July – September 2014 

Perspectives 1

MG Steve Jones; COL Mustapha Debboun; Richard Burton 

The Growing Challenges of Vector-Borne Diseases to Regionally-Aligned Forces 6

COL Leon L. Robert, Jr; COL Mustapha Debboun 

Mosquito Biosurveillance on Kyushu Island, Japan, with Emphasis on Anopheles 11

Hyrcanus Group and Related Species 

Leopoldo M. Rueda, PhD; Benedict Pagac; Masashiro Iwakami; et al 

High-Throughput Vector-Borne Disease Environmental Surveillance by Polymerase 21

Chain Reaction According to International Accreditation Requirements 

Marty K. Soehnlen, PhD, MPH; CPT Stephen L. Crimmins; Andrew S. Clugston, MS; et al 

Evaluation of a Rapid Immunodiagnostic Rabies Field Surveillance Test on Samples 27

Collected from Military Operations in Africa, Europe, and the Middle East 

Kristen M. Voehl, DVM, MPH, DACVPM; LTC Greg A Saturday

Trends in Rates of Chronic Obstructive Conditions Among US Military Personnel, 2001-2013 33

Joseph H. Abraham, ScD; Leslie L. Clark, PhD; Jessica M. Sharkey, MPH; Coleen P. Baird, MD, MPH 

Department of Defense Participation in the Department of Veterans Affairs Airborne 44

Hazards and Open Burn Pit Registry: Process, Guidance to Providers, and Communication 

Jessica M. Sharkey, MPH; Deanna K. Harkins, MD, MPH; Timothy L. Shickedanz; Coleen P. Baird, MD, PhD 

Coinfection of Mycoplasma Pneumonia with Chronic Q Fever in a Nurse Deployed to 51

Operation Iraqi Freedom: A Case Study 

LTC Paul O. Kwon; Jason R. Pickett, MD 

Over the Ear Tactical Communication and Protection System Use by a 55

Light Infantry (Airborne) Brigade in Afghanistan 

MAJ Leanne Cleveland 

Health Hazard Assessment and the Toxicity Clearance Process 59

Mohamed R Mughal, PhD; John Houpt; Timothy A. Kluchinsky, Jr, DrPH 

Chemical and Biological Warfare: Teaching the Forbidden at a State University 61

CDR (Ret) David M. Claborn, USN; Keith Payne, PhD 

An Introduction to Public Health Law for Leaders and Clinicians 68

Joseph Baar Topinka, JD, MHA, MBA, LLM 

The Public Health Specialist Program at the Medical Education and Training Campus 72

MAJ M. G. Colacicco-Mayhugh; LT Carl Blaesing, USN; LTC Kent Broussard 

Using the Army Medical Cost Avoidance Model to Prioritize Preventive Medicine Initiatives 76

Cindy Smith; Kelsey McCoskey, MS; MAJ Jay Clasing; Timothy A. Kluchinsky, Jr, DrPH 

Managing Public Health in the Army Through a Standard Community 82

Health Promotion Council Model 

Anna F. Courie, RN, MS; Moira Shaw Rivera, PhD; Allison Pompey, DrPH, CPH 

Performance Excellence: Using Lean Six Sigma Tools to Improve the US Army 91

Behavioral Health Surveillance Process, Boost Team Morale, and Maximize 

Value to Customers and Stakeholders 

Eren Youmans Watkins, PhD, MPH; Dave M. Kemeter, MBB; Anita Spiess, MSPH; et al

FORCE HEALTH PROTECTION: THE PROVEN FORCE MULTIPLIER
July – September 2014 The Army Medical Department Center & School PB 8-14-7/8/9 

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

A Professional Publication 

of the AMEDD Community 

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AMEDD Journal. 

OFFICIAL DISTRIBUTION: This publication is targeted to US Army 

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organizations, and members of the worldwide professional medical community. 

LTG Patricia D. Horoho 

The Surgeon General 

Commander, US Army Medical Command 

MG Steve Jones 

Commanding General 

US Army Medical Department Center & School 

Administrative Assistant to the 

Secretary of the Army 

GERALD B. O’KEEFE 

1411106 

By Order of the Secretary of the Army: 

Official: 

Raymond T. Odierno 

General, United States Army 

Chief of Staff

DISTRIBUTION: Special 
July – September 2014 1

Perspectives

Commander’s Introduction

MG Steve Jones

Baron Von Steuben introduced Force Health Protection 

to the United States Army at Valley Forge when he instructed regimental commanders that “the preservation 

of the Soldier’s health should be their first and greatest 

care.” Captains, lieutenants, and ensigns were given additional instructions on their role in supporting this new 

leadership responsibility. The concept has served the 

Army well since its introduction, and, with improved 

techniques, we saw significantly higher casualty survival rates and lower disease and nonbattle injury rates 

during the conflicts in Iraq and Afghanistan.

Joint Publication 4-02 defines Force Health Protection 

as “Measures to promote, improve, or conserve the behavioral and physical well-being of Service members 

to enable a healthy and fit force, prevent injury and illness, and protect the force from health hazards.”1(pGL-7)

Among other things, an October 31, 2006 change added 

a chapter on Force Health Protection1(pIV-1) with subordinate core functional capabilities, the first of which is 

Casualty Prevention, which includes all measures taken 

by commanders, leaders, individual military personnel, 

and the healthcare system to promote, improve, or conserve the mental and physical well-being of military personnel. Additional core functional capabilities specified 

and detailed in Joint Publication 4-02 are Preventive 

Medicine, Health Surveillance, Combat and Operational 

Stress Control, Preventive Dentistry, Vision Readiness, 

and Laboratory Services.

In his 1984 article in Military Medicine,

2

 COL Ron Bellamy stimulated critical thinking about our approach to 

combat casualty care. He stated:

Given optimal circumstances, such as in Vietnam, neither 

the application of sophisticated technologies designed to 

improve survival of traumatized patients in surgical intensive care wards or operating rooms, nor greater success in managing the common causes of postoperative 

death—sepsis and multiple organ failure—will have a 

significant impact on improving combat casualty care.

Rather, he insisted that improvement would come with “a 

renewed emphasis on field medical care.” That renewed 

emphasis was realized with implementation of the Combat Lifesaver Program, the 68W Combat Medic, and publication of Tactical Combat Casualty Care guidelines. We 

taught Soldiers to apply tourniquets, open airways, and 

decompress a tension pneumothorax, and issued them 

the Improved First Aid Kit. Also, we taught tactical leaders their role in casualty management and evacuation.

The new approach to field medical care together with 

advances in Force Health Protection contributed to significantly increased survival rates after wounding on the 

battlefield over the past 12 years. Improved individual 

body armor with an increased area of coverage and greater ballistic protection decreased the incidence of thoracic 

and abdominal injuries. The flame-resistant Army Combat Shirt, Advanced Combat Helmet, and ballistic eye 

protection also provided additional personal protection. 

Vehicular armor evolved throughout the conflict from 

the improvised armor added to vehicles by units early in 

the war to up-armored HMMWVs* and MRAPs.† Each 

of these advances enhanced Soldier survivability.

While we should continue to seek technological advances such as improved surveillance for biological weapons, the human dimension of Force Health Protection 

deserves further attention. Just as critical thinking about 

care on the battlefield led to significant improvements in 

combat casualty care, critical thinking about the human 

factors that lead to casualties may significantly reduce 

their numbers. My analysis of casualties as Command 

Surgeon, Multinational-Force Iraq from 2005-2006 

showed that service members were at greater risk of 

becoming a casualty during their first 90 days in theater. When these findings were forwarded up the chain 

of command, they prompted the Secretary of Defense 

to question whether shorter but more frequent tours in 

combat placed warfighters at an increased risk.

The Defense Advanced Research Projects Agency subsequently commissioned a study to identify critical fatality time periods, training, information, and equipment 

gaps.3,4 Researchers analyzed data on 1,770 US and 215 

UK military fatalities in Iraq and Afghanistan from January 1, 2007 to September 1, 2009, and interviewed Soldiers and subject matter experts. They found that nearly 

40% of fatalities occurred in the first 3 months of deployment, most often attributed to a lack of experience. 

Force Health Protection and the Human Dimension

*High mobility multipurpose wheeled vehicle

†Mine resistant ambush protected vehicle
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

Editor’s Perspective

As a new century moves through its second decade, the 

world continues to present increasingly perplexing and 

dangerous challenges for stability and freedom. Threats 

continually ebb and flow, appearing, disappearing, relocating, shifting into different forms, and spreading. 

Military operations planners try their best to anticipate 

the nature and locations of these threats, and design 

strategies and doctrine to best counter them. A common 

thread across all planning is the certainty that future operations will continue to encounter serious threats unrelated to an anticipated military opponent, especially 

in undeveloped, remote areas throughout the world. 

In their article, COL Leon Robert and COL Mustapha 

Debboun address the variety and breadth of the threat 

posed by vector-borne diseases and how Army medical 

planners must tailor their efforts to support the regionalalignment model of building combat capacity and capability. Although the US military has an extensive, worldwide infrastructure involved in disease surveillance and 

research, experience has shown that there continue to be 

gaps in data and information about resources for many 

locations where military operations may be required. 

This article discusses how those existing capabilities 

may take advantage of any locally-based resources, 

and the requirements for planning to work closely with 

other US and foreign government organizations, as well 

as nongovernmental organizations which are providing 

services in the regions.

As with the military threats mentioned above, the vectors 

that carry dangerous pathogens themselves appear, 

disappear, change, and spread, an increasingly serious 

problem in this modern world of ubiquitous modes of 

transportation. Current, accurate data concerning the 

presence and identification of such vectors in areas of 

concern are vital to those planning medical support for 

military operations. An example of the commitment and 

effort involved in gathering and maintaining such data 

is presented by Dr Leopoldo Rueda and his colleagues. 

Their article describes a biosurveillance project targeting 

mosquito species on the southern Japanese island of 

PERSPECTIVES

Loss of local intelligence when an old unit leaves and 

a lack of familiarity with the environment and enemy 

tactics were also cited as contributing factors. A second 

spike in fatalities occurred at the 6-month point in the 

tour which Soldiers attributed to complacency. A minor 

spike in Soldier fatalities noted at the 10-month mark 

was attributed to fatigue, complacency, and stale tactics.

The US Army Human Dimension Concept 5 provides a 

framework to address the human factors of Force Health 

Protection. A better understanding of the cognitive, 

physical, and social components may lead to improvements in training and better communication of successful tactics, techniques, and procedures. Learning, training, repetition, and practice all affect cognition and the 

decision-making process. Initiatives to accelerate learning and compress the time it takes to accumulate experiential competence may shorten the high risk period early 

in a tour. Physical factors such as fatigue, sleep deprivation, dehydration, hunger, and stress from heat or cold 

affect decision-making in combat. Psychological factors 

including complacency, stress, boredom, motivation, 

and a sense of isolation affect decision-making as well. 

Recognition of these factors and actions to mitigate their 

effects may reduce casualty rates. Improved physical fitness, nutrition, and psychological fitness can help delay 

the onset of fatigue. A reduction in the use of energy 

drinks and long hours playing video games after missions will lead to better sleep, and more rested Soldiers. 

Improved social fitness with better self-discipline, valued 

relationships, and good communication with others will 

produce Soldiers who are more resilient and resistant to 

stress. Application of the Human Dimension Concept 

has great potential for not only enhancing performance, 

but also improving health and fitness, and preventing injury and illness—the goal of Force Health Protection.

References

1. Joint Publication 4-02: Health Service Support. 

Washington, DC: Office of the Chairman, Joint 

Chiefs of Staff; July 26, 2012. Available at: http://

www.dtic.mil/doctrine/new_pubs/jp4_02.pdf. Accessed June 11, 2014.

2. Bellamy RF. The causes of death in conventional 

land warfare: implications for combat casualty care 

research. Mil Med. 1984;149(2):55-62.

3. Plank T, Scheff S, Sebok A. First 100 days of deployment critical to soldier survivability. National Defense [serial online]. May 2010. Available at: http://www.nationaldefensemagazine.org/

archive/2010/May/Pages/First100DaysofDeploy

mentCriticaltoSoldierSurvivability.aspx. Accessed 

June 11, 2014.

4. Scheff S, Sebok A. Capturing Insights to Reduce 

Future Warfighter Fatalities [preliminary report]. 

Washington, DC: Defense Advanced Research 

Projects Agency; April 2010. Available at: http://

www.manprint.army.mil/documents/2010/Scott_

Scheff.pdf. Accessed June 11, 2014.

5. TRADOC Pamphlet 525-3-7: The U.S. Army Human Dimension Concept. Fort Eustis, VA: US 

Army Training and Doctrine Command; May 21, 

2014. Available at: http://www.tradoc.army.mil/

tpubs/pams/TP525-3-7.pdf. Accessed June 11, 2014.
July – September 2014 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

Kyushu to update surveillance data and information 

from sites identified as having taxonomic and ecological 

importance. The article provides a detailed look at a 

biosurveillance project: the precollection research to 

better target collection areas; the multiyear collection 

effort itself; and the extensive work required to identify 

the collected specimens and then analyze the results 

against historical data.

Determination of the presence of pathogens among collected specimens of potential vectors is the critical step 

in the surveillance of an area to plan countermeasures 

against diseases. Such testing can be time consuming, 

and sometimes can only be performed at a laboratory 

distant from the area of concern. Dr Marty Soehnlen, 

CPT Stephen Crimmins, and their colleagues developed 

a method of standardized testing of surveillance samples 

using polymerase chain reaction methods which provides high-throughput and allows analysis of multiple 

pathogens from the same sample. They developed tests 

for 9 pathogens under international accreditation standards which can be performed at the US Army Public 

Health Command Region Europe Laboratory Sciences 

laboratory, but have universal Department of Defense 

application. Their detailed report should be of great interest to all those charged with providing surveillance of 

vector-borne diseases throughout not only military resources, but all other government disease management 

agencies as well.

Throughout most of recorded history, rabies has been 

known to mankind as a deadly, infectious disease. It has 

been a target for treatment and elimination from the dawn 

of medical science, yet today it is still present on every 

continent except Antarctica. It is found in many species 

of mammals, both feral and domesticated, in rural and 

urban environments. Although infections in humans is 

relatively rare in the United States, rabies poses a constant threat to military personnel involved in all types 

of deployed settings. As such, prompt and reliable identification of its presence is very important to preventive 

medicine and healthcare delivery personnel. Dr Kristen 

Voehl and LTC Greg Saturday have contributed an article describing a research study in which they evaluated a 

commercially available test kit which can be used in austere settings to confirm rabies infection in brain tissue. 

The results of their study, combined with that of their literature review, could result in another important tool for 

medical support units charged with protecting our troops 

from diseases and other environmental hazards.

Respiratory health has received increasing attention 

from researchers over the last century or so, as the relationship of damage to airborne hazards in the workplace, 

smoking, and general air pollution has been proven 

and publicized. Military personnel can be exposed to 

a complex array of potential hazards and pollutants, 

sometimes highly concentrated, but more often present 

in lower concentrations which become an unnoticed, 

ever-present part of the environment. The Persian Gulf 

conflicts since 1991 have bought the concerns about 

respiratory health of Warfighters to an elevated level. 

Dr Joseph Abraham and his colleagues conducted an 

extensive, detailed study of medical treatment records 

concerning chronic obstructive pulmonary disease and 

associated conditions for active duty military personnel 

across the 13-year period of current combat operations 

in the Middle East and Afghanistan. They were seeking 

information on rates of the conditions, trends, and characteristics of the study population reflecting any trends. 

Their article is a clear description of the extensive data 

collected, the detailed data reduction performed, and 

the careful analysis of that data. The data is presented 

clearly and logically throughout the article. Some of the 

results were unexpected, others are not readily explainable. This study is a significant contribution to the body 

of research into respiratory health of our military personnel, and should generate further investigations.

Indicative of the level of concern regarding the respiratory health of military personnel who have served in 

combat theaters is language contained in the Dignified 

Burial and Other Veterans Benefits Improvement Act of 

2012. That language directs the Department of Veterans 

Affairs to establish a registry to collect information regarding all potential exposures experienced by military 

personnel during deployments that might adversely affect their respiratory health. The article provided by Jessica Sharkey et al presents an excellent description of the 

purpose and parameters of the registry which is slated 

to be active before the end of 2014. Their article details 

the eligibility criteria and registration process for those 

wishing to enter the registry. There is also important 

information for military healthcare providers regarding 

the military healthcare system’s perspective, responsibilities, and obligations to those requesting clinical assessments as part of the registration. This article is an 

excellent “heads up” for participants and caregivers alike 

concerning the impending availability of an important 

new aspect of healthcare for those who have served.

As has been noted in the pages of the AMEDD Journal time and again, military healthcare providers in 

deployed environments must always “expect the unexpected” when faced with confusing, conflicting, unfamiliar diagnostic indications. LTC Paul Kwon and Dr 

Jason Pickett relate such a situation in their excellent 

case study of a patient whose symptoms and diagnostic 
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

indications were varied and complicated. She was eventually diagnosed as having Q fever, which was present 

as a coinfection with mycoplasma pneumoniae, a combination rarely addressed in medical literature. Further, 

she had no history of the typical risk factors associated 

with Q fever during her deployment. This article is a 

well-organized, detailed, and complete; a superb example of medical professionalism at its best.

Over the last 6 years, the Army Hearing Program has 

been addressed in several Journal articles, beginning 

with its conception, its implementation among garrison 

units, and how it was adopted in the deployed, combat 

environment. In this issue, MAJ Leanne Cleveland returns with an article that provides, among other things, 

an update on the level of understanding of the importance 

of hearing protection at the individual Soldier level, and 

how many have “tested” different hearing devices in 

combat, sometimes obtained at their personal expense. 

As part of the returning Soldier health assessments, she 

conducted a survey of returning troops to quantify their 

opinions of effectiveness of protective devices, as well 

as their preferences. The resulting data may be the first 

concerning protective devices to be collected from those 

who very recently experienced actual combat rather than 

a simulated test environment. The results of the surveys 

were then compared to the pre- and postdeployment audiograms to determine any correlation between those 

reporting use of protective devices, and those who did 

not. The information in this article should be of value to 

researchers, designers, and testers of protective hearing 

devices for the military, which will have broad civilian 

application as well.

The safety of the end user has long been a concern for 

developers of military equipment and weapons. In 1983, 

the Army formally established the Health Hazard Assessment Program, which had been operating under The 

Surgeon General since 1981, with the responsibility to 

evaluate and monitor development and procurement of 

all Army materiel systems, including weapons, equipment, clothing, etc. As manufacturing processes and 

the materials used have become more sophisticated and 

complex, the potential for toxicity in resulting products 

to have harmful effects on humans and other living 

things has become an ever more important factor. This 

is addressed by the Army’s Toxicity Clearance process 

which is detailed in the article by Dr Mohamed Mughal 

and his coauthors. They describe the formal investigative 

and clearance requirements involved for a manufacturer 

to obtain approval to use specific chemicals and other 

materials in products before introduction into the Army 

supply system. This is an interesting look at another important function performed by AMEDD professionals, 

largely in the background, that is vital to protecting the 

health of our Soldiers every single day.

History is replete with examples of best-intended, consensus actions proving fruitless because someone does 

not follow the plan. Since 1899, a series of international 

laws, treaties, pronouncements, and unilateral actions 

have been intended to eliminate chemical and biological 

weapons, with the inevitable result that those weapons 

continue to exist under control of the most dangerous of 

lawless regimes and tyrants. However, since the notion 

that the problem was solved was conveyed by the cooperating governments, interest in those weapons waned 

in both academic and official circles. As a result, people 

truly knowledgeable in chemical and biological warfare 

and associated subjects became more difficult to find. A 

number of events over the last 30 years has exposed and 

reestablished the vital need for this area of expertise. 

In their article, CDR (Ret) David Claborn and Dr Keith 

Payne describe a fellowship and graduate program of 

study in Countering Weapons of Mass Destruction now 

offered by Missouri State University in cooperation with 

the National Defense University in the Washington, DC 

area. This is an important and very informative article 

about a proactive approach to dealing with a real-world 

threat with potentially disastrous ramifications. Sadly, 

this threat will likely not be truly eliminated any time 

soon, if ever.

Regular readers of the AMEDD Journal are familiar 

with MAJ (now retired) Joseph Topinka’s contributions, 

along with those of his colleagues, of excellent articles 

focused on various legal topics and considerations specifically related to military medicine. For this issue, he 

has submitted an article providing an overview of public 

health law. This article is written as an introduction for 

military medical personnel and other leaders to convey 

the breadth and depth of legal considerations that pertain when working within the public health sector. It is 

an interesting, easy read, and definitely eye-opening as 

the reader begins to understand how integral and important a basic understanding of the law is to successfully 

functioning in the various areas of public health.

Among the many changes resulting from the 2005 Base 

Realignment and Closure Commission recommendations was the consolidation of all enlisted basic and 

most specialty medical training into a single Medical 

Education and Training Campus (METC) at Fort Sam 

Houston, Texas. The METC became fully operational 

in September 2011. One of the consolidated specialty 

areas taught at METC is the Public Health Specialist 

Program, which graduates Army and Navy Preventive 

Medicine Specialists and Technicians (respectively). 

PERSPECTIVES
July – September 2014 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

MAJ Colacicco-Mayhugh and her coauthors have provided a detailed description of that program, and how it 

has already been revised to optimize both resources and 

schedule based on initial experience teaching a multiservice curriculum. Their article provides excellent insight into the dedication and high level of expertise and 

professionalism that is involved in the design, delivery, 

evaluation, and revision cycle necessary to ensure that 

students receive only the best training possible. The 

future health and readiness of many military members 

may directly depend on the knowledge and skills imparted to these new Soldiers and Sailors.

Throughout history, militaries have always faced the 

Gordian knot of how to satisfy the ever increasing requirements their governments/leaders place on them, 

while simultaneously receiving ever decreasing resources with which to accomplish those tasks. Today’s environment is no different. Politics, economic factors, shifting priorities, new and resurfacing threats, and many 

other factors result in unpredictable financial resources 

which must be divided into many parts. In most cases, 

the amount of available funds is finite, so competition for 

a share of those funds can be intense. Usually that competition hinges on the value to the organization realized 

from the committed funding, the classic return on investment (ROI). The government data source for typical 

personnel costs does not cover all of the categories affecting the true amount of medical costs, thus degrading 

the suitability of the data for use in evaluating preventive medicine program initiatives. Cindy Smith and her 

coauthors have provided a detailed description of a tool 

developed within the Army Institute of Public Health 

which draws specific, relevant data into analysis to calculate a more accurate and realistic ROI for prevention 

programs. This excellent article is, in essence, a tutorial 

for use of the analysis tool, clearly explaining the process 

in a straightforward manner. This powerful analysis tool 

should be of great interest and utility to all preventive 

medicine program developers in Army medicine.

In recent years, the news coverage of the relief responses to large scale disasters have increasingly focused on 

the apparent disorganization and inability to coordinate 

within and among government organizations involved 

in the efforts. While the news organizations overemphasize these problems for the ratings benefits of hyping the latest, biggest scandal, the basic difficulties that 

are highlighted in such reports do in fact reflect the 

complexity of public health systems of virtually every 

scale, even the seemingly benign and routine functioning within a military installation. As Anna Courie and 

her coauthors clearly describe, the public health systems in both the civilian communities and on military 

installations share the same characteristic of dependence 

on various, distinct resources and components which are 

themselves responsible to disparate organizations and 

authorities. This fragmented structure wastes resources, 

causes confusion, is error prone, and is obviously slow 

and ponderous in functioning and reacting to public 

health issues. The Army has adopted a structure across 

its installations called the community health promotion 

council (CPHC) to manage the Army Public Health System. The Army Public Health Command has established 

a standard model for the CPHC to ensure a coordinated 

approach to managing public health responsibilities and 

functions. The standard CPHC has been implemented 

in 12 of the larger Army installation in the United State, 

while 14 others have CPHC processes but have not as yet 

received the additional resources necessary to adopt the 

standard model. Ms Courie et al investigated the relative effectiveness of the public health systems aboard 

installations with standard CPHC processes versus 

those without the features of the standard model. Their 

well-researched article carefully develops the foundation for the CPHC approach, and details the results of 

their study. This is an interesting, informative look at the 

complexity and broad range of concerns, both tangible 

and perceptive, that are involved in managing an effective public health system.

Lean Six Sigma (LSS) is a well-known process improvement, problem-solving methodology that is used by 

activities within the US Army, including those within 

AMEDD. Although best known for its success within 

business and manufacturing, it has also proven valuable in use with knowledge-based processes. Dr Eren 

Youmans Watkins and her colleagues applied LSS to a 

public health surveillance function within the Army’s 

Behavioral Social Health Outcomes Program, specifically the report of the suicide behavior surveillance data. 

Their article clearly details the application of the LSS 

methodology as a carefully designed, step-by-step process to define the project, measure the existing process 

parameters, analyze the data, determine the points of 

substandard performance and the causes, develop and 

imcorporate changes to improve the processes, and 

measure and document the resulting performance. For 

this project, the total number of labor hours (baseline) 

required to produce each report was 448. Following the 

project, the number of hours was 199. Also, it was determined that a quarterly report was not seen to be necessary by its users, so the report is now produced annually, 

resulting in additional savings. This article presents an 

excellent introduction to LSS for those unfamiliar with 

it. It demonstrates how even a seemingly straightforward 

process reveals much room for improvement once the 

components are identified and analyzed in detail.
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

Global factors are interacting together to fundamentally 

change the worldwide vector-borne disease threat and 

the corresponding public health landscape. These challenges are predicted to become increasingly problematic 

in the future. Specific challenges such as climate change, 

rapid urbanization of megacities, lack of clean drinking water, poor sanitation and health, and the growing 

threat of emerging and reemerging vector-borne diseases will certainly present an increasing challenge for 

military entomologists and public health professionals. 

In addition, these challenges will almost certainly place 

increasing demands on regionally-aligned US forces in 

terms of operational requirements, available manpower, 

and resource consumption.

In 2012, the Chief of Staff of the Army announced that 

future Army forces must be tailored to meet local requirements, must be rapidly deployable and scalable 

from squad to corps level.1 The changing strategic environment necessitates organizing the Army for regional 

conditions in an effort to align forces regionally to specific combatant commanders, such as those in Europe, 

the Pacific, and in Africa. In addition, regionally-aligned 

forces will require intimate integration with regional allies and multinational forces. This overall effort seeks 

to increase specialized regional expertise and cultural 

awareness so US forces will be better prepared to meet 

present and future regional requirements. Through the 

regional alignment of forces, we will meet both these 

imperatives, ensuring that our Army remains globally 

responsive and regionally engaged.

As regional alignment of forces begins, Department of 

Defense (DoD) planners and military forces worldwide 

continue to face numerous challenges from vector-borne 

diseases. Not only must military healthcare systems 

continually adapt to emerging and re-emerging diseases 

to protect US forces, but they must operate in developing countries that either cannot or will not address continuing high mortality from infectious diseases.2

 These 

countries have little or no surge capacity (ie, numbers 

of hospital beds, medical supplies, adequate distribution systems, and measures for managing public panic) 

in case of an influenza pandemic, bioterrorist attack, or 

even a regional outbreak of a vector-borne disease. Governments will increasingly rely on regionally-aligned 

US forces to assist and manage unexpected healthcare 

emergencies as they develop. Thus, there is an urgency to continually improve joint adaptability, versatility, 

and training to cope with uncertainty and complexity 

The Growing Challenges of Vector-Borne

 Diseases to Regionally-Aligned Forces

COL Leon L. Robert, Jr, MS, USA

COL Mustapha Debboun, MS, USA

Abstract

The long-term strategic focus of US foreign policy has pivoted to the Pacific, but tensions in the Middle East 

require constant attention in the present. As our current role in Afghanistan diminishes, we must seize the 

opportunity to refocus on the new priority of regionally-aligned forces. The short-term reality requires first reestablishing core warfighting competencies of a smaller Army and then building the capacity of forces focused 

on regional alignment. The continuing threat of vector-borne and other infectious diseases will present growing 

challenges to US forces focused on regional alignment and engagement. Greater understanding of these threats, 

host nation vulnerabilities and capabilities, and the regional presence of international and nongovernmental 

organizations will enable US forces to respond and engage more effectively and appropriately to accomplish 

assigned missions and future contingencies. Effective vector surveillance and control has a longstanding and 

proven record of preventing, reducing, and eliminating vector-borne diseases and must remain a focus of regionally-aligned forces. Operational readiness of armed forces continues to rely heavily on vector surveillance 

and control, and on personal protection strategies. Regionally-aligned forces must also work closely with the 

US Department of State and US Agency for International Development, international governments, governmental and nongovernmental organizations, and private organizations operating in the region and know how 

to effectively interact with these diverse organizations. In addition, a working knowledge of a host country’s 

public health policy, capabilities and economic realities will be essential. Teamwork with previously unfamiliar 

groups and organizations will be an essential component of working in regional environments and can present 

unfamiliar tasks for traditionally-trained military units.
July – September 2014 7

in military preventive medicine and public health as it 

relates to infectious disease surveillance and control.3

Challenges Ahead

United States forces will continue to face challenges in 

remote lands ranging from regular and irregular wars, 

humanitarian relief and reconstruction, to sustained 

global engagement. The challenge to force health protection (FHP) planners and leaders is best summarized 

by the FHP problem statement below.

The problem that faces the joint force is to determine 

how to more effectively provide health protection to a 

force that will operate in a complex and diverse operational environment; confront a range of traditional and 

new adversaries and threats; employ and integrate new 

technologies; and collaborate with other organizations, 

agencies, nations and cultures.4(p15)

The importance of this problem statement is reinforced 

by the Director-General of the World Health Organization who warns that emerging diseases have become a 

much larger menace in a world characterized by high 

mobility and unstable economies.5 Also, climate change, 

widespread land-use change, globalization of trade and 

travel, and social upheaval are driving the emergence 

and changing patterns of zoonotic (animal diseases 

transmissible to humans under natural conditions) and 

vector-borne diseases (infectious diseases transmitted 

host-to-host by another animal, usually an arthropod) 

worldwide.

Throughout history, zoonotic diseases and vector-borne 

diseases have severely reduced the fighting strength of 

armies and changed the course of military operations. 

Since World War I, these infectious diseases are no longer the main causes of morbidity and mortality among 

military personnel. However, even with modern medicine and therapeutics, zoonotic and vector-borne infectious diseases continue to be an important threat to US 

forces both in the United States and worldwide.6 Continual progress in modern medicines, hygiene, and vector control has lessened the effects of some vector-borne 

diseases (eg, plague, yellow fever, and epidemic typhus) 

while others such as malaria and dengue fever remain a 

military concern and new potential threats continue to 

emerge, West Nile encephalitis and chikungunya fever, 

for example.7 As neither effective medication nor vaccines are available for some of these diseases, vector 

control remains pivotal. Therefore, operational readiness of armed forces continues to rely heavily on vector surveillance and control, and on personal protection strategies. Without aggressive application of both 

vector control and personal protection strategies, these 

diseases may again have the same devastating effect on 

service member health and military readiness as they 

did in the past.

The Global Challenge of Vector-Borne

Diseases

The global challenge of infectious diseases cannot be 

underestimated; nearly half of the world’s population is 

at risk from at least one type of vector-borne pathogen.8

Vectors like mosquitoes, ticks, and fleas transmit parasites, viruses, or bacteria between people or between 

animals and people. Because of the increasing threat of 

vector-borne diseases, the World Health Organization 

(WHO) selected vector-borne diseases as the theme of 

the 2014 World Health Day.8 Numerous publications and 

workshops have reviewed the relationship between global change and vector-borne diseases and have provided 

specific recommendations for detection and control capabilities, improving and coordinating surveillance, diagnosis, and response to disease outbreaks.9-11

Vector-borne diseases account for 17% of the estimated 

global burden of all infectious diseases.12 Every year 

more than one billion (109) people are infected and more 

than one million people die from vector-borne diseases, 

including malaria, dengue, schistosomiasis, leishmaniasis, Chagas disease, yellow fever, lymphatic filariasis, 

and onchocerciasis.11 Forty percent of the world’s population is at risk from dengue virus; there are an estimated 390 million dengue infections each year in over 

100 countries. Dengue is the world’s fastest growing 

vector-borne disease, with a 30-fold increase in disease 

incidence over the last 50 years. Southeast Asia and 

Latin America are especially affected, but dengue also 

occurs in Africa, where cases are less often diagnosed. 

Malaria is a vector-borne disease that is one of the most 

severe public health problems worldwide. It is a leading 

cause of death and disease in many developing countries, where young children and pregnant women are 

the groups most affected. The WHO estimates that in 

2012, there were 207 million cases of malaria resulting 

in 627,000 deaths.11

Global trade, rapid international travel, and environmental changes such as climate change and urbanization are causing vectors and vector-borne diseases to 

spread beyond borders. At the same time, the world 

is facing a severe shortage of entomologists and vector control experts.11 Very few African countries have 

entomology programs at the undergraduate university 

level, and some countries have few trained entomologists. Many national and local governments, especially 

in Africa and Asia, are reducing their financial commitments to vector-borne disease surveillance, control, 

and treatment. This has resulted in the silent increase in 
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

vector-borne disease morbidity and mortality in these 

areas. These realities will place increased burden on regionally-aligned US forces as they engage and reengage 

with regional allies and threats.

More closely related to the present and future challenges 

to surveillance and control of zoonotic and vector-borne 

diseases are global threats in sanitation and health, especially the most daunting challenges in megacities.13,14 The 

number of these megacities with populations in excess of 

10 million people is projected to reach 27 by 2015.15 These 

cities will not only pose significant military and public 

health threats to deployed forces, but will certainly be 

characterized by growing lawlessness, increasing poverty, and decreaseng essential services. Public health emphasis to eliminate insect vectors and control associated 

diseases must grow away from “blanket” application of 

pesticides to more integrated and sustainable approaches. 

These integrated approaches must include sound environmental management practices, community education 

and participation, mobilizing community resources, and 

minimal reliance on routine pesticidal spraying.11

DoD Force Health Protection for

Regionally-Aligned Forces

Department of Defense Joint Force Health Protection 

(JFHP) Concept of Operations (CONOPS) strategic 

guidance highlights the need for improving joint warfighting through JFHP transformation and incorporating 

that transformation into the respective military services’ 

operational level JFHP in support of regionally-aligned 

forces.16 In 2011, the FHP CONOPS4 was published as 

part of the overarching Health Readiness CONOPS.17

The FHP CONOPS creates a roadmap for significantly 

improving Military Health System joint interoperability 

and mission effectiveness. The FHP CONOPS supports 

rigorous assessment and analysis of force health protection-related capabilities through analysis of existing 

and new requirements, capability gaps, and shortfalls. 

Subsequently, follow-on recommendations will be made 

for appropriate materiel and nonmateriel solutions to be 

presented and adjudicated as part of broader DoD joint 

capabilities.

Regionally-aligned forces will increasingly rely on early 

warning health protection detection systems, including 

the capability to establish fixed in-theater, early warning of infectious disease trends and characterization that 

will require the capability of access to Level IV and V 

diagnostic laboratories. The full and appropriate use 

of these diagnostic facilities will certainly necessitate 

advanced training of military preventive medicine personnel so they fully understand the requirements and 

capabilities of rapid diagnostic labs.

Regionally-aligned forces will also require a full understanding of the capabilities of overseas DoD regional 

research and surveillance laboratories. There are Naval Medical Research Units in Phnom Penh, Cambodia (NAMRU-2), Cairo, Egypt (NAMRU-3) and Lima, 

Peru (NAMRU-6). In addition, the Walter Reed Army 

Institute of Research has Special Foreign Activity laboratories in Nairobi, Kenya (US Army Medical Research 

Unit-Kenya); Sembach, Germany (USAMRU-Europe); 

and Bangkok, Thailand (US Army Medical Component 

of the Armed Forces Research Institute of Medical Sciences (USAMC-AFRIMS)) with satellite laboratories 

located in rural Thailand and Nepal. The missions of 

these laboratories include prevention of psychiatric 

battle casualties, disease surveillance, vector studies, 

arboviral transmission, basic research, and vaccine and 

drug development for enteric diseases (infectious diarrhea), malaria, tropical viral diseases, and HIV/AIDS to 

increase the operational readiness of forward-deployed 

service members.

The overseas laboratories continuously conduct disease 

surveillance as part of the Armed Forces Health Surveillance Center’s Global Emerging Infections Surveillance 

and Response System which performs surveillance for 

emerging infectious diseases that could affect the US 

military. This mission is accomplished by orchestrating a global portfolio of surveillance projects, capacitybuilding efforts, outbreak investigations, and training exercises. Because overseas laboratories interact with host 

nation medical systems at national and local levels on a 

frequent (often daily) basis, they have a deep understanding of population health trends, needs, and capabilities.

Regionally-aligned forces necessarily work closely with 

the US Department of State, US Agency for International Development, international governments, nongovernmental organizations (NGOs), and private organizations 

operating in the region; so they must understand how 

to effectively interact with these diverse organizations. 

In addition, a working knowledge of the host country’s 

public health policy, capabilities, and economic realities 

is essential. The provincial reconstruction teams partnering with the Afghan government to implement the 

Afghan Ministry of Public Health National Malaria Strategic Plan is an example of implementing the planning 

considerations for foreign internal defense missions that 

will also apply in future regionally-aligned missions.3

This knowledge and associated skills are not learned in 

traditional military operational or training environments.

Thus, military and specialty-specific training must include not only traditional military preventive medicine 

and sanitation topics but be expanded to include country 

THE GROWING CHALLENGES OF VECTOR-BORNE DISEASES TO REGIONALLY-ALIGNED FORCES
July – September 2014 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

and region-specific information, to include cultural 

awareness and rudimentary language skills. This expanded skill set will not be learned from existing training courses and programs. New training opportunities 

must be afforded military preventive medicine personnel to familiarize them with how to interact with and 

synergize the efforts of host nation assets, other governmental agencies, NGOs, and international military 

partners. This training should start with initial entry 

training and be a continual process.

A Glimpse into the Future?

The WHO recently established the integrated vector 

management (IVM) strategy, a rational decision-making 

process to optimize use of resources, as an innovative 

platform for combating vector-borne diseases. The strategy is based on the premise that effective control is not 

the sole responsibility of the health sector but of a wide 

range of public and private agencies, including local 

communities. Five key attributions have been identified 

as being critical to the IVM strategy: (1) advocacy; social 

mobilization and legislation; (2) collaboration with the 

health sector and with other sectors; (3) integrated approach; (4) evidenced-based decision making; and (5) capacity building. The ultimate goal is to prevent the transmission of vector-borne diseases such as malaria, dengue, Japanese encephalitis, leishmaniasis, schistosomiasis, and Chagas disease.18 It has been recently suggested 

that this new IVM be used for rational decision-making 

and sustainable vector control in Southern Sudan and an 

archetype for other similar postconflict environments.19

The signing of the 2005 Comprehensive Peace Agreement in South Sudan marked the end of decades of civil 

war and left the country with enormous infrastructure, 

human and financial resource constraints, and a weak 

healthcare system facing a huge burden of several vector-borne diseases.20 The implementation of IVM, more 

specifically in South Sudan, will require an explicit understanding of spatio-temporal patterns of vector-borne 

diseases and complicating factors that incorporates and 

integrates all necessary information, such as geographic 

information system tools. Establishing a viable IVM 

strategy will face formidable challenges: environmental, 

sociocultural, socioeconomic, technical, and programmatic, to name a few. Challenges will be exacerbated 

by instability, a weak (almost nonexistent) healthcare 

system, limited access to health services, a paucity of 

entomological and epidemiological information, and extremely limited skilled personnel to implement the vector control program.

The potential for using IVM to integrate successful vector control in South Sudan is enormous. However, the 

realities of lack of essential physical infrastructure, financial research and technical expertise, and resources 

are daunting. Even if successful, the IVM process will 

be slow and will require a sustained national and international commitment. A version of this model was 

used in Afghanistan by provincial reconstruction teams, 

agribusiness development teams, and civil affairs units 

to develop the Afghan Ministry of Public Health National Malaria Strategic Plan, 2008-2013,21 and implement this plan to rebuild the nation-wide Afghanistan 

malaria control infrastructure.3 This mission required a 

detailed, advanced knowledge of how other governmental agencies (ie, Department of State and US Agency for 

International Development), international governments, 

NGOs, and private organizations were operating in Afghanistan, and how to effectively interact with these diverse organizations. In addition, a working knowledge 

of the host country’s public health policy, capabilities, 

and economic realities is essential

Military force health protection planners would be 

well-advised to use the current and future IVM efforts 

in South Sudan as a case study for future contingency 

threats to regionally-aligned forces. If successful, IVM 

may serve as a global strategic framework for prevention and control of vector-borne diseases when engaging 

and assisting regional international and national partners and allies.

Summary

Regionally-aligned US forces will certainly face new 

and unforeseen challenges, such as emerging and reemerging vector-borne diseases. These diseases will 

have increasingly negative effects on human health in 

developing countries and growing mega-cities.

The challenges will require traditional preventive medicine training and prevention measures. However, new 

skills such as increased coordination and cooperation 

with host nation assets, other governmental agencies, 

NGOs, and international military partners will be required. These skills must be learned through increased 

didactic training opportunities and field training experiences. Department of Defense and US Army force 

health protection doctrine and training must continually 

adapt to these future challenges.

References

1. Lopez TC. Future Army forces must be regionally 

aligned, Odierno says. Army News Service. October 24, 2012. Available at: http://www.defense.gov/

news/newsarticle.aspx?id=118316. Accessed May 5, 

2014.
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Colacicco-Mayhugh MG, Gosine S, Hughes T, Diclaro J, Larson R, Dunford J. Military entomology 

in Operation Enduring Freedom, 2010-2011. US 

Army Med Dep J. July-September 2012:29-35.

3. Robert LL, Rankin SE. The expanding role of 

military entomologists in stability and counterinsurgency operations. US Army Med Dep J. JulySeptember 2011:12-16.

4. Force Health Protection Concept of Operations 

(CONOPS). Washington, DC: Office of the Assistant Secretary of Defense (Health Affairs), US 

Dept of Defense; November 17, 2011. Available 

at: http://ommfr.dhhq.health.mil/libraries/conops/

FHP_CONOPS_17_NOV_2011.sflb.ashx. Accessed 

May 5, 2014.

5. Chan M. Public Health in the 21st Century: Optimism in the Midst of Unprecedented Challenges. 

Speech [Director-General WHO] presented April 3, 

2007; Singapore. Available at: http://www.who.int/

dg/speeches/2007/030407_whd2007/en/. Accessed 

May 5, 2014.

6. Potter R, Mallak C, Gaydos J. Deaths attributed to 

zoonotic and vector-borne diseases in US military 

forces, 1998-2009 [poster abstract]. Presented at: 

Annual Meeting of Infectious Diseases Society of 

America; October 22, 2011; Boston, MA. Abstract 

1269.

7. Pages F, Faulda M. Orlandi-Pradines E, Parola P. 

The past and present threat of vector-borne diseases in deployed troops. Clin Microbiol Infect.

2010;16(3):209-224.

8. World Health Day–vector-borne diseases. Centers for Disease Control and Prevention website. 

Available at: http://www.cdc.gov/Features/world

healthday2014. Accessed May 5, 2014.

9. Sutherst RW. Global change and human vulnerability to vector-borne diseases. Clin Microbiol Rev.

2004;17(1):136-173.

10. Institute of Medicine. Vector-borne Diseases: Understanding the Environmental, Human Health, 

and Ecological Connections. Washington, DC: 

The National Academies Press; 2008.

11. A Global Brief on Vector-Borne Diseases. Geneva, Switzerland: World Health Organization; 2014. Document number: WHO/DCO/

WHD/2014.1. Available at: http://apps.who.int/

iris/bitstream/10665/111008/1/WHO_DCO_

WHD_2014.1_eng.pdf. Accessed May 5, 2014.

12. Moe C, Rheingans R. Global challenges in water, 

sanitation and health. J Water Health. 2006;4(suppl 

1):41-57.

13. Kahn MMH, Krämer A, Prüfer-Krämer L. Climate change and infectious diseases in megacities 

of the Indian subcontinent: a literature review. In: 

Krämer A, Khan MMH, Kraas F, eds. Health in 

Megacities and Urban Areas. Berlin, Germany; 

Physica-Verlag:2011:135-152.

14. World Urbanization Prospects: The 2003 Revision. 

New York, NY: United Nations; 2004. Available 

at: http://www.un.org/esa/population/publications/

wup2003/WUP2003Report.pdf. Accessed May 5, 

2014.

15. Knudsen AB, Slooff R. Vector-borne disease 

problems in rapid urbanization: new approaches to vector control. Bull World Health Organ. 

1992;70(1):1-6.

16. Joint Force Health Protection Concept of Operations. Washington, DC: US Dept of Defense; July 

2007.

17. Health Readiness Concept of Operations 

(CONOPS). Washington, DC: Office of the Assistant Secretary of Defense (Health Affairs), US 

Dept of Defense; January 21, 2010. Available at: 

http://ommfr.dhhq.health.mil/libraries/conops/

Health_Readiness_CONOPS_21JAN2010.sflb.

ashx. Accessed May 5, 2014.

18. World Health Organization. Integrated vector management (IVM) [internet]. Available at: http://www.

who.int/neglected_diseases/vector_ecology/ivm_

concept/en/. Accessed May 6, 2014.

19. Chanda E, Govere JM, Macdonald MB, Lako RL, 

Haque U, Baba SP, Mnzava A. Integrated vector 

management: a critical strategy for combating 

vector-borne diseases in South Sudan. Malar J.

October 2013;12:369-377. Available at: http://www.

malariajournal.com/content/pdf/1475-2875-12-369.

pdf. Accessed May 6, 2014.

20. Health Policy Government of Southern Sudan 

2007-2011. Juba, Republic of South Sudan: Ministry of Health; 2006. Available at: http://goss-online.

org/magnoliaPublic/en/ministries/Health.html. 

Accessed May 5, 2014.

21. Draft National Malaria Strategic Plan 2008-2013. 

Kabul, Afghanistan: Islamic Republic of Afghnistan Ministry of Public Health; 2007. Available at: 

http://www.nationalplanningcycles.org/planningcycle-file-repository/AFG. Accessed May 5, 2014.

Authors

COL Robert is a Professor and Head, Department of 

Chemistry and Life Science, US Military Academy, 

West Point, New York.

COL Debboun is Chief, Department of Preventive Health 

Services, Academy of Health Sciences, US Army Medical Department Center and School, Fort Sam Houston, 

Texas. He is also the Chairman of the Army Medical Department Journal Editorial Review Board.

THE GROWING CHALLENGES OF VECTOR-BORNE DISEASES TO REGIONALLY-ALIGNED FORCES
July – September 2014 11

Mosquito-borne disease agents can pose a threat to humans, particularly to deployed troops, both in foreign 

environments and, if imported, domestically. Gaps exist 

in the fundamental knowledge regarding mosquito vector species, specifically concerning the species complex 

in subgenera Anopheles, Aedes, and Culex from central 

Japan. These 3 subgenera include major vector species 

that are responsible for transmitting malaria, dengue, 

Japanese B encephalitis, as well as other pathogenic microorganisms in many parts of the world, particularly 

in Asia. Anopheles Hyrcanus Group consists of several 

species that are vectors of malaria, filariasis and other 

mosquito-borne diseases in the Oriental and Palearctic regions. Currently, about 30 species have been described and named.1-3 In 2004, about 27 species were 

listed in the Hyrcanus Group, with 6 species placed in 

the Lesteri Subgroup, 4 in the Nigerrimus Subgroup, 

and 17 in the unassigned subgroup.3 In their 2013 review 

of the malaria vectors in the Greater Mekong subregion, Hii and Rueda4

 created the new Sinensis Subgroup 

that contains those previously unassigned species (An. 

sinensis Wiedemann, An. pullus Yamada, other 6 species). Recently, there is more focus on Anopheles Hyrcanus Group in Asia, primarily to clarify the taxonomy 

of the species complex and to update the distribution 

records of vectors and related species.4-10 Although several Anopheles mosquito publications exist, they were 

not updated to include recent discoveries, taxonomic records, and related pertinent collection data from central 

Japan.11-14 In 2005, Rueda and others5 noted five species 

of An. Hyrcanus Group occurring in Japan, namely: An. 

sinensis, An. engarensis Kanda and Ogama, An. yatsushiroensis Miyazaki, An. sineroides Yamada, and An. 

lesteri Baisas and Hu. In 2013, Imanishi15 recorded for 

the first time An. belenrae Rueda from Hokkaido, Japan. 

Anopheles pullus and An. kleini Rueda, the primary malaria vectors in South Korea, have never been collected 

in Japan.16 Known and potential vectors of malaria in 

the Hyrcanus Group include An. sinensis, An. lesteri, An. 

belenrae, An. kleini, and An. pullus.

16

The purpose of our study was to strengthen mosquitoborne disease biosurveillance capability in Japan by acquiring biogeographic vector data from sites identified 

as having taxonomic and ecological importance, thereby 

enhancing the knowledge base associated with potential malaria vectors, and incorporating this information 

as a component of already in-place mosquito surveillance programs, including the Walter Reed Biosystematics Unit’s VectorMap/MosquitoMap, and the US Army 

Public Health Command Regions – North and Pacific 

mosquito surveillance training programs.

Materials and Methods

Mosquito Field Collection and Identification

Specimen collections were conducted from 2006-2013 

from various areas within Kumamoto, Fukuoka, Saga 

and Nagasaki Prefectures, on Kyushu Island, Japan 

(Figure 1). Additional specimens were previously collected by Dr Motoyoshi Mogi from 1984-2005 from 

localities in Saga and Nagasaki Prefectures. These prefectures were selected because the taxonomic records 

Mosquito Biosurveillance on Kyushu Island,

 Japan, with Emphasis on Anopheles

 Hyrcanus Group and Related Species

 (Diptera: Culicidae)

Leopoldo M. Rueda, PhD Yukiko Higa, PhD

Benedict Pagac, BS Kyoko Futami, PhD

Masashiro Iwakami, BS Nozomi Imanishi, MS

Alexandra R. Spring, MS MAJ Lewis S. Long, MS, USA

Maysa T. Motoki, PhD COL Mustapha Debboun, MS, USA

James E. Pecor, BS

Abstract

This report includes the distribution records of the Anopheles (Anopheles) Hyrcanus Group and associated species in Kyushu Island, Japan, based on our field collections from various localities of 4 prefectures (Fukuoka, 

Kumamoto, Nagasaki, Saga), primarily from 2002-2013. The status of common and potential mosquito vectors, 

particularly Anopheles species, in Japan are noted.
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

for the Anopheles Hyrcanus Group were unclear or 

had conflicting information regarding previously 

reported and described species from this region. 

The Hyrcanus Group includes all known malaria 

vector species in Japan5,14 and it is essential to 

clarify the taxonomy of the group, including geographic distribution records of the group species. 

The mosquito taxonomic classification used in this 

paper follows that of Knight and Stone.19

Depending on the habitats (rice paddies, irrigation 

ditches, permanent and temporary pools, other 

standing water areas (Figures 2 and 3)), larvae 

were collected using a standard larval dipper (350 

ml, 13 cm diameter) or a white plastic larval tray 

(25×20×4 cm) (BioQuip, Rancho Dominguez, CA). 

Each habitat within a location was surveyed for 

up to one hour or until about 100 larvae were collected. The latitude and longitude of each location 

was recorded using a hand-held global positioning 

system (GPS) unit (Garmin International, Olathe, 

KS) set to the WGS84 datum. Sampling locations 

were photographed using a digital camera to assist 

in verifying the accuracy of the habitat description. 

MOSQUITO BIOSURVEILLANCE ON KYUSHU ISLAND, JAPAN, WITH EMPHASIS ON

ANOPHELES HYRCANUS GROUP AND RELATED SPECIES (DIPTERA: CULICIDAE)

33.9

33.4

32.9

32.4

31.9

31.4

30.9

128.5 129 129.5 130 130.5 131 131.5 132

Longitude (degrees)

Latitude (degrees)

Figure 1. Mosquito collection sites on Kyushu Island (right) and Fukue Island (left), Japan.

Figure 2. Larval habitats of Anopheles (Anopheles) species in the Nagasaki Prefecture, Kyushu Island: (A) rice paddies with terraces, with closeup of rice seedlings; (B) rice paddy, with closeup of rhizobium rice plants; (C) irrigation ditch; (D) drainage ditch, 

partially covered by dried grasses (Fukue Island); (E) water well.

A B C

D E
July – September 2014 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

Collected larvae were placed in plastic Whirl-Pak bags 

(118 ml, 8×18 cm) (BioQuip, Rancho Dominguez, CA) 

and filled approximately 1⁄2 full with water from the collection site. The Whirl-Pak was then tightly closed to 

retain air, placed in a cooler, and brought to the laboratory where the larvae were directly preserved in 100% 

ethanol for molecular identification. The remaining 

larvae were individually link-reared to adult stage, as 

morphological voucher specimens for this work (Figure 

4). Emergent adults were pinned on paper points, each 

given a unique collection number, and identified using 

diagnostic morphological characters (Figure 5).

DNA Isolation and Sequencing

For molecular species identification, DNA was isolated 

from individual larvae, pupae, and adults (1 or 2 legs 

per adult) by phenol-chloroform extraction, and the PCR 

amplification protocol, cycling conditions, and direct sequencing were carried out using standard protocol.17 A 

fragment of rDNA ITS2 was amplified using the primers 5.8S (5’-ATCACTCGGCTCGTGGATCG-3’) and 

28S (5’-ATGCTTAAATTTAGGGGGTAGTC-3’).18 The 

PCR products were directly sequenced using Big Dye 

3.0 (Applied Biosystems, Inc (ABI), Foster, CA) with 

an ABI 3100 sequencer. Sequences were edited using 

Sequencher (V4.8, Gene Codes Corporation, Ann Arbor, 

MI) and aligned in Clustal X.Sequences of An. Hyrcanus Group species (An.sinensis, An. lesteri) are those of 

previous studies using the primers therein.17,18 Voucher 

specimens and collection records will be deposited 

in the US National Museum of Natural History (USNMNH) of the Smithsonian Institution, Suitland, MD.

Results

The summary of collection localities and larval habitats 

for Anopheles species (primarily An. sinensis and An. 

lesteri) from 4 prefectures (Fukuoka, Kumamoto, Nagasaki, Saga) of Kyushu Island, Japan, are presented in 

the Table (page 18). The map of Kyushu, with collection sites of mosquitoes, is shown in Figure 1. Prior to 

2013, larvae of An. sinensis were collected from various 

habitats either alone or in association with the following 

Aedes or Culex species: Cx. (Culex) tritaeniorhynchus 

Giles larvae (in rice fields, irrigation ditches, marsh and 

drainage areas, ground pits or depressions) in Nagasaki 

and Kumamoto Prefectures. Aside from An. sinensis, no 

Anopheles species were collected from any larval habitats in association with Aedes or Culex species. In 2013, 

A B C

D E

Figure 3. Larval habitats of Anopheles (Anopheles) species on Kyushu Island: (A) stream margin with small pool (arrow) (Kumamoto Prefecture); (B) stream margin with small water pockets (arrow) (Kumamoto Prefecture); (C) river margin with water pockets 

(arrow) (Yatsushiro, Kumamoto Prefecture); (D) lotus field (Nagasaki Prefecture); (E) hill or road side ditch with water lilies and 

grasses (Nagasaki Prefecture).
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

MOSQUITO BIOSURVEILLANCE ON KYUSHU ISLAND, JAPAN, WITH EMPHASIS ON

ANOPHELES HYRCANUS GROUP AND RELATED SPECIES (DIPTERA: CULICIDAE)

A B

C D

Figure 4. (A) Emergence plastic vials for rearing mosquito larvae and pupae. (B) Newly emerged adult male Anopheles mosquito. 

(C) Collected Anopheles Hyrcanus Group larvae showing diverse morphology. (D) Anopheles Hyrcanus Group larva, fourth instar, 

dorsal view.

Figure 5. (A) Pinned adult mosquito specimens for deposition in the WRBU, Smithsonian Institution, National Mosquito Collections. (B) Pinned adult female of 

Anopheles belenrae, lateral view.

A B
July – September 2014 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

other Hyrcanus Group larvae (still to be identified using molecular sequences) were also found in association 

with the following: Cx. (Cux.) tritaeniorhynchus, Cx. 

(Cux.) spp.; Ae. (Finlaya) spp.; Ae. (Ochlerotatus) spp. in 

rice paddies and irrigation ditches in Nagasaki Prefecture (Isahaya, Moriyama, Obama-Unzen, Onakao).

During the 2013 survey of various localities in Kyushu 

Island, the rice paddies where we collected the larvae 

and pupae of Anopheles Hyrcanus Group had water 

pH ranging from 6.68-8.61 (mean, 7.77), millivoltage (175.00-237.00 mV; mean, 215.10) and temperature 

(30.50°C-32.80°C; mean, 32.10°C). Other water habitats 

(irrigation ditches, ponds, stream margin, pools, and 

drainage) that were positive for Anopheles larvae and 

pupae also exhibited variable pH, mV, and temperatures.

Culicine mosquitoes (nonanophelines) collected from 

Kyushu Island in 2013 included Ae. (Fin.) japonicus

(Theobald) from Moriyama and Nagasaki (artificial containers, shrine stone bowls); Ae. (Fin.) togoi (Theobald) 

from Isahaya (pond); Ae. (Ste.) albopictus (Skuse) from 

Moriyama and Nagasaki (artificial containers, drainage 

ditches, shrine stone bowls, tree stumps or holes, temporary seepage); Cx. (Ocu.) bitaeniorhynchus Giles from 

Moriyama (drainage ditches); and Cx. (Cux.) tritaeniorhynchus from Moriyama, Obama-Unzen, Hitoyoshi 

(drainage ditches, irrigation ditches, rice paddies). About 

60 mosquito larvae collected from Nagasaki Prefecture 

could not be identified morphologically, including those 

in Ae. (Finlaya) from Isahaya; Ae. (Ochlerotatus) from 

Nomozaki and Onakao; and Cx. (Culex) from Moriyama, 

Nagasaki, Obama-Unzen, Setoishi, Isahaya, Aikawa, 

and Onakao. Molecular analysis of those unidentified 

larval specimens of Aedes and Culex, together with both 

larvae and adults of An. Hyrcanus Group from 4 prefectures, will be completed in the future.

Comment

Among the Anopheles Hyrcanus Group species, An. pullus, An. sinensis, An. lesteri, An. kleini, and An. belenrae

are known or potential vectors of vivax malaria in the 

Korean peninsula and other countries. Anopheles sinensis is the most common anopheline species in Japan, including the Ryukyu Islands.14 It has long been suspected 

as the most important vector of malaria in Japan, including Okinawa and Hokkaido. Even though indigenous 

malaria has disappeared, this vector remains abundant 

throughout Japan. It is a known vector of malaria in 

South Korea and China, and it has a wide distribution in 

Asia.4,5,8-10,14,20 Anopheles lesteri (=anthropophagus) is a 

very important vector of malaria in China. To clarify 

and stabilize the taxon, Rueda and others6 designated 

and described the neotype and alloneotype of An. lesteri. 

This species was suspected to be an important vector of 

indigenous malaria in Japan, particularly in Hokkaido 

where it commonly occurs in great numbers. It is also 

common in the Ryukyu Islands and has been found more 

frequently in coastal regions in Honshu and Kyushu.14

Anopheles yatsushiroensis is not known as a vector of indigenous malaria in Japan. Anopheles belenrae (Figure 

4B), first recorded in Japan in 2013 from Hokkaido,15 is a 

potential vector of vivax malaria in Korea.21 Plasmodium 

berghei Vincke and Lips, a nonhuman specific parasite, 

was first detected from An. belenrae adults in South 

Korea.22 The morphological details of the head, thorax, 

abdomen, wings, and legs of An. belenrae are shown 

in the Walter Reed Biosystematics Unit’s website.* The 

other Hyrcanus Group species (ie, An. sineroides and An. 

engarensis), as well as several Anopheles (Anopheles) 

species (An. bengalensis Puri; An. koreicus Yamada and 

Watanabe; An. lewisi Ludlow; An. lindsayi japonicus Yamada; An. omorii Sakakibara; An. saperoi Bohart and 

Ingram; An. yaeyamaensis Somboon and Harbach), are 

not known vectors of indigenous malaria in Japan.

Most mosquito collections, including Anopheles species, noted by Tanaka and others 14 in 1979, are presently 

deposited at the National Institute of Infectious Diseases (NIID), Tokyo, Japan, where most of the Hyrcanus 

Group species were examined by author L. M. Rueda 

during his visit in 2006. In a recent conversation with 

the authors, Dr Kyoko Sawabe mentioned that there are 

some possible specimens of An. yatsushiroensis collected by Dr M. Otsuru in 1951 and 1964 on Kyushu Island 

now deposited at the NIID, Tokyo. These specimens 

should be examined for further morphological and molecular analysis to clarify the existence of this species. 

In 2003, Dr Motoyoshi Mogi inquired to check the type 

specimens of An. yatsushiroensis from the Department 

of Parasitology (DP), Faculty of Medicine, Kyushu University, Fukuoka, Kyushu (reported as the depository of 

An. yasushiroensis types by Miyazaki12 in 1951). However, Professor Isao Tada (former director of the DP) informed Dr Mogi that no type specimens existed at the 

DP. It may be useful to designate neotypes for An. yatsushiroensis, if it is proven as a valid species.

Although previous researchers considered An. yatsushiroensis as a synonym of An. pullus, they used Korean 

specimens to obtain their molecular and morphological 

data.23,24 However, because the type locality of An. yatsushiroensis is in Japan, it is necessary to do a genetic 

comparison of An. pullus from South Korea with the 

topotypic specimens from Japan to resolve definitively 

if the two are synonyms or not. In 1951, Miyazaki,12 who 

*http://www.wrbu.org/SpeciesPages_ANO/ANO_A-det/ANbln_Adet.html
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

first described An. yatsushiroensis, provided elaborate 

morphological descriptions, ecology, and distributions 

of this species. We did not collect An. pullus during our 

previous collections from 2002-2008 in Japan, and no 

report indicates the existence of An. pullus in that country. Furthermore, An. pullus is considered a major vector of vivax malaria in the Korean peninsula.16 Through 

biosurveillance, it is also interesting to investigate if another major Korean malaria vector, An. kleini, is present 

in Japan.

In our attempt to recollect specimens of the Hyrcanus 

Group, particularly An. yatsushiroensis, we recently visited numerous localities and conducted extensive larval 

collections at various habitats in Nagasaki Prefecture 

and Kumamoto Prefecture (including Yatsushiro City, 

the type locality of An. yatsushiroensis reported by Miyazaki12 ) and neighboring areas from 2006 to 2013. Unfortunately, we were not able to collect samples of An. 

yatsushiroensis from 2006 to 2012.

Although Dr Sawabe mentioned that there are some possible specimens of An. yatsushiroensis deposited at the 

NIID, Tokyo, we have not examined them yet. Furthermore, more than 200 larvae and adults of An. Hyrcanus 

Group collected in 2013 from Kumamoto and Nagasaki 

Prefectures are still being examined and analyzed by 

morphological and molecular techniques. Molecular 

data (PCR, sequences) will be reported later, particularly from the 2013 specimens for possible presence of 

An. yatsushiroensis and other species in An. Hyrcanus 

Group on Kyushu Island.

Acknowledgement

This research was performed under a Memorandum of 

Understanding between the Walter Reed Army Institute of Research and the Smithsonian Institution, with 

institutional support provided by both organizations.

We express our sincere appreciation to the following: Dr Motoyoshi Mogi for arranging the visits of Dr 

Rueda to Saga and Fukuoka Prefectures, his help in 

mosquito collections, and for sharing his mosquito 

specimens; CPT Robert Moore and SGT J. Santano 

for their help in collecting mosquito samples from Kumamoto Prefecture; Professor Y. Oneda, for his help 

in collecting samples and guiding us in locating larval 

habitats in Akagawa and Takegima, Fukuoka Prefecture and Tosu City, Saga Prefecture. Special thanks go 

to Dr Noburo Minakawa, particularly for making the 

arrangements for our visit to Nagasaki, and Dr Kyoko 

Sawabe for correspondence and invitation to visit and 

examine the mosquito collections at NIID, Tokyo.

References

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Republic of South Korea. Zootaxa. 2005;941:1-26.

2. Ramsdale CD. Internal taxonomy of the Hyrcanus 

Group of Anopheles (Diptera: Culicidae) and its 

bearing on the incrimination of vectors of malaria in the west of the Palearctic Region. European 

Mosq Bull. 2001;10:1-8.

3. Harbach RE. The classification of genus Anopheles (Diptera: Culicidae): a working hypothesis 

of phylogenetic relationships. Bull Entomol Res.

2004;94:537-553.

4. Hii J, Rueda LM. Malaria vectors in the Greater 

Mekong Subregion: overview of malaria vectors and remaining challenges. Southeast Asian J 

Trop Med Public Health. 2013;44(suppl 1):73-165, 

306-307.

5. Rueda LM, Iwakama M, O’Guinn M, Mogi M, 

Prendergast BF, Miyagi I, Toma T, Pecor JE, Wilkerson RC. Habitats and distribution of Anopheles 

sinensis and associated Hyrcanus Group in Japan. J 

Am Mosq Control Assoc. 2005;21(4):458-463.

6. Rueda LM, Wilkerson RC, Li C. Anopheles 

(Anopheles) lesteri Baisas and Hu (Diptera: Culicidae): neotype designation and description. Proc 

Entomol Soc Washington. 2005;107(3):604-622.

7. Rueda LM, Ma Y, Song GH, Gao Q. Notes on the 

distribution of Anopheles (Anopheles) sinensis Wiedemann (Diptera: Culicidae) in China and the status of some Anopheles Hyrcanus Group type specimens from China. Proc Entomol Soc Washington. 

2005;107(1):235-238.

8. Rueda LM, Kim HC, Klein TA, Pecor JE, Li 

C, Sithiprasasna R, Debboun M, Wilkerson RC. 

Distribution and larval habitat characteristics of 

Anopheles Hyrcanus Group and related mosquito 

species (Diptera: Culicidae) in South Korea. J Vector Ecol. 2006;31(1):199-206.

9. Rueda LM, Zhao T, Ma YJ, Gao Q, Guo Ding Z, 

Khuntirat B, Sattabongkot J, Wilkerson RC. Updated distribution records of the Anopheles (Anopheles) hyrcanus species-group (Diptera: Culicidae) 

in China. Zootaxa. 2007;1407:43-55.

10. Rueda LM, Gao Q. New records of Anopheles 

belenrae Rueda (Diptera: Culicidae) in North Korea. Proc Entomol Soc Wash. 2008;110:523-524.

11. Miyake M. Study on the anopheline mosquitoes in 

Kyushu. Hukuoka Acta Med. 1950;41:918-927.

12. Miyazaki I. On a new anopheline mosquito Anopheles yatsushiroensis n. sp. found in Kyushu, with 

some remarks on two related species of the genus. 

Kyushu Mem Med Sci. 1951;2:195-206.

MOSQUITO BIOSURVEILLANCE ON KYUSHU ISLAND, JAPAN, WITH EMPHASIS ON

ANOPHELES HYRCANUS GROUP AND RELATED SPECIES (DIPTERA: CULICIDAE)
July – September 2014 17

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13. Otsuru M, Ohmori Y. Malaria studies in Japan after World War II. Part II. The search for Anopheles 

sinensis sibling species group. Japan J Exp Med. 

1960;30:33-65.

14. Tanaka K, Mizusawa K, Saugstad ES. A revision 

of the adult and larval mosquitoes of Japan (including the Ryukyu Archipelago and the Ogasawara 

Islands) and Korea (Diptera: Culicidae). In: Contributions of the American Entomological Institute. 

Vol 16. Gainesville, Florida: American Entomological Institute; 1979:1-987.

15. Imanishi N. Morphological and Phylogenetic 

Study of Anopheles belenrae First Recorded from 

Hokkaido, Japan [master’s thesis]. Kanagawa, Japan: Meiji University; 2013.

16. Klein TA, Kim HC, Lee WJ, Rueda LM, et al. Reemergence, persistence and surveillance of vivax 

malaria and its vectors in the Republic of Korea. 

In: Robinson WK, Bajoni D, eds, Proceedings of 

the Sixth International Conference on Urban Pests,

Budapest, Hungary. 2008. 325-331. Available at:

http://www.icup.org.uk/reports/ICUP892.pdf. Accessed May 7, 2014.

17. Wilkerson RC, Li C, Rueda LM, Kim HC, Klein 

TA, Song GH, Strickman D. Molecular confirmation of Anopheles (Anopheles) lesteri from the Republic of South Korea and its genetic identity with 

An. (Ano.) anthropophagus from China (Diptera: 

Culicidae). Zootaxa. 2003;378:1-14.

18. Li C, Lee JS, Groebner JL, Kim HC, Klein TA, 

O’Guinn ML, Wilkerson RC. A newly recognized 

species in the Anopheles Hyrcanus Group and molecular identification of related species from the 

Republic of South Korea (Diptera: Culicidae). Zootaxa. 2005;939:1-8.

19. Knight K, Stone A. A Catalog of the Mosquitoes 

of the World (Diptera: Culicidae). Vol 6. College 

Park, Maryland: Entomological Society of America; 1977.

20. Harrison BA, Scanlon JE. Medical entomology 

studies – II. The subgenus Anopheles in Thailand (Diptera: Culicidae). In: Contributions of the 

American Entomological Institute. Vol 12, No. 1. 

Gainesville, Florida: American Entomological Institute; 1979:1-307.

21. Rueda LM, Li C, Kim HC, Klein TA, Foley DH, 

Wilkerson RC. Anopheles belenrae, a potential 

vector of Plasmodium vivax in the Republic of Korea. J Am Mosq Control Assoc. 2010;26(4):430-432.

22. Harrison GF, Foley DH, Rueda LM, et al. Plasmodium-specific molecular assays produce uninterpretable results and non-Plasmodium spp. sequences in field-collected Anopheles vectors. Am J Trop 

Med Hyg. 2013;89(6):1117-1121.

23. Hwang UW, Yong TS, Ree HI. Molecular evidence for synonymy of Anopheles yatsushiroensis and An. pullus. J Am Mosq Control Assoc.

2004;20(2):99-104.

24. Shin EH. Hong HK. A new synonym of Anopheles 

(Anopheles) pullus Yamada, 1937: A. (A.) yatsushiroensis Miyazaki, 1951. Kor J Entomol. 2001;31:1-5.

Authors

Dr Rueda is a Research Entomologist, Principal Investigator, and Acting 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.

Mr Benedict Pagac is the Chief, Entomology Section at 

the US Army Public Health Command Region-North, 

Fort George G. Meade, Maryland.

Mr Iwakami is an Entomologist at the US Army Public 

Health Command-Pacific, Entomology Program. Camp 

Zama, Japan.

Ms Spring is a Molecular Biologist at the Entomology 

Section, US Army Public Health Command RegionNorth, Fort George G. Meade, Maryland.

Dr Motoki is a Postdoctoral Entomologist at the Entomology Department, Smithsonian Institution, Museum 

Support Center, Suitland, Maryland.

Mr Pecor is a Museum Specialist at the Walter Reed 

Biosystematics Unit, Entomology Branch, Walter Reed 

Army Institute of Research, located at the Smithsonian 

Institution, Museum Support Center, Suitland, Maryland.

Dr Higa, Dr Futami, and Ms Imanishi are Assistant Professors and Graduate Student, respectively, at the Department of Vector Ecology and Environment, Institute 

of Tropical Medicine (NEKKEN), Nagasaki University, 

Nagasaki City, Nagasaki, Japan.

MAJ Long is currently on training leave from his position as 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.

COL Debboun is the Chief of the Department of Preventive Health Services, Academy of Health Sciences, US 

Army Medical Department Center & School, Fort Sam 

Houston, Texas. He is also the Chairman of the Army 

Medical Department Journal Editorial Review Board.
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

MOSQUITO BIOSURVEILLANCE ON KYUSHU ISLAND, JAPAN, WITH EMPHASIS ON

ANOPHELES HYRCANUS GROUP AND RELATED SPECIES (DIPTERA: CULICIDAE)

Summary of collection localities and larval habitats for Anopheles (Anophleles) in 4 prefectures of Kyushu Island, Japan (part 1 of 3).

Prefecture Location Grid coordinates Collection date Stage Collector Habitat

typeb

Collection

No.

Anopheles

(Anopheles) Species

Fukuoka Akagawa, Ogori City 33.34975N/130.51352E 19-20 Sep 2008 Adulta L. M. Rueda, Y. Oneda RC JP08-9 sinensis Fukuoka Takejima, Yasutake- mache, Kurume 33.34975N/130.54597E 19-20 Sep 2008 Adulta L. M. Rueda, Y. Oneda RC KP08-10 sinensis 

Kumamoto Amitsu, Uto City 32.69973N/130.60432E 23 Sep 2008 Adulta L. M. Rueda, M. Iwakami, J. Santano ID, RP JP08-17, 18 sinensis Kumamoto Gyokuto City, Tamana County 32.91638N/130.62565E 22 Sep 2008 Adulta L. M. Rueda, M. Iwakami, J. Santano PO JP08-14 sinensis Kumamoto Hitoyoshi 32.22652N/130.77038E 12 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami ID, RH, RP JP13-19, 21 Hyrcanus GroupcKumamoto Kato shrine, Yatsushiro 32.47998N/130.57202E 15 Sep 2008 Adulta L. M. Rueda, M. Iwakami, J. Santano DD JP08-2 lesteri Kumamoto Lake Ezu 32.77755N/130.73855E 24 Sep 2008 Adult L. M. Rueda, M. Iwakami, J. Santano LM JP08-19 sinensis Kumamoto Matsubase, Uki City 32.65355N/130.67050E 30 Aug 2006 Adulta M. Iwakami, R. Moore RP JP06-2-37A, 40A lesteri Kumamoto Matsubase, Uki City 32.65625N/130.66788E 17 Sep 2008 Adulta L. M. Rueda, M. Iwakami, J. Santano RP JP08-7, 8 lesteri Kumamoto Matsubase, Uki City 32.65355N/130.67050E 30 Aug 2006 Adulta M. Iwakami, R. Moore RP

JP06-2-1A, 2A, 3A, 

JP08-5, 6

4A, 6A, 25A; sinensis 

Kumamoto Sumiyoshi, Uto City 32.70005N/130.60015E 22 Sep 2008 Adulta L. M. Rueda, M. Iwakami, J. Santano ID JP08-17B sinensis Kumamoto Takasima, Yatsushiro 32.52158N/130.57750E 15 Sep 2008 Adulta L. M. Rueda, M. Iwakami, J. Santano HD, WT JP08-1, 4 lesteri Kumamoto Tamana City, Tamana County 32.91638N/130.54523E 22 Sep 2008 Adulta L. M. Rueda, M. Iwakami, J. Santano RP JP08-15, 16 sinensis Kumamoto Ueki City 32.88017N/130.68148E 22 Sep 2008 Adulta L. M. Rueda, M. Iwakami, J. Santano ID, RP JP08-12, 13 lesteri Kumamoto Uto 32.69660N/130.66845E 29 Aug 2006 Adulta M. Iwakami, R. Moore RP JP06-1-50A, 51A lesteri Kumamoto Uto 32.69660N/130.66845E 29 Aug 2006 Adulta M. Iwakami, R. Moore RP JP06-1-1A, 2A, 3A, 4A, 5A, 7A, 16A sinensis Kumamoto Yatsushiro 32.50033N/130.61932E 11 Jul 2013 Larva, pupa, adulta L. M. Rueda, B. Pagac, M. Iwakami SP JP13-18 Hyrcanus GroupcKumamoto Yatsushiro 32.52158N/130.57750E 16 Sep 2008 Adulta L. M. Rueda, M. Iwakami, J. Santano RP JP08-3 sinensis 

Nagasaki Ariake-cho, Nagasaki 32.69414N/130.32505E 20 Jul 1988 Adulta RC JPM-5 sinensis Nagasaki Goto, Fukue Island 32.67867N/128.76802E 17 Jul 2013 Larva, pupa L. M. Rueda, B. Pagac, M. Iwakami ID JP13-31 Hyrcanus Groupc

Nagasaki Goto, Fukue Island 32.67867N/128.76802E 17 Jul 2013 Larva L. M. Rueda, B. Pagac, 

M. Iwakami

RP JP13-30 Hyrcanus Groupc

aField collected larvae or pupae, reared to emerged adults.

b

pool; WT, water tank, trough or PVC tube waterer.

DD, drainage ditch; HD, hill or road side ditch; ID, irrigation ditch; LM, lake margin; PO, pond; RC, resting at cowshed or cattle barn; RH, rock hole, pool; RP, rice paddy; SP, stream or river margin or 

cDNA isolation and sequencing still to be completed.
July – September 2014 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

Summary of collection localities and larval habitats for Anopheles (Anophleles) in 4 prefectures of Kyushu Island, Japan (part 2 of 3).

Prefecture Location Grid coordinates Collection date Stage Collectorb Habitat

typec

Collection

No.

Anopheles

(Anopheles) Species

Nagasaki Goto, Fukue Island 32.67867N/128.76802E 17 Jul 2013 Adulta L. M. Rueda, B. Pagac, M. Iwakami RP JP13-30 Hyrcanus GroupdNagasaki Goto, Fukue Island 32.67867N/128.76802E 17 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-32 Hyrcanus GroupdNagasaki Goto, Fukue Island 32.67867N/128.76802E 17 Jul 2013 Adulta L. M. Rueda, B. Pagac, M. Iwakami RP JP13-32 Hyrcanus GroupdNagasaki Isahaya 32.81308N/130.12767E 12 Jul 2013 Adulta NG1 PO JP13-23 Hyrcanus GroupdNagasaki Isahaya 32.81308N/130.12767E 12 Jul 2013 Larva NG1 PO JP13-23 Hyrcanus GroupdNagasaki Isahaya 32.81308N/130.12767E 12 Jul 2013 Larva NG1 RP JP13-25 Hyrcanus GroupdNagasaki

Isahaya-shi, 

Kamiimuta, 

Moriyama-cho

32.80759N/130.10737E 27 May 2006 Adult T. Yoshio - JPM-5 sinensis 

Nagasaki Mikawa-machi 32.78590N/129.88779E 27 May 1962 Adult NU - JPM-5 sinensis Nagasaki Moriyama 32.83508N/130.11372E 9 Jul 2013 Adulta L. M. Rueda, B. Pagac, M. Iwakami RP JP13-7 Hyrcanus GroupdNagasaki Moriyama 32.83508N/130.11372E 9 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-8 Hyrcanus GroupdNagasaki Nagasaki 32.77217N/129.86950E 20 Jun 1989 Adult M. Mogi RP JPM-5 sinensis Nagasaki Nomozaki 32.58570N/129.75660E 15 Jul 2013 Larva NG2 AC JP13-26 Hyrcanus GroupdNagasaki Obama-Unzen 32.71354N/130.20073E 10 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-14 Hyrcanus GroupdNagasaki Obama-Unzen 32.71354N/130.20073E 10 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-15 Hyrcanus GroupdNagasaki Obama-Unzen 32.71354N/130.20073E 10 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami WC JP13-16 Hyrcanus GroupdNagasaki Obama-Unzen 32.71354N/130.20073E 10 Jul 2013 Adulta L. M. Rueda, B. Pagac, M. Iwakami WC JP13-16 Hyrcanus GroupdNagasaki Onako 32.88408N/129.69598E 16 Jul 2013 Larva NG2 RP JP13-29 Hyrcanus GroupdNagasaki Togitsu 32.82683N/129.84866E 7-9 Aug 1956; 22 Jul 1962 Adult NU - JPM-5 sinensis Nagasaki Tsushima 34.17745N/129.29039E 27 May 1962 Adult NU - JPM-5 sinensis Nagasaki Utzutzugawa 32.79328N/129.92803E 9 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-13 lindsayi japonicusNagasaki Utzutzugawa 32.79328N/129.92803E 9 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-13 Hyrcanus Groupd

Saga Fukutomi 33.17567N/130.17284E

13, 20, 28 Aug 

2005; 11, 13, 

24 Sep 2005; 

10 Oct 2005;

Adult M. Mogi LF JPM-22-1 sinensis 

aField collected larvae or pupae, reared to emerged adults.

bNG1 indicates L. M. Rueda, B. Pagac, M. Iwakami, Y. Higa, K. Futami, N. Imanishi. NU indicates Nagasaki University, Entomology Collection. NG2 indicates L. M. Rueda, B. Pagac, M. Iwakami,

Y. Higa, K. Futami.

cAC, artificial containers (tires, plastic jugs, kettle, etc); CA, road ditch or small canal; ID, irrigation ditch; LF, lotus field; PO, pond; RP, rice paddy; WC, water well/cistern.dDNA isolation and sequencing still to be completed.
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

MOSQUITO BIOSURVEILLANCE ON KYUSHU ISLAND, JAPAN, WITH EMPHASIS ON

ANOPHELES HYRCANUS GROUP AND RELATED SPECIES (DIPTERA: CULICIDAE)

Summary of collection localities and larval habitats for Anopheles (Anophleles) in 4 prefectures of Kyushu Island, Japan

(part 3 of 3).

Prefecture Location Grid

Coordinates

Collection date Stage Collector Habitat

typeb

Collection

No.

Anopheles

(Anopheles) Species

Saga Kase 33.23807N

130.25824E 17 Sep 2005 Adult M. Mogi ID JPM-21-1, -2, -3 sinensis 

Saga Kinyu 33.24204N

130.29149E

2, 5, 10

Jun 1986 Adult M. Mogi RP JPM-8, 9 lesteri 

Saga Morita 33.09454N

130.10894E 16 May 1995 Adult M. Mogi CA JPM-14 sinensis 

Saga Nabeshima 33.27991N

130.26614E

30 May 1985; 

14 Jun 1985; 

3, 5, 6, 7, 20 

Jun 1986;

9 Jun 1990;

7 Jun 1995;

3 Jun 1996

Adult M. Mogi LF JPM-4, 5, 6, 7 lesteri 

Saga Shiroishi 33.17837N

130.14394E 7 May 2000 Adult M. Mogi RP JPM-19-1 lesteri 

Saga Shiroishi 33.17837N

130.14394E

3 Nov 1997;

7 May 2000 Adult M. Mogi NE

JPM-14, 15, 

19-2, 19-3,

19-5, 19-5

sinensis 

Saga Yamato-cho 33.14766N

130.14832E 10 Apr 2000 Adult T. Sunahara CA JPM-18 lesteri 

Saga Yamato-cho 33.14766N

130.14832E

5 Jun 1986; 

24, 25, 26 Apr 

2000; 10, 11, 

12, 25 May 

2000; 24, 25 

Apr 2004

Adult T. Sunahara,

M. Mogi CA JPM-8, 15, 16, 17, 18 sinensis 

Saga Tosu City 33.34463N

130.51352E 20 Sep 2008 Adulta L. M. Rueda,Y. Oneda GT JP08-11 lesteri 

aField collected larvae or pupae, reared to emerged adults.

bCA, road ditch or small canal; GT, ground pit or depression; ID, irrigation ditch; LF, lotus field; NE, caught by insect net; RP, rice paddy.

Articles published in the Army Medical Department Journal are indexed in 

MEDLINE, the National Library of Medicine’s (NLM’s) bibliographic database 

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database ensures that citations to AMEDD Journal content will be identified 

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July – September 2014 21

Vector-borne diseases remain a significant cause of disease for US service members throughout the US European Command, Africa Command, and Central Command, thereby requiring strong surveillance systems 

and outbreak responses.1 There is a need for surveillance or reference laboratories to perform standardized, 

high-throughput testing capable of meeting the needs of 

a changing military environment and response efforts. 

An understanding of the significance and location of 

pathogens is important in the development of prevention 

programs for human and animals, as well as pest-control 

activities. Although there are numerous tests to detect 

arthropod-borne diseases, polymerase chain reaction 

(PCR) assays offer both high sensitivity and specificity 

for either DNA or RNA recovered from field-collected 

arthropod samples.2-4 The use of real-time PCR assays 

offers not only the option of high-throughput testing in 

an otherwise time and labor intensive procedure, but 

also removes the need for any postamplification processing (ie, agarose gel electrophoresis). This study 

describes the development, validation, and standardization of real-time PCR and reverse transcription realtime PCR assays to detect Anaplasma phagocytophilum, 

Ehrlichia spp, Borrelia spp (B burgdorferi, B afzelii, 

and B garinii), Crimean-Congo hemorrhagic fever virus, Leishmania, sandfly fever Sicilian virus, dengue virus, Plasmodium spp, and chikungunya virus at the US 

Army Public Health Command Region-Europe.

Materials and Methods

At the time of this writing, all methods discussed in the 

article are accredited by the American Association for 

Laboratory Accreditation and placed on Laboratory Sciences’ ISO/IEC 17025:2005 Biological Scope of Accreditation (certificate number 2138.01). USAPHCR-Europe 

LS is registered by Bureau Veritas under the DIN EN 

ISO 9001:2008 Quality Management System standard 

(certificate number DE002197-1) and the DIN EN ISO 

14001:2009 Environmental Management System standard (certificate number DE002198-1).

Homogenization of Arthropods

Negative mosquitoes, sandflies (obtained from the Walter Reed Army Institute of Research, Silver Spring, 

MD), and larvae, nymph, and adult ticks (Bayer HealthCare AG: Animal Health, Germany) were stored in 

High-Throughput Vector-Borne Disease

 Environmental Surveillance By Polymerase

 Chain Reaction According To International

 Accreditation Requirements

Marty K. Soehnlen, PhD, MPH* SPC Carlos J. Gomez, USA

CPT Stephen L. Crimmins, MS, USA* Michael E. Cross, MS

Andrew S. Clugston, MS Charles N. Statham, PhD

Nina Gruhn, MS

Abstract

Although vector-borne diseases are specific to the region of the host, there is a necessity for surveillance or reference 

laboratories to perform standardized, high-throughput testing capable of meeting the needs of a changing military 

environment and response efforts. The development of standardized, high-throughput, semiquantitative real-time 

and reverse transcription real-time polymerase chain reaction (PCR) methods allows for the timely dissemination of 

data to interested parties while providing a platform in which long-term sample storage is possible for the testing of 

new pathogens of interest using a historical perspective. PCR testing allows for the analysis of multiple pathogens 

from the same sample, thus reducing the workload of entomologists in the field and increasing the ability to determine if a pathogen has spread beyond traditionally defined locations. US Army Public Health Command RegionEurope (USAPHCR-Europe) Laboratory Sciences (LS) has standardized tests for 9 pathogens at multiple life stages. 

All tests are currently under international accreditation standards. Using these PCR methods and laboratory model, 

which have universal Department of Defense application, the USAPHCR-Europe LS will generate quality data that 

is scientifically sound and legally defensible to support force health protection for the US military in both deployed 

and garrison environments.

*Dr Soehnlen and CPT Crimmins contributed equally to first authorship of this article.
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

70% ethanol at -80°C. Samples were transferred to 

1.5 mL round-bottom tubes (DNA LoBind, Eppendorf 

AG, Hamburg, Germany) with 400 μL phosphate buffered saline (Sigma-Aldrich, St. Louis, MO). A total 

of 5 mosquitoes or sandflies were added to tubes and 

crushed with a micropestle (Kimble Chase, NJ). One 

tick, regardless of life-stage, was added to each tube 

and crushed with a micropestle. One 5-mm tungsten 

carbide bead (Qiagen, Netherlands) was added to each 

tube. Samples were homogenized using the TissueLyser 

system (Qiagen, Netherlands) for 10 minutes at 20 Hz. 

After a short centrifugation step of 20 to 60 seconds at 

9,000 rpm, 200 μL of the supernatants were collected 

and transferred to sample processing cartridges or new 

1.5 mL round-bottom tubes.

Automated Nucleic Acid Extraction

Automated nucleic acid extraction was performed using 

the MagNA Pure96 (Roche Applied Sciences, Germany) and the MagNA Pure LC (Roche Applied Sciences, 

Germany). A total of 200 μL of arthropod homogenate 

supernatant was added to 300 μL of external lysis buffer for the MagNA Pure LC using MagNA Pure LC 

small volume total nucleic acid kit with the External 

Lysis Protocol (Roche Applied Sciences, Germany) according to manufacturer instructions. A total of 200 μL 

arthropod homogenate supernatant was extracted using 

MagNA Pure96 DNA and viral NA small volume kit 

with the Universal Pathogen Protocol. A total volume of 

50 μL nucleic acid was acquired from samples on both 

automated extraction instruments. Isolated total nucleic 

acids were stored at -20°C or below until PCR analysis 

was performed.

DNA and RNA Absorbance Analysis

The 260/280 ratio, 230 nm, and 300 nm results for 2 

μL extracted sample were analyzed using a NanoQuant 

plate (Tecan Group Ltd, Switzerland) on the Mx Pro 

200 microplate reader (Tecan Group Ltd, Switzerland).

Real-Time PCR

Real-time PCR reactions were performed using genesig 

Advanced kit (Primerdesign Ltd, UK) as appropriate 

for the pathogen being tested and 2X One Step qPCR 

Master Mix (Primerdesign Ltd, UK). The real-time PCR 

conditions were: 5 μL of total nucleic acid,10 μL of 2X 

OneStep qPCR Master Mix, one μL of target primer, 

one μL of internal positive control primer, and DNAse/

RNAse free water (Qiagen, Netherlands) to adjust the 

volume to 15 μL. Amplification was performed in LightCycler 480 96-well PCR plates (Roche Applied Sciences, Germany). Plates were sealed with LightCycler 480 

sealing film (Roche Applied Sciences, Germany). The 

cycling conditions for amplification were performed on 

a LightCycler 480 (Roche Applied Sciences, Germany) 

as follows: initial enzyme activation step at 95°C for 10 

minutes, and 40 cycles of 95°C for 10 seconds, 65°C for 

one minute. Melting curve data was collected immediately after cycle 40; one cycle at 60°C for one minute, 

and 95°C (0.06°C/second) for 10 minutes.

Real-Time Reverse Transcription PCR

Real-time reverse transcription PCR reactions were 

performed using genesig Advanced kit and 2X One 

Step qRT-PCR Master Mix. The real-time reverse transcription PCR conditions were as follows: 5 μL of total 

nucleic acid, 10 μL of 2X One Step qRT-PCR Master 

Mix, one μL of target primer, one μL of internal positive 

control primer, and DNAse/RNAse free water to adjust 

the volume to 15 μL. Amplification was performed in 

LightCycler 480 96-well PCR plates. Plates were sealed 

with LightCycler 480 sealing film. The cycling conditions for amplification were performed on a LightCycler 480 as follows: reverse transcription at 55°C for 10 

minutes, enzyme activation step at 95°C for 8 minutes, 

and 40 cycles of 95°C for 10 seconds, 65°C for one minute. Melting curve data was collected immediately after 

cycle 40; one cycle at 60°C for one minute, and 95°C 

(0.06°C/second) for 10 minutes. It should be noted that 

new Master Mix formulas (Precision and PrecisionPLUS) were recently introduced by PrimerDesign and 

have not yet been used by the laboratory. The new consumables will be subjected to the same verification and 

validation procedures presented in this article and in accordance with the LS Quality Management System prior 

to being incorporated into regular use.

Calculations

Method detection limits, defined as the minimum concentration that can be measured and reported with 99% 

confidence that the value determined is above zero, 

were determined as the Student’s t test value at the 99% 

confidence level multiplied by the standard deviation of 

the data set.

Results

It was determined that the method detection limit (MDL) 

for the pathogen kits using 5 adult female arthropods 

as the matrix for Plasmodium ssp, dengue fever virus, 

chikungunya virus, Leishmania ssp, and sandfly fever 

Sicilian virus were 97; 2,500; 25,000; 19,000; and 1,300 

copies, respectively. Tick MDLs were determined using 

one tick per each adult, nymph, and larvae life stage. 

Anaplasma phagocytophilum adult, nymph, and larvae 

MDLs were determined to be 6,300; 6,900; and 5,400 

copies, respectively. Ehrlichia spp adult, nymph, and 

larvae MDLs were determined to be 130,000; 240; and 

480 copies, respectively. Borrelia spp adult, nymph, and 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

larvae MDLs were determined to be 28,000; 24,000; 

and 15,000 copies, respectively. Crimean-Congo hemorrhagic fever virus adult, nymph, and larvae MDLs 

were determined to be 14,000; 810; and 6,200 copies, 

respectively. The microplate reader was used to simultaneously verify the success of the extraction procedure and assess the quality of the total nucleic acid 

extract through absorbency spectroscopy. Results indicating unusual or poor overall nucleic acid purity were 

based upon the 260/280 ratio and noted on quality control checklists, however, based upon these results, there 

was no indication of problems processing the samples 

further.

While only a detect or nondetect result was reported for 

samples, quantization of target sequences present in a 

given sample were used to establish decision-making 

criteria, as well as for in-house quality control purposes. 

A dilution curve is established using manufacturer-provided positive controls (Primerdesign Ltd, United Kingdom) and a 10-fold dilution range from 10 to 1.0×106 

copies per sample. Samples containing each of the 6 

represented concentrations were analyzed along with a 

negative sample and appropriate quality assurance controls. Upon run completion, the LightCycler software 

calculated a best-fit polynomial and second derivative 

curve for each amplification curve. The maximum of 

the amplification curve identified the point at which the 

fluorescence curve underwent the most rapid growth increase or “elbow” (Figure 1).5

For samples tested in separate runs, the LightCycler 

software stored the curves for later use. A new curve 

was established for each primer kit, and samples tested 

in subsequent runs were tested along with duplicate 

positive controls spiked with 1.0×104 copies of target. 

Comparison of these standard concentrations with the 

stored curve allowed the software to compensate for discrepancies between runs.

To measure the melting temperature (Tm), a temperature 

program is added to the end of the amplification protocol which briefly cools the samples to 65°C, then slowly 

increases their temperature to 95°C over the course of 

approximately 10 minutes while continuously acquiring 

the fluorescence. The Tm is approximated via software 

by comparing the resulting melting curve to a best-fit 

polynomial, then calculating the negative derivative of 

this curve and identifying its peak. This peak correlates 

with the point at which the fluorescence decrease was 

strongest, which subsequently correlates with the Tm

value (Figure 2).5 Final results were reported as positive 

or detected if the Tm was within 3 standard deviations of 

the clean matrix average Tm value, shown in the Table, 

and the crossing point or inflection point (Cp) was calculated as less than or equal to 35 cycles.

Comment

The vector-borne disease laboratory (VBDL) encountered many challenges in becoming a modern Army 

disease surveillance laboratory. For the purpose of this 

Figure 1. Demonstration of a typical amplification curve 

and the approximate second derivative. Amplification 

plots are used to determine the inflection point associated 

with a detectable rise in nucleic acid product. An inflection point is often referred to as a crossing point (Cp) or 

a crossing threshold (Ct). Fluorescence is represented on 

the Y-axis and is provided in relative fluorescence units. 

The units are directly associated with the strength of signal from a product. A typical product will result in an “S”

shaped curve. The X-axis represents the number of cycles. 

Cycle numbers performed should be optimized to each individual instrument. Generally, the total number of cycles 

will range from 30 to 50. Relative Fluorescence Units

Cycle Number (increasing →)

Second Derivative

(d2F/dT)

Amplification Curve (Fluorescence)

Inflection Point

(2nd Derivative Maximum)

Figure 2. A typical melting temperature (Tm) curve with the 

negative derivative overlaid. This figure is a representation 

of a typical fluorescence curve with the negative derivative 

overlaid. Fluorescence signal is always represented on the 

Y-axis while the temperature is represented on the X-axis. 

Melting temperature values are used to ensure that the 

product is correct based upon the nucleotide base content. As the strands of nucleic acid being to dissociate a 

change in the melting peak or curve will be visualized. Relative Fluorescence Units

Fluorescence Melting Peak

(-dF/dT)

Fluorescence Melting Curve

Increasing Temperature (°C) →
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

article, these problems will be segregated into the following categories: method accreditation, standardization, traceability, staff turnover and training, proficiency 

testing, flexibility, throughput, and safety.

Method Accreditation

One challenge the lab faced is the development of accredited testing methods. The PHCR-Europe VBDL 

decided to use commercially procured, real-time PCR 

testing kits that contained enumerated positive controls. 

Using the quantitative positive controls, the VBDL was 

able to address the accreditation requirements of assessing MDLs. The VBDL assessed these requirements 

through the spiking of known concentrations of positive 

controls into clean, vivarium-raised, whole arthropod 

matrix. The benefit of MDLs is that the lab is able to decrease the possibility of false negative or false positive 

reporting through proper statistical analysis.

Standardization

Assay standardization was an important consideration 

in the design of the laboratory. In order to perform the 

necessary quantitative analysis, 100% of the PCR detection methods were moved to quantitative real-time and 

quantitative reverse transcription real-time PCR using 

standardized commercially available kits. All extractions were automated, and were performed on 32-well 

or 96-well platforms. PCR assays were also moved to a 

standardized 96-well format, thereby reducing operator 

error from format changes at each step.

Traceability

Traceability of consumables is another requirement for 

accreditation. The VBDL designed all methodologies 

around commercially available consumables that may 

be procured from ISO registered or accredited manufacturers. Such procurement enables the VBDL to trace 

the sourcing of materials through a chain of standardized suppliers and thus meet accreditation requirements. 

Within the lab, the traceability of consumables is maintained through the use of quality control checklists and 

integrated instrument barcode readers. Both the checklists and the barcode readers generate a traceable audit trail used to meet accreditation requirements, track 

analysis problems, and provide multiple checkpoints for 

troubleshooting.

Staff Turnover and Training

Staff turnover in a military laboratory is a paramount 

concern. As Soldiers move from assignment to assignment, staff turnover can place stress on trained personnel to meet production demands. The VBDL was designed to streamline and simplify training time so that 

new staff can quickly begin generating quality scientific 

data. Because all current methods for pathogen detection were developed into a single chemistry type, new 

employees will only require training on 2 procedures, 

nucleotide extraction and PCR detection, with minor 

variation to account for nucleic acid type. Robotic instrumentation and high throughput consumable formats 

will assist in maintaining production demands while 

new staff members are trained on laboratory procedures.

Proficiency Testing

A proficiency testing program for the VBDL was another challenge associated with achieving and maintaining laboratory accreditation. Some of the problems 

initially encountered included shipping and transfer of 

pathogens in an appropriate matrix, ability to challenge 

semiquantitative methods, PCR specific rounds, third 

party management of proficiency testing materials, intellectual property rights, and adaptability of the testing 

program to other commands. Due to the exacting requirements for proficiency testing, the VBDL used the 

services of SeraCare Life Sciences (Milford, MA) in the 

creation of custom proficiency testing panels, the use 

of which addressed our specific requirements. Because 

the intellectual property of the testing kits was being 

used to develop proficiency testing (PT) rounds, SeraCare Life Sciences and Primerdesign Ltd entered into 

a nondisclosure agreement to ensure the protection of 

corporate knowledge. SeraCare Life Sciences was then 

able to develop polycistronic plasmids containing target sequences of interest and produce those plasmids as 

multitarget positive spikes in order to test the VBDL’s 

methods at multiple concentrations. All PT rounds ship 

only as either purified plasmids or purified in vitro transcribed RNA. This allows worldwide distribution of the 

proficiency tests without concern for the shipping of 

pathogens. Other commands in the world may access the 

same proficiency tests used at US Army Public Health 

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Average melting temperature (Tm) values and standard deviation (SD) for individual pathogens determined from a clean 

matrix.

Target in Clean Matrix Tm (°C) ± one SD

A. phagocytophilum 78.49 0.80

Crimean Congo hemorrhagic fever virus 80.90 0.69

Ehrlichia ssp 79.72 0.81

Borrelia ssp 79.34 0.12

Chikungunya virus 81.90 3.53

Dengue virus 81.62 2.96

Leishmania ssp 74.72 1.22

Plasmodium ssp 80.00 1.03

Sandfly fever Sicilian virus 77.96 0.54
July – September 2014 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

Command Region-Europe, provided that they use the 

same PCR targets.

Flexibility

Adaptability was also built into the PT design to accommodate future pathogens and to provide the utmost flexibility to meet the needs of other regions. SeraCare Life 

Sciences is able to subclone other targets into the plasmids to meet local or global test requirements. Finally, 

the PT rounds can be completely managed by SeraCare. 

They are able to create and issue the proficiency tests, 

compile all testing data, and issue comparative results 

for all participating laboratories. This adaptability will 

enable different commands through the world to use an 

established proficiency testing scheme for laboratory accreditation that is adaptable to meet localized needs on 

a flexible timeframe.

Throughput

Due to the ability of the US military to rapidly respond 

throughout the world, it was necessary to build quick 

response into the VBDL. For the purpose of this article, 

rapid response is understood as rapid turnaround time 

(TAT), or rapid assay development. Rapid results production and fast TATs are achieved through streamlining of detection chemistries, high-throughput consumable platforms, commercially available testing kits, and 

robotic instrumentation.

The VBDL was also designed to enable quick response 

to novel pathogen threats encountered by the US military. The VBDL currently uses off-the-shelf testing kits 

developed by Primerdesign Ltd, an ISO 9001:2008 Quality Management System registered company. Primerdesign Ltd provided consultation and development of new, 

certified, quantitative testing kits within approximately 

a 4-week development time. As a result of the expedient 

delivery, local threats can be addressed in accordance 

with accreditation requirements without extensive inhouse research and development, thus allowing personnel to concentrate on maintaining laboratory operations. 

After receipt of the new testing kits, the VBDL, in accordance with USAPHCR-Europe Laboratory Sciences’ 

world class quality management system, was required 

to perform a complete method modification study. The 

studies were performed to test method accuracy, precision, recovery, and detection limit. Performance of 

the method validation study ensures that the new assay 

will meet laboratory accreditation requirements prior to 

use on customer samples. Any newly developed testing, changes to existing operations, and/or changes in 

manufacturer consumables for the VBDL will follow 

the same requirements.

The VBDL wanted to ensure that customers were able 

to analyze a full range of pathogen genotypes for every 

sample submitted. For this end the VBDL implemented all methods for whole nucleotide extraction of both 

DNA and RNA. Whole nucleotide extraction empowers 

the customer to examine the colocalization of multiple 

pathogens up to the fidelity of a single arthropod. Current policy of the VBDL requires storage, as space is 

available, of whole nucleotide extracts for a minimum of 

one year, allowing the customer access to a limited historical record to query for additional pathogens without 

additional field work. Whole nucleotide extraction gives 

the greatest potential to capture the largest data set from 

every sample submission.

Safety

The VBDL adopted the most prudent safety practices to 

meet the requirements of Department of the Army Pamphlet 385-69,

6 Biosafety in Microbiological and Biomedical Laboratories (Centers for Disease Control and 

Prevention),7 and Quality Assurance/Quality Control 

Guidance for Laboratories Performing PCR Analyses 

on Environmental Samples (Environmental Protection 

Agency).8 Laboratory layout and equipment was chosen so that safety standards could be maintained during 

high throughput sample processing with the goal of zero 

laboratory acquired infections.

In PCR analysis, safety and prevention of cross-contamination work together. The VBDL uses a unidirectional 

workflow where sample analysis is performed in 3 separate rooms. The first room is for reagent preparation and 

contains a 6 foot class A2 biosafety cabinet (BSC) where 

reagents are mixed. No customer samples or controls 

are permitted in this area, thereby reducing the likelihood of stock reagent contamination. The second room 

is for sample preparation. All sample homogenization 

is performed inside of another 6 foot class A2 BSC to 

provide ample analyst protection from potentially infectious aerosols. Nucleotide purification is completed on a 

Roche robotic nucleotide extraction instrument to minimize sample handling and to increase safety. After the 

extraction, all nucleotides are considered noninfectious, 

but potential problems associated with cross-contamination exist. The sample preparation room also contains 

3 PCR workstations to provide increased product protection during PCR setup. Because all sample processing is performed in a BSC that is restricted to one laboratory room, the threat of laboratory acquired infections 

is minimized. The final room is used for amplification 

and detection. Any PCR materials, samples, and quality 

assurance controls that are not prepped and intended for 

immediate analysis are not permitted in this room. The 
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

PCR amplification room must be treated with great care. 

The PCR amplicon can cause a catastrophic contamination of sample, instruments, and consumables. Unidirectional laboratory design therefore serves 2 purposes. 

First, the potential for cross-contamination is decreased 

by confining specific PCR procedures to certain areas. 

Second, safety is increased since all sample processing 

is performed in a BSC that is restricted to a single laboratory room.

Conclusion

Results of MDL studies indicate that vector-borne pathogen detection using real-time PCR and real-time reverse 

transcription PCR is a high-throughput, semiquantitative method that is capable of meeting and surpassing 

stringent international accreditation requirements with 

the possibility to be used military-wide with interlaboratory comparable results.

Acknowledgments

We thank COL James T. Boles, COL Daniel H. Jimenez, 

LTC Jerry L. Cowart, MAJ Hee Kim, and CPT Brian 

Knott (USAPHC-Europe), LTC Aziz Qabar (USAPHC 

AIPH), Anoop Pillai (Primer Design Ltd), Sabrina Collica (Bayer Animal Health), Dr Edgar Rowton and Mr 

Tobin Rowland (WRAIR) and the staff of USAPHCNorth and USAPHC-West for their invaluable assistance 

in this work.

References

1. Colacicco-Mayhugh M, Gosine S, Hughes T, Diclaro J, Larson R, Dunford J. Military entomology 

in Operation Enduring Freedom, 2010-2011. US 

Army Med Dep J. July-September 2012:29-35.

2. Courtney J, Kostelnik L, Zeidner N, Massung R. 

Multiplex real-time PCR for detection of anaplasma phagocytophilum and Borrelia burgdorferi. J 

Clin Microbiol. 2004;42(7):3164-3168.

3. Atkinson B, Chamberlain J, Logue CH, Cook N, 

Bruce C, Dowall SD, Hewson R. Development of a 

real-time RT-PCR assay for the detection of Crimean-Congo hemorrhagic fever virus. Vector-Borne 

Zoonotic Dis. 2012;12(9):786-793.

4. Gäumann R, Mühlemann K, Strasser M, Beuret 

CM. High-throughput procedure for tick surveys of 

tick-borne encephalitis virus and its application in 

a national surveillance study in Switzerland. Appl 

Environ Microbiol. 2010;76(13):4241-4249.

5. Sane A, Kurnik R, inventors. Roche Diagnostics 

GmbH, F Hoffman-La Roche AG, assignees. PCR 

elbow determination using quadratic test for curvature analysis of a double sigmoid. European patent 

EP2107470. July 10, 2009.

6. Department of the Army Pamphlet 385-69: Safety 

Standards for Microbiological and Biomedical 

Laboratories. Washington, DC: US Dept of the 

Army; May 6, 2009 [revised February 2, 2013].

7. Biosafety in Microbiological and Biomedical Laboratories. 5th ed. Washington, DC: US Dept of 

Health and Human Services; 2009. HHS Publication No (CDC) 21-1112.

8. Quality Assurance/Quality Control Guidance for 

Laboratories Performing PCR Analyses on Environmental Samples. Washington, DC: US Environmental Protection Agency; October 2004. EPA 

815-B-04-001.

Authors

Dr Soehnlen is the Chief of the Micro & Molecular Biology Division and Deputy Chief of the Veterinary Pathology Division, Laboratory Sciences, US Army Public 

Health Command Region-Europe, Landstuhl, Germany.

CPT Crimmins, the former Chief of the Micro & Molecular Biology Division, Laboratory Sciences, US Army 

Public Health Command Region-Europe, Landstuhl, 

Germany, is currently Chief of Clinical Investigations– 

Bench Lab Section, William Beaumont Army Medical 

Center, El Paso, Texas.

Mr Clugston is a professional associate in Veterinary Pathology Division, Laboratory Sciences, US Army Public 

Health Command Region-Europe, Landstuhl, Germany.

Ms Gruhn is a microbiologist in Micro & Molecular Biology Division, Laboratory Sciences, US Army Public 

Health Command Region-Europe, Landstuhl, Germany.

SPC Gomez is an animal care specialist, US Army Public Health Command, Fort Sam Houston, Texas.

Mr Cross is the Chief of the Quality Assurance Division, 

Laboratory Sciences, US Army Public Health Command 

Region-Europe, Landstuhl, Germany.

Dr Statham is the USAPHCR-Europe Scientific Advisor & Laboratory Director of Laboratory Sciences, US 

Army Public Health Command Region-Europe, Landstuhl, Germany.

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July – September 2014 27

Rabies is an acute, progressive, viral encephalomyelitis 

with the highest case fatality rate of any conventional 

etiological agent. It is one of the oldest described infectious diseases, having been recognized more than 

4,000 years ago. Rabies has a substantial international 

presence in that it is distributed on all continents but 

Antarctica. It is the leading viral zoonosis with a significant global burden on veterinary and human public 

health. Globally, the number of human rabies exposures 

per year is estimated to be in the tens of millions; the 

number of human rabies deaths per year was estimated 

to be over 55,000 in 2005.1 The rabies virus is a negative 

strand RNA-virus belonging to the genus Lyssavirus, 

family Rhabdoviridae of the order Mononegavirales.2,3

Different animal species are involved in the maintenance 

and transmission of rabies around the world. While the 

predominance of any one reservoir species varies by 

geographical region, the domestic dog remains the most 

significant reservoir for human rabies in overall case 

numbers and with regard to transmission, accounting for 

more than 90% of rabies exposures worldwide and more 

than 99% of human rabies deaths. Although rabies control and elimination is possible in dogs, stray and freeroaming, infected dogs present barriers to success.1,4,5

In the Eastern Mediterranean region as defined by the 

World Health Organization (WHO), which includes 

Afghanistan and Iraq,6 rabies continues to be a public 

health problem, predominantly affecting vulnerable, 

impoverished populations living in remote, rural locations. In 2002, 5,000 human rabies deaths were recorded 

in the region, mostly from Afghanistan, the Islamic Republic of Iran, and Pakistan, whereas most other countries reported fewer than 10 cases per country.7

 Unlike 

in developed countries, vaccination coverage of domestic animals in Afghanistan, Iraq, and similar countries 

is low. Absence of adequate vaccination within these 

countries makes them high risk for rabies in terrestrial 

animals and has resulted in a high prevalence of rabies 

within the dog population.7,8

Unfortunately, current reported numbers of animals infected with rabies in Iraq and Afghanistan are variable. 

Infrastructure is not in place to support testing for rabies 

in these regions, so reporting of cases is often based on 

clinical signs and is therefore limited and inconclusive.9

These countries lack a much needed, effective surveillance network to assess the magnitude of disease and to 

focus vaccination and control efforts. These countries 

also lack proper diagnostic facilities. Reliable national, 

systematic surveillance of rabies-related human deaths 

and animal rabies prevalence is urgently needed to garner support for effective prevention strategies.4,10,11

For animal rabies diagnosis, the direct fluorescent antibody test (DFAT) is the most frequently used and is the 

gold-standard test approved by the Centers for Disease 

Control and Prevention (CDC), WHO, and the World 

Organisation for Animal Health. This test is performed 

Evaluation of a Rapid Immunodiagnostic

 Rabies Field Surveillance Test on Samples

 Collected from Military Operations in

 Africa, Europe, and the Middle East

Kristen M. Voehl, DVM, MPH, DACVPM

LTC Greg A. Saturday, MS, USA

Abstract

The Anigen Rapid Rabies Antigen Test Kit (Bionote, Inc, Hwaseong, Korea) was evaluated using 80 clinical samples 

collected by US military veterinary units. Samples for the study were obtained from brain specimens of domestic 

and wildlife animals that were submitted to the US Army Public Health Command’s Veterinary Laboratory Europe 

in Landstuhl, Germany, for rabies testing with the direct fluorescent antibody test. The rapid immunodiagnostic 

test was able to detect rabies virus antigen in clinical samples of brain tissue. The rapid immunodiagnostic test had 

an overall sensitivity of 96.9% and specificity of 100% when compared to the direct fluorescent antibody test. The 

rapid immunodiagnostic test for rabies virus antigen detection is a straightforward test that can be run under field 

conditions and without a microscope or electricity, and yield results in 5 to 10 minutes. This rapid immunodiagnostic test is a quick, inexpensive, and easy to use surveillance tool that can identify rabies positive animals and help 

focus targeted control measures with the goal of reducing the rabies burden.
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

on brain tissue from animals suspected of being rabid 

and can only be performed postmortem.12-15 The DFAT 

is one of the quickest and most reliable testing methods, 

providing an accurate diagnosis in 98% to 100% of rabies suspect cases.13,16,17

In remote locations, the use of DFAT is often not feasible 

because of transportation issues and lack of adequate 

cold chain. Laboratories are not able to comply with the 

strict requirements to perform DFAT accurately. The 

lack of infrastructure and logistical support hinders 

DFAT as a realistic expectation. Currently cases go undetected, and surveillance is not actively pursued. The 

lack of diagnostic and surveillance capability results in 

a low level of awareness of the actual incidences of rabies in these regions, and the virus remains hidden and 

endemic with a potential to increase.18 The US Army did 

evaluate the use of another test, the direct rapid immunohistochemical test, for field surveillance. While this is 

an inexpensive test with excellent sensitivity and specificity comparable to DFAT, the need for CDC-certified 

training, refrigeration, multiple chemicals, and proper 

microscopic training made this unrealistic as a suitable 

surveillance test in military environments.

There are many challenges in the implementation of effective rabies diagnosis and surveillance programs in 

developing countries. Development and international 

acceptance of a validated test that can be used worldwide are essential to overcome these challenges. Financial and logistical barriers are additional obstacles 

that prevent use of such a test in developing countries 

with the greatest need. A rapid immunodiagnostic test 

(RIDT) for rabies virus has been developed, and this 

test shows potential in meeting these criteria. This lateral flow test uses gold conjugated detector antibodies, 

including a monoclonal antibody directed against the 

lyssavirus nucleoprotein.18 Although this method has 

only been used for qualitative analysis, it provides rapid 

detection of rabies antigen. Advantages over conventional immunoassays include lower cost, inexpensive 

equipment, simplicity of procedure, rapid operation, 

and long-term stability over a range of environmental 

conditions. The test is suited for on-site testing by personnel with limited technical expertise.18,19

The objective of this study was to evaluate the use of the 

Anigen Rapid Immunodiagnostic Test Kit for detection 

of rabies virus in clinical samples for application as a 

surveillance test among animal populations in areas with 

deployed military units. Clinical samples had previously 

been submitted to the US Army Public Health Command 

Region Europe Veterinary Laboratory Europe (VLE), in 

Landstuhl, Germany, for rabies testing with the DFAT.

Materials and Methods

Clinical Samples, Field Isolates, and Diagnosis

A total of 79 clinical samples collected between 2004 

and 2011 were examined for rabies using the Anigen 

RIDT. An additional clinical sample from 1996 was also 

tested. Total samples numbered 80. As shown in Table 

1, all specimens were brain tissue collected from the 

following animals: canine (n=46), bovine (n=5), feline 

(n=18), macaque (n=3), porcine (n=1), mongoose (n=1), 

equine (n=1), jackal (n=1), rat (n=1), and bat (n=3). The 

majority of samples tested with RIDT originated from 

Iraq (n=26) or Afghanistan (n=45). Samples also originated from Turkey (n=1), Bosnia (n=1), Germany (n=3), 

Kuwait (n=3), and Qatar (n=1). Detailed information 

about the animals was not available. All samples were 

collected by US military personnel and submitted to 

VLE. When testing with the RIDT was first initiated in 

2010, all specimens were from banked samples stored at 

VLE and previously tested with DFAT and, in some cases, with rabies murine neuroblastoma cell culture (MN). 

Thus, at that time, all results were previously known 

positives or negatives, and the investigators were not 

blinded to the results. Since that initial batch run of 39 

tests, the RIDT was used concurrently on samples at the 

time of testing with DFA and MN. The sensitivity and 

specificity of the RIDT were determined using DFAT as 

the reference method.

Rapid Immunodiagnostic Test Kit

Test Principles

The Anigen Rapid Rabies Antigen Test Kit (Bionote, Inc, 

Hwaseong, Korea) is an immunochromatographic assay 

designed for the qualitative detection of rabies virus antigen in canine, bovine, and raccoon dog salivary secretions and brain homogenates. The test uses gold conjugated detector antibodies to detect rabies virus antigen.20

Application of the RIDT

The rapid immunodiagnostic test was performed according to the instructions supplied by the manufacturer.20 In the study, final results were read 5 to 10 minutes 

after application of the sample as per the guidelines. In 2 

cases, final results were read at 30 minutes after application of the sample to the test well. Examples of positive 

and negative results are shown in the Figure.

Results

Sensitivity and Specificity of the RIDT Kit

Of the 80 samples used in the study, 45 were negative 

on DFAT, 32 were positive on DFAT, and 3 had an indeterminate result on DFAT. When the RIDT was run 

on these samples, there were 49 negative results and 31 

positive results. Although the intensity of the test lines 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

was found to vary among the different 

samples, all tests were clearly readable. 

Seventy-eight samples reacted within 

the 10-minute cut-off time for interpreting the test, but 2 samples were 

negative at 10 minutes and had faint 

positive results at 30 minutes. The 3 

tests that were indeterminate on DFAT 

were negative on the RIDT.

Thirty-six of the 41 samples tested 

with both DFAT and RIDT in 2011 had 

also been tested with rabies murine 

neuroblastoma cell culture (MN). Of 

the 36 samples, 31 were negative on all 

tests, 3 were positive on all tests, and 2 

were indeterminate on DFAT and MN 

but negative on RIDT.

One of the samples that was indeterminate on DFAT and MN but negative 

on RIDT was from a bat from Afghanistan. The other sample that was 

indeterminate on DFAT and MN but 

negative on RIDT was from a canine 

from Afghanistan. The third sample 

that was indeterminate on DFAT and 

negative on RIDT was from a canine 

from Kuwait. This sample was not 

subjected to the MN test.

Using DFAT as the reference method 

for the results of the samples tested, 

the RIDT kit was 96.9% sensitive and 100% specific. 

The 3 tests that were indeterminate on DFAT and MN 

were not used in the calculations.

Results by Species and Geographic Region

Results obtained from using the RIDT were evaluated 

by species (Table 2) and geographic region (Table 3). 

Given the concern regarding interactions between military personnel and canines, the results for this species in 

Afghanistan and Iraq, 2 regions with significant military 

presence, are further highlighted here.

Canine–Forty-six canine samples were tested. Excluding the samples with indeterminate results, sensitivity 

and specificity were both 100% for canine samples in 

the study.

Afghanistan–Excluding the indeterminate results, the 

RIDT was 100% sensitive and specific for Afghanistan 

samples.

Iraq–Based on interpretation of the delayed test results as positive, the RIDT 

was 95% sensitive and 100% specific 

for Iraq samples. Using the 10-minute 

recommended cutoff time for RIDT 

interpretation, the sensitivity was 85%.

Comment

In the present study, we describe a 

simple and rapid surveillance test for 

rabies virus infection based on the 

principle of immunochromatography. 

This lateral flow immunoassay system 

is widely used and accepted for the 

diagnosis of many human and animal 

diseases.

Rabies surveillance is lacking for many 

areas where troops are deployed, and 

no rigorous epidemiological data exist largely because of the lack of operational rabies diagnostic capabilities. 

The RIDT is a practical tool for field 

application to gather surveillance data 

of rabies-suspect animals, especially 

in resource poor regions where fluorescent antibody testing is impractical.18

In this study, the RIDT was highly 

sensitive (96.9%) and highly specific 

(100%) compared to the DFAT. The 

sensitivity and specificity of the RIDT, 

both 100%, compared to DFAT for the 

canine samples tested demonstrate the utility of the 

RIDT as a surveillance tool among canines, the rabies 

reservoir of significant concern for transmission to military troops. The significance of data in species other than 

Table 1. Species and number of brain 

tissue samples tested with RIDT in 

this study from 1996 to 2011

Year Species Number of

Samples Tested

1996 Bovine 1

2004 Canine 1

2005 Canine 2

2005 Porcine 1

2006 Canine 3

2007 Canine 3

2007 Mongoose 1

2008 Canine 5

2008 Bovine 4

2008 Jackal 1

2009 Canine 11

2009 Feline 2

2009 Macaque 2

2009 Equine 1

2010 Canine 1

2011 Canine 20

2011 Feline 16

2011 Rat 1

2011 Bat 3

2011 Monkey 1

NOTE: Bovine – Bos primigenius

Canine – Canis familiaris

Porcine – Sus domesticus

Mongoose – Herpestidae

Jackal – Canis sp.

Feline – Felis catus

Macaque – Macaca sp.

Equine – Equus ferus

Rat – Rattus sp.

Bat – Chiroptera sp.

Examples of positive (top) and negative (bottom) results from 

the current study utilizing the rapid immunodiagnostic test.
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

canines is limited for this study by 

the small sample sizes. Sensitivity 

and specificity were also calculated 

separately for Afghanistan and Iraq, 

the 2 regions that had enough samples for meaningful interpretation. 

Afghanistan samples were 100% 

sensitive and 100% specific with 

the RIDT. Iraq samples were 95% 

sensitive and 100% specific with 

the RIDT. The data are presumably 

not reflective of the true extent of 

rabies in the region since samples 

were collected only by Army personnel in selected locations and not 

by local veterinarians throughout 

the regions. In addition, sensitivity 

and specificity may be affected by 

the ability of the RIDT to detect regional rabies virus variants.

The RIDT can fulfill the CDC surveillance objectives for “uniformity, simplicity, and brevity.”21 It is a 

straightforward test that is simple 

and quick to perform. There are no 

critical points to field use such as 

cold storage since the test kit is self 

contained and stable when stored 

at room temperatures or refrigerated. Kang el al14 demonstrated 

that the test is capable of detecting 

low amounts of virus at an excellent sensitivity level that is slightly 

less than that of a well-executed 

FAT. The study by Markotter et 

al18 found excellent correlation of 

results when testing samples with 

both FAT and the RIDT.

As with any new surveillance or 

diagnostic tool, strict quality control and test validation are essential 

before the test can be relied upon 

for meaningful results. Preliminary validation studies performed 

by Kang et al14 showed the RIDT 

to have significant potential as a rabies diagnostic method. In the present study, the sensitivity of samples from Iraq must be considered in light 

of the 2 DFAT-confirmed positive tests that were initially negative on the RIDT after 10 minutes, but turned 

positive after 30 minutes. The delayed positive results 

could have been a result of the samples having a viral 

load close to the limit of detection, 

thus delaying the result. However, 

accurate interpretation is not possible outside of the manufacturer’s 

recommend time frame, 10 minutes for the RIDT. These 2 samples 

highlight the need for additional 

test validation.

While further laboratory and field 

evaluations are needed, these results are promising for the benefit of 

the RIDT as a surveillance tool in 

those regions without other immediate capability. Capacity for effective rabies surveillance programs 

is crucial to determine those geographical areas of operations where 

soldiers may be at risk for encountering a rabid animal, especially 

among free-roaming dogs and dog 

packs, which are a significant burden on military installations.

Even though the RIDT was not 

evaluated on specimens other than 

dog, cattle, and raccoon dog in the 

initial study by Kang et al,14 the results from the present study suggest 

that the RIDT may have application as a surveillance tool for multiple species. Further research with 

greater case numbers in multiple 

species is necessary to determine 

if the RIDT is capable of detecting 

multiple rabies virus variants.

Surveillance is an essential component of infectious disease risk 

assessment of military members 

during deployments.22,23 As a surveillance tool, the RIDT can help 

guide the most appropriate and cost 

effective use of animal control procedures and resources where they 

are most needed and will be beneficial to long-term rabies control. 

Continued on-site surveillance using the RIDT can also serve as a validation of vaccination control efforts. Military use of the RIDT has the potential to lead to country-wide acceptance and approval 

of this test with implementation among local veterinary 

organizations. Because it does not require specialized 

equipment or training, RIDT kits would be an excellent 

EVALUATION OF A RAPID IMMUNODIAGNOSTIC RABIES FIELD SURVEILLANCE TEST ON SAMPLES

COLLECTED FROM MILITARY OPERATIONS IN AFRICA, EUROPE, AND THE MIDDLE EAST

Table 2. Comparison of the rapid immunodiagnostic test (RIDT) to the direct fluorescent antibody test (DFAT, reference method) and murine neuroblastoma cell culture 

(MN) by species tested.

Species Results Number of 

Samples

RIDT DFAT MN

Canine Positive 23 23 3

Negative 23 21 14

Indeterminate 2 1

Feline Positive

Negative 18 18 15

Indeterminate

Bovine Positive 4 5

Negative 1

Indeterminate

Jackal Positive 1 1

Negative

Indeterminate

Macaque Positive

Negative 3 3 1

Indeterminate

Bat Positive

Negative 3 2

Indeterminate 1 1

Rat Positive

Negative 1 1 1

Indeterminate

Mongoose Positive 1 1

Negative

Indeterminate

Porcine Positive 1 1

Negative

Indeterminate

Equine Positive 1 1

Negative

Indeterminate

Total Positive 31 32 3

Negative 49 45 31

Indeterminate 3 2

NOTE: Canine – Canis familiaris

Feline – Felis catus

Bovine – Bos primigenius

Jackal – Canis sp.

Macaque – Macaca sp.

Bat – Chiroptera sp.

Rat – Rattus sp.

Mongoose – Herpestidae

Porcine – Sus domesticus

Equine – Equus ferus
July – September 2014 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

addition to military veterinary field 

supplies. This will further allow 

easy and accessible rabies surveillance capabilities throughout the 

regions. According to the manufacturer (BioNote, November 6, 2013), 

a single test costs approximately 

$9.60 USD, which is significantly 

less than the costs associated with 

establishing a laboratory equipped 

with fluorescent microscopy.

Acknowledgement

We thank the staff and soldiers of 

the Veterinary Laboratory Europe 

who processed samples and participated in evaluation of the RIDT. 

Special thanks to Leslie Fuhrmann 

for providing quality assurance in 

the rabies department and for her expertise in the testing process, and to 

LTC Jerry Cowart, MS, USA, Veterinary Pathology Division, Laboratory Science, US Army Public Health 

Command Region-Europe, for his 

review of the manuscript.

References

1. Knobel DL, Cleaveland S, Coleman PG, et al. Re-evaluating 

the burden of rabies in Africa 

and Asia. Bull World Health 

Organ. 2005;83(5):360-368.

2. De Benedictis P, De Battisti C, 

Dacheux L, et al. Lyssavirus 

detection and typing using pyrosequencing. J Clin Microbiol. 

2011;49(5):1932-1938.

3. About Rabies: Classification [internet]. Geneva, 

Switzerland: World Health Organization; 2012. 

Available at: http://www.who-rabies-bulletin.org/

about_rabies/classification.aspx. Accessed May 28, 

2012.

4. Horton DL, Ismail MZ, Siryan ES, et al. Rabies in 

Iraq: trends in human cases 2001-2010 and characterisation of animal rabies strains from Baghdad. 

PLoS Negl Trop Dis. 2013;7(2):e2075.

5. Lembo T, Hampson K, Kaare MT, et al. The feasibility of canine rabies elimination in Africa: 

dispelling doubts with data. PLoS Negl Trop Dis. 

2010;4(2):e626.

6. Countries in the WHO Eastern Mediterranean Region [internet]. Geneva, Switzerland: World Health 

Organization; 2012. Available at: http://www.who.

int/about/regions/emro/en. Accessed January 4, 

2012.

7. Main challenges in the control 

of zoonotic diseases in the Eastern 

Mediterranean Region. Paper presented at: World Health Organization regional committee report for 

the eastern Mediterranean, fifth 

session, agenda item 8; 2003:1-9. 

Available at: http://www.emro.who.

int/docs/em_rc50_7_en.pdf.

8. Animal & Insect-Borne Diseases FAQ [internet]. Aberdeen 

Proving Ground, MD:US Army 

Public Health Command. Available 

at: http://phc.amedd.army.mil/top

ics/discond/aid/Pages/FAQ.aspx. 

Accessed November 30, 2011.

9. Saturday G, King R, Fuhrmann 

L. Validation and operational application of a rapid method for rabies 

antigen detection. US Army Med 

Dep J. January-March 2009:42-45.

10. Coleman PG, Fèvre EM, 

Cleaveland S. Estimating the public health impact of rabies. Emerg 

Infect Dis. 2004;10(1),140-142.

11. Wu X, Hu R, Zhang Y, Dong G, 

Rupprecht CE. Reemerging rabies 

and lack of systemic surveillance in 

People’s Republic of China. Emerg 

Infect Dis. 2009;15(8);1159-1164.

12. Centers for Disease Control 

and Prevention. Rabies Diagnosis: 

Accuracy of the Tests [internet]. 

April 22, 2011. Available at: http://

www.cdc.gov/rabies/diagnosis/accuracy.html. Accessed January 11, 

2012.

13. Dean DJ, Abelseth MK, Atanasiu P. The fluorescent antibody test. In: Meslin FX, Kaplan MM, Koprowski H, eds. Laboratory Techniques in Rabies. 

Geneva, Switzerland: World Health Organization; 

1996:88-95. 

14. Kang B, Oh J, Lee C, et al. Evaluation of a rapid 

immunodiagnostic test kit for rabies virus. J Virol 

Methods. 2007;145(1):30-36.

15. WHO Expert consultation on Rabies: First Report. 

Geneva, Switzerland: World Health Organization; 

2005. WHO Technical Report Series; 931. Available at: http://www.who.int/rabies/trs931_%20

06_05.pdf. Accessed June 5, 2014.

16. World Organisation for Animal Health. OIE’s commitment to fight rabies worldwide [internet]. 2012. 

Available at: http://www.oie.int/en/for-the-media/

editorials/detail/article/oies-commitment-to-fightrabies-worldwide/. Accessed June 5, 2014.

Table 3. Comparison of the rapid immunodiagnostic test (RIDT) to the direct fluorescent antibody test (DFAT, reference method) and murine neuroblastoma cell culture 

(MN) by geographic region.

Region Results Number of 

Samples

RIDT DFAT MN

Afghanistan

Positive 11 11 3

Negative 34 32 25

Indeterminate 2 2

Iraq Positive 19* 20†

Negative 7† 6 2

Indeterminate

Bosnia Positive 1 1

Negative

Indeterminate

Turkey Positive

Negative 1 1

Indeterminate

Germany Positive

Negative 3 3 1

Indeterminate

Kuwait Positive

Negative 3 2 2

Indeterminate 1

Qatar Positive

Negative 1 1 1

Indeterminate

Total Positive 31 32 3

Negative 49 45 31

Indeterminate 3 2

*Includes the 2 samples that did not show a 

positive result for 30 minutes

†One sample that was positive for DFAT and 

negative on RIDT was also positive on the DRIT.
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

17. Robles CG, Miranda NLJ. Comparative evaluation 

of the rabies fluorescent antibody test and direct 

microscopic examination at the Research Institute 

for Tropical Medicine. Philipp J Microbiol Infect 

Dis. 1992;21(2):69-72.

18. Markotter W, York D, Sabeta CT, et al. Evaluation 

of a rapid immunodiagnostic test kit for detection of African lyssaviruses from brain material. 

Onderstepoort J Vet Res. 2009;76(2):257-262.

19. Wang H, Feng N, Yang S, et al. A rapid immunochromatographic test strip for detecting rabies virus antibody. J Virol Methods. 2010;170(1-2):80-85.

20. BioNote, Inc. One-step Rabies Antigen Test [Brochure]. 2010. Available at: http://www.bionote.

co.kr/File/Upload/2011/02/16/2011-02-16(10).pdf

Accessed November 22, 2011.

21. Wharton M, Chorba TL, Vogt RL, Morse 

DL, Buehler JW. Case definitions for public health surveillance. MMWR Recomm Rep.

1990:39(RR-13):1-43.

22. Murray CK, Horvath LL. An approach to prevention of infectious diseases during military deployments. Clin Infect Dis. 2007;44(3):424-430.

23. United States Air Force Guide to Operational Surveillance of Medically Important Vectors and Pests: 

Operational Entomology. Version 2.1. Washington, 

DC: US Dept of the Air Force; August 15, 2006. 

Available at: http://www.afpmb.org/sites/default/

files/pubs/guides/operational_surveillance_guide.

pdf. Accessed August 1, 2012.

Authors

Dr Voehl is a staff veterinarian at the Army Veterinary 

Treatment Facility, Kaiserslautern, Germany.

When the study described in this article was conducted, 

LTC Saturday was Chief, Veterinary Pathology Division, 

Army Veterinary Laboratory Europe, Landstuhl, Germany. He is currently with the Comparative Pathology 

Branch, Research Support Division, US Army Medical 

Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland.

EVALUATION OF A RAPID IMMUNODIAGNOSTIC RABIES FIELD SURVEILLANCE TEST ON SAMPLES

COLLECTED FROM MILITARY OPERATIONS IN AFRICA, EUROPE, AND THE MIDDLE EAST
July – September 2014 33

Chronic obstructive pulmonary diseases are a group 

of respiratory conditions characterized by difficulty 

breathing, airflow limitation, and symptoms that include 

cough, wheeze, and sputum production. This category 

of conditions includes bronchitis, not specified as acute 

or chronic, chronic bronchitis, emphysema, asthma, 

bronchiectasis, extrinsic allergic alveolitis, and chronic 

airways obstruction, not elsewhere classified. Asthma is 

a chronic inflammatory condition of the lungs characterized by intermittent, reversible airway obstruction. The 

prevalence of asthma is 8.2% in the general adult population of the United States.1

 Emphysema and chronic 

bronchitis are often associated with a history of cigarette 

smoking, and characterized by fixed, irreversible airway obstruction. In 2011, the prevalence of chronic obstructive pulmonary disease (COPD) (emphysema and 

chronic bronchitis combined) was approximately 6% in 

the US adult population.2 The prevalence of COPD increases with age, rising from 3.2% among those aged 18 

to 44 years to more than 11.6% among those 65 years old 

and older. Together, chronic lower respiratory diseases 

constituted the third leading cause of death in the United 

States in 2008, although deaths from chronic lung disease occur primarily after age 65.3

Trends in Rates of Chronic Obstructive

 Respiratory Conditions Among US Military

 Personnel, 2001-2013

Joseph H. Abraham. ScD

Leslie L. Clark, PhD

Jessica M. Sharkey, MPH

Coleen P. Baird, MD, MPH

Abstract

Background: The US military has been continuously engaged in combat operations since 2001. Assessing 

trends in respiratory health diagnoses during this time of prolonged military conflict can provide insight into 

associated changes in the burden of pulmonary conditions in the US military population.

Purpose: To estimate and evaluate trends in rates of chronic obstructive pulmonary diseases in the active duty 

US military population from 2001 through 2013.

Methods: A retrospective analysis of ambulatory medical encounter diagnosis data corresponding to a study 

base of over 18 million personnel-years was performed to estimate average rates and evaluate temporal trends 

in rates of chronic obstructive lung conditions. Differences in rates and the time trends of those rates were 

evaluated by branch of military service, military occupation, and military rank.

Results: During the 13-year period, we observed 482,670 encounters for chronic obstructive pulmonary disease 

and allied conditions (ICD-9 490-496) among active duty military personnel. Over half (57%) of the medical 

encounters in this category were for a diagnosis of bronchitis, not specified as acute or chronic. There was a 

statistically significant 17.2% average increase in the annual rates of this nonspecific bronchitis diagnosis from 

2001-2009 (95% CI: 13.5% to 21.1%), followed by a 23.6% annual decline in the rates from 2009 through 2013 

(95% CI: 8.6% to 36.2%). Statistically significant declines were observed in the rates of chronic bronchitis over 

time (annual percentage decline: 3.1%; 95% CI: 0.5% to 6.6%) and asthma (annual percentage decline: 5.9%; 

95% CI: 2.5% to 9.2%). A 1.6% annual increase in the rate of emphysema and a 0.1% increase in the rate of 

chronic airways obstruction (not elsewhere classified) over the study period were not statistically significant 

(P>.05). The magnitude of the estimated rates of these chronic obstructive lung conditions, and, to a lesser 

extent, the temporal trends in these rates, were sensitive to the requirement that there be persistence of the 

diagnosis evidenced in the medical record in order qualify as an incident case.

Conclusions: We observed decreases in the rates of asthma and chronic bronchitis over the 13-year study period. 

The increase, and then decrease, over time in rates of bronchitis that has not been specified as acute or chronic 

drives the overall trends in chronic respiratory disease trends.
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

In 2011, respiratory diseases were responsible for over 

250,000 medical encounters among active duty US 

military personnel, excluding respiratory infections.4

Although the burden of respiratory disease among the 

military is dwarfed by those imposed by injuries, mental disorders, and musculoskeletal diseases, respiratory 

conditions can be debilitating and sufferers’ lives can 

be severely affected. Trends in respiratory health have 

implications for force readiness, allocation of military 

healthcare resources, and Veterans’ care.

In October 2001, the US military initiated combat operations in Southwest Asia. More than a decade later, many 

of the impacts of prolonged military engagement on injuries, mental health, and behavioral disorders among 

military personnel have been well documented.5-11 The 

potential effect of deployment-associated environmental exposures on lung health is also of concern,12 but associations between military deployment and incidence 

of chronic obstructive lung conditions are not as well 

characterized. Some studies have reported associations 

between pulmonary health status and deployment,13-17

while others have not.18,19

Changes in the respiratory health of the US military 

population over time may result from variation in the 

demographic profile of the population, trends in accession standards, deployment-associated and other environmental exposures, and trends in smoking behaviors. 

The purpose of this surveillance effort was to estimate 

and evaluate longitudinal trends in rates of chronic 

respiratory conditions in the active duty US military 

population from 2001 through 2013, and answer the following questions: 

1. What are the rates of these conditions in the military population?

2. Have the rates changed over the past 13 years?

3. Do the rates, and particularly the trends in these 

rates, vary by branch of military service, job 

category, or rank?

Methods

Study Population

The study population consists of active duty personnel 

serving in the Army, Air Force, Navy, Marine Corps, or 

Coast Guard, and served by Tricare* at any point during 

the period January 2001 through December 2013.

Ascertainment of Respiratory Diagnoses

Incidence rates (2001-2013) of chronic obstructive pulmonary diseases among US military personnel during 

the period 2001 through 2003 were estimated using 

diagnostic records for ambulatory medical encounters 

maintained in the Defense Medical Surveillance System (DMSS). Records for medical encounters within 

the military health system and doctor visits in the private sector that were paid for by Tricare are included in 

DMSS. Annual rates for the conditions of interest were 

calculated by dividing the total number of cases by the 

total person-years at risk during the year.

Definition of Respiratory Diagnoses

Trends in annual incidence rates were assessed for 

each subclassification in the broad International Classification of Diseases, Clinical Modification (ICD-9) 

category of COPD and allied conditions (ICD-9 codes 

490-496). Case status was defined using 3 increasingly 

specific rules: The primary definition required there to 

be at least 2 ambulatory medical encounters recorded in 

DMSS with identical ICD-9 codes within 2 years (730 

days). For example, to qualify as an asthma case using 

this definition, personnel were required to have a minimum of 2 outpatient encounters coded with ICD-9 493 

within 730 days. The second, more sensitive case definition required the appearance of only a single ambulatory 

medical encounter with a given ICD-9 code. The third, 

more specific case definition required there to be at least 

3 ambulatory medical encounters with identical ICD-9 

codes within 2 years. In all cases, the date of the first 

medical encounter with the corresponding qualifying 

ICD-9 code was defined as the date of incidence for the 

purpose of person-time calculation. Individuals with a 

given diagnosis prior to 2001 were excluded from the 

analysis. Cases identified in a given year were excluded 

from the person-time and rate calculations for subsequent years.

Statistical Analysis

We analyzed anonymized ambulatory encounter diagnoses data that had been aggregated by year. The data 

were received for the entire population and stratified 

by rank (junior enlisted (E1-E3), senior enlisted (E4-

E6), junior officer (O1-O3), senior officer (O4-O6)) and 

branch of military service (Army, Air Force, Navy, Marine Corps, Coast Guard). Trends in rates and natural 

log-transformed annual rates over time were assessed 

using linear regression analyses. Assessment of curvilinear relationships between medical encounter rates 

and year were assessed by including a quadratic term 

for year (year2) in the models.

TRENDS IN RATES OF CHRONIC OBSTRUCTIVE CONDITIONS

AMONG US MILITARY PERSONNEL, 2001-2013

*Tricare is the Department of Defense health care program for 

members of the uniformed services, their families, and their survivors. Information available at http://www.tricare.mil.
July – September 2014 35

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

Differences in annual rates and 

the time trends of those rates were 

evaluated by branch of military service, military job category (combat, 

healthcare, other), and category of 

military rank.

To assess whether time trends differed by branch of military service, 

models were constructed to include 

main effects for year of diagnosis and 

indicator variables for each branch of 

service, as well as interaction terms 

defined as the product of year of diagnosis and each indicator variable. 

The Army was used as the reference 

group for analyses of service-specific trends. Noncombat roles were the 

reference group for military occupation, and junior enlisted personnel 

served as the reference group for categories of military rank.

All statistical analyses were conducted using SAS 9.2 (SAS Institute 

Inc, Cary, NC). The trends over time 

are presented using the primary case 

definition. Differences in the estimated average rates for each respiratory diagnosis using the more strict 

case definitions are also presented.

The Public Health Review Board of 

the US Army Public Health Command reviewed and approved this 

evaluation.

Results

Demographic Summary

A summary of demographic and military characteristics of the study population is presented 

in Table 1. The military population at risk of respiratory 

health conditions in this study included 3,800,676 individuals and over 18.1 million person-years of observation. The majority of the study population were male 

(84%) and of white, non-Hispanic race/ethnicity (64%). 

Army personnel comprised 38% of the study population. 

Almost half of the population (47%) was aged between 

20 and 24 years.

We obtained diagnosis codes for the broad category 

of COPD and allied conditions (ICD-9 490-496) corresponding to 482,670 ambulatory medical encounters 

occurring during the 13-year time 

period from January, 2001 through 

September, 2013. Of these, more 

than half (57%) were encounters 

for bronchitis, not specified as acute 

or chronic (ICD-9 490) and more 

than a third (37%) were for asthma 

(ICD-9 493) (Table 2). Requiring 

2 ambulatory visits with the same 

diagnosis within 2 years to qualify as an incident case results in a 

total of 156,516 personnel with a 

chronic obstructive lung condition. 

Requiring 3 ambulatory visits with 

the same diagnosis within 2 years 

further reduces the total number 

to 81,843 incident cases. Seventyeight percent of the cases for this 

last, most restrictive case definition 

were for asthma, and almost 18% 

were for bronchitis, not specified as 

acute or chronic.

Rates of Bronchitis, Not Specified 

as Acute or Chronic (ICD-9 490)

Over the 13-year study, 276,878 

ambulatory medical encounters for 

“bronchitis, not specified as acute 

or chronic” (ICD-9 490) occurred 

among active duty US military personnel, yielding an average rate for 

this nonspecific diagnosis of 27.7 

cases per 10,000 person-years (95% 

CI: 21.4-35.9) over the study period 

using the primary case definition 

requiring at least 2 visits in 2 years 

(Table 3). Relaxing the requirement 

for there to be at least 2 ambulatory 

encounters coded with ICD-9 490 

within 2 years results in a dramatic increase in the estimated average rate (144.3 cases per 10,000 person-years; 95% CI: 

122.9-169.5). Requiring at least 3 encounters within 2 

years to define case status resulted in a correspondingly 

dramatic lowering of the estimated rate of bronchitis 

not specified as acute or chronic to 7.0 cases per 10,000 

person-years (95% CI: 5.1-9.5). 

Branch of military service was a statistically significant predictor of the rate of bronchitis not specified as 

acute or chronic, independent of the year of diagnosis. 

Army personnel had significantly higher rates relative 

to all other branches of military service except for Marine Corps personnel, although the differences were 

Table 1. Demographic and military characteristics, active component service 

members, 2001-2013.*

n %

Gender

Male 3,189,666 83.9

Female 611,010 16.1

Service

Army 1,454,958 38.3

Navy 890,350 23.4

Air Force 784,278 20.6

Marine Corps 587,395 15.5

Coast Guard 83,695 2.2

Rank

Junior Enlisted (E1-E3) 2,506,273 65.9

Senior Enlisted (E4-E6) 873,722 23.0

Junior Officer (O1-O3) 329,815 8.7

Senior Officer (O4-O6) 90,866 2.4

Military occupation

Combat 818,644 21.5

Healthcare 277,607 7.3

Other 2,704,425 71.2

Age group (years)

<20 475,754 12.5

20-24 1,801,244 47.4

25-29 793,778 20.9

30-34 451,184 11.9

35-39 191,551 5.0

40-44 64,255 1.7

45-49 17,327 0.5

50-54 3,971 0.1

≥55 168 0.0

Race, ethnicity

White, nonhispanic 2,419,033 63.6

Black, nonhispanic 610,109 16.1

Other/unknown 771,534 20.3

*This is a dynamic population. To characterize 

time-varying characteristics (age and occupation), we identified all individuals in service for 

at least one day during the surveillance period 

(the population at risk), then identified the demographic record closest to the midpoint of 

their period of service and used that record to 

identify age and military occupation.

Data Source: Defense Medical Surveillance 

System.
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

only statistically significant in comparison to Navy 

(P =.0017) and Air Force (P=.0425) personnel. Marines 

had a higher average rate of bronchitis, not specified as 

acute or chronic, relative to Army personnel (P=.0425). 

Rates were lower among those with military occupation 

classified as combat, relative to those in noncombat occupations (P<.0001). Rates of bronchitis, not specified 

as acute or chronic, were also lowest among junior enlisted personnel relative to senior enlisted personnel and 

officers (P<.0001).

The temporal trend in rates for this nonspecific bronchitis diagnosis followed a ∩-shaped curve (Pquadratic year

term = .0003) (Table 4). Rates increased by an average 

of 17 cases per 10,000 person-years per year from 2001-

2009 (P<.0001), then decreased by almost 24 cases per 

10,000 person-years per year from 2009-2013 (P=.0175) 

(Figure 1). By 2013, the rate (15 cases per 10,000 person-years) returned to levels similar to those observed in 

2001 (17 cases per 10,000 person-years). Notably, both 

the increase prior to 2010 and the subsequent decrease in 

the rates of this diagnosis were much more pronounced 

for Marines than personnel in any other branch of military service.

Although the magnitudes of the rates differed, the 

∩-shaped pattern of the trend in rates were consistent, 

albeit more pronounced when using the more sensitive 

case definition (Pquadratic year term = .0002), and almost 

identical when using the more specific definition requiring 3 or more ambulatory encounters within 2 years 

(Pquadratic year term =.0020) with diagnoses of bronchitis, 

not specified as acute or chronic.

Significant statistical interactions were not observed between year and branch of service (P interactions ≥ .0697), 

military occupation (P interactions ≥ .8055), or military 

rank (P interactions ≥ .3072).

Rates of COPD: Chronic Bronchitis, Emphysema, 

and Chronic Airways Obstruction, Not Elsewhere 

Classified

Over the 13-year study period, we observed 13,195 

ambulatory medical encounters for chronic bronchitis 

(ICD-9 491), 2,467 encounters for emphysema (ICD-9 

492), and 11,020 encounters for chronic airways obstruction, not elsewhere classified (ICD-9 496). The average of the annual rates for these outcomes were very 

low, ranging from less than one case per 10,000 person-years (emphysema) to less than 2 cases per 10,000 

person-years (chronic bronchitis and CAO) when estimated using the primary case definition (Table 3). Requiring at least 2 encounters within 2 years lowered the 

rates of these 3 conditions to less than 1 case per 10,000 

person-years. 

Rates for chronic bronchitis varied by branch of service, 

with Coast Guard personnel having an average rate that 

was significantly higher than all other service branches by between 1 and 2 cases per 10,000 person-years 

(P<.0001). Rates of emphysema were highest, on average, among Army personnel. Both Air Force and Marine 

Corps personnel had emphysema rates that were significantly lower than those in the Army (P<.0255). The average rates of CAO were highest among Army personnel 

and Air Force personnel, and significantly lower among 

Marine Corps (P<.0001), Navy (P=.0021), and Coast 

Guard (P<.0477) personnel, relative to Army personnel.

Personnel in combat occupations had lower rates of 

chronic bronchitis (P<.0051), emphysema (P=.1147), 

and CAO (P<.0002) relative to those in other military 

occupation categories. Senior personnel had higher rates of chronic bronchitis (P<.0001), emphysema (P≤.0788), 

and CAO (P<.0001), relative to junior 

personnel.

Overall, there was a statistically significant downward trend in the rate of 

chronic bronchitis (Ptrend<.0264) over 

the 13-year period, a small increase 

over time in emphysema rates that 

was borderline statistically significant 

(Ptrend=.0785), and almost no change 

in the rates of CAO (Ptrend=.9547) over 

the study period (Table 4). For each 

of these outcomes, the average annual change was less than one case per 

10,000 person-years. Although rates 

TRENDS IN RATES OF CHRONIC OBSTRUCTIVE CONDITIONS

AMONG US MILITARY PERSONNEL, 2001-2013

Table 2. Number and percentage of cases of selected chronic respiratory conditions in the US military from 2001-2013, by ICD-9-coded condition.

Respiratory

Condition

ICD-9 

Code

Primary Case

Definition*

Sensitive Case

Definition*

Specific Case

Definition*

n % n % n %

Bronchitis,

not specified as acute or chronic

490 55,853 35.5 276,878 57.4 14,575 17.8

Chronic bronchitis 491 2,085 1.3 13,195 2.7 761 0.9

Emphysema 492 826 0.5 2,467 0.5 427 0.5

Asthma 493 94,858 60.2 177,234 36.7 64,026 78.2

Bronchiectasis 494 488 0.3 1,196 0.2 316 0.4

Extrinsic allergic alveolitis 495 104 0.1 680 0.1 55 0.1

Chronic airways obstruction,

not elsewhere classified

496 3,302 2.1 11,020 2.3 1,683 2.1

*The primary case definition required at least 2 ambulatory medical encounters recorded in DMSS 

with identical ICD-9 codes within 2 years (730 days). The more sensitive case definition required 

only a single ambulatory medical encounter with a given ICD-9 code. The more specific case 

definition required at least 3 ambulatory medical encounters recorded in the DMSS with identical 

ICD-9 codes within 2 years.

Data Source: Defense Medical Surveillance System .
July – September 2014 37

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

were lower, the decreasing trend in rates of chronic bronchitis over time was similar when using the case definition requiring at least 3 encounters for chronic bronchitis 

within 2 years (Ptrend=.0241). No linear trend over time 

was observed using the case definition requiring at least 

3 encounters for chronic bronchitis in a 2-year period 

(Ptrend=.434) (Figure 2). Increasing linear trends in emphysema rates over time were observed using the second 

case definition (Ptrend=.0555) and third case definitions 

(Ptrend=.0385) (Figure 3). Using the more specific 

case definitions of CAO resulted in a reversal in 

the downward trend observed for the primary 

case definition, although the linear trends were 

not statistically significant (P ≥.3494) (Figure 5).

Statistically significant interactions between 

year of diagnosis and branch of service were 

not observed for chronic bronchitis rates (Pinteractions≥.06) but were observed by rank, with the 

downward trend in rates being attenuated for senior enlisted personnel (Pinteractions=.0260) and 

junior officers (Pinteractions=.0028), relative to 

junior enlisted personnel. Statistical interactions 

were observed between year and branch of service for emphysema and CAO rates, specifically 

for Navy (Pinteractions≤.0021) and Air Force (Pinteractions≤.0323) personnel. 

A statistically significant interaction between 

year of diagnosis and military occupation was 

observed for CAO, with the slope of the downward trend in the rate over time attenuated among 

personnel in combat occupations, relative to 

those with noncombat military occupations (Pinteractions=.0302). A similar interaction was not observed between military rank and both CAO rates 

over time (Pinteractions>.2012) and rates of emphysema over time (Pinteractions>.3627).

Rates of Asthma

We observed 177,234 ambulatory medical encounters for asthma (ICD-9 493) over the 13-year 

period, yielding an average annual rate of 49.1 

cases per 10,000 person-years (95% CI: 40.5-59.4) 

using the primary definition (Table 3). Requiring 

only one ambulatory encounter to qualify as an 

asthma case resulted in a considerably higher 

rate (91.9 cases per 10,000 person-years (95% CI: 

76.9-109.9)), while requiring at least 3 encounters 

within 2 years decreased the rate to 32.8 cases per 

10,000 person-years (95% CI: 26.2-41.0). Among 

the conditions assessed, asthma diagnoses were 

the most persistent (Table 2).

Independent of the year of diagnosis, rates of asthma 

varied by branch of service. Asthma rates were highest 

among Army personnel and at least 28 cases per 10,000 

person-years lower in all other branches (P<.0001). 

Asthma rates were 27.1 cases per 10,000 person-years 

higher, on average, among those with noncombat military occupations, compared to those with combat occupations (P<.0001). Asthma rates were highest among 

junior enlisted personnel, and significantly lower among 

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

All Army Navy Air Force Marines Coast Guard

Rate (per 10,000 person-years)

0

80

40

30

20

10

50

60

70

A. Primary case definition: requires at least 2 ambulatory healthcare encounters within 2 years.

B. Sensitive case definition: requires at least one ambulatory healthcare encounter.

All Army Navy Air Force Marines Coast Guard

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Rate (per 10,000 person-years)

0

200

100

75

50

25

125

150

225

175

250

C. Specific case definition: requires at least 3 ambulatory healthcare encounters within 2 years.

All Army Navy Air Force Marines Coast Guard

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Rate (per 10,000 person-years)

0

5

25

30

20

10

15

Figure 1. Annual rates of bronchitis, not specified as acute or 

chronic (ICD-9 490), within each US military service, 2001-2013.
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

senior enlisted (P<.0001), junior officer (P<.0001), and 

senior officer (P<.0001) personnel.

Overall, there was a statistically significant linear trend 

over time in the rate of asthma, with the rate decreasing annually by an average of 6.3 cases per 10,000 

person-years (Ptrend=.0019) (Table 4). The slope of the 

time trend in asthma rates varied by branch of military 

service (Pinteractions<.0001). Time trends in asthma rates 

between 2001 and 2013 did not differ significantly by 

military rank (Pinteractions≥.4931) or category of military 

occupation (Pinteractions≥.3150). Although the magnitude 

of asthma rates differed when using alternative case 

definitions, similar statistically significant 

downward trends in asthma rates over time 

were observed when using case definitions 

requiring only one asthma-coded encounter (Ptrend<.0001) and at least 3 encounters 

(Ptrend=.0106) with asthma (Figure 4).

Rates of Bronchiectasis and Extrinsic 

Allergic Alveolitis

We observed 1,196 ambulatory medical encounters for bronchiectasis (ICD-9 494) and 

680 for extrinsic allergic alveolitis (ICD-9 

495) over the 13-year period (Table 2). Requiring at least 2 encounters within 2 years 

for our primary case definition resulted in 

estimated incidence rates that were less than 

3 cases per 100,000 person-years. Although 

we analyzed the trends in rates of these conditions, we present only minimal results, because the rates for these conditions were so 

low. There was no statistically significant 

evidence that time trends in the rates of either bronchiectasis or extrinsic allergic alveolitis varied over time (Ptrend>.2066), nor that 

trends were modified by branch of military 

service (Pinteractions≥.3408), military occupation (Pinteractions≥.0827), or military rank 

(Pinteractions≥.1386).

Comment

The purpose of this study was to estimate and 

evaluate longitudinal trends in rates of chronic respiratory conditions in the active duty US 

military population from 2001 through 2013. 

We observed downward trends in the rates of 

chronic bronchitis and asthma over the study 

period, almost no change in the annual rates 

of chronic airways obstruction, and a nonstatistically significant increase in the rates of 

emphysema. Our findings are not consistent 

with a hypothesis that there have been persistent increases in the rates of respiratory illnesses in the 

US armed forces over the past decade.20

The majority of ambulatory encounters in the large 

group of chronic obstructive respiratory conditions 

were given a diagnosis of bronchitis, not specified as 

acute or chronic (ICD-9 490). Across the entire time 

period, the average rate of this nonspecific bronchitis 

diagnosis was more than double that for any of the other 

diagnoses assessed in this investigation. Rates for bronchitis, not specified as acute or chronic, increased from 

2001 to 2009, and then decreased from 2009 through 

the end of the study period in 2013. Although we have 

TRENDS IN RATES OF CHRONIC OBSTRUCTIVE CONDITIONS

AMONG US MILITARY PERSONNEL, 2001-2013

Table 3. Average rates with 95% confidence intervals of chronic respiratory conditions in the U.S. military for the 2001-2013 study period.*

Chronic Respiratory Condition† Average Rate

per 10,000

Person-years

95%

Confidence

Interval

Lower

Limit

Upper

Limit

Bronchitis,

not specified as acute or chronic (ICD-9 490)

Primary case definition 27.73 21.43 - 35.88

Sensitive case definition 144.30 122.89-169.45

Specific case definition 7.00 5.1 - 9.5

Chronic bronchitis (ICD-9 491)

Primary case definition 1.10 0.95 - 1.26

Sensitive case definition 6.45 4.82 - 8.63

Specific case definition 0.40 0.34 - 0.47

Emphysema (ICD-9 492)

Primary case definition 0.43 0.37 - 0.50

Sensitive case definition 1.31 1.20 - 1.44

Specific case definition 0.21 0.17 - 0.27

Asthma (ICD-9 493)

Primary case definition 49.05 40.49 - 59.42

Sensitive case definition 91.89 76.86 - 109.86

Specific case definition 32.78 26.18 - 41.03

Bronchiectasis (ICD-9 494)

Primary case definition 0.24 0.18 - 0.32

Sensitive case definition 0.63 0.56 - 0.71

Specific case definition 0.15 0.10 - 0.21

Extrinsic allergic alveolitis (ICD-9 495)

Primary case definition 0.05 0.05 - 0.06

Sensitive case definition 0.31 0.22 - 0.45

Specific case definition 0.03 0.02 - 0.04

Chronic airways obstruction,

not elsewhere classified (ICD-9 496)

Primary case definition 1.73 1.47 - 2.02

Sensitive case definition 5.81 5.10 - 6.62

Specific case definition 0.86 0.70 - 1.06

*Averages were calculated by exponentiating the average of natural log-transformed annual encounter rates.

†The primary case definition required at least 2 ambulatory medical encounters recorded in DMSS with identical ICD-9 codes within 2 years (730 days). The more sensitive 

case definition required only a single ambulatory medical encounter with a given ICD-9 

code. The more specific case definition required at least 3 ambulatory medical encounters recorded in the DMSS with identical ICD-9 codes within 2 years.

Data Source: Defense Medical Surveillance System. 
July – September 2014 39

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

not identified a definitive explanation for the increase 

in these rates between 2001 and 2009, nor for the subsequent decrease in the rates, this diagnostic category 

likely includes a large proportion of patients who have 

acute bronchitis or a similar condition. Requiring evidence of persistence of the diagnosis in the medical record by stipulating that cases have at least 2 ambulatory 

encounters within 2 years, for example, resulted in a 

dramatic drop in the estimated rate of this diagnosis, more so than for any other of the conditions 

we assessed. Similar ∩-shaped patterns were observed among all military branches and across all 

categories of military rank and occupation. The 

slope of the trends in the conditions over time 

frequently varied by the service branch of the US 

armed forces, although not in a manner that was 

consistent across diagnoses.

In a study with up to 4 years of postdeployment 

follow-up, Abraham et al observed a 25% increase 

in the rate of medical encounters for respiratory 

symptoms (RR=1.25; 95% CI: 1.20-1.30) and a 

greater than 50% increase in the rate of asthma 

(RR=1.54; 95% CI: 1.33-1.78) among personnel 

formerly deployed in support of Operation Iraqi 

Freedom (OIF), relative to a nondeployed reference group of personnel stationed in the United 

States.13 This same study found elevated rates of 

medical encounters for COPD and allied conditions, although the increased rates were generally 

not statistically significant.

Szema et al reported an elevated risk of asthma 

(OR=1.88; 95% CI: 1.38-2.56) among patients 

who had visited OIF/Operation Enduring Freedom (OEF) clinics at a Veterans Administration 

Medical Center (VAMC) in Long Island, NY, 

relative to patients at the same VAMC who had 

not visited the OIF/OEF clinics.14 Szema et al also 

reported a statistically significant increase in the 

proportion of patients with respiratory symptoms 

and a greater proportion with referrals for spirometry (OR=1.88; 95% CI: 1.38-2.56) among Veterans attending the OIF/OEF clinics, relative to a 

reference group of Veterans who were patients 

at the VAMC, but who did not visit the OIF/OEF 

clinics.15 Among those referred for spirometry in 

this later study, both groups had similar forced 

expired volume in one second/forced vital capacity (FEV1

/FVC) ratios.

Smith et al found deployment to be associated with 

newly reported respiratory symptoms among military personnel and Veterans participating in the 

Millennium Cohort Study.19 This association was modified by branch of military service, being lowest among 

Navy/Coast Guard personnel (OR=1.06; 95% CI: 0.86-

1.32), and highest among Army personnel (OR=1.73; 

95% CI: 1.57-1.91). Chronic bronchitis or emphysema 

and asthma rates were not significantly elevated among 

those who had deployed relative to those who had never 

deployed. Although not explicitly stated by the authors, 

A. Primary case definition: requires at least 2 ambulatory healthcare encounters within 2 years.

All Army Navy Air Force Marines Coast Guard

Rate (per 10,000 person-years)

0

1

5

6

4

2

3

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

B. Sensitive case definition: requires at least one ambulatory healthcare encounter.

All Army Navy Air Force Marines Coast Guard

Rate (per 10,000 person-years)

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

0

5

25

30

20

10

15

C. Specific case definition: requires at least 3 ambulatory healthcare encounters within 2 years.

All Army Navy Air Force Marines Coast Guard

Rate (per 10,000 person-years)

0.0

0.5

2.5

2.0

1.0

1.5

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Figure 2. Annual rates of chronic bronchitis (ICD-9 491), by each 

US military service, 2001-2013.
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

the maximum follow-up time for the Millennium Cohort analysis was approximately 4 years (OEF began in 

the Fall of 2001, and the study used data from questionnaires returned between June 2004 and February 2006). 

Using outpatient medical encounter diagnosis data to 

estimate rates of chronic obstructive lung conditions allowed for efficient and large-scale assessment of trends 

over a long period of time. There is a time-lag between 

true incidence of a condition and clinical diagnosis for 

that condition that is not accounted for in this investigation. However, on average, it is unlikely that the magnitude of this lag changed over the study period. 

False-positive and false-negative misclassification of 

health outcomes is also likely to have occurred. To address this limitation, we used 2 additional case definitions: a more sensitive definition that did not require 

evidence of persistence of the diagnosis and a more specific case definition that required cases to have at least 

3 ambulatory encounters with the same ICD-9 coded 

diagnosis within 2 years.

Using case definitions requiring evidence of persistence of the diagnosis over time resulted in much lower 

estimated rates for the conditions we assessed. This is 

consistent with a hypothesis that many ambulatory encounters are assigned specific diagnostic codes corresponding to chronic obstructive respiratory conditions 

but do not meet diagnostic criteria for those condtions.21

These transient findings may reflect working diagnoses 

which change over time, imprecise coding, or misdiagnoses. Although the rates 

were lower, the overall temporal pattern 

observed in the rates of unspecified bronchitis, chronic bronchitis, and asthma 

were similar when using less sensitive, 

but more specific, case definitions. However, we did note qualitative differences in 

temporal trends for emphysema and CAO. 

The rising temporal trend in emphysema 

became borderline statistically significant when requiring at least 2 encounters 

within a 2 year period, and was statistically significant when requiring at least 3 

encounters within 2 years. The downward 

temporal trend observed using our primary case definition of CAO reversed direction when using the more specific case 

definitions, although the rising temporal 

trends we observed were not statistically 

significant.

Regardless of the specificity of the case 

definition, false-positive cases would have resulted 

from ambulatory care encounters that are assigned an 

incorrect or inappropriate ICD-9 code. Additionally, an 

unknown number of incident chronic obstructive lung 

conditions likely remain undiagnosed and therefore not 

enumerated in our study (false-negatives). If the degree 

of misclassification remained constant over the study 

period, the estimated rates would be biased, but the 

trends in rates would remain unbiased. Changes in the 

frequency of outcome misclassification over time, due 

to changes in coding practices, for example, would result in biased time trends as well.

Potential explanations for the observed relationships 

between time and health condition rates include confounding by time-varying predictors of obstructive pulmonary condition diagnoses, such as an external factor 

that changes from year to year, similar to rates of flu. 

Subsequent work will attempt to parse out these possible co-relationships so that trends independent of these 

confounders can be evaluated. 

Rates of chronic obstructive conditions during this time 

period were generally low, and similar to, or lower than, 

corresponding rates in the general population.2

Branch of military service, military rank, and job category were associated with rates of chronic obstructive 

pulmonary conditions defined using ambulatory medical encounter data. A decreasing temporal trend in asthma rates was consistently observed. Trends in bronchitis 

TRENDS IN RATES OF CHRONIC OBSTRUCTIVE CONDITIONS

AMONG US MILITARY PERSONNEL, 2001-2013

Table 4. Trends in rates of encounters with chronic obstructive pulmonary 

diseases and allied conditions (ICD-9 490-496) in the US military, 2001-2013, 

by diagnosis.*

Chronic Obstructive Pulmonary

Disease or Allied Condition

ICD-9

Code

Percentage

Increase

in Trend†

95% Confidence IntervalP value

Lower

Limit

Upper

Limit

Bronchitis,

not specified as acute or chronic‡

490 -2.54% -3.56 -1.51 0.0003

Chronic bronchitis 491 -3.61% -6.60 -0.52 0.0264

Emphysema 492 3.47% -0.46 7.55 0.0785

Asthma 493 -5.91% -9.23 -2.47 0.0033

Bronchiectasis 494 4.69% -2.89 12.85 0.2066

Extrinsic allergic alveolitis 495 2.35% -2.40 7.33 0.3057

Chronic airways obstruction,

not elsewhere classified

496 0.12% -4.24 4.67 0.9547

*Rates were estimated using a case definition that required evidence of persistence of the 

diagnosis in the medical record, i.e., at least 2 encounters with the same diagnosis code 

within 2 years.

†The percent increase in the linear slope is derived from the slope estimate from a regression 

model of year as a continuous independent predictor of natural log-transformed rates. 

‡A statistically significant curvinear trend was observed for the bronchitis, not specified as 

acute or chronic outcome. As such, we present only the percent change in the quadratic, derived from the quadratic term from a regression model of year2 as a continuous independent 

predictor of natural log-transformed rates in a model that also contains the main effect of 

year as a continuous independent predictor. 

Data Source: Defense Medical Surveillance System.
July – September 2014 41

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

rates, too, generally decreased over time, with the notable exception of the those for bronchitis, not specified as 

acute or chronic, which increased significantly between 

2001 and 2009. This assessment did not discriminate 

between military personnel with and without a history 

of deployment to Southwest Asia. Future work should 

focus on assessing rates of these conditions among 

personnel with prior history of deployment in 

support of OEF, OIF, and Operation New Dawn.

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Figure 3. Annual rates of emphysema (ICD-9 492), by each US 

military service, 2001-2013.

3A. Primary case definition: requires at least 2 ambulatory healthcare encounters within 2 years.

All Army Navy Air Force Marines Coast Guard

Rate (per 10,000 person-years)

0.0

0.2

1.0

0.8

0.4

0.6

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

3B. Sensitive case definition: requires at least one ambulatory healthcare encounter.

All Army Navy Air Force Marines Coast Guard

Rate (per 10,000 person-years)

0.0

0.5

2.5

3.0

2.0

1.0

1.5

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

3C. Specific case definition: requires at least 3 ambulatory healthcare encounters within 2 years. Rate (per 10,000 person-years)

All Army Navy Air Force Marines Coast Guard 0.8

0.0

0.2

0.4

0.6

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

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Proc. 2010;31(5):67-71.

15. Szema AM, Salihi W, Savary K, Chen JJ. 

Respiratory symptoms necessitating spirometry 

among Soldiers with Iraq/Afghanistan war lung injury. J Occup Environl Med. 2011;53:961-965.

16. Baird CP, Debakey S, Reid L, Hauschild VD, 

Petruccelli B, Abraham JH. Respiratory health status of US Army personnel potentially exposed to 

smoke from 2003 Al-Mishraq sulfur plant fire. J 

Occup Environl Med. 2012;54:717-723.

17. Abraham JH, DeBakey SF, Reid L, Zhou J, 

Baird CP. Does deployment to Iraq and Afghanistan affect respiratory health of US military personnel?. J Occup Environl Med. 2012;54:740-745.

18. Abraham JH, Baird CP. A case-crossover study 

of ambient particulate matter and cardiovascular 

and respiratory medical encounters among US 

military personnel deployed to southwest Asia. J 

Occup Environl Med. 2012;54:733-739.

19. Smith B, Wong CA, Smith TC, Boyko EJ, Gackstetter GD. Newly reported respiratory symptoms 

and conditions among military personnel deployed 

to Iraq and Afghanistan: a prospective populationbased study. Am J Epidemiol. 2009;170:1433-1442.

20. Kennedy K. Health alert: respiratory problems, neurological conditions and heart disease 

on rise since 2001. Air Force Times. October 14, 

2010;news:10-11. 

21. Tokunbo M, Abraham JH, Zacher LL, Morris 

MJ. The impact of deployment on COPD in active 

duty military personnel. Mil Med. 2014. In press.

Authors

Dr Abraham is an Epidemiologist, Environmental Medicine, US Army Public Health Command, Aberdeen 

Proving Ground, Maryland.

Dr Clark is a Senior Managing Epidemiologist in the 

Epidemiology and Analysis Division, Armed Forces 

Health Surveillance Center, Silver Spring, Maryland.

Ms Sharkey is an Epidemiologist, Environmental Medicine, US Army Public Health Command, Aberdeen 

Proving Ground, Maryland.

Dr Baird is Program Manager, Environmental Medicine, US Army Public Health Command, Aberdeen 

Proving Ground, Maryland.

TRENDS IN RATES OF CHRONIC OBSTRUCTIVE CONDITIONS

AMONG US MILITARY PERSONNEL, 2001-2013

Figure 4. Annual rates of asthma (ICD-9 493) within each US military service, 2001-2013.

A. Primary case definition: requires at least 2 ambulatory healthcare encounters within 2 years.

All Army Navy Air Force Marines Coast Guard

Rate (per 10,000 person-years)

0

80

60

40

20

100

120

140

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

B. Sensitive case definition: requires at least one ambulatory healthcare encounter. Rate (per 10,000 person-years)

All Army Navy Air Force Marines Coast Guard

0

200

100

75

50

25

125

150

225

175

250

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

C. Specific case definition: requires at least 3 ambulatory healthcare encounters within 2 years. Rate (per 10,000 person-years)

All Army Navy Air Force Marines Coast Guard

0

10

50

80

60

40

20

30

90

70

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
July – September 2014 43

THE UNITED STATES ARMY MEDICAL DEPARTMENT JOURNAL

Figure 5. Annual rates of chronic airways obstruction, not elsewhere classified (ICD-9 491), within each US military service, 

2001-2013.

A. Primary case definition: requires at least 2 ambulatory healthcare encounters within 2 years. Rate (per 10,000 person-years)

All Army Navy Air Force Marines Coast Guard

0.0

0.5

3.5

2.5

4.0

3.0

2.0

1.0

1.5

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

B. Sensitive case definition: requires at least one ambulatory healthcare encounter. Rate (per 10,000 person-years)

All Army Navy Air Force Marines Coast Guard

0

2

10

12

8

4

6

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

C. Specific case definition: requires at least 3 ambulatory healthcare encounters within 2 years. Rate (per 10,000 person-years)

All Army Navy Air Force Marines Coast Guard

0.00

2.00

1.00

0.75

0.50

0.25

1.25

1.50

1.75

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

Background

Concerns related to potential service-related exposures arose following the first Gulf War (1991). Similarly, exposures occurring in theater while supporting 

Operations Enduring Freedom (OEF), Iraqi Freedom 

(OIF), and New Dawn have also caused concern among 

service members.1 During deployment, personnel may 

have been exposed to environmental hazards that could 

affect their respiratory health, such as ambient particulate matter (PM) indigenous to the desert environment, 

local industry-related pollutants, exhaust from the engines of vehicles, machinery, and generators used by 

both military and civilians, and smoke emitted as a result of oil-well fires and during the combustion of waste 

burned in open air burn pits.2-5 With more than 2.3 million US military personnel deployed to Southwest Asia 

since 2001,6,7 concern over myriad possible exposures 

can be far-reaching.

Burn pits were widely used as a method of solid waste 

disposal prior to 2010 at many OEF and OIF locations. 

A burn pit is defined by the US Department of Defense 

(DoD) as:

An area, not containing a commercially manufactured 

incinerator or other equipment specifically designed and 

manufactured for burning of solid waste, designated for 

the purpose of disposing of solid waste by burning in the 

outdoor air at a location with more than 100 attached or assigned personnel and that is in place longer than 90 days.8

Burn pit emissions, which may include PM, volatile organic compounds, and polycyclic aromatic hydrocarbons, 

likely vary due to heterogeneity in the trash stream and 

use of accelerants.9 Personnel activity patterns, distance 

from the burn pit site, and meteorological conditions additionally influence burn pit emissions exposures.

Although no studies have identified as yet an association between burn pit emissions exposure and postdeployment chronic lung conditions, exposures to burn pit 

emissions have been implicated as a cause of chronic 

respiratory illnesses.10,11 Current and future research efforts will continue to investigate potential associations 

between chronic health effects of deployment-related 

airborne hazards and burn pit exposures. Notably, a 2011 

Institute of Medicine report, Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan, found that:

...service in Iraq or Afghanistan—that is, a broader consideration of air pollution than exposure only to burn pit 

emissions—might be associated with long-term health effects, particularly in highly exposed or susceptible populations, mainly because of the high ambient concentrations of PM from both natural and anthropogenic, including military, sources.12

Subsequently, as part of the Dignified Burial and Other 

Veterans Benefits Improvement Act of 2012,13 Congress 

mandated that the Department of Veterans Affairs (VA) 

establish an “Open Burn Pit Registry.” The VA later expanded the scope of the registry, renaming it the “Airborne Hazards and Open Burn Pit Registry,” to capture 

information regarding all potential exposures experienced by our service members during deployment that 

may have possible impacts on future respiratory health. 

The Airborne Hazards and Open Burn Pit Registry will 

collect data concerning potential exposures related to 

emissions from both burn pits and other sources as mentioned above. As such, any veteran or service member 

with a history of deployment to any Southwest Asia contingency operation on or after August 2, 1990, (as defined in 38 CFR §3.317) 14 or in Afghanistan or Djibouti 

on or after September 11, 2001, is eligible to participate. 

Department of Defense Participation in

 the Department of Veterans Affairs

 Airborne Hazards and Open Burn Pit

 Registry: Process, Guidance to Providers,

 and Communication

Jessica M. Sharkey, MPH

Deanna K. Harkins, MD, MPH

Timothy L. Schickedanz

Coleen P. Baird, MD, MPH
July – September 2014 45

These regions include the following countries and bodies of water, and the airspace above these locations:

Iraq Djibouti

Afghanistan Oman

Kuwait Qatar

Saudi Arabia United Arab Emirates

Bahrain

Gulfs of Aden and Oman

Waters of the Persian Gulf, Arabian Sea, Red Sea

The VA will use deployment data provided by the DoD 

to validate eligibility status.

With the creation of the Airborne Hazards and Open 

Burn Pit Registry, both service members and veterans 

are now able to voluntarily document their exposure 

experiences and health concerns collected by way of a 

web-based, self-reported questionnaire. The questionnaire requests information on various topics such as deployment history and exposures, military occupational 

exposures, environmental exposures, air pollution, 

places lived, work history, home environment and hobbies, medical history, health concerns, and healthcare 

utilization. As such, the data collected from the registry 

questionnaire may be the most comprehensive exposure 

profile available for most service members and veterans. 

Potential health effects of interest include, among others, 

breathing problems which may or may not have resolved 

following deployment, although the questionnaire also 

addresses other conditions. Veterans and service members who had more exposure or underlying medical conditions may be more likely to experience or develop reduced lung function or cardiopulmonary disease, which 

can also be captured on questionnaire response.

Individual level benefits of participation in the registry 

include creating a snapshot from which to identify future changes in health status for service members and 

veterans. The completed questionnaire can also be used 

to more easily discuss any concerns with a healthcare 

provider. The registry will allow DoD and VA public 

health officials to monitor health concerns and conditions affecting eligible veterans and service members 

who participate. From a population-level perspective, 

data from the registry will also be used to generate hypotheses for future efforts regarding the health status of 

all service members and veterans who have deployed 

to the above mentioned locations. The data will also be 

used to improve public health programs and initiatives 

geared towards assisting veterans and service members 

with deployment exposure concerns.

Under the leadership of the Director, VA Office of Public Health Post 9/11 Era Environmental Health Program, 

public health professionals from various disciplines 

within the US Army Public Health Command (USAPHC), along with stakeholders from the Air Force, 

Navy, and Marine Corps as well as subject matter experts in web development, collaborated and assisted 

in the creation of the registry. Senior leadership at the 

Office of the Assistant Secretary of Defense for Health 

Affairs has also supported efforts related to the overall 

development of Airborne Hazards and Open Burn Pit 

Registry. Currently, the registry is slated to launch in 

2014.

Veterans

Any veteran meeting the previously discussed eligibility 

criteria is welcome to participate in the Airborne Hazards and Open Burn Pit Registry. Although the registry 

does not require medical evaluation for participation 

purposes, veteran registry participants will have the opportunity to request a no-cost medical assessment for 

deployment-related health concerns. If requested, medical follow-up will be provided to authorized veterans 

through the VA healthcare system. Subsequently, VA 

healthcare providers will be able to access registry questionnaire responses electronically through the speciallydeveloped “VA Provider Portal” data system which is 

accessible by VA physicians during medical evaluations. 

However, it is important to note that the registry is not 

intended to be used for disability and compensation purposes for veterans, and participation does not affect access to healthcare or benefits. Any combat veteran not 

yet enrolled in VA healthcare can receive free medical 

care for any condition possibly related to service for 5 

years after discharge. Application for VA health benefits 

may be submitted online at https://www.1010ez.med.

va.gov/sec/vha/1010ez/.

Active Duty, Reserve, and National Guard

Personnel

Active duty military personnel, including activated and 

inactive National Guard, Reserve, and US Coast Guard, 

who meet the eligibility criteria are also eligible to participate and register. Participation in the registry is entirely voluntary. To ensure the DoD efforts are congruent with those of the VA, upon request, DoD will provide 

medical assessments to active duty service members. 

The VA will provide, upon request, medical assessments 

to members of the National Guard and Reserve forces 

who are not presently on active duty. The extent of the 

assessments should be dictated by an individual’s medical and occupational health history, and the healthcare 

provider’s clinical assessment and concerns.
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

The USAPHC is the lead activity pursuant to a November 

6, 2013, tasking by the Assistant Secretary of Defense 

for Health Affairs to develop a DoD medical follow-up 

program consistent with the VA’s approach. A schematic 

guidance of the medical follow-up process and a summary of the VA’s registry and its purpose have been developed and are intended for use by healthcare providers 

who will manage patients with deployment-related concerns. The USAPHC and the VA have jointly developed 

a “DoD Fact Sheet” for service members, with a brief 

summary of the registry and instructions about where to 

receive the voluntary medical assessment, which can be 

printed from the registry web site, along with the general joint VA/DoD “participation letter.”

Registration Process and Specifics

When an active duty service member logs in to the registry website, then registers and completes the questionnaire, the website will generate the joint VA/DoD individualized participation letter and the DoD Fact Sheet. 

The DoD Fact Sheet instructs the participant that he or 

she should immediately go to the nearest emergency 

room, call 911, or contact their primary care manager 

for instructions if they are currently experiencing any 

urgent symptoms, such as difficulty breathing or chest 

pains. In addition, the letter and Fact Sheet informs service members of the availability of voluntary, no-cost 

follow-up medical evaluation for health concerns related 

to deployment, although it specifically states that it is 

not required for the participant to be considered “in” the 

registry. Upon completion of the questionnaire, the participant may save and print the questionnaire containing 

the individual’s responses, and is encouraged to keep a 

copy for their records and to bring a copy of their completed health questionnaire to their healthcare provider 

if a clinical medical evaluation is desired. The completed questionnaire may also be saved on and printed from 

the registry website, as well as saved electronically to 

the participant’s own computer or other device. When 

requesting a medical appointment, the service member is instructed to indicate that the appointment is for 

“health concerns related to the Airborne Hazards and 

Open Burn Pit Registry exposures.”

The location and scheduling of the voluntary medical 

evaluation differs for those service members currently 

on active duty and those who are not presently on active duty. The DoD Fact Sheet includes the following 

specific instructions:

1. For the location and scheduling of the voluntary 

medical evaluation, active duty service members, 

including the National Guard and Reserve forces 

on active duty orders for greater than 30 days, 

are instructed to obtain the medical evaluation 

through the DoD either at their designated military medical treatment facility, or through their 

DoD primary care manager.

2. For the location and scheduling of the voluntary 

medical evaluation, members of the National 

Guard and Reserve forces not presently on an active duty tour, are specifically instructed to contact the VA for the medical evaluation. National 

Guard and Reserve forces, whether discharged or 

still serving, will be managed by the VA in the 

same manner as other veterans. The VA will provide a voluntary medical evaluation upon request. 

If the participant is a Veteran or inactive/separated National Guard or Reservist, and is enrolled 

in the VA healthcare system, they are instructed 

to contact their primary care physician or Patient 

Aligned Care Team (PACT) to schedule an appointment for a medical evaluation. If the participant is a Veteran or inactive/separated National 

Guard or Reservist, and is not enrolled in the VA 

healthcare system and would like to schedule an 

initial no-cost medical evaluation, please contact 

a VA Environmental Health Coordinator (EHC) 

in your area by visiting this link: http://www.publichealth.va.gov/exposures/coordinators.asp

What Military Healthcare Providers

Should Know

Each service’s medical departments have been directed 

to provide appropriate medical follow-up actions in response to requests by registry participants. Again, guidance on the registry web site recommends that service 

members calling for an appointment for the voluntary 

medical assessment state the purpose is to “address 

health concerns related to the Airborne Hazards and 

Open Burn Pit Registry exposures,” so providers will be 

made aware in advance that a participant requires these 

type of assessments and can prepare. The registry also 

allows the participant to print a paper copy of the completed questionnaire to bring to their medical assessment. 

The questionnaire is lengthy, about 25 pages depending 

on responses. Presently, DoD providers cannot access 

service member registry questionnaires electronically, 

however, DoD is working to provide this access. Currently the service member will have to provide a printed 

copy to the provider. The printed questionnaire may be 

scanned into the medical record.

Healthcare providers are reminded that the extent of 

these medical assessments should be dictated by an individual’s medical and occupational health history, and 

the healthcare provider’s professional judgment and 

DEPARTMENT OF DEFENSE PARTICIPATION IN THE DEPARTMENT OF VETERANS AFFAIRS AIRBORNE 

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July – September 2014 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

skills, clinical assessment, and concerns. To be clear, 

there is no “required registry medical examination,” and 

no “required checklist.” There are no required medical 

tests, and there is no reporting of any results or clinical 

findings back to the registry. Neither “active” follow-up 

(ie, “call backs”) nor “case management” are required 

by either the VA or DoD as a result of responses on the 

questionnaire.

Though the DoD does not require a specific format for 

the clinical assessment, patients with health concerns 

should have their registry questionnaire reviewed and 

discussed by the provider, and receive appropriate reassurance, clinical evaluations, and, when indicated, diagnostic studies and/or specialty consultation. The scope 

of a voluntary medical assessment should depend on the 

individual’s history and clinical findings. While some 

service members may have health concerns that can 

be addressed through a minimal assessment consisting 

of a brief history and review of pertinent positives on 

the questionnaire, others having significant respiratory 

symptoms (such as dyspnea, cough, increased sputum 

production, chest tightness or discomfort, wheezing, or 

decreased exercise tolerance) may require a more comprehensive approach, including diagnostic testing and 

specialty consultation in some circumstances. In the 

latter case, a thorough occupational and environmental exposure history, especially to airborne hazards and 

tobacco smoke, and a physical examination focusing 

on the cardiopulmonary exam may be indicated. The 

provider may also consider requesting pulse oximetry, 

spirometry, radiography, and/or a complete blood count. 

Specialty consultation may be indicated for further evaluation. If providers have questions regarding an individual’s responses on the questionnaire, including reported 

exposures, which cannot be resolved locally, they may 

consider consultation with their respective service’s 

center for occupational and environmental medicine, or 

consultant in occupational medicine:

Navy and Marine Corps Public Health Center:

(757) 953-0700

USAPHC Consult Service: (410) 436-2714,

usarmy.apg.medcom-phc.mbx.emp@mail.mil

US Air Force managers in Public Health: DSN 761-6992, 

commercial (703) 681-6992; or Bioenvironmental Engineering: DSN: 761-7688, commercial (703) 681-7688

Each service’s medical department has also been directed to use procedures and communication products to 

inform healthcare providers and service members about 

the registry, its purpose, and the availability of the voluntary clinical medical assessment for health concerns 

related to deployment. The DoD is developing a communications plan, including press releases and the use 

of social media, to supplement the internal activities of 

the military services. Information for providers and frequently asked questions will be made available through 

the military services. The USAPHC will post communication products, which may be used by the other services, on its e-catalog website: https://usaphcapps.amedd.

army.mil/HIOShoppingCart/default.aspx.

In addition, USAPHC is developing provider education 

and training for physicians, physician-assistants, and 

nurse practitioners who may be seeing these DoD participants for the voluntary medical assessment. The brief 

training will offer continuing medical education units, 

and familiarize military providers with the registry and 

its purpose, coding and recording guidance, and provide 

additional optional clinical tools for assessment which 

have been developed by the VA and DoD, such as an 

algorithm for primary care providers which details a 

clinical approach to the participant/patient requesting a 

voluntary medical assessment. Further details about this 

provider education and training will be distributed by 

the military services.

Risk Communication

Perception of risk is reality for most people, regardless of the risk itself. From a medical perspective, the 

layperson’s perception about perceived health risks or 

exposures can be equally or more important than the 

scientific or medical data. Accepting the patient’s perceptions and understanding of health risks and spending time addressing those concerns is absolutely critical to communicating health risks effectively. Ignoring 

or downplaying stakeholder perceptions or concerns 

because the provider does not consider them valid can 

have detrimental effects. These effects can include a 

loss of credibility, seeming callous or uncaring, and having patients become noncompliant in actions necessary 

to negate potential health risks. Understanding the patient’s perceptions is one of the first steps in a good risk 

communication effort.

A loss of trust and credibility is likely if the patient 

perceives the care provider to imply or somehow demonstrate a lack of value to the Airborne Hazards and 

Open Burn Pit Registry questionnaire. It is absolutely 

essential that the provider instill in the patient a sense of 

value of not only the questionnaire but the entire registry 

process. Use the following guidelines to ensure successful risk communication practices are used during the 

medical evaluation portion of the Airborne Hazards and 

Open Burn Pit Registry process.
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

Important considerations when communicating with 

service member patients who have deployed:

 Accept that scientific and medical knowledge may 

be limited and take advantage of “teachable moments.” Although situational assessments may be 

difficult to explain and understand, use appropriate 

terminology when necessary, followed immediately 

by a brief, understandable explanation.

 Know when facts or data should be secondary to a 

more empathetic response. Trivializing or discounting concerns and emotions will only serve to escalate them (eg, “there’s no reason to worry about 

that...”). Verbally acknowledge and validate risk 

perceptions and emotions related to a health risk, 

regardless of assessment or findings.

 Limit technical data and statistics until perceptions 

and emotions related to the health risk have been 

identified or addressed, to the extent possible.

 Provide information in manageable “layers.” Offer 

concrete examples or actions. Doing so can help 

prioritize important information and provide the 

layperson with some level of control regarding the 

level of information detail.

 Reference third party credible sources, when possible. For instance, stating that the Centers for Disease 

Control and Prevention, the Environmental Protection Agency, the Occupational Safety and Health 

Administration, the National Research Council, etc, 

follow similar assessment guidelines can help demonstrate transparency and increase familiarity.

 Be sensitive that your own perceptions of service 

members can make risk communication efforts 

more difficult. Assuming that a service member will 

not understand the information, would not be interested in it, or is just trying to be difficult will only 

make risk communication efforts harder for you.

 Anticipate the most difficult questions and develop 

key points to reference in all potential responses. 

For example:

Will breathing high levels of dust for a year cause 

lung problems?

Why do they keep using burn pits when they 

know they’re bad for us?

To what was I exposed, and how much?

 Improve your nonverbal skills and strive to match 

words and actions.

 Be willing to say “I don’t know,” combined with 

specific actions and timeframes about how you will 

find the answer if possible.

Communication of health risk information requires very 

specialized skills gained by practice and refinement 

over time. Awareness of how risks are determined and 

perceived and how to identify and develop appropriate 

messages and 2-way dialogue opportunities is critical to 

successful risk communication efforts.15,16

Environmental Medicine Clinical

Consult Service

To supplement the questionnaire responses, site-specific 

deployment exposure summary reports or the Periodic 

Occupational and Environmental Monitoring Summary 

(POEMS) are available for many deployment locations. 

The POEMS is unclassified and intended for service 

members and their healthcare providers, though POEMS is population-based and not an individual’s exposure summary. While they are not intended to go in 

a medical record, they serve as a good starting point 

for an exposure history and evaluation, so we encourage providers and service members (and veterans) to 

request the POEMS for their deployment locations. The 

provider may review it to aid in determining whether 

deployment-related exposures may apply to the participant. A POEMS is quite long, but has brief summaries at 

the beginning for doctors and service members.

More specifically, POEMS documents are official DoD 

location-specific summaries developed by the USAPHC 

to assist healthcare providers and service members. Archived occupational and environmental health (OEH) 

information, monitoring data, reports, and documents 

are used to develop POEMS.17 The POEMS standardizes the documentation of all the acute (during deployment) and chronic (long-term, postdeployment) OEH 

health risks and their potential medical implications at 

major deployment sites. The information is based on 

ambient monitoring data collected from multiple media 

(air, soil, water) over an extended period (eg, a year or 

more). It includes the rationale for health risk estimates 

and recommendations for any medical action/follow-up/

surveillance. While this assessment may reflect similar 

exposures and risks pertaining to historic or future conditions at this site, the underlying data is limited to the 

time period(s) and area(s) sampled and thus may not reflect fluctuations or unique occurrences. It also may not 

be fully representative of all the fluctuations during the 

period. To the extent data allow, this summary describes 

the general ambient conditions at the site and characterizes the risks at the population level. While useful to inform providers and others of potential health effects and 

associated medical implications, it does not represent an 

individual exposure profile, and is therefore inappropriate for inclusion in a medical record. Actual individual 

exposures and specific resulting health effects depend 

on many variables and should be addressed in individual 

medical records by providers as appropriate at the time 

of an evaluation. In addition, POEMS are not medical 

DEPARTMENT OF DEFENSE PARTICIPATION IN THE DEPARTMENT OF VETERANS AFFAIRS AIRBORNE 

HAZARDS AND OPEN BURN PIT REGISTRY: PROCESS, GUIDANCE TO PROVIDERS, AND COMMUNICATION
July – September 2014 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

disability documents since disability is not automatically granted based upon environmental surveillance data, 

exposures, or assessed risks from that data. There may 

not be POEMS documents for some deployment locations, or they may still be in development.

The POEMS documents are available by contacting the 

applicable Service Surveillance Center for most pertinent documentation:

USAPHC, (800) 222-9698

Navy and Marine Corps Public Health Center,

(757) 953-0700

US Air Force School of Aerospace Medicine,

(888) 232-3764

Requests for POEMS can be submitted at https://us

aphcapps.amedd.army.mil/msrv/ServiceRequest.aspx 

(select POEMS). Completed POEMS documents can be 

accessed via request and password at https://mesl.apgea.

army.mil/mesl/ and are also available by email request 

to usarmy.apg.medcom-phc.mbx.emp@mail.mil or by 

phone to 410-436-2714.

The USAPHC’s Environmental Medicine Program offers an Environmental Medicine Clinical Consult Service, the only official environmental medicine level V 

support offered through the Army Medical Command 

which provides documents and presents recommendations regarding diagnostics and/or medical documentation to address individual concerns associated with environmental exposures:

USAPHC Environmental Medicine Consult Service

5158 Blackhawk Road; Building E1570

Aberdeen Proving Ground-Edgewood Area, Maryland 

21010-5403

Telephone: (410) 463-2714

Email: usarmy.apg.medcom-phc.mbx.emp@mail.mil

If providers in the other services have questions regarding an individual’s responses on the questionnaire, including reported exposures, which cannot be resolved 

locally, they may consider consultation with their respective service’s center for occupational and environmental medicine or consultant in occupational medicine:

Navy and Marine Corps Public Health Center

 (757) 953-0700

US Air Force Occupational Medicine Consultant

 (703) 681-6868

Providers for US Coast Guard personnel may contact 

the USAPHC Environmental Medicine Consult Service 

with any questions. These services facilitate more comprehensive evaluation, documentation, and recording of 

various environmental exposure incidents occurring in 

theater, and improve the ability of DoD to address postdeployment health concerns related to such exposures.

References

1. Smith B, Wong CA, Smith TC, Boyko EJ, Gackstetter GD, Ryan MAK. Newly reported respiratory symptoms and conditions among military 

personnel deployed to Iraq and Afghanistan: a prospective population-based study. Am J Epidemiol. 

2009;170(11):1433-1442.

2. Brown KW, Bouhamra W, Lamoureux DP, Evans 

JS, Koutrakis P. Characterization of particulate 

matter for three sites in Kuwait. J Air Waste Manag 

Assoc. 2008;58(8):994-1003.

3. Engelbrecht JP, McDonald EV, Gillies JA, Jayanty RK, Casuccio G, Gertler AW. Characterizing 

mineral dusts and other aerosols from the Middle 

East–part 1: ambient sampling. Inhal Toxicol. 

2009;21(4):297-326.

4. Mosher DE, Lachman BE, Greenberg MD, Nichols T, Rosen B, Willis HH. Green Warriors: Army 

Environmental Considerations for Contingency 

Operations from Planning Through Post-Conflict. 

Santa Monica, CA:RAND Corp; 2008. Available 

at: http://www.rand.org/pubs/monographs/MG632.

html. Accessed May 12, 2014.

5. Weese CB, Abraham JH. Potential health implications associated with particulate matter exposure 

in deployed settings in southwest Asia. Inhal Toxicol. 2009;21(4):291-296.

6. Bonds TM, Baiocchi D, McDonald LL. Army Deployments to OIF and OEF. Santa Monica, CA: 

RAND Corp; 2010. Available at: http://www.rand.

org/pubs/documented_briefings/DB587.html. Accessed May 12, 2014.

7. Tan M. 2 million troops have deployed since 9/11. 

Marine Corps Times. December 18, 2009. Available at: http://www.marinecorpstimes.com/arti

cle/20091218/NEWS/912180312/2-million-troopsdeployed-since-9-11. Accessed May 12, 2014.

8. Department of Defense Instruction 4715.19: Use 

of Open-Air Burn Pits in Contingency Operations. Washington, DC: US Dept of Defense; 2011 

[change 2, March 27, 2014]:12.

9. Taylor G, Rush V, Deck A, Vietas JA. Screening Health Risk Assessment, Burn Pit Exposures, 

Balad Air Base, Iraq and Addendum Report. Aberdeen Proving Ground, MD: US Army Center for 

Health Promotion and Preventive Medicine; 2008. 

USACHPPM 47-MA-08PV-08. Available at: http://

www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA49314

2&Location=U2&doc=GetTRDoc.pdf. Accessed 

May 12, 2014.
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

10. King MS, Eisenberg R, Newman JH, et al. Constrictive bronchiolitis in soldiers returning from Iraq and 

Afghanistan. N Engl J Med. 2011;365(3):222-230.

11. Smith B, Wong CA, Boyko EJ, et al. The effects 

of exposure to documented open-air burn pits on 

respiratory health among deployers of the Millennium Cohort Study. J Occup Environ Med. 

2012;54(6):708-716.

12. Institute of Medicine. Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan. Washington, DC: National Academies 

Press; 2011. Available at: http://www.iom.edu/Re

ports/2011/Long-Term-Health-Consequences-ofExposure-to-Burn-Pits-in-Iraq-and-Afghanistan.

aspx#. Accessed May 12, 2014.

13. Dignified Burial and Other Veterans’ Benefits 

Improvement Act of 2012, Pub L No. 112-260 

(2013). Available at: http://legiscan.com/US/text/

SB3202/2011. Accessed May 12, 2014.

14. 38 CFR Ch 1 §3.317: Compensation for certain disabilities due to undiagnosed illnesses. (e)(2). July 1, 

2011. Available at: http://www.gpo.gov/fdsys/pkg/

CFR-2011-title38-vol1/pdf/CFR-2011-title38-vol1-

sec3-317.pdf. Accessed May 12, 2014.

15. Slovic P. Perception of risk. Science. 1987;236

(4799):280-285.

16. Covello VT, Allen FW. Seven Cardinal Rules of 

Risk Communication. Washington, DC: US Environmental Protection Agency;1988. OPA-87-020. 

Available at: http://www.epa.gov/care/library/7_

cardinal_rules.pdf. Accessed May 12, 2014.

17. Department of Defense Instruction 6490.03: Deployment Health. Washington, DC: US Dept of 

Defense; 2006 [current September 30, 2011]. Available at: http://www.dtic.mil/whs/directives/corres/

pdf/649003p.pdf. Accessed May 12, 2014.

Authors

Ms Sharkey is an Epidemiologist for the Environmental 

Medicine Program of the Occupational and Environmental Portfolio, US Army Public Health Command, Aberdeen Proving Ground, Maryland.

Dr Harkins is a Physician for the Environmental Medicine Program of the Occupational and Environmental 

Portfolio, US Army Public Health Command, Aberdeen 

Proving Ground, Maryland.

Mr Schickedanz is a Health Risk Communication Specialist for the Health Risk Management Portfolio, US 

Army Public Health Command, Aberdeen Proving 

Ground, Maryland.

Dr Baird is the Program Manager for the Environmental 

Medicine Program of the Occupational and Environmental Portfolio, US Army Public Health Command, Aberdeen Proving Ground, Maryland.

DEPARTMENT OF DEFENSE PARTICIPATION IN THE DEPARTMENT OF VETERANS AFFAIRS AIRBORNE 

HAZARDS AND OPEN BURN PIT REGISTRY: PROCESS, GUIDANCE TO PROVIDERS, AND COMMUNICATION
July – September 2014 51

Q fever is considered a worldwide zoonosis due to the 

intracellular rickettsia, Coxiella burnetti. In the United 

States, data has shown a 3.1% seroprevalence.1 However, 

prevalence rates vary widely among countries based on 

their ability to conduct proper surveillance. For example, 

rates are noted to be 18.3% in Morocco, 32.3% in Turkey, and 10% to 37% in northeast Africa.2-4 Cautiously, 

these estimates may underestimate the true incidence 

of disease due to its polymorphic clinical presentation.5

Typically, Q fever is considered an occupational hazard 

affecting persons in greatest contact with farm or laboratory animals. The reservoir includes a variety of wild 

and domestic mammals, birds, and arthropods.5 Urine, 

feces, milk, and birth products of infected animals are 

the main sources for transmission. Human infections 

primarily originate from either inhalation of contaminated aerosols or ingestion of raw milk products. The 

route of inhalation may occur directly from parturient 

fluids of infected animals during the birthing process.5

Additionally, it is highly resistant to harsh environments 

up to several weeks, and prevailing wind patterns have 

been known to transport this organism great distances 

from its source.5 As a result, Q fever may occur in patients without history of animal contact. Furthermore, 

the long incubation period (14-21 days) of this disease 

contributes to its elusive presentation in both acute and 

chronic progression.6

In acute cases, the most common clinical presentation is 

usually a self-limited febrile illness of unknown origin; 

however, there are degrees of its severity. Complications 

include but are not limited to granulomatous hepatitis, 

atypical pneumonia, and meningoencephalitis.7 Although not reported in the United States, progressive 

chronic fatigue has also been described in England and 

Australia; however, this syndrome is not considered diagnostic of an ongoing infection.8-10

Rarely does chronic Q fever develop (1% of acute cases). 

It may occur, however, more often (39%) in patients with 

preexisting cardiac valvulopathy.11 This may be defined 

by a clinical evolution more than 6 months duration 

with the presence of phase 1 immunoglobulin (Ig) G C. 

burnetti antibodies.5 The most common clinical manifestation of chronic infection is endocarditis involving 

the aortic and mitral valves.5 Interestingly, the majority of patients who develop chronic Q fever are older 

men (aged over 40 years) even though both genders may 

have similar exposures.7 Risk factors include immunosuppressed or immunocompromised persons, pregnancy, and vascular abnormalities. Nonetheless, preexisting valvulopathy, specifically prosthetic heart valves, 

remain the most predominant risk factor.5,11,12 Without 

treatment, phase 1 IgG titers remain persistently high 

along with further clinical deterioration.11,13

Diagnosis is primarily made by serologic testing. The 

method of choice is immunofluorescence assay.5,14 In the 

acute phase, phase 2 IgG and IgM antibodies are usually elevated around 1-2 weeks after the onset of symptoms, and around 90% of all cases seroconvert by the 

third week.15 A phase 2 IgG antibody titer of 1:200 or 

more and a phase 2 IgM antibody titer of 1:50 or more 

are highly suggestive of an acute infection.15 In contrast, 

the phase 1 IgG antibodies are predominant during 

chronic infections. In this stage, titers of 1:800 or more 

are considered to be significant.15 Antibodies generally 

peak around 1-2 months after the onset of symptoms.15

Gradually, the titers usually decrease in the following 

year; but IgG antibodies may persist while IgM antibodies disappear.15 When high levels of phase 1 antibodies 

remain positive, chronic Q fever is highly suggestive.15

Case

On March 31, 2011, a 39-year-old white female complained of generalized myalgias, nausea, headache, night 

sweats, subjective fevers, and chills for the past day followed by fatigue. Vitals were remarkable for slightly elevated heart rate (107) and temperature (101.9°F). Her 

occupation was described as an Army Reserve nurse 

deployed to Mosul, Iraq, in a combat support hospital. 

She had no significant past medical or recent surgical 

history. She denied any sick contacts to either humans or 

animals. She also denied any contact to unusual food or 

water sources. Intravenous fluids improved her condition 

Coinfection of Mycoplasma Pneumonia

 with Chronic Q Fever in a Nurse Deployed

 to Operation Iraqi Freedom: A Case Study

LTC Paul O. Kwon, MC, USA

Jason R. Pickett, MD
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

with no significant physical exam findings. Urine pregnancy test, blood counts, chemistries, rapid influenza, 

monospot test, and chest x-ray were all within normal 

limits. Despite the negative influenza swab, symptoms 

were consistent with a flu-like diagnosis. Consequently, 

the patient was prescribed a 5-day course of oseltamivir.

Two days later, her symptoms progressed to nausea, 

vomiting, and physical exam findings of cool, clammy 

skin. Although her blood cultures were negative, she 

was noted to have elevated liver enzymes: alanine aminotransferase (ALT 443), aspartate aminotransferase 

(AST 288) and alkaline phosphatase (AP 364). Yet, her 

right upper quadrant ultrasound was interpreted as normal. Zofran and intravenous fluids were given along 

with outpatient management.

On April 12, 2011, the patient had reoccurring myalgias; however, she now developed rhinitis, headache, 

anorexia and night sweats. She was afebrile on the visit 

but demonstrated sinus tachycardia (heart rate 125) that 

improved with an intravenous fluid bolus. She reported a history of persistent fevers as high as 102°F. Her 

physical exam was unremarkable. Although her urinalysis was normal, her blood counts were significant for 

decreased hemoglobin (Hgb 11) levels, hyperglycemia 

(glucose 200), elevated erythrocyte sedimentation rate 

(ESR 49) and c-reactive protein (CRP 24), but a resolving transaminitis (ALT 90, AST 36, AP 184).

During the second week of illness, the patient developed worsening erythematous, nonpruritic, but tender 

to palpation nodules on her bilateral legs (Figure 1). Initially, the primary diagnosis was presumed insect bites 

although no specific arthropod or species were identified. Follow-up 4 days later revealed nighttime 10/10 

joint pains with nonresolving bilateral leg nodules and 

a progressive rash to both arms. The nodules now appeared confluent including a rash to both palms of the 

hands (Figure 2). A diagnosis of erythema nodosum was 

made. Additionally, she complained of wakening night 

sweats and “hot flashes” during daytime hours. Vitals 

were unremarkable as additional labs continued to reveal anemia (Hgb 9.6 with schistocytes) along with persistent elevation of inflammatory markers (ESR>140 

and CRP 19.2). Other pertinent labs such as human immunodeficiency virus (HIV), hepatitis B and C, rapid 

plasma reagin, leishmaniasis cultures, liver function 

tests, and thyroid panel were all concluded as negative. 

Her pelvic exam was normal, and antigens for gonorrhea and chlamydia were also negative.

As a result, she was diagnosed with fever of unknown origin and evacuated to Landstuhl Regional Medical Center for further evaluation. Additional consultations revealed a negative tuberculin skin test, antistreptolysin O, 

hepatitis panel, nuclear antibody panel, ferritin, rheumatoid factor, histoplasma and coccidiodies antibody titers. 

The TORCH panel* revealed positive IgG antibodies for 

cytomegalovirus, herpes simplex virus, and rubella with 

no active lesions identified. Otherwise, her inflammatory markers were on a declining trend (CRP 3.16, ESR 

65). Notably, her mycoplasma antibody was positive and 

she was treated for mycoplasma pneumoniae.

On day 41, C. burnetti results, shown in the Table, returned with a concern for Q fever. As a result, further 

cardiac testing was completed. An electrocardiogram revealed a sinus arrhythmia while an echocardiogram diagnosed a mild left atrial enlargement, insignificant pulmonary insufficiency, moderate eccentric mitral regurgitation, as well as mild to moderate tricuspid regurgitation.

COINFECTION OF MYCOPLASMA PNEUMONIA WITH CHRONIC Q FEVER IN A NURSE DEPLOYED TO 

OPERATION IRAQI FREEDOM: A CASE STUDY

*A group of tests for toxoplasmosis, rubella, cytomegalovirus, herpes simplex, and HIV, but it can also include other infections.

Figure 1. Worsening erythematous, nonpruritic, but tender 

to palpation nodules on the patient’s bilateral legs that developed during the second week of illness.

Figure 2. Rash nodules on palms and legs.
July – September 2014 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

Detailed questioning failed to reveal any occupational or 

casual exposure to common Q fever vectors. The patient 

did not have any contact with livestock or likely animals. 

She had been quartered in an enclosed containerized 

housing unit (CHU) and denies any field exposure outside the combat support hospital housing area. Her CHU 

was located adjacent to a MEDEVAC helicopter landing 

zone where rotor downwash may have aerosolized soil 

particles that led to infection, although no other case reports were identified in her area of operations.

Based on the diagnosis of Q fever, the patient was treated with doxycycline for a 3-week course and returned 

to the combat theater to complete her tour. Initially, her 

phase 2 IgM titers were elevated consistent with an 

acute infection on day 41. Increasing phase 2 IgG titers 

followed on day 218 even after treatment. Later, her 

constitutional symptoms of fever, rash, and night sweats 

eventually resolved. However, follow-up serologies revealed persistent phase 1 IgG titers, consistent with a 

chronic infection.

Two years after diagnosis, the patient complained only 

of persistent arthralgias varying from 2 to 5 out of 10 

on a visual analog pain scale, a common complication 

of chronic disease. Follow-up titers indicated decreasing 

IgM titers consistent with convalescence, shown in the 

Table. Additionally, her serologic inflammatory markers 

returned to normal levels. Repeat echocardiogram on 

January 24, 2013, showed mild thickening of the anterior 

leaflet of the mitral valve, but otherwise there were no 

significant changes in her condition or cardiac function.

Comment

Since Operation Iraqi Freedom began, there have been 

reports of over 100 cases of Q fever among deployed US 

military personnel ascertained through a Department of 

Defense medical database.6,15-21 The most frequent presentation includes fever, pneumonia, or hepatitis.8,22 Despite these typical nonspecific signs and symptoms of the 

disease, Q fever is also known to possess a wide spectrum of manifestations including 7 distinct presentations 

described by Raoult: fever, pneumonia, hepatitis, meningitis, meningoencephalitis, pericarditis, and myocarditis.8

 Although cases of acute cholecystitis have been associated with this disease in some medical literature,23-26

it is not well described as part of the Q fever diagnosis. 

Consequently, this broad variation in clinical presentation can delay diagnosis and further treatment.

Our patient denied having typical risk factors including 

exposure to livestock or consumption of local meat or 

dairy products. However, it is known that direct exposure to the source is not necessary for an infection to 

occur.8,21,22 Further, coinfection with mycoplasma pneumoniae is not well described in the literature. However, 

atypical pneumonia have been discussed in limited regions of the world27 and more recently with investigations among HIV-infected patients.28

Additionally, chronic Q fever is infrequently reported 

among females. Her valvulopathy discovered on echocardiogram was considered mild to moderate without 

serious untoward symptoms or signs of endocarditis. 

There were no indications of a preexisting cardiac condition in her medical history. Once identified as an infection of C. burnetti, prompt treatment was initiated 

with direct follow-up. Subsequent laboratory studies 

confirmed resolution of her Q fever with an uncomplicated clinical course.

More importantly, Q fever is considered a category B 

biologic agent and is a potential threat to deployed Soldiers.29 In this case, direct contact with infected animals is not required for military personnel to 

be considered exposed. Transmission factors 

within military populations include sleeping 

in barns, tick bites, and living near helicopter 

landing zones where environmental aerosols 

are generated.16

In conclusion, this case report is an important 

reminder to medical providers of the existence 

of a myriad of unique infectious sources among 

deployed Soldiers or those returning from 

abroad. A heightened awareness of this insidious disease will ensure prompt diagnosis and 

treatment ultimately preventing future complications. 

Lastly, the occupational and environmental history is a 

key determinant of success for any clinical practice.

References

1. Anderson AD, Kruszon-Moran D, Loftis AD, et 

al. Seroprevalence of Q fever in the United States, 

2003-2004. Am J Trop Med Hyg. 2009;81(4):691-694.

Results of serologic testing for presence of Coxiella burnetti.

Date Phase 1 IgG Phase 2 IgG Phase 1 IgM Phase 2 IgM ESR CRP

04/27/11 <1:16 <1:16 1:1024 1:2048 65 3.16

05/23/11 1:256 1:4096 1:4096 1:2048 – –

11/03/11 1:1024 1:16384 1:256 1:16 – –

08/22/12a ≥1:256 ≥1:256 Negative Negative – –

10/17/12a 1:4096 1:8192 Negativeb Negative 16 0.63

04/11/13a 1:128 1:128 Not 

Performed

Not 

Performed

11 0.40

aAll subsequent lab results from 08/22/2012 to 04/11/2103 were processed by ARUP 

Laboratories (University of Utah, Salt Lake City).

bAlthough the test was deemed negative by the laboratory’s screening lab, titers were 

processed by the Director of Laboratory Operations and read as 1:16.
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Botros BA, Soliman AK, Salib AW, et al. Coxiella 

burnetii antibody prevalences among human populations in north-east Africa determined by enzyme 

immunoassay. J Trop Med Hyg. 1995;98(3):173-178.

3. Meskini M, Beati L, Benslimane A, Raoult D. Seroepidemiology of rickettsial infections in Morocco. Eur J Epidemiol. 1995;11(6):655-660.

4. Kilic S, Yilmaz GR, Komiya T, Kurtoglu Y, Karakoc EA. Prevalence of Coxiella burnetii antibodies 

in blood donors in Ankara, Central Anatolia, Turkey. New Microbiol. 2008;31(4):527-534.

5. Maurin M, Raoult D. Q fever. Clin Microbiol Rev. 

1999;12(4):518-553.

6. Gleeson TD, Decker CF, Johnson MD, Hartzell JD, 

Mascola JR. Q fever in US military returning from 

Iraq. Am J Med. 2007;120(9):e11-e12.

7. Raoult D, Tissot-Dupont H, Foucault C, et al. Q 

fever 1985-1998. Clinical and epidemiologic features of 1,383 infections. Medicine (Baltimore). 

2000;79(2):109-123.

8. Raoult D, Marrie T, Mege J. Natural history and 

pathophysiology of Q fever. Lancet Infect Dis. 

2005;5(4):219-226.

9. Ayres JG, Flint N, Smith EG, et al. Post-infection fatigue syndrome following Q fever. QJM. 

1998;91(2):105-123.

10. Ayres JG, Wildman M, Groves J, Ment J, Smith 

EG, Beattie JM. Long-term follow-up of patients 

from the 1989 Q fever outbreak: no evidence of 

excess cardiac disease in those with fatigue. QJM. 

2002;95(8):539-546.

11. Fenollar F, Fournier PE, Carrieri MP, Habib 

G, Messana T, Raoult D. Risks factors and prevention of Q fever endocarditis. Clin Infect Dis. 

2001;33(3):312-316.

12. Fenollar F, Thuny F, Xeridat B, Lepidi H, Raoult 

D. Endocarditis after acute Q fever in patients with 

previously undiagnosed valvulopathies. Clin Infect 

Dis. 2006;42(6):818-821.

13. Landais C, Fenollar F, Thuny F, Raoult D. From 

acute Q fever to endocarditis: serological follow-up 

strategy. Clin Infect Dis. 2007;44(10):1337-1340.

14. Fournier PE, Marrie TJ, Raoult D. Diagnosis of Q 

fever. J Clin Microbiol. 1998;36(7):1823-1834.

15. Leung-Shea C, Danaher PJ. Q fever in members of 

the United States armed forces returning from Iraq. 

Clin Infect Dis. 2006;43(8):e77-e82.

16. Hartzell JD, Peng SW, Wood-Morris RN, et al. 

Atypical Q fever in US Soldiers. Emerg Infect Dis. 

2007;13(8):1247-1249.

17. Hartzell JD, Wood-Morris RN, Martinez LJ, Trotta 

RF. Q fever: epidemiology, diagnosis, and treatment. Mayo Clin Proc. 2008;83(5):574-579.

18. Faix DJ, Harrison DJ, Riddle MS, et al. Outbreak of 

Q fever among US military in western Iraq, JuneJuly 2005. Clin Infect Dis. 2008;46(7):e65-e68.

19. Ellis SB, Appenzeller G, Lee H, et al. Outbreak of 

sandfly fever in central Iraq, September 2007. Mil 

Med. 2008;173(10):949-953.

20. Aronson NE, Sanders JW, Moran KA. In harm’s 

way: infections in deployed American military 

forces. Clin Infect Dis. 2006;43(8):1045-1051.

21. Anderson AD, Smoak B, Shuping E, Ockenhouse C, 

Petruccelli B. Q fever and the US military. Emerg 

Infect Dis. 2005;11(8):1320-1322.

22. Parker NR, Barralet JH, Bell AM. Q fever. Lancet. 

2006;367(9511):679-688.

23. Rolain JM, Lepidi H, Harle JR, et al. Acute acalculous cholecystitis associated with Q fever: report of 

seven cases and review of the literature. Eur J Clin 

Microbiol Infect Dis. 2003;22(4):222-227.

24. Reina-Serrano S, Jimenez-Saenz M, HerreriasGutierrez JM, Venero-Gomez J. Q fever-related 

cholecystitis: a missed entity?. Lancet Infect Dis. 

2005;5(12):734-735.

25. Modol JM, Llamazares JF, Mate JL, Troya J, Sabria M. Acute abdominal pain and Q fever. Eur J 

Clin Microbiol Infect Dis. 1999;18(2):158-160.

26. Kelly RP, Byrnes DJ, Turner J. Acute, severe hepatitis due to Coxiella burneti infection. Med J Aust. 

1986;144(3):151-152,154.

27. Marrie TJ, Haldane EV, Noble MA, Faulkner RS, 

Martin RS, Lee SH. Causes of atypical pneumonia: results of a 1-year prospective study. CMAJ. 

1981;125(10):1118-1123.

28. Marrie TJ, Peeling RW, Fine MJ, Singer DE, Coley CM, Kapoor WN. Ambulatory patients with 

community-acquired pneumonia: the frequency 

of atypical agents and clinical course. Am J Med. 

1996;101(5):508-515.

29. Daya M, Nakamura Y. Pulmonary disease from 

biological agents: anthrax, plague, Q fever, and tularemia. Crit Care Clin. 2005;21(4):747-763,vii.

Authors

When this article was written, LTC Kwon was with the 

Department of Preventive Medicine, Madigan Army 

Medical Center, Tacoma, Washington. He is currently 

Chief of Preventive Medicine, US Army Medical Activity-Alaska, Fort Wainwright, Alaska.

Dr Pickett is an Assistant Professor, Department of 

Emergency Medicine, Wright State University, Dayton, 

Ohio. He is also a Major in the West Virginia Army National Guard where he serves as a battalion surgeon.

COINFECTION OF MYCOPLASMA PNEUMONIA WITH CHRONIC Q FEVER IN A NURSE DEPLOYED TO 

OPERATION IRAQI FREEDOM: A CASE STUDY
July – September 2014 55

History

The acronym TCAPS, for Tactical Communication and 

Protection Systems, was introduced in the Army Hearing Program Special Text 4-02.501, released in 2008,1

and is quickly becoming a known and understood acronym in the vernacular of many American Soldiers’ 

Army line units. Broadly categorized as in-the-ear, overthe-ear, wired, or wireless, TCAPS is the generic term 

for the growing selection of amplified hearing protection systems available for purchase.

A number of manufacturers have employed modern 

hearing aid technology to create these systems for the 

military population using a variety of modern digital 

signal processing algorithms, including digital compression and/or active noise reduction. In 1993, the Bose 

Corporation (Framingham, MA) became the first company to supply an active noise reduction (ANR) system 

to the US Army’s armored vehicle personnel with the 

combat vehicle crewman headset.2 The more current 

TriPort Tactical Headset Series 2 ANR headset was 

used in many wheeled armored vehicles throughout Operation Iraqi Freedom and continues to be used today 

in noise hazardous military vehicles such as the M-1114 

High-Mobility, Multipurpose Wheeled Vehicle and the 

Stryker. In 2007, the US Marine Corps contracted with 

Honeywell Safety Products (Smithfield, RI) to provide 

Marines with in-the-ear, wired TCAPS under the trade 

name of Integrated Intra Squad Radio Hearing Protection Headsets.3

 In 2012, the US Army Rapid Equipping 

Force acquired a source of supply code for the Peltor 

over-the-ear ComTac III headsets (3M Personal Safety 

Division, St Paul, MN) TCAPS for regular Army purchase through the Defense Logistics Agency. Previously, 

the source of supply code had been maintained and used 

only by Special Operations Forces.4 The TEA INVISIO 

X50 (TEA Inc, Brewster, NY) is one of the most current 

TCAPS receiving attention from the US Army Hearing 

Program. In October 2013, the US Army’s Program Executive Office Soldier awarded a $7.5 million contract 

to TEA Inc for INVISIO X50 systems to address the 

TCAPS requirement.5 The X50 will be fielded to 3 brigade combat teams during 2014 at Ft Campbell, Ft Drum, 

and Ft Bragg.6 Even amidst these large scale contracts 

and research endeavors, we still see small groups of 

Soldiers who spend precious, limited unit funds or even 

their personal funds on one or more TCAPS devices and 

accessories.

Data Collection

This quality assurance data report concerns a US Army 

Alaska light infantry brigade (airborne) which redeployed to their home duty station, the Fort Richardson 

side of Joint Base Elmendorf-Richardson, after a yearlong combat tour in Afghanistan. The infantryman’s 

job description includes 3 tasks: shoot, move, and communicate. Good hearing is a force multiplier. A sudden 

temporary or permanent hearing loss from acoustic 

trauma in combat has the potential to render the individual Soldier, or even the entire unit, ineffective, which 

could result in mission failure. Experience has shown 

that Soldiers completely understand the importance of 

both having robust, clear, communication abilities on 

the battlefield and the protection of the precious sense 

for that capability—hearing.

All Soldiers who deploy or redeploy from combat are required to undergo a series of health assessments through 

a process known as Soldier Readiness Processing. US 

Army Alaska refers to this process as deployment cycle 

support (DCS). At the Fort Richardson Soldier Centered 

Medical Home, the DCS health assessment process includes, among other things, a check of each Soldier’s 

current hearing ability to determine and document each 

individual’s Hearing Readiness status in the US Army 

Medical Protection System per Army Regulation 40-501.

7

The Soldier is fitted with a new pair of hearing protection, typically filtered (nonlinear) or nonfiltered (linear) 

hearing protection in conjunction with the DCS hearing check. The entire process is fairly intense, with long 

lines of jetlagged, homesick Soldiers who want to finish 

quickly so that they can go home and decompress with 

their family and friends. It was during the postdeployment DCS hearing check and earplug fitting that each 

Soldier was asked: “what type of hearing protection did 

you wear in Afghanistan?” After asking this question to 

the first few hundred troops, we noticed that several indicated they had used an identical brand of over-the-ear 

Over the Ear Tactical Communication and

 Protection System Use by a Light Infantry

 (Airborne) Brigade in Afghanistan

MAJ Leanne Cleveland, MS, USA
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

(OTE) TCAPS during dismounted operations. Recognizing this to be a good opportunity for data collection 

and quality assurance reporting, I prepared a questionnaire that evening and began handing it out through the 

rest of the DCS process to any Soldier who reported that 

he had used this particular OTE TCAPS. In addition to 

analyzing the subjective data from the surveys, objective data (the pre- and postdeployment hearing tests) 

of the 56 OTE TCAPS users was compared to the nonTCAPS users. Both subjective and objective outcomes 

are presented.

Subjective Responses: Questionnaire Results

Fifty-six surveys were collected from October 13 to October 21, 2012. All respondents were male. The average 

age was 29 years. More than 50% were infantry or mortar team Soldiers (43% and 11% respectively). The survey used a Likert scale of 5 simple “smiley faces” ranging from a big smile to a big frown, shown in Figure 1, 

for Questions 1 to 4. The smiley face Likert scale was 

selected over a numeric scale because the goal was to 

keep the survey as simple and user-friendly as possible, 

especially given that the respondents were, for the most 

part, very sleepy and experiencing jetlag, and were not 

enthusiastic about the DCS process.

The subjective data collected from Questions 1 through 5 

of the surveys are as follows:

Many responses to Questions 6 and 7 included additional information and/or explanations which are synopsized as follows:

The 27% of respondents who indicated “Other” for 

Question 6 typically included some explanation of how 

impressed and satisfied they were with a system that amplifies quiet speech sounds while dampening unexpected 

impulse noises, which is encouraging for Army audiologists who are searching for incentives to convince Soldiers to wear hearing protection in hazardous noise environments. The statistic that 14% of Soldiers indicated 

that they liked the ability to localize sound is surprising. 

Situational awareness is key for survivability on the battlefield. The human brain uses subtle differences in intensity, spectral, and timing cues in an open, uncovered 

ear to determine the location of a sound source. One of 

the concerns with OTE TCAPS is that covering the ear 

adversely affects the ability of the wearer to use interaural time delays between the ears and the head shadow 

effect, which could compromise their ability to localize 

the origin of dangerous sounds. This is especially true 

given the microphone placement on the front of the OTE 

TCAPS, which would give the wearer the impression 

that all sounds originate directly from the front. However, consider the infantry patrol for a moment. Every 

dismounted patrol is set up with a point, rear, and flank 

guard. Each individual is responsible for their assigned 

sector in front of them, which may explain why amplifying sounds from directly in front helped this group 

of Soldiers, primarily infantrymen, and gave them the 

impression of improved localization ability.

In response to Question 7, 60% specifically wrote that 

the OTE TCAPS became too hot and/or too tight after a while, typically after 8 to 12 hours of continuous 

use. Several surveys described pouring out their “sweat 

2. How do you rate the clarity of radio communications 

with the OTE TCAPS?

Very

Good

Good Neither

Good Nor

Bad

Bad Very

Bad

75% 25% 0 0 0

OVER-THE-EAR TACTICAL COMMUNICATION AND PROTECTION SYSTEM USE BY A LIGHT INFANTRY 

(AIRBORNE) BRIGADE IN AFGHANISTAN

Figure 1. “Smiley face” Likert scale used for responses to 

Questions 1 through 4 on the DCS hearing assessment 

questionnaire.

Very Good Good Neither Good Bad Very Bad

 Nor Bad

6. What OTE TCAPS feature did you LIKE the most?

Radio communications 40%

Dismounted operations 19%

Localization of sound 14%

Other 27%

1. How do you rate the comfort of the OTE TCAPS?

Very

Good

Good Neither

Good Nor

Bad

Bad Very

Bad

41% 36% 21% 2% 0

4. Overall, how much do you think the OTE TCAPS helped 

to improve your warfighter lethality and survivability 

on the battlefield?

Very

Good

Good Neither

Good Nor

Bad

Bad Very

Bad

63% 33% 4% 0 0

3. How clear was spoken language from other Soldiers 

around you using the external microphone in dismounted operations (not radio communications)?

Very

Good

Good Neither

Good Nor

Bad

Bad Very

Bad

54% 39% 5% 2% 0

5. Did the OTE TCAPS improve your situational awareness?

Yes No No

Response

84% 14% 2%
July – September 2014 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

pools” that collected in the ear cups after extended periods of use. At first this appears contradictory to the 

responses in Question 1, in which 77% described the 

comfort as Good or Very Good. But it is also possible 

that the comfort issues that arise after 8 to 12 hours of 

continuous use may be a reflection of their environment. 

The vast majority of Afghanistan is undeveloped, usually only dirt and sand, where Soldiers can go 

for days without a shower. Sweat will always 

attract dirt and sand. The combination of sweat 

and dirt may have made the OTE TCAPS feel 

like sandpaper being worn on their ears, and yet 

the 56 survey respondents continued to wear 

them. The comfort issues described may have 

more to do with the basic challenges a Soldier 

faces living in a war zone than issues with the fit or design of the OTE TCAPS.

The responses to Question 8 speak to the frugality of 

experienced Soldiers. Perhaps not all Soldiers need 

TCAPS. If everybody had one, it could get very costly 

which should be considered during this time of fiscal constraint. Then again, every Soldier is exposed 

to noise just by being in the Army, especially in 

field training and deployed environments. Priority 

should initially be given to those who need them 

the most, but a universal Army-wide or even Department of Defense-wide TCAPS issue is something that almost half of this survey group would 

like to see.

Objective Data: Comparison of Pre- and

Postdeployment Hearing Levels

Every US Army Soldier’s hearing test data is stored 

in the Defense Occupational and Environmental 

Readiness System–Hearing Conservation (DOEHRS-HC) data repository. Queries to that repository for data of the 2,801 Soldiers who underwent 

postdeployment hearing tests at Fort Richardson 

from October 13 to October 21, 2012, indicated that 

1,068 were non-OTE TCAPS users assigned to the 

same units as the 56 OTE TCAPS users who responded to the questionnaire. Further, comparison 

of pre- and postdeployment hearing test data showed a 

positive, significant threshold shift (STS) in 85 of those 

1,068 non-OTE TCAPS users, as shown in the Table. 

The Department of Defense uses the Occupational Safety and Health Administration’s definition of an STS8

: 

a change in hearing threshold relative to the baseline 

audiogram of an average of 10 dB or more at 2000 Hz, 

3000 Hz, and 4000 Hz in either ear. Only one of the 56 

OTE TCAPS users showed a STS, which is equivalent 

to a 1.78% STS rate. Figure 2 presents the average preand postdeployment audiograms for the 56 OTE TCAPS 

users. In contrast, the non-OTE TCAPS group from the 

same units had a 7.95% STS rate. 

A χ2 analysis compared the STS rate in the group of 56 

OTE TCAPS users to the STS rate in the group of 1,068 

non-OTE TCAPS users, with the assumption that, given 

that they were assigned to the same units, a portion of 

the 2 groups of Soldiers must have gone together on the 

same missions, and therefore were exposed to a similar 

level (if not the exact same) of hazardous noise. Results 

showed a significant difference between the 2 groups’ 

STS rates (P=.022642), demonstrating that OTE TCAPS 

users had significantly less hearing loss than those who 

did not wear OTE TCAPS.

8. Would you recommend that OTE TCAPS become 

a unit issue for Soldiers?

Yes No

In your military occupational specialty (MOS) 98% 2%

In another MOS 75% 25%

In every MOS 49% 51%

7. What did you DISLIKE the most about the OTE TCAPS?

Too hot and/or too tight after 

extended wearing, typically 8 to 

12 hours

60%

Wires 7%

Other 33%

Questionnaire Data Used for χ2 Analysis.

TCAPS Users

Surveyed Oct 13-21

1.78% STS Rate

No TCAPS Use

Surveyed Oct 13-21

7.59% STS Rate

Rest of Brigade

No TCAPS Use

10% STS Rate

Total

STS 1 85 168 254

No STS 55 983 1,509 2,547

Total 56 1,068 1,677 2,801

Predeploy Right

Predeploy Left Postdeploy Left

Postdeploy Right

500 HZ 1000 HZ 2000 HZ 3000 HZ 4000 HZ 6000 HZ

Tone Frequency

20

18

16

14

12

10

8

6

4

0

2

Decibels Hearing Level

Figure 2. Average pre- and postdeployment audiogram results for the 

56 questionnaire respondents who indicated that they had consistently worn OTE TCAPS throughout the deployment.
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

Summary and Conclusion

The value of this quality assurance data report is that it 

was initiated at the individual Soldier level, using one 

of the oldest and most basic OTE TCAPS technologies 

available. The device that was used by the Soldiers in this 

report meets ruggedization standards per MIL-STD 810 9

and electromagnetic compatibility per MIL-STD-461.

10

Also of interest considering the repeated exposure to often considerable perspiration, these OTE TCAPS meet 

the standard for salt water submersion (3 feet for 30 

minutes).11 Over-the-ear devices do not require special 

fitting, as opposed to in-the-ear devices which must be 

fitted by medically trained personnel.12 Although the 

system is technically complex and sophisticated, it is 

very user-friendly. There are only 2 control buttons on 

this OTE TCAPS: press and hold one button to turn on 

or off; press each button in short duration to adjust the 

volume level to louder or softer. Batteries (AA) are easy 

to find, inexpensive, and last approximately 270 hours. 

Analog compression technology uses a peak clipping 

strategy to block any hazardous impulse noise. There 

is no active noise reduction for protection from steady 

state noise, but the tight fitting and well-sealed gel ear 

cups provide maximum passive attenuation. There are 

optional push-to-talk (PTT) devices for radio connectivity. Soldiers who carry 2 radios can use 2 PTTs, or a 

single PTT with a toggle switch. Given the current and 

future TCAPS innovations using smaller, smarter digital, custom, and wireless technology, there is considerable potential for advancement in active noise reduction 

for protection from steady-state noise, as well as digital compression for protection from hazardous impulse 

noise. As the Army continues to endorse a more preventive approach and emphasis in all aspects of healthcare, 

the provision of hearing aids for service-related hearing 

loss may some day become only a minor component of 

the Army Hearing Program.

References

1. Special Text 4-02.501: Army Hearing Program.

Fort Sam Houston, Texas: US Army Medical 

Department Center & School; February 1, 2008. 

Available at: http://militaryaudiology.org/site/wpcontent/images/st_4_02_501.pdf. Accessed February 17, 2014. 

2. Military Application: Combat Vehicle Crewman 

Headset page. Bose Corporation Web site. Available 

at: http://www.bose.com/controller?event=view_

static_page_event&url=/professional/military/

crewman.jsp. Accessed February 19, 2014. 

3. Defense Update. International, Online Defense 

Magazine [serial online]. Available at: http://de

fense-update.com/newscast/0907/news_27_09_07.

htm#quietpro. Accessed February 19, 2014. 

4. Peltor No Longer Restricted. PS Magazine online. 

Fort Belvoir, VA: US Army Logistics Support Activity; 2012;715:50. Available at: https://www.logsa.

army.mil/psmag/archives/PS2012/715/715-50.pdf. 

Accessed February 19, 2014. 

5. TEA Headsets Awarded TCAPS Order For INVISIO X50 System. Soldier Systems [serial online]. 

October 9, 2013; Comms section. Available at: 

http://soldiersystems.net/2013/10/09/tea-headsetsawarded-tcaps-order-for-invisio-x50-system/. Accessed February 19, 2014. 

6. Cissna M. Aberdeen Proving Grounds, MD: US 

Army Public Health Command; email, December 

4, 2013.

7. Army Regulation 40-501: Standards of Medical Fitness. Washington, DC: US Dept of the Army; December 14, 2007 [revision August 4, 2010]:116[chap 

11-4.g]. Available at: http://www.apd.army.mil/pdf

files/r40_501.pdf. Accessed February 20, 2014. 

8. Occupational Noise Exposure, 29 CFR §1910.95(g). 

Available at: https://www.osha.gov/pls/oshaweb/ow

adisp.show_document?p_table=standards&p_

id=9735. Accessed February 20, 2014.

9. MIL-STD-810G: Department of Defense Test 

Method Standard: Environmental Engineering 

Considerations and Laboratory Tests. Washington, 

DC: US Dept of Defense; October 31, 2008. Available at: http://www.atec.army.mil/publications/

Mil-Std-810G/Mil-Std-810G.pdf. Accessed February 20, 2014. 

10. MIL-STD-461F: Department of Defense Interface 

Standard: Requirements for the Control of Electromagnetic Interference Characteristics of Subsystems and Equipment. Washington, DC: US Dept of 

Defense; December 10, 2007. Available at: http://

snebulos.mit.edu/projects/reference/MIL-STD/

MIL-STD-461F.pdf. February 20, 2014. 

11. Fallon E. Technical Services, 3M Personal Safety 

Division; email, 2013.

12. Department of the Army Pamphlet 40-501: Hearing Conservation Program. Washington, DC: US 

Dept of the Army; December 10, 1998. Available 

at: http://www.apd.army.mil/pdffiles/p40_501.pdf. 

Accessed April 11, 2014.

Author

MAJ Cleveland is Officer in Charge, Army Hearing Program US Army-Alaska, Joint Base Elmendorf-Richardson, Alaska.

OVER-THE-EAR TACTICAL COMMUNICATION AND PROTECTION SYSTEM USE BY A LIGHT INFANTRY 

(AIRBORNE) BRIGADE IN AFGHANISTAN
July – September 2014 59

In 1981, The Army Surgeon General established the 

Health Hazard Assessment (HHA) Program to evaluate the potential adverse health effects on Soldier users 

and maintainers of operating military weapon systems.1

In 1983, Department of Defense Directive 5000.1 (redesignated as DoDD 5000.012

 in 2003) directed all uniformed services to consider health hazards as an integral 

part of their materiel acquisition process. Also in 1983, 

Army Regulation 40-10 3 formally established the US 

Army Center for Health Promotion and Preventive Medicine (USACHPPM) HHA Program. The Army Surgeon 

General designated the USACHPPM (now the US Army 

Public Health Command) as the lead agent of the HHA 

process in 1985, with the primary goal of identifying 

health hazards, assigning risk, and providing recommendations to eliminate or control those health hazards 

associated with the life cycle management of weapons, 

equipment, clothing, training devices, and other materiel systems.

Health Hazard Assessment Program and

Toxicology Portfolio

When health hazards are identified, estimates of health 

risk severity and probability are established using risk 

assessment codes. The risk assessment code procedure, adopted from Military Standard 882E,

4

 is used to 

quantify health risks to military personnel who will be 

operating or maintaining Army systems during testing, 

training, or combat. The following health hazards categories are assessed by the HHA program and defined 

in Army Regulation 40-10 3:

acoustic energy shock

biological substances temperature extremes

chemical substances trauma

oxygen deficiency ultrasound

radiation energy vibration

This article focuses exclusively on toxicity clearances 

(TC) and the HHA process that deals with chemical substances. When a new chemical substance not previously 

approved for Army use is proposed for use in an item 

under assessment by the HHA Program, the HHA Program will normally ask the AIPH Toxicology Portfolio 

(TOX) to conduct a toxicity evaluation of the chemical. 

The toxicity evaluation leads to the development of a 

TC for inclusion or reference in the HHA report. When 

a new chemical is proposed for use not associated with 

a particular weapon or piece of equipment but generically throughout the Army, approval must be obtained 

via a TC. The Army Surgeon General’s TOX Portfolio at 

AIPH is described in Army Regulation 40-5.

5

A toxicity evaluation and clearance for a specific chemical or material prior to its use helps to ensure the safety 

of Army personnel. A TC involves a toxicity evaluation 

of chemicals and materials prior to the introduction into 

the Army supply system. In some cases, a TC given 

for one item with a given use scenario may not be accepted for an item with the same compound for another 

use scenario. The materiel developer is responsible for 

identifying technically feasible materials and requesting 

appropriate consultation from AIPH TOX Portfolio.

In order to initiate the TC, the materiel developer must 

provide background information concerning the product 

material along with the request for the TC. The information should include the scope and length of use on 

the commercial market, human and/or animal toxicity 

data, a safety data sheet,* reports of any known adverse 

health effects, and manufacturing use information that 

will help ascertain the means and magnitude of exposure to military personnel. The requirement for additional toxicity testing will vary with the intended use of 

the candidate item and its chemical attributes. Examples 

of items requiring a TC are:

solvents energetics

fire extinguishing agents propellants

repellents pyrotechnics

fabric finishes hydraulic fluids

refrigerants metals/alloys

explosives pest control agents

Toxicity clearances are granted for specific applications, 

In many cases, approval for one situation may not apply 

for a different use if the exposure scenario has changed.

Health Hazard Assessment and the

 Toxicity Clearance Process

Mohamed R. Mughal, PhD

John Houpt

Timothy A. Kluchinsky, Jr, DrPH

*Occupational Safety and Health Administration Form 20
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

Following the TOX Portfolio review of the pertinent information, guidance is issued in the form of a TC memorandum regarding the safe use of the proposed material. 

It is possible that a TC may not be granted because of 

insufficient toxicological data. In that case, additional 

toxicological testing is recommended. It is also possible 

that additional safety and health procedures, equipment, 

and/or controls are recommended for the safe use of a 

particular material in a specific application.

The HHA Program then reviews the TC developed by 

the TOX Portfolio and incorporates the applicable findings into the HHA report. A risk assessment code and 

a mitigation strategy may be developed with a residual 

risk assessment code assigned by the subject matter expert assuming the mitigation strategy is applied.

A TC is an extremely valuable tool for the materiel developer to make a more-informed decision on the possible 

use of a chemical or material. It is important to remember 

that a TC is application and exposure scenario specific.

The TOX Portfolio does recommend substitute material(s) based on efficacy of a product (for example: is 

chemical X a better solvent than chemical Y?) during 

the research, development, test and evaluation phase of 

acquisitions. The decision-maker at the requesting organization, with appropriate medical health and safety 

guidance from the AIPH, is responsible for those decisions and recommendations for a candidate substitute.

Formerly, chemicals and materials used in the development and sustainment of Army systems were addressed 

in military specifications and standards. As a result of 

the implementation of acquisition reform/streamlining 

throughout the Department of Defense, performance 

specifications, commercial item descriptions, and consensus standards are replacing military specifications 

and standards. Military specifications and standards 

that may have received an initial toxicity review upon 

development, and those still in effect, are reviewed periodically to evaluate newly developed toxicity information. Because numerous products and chemicals without 

appropriate medical and toxicological evaluation are 

being proposed as alternatives, the TC is an even more 

valuable tool for Army leadership responsible for procurement or acquisition-related decisions.

The materiel developer must contact the AIPH TOX 

Portfolio to request a TC on a chemical or material early 

in the acquisition process to avoid delays. Direct contact 

with TOX Portfolio to determine if a TC has been completed on a chemical/material is recommended.

Conclusion

Since 1981, the Army HHA Program has provided an 

invaluable service to capability and materiel developers 

by providing recommendations designed to eliminate or 

control health hazards associated with weapon systems 

and other materiel. The HHA Program has consistently 

strived to improve its services by providing more meaningful and efficient assistance to the acquisition community, such as incorporation of the TC process. In the 

uncertain fiscal times ahead, the Army HHA Program 

and TOX Portfolio will continue to provide valuable and 

cost-effective solutions to mitigate health risks associated with the use of new and improved materiel systems.

Acknowledgement

The authors thank the following individuals for their 

contributions to the development of this article: Dr Mark 

Johnson, Director of the TOX Portfolio; Dr Wilfred McCain, a Toxicologist in the TOX Portfolio; and MAJ Sang 

Lee, MS USA, Executive Officer of the TOX Portfolio.

References

1. Gross R, Broadwater T. Health hazard assessments. In: Deeter DP, Gaydos JC, eds. Occupational Health: The Soldier and the Industrial Base. 

Fort Sam Houston, TX: The Borden Institute; 

1993:165-206.

2. Department of Defense Directive 5000.01: The 

Defense Acquisition System. Washington, DC: US 

Dept of Defense; 2003 [current as of 2007].

3. Army Regulation 40-10: Health Hazard Assessment 

Program in Support of the Army Acquisition Process. Washington, DC: US Dept of the Army; 2007.

4. MIL-STD-882E: Department of Defense Standard 

Practice-System Safety. Washington DC: US Dept 

of Defense; 2012.

5. Army Regulation 40-5: Preventive Medicine. Washington, DC: US Dept of the Army; 2007.

Authors

All authors are assigned to the Army Institute of Public 

Health, US Army Public Health Command, Aberdeen 

Proving Ground, Maryland.

Dr Mughal and Mr Houpt are Industrial Hygienists with 

the HHA Program.

Dr Kluchinsky is the Manager of the HHA Program.

HEALTH HAZARD ASSESSMENT AND THE TOXICITY CLEARANCE PROCESS
July – September 2014 61

Interest in the subject of chemical and biological warfare 

has resurged recently. In the United States, the interest 

had waned substantially due in part to the 1969 decision by President Richard Nixon to ban research on the 

development or use of these weapons for offensive purposes.1

 Although chemical and biological weapons have 

always been perceived as potential hazards in the world 

of asymmetric warfare, the general focus of those concerned with weapons of mass destruction (WMD) tended to be on nuclear weapons. Several events led policy 

makers, medical planners and others to reconsider this 

narrow focus. Among the first of these events was the 

realization that the Soviet Union had continued to develop a broad range of biological and chemical weapons 

despite being a signatory of treaties that banned such 

research and development. The defection of Ken Alibek, 

a high-ranking Soviet scientist involved in development 

of biological weapons, revealed a sizeable infrastructure in the Soviet Union for development of biological 

WMD.2 The dissolution of the Soviet Union raised concerns among scientists in the west that the substantial 

stocks of biological agents in the Soviet laboratories 

could make their way into the hands of terrorists or 

rogue nations.3 An earlier event in which a weaponized 

chemical was used in the subways of Tokyo by a religious cult seemed to justify this concern,4

 as did the stated interest by other terrorist groups, including Al Qaida, 

in obtaining and using these weapons. The heavy use 

of chemical weapons in the Iran-Iraq war of the 1980s 

also brought attention to these agents, especially with 

the increased involvement of the United States in the 

Middle East beginning with Operations Desert Shield 

and Desert Storm. The suspected presence of chemical and biological weapons in Iraq eventually played 

an important role in the decision to invade that country in 2003. Although weaponized chemicals may not 

have played a significant role in the decision to invade 

Afghanistan, subsequent suspected use of toxic agricultural chemicals against the students in girls’ schools of 

that country5 in 2010 suggested a willingness by groups 

hostile to the United States to use such chemicals. More 

recently, the chemical weapons of the Syrian regime and 

the suspected use of those weapons in that country’s civil war have ensured that WMDs have continued to be in 

the public eye. The United States and other countries 

are currently working to obtain and destroy the Syrian 

chemical weapons.

Since 2012, the graduate Missouri State University 

(MSU) Department of Defense and Strategic Studies 

(DDSS) has taught an online graduate course in chemical and biological warfare to students in the university’s 

Master of Science degree in Defense and Strategic Studies. More recently, the course has become a requirement 

in the Master of Science Degree in Weapons of Mass 

Destruction Studies, a collaborative program of Missouri State University and the National Defense University. The course has evolved over a short time to address 

the needs of an increasingly diverse group of students. 

This article describes the development, content, and current status of that course. The purpose is to demonstrate 

how collaboration between the military, the government, 

and academia can address the nation’s need for persons 

trained in the study of chemical and biological warfare.

Course History and Development

The need for an online graduate course in chemical and 

biological warfare is a reflection of the unique mission 

of the MSU DDSS. The graduate DDSS was established 

at the University of Southern California in 1972 and 

flourished under the directorship of the late Professor 

William R. Van Cleave. Based on his experience as a 

member of the original US delegation to the US-Soviet 

Strategic Arms Reductions Talks, Professor Van Cleave 

was concerned that the academic approach to the study 

of international security issues was overly theoretical, 

and did not prepare students well for professional careers in the field, either in government or industry. Consequently, Professor Van Cleave designed the Defense 

and Strategic Studies (DSS) graduate curriculum to include the practice of international relations as a main 

focus of the curriculum. Every course included an understanding of the actual practice of international relations and the practical application of concepts and theory as a student learning goal. While some graduates of 

the DSS program moved into academic positions, most 

pursued careers in government, the military, defense industry, and the “think tank” community. Many of the 

early graduates now hold senior positions in government, industry, or think tanks. For example, the recent 

Chemical and Biological Warfare: Teaching

 the Forbidden at a State University

CDR (Ret) David M. Claborn, MSC, USN

Keith Payne, PhD
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

Secretary of the Air Force, Michael Donley, is a graduate of the Defense and Strategic Studies program, as is J. 

D. Crouch, who served as the Deputy National Security 

Advisor to President George W. Bush.

Professor Van Cleave moved the DSS program to MSU 

in Springfield, Missouri, in 1987 and continued to emphasize professional education for public service. Upon 

his retirement in 2005, MSU relocated the entire department to Fairfax, Virginia, to enable students to take 

advantage of the many resources available only in the 

Washington, DC, area for students in this field. Such resources include unparalleled access to professors with 

deep and pertinent professional experience in government, and readily available internships in government 

and industry offices. The program’s focus continued 

to follow the guidelines established by Professor Van 

Cleave, that is, professional training for students interested in careers in national security.

In 2012, DDSS participated in an open competition 

among universities in the Washington, DC, metropolitan 

area to work in cooperation with the National Defense 

University on a 2-year MS degree program in Countering Weapons of Mass Destruction (CWMD). The degree would be for personnel from the Department of Defense. The DDSS of MSU won the competition and was 

awarded the effort. Following a rigorous application and 

selection process from among Department of Defense 

personnel, the first cohort of National Defense University CWMD Fellows entered the new DSS CWMD degree program in August 2012. This initial class included 

17 CWMD fellows. These Fellows were sponsored by 

the Department of Defense, but had to attend classes 

and complete assignments on their own time. Consequently, the CWMD degree program will be completed 

while the Fellows maintain a fulltime work-load for the 

Department of Defense. Obviously, CWMD Fellows are 

highly-motivated, serious students. The initial 2012 cohort is a highly-diverse class by all measures, and consists largely of mid-career civil servants engaged professionally in a broad range of the Department of Defense’s 

counter WMD efforts. Almost all members of this initial 2012 class already hold graduate degrees, including 

doctoral degrees in chemistry, biology, microbiology, 

and medicine. In addition, many Fellows have extensive 

operational experience. For example, one CWMD Fellow in the initial 2012 class had just completed a tour 

in Afghanistan as an emergency room physician, and 

another is playing a pivotal role in current operations 

associated with chemical weapons in Syria.

Few members of the entering class had any previous academic background in the areas of the CWMD 

curriculum, which focuses on international relations 

theory and practice, nuclear deterrence policy, proliferation, arms control, public health issues associated with 

chemical and biological weapons, counterterrorism, and 

regional area security studies. The goal of the CWMD 

Fellows Program is to provide a cadre of professionals 

within the Department of Defense who have a broad 

base of expertise in countering WMD. The program 

is jointly operated by the National Defense University 

(NDU) and the MSU DDSS.

At this writing, it appears that the graduation rate for the 

initial 2012 NDU cohort (commencement set for July, 

2014) will be approximately 80% of the entering class. 

This is an extremely high graduate degree completion 

rate compared to national averages. The NDU Fellows 

who entered the CWMD degree program in the 2013 cohort are progressing with comparable success.

The NDU and the DDSS worked collaboratively on 

developing the curriculum for the master’s degree and 

agreed that a course on chemical and biological warfare 

was essential to the completeness of the curriculum. A 

MSU faculty member on the university’s main campus 

in Springfield, Missouri, was first approached about developing an introductory course to chemical and biological warfare in the fall of 2011, and the first iteration was 

offered in the spring semester of 2012. As of April, 2014, 

the course had been taught 5 times, including once during a summer term (the summer term is 8 weeks long as 

opposed to the 16-week fall and spring semesters.) Initially, the course was offered exclusively to students in 

MSU’s regular master’s degree in defense and strategic 

studies. The course has evolved significantly with each 

iteration, but the most important changes were made 

when the course became a requirement for the CWMD 

Fellowship. At that time, the course reading list was 

expanded to allow a greater focus on policy aspects of 

the subject. Nevertheless, the very nature of the biological and chemical agents requires a solid foundation in 

the epidemiological and toxicological aspects of these 

weapons. The instructor considered this foundation 

essential because policy that is based on an erroneous 

understanding of the weapons or agents can itself be 

flawed.

However, the CWMD degree program is not intended to 

be limited to biologists or medical professionals. As noted earlier, the original degree program in the DDSS was 

essentially an international security affairs program in 

which the students were primarily focused on policy and 

operational aspects of defense studies. With the advent 

of the CWMD Fellowship, a broader spectrum of highly 

experienced students entered the course with the result 

CHEMICAL AND BIOLOGICAL WARFARE: TEACHING THE FORBIDDEN AT A STATE UNIVERSITY
July – September 2014 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

that the typical class included political scientists, intelligence analysts, military officers, medical personnel and 

others. This more diverse and experienced student body 

created a need to improve the definition of course objectives. More specifically, the course needed a balance 

of the medical or technical aspects of the course with 

the policy focus of the program. Therefore, new, more 

specific objectives, listed below, were written to guide 

further development of the class.

After completion of this course, the student will be able 

to:

1. Identify and describe the most important agents 

that have been developed for use in chemical 

warfare and categorize the agents by class.

2. Identify and describe the most important agents 

that have been developed or used in biological 

warfare.

3. Discuss the advantages and disadvantages of using weapons of mass destruction in the form of 

chemical and biological warfare from the perspective of the user.

4. Discuss the environmental and logistical problems associated with attempts to deploy chemical and biological weapons.

5. Describe how response efforts and preparedness 

can reduce the effects of chemical and biological 

agents.

6. Identify barriers to the implementation of effective response initiatives.

7. Identify important events in the history of chemical and biological weapons and rank them in order of importance with regard to impact on the 

outcome of war, health of the public and military 

populations, and changes in public policy.

8. Compare and contrast the strategies for the use 

of chemical weapons as demonstrated during 

wars of the 20th century.

9. Contrast the potential use of chemical and biological agents by terrorists with the historical 

use of these agents during war, discussing the 

motivations for use of these weapons by state as 

opposed to nonstate actors.

10. Describe current events that involve the potential or realized use of chemical and biological 

warfare or terrorism and discuss efforts to eliminate or reduce the use of the weapons.

11. Discuss the role that technology and globalization may have on the development, dissemination, disarmament, and use of chemical and biological agents.

The objectives require extensive background reading to 

address issues ranging from the epidemiology of relevant 

diseases to the history of treaties and official policy regarding the use of weapons of mass destruction. Initially, 

the course did not use a textbook and the course reading 

list was gathered from a variety of online sources. The 

Homeland Security Digital Library proved very useful 

in obtaining relevant readings. The Borden Institute’s 

Textbooks of Military Medicine (http://www.cs.amedd.

army.mil/borden/) were also very useful, especially the 

sections on the history of development and use of biological and chemical weapons. The Borden Institute’s 

textbooks also provide extensive sections on technical, 

biological, and medical subjects. However, some chapters were too medically oriented for some students, so 

only select parts of many chapters were required. The 

most recent reading list is provided in Table 1.

A textbook was identified and used during two of the later iterations of the class, The Soviet Biological Weapons 

Program: A History.

6

 A large book of over 900 pages, 

it provides an exhaustive treatment of the subject, but 

some students thought that its use resulted in an overemphasis on the biological weapons at the expense of 

the chemicals. The book is inexpensive when bought in 

electronic form, so portions of it are still used in the 

course, though only about a quarter of the book will be 

assigned in future classes. All of the other readings are 

available online for free either through the Borden Institute (online) or the university library.

Teaching with an Online Modality

For a variety of reasons (including the fact that the 

instructor is on the main campus in Springfield, Missouri, and the university’s graduate DDSS is located in 

Fairfax, Virginia), the decision was made to offer the 

chemical and biological warfare course exclusively 

online. Although this modality expands access to the 

course for many students, it also presents some limitations, particularly the potential of reduced interaction 

between the instructor and students. The university 

uses the Blackboard teaching software to offer online 

courses in many departments, so the course was built on 

this platform. One major advantage of this platform is 

that it can store very large files such as PowerPoint lectures with a recorded voice track. Such lectures would 

be difficult to send through most e-mail services. The 

instructor wrote the lectures and recorded them using 

Microsoft PowerPoint software, then posted them on the 
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

Blackboard (Blackboard, Inc, Washington, DC) course 

website. This technology worked well for disseminating 

the lectures which were as large as 86,463 kb, including the voice track. Table 2 lists the titles of lectures 

that were used in the course as presented in the fall semester of 2013. Lectures varied in length, some were as 

long as 70 minutes. Subsequent student evaluations of 

the course called for the use of multiple, shorter lectures 

that are easier to download, so future iterations of the 

class will use more but shorter lectures not to exceed 30 

minutes in length.

As mentioned earlier, the online modality can sometimes result in limited student participation in distance 

courses. Students may have minimal involvement especially if there is a long period of time between due dates 

for assignments or tests. For this reason, it is important 

to encourage multiple interactions between the student 

and the instructor via the course website. For the chemical and biological warfare course, the student is required 

to log onto the course website for a specific task at least 

4 times each week. The tasks are divided into 3 categories: essays, comments/questions, and answers. Each 

CHEMICAL AND BIOLOGICAL WARFARE: TEACHING THE FORBIDDEN AT A STATE UNIVERSITY

Table 1. Required reading list for graduate course in chemical and biological warfare taught as part of the Countering Weapons 

of Mass Destruction fellowship and degree program for the National Defense University.

History and Policy

Weapons of Mass Destruction: A Primer. Berstein PI. 2006. Prepared by SAIC, Inc, for the Advanced Systems and Concepts Office of the 

Defense Threat Reduction Agency.

History of Chemical Warfare. Hilmas CJ, Smart JK, Hill BA Jr. Chapter 2; Medical Aspects of Chemical Warfare. 2008. Borden Institute.

History of Biological Weapons: From Poisoned Darts to Intentional Epidemics. Martin JW, Christopher GW, Eitzen EM Jr. Chapter 1; Medical 

Aspects of Biological Warfare. 2007. Borden Institute.

Historical trends related to bioterrorism: An empirical analysis. Tucker JB. Emerging Infectious Diseases. 1999, vol 5, no 4, pp 498-504.

A farewell to germs: the US renunciation of biological and toxin warfare, 1969-70. Tucker JB. International Security. 2002, vol 27, no 1, pp 

107-148.

The development of the norm against the use of poison: what literature tells us. van Courtland Moon JE. Politics and the Life Sciences. 2008, 

vol 27, no 1, pp 55-77.

Chemical Agent Classes

Decontamination of Chemical Casualties. Braue EH Jr, Boardman CH, Hurst CG. Chapter 16; Medical Aspects of Chemical Warfare. 2008. 

Borden Institute.

Vesicants. Hurst CG, Petrali JP, Barillo DJ, Graham JS, Smith WJ, Urbanetti JS, Sidell FR. Chapter 8; Medical Aspects of Chemical Warfare. 2008. 

Borden Institute.

Nerve Agents. Sidell FR, Newmark J, McDounough JH. Chapter 5; Medical Aspects of Chemical Warfare. 2008. Borden Institute.

Toxic Inhalational Injury and Toxic Industrial Chemicals. Tuorinsky SD, Sciuto AM. Chapter 10; Medical Aspects of Chemical Warfare. 2008. 

Borden Institute.

Specific Biological Agents

Anthrax. Purcell BK, Worsham PL, Friedlander AM. Chapter 4; Medical Aspects of Biological Warfare. 2007. Borden Institute.

Plague. Worsham PL, McGovern TW, Vietri NJ, Friedlander AM. Chapter 5; Medical Aspects of Biological Warfare. 2007. Borden Institute.

Glanders. Gregory BC, Waag DM. Chapter 6; Medical Aspects of Biological Warfare. 2007. Borden Institute.

Melioidosis. Vietri NJ, Deshazer D. Chapter 7; Medical Aspects of Biological Warfare. 2007. Borden Institute.

Tularemia. Hepburn MJ, Friedlander AM, Dembek ZF. 2007. Chapter 8; Medical Aspects of Biological Warfare. 2007. Borden Institute.

Brucellosis. Purcell BK, Hoover DL, Friedlander AM. Chapter 9; Medical Aspects of Biological Warfare. 2007. Borden Institute.

Q Fever. Waag DM. Chapter 10; Medical Aspects of Biological Warfare. 2007. Borden Institute.

Smallpox and Related Orthopoxviruses. Jahrling PB, Huggins JW, Ibraham MS, Lawler JV, Martin JW. Chapter 11; Medical Aspects of Biological Warfare. 2007. Borden Institute.

Alphavirus Encephalitides. Steele KE, Reed DS, Glass PJ, Hart MK, Ludwig GV, Pratt WD, Parker MD, Smith JF. Chapter 12; Medical Aspects of 

Biological Warfare. 2007. Borden Institute.

Viral Hemorrhagic Fevers. Jahrling PB, Marty AM, Geisbert TW. Chapter 13; Medical Aspects of Biological Warfare. 2007. Borden Institute.

Agricultural Terrorism or Warfare

State Agro-BW Programs. Millett PD, Whitby SM. Agro-Terrorism: What is the Threat? Proceedings of a Workshop Held at Cornell University, 

Ithaca, NY, November 12-13, 2000. Available at https://www.hsdl.org/?view&did=3513.

Covert Biological Weapons Attacks Against Agricultural Targets: Assessing the Impact Against US Agriculture. Pate J, Cameron G. Agro-Terrorism: What is the Threat? Proceedings of a Workshop Held at Cornell University, Ithaca, NY. November 12-13, 2000. Available at https://

www.hsdl.org/?view&did=3513.

NOTE: Only portions of some readings are required as they may be too medically oriented for some students whose focus is more on policy and international 

affairs.
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THE ARMY MEDICAL DEPARTMENT JOURNAL

week, an essay is assigned based on the lecture of the 

week and part of the reading list. The essays are at least 

500 words in length and must answer a specific question 

posed by the instructor. Example assignments or questions include:

3⁄4 Propose a list of the top 10 most important events 

in the history of chemical warfare and terrorism 

in descending order. Justify your choice and the 

ranking of each event.

3⁄4 Describe how the strategies for the use of chemical warfare agents by a nation-state might differ 

from those of a terrorist organization, using examples from World War I, the Italian-Ethiopian 

War, and the Iran-Iraq War. Address purpose, 

means of dispersal, and limitations as appropriate

3⁄4 From the assigned readings, construct a table of 8 

important characteristics and variables for 7 biological agents. Based on the table that you have 

constructed, identify the 2 agents in your table 

that have the most potential in biological warfare. 

Justify your choices.

3⁄4 Explain the concept of the offense-defense balance and describe why it affects the decision to 

use biological weapons.

The essays that answer the questions are posted on 

Thursday of each week. Every student must then select 2 essays written by classmates on which to make a 

thoughtful comment of at least 50 words. At the end of 

that comment, the student must pose a question to the 

author of the essay. The comments with questions are 

due by Monday at midnight. Students must then answer 

the questions on their own essays that were posed by 

their classmates; those answers are due by Wednesday 

night. Thus, students must log onto the site at least 4 

times each week: first, to download the assignment and 

supplemental readings; second, to post an essay on the 

discussion board; third, to read the essays of 2 classmates and to post comments with questions; and fourth, 

to answer the 2 questions from classmates on their own 

essays. Even though some of these tasks may take only 

a few minutes, the multiple interactions between the student and the web site ensure consistent student involvement throughout the course. Essays are graded by the 

instructor each week and sent to the students privately. 

The instructor also reviews the discussion board and 

comments on students’ discussions that are based on the 

comments, questions, and answers. This process is very 

time-consuming for the instructor but the routine of the 

class encourages maximum, sustained student participation. New assignments are posted weekly.

Individual Projects

As with most graduate level courses, the faculty saw a 

need for an individual project that would provide the 

students with the ability to explore topics of particular 

interest to them. The project encourages students to become familiar with the scholarly and technical literature 

of chemical and biological warfare and to become more 

familiar with current events in the field. The students 

were thus given a choice between doing an annotated bibliography on an instructor-approved subject, or a news 

journal in which the student summarized the content of 

50 news articles on chemical and biological warfare that 

had been published in the last 25 years. Although the 

student could write the annotated bibliography on any 

approved subject, several were suggested by the instructor and most students chose to write the bibliographies 

on the suggested topics. The instructor-suggested topics 

are listed in Table 3. The suggested topics were provided 

to reflect the great diversity of interest of the students 

and to encourage a degree of self-direction. The bibliography had to have a minimum of 20 annotations from 

reliable sources of literature. Some students, however, 

wanted to become more familiar with current events as 

reported in the news media. Those students opted for 

the 50-article news journal. In fact, in the latest iteration 

of the class, the majority of the students chose the news 

journal option.

Evaluation of Students

The students were evaluated primarily on the essays that 

were submitted weekly, though some credit was also 

given for participation in the class discussion board. Essays were worth 50% of the score, and discussion 10%. 

Table 2. Online lectures used in class on chemical and biological warfare taught by Missouri State University for the National 

Defense University’s Countering WMD Fellows program.

Course Introduction, Procedures and Expectations

Basic Biology for the Non-biologist Interested in Chemical and 

Biological Warfare Agents: Toxicology

Basic Biology for the Non-biologist Interested in Chemical and 

Biological Warfare Agents: Epidemiology

History of Chemical and Biological Warfare

Introduction of Chemical Warfare Agents: Chemical Classes

Toxicology of Neurotoxins and Applications in War

The Vesicants

Strategies for Use of Chemical Agents in WWI, the Italy-Ethiopia 

War, and the Iran-Iraq War

Toxic Industrial Chemicals and Materials: Potential in War and 

Terrorism

Decontamination of Chemical and Biological Warfare Agents

Concepts of Biological Warfare

Agricultural Terrorism and Warfare

NOTE: All lectures are PowerPoint presentations delivered through the 

Blackboard online education platform. Each lecture has a voice track 

and length varies from 15 to 70 minutes.
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

The individual project (annotated bibliography or news 

journal) was worth 16%. A proctored final exam composed primarily of objective questions accounted for the 

rest of the grade. The instructor added a final exam to 

the course when it became part of the CWMD fellows 

program to ensure a more thorough knowledge of the 

assigned readings on the part of the students. The final 

exam questions came primarily from the readings and 

from weekly comments on the assignments provided by 

the instructor.

Student Evaluations of the Course

Initial student evaluations of the course were generally, 

though not universally, favorable. The most recent student evaluations have been quite positive. Earlier, some 

students saw the material as too difficult, others as too 

easy, but most were satisfied with the content, pace, and 

presentation of the course. One consistent concern has 

been the online format which some students do not like, 

finding the subject matter difficult to address in that modality. Another consistent trend is that the students find 

the online discussion board using comments and questions from the students themselves to be the least advantageous part of the course. On a scale of 1 to 5 with 5 

being excellent, the discussion board has been the only 

component to receive a score of less than 4. The news 

journal that many of the students complete as a project is 

routinely very popular. Students report that it provides 

them with a systematic opportunity to become familiar 

with current events.

Lessons Learned

After 5 iterations of the course, several improvements 

have been made based on student evaluations and other 

observations. Some of the lessons learned are discussed 

below:

 Student understanding and participation is improved when the student must log onto the course 

web page multiple times each week. Otherwise, the 

student may lose track of class subject matter and 

discussion material.

 The online modality is generally suitable for the 

chemical and biological warfare subject, but some 

students require additional instruction on the use of 

online technology such as the instructional software. 

This is difficult to do when the instructor is in a different geographical area. Also, the online modality 

is potentially susceptible to plagiarism and other 

forms of academic dishonesty. Instructors must be 

well-versed in ways to prevent and detect violations.

 Some review and instruction in the biology and 

toxicology of chemical and biological agents is essential, especially for those who do not have academic backgrounds in science. The amount of review varies with each iteration of the class. One 

way to address this issue is to have a series of short 

online review lectures that are available to those 

students in need of the review. Students are held 

responsible for the information in the lectures but 

students with backgrounds in biology, chemistry, or 

medicine usually need only a cursory examination 

of the material.

 The academic and professional backgrounds of students in this course vary greatly, probably more so 

than in many other classes. Some exhibit a very 

complete knowledge of various aspects of the field, 

but may have little knowledge of others. Other students may initially have almost no understanding of 

the material. The use of student biographies in the 

first week of the class provides the instructor with 

the opportunity to gauge the range of knowledge 

and experience within the class. The biographies 

can also help direct student discussions. Students 

with particular expertise may be asked to address 

a subject in a special online discussion board. The 

student biographies can also allow the instructor 

to make last-minute modifications that allow the 

course to address areas of particular interest to a 

CHEMICAL AND BIOLOGICAL WARFARE: TEACHING THE FORBIDDEN AT A STATE UNIVERSITY

Table 3. Suggested topics for the annotated bibliography 

required as part of the course Chemical and Biological 

Warfare in the Department of Defense and Strategic Studies, Missouri State University.

Agroterrorism

Domestic Terrorism and the Chem-Bio Threat

The Role of Chembio in the Decision to go to War in Iraq

Tularemia as a Bioagent

Bhopal as a Model of Chemical Agent Terrorism

Decontamination of Equipment and Sites

Potential Chemical Weapons Use in the Middle East

Detection of Chemical and Biological Agents

Toxicology of Blood Agents

Dispersal Techniques For Chem/Bio Agents

Allegations of Chem/Bio Warfare in WWII

Treaties and Chem/Bio Weapons

Business and Organizational Continuity 

History of the Soviet BW/Chem Program

Anthrax as a Bioagent

Smallpox as a Bioagent

Decontamination of Personnel

Emerging Diseases as Potential Bioagents

Medical Preparedness For a Chemical Event

Toxicology of Vesicating Agents

Biotoxins as Chemical/Biological Agents

History of Incapacitating Agents

The Role of Immunization in Biodefense

Disarmament and Chem/Bio Weapons
July – September 2014 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

particular cohort of students or to provide additional leveling material prior to introducing an unfamiliar subject.

Conclusion

The graduate course on biological and chemical warfare 

taught by the Missouri State University Department 

of Defense and Strategic Studies in conjunction with 

the National Defense University Countering Weapons 

of Mass Destruction Fellows program offers a unique 

combination of perspectives, from the academic to the 

military to the political and diplomatic. Teaching with 

such a broad range of perspectives to a group of students 

with an even broader range of education and professional experience can be challenging. The ability to effectively address the nation’s needs in the field requires 

people with cross-disciplinary education and the ability 

to operate in diverse environments. Recent events have 

demonstrated the need for people with field experience, 

technical training, and significant academic education 

in the field of weapons of mass destruction. The course 

described herein is a part of a larger degree program 

that includes courses in nuclear strategy, arms control, 

counter-proliferation, intelligence-counterintelligence, 

terrorism, ethics, defense policy, and other subjects. The 

content of the course will, of necessity, evolve to address 

the changing issues of terrorism, insurgency, diplomacy, 

globalization, and war, but it will hopefully contribute 

to a cadre of professionals with the backgrounds, critical 

thinking skills, and education to protect the nation from 

the threat of chemical and biological agents and other 

weapons of mass destruction.

References

1. Tucker JB. A farewell to germs: the US renunciation of biological and toxin warfare, 1969-70. Int Secur. 

2002;27(1):107-148.

2. Alibek K. Biohazard: The Chilling True Story of The Largest Covert Biological Weapons Program in the World—

Told From the Inside by the Man Who Ran It. New York: Random House; 1999. Available at: http://www.nlm.nih.

gov/nichsr/esmallpox/biohazard_alibek.pdf. Accessed April 22, 2014.

3. Garret L. Biowar. In: Betrayal of Trust: The Collapse of the Global Public Health System. New York: Hyperion; 

2000:486-550.

4. Hoffman B. Inside Terrorism. New York: Columbia University Press; 2006.

5. Nordland R. Poison gas used to sicken schoolgirls, Afghans say. New York Times. September 1, 2010:A8. Available 

at: http://www.nytimes.com/2010/09/01/world/asia/01gasattack.html?_r=0. Accessed April 22, 2014.

6. Leitenberg M, Zilinskas RA. The Soviet Biological Weapons Program: A History. Cambridge, MA: Harvard University Press; 2012.

Authors

CDR (Ret) Claborn, a career US Navy medical entomologist, is an Assistant Professor of Public Health and Homeland 

Security at Missouri State University, Springfield, MO. He is the instructor for the Defense and Strategic Studies chemical and biological warfare course described in this article.

Dr Payne is the Head of the Graduate Department of Defense and Strategic Studies, Missouri State University (Washington Campus). He is the Director of the Countering Weapons of Mass Destruction Fellows Program for Missouri State 

University. Previously, Dr Payne served in the Department of Defense as the Deputy Assistant Secretary of Defense for 

Forces Policy.
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

Military preventive medicine is, in fact, the product of military 

thought and activities and of the intellectual, scientific, 

economic, and political movements and forces in the civilian 

world. Therefore, the evolution of preventive medicine in 

the United States Army cannot be considered as an isolated 

affair. Rather, it is to be regarded and understood as the result 

of the interaction between civilian and military knowledge 

and opinion as to what should be done, and how to do it, to 

preserve the health of soldiers.

BG Stanhope Bayne-Jones1

The words of BG Bayne-Jones stand the test of time, 

providing a wonderful perspective on the subject of public health law. This area of law is truly about the interaction between the military and civilian world, but so often, leaders and clinicians do not understand its breadth. 

They often think of public health law in terms of public 

health emergency law, but that is just a very small part 

within this area of law. Public health law covers so many 

areas which have made headlines in recent years, such 

as childhood obesity and its effect on chronic disease, 

the controversial reduction in drink sizes for carbonated 

beverages in New York City, municipal bans on foods in 

restaurants in Chicago, nosocomial infections and their 

effect both inside and outside the hospital setting, along 

with national pharmaceutical shortages to name a few. 

While I certainly do not expect leaders and clinicians to 

be experts in this broad practice field, I do believe some 

heightened sensitivity to this area of the law is critical.

The Fundamentals

In his text, Public Health Law: Power, Duty, and Restraint,

2

 Professor Lawrence Gostin notes that the legal 

powers and duties of the state are to assure conditions 

for people to be healthy, and the limitations on the power 

of the state to constrain autonomy, privacy, liberty, propriety, or other legally protected interests of individuals 

for the protection or promotion of the community health. 

“State” is a general term of government which does not 

specifically refer to a particular level of government. As 

such, state can refer to the federal, state, county, borough, parish, township, and/or municipal governments. 

Because each refers to a different level of government, 

it is important to be clear whether the reference is to 

the federal government, especially when dealing with 

military issues, or the government of, or within, a particular state in the Union. There is a relationship, however, 

between the federal and state governments referred to as 

federalism. Federalism can sometimes create a tension 

between the federal and the state levels of governments 

because each of the 50 states and their subordinate governments possess substantial, independent legal authority which is still subject to the supremacy of federal authority, to the extent it exists in regard to certain matters. 

Often, the authorities overlap and the astute leader and 

clinician will embrace that overlap and facilitate a sense 

of teamwork at all opportunities despite any counter influences. Just as parochialism exists among the Army, 

Navy, Air Force, and Marine Corps, so too do parochial 

attitudes exist between different levels of government. 

Overcoming these attitudes is a challenge.

Sources of Law

The defining document of our legal system is the US 

Constitution. It is the source of all legal authority for the 

federal government and state governments. Each state 

has its own constitution, and subordinate levels of government often have their own legal sources of government such as a charter or statute. Since they all differ, 

their style of government may be different as well, yet 

all fall under the authority of the US Constitution. The 

US Constitution is truly the supreme law of the land, except that the 10th Amendment specifically states:

The powers not delegated to the United Sates by the Constitution, nor prohibited by it to the States, are reserved 

to the States respectively, or to the people.

In other words, if the US Constitution does not contain 

a provision dealing with a certain matter, that matter is 

reserved to the states; those powers are often referred to 

as “police powers.” There is no mention of public health 

in the US Constitution, so, as a result, public health has 

normally been the primary responsibility of the states, 

and public health law has normally been a creature of 

state and local governments. Despite that responsibility, 

the federal government has often asserted its authority 

over public health-related activities through its interstate 

commerce, taxation, and spending powers under Article 

I, Section 8, of the US Constitution. These powers explain such policies in the past as national speed limits 

An Introduction to Public Health Law for

 Leaders and Clinicians

Joseph Baar Topinka, JD, MHA, MBA, LLM
July – September 2014 69

and tobacco taxes, seemingly local matters controlled 

or influenced by the federal government—a source of 

tension under the concept of federalism.

Statutes and regulations are outgrowths of the US Constitution and the respective state constitutions. The 

constitutions give the US Congress and the various 

state legislatures the power to pass laws in the form of 

statutes. Federal agencies and state agencies then write 

regulations that implement the statutes. These statutes 

can affect public health at the federal, state, and local 

levels. For example, Congress passed statutes that created the US Public Health Service with its authorities 

and powers. It also created explicit regulatory agencies 

like the Food and Drug Administration or the Occupational Safety and Health Administration (OSHA) and 

nonregulatory agencies like the Centers for Disease 

Control and Prevention (CDC). State legislatures also 

created agencies with regulatory and nonregulatory 

powers and those same state legislatures delegated similar regulatory authority to lower levels of government 

to create entities such as departments of public health 

which possess similar regulatory powers but only within their local jurisdictional limits. This mix of federal, 

state, and local laws and regulations can be a challenge 

for the leader or clinician who finds him or herself on a 

federal military installation surrounded by several local 

and state jurisdictions. Everyone may or may not be operating in the same or similar manner in regard to public 

health, yet each is certainly in compliance with federal 

law, except that military installations must comply with 

their respective agency and department regulations as 

well. A daunting challenge? Yes, but not an impossible 

one if everyone from all the levels of government come 

together to work through the issues.

A summary of the sources of law would not be complete 

without mention of the common law. Local, state, and 

federal courts determine the guilt of accused criminals, 

resolve private law disputes between individuals, and 

review actions of agencies enforcing civil laws such as 

those addressing public health. In general, lower courts 

follow the decisions of higher courts, and state courts 

review state laws to determine if they violate the state or 

federal constitutions. Federal courts review the constitutionality of state and federal laws, and the US Supreme 

Court’s decisions bind all state and federal courts. The 

federal courts and most state courts use common law 

precedent which is critical, especially when it involves 

decisions that affect public health matters. That precedent established by some decision will then bind us in 

terms of what we can or cannot do in a public health 

scenario.

Jacobson v Massachusetts, a Landmark Case

Many would regard Jacobson v Massachusetts (197 US 

11 (1905)) as the most famous case in public health law 

and the foundation of public health common law. This 

1905 US Supreme Court case concerned an order based 

on a state statute compelling vaccinations of residents 

against smallpox after a recent smallpox outbreak in 

Massachusetts. The Cambridge Board of Health ordered the vaccinations. Mr Henning Jacobson refused 

the vaccination and refused to pay the $5.00 fine. The 

US Supreme Court decided that:

Upon the principle of self-defense, of paramount necessity, a community has the right to protect itself against 

an epidemic of disease which threatens the safety of its 

members.

With its decision in support of the law, the US Supreme 

Court began our modern constitutional analysis of disease control law which includes:

 Use of police powers for public health concerns.

 Delegation of certain authorities to health agencies and other government subdivisions.

 Use of actions limiting liberty for well-established public health interventions.

More importantly, though, the case addressed the balancing of public good vs individual rights, a concept 

which leaders and clinicians will have to understand as 

they face future public health matters.

Ethics and the Law

...laws are often broadly framed, leaving much room for 

administrative discretion about when to use public health 

authority and about which intervention is more ethically 

appropriate when more than one alternative course of action is legally permissible.3

Public health law provides authority, limitations on state 

power, and incentives and disincentives for behavior. It 

is very formal, focusing on statutes, regulations, and 

court decisions as previously described. Unfortunately, 

law does not always cover every situation or every issue 

which arises. Sometimes, less formal actions and decisions must be taken based on norms, values, professional codes, and previous experience. In other words, sometimes the law will simply not have the clear answers to 

the questions posed and a more informal but deliberate 

approach is necessary. Therefore, ethics help in filling 

the gaps not specifically addressed within the law.

Federal executive branch employees must conduct themselves within the parameters of executive branch ethics. 
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

In the military, the Joint Ethics Regulation4 supplements the general executive branch rules. However, ethics rules for government employees are really standards 

of conduct; norms and morality go beyond these defined 

standards. Norms and morality address the rights and 

wrongs that are widely shared by society. Some are universal, while others are particular to certain communities. They are not absolute. Sometimes they conflict and 

then require balancing. In many ways, balancing norms 

and moral claims is similar to the process leaders and 

clinicians use when balancing public good versus individual needs; it could be characterized as a public health 

cost-benefit analysis. Instead of quantifiable health gains 

or losses, leaders and clinicians identify, weigh, and balance the moral interests that are at stake.

This reflection and balancing is not easy and often 

people take different ethical approaches such as utilitarianism, liberalism, or communitarianism, to name a 

few. Since ethical reflection, deliberation, and analysis 

is difficult, codes of ethics have been developed over 

the years. A code provides a statement of moral norms 

to guide professionals within their practice and professional lives. A code lays a foundation of trust between 

professionals and those they serve. For example, federal 

executive branch employees follow the Standards of 

Ethical Conduct for Employees of the Executive Branch 

(5 CFR §2635). Another example relevant to public 

health officials is the Principles of Ethical Practice of 

Public Health developed by the Public Health Leadership Society.5

Common Public Health Issues

While the modern health officer must be an educator and 

a statesman, rather than merely a police officer, many 

of his duties are still necessarily concerned with law 

enforcement...Health officers must be familiar not only 

with the extent of their powers and duties, but also with 

the limitations imposed upon them by law.6

Emergencies

Generally, emergency declarations are issued after a 

public health event begins. Some states have adopted 

statutes that provide very detailed standards for actions 

in a public health emergency. Some declarations limit 

police powers while others are silent, which may give 

local health departments broad powers under a state’s 

police powers. The US Constitution gives the President 

broad powers to manage national security threats like 

bioterrorism, and the President can also react to a state’s 

request for emergency support. The Federal Emergency 

Management Agency can then assist local authorities 

by providing emergency housing, water, and other supplies and loans. Of great interest is the development of 

Emergency Management Assistance Compacts (EMAC) 

between the states. These contracts, administered by 

state emergency management agencies and activated 

by governor-declared emergencies, allow states to share 

personnel and other resources across state boundaries. 

Instead of a federal-state relationship, EMACs create a 

state-state relationship which can be established with or 

without federal assistance.

Surveillance, Reporting, and Personal Privacy

In the spirit of federalism, state and local governments 

conduct most communicable disease surveillance, investigation, and intervention under their police powers, 

while the federal government has the responsibility in 

controlling diseases related to goods moving in interstate 

commerce, such as food. Both ideally cooperate when 

disease threats cross state lines and authorities overlap.

Reporting disease is not a new concept. State and local governments report this information to the CDC, 

which acts as a national clearing house for state disease 

reports looking for patterns, tracking emerging diseases, and advising states. However, the CDC does not 

regulate state or local government public health entities. 

The OSHA also requires reporting and tracking of occupational diseases based on its authority legislated as 

allowed under the Commerce Clause (Article I, Section 

8, Clause 3) of the US Constitution.

There is no common law physician-patient privilege. 

Such a privilege was created by state laws in the 1950s. 

There was no general right of medical privacy until passage of the Health Insurance Portability and Accountability Act of 1996 (Pub L No. 104-191, 110 Stat 1936) 

enacted on August 21, 1996. The final regulation, the 

Privacy Rule, was published in December of 2000. However, personal privacy is not absolute when it comes to 

public health. In 1977, the US Supreme Court found in 

Whalen v Roe (429 US 289 (1977)) that public health reporting of narcotics prescriptions to the New York State 

Health Department did not violate any constitutionally 

protected rights. States can require access to records as a 

condition for medical and facility licensure. The federal 

government also requires access to records as a condition for participating in federal payments programs. Finally, even when individuals or businesses are not regulated by a state or the federal government, a court order 

may grant access to information otherwise inaccessible.

Environmental Health

Leaders and clinicians also must consider environmental matters when considering public health. Are environmental law and public health law 2 separate legal 

disciplines? Yes, but they often overlap and must be 

AN INTRODUCTION TO PUBLIC HEALTH LAW FOR LEADERS AND CLINICIANS
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THE ARMY MEDICAL DEPARTMENT JOURNAL

considered together. Until the early 1900s, almost all 

environmental health regulation was done by state and 

local governments. Since the 1960s, the federal government has taken the lead with laws such as the Clean Air 

Act (Pub L No. 88-206, 77 Stat 392 (1963)), the Clean 

Water Act (Pub L No. 92-500, 86 Stat 816 (1972)), and 

the Comprehensive Environmental Response, Compensation, and Liability Act (42 USC §9601-9675 (1988)). 

These laws may in fact preempt state laws. Then again, 

the federal laws set minimum standards which are implemented and enforced by the states. In some instances, 

the state standards may be stricter than the federal standards or incorporate a wider scope. In addition, federal 

agencies such as the Environmental Protection Agency, 

the Department of Agriculture, the Agency for Toxic 

Substances and Disease Registry, and state environmental departments along with large city and county health 

departments have roles in the regulation of environmental public health. Many players are involved in the mix 

and cooperation among them is vitally important.

Occupational Health

As with environmental health, occupational health law 

often finds itself separate from public health law, but the 

two cannot help but overlap. When there is workplace 

injury, states have worker’s compensation laws that are 

administered by state agencies rather than the courts to 

provide limited compensation to employees. The federal equivalent is the Federal Employee’s Compensation 

Act (5 USC 8101 et seq (1916)) which provides workers’ 

compensation to civilian federal employees for workplace injuries. However, the US Congress recognized 

that worker’s compensation laws did not create sufficient incentive to reduce occupational injury, so it created OSHA and the National Institute for Occupational 

Safety and Health (NIOSH), which is part of the CDC 

and researches and funds programs to reduce work-related injury. As part of the Department of Labor, OSHA 

sets and enforces standards for workplace safety and 

health. The NIOSH provides scientific input for OSHA 

regulations.

Conclusion

This article has briefly touched the surface of public 

health law, but hopefully it has given the reader a sense 

of the extent and depth of this incredible area of the law. 

Like the public health sector itself, this area of the law 

is constantly growing and constantly changing. Public 

health law is by no means static. It is a challenging area 

of law which is regularly, invariably addressing new issues. The necessity for public health and legal professionals well-versed in both the substance and nuance of 

public health law is growing, with no end in sight.

Acknowledgements

I thank University Professor Lawrence O. Gostin of the 

Georgetown University Law Center and Professor John 

D. Blum of the Loyola University Chicago School of 

Law for their mentorship and support in the development 

of my knowledge and capabilities in the area of public 

health law.

References

1. Bayne-Jones S. The Evolution of Preventive Medicine in the United States Army, 1607-1939. Washington, DC: Office of The Surgeon General, US 

Dept of the Army; 1968:182. Available at: http://

history.amedd.army.mil/booksdocs/misc/evprev/

default.html. Accessed June 9, 2014.

2. Gostin LO. Public Health Law: Power, Duty, Restraint. Berkeley, CA: University of California 

Press; 2008.

3. Bernheim RG, Nieburg P, Bonnie RJ. Ethics and 

the practice of public health. In: Goodman RA, 

ed-in-chief; Hoffman RE, Lopez W, Matthews 

GW, Rothstein MA, Foster KL, eds. Law in Public 

Health Practice. 2nd ed. New York, NY: Oxford 

University Press; 2007:110-135.

4. Department of Defense 5500.7-R: Joint Ethics 

Regulation. Washington, DC: US Dept of Defense: 

1993 [with changes 1-7, November 17, 2011].

5. Principles of the Ethical Practice of Public Health. 

New Orleans, LA: Public Health Leadership Society; 2002. Available at: http://www.phls.org/home/

section/3-26/. Accessed June 9, 2014.

6. Tobey JA. Public Health Law. 3rd ed. New York, 

NY: The Commonwealth Fund; 1947.

Author

Mr Topinka, a retired military attorney, is an Adjunct 

Professor for the Texas A&M University Health Science 

Center School of Rural Public Health who teaches Public Health Law in the Department of Preventive Health 

Services, Academy of Health Sciences, US Army Medical Department Center and School, Fort Sam Houston, 

Texas.
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

An ounce of prevention is worth a pound of cure.

Benjamin Franklin

In today’s fiscally constrained environment, Benjamin 

Franklin’s words could not be more relevant. As budgets 

shrink, the importance of prioritizing resources to yield 

the greatest effect is paramount. Demonstrating the effectiveness of newly proposed programs or program 

modifications is a challenging task that demands objective data in order to make informed decisions. Statistical 

data can be a powerful tool to demonstrate the potential 

of a medical prevention program, however, the available 

statistics have limited application to specific prevention 

programs. Typically, information from the Bureau of 

Labor Statistics (BLS) is used to support a global preventive medicine program’s potential. The available 

information from BLS is limited to the number of lost 

work days due to injuries and illnesses for general occupations.1

 The BLS information is dependent on reporting and does not include lost time cost and permanent 

disability cost. Information, such as that from the BLS, 

is aggregated in such a manner that the assumptions 

and limitations required to use it degrades the usefulness of the data, resulting in limited utility. For example, 

BLS-presented data on nonfatal injuries and illness requiring time away from work is categorized by general 

occupational (ie, laborers, nursing assistants) and injury 

category (overexertion, falls, slips, trips) to report the 

top occupation and injuries in the workforce. The BLS 

provides the number of lost work days but no associated 

costs for medical treatment or lost time. These metrics 

captured from workers’ compensation and employer reporting data do not provide the user the capability to 

accurately predict costs. There are a variety of return 

on investment (ROI) models available which are simply 

performance measures that analyze the efficiency of an 

investment. In a business sense, it is one way of comparing profit or loss compared to the amount invested. 

Two key elements are required to accurately apply a ROI 

model to the avoidance of medical costs: the total medical costs associated with an injury or illness, and the 

total mitigation or prevention costs. The Medical Cost 

Avoidance Model (MCAM) ICD-9* Analysis Tool was 

developed to meet the challenging need for an ROI model that captures the full spectrum of medical costs.

The Medical Cost Avoidance Model ICD-9

Analysis Tool

The Health Hazard Assessment Program, a program 

within US Army Institute of Public Health, has developed a MCAM ICD-9 Analysis Tool that bridges the 

gaps among medical cost components (medical costs, 

lost time, disability, etc.) and provides the user with a 

comprehensive tool to demonstrate ROI for prevention 

programs. The MCAM is a web-based tool now available 

on the US Army Public Health Command website.3 The 

ICD-9 Analysis Tool of the MCAM was designed with 

prevention program developers in mind and provides the 

medical costs associated to specific ICD-9 codes.2 When 

a patient is seen by a healthcare provider, the visit is documented through the use of one or more ICD-9 diagnosis 

codes, which is associated with a specific treatment cost.

The MCAM ICD-9 Analysis Tool links cost data from 

3 primary sources to calculate total medical costs: the 

Military Health System (MHS) (medical treatment and 

fatality costs), the Army Military-Civilian Cost System 

(AMCOS) (personnel cost for lost time), and the US Department of Veterans Affairs (VA) (permanent disability cost). Medical treatment data from the MHS includes 

outpatient and inpatient treatment provided to eligible 

personnel in military and civilian treatment facilities. 

The MCAM uses data from the active duty Army population from fiscal years (FY) 2010, 2011, and 2012.

Each of the MCAM cost components defined in Table 1 

are summed to produce the total medical cost (Ct) using the simple calculation: Ct=Cc+Ch+Cl+Cf+Cd .

The MHS data are the backbone for the ICD-9 Analysis 

Tool, while the ICD-9 code itself is the common link in 

Using the Army Medical Cost Avoidance Model

 to Prioritize Preventive Medicine Initiatives

Cindy Smith

Kelsey McCoskey, MS

MAJ Jay Clasing, SP, USA

Timothy A. Kluchinsky, Jr, DrPH

*The International Classification of Diseases, Ninth Revision, 

Clinical Modification (ICD-9-CM) is the official system of assigning codes to diagnoses and procedures associated with hospital 

use in the United States.2
July – September 2014 73

determining total medical cost from medical treatment, 

lost time, fatality, and disability. The methodology used 

to capture these medical costs is summarized below.

Medical Treatment Cost. The medical treatment cost 

(known in the model as clinic and hospital cost) is derived from the average cost per diagnoses by calculating 

the average number of clinic visits or hospital stays and 

the average cost per clinic visit or hospital stay per ICD9 diagnosis.

Lost Time Cost. The lost time metric for each clinic visit 

and hospital stay is calculated using the assumptions 

that a direct care clinic visit at a military treatment facility requires 2 hours; a purchase care clinic visit at 

a civilian provider requires 4 hours, and each day in 

the hospital equates to 8 hours of lost time from work. 

These assumptions were developed through interviews 

with military healthcare providers. A disposition is recorded in the MHS at the conclusion of a clinic visit or 

hospital stay for direct care and inpatient purchased care. 

The 3 dispositions captured per ICD-9 diagnosis code 

in support of the lost time portion of the MCAM are: 

(a) assignment to quarters (bed rest), (b) convalescent 

leave, and (c) limited duty assignment (reduced productivity). A timeframe is assigned with each disposition 

and linked to the averaged adjusted military personnel 

salary from the AMCOS Lite database.4 The military 

personnel salary is adjusted to reflect the full burden 

of the lost time cost, including costs of other benefits 

and entitlements such as retired pay accrual and medical support cost attributed to each Soldier outside of the 

base pay. The method of capturing lost time by specific 

ICD-9 codes is unprecedented. Linking lost time directly to ICD-9 diagnoses captures information on injuries 

and illnesses that otherwise go unreported.

Fatality Cost. Fatality costs are also derived from disposition data in the MHS. Each fatality per ICD-9 diagnosis is assigned $500,000, which is the combined 

maximum amount of Servicemember’s Group Life Insurance (SGLI) and the death gratuity benefit paid to 

the survivors of a Soldier who dies while on active duty. 

The SGLI is a VA program that provides group life insurance to members of the uniformed services. Service 

members are automatically insured under SGLI for the 

maximum amount of $400,000 unless they elect to reduce the insurance coverage.5

 The death gratuity is a 

one-time, nontaxable payment of $100,000 to help surviving family members deal with the financial hardships 

that accompany the loss of the service member.6

Disability Cost. The ICD-9 diagnoses are associated to 

VA disability compensation through a mapping tool 

developed by the Veterans Health Administration 

(VHA).7 The VA disability compensation is a tax-free 

monetary benefit paid to Veterans on a monthly basis.8

The amount paid is dependent on the severity of the disability as rated by the specific Veterans Administration 

Schedule for Rating Disabilities (VASRD) coding.9 The 

mapping used in the MCAM correlates ICD-9 codes to 

the 4-digit VASRD code in order to determine the permanent disability costs. It is important to note that not 

all ICD-9 diagnoses result in a permanent disability.

The MCAM in Action: An ICD-9 Analysis for the

Safe Patient Handing and Mobility Program

Healthcare providers are at a high risk for musculoskeletal disorders (MSD) because they are required to manually move patients. According to the BLS, nursing-related professions have among the highest rate of workplace 

injuries. In 2012, the BLS reported that

In healthcare and social assistance,...MSDs made up 

42[%] of cases and had a rate of 55 cases per 10,000 fulltime workers. This rate was 56[%] higher than the rate 

for all private industries and second only to the transportation and warehousing industry.10

However, the true number of musculoskeletal injuries 

related to manually handling patients is unknown because there is a high rate of underreporting in nursing 

staff. According to Hart, about one in 4 (25%) nurses 

and one in 3 (33%) radiology technicians who have experienced on-the-job injuries did not report those injuries to their employer in at least one instance.11 The most 

common reasons cited for not reporting injuries among 

both groups of hospital employees are: injuries are a part 

of the job; it’s not worth making a report because nothing will happen; and not having enough time.11 The musculoskeletal injuries suffered by healthcare workers can 

result in early retirement and lifelong disability resulting 

in a loss of experienced clinical providers. An estimated 

12% to 18% of nursing personnel leave the profession 

annually due to chronic back pain, and another 12% consider a job transfer to reduce their risk of back injury.12

Table 1. The MCAM Medical Cost Components, Definitions, 

and Descriptions.

Cost

Component

Definition Description

Cc Clinic cost Outpatient treatment 

Ch Hospital cost Inpatient treatment

Cl Lost time cost Time away from work due to clinic 

visits, hospital stays, assignment 

to quarters, convalescent leave, 

and the limited ability to perform.

Cf Fatality cost Insurance and gratuity pay

Cd Disability cost VA compensation disability 
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

The Ergonomic Program of the US Army Public Health 

Command developed Safe Patient Handling and Mobility Programs (SPHMP) for the US Army Medical Command to reduce the incidence of musculoskeletal disorders related to patient handling in civilian and military 

healthcare providers. The SPHMP program elements 

were designed through collaboration with the VHA, a 

leader in research and innovation regarding safe patient 

handling practices worldwide. The SPHMP is a wellcoordinated programmatic approach to implementing a 

new standard of practice that is designed to focus on 

the patient’s care and clinical outcomes while minimizing staff injury. The SPHMP is a multifactorial model 

that includes ergonomic patient handling and movement 

site assessments, education and training, and the facility wide installation of safe patient handling equipment, 

policy and unit champions. Additionally, the 2010 Facility Guidelines Institute (FGI) Guidelines for Design and 

Construction of Healthcare Facilities13 requires that patient handling and movement assessments (PHAMA) 

be conducted for new construction and renovation to 

identify appropriate patient handling equipment requirements for each area and to determine the space and 

construction needs to incorporate safe patient handling 

equipment.

The majority of the cost required for SPHMPs is safe patient handling equipment costs. In addition to the 2010 

PHAMA requirement, the FGI published a white paper 

which included guidance on appropriate ceiling lift coverage.14 Traverse ceiling lifts are recommended for the 

majority of inpatient rooms in acute care settings and 

are preferable to floor-based lifts due to their usability, 

convenience, and space-saving accessibility. Ancillary 

equipment such as patient lift slings are stored in patient 

rooms and are laundered with general linens. In contrast, 

floor-based patient lift equipment has a large footprint 

and is frequently kept in storage closets away from patient rooms. In a study by Marras, the use of ceiling lifts 

resulted in safe forces on the lumbar spine while use of 

floor-based equipment had potential to increase forces 

acting on the lumbar spine to unacceptable levels.15

Generally, traverse ceiling lifts can range from $5,000 to 

$10,000 per unit depending on manufacturer, weight capacity, and design features. Additional costs include ancillary equipment such as repositioning sheets and slings. 

The estimated cost for a 200 bed hospital to install ceiling lifts is $750,000, which includes the installation of 

ceiling lifts and supporting equipment for approximately 

half of all inpatient rooms as well as physical therapy, 

radiology, operating room, emergency department, and 

other ancillary areas. For the purposes of this article, 

$750,000 will be considered the project costs. 

Collins reported that SPHMPs reduce workers’ compensation injury rates by 61%, lost workday injuries rates by 

66%, restricted workdays by 38%, as well as the number 

of workers suffering from repeat injuries.16 The VHA 

has been successful in increasing patient and staff satisfaction while decreasing modified duty days (70%), lost 

time for injuries (18%), and the number (30%) and severity of injuries among patient handlers by implementing a SPHMP.17 In addition to the health outcomes for 

both patient and provider, it is important to demonstrate 

the cost effectiveness and return on investment for the 

costs associated with implementation of these programs. 

The ICD-9 Analysis Tool2 can provide the medical cost 

avoidance to support the implementation of SPHMPs.

The ICD-9 Analysis Tool User Interface

The ICD-9 Analysis Tool user interface is straightforward and requires only minimum information from the 

user to provide the total medical cost avoided. The user 

is required to name the project, select the ICD-9 code 

either through the drop down list for the 3 digit filter or 

through the text filter, and provide the number of cases 

expected to be avoided with the number of years of the 

given project. Model background information and input 

guides are available by clicking on the question mark 

buttons on the user interface as shown in Figure 1. The 

total medical cost avoidance is delivered by clicking the 

Calculate Cost Avoidance button (outlined in red in Figure 1). The Details link provides a pop-up window itemizing the cost components. A full report is produced by 

clicking the Print Results button.

A recommended starting point for using the MCAM’s 

ICD-9 Analysis Tool is to determine the number of 

cases expected to be avoided per year and the number 

of years the program is anticipated to be in effect. Our 

example for the Army Healthcare Specialist (military 

occupation specialty (MOS) 68W) begins with a 3-year 

(FY 2010-FY 2012) data analysis of ICD-9 and MOS 

from the MHS using the MHS Management Analysis 

and Reporting Tool (M2). Table 2 presents the average 

case count, average cost per case, and accumulated incidence of selected ICD-9 diagnoses in active duty Army 

Healthcare Specialists for an unnamed medical facility. 

The Healthcare Specialists are a population of enlisted 

Soldiers working in medical facilities who are subject 

to performing tasks associated with manual transfer of 

patients. The data in Table 2 was derived by catchment 

area Defense Medical Information System ID Code for 

a hospital identified as “Hospital X.” The data includes 

inpatient and outpatient treatment performed through 

direct and purchased care. The ICD-9 codes identified 

in Table 2 were selected because they are injuries commonly associated with patient handling.

USING THE ARMY MEDICAL COST AVOIDANCE MODEL

TO PRIORITIZE PREVENTIVE MEDICINE INITIATIVES
July – September 2014 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

The ICD-9 Case Analysis Report

Theoretically, the medical treatment cost presented in 

Table 2 provides some medical cost savings on its own, 

however, it only presents a portion of the cost. The lost 

time associated with the treatment is often the largest 

cost component. We assumed that 25% of the case count 

for the 2 ICD-9 codes with the highest case count from 

Table 2 was attributed to patient handling. We entered 

45 cases for ICD-9 code 7242 (lumbago) and 17 cases 

for ICD-9 code 7245 (backache NOS (not otherwise 

specified)) for cases avoided per year. We entered 10 for 

the total years because the expected life for a ceiling lift 

is 10 years. The cost of the equipment ($750,000) was 

entered as the project cost.

The ROI estimated by the ICD-9 Analysis Tool for the 

SPHMP is $13,499,480, approximately 18 times the 

amount invested. The user is provided a summarized 

report (Figure 2) that itemizes the cost components for 

each ICD-9 code entered. The ROI is the net grand total 

located at the bottom line of the report. A one-year 

cost is also provided in each report. The report can 

be printed directly from the application.

There are no calculated costs for the disability and 

fatality components in this example. As noted on 

the bottom of each MCAM ICD-9 Case Analysis report, both of these components will remain 

zero until the number of avoidable cases entered 

exceeds certain thresholds. The disability costs 

are based on the prevalence of the most probable VASRD associated with the queried ICD-9 

diagnosis among the Army veteran population. 

Table 2. Back Injuries for Active Duty Healthcare Specialists* at 

Hospital X.

3 Year Average (FY 2010 - 2012)

ICD-9 Description, Short Case Count Average

Cost/Case

Incidence†

7241 Pain in thoracic spine 37 $364 2.87

7242 Lumbago 181 $451 14.06

7244 Lumbosacral neuritis NOS‡ 23 $1,228 1.75

7245 Backache NOS‡ 66 $318 5.10

7248 Other back symptoms 27 $332 2.10

*Military Occupational Specialty 68W

†Accumulative incidence per 100

‡NOS indicates not otherwise specified.

Figure 1. MCAM ICD-9 Analysis Tool user interface.

Cost Details 

Lost Time: $9,085,936

Clinic: $309,206

Hospital: $2,308,938

Disability: $0

Fatality: $0

Lifecycle Cost $11,704,080

See Print Results for additional details.

Ok

Model

Background

Input

Guides
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

Fatality costs are based on the incidence of fatality for 

the queried ICD-9 diagnosis in active duty Army personnel. Not every ICD-9 diagnosis will result in disability or a fatality.

Summary

The MCAM’s ICD-9 Analysis Tool provides preventive 

medicine program developers with a powerful tool to 

demonstrate ROI. Previously disjointed cost components have been brought together in the MCAM to calculate the total medical cost avoided. Users are required 

to make 4 data entries. In response, the user receives the 

highly coveted medical cost avoidance that should be realized. The SPHMP example demonstrates how simple 

it is to use the MCAM to determine the expected ROI.

References

1. Bureau of Labor Statistics. Injuries, illness, and 

fatalities [internet]. Washington, DC: US Dept of 

Labor. Available at: http://www.bls.gov/iif/#tables. 

Accessed February 28, 2014.

2. National Center for Health Statistics. International 

Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Atlanta, GA: US 

Centers for Disease Control and Prevention; 2013. 

Available at: http://www.cdc.gov/nchs/icd/icd9cm.

htm. Accessed February 28, 2014.

3. Medical Cost Avoidance Model [internet]. US 

Army Public Health Command. Available at: 

https://usaphcapps.amedd.army.mil/mcam/ICD9Cost.aspx. Accessed March 5, 2014.

Figure 2. The MCAM ICD-9 Case Analysis Report.

User Inputs

Grand Total: $14,999,480

Project Costs ($): $750,000

Net Grand Total: $13,499,480

Return on

Investment

USING THE ARMY MEDICAL COST AVOIDANCE MODEL

TO PRIORITIZE PREVENTIVE MEDICINE INITIATIVES
July – September 2014 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

4. The Army Military-Civilian Cost System [internet]. 

US Dept of the Army. Available at: https://www.

osmisweb2.army.mil/amcos/app/home.aspx. Accessed February 28, 2014.

5. Servicemembers group life insurance (SGLI) [internet]. US Department of Veterans Affairs. Available at: http://benefits.va.gov/insurance/sgli.asp. 

Accessed verified February 28, 20

6. Under Secretary of Defense, Personnel & Readiness. Military compensation: death gratuity [internet]. Washington, DC: US Dept of Defense. Available at: http://militarypay.defense.gov/benefits/

deathgratuity.html. Accessed February 28, 20

7. VA Information Resource Center (VIReC) [internet]. US Department of Veterans Affairs. Available 

at: http://www.virec.research.va.gov/. Accessed 

February 28, 2014.

8. Compensation: Veterans Compensation Benefits 

Rate Tables-Effective 12/1/11 [internet]. US Department of Veterans Affairs. Available at: http://

www.benefits.va.gov/COMPENSATION/resourc

es_comp0111.asp. Accessed February 28, 2014.

9. Schedule for Rating Disabilities: 38 CFR §4. Available at: http://www.benefits.va.gov/warms/bookc.

asp#d. Accessed February 28, 20

10. Bureau of Labor Statistics. Nonfatal Occupational 

Injuries and Illnesses Requiring Days Away From 

Work, 2012 [internet]. Washington, DC: US Dept 

of Labor. Available at: http://www.bls.gov/news.

release/osh2.nr0.htm. Accessed February 28, 2014.

11. Safe Patient Handling: A Report. Washington, DC: 

Peter D Hart Research Associates; March 2006. 

Available at: http://www.aft.org/pdfs/healthcare/

safepatienthandling0306.pdf. Accessed April 17, 

2014.

12. Nelson A, Baptiste AS. Evidence-based practices 

for safe patient handling and movement. Online 

J Issues Nurs [serial online]. 2004;9(3). Available at: http://www.nursingworld.org/MainMe

nuCategories/ANAMarketplace/ANAPeriodicals/

OJIN/TableofContents/Volume92004/No3Sept04/

EvidenceBasedPractices.aspx. Accessed April 17, 

2014.

13. Guidelines for Design and Construction of Health 

Care Facilities. Dallas, TX: Facility Guidelines 

Institute; 2010. Available at: http://www.fgiguide

lines.org/guidelines2010.php. Accessed April 17, 

2014.

14. Borden CM, ed. Patient Handling and Movement 

Assessments: A White Paper. Dallas TX: Facility Guidelines Institute; April 2012. Available at: 

http://www.fgiguidelines.org/pdfs/FGI_PHAMA_

whitepaper_042810.pdf. Accessed April 16, 2014.

15. Marras WS, Knapik GG, Ferguson SS. Lumbar 

spine forces during maneuvering of ceiling-based 

and floor-based patient transfer devices. Ergonomics. 2009;52(3):384-397.

16. Collins J, Wolf L, Bell J, Evanoff B. An evaluation of a “best practices” musculoskeletal injury 

prevention program in nursing homes. Inj Prev. 

2012;10(4):206-211.

17. Nelson A, Matz M, Chen F, Siddharthan K, Lloyd 

J, Fragala G. Development and evaluation of a multifaceted ergonomics program to prevent injuries 

associated with patient handling tasks. Int J Nurs 

Stud. 2006;43:717-733.

Authors

Ms Smith is an industrial hygienist with the US Army 

Public Health Command, Aberdeen Proving Ground, 

Maryland.

Ms McCoskey is an ergonomist with the US Army Public 

Health Command, Aberdeen Proving Ground, Maryland.

MAJ Clasing is a manager in the Ergonomic Program, 

US Army Public Health Command, Aberdeen Proving 

Ground, Maryland.

Dr Kluchinsky is the Manager of the Health Hazard Assessment Program, US Army Public Health Command, 

Aberdeen Proving Ground, Maryland.
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

The Medical Education and Training Campus (METC) 

was established as part of the 2005 Base Realignment 

and Closure Commission legislation requiring the Air 

Force, Army, and Navy to collocate enlisted basic and 

(most) specialty medical training at Joint Base San Antonio Fort Sam Houston, Texas. The METC achieved 

initial operating capability on June 30, 2010, becoming fully operational on September 15, 2011. Currently, 

METC has 9 academic Departments and 51 programs. 

More than 21,000 Air Force, Army, Navy, Marines, 

Coast Guard, and international students graduate from 

METC each year. An average of 7,000 students are on 

campus at a given time.

The Public Health Specialist Program, along with the 

Behavioral Health Program, falls under the Department of Public Health. Originally named the Preventive Medicine Program, the name was changed to the 

Public Health Specialist Program in the fall of 2013 to 

better align the training with civilian equivalents. The 

program graduates Army Preventive Medicine Specialists (Military Occupational Specialty 68S) and Navy 

Preventive Medicine Technicians (Navy Enlisted Classification Code HM-8432). The first class of the Preventive Medicine Program graduated on October 26, 2011. 

Since then, more than 1,000 students have graduated 

from the program at METC.

In 2013, the program initiated a major curriculum overhaul to improve the quality of the training by updating 

courses, better incorporating technology into instruction, and realigning some courses. The new curriculum is scheduled for implementation in the summer of 

2014. This article describes both the current and revised 

curriculum for the Public Health Specialist Program at 

METC and discusses the benefits of the program for students, faculty, and the military services.

Overview

The Public Health Specialist Program consists of a consolidated phase as well as service-specific tracks. Each 

course begins with the consolidated phase, during which 

Army and Navy students are together for 400 hours of 

training, covering a variety of topics required by both 

services. Once the consolidated portion of the training 

is complete, the students separate into service-specific 

tracks to receive instruction on requirements unique to 

the Army and Navy respectively. Army students have 

208 instructional hours in the Army-specific portion of 

their training, while Navy students have 544 instructional hours in their service-specific training. Under the 

current curriculum, the American Council on Education 

recommends that award of 9 undergraduate credit hours 

for Army students and 12 hours for Navy students.

The program faculty consists of 2 Army officers (one 

Entomologist and one Environmental Science and Engineering Officer), one Navy Environmental Health Officer, 9 Army noncommissioned officers (NCOs), and 7 

Navy NCOs. The Program Director is either an Army 

or Navy officer, as the position alternates between the 

services.

There are 7 courses within the consolidated portion of 

the training: Introduction to Preventive Medicine, Medical Threat, Food Service Sanitation, Aspects of Water, 

Entomology, Operational Preventive Medicine, and Deployment Environmental Surveillance Program. Introduction to Preventive Medicine provides students with a 

brief overview of Preventive Medicine and sets the stage 

for the remainder of the training. The Medical Threat 

course prepares students to prevent and reduce disease 

and injury in operational settings and to communicate 

preventive medicine issues in a briefing format. Food 

Service Sanitation prepares students to inspect food service operations and provide consultation to food service 

staff to correct deficiencies. As part of the Food Service 

Sanitation Course, students have the opportunity to earn 

the ServSafe certification from the National Restaurant 

Association. During Aspects of Water, students learn 

to test water for a variety of uses, interpret those results, and make appropriate recommendations to ensure 

that water is safe for its intended use. The Entomology 

course introduces students to the basics of pest control 

and vector borne disease prevention. Upon successful 

completion of this course, students earn Department 

The Public Health Specialist Program at the

 Medical Education and Training Campus

MAJ M. G. Colacicco-Mayhugh, MS, USA

LT Carl Blaesing, MSC, USN

LTC Kent Broussard, MS, USA
July – September 2014 79

of Defense Pesticide Applicator Certification in the following Environmental Protection Agency pest control 

categories: Right-of-Way Pest Control; Industrial, Institutional, Structural, and Health-related Pest Control; 

and Public Health Control. The Operational Preventive 

Medicine course concentrates on specific preventive 

medicine measures, including operational risk management procedures used during disaster and humanitarian 

relief missions, base camp assessments, and medical 

threat assessment. Finally, the Deployment Environmental Surveillance Program prepares students to perform 

air, water, and soil surveillance, and document potential 

adverse health exposures in an operational environment.

The Army-specific training consists of Army Public 

Health, Health Physics, Industrial Hygiene (IH), and 

a Situational Training Exercise (STX). Army Public 

Health provides students with an understanding of Army 

programs related to health and wellness, including the 

Military Vaccine (MILVAX) program, sexually transmitted disease prevention, and epidemiological investigations. The Health Physics course provides students an 

introduction to chemical, biological, radiological, and 

nuclear event response. In the IH course, students learn 

the fundamentals of industrial hygiene. Upon successful 

completion of IH, students receive certification in Basic 

Industrial Hygiene from the Army Medical Department 

Center and School (AMEDDC&S). The final event for 

Army students is a capstone STX. The STX is scenario driven and requires students to draw from all of the 

courses they have taken to address a variety of preventive medicine problems and deliver a briefing summarizing their findings and recommendations to mitigate 

health threats in the given scenario.

The Navy-specific training consists of Public Health Administration, Communication, Biostatistics, Epidemiology, Microbiology, Parasitology, Immunization Programs, 

Occupational Safety and Health, Shipboard Preventive 

Medicine, Environmental Sanitation, and a Final Evaluation Exercise (FEX). Public Health Administration provides Navy students with a basic understanding of how 

Preventive Medicine fits into Navy Medicine. The Communication course lays the groundwork for students to 

effectively communicate public health messages in their 

future assignments. Biostatistics gives students an introduction into the fundamentals of statistics. Epidemiology 

covers the principles of disease investigation, reporting, 

and prevention. The Microbiology course examines the 

impacts that microorganisms have on humans and the 

environment. Parasitology introduces students to parasites that can affect human health and their epidemiology. The Immunization Programs course provides students with an understanding of the MILVAX program 

and prepares them to manage immunization programs 

in their future assignments. Occupational Safety and 

Health provides an introduction to the Navy’s Occupational Safety and Health Programs. Shipboard Preventive 

Medicine covers potable water supply requirements for 

operational forces afloat and the procedures for wastewater treatment and disposal for forces afloat. Environmental Sanitation covers sanitation and infection control, 

both ashore and afloat. The FEX is the capstone event for 

Navy students. The FEX is scenario driven and requires 

students to synthesize the information that they learned 

throughout the program to address real-world situations, 

preparing written and oral products for evaluation.

Revised Curriculum

In the summer of 2014, the Public Health Specialist program will begin teaching the revised curriculum, which 

is designed to increase the individual Soldier or Sailor’s 

readiness to perform their mission upon graduation. 

While many of the individual courses have the same 

titles in the revised curriculum, the entire program was 

carefully reviewed for accuracy of content, currency of 

materials, and synchronization between test questions 

and lesson objectives. Ensuring that the program addresses requirements outlined in the Army Critical Task 

List (CTL) for Preventive Medicine Specialists and the 

Navy Job Duty Task Analysis (JDTA) for Preventive 

Medicine Technicians was a major consideration in developing the new curriculum. Once the training requirements for Army and Navy students were identified from 

the CTL and JDTA, they were cross-referenced to determine which can be taught in a consolidated environment and those that are so unique to one of the services 

that they must be taught in the service-specific portions 

of the course. In addition, the new curriculum seeks to 

target higher levels of learning in both the cognitive 

and psychomotor domains than presented by the earlier 

curriculum. This will increase the level of difficulty in 

many of the courses and help to ensure that better prepared students are graduating from the program.

Under the revised curriculum, the order of courses within the consolidated phase was shifted to generate a better flow and some content was moved from the servicespecific portion of the training to the consolidated portion to reduce redundancy. As a result, the consolidated 

portion of the program will increase from 400 to 460 

instructional hours; the Army phase will decrease from 

208 to 180 instructional hours; and the Navy phase will 

decrease from 544 to 516 instructional hours. The comparison of the current and revised curriculum in terms 

of hours spent in each course and the order of courses 

is presented in the Table. After implementation, the new 

curriculum will be presented to the American Council 
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

on Education for review to determine the number of undergraduate credits earned by Army and Navy students.

Under the revised curriculum, Military Public Health 

and Communication are added to the consolidated portion of the training. Military Public Health brings material previously taught in each of the service-specific portions of the program together to provide Army and Navy 

students an overview of public health in the military, 

and better sets the stage for the courses that they will 

take throughout the rest of the program. The Communication course is moved from the Navy-specific portion 

of the program to the consolidated phase to provide both 

Army and Navy students with the fundamentals of preparing and presenting briefings, a critical skill for success throughout the program as well as in their careers. 

In an effort to better streamline the program, the Medical Threat and Operational Preventive Medicine courses 

are combined into a single course named Operational 

Preventive Medicine. The order of courses was adjusted 

in the new curriculum to create a more natural flow with 

courses that build on each other grouped together. The 

order of courses is shown in the Table.

The Army Public Health course is removed from the Army-specific training under the revised curriculum, with 

the tasks previously taught in that portion of the curriculum moved to the Military Public Health 

course in the consolidated phase. Health 

Physics and Industrial Hygiene remain in 

the Army-specific portion of the curriculum, with students still receiving the Basic 

Industrial Hygiene certification from the 

AMEDDC&S following completion of the 

latter course. The STX now conducted on 

Ft. Sam Houston will transition to a Field 

Training Exercise (FTX) which will be 

conducted at Camp Bullis, Texas.

The Navy-specific portion of the course is 

slightly shorter under the revised curriculum, with the Communication course shifted to the consolidated curriculum. Furthermore, the new curriculum will incorporate 

Shipboard Pest Management, which has not 

been previously taught at METC, into the 

Shipboard Preventive Medicine course. In 

order to better prepare our Sailors for their 

missions afloat, the Navy-specific training will incorporate a field trip to Corpus 

Christi Naval Air Station to give Sailors an 

opportunity for hands-on training in some 

of the tasks that are unique to Shipboard 

Preventive Medicine.

Comment

Consolidated training at METC presents a wide array of 

benefits to the students, instructors, and the military services. In order to maximize the benefits of an education 

at METC, curriculum should be developed that incorporates consolidated training as much as possible while 

balancing the unique needs of each service. The Public 

Health Specialist Program presents an effective, highquality, academic program that strives to exploit the advantages of training within the METC environment.

By far, the greatest advantage of the consolidated Public 

Health Specialist Program at METC is that it prepares 

our students from very early in their careers to understand and work with individuals from other services. 

During Operations Iraqi Freedom and Enduring Freedom, military preventive medicine personnel worked in 

an increasingly joint environment. For many of our service members, the first time that they were exposed to 

another service culture was in the high stress, deployed 

environment. The establishment of METC enabled this 

experience to become part of the early indoctrination of 

our service members into military medicine.

During the consolidated portion of training, Army and 

Navy students begin each day reciting in turn the Soldier’s Creed and the Sailor’s Creed, and singing both 

Current and Revised METC Public Health Specialist Program Curricula.

Phase Current Curriculum Revised Curriculum

(Effective summer 2014)

Consolidated Introduction to Preventive 

Medicine

Medical Threat

Food Service Sanitation

Aspects of Water

Entomology

Operational Preventive Medicine

Deployment Environmental 

Surveillance Program

Introduction to Preventive 

Medicine

Military Public Health

Communication

Food Service Sanitation

Aspects of Water

Deployment Environmental 

Surveillance Program

Operational Preventive Medicine

Entomology

Army-specific Army Public Health

Health Physics

Industrial Hygiene

Situational Training Exercise

Health Physics

Industrial Hygiene

Field Training Exercise)

Navy-specific Communication

Public Health Administration

Biostatistics

Epidemiology

Microbiology

Parasitology

Immunization Programs and 

Vaccines 

Shipboard Water Sanitation

Occupational Safety and Health

Environmental Health

Final Evaluation Exercise

Public Health Administration

Microbiology

Biostatistics

Epidemiology

Parasitology

Immunization Programs and 

Vaccines

Occupational Safety and Health

Environmental Sanitation

Shipboard Preventive Medicine 

Navy Final Evaluation Exercise

THE PUBLIC HEALTH SPECIALIST PROGRAM AT THE MEDICAL EDUCATION AND TRAINING CAMPUS
July – September 2014 81

THE ARMY MEDICAL DEPARTMENT JOURNAL

Anchors Aweigh and The Army Goes Rolling Along. 

Throughout the first 3 months of training, students work 

together across services on projects, in study groups, 

and as teammates. They are taught by members of each 

service, getting different perspectives and experiences 

to draw from in their own careers. By the completion 

of the consolidated courses, they are a cohesive team 

in which students better understand the culture of each 

service and are prepared to work in joint environments 

in the future.

Faculty members also benefit from the consolidated 

nature of the program for many of the same reasons. 

Regardless of the uniform that an individual instructor wears, all instructors in the program are responsible 

for teaching and mentoring both Army and Navy students at the start of their careers in preventive medicine. Working together as a team, the instructors learn 

to communicate effectively within each service culture. 

By the time program faculty depart METC, they have a 

solid understanding of both the similarities and the differences of the military services and are themselves better prepared to serve in joint environments in the future.

Given the benefits of the consolidated training in the 

Public Health Specialist Program to both students and 

faculty, it is clear that the nature of the program will ultimately benefit the services by helping to develop Sailors 

and Soldiers who have a less parochial view of their role 

within the military. As more service members graduate 

from the academic programs at METC and begin their 

careers in Military Medicine, the benefit of consolidated training will continue to grow. By developing curricula that seeks to reduce service-specific channeling as 

much as possible, the Public Health Specialist Program 

at METC is one small piece of the larger effort to improve integration of the capabilities and interoperability 

of military services across the full spectrum of Military 

Medicine.

Acknowledgement

The authors thank the following individuals for their 

contributions to the development of this article: HMC 

Paul Langrehr, USN; SFC Joseph Barton, USA; HMC 

Kelly Wallen, USN; SSG Mark Almendares, USA; SSG 

Danielle Maddox, USA; and SSG James Stephens USA.

Authors

MAJ Colacicco-Mayhugh is Director, Public Health 

Specialist Program, Department of Public Health, Medical Education and Training Campus, Joint Base San Antonio Fort Sam Houston, Texas.

LT Blaesing is the Navy Service Lead, Public Health 

Specialist Program, Department of Public Health, Medical Education and Training Campus, Joint Base San Antonio Fort Sam Houston, Texas.

LTC Broussard is the Force Health Protection Officer of 

the US Special Operations Command, Fort Bragg, North 

Carolina.

Medical Education and Training Campus Public Health Specialist Program students performing entomological surveillance. 

Photo courtesy of Ms Lori Newman, JBSA Fort Sam Houston Public Affairs Office.
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

The United States Army uses a community coalition 

approach called community health promotion councils 

(CHPC) as a strategic platform to manage the Army 

Public Health System. The Army is organized across 

functional chains of command. The Army Public Health 

System has subject matter experts on various public 

health concerns in these different systems. Assets can 

be found as a part of the medical system, the installation 

management system, or as a part of tactical operations at 

the mission level. Each of these systems plays a part in 

managing the overall public health system for the Army 

installation. The driving force for the standardization of 

integrating the Army’s Public Health System through 

the CHPC is Army Regulation 600-63.

1

 It defines health 

promotion as:

...any combination of health education and related organizational, political, and economic interventions designed to facilitate behavioral and environmental changes conducive to the health and well-being of the Army 

community.1(p6)

Community health promotion councils are designed to 

manage a coordinated approach to local public health at 

Army installations and integrate health promotion and 

disease prevention into the Army’s business practices. 

Because CHPCs are essential to the Army’s strategy to 

Managing Public Health in the Army

 Through a Standard Community Health

 Promotion Council Model

Anna F. Courie, RN, MS

Moira Shaw Rivera, PhD

Allison Pompey, DrPH, CPH

Abstract

Context: Public health processes in the US Army remain uncoordinated due to competing lines of command, 

funding streams and multiple subject matter experts in overlapping public health concerns. The US Army 

Public Health Command (USAPHC) has identified a standard model for community health promotion councils 

(CHPCs) as an effective framework for synchronizing and integrating these overlapping systems to ensure a 

coordinated approach to managing the public health process.

Objective: The purpose of this study is to test a foundational assumption of the CHPC effectiveness theory: the 

3 features of a standard CHPC model—a CHPC chaired by a strong leader, ie, the senior commander; a full 

time health promotion team dedicated to the process; and centralized management through the USAPHC—

will lead to high quality health promotion councils capable of providing a coordinated approach to addressing 

public health on Army installations.

Design: The study employed 2 evaluation questions: (1) Do CHPCs with centralized management through the 

USAPHC, alignment with the senior commander, and a health promotion operations team adhere more closely 

to the evidence-based CHPC program framework than CHPCs without these 3 features? (2) Do members of 

standard CHPCs report that participation in the CHPC leads to a well-coordinated approach to public health 

at the installation?

Conclusions: The results revealed that both time (F(5,76)=25.02, P<.0001) and the 3 critical features of the standard CHPC model (F(1,76)=28.40, P<.0001) independently predicted program adherence. Evaluation evidence 

supports the USAPHC’s approach to CHPC implementation as part of public health management on Army 

installations. Preliminary evidence suggests that the standard CHPC model may lead to a more coordinated approach to public health and may assure that CHPCs follow an evidence-informed design. This is consistent with 

past research demonstrating that community coalitions and public health systems that have strong leadership; 

dedicated staff time and expertise; influence over policy, governance and oversight; and formalized rules and 

regulations function more effectively than those without. It also demonstrates the feasibility of implementing 

an evidence-informed approach to community coalitions in an Army environment.
July – September 2014 83

address public health concerns, there is a strong need 

to document and evaluate the evidence supporting their 

effectiveness.2 Therefore, this study:

1. Describes the need for a CHPC model to coordinate the Army public health system.

2. Outlines the CHPC model and the evidence that 

informs its development.

3. Reports the results of initial studies of CHPC 

effectiveness.

4. Establishes an agenda for future research.

The Need for Army Community Health Promotion

Councils

Within most public health systems, the various components are typically owned and operated by different organizations such as schools, hospitals, and community 

health departments. Integration among these elements 

in the public health system is defined by their ability to 

agree on overall objectives, freely share information, 

and plan and implement complementary activities in the 

context of an agreed upon overall health response plan.3

Research shows that effective coordination among 

stakeholders in public health allows public health systems to achieve their mission, address health problems 

and respond to economic and performance demands.4

For example, integrating stakeholders within a public 

health system resulted in a dramatic rise in funding for 

single-disease or population-group-specific programs 

such as immunizations, malaria, and HIV/AIDS.5

Conversely, a fragmented approach to public health 

leads to duplication of services, conflicting recommendations to fix problems, medical errors, misunderstanding or lack of awareness of the true causes of problems, 

increased costs, public health errors, and ultimately 

poorer population health.6 The Institute of Medicine 

reports that failures in system capabilities are often a 

result of how public health services are organized and 

delivered across communities.7,8 Systemic errors occur, 

including poor reporting and communication of population health trends rather than technical failures.9,10 These 

concerns led the field of public health to a wide-spread 

acknowledgement of a need for strong and integrated 

services within public health systems.11

Research demonstrates that integration within a public 

health system is largely driven by the extent to which 

there are clear processes and a strong governing body 

regulating the interaction of agencies and organizations. 

Further, effective governance involves bringing constituents together and facilitating their actions within the 

system to accomplish system-wide goals. The system 

should document and disseminate how the various 

components of a public health system function; provide 

their constituents with information about the evidence 

supporting programs, policies, services, and the effectiveness of other public health practices; and ensure 

the access of target populations to those services.12 The 

information collected through the public health system 

and its governing body allows the effective allocation 

of resources, maximizes the collective impact of public health practices within the system, and allows public health stakeholders to methodically identify system 

strengths and weaknesses.13

Similarly, Army installations operate with interdisciplinary, complex systems that affect the health and wellbeing of the Army communities. For example, Army installations are governed through traditional, functional 

chains of command. Generally, these functional lines 

are mission or tactical operations (war-fighting, Soldier 

training and development, strategic operations); garrison operations (programs, services, facilities); and medical operations (healthcare services). The functional areas create many unique and overlapping systems within 

the overall Army public health system. The functional 

chains of command have the tendency to stovepipe and 

create natural silos. This is an efficient approach to ensuring leadership and accountability in achieving specific, clearly-defined missions. However, it creates obstacles and inefficiencies in addressing complex public 

health issues that require a multidisciplinary approach.

An example: suicide is a major, current public health 

concern in the Army. However, the ability to prevent 

suicide in the Army is within the purview of multiple 

commands and Army agencies. The Medical Command 

(MEDCOM) employs behavioral health providers that 

treat behavioral health disorders among Soldiers,14 the 

Army G1 (the Chief of Staff for Manpower and Human 

Resources) develops and administers a suicide prevention program and other programs that affect risk factors 

associated with suicide, such as the Army Substance 

Abuse Program,15 and the Army G3/5/7 (the Director of 

Strategy, Plans, and Policy) administers Comprehensive 

Soldier Fitness, a program designed to train Soldiers to 

become more psychologically resilient.16,17 These programs have complementary missions, but had no formal 

forum to coordinate their approach to suicide prevention 

at an installation level.18 Therefore, Army installation 

CHPCs evolved to bring representation from different 

stakeholders to the same table to develop efficient, coordinated approaches to public health concerns without 

reducing the autonomy of existing systems or disturbing the functional chain of commands in the Army organizational structure. In other words, the goal of the 
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

CHPC is to build a public health infrastructure and public health system that efficiently and systematically promotes health and prevents disease within the existing 

Army organizational structure on an installation.

The standard CHPC model, illustrated in Figure 1, is 

marked by 3 critical features. First, the CHPC is chaired 

by the highest level of leadership on an Army installation 

(the installation’s senior commander). The senior commander champions and leads the CHPC, and provides 

the authority to influence the programs, policies, and 

environments that affect the health of the installation’s 

population. Second, the CHPC is organized and managed by a health promotion operations team. The health 

promotion operations team consists of a health promotion officer (HPO) and a health promotion research assistant (HPRA). The health promotion operations team 

consists of members of the senior commander’s full time 

staff and is responsible for facilitating the CHPC and ensuring it is consistent with Army regulations and meets 

the standards developed by the Army Institute of Public 

Health of the USAPHC. The health promotion team provides subject matter expertise on the public health process to the senior commander’s staff and ensures coordination and fidelity to the standard process. This includes 

ensuring that the CHPC identifies health needs through 

systematic data collection, sets priorities through a 

health promotion strategic plan, oversees the development and implementation of health promotion programs 

and policies to address these priorities, and oversees the 

evaluation of the effectiveness of programs and policies. 

The third critical feature of the standard CHPC model 

is centralized management through the USAPHC. The 

USAPHC is a subordinate command to MEDCOM 

and oversees the administration of public health in the 

Army. It also collaborates with other Army oversight 

agencies such as the US Army Forces Command, US 

Army Training and Doctrine Command, the Army Materiel Command, the Army Installation Management 

Command, as well as other Army senior leaders such 

as deputy chiefs of staff of the Army and assistant secretaries of the Army to address the Army’s public health 

concerns. Through centralized management, HPOs, 

CHPCs, and senior commanders are able to remove barriers to healthier communities through USAPHC’s influence over programs and policies that are set at higher, 

strategic levels of the Army. Furthermore, USAPHC’s 

direct oversight of the CHPCs ensures that the CHPCs 

adhere to an evidence-informed program framework.

Currently, USAPHC funds health promotion officers 

and health promotion research assistants at Army installations that adhere to the standard CHPC model. The 

HPOS and HPRAs are located at 12 posts across the 

continental United States: Aberdeen 

Proving Ground, MD; Fort Bliss, TX; 

Fort Bragg, NC; Fort Carson, CO; 

Fort Campbell, KY; Fort Drum, NY; 

Joint Base Lewis-McChord, WA; Fort 

Polk, LA; Fort Hood, TX; Fort Irwin, 

CA; Fort Riley, KS; and Fort Stewart, GA. Fourteen other installations in this evaluation have established CHPC 

processes but do not have a designated health promotion 

officer or health promotion research assistant.

Evidence in Forming the CHPC Model and Process: 

Community Coalitions

The CHPC standard model is rooted in community coalition action theory19 and other research on effective 

community health coalitions. A community coalition is 

defined as:

...an organization of individuals representing diverse 

organizations, factions or constituencies within the community who agree to work together to achieve a common 

goal.20(p1)

The functions of community coalitions are generally to 

increase capacity through collaboration, help communities build social capital to apply to social and health issues, and to serve as catalysts for change and movement 

towards desired outcomes (eg, policy change).21

The community coalition approach grew out of multiple 

lines of research. For example, public health research 

indicates that public health problems are complex and 

rooted in a society’s social and ecological context and 

should be addressed from multiple directions by multiple actors in the community. Therefore, community 

coalitions aim to create synergy and opportunities for 

collaboration to address public health problems across 

multiple sectors.22 Community coalitions seek to empower communities to advocate for their own health and 

wellness, which is consistent with research demonstrating that a population’s health is more likely to improve 

when the community itself is engaged and invested in 

the community coalition process.23 Furthermore, better 

health in a community is more linked with the community health system characteristics (eg, health behaviors 

and environmental factors in the community) than the 

performance of the healthcare system (eg, accessibility 

of healthcare).24 Finally, community coalitions that aim 

to advocate for policy changes are supported by research 

demonstrating that the most effective strategies to improve the public’s health result from changes in policy.25

Standard Community Health Promotion Council Model

Chaired by the

senior commander

Organized and managed by 

the health promotion team

Centrally managed by the

US Army Public Health Command

Figure 1. Three critical features of a standard community health promotion 

council.

MANAGING PUBLIC HEALTH IN THE ARMY THROUGH

A STANDARD COMMUNITY HEALTH PROMOTION COUNCIL MODEL
July – September 2014 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

Research on community coalitions indicates that coalitions can positively attect health indicators such as 

lead poisoning, adolescent pregnancy, infant mortality, 

motor vehicle accidents, and tobacco use. For example, 

the Community Trails Project (a collaborative partnership) contributed to a 10% annual reduction in alcohol 

involved automobile crashes.26 Also, the Community Intervention Trial for Smoking Cessation contributed to 

increased quit rates among light to moderate smokers.27

Additional case studies from 20 community coalitions 

indicate that they have a strong and positive impact on 

organizational change including leveraging financial resources, developing programs, changing policy, increasing collaboration, increasing community engagement, 

involvement, and strengthening an organization’s health 

promotion structure.28

Not all community coalitions are equally effective.28 Research consistently finds that the effectiveness of community coalitions is affected by multiple factors. For 

example, a review of 26 studies concerning community 

coalition effectiveness found that 5 factors predicted 

community coalition success in at least 5 studies. These 

factors include formalization of rules and procedures, 

leadership style, member participation, membership diversity, agency collaboration, and group cohesion.29 Coalition leadership is a recurring predictor across several 

reviews. For example, a study of 10 coalitions formed 

as a part of the America Stop Smoking Intervention 

Study for Cancer Prevention highlights the importance 

of good coalition leadership.30

These case studies revealed that task-focus, good communication, quality action plans, and dedicated staff 

time were related to measures of community coalition 

effectiveness such as membership satisfaction, successful action plan implementation, and resource mobilization.30 Other studies suggest that coalition success is facilitated by a supportive organizational climate, ability 

to affect community norms, power to influence policy, 

and ability to develop and advocate for primary prevention resources within the community.31 Finally, diverse 

membership, a clear strategic vision, effective conflict 

resolution processes, a theory-driven approach to the 

community coalitions, the ability of coalitions to evaluate their effectiveness, and dedicated and competent staff 

all contribute to the success of community coalitions.21

The 3 critical features of the standard CHPC model 

ensure that many of the indicators of coalition and 

public health system effectiveness are present in the 

Army CHPC model. The Army CHPC model is wellpositioned to have an affect on policy. The senior commander at an Army installation has the authority to develop, disseminate, and enforce policies that affect the 

public health. For example, a senior commander at one 

Army installation learned that Soldiers were experiencing adverse effects from polypharmacy (the prescription 

of 5 or more medications) because providers were not 

receiving warnings when placing prescriptions through 

the electronic profile and pharmacy system.32 The senior 

commander used the CHPC to convey this issue to the 

Army hospital commander who ensured warnings to 

prevent polypharmacy were added to the system.

The Army CHPC model also places a strong emphasis 

on formalization of rules and policies and can ensure 

these rules are executed through centralized management. Each standard CHPC is required to execute the 

prescribed model with specific deliverables, including 

Figure 2: Health promotion officer-facilitated CHPC model effectiveness theory. The 3 key features of the CHPC model and the 

intermediate outcomes of adhering to an evidence-informed community coalition model and improved public health system 

performance.

Effective 

health 

promotion 

officers 

and health 

promotion 

research 

assistants

Adherence to 

an evidenceinformed 

community 

coalition 

model

Improved 

public health 

system 

performance

Improved 

community 

health and 

wellness, 

reduced 

morbidity 

and mortality

A Fit

and

Ready 

Force

Training, 

standardization, 

accountability, 

and strategic 

influence through 

the US Army 

Public Health 

Command

Local influence 

through 

alignment 

with the Army 

installation 

senior 

commander
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

reports of change in public health programs, practices, 

and policies; annual survey of CHPC effectiveness; report on adherence to the program framework; annual 

strategic plan; annual marketing plan; annual working 

group action plans; annual community profile; annual 

community resource guide; and quarterly program status reports. Health promotion officers provide these deliverables to centralized managers at the USAPHC who 

ensure the installation health promotion team adhere to 

the program framework and Army Regulation 600-63.

1

Another characteristic of effective coalitions, staff dedication time and expertise, is the primary reason for the 

HPO position. The HPOs are hired based on their competence in Army culture, leadership, and business management skills, and are trained to appreciate their public 

health role in improving community health as they collaborate with local and USAPHC public health professionals in areas of surveillance, community health, program planning, implementation, and evaluation.

In summary, the standard CHPC model has several of 

the core components of an effective community coalition; dedicated staff time and support, formalized rules 

and procedures, oversight to ensure quality action plans, 

and power to affect policy and advocate for primary prevention resources through the senior commander. Nonetheless, there are currently no published studies testing 

the effectiveness of the standard CHPC model. Because 

the standard CHPC is becoming a key strategy for promoting health and preventing disease and injury within 

Army populations, additional study to evaluate the model is critical. In an effort to evaluate the standard CHPC 

model, USAPHC is establishing a process for evaluating 

and monitoring the model to ensure quality, satisfaction, 

fidelity, and impacts. The next sections establish the 

study design, participants, and results.

The purpose of this study is to test a foundational assumption of the CHPC effectiveness theory: the 3 features of a standard CHPC model—a CHPC chaired by 

a strong leader, ie, the senior commander; a full time 

health promotion team dedicated to the process; and 

centralized management through the USAPHC—will 

lead to high quality health promotion councils capable 

of providing a coordinated approach to addressing public health on Army installations.

Method

Evaluation Questions and Study Design

The study employed 2 evaluation questions:

1. Do CHPCs with centralized management through 

the USAPHC, alignment with the Senior Commander, 

and a Health Promotion Operations Team adhere more 

closely to the evidence based CHPC program framework than CHPCs without these 3 features? 

2. Do members of standard CHPCs report that participation in the CHPC leads to a well-coordinated approach to public health at the installation? 

The study addressed the first question with a single factor (CHPC type), 2-level (standard CHPC vs. nonstandard CHPC) evaluation design with CHPC program 

adherence as the outcome variable. A past evaluation of 

CHPC effectiveness conducted by the Office of the Secretary of Defense for Health Affairs showed that the effect of the critical features of the standard CHPC model 

was moderated by the amount of time a CHPC had been 

established.* Therefore, the amount of time a CHPC had 

been operating was included as an additional predictor 

of program adherence.

The study addressed the second question through a survey that measured members’ perceptions that the CHPC 

led to a more coordinated public health system.

Instruments

Program adherence was measured through an instrument called the “structure process evaluation tool” 

(SPET). The SPET is a 58-item self-assessment for 

CHPC leadership (HPOs, centralized HPO managers, 

and CHPCs) to measure the extent to which the CHPC is 

meeting the requirements set forward in Army Regulation 600-63.

1

 It includes items such as “Does the installation have a CHPC that meets quarterly?” and “Does 

CHPC membership include representatives from each of 

the following: medical tactical, community, local?”

Perception of public health coordination is measured 

through the CHPC Effectiveness Survey. The Effectiveness Survey is a 20-item assessment administered 

yearly to CHPC members to assess the extent to which 

they perceive the CHPC as achieving its objectives and 

member satisfaction. In this assessment, participants respond to items regarding member satisfaction such as 

“in general, how would you rate the overall functioning 

of the HPO position at your installation” on a scale from 

1 (Strongly Disagree) to 5 (Strongly Agree).

However, only 5 of these items are directly relevant to 

members’ perceptions that the CHPC is achieving a 

more coordinated public health system. Therefore, only 

these items were analyzed to address evaluation question 2. The items include:

*Internal military document not readily accessible by the general 

public. 

MANAGING PUBLIC HEALTH IN THE ARMY THROUGH

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July – September 2014 87

THE ARMY MEDICAL DEPARTMENT JOURNAL

3⁄4 The CHPC identified gaps in existing resources for 

needs/risks. 

3⁄4 The CHPC uses data to identify community needs/

risks.

3⁄4 The CHPC assesses existing resources for overlaps.

3⁄4 The CHPC develops action plans for identified 

priorities.

3⁄4 The CHPC facilitates relationships and networking 

between garrison, medical and tactical assets.

Participants and Procedure

The SPET and Effectiveness Survey are completed annually between July and September of the Army fiscal 

year by all HPOs or a member of the CHPC (for installations without the standard CHPC model). The results 

of the SPET were aggregated across 6 years (2007-2012) 

and represents responses from 11 installations with the 

standard CHPC model and 18 installations without the 

standard CHPC model. There were a total of 83 (N=83) 

responses to the SPET. The CHPC Effectiveness Survey was completed once per year for 6 years (2007-

2012) by the CHPC membership only where there is 

a standard CHPC model (N=454). This study was 

reviewed by the US Army Public Health Review 

Board and all tools and methods were validated as 

approved methods of public health practice. The 

study did not require Institutional Review Board approval as all methods and data collected were a part 

of standard public health practice for community 

health promotion councils in the US Army.

Results

Evaluation Question 1

Ordinary least squares regression was used to determine the extent to which the 3 critical features of 

the CHPC model and time operating positively predicted program adherence. The results revealed that 

both time (F(5,76)=25.02, P<.0001) and the 3 critical features of the standard CHPC model 

(F(1,76)=28.40, P<.0001) independently predicted program adherence. Contrary to prior 

research, however, the relation between adherence to the standard CHPC model was 

not moderated by the time that had elapsed 

since the CHPC began meeting (F(1,76)=0.06, 

P=.81).33 These results are displayed in Figures 3 and 4.

Evaluation Question 2

Data from the CHPC Effectiveness Survey 

were analyzed with descriptive statistics 

measuring the extent to which members perceived the standard CHPCs as achieving the 

goal of integrating the Army installations’ local public 

health systems. The survey results indicated that members responded on the positive side of the scale. In other 

words, members generally agreed that participating in 

the standard CHPC model is associated with a more 

coordinated approach to addressing public health at the 

installation. Figure 5 presents the results of this analysis.

Comment

These results provide preliminary evidence that the 

Standard CHPC Model may lead to a more coordinated 

approach to public health and may assure that CHPCs 

follow an evidence-informed design. This data supports 

the standard CHPC Model where the Army senior commander provides strong leadership; the health promotion 

team drives the process with expertise and coordination; 

and centralized management ensures a standardized approach to policy and procedure execution is maintained 

through evidence of delivery. This is consistent with 

past research demonstrating that community coalitions 

and public health systems that have strong leadership, 

Figure 4. Community health promotion council structure process scores plotted by year, demonstrating the relationship between the time the CHPC is 

operating and adherence to an evidence-informed model.

2007 2008 2009 2010 2011 2012

1.4

0.8

1.0

1.2

0.6

0.4

0.2

0

Structure Process Scores

Figure 3. Structure process score plotted by type of community 

health promotion council, demonstrating the effect of a senior commander aligned and centrally managed health promotions operations team (standard CHPC) on program adherence.

0.80

0.77

0.78

0.79

0.76

0.75

0.74

0.73

0.72

Structure Process Scores

Nonstandard CHPC Standard CHPC
88 http://www.cs.amedd.army.mil/amedd_journal.aspx

dedicated staff time and expertise, influence over policy, 

governance and oversight, and formalized rules and regulations function more effectively than those without.3,4

It also demonstrates the feasibility of implementing an 

evidence-informed approach to community coalitions 

in an Army environment. The Army model is not only 

supported by methodologies described in the literature, 

the evidence from the process validates those same 

methodologies and contributes to the body of knowledge on the effect of coalitions on public health process 

management in communities.

Limitations

The findings in this study are limited by several factors. Because the SPET is a self-report and completed by 

HPOs who are motivated to appear successful in developing an effective CHPC, the data from the SPET may 

be biased. However, this study assumes that participants 

in the study representing nonstandard CHPCs are also 

motivated to adhere to the regulations for installations 

CHPCs. Most likely, this bias is present in both standard 

and nonstandard CHPCs. At this time, the CHPC effectiveness survey is only completed at installations with a 

standard CHPC. Therefore, there is no way to compare 

whether or not standard CHPCs perform better on this 

survey than nonstandard CHPCs.

An Agenda For Future Research

The studies support the link in the effectiveness theory 

between the 3 critical features of the standard CHPC 

model and a better coordinated approach to public health. 

However additional evaluation studies are needed to 

substantiate the effect of the standard CHPC model on 

community health and wellness and efficient resource 

management. Reviews of past research suggest 

that traditional program evaluation methods 

are often inadequate to capture the effect of 

community coalitions on population health.21

For example, there are only 12 standard CHPCs 

in the Army. At the community level, there are 

many outside influences that affect population 

health and it is difficult to account for all potential confounders that may cloud the effects 

of standard CHPCs. Thus, traditional research 

designs and tests of statistical significance may 

be underpowered to detect the direct effect of a 

CHPC on community health and wellness.

However, evaluations of the effect of specific 

policy, program, and environmental changes 

initiated through CHPCs could potentially demonstrate the positive effects of the standard CHPC on 

population health and wellness. For example, one CHPC 

implemented an additional wellness service which was 

associated with a decrease in Soldiers’ body mass index 

and increased help-seeking behaviors.* According to an 

annual report provided to USAPHC, the CHPCs implemented 1,050 similar actions and initiatives during fiscal year 2012 that aimed to improve community health 

and wellness and more efficiently manage public health 

resources at an installation. Using program evaluation 

methodologies to assess the impact of these individual 

initiatives may dramatically increase the evidence to 

support the effectiveness of the standard CHPC model, 

as well as provide greater insight into what programs, 

policies, and environmental changes will effect health 

promotion and disease prevention in the Army.

Conclusion

The standard Army CHPC model evolved to meet a 

need for better coordination within the Army public 

health system and presents a key strategy to achieving 

better health among Soldiers and their Families, retirees, and civilians. Based on past research and the studies presented here, the standard Army CHPC model is 

poised to positively affect the Army public health system, community health and wellness, public health resource management, and ultimately military readiness. 

The potential effect of the Army CHPC model, together 

with the opportunities it presents for interesting and revealing evaluation studies, suggest an exciting future for 

the study of public health management in the Army.

4.06

3.72

3.80

3.99

3.64

Average CHPC Effectiveness Scores

The CHPC facilitates 

relationships and 

networking between 

garrison, medical 

and tactical assets.

The CHPC uses data 

to identify needs.

The CHPC identifies 

gaps in existing 

resources.

The CHPC develops 

action plans for 

identified priorities.

The CHPC identifies 

overlaps in existing 

resources.

Figure 5. Perceptions of community health promotion council members 

that the council effectively coordinates the public health system in 2012. 

Total possible score for each question is 5 points (N=454).

*Internal military document not readily accessible by the general 

public. 

MANAGING PUBLIC HEALTH IN THE ARMY THROUGH

A STANDARD COMMUNITY HEALTH PROMOTION COUNCIL MODEL
July – September 2014 89

THE ARMY MEDICAL DEPARTMENT JOURNAL

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havioralhealth.army.mil/. Accessed March 25, 2013.

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26. Roussos ST, Fawcett SB. A review of collaborative 

partnerships as a strategy for improving community 

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Brownson RC, Owens NW. Neighborhood for a 

smoke free north side: evaluation of a community 

organization approach to promoting smoking cessation among African Americans. Am J Public 

Health. 1998;88(11):1658-1663.

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promotion coalitions: A study of 10 Project ASSIST coalitions in North Carolina. American Stop 

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Authors

Ms Courie is a Health Promotion Policy and Operations 

Project Officer, Army Institute of Public Health, Health 

Promotion and Wellness Portfolio, Health Promotion 

Operations Program, US Army Public Health Command, 

Aberdeen Proving Ground, Maryland.

Dr Rivera is a Public Health Scientist, Army Institute of 

Public Health, Health promotion and Wellness Portfolio, 

Public Health Assessment Program, US Army Public 

Health Command, Aberdeen Proving Ground, Maryland.

Dr Pompey is a Program Evaluator, Army Institute of 

Public Health, Health promotion and Wellness Portfolio, 

Public Health Assessment Program, US Army Public 

Health Command, Aberdeen Proving Ground, Maryland.

MANAGING PUBLIC HEALTH IN THE ARMY THROUGH

A STANDARD COMMUNITY HEALTH PROMOTION COUNCIL MODEL
July – September 2014 91

In an effort to stay relevant and competitive, companies 

and organizations explore ways to streamline processes while continuing to deliver quality products and/or 

services to their customers. Two hallmarks of process 

improvement are the “Lean” principle, with its focus 

on speed, and the “Six Sigma” principle, with its focus 

on quality.1(p15) Combining these principles, Lean Six 

Sigma (LSS) is a complementary process-improvement, 

problem-solving methodology used in the business and 

manufacturing industries to improve the speed, quality, 

and cost of products.1(p15)

LSS is commonly associated with manufacturing entities and corporations such as GE, Motorola, Toyota, and 

Lockheed Martin. However, over the past decade, the 

LSS methodology has expanded into other organizational realms. LSS has been used to improve knowledgebased products from service organizations such as hospitals,2

 government offices,3 and research and development organizations.4

 This article presents an example of 

the use of LSS to improve knowledge-based products in 

the public health sector.

In July 2008, the Army Institute of Public Health Behavioral and Social Health Outcomes Program (BSHOP) was 

established at US Army Public Health Command. The 

mission of BSHOP is to maximize total Soldier health 

and combat readiness by identifying and assessing the 

relative impact of psychological and social threats using 

a mixed methodological approach. At inception, one of 

the primary missions of BSHOP involved routine reporting and surveillance of suicidal behavior among Soldiers 

using data from the Army Behavioral Health Integrated 

Data Environment (ABHIDE). The ABHIDE is one of the 

most comprehensive data sources for suicidal behavior 

and includes data from 27 disparate administrative data 

sources. The BSHOP created the Surveillance of Suicidal 

Behavior Publication (SSBP), which is disseminated to 

key military leaders including the Vice Chief of Staff 

of the Army, the Army Surgeon General, public health 

practitioners, and behavioral health providers at regional 

medical commands and military treatment facilities.

As the mission and scope of BSHOP expanded, it became apparent that preparation of the SSBP was a timeand resource-intensive process that prevented epidemiologists and analysts from exploring other behavioral 

health-related topics of public health significance. The 

SSBP production process had to be refined. Refining 

the process allows consistency in methods and provides 

Performance Excellence: Using

 Lean Six Sigma Tools to Improve the

 US Army Behavioral Health Surveillance

 Process, Boost Team Morale, and Maximize

 Value to Customers and Stakeholders

Eren Youmans Watkins, PhD, MPH John V. Wills, BS

Dave M. Kemeter, MBB Brent Edward Mancha, PhD, MHS

Anita Spiess, MSPH Jerrica Nichols, MPH

Elizabeth Corrigan, MS Amy Millikan Bell, MD, MPH

Keri Kateley

Abstract

Lean Six Sigma (LSS) is a process improvement, problem-solving methodology used in business and manufacturing 

to improve the speed, quality, and cost of products. LSS can also be used to improve knowledge-based products integral to public health surveillance. An LSS project by the Behavioral Social Health Outcomes Program of the Army 

Institute of Public Health reduced the number of labor hours spent producing the routine surveillance of suicidal 

behavior publication. At baseline, the total number of labor hours was 448; after project completion, total labor hours 

were 199. Based on customer feedback, publication production was reduced from quarterly to annually. Process 

improvements enhanced group morale and established best practices in the form of standard operating procedures 

and business rules to ensure solutions are sustained. LSS project participation also fostered a change in the conceptualization of tasks and projects. These results demonstrate that LSS can be used to inform the public health process 

and should be considered a viable method of improving knowledge-based products and processes.
92 http://www.cs.amedd.army.mil/amedd_journal.aspx

time to explore not only other negative outcomes important to public health, but also to expand what can be 

included in the SSBP. This article describes an LSS project completed by the BSHOP Behavioral Health Surveillance Section (BHSS). Unlike other publications related 

to process improvement,5 this article describes how an 

industry tool was used to enhance a public health surveillance process for the US Army.

Methods

The LSS problem-solving model is known as DefineMeasure-Analyze-Improve-Control (DMAIC). Using 

DMAIC, LSS teams confirm the nature and extent of 

the problem they wish to solve, identify the true cause 

of the problem, develop solutions based upon data, and 

establish procedures for maintaining the solutions.1(p57)

Before initiation, the LSS team created a project charter, 

a 1- to 2-page iterative document that includes the problem and goal statement, a timeline, and a list of the LSS 

team members. The charter was updated as the project 

developed through each of the DMAIC phases.

The DMAIC methodology and associated tools are discussed in detail by George et al.6

 A brief description of 

each phase as it pertains to the SSBP project is presented in the following sections.

Define

The LSS team and the Project Sponsor (the BSHOP Program Manager) first determined the scope of the project, 

reviewed existing data to better define the problem, and 

set up a communication plan. The team created a highlevel (overview) map of the process and established the 

project scope (Figure 1). The project process begins 

when the team receives the data to begin producing the 

SSBP and ends when the BSHOP Program Manager approves the publication.

Next, the team created a detailed map of the process, 

describing each team member’s position and the tasks 

associated with each section of the publication. In doing 

so, project team members depicted the flow of the process, determined the value of specified tasks, and improved their understanding of each team member’s role 

and responsibilities. Like the project charter, the process 

map is an iterative document and was updated throughout the project as the process was refined.

Measure

During this phase, the LSS team used baseline data and 

determined process performance/capability using Sigma Quality Level (SQL), a measure of process performance with respect to meeting customer requirements. 

A 3 SQL process meets customer requirements 93.3% 

(yield) of the time; a 6 SQL process meets customer requirements 99.9% of the time.3(p25)

The team also developed a data collection plan to assist 

in the Measure phase. As part of this plan, team members recorded the number of hours they spent on each 

section of the publication. At the end of each publication 

cycle, a data technician compiled the information and 

created a table summarizing completion time by task 

and section of the publication. Operational definitions 

were also created to ensure clarity and consistent interpretation for each task. For example, New Code was 

defined as “Data analyst writes SAS code for data that 

has not been included in previous reports. Data analyst 

writes code to pull the same values in Structured Query 

Language to validate SAS code.” (SAS v9.2 software 

(SAS Institute Inc, Cary, North Carolina) was used for 

data analysis.) Estimated financial benefits were calculated by the resource manager (RM). Estimates were 

based on a fully burdened labor rate (base rate +34.1% 

fringe benefit rate) added to overall report hours, manager review hours, and RM hours.

Analyze

During the Analyze phase, the LSS team analyzed the 

data collected during the Measure phase. A Pareto chart 

was used to specify the process steps that required the 

most labor hours and the most common source of defects. A Cause & Effect (C&E) Diagram, shown in Figure 2, and Matrix helped the team organize ideas and 

determine which critical factor(s) were increasing the 

number of hours required to produce the SSBP. Using 

the nominal group technique, the team identified and 

prioritized 3 root causes that had the most effect on publication production hours.

PERFORMANCE EXCELLENCE: USING LEAN SIX SIGMA TOOLS TO IMPROVE THE US ARMY’S BEHAVIORAL HEALTH 

SURVEILLANCE PROCESS, BOOST TEAM MORALE, AND MAXIMIZE VALUE TO CUSTOMERS AND STAKEHOLDERS

Figure 1. High level (overview) process map of the Lean Six Sigma project to enhance a public health surveillance process 

for the US Army Public Health Command.

START

Receive 

Data

BSHOP

Program

Manager

Approval

END

Submit to

BSHOP

Program

Manager

Prepare

SAS

Code

Perform

Analysis Edit Text

Internal

Peer

Revisions

Create

Tables

and/or

Graphs
July – September 2014 93

THE ARMY MEDICAL DEPARTMENT JOURNAL

Improve

The Improve phase involved changes in the process that 

would reduce the number of labor hours spent producing 

the publication. Based upon the information obtained 

during the Analyze phase, the team conducted a pilot assessment to test their proposed improvement. The goal 

of the pilot was to demonstrate that changes in the critical factor identified as most influential would reduce the 

number of hours in the process while simultaneously 

maintaining the quality and integrity of the SSBP. Team 

members also developed potential solutions to other prioritized causes by brainstorming ideas, then evaluated 

those solutions using agreed-upon criteria.

Control

The Control phase ensured that solutions would be 

maintained after LSS project completion. To that end, 

the LSS team documented the solutions. A process control plan was created and the new and improved process 

performance and capability were compared to the old 

process performance and capability. Revised financial 

and operational benefits were also calculated.

Results

Baseline

Four data points (previous SSBPs) were used to determine the average number of hours spent to complete a 

single publication (baseline). The LSS team and sponsor recognized that a larger sample size would be ideal. 

However, given that the section produces surveillance 

publications for a rare event (suicidal behavior), 4 data 

points were appropriate and scientifically sound. On average, each of the previous publications took 448 (95% 

confidence interval, 373-523) hours to complete. This 

exceeded the expected standard of 308 hours which was 

established based on comparison with the time another 

organization takes to produce a similar document.

At baseline, the process was stable over time (in statistical control). However, process SQL was less than 

one. This indicated that the process was not capable of 

consistently producing the SSBP within the determined 

specification limits (308 hours).

Using a Pareto chart, the team determined that preparing SAS code and running statistical analyses accounted for 75% of the labor hours. Based on analysis 

of the C&E Diagram and Matrix, the team identified 3 

root causes that needed solutions: (1) lack of personnel, 

(2) lack of analytic datasets and methodology, and (3) 

lack of standardization in SAS coding. The team agreed 

that focusing efforts on the SAS coding process would 

have the greatest effect on reducing the number of labor 

hours. Therefore, this part of the process was used as the 

pilot for the Improve phase.

For the pilot, SAS and Structured Query Language labor 

hours for the 1st Quarter 2012 Surveillance of Suicidal 

Behavior Update and the 2012 Semiannual SSBP were 

used as the “before” period, while SAS and Structured 

Average 

number of 

labor hours to 

produce

a report

Y≈448 hrs

Figure 2. Cause and effect diagram used to organize ideas and determine which critical fators were increasing the number of 

hours required to produce the publication.

Lack of analytic

data set(s)

No detailed schedule

Inconsistent denominator

data

Inconsistent denominator data 

forcing recalculation of rates

Proper training

No standard code

No standard format

No standard content

Small number of staff

Difficult to replicate

Difficult to use

Competing priorities (RFIs, 

Taskers)

Number of full reports

to be produced

Number of full reports

to be produced

Awkward and unappealing 

report design

Absence of specific task 

assignments among staff

Lack of outside statistical

tool to check coding

Lack of outside statistical

tool to check coding

Review of formatting text added 

time to incorporation of edits

Lack of documented standard 

operating procedures

Reran data each time information

was updated in the ABHIDE

Need to verify data to be 

eliminated

Data errors necessitate many

checks and rechecks

Manpower Data Errors

Product Standardization Administrative

Method

3

2

1 indicates

a critical X
94 http://www.cs.amedd.army.mil/amedd_journal.aspx

Query Language labor hours for the 3rd Quarter 2012 

Update and the 2012 Annual SSBP were used as the 

“after” period. Results from the pilot demonstrated that 

the team spent 223 hours on SAS coding and Structured 

Query Language verification (combined) in the “before” 

period and 90 hours in the “after” period. Notably, the 

majority of the time in the “after” period was spent on 

code for new analyses not included in previous publications. The reduction in hours (178) during the pilot assessment demonstrated that SAS coding and Structured 

Query Language verification were correlated with overall production hours, resulting in a significant reduction 

in SSBP production hours.

Final Improvements

Project improvements resulted in a significant reduction 

in labor hours (-249 hours) and a significant increase in 

yield (+89.4%) and SQL (+3.25) as shown in the Table. 

The projected 7-year cost avoidance for US Army Public Health Command was $707,045. Control measures 

were implemented to ensure improvements would be 

maintained after project completion. The team created 8 

Business Rules and standard operating procedure (SOP) 

documents. Chief among these is the Technical Notes, 

which describe, in detail, epidemiologic methodologies (data sources, variables, coding decisions) used for 

SSBP production. The Technical Notes are updated with 

each iteration of the SSBP.

Comment

The LSS team exceeded the project goal and significantly reduced the SSBP production hours by 42% (199 

hours). The results of this project are important because, 

to our knowledge, this is one of only a few LSS projects 

that applied this industry tool to the improvement of a 

public health surveillance system. These results demonstrate that LSS can inform the public health process 

and provides a viable method of improving knowledgebased processes and products.

As determined during the Analyze phase, SAS coding 

and Structure Query Language verification accounted 

for the majority of the time during the production process. The verification acted as a fail-safe to ensure coding and analysis were consistent and correct. When the 

SAS code became standardized and error-free, the LSS 

team determined this practice no longer added value. 

However, this verification process continues to be used 

for new SAS code. When discrepancies have been addressed and accounted for, that step is removed from the 

production process.

As a result of the LSS process, the team maintained the 

quality of the SSBP and reduced production time, while 

at the same time adding valuable information. This included measures from 4 datasets in the ABHIDE pertaining to deployment, drug testing, screening for the 

Army Substance Abuse Program, and medical problems 

related to sleep and to pain. These indicators are now 

routinely included in the SSBP.

In addition to revising and standardizing SAS coding, 

the format and design of the SSBP was reconfigured to 

better align with the overall process of analysis and reproduction. Prior to the redesign, project team members 

were rewriting the entire document every quarter. The 

new design is not only aesthetically pleasing and more 

appealing to the customer, it also allows easy duplication 

and transfer of the data from SAS outputs to the table 

and text. To maintain consistency, the team developed a 

detailed SOP describing all aspects of document design 

and format, such as text specification, table and figure 

configuration, color scheme, and font size and style.

The development of business rules also led to gains in 

consistency in epidemiologic methodologies and analytic processes, thereby enhancing the scientific integrity 

of the SSBP. These included Business Rules for Data Set 

Exploration and 3 Business Rules for Statistics: US Population Data Sources (US Census Data and Web-based 

Injury Statistics Query and Reporting System (WISQARS)), Crude and Stratified Rates, and Standardized Mortality Ratios. Other methodological advances included 

the following: (1) use of Health Care Effectiveness Data 

and Information Set rules to determine what constitutes 

a behavioral health diagnosis; (2) internal review of behavioral health diagnoses and their International Classification of Diseases-9 (ICD-9) codes (by the BSHOP 

Strategic and Clinical Integration and Evaluation Section) and external review by clinicians (colleagues and 

subject matter experts); (3) alignment of race/ethnicity categories with Office of Management and Budget 

guidelines; (4) creation of a process to resolve discrepancies in static demographic variables (gender, date of 

birth, race/ethnicity). The team also created a welcome 

packet that is used as a training tool to systematically introduce new personnel to section processes and products.

The LSS team developed and distributed a stakeholder 

SSBP feedback survey. Based on team discussion of 

feedback from the survey, the SSBP is now released 

PERFORMANCE EXCELLENCE: USING LEAN SIX SIGMA TOOLS TO IMPROVE THE US ARMY’S BEHAVIORAL HEALTH 

SURVEILLANCE PROCESS, BOOST TEAM MORALE, AND MAXIMIZE VALUE TO CUSTOMERS AND STAKEHOLDERS

Process improvements realized as a result of the Lean 

Six Sigma project .

Metric Before After +/-

Reduced number of Labor Hours 448 199 -249

Increased Sigma Quality Level <0 3.25 +3.25

Increased Yield <6.6% 96% +89.4%
July – September 2014 95

THE ARMY MEDICAL DEPARTMENT JOURNAL

annually rather than quarterly. Data on cases of suicidal behavior that occurred during the first 3 quarters of 

each calendar year are analyzed but disseminated only if 

trends change significantly. The decrease in the frequency of reporting also enhanced interpretation of the data. 

In particular, the variability in the proportions from 

quarter to quarter resulting from the small numbers of 

suicidal events suggested changes that appear large but 

are unimportant in the context of a longer period.

In addition to the successes described above, the team 

realized substantial gains in team building and enhanced 

workplace morale. Project participation turned LSS 

skeptics into champions of the process and fundamentally changed the way team members conceptualized 

tasks and projects. As a whole, individuals now think in 

terms of process improvement. Statements such as “from 

an LSS perspective we should...” or “is this the most efficient way to...” or “what does our customer want?” are 

now commonplace in the work environment. The involvement of BHSS in the project also piqued interest in 

LSS tools and methodologies among other sections within BSHOP and resulted in 15 employees obtaining their 

Yellow Belt certification. There has also been an increase 

in cross-section collaboration, and the sharing of ideas 

has aided in the scholastic enrichment of individuals and 

teams. Support from the BSHOP Program Manager and 

excellent mentorship and guidance from the LSS expert 

from the USAPHC Strategy & Innovation Office were 

also integral to the success of the project.

Conclusion

There are 3 reasons why service-oriented organizations 

should consider LSS tools and methodologies when trying to improve a process, all stemming from the fact that 

service processes are typically slow.3 First, slow processes are subject to poor quality, which increases cost and 

drives down customer satisfaction.3 Second, service processes are often slow because too much work is in progress, which results in unnecessary complexity in the service or product.3

 Third, in any slow process, 80% of the 

delay is caused by less than 20% of the activities.3 Individuals who work in service functions typically find that 

most of the steps in the process add no value to the product they are producing. Use of LSS to identify and quantify the steps in the process that are not of value will result 

in improvements3 as demonstrated by the BSHOP LSS 

project described here. The time and knowledge gained 

from this project have enabled the exploration of other 

behavioral health-related topics of significance, such as 

those added to the SSBP during the course of the project. In addition, the team has begun applying LSS tools 

and methodologies to other surveillance publications, 

including those on all-cause mortality in the US Army, 

risk assessment, and sexual assault. Other programs and 

organizations within the Army and, more specifically, 

the US Army Medical Command, could use LSS tools to 

improve relatively simple (organization and structure of 

public access drives, version control for document review 

staffing of documents), and complex processes (patient 

intake process or routine medical procedures) in need of 

refinement. Interested parties should contact their organization’s Strategy & Innovation Office for guidance to 

determine feasibility of a proposed project.

Acknowledgments

The project was supported in part by an appointment to the 

Research Participation Program for the US Army Public 

for Health Command (USAPHC) administered by The Oak 

Ridge Institute for Science and Education through an agreement between the US Department of Energy and the USAPHC. We thank the following individuals for their support 

and/or contribution to this work: Christopher Watts, MPH; 

Sara Parker, Director, Strategy and Innovation Office, USAPHC; Dr Bradley Nindl, Science Advisor, Army Institute of 

Public Health; John Resta, Director, Army Institute of Public 

Health; MG Dean Sienko, Commander, USAPHC.

References

1. George M, Rowlands D, Kastle B. What is Lean Six 

Sigma?. New York, NY: McGraw-Hill; 2004.

2. Feng Q, Manuel CM. Under the knife: a national 

survey of six sigma programs in US healthcare 

organizations. Int J Health Care Qual Assur. 

2008;21(6):535-547.

3. George M. Lean Six Sigma for Service. New York, 

NY: McGraw-Hill; 2003.

4. Schweikhart SA, Dembe AE. The applicability of Lean and Six Sigma techniques to clinical 

and translational research. J Investig Med. 2009; 

57(7):748-755.

5. Laureani A, Antony J. Reducing employees’ 

turnover in transactional services: a Lean Six 

Sigma case study. Int J Prod Perform Manag. 

2010;59(7):688-700.

6. George M, Rowlands D, Price M, Maxey J. The 

Lean Six Sigma Pocket Toolbox. New York, NY: 

McGraw-Hill; 2004.

Authors

Dr Watkins, Ms Spiess, Mr Wills, Dr Mancha, Ms 

Nichols, and Dr Bell are with the Behavioral and Social 

Health Outcomes Program, Army Institute of Public 

Health, US Army Public Health Command, Aberdeen 

Proving Ground, Maryland.

Mr Kemeter is with the Stategy & Innovation Office, 

US Army Public Health Command, Aberdeen Proving 

Ground, Maryland.

Ms Corrigan and Ms Kately are with the Batelle Eastern 

Science and Technology Center, Aberdeen, Maryland.
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