary Status, 

2009-2015. 

Demographic

Category

No Prior TRICARE Beneficiary Status Prior TRICARE Beneficiary Status

Total

n1

1 Dose

%n1

2 Doses

%n1

3 Doses

%n1

Total

n2

1 Dose

%n2

2 Doses

%n2

3 Doses

%n2

Study Population Total 176,168 0.14% 0.09% 0.32% 22,270 2.79% 1.94% 4.85%

Sex

Male 140,519 0.03% 0.02% 0.03% 16,610 1.61% 0.92% 1.30%

Female 35,649 0.56% 0.40% 1.46% 6,110 6.01% 4.71% 14.50%

Age Group, years

17-20 113,942 0.11% 0.10% 0.32% 15,754 2.98% 1.98% 4.96%

21-23 43,719 0.18% 0.09% 0.29% 5,503 2.38% 1.76% 4.51%

24-26 18,507 0.22% 0.10% 0.38% 1,463 2.32% 2.12% 4.92%

Cohort Year*

1983-1986 10,531 0.28% 0.15% 0.39% 255 2.75% 1.96% 4.71%

1987-1990 51,319 0.18% 0.09% 0.30% 5,852 2.05% 1.42% 3.42%

1991-1994 89,020 0.12% 0.10% 0.33% 13,018 2.72% 1.77% 4.56%

1995-1998 25,275 0.07% 0.06% 0.28% 3,588 4.29% 3.37% 8.28%

Race/Ethnicity

White, non-Hispanic 119,929 0.10% 0.06% 0.31% 13,086 2.12% 1.72% 4.42%%

Black, non-Hispanic 26,898 0.24% 0.14% 0.23% 4,237 3.68% 1.82% 4.30%

Hispanic 17,123 0.13% 0.16% 0.38% 2,249 3.47% 2.67% 6.36%

Asian/Pacific Islander 6,785 0.28% 0.18% 0.46% 985 5.28% 3.35% 5.69%

Other 5,433 0.26% 0.22% 0.57% 2,163 3.28% 2.08% 6.61%

Marital Status

Married 52,797 0.14% 0.12% 0.40% 7,070 2.87% 2.16% 5.09%

Single 122,291 0.13% 0.08% 0.27% 15,498 2.73% 1.84% 4.74%

Other 1,072 1.21% 0.47% 0.84% 151 5.96% 1.32% 5.30%

Year of Entry

2009 10,477 0.49% 0.22% 0.57% 27 0.00% 0.00% 0.00%

2010 30,137 0.14% 0.08% 0.25% 3,349 1.40% 0.99% 2.36%

2011 30,999 0.14% 0.13% 0.30% 4,101 2.07% 1.00% 3.54%

2012 30,807 0.11% 0.08% 0.34% 4,465 2.60% 1.34% 3.90%

2013 27,605 0.13% 0.08% 0.35% 4,022 3.21% 2.41% 4.67%

2014 25,898 0.07% 0.08% 0.29% 3,794 3.29% 2.87% 6.64%

2015 20,245 0.11% 0.05% 0.25% 2,962 4.49% 3.38% 8.91%

*Cohort year not determined for 6 recruits.
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

electronic medical records. Also, this study population 

is comprised primarily of men in the catch-up age group 

for which HPV vaccination may not be readily available in the outpatient setting. In addition, validation of 

the number of HPV vaccine doses by specific dates and 

information on the timing to receive a second or third 

dose of the vaccine series during basic training could 

not be determined for vaccine-eligible recruits. It was 

only possible, therefore, to estimate missed opportunities among recruits who never received the vaccine, but 

information was not available to determine missed opportunities for the second or third dose. Moreover, some 

recorded missed opportunities may have resulted from 

administrative medical encounters rather than encounters for preventive care. Finally, the study population 

was comprised of AD AF recruits 

only, so the results may not be generalizable to recruit populations in 

the other branches of the US armed 

forces.

Conclusion

Universal access to HPV vaccination among this at-risk population 

of AD AF military recruits, representing the catch-up age group, will 

help reduce missed opportunities 

for HPV vaccination. In turn, this 

will ultimately lead to the reduction in several cancers that are causally linked to HPV. Targeted efforts 

should be made to address barriers to administer HPV vaccines 

in medical care encounters during basic training as this is a readily accessible population.46 Public 

health efforts to reach goals of increased HPV vaccination uptake 

and decreased missed opportunities

among the AD recruit population 

are feasible and necessary. Coordinated efforts by multiple agencies 

within the AF as well as in the other 

services are needed to improve HPV 

vaccine utilization. Goals should 

include increased initiation of the 

first HPV dose and completion of all 

recommended doses for age-eligible 

service members. Overall, promotion of DoD HPV immunization 

policies to provide access to vaccination for all age-eligible recruits 

will benefit the force health protection of US military in order to reach the goals of DoD, 

Healthy People 2020,

39 and the President’s Cancer Panel.1

 Further research in HPV vaccination uptake rates in 

the catch-up age group among the other branches of the 

armed forces is warranted.

Acknowledgements

We thank the technical staff of Joint Base San AntonioLackland for their assistance in preparing the ASIMS 

dataset for this study. Particularly, Dr Rebecca Hall and 

Mr David Tucker were instrumental in the collection and 

coordination of the ASIMS data. We also thank Ms Janice Gary of the Walter Reed Army Institute of Research 

who played a key role in the overall management of this 

research.

MISSED OPPORTUNITIES IN HUMAN PAPILLOMAVIRUS VACCINATION UPTAKE

AMONG US AIR FORCE RECRUITS, 2009-2015

Table 4. Number of Missed Opportunities for HPV Vaccination Among US Air Force 

Recruits Who Had Not Been Vaccinated Upon Reporting for Initial Training, 2009-2015. 

Demographic

Category

Number of Missed Opportunities

Total

n1

1 or 

More

n2

%n2

2 or 

More

n3

%n3

3 or 

More

n4

%n4

Study Population Total 195,744 195,607 99.9% 186,516 95.3% 148,705 76.0% 

Sex

Male 156,385 156,272 99.9% 148,373 94.9% 120,030 76.8% 

Female 39,359 39,335 99.9% 38,143 96.9% 28,675 72.9% 

Age Group, years

17-20 127,534 127,434 99.9% 121,964 95.6% 100,019 78.4% 

21-23 48,506 48,482 100.0% 45,886 94.6% 34,785 71.7% 

24-26 19,704 19,691 99.9% 18,666 94.7% 13,901 70.5% 

Cohort Year*

1983-1986 10,676 10,671 100.0% 10,469 98.1% 8,999 84.3% 

1987-1990 56,478 53,448 94.6% 51,443 91.1% 42,579 75.4% 

1991-1994 100,372 100,314 99.9% 95,166 94.8% 75,187 74.9% 

1995-1998 28,188 28,145 99.8% 26,411 93.7% 21,920 77.8% 

Race/Ethnicity

White, non-Hispanic 131,365 131,268 99.9% 125,795 95.8% 101,227 77.1% 

Black, non-Hispanic 30,556 30,529 99.9% 29,018 95.0% 22,443 73.4% 

Hispanic 18,976 18,971 100.0% 17,864 94.1% 14,082 74.2% 

Asian/Pacific Islander 7,567 7,566 100.0% 7,200 95.1% 5,797 76.6% 

Other 7,280 7,273 99.9% 6,639 91.2% 5,156 70.8% 

Marital Status

Married 58,803 58,785 100.0% 56,552 96.2% 45,698 77.7%

Single 135,755 135,636 99.9% 128,975 95.0% 102,218 75.3%

Other 1,186 1,185 99.9% 988 83.3% 788 66.4%

Year of Entry

2009 10,370 10,350 99.8% 9,975 96.2% 8,196 79.0% 

2010 33,183 33,179 100.0% 32,989 99.4% 27,790 83.7% 

2011 34,655 34,645 100.0% 34,369 99.2% 29,803 86.0% 

2012 34,755 34,732 99.9% 33,134 95.3% 27,414 78.9% 

2013 31,060 31,043 99.9% 28,185 90.7% 18,713 60.2% 

2014 29,094 29,072 99.9% 26,769 92.0% 19,711 67.7% 

2015 22,627 22,586 99.8% 21,095 93.2% 17,078 75.5% 

*Cohort year not determined for 6 recruits.
January – June 2018 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

References

1. Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer. A Report to the President 

of the United States from The President’s Cancer 

Panel. Bethesda, MD: National Cancer Institute; 

2014. Available at: https://deainfo.nci.nih.gov/ad

visory/pcp/annualreports/HPV/PDF/PCP_Annu

al_Report_2012-2013.pdf. Accessed February 23, 

2018.

2. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and 

men: prevalence and incidence estimates, 2008. 

Sex Transm Dis. 2013;40(3):187-193.

3. Hariri S, Unger ER, Sternberg M, et al. Prevalence 

of genital human papillomavirus among females in 

the United States, the National Health and Nutrition Examination Survey, 2003-2006. J Infect Dis. 

2011;204:566-573.

4. Dunne EF, Sternberg M, Markowitz LE, et al. Human papillomavirus (HPV) 6, 11, 16, and 18 prevalence among females in the United States-National 

Health and Nutrition Examination Survey, 2003-

2006: Opportunity to measure HPV vaccine Impact? J Infect Dis. 2011;204:562-565.

5. Agan BK, Macalino GE, Nsouli-Maktabi H, et al. 

Human papillomavirus seroprevalence among men 

entering military service and seroincidence after 

ten years of service. MSMR. 2013;20(2):21-24.

6. Goyal V, Mattocks KM, Sadler AG. High-risk behavior and sexually transmitted infections among 

U.S. active duty servicewomen and veterans. J Womens Health (Larchmt). 2012;21(11):1155-1169.

7. Shah KV, Daniel RW, Tennant MK, et al. Diagnosis of human papillomavirus infection by dry vaginal swabs in military women. Sex Transm Infect. 

2001;77:260-264.

8. Nsouli-Maktabi H, Ludwig SL, Yerubandi UD, 

et al. Incidence of genital warts among U.S. service members before and after the introduction of 

the quadrivalent human papillomavirus vaccine. 

MSMR. 2013;20:17-20.

9. Maktabi H, Ludwig SL, Eick-Cost A, et al. Quadrivalent human papillomavirus vaccine initiation, coverage, and compliance among U.S. active 

component service women, 2006-2011. MSMR. 

2012;19:16.

10. Armed Forces Health Surveillance Center. Sexually transmitted infections, active component, U.S. 

Armed Forces, 2000-2012. MSMR. 2013;20(2):5-10.

11. Trottier H, Franco EL. The epidemiology of genital human papillomavirus infection. Vaccine. 

2006;24(suppl 1):S4-S15.

12. Fahn S, Cohen G. The oxidant stress hypothesis in 

Parkinson’s disease: evidence supporting it. Ann

Neurol. 1992;32:804-812.

13. Yakar S, Liu JL, Stannard B, et al. Normal growth 

and development in the absence of hepatic insulinlike growth factor I. Proc Natl Acad Sci U S A. 

1999;96:7324-7329.

14. Shiels MS, Kreimer AR, Coghill AE, et al. Anal 

cancer incidence in the United States, 1977-2011: 

distinct patterns by histology and behavior. Cancer

Epidemiol Biomarkers Prev. 2015;24:1548-1556.

15. Saraiya M, Unger ER, Thompson TD, et al. US assessment of HPV types in cancers: implications for 

current and 9-valent HPV vaccines. J Natl Cancer

Inst. 2015;107(6):djv086. Available at: https://aca

demic.oup.com/jnci/article/107/6/djv086/872092. 

Accessed February 23, 2018.

16. Wheeler CM, Hunt WC, Schiffman M, et al. Human papillomavirus genotypes and the cumulative 2-year risk of cervical precancer. J Infect Dis. 

2006;194:1291-1299.

17. Lacey CJ, Lowndes CM, Shah KV. Chapter 4: 

Burden and management of non-cancerous HPVrelated conditions: HPV-6/11 disease. Vaccine. 

2006;24(suppl 3):S3/35-41.

18. Mast EE, Margolis HS, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United 

States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents. 

MMWR Recomm Rep. 2005;54:1-31.

19. Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 

2007;56:1-24.

20. Centers of Disease Control and Prevention. FDA licensure of bivalent human papillomavirus vaccine 

(HPV2, Cervarix) for use in females and updated 

HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). 

MMWR Morb Mortal Wkly Rep. 2010;59:626-629.

21. Centers of Disease Control and Prevention. FDA 

licensure of quadrivalent human papillomavirus 

vaccine (HPV4, Gardasil) for use in males and 

guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal

Wkly Rep. 2010;59:630-632.

22. Markowitz LE, Dunne EF, Saraiya M, et al. Human 

papillomavirus vaccination: recommendations of 

the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63:1-30.
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

23. Petrosky E, Bocchini JA Jr, Hariri S, et al. Use of 

9-valent human papillomavirus (HPV) vaccine: 

updated HPV vaccination recommendations of the 

Advisory Committee on Immunization Practices. 

MMWR Morb Mortal Wkly Rep. 2015;64:300-304.

24. Meites E, Kempe A, Markowitz LE. Use of a 

2-dose schedule for human papillomavirus vaccination - Updated recommendations of the Advisory 

Committee on Immunization Practices. MMWR

Morb Mortal Wkly Rep. 2016;65:1405-1408.

25. Kim DK, Bridges CB, Harriman KH. Advisory 

Committee on Immunization Practices recommended immunization shedule for adults aged 19 

years or older--United States, 2016. MMWR Morb

Mortal Wkly Rep. 2016;65:88-90.

26. Hariri S, Unger ER, Schafer S, et al. HPV type attribution in high-grade cervical lesions: assessing 

the potential benefits of vaccines in a populationbased evaluation in the United States. Cancer Epidemiol Biomarkers Prev. 2015;24:393-399.

27. Viens LJ. Human papillomavirus–associated cancers—United States, 2008-2012. MMWR Morb

Mortal Wkly Rep. 2016;65.

28. Joura EA, Giuliano AR, Iversen OE, et al. A 

9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med. 

2015;372:711-723.

29. Wu XC, Watson M, Wilson R, et al. Human papillomavirus-associated cancers - United States, 

2004-2008. MMWR Morb Mortal Wkly Rep. 

2012;61:258-261.

30. Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 

years - United States, 2015. MMWR Morb Mortal

Wkly Rep. 2016;65:850-858.

31. Adams M, Jasani B, Fiander A. Prophylactic HPV 

vaccination for women over 18 years of age. Vaccine. 2009;27:3391-3394.

32. Liu G, Markowitz LE, Hariri S, et al. Seroprevalence of 9 human papillomavirus types in the United States, 2005-2006. J Infect Dis. 2016;213:191-198.

33. Chesson HW, Markowitz LE. The cost-effectiveness of human papillomavirus vaccine catch-up 

programs for women. J Infect Dis. 2015;211:172-174.

34. Burger EA, Sy S, Nygård M, et al. Too late to vaccinate? The incremental benefits and cost-effectiveness of a delayed catch-up program using the 

4-valent human papillomavirus vaccine in Norway. 

J Infect Dis. 2015;211:206-215.

35. Williams WW, Lu PJ, O’Halloran A, et al. Vaccination coverage among adults, excluding influenza 

vaccination - United States, 2013. MMWR Morb

Mortal Wkly Rep. 2015;64:95-102.

36. Williams WW, Lu PJ, O’Halloran A, et al. Surveillance of vaccination coverage among adult populations - United States, 2014. MMWR Surveill Summ. 

2016;65:1-36.

37. Forbes GB, Brown MR, Welle SL, et al. Hormonal response to overfeeding. Am J Clin Nutr. 

1989;49:608-611.

38. Bureau of Medicine and Surgery. BUMED Notice 

6230: Recommendations for the Use of Quadrivalent and Bivalent Human Papilloma Virus Vaccines in the Navy and Marine Corps. December 

10, 2012. Available at: http://www.med.navy.mil/

sites/nmcphc/Documents/nepmu-6/Epidemiol

ogy/BUMED-NOTE-6230-Recommendations-forHPV-Vaccine-Use-Dec2012.pdf. Accessed February 23, 2018.

39. DoD Instruction 1010.10: Health Promotion and

Disease Prevention. Washington, DC: US Department of Defense; April 28, 2014. Available at: 

http://www.esd.whs.mil/Portals/54/Documents

/DD/issuances/dodi/101010p.PDF?ver=2018

-01-12-113645-193. Accessed February 23, 2018.

40. US Department of Health and Human Services. 

Objective IID-11.4: Increase the vaccination coverage level of 3 doses of human papillomavirus 

(HPV) vaccine for females and males by age 13 to 

15 years. Immunization and Infectious Diseases 

page, HealthyPeople.gov web site. Available at: 

https://www.healthypeople.gov/2020/topics-objec

tives/topic/immunization-and-infectious-diseases/

objectives. Accessed February 28, 2018.

41. DiGiulio S. All 69 NCI-designated cancer centers 

issue joint statement on HPV vaccine. Oncol Times. 

2016;38:14. Available at: https://journals.lww.com/

oncology-times/Citation/2016/03100/All_69_NCI_

Designated_Cancer_Centers_Issue_Joint.5.aspx. 

Accessed February 23, 2018.

42. LaRocque JD, Berry-Caban CS. Human papilloma virus vaccination coverage among Soldiers 

in a military treatment facility, 2007-2010. J Vaccines Vaccin. 2011;2(1):116. Available at: https://doi.

org/10.4172/2157-7560.1000116. Accessed February 23, 2018.

43. Shen-Gunther J, Shank JJ, Ta V. GardasilTM HPV 

vaccination: surveillance of vaccine usage and adherence in a military population. Gynecol Oncol. 

2011;123:272-277.

44. Dunne EF, Stokley S, Chen WW, et al. human papillomavirus vaccination of females in a large health 

claims database in the United States, 2006-2012. J

Adolesc Health. 2015;56:408-413.

45. Clarke MA, Coutinho F, Phelan-Emrick DF, et al. 

Predictors of human papillomavirus vaccination in 

a large clinical population of males aged 11 to 26 

years in Maryland, 2012-2013. Cancer Epidemiol

Biomarkers Prev. 2016;25:351-358.

MISSED OPPORTUNITIES IN HUMAN PAPILLOMAVIRUS VACCINATION UPTAKE

AMONG US AIR FORCE RECRUITS, 2009-2015
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46. Wedel S, Navarrete R, Burkard JF, et al. Im- proving human papillomavirus vaccinations in 

military women. Mil Med. 2016;181:1224-1227.

Authors

COL Kwon is Director, US Medical Research Directorate-Georgia, Walter Reed Institute of Research, Silver 

Spring, Maryland.

Ms Lay is Chief, Department of Health Systems, Preventive Medicine Branch, Walter Reed Institute of Research, 

Silver Spring, Maryland.

Dr Hrncir is Regional Medical Director, Immunizations 

Healthcare Branch, Defense Health Agency, Joint Base 

San Antonio-Lackland, San Antonio, Texas.

Dr Levin is Senior Epidemiologist, Department of Epidemiology, Preventive Medicine Branch, Walter Reed 

Institute of Research, Silver Spring, Maryland.
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

Much of the world faces a growing obesity epidemic.1,2(pp92-97) The consequences of this serious problem are well established and potentially devastating. 

Conditions associated with an elevated body mass include diabetes, hypertension, coronary heart disease, 

and certain malignancies.2(pp97-100),3 For many, obesity 

and elevated body mass are a consequence of decreased 

physical activity; industrial advancements (eg, convenient transportation, technological advancements, and 

decreased need for manual labor) have contributed to an 

overall decrease in physical activity worldwide.4

Multiple studies have examined the reasons for becoming physically inactive, as well as the perceived barriers 

to activity and overall wellness.5-10 Common barriers include lack of time, inexperience with exercise, and lack 

of motivation.5,6,8-10 Although barriers to wellness and 

physical activity can affect anyone, certain professions 

demand an inherently more difficult work schedule that 

can itself be an obstacle to good health. Healthcare providers often have nontraditional work schedules and 

cite their challenging schedule as a barrier to healthy 

behavior.8 These issues are magnified in the United 

States, as the American workweek for all industries is 

already longer than other wealthy industrialized countries and employees are more likely to work odd and/or 

weekend hours.11 Long shifts, odd hours, and atypical 

schedules that are common among healthcare workers 

are barriers that logically detract from their ability to be 

physically active, beyond that which is required for their 

employment.

Before policy change can occur, leaders must understand if and how barriers to physical activity affect their 

specific population. Researchers have studied barriers 

in various settings, including corporate and healthcare 

worksites, but there is sparse evidence about how barriers affect those working at military hospitals.8,12 Military 

hospitals are unique in that employees may be active 

duty military members, civilian employees, or contractors. Each employee type has different training requirements and benefits.

In order to better inform military hospital leadership, 

the purposes of this study were to describe the common 

barriers to physical activity for employees at a military 

hospital, and investigate the association of barriers to 

physical activity with subjects’ perception of personal 

health status.

Methods

The health promotion team at a 42-bed military hospital with 1,147 military and civilian staff * and a large 

catchment area serving approximately 39,900 beneficiaries investigated current barriers to physical, nutritional, and spiritual wellness as part of the development 

of an employee wellness program. In the summer of 

2014, the team designed a survey to gather this information in partnership with the Army Public Health Center 

(APHC). The Injury Prevention Division at the APHC 

designed the electronic survey using Verint Enterprise 

Edition software (Melville, NY) and provided a secure 

link through which employees could access the survey. 

The study was approved by the APHC Public Health 

Review Board as public health practice and a data use 

agreement was formally put in place between the hospital team and APHC. The study was later presented to the 

Institutional Review Board at the University of North 

Carolina, which concurred that the investigation did not 

constitute human research.

The survey was intended to be inclusive of all hospital 

employees. There were no prerequisites to completing 

the survey and participation was anonymous and optional.13 Availability of the survey was announced via 

digital daily announcements, verbal advertisement to 

large groups of employees, word of mouth, and specific 

emails to the staff from hospital executives. The survey 

was open for a total of 45 days from October to December 2014.

In order to gain a true perspective of the holistic wellness state of hospital employees, subject matter experts 

Barriers to Physical Activity Among

 Military Hospital Employees

Darren Hearn, DPT, MPH

Anna Schuh-Renner, PhD

Michelle Canham-Chervak, PhD, MPH

Elina Urli Hodges, MSPH

Lori Evarts, MPH

*As of November 2014: 420 (37%) active duty military personnel, 

727 (63%) Department of the Army civilian employees.
January – June 2018 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

in the hospital from public health, physical therapy, dietetics, social work, and religious departments submitted survey questions related to wellness. Although the 

focus of this article is on responses regarding barriers 

to physical activity and perceived health, the survey included 49 total questions regarding health behaviors and 

obstacles to wellness.

The survey team took measures to be as inclusive as 

possible, but also as efficient as possible. When asked 

about barriers to healthy behaviors, respondents were 

instructed to mark all barriers that applied to them. The 

survey contained predetermined response options with 

an “other” category to capture write-in responses. To 

improve speed and efficiency, certain questions were 

not presented to the participant if it was appropriate for 

that person to skip those questions, based on previous 

responses. The average time to complete the survey was 

17 minutes.

Following survey closure, researchers cleaned the data 

and, when possible, categorized responses where participants marked “other.” From January through March of 

2015, data were analyzed using IBM SPSS, version 19 

IBM Corp, Amont, NY). Initial categorization of data 

was by state of perceived wellness and stratified by age 

range and military affiliation. Military affiliation was delineated by military rank, and healthcare occupational 

specialty was included as a category. Specific 

barriers to physical activity were highlighted 

along with the percentage of respondents who 

indicated that the specific barrier affected their 

level of physical activity.

Chi-square analysis was performed on individual barriers to physical activity with the dichotomized dependent variable of perceived health. 

This variable was determined by the answer to 

the required question “Do you perceive yourself 

as being healthy?” with the possible answers of 

“Yes” or “No.” Statistical tests of factors associated with perceived lack of health (ie, “no” responses) were evaluated at the alpha 0.05 level.

Univariate logistic regression was then conducted, examining the association of the number of 

reported barriers with the dichotomous dependent variable of perceived health. The number of 

variables was a count based on the number of affirmative answers the participant marked when 

asked about various types of barriers.

Finally, multiple logistic regression was performed to assess the relationship between a greater 

number of barriers and perceived health, controlling for demographic variables that were found to 

be associated with perceived health in the previous univariate logistic regression analyses.

Results

The survey population (N=380) was primarily 

active duty personnel (officer and enlisted) and 

government civilians (Table 1). There was minor 

representation of government contractors and 

retired military serving as hospital volunteers, 

identified as “other.” Predominant population 

subgroups: women (56%); age group 26-39 years 

(47%); and government civilians (45%). The 

Table 1. Demographics of Survey Respondents (N=380).

Demographic Military

Personnel

n1=205

(%n1)

DOA*

Civilian

Employees

n2=169

(%n2)

Other†

n3=6

(%n3)

All

Respondents

N=380

(%N)

Sex

Female 71 (35%) 141 (83%) 2 (33%) 214 (56%)

Male 134 (65%) 28 (17%) 4 (67%) 166 (44%)

Age, years

18-25 32 (16%) 1 (1%) 1 (17%) 34 (9%)

26-39 109 (53%) 34 (20%) 2 (33%) 145 (47%)

40-54 61 (30%) 76 (45%) 1 (17%) 138 (36%)

55 or older 3 (2%) 58 (34%) 2 (33%) 63 (17%)

Military Affiliation

Enlisted 118 (58%) - 118 (31%)

Officer 87 (42%) - 87 (23%)

DOA civilian - 169 (100%) 169 (45%)

Other - - 6 (100%) 6 (2%)

Education

High school or GED 49 (24%) 37 (22%) 86 (23%)

Associate’s 39 (19%) 41 (24%) 80 (21%)

Bachelor’s 42 (21%) 39 (23%) 2 (33%) 83 (22%)

Master’s or 

Doctorate

65 (32%) 33 (20%) 4 (67%) 102 (27%)

Other professional 

degree

10 (5%) 19 (11%) 29 (8%)

Occupation

Nurse 31 (15%) 30 (18%) 61 (16%)

Physician 22 (11%) 1 (1%) 23 (6%)

Medic 47 (23%) 3 (2%) 50 (13%)

Technician 18 (9%) 19 (11%) 1 (17%) 38 (10%)

Pharmacy 3 (2%) 5 (3%) 8 (2%)

Other medical 

profession‡ 62 (30%) 13 (8%) 2 (33%) 77 (20%)

Administration 14 (7%) 39 (23%) 53 (14%)

Other nonmedical 

or unspecified

8 (4%) 59 (35%) 3 (50%) 70 (18%)

*DOA indicates Department of the Army.

†Contract employees and volunteers (retired military).

‡This category includes clinical providers who could not be grouped into broad 

categories (eg, behavioral health professionals, physical therapists, and dentists).
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

survey was largely representative of clinical staff with 

86% of those surveyed employed in direct clinical care.

Ninety percent of respondents considered themselves to 

be healthy, and of those who considered themselves to 

be unhealthy (n=38), 95% were interested in becoming 

healthier. Although the survey population largely considered itself to be healthy, many respondents reported 

unhealthy behaviors such as not enough exercise and 

poor eating habits. Over half of all respondents (n=222, 

58%) indicated that they did not get enough exercise and 

158 participants (42%) responded that they were either 

somewhat or very dissatisfied with their personal physical activity and exercise. As reported by Schuh-Renner 

et al,14 47% of respondents reported at least one injury in 

the previous 12 months. Active duty military members 

had greater risk for injury, and activities associated with 

injuries in this population were similar to those in other 

military populations (physical training, walking/hiking, 

and lifting or moving objects).

Despite a long list of possible barriers from which to 

choose and the freedom to select multiple barriers, as 

shown in Table 2, the top 3 barriers were nearly twice as 

prevalent among respondents as all others. Lack of time 

was common to 65% of participants and lack of motivation affected nearly half (45%) of participants. A previous 

medical condition was reported as a barrier in just over a 

quarter (27%) of all participants. Those citing pain/other 

medical conditions, lack of experience, financial burden, 

and discomfort with the gym crowd as barriers to physical activity were more likely to perceive themselves as 

unhealthy, as 26%, 26%, 25%, and 22% of respondents 

citing those barriers, respectively, reported perceived 

lack of health. Enlisted respondents identified previous 

medical conditions and lack of experience as barriers to 

physical activity more frequently than other affiliations, 

while civilians were more likely to cite the financial burden and being uncomfortable with the gym crowd.

Participants also answered questions about aspects of 

the work environment and available health promotion 

activities that might improve their physical activity levels. Almost two-thirds of participants (n=243, 64%) indicated that time off during the workday to devote to 

exercise would improve their physical activity, an aspect 

nearly 3 times as important as any other as shown in 

the Figure. This illustrates the importance of time to 

employees and how closely they associate personal time 

with their ability to be physically active. Incentives and 

access to personal trainers, 2 potential factors to improve motivation, were cited as being the next 2 most 

important aspects that would improve physical activity.

The data suggest that barriers not only affect participation in physical activity itself, but also the organization’s 

Percentage of Study Participants Providing a Response

Officer

Enlisted

All Employees

Civilian

Increased access to personal trainers

Incentive

Increased access to group classes

Increased access to exercise facilities

Child care during workout hours

More indoor facilities

Beginner’s only time at the gym

Increased access to running trails

Formation of exercise clubs

Other

None

Time off during the day to exercise

0 10 20 30 40 50 60 70 80 90

Reported aspects that would improve physical activity among hospital staff by military status (N=380; multiple 

responses allowed).

BARRIERS TO PHYSICAL ACTIVITY AMONG MILITARY HOSPITAL EMPLOYEES
January – June 2018 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

outlook on physical activity. The 

sample population indicated that 

adult physical fitness was the health 

education topic of greatest interest. 

However, the follow-on questions 

indicated that nearly 65% of participants anticipated that lack of time 

would be a barrier to attending health 

education classes. Respondents who 

reported a previous medical condition, lack of experience with exercising, or financial burden as barriers to 

physical activity were more likely to 

also report a perceived lack of health 

(26%, 26%, and 25%, respectively), 

as shown in Table 2.

Given that specific perceived barriers showed correlation to lack of perceived health, the overall number of 

barriers an individual experienced 

was examined as another potential 

factor related to perceived lack of 

health. Univariate regression analysis showed higher odds ratios with increasing number 

of barriers indicated (Table 3). This result was statistically significant when 4 or more barriers were reported 

(P≤.01). Selected demographic variables (age 55 or older, 

female gender, and civilian employee status) were also 

significantly or marginally associated with perceived 

lack of health (P≤.10).

Multiple logistic regression analysis was performed 

with the variables that were found to be significant in 

univariate analyses. The presence of 4 or more barriers 

to physical activity was the only statistically significant 

factor associated with respondents’ perception of health 

(P=.04), as shown in Table 4.

Comment

Addressing the obesity epidemic is paramount in preventing devastating disease processes and decreasing 

barriers to physical activity is a key component of prevention. Previous studies have found that lack of time, 

motivation, and knowledge are barriers to an individual’s wellness,5,6,8-10 but there is little evidence available 

about barriers to physical activity among employees of 

a military medical facility, given the unique aspects of 

that population. This study confirms that the same barriers (time, motivation, and knowledge) also influence the 

perceived wellness of military medical facility employees. Additionally, survey participants indicated that they 

would change aspects of their environment that directly 

related to these same barriers, if possible, including 

finding time for exercise during the day and adding 

exercise facilities. Furthermore, the current analyses 

indicated that the barriers not only affect respondents’ 

ability to be physically active, but employees anticipate 

that similar barriers would affect participation in the 

organization’s offering of physical exercise groups and 

wellness education sessions.

These barriers not only affect the individual’s participation in physical activity, but are also correlated with 

perception of one’s own health. Regression analysis controlling for demographic characteristics indicated that if 

a person identified 4 or more barriers affecting their participation in physical activity, they were 9 times more 

likely to perceive themselves as unhealthy. While this 

result may be intuitive, the consequences are significant. 

Additional research examining the combinations of perceived barriers to physical activity would increase understanding of their effects on various populations.

The active duty military members in this population 

(54% of respondents) face unique challenges. The highly 

transient life of most military personnel often leads to 

greater distances between the Soldier and family members and traditional social support networks. Furthermore, requirements to maintain physical fitness, mandatory attendance at unit physical training activities, 

and additional military duties lead to unique challenges 

for military providers when compared to traditional 

patient care providers. Despite these differences, our 

Table 2. Barriers to Physical Activity and Perceived Lack of Health (N=380, multiple 

responses were allowed).

Barrier to Physical 

Activity

All

Respondents

N=380

n1 (%N)

Enlisted

n2=118

(%n2)

Officer

n3=87

(%n3)

Civilian

n4=175*

(%n4)

Respondents

Reporting 

Lack of Health

(%n1)

Lack of time 247 (65%) 65 (55%) 70 (80%) 112 (64%) 21 (9%)

Lack of motivation 171 (45%) 49 (42%) 24 (28%) 98 (56%) 21 (12%)

Pain or previous 

medical condition

104 (27%) 39 (33%) 18 (21%) 47 (27%) 27 (26%)

Not comfortable 

with gym crowd

58 (15%) 12 (10%) 7 (8%) 39 (22%) 13 (22%)

Lack of support 

network

54 (14%) 14 (12%) 9 (10%) 31 (18%) 8 (15%)

Weather 54 (14%) 16 (13%) 17 (20%) 21 (12%) 8 (15%)

No child care 46 (12%) 16 (14%) 14 (16%) 16 (9%) 4 (9%)

Financial burden 20 (5%) 1 (1%) 0 (0%) 19 (11%) 5 (25%)

Lack of experience 

or knowledge

19 (5%) 9 (8%) 1 (1%) 9 (5%) 5 (26%)

Work 11 (3%) 2 (2%) 6 (7%) 3 (2%) 1 (9%)

No parking at gym 0 (0%) - - - -

Other 16 (4%) 2 (2%) 4 (5%) 10 (6%) 1 (6%)

None 32 (9%) 19 (16%) 3 (3%) 10 (6%) 1 (3%)

*Total (n4) includes 169 Department of the Army civilian employees and 6 contract employees or 

hospital volunteers.
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

results indicate that barriers common to other populations (lack of time and motivation) exist in a military 

medical facility. Additionally, these very same barriers are statistically related to the employee’s perceived 

health, giving more credence to the idea that barriers 

must be addressed in a fashion that is meaningful to the 

individual. Recommendations from the American Heart 

Association state that employers should seek to 

reduce or eliminate barriers that discourage use 

of worksite wellness programs.15 Further research 

should be performed to identify the most effective ways to both measure and efficiently address 

those barriers.

Since workplaces are now taking more prominent 

roles in advancing the health of their employees,16

organizational leaders must carefully consider 

barriers to participating in wellness activities and 

their impact on the overall health of employees. 

Large multinational corporations like Google are 

providing employees access to state-of-the-art fitness centers and multiple opportunities for physical activity.17 The need to eliminate these barriers 

is necessary not simply to enhance the employee 

experience, but also to financially benefit the organization. Financial incentive is gained through 

decreased healthcare costs, increased productivity, improved morale, increased retention, and decreased absenteeism. As Baicker and colleagues18

explain, savings are not simply associated with 

decreased healthcare costs; rather, additional revenue is appreciated when workers are present and 

well. Decreased absenteeism, for example, allows 

workers to focus on their own productivity, rather 

than making up for the work not completed by 

an absent colleague. Baicker et al found that the 

return on investment in wellness programs was 

$3.27 for every dollar spent through decreased 

healthcare cost and $2.73 for every dollar spent 

through decreased absenteeism.18

This study had some limitations. With approximately 32% of the hospital population responding to the survey, it is possible that those who 

responded did not represent the entire population. 

The people who were interested enough in wellness to complete the survey may have different 

barriers than those who chose not to participate. 

Furthermore, the dichotomized self-assessment 

of health may have led to a decreased ability to 

detect differences. Small sample sizes among 

some subgroups led to large confidence intervals 

on risk ratios and odds ratios, making it difficult 

to draw statistically sound conclusions from the data. 

With only 10% of individuals reporting themselves to 

be unhealthy, there may not have been enough power 

to assess the correlation of all barriers with perceived 

health. In future studies, the use of a Likert scale may 

be a more efficient and powerful tool to evaluate selfassessed health metrics.

Table 3. Injury Incidence: Factors Associated with Perceived Lack of 

Health (N=380).

Variable Total in

Variable

Category

n1

Perceived

Lack of 

Health

n2 (%n1)

Odds Ratio

(95% CI)

P

Value

Number of Barriers to

Physical Activity

0 39 1 (3%) 1.00

1 108 7 (6%) 2.53 (0.32-19.89) .36

2 102 9 (9%) 3.44 (0.45-26.27) .20

3 79 8 (10%) 3.95 (0.51-30.47) .15

4 or more 52 13 (25%) 9.75 (1.33-71.40) <.01

Age, years

18-25 34 1 (3%) 1.00

26-39 145 10 (7%) 2.35 (0.31-17.70) .39

40-54 138 16 (12%) 3.94 (0.54-28.69) .13

55 or older 63 11 (17%) 5.94 (0.80-44.04) .04

Sex

Female 214 27 (13%) 1.90 (0.97-3.73) .05

Male 166 11 (6%) 1.00

Military Affiliation

Enlisted 118 8 (7%) 1.48 (0.46-4.74) .51

Officer 87 4 (5%) 1.00

DOA* civilian 169 25 (15%) 3.22 (1.16-8.95) .01

Other† 6 1 (17%) 5.44 (0.77-38.16) .08

Education

High school or GED 86 9 (10%) 1.30 (0.53-3.24) .57

Associate’s 80 9 (11%) 1.43 (0.58-14.53) .43

Bachelor’s 83 9 (11%) 1.38 (0.56-3.43) .48

Master’s or Doctorate 102 8 (8%) 1.00

Other professional 

degree

29 3 (10%) 1.32 (0.37-4.66) .67

Occupation

Nurse 61 6 (10%) 0.98 (0.35-2.77) .98

Physician 23 0 0 .12

Medic 50 3 (6%) 0.60 (0.16-2.21) .44

Technician 38 5 (13%) 1.32 (0.45-3.87) .62

Pharmacy 8 1 (13%) 1.25 (0.18-8.90) .83

Other medical 

profession‡

77 6 (8%) 0.78 (0.28-2.21) .64

Administration 53 10 (19%) 1.89 (0.77-4.63) .16

Other nonmedical or 

unspecified

70 7 (10%) 1.00

*DOA indicates Department of the Army.

†Contract employees and volunteers (retired military).

‡This category includes clinical providers who could not be grouped into broad 

categories (eg, behavioral health professionals, physical therapists, and dentists).

BARRIERS TO PHYSICAL ACTIVITY AMONG MILITARY HOSPITAL EMPLOYEES
January – June 2018 81

THE ARMY MEDICAL DEPARTMENT JOURNAL

Approaches to improving barriers to physical activity, 

including environmental changes, are necessary to facilitate an environment of disease, injury, and obesity prevention. Institutional leaders should continue to explore 

programs that investigate and address common barriers 

to physical activity. Leaders in military hospitals should 

consider programs that promote the principles of the 

Department of Defense initiative Operation Live Well, a 

program that intends “to make healthy living the easier 

choice and social norm....”19 Policies that address barriers 

of time and motivation, such as authorizing employees 3 

paid hours per week to participate in a fitness program, 

are particularly beneficial and have been successful in 

other military workplaces.20 Agreements between leadership and employees facilitate participation in exercise 

activities, but also require consistent documentation of 

the workouts, approved routines, and health clearances 

to continue participation. A cultural change that embraces physical activity and encourages it as a part of each 

day would be a useful step toward preventing chronic 

disease processes among military healthcare employees. 

The analysis and reporting of the successes and failures 

of these programs will pay dividends financially, emotionally, and physically for many in our communities.

References

1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of 

overweight and obesity in the United States, 

1999-2004. JAMA. 2006;295(13):1549-1555. 

doi:10.1001/jama.295.13.1549.

2. Institute of Medicine Committee on Health 

and Behavior: Research, Practice, and Policy. 

Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: National Academies Press; 2001. 

Available at: http://www.ncbi.nlm.nih.gov/

books/NBK43743/. Accessed June 21, 2015.

3. Pi-Sunyer FX. The obesity epidemic: pathophysiology and consequences of obesity. Obes Res. 

2002;10(S12):97S-104S. doi:10.1038/oby.2002.

202.

4. Harvard T.H. Chan School of Public Health. 

Physical Activity. Obesity Prevention Source 

[internet]. Cambridge, MA: Harvard University; 2015. Available at: http://www.hsph.harvard.

edu/obesity-prevention-source/obesity-causes/

physical-activity-and-obesity/. Accessed November 22, 2015.

5. Bautista L, Reininger B, Gay JL, Barroso CS, 

McCormick JB. Perceived barriers to exercise 

in hispanic adults by level of activity. J Phys Act 

Health. 2011;8(7):916.

6. Justine M, Azizan A, Hassan V, Salleh Z, Manaf 

H. Barriers to participation in physical activity and 

exercise among middle-aged and elderly individuals. Singapore Med J. 2013;54(10):581-586.

7. Matson-Koffman DM, Brownstein JN, Neiner JA, 

Greaney ML. A site-specific literature review of 

policy and environmental interventions that promote physical activity and nutrition for cardiovascular health: what works?. Am J Health Promot. 

2005;19(3):167-193.

8. Phiri LP, Draper CE, Lambert EV, Kolbe-Alexander TL. Nurses’ lifestyle behaviours, health priorities and barriers to living a healthy lifestyle: a qualitative descriptive study. BMC Nurs. 2014;13(1):38. 

Available at: https://bmcnurs.biomedcentral.com/

articles/10.1186/s12912-014-0038-6. Accessed February 1, 2018.

9. Sjörs C, Bonn SE, Lagerros YT, Sjölander A, Bälter K. Perceived reasons, incentives, and barriers to 

physical activity in Swedish elderly men. Interact J 

Med Res. 2014;3(4):e15. doi:10.2196/ijmr.3191.

10. Trost SG, Owen N, Bauman AE, Sallis JF, Brown 

W. Correlates of adults’ participation in physical 

activity: review and update. Med Sci Sports Exerc. 

2002;34(12):1996-2001.

Table 4. Multivariable Logistic Regression Results: Factors Associated with Perceived Lack of Health (N=380).

Variable Total in

Variable

Category

n1

Perceived

Lack of 

Health

n2 (%n1)

Risk Ratio

(95% CI)

P

Value

Number of Barriers to

Physical Activity

0 39 1 (3%) 1.00

1 108 7 (6%) 2.05 (0.24-17.66) .51

2 102 9 (9%) 3.06 (0.37-25.88) .30

3 79 8 (10%) 3.51 (0.42-25.88) .25

4 or more 52 13 (25%) 9.46 (1.14-78.66) .04

Age, years

18-25 34 1 (3%) 1.00

26-39 145 10 (7%) 2.76 (0.32-24.02) .36

40-54 138 16 (12%) 4.45 (0.49-40.80) .19

55 or older 63 11 (17%) 6.79 (0.66-70.06) .11

Sex

Female 214 27 (13%) 1.34 (0.55-3.27) .53

Male 166 11 (6%) 1.00

Military Affiliation

Enlisted 118 8 (7%) 2.21 (0.59-8.28) .24

Officer 87 4 (5%) 1.00

DOA* civilian 169 25 (15%) 2.08 (0.62-6.94) .23

Other† 6 1 (17%) 3.45 (0.25-46.66) .35

*DOA indicates Department of the Army.

†Contract employees and volunteers (retired military).
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

11. Hamermesh DS, Stancanelli E. Long Workweeks 

and Strange Hours [internet]. Cambridge, MA: National Bureau of Economic Research; 2014. Available at: http://www.nber.org/papers/w20449.pdf. 

Accessed November 22, 2015.

12. Blackford K, Jancey J, Howat P, Ledger M, Lee 

AH. Office-based physical activity and nutrition intervention: barriers, enablers, and preferred strategies for workplace obesity prevention, Perth, Western Australia, 2012 [internet]. Prev Chronic Dis. 

2013;10:E154. Available at: https://www.cdc.gov/

pcd/issues/2013/13_0029.htm. Accessed February 

1, 2018.

13. Schuh A, Canham-Chervak M. Technical Report 

No. S.0032417-16: Assessment of Health Behaviors, 

Health Education Interests, and Injuries among 

Employees at the General Leonard Wood Army 

Community Hospital, October 2014-December 

2014. Aberdeen Proving Ground, MD: US Army 

Public Health Center; 2016. Available at: www.dtic.

mil/get-tr-doc/pdf?AD=ADA633025. Accessed 

February 1, 2018.

14. Schuh-Renner A, Canham-Chervak M, Hearn DW, 

Loveless PA, Jones BH. Factors Associated With 

Injury Among Employees at a U.S. Army Hospital. 

Workplace Health Saf. December 14, 2017 (epub 

ahead of print). Available at: http://journals.sage

pub.com/doi/10.1177/2165079917736069. Accessed 

February 1, 2018. 

15. Carnethon M, Whitsel LP, Franklin BA, et al. 

Worksite wellness programs for cardiovascular disease prevention: a policy statement from 

the American Heart Association. Circulation. 

2009;120(17):1725-1741.

16. Sorensen G, Stoddard A, Peterson K, et al. Increasing fruit and vegetable consumption through worksites and families in the treatwell 5-a-day study. 

Am J Public Health. 1999;89(1):54-60. Available 

at: https://www.ncbi.nlm.nih.gov/pmc/articles/

PMC1508509/. Accessed November 19, 2015.

17. Athletic Business. Corporate Fitness Centers Increasing Across the Nation [internet]. Available at: 

http://www.athleticbusiness.com/fitness-training/

corporate-fitness-centers-increasing-across-thenation.html. Published June 2015. Accessed November 22, 2015.

18. Baicker K, Cutler D, Song Z. Workplace Wellness Programs Can Generate Savings. Health 

Aff (Millwood). 2010;29(2):304-311. Available at: 

https://www.healthaffairs.org/doi/pdf/10.1377/

hlthaff.2009.0626. Accessed February 1, 2018.

19. Military Health System. Operation Live Well [internet]. Available at: http://www.health.mil/Military-Health-Topics/Operation-Live-Well. Accessed 

January 7, 2016.

20. Close K. Civilian Wellness Letter and Fitness Program Guidance. Hill Air Force Base, UT: Ogden 

Air Logistics Center; May 12, 2009. Available 

at: http://75thforcesupport.com/sites/default/files/

AFMC%20Civilian%20Wellness%20Letter_0.pdf. 

Accessed January 7, 2016.

Authors

Dr Hearn, a Major in the US Army Reserve, is a doctoral 

student in the Human Movement Science Curriculum at 

the University of North Carolina, Chapel Hill, NC.

Dr Schuh-Renner and Dr Canham-Chervak are with 

the Injury Prevention Division, US Army Public Health 

Center, Aberdeen Proving Ground, MD.

Ms Hodges is with Prevention Partners, Chapel Hill, NC.

Ms Evarts is with the Gillings School of Global Public 

Health, University of North Carolina, Chapel Hill, NC.

BARRIERS TO PHYSICAL ACTIVITY AMONG MILITARY HOSPITAL EMPLOYEES

ARMY MEDICINE

One Team...One Purpose!

Conserving the Fighting Strength Since 1775
January – June 2018 83

Women have always played a crucial role in the support of our nation’s military, directly and indirectly. Not 

until recently, however, have women been allowed to 

serve in unrestricted roles. Prior to 1993, women were 

not permitted to serve on combatant aircraft, vessels, or 

in direct ground combat. One decade later, recension 

of outdated policy allowed women into the aforementioned roles including combat units, generating the need 

for review of occupational standards and assignment 

policies. On March 10, 2016, the Secretary of Defense 

announced approval for women to be assigned to direct 

ground combat roles, including all military services and 

the US Special Operations Command.1 With the unprecedented expansion of women’s role in combat combined 

with the longest period of continuous active combat in 

US history,2 it is time that research be expanded to include the nutritional and hydration requirements of our 

female tactical athletes.

Scofield and Kardouni define the tactical athlete as “professionals that require expertise in their occupational 

skills concomitant with general physical preparedness, 

which enable them to perform physically demanding 

occupational tasks while mitigating injury.” 3 These tactical professionals are required to possess physical and 

mental preparedness necessary to effectively operate in 

their occupation emphasizing the importance of up-todate hydration guidelines to optimize performance and 

highlight potential differences in traditional athletes 

and their tactical counterparts. Uniformity of tactical 

athletes becomes the explicit requirement of baseline 

physical fitness, with the potential occupational requirement of confronting and overcoming physical, environmental, and human threats with little to no advanced 

notice setting them apart from civilian athletes. While 

traditional players train and compete in seasons, those 

considered tactical know their position requires them to 

operate “in season” constantly.

Anything short of optimal performance for any tactical athlete can be the difference between life and death. 

However, performance for a new recruit plays a vital 

role in acceptance and integration into their new unit in 

addition to survival. An assessment of these guidelines 

will further facilitate female integration and acceptance 

by their new team. As combat is frequently in austere 

conditions and physically demanding, hydration status 

and strategies are paramount. Not only is hydration crucial to performance optimization, but also prevention 

of dehydration, as the result can be lethal. This review 

focuses on what is known in the literature regarding hydration, summarizes the best strategies for optimal performance while avoiding exercise-related illness, and a 

call for further research in the developing group of female tactical athletes.

Deleterious Effects of Dehydration

Water is essential to life down to the cellular level. Without it our species can survive mere days. The lack of a 

firm definition of dehydration emphasizes the dynamic 

nature of our regulatory systems. It is understood as 

“the process of uncompensated water loss via urine, 

sweat, feces, and respiratory vapor thus reducing total 

body water below the average basal value.” 4-9 However, 

amongst those who strive to measure hydration status 

for the purposes of assessing its effects on performance, 

the accepted value is 2% loss in body weight during activity that otherwise isolates fluid loss as the primary 

route. Components that lead to dehydration can be broken into categories such as lack of access, physiologic 

loss, and environmental stressors. Access pertains to 

fluid unavailability, inadequate time to drink, lack of 

Hydration Strategies for the Female

 Tactical Athlete

Capt Taylor K. Zak, USAF, MC

MAJ Christina M. Hylden, MC, USA

COL Anthony E. Johnson, MC, USA

Abstract

With unprecedented expansion of the roles of women in the military and the longest period of continuous active 

combat in US history, it is time that research expanded, including the nutritional and hydration requirements of 

the female tactical athlete. Dehydration has a negative effect on athletic performance, most significantly in high 

intensity, aerobic endurance activities. There is evidence female athletes may be more prone to the potentially 

lethal effects of over hydration. The purpose of this article is to provide a review of the literature to ascertain 

optimal hydration strategies for the female tactical athlete.
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

food intake, and unpalatable fluids that can compound 

the delay in rehydration.10-12 Physiologic losses are maintained by fluid and electrolyte homeostasis despite wide 

variations of intake and output. Regarding these measures in the context of rigorous training, the body’s renal, hypothalamic, and neurologic control can be taxed 

to their extremes in a matter of hours.13 Lastly, and the 

hardest to control, the environmental factors of ambient 

temperature, humidity, altitude, air currents, and clothing14 must be noted when discussing factors affecting 

water loss. Battle dress uniform and body armor add a 

minimum of 5°F to the ambient temperature.15 When 

envisioning both the training and operations of tactical 

athletes, the austerity of their locations often impose 

physical, behavioral, and environmental conditions beyond the bounds of homeostatic norms and demand an 

optimized hydration strategy.

It is well documented that dehydration has a negative 

effect on athletic performance.16,17 While, by definition, 

dehydration is the loss of 2% body weight, athletes have 

been documented to have up to 6% to 10% losses or 

more in rare cases.18 Under relatively mild dehydration, 

individuals engaging in rigorous physical activity, even 

in temperate climates, will experience decrements in 

performance due to altered thermoregulatory capability, 

compromised cardiovascular function, and increased 

fatigue, resulting in reduced endurance, reduced motivation, and increased perceived effort.5

 Inadequate hydration consistently shows a more significant effect on 

high intensity,19 aerobic,20-22 endurance activities such 

as long-distance running,23 as well as decrements in accuracy24,25 with even larger scope application of negative functional effect on team sport performance that 

demand high levels of skill and precision.21 Assessment 

outcomes such as reduced accuracy, speed of complex 

tasks, and distance judgement were also negatively 

affected.24,26-32

It is less clear to what degree dehydration worsens cognition, originally suggested by Sharma and Gopinathan 

separately in 1986 and 1988 respectively.33,34 Lieberman 

counters with the rational argument that the effect of 

hypohydration on cognition was rather equivocal until 

recently due to the difficulty in assessing any independent variable on human behavior, the difficulty of attaining consistent levels of dehydration that do not confound 

with the stressors used to get there, and our inability to 

accurately and reliably measure hydration status from 

moment to moment in addition to our limitations on 

cognitive measure itself.35 Research shows that concentration, alertness, and short term memory all decrease 

while dehydrated.29,31,35-37 This is in addition to the well 

documented negative effects on perception of the work 

being done, otherwise categorized as mood,31 and alertness that can be subjectively improved by hydrating.37

Deleterious Effects of Overhydration

While not drinking enough fluid can result in underperformance, so too can the consequences of drinking 

too much. Overhydration, once considered a pre-event 

strategy, has shown to be an illegitimate solution to dehydration.29 To date, there is no reported benefit in trials 

to enhance performance, in either gender, by intentional 

overhydration. Whatever the marginal competitive advantage may be, it does not outweigh the risks. These 

risks have been recorded in endurance athletes, hikers, 

and Soldiers in the form of hyponatremia, seizure, and 

death. In the wake of a military training-related death,38

the fluid replacement guidelines were changed and 

found to be successful.15 By reducing the incidence of 

significant serum sodium loss without increasing the 

risk of dehydration, Kolka et al 15 proposed safer hydrating strategies for strenuous training and expanded the 

guidelines including female subjects previously unavailable. Similarly, the increasingly high numbers of serious 

illness and death in female athletes in the last quarter 

century further emphasize the ongoing problem of overhydrating. In an attempt to prevent heat injury, these endurance athletes are increasing their risk of hyponatremia by way of water overload. Hyponatremia is defined 

as more than 135 mmol/L of sodium and is associated 

with a number of sodium and water disorders.39 Perhaps 

the most concerning risk is the similarity in presentation 

of acute overhydration to the antithesis symptomatic dehydration. Mistaking one diagnosis for the other can be 

devastating, as was demonstrated in the incident of the 

military trainee; the symptoms of altered mental status, 

emesis, and nausea were interpreted and treated as if a 

common case of dehydration or heat-related illness and 

treated as would have been appropriate for dehydration. 

Instead, however, his hyponatremia worsened with the 

treatment for dehydration, and as a result, he died due to 

irreversible damage of the brain and lungs.38,40 Another 

main concern specific to female athlete heat illness is 

the fact that research shows women are more compliant 

when it comes to replenishing fluid losses. This might 

be seen as an advantage; however, research at the other 

extreme of the spectrum found that female athletes are 

25 times more likely to die from hyponatremia during 

an endurance race.41 These unfortunate events indicate 

the need for further research and continued education 

within the athletic community.

How to Assess Hydration Status

There are many proposed techniques for measuring hydration status in athletes. To date, there is no one biomarker that is accepted as the gold standard indicator of 

HYDRATION STRATEGIES FOR THE FEMALE TACTICAL ATHLETE
January – June 2018 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

hydration. After all, euhydration is the concept of the 

body in water balance. This is a dynamic state difficult 

to define physiologically as well as numerically due to 

its constant flux. The ideal biomarker for athletic standards should be sensitive and accurate enough to detect 

body water fluctuations of ≈2% body weight in real time, 

minimally invasive, inexpensive, mobile, expedient, 

easy to use and require little training. All modern tools 

hinge around singular measures of the highly dynamic 

fluid system of interconnected compartments. Armstrong42 contrasts the importance of accuracy in laboratory measures with the goals of field assessment desiring 

portability, ease of use, and cost effectiveness. Assessment techniques reviewed for this article included thirst, 

change in body weight, sweat volume, urine osmolality, 

urine specific gravity, plasma osmolality, bioelectric impedance analysis, among others.20,30,42-46

Water balance is the net difference between water gained 

and water lost. Daily sources of water include beverages 

(81%), food (19%),20 and metabolic production (a negligible volume in comparison, and approximately equal 

to respiratory water losses of ≈0.12 g/kcal).47,48 Water 

is lost through respiratory, gastrointestinal, renal, and 

sweat functions.49 Total body water can be estimated 

using tracer methods, most commonly deuterium oxide, 

with an accuracy of 1% to 2%.8,43 This is the most valid 

and precise estimation modern science can offer.50 However, as functional dehydration is 2% or greater body 

weight (BW) change, this margin of error meets the sensitivity requirement but does not outdo simply tracking 

body weight fluctuations. Furthermore, tracer methods 

are less practical in the field due to cost, time-to-result, 

and technical requirements. Variability due to differences in body composition also make tracer methods a 

suboptimal technique for operational tactical athletes.20

As sweating is the primary avenue of water loss during 

exercise-heat stress, acute changes in body weight can 

be used to calculate an athlete’s sweat rate.51 Following 

the equation used in the 2000 National Athletic Trainers’ Association Position Statement, each athlete can, 

and should, calculate their individual sweat rate: (sweat 

rate = pre-exercise BW - postexercise BW + fluid intake 

- urine volume)/exercise time in hours. Sweat rates found 

in the literature range from 0.5 L/h to more than 4 L/h 

(0.50 kg/h to 4 kg/h) 5,14,49 with conclusive evidence that, 

in general, females sweat less than males.52 As sweat 

rates vary drastically due to individual metabolic and 

sweat rates, variance in fitness protocols, type of exercise, and environmental factors, it is imperative that athletes begin to consider hydration with the same regard 

as nutrition. Many argue that water is in fact the principal nutrient, more important than sources of fuel. It is 

advised that athletes, be it an individual or as a team for 

an average, calculate their sweat rate in various environmental conditions as well as periodically account for 

conditioning and heat acclimatization.

Without a gold standard, a single assessment technique 

is inadequate to evaluate body hydration status. Therefore, combining several techniques for multiple points 

of reference is encouraged. After consideration of barriers such as time required, cost, portability, ease of use, 

etc, the recommendation is to combine BW changes 

with urine indices. Body weight measurement should be 

postvoid but premeal and with as few confounding articles of clothing as possible. A baseline value can be established with at least 3 consecutive morning nude BW 

measures to approximate euhydration if athletes have 

access to food and fluid ad libitum.53 Female athletes 

may require additional BW measurements as menstrual 

cycles can alter body weight and fluid distribution.49,54,55

When acute water losses are estimated by pre- and 

postexercise BW measures, consideration should be 

made for sweat trapped in clothing.56 Body weight measures with calculated percentage of body weight change 

should be conducted before, during (if exercise exceeds 

3 hours), and after exercise sessions to estimate fluid 

balance.5

Pre-exercise urine biomarkers can allow discrimination 

between euhydration and dehydration.9,57,58 Urine specific gravity (USG), color, volume, and osmolality (UOsmol) together provide the most insight to an athlete’s hydration status. A USG of 1.020 or less is indicative of being euhydrated.57-59 Osmolality is more variable, but values of 700 mOsmol/kg or less are generally accepted as 

euhydration.9,57,58 Color comparison and USG read by a 

refractometer should be done on midstream samples preexercise for consistency. Urine values can be misleading 

if obtained during rehydration periods, especially during 

periods of rapid recovery. Consumption of large volumes 

of fluid will produce copious volumes of hypotonic or dilute urine, falsely reflecting a state of euhydration.8,58,60 If 

context considerations are made stacked with consistent 

BW measures, these techniques provide the most reliable, practical, expedient, easy-to-use, and cost effective 

methods of assessing hydration status.

Hydration Strategy

The athletic community has no problem accepting that 

hydration is crucial to exercise performance. This article recommends guidelines consistent with the American College of Sports Medicine (ACSM) Position Stand 

200749 with a call for continued research on the topic 

in the direction of both tactical and female athletes. 

The history of hydration standards is saturated with 
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

misunderstanding. The commonly quoted “8 by 8,” eight 

glasses of 8 ounces of water daily, is best explained as a 

misinterpretation of the 1945 Food and Nutrition Board 

Recommendation, which was 2.5 L total water per day 

and ignoring the phrase that much dietary water comes 

from food.20,61 The most recent issue (2005) by the Food 

and Nutrition Board of the Institute of Medicine (now 

renamed the National Academy of Medicine), states 

2.7 L per day as the adequate intake for women aged 

19 to 30 years, the most inclusive age range for tactical 

athletes. Because euhydration can be maintained over a 

wide range of water intakes, it is not possible to determine an estimated average requirement, and this value 

is based on median total water intake from US survey 

data.20,62 The committee recognizes the iterative process 

and continues to refine these values. An additional consideration when determining baseline is caloric intake. 

It is often cited and generally accepted that 1 to 1.5 mL 

of water should be ingested per kilocalorie consumed.63

This can significantly increase the water demands of tactical athletes. For example, a woman consuming 3,000 

kilocalories per day would require 4.5 L of dietary water 

not including sweat loss deficits. Therefore, hydration 

must be executed in phases of a continuum: preparation, 

maintenance, recovery with respect to timing of the athletic event, practice or operation.

Preparation

Hydration before exercise should be at a comfortable 

rate of ≈5 to 7 mL/kg at least 4 hours prior to the event 

in order to allow for sufficient absorption, distribution, 

and regulation of urine output.49 Athletes should take 

note of signs and symptoms of inadequate hydration: 

dark colored urine or lack of urine production, headache, 

lightheadedness, or evidence of orthostasis (“head-rush” 

or light headedness upon standing from a laying or 

seated position).5,64 If any are present, the athlete should 

drink an additional ≈3 to 5 mL/kg at the same slow rate. 

If time leading up to event is too short (overlaps significantly with recovery from last exercise), the addition of 

salted or sodium-containing foods are of benefit as they 

act to stimulate thirst and retain the consumed fluids.65-67

Hyperhydration, with water or glycerol-containing beverages has not been shown to provide physiologic or 

performance advantages over euhydration. To the contrary, it increases the risk of lowering athlete’s plasma 

sodium,68,39 therefore increasing the chance of dilutional 

hyponatremia. The recommendation remains against its 

use.69

Maintenance

The goal of hydration in the maintenance phase is to replace fluid at a rate to offset sweat losses, keeping body 

weight loss less than 2%, while retaining electrolyte balance. Mathematical analysis of Table 5 in the ACSM Position Stand 200749 derived projections that proved satisfactory for both male and female athletes when looking 

at the variables of runner size, speed, and environmental 

condition. The upper end of the suggested range of rates 

is directed towards faster runners with greater BMI, inherently heavier sweaters who are training or operating 

in warmer environments with the lower suggested rate 

for the slower, lower BMI, working in cooler conditions. 

The importance of customized hydration plans cannot 

be overemphasized, but a suggested starting rate ranges 

from 0.4 to 0.8L/hour drawn from marathon runners.49,70

Depending on individual sweat rate, exercise duration 

and fluid availability, a maintenance phase may not be 

required. Hydration efforts made during exercise lasting 

less than 1 hour has shown very little difference in overall hydration strategy.71 In this case, athletes will transition from preparation directly to recovery.

As for what athletes should drink, in 2005 the Institute 

of Medicine published the recommended composition 

of “sports beverages” and electrolytes to be ≈20 to 30 

mEq/L of sodium (chloride as the standard anion), ≈2 

to 5 meq/L potassium, and ≈5% to 10% carbohydrate.20

Fluid palatability is influenced by temperature, osmolality, and flavoring. Preference varies greatly by individual as well as culture. Preferred water temperature 

is found to be between 15°C and 21°C. The vessel in 

which the electrolytes are consumed plays a negligible 

difference and are up to the preference of the athlete. 

Sources include drinks, gels, energy bars, and other 

foods. Ingesting carbohydrate in any of these forms allows the athlete to go harder longer as the provision of 

carbohydrate decreases the use of stored glycogen.72-78 A 

rate of ≈30 to 60 grams/hour will maintain blood glucose 79,80 and are recommended for exercise lasting more 

than an hour.73,81-85 While sports beverages provide the 

allure of rehydrating as well as a source of carbohydrate, 

athletes are warned against products that have a carbohydrate concentration greater than 7% as they reduce 

gastric emptying, the anatomic limiting step to rehydration efforts.86

Often times, products used to supplement contain caffeine which are thought to help sustain exercise.87 It is 

concluded that caffeine, especially once sensitized, has 

little effect on hydration status during exercise or even in 

the 24-hour period.88-90 Of note, these results were based 

on unrestricted access to fluids and ability to void as necessary, both of which are not always available to a tactical athlete in the field. Therefore, consideration should 

be given prior to ingestion of increased doses of caffeine 

as even a minimal diuretic effect could potentially drive 

HYDRATION STRATEGIES FOR THE FEMALE TACTICAL ATHLETE
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THE ARMY MEDICAL DEPARTMENT JOURNAL

the athlete into an acute phase of hypovolemia without 

the ability to replenish the losses. Casa et al5 also warns 

against consumption of alcohol and carbonated beverages when prioritizing athletic rehydration.

Recovery

During the recovery phase, the goal is to fully replace 

any fluid and electrolyte deficits that have accumulated 

throughout exercise. If recovery time and opportunity 

permit, common sodium-containing meals and snacks 

consumed with a sufficient volume of plain water is 

enough to bring the athlete back to baseline.20 While 

many focus on water, during any recovery period, failure to replace sodium will greatly hamper return to 

euhydration. In many, if not most situations, tactical 

athletes will be required to have shortened recovery periods. If time between the end of one exercise and the 

beginning of the next is less than 12 hours, one should 

consider this a rapid recovery, and steps should be taken 

to expedite the athlete’s return to equilibrium. While sodium losses are even more difficult to assess than water 

losses, their intake becomes significantly more important during this rapid recovery and extra salt in meals 

and recovery fluids may be appropriate.91,92

For situations that require faster recovery, ≈1.5 L of fluid 

should be consumed for every kg of body weight lost 

during the activity. Due to the increase of fluid loads at 

a faster than normal intake, the body compensates with 

increased urine output. The suggested extra fluid halfliter is to offset these losses and bring balance as soon 

as possible. For best absorption and retention, efforts 

should be made to consume recovery fluids gradually 

over longer periods of time as opposed to boluses.93,94

Contrary to common belief, intravenous fluids do not 

provide an advantage over oral hydration and electrolyte 

replacement in the absence of either a dysnatremia 64 or 

severe dehydration evidenced by greater than 7% body 

weight loss, nausea, vomiting, or diarrhea.5

Summary

Very few studies have been done on female athletes or 

tactical athletes. The overall lack of data on female tactical athletes in the deployment setting simply points to 

an area needing further discovery. With the current literature, the recommendations in this article are almost 

entirely gender-specific (male) extrapolation, summarized so athletes, coaches, and those caring for athletes 

might apply the best data available. While superimposition might be considered a critique of this review, the 

differences amongst individual athletes is likely more 

than the differences between genders. The combination 

of variance in data collection methods and application 

towards the dynamically imprecise prevents greater 

external validity. In summary, this article provides the 

basics of fluid replacement and recommendations that 

form the foundation of a hydration strategy to prevent 

heat illness and avoid overhydration injury. It encourages the combined use of body weight changes surrounding 3 phases of the hydration continuum: preparation, maintenance, and recovery. Included are the latest 

recommended hydration composition and rate for optimized performance. It cannot be overemphasized that 

athletes must determine what works best for them as an 

individual and are encouraged to fine-tune their own 

hydration strategy. As the female’s role in the military 

expands, so too should the research pertaining to the 

needs of female tactical athletes.

References

1. Burelli DF. Women in Combat: Issues for Congress. 

Washington, DC: Congressional Research Service; 

2013. Available at: http://www.dtic.mil/dtic/tr/full

text/u2/a590333.pdf. Accessed January 11, 2018.

2. Butler FK. Two decades of saving lives on the battlefield: tactical combat casualty care turns 20. Mil 

Med. 2017;182:e1563-e1568.

3. Scofield DE, Kardouni JR. The tactical athlete: a 

product of 21st century strength and conditioning. 

Strength Cond J. 2015;37:2-7.

4. Armstrong LE. Hydration assessment techniques. 

Nutr Rev. 2005;63:S40-S54.

5. Casa DJ, Armstrong LE, Hillman SK, et al. National Athletic Trainers’ Association Position Statement: Fluid Replacement for Athletes. J Athl Train. 

2000;35(2):212-224. Available at: https://www.ncbi.

nlm.nih.gov/pmc/articles/PMC1323420/. Accessed 

January 11, 2018.

6. Kavouras SA. Assessing hydration status. Curr 

Opin Clin Nutr Metab Care. 2002;5:519-524.

7. Manz F, Wentz A. 24-h hydration status: parameters, epidemiology and recommendations. Eur J 

Clin Nutr. 2003;57(suppl 2):S10-S18.

8. Shirreffs SM. Markers of hydration status. Eur J 

Clin Nutr. 2003;57:S6-S9.

9. Shirreffs SM, Maughan RJ. Urine osmolality and conductivity as indices of hydration status in athletes in the heat. Med Sci Sports Exerc. 

1998;30:1598-1602.

10. Rolls B. Homeostatic and non-homeostatic controls of drinking in humans. In: Arnaud EJ, ed. Hydration Throughout Life. London: John Libbey and 

Company Ltd; 1998:19-28.

11. Szlyk PC, Sils IV, Francesconi RP, Hubbard RW, 

Armstrong LE. Effects of water temperature and 

flavoring on voluntary dehydration in men. Physiol 

Behav. 1989;45,639-647.
88 http://www.cs.amedd.army.mil/amedd_journal.aspx

12. Szlyk PC, Sils IV, Francesconi RP, Hubbard RW, 

Matthew WT. Variability in intake and dehydration 

in young men during a simulated desert walk. Aviat 

Space Environ Med. 1989;60:422-427.

13. Grandjean AC, Reimers KJ, Buyckx ME. Hydration: issues for the 21st century. Nutr Rev. 

2003;61:261-271.

14. Gisolfi CV. Water requirements during exercise in 

the heat. In: Marriott BM, ed. Nutritional Needs in 

Hot Environments: Applications for Military Personnel in Field Operations. Washington, DC: National Academies Press; 1993:chap 5. Available at: 

https://www.ncbi.nlm.nih.gov/books/NBK236237/. 

Accessed January 11, 2018.

15. Kolka MA, Latzka WA, Montain SJ, Corr WP, 

O’Brien KK, Sawka MN. Effectiveness of revised fluid replacement guidelines for military 

training in hot weather. Aviat Space Environ Med. 

2003;74(3):242-246.

16. Hillyer M, Menon K, Singh R. The effects of dehydration on skill-based performance. Int J Sports 

Sci. 2015;5(3):99-107.

17. Popkin BM, D’Anci KE, Rosenberg IH. Water, hydration and health. Nutr Rev. 2010;68:439-458.

18. Coris EE, Ramirez AM, Van Durme DJ. Heat illness in athletes: the dangerous combination of heat, 

humidity and exercise. Sports Med. 2004;34(1):9-16.

19. Judelson DA, Maresh CM, Anderson JM, et al. 

Hydration and muscular performance: does fluid 

balance affect strength, power and high-intensity 

endurance?. Sports Med. 2007;37(10):907-921.

20. Institute of Medicine. Dietary Reference Intakes 

for Water, Potassium, Sodium, Chloride, and 

Sulfate. Washington, DC: National Academies 

Press; 2005. Available at: https://www.nap.edu/

read/10925/chapter/1. Accessed January 11, 2018.

21. Montain SJ. Hydration recommendations for sport 

2008. Curr Sports Med Rep. 2008;7:187-192.

22. Sawka MN, Noakes TD. Does dehydration impair exercise performance?. Med Sci Sports Exerc. 

2007;39:1209-1217.

23. Cheuvront SN, Montain SJ, Sawka MN. Fluid replacement and performance during the marathon. 

Sports Med. 2007;37:353-357.

24. Baker LB, Dougherty KA, Chow M, Kenney WL. 

Progressive dehydration causes a progressive decline in basketball skill performance. Med Sci 

Sports Exerc. 2007;39:1114-1123.

25. Devlin LH, Fraser SF, Barras NS, Hawley JA. 

Moderate levels of hypohydration impairs bowling 

accuracy but not bowling velocity in skilled cricket 

players. J Sci Med Sport. 2001;4:179-187.

26. Epstein Y, Keren G, Moisseiev J, Gasko O, Yachin 

S. Psychomotor deterioration during exposure to 

heat. Aviat Space Environ Med. 1980;51:607-610.

27. Smith MF. The role of physiology in the development of golf performance. Sports Med. 

2010;40:635-655.

28. Smith MF, Newell AJ, Baker MR. Effect of acute 

mild dehydration on cognitive-motor performance 

in golf. J Strength Cond Res. 2012;26:3075-3080.

29. Cian C, Koulmann N, Barraud P-A, Raphel C, 

Jimenez C, Melin B. Influence of variations in body 

hydration on cognitive function: Effect of hyperhydration, heat stress, and exercise-induced dehydration. J Psychophysiol. 2012;14:29-36.

30. Shirreffs SM, Merson SJ, Fraser SM, Archer 

DT. The effects of fluid restriction on hydration 

status and subjective feelings in man. Br J Nutr. 

2004;91:951-958.

31. Szinnai, G, Schachinger, H, Arnaud MJ, Linder 

L, Keller U. Effect of water deprivation on cognitive-motor performance in healthy men and 

women. Am J Physiol Regul Integr Comp Physiol. 

2005;289(1):R275-R280.

32. Patel AV, Mihalik JP, Notebaert AJ, Guskiewiciz 

KM, Prentice WE. Neurophysiological performance, postural stability and symptoms after dehydration. J Athl Train. 2007;42(1):66-75.

33. Gopinathan PM, Pichan G, Sharma VM. Role 

of dehydration in heat stress-induced variations 

in mental performance. Arch Environ Health. 

1988;43:15-17.

34. Sharma VM, Sridharan K, Pichan G, Panwar MR. 

Influence of heat-stress induced dehydration on 

mental functions. Ergonomics. 1986;29:791-799.

35. Lieberman HR. Hydration and human cognition: 

a critical review and recommendations for future 

research. Nutr Today. 2010;26(suppl 5):555S-561S.

36. Adam GE, Carter R 3rd, Cheuvront SN, et al. Hydration effects on cognitive performance during 

military tasks in temperate and cold environments. 

Physiol Behav. 2008;93(4-5):748-756.

37. Neave N, Scholey AB, Emmett JR, Moss M, Kennedy DO, Wesnes KA. Water ingestion improves 

subjective alertness, but has no effect on cognitive 

performance in dehydrated healthy young volunteers. Appetite. 2001;37(3):255-256.

38. Garigan TP, Ristedt DE. Death from hyponatremia 

as a result of acute water intoxication in an Army 

basic trainee. Mil Med. 1999;164:234-238.

39. O’Brien C, Freund BJ, Young AJ, Sawka MN. 

Glycerol hyperhydration: physiological responses 

during cold-air exposure. J Appl Physiol (1985). 

2005;99:515-521.

HYDRATION STRATEGIES FOR THE FEMALE TACTICAL ATHLETE
January – June 2018 89

THE ARMY MEDICAL DEPARTMENT JOURNAL

40. O’Brien KK, Montain SJ, Corr WP, Sawka MN, 

Khapik JJ, Craig SC. Hyponatremia associated 

with overhydration in U.S. Army trainees. Mil Med. 

2001;166(5):405-410.

41. Eichner ER. Exertional hyponatremia: why so 

many women?. Sports Med Digest. 2002;24:54-56.

42. Armstrong LE. Assessing hydration status: the elusive gold standard. J Am Coll Nutr. 2007;26(suppl 

5):575S-584S.

43. Schoeller D. Hydrometry. In: Heymsfield SB, 

Lohman TG, Wang Z, Going SB, eds. Human Body 

Composition. 2nd ed. Champaign, IL: Human Kinetics; 1996:35-49.

44. Shirreffs SM. Markers of hydration status. Eur J 

Clin Nutr. 2003;57(suppl 2):S6-S9.

45. Singh NR, Peters EM. Markers of hydration status 

in a 3-day trail running event. Clin J Sport Med Off 

J Can Acad Sport Med. 2013;23:354-364.

46. Sommerfield LM, McAnulty SR, McBride JM, et al. 

Validity of urine specific gravity when compared 

with plasma osmolality as a measure of hydration 

status in male and female NCAA collegiate athletes. J Strength Cond Res. 2016;30(8):2219-2225.

47. Consolazio FC, Johnson RE, Pecora LJ. The computation of metabolic balances. In: Consolazio CF, 

Johnson RE, Pecora LJ. Physiological Measurements of Metabolic Function in Man. New York, 

NY: McGraw-Hill; 1963:313-339.

48. Mitchell JW, Nadel ER, Stolwijk JA. Respiratory weight losses during exercise. J Appl Physiol. 

1972;32:474-476.

49. American College of Sports Medicine, Sawka MN, 

Burke LM, et al. American College of Sports Medicine position stand. Exercise and fluid replacement. 

Med Sci Sports Exerc. 2007;39(2):377-390.

50. Ritz P. Methods of assessing body water and 

body composition. In: Arnaud EJ, ed. Hydration 

Throughout Life. London: John Libbey and Company Ltd; 1998:63-74. 

51. Gosselin RE, Adolph E. Rates of sweating in the 

desert. In: Adolph EF. Physiology of Man in the 

Desert. New York, NY: Intersciences Publishers, 

1947:44-76.

52. Eijsvogels TM, Scholten RR, van Duijnhoven 

NT, Thijssen DH, Hopman MT. Sex difference in 

fluid balance responses during prolonged exercise. 

Scand J Med Sci Sports. 2013;23(2):198-206.

53. Cheuvront SN, Carter, R, Montain SJ, Sawka MN. 

Daily body mass variability and stability in active 

men undergoing exercise-heat stress. Int J Sport 

Nutr Exerc Metab. 2004;14:532-540.

54. Volpe SL, Poule KA, Bland EG. Estimation of prepractice hydration status of National Collegiate 

Athletic Association Division I athletes. J Athl 

Train. 2009;44:624-629.

55. Bunt JC, Lohman TG, Boileau RA. Impact of total body water fluctuations on estimation of body 

fat from body density. Med Sci Sports Exerc. 

1989;21:96-100.

56. Cheuvront SN, Haymes EM, Sawka MN. Comparison of sweat loss estimates for women during 

prolonged high-intensity running. Med Sci Sports 

Exerc. 2002;34:1344-1350.

57. Armstrong LE, Maresh CM, Castellani JW, et al. 

Urinary indices of hydration status. Int J Sport 

Nutr. 1994;4(3):265-279.

58. Popowski LA, Oppliger RA, Gisolf CV, et al. Blood 

and urinary measures of hydration status during 

progressive acute dehydration. Med Sci Sports Exerc. 2001;33(5):747-753.

59. Bartok, C, Schoeller DA, Sullivan JC, Clark RR, 

Landry GL. Hydration testing in collegiate wrestlers undergoing hypertonic dehydration. Med Sci 

Sports Exerc. 2004;36:510-517.

60. Kovacs EM, Senden JM, Brouns F. Urine color, 

osmolality and specific electrical conductance are 

not accurate measures of hydration status during 

postexercise rehydration. J Sports Med Phys Fitness. 1999;39:47-53.

61. Vreeman RC, Carroll AE. Medical myths. BMJ. 

2007;335:1288-1289.

62. Erdman JW. Preface. In: Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: National Academies Press; 2005. Available at: https://

www.nap.edu/read/10925/chapter/1. Accessed January 11, 2018.

63. Dwyer J. Nutrient requirements and dietary assessment. In: Longo DL, Fauci AS, Kasper DL, Hauser 

SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York, 

NY: McGraw-Hill; 2012:588-594.

64. Sallis RE. Fluid balance and dysnatremias in athletes. Curr Sports Med Rep. 2008;7(4):S14-S19.

65. Maughan RJ, Leiper JB, Shirreffs SM. Restoration 

of fluid balance after exercise-induced dehydration: 

effects of food and fluid intake. Eur J Appl Physiol. 

1996;73:317-325.

66. Ray ML, Bryan MW, Ruden TM, Baier SM, Sharp 

RL, King DS. Effect of sodium in a rehydration 

beverage when consumed as a fluid or meal. J Appl 

Physiol (1985). 1998;85(4):1329-1336.

67. Shirreffs SM, Maughan RJ. Volume repletion after 

exercise-induced volume depletion in humans: replacement of water and sodium losses. Am J Physiol. 1998;274(5 Pt 2):F868-F875.
90 http://www.cs.amedd.army.mil/amedd_journal.aspx

68. Freund BJ, Montain SJ, Young AJ, et al. Glycerol hyperhydration: hormonal, renal, and vascular fluid responses. J Appl Physiol (1985). 

1995;79(6):2069-2077.

69. Montain SJ, Coyle EF. Influence of graded dehydration on hyperthermia and cardiovascular drift during exercise. J Appl Physiol (1985). 

1992;73:1340-1350.

70. Montain SJ, Cheuvront SN, Sawka MN. Exercise 

associated hyponatraemia: quantitative analysis to understand the aetiology. Br J Sports Med. 

2006;40(2):98-105;discussion 98-105.

71. Jones B, Till K, King R, Gray M, OʼHara J. Are 

habitual hydration strategies of female rugby 

league players sufficient to maintain fluid balance 

and blood sodium concentration during training 

and match-play? A research note from the field. J 

Strength Cond Res. 2016;30:875-880.

72. Below PR, Mora-Rodríguez R, González-Alonso J, Coyle EF. Fluid and carbohydrate ingestion independently improve performance during 1 h of intense exercise. Med Sci Sports Exerc. 

1995;27(2):200-210.

73. Coyle EF, Montain SJ. Carbohydrate and fluid ingestion during exercise: are there trade-offs? Med 

Sci Sports Exerc. 1992;24:671-678.

74. Coyle EF. Fluid and fuel intake during exercise. J 

Sports Sci. 2004;22:39-55.

75. Jeukendrup A. The new carbohydrate intake recommendations. Nestle Nutr Inst Workshop Ser. 

2013;75:63-71.

76. Jeukendrup AE. Carbohydrate intake during exercise and performance. Nutrition. 

2004;20(7-8):669-677.

77. Kleiner SM, Greenwood-Robinson M. Power Eating. Champaign, IL: Human Kinetics; 1998.

78. Welsh RS, Davis JM, Burke JR, Williams HG. Carbohydrates and physical/mental performance during intermittent exercise to fatigue. Med Sci Sports 

Exerc. 2002;34:723-731.

79. Jentjens RL, Shaw C, Birtles T, Waring RH, Harding LK, Jeukendrup AE. Oxidation of combined 

ingestion of glucose and sucrose during exercise. 

Metabolism. 2005;54(5):610-618.

80. Wallis GA, Rowlands DS, Shaw C, Jentjens RL, 

Jeukendrup AE. Oxidation of combined ingestion 

of maltodextrins and fructose during exercise. Med 

Sci Sports Exerc. 2005;37(3):426-432.

81. Burgess WA, Davis JM, Bartoli WP, Woods JA. 

Failure of low dose carbohydrate feeding to attenuate glucoregulatory hormone responses and 

improve endurance performance. Int J Sport Nutr. 

1991;1:338-352.

82. Coggan AR, Coyle EF. Reversal of fatigue during 

prolonged exercise by carbohydrate infusion or ingestion. J Appl Physiol (1985). 1987;63:2388-2395.

83. Coyle EF, Hagberg JM, Hurley BF, Martin WH, 

Ehsani AA, Holloszy JO. Carbohydrate feeding 

during prolonged strenuous exercise can delay fatigue. J Appl Physiol. 1983;55(1 Pt 1):230-235.

84. Coyle EF, Coggan AR, Hemmert MK, Ivy JL. 

Muscle glycogen utilization during prolonged 

strenuous exercise when fed carbohydrate. J Appl 

Physiol (1985). 1986;61(1):165-172.

85. Knipscher BW. Thor3: Humans Are More Important Than Hardware [master’s thesis]. Monterey, 

CA: Naval Postgraduate School; 2010.

86. Gisolfi CV. Fluid balance for optimal performance. 

Nutr Rev. 1996;54:S159-S168.

87. Cox GR, Desbrow B, Montgomery PG, et al. Effect 

of different protocols of caffeine intake on metabolism and endurance performance. J Appl Physiol 

(1985). 2002;93(3):990-999.

88. Heneghan C, Gill P, O’Neill B, Lasserson D, Thake 

M, Thompson M. Mythbusting sports and exercise 

products. BMJ. 2012;345:e4848.

89. Maughan RJ, Griffin J. Caffeine ingestion and fluid 

balance: a review. J Hum Nutr Diet. 2003;16:411-420.

90. Zhang Y, Coca A, Casa DJ, et al. Caffeine and diuresis during rest and exercise: a meta-analysis. J 

Sci Med Sport. 2015;18(5):569-574.

91. Maughan RJ, Leiper JB. Sodium intake and postexercise rehydration in man. Eur J Appl Physiol. 

1995;71:311-319.

92. Nose H, Mack GW, Shi XR, Nadel ER. Involvement of sodium retention hormones during rehydration in humans. J Appl Physiol (1985). 

1988;65(1):332-336.

93. Kovacs EM, Schmahl RM, Senden JM, Brouns F. 

Effect of high and low rates of fluid intake on postexercise rehydration. Int J Sport Nutr Exerc Metab. 

2002;12(1):14-23.

94. Wong SH, Williams C, Simpson M, Ogaki T. Influence of fluid intake pattern on short-term recovery from prolonged, submaximal running 

and subsequent exercise capacity. J Sports Sci. 

1998;16:143-152.

Authors

Capt Zak is with the Stapp Aerospace Medical Facility, 

Edwards Air Force Base, California. When this article 

was written, he was a 4th year medical student in rotation 

at the Department of Orthopaedic Surgery, San Antonio 

Military Medical Center, Joint Base San Antonio-Fort 

Sam Houston, Texas.

MAJ Hylden is Chief of Orthopaedic Surgery at Bassett 

Army Community Hospital, Fort Wainwright, Alaska.

When this article was written, COL Johnson was Chairman, Department of Orthopaedic Surgery, San Antonio 

Military Medical Center, Joint Base San Antonio-Fort 

Sam Houston, Texas.

HYDRATION STRATEGIES FOR THE FEMALE TACTICAL ATHLETE
January – June 2018 91

In the Vietnam War, the United States military created a parallel hospital system to care for the indigenous 

armies they raised to fight the Communists. Comprised 

of ethnic minorities, these militias faced fierce discrimination that denied them adequate access to the Vietnamese health care system; their semiofficial status simultaneously complicated integration into American hospitals. The lack of effective medical care not only led to 

unnecessary morbidity and mortality but also severely 

damaged the morale of these units. Relying on extensive 

archival records in both the National Archives and collections at Ft. Bragg that features hundreds of unique 

interviews, this paper explores how the Special Forces 

designed, built, and implemented a hospital system to 

care for these Soldiers. Evolving into surgery-capable 

frontline hospitals and using a joint US-Montagnard 

staff, these establishments served as on-the-job training 

locations for American and indigenous medics, treating 

both battle injuries and endemic diseases. Perhaps most 

importantly, they raised the morale of thousands of Soldiers by guaranteeing superior medical care.

Background

The Special Forces (SF) were founded in 1952 as a covert 

unit intended to fight the Soviets in the event of World 

War III.1 Based off World War II era groups like the Jedburghs, SF A-Teams would, in theory, parachute behind 

Russian lines, raise guerilla armies, and fight as a fifth 

column force.2 This mission required autonomous medical support given the inaccessibility of conventional military medical resources. Accordingly, the Special Forces 

established an intensive training regimen designed to 

prepare Army medics to function as autonomous clinicians.3

 Rigorous, demanding, and with a nearly 50% 

failure rate, this medical education included classroom 

lessons and on the job training in local hospitals.4

In the 1960s, the mission focus of the Special Forces 

evolved from guerilla warfare to counter-insurgency. 

Communist insurrections flared around the globe, and 

after the CIA’s debacle at the Bay of Pigs, Kennedy 

placed his faith in the US military and specifically the 

Special Forces.5 This shift demanded SF teams stabilize 

a region by winning the hearts and minds of the local 

populace.6 Medicine became especially important to 

this mission, with counterinsurgency experts envisioning it as powerful tool to appeal to and recruit locals. 

But this medicine differed substantially from that intended in 1952; rather than just providing trauma care to 

otherwise healthy guerilla fights, SF medics were now 

expected to manage the tropical infections, pediatrics, 

geriatrics and other sundry diseases associated with any 

given population. The medic transformed from essentially a trauma specialist to a family practitioner. Training correspondingly expanded and came to include the 

famous “dog lab” where students could practice surgery 

on anesthetized animals.7

This counter-insurgency focus soon landed the Special 

Forces in Vietnam.8 In an effort to staunch the communist infiltration, they began setting up outposts in villages that served a mini-basecamps for patrols and for 

protecting the local civilian population.9 SF founded 

their first camp in Buon Enao in 1961. The medic served 

as the primary ambassador, ingratiating the SF team 

into the local village and securing local cooperation 

and participation.10 The Special Forces worked to recruit these locals into a militia to help defend the village, 

America’s Guerilla Hospitals in the

 Vietnam War: the CIDG Experience

Justin Barr, MD

2017

Spurgeon Neel Annual Award Winner

The Army Medical Department Museum Foundation sponsors the Spurgeon Neel Annual 

Award competition for the original essay that best exemplifies the history, legacy, and 

tradition of the US Army Medical Department. The following essay by Dr Justin Barr was 

selected as the best submission of the 2017 competition.
92 http://www.cs.amedd.army.mil/amedd_journal.aspx

forming what came to be called Civilian Irregular Defense Groups (CIDG). Efforts focused on the Montagnard populations occupying the highlands of Vietnam.

Medical Problems for the CIDG

The Montagnard makeup of the CIDG units created immense medical challenges for the Special Forces. The 

majority (87%) of the population of Vietnam is Viet 

Kinh and lives in the flat, fertile eastern seaboard. The 

ethnic minorities, dubbed Montagnards, or mountain 

men, by the French, consist of a constellation of small 

tribes residing in the Annamite Mountains on Vietnam’s western border.11 The Montagnards’ strategic 

location along the Ho Chi Minh Trail made them valuable allies for whichever side could recruit them, but 

centuries of discord between the minority people and 

the Viet Kinh hampered the ability of either the North 

Vietnamese or South Vietnamese armies to ally with the 

Montagnards.12 This same discord undermined medical cooperation between the CIDG and the Vietnamese 

medical system. As the war expanded in breadth and 

ferocity through the 1960s, CIDG casualties mounted, 

but medical care remained markedly deficient.

Preexisting prejudices against the Montagnard people 

combined with an inadequate health care system for 

the Vietnamese to create a forbidding medical environment. The Montagnard uprising that killed several South 

Vietnamese Soldiers in 1963 further inflamed tensions.13

That same year, the South Vietnamese Army reclassified 

all CIDG Soldiers as civilians, thus denying them entry 

into the military hospital system.14 Given that in 1963 

over 50% of Vietnam’s physicians wore a uniform and 

that remaining civilian doctors practiced chiefly in urban areas, the exclusion prevented the men from receiving effective medical care.15 Furthermore, this change 

blatantly indicated the government’s continuation of its 

policy of considering Montagnards second-class citizens despite their continued, joint war against the North.

As civilians, the CIDG retained access to provincial 

hospitals. Hospitals more in name than in reality, the 

understaffed facilities (there was one physician for every 20,000 people; by comparison, the United States 

had a rate of 1/743)16 provided inadequate care for ethnic Vietnamese. Special Forces MSC officer Captain 

Clayton Peacock found “the [Vietnamese] doctors know 

little more than some of our medics. The surgeons are 

butchers by and large...I honestly don’t think there is a 

Vietnamese in all Vietnam who really understands what 

sterile technique is.” 17 While undoubtedly hyperbole, 

statements like these reflected American impressions of 

any faith in local health care and came to reinforce the 

perceived necessity of creating a separate system.

Special Forces personnel disparaged the poor medical care Montagnard received at Vietnamese hospitals. 

“There were instances...where the CIDG were taken to 

the hospital there [South Vietnamese military hospital] 

and assured they would be taken care of, and the patients were found dead in the same place that they had 

been left three or four days earlier,” noted Barry Zindel, 

an SF physician.18 Americans regularly recalled anecdotes of Montagnard wounded left in hallways, bereft of 

food and water, and denied care.19

This situation created an immense medical problem for 

the Special Forces. They could not evacuate wounded 

CIDG to Vietnamese hospitals because of the inadequate care provided. Montagnards, aware of the situation, actively refused transfer to local hospitals.20 SF 

medics tried to provide as much care as possible in the 

villages themselves, but they did not have adequate 

training to treat penetrating wounds to the chest, abdomen, or head, nor did they have the facilities to manage 

complicated postoperative care.21 United States Army 

hospitals admitted some of the most desperate CIDG 

patients, but facilities remained few and far between in 

the early 1960s and swamped with American casualties, 

who took priority, by the late-1960s.22 While frequently 

flouted, USARV Regulation 40-11 technically prohibited Montagnard Soldiers from accessing American hospitals, and despite much effort, the Special Forces community could not get the Army to rescind that policy.23

Wounded Montagnards had nowhere to go.

This difficulty extended beyond just medical logistics. 

From a moral stance, asking men to fight for you without 

providing them adequate medical support unsettled and 

frustrated the Special Forces men who lived, and died, 

alongside the Montagnards. From the ever-important 

counter-insurgency facet, it hurt the underlying mission. 

Forces became less aggressive, fearing the consequences of getting wounded. Recruitment into the CIDG units 

suffered. It proved challenging to win the hearts and 

minds of a population when unable to provide effective 

medical care for their arms and legs.

Improvising a Solution

Attempting to redress this deficiency, the Special Forces created and operated local hospitals that eventually 

evolved into a mini-health care system. It started at Bien 

Hoa, which provided the model that other regions followed. Captain Richard Hobson II, MC and Captain 

John Slaughter, MC arrived in Bien Hoa in the fall of 

1965 and immediately took notice of the disparity in 

care. “The civilian irregulars were essentially getting 

very poor medical support, insofar as care that could not 

be handled at the A-Team,” commented Hobson.24 He 

— SPURGEON NEEL ESSAY AWARD COMPETITION —

AMERICA’S GUERILLA HOSPITALS IN THE VIETNAM WAR: THE CIDG EXPERIENCE
January – June 2018 93

THE ARMY MEDICAL DEPARTMENT JOURNAL

and Slaughter decided a “Civilian Irregular Treatment 

Center” would best remedy the problem.

They launched this idea without any material support. 

Certainly, the Government of Vietnam did not offer any 

assistance, as they wanted to build up the hospital system for the Viet Kinh before attending to the minorities.25 SF headquarters lacked the budgetary flexibility 

to contribute resources, pecuniary or otherwise. According to Captain James Gay, MC, who later worked in the 

Bien Hoa Hospital, “I do not think enough can be said 

about the ingenuity and aggressiveness of Dr. Hobson 

in obtaining permission to attempt to build such a complex and convincing his Commanding Officer and fellow 

staff officers to help him build such a hospital.” 26 Slaughter and Hobson plowed onwards, improvising, begging, 

and “requisitioning” in true-SF fashion. They received a 

plot of land in October of 1965 and then used a $12,500 

civil affairs grant to fund construction. The American 

93rd Evacuation Hospital at Bien Hoa donated operating 

room equipment, and a spare anesthesia machine came 

with the compliments of the 3rd Surgical Hospital. “The 

beds in the unit came from the 93rd Evac with the help 

of some flags, cross-bows, and ChiCom machineguns,” 

recalled Hobson.27 According to SF medic Clarence 

Page, who assisted in founding the Bien Hoa hospital, 

“we had no authorization for a damn piece of equipment. 

We scrounged, we stole, we borrowed, we used out of 

our supplies, used S-5 supplies, we did everything.”28

Through some subterfuge, the cement slated for the Officer’s Club swimming pool in Bien Hoa instead became 

as the floor of the CIDG hospital there.29

Because the SF had never managed or even conceived 

of opening this type of hospital, Medical Service Corps 

officers created doctrine and standard operation procedures from scratch.30 Its unofficial, ad hoc stature also 

complicated personnel assignments; the table of organization and equipment did not billet any slots for the 

CIDG Hospital, so they had to second physicians and 

medics from the field. This action created a tension with 

the primary mission of providing medical personnel to 

US and indigenous forces actively patrolling the countryside.31 In 1968, with increased resources dedicated to 

the overall war effort in Vietnam, the Special Forces formally acknowledged the CIDG hospitals, enabling them 

to provide staffing and more advanced medical supplies. 

Families of the patients provided most of the nursing 

care, including feeding, bathing, and dressing changes.32

What began as a glorified dispensary evolved into a 

fully functional combat hospital. In December of 1965, 

Slaughter, Hobson, and engineer Carl Schmidt finished 

constructing the four structures that initially comprised 

the Bien Hoa CIDG Hospital. These included two fortybed patient wards, a medical supply warehouse (which 

doubled as staff quarters), and an administration/OR/

clinic building.33 The physical plant soon outstripped 

the medical abilities of the first SF physicians, who had 

themselves just completed internship and were ill-prepared to treat the complicated combat wounds arriving 

in triage.

Interactions between the CIDG and US Army hospitals were crucial to the delivery of effective care, and 

SF physicians from the Command Surgeon on down 

went to extraordinary lengths to cultivate these relationships.34 “Not that there was any sort of formal agreement 

between our unit and the hospital,” commented Captain 

Robert Drake, MSC, “it was handled primarily on a 

personal relationship between our physicians.” 35 Each 

CIDG hospital paired with a corresponding American 

one, and at Bien Hoa that meant the 93rd Evacuation and 

3rd Surgical Hospital.36 Army surgeons took the most 

complicated cases, including all neurosurgeries, into 

their own facilities, and used their own equipment and 

instruments; they then returned the patients to convalesce in the CIDG hospital’s ward.37

As years passed, the facilities improved and capabilities 

increased. With the arrival of Captain Eugene Edynak, 

MC, in 1967, the hospital at Bien Hoa acquired a trained 

surgeon, which vastly expanded the range of procedures 

they could perform to include thoracic and abdominal 

operations.38 By 1970, the hospital included 160 beds, 

with ten classified as an Intensive-Care Unit, an elaborate laboratory, powerful x-ray equipment, and several full-fledged operating suites manned by residency 

trained surgeons. By 1968, the demand for beds had outstripped their availability, so the administration splintered off a separate convalescence center approximately 

forty kilometers from Bien Hoa at Long Hai. Here, a SF 

medic and a few local orderlies took charge of the forty 

to sixty patients who resided there until they healed or 

returned for further care.39 This facility coupled with a 

prosthetic center that tried to replace amputated limbs 

and return some semblance of normalcy to the lives of 

disabled CIDG Soldiers.40

Expansion of the CIDG Hospital Program

Other regions followed the model of Bien Hoa. Captain 

Paul Ferguson, MC, Captain Brenton Burgoyne, MC, 

and Captain Homer House, MC, created facilities at 

Pleiku after spending a couple of months working in the 

original hospital down south in Bien Hoa. The Pleiku 

CIDG Hospital collaborated with the local American 

71st Evacuation Hospital for complicated cases.41 They 

also founded a small, satellite hospital in Ban Me Thuot 
94 http://www.cs.amedd.army.mil/amedd_journal.aspx

in an effort to accommodate the large size of the military 

region. Staffed by a physician, it handled minor trauma, 

sickness, and convalescent care.42

In northern South Vietnam, the Special Forces established a CIDG hospital at Da Nang, where it partnered 

with American Naval medical facilities.43 Captain Barry 

Zindel, the surgeon who founded the SF hospital here, 

had a unique methodology for acquiring the supplies 

and services of the Navy Seabees: in return for vasectomies, Seabees lent their assistance in building the physical plant.44 Bartering like this again emphasizes the ad 

hoc nature of these efforts and the determination – and 

creativity – of the SF medical personnel supporting 

them. Compared to Bien Hoa and Pleiku, the hospital at 

Da Nang remained relatively small due to comparatively 

fewer CIDG camps and excellent cooperation with the 

Navy.

The Mekong Delta region never established a CIDG 

hospital. This absence partly reflected ethnic distribution: no Montagnards lived this far south, although the 

Nungs and Khmer Soldiers faced only slightly less discrimination. Closer to the capital in Saigon, the area had 

established a more robust medical infrastructure, and 

the Vietnamese hospital in Can Tho also did a more 

acceptable job treating the locals. SF doctors commandeered one of the wards to ensure their forces received 

equitable and adequate care, but in contrast to the other 

three military regions, the Mekong Delta had an effective hospital system already in place. The Special Forces 

preferred to prop up an extant system rather than try to 

create their own.45

Established to care for CIDG Soldiers, the CIDG hospital saw its patient load come include not only the armed 

fighters but also their families.46 The US Army Special 

Forces built these hospitals for moral and morale reasons: 

they wanted to provide medical care for its fighters, and 

in doing so, hoped that more combatants would enlist. 

Including the families satisfied both of these intentions. 

Since the A-Team medics treated the quotidian cases, 

the staff at the hospitals saw only the most severely ill 

or wounded patients, evidenced by the preponderance of 

battle injuries in the patient load. Between 50% and 70% 

of CIDG admissions resulted from war wounds, compared to around 30% of the SF admissions.47

While the hospitals primarily existed to care for injured 

CIDG and their families, the institutions also served 

as ideal locations for practical on the job training, both 

for indigenous and SF medics. By 1966/1967 when the 

CIDG hospital program began, many of the SF medics 

rotating into Vietnam came straight from school in the 

United States, and while most received excellent education, they lacked practical experience. Spending two 

weeks in a CIDG hospital at the start of their tour allowed them to gain this necessary experience before 

transferring to a village in the hinterlands. Other medics 

sought some continuing medical education in the middle of their tour, either brushing up on skills or increasing their surgical acumen.48 Indigenous medics also 

trained there. Ranging between six to ten weeks, the 

instruction given to the natives usually augmented that 

already received in an A-Camp.49 For both groups, the 

location served as an ideal school. An extensive and diverse patient population presented a variety of medical 

and surgical ailments, while full-fledged physicians and 

experienced paramedical personnel provided a wealth 

of medical knowledge for the students.

By the mid to late 1960s, the CIDG hospital system provided extensive care. At its peak, it boasted 420 beds 

and nine dedicated physicians, along with dozens of SF 

medics and scores of indigenous personnel serving as 

X-technicians, laboratory assistants, and such.50 With 

nearly 60,000 CIDG Soldiers and their dependents, the 

facilities could not provide definitive care to each but 

did service over 16,000 patients through the course of 

the war.51 Evolving from glorified clinics into fully functional hospitals, they featuring fully-equipped operating 

rooms with surgeons to staff them, intensive care units, 

and even rehabilitation departments. They provided a 

level of care otherwise unavailable to the Montagnard 

population, who recognized the value and quality of 

these institutions. When one CIDG sergeant with femur 

fractured from a gunshot wound was mistakenly deposited in the South Vietnamese army hospital in Saigon 

realized the mistake, he literally hopped out of the bed 

and hailed a taxicab so as to receive care at the Bien Hoa 

CIDG hospital.52

As important as the medical value was the morale these 

establishments inspired. Before their existence, Montagnards suffered from the nonfeasance and malfeasance of Vietnamese doctors; the tribesmen knew they 

received substandard medical care, and this knowledge 

affected their willingness to fight. After the construction of the hospitals, “the morale went up 300%,” according to SF medic John McCray.53 Other medics and 

officers echoed this sentiment. Richard Miller, a field 

officer with the Special Forces in Vietnam in 1968 credited the CIDG hospitals as “one of the finest projects undertaken by the USASF that I have witnessed during my 

tour...the effect that the facility has on the morale of the 

CIDG is most significant...the facility at Bien Hoa has 

reduced the fatality and disability rate significantly. It is 

felt that the maintenance of this facility, with qualified 

— SPURGEON NEEL ESSAY AWARD COMPETITION —

AMERICA’S GUERILLA HOSPITALS IN THE VIETNAM WAR: THE CIDG EXPERIENCE
January – June 2018 95

THE ARMY MEDICAL DEPARTMENT JOURNAL

surgical support, is essential to the morale of CIDG in 

III CTZ.” 54 These establishments also improved the SF 

medic’s morale; by working there, they took away a 

well-deserved sense of accomplishment and a skill set 

unobtainable through their normal training. More importantly, medics in the CIDG camps finally could evacuate their patients with the confidence that they would 

receive good care.

With Operation Keystone Robin in 1970-1971, SF lost 

responsibility for the CIDG militias, and most A-Teams 

departed. The CIDG hospitals remained after the last 

camps shut down,55 but as the CIDG program soon dissolved under South Vietnamese leadership, the Special 

Forces decided to close all the hospitals by 12 January 

1972.56 The institutions proved successful in multiple 

facets. The clearly provided significantly better care 

to the Montagnards than previously existed, reducing 

the morbidity and mortality of the fighting force. They 

served as effective training locales for both American 

and Montagnard medics before they deployed into the 

field. And they markedly elevated the morale of the 

CIDG units, whose Soldiers for the first time could expect competent, compassionate medical care when sick 

or injured. Simultaneously improving both health outcomes and the counterinsurgency objective of winning 

the hearts and minds, CIDG Hospitals represented a 

creative solution to a nuanced problem that ultimately 

fulfilled the mission to preserve the fighting force.

Endnotes

1. Alfred H. Paddock, Jr. US Army Special Warfare: 

Its Origins (Washington DC: National Defense 

University, 1984). Aaron Bank, From OSS to 

Green Berets: the Birth of the Special Forces (Novato: Presidio, 1986).

2. For more on Jedburghs, see: Colin Beavan, Operation Jedburgh: D-Day and America’s First Shadow 

War (New York: Viking, 2006) and Will Irwin, The 

Jedburghs: The Secret History of the Allied Special 

Forces, France 1994 (New York: Public Affairs, 

2005). For more on Special Operation in World War 

II generally, see David W. Hogan, Jr. U.S. Army 

Special Operations in World War II (Washington 

DC: Center of Military History, 1992).

3. Louis T. Dorogi, “Early Special Forces Medical 

Training, 1952-1971,” Special Warfare 3 (Winter 

1990), 28-35.

4. Thomas Bain, Letter to Louis Dorogi, Winter 1977, 

p. 4, National Archives and Records Administration 

at College Park (hereafter NARA), Historical Files 

on SF Medical Activities in the VN War, Record 

Group 319, Stack Area 270, Row 20, Compartment 

06, Shelf 4-6, Box 6, Folder 10 (hereafter shortened 

to 319/270/20/06/4-6/6/10). Richard L. Coppedge, 

Interview with Louis Dorogi (22 February 1976) 

pp. 42-3, John F. Kennedy Special Warfare Center 

and School, Army Special Operations Archives 

in Aaron Bank Hall at Fort Bragg, North Carolina 

(hereafter: ARSOF Archives), Dorogi Collection, 

Box 6, Folder 32. William Posey, “Special Forces 

Medical Training,” for Communicative Area Program (April 1970), p. 1, ARSOF Archives, Dorogi 

Collection, Box 1, Folder 57. Ralph G. Drouin, Letter to Louis Dorogi, February 1977, p. 1, NARA, 

319/270/20/06/4-6/6/6.

5. See especially National Security Action Memoranda numbers 2, 26, 52, 55-56, 110, 114, 124, 131-

132, 162-163, 182, and 204. These are available 

from the Papers of the John F. Kennedy, Presidential Papers Collection, at www.jfklibrary.org/

Historical+Resources/Archives/Reference+Desk/

NSAMs.htm.

6. A Summary of Counter Guerilla Operational Concepts (Fort Bragg: USASWC, 1961); A Textbook 

on Guerilla Warfare (Fort Bragg Counter Guerilla 

Department: USASWC, n.d.); Counterinsurgency 

Operations: A Handbook for the Suppression of 

Communist Guerilla/Terrorist Operations (Fort 

Bragg: USASWC, 1960); Tactics and Techniques in 

Counter Guerilla Operations (Fort Bragg Counter 

Guerilla Department: USASWC, 1961).

7. Coppedge, Interview with Dorogi, 21. Roger A. 

Juel, Interview with Louis Dorogi (17 December 

1976) p. 5, 8, 14, ARSOF Archives, Box 6, Folder 

49. “Capabilities of the Special Forces Medical Specialist: Lesson Plan” (n.d.) p. 2-4, ARSOF Archives, 

Dorogi Collection, Box 1, Folder 69. “Program of 

Instruction for 91B4S Medical NCO/Supervisor 

Candidate Course (Special Forces),” Ft. Bragg, 1 

October 70, ARSOF Archives, Dorogi Collection, 

Box 6, Folders 1-3. Ian Sutherland, Special Forces 

of the United States Army, 1952-1982 (San Jose: R. 

James Bender Publishing, 1990) 142-143.

8. Francis J. Kelly, Vietnam Series: U.S. Army Special 

Forces, 1961-1971 (Washington DC: Department of 

the Army, 1972). Shelby L. Stanton, Green Berets 

at War: The U.S. Army Special Forces in Southeast 

Asia 1956-1975 (Novato: Presidio, 1985).

9. Dora Layton, Bonnie Layton Ensor, Charles Layton, Interview with Author (20 April 2007) p. 22-

23. Ronald Shackleton, Village Defense: Initial 

Special Forces Operations in Vietnam, (Arvada, 

CO: Phoenix Press, 1975). All interviews with the 

author are available at ARSOF Archives.

10. Paul Campbell, Interview with Louis Dorogi (10 

January 1976) p. 7, ARSOF Archives, Dorogi Collection, Box 6, Folder 28. Campbell, Email to Author, 2 March 2007 and 8 March 2007.
96 http://www.cs.amedd.army.mil/amedd_journal.aspx

11. Montagnard: Tribal Groups of the Republic of 

South Viet-Nam (Fort Bragg: USASWCS, July 

1964).

12. For a history of the Ho Chi Minh Trail and American efforts to interdict it, see: John Prados, The 

Blood Road: The Ho Chi Minh Trail and the Vietnam War (New York: John Wiley and Sons, 1999).

13. Kelly, U. S. Army Special Forces, 1961-1971, 63-

64. Stanton, Green Berets at War, 79-83. Thomas 

K. Adams, US Special Operation Forces in Action: 

the Challenge of Unconventional Warfare (London: Cass, 1998) 89.

14. “Medical Evacuation and Management of Irregular 

Troops and Civilians” (CSD/SF/JOCG No. 28, 10 

December 1962) p. 1, NARA, 5th Special Forces 

Group Headquarters Assistant Chief of Staff for 

Personnel General Records, 472/270/25/2/1/3. See 

also: William J. Bowen, Interview with Louis 

Dorogi (20 July 1976) p. 20, ARSOF Archives, 

Dorogi Collection, Box 6, Folder 24. Jim Cass, Interview with Louis Dorogi (n.d.) p. 20, ARSOF Archives, Dorogi Collection, Box 6, Folder 4.

15. Raymond H. Bishop, “Medical Support of Stability 

Operations: A Vietnam Case Study” (Research Element, US Army War College, 18 February 1969) 

p. 2, ARSOF Archives, Dorogi Collection, Box 3, 

Folder 30.

16. Bishop, “Medical Support of Stability Operations: 

A Vietnam Case Study,” 2. Richard Manson, Letter to Louis Dorogi, 18 March 1976, p. 10, ARSOF 

Archives, Dorogi Collection, Box 7, Folder 1. John 

W. Ferrantello, “Area Assessment of Dak To,” (1 

June 1964) ARSOF Archives, Dorogi Collection, 

Box 4, Folder 31. For US data from 1965, see World 

Bank’s “Physicians (per 1000 people),” https://data.

worldbank.org/indicator/SH.MED.PHYS.ZS?end=

2013&locations=US&start=1960&view=chart

17. Clayton W. Peacock, Interview with Louis Dorogi 

(20 December 1975) p. 47, ARSOF Archives, Dorogi Collection, Box 6, Folder 15.

18. Barry Zindel, Interview with Louis Dorogi (4 June 

1976), p. 4, ARSOF Archives, Dorogi Collection, 

Box 7, Folder 38.

19. “Inclosure [sic] 1 to Annex A to Memo Nr 12, Hq 

5th SFG (Abn), 1st Special Forces” (26 December 

1964) p. 1, NARA, Historical Files on SF Medical 

Activities in the VN War, 319/631/30/20/2-6/32/5. 

William Gates, Interview with Louis Dorogi (20 

May 1976) p. 26, ARSOF Archives, Dorogi Collection, Box 6, Folder 40. James Gay, Letter to Louis 

Dorogi, (n.d.) p. 5, US Army Heritage and Education Center, Medical Historical Unit Collection, 

AMEDD Oral History Files, Box 12. Dennis J. Pollard, Interview with Louis Dorogi (1976) p. 7, ARSOF Archives, Dorogi Collection, Box 7, Folder 12.

20. Peacock, Interview with Dorogi, 46. Richard D. 

Haskell, Interview with Louis Dorogi (16 April 

1976) p. 3, ARSOF Archives, Dorogi Collection, 

Box 6, Folder 43.

21. Haskell, Interview with Dorogi, 3. Henry Caesar, 

Interview with Louis Dorogi (18 May 1976) p. 17 

ARSOF Archives, Box 6, Folder 26.

22. Spurgeon Neel, Medical Support of the U.S. Army 

in Vietnam 1965-1970 (Washington DC: Department of the Army, 1973) 1-5.

23. “5th Special Forces Group Operational Report, Lessons Learned for period ending 31 July 1967,” (15 

August 1967) p. 60, ARSOF Archives, Dorogi Collection, Box 4, Folder 66. Demetrious Tsoulos, Interview with Louis Dorogi (25 February 1976) p. 

53, ARSOF Archives, Dorogi Collection, Box 7, 

Folder 26.

24. Robert W. Hobson III, Interview with Louis Dorogi (19 April 1976) p. 6, ARSOF Archives, Dorogi 

Collection, Box 7, Folder 49. Gay, Interview with 

Dorogi, 5.

25. George Morton, “Debriefing of Colonel George 

Morton,” ed. Ruben W. Shay (6 November 1963) p. 

58, NARA, Historical Files on SF Medical Activities in the VN War 319/631/30/20/2-6/12/24.

26. Gay, Interview with Dorogi, 6.

27. Contractors in Saigon had asked for $50,000-

$70,000. Hobson, Interview with Dorogi, 38-39. 

The SF table of organization and equipment had 

not prepared for this type of establishment and 

did not include complicated medical support items 

like anesthesia machines, which resulting in some 

of the scrounging. Robert Drake, Interview with 

Louis Dorogi (24 January 1976) p. 24, ARSOF Archives, Dorogi Collection, Box 6, Folder 36. Tsoulos, Interview with Dorogi, 14-15.

28. Clarence A. Page, Interview with Louis Dorogi (19 

January 1977) p. 3, ARSOF Archives, Dorogi Collection, Box 7, Folder 53.

29. Craig Llewellyn, Interview with Author (15 May 

2007) 16-17. An SF sergeant’s brother worked on 

the Saigon docks, and in exchange for alcohol and 

other gifts, he changed the bill of lading for the cement shipment so that it went straight to the C- Detachment at Bien Hoa.

30. SF did have plans and contingencies for a guerilla hospital deep in denied, enemy territory (see 

Dwight R. Wade and John Erskine, “Medical Support of Guerilla Forces,” Military Medicine 134, no. 

3 (March 1969): 211-214), but they had not developed any doctrine for creating a fully functional 

hospital in friendly (relatively) terrain. For information on the creation of de novo procedures, see 

Garrett W. Barron, Interview with Louis Dorogi 

(21 January 1977) p. 2, ARSOF Archives, Dorogi 

Collection, Box 7, Folder 41.

— SPURGEON NEEL ESSAY AWARD COMPETITION —

AMERICA’S GUERILLA HOSPITALS IN THE VIETNAM WAR: THE CIDG EXPERIENCE
January – June 2018 97

THE ARMY MEDICAL DEPARTMENT JOURNAL

31. John J. Bohannon, Interview with Louis Dorogi 

(22 April 1977) p. 35-36, ARSOF Archives, Dorogi 

Collection, Box 7, Folder 42. Stanley Allison, “Debriefing of Major Stanley Allison” (7 July 1969) p. 

1, NARA, 5th SFG (Abn) Headquarters, Assistant 

Chief of Staff for Operations (S3), Field Grade Officer Debriefing Reports, 472/270/73/24/5/2/8.

32. Stanley C. Allison, Interview with Louis Dorogi 

(20 December 1976) p. 11, ARSOF Archives, Dorogi Collection, Box 6, Folder 50. Later, a mess hall 

developed that employed two Vietnamese cooks 

to prepare meals for patients whose families could 

not come or who had been killed. Drake, Interview 

with Dorogi, 13.

33. Hobson, Interview with Dorogi, 17-21. Before the 

construction of buildings, Hobson and Slaughter operated out of a ward in the local provincial 

hospital.

34. Allison, Interview with Dorogi, 15.

35. Drake, Interview with Dorogi, 46.

36. Gay, Interview with Dorogi, 11. Hobson, Interview with Dorogi, 27. Page, Interview with Dorogi, 

12. Wehland G. Steenken, Interview with Louis 

Dorogi (24 February 1976) p. 11, ARSOF Archives, 

Dorogi Collection, Box 7, Folder 22. Tsoulos, Interview with Dorogi, 7.

37. Elvin R. Hamlin, Interview with Louis Dorogi 

(19 February 1976) p. 11-2, 20, ARSOF Archives, 

Dorogi Collection, Box 6, Folder 41. William Frew, 

“Army Medical Services Activities Report (RCS 

MED-41 (R4))” (1966) p. 29, NARA, Historical Files on SF Medical Activities in the VN War, 

319/631/30/20/2-6/16/3.

38. Edynak had completed his first year of surgical 

residency before arriving in Vietnam; some subsequent surgeons finished their residencies. The 

CIDG Hospitals still outsourced their neurosurgery 

and tried to outsource particularly complicated 

orthopedic cases to Army hospitals. Gay, Interview with Dorogi, 38-9. Hobson, Interview with 

Dorogi, 73. Rodolfo H. Villarreal, Interview with 

Louis Dorogi (18 May 1976) p. 4, ARSOF Archives, 

Dorogi Collection, Box 7, Folder 27.

39. The average patient stayed at the convalescent 

center between five and eight weeks. “5th Special 

Forces Group Operations Report, Lessons Learned 

for period ending 31 January 1969” (28 May 1969) 

p. 87, NARA, Historical Files on SF Medical Activities in the VN War, 319/270/20/06/4-6/3/1. Sean 

Fitzpatrick, “CIDG Convalescent Center,” Green 

Beret Magazine III, no. 10 (October 1968): 20. Rolland Bogguess, “Hope for the Disabled,” Green 

Beret Magazine IV, no. 9 (September 1969): 20-21. 

Drake, Interview with Dorogi, 6.

40. The newly ambulated soldiers also received physical therapy and, when feasible, employment with 

the Special Forces in some type of staffing position. They (or in case of death, their family) also 

received financial compensation. Drake, Interview with Dorogi, 48-50. Hobson, Interview with 

Dorogi, 50. “CIDG Hospital: Helping your Brother 

Help Himself” Green Beret Magazine V, no. 7 (July 

1970): 8-9.

41. “New Hospital at Pleiku,” Green Beret Magazine 

I, no. 3 (October 1966): 18. Lynn A. Dievendorf, 

Interview with Louis Dorogi, (18 December 1976) 

p. 10-11, 28, ARSOF Archives, Dorogi Collection, 

Box 6, Folder 35.

42. Gary Clark was the sole physician at B-23 for eighteen months and kept an unpublished diary that describes his medical, tactical, and personal experiences there. A copy of that diary is available in at 

NARA, Historical Files on SF Medical Activities 

in the VN War, 319/631/30/20/2-6/30/6. See also: 

Arthur Steinberg, Interview with Louis Dorogi (19 

December 1976) p. 2, ARSOF Archives, Dorogi 

Collection, Box 7, Folder 23. Tsoulos, Interview 

with Dorogi, 101.

43. Barry Zindel, Letter to Louis Dorogi, 4 June 1976, 

pp. 3-4, ARSOF Archives, Dorogi Collection, Box 

7, Folder 38. Richard Webb, Interview with Louis 

Dorogi (26 February 1976) p. 27-37, ARSOF Archives, Dorogi Collection, Box 7, Folder 31. Ronald Nuzzo, “Miniature Walter Reed,” Green Beret 

Magazine III, no. 6 (June 1968): 6-7. Richard Carmona, Interview with Author (1 March 2007), 5-6.

44. Llewellyn, Interview with Author, 17. Zindel had 

undergone a year of urological surgery residency 

in the United States before deploying to Vietnam.

45. Hobson, Interview with Dorogi, 67. Bohnannon, 

Interview with Dorogi, 14-20. David G. Tittsworth, 

Interview with Louis Dorogi (18 May 1976) p. 9, 

ARSOF Archives, Dorogi Collection, Box 7, Folder 

25. “Operational Report, Lessons Learned for period ending 31 January 1969,” 89. Bohannon’s lack of 

enthusiasm for the CIDG Hospital concept contributed to its reduced stature in IV Corps; Bohannon 

served as the SF Surgeon at IV Corps for two years.

46. Clark, Diary. Gay, Interview with Dorogi, 40, 42. 

Tsoulos, Interview with Dorogi, 61.

47. “Monthly Command Summary, October 1969” (18 

November 1969) p. A-3, A-4, NARA, Historical Files on SF Medical Activities in the VN War, 

319/270/20/06/4-6/2/9. “Monthly Command Summary, November 1969” (18 December 1969) p. A-3, 

NARA, Historical Files on SF Medical Activities 

in the VN War, 319/270/20/06/4-6/2/10.
98 http://www.cs.amedd.army.mil/amedd_journal.aspx

48. Robert Fechner, Interview with Louis Dorogi (30 

December 1976) p. 8, ARSOF Archives, Dorogi 

Collection, Box 6, Folder 38. Craig Roberts, Combat Medic: Vietnam (New York: Pocket Books, 

1991) 156. Gay, Interview with Dorogi, 35. Webb, 

Interview with Dorogi, 37. Tsolous, “Army Medical Services Activity Report,” 15.

49. Gerald W. Foy, Interview with Louis Dorogi (30 

June 1976) p. 26, ARSOF Archives, Dorogi Collection, Box 6, Folder 39. Hugh R. Hubbard, Interview 

with Louis Dorogi (1977) p. 24, ARSOF Archives, 

Dorogi Collection, Box 7, Folder 51. “Operational 

Report, Lessons Learned for period ending 31 January 1969,” 85.

50. Demetrious Tsoulos, “Army Medical Service Activities Report, CY 67 (RCS MED 41 (R-4))” (1 February 1968) p. 5, NARA, Historical Files on SF Medical Activities in the VN War, 319/270/20/06/4-6/5/6.

51. Donald Lawrence, “Medical History, 5th Special 

Forces Group (Airborne),” p. A4, NARA, 5th SFG 

(Abn) Headquarters, Surgeon, Command Reporting Files, 472/270/7328/3/1/1. CIDG hospitals averaged 600-700 admissions each month.

52. Page, Interview with Dorogi, 3.

53. John McCray, Interview with Louis Dorogi (7 November 1975) p. 10, ARSOF Archives, Dorogi Collection, Box 7, Folder 6.

54. Richard Miller, “Field Officer Debriefing Report,” 

(22 December 1968) p.8, NARA, 5th SFG (Abn) 

Headquarters, Assistant Chief of Staff for Operations (S3), Field Grade Officer Debriefing Reports 

472/270/73/24/5/1/13. See also: “CIDG Hospital at 

Bien Hoa,” Green Beret Magazine II, no. 1 (January 

1967): 18-19.

55. “KEYSTONE ROBIN C After Action Report” (5th 

Special Forces Group (Airborne), 28 February 

1971) G-2, MHI Archives, MACV Command Historian Collection Preliminary Box Inventory List, 

Unit History Files. See especially Appendix G for 

Medical Support.

56. Lawrence, “Medical History, 5th Special Forces 

Group (Airborne),” A3.

Author

Dr Barr is with the Department of Surgery, Duke University Medical Center, Durham, North Carolina.

— SPURGEON NEEL ESSAY AWARD COMPETITION —

AMERICA’S GUERILLA HOSPITALS IN THE VIETNAM WAR: THE CIDG EXPERIENCE
January – June 2018 99

In the fall of 1918, just outside the small French hamlet 

of Grandpré, American Red Cross (hereinafter referred 

to as the Red Cross*) nurse Estelle Davis struggled 

to stay awake. Death and misery surrounded her as 

she toiled in an American Expeditionary Force (AEF) 

surgical hospital. Just two years before, three hundred 

thousand French and German Soldiers had perished at 

Verdun, only a few miles to her southeast, and now Estelle’s countrymen entered the fray. Her hospital served 

the 89th Infantry Division, a unit which had recently undergone a baptism by fire at the Battle of Saint-Mihiel. 

Estelle now supported the unit during the final MeuseArgonne offensive. Men came into the hospital with 

grave wounds while Estelle and her Army counterparts 

worked feverishly to save as many as possible. The beds 

filled up quickly in the small hospital, leaving no room 

for long term recuperation. Only terminal patients could 

remain, and they rarely stayed long either. After surgery, 

the staff quickly shuttled patients to the hospital trains 

in order to evacuate them to hospitals equipped for long 

term care. Men with freshly amputated legs hobbled to 

the nearby train station in order to evacuate further west, 

away from the front. The hospital carried little in the 

way of drugs, except for the morphine administered on 

a regular basis which often did little more than dull the 

pain of the expectant. Estelle witnessed Army doctors 

make do by utilizing ancient, but effective techniques, 

such as filling festering wounds with maggots to eat 

away at rotting flesh. Like so many other American field 

and evacuation hospitals in France during the war, they 

were understaffed and often ill-equipped to deal with 

the brutality of industrial warfare.

Estelle’s very presence was symptomatic of an Army ill 

prepared for war. Prior to the war, the federal government had designated the Red Cross Nursing Service as 

the Army Nursing Corps’ reserve force. When the United 

States became an official belligerent, the Army enlisted 

thousands of nurses into the Army Nursing Corps from 

the Red Cross. But some nurses like Estelle remained —

administratively at least — under the purview of the Red 

Cross. When they deployed to France, they were meant 

to serve in the safety of Paris and other relatively safe 

areas, working in canteens or convalescence hospitals. 

Despite this, Estelle found herself working as a civilian 

in an Army field hospital, as close to the front as any 

women could be in the war. The Army had ordered the 

Red Cross to send nurses to the front as if the organization fell under the military’s command — and in a very 

real way this was true. Today, the idea of a militarized 

Red Cross might seem odd. The modern organization 

focuses primarily on humanitarianism, and maintains a 

guarded distance from the American military, limiting 

its interaction to providing support services to service 

members during family emergencies.1 However, this 

was not always the case. Estelle’s story raises numerous 

questions about the nature of both the Red Cross and 

the Army during the early twentieth century. How did 

it come to be that the Army relied upon the Red Cross 

for its nursing reserve? How did Red Cross recruitment 

compare to military recruitment? As the situation at the 

front deteriorated, the Army called upon the Red Cross to 

send forth even its civilian nurses. How did these women 

respond to militarization? This essay seeks to untangle 

the complicated relationship between the Red Cross and 

Ambiguous Duty: Red Cross Nurses

 and the First World War

CPT Denis L. Alfin, USA

2017

Spurgeon Neel Annual Award Runners-up

The Army Medical Department Museum Foundation sponsors the Spurgeon Neel Annual 

Award competition for the best original essay that best exemplifies the history, legacy, and 

tradition of the US Army Medical Department. The following essays by CPT Denis Alfin 

and MAJ Michael Mobbs (US Army) were selected as runners-up for the 2015 competition.

*For simplicity, I refer to the American Red Cross as the Red Cross throughout this essay. References to the International Committee of 

the Red Cross (ICRC) or other countries Red Cross branches are explicitly specified.
100 http://www.cs.amedd.army.mil/amedd_journal.aspx

the United States Army, and by so doing, uncover the 

critical role these civilian nurses played in the war effort.

Historiography

During the First World War, the American Red Cross 

functioned as an extension of the United States military. 

Recently, historians have debated the significance of the 

Red Cross’ militarization in relationship to the organizations long history. The late John Hutchinson argued 

that the American Red Cross had long been complicit 

in the militarization of civilians, and when its leaders 

rejected neutrality, it was simply the logical result of a 

long process.2 More recently, Marian Jones criticized 

Hutchinson’s depiction as reductionist, asserting that 

the Red Cross’ nationalistic turn during the war was 

an aberration, and she focuses on the large amounts 

of humanitarian relief work done by the organization 

during and after the war. Jones dismisses the military 

reserve function of the Red Cross nursing service as insignificant compared to its broader humanitarian functions.3

 Although keeping this debate in mind, I largely 

sidestep the issue of neutrality. Understanding how the 

Red Cross interpreted neutrality during this time period 

requires in-depth analysis of the Geneva Conventions 

of 1864 and 1906, and American society — all well beyond the scope of this essay. However, it is important 

to keep this debate in mind, particularly when analyzing Red Cross recruitment material. As the war escalated and the Red Cross ramped up its nurse recruitment 

campaign, the organization operated along an ambiguous ideological boundary between humanitarianism and 

militarism. But before we look at recruitment, it is important to understand how the relationship between the 

Red Cross and the military was born.

Creating the Reserve

During the Spanish-American War in 1898, the United 

States Army suffered enormous systemic failures trying to enlist various state militias into active service. 

Volunteers languished in mobilization camps stateside, 

overburdening a weak federal Army bureaucracy. Thousands perished in filthy and disorganized camps as Soldiers lacked a basic understanding of field sanitation and 

the camps retained few trained medical personnel. The 

few doctors and nurses present offered advice on how to 

improve conditions in the camps, but that often fell on 

the deaf ears of officers that either did not care or did 

not have the resources to make any tangible improvements.4

 The Army Medical Department took these lessons to heart and worked with war department leaders 

to revise a variety of policies: Army medical authorities 

received authority to dictate camp sanitation procedures, 

medical supply lines became standardized, and female 

nurses became a standard component of Army field 

hospitals.5 However, the incorporation of nurses did 

not mean that they would become a regular part of the 

peacetime Army. War department leaders had little appetite for excess personnel in the peacetime Army, and 

nurses would have to be recruited only when necessary.

With this new demand for nurses, the Army Medical Department became yet another thorn in the side for military planners. President McKinley and United States 

Army leaders recognized that there needed to be major 

institutional changes to the manner in which the Army 

organized in times of war. McKinley tasked secretary of 

war Elihu Root with this mission. The military’s newly 

minted civilian leader determined that the source of the 

problem lay in a poorly defined relationship between the 

state militias and the federal military. Although states 

had long resisted federal oversight of their militaries, 

Root and congressional leaders negotiated with them to 

reach deals in the Militia Act of 1903 and a subsequent 

major amendment in 1908. The crux of the new legislation stipulated that the federal government would provide increased funding to the state militias, while the 

states would subordinate their militaries to the president 

in times of war. Before this legislation, states had often 

balked at orders to leave the borders of the continental 

United States, some even refusing to leave the confines 

of their state. With this new legislation, they submitted 

deployments outside the boundaries of the United States. 

States would resist and grumble for many years over 

what they saw as federal meddling in state affairs, but 

they would never regain absolute control of their reserve 

and militias.6

It was in this historical moment that congress and the 

War Department designated the Red Cross as a reserve 

for the Army Nursing Corps. President Taft signed the 

legislation into law on April 24, 1912. The law’s wording was relatively vague as to who would be called up 

and what kind of services they would provide. In fact, 

the bill referred to anyone called up as “civilian employees.” 7

 Based off a reading of various correspondence 

however, it was understood by the leadership of the 

main parties involved — the war department, the Army 

Nursing Corps, and the Red Cross — that the new policy designated Red Cross nurses as a military reserve 

force.8 The Red Cross took up this new role with great 

enthusiasm, as it had in fact been designed by one of its 

own leaders, Jane A. Delano.

Jane Delano graduated from Bellevue Nursing School 

in 1886, and served with the Red Cross during the Spanish-American War. She loomed large in the American 

nursing world, serving as the president of the American 

Nursing Association, and the president of the Board of 

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Directors for the American Journal of Nursing. In 1909 

United States Army Surgeon General George H. Torney 

called on Delano to serve as the Superintendent of the 

Army Nurse Corps.9 Later that same year, the Red Cross 

created a new division, the Red Cross Nursing Service, 

and tapped Delano to be its director. Delano now led 

some of the most influential American civilian and military nursing administrations. Delano had long been disappointed with the inability of the Army to quickly enroll nurses into wartime service. She saw an opportunity 

to leverage the Red Cross’ powerful administrative capabilities into a nursing reserve. Delano recommended 

that the Red Cross and the Army create a reserve system 

with two main components.10 First, enrollment into the 

Red Cross nursing service would also mean enrollment 

as a reservist for the Army Nursing Corps. Second, the 

Red Cross designated entire hospitals along with their 

medical staffs as deployable medical reserve units. Red 

Cross and Army medical leaders designated some hospitals to fall under Army control and support combat 

units while others would remain under the Red Cross to 

perform civilian relief work.11

The plan for separate hospitals worked better in theory 

than in practice. As the war developed, many Red Cross 

hospitals would fall under the de facto command of the 

Army. A report written after the war explains how the 

Army used the Red Cross to set up “camouflage” AEF 

hospitals. The French government restricted where the 

AEF could set up military hospitals throughout the 

country. They also required that American military hospitals receive a specific permit from the central government, bogging down the effort to rapidly set up hospitals. 

As a supposedly civilian institution, the Red Cross had 

much more leeway when choosing a location to set up 

its hospitals. The AEF and the Red Cross then set up 

military hospitals in multiple locations, including one 

at Beauvais near the Cantigny front. These were Red 

Cross hospitals in name only, and operated with a full 

contingent of Army medical staff. The report concluded 

that such methods should be avoided in the future, as a 

“matter of principle.” 12 There would be many gaps between Red Cross pre-war plans and the realities of operations during the war. Turning to the nursing recruitment campaign of 1917, we can see that there was still 

much ambiguity in the role of the Red Cross during the 

early days of the war.

Recruitment

As the Red Cross ramped up its nursing recruitment 

campaign during the early days of the war, it wove together a narrative of professionalism, humanitarianism, 

and militarism. Red Cross leaders were still searching 

for their place in the war effort. They had their support 

for the American military clear, but still maintained 

their ideological grounding in humanitarianism. In August 1917, the Red Cross released a bulletin that stated, 

“When war was declared between the United States and 

Germany, the neutrality of the American Red Cross of 

course ended automatically.” 13 In the same breath that 

they rejected neutrality, the Red Cross acknowledged 

that they would treat all wounded Soldiers, stating “The 

Red Cross knows no such thing as the nationality of a 

wounded man.” 14 The Red Cross needed to find a way to 

express these ideals in a cohesive recruitment campaign 

that would convince American women of the 1910s to 

enroll.

Christopher Capozzola argued that the First World War 

saw the rise of an American society based around “coercive volunteerism.” At its worst, it silenced, sometimes 

violently, the voices of pacifists and others who objected 

to the war.15 Capozzola discusses women’s involvement 

in this process at length, but primarily focused on how 

they functioned in the home front economy as workers. 

Exploring the Red Cross nursing service’s recruitment 

campaign during the early years of the war presents another angle into the ways in which women were brought 

into the war effort.

Prior to World War I, nurses generally operated within 

the domestic sphere of American life. Women often 

worked privately in patients’ homes for little pay. The 

American public had only just begun to view nursing as 

a legitimate profession.16 In a 1917 recruiting pamphlet, 

the Red Cross emphasized the professional opportunities that came with Red Cross service. American Red 

Cross leadership saw the war’s potential to grow the 

profession for the long term. The brochure proclaimed 

the ability for a Red Cross nurse to earn an “assured 

livelihood” and demonstrate her capability as a genuine 

medical professional. Red Cross leaders envisioned the 

upcoming war as a potential way to cultivate new leaders in American nursing, and highlighted the possibilities for nurses to attain advanced positions of leadership 

within the Red Cross and other medical organizations. 

At the same time, the brochure also attempted to rally 

women with a nationalist message, arguing that it was 

their duty to join the Red Cross, comparing time in nursing school as an honorable duty akin to that of the drafted men training in Army camps. Alongside this call to 

patriotism, the brochure emphasized the domestic and 

humanitarian work that Red Cross nurses would be doing, such as prenatal care and in-home care for the sick 

and elderly. Beyond the implications of patriotic obligation, the brochure had no details regarding the duties of 

a Red Cross nurse at war.17
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American Red Cross recruitment posters simultaneously 

emphasized humanitarianism and militarism. One 1917 

recruitment poster stated that “the Red Cross serves humanity,” emphasizing the universal nature of the organizations healing mission. Another poster calling for “Five 

Thousand [nurses] By June” depicted a Red Cross nurse 

in the foreground, with a military encampment behind 

her.18 The American flag stands tall above the military 

side of the camp, and the Red Cross flag on the other. In 

this portrayal, the Red Cross was depicted as an extension of the military. If the Red Cross served humanity at 

large, then the United States military at least would be 

its first, if not primary customer. While various recruitment campaigns muddled the nature of service with the 

Red Cross, they all shared a similar theme of American 

patriotism. One rather blunt poster depicted a Red Cross 

nurse soothing a wounded American Soldier, while in 

the background — ostensibly somewhere far from the 

nurse’s location — Soldiers charge across “No Man’s 

Land,” bayonets fixed, carrying the American flag into 

battle, all the while a nurse sits at a desk ready to enlist 

women.19 If soothing the pain of the sick and injured was 

the Red Cross nurse’s primary duty, assisting in the prosecution of the American war effort held near equal importance. The posters implied that the nurses would be 

far from the fighting, somewhere that they could tend to 

the wounded safely. As we see from the stories of Estelle 

and other nurses I discuss later, this would not be the case. 

The Red Cross advertisement campaign continually reinforced a humanitarian mission that laid within a nationalist framework. In its posters, the Red Cross affirmed its 

place as an American organization that dedicated itself 

to supporting the American military. Yet still, it did so 

by stressing the humanitarian work its nurses would do 

to support the mission, and not necessarily focusing on 

the employment of nurses near the front. Moving from 

an interpretive lens, if we turn to the early days of the 

war we uncover very tangible problems stemming from 

the relationship between the Army and the Red Cross.

Bureaucratic Limitations

The ambiguous relationship between the Red Cross and 

the Army created logistical problems from the onset of 

the war. The Army took no responsibility for providing equipment to American nurses during the war, even 

those that were officially part of the Army Nursing 

Corps. The Office of the Quartermaster cited the original plan crafted by Red Cross and Army leaders prior 

to the war, which placed the obligation to outfit nurses 

solely on the Red Cross. Although the policy was no 

doubt shortsighted, it should also be understood in the 

context of the era. Prior to the war, there were only a few 

hundred active nurses. During peacetime, nurses were 

not considered an organic element of modern militaries, 

and leaders from all organizations believed the logistics 

plan sufficient. Yet even as the first nurses began deploying to Europe, the Red Cross could not keep up with 

equipment requirements of a field environment.20

During the early days of American involvement in the 

war, the Red Cross struggled to properly outfit nurses for 

the kind of field duty they found themselves performing. Nurses received a single outfit consisting of a blue 

dress, overcoat, cape, and a few varieties of hats. Their 

winter issue consisted of a single blanket. The uniform 

issue did not include the white dress they were required 

to wear, and the nurses had to purchase the required 

white uniform out of their own pockets.21 The whites 

would prove to be ill suited to the muddy conditions of 

field duty, and they eventually switched to a grey crepe 

uniform.22 Over time, the Red Cross fleshed out its supply chain (with little help from the Army) and nurses 

received a more adequate collection of field equipment. 

The responsibility fell on Marie B. Rhodes, head of the 

Red Cross outfitting department. She leveraged assistance from the English and French chapters of the Red 

Cross, successfully procuring much needed equipment 

for nurses all over France. By the spring of 1919, Rhodes 

had spent over three million francs to outfit Red Cross 

nurses in Europe. Aside from uniforms, Army and Red 

Cross nurses also lacked a general military equipment 

issue. The allied armies generally issued their Soldiers 

“camp kits,” standard layouts that included a cot, blankets, cups, silverware, and other essentials of field life. 

Nurses received no such issue in the beginning, and had 

to rely on the generosity of French and British Red Cross 

supplies. The Army would eventually rectify the nursing equipment oversight, but not until December, 1918, 

a month after the war ended. 23 This equipment shortage 

was just one of many dilemmas Red Cross Nurses would 

face as the war developed. As conditions worsened on 

the front, the Army demanded the service of all spare 

nurses — military or not.

During the War

The Red Cross attempted to retain a division of duties 

between those nurses that were sworn into the Army, 

and those that remained with the Red Cross. In March 

of 1917, just prior to the United States officially becoming a belligerent, the Army Nursing Corps maintained 

just 403 nurses on active duty, while the Red Cross listed nearly 8,000 nurses on their rolls.24 Many of these 

nurses would fulfill their reserve obligation and be inducted into the Army Nursing Corps, but the Red Cross 

also sent hundreds of nurses, like Estelle, who retained 

their affiliation with the Red Cross. Red Cross and military leaders intended for these women to serve in the 

rear echelons during the war, far from the front lines. A 

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regulation from the 1916 United States Army’s Manual 

for the Medical Department stated:

Except in cases of great emergency, Red Cross personnel serving with the land forces will not be assigned to 

duty at the front, but will be employed in hospitals in the 

service of the interior, at the base, on hospital ships and 

along lines of communications of the military forces of 

the United States.25

However, as casualties soared and the medical situation 

in eastern France deteriorated, the plans for a separation 

of duties came to an end. In the spring of 1918, the fighting became so intense that AEF leadership urgently requested a surge of medical personnel to the front.26 The 

Red Cross responded by ordering their nurses in Paris to 

serve near the front in field and surgical hospitals.

Writing about her experience being militarized, one unnamed nurse described how as the German spring offensive of 1918 kicked off, her cohort of Red Cross nurses 

was sent to the Army hospital at Beauvais. The hospital 

was poorly equipped, and was little more than an old 

French schoolhouse with beds. There they worked under threat of constant German air raids. Fearing that 

German warplanes might spot the hospital, the hospital 

commander banned the use of lamps and matches. During one particularly bad raid, she wrestled to calm men 

suffering from “shell shock,” all in pitch black conditions. She referred to her service there as being “loaned 

to the military,” but in fact she was essentially operating 

as a military nurse. Without any kind of military training, she was working under the command of an Army 

doctor, subjecting herself to as much danger as any 

woman in the Army Nursing Corps.

Anna Johnson was another such nurse. The Red Cross 

sent her from Paris to Evacuation Hospital No. 9 at Vaubecourt, just outside of Verdun. There, Johnson and 

other Red Cross nurses worked in dreadful conditions 

alongside Army medical personnel. They worked in torrential downpours that would turn the entire base hospital into what she called a “sea of yellow clay mud.” 

Johnson and other nurses at Vaubecourt worked excruciatingly long hours, and often felt that their efforts to 

save the injured were in vain. Patients streamed into the 

hospital from the front, but oftentimes the medical staff 

could do little but try and ease their suffering.27 Johnson had few qualms about working so close to the front 

lines. She was among many Red Cross nurses that were 

exceedingly proud to support her countrymen. As the 

AEF continued to demand more medical personnel near 

the front, countless Red Cross nurses volunteered for 

the duty. Like so many men, these women often viewed 

service near the front as the epitome of patriotic duty. 

Writing about the situation after the war, Julia Stimson 

wrote that when the call went out for service near the 

front, there always were more volunteers than the Red 

Cross could afford to send. She believed that “No special 

credit should be given [to] the nurses who achieved it,” 

because “a hundred were anxious to take her place.” 28

Forced Militarization

Despite Stimson’s claim, there were some nurses who 

did not share her patriotic sentiments. The official history of the Army Nurse Corps in the Great War sheds 

some light on the story of these women. Julia Stimson, 

Superintendent of the Army Nurse Corps wrote the history in 1927, wherein she downplayed some of the issues 

that arose from the convoluted relationship between the 

Red Cross and the Army. However, in doing so she confirmed one important fact: The Red Cross (or the Army 

depending on your point of view) had forced some nurses into service with the Army Nurse Corps when these 

women had been expressly promised that they would 

remain under the purview of the Red Cross, and would 

serve in a civilian capacity. Prior to American involvement in the war, many of these women adamantly expressed that they had no desire to serve in the military. 

The Red Cross leadership soothed their fears that no 

such change in status would occur. In her book, Stimson 

acknowledged the forced enlistment, but explains that 

Army Nurse Corps and Red Cross officials in France 

were unaware of any such previous agreements with the 

Red Cross staff in the United States. She explained that 

ultimately, the rapidly filling military hospitals warranted such extreme measures, explaining:

The office in Paris had no means of knowing this fact or of 

the institution of this policy on the part of the Red Cross 

in Washington, but even if it had been known it is not 

probable that any other action could have been taken 

than that which was taken when these nurses were called 

from their civilian work and placed upon active duty 

with the Army.29

A memo written to Stimson just a month after the armistice further expands upon the issue of forced enlistments. Clara Noyes, the Director of the Field Nursing 

Service Bureau, lamented that she and her aides had 

personally assured a great number of women that they 

would not be enlisted into the Army. She wrote:

There was no nurse who left this country who did not 

have a formal communication from me saying that it was 

definitely understood that she was accepting service under the Red Cross and that transfer to the Army would 

not be permitted.30

Noyes did not feel particularly sympathetic to those 

women who did not wish to serve in the Army, calling 
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them “unpatriotic” later on in the same letter. She and 

other Red Cross and Army leaders believed that the circumstances of the war in 1918 necessitated the measures 

taken, but still lamented that they had broken trust with 

so many women.

The problem of forced enlistments continued to fester 

after the armistice. Women enlisted into Army Nurse 

Corps, including those who had never wished to serve in 

the military, remained in the Army for some time. This 

only exacerbated the moral conundrum for the nurses 

that had never intended to be a part of the military. They 

had joined the Red Cross with the promise of humanitarian work, and now found themselves still languishing 

in the AEF, months after hostilities had ended. Some 

nurses officially protested the situation, stating that they 

believed the Army was irrevocably militarizing the 

Red Cross, and destroying the concept of neutrality on 

which the organization had been founded.31 The crisis 

did not last too long however, as over the following few 

months base hospital units rapidly demobilized and the 

Army released most nurses from service. Those nurses 

who wished to remain in active service could apply directly to the superintendent of the Army Nurse Corps. 

However, either due to lack of interest, or more likely 

bureaucratic impediments, only forty-eight nurses had 

gone through this process by mid 1919.32

Conclusion

Problems stemming from the complicated relationship 

between the Red Cross and the Army continued to appear long after the armistice. Red Cross and Army Nursing Corps leaders lobbied successfully for Army nurses 

to receive rank in 1920, and then again for equal retirement benefits in 1926. However, the legislation regarding 

retirement only applied to “active nurses” and not those 

who had entered the Army Nursing Corps as “reserve 

nurses” through the Red Cross, even if they had continued to serve on active duty after the war. One such nurse, 

Edith Thorsen, attempted to retire from active duty in 

1930 but was denied retirement by the Army comptroller 

on the basis that she was not eligible for retirement as a 

“reserve nurse.” The case made its way to federal court in 

1934 where the judges eventually decided unanimously 

in Edith’s favor.33 Still, she had trudged through a legal 

battle over four years, spending precious time and money to fight the Army over a matter of semantics in the 

law’s interpretation. The fact that Edith had entered the 

Army through the Red Cross labelled her as a “reserve 

nurse” for the entirety of her career. Jane Delano’s plan 

had certainly succeeded in supplying nurses in a time of 

need, but it had a variety of unintended effects long after 

the war ended.

Searching for its place in the war effort, Red Cross 

leadership struggled to balance its role as a civilian humanitarian organization while simultaneously serving 

as a de facto wing of the American military. The recruitment campaign in 1917 and 1918 laced principles 

of militarism and humanitarianism in a way that found 

widespread appeal among American nurses. Those like 

Estelle Davis joined the Red Cross out of a deep-seated 

sense of patriotism. In an interview in 1982, she said 

that she “could not think of not being with my country at a time like that.” 34 Like many other nurses, Estelle did not find anything odd in the dynamics of her 

service with the Red Cross. She understood the Red 

Cross’ principles in the same way that the organization 

depicted them: service with the military was humanitarianism. Yet still there were others who felt that the 

Army had forced militarization upon them, even though 

the Red Cross had promised no such thing would happen. As we find ourselves deep in the centennial of the 

United States’ participation in the First World War, this 

essay tries to recover both the stories of nurses like Estelle and also those Red Cross nurses that believed in a 

different brand of humanitarianism. While others have 

documented the struggle of pacifists and other anti-war 

protestors,35 these particular nurses have unfortunately 

been silenced by the historical record.36

In her book Doughboys, the Great War, and the Remaking of America, Jennifer Keene argues that the integration of citizen-Soldiers into the Army profoundly shaped 

both the Army bureaucracy and American society after 

the war. Keene points out that despite the coercive power of the military establishment at the time, citizen-Soldiers made their voices heard and significantly impacted 

the way the U.S. Army trained and fought.37 In the same 

light, civilian Red Cross nurses represented a critical element of the American war effort. Through their valiant 

efforts in the face of danger, both Red Cross and regular 

Army nurses cemented the place of nurses as a permanent asset within the Army’s medical establishment.

Acknowledgement

This essay was made possible in part by the US Army 

Center of Military History through the Omar N. Bradley Historical Research Grant. There exists no conflict 

of interest.

Endnotes

1. American Red Cross, “Missions & Values,” American Red Cross Website, http://www.redcross.org/

about-us/who-we-are/mission-and-values (accessed August 30, 2017).

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2. John Hutchinson, Champions of Charity: War and 

the Rise of the Red Cross, Adobe Digital ed. (Boulder: Westview Press, 1996), 735-736.

3. Marian Moser Jones, The American Red Cross 

from Clara Barton to the New Deal (Baltimore: 

Johns Hopkins University, 2012), 159-160.

4. Allan R. Millet, Peter Maslowski, and William B. 

Feis, For the Common Defense: A Military History 

of the United States from 1607 to 2012 (New York: 

Free Press, 2012), 269-270.

5. Graham A. Cosmas, An Army for Empire: The 

United States Army in the Spanish-American War 

(College Station: Texas A&M University Press, 

1998), 302-304.

6. Jerry Cooper, The Rise of the National Guard: The 

Evolution of the American Militia (Lincoln: University of Nebraska Press, 1997), 108-109.

7. An Act To provide for the use of the American National Red Cross in aid of the land and naval forces 

in time of actual or threatened war, Public Law 132, 

66th Cong., 2nd sess. (April 24, 1912).

8. Jane A. Delano, “The Red Cross,” The American 

Journal of Nursing 11, no. 11 (July 1911): 807.

9. Mary T. Sarnecky, A History of the U.S. Army 

Nurse Corps (Philadelphia: University of Pennsylvania Press, 1999), 69-74.

10. Foster Rhea Dulles, the Red Cross: A History (the 

Red Cross, 1950), 96.

11. Sarnecky, 80-81.

12. United States Army, American Red Cross Military 

Hospitals, 1919, RG 112, Box 8, Folder Correspondence between Miss Carrie Hall and Miss Stimson 

re A.E.F Nurses, etc., NARA, Washington D.C.

13. The American Red Cross, The Red Cross Bulletin (Bureau of Publications for the Department of 

Chapters, August 17, 1917), 3.

14. Ibid., 3.

15. Christopher Capozzola, Uncle Sam Wants You: 

World War I and the Making of the Modern American Citizen (Oxford, Oxford University Press, 

2008), 18-19.

16. Kay Hawes, “World War I and its Impact on the 

Nursing Profession, http://www.kumc.edu/newslisting-page/lworld-war-and-its-impact-on-thenursing- profession.html, (February 3, 2016).

17. American Red Cross Recruitment Pamphlet, “Nursing: A National Service in This Time of Stress” [ca. 

1917], digitalcollections.archives.nysed.gov/index.

php/nysa/ Download/Full/occurrence_id/126 (accessed August 30, 2017).

18. American Red Cross, “Five Thousand by June,” Library of Congress Web site, https://www.loc.gov/

resource/cph.3g07782/ (accessed August 30, 2017).

19. American Red Cross, “If I Fail He Dies: Work For the 

Red Cross,” https://www.loc.gov/item/00651856/. 

Accessed August 30, 2017.

20. Julia C. Stimson, History of Nursing Activities, 

A.E.F. on the Western Front During War Period 

May 8, 1917-May 31, 1919, RG 112, Box 8, Folder History Nursing Activities A.E.F. (Stimson), 

NARA, Washington D.C.

21. Julia C. Stimson, Summary of the History of the 

Nursing Service of the A.E.F., February 26, 1920, 

RG 112, Box 8, Folder History Nursing Activities 

A.E.F. (Stimson), NARA, Washington D.C.

22. Stimson, History of Nursing Activities, A.E.F. on 

the Western Front During War Period May 8, 1917-

May 31, 1919.

23. Stimson, Summary of the History of the Nursing 

Service of the A.E.F.

24. Ibid., 99.

25. United States Army, Manual for the Medical Department United States Army, Corrected edition, 

(Washington: Government Printing Press, 1918), 

179.

26. Stimson, History of Nursing Activities, A.E.F. on 

the Western Front During War Period May 8, 1917-

May 31, 1919.

27. Lavinia L. Dock et al, 648.

28. Stimson, Summary of the History of the Nursing 

Service of the A.E.F.

29. Stimson, The Medical Department of the United 

States Army in the World War, Part two (Washington, D.C. U.S. Government Printing Office, 1927), 

327.

30. Clara D. Noyes to Julia C. Stimson, December 21, 

1918, RG 112, Box 8, Folder Correspondence between Miss Carrie Hall and Miss Stimson re A.E.F. 

Nurses, etc., NARA, Washington D.C.

31. Ibid.

32. Sarnecky, 135.

33. Edith C. Thorsen v. The United States, no. 42046 

(Federal Court of Claims, 1934).

34. Davis.

35. For analysis of resistance to the war and the draft, 

see Charles Chatfield, For Peace and Justice: Pacifism in America (Knoxville: University of Tennessee Press, 1971).

36. Sarnecky, 173-174.

37. Jennifer D. Keene, Doughboys, the Great War, and 

the Remaking of America (Baltimore, The Johns 

Hopkins University Press, 2001), 3.

Author

When this essay was written, CPT Alfin was a graduate student at the University of Wisconsin, Madison, 

Wisconsin.
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The experience set forth herein is largely that of the 

World Wars. Weapons and methods of warfare have 

changed since that time and such changes have always 

been reflected in battle casualties. The experience of the 

American Civil War would have proved to be largely unreliable in 1917-1918; and it may well be that the experience of the World Wars will prove to be equally unreliable in future wars. But, even if such an experience is of 

no greater value than to serve as the basis of an educated 

guess, it is still better than no experience at all.

1

To engage in war is to engage with risk. From the American Revolution onward, American military leaders 

strove to reduce the cost in human lives inflicted by war. 

For most of the 18th and 19th centuries, American military commanders — officers charged with applying human and material resources against an opponent — believed risk was seated in the unknowable and unpredictable nature of conflict. They perceived reduced casualty 

rates as the happy consequence of a sound military plan. 

However, around the start of the 20th century, there 

arose within the American military medical community 

a perception that casualty rates represented a risk that 

could be predicted and controlled. This shift in perception was predicated on two events: the vast amounts of 

casualty statistics that only entered the printed record 

following the American Civil War, and the invention of 

tabulating and sorting machines that could reveal the 

patterns within this data. Within the recorded statistics of casualties, some medical officers believed, there 

existed a mathematical logic that could be deciphered 

to quantify risk in future engagements. Reduced casualty rates, then, were not a consequence but the actual 

goal of proper medical planning based in a mathematical approach to controlling risk. Spurred by the American experience during World War I, these events led to 

the publication of Field Manual 8-55 Medical Field 

Manual, which represented the culmination of the US 

Army’s institutional experience with casualties in war, 

and a revolution in thinking about risk within the US 

Army.2

The collection of casualty data following the Civil War 

represented a first step towards risk prediction and 

mitigation on the battle field. This collection of statistics 

became the foundation of Army medical planning in the 

beginning of the 20th century and represented a deliberate choice to represent casualties as a martial risk that 

could be understood and, perhaps, controlled. Military 

medical officers recognized that in order to ensure sufficient medical staff and supplies prior to an expected 

battle, they had to predict the number of battle casualties 

in advance. This was a problem that military thinkers on 

both sides of the Atlantic examined closely as Europe, 

and shortly thereafter, America entered into an unprecedented world war.3

America’s entry in to World War I heralded a massive 

mobilization and deployment effort that revealed the 

inadequacies of military medical planning and casualty 

prediction. By November 11, 1918, America sent over 

2,000,000 service members to the European continent, 

the first American expeditionary force of this scale.4 It 

soon became the opinion of World War I medical planners that the experiences of the American Civil War, 

preceding US conflicts, and observations of other wars 

were of little value.5 New technologies, weaponized gas, 

and trench warfare represented new risks which rendered past experience completely obsolete in the eyes 

of the Army medical community. While military medical planners recognized the new challenges — mainly, 

that “the field army could not rely on evacuation to the 

United States in a few days” — articulating the medical 

equipment and personnel necessary for proper medical 

care without a relevant planning method proved problematic.6

 As a result, casualty predictions were sporadic and inaccurate, and the medical planning based on 

these predictions were wholly inadequate. The MeuseArgonne offensive, for example, laid bare the consequences of inadequate casualty prediction and medical 

planning. Though military commanders understood the 

importance of providing adequate medical care, “they 

knew that transportation was so urgently needed for 

many other things that they did not feel that it should 

be provided for unnecessary hospital equipment or 

personnel.” 7 Because there was no suitable method of 

predicting battle casualties, only 18,000 hospital beds 

were planned to support an American force of 600,000.8

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The Figures of Experience: A Brief History

 of Risk and Planning Within the Army

 Medical Community

MAJ Michael H. Mobbs, USA
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THE ARMY MEDICAL DEPARTMENT JOURNAL

American battle casualties exceeded 18,000 in the first 

few days alone, requiring the evacuation of over 10,000 

Soldiers, delaying lifesaving surgery and increasing 

morbidity and mortality rates.9 The failure of military 

medical planners to predict casualties in advance of a 

combat operation represented a medical risk effecting 

tens of thousands of service members.

The military medical community knew it had to do better. This task fell to the Army’s Medical Statistics Section, and to one officer in particular, Major Albert Gallatin Love. Love, a career Army Medical Officer, was 

assigned to the Medical Records section of the Surgeon 

General’s Office in Washington, DC in 1910.10 This position familiarized Love with the administration of the 

Surgeon General’s Office and the methods of collecting 

and organizing the medical statistics of the Army. As 

Love would later write, this experience gave him the 

“unusual opportunity to become indoctrinated with the 

spirit that animated the office with the desire to improve 

the organization and administration of the medical service so that it could better preserve the health of the 

Army.” 11 Love had a passion for medical statistics and 

for serving the Army’s medical needs, traits that would 

set him apart in the eyes of his superiors. Love’s assignment paved the way for his return to the Surgeon General’s Office in 1917 as a newly promoted major, when he 

assumed charge of the Medical Records Section, Division of Sanitation.12

Major General William Gorgas, then Surgeon General 

of the Army, recognized that the poor performance of 

the Army’s medical service in World War I highlighted 

the need to upgrade the Medical Department’s record 

keeping and revisit the use of statistics to aid medical planning. Gorgas charged Love with overhauling 

the Medical Records Section and updating the records 

keeping process. As head of the Medical Records Section, and later as chief of the Medical Statistical Division, Love oversaw the collection and analysis of all the 

Army’s medical statistics. Not only was Love responsible for the statistical tabulation of casualty data from 

the front, his department also worked with the Provost 

Marshall’s office to tabulate the medical statistics of Selective Service registrants.13 A proficient operator could 

process 1,500 cards a day, and by the end of the war, 

Love’s section had processed the statistics of over 2.5 

million records.14 From 1921 until 1927, the Statistical 

Division under Love’s leadership compiled over 2,000 

pages of data, representing the complete statistical record of the anthropological, medical, and casualty data 

of World War I. Using a computerized tabulating machine and statistical analysis, Love generated mathematical models that accomplished three significant things: a 

predictive model for hospital admission and discharge 

rates; a model predicting discharged patients that could 

return to battle; and a model that could predict combat 

casualties prior to an engagement.

Titled “War Casualties: Their Relation to Medical Service and Replacements,” Love’s study was published 

in The Army Medical Bulletin Number 24 in 1931. 

Writing in the Forward, Colonel C. R. Reynolds, commandant of the Medical Service Field School, noted that 

Love’s study furnished “the soundest basis for war planning,” but offered the following warning:

“These data must be subjected to careful analysis, taking into consideration all evident and conceivable factors 

creating or influencing them. Upon the figures of experience thus obtained, and comparing the past with present 

and future conditions, must be based our estimates of 

the losses to be expected and of medical service requirements in future military operations.” 15

Reynolds continued, writing that Love’s study was 

“valuable in determining more accurately than by previous methods the hospitalization requirements in any 

given situation... [and] will also be of value in studies 

relating to personnel procurement and replacement.” 16

Love also expressed lofty goals for his study, presenting 

what he described as “a system for estimating, on the basis of our casualty experience in past wars, the requirements for medical service including hospitalization and 

evacuation of front line casualties.” 17 Love presented his 

system in a simple table that provided a “summary of the 

daily casualty rates...to be used as a basis for estimating 

the requirement for medical personnel and equipment” 

in future conflicts (Figure 1).18

The data in this table gave a method for estimating the 

medical needs prior to an engagement while also estimating likely replacement needs.19 For example, an 

infantry regiment comprising 1,000 Soldiers engaged 

in “severe combat” could expect a battle casualty rate 

of 15%, or 150 combat casualties. Medical officers in 

World War I, attempting to predict casualties for units 

in combat, fell victim to their inability to predict casualties and provide consistent and sufficient medical 

care. Love’s method appeared to mitigate this risk, as 

medical officers could now plan to have the appropriate 

amount of personnel, supplies, litters, hospital beds, etc, 

on hand prior to an engagement. It appeared that Love 

had exceeded expectations and the demands identified 

by Army planners in France a decade prior.

As early as 1936, it seemed clear to senior military leaders that another war was near at hand, and Love’s model 

was considered an important contribution to military 
108 http://www.cs.amedd.army.mil/amedd_journal.aspx

planning necessary for this next conflict.20 By 1941, 

mere months before the attack on Pearl Harbor, the 

Army instituted Love’s method as doctrine, the “fundamental principles by which the military forces or elements thereof guide their actions in support of national 

objectives.” 21 Published on March 5, 1941, as FM 8-55, 

Medical Field Manual, Reference Data, Love’s model became not merely a suggestion, but the institutionally sanctioned method for conducting objective military 

medical planning. As FM 8-55 acknowledged, even if 

the planning method “was of no greater value than to 

serve as the basis of an educated guess, it [was] still better than no experience at all.” 22 This “educated guess” 

was all the Army had as World War II progressed and 

the Allies turned their eyes to the shores of Normandy 

and began planning the largest amphibious operation in 

military history.

British and American medical officers assigned to plan 

the cross-Channel invasion agreed that they needed a 

common basis for estimating casualties, but were hampered by the fact that in 1941 and early 1942 the size 

of the Allied assault force was not yet known, nor was 

there previous experience with amphibious assaults of 

the scale proposed.23 The British planners offered generic predictions, virtually meaningless absent the invasion 

plan itself: 2% casualties in the embarkation area, 25% 

casualties during the assault itself, 10% casualties per 

month during subsequent fighting, with an estimated 

22,500 total casualties on the first day of an invasion.24

Meanwhile, American medical officers advocated for 

the casualty estimation standards outlined in Army 

Medical Bulletin No. 24 and FM 8-55.

25 Commenting on these documents in June of 1942, Colonel Paul R. 

Hawley (an American medical officer assigned to Britain in the fall of 1941, where he remained throughout the 

invasion planning) wrote that “insofar as battle casualties are concerned, these data are the most comprehensive in the world. The experience of [World War II] may 

indicate the necessity of revising these tables; but, until 

such necessity is demonstrated, US estimates will follow this experience closely.” 26

The first fully formed invasion plan, written by the British officer Lieutenant General Fredrick E. Morgan, acting as Chief of Staff Supreme Allied Commander (COSSAC), called for three assault divisions and four detached brigades on the first day.27 Morgan’s plan called 

for an invasion force of roughly 78,000 Soldiers, and this 

figure was the prime consideration for all other martial 

resources, especially landing craft.28 In fact, when Morgan presented his plan to the Combined Chiefs in July 

1943, he advised that “in proportion as additional shipping, landing craft, and transport aircraft can be made 

available, so the chances of success in the operation will 

be increased.” 29 Although the primary consideration for 

Morgan’s request of additional landing craft was the size 

of the invasion force, it also hinged on the casualty forecast devised by COSSAC planners. In his report to the 

Combined Chiefs of Staff, Morgan asserted that “unless 

suitable ships and/or crafts are earmarked and adapted 

where necessary for [the evacuation of wounded], adequate provisions for medical evacuation will not be possible.” 30 While Morgan admitted that “no definite plan 

at present exists for the evacuation of wounded during 

the assault,” the casualty estimate forecasted a total of 

19,500 wounded in the first 48 hours of the invasion.31

This figure accounted for 25% of the planned invasion 

force, indicating that Morgan and the COSSAC medical staff used the generic estimation method established 

by British planners the previous year. In fact, the chief 

medical officer advising COSSAC was a British doctor 

named Lieutenant Colonel G. M. Denning, and his small 

informal section also included a Royal Navy medical 

officer. It is possible that these men applied the British 

method of casualty estimation to Morgan’s original invasion plan.32

While these initial numbers derive from the British 

method, COSSAC documents make it clear that the 

— SPURGEON NEEL ESSAY AWARD COMPETITION —

THE FIGURES OF EXPERIENCE: A BRIEF HISTORY OF RISK AND PLANNING WITHIN THE ARMY MEDICAL COMMUNITY

Figure 1. Love presented a full explanation of where he drew his data and how he applied statistical analysis. This table 

represented “casualty rates per 100(%) of unit strength suggested as a basis for estimating the necessary medical relief 

on severe combat days, as determined by the American Expeditionary Forces experience.”
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THE ARMY MEDICAL DEPARTMENT JOURNAL

American doctrine for casualty estimation became the 

favored method as early as mid-August of 1943. A table 

titled “casualty estimates” produced by the COSSAC 

medical staff and dated August 12, 1943 placed total 

casualties for the first day of the invasion at 26,223.33

Written in pencil at the top of the casualty table a planner noted that the data was derived using “Gen Love’s 

Scheme of Estimation of Casualties.” 34 In addition to the 

British officers serving on the COSSAC medical staff, 

an American medical officer named Lieutenant Colonel 

Thomas J. Hartford also advised the medical support 

planning for OVERLORD.35 Hartford was on loan from 

the medical section of the American command structure set up to oversee American forces in Britain, and 

would have been aware of FM 8-55 and Army Medical 

Bulletin No. 24.

36 Whether or not Hartford had direct 

influence on the casualty estimation is unknown, but 

an unsigned memo dated September 25, 1943 and produced by the COSSAC operations staff outlined a new 

method for estimating casualties.37 The memo stated 

that given that the “battle casualty rate will depend upon 

the strength, composition and organization of the forces 

involved and the type and severity of the action anticipated,” a new method would be used to “determine the 

severity of losses.” 38 This new method, adopted merely 

two months after Morgan submitted his report, mirrored 

that process outlined in FM 8-55 (Figure 2).39

Love’s model forecasted significantly more casualties 

than the figures cited by Morgan to the Combined Chiefs 

of Staff in July, and this new estimate served to amplify Morgan’s request for additional transportation craft. 

As a result, in order to meet the demands of the crossChannel invasion, American war production increased 

its output of landing craft by 25% at the direction of the 

US Chiefs of Staff.40 Even with this increase, the COSSAC staff faced the fact that landing craft was “the most 

critical item of equipment for the world-wide strategical 

program. Every operation contemplated [was] a landing 

of one sort or another,” and the plan for OVERLORD 

was in competition for this scarce resource.41 A comparison of expected casualties to available evacuation 

craft illustrated the point of these urgent requests for 

more landing vessels. An April 1944 study showed that 

after the first wave of landing craft delivered the initial invasion force, the US wounded would reach 4,600. 

Meanwhile, the second wave of landing craft, scheduled 

to arrive within hours on the next tide, was supposed to 

evacuate these casualties after depositing fresh troops. 

The only problem was that after the second wave landing craft were reconfigured to accommodate litters, they 

could only evacuate a total of 1,950, leaving an excess 

of 2,650 casualties on the beach. The study showed that 

this excess of wounded would continue to compound 

from D Day through D+14, when the number of available landing craft for casualty evacuation would finally 

catch up with demand.42

Though casualty estimates drove much of the discussion over landing craft resources, the significance of 

these estimates reached well beyond landing craft alone. 

SHAEF planners used the casualty estimates to request 

hundreds of thousands of hospital beds, tens of thousands of bags for patients’ personal effects, dozens of 

hospital trains capable of transporting thousands of casualties at a time throughout Britain.43 Medical supplies 

included hundreds of blankets, a hundred liters of blood, 

splint sets, cases of dressings, and boxes of plasma for 

every landing craft.44 Military litters were converted to 

fit into civilian ambulances, while hundreds of medical officers and thousands of corpsmen were assigned 

to support the invasion and the expected number of casualties.45 Meanwhile, commanders used the casualty 

estimates to plan for replacements needed to keep the 

invasion moving forward.46

Figure 2. Comparing the rates listed in this table to the rates listed in FM 8-55 make it clear that COSSAC planners adopted 

the American doctrine of casualty estimation. There are only minor points of variation between the above table and that 

printed in FM 8-55. For example, the “‘Light’ battle day” column above is a direct copy of the “Average for all days in line” 

column listed in FM 8-55. While FM 8-55 lists a range for “Severe battle day” (ie, 12-15, 6-8, 2-3, and .7-1.5) the table above 

adopts the high end of these ranges. Finally, FM 8-55 lists 35% for Brigades and 12% for Divisions on “Maximum battle 

days.” There is no accounting for the adjustments made in the table above, but while the reader may conclude the adjustment to 25% for a brigade or regiment listed above is evidence of the influence of the British method, it should be noted 

that the British method applied a 25% casualty rate to all types of formations, without variation.
110 http://www.cs.amedd.army.mil/amedd_journal.aspx

In the aftermath of the invasion, Love’s casualty prediction model proved less than accurate. While the realities 

of a chaotic battlefield prevent an exact count, historians 

generally place Allied casualties closer to 10,000 — far 

less than the number predicted by Love’s model. Nevertheless, after World War II, FM 8-55 was updated to 

include new elements of warfare that were not present 

in the World War I data Love used.47 Statistics from armored, amphibious, and airborne operations, as well as 

casualty data from the Korean and Vietnam wars were 

incorporated into future planning manuals.48 These updated manuals stated that Love’s method was “designed 

for rough, quick estimates only and not as a substitute 

for factors carefully chosen to fit the specific assumptions and conditions of a particular operation plan.” 49

The updated publications advise planners that experience “clearly indicates that the estimation of probable 

casualty rates in advance is not a simple matter that can 

be reduced to a general formula,” while providing updated formulas based on Love’s original work.50 Nearly 

100 years later, Albert Love’s legacy and influence on 

Army medical planning lives on.

Endnotes

1. Field Manual 8--55 Medical Field Manual Reference Data (Washington, DC: United States Government Printing Office, 1941), 46.

2. For this paper I will use the modern military definition of casualties: “Any person who is lost to the 

organization by having been declared dead, duty 

status – whereabouts unknown, missing, ill, or 

injured” (JP 1-02, 2010). Medical planning, especially by World War II, attempted to predict not 

only casualties resulting from battle, but also rates 

of sickness and disease. The word “casualties” was 

ubiquitous and did not always make a distinction 

between casualties occurred in direct combat with 

an opposing force versus casualties caused by illness or accidents. As much as possible I will try to 

use the term “battle casualty” to specifically refer 

to killed, wounded, or missing as a direct result of 

combat operations. Otherwise I will use the more 

general term “casualty” to refer to military service 

members who become sick, or otherwise sustain an 

injury or are killed by causes not related to direct 

combat with an enemy force.

3. D. M. Giangreco, “Casualty Projections for the U.S. 

Invasions of Japan, 1945-1946: Planning and Policy 

Implications,” The Journal of Military History 61, 

no. 3 (1997): 527. As Giangreco points out, as does 

Paul Straub (a medical officer in the Philippine War 

and Medal of Honor recipient who was the first to 

develop a casualty prediction model in America), 

much of the methodology applied to the statistics 

of the Civil War came from Prussian officers and 

their examination of battle casualties in the FrancoPrussian War. In general, there was a fascination 

among American officers of how the Prussians organized their staff and planning structure, and of 

their approach to war fighting. It is no exaggeration 

to state that the structure of the American Expeditionary Force in Word War I was based on the 

Prussian model.

4. Marvin A. Kreidberg and Merton G. Henry, History of Military Mobilization in the United States 

Army: 1775-1945 (Washington, DC: Department of 

the Army, 1955), 336.

5. Love, Albert Gallatin, Eugene L. Hamilton, and 

Ida Levin Hellman, Tabulating Equipment and 

Army Medical Statistics, (Washington, DC: U.S. 

Government Printing Office, 1958), 87.

6. Sanders Marble, “How Many Hospitals to Deploy?,” 

The AMEDD Historian 17 (2017): 3.

7. Love, et al, 87.

8. Marble, 3.

9. Ibid.

10. Rohlader, Esther E., “A Concise Biography of Brigadier General Albert Gallatin Love, M.C.,” (Washington, D.C.: General Reference and research 

Branch, Historical Unit, US AMEDS, Forest Glen 

Section, Walter Reed Army Medical Center, 1964), 

1-8.

11. Love, et al, 31.

12. Rohlader.

13. Ibid., 73. There is a separate history behind Love’s 

project to analyze Selective Service data. The Provost Marshall intended that the data analysis aid 

future wars by providing estimates for uniforms, 

equipment, etc., based on the measurements of the 

“average” draftee. Additionally, this data was used 

to gather eugenics data on draftees and much of the 

data published by Love and the Medical Statistics 

Division presents data on race, geography, health, 

etc.

14. Ibid., 64 and 74.

15. Love, v.

16. Ibid.

17. Ibid., vii.

18. Ibid., 122.

19. Included in Love’s monograph was a lengthy discussion of what percentage of casualties who would 

return to the front based on their wound or injury. 

This information is not presented in the table above, 

but medical planners would account for this as they 

allocated medical supplies and personnel into their 

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plan. For example, of the 12.6% expected wounded 

in an infantry regiment, some percentage of that 

would quickly recover and be discharged from a 

care facility and be returned to the front.

20. Patton, George, letter to George C. Marshall, 26 

August 1936, private collection of Ellene Winn, 

Baltimore, MD, 1 January 2017. On the occasion of 

Marshall’s promotion to brigadier general, Patton 

wrote that “as things look now we seem to be about 

to have some sort of a new war, dont [sic] forget 

me if we do.” At the time Patton was a lieutenant 

colonel assigned to a military intelligence unit in 

Hawaii.

21. Joint Publication 1-02 Dictionary of Military and 

Associated Terms (Washington, DC: United States 

Government Printing Office, 2010), 71.

22. Field Manual 8-55, 46.

23. Sanford V. Larkey, Administrative and Logistical 

History of the Medical Service Communication 

Zone, European Theater of Operations, Record 

Group 498, Entry 54a, Stack Area 290, Row 57, 

Compartment 18, Shelf 4, Box 164 (College Park, 

M.D.: National Archives of the United States), 59.

24. Ibid., 60.

25. Blanche B. Armfield, Medical Department, United 

States Army, Organization and Administration in 

World War II (Washington, D.C.: Office of the Surgeon General, Department of the Army, 1963), 305.

26. Paul Hawley, “M.P.S. (42) 9, War Cabinet, BOLERO Combined Committee (London) Provision of 

Medical Services SubCommittee,” June 14, 1942. 

Record Group 112, Entry 31 (ETO), Stack Area 390, 

Row 17, Compartment 5, Shelf 2, Box 309 (College Park, M.D.: National Archives of the United 

States), 1.

27. “War Cabinet, Chiefs of Staff Committee, Operation ‘Overlord’ Report and Appreciation with Appendices,” July 30, 1943, File: Committee Report 

COSSAC Planning Report (Dwight D. Eisenhower 

Library, Walter Bedell Smith Papers).

28. Ibid., 85.

29. Ibid., ii.

30. Ibid., 106.

31. Ibid.

32. Graham A. Cosmas and Albert E. Cowdrey, The 

Medical Department: Medical Services in the European Theater of Operations (United States Army 

in World War II: The Technical Services) (Washington D.C.: Center of Military History), 153. From 

the primary historical record available to me at this 

time, it is impossible for me to definitively state 

what methodology was used to forecast casualties 

when Morgan presented his plan to the Combined 

Chiefs of Staff in July of 1943. I draw my conclusion by comparing the number of casualties Morgan presented (19,500) against the proposed assault 

force (~78,000). The resulting percentage is 25%. It 

is clear that if COSSAC planners in July, 1943 were 

using Love’s method, then the appropriate planning 

factor for Division casualties would have been 15%. 

Thus, I conclude the 25% method was a carryover 

from the ROUNDUP staff that were reassigned to 

support COSSAC.

33. “Operation ‘Overlord,’ Casualty Estimates (Excl of 

Air Force)” August 12, 1943, Evelyn A Sutton Papers. The Museum of Military Medicine Archives. 

Keogh Barracks, U.K.

34. Ibid.

35. Cosmas and Cowdrey, 153.

36. Ibid.

37. “Estimate of Casualties,” September 25, 1943, Entry 1, Evelyn A Sutton Papers, The Museum of 

Military Medicine Archives, Keogh Barracks, 

U.K.. For the same reasons cited previously, I cannot definitively state that Hartford was the driving 

force behind the revision in planning method. From 

the record it is clear that the method of estimating 

casualties changed between July and August of 

1943, and that the subsequent casualty prediction 

changed as well. The record also makes explicitly 

clear that the method used to forecast casualties 

was the method outlined by Love. As Hartford was 

the senior American medical planner on the COSSAC staff, it is reasonable to infer that he was a part 

of this change.

38. Ibid.

39. Ibid., 1a.

40. “Minutes of COSSAC Held on Saturday, 28th August 1943, Report on ‘QUADRANT,’” August 30, 

1943, Record Group 331, Entry 3, Box 122 (College 

Park, M.D.: National Archives of the United States).

41. Ibid. During this meeting the staff conference discussed comments made during the QUADRANT 

Conference, and this quote was among the items 

discussed, originally stated at the QUADRANT 

Conference.

42. “Table - Estimated Casualties,” April 8, 1944, File 

SHAEF 370-05 MED, Record Group 331, Entry 65, 

Stack Area 290, Row 7, Compartment 34, Shelf 4, 

Box 3 (College Park, M.D.: National Archives of 

the United States).

43. “Conference with General Hawley,” April 18, 1951, 

Page 4, File HD 000.71 Interviews Shoock-Beasley-Fitzpatrick-Gorby-Hawley-Kenner McGee Mason Welch, Record Group 112, Entry 1013 (Center 
112 http://www.cs.amedd.army.mil/amedd_journal.aspx

of Military History Refiles, Stack Area 390 Row 

18, Compartment 19, Shelf 02, Box 1 (College Park, 

M.D.: National Archives of the United States), and 

“Receipt and Shipment of Bags, Patient’s Effects,” 

June 1, 1944, File 370.05 Planning-Evacation-ETO, 

Record Group 112, Entry 31 (ETO), Stack Area 390 

Row 17, Compartment 5, Shelf 3, Box 311 (College 

Park, M.D.: National Archives of the United States), 

and “Page 13 - Reception and Distribution of Casualties in U.K. - Operation OVERLORD, Appendix 

A,” May 25, 1944, File Evacuation, Record Group 

112, Entry 31 (ETO), Stack Area 390 Row 17, Compartment 5, Shelf 3, Box 312 (College Park, M.D.: 

National Archives of the United States).

44. “Initial Evacuation of Casualties from Far to Near 

Shore: Army/Navy Responsibilities,” May 19, 

1944, File 370.05 Planning-Evacation-ETO, Record 

Group 112, Entry 31 (ETO), Stack Area 390 Row 

17, Compartment 5, Shelf 3, Box 311 (College Park, 

M.D.: National Archives of the United States)

45. F. J. Horne, “LSTs Special Fittings for Casualty 

Evacuation, page 1,” October 28, 1943, File COSSAC, Record Group 112, Entry 31(ETO), Stack 

Area 390, Row 17, Compartment 4, Shelf 6, Box 

282 (College Park, M.D.: National Archives of the 

United States).

46. “Operation ‘Overlord,’ Casualty Estimates (Excl of 

Air Force)” August 12, 1943, Evelyn A Sutton Papers. The Museum of Military Medicine Archives. 

Keogh Barracks, U.K.

47. Giangreco, 528.

48. Ibid., 529.

49. Field Manual 101-10-1/2: Staff Officers’ Field 

Manual, Organizational, Technical, Data Planning Factors (Volume 2) (Washington, D.C: Headquarters, Department of the Army, 1987), 4-7. See 

Giangreco, p 540, “Early in the Pacific war, medical and campaign planners built their casualty estimates as best they could using tables constructed 

from the U.S. Army’s World War I experience 

when factored with projected troop strength, operational plans, and intelligence estimates of Japanese capabilities, terrain, and relative firepower. By 

the invasion of the Philippines, planners at various 

echelons in MacArthur’s headquarters were able to 

realistically replace the World War I baseline figures with data compiled from the hard-won battles 

on and around New Guinea.” Giancrego does not 

provide any reference or analysis to back up this 

claim, but the idea of incremental updates based on 

timely data is an accepted fundamental of sound 

forecasting. If Giangreco is correct, it would seem 

inexcusable that planners in the European Theater 

did not do the same thing because they too, like 

their counterparts in the Pacific Theater, had access to all the casualty experience of the British.

50. Ibid., 5-1.

Author

MAJ Mobbs is a 2007 graduate of the US Military Academy and holds an MA in history from the University of 

Pennsylvania. MAJ Mobbs is an infantry officer, serving 

most recently as a troop and company commander in 1st 

Brigade, 82nd Airborne Division, Fort Bragg, NC. He 

is currently assigned to the US Military Academy as an 

instructor, teaching a course in American History.

— SPURGEON NEEL ESSAY AWARD COMPETITION —

THE FIGURES OF EXPERIENCE: A BRIEF HISTORY OF RISK AND PLANNING WITHIN THE ARMY MEDICAL COMMUNITY
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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.

Informed Consent

Identifying information, including names, initials, or hospital numbers, should not be published in written descriptions, photographs, 

or pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed 

consent for publication. Informed consent for this purpose requires that an identifiable patient be shown the manuscript to be 

published. Authors should disclose to these patients whether any potential identifiable material might be available via the Internet 

as well as in print after publication. Patient consent should be written and archived, either with the Journal, the authors, or both, 

as dictated by local regulations or laws.

Guidelines for Manuscript Submissions

1. Manuscripts may be submitted either via email (preferred) or by regular mail. Mail submissions should be in digital format (preferably an MS Word document on CD/DVD) with 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.

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, with the following required data:

• 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 imagery 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, TIFF, GIF) are preferred. 

Editable versions with data sets of any Excel charts and graphs must be included. Charts/graphs embedded in MS Word cannot 

be used. Prints of photographs are acceptable. If at all possible, please do not send photos embedded in PowerPoint or MS Word. 

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. Submit manuscripts to:

DSN 471-6301

Comm 210-221-6301

Email: usarmy.jbsa.medcom-ameddcs.list.amedd-journal@mail.mil

Editor, AMEDD Journal

DOTAA Borden Institute

3630 Stanley RD RM 1340

JBSA Fort Sam Houston, TX 78234-7697
PIN: 203236-000