January – March 2015 

Perspective 1

MG Steve Jones 

US Army Public Health: One Health, One Medicine, One Team 3

LTC Ronald L. Burke; COL Casmere H. Taylor 

Agroterrorism: The Risks to the United States Food Supply and National Security 9

SFC Kevin M. Gill 

Evaluation of the US Army Institute of Public Health Destination 16 

Monitoring Program, A Food Safety Surveillance Program 

MAJ Kamala Rapp-Santos; Karyn Havas, DVM, PhD; Kelly Vest, DVM, DrPH, MPH 

Environmental Requirements Related to Patient Care and the Team 25 

Working to Ensure Compliance 

Diane Roberts 

Preventive Medicine Oversight of Splash Pads on Military Installations 32

Lisa Raysby Hardcastle, PE; MAJ Matthew Perry; CPT Ashley Browne 

Fluoridating Army Community Water Systems in the US Army 38

Public Health Command Region-West Area of Responsibility 

Lisa Raysby Hardcastle, PE; CPT Ashley Browne; 1LT Charles Pham 

Tick-borne Disease Surveillance 49

MAJ Wade H. Petersen; CPT Erik Foster; 1LT Beven McWilliams; William Irwin 

Managing Your Differential Diagnosis List: Considering Bias and Recognizing 56

Unexpected Infectious Agents 

CPT Lauren Seal; CPT Aimee Hunter 

Fielding the Remote Online Veterinary Record, a Veterinary Electronic Health 61 

Record to Improve Patient Care and Practice Management 

CPT Meghan C. Nelson; LTC Ronald L. Burke 

Joint Base Lewis-McChord First Year Graduate Veterinary Education: 67

Observations and Lessons Learned 

CPT Aimee Hunter; CPT Teresa Villers; CPT Lauren Seal; David Galloway, DVM 

ALSO IN THIS ISSUE

Associations Between Operationally Estimated Blast Exposures and Postdeployment 73 

Diagnoses of Postconcussion Syndrome and Posttraumatic Stress Disorder 

MAJ Jonathan L. Saxe; Christopher L. Perdue, MD, MPH

Temperament Dimensions and Posttraumatic Stress Symptoms in a Previously 79 

Deployed Military Sample 

LTC Sandra M. Escolas; Hollie D. Escolas, BA

Predicting Willingness to Report Behavioral Health Problems and Seek Treatment 86

Among US Male Soldiers Deployed to Afghanistan: A Retrospective Evaluation 

LTC Ronald J. Whalen 

A Heart Gripping Case: Carcinoid Heart Disease 93

Capt John P. Magulick, Maj Frederick L. Flynt, & LtCol Kevin E. Steel (USAF); LTC Nathan M. Shumway 

Abstracts and Winning Posters Presented at the Graduate School 4th Annual Research Day, 97

Academy of Health Sciences, US Army Medical Department Center & School 

THE ONE HEALTH CONCEPT IN MILITARY PUBLIC HEALTH
January – March 2015 The Army Medical Department Center & School PB 8-15-1/2/3 

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

A Professional Publication 

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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 

1432501 

By Order of the Secretary of the Army: 

Official: 

Raymond T. Odierno 

General, United States Army 

Chief of Staff

DISTRIBUTION: Special 
October – December 2014 1

Perspectives

Commander’s Introduction

MG Steve Jones

Public health is a discipline concerned with protecting 

and improving the health of entire populations. Those 

populations may be a community, a nation, or a military 

force. Public health is practiced through recommendation of policies to elected leaders, administration of services, educational programs, promotion of healthy lifestyles, and research. Major focus areas for public health 

are prevention of disease and injury and the detection 

and control of infectious diseases. The Army Medical 

Department is responsible for protecting and improving the health of the Army, families and retirees. While 

executing these responsibilities it has made significant 

advances in the science of public health.

In April 1776, Dr John Morgan, Director General of the 

Hospitals and Physician in Chief to the American Army, 

recommended inoculation of the Continental Army 

against smallpox. Hundreds of Soldiers died from the 

disease which was a major factor in the failure in the 

Quebec Campaign, and fear of the disease discouraged 

recruiting. With implementation of the inoculation program, the US Army became the first military organization to immunize an entire Army. Over a century later in 

1900, under the leadership of MAJ Walter Reed, the US 

Army Yellow Fever Commission established the mosquito as the vector for transmission of yellow fever. A 

control program implemented by MAJ William Crawford Gorgas effectively reduced the incidence of yellow fever and malaria in Cuba, and a similar program 

he later implemented in Panama allowed the Corps of 

Engineers to construct the Panama Canal. 1LT Bailey 

K. Ashford studied the severe anemia common in Puerto Rico and determined it was caused by infestation of 

the hookworm Ancylostoma. His work led to a worldwide campaign by the Rockefeller Foundation to control 

hookworm disease. MAJ Carl R. Darnall developed a 

system for the chlorination of drinking water supplies 

by treatment with anhydrous chlorine gas.1

World War II brought the discipline of public health to 

military government and civil affairs. Army leaders 

understood that disease in civilians could impede military operations, that public health is an integral part of 

government (including military government), and that 

providing medical care for civilians under their control 

could establish good will and cooperation of the civil 

population.2

The current campaign in Afghanistan demonstrates 

how the role of public health in military operations has 

evolved. Today the Army provides foundational capabilities to a team that includes US governmental agencies, international organizations, and nongovernmental 

organizations. In Afghanistan, 25 years of war and five 

years of drought produced major health problems. The 

physical infrastructure and human resource base had 

severely deteriorated, resulting in a health status that 

was the worst in Asia and among the worst in the world. 

One in four infants died before age five, and one in six 

women died in childbirth. Over 800,000 Afghans were 

disabled from war-related injuries, birth complications 

and weak preventive healthcare services. Each year, 

almost 300,000 children under the age of 5 died; 60% 

of those deaths were preventable, the result of diarrhea, 

respiratory infections, measles and pneumonia. After 

the collapse of the Taliban in the fall of 2001, the World 

Bank, Asian Development Bank, and United Nations 

Development Programme conducted an assessment of 

reconstruction requirements. They determined a major 

need was the development of a basic healthcare system 

to provide preventive and public health services. Implementation of a few vital but low-cost programs would 

provide the most benefit: basic immunizations, control 

of communicable diseases, maternal newborn and child 

health, nutrition supplementation, treatment of mine and 

war related injuries, and promotion of a healthy lifestyle. 

The US Agency for International Development led the 

reconstruction effort and Coalition forces played a supporting role. Despite ongoing conflict with Taliban forces, dramatic improvements were achieved and today life 

expectancy has increased from 42 to over 62 years, maternal mortality rates have declined by 80%, and child 

mortality rates by almost 50%.3-5

The global security environment is continuously becoming more complex and volatile, and the Army must 

prepare for the rapid emergence of new and increasingly dangerous threats. At the Army’s Unified Quest 

Innovation Symposium on January 13, 2015, Dr Michael 

O’Hanlon, Senior Fellow at the Brookings Institute, 

The US Army and Public Health
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

discussed potential conflicts for which the United States 

should plan.6 Several scenarios he discussed present 

potentially significant public health challenges for the 

Army, such as the possibility of war on the Korean 

peninsula. For example, as more capable South Korean 

forces advanced, an always unpredictable and historically unstable North Korean regime could use a nuclear 

weapon on the battlefield as a negotiation tool, threatening to use another against Seoul. In this admittedly 

unlikely scenario, the Army would have to fight in an 

area where nuclear weapons had been employed, while 

responding to the accompanying civilian humanitarian 

disaster.

Future humanitarian disasters may be significantly 

larger and more difficult to manage than those of the 

past. This is partly due to the emergence of megacities 

with populations of 10 million or more. For example, a 

nuclear reactor meltdown near a megacity such as Karachi could affect 20 to 30 million people, and require 

a response far greater than that required after the 2011 

disaster at Fukushima, Japan. Many large cities lack effective governance, basic infrastructure, public health 

services, and communication systems which would 

greatly complicate humanitarian relief efforts. Ongoing 

conflict makes relief operations more difficult. Today 

the US Army is supporting the fight to control Ebola in 

West Africa. In view of the instability that is endemic 

across the continent, it is not implausible that one day 

we may be contending with Ebola in the midst of a civil 

war. In that environment, the Army could be assigned 

the mission of both cordoning off an area of infection 

and administering health care. The public health challenges of such a mission would be immense.

Public health has been an important mission of the 

Army Medical Department since its establishment 

on July 27, 1775. We have responded to numerous 

humanitarian crises at home and abroad, and made 

significant contributions that improved the health 

of billions of people around the world. As the Army 

modernizes under Force 2025 and Beyond, Army 

Medicine will maintain its focus on this important 

mission.

REFERENCES

1. Baynes-Jones S. The Evolution of Preventive Medicine in the United States Army, 1607-1939. Washington, DC: US Dept of the Army; 1968. Available 

at: http://history.amedd.army.mil/booksdocs/misc/

evprev/default.html. Accessed January 20, 2015.

2. Baynes-Jones S, Church WD, Dehne EJ, et al. Civil 

affairs/military government public health activities. In: Lada J, ed-in-chief; Hoff EC, ed. Preventive Medicine in World War II. Vol 8. Washington 

DC: US Dept of the Army; 1976. Available at: 

http://history.amedd.army.mil/booksdocs/wwii/

civilaffairs/. Accessed January 20, 2015.

3. Asian Development Bank, United Nations Development Programme, World Bank Preliminary Needs 

Assessment Team. Afghanistan, Preliminary Needs 

Assessment for Recovery and Reconstruction. January 2002. Available at: http://reliefweb.int/sites/

reliefweb.int/files/resources/748E9C42622856FBC

1256B430045B74C-undp-afg-15jan.pdf. Accessed 

January 20, 2015.

4. World Health Organization. Health in Afghanistan 

Situation Analysis. January 2002. Available at: 

http://www.who.int/disasters/repo/7543.doc?ua=1. 

Accessed January 20, 2015.

5. US Agency for International Development. USAID Fact Sheet, USAID Engagement in Afghanistan – 2014 and Beyond [internet]. February 2014. 

Available at: http://www.usaid.gov/news-informa

tion/fact-sheets/usaid-engagement-afghanistan2014-and-beyond. Accessed January 20, 2015.

6. O’Hanlon M. Future environments, threats, adversaries and future Army missions. Paper presented 

at: Unified Quest Innovation Symposium; January 

13, 2015; College of William and Mary, Williamsburg, Virginia.

PERSPECTIVES
January – March 2015 3

One Health is the concept for bringing together health 

promotion and delivery for humans, animals, and the 

environment (Figure 1).1 The One Health concept recognizes that success in one profession such as human 

health often requires coordination with the other two. 

Failure to account for these relationships can have disastrous consequences.

Vector-borne disease control is an example of how the 3 

disciplines are related. Over one million people die each 

year from diseases such as malaria, dengue, and yellow fever, which are transmitted by mosquito vectors.2

When dichlorodiphenyltrichloroethane (DDT) was first 

identified as an insecticide in 1939, it was lauded as the 

solution to vector-borne diseases. It was inexpensive 

and persistent, and over the next few decades, DDT was 

widely used throughout the world with great success at 

reducing mosquitoes. For example, the Aedes aegyptii mosquito was eradicated from dozens of countries 

within the western hemisphere, which in turn led to significant reductions in the number of dengue cases. The 

vector control programs were so successful that some 

people soon began asserting that these diseases would 

be wiped out and no longer threaten the human race. 

Unfortunately, these assertions failed to recognize the 

negative impacts of DDT on the environment and animals. Bioaccumulation within the environment (a result 

of DDT’s persistence) was linked to eggshell thinning 

and decreased reproduction rates in birds of prey.3 Concern was also voiced that the birds were biosentinels and 

an early warning to potential human risks, which is supported by recent studies suggestive of possible adverse 

effects in humans.4

The negative animal and environmental effects of DDT 

eventually led to use restrictions and bans in the United 

States and many other countries. The bans in turn have 

been criticized as harmful to humans by increasing exposure to vector-borne diseases leading to increased 

mortality.5 These criticisms may be partially responsible 

for the recent resurgence of DDT use. However, whereas 

DDT was indiscriminately used during the 1940s and 

1950s, its use is more focused today. Perhaps the greatest change in DDT usage (as well as other pesticides) 

was the shift from widespread agricultural application 

to targeted indoor residual spraying. Indoor residual 

spraying takes advantage of the persistent tendencies of 

DDT to provide inexpensive protection against Anopheles species and other indoor feeding mosquitoes which 

transmit diseases,6 while at the same time avoiding bioaccumulation in lakes, streams, and soils that harm the 

environment, animals, and humans. Used appropriately, 

such as treating bed nets and rotating insecticides to reduce resistance, indoor residual spraying saves human 

lives while protecting animal and environmental health.

The One Health Initiative recognizes the importance 

of an interdisciplinary medical team and “is dedicated 

to improving the lives of all species—human and animal—through the integration of human medicine, veterinary medicine and environmental science.” 7

 The One 

Health Initiative is supported by numerous organizations including the American Medical Association, the 

American Veterinary Medical Association, and the National Environmental Health Association. Multiple US 

government agencies, including the Centers for Disease 

Control and Prevention (CDC), the Department of Agriculture, and the Food and Drug Administration, have 

recognized the importance of One Health and are working together to improve health promotion cooperation 

across the 3 health disciplines.

For example, the CDC’s Healthy Pets, Healthy People 

initiative seeks to improve human health through animal health.8

 Over 60% of the diseases affecting humans, 

and 75% of newly emerging diseases, are zoonotic.9

Pets are an integral part of many US households and are 

often considered part of the family. Americans spend 

countless hours each day walking, grooming, and playing with their pets, and over 60% share their beds with 

the cat or dog. This close contact facilitates transmission of bacterial, parasitic, and viral infections such as 

plague, scabies, and rabies.10 Ensuring pets are healthy 

and disease free protects human health. Of course, the 

reverse is also true; healthy people promote healthy 

pets as diseases can be transmitted from people to pets 

(zooanthroponosis).

Pet ownership can also be used to improve human 

health. Pets have been shown to decrease blood pressure, 

US Army Public Health:

 One Health, One Medicine, One Team

LTC Ronald L. Burke, VC, USA

COL Casmere H. Taylor, MS, USA
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

and cholesterol and triglyceride levels, and increase opportunities for exercise and socialization.11,12 An owner’s 

desire to keep the pets healthy can impact their own behavior. Although obesity is not infectious, canine and 

feline obesity is associated with owner obesity. While 

some owners may be unconcerned or unwilling to address their own health, they may be motivated to improve the health of their beloved pets, even if it means 

making personal changes. Addressing canine obesity 

in particular is a potential method of improving human 

health, as exercise (walks, runs or playing in the park) 

will benefit both the dog and the owner. Similarly, addressing canine nutrition requirements may encourage 

the owner to examine their own eating habits.

US Army Public Health Command Region – West: 

Putting One Health Into Practice

The One Health initiative is also being implemented 

within the US military, particularly within the US Army 

Public Health Command (USAPHC). The USAPHC 

achieved full operational capability on October 1, 2011 

with the mission to “promote health and prevent disease, 

injury, and disability of Soldiers and military retirees, 

their Families, and Department of the Army civilian employees; and assure effective execution of full spectrum 

veterinary service for Army and Department of Defense 

Veterinary missions.” 13,14 The USAPHC distinctive unit 

insignia includes the One Health triangle representing 

the triad of human, animal, and environmental health, 

as well as the motto Una Sanitas, Latin for One Health 

(Figure 2). The USAPHC internal command publication 

is entitled “One Health,” further evidence of the organization’s commitment to the concept.

The Public Health Command provides technical oversight for its broad One Health mission through portfolio 

management. Functional specialties such as environmental health engineering, epidemiology and disease 

surveillance, health promotion and wellness, and veterinary services are managed within the Army Institute of 

US ARMY PUBLIC HEALTH - ONE HEALTH, ONE MEDICINE, ONE TEAM

Figure 1. Pictorial representation demonstrating how human, animal, and environmental health are related under the One 

Health “umbrella” concept. Illustration courtesy of One Health Initiative, reprinted with permission.
January – March 2015 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

Public Health to ensure information is communicated 

and resources are coordinated effectively. Command 

and control is subordinated through 5 regional commands (North, South, West, Europe, and Pacific), which 

are aligned with the regional medical commands (Figure 3). Although this issue focuses on Public Health 

Command Region–West (PHCR-W) activities, the basic 

structure, functions, and missions are the same at the 

other regional commands. The PCHR-W is a multidisciplinary unit with Soldiers and civilians from each of the 

One Health professions (human, animal, and environment). The disciplines are assigned to divisions, which 

are aligned with the technical portfolios at the Army 

Institute of Public Health. This structure and alignment 

allows for communication and coordination of efforts at 

all levels.

One area in which USAPHC has a long 

history of coordinating interdisciplinary health efforts is the human-environment interface. The World Health 

Organization estimates that environmental hazards account for 25% of the 

total disease burden worldwide.15 The 

environment is associated with communicable and infectious diseases, such 

as the previously discussed vectorborne diseases, but also noncommunicable diseases such as cancers, respiratory illnesses, and cardiovascular 

issues.16 While these environmental 

hazards can occur naturally, they can 

just as easily be man-made. In other 

words, unhealthy human actions lead 

to unhealthy environments, which in 

turn lead to unhealthy humans—One 

Health at its worst. In recognition of 

the environment-human health connection, PHCR-W activities are directed 

towards both detecting environmental 

hazards and preventing them.

An important tool for identifying environmental health hazards is the Defense Occupational and Environmental 

Health Readiness System (DOEHRS). It is a centralized 

system for storing and managing occupational and environmental health hazard (biological, physical, chemical) data.* Of course, DOERHS is only as good as the 

samples that are collected and the data which are entered into the system. While PHCR-W personnel have 

the ability to conduct environmental surveillance and 

enter the data, they cannot be at every Army installation, including those in deployed environments. Instead, 

PHCR-W personnel provide training to preventive medicine units on how to conduct environmental surveillance and enter the data into DOEHRS. Over the past 

several years PHCR-W has provided training to over a 

dozen garrison and deploying preventive medicine units 

annually. Each year approximately 200 individuals from 

Army, Navy, and Marine units have received training 

on environmental sample collection and data entry. The 

result is that deployed commanders are given accurate 

risk assessments for exposed personnel on the ground 

and recommendations to mitigate health risks, such as 

the elimination of burn pits. The DOERHS data repository can also be accessed by medical professionals for 

identification and management of human health concerns resulting from potential environmental exposures during 

past deployments.

More recently, the formation of USAPHC has led to new One Health collaborations. For example, the merging 

of Army preventive medicine and veterinary medical assets into a single organization has strengthened food and 

water safety at Army installations. Traditionally, Army veterinary personnel 

have been responsible for auditing commercial food and water suppliers and 

inspecting deliveries through receipt 

to ensure the subsistence is safe and 

wholesome. Inspection of food storage, 

preparation, and serving, as well as 

ensuring the safety of installation water treatment facilities, is performed by 

preventive medicine personnel. While 

these groups have worked well together, 

there was the potential for information 

loss during the handover of responsibility. Bringing expertise from both 

groups together under a single organization improves coordination, assists 

in the timely identification of issues or 

problems, and fosters cooperation to 

develop improved food safety product and measures. 

One example of this improved collaboration was evident 

in preparing and staffing the new revision of the Department of Defense (DoD) Tri-Service Food Code.

17

Vector-borne disease surveillance is another aspect 

which has benefited from the formation of USAPHC. 

The Army, as well as the other military services, *Restricted access: https://doehrswww.apgea.army.mil/doehrs

dr/index.jsp

Figure 2. US Army Public Health 

Command Distinctive Unit Insignia. Each side of the triangle represents a component of the OneHealth triad: people, animals, 

and the environment. The shield 

represents the mission of protecting the Army family. The green and 

maroon represent the past and 

current colors associated with the 

Medical Corps, respectively. The 

spear tip represents the organization’s leading role in promoting 

Soldier health. Medicine and healing are represented by the twin 

serpents around the spear. The 

unit motto is Una Sanitas, Latin 

for “One Health. 
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

collects and tests arthropod vectors for pathogens such 

as Babesia canis, Borrelia burgdorferi, and Rickettsia 

parkeri, the causative agents for babesiosis, Lyme disease, and tidewater fever, respectively. The arthropods 

are generally submitted by clinicians following removal 

from patients or collected as part of environmental surveillance such as tick drags. These surveillance efforts 

capture 2 of the 3 populations (humans and environment), but they miss the local animal population. Ticks 

can bite and feed from dogs and cats as easily as humans, especially if pets are not treated with an acaricide, 

which can lead to infection and diseased pets. One of 

the ways PCHR-W has improved vector-borne disease 

surveillance is through coordination of the environmental health, laboratory sciences, and veterinary services 

divisions to collect, identify, and test ticks collected at 

installation veterinary clinics throughout the Region. 

This program not only identifies pets which should be 

prophylactically treated for infection, but also helps to 

better quantify the disease transmission risk to other 

animals, as well as their owners, which in turn shapes 

future risk mitigation strategies and communications 

at the installation. The information is also transmitted 

through the technical portfolio channels and analyzed 

in conjunction with other surveillance efforts (reportable medical events, for example) to prepare products 

like the monthly Army Vector-borne Disease Report,18

available through the USAPHC website* or via e-mail 

subscription. The monthly report provides a quick snapshot of vector-borne disease activity within the United 

States as a whole, within the Army active duty and beneficiary medical populations, and environmental surveillance. Eventually, the vector-borne information may 

be combined with information from veterinary treatment facilities using the newly fielded Remote Online 

Veterinary Record (ROVR) to further quantify the risk 

of vector-borne disease transmission at Army installations. The ROVR is the DoD electronic animal health 

record system for both government and privately-owned 

animals and can be queried to identify disease trends 

and outbreaks.

Future Directions

One Health will continue to shape USAPHC’s efforts to 

improve Soldier and family readiness through marketing and leveraging of public health in support of larger Army and DoD programs. For example, the DoD’s 

Healthy Base Initiative seeks to improve the health and 

wellness of service members, families, and civilians 

through better nutrition. Several DoD installations have 

recently implemented local farmers markets to improve 

service members’ eating habits by providing healthy alternatives to the traditional fast food options on military 

US ARMY PUBLIC HEALTH - ONE HEALTH, ONE MEDICINE, ONE TEAM

*http://phc.amedd.army.mil

Figure 3. US Army Public Health Command Regions North, South, West, Pacific, and Europe. Image courtesy of the USAPHC 

Geographic Information Systems Branch (July 2014).
January – March 2015 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

installations. However, while these farmers markets 

may have more nutritious fruits and vegetables in comparison to a burger and extra-large fries, there are health 

risks. One need look no further than the 2011 Listeria 

monocytogenes cantaloupe outbreak, with nearly 150 

cases in 28 states, for evidence that even fresh fruits and 

vegetables can be linked to infectious disease transmission.19 To minimize these risks, USAPHC personnel are 

developing food sanitation guidance material for consumers and food surveillance inspection programs for 

farmers markets to ensure food safety supports healthy 

eating behaviors.

One Health activities also support The Army Surgeon 

General’s Performance Triad.20 The USAPHC oversees Army Wellness Centers, which provide individual 

health assessments and information on physical fitness, 

nutrition, stress management, tobacco cessation, and 

general wellness to assist individuals in developing and 

reaching their health goals.21 The program engages individuals in their “lifespace,” their environment, to help 

them make lifestyle changes, which improve short- and 

long-term health. These health promotion efforts also 

extend beyond Army Wellness Centers into all aspects 

of the USAPHC mission. For example, the veterinary 

clinic is not a traditional setting for discussing human 

obesity, yet as previously mentioned, pet owners may be 

willing to make lifestyle changes for their pet’s health 

that they would not make for their own health. These 

lifestyle changes are not limited to just nutrition either. 

Dog runs/walks are an excellent way to encourage owner and pet exercise and multiple veterinary clinics are 

partnering with their local medical treatment facilities 

or morale, welfare, and recreation activities to organize 

and promote these events.

Looking towards the future, the One Health concept will 

remain a fundamental element of public health. While 

the structure of USAPHC and its subordinate units will 

likely undergo significant changes as part of the Army 

Medical Department reorganization, the public health 

duty will remain a key component mission of the unit, 

its successor, and the Army Medical Department. As 

the world becomes more populated and increasingly interconnected, the interactions between human, animals, 

and the environment will only increase. The recent introduction of the Chikungunya virus into the western 

hemisphere and the ongoing outbreak of Ebola in western Africa are 2 examples of outbreaks which are reshaping our thinking. We cannot assume that the way things 

were will be the way things are in the future. Effectively 

preparing for and addressing these future health threats 

requires coordination across all health fields, human, 

animal, and environment. The 3 fields are inextricably 

linked and lasting success cannot be achieved unless the 

medical professions work together—One Health, One 

Medicine, One Team.

References

1. King LJ, Anderson LR, Blackmore CG, et al. Executive summary of the AVMA One Health Initiative Task Force report. J Am Vet Med Assoc. 

2008;233(2):259-261.

2. World Health Organization. The Health and Environment Linkages Initiative (HELI): Vector-borne 

disease. 2014. Available at: http://www.who.int/

heli/risks/vectors/vector/en/. Accessed August 10, 

2014.

3. US Environmental Protection Agency. A Review 

of Scientific and Economic Aspects of the Decision 

to Ban Its Use as a Pesticide. Washington, DC: 

US Environmental Protection Agency. July 1975. 

EPA-540/1-75-022. Available at: http://www2.epa.

gov/aboutepa/ddt-review-scientific-and-economicaspects-decision-ban-its-use-pesticide. Accessed 

October 31, 2014.

4. Rogan WJ, Chen A. Health risks and benefits of 

bis(4-chlorophenyl)-1,1,1-trichloroethane (DDT). 

Lancet. 2005;366(9487):763-773.

5. Finkel M. Malaria: stopping a global killer. National Geographic. July 2007. Available at: http://ngm.

nationalgeographic.com/2007/07/malaria/finkeltext. Accessed July 20, 2014.

6. Walker K. Cost-comparison of DDT and alternative insecticides for malaria control. Med Vet Entomol. 2000;14(4):345-354.

7. One Health Initiative. Mission Statement. One 

Health Initiative Website. Available at: http://one

healthinitiative.com/mission.php. Accessed July 

20, 2014.

8. Centers for Disease Control and Prevention. 

Healthy Pets Healthy People. Available at: http://

www.cdc.gov/healthypets/. Accessed July 20, 2014.

9. Taylor LH, Latham SM, Woolhouse ME. Risk factors for human disease emergence. Philos Trans R 

Soc Lond B Biol Sci. 2001;356(1411):983-989.

10. Chomel BB, Sun B. Zoonoses in the bedroom. 

Emerg Infect Dis. 2011;17(2):167-172.

11. Anderson WP, Reid CM, Jennings GL. Pet ownership and risk factors for cardiovascular disease. 

Med J Aust. 1992;157(5):298-301.

12. Beck AM, Meyers NM. Health enhancement and 

companion animal ownership. Annu Rev Public 

Health. 1996;17:247-257.

13. Ugalde RM, Resta JJ. The US Army Public Health 

Command initiative: transforming public health 

services for the Army. US Army Med Dep J. AprJun 2010:4-10.
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

14. US Army Public Health Command. Organization. 

USAPHC Website. Available at: http://phc.amedd.

army.mil/organization/Pages/default.aspx. Accessed July 20, 2014.

15. Smith KR, Corvalan CF, Kjellstrom T. How much 

global ill health is attributable to environmental 

factors?. Epidemiology. 1999;10(5):573-584.

16. Lim SS, Vos T, Flaxman AD, et al. A comparative 

risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters 

in 21 regions, 1990-2010: a systematic analysis for 

the Global Burden of Disease Study 2010. Lancet. 

2012;380(9859):2224-2260.

17. TB MED 530/NAVMED P-5010-1/AFMAN 48-

147_IP: Tri-Service Food Code. Washington, DC: 

US Dept of the Army; April 30, 2014. Available at: 

http://www.med.navy.mil/directives/Pub/5010-1.

pdf. Accessed October 31, 2014.

18. US Army Public Health Command. Army Vectorborne Disease Report. Periodic Publications and 

Surveillance Reports page, USAPHC Website. 

Available at: http://phc.amedd.army.mil/whatsnew/

Pages/PeriodicPublications.aspx. Accessed July 20, 

2014.

19. McCollum JT, Cronquist AB, Silk BJ, et al. Multistate outbreak of listeriosis associated with cantaloupe. N Engl J Med. 2013;369(10):944-953.

20. Horoho PD. A system for health: essential element 

of national security. US Army Med Dep J. OctoberDecember 2013:5.

21. US Army Public Health Command. Army Wellness Center Services. USAPHC Website. Available 

at: http://phc.amedd.army.mil/topics/healthyliving/

al/Pages/ArmyWellnessCenters.aspx. Accessed 

August 26, 2014.

Authors

LTC Burke is the Veterinary Public Health Instructor for 

the First Year Graduate Veterinary Education Program, 

Joint Base Lewis-McChord, Washington.

COL Taylor is the Commander, Public Health Command 

Region - West, Joint Base Lewis McChord, Washington.

US ARMY PUBLIC HEALTH - ONE HEALTH, ONE MEDICINE, ONE TEAM
January – March 2015 9

When we hear the word “terrorism,” we often think of 

weapons of mass destruction. However, agroterrorism 

is another, even more insidious threat to our way of life. 

The Oxford Dictionary defines agroterrorism as “Terrorist acts intended to disrupt or damage a country’s agriculture, especially the use of a biological agent against 

crops or livestock.”1 The threat is real. Evidence of such 

was discovered when American forces uncovered documentation that demonstrated Al Qaeda and the Taliban 

had extensive knowledge of agricultural diseases and 

the effects an agroterrorism attack would have on our 

food system.2 According to Tim Downs, author of Ends 

of the Earth,3 terrorists would most likely use genetically 

modified organisms such as insects to spread pathogens 

to infest crops, kill livestock, and sicken or kill humans. 

Potential agents that terrorists may use include bacteria, 

viruses, fungi, and invasive or nonnative insect species.

Congress took action to protect our national food supply in the wake of the terrorist attacks on September 11, 

2001, by passing the Public Health Security and Bioterrorism Preparedness and Response Act,4

 signed into law 

on June 12, 2002. Title III of the Act directed that the 

President’s Council on Food Safety, in consultation with 

other federal and state agencies, the scientific community, the food industry, and consumer and producer groups, 

develop a crisis communication plan and an educational 

program that takes proactive steps to protect the national 

food supply from intentional acts of contamination. It 

directed that this strategy address “threat assessments; 

technologies and procedures for securing food processing and manufacturing facilities and modes of transportation; response and notification procedures; and risk 

communications to the public.” Nearly 10 years later, the 

Government Accountability Office (GAO) found that, 

despite the best intentions of the Bioterrorism Act, the 

expenditure of billions of food defense dollars was not 

well coordinated. Testifying before a Senate committee 

on the matter, Lisa Shames, the GAO Director of Natural Resources and the Environment, stated “There is no 

centralized coordination to oversee the federal government’s overall progress implementing the nation’s food 

and agriculture defense policy.” 5 This lack of centralized 

coordination of work by different agencies means that 

we as a nation are unsure that our efforts, and billions 

of our tax dollars are not being used wisely to counter 

agroterrorism. It also seriously hinders the implementation of effective, well-designed strategies to reduce the 

vulnerabilities of our nation’s agriculture to terrorists 

attacks.5 In testimony before a senate subcommittee on 

counter-terrorism on September 14, 2011, John Hoffman, 

a former senior adviser in the Department of Homeland 

Security, made this sobering assessment: “We may be 

blindsided by an intentional food-based attack on this 

nation sometime soon.... At present, our primary detection capability is the emergency room.” 5

The Food Safety Modernization Act of 2011 is the first 

legislation aimed at preventing an attack rather than responding to one.6

 The Food and Drug Administration 

now has the challenge of shifting the perspective of protection from unintentional (food safety) contamination 

to that of prevention of the intentional adulteration (food 

defense) of human food and animal feed. This approach 

is quite different in many ways and is a paradigm shift 

in how our nation protects its food supplies. The FDA 

Agroterrorism: The Risks to the United States

 Food Supply and National Security

SFC Kevin M. Gill, USA

Abstract

Agroterrorism is a collective term that describes an intentional criminal attack against crops or mankind using 

viral, bacterial, fungal, or insect-borne agents. Agroterrorism also includes attacks against animals using infectious pathogens such as Burkholderia mallei (glanders), Bacillus anthracis (anthrax), viral avian influenza, foot 

and mouth disease, and several equine encephalitis viruses. Agents that could be used against crops include 

the causative agents of wheat blast, rice blast, rice brown spot disease, and wheat stem rust. The primary goal 

of terrorists using agroterrorism is to spread fear and cause massive economic loss. Subsequent goals include 

causing disease and death to humans and animals. The use of bioterrorism agents is a much more practical 

approach than using explosives, for example, to achieve those results since many of these biological agents are 

commonly found naturally in the environment and are difficult to detect with modern technology. The effective 

use of biological warfare dates back centuries and can still can be employed by terrorist groups, lone wolves, 

and political and religious groups to cause death and mayhem on a grand scale.
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

proposed rule on food defense would require that food 

facilities take a proactive, targeted approach within their 

establishments that focuses on the progression of food 

processes where the intentional contamination of product is most likely to occur. Effective efforts could then 

be implemented to best reduce those targets of opportunities. Finally, the proposed rule will require the largest food operations create and implement a food defense 

plan.6

Obviously, the US military is essential in defending this 

nation against threats from terrorists, whether in foreign 

environments or within our borders. As such threats 

have multiplied and evolved over the last decade, concerns about protection of the food supply of the US military have never been greater. Department of Defense 

(DoD) Directive 5200.08,7 DoD Directive 6400.04E,8

DoD Instruction 2000.12,9 DoD Instruction 2000.16,10

Homeland Security Presidential Directives 711 and 912, 

and Presidential Policy Directive 813 are the framework 

within which the US Army Veterinary Service designs, 

implements, and operates specific food protection programs to protect our military personnel and their families. These programs include:

` Commercial food protection audits

` Installation food vulnerability assessments

` Food and water defense assessments for special 

events

` Food and water risk assessments overseas

These directives and programs established global organizational policy and support for the prevention of intentional contamination of our food supply and provide a 

framework from which we can provide the best possible 

protection for our food systems.

Background

Production and distribution of the food supply in the 

United States is one of the most complex systems in the 

world. The United States imports food from many nations, some of which have ideologies that do not align 

with ours and may seek to do us harm. When this situation is paired with lax or nonexistent safety standards of 

some foreign countries, it clearly represents a potential 

threat to the US food supply. It is estimated that in 2010, 

more than 10 million food shipments were received 

from overseas manufacturers, and approximately only 

1.6% received any type of federal inspection at the point 

of entry.14 Imported foods make our food system vulnerable to terrorist attacks as these products may harbor 

disease or insect vectors that could spread and decimate 

our agricultural fields. One successful, grand scale attack on the US agriculture system could cause death and 

disease to Americans from coast to coast and result in 

devastating physical, economic, and, more importantly, 

psychological damage among our citizens. Terrorists realize that the strength of our nation is its economy, and 

they are focusing more of their efforts on attacks that 

yield the most economic damage.

The intentional contamination of food goes far beyond 

imported foods. To combat this threat, we must examine 

our food supplies from farm-to-fork. Farm-to-fork is the 

linear progression that food travels from the farm where 

it is grown and harvested, to the storage facilities while 

it waits for shipment, to the food manufacturers where 

it is processed and packaged, to retailers where it is sold, 

and finally to our dining tables.15 Protecting such an extensive and complex system is a monumental task that 

requires diligence by professionals trained in food protection and hazard communications. Throughout this 

flow there exists the potential for contamination, and 

therefore the need for vigilance. In order to remain one 

of the safest food supply systems in the world today, we 

must employ at the local, state, and federal levels skilled 

professionals who are equipped to respond to and recover from the crisis of an agroterrorism event. Over 

the last decade, the federal government has launched 

numerous initiatives to provide enhancements to the defense of our national food supply.

The Threat

Agroterrorism is not flashy and does not generally produce immediate results, so terrorists have traditionally 

considered it to be a secondary tactic. It does, however, 

have the ability to spread fear and anxiety, produce large 

economics losses, create social instability, and result in 

foodborne disease outbreaks. It is most often used as act 

of economic sabotage rather than a violent act against 

animals or mankind. However, the use of agroterrorism is a much cheaper and easier alternative to building 

a “dirty bomb,” and would capture the attention of the 

entire nation for a long time.16 Several factors have contributed to the belief that terrorists could begin targeting 

our food supply. First, Al Qaeda leadership has been reduced dramatically over the last decade, leaving mostly 

low to midlevel terrorists who lack the ability to mount 

large-scale attacks. Second, economic harm to the United States remains one of the pillars of Al Qaeda’s network. Third, microorganisms are inexpensive and can 

be cultured in clandestine labs by nearly anyone with 

a microbiology background.2 Methodologies for culturing these pathogens can easily be found on the internet. 

Furthermore, many potential biological weapons occur 

naturally in the environment and do not require the use 

of laboratories.16

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Motivation

Terrorists know that America’s strength lies with its 

economy and a successful attack on our nation’s food 

supply would be economically devastating for millions 

of its citizens. It could even affect our ability to project 

our military power abroad and lead to the overthrow of 

allied governments. Osama Bin Laden once bragged that 

the attacks on September 11, 2001, cost $500,000 dollars 

but caused more than $500 billion dollars in economic 

losses to the United States.2 It is essential to understand 

what motivates an aggressor if we expect to generate 

effective risk mitigation strategies to stop acts of terrorism. The National Institute of Justice funded a research 

project to determine the extent a foot-and-mouth disease 

outbreak would have on the cattle industry in the state of 

Kansas.17 The study found that those who would attack 

our agriculture fall into one of 4 categories17(p24):

1. International terrorists

2. Economic opportunists

3. Domestic terrorists (including unbalanced individuals and disgruntled employees)

4. Militant animal rights groups

Terrorists are typically politically or ideologically motivated and they may work alone or in small organized 

groups. Economic opportunists use agroterrorism to 

manipulate markets and exploit the situation for their 

personal financial gain. Disgruntled employees are motivated by a sense of revenge for some real or perceived 

wrongdoing, and they actually pose a greater risk than 

most other aggressors as they are likely to be less scrutinized due to their legitimate reason for being on the 

premises. Militant animal rights activists, such as the 

Earth Liberation Front, are motivated by a moral obligation to prevent animal abuse and have committed more 

than 2,000 crimes costing an estimated $110 million 

dollars in damage. Militant animal rights activists (or 

eco-terrorists as they are often called) ranked number 1 

on the FBI’s domestic terrorism threats in 2004.18

Incidents of Agroterrorism

There are many recorded examples of agroterrorism in 

history dating from the sixth century bc when Assyrian forces poisoned well water with rye ergot. During 

World War I, German forces attempted to infect horses 

bound for Europe from the United States with glanders

(Burkholderia mallei) and anthrax (Bacillus anthracis).

2

 While glanders is a bacterial disease that primarily affects horses, it and anthrax can spread to humans, 

donkeys, mules, and other mammals.19 The single largest biological terrorist attack ever occurring on US soil 

was perpetrated in 1984 by a religious cult in Oregon 

who sought to influence the outcome of an election by 

poisoning their opponents and thereby causing a lower 

voter turnout. The cult did so by cultivating Salmonella

typhimurium in a covert laboratory on their ranch and 

spreading the potentially dangerous pathogen on bathroom fixtures and salad bars in 10 restaurants in the local town of The Dalles. Just prior to election day, emergency rooms, hospitals, and clinics were overrun with 

people suffering from extreme nausea and diarrhea. The 

attack sickened 751 people, but fortunately there were 

no fatalities.20,21

In 1985, the USDA accused contract workers of intentionally introducing the Mexican screw worm (Cochliomyia hominivorax) to livestock farmed near the United 

States/Mexico border in an attempt to spread this parasitic problem and keep their jobs in a screw worm eradication program.16

In 1996, animal feed was the target of disgruntled workers at a rendering plant when a cow carcass was intentionally contaminated with the pesticide chlordane. The 

animal was ground with others to produce nearly 80,000 

lbs of feed which found its way onto 4,000 dairy farms 

in 4 states, and resulted in a dairy food recall that cost 

the industry an estimated $250 million loss.22

In 1997, economic opportunists adulterated spent animal grease from local restaurants intended for chicken 

feed with a fungicide. This criminal act was perpetrated 

by a rival feed company owner, and the investigation 

and apprehension of the suspect required the concerted 

effort of law enforcement officials in 17 states.22

In 2003 a disgruntled meat department employee was 

arrested for intentionally contaminating an estimated 

200 lbs of ground beef with a nicotine-based insecticide 

known as Black Leaf 40. The Centers for Disease Control and Prevention reported that 92 individuals became 

ill with symptoms including burning of the mouth, nausea, vomiting, and dizziness.23

In 2014 Japanese factory worker Toshiki Abe was sentenced to 3.5 years in prison for intentionally contaminating frozen food products with the pesticide malathion. Detected concentration levels of this poison were 2.6 

million times higher than what is permitted by law. The 

processor of these frozen food products does not use the 

insecticide malathion, so the presence of this toxic substance at such a high concentration is proof of a deliberate act. Abe’s actions sickened nearly 900 persons. This 

case is one of the largest proven acts of intentional food 

product contamination.24
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

Foot-and-Mouth Disease

The 2005 National Institute of Justice study categorized 

foot-and-mouth disease (FMD) as a “Primary threat to 

agriculture.”17(p18) This viral disease is 20 times more 

contagious than small pox and causes painful sores on 

the hooves and mouths of cloven-hoofed animals such 

as cattle, pigs, sheep, goats, and deer. These sores are 

so debilitating that the animals are unable to walk, eat, 

and drink, until they finally succumb to the disease. 

Although humans are not affected by FMD, they can 

carry and transmit the disease for up to 48 hours from 

exposure, and the spread from animal to animal can 

extend as far as 50 miles. An outbreak of FMD in the 

United Kingdom in 2001 affected 9,000 farms and required the destruction and disposal of more than 4 million animals. That outbreak cost the United Kingdom an 

estimated $21 billion dollars. A similar outbreak in the 

United States would cost more than $60 billion dollars. 

Not only would such an event have a dramatic effect on 

the availability of meat products in the United States, it 

could also halt exports to other countries for years in the 

future. The loss of jobs would be devastating and result 

in billions of dollars in economic costs.2

The sequence for dealing with FMD as presented in the 

National Institute of Justice study17(p23) includes the use of 

law enforcement to establish a strict quarantine around 

the affected area, roadblocks established to exclude sick 

animals and prevent contaminated vehicles from leaving the area and spreading the infections, and sound 

crime scene investigation procedures. An outbreak of 

FMD would require a quarantine area 6 miles in radius and last at least 30 days. Roadblocks would have to 

be strategically placed along all thoroughfares leading 

from the point-of-origin of the outbreak outward in all 

directions. Law enforcement must conduct interviews 

with drivers to determine if the passengers had recently 

been in a contaminated area. If so, stations manned by 

trained personnel would have to be established close to 

the roadblocks to allow for the proper decontamination 

of both vehicles and persons. Crime scene investigators 

would be responsible for collecting tissue samples and 

identification of potential suspects. Finally, all clovenhoofed animals in the affected area would have to be 

destroyed and disposed of properly.25 This would be an 

enormous undertaking that not many of our local and 

state official personnel are properly prepared to execute. 

Clearly, the value of preventing FMD outbreaks using 

sound biosecurity measures far outweighs the monumental task of containing such an event.

Vulnerabilities

According to the National Defense Research Institute, 

there are several key factors that make US agriculture 

particularly vulnerable to attack.26 First, the farms that 

produce our food have become ever more concentrated 

and rely on old fashioned farming practices. This concentration of animals into relatively small areas greatly 

increases the infection rate and creates a very difficult 

containment situation. Second, livestock are more susceptible to disease infection due to husbandry tactics 

and the overuse of antibiotics. Such tactics include sterilization programs, dehorning, and even hormone injections. The overuse of antibiotics causes many pathogenic bacteria to develop resistance to therapy. Third, most 

farms are devoid of any real, organized surveillance 

detection systems. Animal feed lots and barns are often 

left unguarded and therefore indefensible. Fourth, the 

passive reporting system that farmers are expected to 

use when they discover an animal suspected of having 

a communicable disease relies on the farmer to self-report the suspected diseased animal to authorities. Such a 

system puts farmers in an awkward situation which can 

negatively impact their livelihood and forces them into 

a “shoot, shovel, and shut-up” mindset in fear the government may condemn their entire livestock if they ever 

found out. The last factor is the lack of veterinarians in 

the United States that have a sufficient level of training 

to recognize and properly diagnose animal diseases that 

are not commonly found in this country.

Protection of the Military Food System

Ever since the terrorist attacks on the World Trade Center on September 11, 2001, our country’s leaders recognized that an attack on our food supply could threaten 

our very existence. Much has changed to protect our national food supply since the then Secretary of Health and 

Human Services, Tommy Thompson, said in 2004 “I, for 

the life of me, cannot understand why the terrorist have 

not attacked our food supply, because it is so easy to 

do.”27 The Bioterrorism Act of 20024 supplied the impetus for DoD Directive 6400.04E,

8

 which assigned to the 

US Army Veterinary Service the overarching authority 

to execute food defense programs within the DoD. DoD 

Directive 6400.04E also mandates the standardization 

of commercial food protection audits, installation food 

vulnerability assessments, food and water defense assessments, and food and water risk assessments. The 

Veterinary Services Portfolio of the Army Institute of 

Public Health is charged with providing a proactive approach to protect military food systems and deny terrorists the ability to attack those food supplies. It met this 

directive by creating specific procedures for assessing 

food establishments both on and off installations wherever military service personnel are stationed. These experts do so by working closely with the United States 

Department of Agriculture, Food and Drug Administration, local agricultural groups, contracting officers, and 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

installation garrison commanders to identify potential 

weak areas in food systems and offer simple and costeffective strategies to reduce or eliminate such vulnerabilities. Further, standardized inspections of food deliveries and storage areas are conducted on a regular 

basis by personnel who have been specially trained in 

food defense by the Army Medical Department Center 

& School. This determined effort is integral in preventing and detecting the intentional contamination of food 

systems by terrorists using conventional chemical, biological, radiological, nuclear, or physical agents.

The threat of the intentional contamination of the military food supply is much more complex in deployed 

environments and presents an increased level of danger in terms of possible nonbattle injuries and potential mission failures. The major challenge to preventing 

terrorists from using agroterrorism is that food distribution systems are quite expansive and therefore food 

protection programs designed to protect them are very 

expensive, both in terms of personnel and dollars. Such 

systems must protect nodes along a sizeable geographical area and take into consideration susceptibilities of 

food transported over potentially hostile territory with 

numerous handlers. It must also take into account food 

processes such as mixing of large batches, short product shelf-life, and global distribution. This is quite ambitious, even in the relative safety of the United States, 

and as author Tim Downs says, “The concern about an 

agricultural act of terrorism is we just can’t defend a 

thousand-acre farm,” he explains. “You can put up a 

metal detector in an airport — but how do you protect a 

thousand acres of corn or wheat?”3

The DoD has several initiatives in place to improve the 

defense posture of our food supply such as commercial 

food protection audits, installation food vulnerability 

assessments, food and water defense assessments, and 

food and water risk assessments. The food protection 

audit was enacted to systematically evaluate the food 

defense programs of commercial food facilities supplying subsistence to the DoD. These approved food facilities provide a large portion of the subsistence in the 

military food supply. Of particular significance were the 

efforts taken to prevent adulteration at Meals Ready-toEat plants, as these rations are vital to the Warfighter.

Installation food vulnerability assessments provide installation commanders and their antiterrorism officers 

(ATOs) with an overall picture of the food protection 

posture of all food facilities on an installation at any 

given time. The assessments are directly tied to current force protection condition measures and results are 

briefed to ATOs and installation commanders using the 

deliberate risk assessment model. Additionally, these results are used to develop the Veterinary Service annex 

to the installation emergency response plan. Incorporation of these assessments into the installation emergency 

response plan helps all key players understand the vital 

role that food defense personnel play during an actual 

emergency.

Food and water defense assessments at special events 

were designed specifically to reduce the vulnerability 

of food and water during large gatherings of DoD personnel. Veterinary Service personnel work closely with 

other public health entities and the installation ATO to 

identity vulnerabilities at these events and make recommendations that will effectively mitigate those hazards.

Food and water risk assessments were developed to address the insufficient number of approved food facilities 

in foreign countries hosting military exercises. In these 

situations, access to foods from approved sources is extremely limited, yet contracting officers must meet the 

intent of regulatory requirements. Highly-trained DoD 

public health specialists assess the risks associated with 

consumption of food from caterers, restaurants, and local host nation food facilities. These assessments are not 

inspections and do not produce a “pass” or “fail” but 

rather determine for operational commanders the expected overall risk exposure for their personnel if these 

establishments are used.

Conclusion

Thanks to the cooperative efforts of multiple local, state, 

and federal agencies across the country, we still have 

the safest food supply in the world. These public health 

professionals provide technical expertise throughout the 

continuum of the food supply chain from farm-to-fork. 

The defense of our nation’s food and agriculture resources is now fully integrated in the day-to-day mission of 

US Army Veterinary Service personnel. The DoD mission will continue to change and budget constraints will 

inevitably challenge these professionals in their mission to ensure that critical resources are protected from 

those who mean us harm. Our collective national effort 

to support the safest food supply in the world will remain highly effective utilizing the systemic approaches 

developed by US Army Veterinary Service personnel to 

anticipate, detect, and mitigate our enemies’ attempts to 

strike our food supply.

References

1. Oxford Dictionary [online]. Oxford University 

Press. 2014. Available at: http://www.oxforddic

tionaries.com/definition/english/agroterrorism. 

Accessed December 11, 2014.
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Olson D. Agroterrorism: threats to America’s 

economy and food supply. Federal Bureau of Investigation Web site; 2012. Available at: http://leb.

fbi.gov/2012/february/agroterrorism-threats-toamericas-economy-and-food-supply. Accessed December 11, 2014.

3. Downs T. Ends of the Earth. Nashville, TN: Thomas Nelson, Inc; 2009. Cited by: Homeland Security 

News Wire [serial online]. Agro-terrorism threat is 

real. September 3, 2009. Available at: http://www.

homelandsecuritynewswire.com/agro-terrorismthreat-real. Accessed December 11, 2014.

4. Public Health Security and Bioterrorism Preparedness and Response Act, Pub L No. 107-188, 116 

Stat 594 (2002). Available at: http://www.fda.gov/

RegulatoryInformation/Legislation/ucm155769.

htm. Accessed December 12, 2014.

5. Bottemiller H. GAO: Lack of coordination for U.S. 

food defense. Food Safety News [serial online]. 

September 16, 2011. Available at: http://www.foodsafetynews.com/2011/09/gao-lack-of-coordinationfor-us-food-defense/. Accessed December 11, 2014.

6. FDA Food Safety Modernization Act, Pub L No. 

111-353, 24 Stat 3885 (2011). Available at: http://

www.fda.gov/Food/GuidanceRegulation/FSMA/

default.htm. Accessed December 22, 2014.

7. Department of Defense 5200.08: Physical Security 

Program. Washington, DC: US Dept of Defense; 

May 2009. Available at: http://www.dtic.mil/whs/

directives/corres/pdf/520008r.pdf. Accessed December 22, 2014.

8. Department of Defense Directive 6400.04E: DoD 

Veterinary Public and Animal Health Services. 

Washington, DC: US Dept of Defense; June 2013. 

Available at: http://www.dtic.mil/whs/directives/

corres/pdf/640004E.pdf. Accessed December 22, 

2014.

9. Department of Defense Instruction 2000.12: DoD 

Antiterrorism (AT) Program. Washington, DC: US 

Dept of Defense; September 2013. Available at: 

http://www.dtic.mil/whs/directives/corres/pdf/200

012p.pdf. Accessed December 22, 2014.

10. Department of Defense Instruction 2000.16: DoD 

Antiterrorism (AT) Standards. Washington, DC: 

US Dept of Defense; December 2006. Available at: 

http://www.dtic.mil/whs/directives/corres/pdf/200

016p.pdf. Accessed December 22, 2014.

11. Homeland Security Presidential Directive 7: Critical Infrastructure Identification, Prioritization, and 

Protection. Washington, DC: The White House. 

December 17, 2003. Available at: http://www.dhs.

gov/homeland-security-presidential-directive-7#1. 

Accessed December 22, 2014.

12. Homeland Security Presidential Directive 9: Defense of United States Agriculture and Food. Washington, DC: The White House; January 30, 2004. 

Available at: http://www.gpo.gov/fdsys/pkg/PPP2004-book1/pdf/PPP-2004-book1-doc-pg173.pdf. 

Accessed December 22, 2014.

13. Presidential Policy Directive/PPD-8: National Preparedness. Washington, DC: The White House. 

March 30, 2011. Available at: http://www.dhs.gov/

presidential-policy-directive-8-national-prepared

ness#. Accessed December 22, 2014.

14. Racino B. Flood of food imported to United States, 

but only 2 percent inspected. NBCNEWS.com [serial online]. October 3, 2011. Available at: http://

www.nbcnews.com/id/44701433/ns/health-food_

safety/t/flood-food-imported-us-only-percent-in

spected/. Accessed December 22, 2014.

15. Oxford Dictionary [online]. Oxford University 

Press. 2014. Available at: http://www.oxforddictionaries.com/us/definition/american_english/

from-farm-to-fork-or-table-. Accessed December 

22, 2014.

16. Keremidis H, Appel B, Menrath A, Tomuzia K, 

Normark M, Roffey R, Knutsson R. Historical perspective on agroterrorism: lessons learned from 

1945 to 2012. Biosecur Bioterror. 2013;11(suppl 

1):S17-S24. Available at: http://online.liebertpub.

com/doi/pdf/10.1089/bsp.2012.0080. Accessed December 11, 2014.

17. Knowles T, Lane J, Bayens G, Speer N, Jaax J, 

Carter D, Bannister A. NIJ Research Report: Defining Law Enforcement’s Role in Protecting American Agriculture from Agroterrorism. Washington, 

DC: National Institute of Justice; June 30, 2005. 

Available at: https://www.ncjrs.gov/pdffiles1/nij/

grants/212280.pdf. Accessed December 23, 2014.

18. Masters J. Militant extremists in the United States 

[internet]. Council on Foreign Relations Web site. 

February 7, 2011. Available at: http://www.cfr.org/

terrorist-organizations-and-networks/militant-ex

tremists-united-states/p9236#. Accessed December 22, 2014.

19. Centers for Disease Control and Prevention. Glanders. CDC Website. Available at: http://www.cdc.

gov/glanders/. Accessed December 22, 2014.

20. Zaitz L. Rajneeshees in Oregon – the untold story [internet]. The Oregonian. February 14, 2014. 

Available at: http://www.oregonlive.com/rajneesh/

index.ssf/2011/04/part_one_it_was_worse_than_

we.html. Accessed December 22, 2014.

21. Torok TJ, Tauxe RV, Wise RP, et al. A large community outbreak of salmonellosis caused by intentional contamination of restaurant salad bars. 

JAMA. 1997;278(5):389-395.

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22. What are some examples of agroterrorism?. Extension.org Website. April 26, 2010. Available at: 

https://www.extension.org/pages/37146/what-aresome-examples-of-agroterrorism. Accessed December 22, 2014.

23. Center for Disease Control. Nicotine poisoning 

after ingestion of contaminated ground beef–

Michigan, 2003. MMWR Morb Mortal Wkly Rep. 

2003;52(18):413-416. Available at: http://www.cdc.

gov/mmwr/preview/mmwrhtml/mm5218a3.htm. 

Accessed December 22, 2014.

24. Lui M. Frozen foods in pesticide recall sicken 900 

in Japan, NHK says. Bloomberg News [serial online]. January 17, 2014. Available at: http://www.

bloomberg.com/news/2014-01-08/frozen-foodsin-pesticide-recall-sicken-900-in-japan-nhk-says.

html. Accessed December 22, 2014.

25. Schmitt G. Agroterrorism-why we’re not ready: a 

look at the role of law enforcement. NIJ Journal. 

June 2007(257). Available at: http://www.nij.gov/

journals/257/pages/agroterrorism.aspx. Accessed 

December 22, 2014.

26. National Defense Research Institute. Agroterrorism. What is the threat and what can be done about 

it? [internet]. Rand Corp Web site. 2003. Research 

Brief. Available at: http://www.rand.org/content/

dam/rand/pubs/research_briefs/2005/RB7565.pdf. 

Accessed December 22, 2014.

27. Branigin W, Allen M, Mintz J. Tommy Thompson resigns From HHS. WashingtonPost.com

[serial online]. December 3, 2004. Available at: 

http://www.washingtonpost.com/wp-dyn/articles/

A31377-2004Dec3.html. Accessed December 22, 

2014.

Author

SFC Gill is a Veterinary Services Senior Noncommissioned Officer, Food Protection Program, Army Institute 

of Public Health, US Army Public Health Command, Aberdeen Proving Ground, Maryland.
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

Background

Each year, foodborne diseases cause an estimated 48 

million illnesses in the United States, with an estimated 

9.4 million caused by 31 major pathogens.1-3 Relatively 

few foodborne illnesses are associated with an outbreak, 

and even fewer can be attributed to a specific etiologic 

agent or food product. Given the potential impact of a 

foodborne illness outbreak and the resultant negative 

effect on mission readiness and national security, the 

military employs several programs aimed at protecting 

the food supply.4 These programs operate on many levels from acquisition to consumption, with the objective 

of providing broad, overall protection from foodborne 

pathogens and contamination. As part of this overall 

goal, the US Army Public Health Command’s (APHC) 

Destination Monitoring Program was developed as an 

active food surveillance program with the primary goal 

of verifying the effectiveness of food safety systems 

and providing primary prevention against foodborne 

disease.4

The Army Institute of Public Health Veterinary Services (AIPH-VS) is responsible for operating the Destination Monitoring Program, illustrated in Figure 1. 

The AIPH-VS determines, on a quarterly basis, what 

types and how many food items should be collected and 

submitted from all regions and districts within those regions (COL T. Honadel, oral communication, December 

11, 2013). Leadership at the district level assigns sampling to each installation and facility within that district. 

Veterinary Food Inspection Specialists assigned to these 

installations then select, collect, prepare, and ship food 

samples to the Food Analysis Diagnostic Laboratory 

(FADL) at Joint Base San Antonio Fort Sam Houston, 

Texas. The FADL performs testing on the food samples 

according to published guidelines.5,6 The FADL is accredited by the American Association for Laboratory 

Accreditation, and thus is capable of confirming positive 

microbial and chemical tests. Samples that test positive 

for zero tolerance pathogenic organisms are reported 

to the Texas State Department of Health for pulse field 

gel electrophoresis “finger-printing” (CW3 J. D. Mitchell, email, November 7, 2014). All laboratory results are 

then loaded into the Veterinary Services Lotus Notes 

database, an internal database used for tracking animal 

health and food safety within the APHC. Positive test 

results are sent back to the submitter, the region, and the 

AIPH-VS (Dr R. Benisch, oral communication, December 11, 2013). The district headquarters of the submitting branch is responsible for actively reviewing the final laboratory report within the database for verification 

of sampling accuracy, to include food processor name, 

Evaluation of the US Army Institute of Public

 Health Destination Monitoring Program,

 A Food Safety Surveillance Program

MAJ Kamala Rapp-Santos, VC, USA

Karyn Havas, DVM, PhD

Kelly Vest, DVM, DrPH, MPH

Abstract

The Destination Monitoring Program, operated by the US Army Public Health Command (APHC), is one component that supports the APHC Veterinary Service’s mission to ensure safety and quality of food procured for the 

Department of Defense (DoD). This program relies on retail product testing to ensure compliance of production 

facilities and distributors that supply food to the DoD. This program was assessed to determine the validity and 

timeliness by specifically evaluating whether sample size of items collected was adequate, if food samples collected 

were representative of risk, and whether the program returns results in a timely manner. Data was collected from 

the US Army Veterinary Services Lotus Notes database, including all food samples collected and submitted from 

APHC Region-North for the purposes of destination monitoring from January 1, 2013 to December 31, 2013. For 

most food items, only one sample was submitted for testing. The ability to correctly identify a contaminated food 

lot may be limited by reliance on test results from only one sample, as the level of confidence in a negative test result 

is low. The food groups most frequently sampled by APHC correlated with the commodities that were implicated 

in foodborne illness in the United States. Food items to be submitted were equally distributed among districts and 

branches, but sections within large branches submitted relatively few food samples compared to sections within 

smaller branches and districts. Finally, laboratory results were not available for about half the food items prior to 

their respective expiration dates.
January – March 2015 17

processing plant location, lot/production 

code, and product size.

A number of actions may occur in response to a positive test result, depending 

on whether the nonconforming result is 

due to a pathogenic organism such as Salmonella spp or Escherichia coli O157:H7, 

an indicator organism shown by total coliforms or psychrotrophic count, or another 

measure of food quality or safety such as 

mercury or pH. The AIPH-VS evaluates 

the potential risk to public health, and 

collaborates with DoD procurement agencies when determining if a product should 

be recalled or if the manufacturing plant 

should be suspended. The AIPH-VS also 

notifies the commercial establishment and 

appropriate regulatory agency in the case 

of a pathogen positive result (COL T. Honadel, oral communication, December 11, 

2013). Nonconforming results typically 

will result in scheduling of a directed food 

protection audit of the commercial establishment, and additional food samples may 

be collected and tested. 7

The Destination Monitoring Program has 

several goals, an important one of which 

is to ensure that food procured by the 

DoD is safe for consumers. With limited 

resources, this is best accomplished by 

testing the foods that present the greatest 

risk of contamination with pathogens that 

cause the most severe illnesses. As the DoD procures a 

wide variety of food items for consumption by military 

personnel and beneficiaries, a second objective is to ensure that many different items are tested to adequately 

represent all military installations. Finally, the program 

is enhanced when all personnel involved in food sampling and testing receive adequate training, especially 

considering the wide variety of food items procured by 

the DoD. This often influences the type of food items 

that are requested for testing, which may not necessarily 

reflect foods that present the greatest risk. All 3 goals 

were identified by AIPH-VS as important to the success 

of the program (COL T. Honadel, oral communication, 

May 6, 2014). However, achievement of all goals, especially in the context of limited resources, may not be 

possible, and prioritization will help determine the best 

methods to conduct the program. This assessment was 

focused on the goal of identifying and testing high-risk 

food items with the purpose of ensuring food safety and 

preventing foodborne illness.

The objective of this study was to evaluate the processes 

currently utilized by the APHC to identify, collect, and 

submit food samples for laboratory testing, and assess 

them for validity and timeliness. Focus was primarily 

on 3 processes: (1) assessment of sample size and discussion of how sample size relates to statistical power 

and level of confidence in the system; (2) identification 

of food samples to be tested and discussion of the risk 

of foodborne illness associated with different types of 

food; and (3) assessment of the timeliness of the program, 

especially regarding the timing of sample submission, 

reporting of results, and expiration of the food product.

The Uniformed Services University of the Health Sciences Office of Research approved this project.

Methods

Study Design

A descriptive analysis of the Destination Monitoring Program was performed to assess validity and 

Figure 1. Overview of the Destination Monitoring Program - Sample selection 

and testing.

Negative Positive

Army Institute 

of Public Health

PHC

District

PHC

Region

Veterinary 

Services 

Branch

Database

Collect 

Samples

Complete Paperwork

and Ship Samples

Errors

Food Analysis 

and Diagnostic 

Lab

Conduct Tests

FLAGGED ITEM

NOTIFICATION

Paperwork

Damaged

Sample

Confirm

Test

Samples may be 

sent to state 

laboratory

Issue Quarterly

Sample Directives

Assign Samples

Assign Samples

Record

Results

Record Results
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

timeliness of the program. Assessment of the program 

occurred within the APHC Veterinary Services, which 

both implements the program and has oversight of the 

veterinary personnel who execute the program at the region, district, and branch levels. 

Analysis was limited to existing data from the US Army 

Veterinary Services Lotus Notes database provided by 

the AIPH-VS, which consisted of laboratory results and 

administrative information on food samples collected, 

submitted, and tested from January 1, 2013 to December 31, 2013. The analysis was limited to samples collected from the veterinary branches that fall under the 

purview and command of Fort Belvoir, Fort Eustis, and 

Fort Knox Districts within APHC Region North (APHCR-N). The data consisted of sample request forms sent 

to the FADL, which list administrative information (district, branch, fiscal year, quarter), information regarding 

the sample collection (location, date collected/submitted), sample characteristics (brand, category of food, 

weight, number of samples, expiration, plant code), and 

information from the laboratory (date received, errors, 

laboratory results).

All data was manually extracted from the Lotus Notes 

database and compiled into Microsoft Office Excel 2010. 

IBM SPSS Statistics 22 was used for the descriptive 

analyses. 

Evaluation of Sample Size

Descriptive statistics were obtained on the number of 

food samples collected and tested to determine the appropriateness of sample size and the level of confidence 

that could be expected. This information was used to 

develop an operating characteristic curve, which relates 

the probability of concluding a food lot is safe to the 

proportion of units in the lot that exceed a specified acceptable level based on sample size.8

 Operating characteristic (OC) curves are frequently used in development 

and assessment of sampling plans, and the process is 

well documented in the literature.8-11 They are based on 

the probability of detecting a contaminated lot based on 

a number of factors, including level of contamination in 

the source lot, the number of positive samples desired in 

order to reject the lot, and the mean and standard deviation of the bacterial concentration in the source lot. In 

this assessment, the sample size (n) evaluated was based 

on the median number of sample units (c) selected from 

each lot. The maximum allowable number of sample 

units that could test positive for an organism before a lot 

was rejected was set to zero, as is typical for pathogens. 

Mean bacterial concentration was converted to a logarithmic scale, with a standard deviation of 0.8 colonyforming units per gram (cfu/g). This standard deviation 

was selected based on use in the literature to represent 

typical distribution of bacteria in a heterogeneous solid 

food.9-11 E Coli is a common indicator organism, therefore, a hypothetical example using detection of E Coli

in fresh fruits and vegetables, with an acceptable limit 

of less than 10 cfu/g (log 1 cfu/g) was considered. The 

desired acceptance level was designated at 5%, meaning 

that the sampling plan identified would be acceptable 

if it rejected a contaminated lot 95% of the time. For 

comparison, OC-curves were also constructed to depict 

the confidence in the sampling plan if the number of 

samples drawn from each lot was increased to n=2, 5, 

and 10.

Representative of Risk

To determine if the food items selected as part of the 

Destination Monitoring Program were representative of 

the risk of foodborne illness, the frequency and percentage of items tested were determined by food category, as 

defined by the FADL and APHCR-N, and the frequency 

and percentage of positive results were tabulated for 

each category. In addition to the food categories defined 

by APHCR-N, all food items tested were recategorized 

according to 17 food commodity groups, based on the 

nature of the food source and ingredient, as developed by 

Painter, et al.1,12 Some items were categorized into more 

than one of the 17 food commodities if they contained 

more than one ingredient.12 Frequency and percentage of 

food items tested by district and branch were also tabulated. Microbial and chemical testing was summarized 

by tabulating the number of food items that were tested 

for each organism or chemical.

Timeliness

Timeliness of the program was determined by using 

the median days that elapsed from when the food items 

were submitted to laboratory and when the results were 

available. Additionally, the median time from when 

laboratory results were available to when the food item 

expired was calculated. Median values were selected 

due to the skewed distribution of values as well as to 

minimize the effect of outliers.

Results

Evaluation of Sample Size

A total of 668 food samples from APHCR-N were collected and submitted to the FADL for the Destination 

Monitoring Program in 2013. Of those, 577 (86.4%) 

were actually tested by the FADL. Duplicate samples 

submitted for the same item were often not tested unless required by FADL, such as when needed for additional chemical testing or to meet minimum weight 

requirements for microbial sampling (R. Leo, oral communication, May 20, 2014). The submitted food samples 

EVALUATION OF THE US ARMY INSTITUTE OF PUBLIC HEALTH DESTINATION MONITORING PROGRAM,

A FOOD SAFETY SURVEILLANCE PROGRAM
January – March 2015 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

comprised 514 individual food items. The majority of 

food items submitted and tested contained one sample 

(73.5%, 89.2% respectively). The number of samples 

submitted and tested per item ranged from one to 8, 

with a median of one. Seven items were submitted but 

not tested at all. Of those not tested, 3 were not received 

and 4 were not tested due to lost integrity of packaging 

(broken, leaking). The distribution of number of samples submitted and tested for each food item is shown 

in Table 1.

As the median number of samples submitted and tested 

was one, the OC-curves were constructed using n=1 

and c=0 (Figure 2). The probability of accepting a lot 

differed depending on the sample size (n) and the proportion of contamination within a lot. When n=1 and if 

the proportion of contamination within the lot was 10%, 

there is a 90% probability of accepting the lot based on 

the negative results of that one sample. This probability 

decreased in a linear fashion as the level of contamination increased. At 50% contamination, the lot is accepted 50% of the time with a sample size of one. In contrast, 

when the sample size was increased to n=5, and if the 

proportion of contamination within the lot was 10%, the 

probability of accepting the lot is 59%. At a contamination level of 50%, the probability of accepting the lot 

based on 5 negative samples is reduced to 3% (Figure 3). 

A comparison of the probability of accepting a lot based 

on a variety of levels of contamination and several hypothetical sampling plans is presented in Table 2.

Representative of Risk

The AIPH-VS requested food items from 14 food categories during 2013. The food groups represent categories of interest as they are considered potentially 

hazardous foods and give guidance to veterinary personnel in selecting items off the shelf (Table 3). Of the 

507 food items collected and tested, the individual category with the most items tested was ground meat 

(n=78, 15.4%). When categories were collapsed 

based on food origin, 35.1% of the food items 

consisted of fresh fruits and vegetables. This included processed fruits and vegetables (12.2%), 

bagged salads (12%), and whole fresh fruits and 

vegetables (10.9%). Other categories with significant representation included prepared salad (9.5%), 

kimchee/tofu (5.7%), and raw seafood (5.5%). Over 

the period of one year, 3 food items tested positive 

for indicator organisms. This included one liquid 

dairy item, which represented 4.4% of all fresh 

dairy items tested, and 2 unprocessed fresh fruit 

and vegetable items, representing 3.6% of all items 

in that category tested. 

The frequencies of microbial and chemical testing on 

food samples were determined. Of the pathogenic bacteria, tests for the presence of Salmonella spp were most 

frequent (n=350, 69%). Testing for other pathogenic bacteria included Listeria monocytogenes (n=323, 63.7%), 

Staphylococcus aureus (n=315, 62.1%), and E Coli

O157:H7 (n=232, 45.8%). Tests for indicator organisms 

included E Coli (n=403, 79.5%), total coliforms (n=270, 

53.3%), and psychrotrophic count (n=83, 16.4%). Three 

food samples tested positive for indicator organisms 

(Table 3), including whole bagged salad and dairy. The 

dairy food item tested positive for both total coliforms 

and standard plate count.

The total number of food items requested by AIPH-VS 

was similar for each district, and were evenly assigned 

across the branches and sections within each district. 

Table 1. Comparison of Number of Samples Submitted 

and Tested by the Department of Defense Food Analysis Diagnostic Laboratory for the Destination Monitoring 

Program, January 1 - December 31, 2013.

Number of Samples

Submitted Tested

Total number of samples 668 577a

Median samples per item 1 1

Minimum samples per item 1 1

Maximum samples per item 8 8

Number of Items

Total N=514 N=507b

n(%N) n(%N)

Items containing 1 sample 378(73.5%) 452(89.2%)

Items containing 2 samples 127(24.7%) 49(9.7%)

Items containing 3 samples 

or more

9(1.8%) 6(1.2%)

a

Duplicate samples submitted for the same item were often not 

tested except in certain cases such as chemical analysis to meet 

minimum weight requirements for microbial testing.

b

Seven items were not tested (not received or suspect package 

integrity).

Figure 2. Based on sample size of one, the probability of accepting 

a contaminated lot decreases in a linear fashion as the level of contamination in the lot increases.

0.00 0.20 0.40 0.60 0.80 1.00

0.80

0.60

0.40

0.20

0.00

1.00

P(acceptance)=90%

P(acceptance)=50%

Proportion Defective

Probability of Acceptance
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

Some sections in large districts, such as 

Fort Belvoir District, were assigned a relatively small number of food items to collect 

compared to sections in smaller districts 

(Table 4). For example, the Fort Knox commissary collected a greater total number of 

food items (10.7%) compared to other larger 

commissaries in the region, such as Fort 

Belvoir (1.8%).

Timeliness

The median number of days elapsed between food sample submission to the FADL 

and availability of laboratory results was 9 

days, ranging from 1 to 49 (Table 5). For 

those food items that had an expiration 

date (n=424), the median number of days 

between availability of laboratory results 

and expiration of the product was 2 

days, and ranged from -26 (product 

expired 26 days before laboratory 

results reported) to 1,801. When 

considering items with an expiration date, 46.7% of food items expired before or on the same day that 

laboratory results were reported. In 

many cases, these items represent 

highly perishable foods with a short shelf life. Figure 4 

depicts the distribution of days elapsed between date of 

submission and laboratory results.

Comment

The purpose of this evaluation of the APHC’s Destination Monitoring Program was to determine the effectiveness, timeliness, and validity of the program and to 

inform stakeholders and policymakers on the strengths 

and limitations of the program. 

Most food item submissions contained only one food 

sample. Even if two or more samples were submitted, 

often only one sample was actually tested. By selecting 

only one food sample to test, there is a significant potential to fail to detect a contaminated lot, even when the 

contamination is significant. As the level of contamination in a lot decreases, it becomes even more difficult 

to detect with a sampling plan that includes collection 

of only one sample. However, increasing the sample 

size even moderately would greatly increase the probability of correctly identifying contaminated lots. Taking a single sample, particularly if negative, affords 

virtually no ability to discriminate between conforming 

and nonconforming lots.10 Recommendations include 

collecting more samples of each requested item from 

each commissary. If current inventory will not allow 

this, sample collection could be coordinated among commissaries in 

each branch, to allow for collection 

of samples from the same lot, or at 

least the same brand with similar 

production dates.

The program was also evaluated to 

determine if the food items selected 

for testing adequately represented the risk of foodborne 

illness. The AIPH-VS makes the decision on what categories of food to test based on a variety of factors, such 

as recent food recalls, reports of foodborne illness attributed to certain foods, past knowledge of contaminated food items, and training needs (Dr R. Benisch, oral 

communication, December 11, 2013). Although a formal, 

objective risk assessment process has never been developed to assist in determining what food categories pose 

the greatest risk to consumers, the food categories selected for testing in 2013 did appear to represent those 

food categories most often implicated in foodborne 

disease outbreaks, as assessed by Painter et al.1 Only 3 

food items tested positive for contaminants during the 

study period, which is too few to accurately assess or 

recommend what food categories are historically associated with increased risk of contamination within this 

system. A more extensive study reviewing several years 

and other regions globally would be beneficial to provide 

these recommendations. Development of a formal risk 

assessment plan could be beneficial, especially if based 

on publications such as those that track foodborne illness 

by food category, food items produced from commercial 

establishments with multiple major or critical findings 

during sanitation audits, data from the All Food and 

Drug Activities announcements released by the Defense 

Logistics Agency, etc.

Table 2. Probability of Accepting a Lot in 

Relation to Proportion of Contamination 

and Sample Size.

Proportion of

Contamination

Sample Size

n=1 n=2 n=5 n=10

10% 0.9 0.81 0.59 0.35

20% 0.8 0.64 0.33 0.11

50% 0.5 0.25 0.03 0.01

Figure 3. When 5 samples are tested, the probability of accepting a contaminated lot decreases drastically as the level of contamination increases, 

greatly reducing the risk of allowing a contaminated food item to remain available to consumers.

0.00 0.20 0.40 0.60 0.80 1.00

0.80

0.60

0.40

0.20

0.00

1.00

P(acceptance)=3%

P(acceptance)=59%

Proportion Defective

Probability of Acceptance

EVALUATION OF THE US ARMY INSTITUTE OF PUBLIC HEALTH DESTINATION MONITORING PROGRAM,

A FOOD SAFETY SURVEILLANCE PROGRAM
January – March 2015 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

Although each district in the study collected a similar 

distribution of products, there was a large difference 

when comparing individual sections. This was because 

some districts, such as Fort Belvoir, are comprised of 

many more sections responsible for more commissaries. The current program allows for representation of 

many facilities, but the proportion of samples collected 

at each facility is not based on the size of the facility nor 

the population served at each facility. Readjusting the number of samples requested 

from each section to better reflect the risk 

of contamination and proportion of people 

served at each facility would improve the 

representation of samples requested. This 

would require information on the relative 

size of each facility, number of patrons 

served, and number of veterinary personnel assigned to support each facility.

Finally, this evaluation examined the timeliness of the program. Most laboratory results were reported within 15 days. Food 

items typically arrived at the FADL within 

one business day, and FADL personnel 

did not indicate an overwhelming burden 

of samples. In fact, the majority of the time 

lapse between sample submission and reporting of results was likely due to typical processing associated with conducting laboratory tests. Due to the nature of some perishable food items, almost half of items sampled 

expired before results were reported. Many 

of the highly perishable food items are also 

considered a higher risk, potentially hazardous food. Thus, they should continue to be 

included in the program, with the recognition 

that if a positive laboratory test is reported, 

the food lot from which the sample was taken 

will no longer be available for purchase, and 

may in fact already be consumed or discarded. Procedures should be developed to inform 

military public health personnel of the potential health threat. Further, program managers should consider the value of additional 

laboratory support through the use of satellite facilities or contracted civilian laboratories. This may allow for more rapid testing 

of highly perishable food items, and may be 

considered if a significant increase in sample 

collection is pursued.

Analysis of the destination monitoring program revealed several strengths. First, although the program does not employ a formal risk analysis process to determine what food items 

should be collected, the data suggest that the informal 

process based on current trends and subject matter expertise resulted in selection of a variety of food items 

representing a moderate to high potential for contamination. Second, the shipping and processing of food 

items happened quickly, and results were reported in a 

timely manner. Lastly, recent accreditation of the FADL 

Table 3: Distribution of Unique Food Samples Collected and Tested Based 

on Category, and Number of Items Positive for Indicator Organisms.

Food Category Food Items

Tested, N=507

n(%N)

Food Items Positive 

for Indicator

Organisms, N=507

n(%N)

Proportion Positive

Within Category

Ground meat 78(15.4%) – –

Processed fruits

and vegetables

62(12.2%) – –

Bagged salad 61(12.0%) – –

Whole fresh fruits

and vegetables

55(10.9%) 2(0.4%) 3.60% (n=55)

Prepared salad 48(9.5%) – –

Frozen dairy 30(5.9%) – –

Other PHF

(kimchee/tofu)

29(5.7%) – –

Raw seafood 28(5.5%) – –

RTE meats 23(4.5%) – –

Fresh liquid dairy 23(4.5%) 1(0.2%) 4.40% (n=23)

Powdered

infant formula

22(4.3%) – –

Cheese 21(4.1%) – –

Seafood fresh RTE 19(3.8%) – –

Seafood

(canned RTE)

8(1.6%) – –

Total 507(100%) 3(0.6%)

PHF indicates potentially hazardous food.

RTE indicates ready-to-eat.

Figure 4. Days from the date of sample submission to the date results were 

available.

1 3 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 24 49

180

160

140

120

100

80

60

40

20

0

Frequency

Days
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

confirms the high quality of laboratory 

procedures used to determine contamination in submitted food items.

Several limitations of the program were 

recognized. Perhaps the most significant limitation was the reliance on small 

sample sizes to make decisions about 

the safety of food lots. Additionally, although the Lotus Notes database was 

functional, it was difficult to navigate 

and did not provide an easy method to 

extract data for analysis. All records had 

to be individually accessed and transcribed to an Excel worksheet for analysis. Currently, the database does not provide an easy way for users to evaluate 

data from an epidemiologic perspective. 

The program is also not well integrated 

with other surveillance systems, such 

as the Armed Forces Reportable Medical Events passive surveillance system14

or the Centers for Disease Control and 

Prevention FoodNet15 or PulseNet16

systems. It should be noted that while 

FADL does not directly communicate 

with other surveillance systems, it does 

send samples from food items testing 

positive for zero-tolerance pathogens to 

the Texas State Department of Health, 

which communicates with PulseNet 

(CW3 J. D. Mitchell, oral communication, November 7, 2014). Improving the 

communication and integration between 

the AIPH-VS and other foodborne disease surveillance systems as well as other military public health infrastructure 

may be vital in linking human disease 

cases to potential foodborne pathogens 

detected within the Destination Monitoring Program. Although this analysis 

was limited to the APHC Region North, 

many conclusions will likely apply to 

APHC Regions South and West, because 

the same type and number of food items 

are typically requested from each region, and food samples are all processed 

at FADL. However, one would expect 

the distribution of sample collection to 

vary between individual sections. Additional research may give more information as to how the program functions in 

other regions, especially APHC Pacific 

and Europe.

Table 4. Frequency of Food Item Submissions by District, Branch, and Section of 

the APHC Region-North, January 1 - December 31, 2013.

District Branch Section Frequency % of District

Submissions

% of Total

Submissions

Fort Belvoir

Fort Meade Andrews/

Annapolis

5 3.0% 1.0%

Forest Glen 5 3.0% 1.0%

Carlisle Barracks 4 2.4% 0.8%

Fort Detrick 4 2.4% 0.8%

Fort Meade 4 2.4% 0.8%

Branch Total 22 13.0% 4.3%

New London Groton 12 7.1% 2.3%

Newport 9 5.3% 1.8%

Branch Total 21 12.4% 4.1%

Dover Aberdeen

Proving Ground

21 12.4% 4.1%

Fort Belvoir Fort Belvoir 9 5.3% 1.8%

Quantico 8 4.7% 1.6%

Patuxent River 3 1.8% 0.6%

Branch Total 20 11.8% 3.9%

McGuire/

Dix

Fort Dix 20 11.8% 3.9%

Fort Drum Fort Drum 20 11.8% 3.9%

West Point West Point 13 7.7% 2.5%

Tobyhanna 6 3.6% 1.2%

Branch Total 19 11.2% 3.7%

Fort Myer Fort Myer 17 10.1% 3.3%

Hanscom Portsmouth 9 5.3% 1.8%

District Total 169 100.0% 32.9%

Fort Eustis

Fort Bragg Fort Bragg 35 20.5% 6.8%

Norfolk Norfolk 17 9.9% 3.3%

Portsmouth 17 9.9% 3.3%

Branch Total 34 19.9% 6.6%

Fort Lee Fort Lee 27 15.8% 5.3%

Fort Eustis Fort Eustis 26 15.2% 5.1%

Camp

Lejeune

Camp Lejeune 25 14.6% 4.9%

Cherry Point Cherry Point 24 14.0% 4.7%

District Total 171 100.0% 33.3%

Fort Knox

Fort Knox Fort Knox 55 31.6% 10.7%

Harrison Village 10 5.7% 1.9%

Branch Total 65 37.4% 12.6%

Great Lakes Great Lakes 38 21.8% 7.4%

Rock Island 7 4.0% 1.4%

Fort McCoy 16 9.2% 3.1%

Branch Total 61 35.1% 11.9%

WrightPattersonSelfridge ANGB 29 16.7% 5.6%

Kelly Support 19 10.9% 3.7%

Branch Total 48 27.6% 9.3%

District Total 174 100.0% 33.9%

Grand Total 514 100.0%

EVALUATION OF THE US ARMY INSTITUTE OF PUBLIC HEALTH DESTINATION MONITORING PROGRAM,

A FOOD SAFETY SURVEILLANCE PROGRAM
January – March 2015 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

The purpose of the Destination Monitoring Program 

is to assess and validate producer compliance with 

good hygiene practices, good manufacturing practices 

(GMPs), and implementation of food safety risk management systems such as Hazard Analysis Critical Control Point (HACCP). Increasingly, it is recognized that 

preventive measures such as GMPs and HACCP are 

much more effective food safety management tools than 

end-product testing.8,13 Some suggest that while microbial monitoring has its place, particularly in high-risk 

situations like intentional botulinum toxin poisoning in 

milk, a better return on investment might be realized 

through increased funding of foodborne disease surveillance systems.13 However, the Destination Monitoring 

Program has the potential to yield important information, serves as an additional level of protection against 

foodborne pathogens, and is used to verify safety and 

wholesomeness of food purchased by DoD.

Acknowledgements

The authors thank the AIPH-VS for providing valuable 

background information and perspective on the program, especially COL Thomas Honadel, Dr Rebecca 

Benisch, and CW5 Christopher Finch. Several others 

within the Public Health Command Region North provided essential background information and perspective, 

including CW4 Donald Smith, CW2 Stephanie McClain, 

and CW2 Garry McNair. Personnel from the DoD Food 

Analysis and Diagnostic Laboratory also provided valuable information on the program, including CW4 Keith 

Pritts and Mr Robert Leo.

References

1. Painter JA, Hoekstra RM, Ayers T, et al. Attribution of foodborne illnesses, hospitalizations, and 

deaths to food commodities by using outbreak 

data, United States, 1998-2008. Emerg Infect Dis. 

2013;19(3):407-415.

2. Gould LH, Walsh KA, Vieira AR, et al. Surveillance for foodborne disease outbreaks - United States, 1998-2008. MMWR Surveill Summ. 

2013;62(2):1-34.

3. Scallan E, Hoekstra RM, Angulo FJ, et al. Foodborne illness acquired in the United States–major 

pathogens. Emerg Infect Dis. 2011;17(1):7-15.

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

Safety, Quality Assurance, and Laboratory Service. 

Washington, DC: US Dept of the Army; 2005.

5. US Army Public Health Command. DoD Lab Sample Submission Guide [internet]. 2013. Available at: 

http://phc.amedd.army.mil/topics/labsciences/fad/

Pages/SampleSubmission.aspx. Accessed December 17, 2014.

6. Department of Defense Food Safety and Quality 

Assurance Laboratory Action Levels. In: USASPH 

Circular 40-1: Worldwide Directory of Sanitarily 

Approved Food Establishments for Armed Forces 

Procurement. Aberdeen Proving Ground, MD: US 

Army Public Health Command: June 2014: Appendix O.

7. Military Handbook 3006C: Guidelines for Auditing 

Food Establishments. Washington, DC: US Dept of 

Defense; June 2008: MIL-HDBK-3006C.

8. Legan JD, Vandeven MH, Dahms S, Cole MB. Determining the concentration of microorganisms 

controlled by attributes sampling plans. Food Control. 2001;12(3):137-147.

9. Joint FAO/WHO Codex Alimentarius Commission. 

Codex Alimentarius General Guidelines on Sampling. Rome Italy: Food and Agriculture Organization of the United Nations; 2004. CAC/GL 50-2004.

10. van Schothorst M, Zwietering MH, Ross T, Buchanan RL, Cole MB. Relating microbiological 

criteria to food safety objectives and performance 

objectives. Food Control. 2009;20(11):967-979.

11. Dahms S. Microbial sampling plans – statistical 

aspects. Paper presented at the 36th Symposium 

of the Swiss Society of Food Hygiene; October 

8, 2003; Zurich, Switzerland. Available at: http://

www.icmsf.org/pdf/032-044_Dahms.pdf. Accessed December 17, 2014.

12. Painter JA, Ayers T, Woodruff R, Blanton E, Perez N, Hoekstra RM, et al. Recipes for foodborne 

outbreaks: a scheme for categorizing and grouping implicated foods. Foodborne Pathog Dis. 

2009;6:1259-1264.

13. Institute of Medicine Forum on Microbial Threats. 

Addressing Foodborne Threats to Health: Policies, 

Practices, and Global Coordination. Washington, 

DC: National Academies Press; 2006.

14. Armed Forces Health Surveillance Center. Armed 

Forces Reportable Events Guidelines and Case 

Definitions [internet]. Available at: http://afhsc.mil/

home/reportableEvents. Accessed January 30, 2014.

Table 5. Days Elapsed from Submission to Results, and 

Results to Product Expiration Date.

Submission to

Results (Days)

Results to

Expiration (Days)

Number of food items 507 424a

Median 9 2

Minimum 1 -26.0b

Maximum 49 1801

a

Data only available for food items that had an expiration date.

b

Negative numbers indicate that product expired prior to 

reporting of laboratory results.
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

15. Centers for Disease Control and Prevention. Foodborne Diseases Active Surveillance Network (FoodNet) [internet]. 

2013. Available at: http://www.cdc.gov/foodnet/. Accessed January 30, 2014.

16. Centers for Disease Control and Prevention. PulseNet. 2013. Available at: http://www.cdc.gov/pulsenet/. Accessed 

January 30, 2014.

Authors

MAJ Rapp-Santos is a Laboratory Animal Medicine Resident at the US Army Medical Research Institute of Infectious 

Diseases, Fort Detrick, Maryland.

At the time this article was written, Dr Havas was an Epidemiologist with the Division of Integrated Surveillance at the 

Armed Forces Health Surveillance Center, Silver Spring, Maryland.

Dr Vest is the Deputy Chief of Staff, Operations, and a Veterinary Epidemiologist at the Armed Forces Health Surveillance Center, Silver Spring, Maryland.

EVALUATION OF THE US ARMY INSTITUTE OF PUBLIC HEALTH DESTINATION MONITORING PROGRAM,

A FOOD SAFETY SURVEILLANCE PROGRAM
January – March 2015 25

The US Environmental Protection Agency (EPA) was 

established in 1970 to protect the environment, which 

has the attendant effect of protecting people’s health. 

This correlates with one goal of the US Army Public 

Health Command (USAPHC):

To protect Soldiers and Army communities, worldwide, 

from environmental conditions that could adversely affect human health.1

One example of an environmentally regulated process 

frequently used in patient care is cervical cancer screening. Historically, samples of cervical cells were manually smeared directly on a glass slide which was then 

sent to a lab for processing and review. This screening 

procedure was not reliable. Sometimes the cells were 

smeared too thick or too thin, commonly resulting in 

false positive or false negative results. In 1996, the Food 

and Drug Administration approved the ThinPrep Pap 

System (Hologic Inc, Bedford, MA) 2 which suspends 

the cervical cells in a methanol-based solution, then uses 

an automated process that places the cells uniformly on 

a slide. The new process has improved accuracy for cervical cancer screening, but generates a hazardous waste 

(HW) in the process. Personnel ordering and using this 

equipment and its reagents were not initially aware this 

process generated a HW. Since chemical and pharmaceutical manufacturing companies are not required to 

communicate disposal requirements for their products, 

the person generating the waste must make the determination. In this as in most cases, the process is simple and personnel are available to assist. Each medical 

activity (MEDDAC) has personnel within the logistics 

and preventive medicine divisions who can assist in determining which wastes are hazardous and which are 

not. Logistics and preventive medicine personnel can 

seek assistance, if needed, from their USAPHC regions. 

Determining which regulations apply can be tricky, and 

collaboration is often required to ensure the facilities are 

in compliance.

There are 22 regulatory acts and 3 executive orders under the jurisdiction of the EPA. Although all of the acts 

and executive orders can be applied to healthcare facilities, the most significantly relevant are the Resource 

Conservation and Recovery Act (RCRA) 3 and the Clean 

Water Act.4

The Resource Conservation and Recovery Act

The RCRA was first enacted in 1976 and amended in 

1984.5 According to the US Department of Agriculture, 

the objectives of the RCRA are:

...to protect human health and the environment from 

the potential hazards of waste disposal, to conserve 

energy and natural resources, to reduce the amount of 

waste generated, and to ensure that wastes are managed 

in an environmentally sound manner. RCRA regulates 

the management of solid waste (eg, garbage), hazardous 

waste, and underground storage tanks holding petroleum 

products or certain chemicals.6

The RCRA requirements are not industry-specific. Any 

industry generating HW or storing petroleum, oils, and 

lubricants is regulated. Patient care, including dental 

and veterinary care, generates HW. Hospitals store petroleum to power emergency generators, dining facilities generate used oil from cooking, and facilities maintenance generates used oil during regular maintenance 

activities. The RCRA relates to patient care, both directly and indirectly.

The RCRA divides HW into 2 broad categories, Characteristic and Listed. The Characteristic subcategories are 

Environmental Requirements Related to

 Patient Care and the Team Working to

 Ensure Compliance

Diane Roberts

Abstract

Healthcare providers are often surprised that regulations promulgated by the US Environmental Protection 

Agency (EPA) apply to patient care settings. Many find it strange that processes meant to heal have the potential 

to harm human health and the environment, and are, therefore, regulated by federal and state environmental 

agencies. The importance of compliance is emphasized by the fact that both the EPA and individual state agencies have the authority to impose civil and criminal penalties if they discover violations. The Joint Commission 

considers compliance important enough to include it as an element of performance in the Environment of Care 

standard.
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

Ignitable, Corrosive, Reactive, and Toxic. The 

Listed categories are F, K, P and U. All HWs are 

given a 4 digit EPA HW Identification Number.

Ignitable HW includes, but is not limited to, 

liquids containing at least 24% alcohol with a 

flashpoint of 60°C/140°F or higher. With a flashpoint of 60°C, the methanol-based waste generated from cervical cancer screening becomes 

an ignitable HW upon disposal. The EPA HW 

number for ignitable HW is D001. The characteristic of corrosive HW (D002) include liquids 

having a pH of 2 or lower, or 12.5 or higher. 

These pH ranges apply to many acids and bases 

used in clinical laboratories. Reactive (D003) 

HW includes wastes reactive with water, capable of detonation if heated or under confinement, or 

items that can undergo violent change without detonation. Lithium batteries and non-empty aerosol cans are 

waste that can fall into this category upon disposal.

The toxicity characteristic is based on the type and concentration of specific chemical constituents such as silver or mercury that may be present in waste. These constituents are harmful or fatal when ingested or absorbed; 

can enter the environment as leachate from improperly 

discarded waste; and pollute ground water. Toxicity is 

defined through a laboratory procedure called the toxicity characteristic leaching procedure (TCLP). The TCLP 

helps identify constituents in items such as silver nitrate 

sticks (see illustration) that are likely to leach into the 

environment. Table 1 provides a list of constituents 

commonly found in patient care settings, with the associated EPA HW Number and the regulatory level that, 

when reached or exceeded, makes the item a HW.

The K-list consists of specific industrial 

processes. Examples include pressure treating wood or developing explosives, such as 

trinitrotoluene or TNT. The wastes generated from these processes are HWs. This 

category is not applicable to patient care.

The F-list consists of waste generated from 

processes common to multiple types of industrial processes. Acetone, xylene, and 

methylene chloride are used as solvents in paint, leather, 

and pesticide manufacturing, as well as by the auto industry for degreasing. In cases when these are used for 

their solvent properties, they are F-listed HW. The hospital may not seem “industrial,” but xylene is used in 

a histology laboratory during tissue processing to dissolve paraffin and tissue-based fats. Because xylene is 

used in this process as a solvent, RCRA characterizes 

it as an F-listed HW upon disposal. Various chemicals 

with solvent properties are often used in facilities maintenance, which would be the only other activity that may 

regularly generate this waste.

The P-list and U-list consist of commercial chemical 

products such as formaldehyde, methanol, xylene, and 

warfarin (Coumadin). If such products require disposal, 

they will be a P or U-listed HW only when unused and 

if the product has only one active ingredient which is on 

the P or U-list. For example, an unused, expired bottle of 

phenol used in physical therapy would be a U188 RCRA 

HW because the item is an unused commercial chemical 

product and phenol is its sole active ingredient. In contrast, yellow fever vaccine preserved with phenol is not a 

U188 HW because phenol is not the sole active ingredient in the vaccine. Similarly, xylene used in a histology 

laboratory for its solvent properties would not be a U-listed waste for disposal. However, if the xylene is expired 

and cannot be used, it would be managed as a U239 HW 

upon disposal. Table 2 lists additional items 

used in patient care that would be P or Ulisted HW upon disposal.

The difference between the P and U-lists is 

that P-listed chemical products are acutely 

toxic. Acutely toxic refers to HW that could 

pose a threat to human health and the environment even when properly managed. 

Toxic HW is considered capable of posing 

a threat to human health and the environment in the absence of special handling and storage procedures. Because P-listed wastes are acutely toxic, the containers 

that hold them are also considered acutely toxic. A container that held Coumadin would therefore be a P-listed 

HW. The same categorization applies to wrappers that 

contained nicotine patches and blister packs that contained nicotine gum.

ENVIRONMENTAL REQUIREMENTS RELATED TO PATIENT CARE AND

THE TEAM WORKING TO ENSURE COMPLIANCE

Table 1. Toxic Hazardous Waste Generated in Patient Care

Constituent EPA HW

Number

Regulatory

Level

(mg/L)

Sources of the Waste

Stream in Healthcare

Concentration

Range

m-Cresol D024 200.0 Insulin (m-Cresol is a 

preservative)

1800mg/L and 

up

Lindane D013 0.4 Lice and scabies 

treatment

10,000 mg/L

Mercury D002 0.2 Thimerosal preserved 

vaccines

200 mg/L

Ophthalmic solutions 200 mg/L

Amalgam Up to 400 mg/L

Selenium D010 1.0 Topical or shampoo 250 mg/L and 

up

Silver D011 5.0 Silver nitrate cauterizing sticks

200 mg/L

Silver nitrate sticks
January – March 2015 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

The Clean Water Act, RCRA, and Petroleum,

Oils and Lubricants

The majority of petroleum, oils, and lubricants (POL) associated with hospitals are stored in above ground storage tanks (ASTs), underground storage tanks, or 55-gallon drums. Fuel for emergency generators is stored in 

ASTs with capacities ranging from 500 to 12,000 gallons. Used cooking oil generated in a dining facility is 

commonly stored in 55-gallon drums or in 400-gallon 

leak proof ASTs that look like dumpsters.

Sites with POL storage in containers with a capacity of 

55 gallons or more are regulated by EPA under 40 CFR 

§112–Oil Pollution Prevention which mandates a spill 

prevention, control, and countermeasures plan (SPCCP). 

The SPCCP must be updated by DPW every 5 years. 

Additionally, anything stored in underground storage 

tanks is also regulated by the RCRA. Each regulated 

containment system must be documented in the installation’s SPCCP. The SPCCP prescribes inspections, spill 

response, and spill reporting requirements. Facilities 

Maintenance and dining facility personnel are required 

to comply with the SPCCP as this document is effectively the regulation to which the facility must comply, or be 

cited. In 2014, one Army installation paid $158,700 for 

RCRA violations related to improper management of underground storage tanks.7

 The site had 20 tanks storing 

gasoline, diesel, used oil, jet fuel, and anti-freeze for use 

in vehicles, aircraft, emergency generators, and maintenance carts. The EPA found 19 tanks out of compliance.

Characterizing Hazardous Wastes

By regulation, any person or entity generating waste is 

required to determine if their waste is hazardous. The 

process commonly begins with a review of the materials 

safety data sheets, which provide information such as pH 

or flashpoint, or package inserts which are commonly 

provided with pharmaceuticals. When a process 

mixes various chemicals, such as in a laboratory, 

a waste may require chemical analysis. This is 

accomplished by taking a sample of the waste 

and contracting with an EPA or state certified 

laboratory for analysis. If the analysis indicates 

the waste fits within one of the Characteristic 

subcategories, it must be managed and discarded 

as a HW. The Army Institute of Public Health 

(AIPH) and the USAPHC Regions are available 

to assist with this process.

Managing Hazardous Waste

The EPA requirements for management of HW 

are straightforward. At a minimum, the person 

generating the waste must store the waste at or 

near points of generation, and the storage site 

must be under the control of the waste generator. These 

storage sites are commonly called satellite accumulation 

points or areas. Containers at the accumulation point 

must be closed and marked “Hazardous Waste,” or with 

words indicating the contents. Containers must be in 

good condition, compatible with contents, closed when 

not adding or removing waste, vapor tight, and spill proof. 

The quantity of HW permitted at satellite accumulation 

points or areas is 55 gallons of nonacute HW, or 1 quart 

acute HW (ie, P-listed). If either limit is reached, the generator must remove the waste in excess of 55 gallons or 

1 quart within 3 days. The waste is normally removed 

by the installation’s Directorate of Public Works (DPW) 

and stored at a DPW maintained facility before being 

sent to a HW disposal contractor. In some cases, patient 

care facility personnel will transfer waste to the DPW 

storage facilities. This is allowed only when the DPW 

storage facility and the patient care facility are on the 

same installation. Medical personnel may not transport 

HW off the installation or bring HW onto the installation 

unless specific conditions are met. This is relevant for 

personnel who generate HW at off-post clinics. Under 

most conditions, transport off the installation is allowed 

only by personnel who have formal permits and required 

certifications to transport HW on public roadways. The 

regional USAPHC must be contacted to confirm legality 

if HW generated at off-post clinics is to be transported 

by medical facility personnel to a HW storage or disposal facility. Transport (off post), treatment, and disposal of HW are contracted through the Defense Logistics 

Agency – Disposition Services (DLA-DS), formerly the 

Defense Reutilization and Marketing Office.

As a tenant on an installation, the hospital will reimburse the DLA-DS, via DPW, for HW disposal. The 

conditions and costs will be outlined in an interservice 

support agreement between the hospital and DPW. The 

Table 2. Listed Category P and U Hazardous Waste Generated from 

Patient Care.

P or U Listed

Chemical

EPA HW 

Number

Trade Name Areas Where

Commonly Generated

Cyclophoshamide U058 Cytoxan

Neosar

Inpatient, outpatient, 

and oncological 

pharmacies

Lindane U129 Gamen

Kwell

Scabene

Inpatient and outpatient 

pharmacies

Methanol U154 N/A Laboratories

Mitomycin-C U010 Mutamycin

Mitosol

Oncology, ophthalmology, and dermatology

Nicotine and 

salts

P075 Nicorette Gum

Thrive Gum

Nicoderm CQ Patch

Nicotrol Patch

Obstetrics and inpatient 

behavioral health

Phenol U188 Physical therapy
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

hospital reimburses DPW using environmental program 

requirement funds disbursed by the US Army Medical 

Command, and managed by the MEDDAC Environmental Science and Engineering Officer (ESEO). The 

ESEO is normally the Chief of Environmental Health 

within the Preventive Medicine Division. Although the 

ESEO manages the funding for disposal, Army Regulation 40-38

 designates Medical Logistics as responsible 

for the hospital waste program. Waste management programs are successful when the ESEO and Medical Logistics have a close working relationship. Each role has 

the support of the installation DPW, with higher level 

support available from the regional USAPHC.

State and Host Country Requirements

Because our uniformed personnel move from state to 

state, it is important to understand that with the exception of Iowa, Alaska, and Hawaii, individual states have 

the jurisdiction to enact more stringent environmental 

regulations. For example, the state of Washington defines Sodasorb, a corrosive salt used to absorb carbon 

dioxide from anesthetized patients, as a corrosive D002 

HW. The Washington regulations require any caustic 

solid that causes a liquid to have a pH of 2 or lower or 

higher than 12.5 (when exposed to an equal volume of 

liquid) to be disposed of as a corrosive HW. In contrast, 

the EPA only regulates liquids.

Pharmaceutical waste is another area where states have 

applied more stringent requirements or regulatory interpretations. The DLA-DS has contracted with a pharmaceutical reverse distributor that picks up unusable/unwanted pharmaceuticals directly from MEDDAC pharmacies. The process provides credit for the pharmacy 

to use for future purchases, so this system is utilized 

Army wide. The contractor will take opened, unopened, 

expired, unexpired, uncontrolled, and controlled pharmaceuticals from animal and patient care. The dilemma, 

as indicated earlier, is that some pharmaceuticals are a 

HW upon disposal. Colorado, Connecticut, California, 

Kansas, Kentucky (except for Ireland Army Community 

Hospital), Missouri, New Mexico, New York, Oklahoma, South Carolina, and West Virginia will not allow a 

pharmacy to return expired or unusable (such as opened 

containers) HW pharmaceuticals through the reverse 

distributor. These states require HW pharmaceuticals 

to be managed and disposed of from the site they were 

deemed nonusable.

We cannot forget that we have installations and bases 

overseas. Although host nation environmental agencies 

do not have the jurisdiction to impose penalties like the 

EPA, requirements exist overseas., In those locations 

where the US military is well-established, requirements 

are published in Final Governing Standards. These exist for Germany, Korea, and Kuwait, for example. Final Governing Standards are a consolidation of status 

of forces agreements, host nation laws, and DoD Publication 4715.05-G.

9

 These differ from US requirements, 

but not significantly. In the absence of Final Governing 

Standards, personnel follow DoD Regulation DoD Publication 4715.05-G.

The Joint Commission

The 2014 Joint Commission EC Standard EC.01.01.01 

EP110 requires a hospital to have “a written plan for managing the following: Hazardous Materials and Wastes.” 

The Standard EC.02.02.0110 requires the hospital to:

maintain a written, current inventory of hazardous materials and waste that it uses, stores, or generates. The only 

materials that need to be included on the inventory are 

those for which handling, use and storage are addressed 

by law and regulation.

Compliance with environmental laws is required for 

conformance with The Joint Commission. Most hospitals have an Environment of Care Committee, a team of 

personnel that performs internal audits for conformance 

with the Environment of Care Standard. Personnel conducting a review of a waste management program will 

be successful only if they have adequate training. On 

many occasions, the knowledge of personnel assessing 

the hazardous material and waste programs is limited 

to hazardous material requirements of the Occupational 

Safety and Health Act (Pub L 91-596, 84 Stat (1970)). 

There are several ways to remedy this. The AIPH provides an online waste management course that includes 

training on the EPA waste management requirements as 

they relate to patient care. The USAPHC Regions provide training to hospital personnel during assistance visits provided for the ESEO. Local classes are often mandated by the installation. Although those classes normally do not cover hospital wastes and commonly focus 

on maintenance activities of field units, they are useful 

to understand local procedures for waste management.

Relevant Army Regulations

Army Regulation 200-111 directs compliance with environmental legal mandates. Installation tenants are required to comply with federal, state, and local laws as 

well as installation policies.

Army Regulation 40-6112 assigns operational responsibility for waste collection and disposal to the MEDDAC’s 

chief of logistics. The ESEO acts as the principal advisor for the waste management program per Army Regulation 40-11.

13 In most cases, the ESEO is not trained 

for this responsibility. Therefore, MEDCOM has tasked 

ENVIRONMENTAL REQUIREMENTS RELATED TO PATIENT CARE AND

THE TEAM WORKING TO ENSURE COMPLIANCE
January – March 2015 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

AIPH, through the USAPHC Regions, to provide on-site 

assistance to ESEOs. Each region provides such assistance to each MEDDAC ESEO within 6 months of the 

ESEO’s arrival. This process is part of the framework 

established to help the facility avoid potential liabilities 

from noncompliance.

Internal and External Inspections

A variety of inspection programs internal to the Army, 

installation, or MEDDAC exists to ensure that hospitals 

maintain compliance. The inspections, led by MEDCOM assets, include the Organizational Inspection Program conducted by regional medical commands, and 

Table 3. Civil Penalties Incurred by Federal Facilities for Violations of EPA Rules and Regulations.

Agency/Installation 

Type

Year Description Actual Penalty:

Settlement Agreement

Joint Army/Air Force 

Installation14 2013 Failure to: 

•	 conduct weekly inspections of HW facilities and containers for 

leakage or deterioration 

•	 ensure staff participation in annual HW management training 

•	 submit HW tracking reports

$21,000

Air Force Base15 2012 Improper labeling to clearly identify HW, improper management of 

fluorescent lamps containing mercury, and failure to:

•	 determine if a waste was hazardous 

•	 have adequate training plan in place for facility workers handling HW 

•	 conduct regular inspections of HW containers 

$45,700: Make improvements to 

standard operating procedures 

and management controls to 

comply with federal hazardous 

waste laws.

Army Installation16 2011 Failure to:

•	 have adequate release detection with respect to piping associated with underground storage tanks

•	 operate an incinerator at adequate temperatures

•	 maintain adequate service records regarding appliances containing 50 or more pounds of ozone depleting refrigerants

$33,000: Agreement to purchase 

environmental friendly refrigerants for $310,000.

VA Medical Center17 2011 Improper disposal of hazardous waste through the biological waste 

system and failure to:

•	 make HW determinations

•	 inspect, label, date, and close HW containers

•	 make arrangements with emergency responders for spill 

response support

•	 label used oil containers

$18,000: Agreement to spend 

$62,000 to erect an HW accumulation building.

VA Medical Center18 2009 Unlawful shipping of HW, unpermitted on-site incineration of HW, 

and failure to:

•	 perform proper HW determinations

•	 properly manage HW satellite accumulation containers

•	 keep proper emergency information posted near telephones

•	 conduct weekly inspections of HW storage areas

•	 make proper advance arrangements with local fire and police 

departments and other emergency responders for responding 

to emergencies

•	 develop a proper emergency contingency plan

•	 document a personnel training plan

•	 store incompatible wastes without proper segregation

$52,000: $482,000 to develop and 

implement a program to properly 

manager pharmaceutical and 

chemical wastes.

Army Installation19 2009 Accumulated hazardous waste in an area with a floor drain without 

taking measures to prevent a leak or spill, and failure to:

•	 determine whether numerous containers held HW

•	 properly label HW containers

$89,500

Coast Guard20 2008 For operating a hazardous waste storage facility without a permit or 

interim status and failure to label universal waste batteries.

$9,280: $89,290 to purchase a 

new digital x-ray machine for its 

dental clinic.

VA Hospital21 2008 For:

•	 storage of HW without a permit

•	 open containers

•	 inadequate facility maintenance

•	 ignitable waste within 50 ft of property line

•	 failure to make a HW determination

$32,500

Army Medical 

Center22 1999 For improperly storing laboratory chemicals without a permit, and failure to notify the EPA prior to receiving a shipment of hazardous 

waste from a US Army facility in Thailand

$50,400: Agreement to complete a 

$1.6 million project to purchase 

and implement a hazardous material management system.
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

the Command Logistics Review Program conducted by 

MEDCOM Logistics and augmented by AIPH, which 

reviews the waste management program. The installation’s DPW Environmental Division normally has personnel who inspect units and tenants. Some installation 

DPW programs inspect weekly, others annually. Another type of internal inspection is the Army Environmental Command Environmental Performance Assessment 

System (EPAS) which audits the entire installation, including tenant organizations. An installation undergoes 

an EPAS audit every 2 to 3 years.

Inspections external to the Army include EPA and state 

inspections. These agencies can impose notices of violations upon the installation that can result in civil or 

criminal penalties. A listing of violations resulting in 

civil penalties is provided in Table 3. The funds to pay 

these penalties do not come from the environmental 

funds managed by the ESEO. The penalties are paid for 

by the hospital’s operating costs, and payment means 

less money for patient care.

Thankfully, Army MEDDACs have not received a fine 

since 1998. This is comforting because in the past 3 

years, Walgreen’s, Target, Walmart, and CVS Pharmacy, 

paid fines ranging from $800,000 to $22.5 million due 

to failure to implement successful compliance programs, 

such as those in the Army.23

The Waste Management Assistance Visit

Within 6 months of an ESEO’s arrival, USAPHC Region personnel provide a Waste Management Assistance Visit (WMAV). The visit introduces the ESEO 

to key personnel of the MEDDAC and installation environmental programs (MEDDAC logistics, DPW HW 

manager, The Joint Commission team, resource management), provides formal training, assists with a facility walk-through with the ESEO, reviews EPR funding, coordinates waste analysis if necessary, etc. The 

walk-through identifies instances of noncompliance, but 

rather than reporting them to a higher echelon, they are 

used as training aids to teach the ESEO to implement 

corrective actions based on root causes. If the root cause 

is systemic, AIPH will engage MEDCOM for a solution. 

The entire process works to help the hospital attain and 

maintain compliance.

The USAPHC Region personnel coordinate formal 

training opportunities, based on the patient care area/

activity prior to the site visit which include state and local regulations, and are catered to personnel. Examples 

of classes USAPHC Regions provide: Waste Characterization and Management in the Laboratory, Pharmaceutical Waste Management, Environmental Requirements 

of Joint Commission, and Environmental Liabilities for 

Commanders and Chiefs.

The assistance team also ensures required waste analysis is completed. All of this provides an effective assistance visit that equips the ESEO to oversee the program 

and ensures they are introduced to the key players so 

they may work as a team. The program allows the ESEOs to have direct contact with the respective USAPHC 

Region, which provide support during their tenure as 

a MEDDAC ESEO. Compliance is not always simple 

or straightforward. All parties involved fully support MEDCOM’s efforts in the area of environmental 

stewardship.

Conclusion

Patient care encompasses a wide variety of processes 

and procedures regulated by a variety of federal, state, 

local, and host nation requirements. Although these requirements are in place to ensure the health of people 

and their environment, they can be challenging to understand. The ESEO, with the help of the WMAV, is 

trained to assist MTF personnel to comply with these 

requirements. In turn, the ESEO can, at any time, contact the USAPHCR Region for support.

References

1. US Army Public Health Command. Environmental Health Portfolio [internet]. 2014. Command 

Information Sheet CIS-011. Available at: http://

phc.amedd.army.mil/Documents/USAPHC_CIS011_EHE.pdf. Accessed November 19, 2014.

2. US Food and Drug Administration, Office of In 

Vitro Diagnostics and Radiological Health. ThinPrep 2000 System PMA P950039. Decision Date 

October 8, 1997. Retrieved from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.

cfm?id=6530.

3. Resource Conservation and Recovery Act, 42 USC 

§6901 et seq (1976).

4. Clean Water Act, 33 USC §1251 et seq (1972)

5. Hazardous and Solid Wastes Amendments of 1984, 

Pub L 98-616, 98 Stat 3224 (1984).

6. US Environmental Protection Agency. Resource 

Conservation and Recovery Act. US EPA Website. 

Available at: http://www.epa.gov/agriculture/lrca.

html. Accessed November 20, 2014.

7. Fort Wainwright Reduces water contamination risk 

from fuel tanks in EPA settlement [press release]. 

Washington, DC: US Environmental Protection 

Agency; July 2, 2014. Available at: http://www2.

epa.gov/newsroom/news-releases. Accessed November 26, 2014.

ENVIRONMENTAL REQUIREMENTS RELATED TO PATIENT CARE AND

THE TEAM WORKING TO ENSURE COMPLIANCE
January – March 2015 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

8. Army Regulation 40-3: Medical, Dental, and Veterinary Care. Washington, DC: US Dept of the 

Army; 2013.

9. US Department of Defense. Overseas Environmental Baseline Guidance Document: DoD 4715.05-G. 

Washington, DC; US Dept of Defense: 2013.

10. The Joint Commission. 2014 Comprehensive Accreditation Manual for Hospitals. Oak Brook, IL: 

The Joint Commission; 2014.

11. Army Regulation 200-1: Environmental Protection 

and Enhancement. Washington, DC: US Dept of 

the Army; 2007.

12. Army Regulation 40-61: Medical Logistics Policies. 

Washington, DC: US Dept of the Army; 2005.

13. Army Regulation 40-5: Preventive Medicine. Washington, DC: US Dept of the Army; 2007.

14. Joint Base Elmendorf-Richardson settles with EPA 

for hazardous waste law violations [press release]. 

Washington, DC: US Environmental Protection 

Agency; September 18, 2013. Available at: http://

www2.epa.gov/newsroom/news-releases. Accessed November 26, 2014.

15. Eielson Air Force Base near Fairbanks mismanaged hazardous waste and failed to maintain adequate training plan for personnel handling waste 

[press release]. Washington, DC: US Environmental Protection Agency; March 13, 2012. Available 

at: http://www2.epa.gov/newsroom/news-releases. 

Accessed November 26, 2014.

16. Fort Belvoir to pay civil penalty for environmental violations [press release]. Washington, DC: 

US Environmental Protection Agency; September 

14, 2011. Available at: http://www2.epa.gov/news

room/news-releases. Accessed November 26, 2014.

17. Veterans Administration Medical Center in Wichita, Kan., to pay $17,979 civil penalty to settle hazardous waste issues [press release]. Washington, 

DC: US Environmental Protection Agency; July 

26, 2011. Available at: http://www2.epa.gov/news

room/news-releases. Accessed November 26, 2014.

18. VA hospitals in Leavenworth and Topeka, Kan., 

agree to pay civil penalty and implement plan to 

manage hazardous wastes [press release]. Washington, DC: US Environmental Protection Agency; 

August 18, 2009. Available at: http://www2.epa.

gov/newsroom/news-releases. Accessed November 

26, 2014.

19. Army research facility agrees to pay penalty for 

hazardous waste violations [press release]. Washington, DC: US Environmental Protection Agency; 

May 28, 2009. Available at: http://www2.epa.gov/

newsroom/news-releases. Accessed November 26, 

2014.

20. EPA and the Coast Guard settle hazardous waste 

violations at Portsmouth, Va. facility [press release]. Washington, DC: US Environmental Protection Agency; October 8, 2008. Available at: 

http://www2.epa.gov/newsroom/news-releases. 

Accessed November 26, 2014.

21. US EPA enforcement prompts VA medical center 

to make changes Palo Alto Veterans Affairs Medical Center corrects federal environmental violations [press release]. Washington, DC: US Environmental Protection Agency; September 9, 2008. 

Available at: http://www2.epa.gov/newsroom/

news-releases. Accessed November 26, 2014.

22. Army settles EPA complaints over waste storage 

at Walter Reed Hospital and Fort Belvoir [press release]. Washington, DC: US Environmental Protection Agency; August 30, 1999. Available at: http://

yosemite.epa.gov/r3/press.nsf/7f3f954af9cce39b88

2563fd0063a09c/f55cfd374f93b31085256a07006b7

35b!OpenDocument.

23. Berlin SR. EPA is hitting retail stores for hazardous waste violations. Kilpatrick Townsend 

Legal Alert [online serial]. June 11, 2013. Available at: http://www.kilpatricktownsend.com/en/

Knowledge_Center/Alerts_and_Podcasts/Legal_

Alerts/2013/06/EPA_is_Hitting_Retail_Stores_

for_Hazardous_Waste_Violations.aspx. Accessed 

November 20, 2014.

Author

Ms Roberts is an Environmental Scientist in the Environmental Health Engineering Division, US Army Public Health Command Region-West, Joint Base LewisMcChord, Washington.
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

For many years, splash pads have been constructed all 

over the world and are growing in popularity in the 

Unites States as a fun, economical way to entertain 

children and adults. There are an estimated 1,200 water 

parks in North America and about 720 in other countries around the world. In North America alone, water 

park attendance for 2012 was estimated to be approximately 85 million people, with an anticipated annual attendance growth rate of 3% to 5%.1

A splash pad is a recreational play structure that sprays 

treated or recycled water above the ground and is independently operated from another recreational water 

facility such as a pool.2 Splash pads are also referred to 

as recreational spray parks, spraygrounds, spray pads, 

splash pads, spray pools, water parks, splash deck, interactive fountains, and wet decks (Figure 1).

Medical Concerns

A splash pads features equipment that is designed to 

spray or splash patrons with water that then flows into a 

drain and is either filtered, disinfected, and recirculated 

through the spray feature or discharged into a wastewater system. A major advantage inherent in the design of 

splash pads is the elimination of standing water, which 

significantly reduces the risk of drowning. In the United 

States, drowning is the number one cause of injury related death in children aged 1 to 4 years.3

Despite the very low risk of drowning and seemingly 

benign nature of these parks, there remains a very real 

public health risk from bacteriological infections. Splash 

pads have the potential to become a breeding ground 

for communicable diseases due to 3 problems: poorly or 

inadequately disinfected water sources, poorly or inadequately disinfected skin contact surfaces, and poorly 

designed and engineered park structures.

Since 1978, the Centers for Disease Control and Prevention (CDC), the US Environmental Protection Agency, 

and the Council of State and Territorial Epidemiologists 

have maintained the Waterborne Disease and Outbreak 

Surveillance System (WBDOSS) for the collection of 

waterborne disease outbreak (WBDO) information associated with recreational water activities. When a WBDO 

is suspected, the state and local public health departments are expected to investigate it and voluntarily provide this data to the CDC for inclusion in the WBDOSS.1

Outbreaks at splash pads are the result of nonhygienic 

behaviors which contaminate the surrounding water. Patrons ingest the contaminated water and illness can ensue if the infective dose is high enough. Common nonhygienic behaviors include exposing buttocks to splash 

features, drinking water directly from a splash feature, 

Preventive Medicine Oversight of

 Splash Pads on Military Installations

Lisa Raysby Hardcastle, PE

MAJ Matthew Perry, MS, USA

CPT Ashley Browne, MS, USA

Abstract

Over the past several years, an increasing number of military installations have installed splash pads that provide fun, recreational water entertainment for Soldiers and their families. The addition of splash pads brings 

added responsibilities for medical treatment facility preventive medicine oversight and installation facilities 

maintenance to ensure a safe and healthy environment. Currently, there are no consistent standards or detailed 

guidance for military installations to follow when installing and maintaining splash pads. The central issues 

associated with splash pads on military installations are water quality and risk for waterborne illnesses, responsibility for safety and health oversight, and federal energy and water sustainability mandates. This article 

examines the importance of implementing a standard for design and oversight to ensure the health and safety 

of Soldiers and their families.

Figure 1. A typical splash pad layout.
January – March 2015 33

not showering prior to using the splash pad, and allowing diapered children to sit in the water puddles that other children then intentionally or inadvertently ingest.4

From 1995 to 2004, exposure to recreational water in 

the United States resulted in more than 255 WBDOs, 

18,500 illnesses, and 24 deaths. Seventy-six of the 255 

WBDOs were linked to treated water venues (pools, 

spas, hot tubs), with cryptosporidiosis being responsible 

for 61.8% of the illnesses.5 During this same time period, there were 6 outbreaks linked to recreational use 

of splash pads. Shigella infection resulted in 3 of the 

outbreaks, Cryptosporidium caused 2 outbreaks, and a 

coinfection of both Cryptosporidium and Shigella was 

the cause of one outbreak.

Data collected from the WBDOSS from 2005 to 2006 

indicated a total of 78 WBDOs, resulting in 4,412 illnesses, 116 hospitalizations, and 5 deaths. Three-quarters of the outbreaks (58 of the 78) occurred at treated 

water venues. Gastroenteritis was associated with 48 

outbreaks and accounted for 4,015 of the 4,412 total reported illnesses. Of the 48 gastrointestinal outbreaks, 

Cryptosporidium was associated with 31 outbreaks, and 

all but 2 of these outbreaks were related to treated water.1

In 2005, the state of New York reported a massive outbreak associated with the use of splash pads.6

 This event 

resulted in more than 3,000 people reporting as ill from 

their exposure to the water fountain and at least 425 confirmed cases of Cryptosporidium hominis. Although the 

interactive fountain water was filtered and chlorinated, it 

was determined that the residual chlorine level was inadequate to inactivate Cryptosporidium in the water holding tanks. This outbreak likely occurred as a result of fecal contamination of the water by an infected individual.

In 2006, an outbreak of gastroenteritis was epidemiologically linked to a splash pad in Orange County, Florida.5

 Forty-nine individuals became ill from infections 

caused by Cryptosporidium (9 cases), and Giardia (38 

cases). Two individuals were found to have a coinfection with both Cryptosporidium and Giardia. Multiple 

breaches of proper sanitation which resulted in several 

contamination incidents were identified. The cause of 

the outbreak could not be determined conclusively, but 

is presumed to have been from asymptomatic carrier(s).

In 2007, an outbreak of cryptosporidiosis occurred from 

a municipal splash pad in Idaho, sickening 50 people.7

Samples from the splash feature’s sand filters and nearby drinking water fountains identified C hominis in both 

water sources. The initial cause of this outbreak was assumed to be from an ill patron that frequented the park 

and the subsequent illnesses were due to the ingestion of 

the fecally contaminated splash features and drinking 

water. It was also determined that the 2 drinking water 

fountains that shared a water line with the splash pad 

had faulty backflow prevention devices that may have 

led to the contamination of the drinking water and further contributed to the number of sick people.

From 2009 and 2010, the WBDOSS identified 81 recreational water-associated disease outbreaks from 28 

states and Puerto Rico. These outbreaks resulted in 

more than 1,326 illnesses and 62 hospitalizations. Of the 

81 total outbreaks, there were 57 outbreaks associated 

with treated recreational water venues and 24 associated 

with untreated recreational water venues (lakes, oceans). 

Of the 57 treated water recreational water venues, 24 

were caused by Cryptosporidium.

8

 Large outbreaks are 

more frequently seen in the summer months and are 

usually due to problems maintaining proper water quality, structural design, improper usage, and inadequate 

facility maintenance.1

These examples demonstrate why Cryptosporidium has 

become the leading concern for outbreaks of gastrointestinal illness associated with disinfected recreational 

water venues6 (Figure 2). The number of confirmed 

cryptosporidiosis cases each year in the United States is 

approximately 748,000, with an estimated annual health 

care cost of $45.8 million.8

The features of Cryptosporidium that make it so menacing are its high resistance to normal water disinfection 

concentrations, its small size, its low infective dose, the 

high number of oocysts that are shed, and the extended 

duration of time that they can be shed.8 Shedding of the 

parasites begins at the onset of symptoms and may continue for weeks after the illness stops. Infection spreads 

by ingestion of the parasite. The incubation period averages 2 to 10 days and the illness usually lasts 1 to 2 

weeks. Although an infection can be asymptomatic (no 

symptoms), typical signs and symptoms of infection are 

stomach cramps and pain, dehydration, nausea, vomiting, fever, weight loss, headache, joint pain, and profuse 

diarrhea. Young children, pregnant women, and individuals who are immune deficient have a higher chance 

of contracting cryptosporidiosis and may suffer more 

severe symptoms.8

Military Regulations and Guidance

Technical Bulletin MED 5752 governs splash pads on all 

military installations. However, it only regulates splash 

pads designed to recirculate water. In addition, TB MED 

575 does not include guidance specifying who on an installation has operation and maintenance oversight of 
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

Figure 2. Recreational water-associated outbreaks of gastroenteritis, by type of exposure and etiology–United States, 2001-

2010. Data from CDC (http://www.cdc.gov/healthywater/surveillance/recreational/figures.html).

*Other includes outbreaks caused by Salmonella, Campylobacter, Plesiomonas, cyanobacterial toxin(s), or multiple etiologies.

†Sum of percentages does not total 100.0% due to rounding.

Unidentified

19.0%

Cryptosporidium spp

15.9%

Norovirus

19.0%

E coli 15.9%

Other* 12.7%

G intestinalis 3.2%

Shigella spp 14.3%

Etiology: Untreated Water (n=63)

Unidentified 7.0%

Cryptosporidium spp 76.2%

Norovirus 4.7%

E coli 2.3%

Other* 2.3%

G intestinalis 3.5%

Shigella spp 4.1%

Etiology: Treated Water (n=172)†

Unidentified 10.2%

Cryptosporidium spp

60.0%

Norovirus 8.5%

E coli 6.0%

Shigella spp 6.8%

Other* 5.1%

G intestinalis 3.4%

Etiology: (N=235)

Treated water 73.2%

Untreated water 26.8%

Type of Exposure: (N=235)

splash pads. In response to these shortcomings, the document is currently being updated by the US Army Public Health Command. The proposed updates to TB MED 

575 refer to the Model Aquatic Health Code (MAHC) 3

for information on design, construction, operation, and 

maintenance of recreational facilities not addressed in 

the current version.

The MAHC was developed by CDC through a national partnership approach as a guidance document 

for state and local agencies to use as a model of public 

health standards for swimming pools and other aquatic 

facilities. However, like TB MED 575, the MAHC does 

not address nonrecirculating splash pads. The CDC 

elected to remove language regarding nonrecirculating 

splash pads from the draft MAHC. Based on comments 

received from the public, primarily through local governments, the general concern with nonrecirculating 

splash pads appeared to be economic.3

In addition to TB MED 575 and the MACH, military 

installations must comply with Executive Order 131239

when installing splash pads. Under that order, military 

installations will reduce water consumption and energy 

PREVENTIVE MEDICINE OVERSIGHT OF SPLASH PADS ON MILITARY INSTALLATIONS
January – March 2015 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

use throughout the installation to reach goals established by the installation. Under the Army’s Net Zero 

initiative, Army installations are focused on limiting 

use of freshwater resources and returning water to the 

same watershed in an effort to preserve the ground and 

surface water resources.10

Generally, most designs for military installation buildings and facilities are based on Department of Defense 

(DoD) Unified Facilities Criteria:

Unified Facilities Criteria documents provide plan- ning, design, construction, sustainment, restoration, 

and modernization criteria.11

Unfortunately, design, operation, and maintenance documents containing specific guidance have not been created for recirculating and nonrecirculating splash pads.11

Design Recommendations

In order to limit the occurrence of waterborne illnesses 

and ensure the health and safety of Soldiers and families, 

military installations should follow the following design 

recommendations:

` Use the best available water source.

` Use and maintain the best available technology for 

water treatment.

` Consider energy and water sustainability measures.

To ensure installations are using the best design recommendations, installation medical treatment facility (MTF) preventive medicine (PM) personnel should 

have oversight of the design of the splash pads.

A study by de Man et al12 found that higher concentrations of E coli have been measured at splash parks using 

rainwater or surface water as compared to sites using 

potable water, independent of the routine inspection intervals and disinfection method used. To mitigate such 

risk, Army installations should use potable water. Any 

other alternative sources of water use would be subject 

to applicable state law.

Untreated or inadequately treated water at splash parks 

may allow waterborne pathogenic organisms to survive and infect users. Best available technology water 

treatment can remove and/or destroy these organisms. 

For example, while cryptosporidium cysts are resistant 

to chlorine, ultraviolet (UV) is an effective best available technology. Recirculating splash pads should have 

treatment that includes pH adjustment, filtration (sand 

or cartridge), UV, and chlorination. Water treatment 

systems should be Underwriter Laboratories Listed 

and incorporate chemicals listed by NSF International 

(NSF)/American National Standards Institute (ANSI) 

Standard 60, and NSF/ANSI Standard 61 components or 

equipment in contact with potable water.13,14 Nonrecirculating facilities should consider booster chlorination 

when the background level of free available chlorine 

from the public water system is not to recreational water standards. Higher levels of disinfectant will sanitize 

the splash pad which is often used interactively by the 

youngest, highest at-risk population. Highly chlorinated 

water may require dechlorination before discharge to 

sanitary sewers or to a stormwater detention ponds in 

accordance with local and/or state governing authorities. Not properly maintaining or using water treatment 

equipment in accordance with standard or standing operating procedures and/or manufacturer’s specifications 

can result in waterborne illness outbreaks, such as the 

outbreaks in New York in 200515 and Idaho in 2007.7

Health considerations and safety practices must be incorporated into the design during planning of a splash 

pad on an installation. To that end, it is important to 

seek advice from representatives of the installation PM 

staff. When feasible, planners will also include morale, 

welfare, and recreation representatives during concept 

discussions and planning charrettes. In addition to ensuring that splash pad designs take into account health 

and safety concerns, installation planners should consider energy and water conservation measures.16

In accordance with multiple Army requirements, MTF 

PM personnel provide technical assistance and support 

on the requirements and methods of water conservation.17 Recirculating systems use more energy at the facility (for booster pumping), but conserve more water 

overall than one-use, pass-through potable water splash 

parks. They also eliminate the extra energy cost of supplying more water to a nonrecirculating system. Variable frequency drive pumps are typically more energy 

efficient than standard pumps and should be included 

as a design element, even though the initial cost may 

be higher. Also, instead of dumping filter backwash and 

underground recycle water from recirculating systems, 

the installation could further conserve overall water use 

by collecting, storing, and pumping such water to irrigation systems. Some states have reuse standards which 

must be satisfied before reclaimed water can be used. 

Overall, when possible, all splash pads should be recirculating to conserve water in accordance with federal 

executive orders and water conservation mandates of 

DoD and the Department of the Army.

Best Management Practice Recommendations

After design and construction, military installations 

should properly operate and maintain the facility, 

conduct baseline audits and routine inspections, and 
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

perform quality assurance monitoring to ensure Soldiers and families continue to enjoy splash pads without risk of illness. The installation MTF PM personnel 

should continue to have oversight on splash pads after 

construction to ensure such best management practices 

are employed and health risks are minimized.

The health and safety of children using splash pads depends largely on the operation, maintenance, and inspection of the facility. It is important that trained personnel 

such as lifeguards and pool operators who are responsible for the water play areas understand their role in protecting child health and safety. The personnel responsible for the splash pads should be trained to conduct 

inspections and how to handle contamination by bodily 

fluids, especially blood, excrement, and vomitus. Preventive medicine personnel should assess environmental and public health planning considerations, including 

but not limited to capacity (number of children allowed 

per square foot), daily water use, chemical requirements, 

seating, shade, drinking fountains, restroom and diaper 

changing access, foot and body showers, signage, trash 

receptacles, and safety and security concerns.

It is important that all installation organizations involved 

in oversight of splash pads, including but not limited to 

the directorate of public works; installation safety office; morale, welfare, and recreation; installation housing; and MTF PM personnel, have a clear understanding 

of inspection and maintenance program procedures and 

requirements, including child safety requirements in the 

outdoor play area. Water quality monitoring and maintenance of water treatment equipment is essential. Without clear guidance and current regulations, installations 

should follow the same procedures for sanitary control 

and operation of other recreational facilities outlined in 

Army Regulation 420-1,

18 Technical Manual 5-662,19 and 

Technical Bulletin MED 575.

2

Unfortunately, splash pads are not often inspected by 

state or local health authorities or MTF PM personnel. 

An inspection program is necessary to identify hazards 

and ensure deficiencies are corrected. The MTF personnel should perform preopening, annual, baseline, and 

routine sanitary inspections on all splash pads, recirculating and nonrecirculating, located on the installation, 

whether or not the state or local health authorities perform inspections. Nonrecirculated pools are typically 

unregulated and therefore not included in any sanitary 

inspection. They are also more likely to be operated by 

untrained personnel. Although risk for illness appears 

to be greatest at recirculated treated systems, safety 

and health issues could quickly become a rapidly escalating public health problem if personnel operating 

nonrecirculated splash parks do not handle incidents 

of animal or human bodily fluid contamination appropriately. Therefore, sanitary inspections should also include nonrecirculating splash parks. Further, the draft 

update to Technical Bulletin MED 5752 assigns to MTF 

PM the responsibility to ensure state and/or local public health jurisdictions are aware of and have access to 

privately owned water recreational facilities and/or public natural swim areas. It should be reemphasized that 

state and local health authorities do not always come 

onto military installations to conduct these inspections, 

making it even more important that MTF PM personnel 

conduct the sanitary inspections on a regular basis.

Children will inadvertently or intentionally drink water 

emitted from water features at a splash pad. Water quality records should be regularly reviewed by MTF PM 

who should also perform quality assurance sampling representative of the quality of water coming from the water 

features, including pH, free available chlorine, presence/

absence of coliform, and heterotrophic plate count. Particularly in the case of recirculating systems, heterotrophic plate count monitoring can be used as a tool to optimize treatment and ensure water use efficiency.

Army regulations and guidance are currently available 

or being updated to address recirculating splash pads. 

However, there is still no regulation or guidance that 

addresses nonrecirculating splash pads. While nonrecirculating splash pads may inherently be less of a risk 

for contamination, there is still a risk of contamination 

because individuals responsible for the facility may be 

untrained in sanitation practices when a contamination 

event occurs (ie, blood, fecal). Furthermore, nonrecirculating splash pads, even if less costly to maintain, are not 

in compliance with Federal, DoD, and Department of 

the Army mandates to conserve water. To ensure installations are properly maintaining the correct operations 

and maintenance of already existing recirculating and 

nonrecirculating splash pads, there must be clear regulation and guidance standards. The MTF PM personnel 

should be involved with the installation planners on the 

design of all splash pads and continue to maintain oversight of the splash pads during operations to ensure the 

health and safety of Soldiers and their families.

References

1. Yoder JS, Hlavsa MC, Craun GF, et al. Surveillance 

for waterborne disease and outbreaks associated 

with recreational water use and other aquatic facility-associated health events-United States, 2005-

2006. MMWR Surveill Summ. 2008;57(9):1-29. 

Available at: http://www.cdc.gov/mmwr/preview/

mmwrhtml/ss5709a1.htm. Accessed 11/18/2014.

PREVENTIVE MEDICINE OVERSIGHT OF SPLASH PADS ON MILITARY INSTALLATIONS
January – March 2015 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

2. Technical Bulletin Medical 575: Occupational and 

Environmental Health Recreational Water Facilities. Washington, DC: US Dept of the Army; 1993.

3. Centers for Disease Control and Prevention. Model 

Aquatic Health Code [internet]. August 29, 2014. 

Available at: http://www.cdc.gov/healthywater/

swimming/pools/mahc/structure-content/index.

html. Accessed November 18, 2014.

4. Nett RJ, Toblin R, Sheehan A, Huang WT, Baughman A, Carter K. Nonhygienic behavior, knowledge, and attitudes among interactive splash park 

visitors. J Environ Health, 2010;73(4):8-14.

5. Eisenstein L, Bodager D, Ginzl D. Outbreak of 

giardiasis and cryptosporidiosis associated with a 

neighborhood interactive water fountain--Florida, 

2006. J Environ Health. 2008;71(3):18-22.

6. Yoder JS, Beach MJ. Cryptosporidiosis surveillance–United States, 2003-2005. MMWR Surveill 

Summ. 2007;56(7):1-10. Available at: http://www.

cdc.gov/mmwr/preview/mmwrhtml/ss5607a1.htm. 

Accessed November 18, 2014.

7. Centers for Disease Control and Prevention. Outbreak of cryptosporidiosis associated with a splash 

park---Idaho, 2007. MMWR Morb Mortal Wkly 

Rep. 2009;58(22);615-618.

8. Yoder JS, Wallace RM, Collier SA, Beach MJ, 

Hlavsa MC. Cryptosporidiosis surveillance-United 

States, 2009-2010. MMWR Morb Mortal Wkly Rep. 

2012;61(NSS05):1-12.

9. Executive Order 13123: Greening the Government 

through Efficient Energy Management, 64 Federal 

Register 109 (1999). Available at: http://www.gpo.

gov/fdsys/pkg/FR-1999-06-08/pdf/99-14633.pdf. 

Accessed August 27, 2014.

10. US Department of the Army. Net Zero: A Force 

Multiplier [internet]. December 15, 2010. Available 

at: http://www.asaie.army.mil/Public/IE/netzero_

info.html. Accessed June 10, 2014.

11. National Institute of Building Sciences. Whole 

Building Design Guide [internet]. 2014. Available 

at: http://www.wbdg.org/ccb/browse_cat.php?c=4. 

Accessed September 22, 2014.

12. de Man H, Leenen EJ, van Knapen F, de Roda Husman AM. Risk factors and monitoring for water 

quality to determine best management practices for 

splash parks. J Water Health. 2014;12(3):399-403.

13. NSF/ANSI Standard 60. NSF Website. 2014. Available at: http://www.nsf.org/services/by-industry/

water-wastewater/water-treatment-chemicals/nsfansi-standard-60/. Accessed September 10, 2014.

14. NSF/ANSI Standard 61. NSF Website. 2014. Available at: http://www.nsf.org/services/by-industry/

water-wastewater/municipal-water-treatment/nsfansi-standard-61/. Accessed September 10, 2014.

15. Centers for Disease Control and Prevention. Water Play Areas & Interactive Fountains [internet]. 

20013. Available at: http://www.cdc.gov/healthy

water/swimming/pools/water-play-areas-interac

tive-fountains.html#one. Accessed September 22, 

2014.

16. United Facilities Criteria (UFC): Installation 

Master Planning. Washington, DC: US Dept of 

Defense; 2012. UFC 2-100-01. Available at: http://

wbdg.org/ccb/DoD/UFC/ufc_2_100_01.pdf. Accessed September 10, 2014.

17. Department of the Army Pamphlet 40-11: Preventive Medicine. Washington, DC: US Dept of the 

Army; 2009. Available at: http://www.apd.army.

mil/pdffiles/p40_11.pdf. Accessed September 10, 

2014.

18. Army Regulation 420-1: Facilities Engineering: 

Army Facilities Management. Washington, DC: US 

Dept of the Army; 2008 (revised 2012):264. Available at: http://www.apd.army.mil/pdffiles/r420_1.

pdf. Accessed November 18, 2014.

19. Technical Manual 5-662: Swimming Pool Operation and Maintenance. Washington, DC: US Dept 

of the Army; 1986:4-1. Available at: http://army

pubs.army.mil/eng/DR_pubs/dr_a/pdf/tm5_662.

pdf. Accessed November 18, 2014.

Authors

Ms Hardcastle is a Supervisory Environmental Engineer 

and Deputy Chief of the Environmental Health Engineering Division, US Army Public Health Command 

Region-West, Joint Base Lewis-McChord, Washington.

MAJ Perry is Chief, Environmental Health Engineering 

Division, US Army Public Health Command RegionWest, Joint Base Lewis-McChord, Washington.

CPT Browne is the Environmental Science Engineering 

Officer-in-Charge, Environmental Health Engineering 

Division, US Army Public Health Command RegionWest, Joint Base Lewis-McChord, Washington.
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

All government-owned Army community 

water systems (CWSs) serving a population larger than 3,300 should be optimizing 

fluoridation, in accordance with Department 

of Defense (DoD) and Department of Army 

directives. Existing privately-owned CWSs 

serving Army installations are instructed to 

fulfill this fluoridation requirement as circumstances allow. All future water utilities must 

meet the fluoridation requirements.1,2

In the Public Health Command Region-West 

(PHCR-West) Area of Responsibility, shown 

in Figure 1, none of the CWSs serving more 

than 3,300 people that adds fluoride does so 

at optimal levels, based on 2013 water quality 

data reported in annual consumer confidence 

reports (CCRs).* However, some CCR data 

appear to be incomplete for CWSs practicing 

fluoridation. Some CCRs do not include annual water treatment plant fluoridation minimum and maximum levels, nor do most include average 

annual value or running annual average value. Evaluation in this article is based solely on CWSs in the PHCRWest Area of Responsibility.

Background

Fluoride is a naturally occurring compound derived 

from fluorine. It is found in rocks, soil, and both fresh 

and ocean water. Though a nonessential nutrient in the 

human diet, fluoride is present in varying levels naturally in almost all foods and beverages (Figure 2). It 

is a tasteless, odorless, and colorless element added to 

drinking water to protect the public from dental caries 

(cavities), although some areas in the United States and 

other countries naturally have high levels of fluoride.3

Some communities in the United States and some countries have elected not to fluoridate CWS supplies. In the 

last few years, Portland, Oregon, and Wichita, Kansas, have rejected fluoridation.4,5 This past August, Israel stopped mass fluoridating its drinking water due 

to potential health concerns.6 There are also a number 

of alternative fluoridation practices that are practiced 

whether or not CWSs are fluoridated, including medical supplementation and dental treatments. For example, 

some countries have introduced fluoridated edible salt 

which is conceptually similar to iodized salt.6,7

The US Public Health Service and the Centers for Disease Control and Prevention (CDC) began, in 1945 and 

1975 respectively, tracking the number of persons in the 

United States receiving fluoridated water. According to 

the CDC, in 2012 approximately 79.6% of the US population, or a total of 210,655,401 people, had access to fluoridated water.8

 Water systems that add fluoride to their 

potable water supply are regulated by the Safe Drinking 

Fluoridating Army Community Water Systems

 in the US Army Public Health Command

 Region-West Area of Responsibility

Lisa Raysby Hardcastle, PE

CPT Ashley Browne, MS, USA

1LT Charles Pham, MS, USA

*Federal regulation requires public water suppliers that serve the same people year-round (community water systems) to provide consumer confidence reports to their customers by July 1 annually. These reports summarize information regarding sources used (rivers, 

lakes, reservoirs, aquifers), any detected contaminants, and compliance and educational information.

PHCD Ft Carson

PHCD JBLM

Region HQ

District HQ

PHCD San Diego

PHCD San Diego

PHCD Ft Carson

PHCR West

PHCD JBLM

Figure 1. Map illustrating the US Army Public Health Command RegionWest Area of Responsibility and its 3 districts. Note: PHCR indicates Public 

Health Command Region; PHCD indicates Public Health Command District; 

JBLM indicates Joint Base Lewis-McChord; HQ indicates headquarters.
January – March 2015 39

Water Act (SDWA) (Pub L No. 93-523, 88 Stat 1660 

(1974)). Fluoride levels in these systems must be monitored daily and reported monthly to state agencies with 

SDWA primacy. The SDWA also requires all CWSs to 

report fluoride levels in the annual CCRs,9 This article 

uses data in these CCRs to analyze compliance with fluoridate level mandates and optimum fluoride guidance.

Benefits and Concerns

Fluoridation of community drinking water is a major 

factor responsible for the decline in dental caries (tooth 

decay) during the second half of the 20th century. The 

history of water fluoridation is a classic example of clinical observation leading to epidemiologic investigation 

and community-based public health intervention. Although other fluoride-containing products are available, 

water fluoridation remains the most equitable and costeffective method of delivering fluoride to all members of 

most communities, regardless of age, educational attainment, or income level.

Centers for Disease Control and Prevention10

Studies have shown that fluoridating water in CWSs, the 

food supply chain, and bottled water can reduce caries in 

nonfluoridated communities. However, there are risks involved in the use of fluoride. A major concern with CWSs 

treating with fluoride is that an intentional misuse or unintentional overfeed can result in consumer overexposure 

to fluoride, and too much fluoride exposure can lead to 

dental fluorosis (mottled teeth), bone loss, and even death 

(Figure 3). Additionally, according to the EPA:

Exposure to excessive consumption of fluoride over a 

lifetime may lead to increased likelihood of bone fractures in adults, and may result in effects on bone leading to pain and tenderness. Children aged 8 years and 

younger exposed to excessive amounts of fluoride have 

an increased chance of developing pits in the tooth enamel, along with a range of cosmetic effects to teeth.”10

Some proponents, including the Fluoride Action Network, Citizens for Safe Drinking Water, and some 

medical and environmental professionals, do not consider fluoridation of drinking water supplies necessary, 

and equate adding fluoride to CWS supplies to be a 

form of mass medication. In 2007, the Fluoride Action 

Network reported more than 4,000 medical and environmental professionals have signed a petition urging 

an end to the fluoridation of CWS.11,12

Furthermore, reports from the CDC and the National 

Research Council indicate fluoride effect is predominantly posteruptive (teeth after surfacing) and topical, 

not systemic.13,14 Several Journal of Public Health Dentistry studies indicate similar findings, namely that the 

benefits of fluoride are topical and that intake has more 

of an effect on dental fluorosis than on preventing 

cavities.15-17 These studies challenge the proponent benefits of fluoride exposure through drinking water.

Despite concerns regarding water fluoridation, the majority of public health officials have concluded that water 

fluoridation at optimal levels is safe and effective. Past US 

Surgeons General have endorsed water fluoridation and 

encourage communities to add fluoride to the optimal 

level for oral health. The American Dental Association, 

the CDC, the American Medical Association, the American Water Works Association, and the World Health Organization, as well as many state and local public health 

agencies, all advocate fluoridation of CWSs.18-20

There is a significant difference between fluoridated and 

nonfluoridated CWS. Fluoridated communities show 

18% to 40% fewer caries among children and nearly 

35% fewer in adults than those living in nonfluoridated 

communities. Also, fluoridation is very cost-effective 

Figure 2. Illustration of the sources of fluoride in the environment, both natural and manmade.

Fluoridated

Water

Supplies

Naturally

Occurring

Fluoride in

Water and the Environment

Pesticides

Containing

Fluoride

Food and

Beverages

Including

Bottled Water Containing

Fluoride

Worker Industrial

Exposure Air

Fluoride Supplements

Toothpaste

and

Mouthwash

Enhanced with

Fluoride

Dental

Fluoride

Treatments (Rinses, Foams,

and/or Resins

or Varnishes

Figure 3. The physiological effects of each of the 3 general levels 

of ingested fluouride: insufficient, optimum, and excessive.

Too Much Fluoride

Sources

of

Fluoride

Dental Caries

(cavities)

Healthy Teeth

and Bones

Skeletal

(bone)

Loss

Death

Other

Potential

Health Issues

(controversial)

Too Little

Fluoride

Optimum Fluoride

Dental

Fluorosis

(mottled teeth)
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

for most large communities. Drinking water costs to 

consumers increase by less than 1% for large CWSs, 

and up to $3.90 a year per person for small communities 

(2004 dollars). Every dollar spent on water fluoridation 

avoids $38 in dental treatment costs.21

CWS Drinking Water Fluoridation Regulations

The EPA and the majority of states do not mandate fluoridation, and fluoridation when practiced is strictly regulated by state and local health departments. Furthermore, 

approval to add fluoride, or make any modification to a 

public water system generally requires state drinking 

water agency approval.

Under the SDWA Amendment of 1986, the EPA set 

a maximum contaminant level goal (MCLG) and a 

maximum contaminant level (MCL) for fluoride at 4.0 

mg/L for drinking water for public water systems. The 

MCLGs are unenforceable health goals, based solely on 

possible health risks and exposure over a lifetime with 

an adequate margin of safety, whereas the MCLs are 

enforceable standards set as close to MCLGs as considered feasible based on factors such as available analytical methods, treatment technologies, and cost. For 

fluoride, the EPA’s MCL equals the MCLG because no 

feasibility factors pose any limitations. States, however, 

may set more restrictive drinking water quality standards. California standards, for example, are more stringent; the public health goal (MCLG) is 1 mg/L and the 

MCL is 2 mg/L.22-24 In addition to the MCL and MCLG, 

the EPA has also set a secondary maximum contaminant level (SMCL) standard of 2.0 mg/L. The level of 

the SMCL for fluoride is based on a balancing of the 

beneficial effects of protection from tooth decay against 

the undesirable effects of excessive exposures leading 

to discoloration.4,25 The federal regulations establishing 

the respective fluoride standards for drinking water are 

shown in Table 1. A variance in treatment may be granted in accordance with 40 CFR §142.6126 if the EPA or 

the appropriate state authority determines the treatment 

method to control fluoride is not “technically appropriate and technically feasible” for a CWS.

For SDWA public notification, a CWS with a source 

that exceeds the fluoride secondary MCL of 2.0 mg/L 

but does not exceed the fluoride primary MCL of 4.0 

mg/L must provide notice in accordance with the form, 

manner, timing, distribution, and content requirements 

of 40 CFR §141.208.30,31 In accordance with 40 CFR 

§141.203(b) under Tier 2 public notice requirements, water suppliers must notify their customers as soon as practical, but no later than 30 days after the system learns of 

the violation.31,32 Fluoride in excess of 4 mg/L is a major 

violation and would require the water supplier to take 

action to reduce fluoride levels below the MCL in addition to the issuance of a Tier 2 public notice in most 

states. In California, a Tier 2 violation occurs when fluoride is in excess of 2 mg/l (California’s MCL).22-24

The regulating authority with primacy must be consulted to determine the appropriate resolution for violations 

that result from fluoridating public water systems operating outside the optimal range. For example, if a water 

system in California operates 0.1 mg/L or more above 

the control range, up to 10.0 mg/L, the water supplier 

must notify the California Department of Public Health 

(CDPH) within 3 business days. If the fluoride overfeed 

exceeds 10.0 mg/L, the water system must notify the 

CDPH by the end of the same business day, or within 24 

hours if the office is closed. Water suppliers must notify 

the consumers, local health departments, pharmacists, 

dentists, and physicians in the area served by the water 

system of the status of fluoridation treatment when fluoridation is suspended and when fluoridation is resumed 

following 90 days of suspension.33

Bottled Water Fluoridation Regulations

Sales of bottled water have nearly tripled in the last decade.34 Many individuals who drink bottled water are 

replacing tap water, either partially or completely, as a 

source of drinking water. And while some bottled waters marketed in the United States contain an optimal 

concentration of fluoride, whether naturally or added, 

not all do. Thus, individuals substituting a bottled water 

source for fluoridated CWS tap water may be receiving 

the full benefits of CWS fluoridation. Additionally, bottled water does not have the same rigorous sampling and 

consumer right-to-know requirements as CWSs.35 This 

is just one of the key differences between SDWA drinking water regulations promulgated by the EPA, and the 

US Food and Drug Administration’s (FDA) Bottled Water Rules.

The EPA and the FDA have a memorandum of agreement, originally signed in 1979, specifying that the 

EPA regulates safe drinking water in accordance with 

the Safe Drinking Water Act, and that the FDA regulates bottled water as a consumer beverage under the 

Food, Drug, and Cosmetic Act (21 USC, Chp 9 §301 et 

Table 1. Federal Safe Drinking Water Act Fluoride 

Drinking Water Standards.

Standard Fluoride Level

(mg/L or ppm)

Regulatory Citation

Secondary MCL 2.0 40 CFR §143.326

MCLG 4.0 40 CFR §141.41(b)27

MCL 4.0 40 CFR §141.62(b)28

MCL indicates maximum contaminant level.

MCLG indicates maximum contaminant level goal.

FLUORIDATING THE ARMY’S COMMUNITY WATER SYSTEMS IN THE US ARMY

PUBLIC HEALTH COMMAND REGION-WEST AREA OF RESPONSIBILITY
January – March 2015 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

seq (1938)).36,37 Water is classified as “bottled water” if 

it meets all applicable federal and state standards, is 

sealed in a sanitary container, is intended for human 

consumption, and has no added ingredients except that 

it may optionally contain safe and suitable antimicrobial 

agents.38

For water bottled in the United States, FDA regulations 

require that fluoride be listed on the label only if the bottler adds fluoride during processing. The concentration 

of fluoride is regulated but does not have to be stated on 

the label. Few bottled water brands have labels listing 

the fluoride concentration. The FDA has approved labeling with the statement, “Drinking fluoridated water may 

reduce the risk of dental caries or tooth decay,” if the 

bottled water contains from 0.6 mg/L to 1.0 mg/L and is 

not for infants.36,39

The allowable values for fluoride added and naturally 

occurring fluoride levels for bottled water are established in 21 CFR §165.11038 and are a function of ambient temperature (Table 2). The FDA standards of quality 

state that domestic bottled water with no added fluoride 

may contain between 1.4 and 2.4 mg/L of fluoride, depending on the annual average daily air temperatures 

at the location where the bottled water is sold, which 

exceeds not only optimal levels, but the SDWA secondary MCL level for fluoride. Domestic bottled water with 

added fluoride may contain between 0.8 and 1.7 mg/L, 

again depending on the annual average daily air temperatures where the bottled water is sold. Imported bottled 

water with no added fluoride may not contain more than 

1.4 mg/L of fluoride, and imported bottled water with 

added fluoride may not contain more than 0.8 mg/L of 

fluoride.39

Military Requirements for CWS Fluoridation

Noting that “the most effective preventive program for 

preventing dental decay is water fluoridation,” a Memorandum from the Assistant Secretary of Defense (Health 

Affairs) dated July 18, 2011, directed all DoD facilities 

operating a water system that serves more than 3,300 

personnel to provide optimal fluoridation and ensure ongoing education for DoD water treatment plant (WTP) 

personnel with appropriate surveillance by state and local health officials.2

 This requirement was reiterated and 

expanded to include both existing and future privatized 

water systems on all DoD installations by a Memorandum from the Under Secretary of Defense (Acquisition, 

Technology, and Logistics) dated March 18, 2013.1 The 

Unified Facilities Criteria 3-230-0340 further emphasizes the fluoridation requirement of DoD water treatment systems serving 3300 people or greater. Treatment 

systems serving fewer people will be considered on a 

case-by-case basis.

Army Regulation 40-3541 requires commanders of US 

Army medical activities and US Army medical centers to provide water quality reports that include fluoride concentration to the dental activities, dental clinic 

commands, or dental unit commander (or designated 

representative) on at least a quarterly basis. The dental 

readiness officer will then interpret the results regards 

to fluoridation treatment on children and adults and provide expert guidance on fluoride practices to health care 

providers, water engineers, and preventive medicine 

personnel. Army Regulation 40-35 also states the condition when the fluoridation of post water supplies should 

occur is when “the level of natural fluoridation is less 

than one-half the optimal concentration for that climate,” 

and “the fluoridation process is otherwise considered 

practical and feasible.”41 When natural fluoridation exceeds acceptable levels, defluoridation measures should 

be considered. Other regulations that mention CWS fluoridation requirements include Army Regulation 40-3,

42

Army Regulation 40-5,

43 and Army Regulation 600-3.44

Specific guidance for preventive medicine (PM) personnel can be found in Department of the Army Pamphlet 

40-11.

45 Accordingly, PM personnel provide drinking 

water medical oversight and technical assistance support to fixed Army installations that produce or purchase 

drinking water from another regulated supplier. Under 

this guidance, when either the initiation or discontinuation of fluoridation is sought, the action should receive 

approval from the functional proponent for PM. Preventive medicine responsibilities include review and recommendations for concentration and type for any chemical 

additive, including fluoride, to a potable water system.

Table 2. Bottled Water Maximum Fluouride Content (based 

on where the bottled water is sold).

Annual Average of

Maximum Daily

Air Temperature (°F)

No Fluoride

Added

(mg/L or ppm)

Fluoride Added

(mg/L or ppm)

53.7 and below 2.4 1.7

53.8-58.3 2.2 1.5

58.4-63.8 2.0 1.3

63.9-70.6 1.8 1.2

70.7-79.2 1.6 1.0

79.3-90.5 1.4 0.8

Note: The values in this table do not take into account the US Public 

Health Service proposal that optimum fluoride levels be set at 0.7 

mg/L when fluoride is added. Furthermore, the maximum permissible 

level for annual average maximum day temperatures below 63.8°F 

for nonfluoridated bottled water exceeds the secondary maximum 

contaminant level for drinking water under the Safe Drinking Water 

Act. Specifically, if this same water came from a CWS water tap, public 

notice would be mandated. This is an example of more stringent 

standards for CWS drinking water than for bottled water.
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

What is Optimal Fluoridation?

In 1962, the US Public Health Service established the 

“optimal level” for fluoride content in drinking water to 

be in the range of 0.7 to 1.2 mg/L.46 In 1994, a World 

Health Organization committee suggested a level of 

0.5 to 1.0 mg/L, depending on the climate.47 In January 

2011, the US Department of Health and Human Services 

published a proposal recommending that water systems 

practicing fluoridation adjust their fluoride content to 

0.7 mg/L, as opposed to the previous temperature-dependent optimal levels ranging from 0.7 to 1.2 mg/L.47,48

This revision was aimed at minimizing the chance that 

children develop dental fluorosis, a typically mild condition that causes a discoloration of the teeth. It was also 

based on more updated studies that shows a lack of association between daily temperature and children’s water 

intake such as the one conducted by the CDC’s Division of Oral Health, National Center for Chronic Disease 

Prevention and Health Promotion that used data ranging 

from 1999-2004.49 The earlier, temperature-dependent 

guidance is still the standard for most states and/or local 

jurisdictions, as well as the Army in Technical Bulletin 

MED 576,

50 shown in Table 3.

Since the late 1970s, the CDC has provided guidelines 

and recommendations for fluoridated water supplies to 

help water systems maintain appropriate concentrations. 

The last revision to these guidelines was published in 

1995 and is average ambient temperature-based (Table 

4). Because it may be difficult to maintain an exact level 

of fluoride at a WTP, the CDC recommends a control 

fluoride range of 0.1 mg/L below to 0.5 mg/L above optimum.51 As an example, if the optimal level for a state 

is 0.8 mg/L, the control range would be 0.7 to 1.3 mg/L. 

This varies from state to state. The state of Washington, 

for instatnce, has established a range of 0.8 mg/L to 1.3 

mg/L.52 Therefore, the WTP operator should consult 

with state or local water fluoridation program for specific requirements.

Community Water Systems should maintain fluoride 

concentrations in drinking water at optimal levels to 

achieve effective caries prevention and to avoid measurable changes in the prevalence and severity of enamel 

fluorosis that can occur with changes in fluoride concentration as low as 0.2 mg/L.53 The benefits of water fluoridation decline as the concentration falls below optimum. 

As it exceeds 2.0 mg/L, there is very little additional 

tooth decay prevention benefit and a greater potential 

for fluorosis.54

Fluoride Overfeeds

Although the risk of overfeeds has declined, inherent 

risk is still present to this day. Between 1976 and 1992, 

the CDC documented 15 cases of nationwide fluoride 

overfeed events. Of the 15 total cases documented, 6 

episodes were from CWSs and 9 involved school water supplies. The root cause identified was mechanical failure in 6 cases, electrical failure in 3 cases, and 

operational/installation error in the remaining 6 cases. 

In 1993, an overfeed event occurred causing acute fluoride poisoning in Mississippi. This event was due to 

a faulty feed pump that allowed saturated fluoride solution to siphon from the solution tank to the ground 

reservoir.55 The 1995 CDC Engineering and Administrative Recommendations for Water Fluoridation have 

recommendations for a CWS to follow in the event of 

an overfeed.51 However, state primacy regulations and 

guidance should always take precedence in the event 

that an SMCL or MCL is exceeded.

One recent overfeed occurred on a military installation. On April 28, 2010, fluoride levels at Joint Base 

Elemendorf-Richardson (JBER), Alaska, were found to 

Table 4. Optimum Fluoride Levels and Operational Variability.

Annual Average of

Maximum Daily

Air Temperature (°F)

Optimum

Fluoride Level

(mg/L or ppm)

Recommended

Control Range

(mg/L or ppm)

50.0 to 53.7 1.2 1.1-1.7

53.8 to 58.3 1.1 1.0-1.6

58.4 to 63.8 1.0 0.9-1.5

63.9 to 70.6 0.9 0.8-1.4

70.7 to 79.2 0.8 0.7-1.3

79.3 to 90.5 0.7 0.6-1.2

Source: Centers for Disease Control and Prevention51

Note: The data in this table is the current standard. The current US 

Department of Health and Human Services proposal of an optimum 

level of 0.7 for all of the United States is not ambient temperature 

dependent.46,48

Table 3. The US Army Recommended Fluoride Levels in 

Drinking Water.

Annual Average of

Maximum Daily

Air Temperature 

(°F)

NIPDWR Recommended Control Limits

Fluoride Concentrations in mg/L

(maximum allowable)

Low Optimum Upper Maximum

Contaminant

Level

50.0 to 53.7 1.1 1.2 1.3 2.4

53.8 to 58.3 1.0 1.1 1.2 2.2

58.4 to 63.8 0.9 1.0 1.1 2.0

63.9 to 70.6 0.8 0.9 1.0 1.8

70.7 to 79.2 0.7 0.8 0.9 1.6

79.3 to 90.5 0.6 0.7 0.8 1.4

Source: Technical Bulletin MED 57650

Note: The values in this table precedes the finalization of the Safe Water 

Drinking Act. It is based on the National Interim Primary Drinking Water 

Regulations. Technical Bulletin MED 576 is being revised by the US 

Army Public Health Command.

FLUORIDATING THE ARMY’S COMMUNITY WATER SYSTEMS IN THE US ARMY

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THE ARMY MEDICAL DEPARTMENT JOURNAL

be excessive.56,57 They exceeded the EPA’s MCL for a 

period of 40 hours; the water was not declared safe to 

drink until 2 days later.57 According to the 2010 CCR, 

the fluoride injector malfunctioned and the highest 

fluoride daily level was 19.8 ppm, exceeding the MCL/

MCLG for fluoride.58 According to JBER Air Force Bioenvironmental Engineering,

the excess fluoride levels were caused by human error 

when a fluoride injection feeder control was adjusted improperly. Within hours the excess fluoride was detected 

by the operator in charge at the WTP and immediate 

action was taken to notify JBER residents of the issue 

while activating a response team effort to flush the water 

distribution mains and individual services.59

Fluoridation did not resume operation until December 

1, 2010, after a number of administrative and physical 

controls were implemented to correct the problem and 

prevent reoccurrence.

Fluoridation Status of Contiguous United States

Army Installations with Community Water

Systems

A 1993 study by the US Army Medical Department 

(AMEDD) Center and School showed that 70 military 

installations reported 58 water systems (8 within the 

PHCR-West AOR) with fluoride levels within the optimum range (0.7 to 1.2 mg/L or ppm), 16 water systems 

with fluoride levels below 0.7 mg/L, and 3 water systems with fluoride levels above 1.2 mg/L. Two of the 70 

military installations had treatment systems to defluoridate.60 The study reported only one day of sampling 

in 1993 for each installation and civilian water source, 

with the one exception of the Fort Bliss installation 

sample that was collected in 1991. On the one day in 

1993 examined in the study, 8 of the 11 areas served in 

the PHCR-West AOR were within optimal fluoridation 

levels.60

There are 19 installations with 22 active CWSs in the 

PHCR-West AOR. Of these 22 CWSs, only 15 CWSs (8 

government-owned and 7 privately-owned) serve more 

than 3,300 people. Most of these installations add fluoride, a few have naturally high fluoride levels, and two 

need defluoridation (one serving a population less than 

3,300). Most of the installations that fluoridate based on 

CCR data appear to be suboptimally fluoridating, meaning the water system operators are keeping fluoridation 

levels below 0.7 mg/L, as shown in Table 5. Only 2 of 

these CWSs (one privately-owned and one governmentowned at Fort Bliss, TX) are within the optimal fluoride 

ranges based on the CCRs reviewed, both of which are 

due to naturally occurring background levels.

Based on its annual CCRs, one government-owned 

CWS (serving Fort Irwin, CA) continually violates the 

state and federal MCL for fluoride for one of its water 

distribution systems that currently does not have a WTP 

to remove naturally occurring excessive fluoride (and arsenic). This installation is the only one within the PHCRWest AOR that reports the annual average fluoride level 

provided to military personnel and families. However, 

this installation has also been ordered to do so to be in 

compliance with the SDWA by the California Department of Public Health for excessive fluoride since 2012.9

A second reverse osmosis WTP is currently under construction with a projected date to be in operation in 2016.

Fluouride levels considered suboptimal according to the 

CDC’s 1995 guidelines and recommendations (Table 4) 

appear to be the most common problem in the PCHRWest AOR for Army CWSs that fluoridate. This assessment is based on fluoride ranges reported in the 2013 

Army CWS annual CCRs published in 2014. In our opinion, the method of data reporting may be problematic.

One government-owned CWS (serving Fort Leonard 

Wood, MO) CCR indicated that only the highest measured fluoride level was reported, 0.75 mg/L in 2013, 

and 2.5 mg/L in 2012, the latter of which exceeds the 

secondary MCL. According to the installation drinking 

water program compliance manager, those were the only 

reported values provided by the state laboratory. Those 

values were from grab samples—single samples taken 

which are not necessary indicative of the state of fluoridation of the water system. According to this installation, 

the surface water WTP provides 98% of the installation’s 

water and is within the operating range of 0.8 to 1.2 mg/L, 

the optimum being 1.0 mg/L. They also report these are 

typical operating levels for the WTP process, although 

on occasion levels can fall outside of this range.45

A privately-owned CWS (serving Fort Leavenworth, KS) 

indicates suboptimal fluoridation on its CCR, but these 

data are based only on 4 quarterly samples collected for 

regulatory purposes. According to the company’s utilities manager, the operational goal for fluoride is 0.7 mg/L. 

They measure daily at the WTP and once per week in the 

distribution system.3 This CCR data may also not be sufficient for reporting to the medical and dental community.

One privately-owned CWS (serving JBER, AK) that 

fluoridates its drinking water supply exceeded the secondary MCL of 2.0 mg/L in 2013 and the MCL of 4.0 

mg/L in 2010, based on its CCR records. The 2010 MCL 

exceedance was due to an accidental overfeed of the 

chemical caused by a fluoride injector malfunction.
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

Obviously, suboptimal fluoridation levels on installations directly affect the benefits of fluouridation for residents on those 

installations. However, an even 

larger potentially affected population may be those service personnel and families who do not 

live on military installations. 

Depending on the community 

in which they reside, they may 

or may not have access to fluoridated water. For example, both 

CWSs serving Joint Base Lewis-McChord (JBLM) in Washington closely maintain optimal 

fluoridation based on 2013 annual water quality data. However, according to Washington 

State Department of Health 

Drinking Water Program data, 

among the communities nearby 

JBLM, only the cities of Fircrest 

and Tacoma fluoridate their 

drinking water supplies. Other 

CWS in serving nearby communities do not, including but 

not limited to the cities or towns 

of Dupont, Gig Harbor, Lacey, 

Olympia, Lakewood, Puyallup, 

Steilacoom, and Yelm where 

many JBLM soldiers and their 

families reside.62

Conclusion and Recommendations for

Future Action

The report from the 1993 AMEDD study indicated most 

installations were at or near optimum fluoridation, but 

the data was only for single, specific date in time. The 

1993 AMEDD report concluded:

The dental fitness officer and/or community health dental hygienist need to carefully review the fluoride status 

of post drinking water and advise the preventive medicine officer if the concentration is not within the optimal 

range.60

An annual conference for all dental fitness officers and 

community health dental hygienists was also recommended to provide updates on the most current preventive dentistry techniques. A conference or other training 

application would be valuable to ensure dental caregivers remain current regarding the wide variety of fluoridation methods now available and proposed new fluoride optimal standards.

The Assistant Secretary of Defense (Health Affairs) 

Memorandum of July 18, 20112 included the results 

of a survey* of the level of fluoride in drinking water 

at DoD installations in the United States. The survey, 

which used CCR data, indicated that many CWSs that 

fluoridated were within optimal fluoridation ranges. In 

contrast, the 2013 CCRs reported within the PCHRWest AOR in 2014 indicate suboptimal fluoridation for 

privately-owned and government-owned CWSs providing water to installations serving more than 3,300 people. However, inconsistencies in the methodologies used 

by water utilities and/or installations in obtaining and 

reporting fluoridation data raise questions of the validity 

of the conclusions.

Ultimately, drinking water below optimal fluoridation 

levels will reduce the effectiveness of water fluoridation, 

*The survey conducted by the Pew Charitable Trusts and the TriService Center for Oral Health Studies examined CCRs for 189 

water systems on 158 military installations.

Table 5. Flouride Levels in PHCR-West AOR of Community Water Systems Serving More 

than 3,300 People.

Installation or Facility Number 

of

Regulated

CWS

1993 Report Data 2013 CCR Data

GO PO Level

(mg/L)

Optimally

Fluoridated

Range

(mg/L)

Optimally

Fluoridated

Fort Wainwright, AK 1 1.12 Yes 0.29-0.69 No (low)

Joint Base

Elmendorf-Richardson, AK

1 0.63 No 0.2-2.08 No 

Fort Hunter Liggett, CA 1 0.3 No Not reported No (low)

Fort Irwin, CA 1 0.55 No RO: 0.3-3.3

Avg. 1.06

Other DW: 

2.4-16

(Avg. 8.75)

No

Ord Military Community, CA 1 1.00 Yes ND-0.25 No

Fort Carson, CO 1 1.20 and

0.54

Yes 0.13-1.36 No 

Fort Leavenworth, KS 1 0.98 Yes 0.4-0.56 No

Fort Riley, KS 1 0.98 Yes 0.51-0.58 No 

Fort Leonard Wood, MO 1 1.08 Yes 0.75 (High) Yes

White Sands

Missile Range, NM

1 Not

reported

N/A 0.4 (High) No 

Fort Bliss, TX: Main Post (MP),

Biggs Army Airfield (BAAF),

East Biggs (EB)

1 2 0.8 and

1.08

Yes MP: 0.954-1.04

BAAF: ND-1.30

EB: 0.76-0.80

MP: Yes

BAAF: No

EB: Yes 

Joint Base

Lewis-McChord, WA

2 1.10 and

1.10

Yes 0.38-1.29 and

0.4-1.4 

No 

TOTAL 8 7 0.3-1.20 Yes:

8 of 11

Low: ND

High: 16

Yes:

2 of 12 

Sources: Army Medical Department Center & School study, 199360; EPA drinking water database61; 2013

PHCR-West AOR community water system community confidence reports distributed in 2014.

Glossary

CWS – community water system RO – reverse osmosis

GO – government-owned DW – domestic water

PO – privately-owned ND – nondetectable

FLUORIDATING THE ARMY’S COMMUNITY WATER SYSTEMS IN THE US ARMY

PUBLIC HEALTH COMMAND REGION-WEST AREA OF RESPONSIBILITY
January – March 2015 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

while those supplies above optimal levels may contribute to dental fluorosis. Both scenarios should be 

considered by medical and dental personnel when prescribing fluoride supplements or when the effects of 

fluoride overexposure (eg, dental fluorosis) are observed. 

Therefore, it is important that dental and medical personnel are knowledgeable about fluoridation on and off 

installations.

Installation preventive medicine departments should 

encourage government-owned CWSs (via the chain of 

command) to optimally fluoridate in accordance with 

DoD and Army directives, and ensure fluoride information in annual CCRs includes the running annual average (RAA). If this data is not reported in the CCR, the 

preventive medicine department should collect this data 

directly from WTP records, and/or sample for fluoride 

as part of its drinking water quality assurance monitoring. It is not necessary for preventive medicine personnel to measure fluoride throughout the distribution system unless there are multiple treatment entry points, as 

fluoride does not dissipate in a distribution system like 

disinfectants such as chlorine.

Military personnel and military families can request 

copies of the latest CCRs from their local water utility or 

the environmental division of the installation’s department of public works if residing on the installation. The 

CCRs, if prepared correctly, should include the natural 

fluoride found in sources required to be sampled with 

other organics, but should also include the operational 

range of fluoride (ie, low and high), along with a RAA 

for all CWSs that add fluoride. The RAA should be at 

or near 0.7 mg/L for optimal fluoridation based on the 

most current published guidance, although most local 

and state standards still fall within the 0.6 to 1.7 mg/L 

range depending on the locality if still based on the ambient temperature recommendations.

Although fluoride overfeeds are rare, the 2012 overfeed 

at JBER shows that due diligence in design, operation, 

and management is still important. Fluoride system 

design, operation, and maintenance, including water 

quality records, should be assessed during preventive 

medicine water system sanitary surveys, and water/

sanitation assistance visits. State primacy agencies will 

also be evaluating fluoridation treatment systems and 

practices during SDWA water system sanitary surveys. 

The US Army Public Health Command should provide 

fluoridation design, operation, maintenance, and reporting details in the next update to Technical Bulletin MED 

575,

63 as well as adopt the most current US Department 

of Health and Human Services recommendation for optimal fluoride.

For any drinking water supply with excessive fluoride 

levels, other sources of drinking water should be considered, especially for children in teething forming 

years. Individuals can use bottled water that is lower 

in fluoride content. Individuals can also install point of 

use reverse osmosis filters in their homes. These filters should be NSF International/American National 

Standard Institute (ANSI) for Drinking Water System 

Components - Health Effects (Standard 61) certified for 

fluoride removal.64

Since consumption of bottled water has been on the 

rise, medical and dental personnel should consider it as 

well. Depending on the brand and type of bottled water, it may or may not contain optimal fluoride levels. 

Like CWS drinking water supplies, bottled water may 

have suboptimal or excessive fluoride levels. The FDA 

regulations allow higher levels as described above. It is 

always best to check with the manufacturer’s website.

References

1. Under Secretary of Defense; Acquisition, Technology, and Logistics. Memorandum: Fluoridation at 

DoD Owned or Operated Potable Water Treatment 

Plants. Washington, DC: US Dept of Defense; May 

6, 2013. Available at: http://www.ilikemyteeth.org/

pentagon-salutes-fluoride/. Accessed September 11, 

2014.

2. Assistant Secretary of Defense; Health Affairs. 

Memorandum: Fluoridation of Water Supplies 

under the Control of the Department of Defense. 

Washington, DC: US Dept of Defense; May 6, 2013. 

Available at: http://www.ilikemyteeth.org/penta

gon-salutes-fluoride/. Accessed September 9, 2014.

3. Water Research Foundation. Fluoride in Drinking 

Water; 2014 [internet]. 2014. Available at: http://

www.waterrf.org/resources/StateOf TheScien

ceReports/Fluoride_StateOf TheScience.pdf. 

Accessed September 9, 2014.

4. Portland, Ore., rejects adding fluoride to drinking 

water [internet]. USA Today. May 22, 2013. Available at: http://www.usatoday.com/story/news/na

tion/2013/05/22/portland-fluoride-water/2350329/. 

Accessed September 15, 2014.

5. Lefler D, Calovich A. Wichita voters reject fluoridated water [internet]. The Wichita Eagle. November 7, 2012. Available at: http://www.kansas.com/

news/article1102401.html. Accessed September 15, 

2014.

6. Main D. Israel has officially banned fluoridation 

of its drinking water [internet]. Newsweek. August 

29, 2014. Available at: http://www.newsweek.com/

israel-has-officially-banned-fluoridation-its-drink

ing-water-267411. Accessed September 12, 2014.
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

7. Marthaler TM, Petersen PE. Salt fluoridation- an 

alternative in automatic prevention of dental caries. 

Int Dent J. 2005;55(6):351-358.

8. Centers for Disease Control and Prevention. 2012 

Water Fluoridation Statistics [internet]. December 

31, 2012. Available at: http://www.cdc.gov/fluorida

tion/statistics/2012stats.htm. Accessed August 29, 

2014.

9. US Environmental Protection Agency. Basic Information about Fluoride [internet]. July 23, 2013. 

Available at: http://water.epa.gov/drink/contami

nants/basicinformation/fluoride.cfm. Accessed 

September 9, 2014.

10. Achievements in public health, 1900-1999: fluoridation of drinking water to prevent dental caries. 

MMWR Morb Mortal Wkly Rep. 1999;47(41):933-

940. Available at: http://www.cdc.gov/mmwr/pre

view/mmwrhtml/mm4841a1.htm. Accessed August 29, 2014.

11. Fluoride Action Network. FAN’s Professionals 

Statement to End Water Fluoridation [internet]. 

July 9, 2014. Available at: http://fluoridealert.org/

researchers/professionals-statement/. Accessed 

August 29, 2014. 

12. Citizens for Safe Drinking Water. NoFluoride.com 

website. Available at: http://www.nofluoride.com/. 

Accessed August 29, 2014.

13. National Research Council Committee on Fluoride 

in Drinking Water. Fluoride in Drinking Water: A 

Scientific Review of EPA’S Standards. Washington 

DC: The National Academies Press; 2006.

14. Recommendations for using fluoride to prevent and 

control dental caries in the United States. MMWR 

Morb Mortal Wkly Rep. 2001;50(RR14):1-42.

15. Fomon SJ, Ekstrand J, Ziegler EE. fluoride intake 

and prevalence of dental fluorosis: trends in fluoride intake with special attention to infants. J Public Health Dent. 2000;60(3):131-139.

16. Featherstone, JD. The science and practice of caries 

prevention. J Am Dent Assoc. 2000;131(7);887-899.

17. Revelant J. Fluoride: necessary or too much of 

a good thing [internet]. Fox News. February 24, 

2013. Available at: http://www.foxnews.com/

health/2013/02/20/f luoride-necessary-or-toomuch-good-thing/. Accessed September 11, 2014.

18. American Medical Association, Statewide Fluoridation and Fluoride Content of Municipal Water Supplies, H-440.972 and H440.945. Available 

at: http://www.ama-assn.org/ama/pub/physicianresources/clinical-practice-improvement/clinicalquality/accreditation-collaboration/ada-council.

page. Accessed September 11, 2014.

19. American Water Works Association. Fluoridation 

of Public Water Supplies; Revised January 22, 

2012. Available at: http://www.awwa.org/about-us/

policy-statements/policy-statement/articleid/202/

f luoridation-of-public-water-supplies.aspx. 

Accessed September 11, 2014.

20. Fawell J, Bailey K, Chilton J, Dahi E, Fewtrell 

L, Magara Y. Fluoride in Drinking-water; 2006. 

Available at: http://www.who.int/water_sanitation_

health/publications/fluoride_drinking_water_full.

pdf?ua=1, Accessed September 11, 2014.

21. American Dental Association, Center for Disease 

Control and Prevention. Nature’s Way to Prevent 

Tooth Decay, Water Fluoridation; 2006. Available 

at: http://www.cdc.gov/Fluoridation/pdf/natures_

way.pdf. Accessed August 29, 2014.

22. Title 17 CCR Ch 15 Article 4: Primary StandardsInorganic Chemicals. July 1, 2014. Available at: 

http://www.waterboards.ca.gov/drinking_water/

certlic/drinkingwater/documents/lawbook/dwreg

ulations-2014-07-01.pdf. Accessed September 2014.

23. Title 17 CCR Ch 15 Article 16: Secondary Drinking Water Standards, Table 64449-A. July 1, 2014. 

Available at: http://www.waterboards.ca.gov/drink

ing_water/certlic/drinkingwater/documents/law

book/dwregulations-2014-07-01.pdf. Accessed 

September 11, 2014.

24. California Department of Public Health. Fluorides. 

Available at: http://www.cdph.ca.gov/programs/

Pages/FluorideandFluorides.aspx. Accessed 1 September 2014.

25. US Environmental Protection Agency. Questions 

and Answers on Fluoride; January 2011. Available 

at: http://water.epa.gov/lawsregs/rulesregs/regulat

ingcontaminants/sixyearreview/upload/2011_Fluo

ride_QuestionsAnswers.pdf. Accessed August 29, 

2014.

26. 40 CFR Ch 1 §142.61: Variance from the Maximum 

Contaminant Level from Fluoride. July 1, 2012. 

Available at: http://www.gpo.gov/fdsys/granule/

CFR-2012-title40-vol24/CFR-2012-title40-vol24-

sec142-61/content-detail.html. Accessed September 11, 2014.

27. 40 CFR Ch 1 §143.3: Secondary Maximum Contaminant Levels. July 1, 2012. Available at: http://

www.gpo.gov/fdsys/pkg/CFR-2013-title40-

vol24/pdf/CFR-2013-title40-vol24-sec143-3.pdf. 

Accessed September 11, 2014.

28. 40 CFR Ch 1 §141.51(b): Maximum Contaminant 

Level Goals for Inorganic Contaminants. July 1, 

2012. Available at: http://www.gpo.gov/fdsys/pkg/

CFR-2013-title40-vol24/pdf/CFR-2013-title40-

vol24-sec141-51.pdf. Accessed September 11, 2014.

FLUORIDATING THE ARMY’S COMMUNITY WATER SYSTEMS IN THE US ARMY

PUBLIC HEALTH COMMAND REGION-WEST AREA OF RESPONSIBILITY
January – March 2015 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

29. 40 CFR Ch 1 §141.62: Maximum Contaminant 

Level for Inorganic Contaminants. July 1, 2012. 

Available at: http://www.gpo.gov/fdsys/pkg/CFR2013-title40-vol24/pdf/CFR-2013-title40-vol24-

sec141-62.pdf. Accessed September 11, 2014.

30. 40 CFR Ch 1 §141.208: Special Notice for Exceedance of the SMCL for Fluoride. July 1, 2012. 

Available at: http://www.gpo.gov/fdsys/pkg/CFR2012-title40-vol24/pdf/CFR-2012-title40-vol24-

sec142-61.pdf. Accessed September 11, 2014.

31. US Environmental Protection Agency. Revised 

Public Notification Handbook: 2nd Revision, EPA 

816-R-09-013; March 2010. Available at: http://

www.epa.gov/safewater/publicnotification/pdfs/

Revised-Public-Notification-Handbook-CWS.pdf. 

Accessed September 11, 2014.

32. 40 CFR Ch 1 §141.203: Tier 2 Public Notice Form, 

Manner and Frequency of Notice. July 1, 2012. 

Available at: http://www.gpo.gov/fdsys/pkg/CFR2011-title40-vol23/pdf/CFR-2011-title40-vol23-

sec141-203.pdf. Accessed September 11, 2014.

33. Title 17 CCR Ch 15 Article 4.1 §64433.3: Monitoring and Compliance—Fluoride Levels. July 1, 

2014. Available at: http://www.waterboards.ca.gov/

drinking_water/certlic/drinkingwater/documents/

lawbook/dwregulations-2014-07-01.pdf. Accessed 

September 2014.

34. Natural Resources Defense Council. Bottled Water: Pure Drink or Pure Hype; July 15, 2013. Available at: http://www.nrdc.org/water/drinking/bw/

chap2.asp. Accessed September 1, 2014.

35. Natural Resources Defense Council. Table 1, Key 

Differences Between EPA Tap Water and FDA 

Bottled Water Rules. Available at: http://www.nrdc.

org/water/drinking/bw/table1.html. Accessed September 1, 2014.

36. Center for Disease Control and Prevention. Bottled 

Water and Fluoride; July 10, 2013. Available at: 

http://www.cdc.gov/fluoridation/faqs/bottled_wa

ter.htm. Accessed September 11, 2014.

37. US Food and Drug Administration, US Environmental Protection Agency. Memorandum of Understanding 225-79-2001; signed June 12, 1979 by 

EPA and signed June 22, 1979 by FDA. Available 

at: http://www.fda.gov/AboutFDA/Partnership

sCollaborations/MemorandaofUnderstanding

MOUs/DomesticMOUs/ucm116216.htm. Accessed 

September 11, 2014.

38. 21 CFR Ch 1 §165.110: Bottled Water. Revised 01 

April 2014. Available at: http://www.accessdata.fda.

gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=1

65.110&SearchTerm=bottled%20water. Accessed 

September 11, 2014.

39. US Food and Drug Administration. Guidance for 

Industry: A Food Labeling Guide (11. Appendix C: 

Health Claims); January 2013. Available at: http://

www.fda.gov/food/guidanceregulation/guidanced

ocumentsregulatoryinformation/labelingnutrition/

ucm064919.htm. Accessed September 11, 2014.

40. Unified Facilities Criteria: Water Treatment. November 1, 2012. Available at: http://www.wbdg.org/

ccb/DoD/UFC/ufc_3_230_03.pdf. Accessed September 11, 2014.

41. Army Regulation 40-35: Dental Readiness and 

Community Oral Health Protection. Washington, 

DC: US Dept of the Army; 2004.

42. Army Regulation 40-3: Medical, Dental, and Veterinary Care. Washington, DC: US Dept of the 

Army; 2013.

43. Army Regulation 40-5: Preventive Medicine. Washington, DC: US Dept of the Army; 2007.

44. Army Regulation 600-3: Army Health Promotion. 

Washington, DC: US Dept of the Army; 2009.

45. Department of the Army Pamphlet 40-11: Preventive Medicine. Washington, DC: US Dept of the 

Army; 2009.

46. US Health and Human Services Department. Proposed HHS Recommendation for Fluoride Concentration in Drinking Water for Prevention of Dental 

Caries; January 13, 2011. Available at: https://www.

federalregister.gov/articles/2011/01/13/2011-637/

proposed-hhs-recommendation-for-fluoride-con

centration-in-drinking-water-for-prevention-ofdental. Accessed September 12, 2013.

47. World Health Organization Expert Committee on 

Oral Health Status and Fluoride Use. Fluorides and 

Oral Health; 1994. Available at: http://whqlibdoc.

who.int/trs/WHO_TRS_846.pdf. Accessed September 9, 2014.

48. Water Research Foundation. Fluoride in Drinking Water: State of the Science, Regulatory Update, and Additional Resources; 2014. Available 

at: http://www.waterrf.org/resources/StateOfThe

ScienceReports/Fluoride_StateOfTheScience.pdf, 

Accessed September 9, 2014.

49. Beltran-Aguilar ED, Barker L, Sohn W. Total Water Intake: Lack of association between daily temperature and children’s water intake in the United 

States- 1999-2004; July 10, 2013. http://www.cdc.

gov/fluoridation/factsheets/totalwaterintake.htm. 

Accessed September 9, 2014.

50. Technical Bulletin Medical 576: Occupational and 

Environmental Health–Sanitary Control and Surveillance of Water Supplies at Fixed Installations.

Washington, DC: US Dept of the Army; 1982.
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

51. Center for Disease Control and Prevention. Engineering and Administrative Recommendations 

for Water Fluoridation, 1995; September 29, 1995. 

Available at: http://www.cdc.gov/mmwr/PDF/rr/

rr4413.pdf. Accessed September 12, 2014.

52. Washington State Department of Health. Fluoride: 

Is my drinking water fluoridated?; February 2013. 

Available at: http://www.doh.wa.gov/Portals/1/

Documents/Pubs/331-409.pdf. Accessed September 12, 2014.

53. Evans RW, Stamm JW. Dental fluorosis following downward adjustment of fluoride in drinking water. Journal of Public Health Dentistry. 

2003;51(2):91-98.

54. Szpunar SM, Burt BA. Dental caries, fluorosis, 

and fluoride exposure in Michigan schoolchildren. 

Journal of Dental Research. 2003;67(5):802-806.

55. Penman AD, Brackin BT, Embrey R. Outbreak 

of acute fluoride poisoning caused by a fluoride 

overfeed, Mississippi, 1993. Public Health Reports.

1997;112.

56. Bluemink E. Excess Fluoride Taints Water at Anchorage Military Bases. Alaska Dispatch News. 

April 28, 2010. Available at: http://www.adn.com/

article/20100428/excess-fluoride-taints-water-an

chorage-military-bases. Accessed September 12, 

2014.

57. Bluemink E. Water at local military bases declared 

safe to drink. Alaska Dispatch News. April 29, 2010. 

Available at: http://www.adn.com/node/1377831. 

Accessed September 12, 2014.

58. Doyon Utilities. Second Annual Water Quality Report; June 2010. Available at: http://doyonutilities.

com/wp-content/uploads/docs/reports/ft_richard

son/FortRichardsonJune2010CCR.pdf. Accessed 

September 12, 2014.

59. JBER Bioenvironmental Engineering. Drinking 

Water Consumer Confidence Report; June 27, 2011. 

Available at: http://www.jber.af.mil/news/story.

asp?id=123261689. Accessed September 12, 2014.

60. US Army Medical Department Center and School. 

Fluoridation Status of US Army CONUS Installations; 1993. Available at: http://cdm15290.con

tentdm.oclc.org/cdm/ref/collection/p15290coll2/

id/30#img_view_container. Accessed August 29, 

2014.

61. US Environmental Protection Agency. Drinking 

Water Data & Databases [internet]. Available at: 

http://water.epa.gov/scitech/datait/databases/drink/. 

Accessed October 28, 2014.

62. Washington State Department of Health. Fluoride 

in Drinking Water. Available at: http://www.doh.

wa.gov/DataandStatisticalReports/EnvironmentalHealth/DrinkingWaterSystemData/FluorideinDrinkingWater. Accessed September 12, 2014.

63. Technical Bulletin MED 575: Occupational and Environmental Health – Swimming Pools and Bathing 

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

July 1993.

64. National Sanitation Foundation International. International/ANSI Standard 61. Available at: http://

www.nsf.org/services/by-industry/water-waste

water/municipal-water-treatment/nsf-ansi-stan

dard-61/. Accessed September 15, 2014.

Authors

Ms Hardcastle is a Supervisory Environmental Engineer 

and Deputy Chief of the Environmental Health Engineering Division, US Army Public Health Command 

Region-West, Joint Base Lewis-McChord, Washington.

CPT Browne is the Environmental Science Engineering 

Officer-in-Charge, Environmental Health Engineering 

Division, US Army Public Health Command RegionWest, Joint Base Lewis-McChord, Washington.

1LT Pham is an Environmental Science Engineering Officer in the Environmental Health Engineering Division, 

US Army Public Health Command Region-West, Joint 

Base Lewis-McChord, Washington.

FLUORIDATING THE ARMY’S COMMUNITY WATER SYSTEMS IN THE US ARMY

PUBLIC HEALTH COMMAND REGION-WEST AREA OF RESPONSIBILITY
January – March 2015 49

Tick-borne diseases (TBDs) represent some of the 

world’s most rapidly expanding arthropod-borne infectious diseases.1(p1) In the United States, ticks are responsible for more human disease than any other arthropod 

group. The incidence and the number of pathogens 

transmitted by ticks are increasing. For example, Lyme 

disease is now the most commonly reported arthropodborne illness in the United States.2

 Anaplasmosis, ehrlichioses, and rickettsioses are also on the rise.1(p1) In 

most parts of the world, TBDs are potentially serious 

health threats to troops, civilian employees, and residents at military installations.2(p6) Companion animals 

and military working dogs (MWD)are also at risk in 

areas where ticks and TBDs are endemic or emerging.

Risk of TBD increases with the introduction of exotic 

tick species into new areas and the expansion of historical tick ranges. One example of exotic ticks that effects 

the United States is Boophilus annulatus and B microplus, also known respectively as the cattle fever tick 

and the southern cattle tick, that were imported here by 

Spanish colonists who brought tick-infested cattle and 

horses with them. These ticks transmit a severe disease 

to cattle called Texas fever or cattle fever that caused 

enormous losses to the US cattle industry in the past. 

Present efforts to keep this tick out of the United States 

exist as the Cattle Fever Tick Eradication Program.3 Nilgai antelopes, native to India, Nepal, and Pakistan, that 

were released into southern Texas are also hosts to the 

cattle fever ticks, posing a threat as maintenance hosts 

of cattle fever.4 There are many other examples of exotic tick introductions from migratory birds, exotic and 

wildlife species, and domestic animals.5

Changes in climate may also alter the geographic distribution of tick vectors, and in turn, cause a change in the 

currently recognized demographic patterns, seasonality, 

and incidence of TBDs.1(p61) For example, the range of 

the Gulf Coast tick (Amblyomma maculatum) has historically been along the Gulf of Mexico and southern 

Atlantic coast as far north as South Carolina, and extending approximately 100-150 miles inland. However, 

resident populations of these ticks are now established 

in Arkansas, Oklahoma, and Kansas,6 and they have 

been collected on the east coast as far north as Delaware 

and Maryland.7 Another example is the lone star tick 

(A americanum) which has moved northward as far as 

Maine and westward into central Texas and Oklahoma.8

Incidental introductions of these ticks, and the diseases 

they carry beyond endemic regions, occur with increasing frequency. This is likely due to the feeding of immature ticks on migrating birds, and the transportation 

of tick-infested livestock and wildlife into new areas.6

These introductions may also come from pets belonging 

to people who move from one area to another.

In addition, suburbanization has contributed to the increase in TBD transmission in North America by bringing people and their pets close to ticks and by creating 

new tick habitat.9 In the northeastern United States, the 

highest risk for Lyme disease occurs around the homes 

of those who have been infected.10 As communities continue to expand into tick habitat, and people are encouraged to enjoy outdoor recreation and pursue activities 

such as urban farming, the risk for peridomestic exposure to ticks and TBDs may increase.

The National Notifiable Disease Surveillance System 

(NNDSS) of the Centers for Disease Control and Prevention (CDC) maintains a list of diseases that are considered to be of public interest by reason of their contagiousness, severity, or frequency. The 7 TBDs on the 

NNDSS list are shown in the Table.

Many of these diseases, which are caused by closely related tick-borne pathogens, can also be acquired internationally. There are also many TBDs that can be acquired 

abroad that do not occur in the continental United States. 

In addition to transmitting disease, ticks can cause irritation, pain, and swelling at attachment sites, otoacariasis 

(invasion of the auditory canal), paralysis, allergic reactions, and anaphylactic reactions.11 Heavy infestations of 

ticks on animals can cause debilitation due to blood loss.

Direct effects from TBDs include troop and MWD 

morbidity and mortality. There are also many indirect effects, such as illness of dependents or Department of Defense (DoD) civilian personnel, and related 

healthcare costs. Both types of effects can be mitigated 

through aggressive surveillance, public education, and 

Tick-borne Disease Surveillance

MAJ Wade H. Petersen, MS, USA

CPT Erik Foster, MS, USAR

1LT Beven McWilliams, MS, USA

William Irwin
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

prevention/control programs, together with prompt diagnosis and treatment.2(p6)

Tick Biology and Disease Transmission

Ticks are grouped into 2 separate families. Family Ixodidae, also called hard ticks, have 4 developmental stages: 

egg, larva, nymph, and adult. The latter 3 each take one 

large blood meal and then molt to the next stage, or lay 

eggs in the case of the adult. Hard ticks have mouthparts 

with recurved teeth that allow them to firmly anchor 

themselves to hosts while feeding with the assistance of 

a cement-like substance secreted by the salivary glands. 

This allows them to feed for extended periods of time 

that can vary from 2 to 12 days or longer, depending on 

species, life stage, and gender. Family Argasidae, also 

called soft ticks, have the same 4 developmental stages, 

but most have multiple nymph stages. Soft ticks have 

mouthparts that allow them to hold fast to their host, as 

hard ticks do, but they do not secrete cement. Although 

some soft ticks can remain attached to the host for several days,11(p501) others can complete a meal within minutes 

to hours.12 This is still much longer than other bloodsucking arthropods such as mosquitoes, and is one of 

the factors that contribute to their high vector potential 

because it increases the likelihood of pathogen ingestion and allows them to secrete large amounts of hostderived fluid and salivary secretions, which contain 

pathogens, back into the host.

Other factors that make ticks efficient disease vectors include a highly sclerotized body that protects them from 

environmental stresses, high reproductive potential, and 

a long life span (compared to other blood feeding arthropods). Although the majority of TBDs are transmitted 

during normal feeding activity, they can be transmitted by other routes as well, including through regurgitation and feces. Argasid ticks can also release pathogens 

through excess liquid excreted from the coxal glands 

located adjacent to the first segment (coxa) of the front 

legs.11(p512) Adding to their efficiency as vectors, the larvae and nymphs are very small. The presence of an immature tick on a host often goes unnoticed, enabling the 

tick to feed to repletion and drop off without detection, 

which increases the likelihood of pathogen transmission.

Ticks can also transmit more than one pathogen at a 

time. For example, Ixodes ticks can simultaneously or 

sequentially infect their hosts with Borrelia burgdorferi, 

Anaplasma phagocytophilum, and Babesia microti.

1(p61)

Co-infections with these pathogens have been reported 

from wild and domestic animals, including dogs, as well 

as humans. These infections can result in more severe 

and longer illnesses and can complicate diagnoses.1(p493)

Ticks are also effective disease reservoirs. In some species, pathogens can be transmitted from the adult female 

to its offspring (transovarial transmission) and from one 

developmental stage to the next (transstadial transmission). Infected ticks can also transmit viruses to uninfected ticks while feeding simultaneously on an uninfected 

host.11(p512) Therefore, they can maintain and transmit infections even if they have not fed on an infected host.

TICK-BORNE DISEASE SURVEILLANCE

Tick-borne Diseases Listed in the National Notifiable Disease Surveillance System.

Disease Agent Vector Symptoms US Region

Anaplasmosis Anaplasma

phagocytophilum

Ixodes

scapularis,

I pacificus

Fever, headache, muscle pain, chills, 

malaise, nausea/abdominal pain, 

cough, confusion, rash (rare)

Northeastern and upper midwestern 

states, northern California

Babesiosis Babesia microti,

B. divergens,

B. duncani

Ixodes spp Fever, fatigue, headache, body ache, 

chills, nausea, loss of appetite

Northeast and upper midwest

Lyme Disease Borrelia

burgdorferi

Ixodes

scapularis,

I pacificus

Fever, fatigue, headache, chills, 

muscle and joint aches, swollen 

lymph nodes, erythema migrans 

(red, expanding rash)

Northeast and upper midwest

Ehrlichiosis Ehrlichia chaffeensis,

E. ewingii,

E. muris-like

Amblyomma 

americanum

Fever, fatigue, headache, muscle 

aches

Southeast and south-central US from 

the eastern seaboard extending westward to Texas.

Spotted Fever 

Rickettsiosis

Rickettsia rickettsii,

R. parkeri,

R. philippi

Dermacentor

andersoni,

D variabilis

Fever, fatigue, headache, muscle 

aches, eschar at bite site, rash

Throughout the US but primarily in 

North Carolina, Oklahoma, Arkansas, 

Tennessee, and Missouri

Tularemia Francisella

tularensis

Dermacentor

andersoni,

D variabilis,

Amblyomma 

americanum

Fever, fatigue, headache, swollen and 

painful lymph glands, ulcer, chills

Tularemia has been reported from all 

states except Hawaii, but is most 

common in south-central states, 

the Pacific northwest, and parts of 

Massachusetts

Powassan 

Disease

(Deer tick virus)

Powassan virus

lineage I & II

Ixodes spp Fever, headache, vomiting, weakness, 

confusion, loss of coordination, 

speech difficulties, seizures

Northeastern states and the Great Lakes 

region
January – March 2015 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

Surveillance

Surveillance is the process of determining the presence 

of vectors and pests, estimating their general population 

levels, and determining if pathogens of concern are present in the population. It gives quantifiable data on which 

to base control and education programs and is the starting 

point in the prevention of any arthropod-borne disease. 

The analysis and interpretation of information gained 

from surveillance is the basis for developing quantitative and qualitative risk assessments that can be used to 

predict the occurrence of pest outbreaks or vector-borne 

diseases.13(p7) Various methods can be used to describe 

disease risk. One commonly used index is called the Entomologic Risk Index (ERI), an indicator of the number 

of infected ticks that a person might come into contact 

with over a set distance. The ERI is calculated as the 

number of infected ticks collected over a 1,000-meter 

drag (described below). Accurate ERIs are obtained by 

testing ticks for pathogens to determine tick infection 

rate. Public health officials can use indices like the ERI 

in public education efforts and to determine if, when, 

and what control measures should be implemented.13(p7)

Information on vector quantity, type, and infection 

rates obtained from environmental sampling can be 

combined with human case data to help predict risk of 

acquiring vector-borne diseases. Ticks are active year 

round in some of the warmer areas of the continental 

United States. In fact, 31% of the ticks received at US 

Army Public Health Command (USAPHC) Region-West 

between the years 1944 and 2013 were collected in the 

months of November, December, January, and February. 

Therefore, surveillance and pathogen testing should occur throughout the year.

Surveillance Types

Surveillance for ticks and TBDs can be accomplished 

both actively and passively. Public health personnel who 

go into the field to collect ticks directly from animals 

or brush, as described in the following paragraphs, are 

conducting active surveillance. Passive surveillance 

depends on the voluntary submission of ticks to public health entities for identification and pathogen analysis. Passive surveillance also includes the gathering of 

TBD data from sources such as the CDC Morbidity and 

Mortality Weekly Report,

a the USAPHC Vector-borne 

Disease Report,

b or the Armed Forces Health Surveillance Center Medical Surveillance Monthly Report.

c

This type of passive surveillance is important as it can 

give military public health personnel a rough picture of 

tick and pathogen presence or activity in a broad area. 

No single surveillance method can give a complete picture of TBD risk; therefore, it is important to employ as 

many techniques as possible.

Surveillance Methods

Tick Drags. Tick drags are typically constructed of a one 

meter square sheet of light colored, soft material, such 

as muslin or flannel. A 1.2 meter dowel is attached to the 

leading edge of the material to keep it spread apart as it 

is pulled through the tick habitat and a two meter cord 

attached at both ends of the dowel can be used to pull 

the drag. Tick drags are conducted by passing the cloth 

over likely tick habitat, with the goal of collecting ticks 

that are questing (seeking a host). This method collects 

representative samples of Ixodid ticks present, and generally mirrors the actual exposure that a person might 

experience in a given area.

Tick Flags. Tick flagging is similar to tick drags. A flag 

is made by attaching a one meter square piece of cloth 

to a stick or dowel so that it resembles a flag. The flag is 

then waved back and forth under, in, and over vegetation 

or leaf litter, taking advantage of those areas where ticks 

are most likely to quest for their preferred host.

Tick Walks. A tick walk is accomplished by walking in a 

sampling area and collecting ticks that cling to the walker. This is the best estimate of the tick threat to humans. 

Precautions must be taken when using this method to 

protect the walkers. Coveralls should be worn with tube 

socks pulled over the leg openings and wrist openings 

sealed with tape. Coveralls and socks should be white 

or some other light color in order to better see any ticks 

that may be crawling on the clothing.

Traps. Traps vary in design. Their basic construction 

consists of a collecting device that attracts ticks using 

carbon dioxide. Effectiveness of this method differs by 

species. For instance, A americanum may be collected 

effectively with this method. Ixodes scapularis, on the 

other hand, are slower moving and are not effectively 

collected using traps.2(p29)

Wildlife Trapping and Examination. Various methods are 

used to collect ticks from wildlife hosts. Ticks can be 

removed from harvested deer that are brought to check 

stations during hunting season. This method allows for 

the collection of both the tick for testing for pathogens, 

as well as blood and tissue from the deer. Small mammals, including mice, chipmunks, voles, and ground 

squirrels are primary hosts for immature stages of ticks 

and can be trapped and then examined for ticks. Small 

mammal trapping, while labor intensive, is the most 

ahttp://www.cdc.gov/mmwr/

b http://phc.amedd.army.mil/whatsnew/Pages/Periodic

Publications.aspx

chttp://www.afhsc.mil/
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

sensitive method to detect immature stages of ticks and 

to detect pathogens in host populations. Small mammal 

host tissues or blood samples may be collected to determine if pathogens are circulating in wildlife reservoirs. 

Nesting material can also be placed in Berlese funnels 

(traps used for extracting arthropods from soil and litter 

samples) to extract ticks.

Ticks Collected at Veterinary Treatment Facilities. Ticks 

removed from pet dogs, stray animals, and MWDs can 

enhance public health surveillance because they can 

be tested for animal and human pathogens that may 

circulate in the area. Pets often frequent the edges of 

trails or wooded areas and may come in contact with 

tick-infested habitats more often than people. They may, 

therefore, play an important role in bringing diseasetransmitting ticks into close proximity to their owners 

or handlers. Pets and MWDs are compliant and easily 

sampled. In addition to dogs, horses can be hosts to ticks 

that can transmit disease to humans. Clearly, surveillance of domestic animals may assist in determining 

whether TBD is present. Common commercial tests, 

such as TickChek (TickChek LLC, East Stroudsburg, 

PA), Lyme-Aid (Lyme-Aid, East Stroudsburg, PA), and 

ProTickMe (Mainely Ticks Inc, Sanford ME), can determine infection with several common TBDs. There is 

some evidence that canine tick infestation precedes the 

onset of human tick-related health events and could possibly be a useful sentinel for human diseases.14 Moreover, 

owners are often motivated to have their animals tested. 

Most military bases have veterinary support that can coordinate on- and off-base surveillance. When dogs are 

brought in for examination, ticks should be collected 

and forwarded to public health entities for identification 

and pathogen testing. This type of surveillance can be 

facilitated through the use of preconstructed submission 

kits. The kits include instructions on how to submit a 

tick, a collection container (such as a plastic vial), a standardized submission form, and a preaddressed padded 

envelope for shipment.

Ticks Collected From People. Ticks removed from people can be sent to the USAPHC Army Institute of Public Health Entomological Sciences Program through the 

DoD Human Tick Test Kit Program, which is a free tick 

identification and testing service for DoD healthcare facilities. More information can be found at the Human 

Tick Test Kit Program web site.* Care should be taken 

to remove ticks promptly and properly to prevent infection with TBD, to ensure mouthparts are not left in the 

skin, and to allow for tick identification and testing. The 

proper methods to remove ticks are listed in the inset.

Importance

The geographic ranges of many tick species are expanding, and the serious diseases transmitted by ticks are 

becoming more common.15 Due to overlapping tick and 

host ranges, this expansion may also lead to more co-infections and areas with multiple pathogens and vectors. 

As previously discussed, co-infections are not unusual 

and can result in more severe illness than infection with 

a single pathogen.1(p243) In the United States alone, TBDs 

produce tens of thousands of illnesses every year, many 

of which are severe and result in hospitalization, longterm illness, disability, and death.1(p155)

Tick surveillance is the starting point for effective TBD 

prevention. Surveillance establishes species and densities of tick populations present in a given area, and provides data for establishing the potential TBD risk. This 

data provides leaders, preventive medicine personnel, 

pest management professionals, and individuals the information they require to promote proactive measures, 

including behavior change such as using personal protective measures and avoiding tick habitat, and tick-targeted strategies (tick checks or tick population reduction 

measures)1(p155) to prevent TBDs.

Tick surveillance will be most effective when multiple 

entities are involved. The USAPHC personnel can visit 

installations and collect ticks. Given the limited scope of 

this method, it alone will not be sufficient to accurately 

assess the risk of TBDs. Limited budgets also make this 

a less than cost-effective way to address TBDs. Local 

entities, most notably from installation preventive medicine and veterinary personnel, should make efforts to 

augment the work currently performed by USAPHC 

personnel. For example, Public health Command Region-West (PHCR-W) personnel collected ticks from 

8 installations during 2014 while only 2 installations 

TICK-BORNE DISEASE SURVEILLANCE

*http://phc.amedd.army.mil/topics/envirohealth/epm/Pages/

HumanTickTestKitProgram.aspx

Proper Tick Removal

Do:

Use fine-tipped tweezers to grasp the tick as close to 

the skin as possible, then pull straight out with a slow, 

steady motion. This will ensure the mouthparts do not 

break off in the skin.

Wash the wound after removal and apply antiseptic.

Do Not:

Squeeze or smash the tick.

Burn the tick.

Cover the tick with petroleum jelly, sport creams, 

alcohol, nail polish, or any other substance.
January – March 2015 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

collected and sent a significant number of ticks. If all of 

the installations within our 20-state region would collect and send ticks for analysis, the knowledge of TBD 

risk in the region would be greatly improved.

Analysis of TBDs should be expanded to include all 

tick species that are considered vectors as well as the 

pathogens they transmit because the epidemiology of 

newly emerging TBDs is not well known. For example, 

in 2008, the first human infection with Rickettsia 364D 

was confirmed in a patient from northern California.16

Illness caused by this pathogen is now a reportable disease under the California Code of Regulations Title 17.17

It is also listed on the CDC web site as a source of Rickettsial infections.10 Because R rickettsii (the causative 

agent of Rocky Mountain spotted fever) is rarely identified in human-biting ticks in CA, it has been suggested 

that Rickettsia 364D, provisionally named Rickettsia 

phillipi, is responsible for many of the illnesses in this 

region that resemble and are misdiagnosed as Rocky 

Mountain spotted fever.18(p671) Dermacentor occidentalis, 

the Pacific Coast tick, is the vector of Rickettsia 346D 

and occurs throughout California and in parts of Oregon. 

Both immature and adult stages of this tick are relatively 

indiscriminant feeders and will readily bite humans.19

Rickettsia 364D has been detected in up to 11% of D 

occidentalis from 8 California counties.16(p542) Without 

diligent surveillance and pathogen testing, changes in 

tick distributions and the risk of acquiring TBDs will 

remain unknown, especially for newly emerging TBDs.

Two other recent examples of newly described, emerging TBDs include Heartland virus20 and Ehrlichia murislike infection. The Ehrlichia muris-like organism was 

isolated from I scapularis ticks during an outbreak investigation in Wisconsin in 2009.21 Previously, only Ehrlichia chaffeensis and E ewingii were thought to cause 

tick-borne Ehrlichiosis in humans in the US, and neither 

is endemic in Wisconsin or Minnesota. When patients 

in these states, without travel to endemic areas of the 

United States, began to present to their healthcare providers with symptoms of Ehrlichiosis and were further 

investigated, blood samples submitted for polymerase 

chain reaction (PCR) screening identified the previously 

undescribed Ehrlichia species. Field surveys and retrospective testing of I scapularis ticks further established 

that Ehrlichia muris-like is present in tick and wildlife 

populations.22,23

In 2012, Heartland virus became the first phlebovirus 

associated with human infection described in the United 

States.24 Two hospitalized patients with a history of exposure to lone star ticks, A americanum, presented to 

hospitals in northwestern Missouri in June 2009. Both 

patients, males over 55 years-old, presented with fever, 

fatigue, anorexia, nausea, low white-blood-cell count, 

low platelet count, and elevated liver enzymes. The patients were thought to have Ehrlichiosis, but failed to 

improve upon treatment with antibiotics. Further blood 

tests including PCR, sequencing, and electron microscopy eventually identified the causative virus as Heartland, 

which is classified as a distinct virus, but phylogenetically similar to the severe fever with thrombocytopenia 

syndrome virus. In 2012, ticks were collected from 12 

sites including both patients’ farms, and infection rates 

in A americanum nymphs were found to range from 0.47 

to 3.91 infected ticks per 1,000 throughout the tick season. These examples highlight the importance of TBD 

surveillance as the collaboration between the medical, 

laboratory, and public health entomology communities 

led to the discovery early in the course of disease emergence of both of these pathogens.

Public Health Command Region-West conducts surveillance and testing for military installations in the western 

region of the United States including Missouri, Minnesota, Iowa, and parts of Texas and was the first governmental agency to detect Lyme disease from ticks or rodent biopsies in Santa Barbara and San Louis Obispo 

County, California. Once the detection techniques for 

Lyme disease were perfected, PHCR-W expanded its capabilities to test ticks and rodent tissue for other TBDs 

to include Ehrlichia chaffeensis, Anaplasma phagocytophilum, and Spotted Fever group Rickettsias.

We have since detected Ehrlichia from 4 installations 

in Missouri and A phagocytophilum in Minnesota and 

California. Several Rickettsia rickettsia and Ehrlichia 

chaffeensis tick pools were detected among ticks from 

dogs at Fort Leonard Wood, Missouri, in 2011. These 

surveillance activities have led to installation awareness 

and TBD risk assessments at numerous installations. 

Several installations have mandated briefings to field 

sanitation teams, environmental science officers, medics, 

and leaders prior to training operations in tick habitat 

to increase awareness and personal protective measures 

needed to minimize the transmission of TBDs.

The surveillance activities initiated by PHCR-W have 

also detected ticks transported on pets from other areas 

of the world, including German ticks on MWDs arriving at Joint Base Lewis-McCord (JBLM) and Beale Air 

force Base, an African tick off a tortoise in Washington 

state, a Missouri tick off of a MWD to JBLM, and a tick 

from the state of Georgia transported to Arizona during 

a PCS move. These examples highlight the importance 

of maintaining active surveillance and expanding tick 

testing capabilities for newly emerging TBD pathogens.
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

Equally important to increasing laboratory capabilities 

for the detection of TBDs is the assurance of reasonable but quick turnaround times for laboratory results. 

The public health value of any information gained from 

laboratory tests diminishes quickly over time. Further, 

customers who receive reports weeks or months after 

submitting specimens will be less likely to continue to 

make the effort to collect and send ticks to public health 

entities. Promptly detecting pathogens in submitted 

ticks is important in making determinations of the risk 

of TBD in military personnel, dependents, companion 

animals, and MWDs. It is also crucial in the planning 

and timing of disease control efforts, including vector 

control and educational activities. Public Health Command Region-West provides TBD laboratory analysis 

results in pathogen-specific reports that include tick 

collection data (species, site, collection date), laboratory 

analysis findings (positive or not detected), and recommendations on continued surveillance.

The prevention of TBDs is based on personal protective 

measures, landscape and environmental measures, and 

preventive treatments to ensure that infected ticks do 

not bite people or animals.The determination of disease 

risk and the employment of environmentally and economically sound tick control methods effectively result 

from TBD surveillance. Possibly of even greater importance, information acquired through tick surveillance 

can bolster public education and improve the awareness 

and health literacy of the military community regarding 

TBDs. Properly informed and aware personnel make 

more intelligent decisions about activities that put them 

at risk of TBD exposure and the personal protective 

measures that can be taken to reduce that risk. Clinical, 

preventive medicine, veterinary, pest management, and 

Army Public Health Command personnel must work cooperatively to improve the knowledge of tick species distributions and the incidence of the diseases they transmit. Liaisons with these entities and with state and local 

public health departments should also be established.

Conclusion

Ticks are one of the major vectors of disease that threatens military personnel, families, and civilian employees on US military installations.25 The presence of tickborne disease in military personnel, including our military working animals, may result in the loss of training 

days, decreased force strength, and may adversely affect unit readiness and effectiveness. Tick-borne disease 

also affects DoD civilians and the families of our troops. 

Soldier and unit readiness may be affected when family members and companion animals are sickened by 

TBDs. The information gained from tick surveillance 

regarding tick vectors, disease incidence, and pathogen 

prevalence is invaluable. It allows medical personnel to 

educate personnel regarding tick-bite and TBD recognition and prevention. Tick surveillance information also 

enables leaders to make decisions regarding the application of safety and control measures during training 

and operations to prevent TBDs. As with any disease, 

prevention of TBDs is highly preferable to treating the 

short- and long-term consequences once they occur.1(p155)

References

1. Institute of Medicine. Critical Needs and Gaps in 

Understanding Prevention, Amelioration, and Resolution of Lyme and Other Tick-Borne Diseases: 

The Short-Term and Long-Term Outcomes: Workshop Report. Washington, DC: Washington, DC: 

The National Academies Press; 2011. Available at: 

http://www.nap.edu/catalog/13134/critical-needsand-gaps-in-understanding-prevention-ameliora

tion-and-resolution-of-lyme-and-other-tickbornediseases. Accessed December 1, 2014.

2. Armed Forces Pest Management Board Technical 

Guide No. 26. Tick-borne Diseases: Vector Surveillance and Control. Silver Spring, MD: Armed 

Forces Pest Management Board Information Services Division; 2012. Available at: http://www.af

pmb.org/sites/default/files/pubs/techguides/tg26.

pdf. Accessed December 1, 2014.

3. Animal and Plant Health Inspection Service; Veterinary Services. Controlling Cattle Fever Ticks 

Factsheet. Washington, DC: US Department of 

Agriculture; August 2010. Available at: http://www.

aphis.usda.gov/publications/animal_health/con

tent/printable_version/cattle_fever_ticks.pdf. Accessed December 1, 2014.

4. Moczygemba J, Hewitt D, Campbell T, et al. Home 

ranges of the Nilgai antelope (Boselaphus tragocamelus) in Texas. Southwest Nat. 2012;57(1):26-30.

5. Madder M, Pascucci I. Factors Influencing the 

spread and distribution of ticks. In: Salman M, 

Tarrés-Call J, eds. Ticks and Tick-borne Diseases: 

Geographical Distribution and Control Strategies 

in the Euro-Asia Region. Boston, MA: CABI Publishing; 2013;27-32.

6. The TickApp for Texas & the Southern Region: 

Gulf Coast tick [internet]. The Texas A&M University System Web site; 2011. Available at: http://tick

app.tamu.edu/ticks/gulfcoasttick.php. Accessed 

August 29, 2014.

7. Florin D, Brinkerhoff R, Gaff H, et al. Additional 

US collections of the Gulf Coast tick, Amblyomma maculatum (Acari: Ixodidae), from the State 

of Delaware, the first reported field collections of 

adult specimens from the State of Maryland, and 

data regarding this tick from surveillance of migratory songbirds in Maryland. Syst Appl Acarol. 

2014;19(3):257-262.

TICK-BORNE DISEASE SURVEILLANCE
January – March 2015 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

8. Centers for Disease Control and Prevention. Lone 

star tick a concern, but not for Lyme disease [internet]. October 21, 2011. Available at: http://www.cdc.

gov/stari/disease/. Accessed September 17, 2014.

9. Ginsberg H, Faulde M. Ticks. In: Bonnefoy X, 

Kampen H, Sweeney K, eds. Public Health Significance of Urban Pests. Copenhagen, Denmark: 

WHO Regional Office for Europe; 2008:304-346.

10. Connally NP, Durante AJ, Yousey-Hindes KM, 

Meek JI, Nelson RS, Heimer R. Peridomestic 

Lyme disease prevention: results of a population-based case - control study. Am J Prev Med. 

2009;37(3)201-206.

11. Nicholson WL, Sonenshine DE, Lane RS, Uilenberg G. Ticks (Ixodidae). In: Mullen G, Durden L, 

eds. Medical and Veterinary Entomology. 2nd ed. 

London, UK: Academic Press; 2009:483-532.

12. Sonenshine DE, Anderson JM. Mouthparts and 

digestive system: anatomy and molecular biology 

of feeding and digestion. In: Sonenshine DE, Roe 

RM, eds. Biology of Ticks. 2nd ed. New York, NY: 

Oxford University Press; 2014;122-162.

13. United States Air Force Guide to Operational 

Surveillance of Medically Important Vectors and 

Pests-Operational Entomology. Ver 2.1. Washington, DC: Dept of the Air Force; August 15, 2006.

Ver. 2.1. Available at: http://www.afpmb.org/sites/

default/files/pubs/guides/operational_surveillance_

guide.pdf. Accessed December 2, 2014.

14. Glickman L, Rhea S, Glickman S, Waller A, Ising 

A, Engel J. Canine tick diagnoses are a sentinel 

for tick-borne diseases in people. Adv Dis Surveill. 

2008;5:176.

15. McKenna M. The advance of ticks: new areas, new 

diseases, and a weird allergy to meat [internet]. 

Wired Science Blogs. December 28, 2012. Available 

at: http://www.wired.com/wiredscience/2012/12/

ticks-new-meat/. Accessed August 30, 2014.

16. Shapiro M, Fritz C, Tait K, et al. Rickettsia 364D: a 

newly recognized cause of eschar-associated illness 

in California. Clin Infect Dis. 2010;50(4):541-548.

17. California Department of Public Health. Laboratory testing for spotted fever rickettsiosis. Richmond, CA: Viral and Rickettsial Disease Laboratory Branch/Division of Communicable Disease 

Control. July 2012. Available at: http://www.cdph.

ca.gov/programs/vrdl/Documents/VRDLTesting

forSpottedFeverGroupRickettsia_FINAL.pdf. Accessed December 1, 2014.

18. Parola P, Paddock CD, Socolovschi C, et al. Update on tick-borne rickettsioses around the world: 

a geographic approach. Clin Microbiol Rev. 

2013;26(4):657–702.

19. Mediannikov O, Paddock CD, Parola P. Other rickettsiae of possible undetermined pathogenicity. In: 

Raoult D, Parola P, eds. Rickettsial Diseases. 1st ed. 

New York, NY: Informa Healthcare; 2007:163-177.

20. Savage HM, Godsey MS Jr, Lambert A, et al. 

First detection of heartland virus (Bunyaviridae: 

Phlebovirus) from field collected arthropods. Am J 

Trop Med Hyg. 2013;89(3):445-452.

21. Pritt BS, Sloan LM, Johnson DK, et al. Emergence of a new pathogenic Ehrlichia species, 

Wisconsin and Minnesota, 2009. N Engl J Med. 

2011;365(5):422-429.

22. Stromdahl E, Hamer S, Jenkins S, et al. Comparison of phenology and pathogen prevalence, including infection with the Ehrlichia muris-like (EML) 

agent, of Ixodes scapularis removed from soldiers 

in the midwestern and the northeastern United 

States over a 15 year period (1997-2012). Parasit 

Vectors. 2014;7(1):553 (Epub ahead of print).

23. Castillo CG, Eremeeva ME, Paskewitz SM, et al. 

Detection of human pathogenic Ehrlichia murislike agent in Peromyscus leucopus. Ticks Tick 

Borne Dis. In press.

24. McMullan LK, Folk SM, Kelly AJ, et al. A new 

phlebovirus associated with severe febrile illness 

in Missouri. N Engl J Med. 2012;367(9):834-841.

25. Beard CB, Strickman D, eds. Federal Initiative: 

Tick-borne Disease Integrated Pest Management 

White Paper. Washington, DC: Federal Tick-Borne 

Disease Integrated Pest Management Workgroup; 

2014. Available at: http://www.epa.gov/pestwise/

ticks/tick-ipm-whitepaper.pdf. Accessed December 1, 2014.

Authors

MAJ Petersen is Officer-in-Charge, Laboratory Sciences 

Division, US Army Public Health Command RegionWest, Joint Base Lewis-McChord, Washington.

CPT Foster is assigned to the Entomological Sciences 

Program, US Army Public Health Command RegionSouth, Joint Base San Antonio Fort Sam Houston, Texas.

1LT McWilliams is Officer-in-Charge, Entomological 

Sciences Program, US Army Public Health Command 

Region-West, Joint Base Lewis-McChord, Washington.

Mr Irwin is assigned to the Entomological Sciences Program, US Army Public Health Command Region-West, 

Joint Base Lewis-McChord, Washington.
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

Many recent veterinary school graduates will recall 2 

pieces of advice; “when you hear hoof beats, think horses, not zebras,” and “the simplest explanation is usually 

the correct one.” In any medical field, these “tidbits” 

are crucial to keeping providers’ differential diagnosis 

list concise and making sure it is prioritized correctly. 

When teaching new veterinary or medical students, it 

is logical that one should not spend as much time on 

diseases that they are less likely to see in practice. For 

example, veterinary students outside of the Pacific 

Northwest may only learn about Salmon Poisoning Disease (SPD) in the theoretical sense as they may never 

see a case during their studies, let alone treat a patient 

while in school. SPD is a disease caused by the bacterium Neorickettsia helmintheoca which is carried by 

the fluke, Nanophyetus salminocola. The fluke is found 

most classically in salmon, which is why the disease is 

so common in the Pacific Northwest. Thus, veterinary 

students in that area will be far more likely to see and 

treat the disease while in school than their colleagues 

in other locations. It causes a sudden onset of vomiting, 

diarrhea, decreased appetite and lethargy, and is often 

fatal without appropriate treatment.1 The importance of 

this geographic bias is illustrated by the experiences of 

a recent Veterinary Corps officer (VCO) at Joint Base 

Lewis-McChord (JBLM) who saw a 3-year-old female 

spayed Labrador presenting for vomiting, diarrhea, and 

decreased appetite of about 5 days duration. The VCO 

considered the typical differentials; foreign body, gastroenteritis, infectious causes, nongastrointestinal signs, 

but did not consider SPD as she went to school in another 

area and was thus unfamiliar with the disease. Luckily a 

senior clinician at the clinic brought SPD to the VCO’s 

attention. The diagnosis was confirmed and the dog was 

treated successfully. This example serves as a reminder 

to clinicians that geographical bias can preclude the correct diagnosis.

Army VCOs must ensure they account for their regional 

biases when seeing patients. Due to the international 

and mobile nature of the Department of Defense and 

its members, these geographic “zebras” are even more 

likely to walk into our exam rooms. Recognizing and 

addressing these biases is important, not only for treating the individual patient but also for general public 

health. Many of the diseases discussed below are communicable and potentially zoonotic. When we are asking questions about a pet’s history and performing our 

physical exam, we must recognize our own biases and 

remind ourselves to use a problem-oriented approach to 

our patients. In doing so, we can remind ourselves that 

while those biases might be valid in certain situations, 

they may hinder an accurate diagnosis in another. Furthermore, we must consider diseases that are endemic 

in the patient’s previous geographic location or areas to 

which the pet may have traveled. Remembering our biases and considering travel will help practitioners manage their differential diagnosis list.

Recognizing Bias and Uncovering “Zebras”

As explained above, certain diseases are not discussed 

in detail at veterinary schools in different geographical locations because they are absent or have a very 

low prevalence which may lead to a basic geographical 

bias preventing us from considering different causative 

agents. Veterinary clinicians may leave certain diseases 

off of their differential diagnosis list because they have 

not considered travel (whether international or within 

the United States). This travel may be by the presenting 

animal, disease vectors, owners, or other domestic and 

wild animals with which the patient had contact. Failure 

to account for this geographic bias may result in numerous diseases not considered, although those diseases 

could be the cause of the patient’s clinical signs.

One source of bias is failure to account for the international movement of humans and animals from areas 

with different endemic diseases. For example, rabies 

has been around for thousands of years and has great 

public health significance, but it is often not included 

on differential diagnoses lists for neurologic canine patients within the United States. International travel allows rabies to enter new geographic regions, and should 

make it mandatory to include on the differential diagnosis list for any animal with neurologic symptoms. The 

canine rabies virus variant, associated with dog-to-dog 

Managing Your Differential Diagnosis List:

 Considering Bias and Recognizing

 Unexpected Infectious Agents

CPT Lauren Seal, VC, USA

CPT Aimee Hunter, VC, USA
January – March 2015 57

transmission, is most often responsible for the estimated 

55,000 human rabies virus deaths worldwide each year.2

By contrast, there were 5,000 rabid dogs reported in the 

United States in 1950. That number was down to 79 in 

2006, when the canine rabies virus variant was declared 

eradicated in the United States.3 Today, rabies is well 

controlled in the United States due to effective and readily available vaccines along with stray animal control. 

Consequently, when presented with a neurologic case in 

the United States, many clinicians may not initially consider rabies as a possible differential. However, recent 

events have served as reminder to the military importance of rabies. This disease is enzootic in the Middle 

East where many of our Soldiers deploy. Unfortunately, 

Soldiers may not understand why they are not allowed 

to keep stray dogs as pets; the stray dog may remind 

them of home, and they are often very resentful when 

these “pets” are removed. In fact, there are several organizations who are dedicated to bringing these stray 

dogs from the Middle East to the United States, and 

other countries, to be reunited with the Soldiers. This 

action has directly resulted in at least one case of a rabid dog being imported into the United States, and the 

exposure of numerous American citizens to the deadly 

rabies virus.4 The act of keeping pets while deployed, 

although against policy, has also resulted in the unfortunate and unnecessary death of a Soldier from rabies and 

countless others receiving postexposure prophylaxis; a 

treatment which can be both painful and expensive.5 It 

is so important for Veterinary Corps officers and other 

medical providers to understand the prevalence of rabies and other endemic diseases where our Soldiers deploy, when considering differential diagnoses. This is 

also a concern for civilian veterinarians as they are even 

less likely to include foreign diseases such as rabies on 

a differential list, but it is possible for them to see a dog 

adopted from an area where those diseases are endemic. 

Rabies is a real possibility, even in the United States, 

when you consider the mobility of our population and 

the possibility of international travel.

But there are also other “zebras” to consider which are 

far more likely within the United States, but are still 

often overlooked due to “localized” geographical location. Lyme disease, for example, is caused by Borrelia 

burgdoferi, a bacterium carried by the Ixodes tick, the 

most common in the United States being I scapularis

and I pacificus. Previously, Lyme disease has had a few 

endemic areas of the United States, most commonly in 

the northeast (by far the most common location), while 

also being reported with some frequency in Wisconsin, 

Minnesota, California, and Oregon.6 Recent surveillance 

data indicates that Lyme disease is increasing in terms 

of reported cases, as shown in the Table.7 A review of 

Centers for Disease Control and Prevention data clearly 

shows an expansion (illustrated in the Figure) of Lyme 

from those previously endemic areas to many cases in 

previously unaffected states as it is now present in all 

of the lower 48 states. Over the last few decades, Lyme 

disease has spread for a variety of reasons including 

temperature, moisture, forest cover, and population density. All of these factors were used by the Companion 

Animal Parasite Council to predict the spread of Lyme 

disease occurrence within the United States.8 Lyme 

disease can present with numerous signs including fever, lameness, anorexia, lethargy, and lymphadenopathy, and may or may not present with swollen joints.1

These general signs can make the disease somewhat 

challenging to diagnose. But, there are risk factors to 

help clinicians determine likelihood of infection. One 

study evaluated the potential predictive value of canine 

seroprevalence as it relates to human cases of Lyme disease in a given county. The study found that there was 

correlation between canine seroprevalence and human 

incidence. Specifically, the presence of Lyme in more 

than 5% of dogs was associated with human Lyme incidences that were above average—the median number 

of human cases increased by more than 20 individuals 

(compared to a canine seroprevalence of 1.1% to 5%).9

However, a much earlier study (1991)10 was not able to 

prove the same association between canine and human 

cases. (It is important to note that the studies were performed 10 years apart and on different continents, so 

it is possible that the predictive value of canine Lyme 

cases is very location-dependent.) However, the earlier 

study still concluded that canines are good sentinels for 

human cases, given that they are much more likely to 

come in contact with the tick vector. They are, therefore, 

more likely to be infected early after the vector enters 

their geographic location.

Chagas’ disease is another example of a diagnosis that can 

be missed due to geographical bias, and, according to the 

World Health Organization, its distribution is expanding 

due to the movement of people from Latin American to 

other locations around the world.11 It is a parasitic disease 

caused by Trypanosoma cruzi that initially presents with 

fever, lymphadenopathy, and hepatosplenomegaly, along 

with other general symptoms.7 The protozoa are spread 

by the Reduviidae or triatomine (kissing bug). Among 

humans, Chagas’ disease is the most common cause of 

congestive heart failure in the world.12 Within endemic 

areas, the disease has moved from the more rural areas 

into cities via human migration.13 The infection has also 

been shown to spread into many southern states in the 

United States from Georgia to California because of the 

high population of animals involved in the protozoa’s 

life cycle: raccoons, opossums and canines. It is also 
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

important to remember that eleven different species of 

the triatomine bug are present in the United States. Bern 

et al. noted that “there are more than 130 triatomine species in the Americas, many of which can be infected by 

and transmit T cruzi.”14 This is particularly concerning 

given the risk of long-term carriers with Chagas’ disease. 

Studies have proven that a chronic phase of infection 

is possible in humans and they can serve as reservoirs 

for subsequent T cruzi infections.15 It is theorized that 

chronically infected canines may also serve as potential reservoirs for canine and human disease transmission.16 The US Department of Defense trains all of its 

military working dogs (MWDs) at Lackland Air Force 

Base (AFB) in San Antonio, Texas, where the disease is 

endemic. These MWDs are potentially exposed to Chagas’ disease during training, and could serve as potential reservoirs for disease transmission at their new duty 

site, particularly if the MWDs are asymptomatic prior to 

their permanent change of station move. Multiple dogs 

previously located at Lackland AFB have tested positive 

for Chagas’ antibody, and at least one MWD has died of 

the myocardial effects of the disease (unpublished data, 

Department of Defense Military Working Dog Hospital, 

2014). Thus, VCOs in all areas of the United States must 

consider Chagas’ as a diagnosis.

New or emerging diseases in certain areas of the world 

are also concerning given human animal and human 

travel. Leishmaniasis is endemic in several regions 

throughout the world including locations where US military personnel and animals are stationed (eg, Middle 

East, southern Europe).15 A case of canine leishmaniasis was recently diagnosed at the Joint Base LewisMcChord Veterinary Center in Washington state. The 

patient was a 2-year-old male mixed-breed dog who 

initially presented to a civilian veterinarian for inability 

to gain weight, lethargy, and decreased appetite. A thorough history revealed that the dog was adopted from Afghanistan. Unfortunately, no records were available as 

to whether the dog received a health examination by an 

accredited veterinarian prior to travel or whether he was 

healthy and free of disease at that time, though the adoption agency stated that animals are free of clinical signs 

prior to entry into the United States. He was started on 

antibiotics, but because he showed no improvement, the 

clients brought him to the Joint Base Lewis-McChord 

clinic for a second opinion. At the second presentation, 

he had persistent weight loss in addition to 2 mm to 5 

mm white nodules around his eyes and on his muzzle. 

These nodules were aspirated and contents examined 

under microscopy where it was revealed that they contained the protozoon that causes leishmaniasis, which 

is an obligate intracellular parasite. The patient was 

started on oral medications based on case reports using the medications available. Later, the client opted to 

move to a civilian clinic and at last follow-up was doing 

very well, gaining weight, increased energy, and ownerperceived less pain.

Geographic distribution of cases of Lyme disease reported in the United States in 2001 and 2013 respectively. One dot is 

placed randomly within the county of residence for each confirmed case. Data from Centers for Disease Control and Prevention (http://www.cdc.gov/lyme/stats/maps/interactiveMaps.html).

2001 2013

Cases of Lyme disease reported in the United States for each of the years 2001 through 2013. Data from Centers 

for Disease Control and Prevention (http://www.cdc.gov/lyme/stats/index.html).

Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Total

Reported

Cases

17,029 23,763 21,273 19,804 23,305 19,931 27,444 28,921 29,959 22,561 24,364 22,014 27,203

MANAGING YOUR DIFFERENTIAL DIAGNOSIS LIST:

CONSIDERING BIAS AND RECOGNIZING UNEXPECTED INFECTIOUS AGENTS
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THE ARMY MEDICAL DEPARTMENT JOURNAL

As previously mentioned, leishmaniasis is a disease of 

military importance; more than 600 soldiers have been 

diagnosed with the cutaneous form of the disease after deployments to Iraq, Kuwait, and Afghanistan.17

Clearly, human and animal travel is playing a role in 

the expanding distribution of leishmaniasis cases at diagnosis. Leishmaniasis is a disease caused by the protozoa, Leishmania spp and it is spread by the sand fly.1

Numerous different species of the protozoa have been 

known to cause infection including L major and L tropica which tend to cause the cutaneous form, and L infantum and L donovani which cause the visceral form.15

This has typically only been found in areas where the 

sand fly is established. But there is the possibility of 

spread without the sand-fly vector. One meta-analysis 

explained that dogs can spread the disease sexually or 

transplacentally.18 Additionally, while direct zoonotic 

transmission is believed to be a rare occurrence,19 there 

are phlebotomine sand files (genus Lutzomyia) within 

the United States.20 While a competent vector has not 

been identified, vector-borne transmission is nonetheless theoretically possible. All of these issues mean that 

leishmaniasis has potential to become an issue for both 

veterinary and human medicine in the United States, 

which could pose challenges for clinicians in diagnosis 

and successful treatment, especially considering that 

medications for treatment are not readily available in 

the United States. Late diagnosis could therefore be catastrophic for a patient in that treatment could be delayed 

and insufficient.

Management of Differential Lists

How does the clinician manage a differential diagnosis 

list when theoretical possibilities are almost endless? 

The most important management tool is a thorough history. It is crucial that the clinician determines any travel 

history, human or animal, since all diseases discussed 

here are a concern for both human and animal health, 

and most are zoonotic. Another possibility is to recommend preventive measures for disease even when not in 

an area considered endemic. For example, should military veterinarians recommend a Lyme disease vaccine 

to all patients, even in those areas where Lyme is not 

considered endemic? In addition, clinicians must consider diagnostics, such as the bloodwork, imaging, or 

cytology that may help to diagnose a disease that may 

not even be on their differential list. This means considering tests that give enough information to direct 

later diagnostics and remembering to use the problemoriented approach. Even basic tests such as in-house cytology can be crucial in identifying certain infectious 

diseases, including parasites or fungus. Finally, VCOs 

as well as other clinicians must maintain an open line of 

communication, meaning that we need to discuss cases, 

write case-reports, and otherwise keep our colleagues 

informed of new diseases within a geographic location. 

This will help our colleagues keep these “zebras” in 

mind.

In Summary

Every day, providers must manage cases based on the 

most likely explanation for the information presented. 

But, it is the responsibility of the provider to ensure that 

all of the needed information is attained. We are constantly biased by various factors as clinicians, including 

geographic location (as the examples above illustrate). 

Providers must ensure that these “zebras,” and others 

like them, are always kept on our differential diagnosis 

list. It is also crucial to ensure that the historical information is complete and the physical exam is thorough. 

In truth, rabies virus must also be on the differential for 

a dog with unknown vaccination history with neurologic symptoms, and SPD should be on the list for any dog 

that is vomiting. How far up we rank them on the list of 

differential diagnoses depends on how thoroughly we 

conduct our patient histories and account for potential 

geographic biases. Only by doing so can we endeavor 

to reach the correct diagnoses in time to implement appropriate treatment.

References

1. Kahn CM, Line S, eds. The Merck Veterinary Manual. 9th ed. New York: John Wiley & Sons, Inc; 

2005.

2. 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_%2006_05.

pdf. Accessed December 3, 2014.

3. Blanton JD, Hanlon CA, Rupprecht CE. Rabies 

surveillance in United States during 2006. J Am 

Vet Med Assoc. 2007;231(14):540-556.

4. Centers for Disease Control and Prevention. 

Rabies in a dog imported from Iraq--New Jersey, June 2008. MMWR Morb Mortal Wkly Rep. 

2008;57(39):1076-1078.

5. Centers for Disease Control and Prevention. 

Imported human rabies in a US Army Soldier – 

New York, 2011. MMWR Morb Mortal Wkly Rep. 

2012;61(17):302-305.

6. Heymann DL, ed. Control of Communicable Diseases Manual. 18th ed. Washington, DC: American 

Public Health Association; 2004.

7. Centers for Disease Control and Prevention. Lyme 

Disease [internet]. Available at: http://www.cdc.

gov/lyme/stats/maps/interactiveMaps.html. Accessed October 20, 2014.
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

8. Little SE, Lund C, DeBess E. Lyme disease is 

expanding its range westward in 2014 [internet]. 

Companion Animal Parasite Council Web site; 

2014. Available at: http://www.capcvet.org/expertarticles/lyme-disease-is-expanding-its-range-west

ward-in-2014/. Accessed December 3, 2014.

9. Mead P, Goel R, Kugeler K. Canine serology as adjunct to human Lyme disease surveillance. Emerg 

Infect Dis. 2011;17(9):1710-1712.

10. Lindenmayer JM, Marshall D, Onderdonk AB. 

Dogs as sentinels for Lyme disease in Massachusetts. Am J Public Health. 1991;81(11):1448-1455.

11. WHO Fact Sheet No. 340: Chagas’ disease (American trypanosomiasis) [internet]. World Health Organization Web site; 2014. Available at: http://www.

who.int/mediacentre/factsheets/fs340/en/. Accessed December 3, 2014.

12. Barr S. Canine Chagas’ disease (American trypanosomiasis) in North America. Vet Clin North 

Am Small Anim Pract. 2009;39(6):1055-1064.

13. Bern C, Kjos S, Yabsley MJ, Montgomery SP. Trypanosoma cruzi and Chagas’ Disease in the United 

States. Clin. Microbiol. Rev. 2011;24(4):655-681.

14. Sarkar S, Strutz SE, Frank SM, Rivaldi CL, Sissel B, Sanchez-Cordero V. Chagas disease risk in 

Texas. PLos Negl Trop Dis. 2010;4(10):e836.

15. Shanks GD, Karwacki JJ, Kanesa-thasan N, et al. 

Diseases transmitted primarily by arthropod vectors. In: Kelley PW, ed. Military Preventive Medicine: Mobilization and Deployment. Vol 2. Fort Sam 

Houston, TX: The Borden Institute; 2005:803-936.

16. Crisante G, Rojas A, Teixeira MM, Añez N. Infected dogs as a risk factor in the transmission of 

human Trypanosoma cruzi infection in western 

Venezuela. Acta Trop. 2006;98(3):247-254.

17. Weina PJ, Neafie RC, Wortmann G, Polhemus M, 

Aronson NE. Old world leishmaniasis: an emerging 

infection among deployed US military and civilian 

workers. Clin Infect Dis. 2004;39(11):1674-1680.

18. Quinnell RJ, Courtenay O. Transmission, reservoir 

hosts and control of zoonotic visceral leishmaniasis. Parasitology. 2009;136(14):1915-1934.

19. Ferrer L. Canine leishmaniais: overview. Clinician’s Brief [serial online]. April 2013. Available 

at: http://www.cliniciansbrief.com/article/canineleishmaniasis-overview. Accessed December 3, 

2014.

20. Mann RS, Kaufman PE, Bulter JF. Feature Creatures: sand fly [internet]. University of Florida 

Web site; 2013. Available at http://entnemdept.ufl.

edu/creatures/misc/flies/Lutzomyia_shannoni.htm. 

Accessed October 29, 2014. 

Authors

CPT Seal is Veterinary Officer-in-Charge of the Veterinary Section, Naval Submarine Base Kings Bay, Georgia.

CPT Hunter is Chief of Veterinary Services Fort Bliss 

Branch, Texas.

Articles published in the Army Medical Department Journal are indexed 

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

database of life sciences and biomedical information. Inclusion in the 

MEDLINE database ensures that citations to AMEDD Journal content will 

be identified to researchers during searches for relevant information using any 

of several bibliographic search tools, including the NLM’s PubMed service.

MANAGING YOUR DIFFERENTIAL DIAGNOSIS LIST:

CONSIDERING BIAS AND RECOGNIZING UNEXPECTED INFECTIOUS AGENTS
January – March 2015 61

Department of Defense Directive 6400.04E1 designates 

the Secretary of the Army as the Department of Defense 

(DoD) Executive Agent for DoD veterinary public and 

animal health services. This directive is accomplished 

through the Army Veterinary Services which operates 

military veterinary facilities throughout the United 

States (including Alaska, Guam, Hawaii, and Puerto 

Rico), as well as in countries in Europe and the Pacific. 

Although these facilities are maintained to provide veterinary care to the DoD military working dogs (MWDs), 

but they also provide veterinary care to pets of military 

service members and beneficiaries, such as retirees, as 

mission priorities permit. While the geographic dispersion of the veterinary facilities is necessary to ensure 

MWDs have timely access to veterinary care, it does 

present challenges, particularly regarding centralized 

practice management.

Although all US Army veterinary facilities were using 

a commercial veterinary practice management software program for their patient encounters, the clinics 

were still reliant on paper records for patient files prior 

to 2014. While the reliance on paper record systems is 

associated with notable limitations such as difficulty 

transferring radiographs and laboratory results, loss of 

files during moves, and time-consuming data mining, it 

was necessary due to DoD data network restrictions like 

prohibition of automatic third party software updates. 

Additional limitations of the previous system included 

impaired disease surveillance, network management, 

and standardization efforts due to the lack of centralized data reporting. In recognition of these restrictions 

and limitations, the US Army Veterinary Service began 

exploring options for a veterinary electronic health record (EHR) in 2003.

A primary prerequisite for the program was that it be 

100% web-based with no end user software installation 

requirement. This was particularly important as the 

Veterinary Service provides veterinary support for all 

military services, not just the Army. By stipulating a 

no-end user software requirement, the Veterinary Service minimized potential issues with individual military 

service and installation specific information technology 

requirements. Although not a primary requirement, the 

program also had to support a geographically dispersed 

global practice, something not typically necessary for 

most veterinary EHRs.

The Veterinary Service received 7 competing proposals 

for the original request for proposals, however, only two 

of them met the primary requirements. Initially, a commercial, veterinary-specific product was identified as a 

potential solution. However, when the product failed initial testing, the Veterinary Service sought to modify another product which had been previously developed for 

the military, HEALTHeFORCES (HEALTHeSTATE, 

LLC, Fairfax, VA). HEALTHeFORCES was the EHR 

for the North Atlantic Regional Medical Command 

from 1999 until 2004, when it was replaced by AHLTA 

as the DoD Enterprise System. Following its replacement, HEALTHeFORCES was transitioned for use in 

43 federal and community health centers within West 

Virginia as HEALTHeWV,2 strictly as an EHR with no 

practice management components.

HEALTHeWV was modified to make it a veterinary 

EHR subsequent to its selection. Four new practice 

management components (scheduling, inventory management, invoicing, and reporting) were added as part of 

the modification. The modified product was designated 

the Remote Online Veterinary Record (ROVR). Veterinary personnel participated in all ROVR design meetings and the software qualification test was performed 

by personnel from 5 different military veterinary treatment facilities and by the Veterinary Services Central 

Fund staff (LTC K. Burkman, ROVR Program Officer, 

email, October 24, 2014). The application was beta tested at 4 locations for 3 to 6 months and independently 

tested by the Army Medical Department Board at the 

Fielding the Remote Online Veterinary

 Record, a Veterinary Electronic Health

 Record to Improve Patient Care and

 Practice Management

CPT Meghan C. Nelson, VC, USA

LTC Ronald L. Burke, VC, USA
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

Army Test and Evaluation Center to ensure it legally met 

all operational contract requirements prior to full operational fielding in 2014.

The vendor was responsible for the design, development, 

and delivery of the training required for implementing 

this program DoD-wide. Initially, a plan was developed 

to train all personnel at a central location within each US 

Army Public Health Command District. However, due to 

funding restrictions, participation was reduced to only 

key personnel (ie, clinic veterinarian, senior technician, 

and senior receptionist) from each location being trained 

in a geographically tiered method at 42 different sites in 

a train-the-trainer approach. The goal of these training 

sessions was to have no more than 15 personnel at each 

site attending the training to maximize student-trainer 

interaction. The vendor created a training environment 

for users to practice all of the functions without creating real charges or making false medical records within 

the active production environment. The key personnel 

subsequently trained individuals who did not attend the 

initial training. This training was facilitated by an extensive training module incorporated within the ROVR 

application to be used to provide such on-site training.

The key personnel training program encompassed 5 

days of hands-on learning designed to provide a general 

working knowledge of the program’s functional capabilities. Each day was dedicated to a different aspect of the 

program, allowing the new users to experience the entire 

program prior to implementing the application within 

their home veterinary facility. Key aspects of the training focused on the basic functionality of the application, 

including scheduling and patient administration, inventory management, invoicing and financial management, 

data warehousing and reporting, and the capture, storage, retrieval, and reporting of clinical episodes of care.

A large amount of time was dedicated to the use of the 

eNOTE, which is the actual medical documentation 

of the veterinary encounter. Within this portion of the 

EHR, illustrated in the Figure, the user can record all aspects of the encounter from the patient’s medical history 

to the findings, diagnosis, and treatment. Significant 

time is also spent reviewing the patient registry functions in ROVR (diabetes, MWD, and screening registries) which allow users to quickly and easily monitor 

patient populations to ensure they are meeting specific 

health goals, such as food consumption, body condition, 

and body weight.

Veterinary facilities were required to use ROVR as their 

sole medical record and practice management program 

upon completion of the training course. Productivity 

goals were established to allow the clinics to initially 

start running at 25% of their normal capacity the first 

week using the program, 50% the next, 75% the third 

week, and be fully operational using the application by 

the fourth week.

Benefits of a Veterinary Electronic Health Record

Perhaps the most important, but as of yet unrealized, 

benefit of ROVR is enhanced disease surveillance. The 

Daniel E. Holland MWD Hospital at Lackland Air 

Force Base, Texas, serves as the DoD role 4 facility for 

veterinary care. It also serves as the storehouse for all 

MWD patient records after the animal has retired from 

military service into adoption, as well as the MWD serum repository. Veterinary epidemiologists have previously used these records and serum to examine morbidity and mortality trends in MWDs, including potentially 

zoonotic diseases.3-5 However, the studies were often 

retrospective, which present limitations with regard to 

developing timely policies designed to limit future diseases. By contrast, veterinary EHRs have the potential 

to significantly improve the ability of public health personnel to identify and monitor disease trends.6

 In fact, 

veterinary EHRs have previously been used to examine 

whether companion animals can be used as sentinels for 

zoonotic diseases such as Lyme disease and leptospirosis.7

 With the implementation of ROVR, the Veterinary 

Service now has the ability to conduct similar surveillance among MWDs and also among privately-owned 

animals. The ROVR provides clinicians with dropdown selection menus for diagnosing their patients, as 

well as capturing the patient’s signs and symptoms. Users can then query ROVR using keywords to compile a 

report. The information can be used to identify diseases 

affecting our pets and military working animals, as well 

as zoonotic diseases which may affect the service member. This allows preventive measures to be implemented 

in a timely manner to prevent future cases. Importantly, 

ROVR has the ability to not only conduct near-real time 

disease surveillance using case diagnoses, but can also 

be used to conduct syndromic surveillance as well. For 

MWDs specifically, the data from ROVR can be combined with the aforementioned MWD serum repository 

to conduct seroepidemiologic studies to not only identify cases of disease, but risk factors as well.

One of the important, realized benefits of the ROVR 

system is enhanced portability of patient records. All 

MWDs begin their military service at Lackland Air 

Force Base with the 341st Training Squadron where they 

receive care at the Holland MWD Hospital. Upon completion of their training, the MWDs are assigned to other military installations. While the majority of MWDs 

will spend their entire service permanently assigned 

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TO IMPROVE PATIENT CARE AND PRACTICE MANAGEMENT
January – March 2015 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

to their respective second installations, a small subset 

will be stationed at several locations during the course 

of their years of service. The implementation of ROVR 

simplified medical records transfer during MWD reassignments and should reduce accidental record losses. 

Additionally, ROVR will hopefully improve the timeliness and ease of MWD teleconsultations and the records 

review required for all MWDs to ensure they are suitable candidates for adoption. Users can also build report 

functions within ROVR for management and review of 

MWD records.

The ROVR has similarly improved record portability 

for privately-owned animals when their military owners are reassigned. Unlike MWDs, privately-owned 

animals frequently leave and re-enter the military veterinary system, increasing the likelihood for paper record loss. Now ROVR allows a more thorough and well 

documented medical record to be in place for each pet, 

potentially covering their entire lifespan instead of having just a few small snapshots of history, as was the case 

with the old system.

With the fielding of ROVR, the established Army Veterinary Services pharmacy and retail formulary was 

further standardized and uniform prices were created 

for all services to provide clients with consistent charges, 

regardless of their assignment location. Most significantly, ROVR improved practice management. It enables the 

electronic transmission of all financial reports directly 

to the Veterinary Services Central Fund (VSCF). Additionally, while each clinic still maintains individual autonomy for their appointments and inventory, the VSCF 

can now easily look at these items as well to help identify and correct issues in real time. For example, the Appointment Statistics Report, shown in the Table, enables 

the VSCF to identify not only issues related to missed or 

canceled appointments, but also examine whether examination rooms are maximized and if changes to staffing 

are needed to optimize access to patient care.

Unanticipated Issues

As with any new program, unanticipated issues appeared during the fielding. One of the most significant 

issues was poor connectivity between some of the outlying sites and the ROVR server. During the beta testing, 

a 3-ping test was conducted at each location to ensure 

that the network would be able to support the workload 

estimated for DoD-wide use of the program. Unfortunately, the predictions underestimated the actual volume 

of users that used the server during a typical clinic day. 

Another factor which further degraded connectivity 

was clogged bandwidth at individual sites. Several veterinary clinics shared bandwidth with the local military 

The eNOTE function within the Remote Online Veterinary Record allows providers to enter all veterinary healthcare information for a patient visit. Each data entry tab has drop-down menus to standardize entry for subsequent data queries. 

Providers can also create autotext scripts to facilitate routine data entry.
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

medical treatment facilities that use AHLTA, which also 

requires considerable bandwidth for patient file transfers. In some locations, facilities were still using copper 

wire instead of fiberoptic cables. These limitations resulted in extremely long refresh times to toggle between 

the different aspects of the eNOTE, and occasionally resulted in application lockup at the point of entry.

In order to address this problem, the slower networks 

were identified and local information technology (IT) 

resources developed and incorporated upgrades. Fixes 

included upgrades to computer operating systems, better use of route and bridge space to support the clinics 

in the infrastructure, and installation of new fiberoptic 

cables. A continuous process is in place to work with all 

local IT departments to troubleshoot and provide better connectivity. Additional IT network solutions, discussed below, are also being examined to further improve connectivity.

Another issue that arose was the ROVRs incompatibility with Microsoft Internet Explorer (IE) 11. The ROVR 

was initially created to work with IE 8 and IE 9 which 

were the DoD standard at the time of its development. 

However, several installations have recently upgraded 

the operating systems to IE 11 which created an issue 

for facilities on those installations. Addressing this issue required an exemption so individual computers using ROVR would not be upgraded to IE 11 until ROVR 

is reprogrammed for compatibility.

Aside from network connectivity problems, some users 

found that the new eNOTE format required substantially 

more time for entry of all of the required information 

than did the previous record-keeping system. It is anticipated that this will improve as users gain familiarity 

with ROVR, especially the auto text and other timesaving features. Additionally, the program was initially 

designed to load smaller quantities of data in each tab 

of the eNOTE which required the user to toggle through 

several different tabs (Encounter, Clinical Summary, Exam/Assessment/Diagnosis, Standard Treatment 

Plan, Additional Treatment Plan, Laboratory Tests/

Radiographs) to enter patient examination findings. Efforts are currently underway to develop and test a new 

eNOTE template in which all exam room findings will 

be available on a single tab. This should eliminate the 

data lag delays associated with switching tabs.

Issues also arose with the veterinary formulary in 

ROVR. Prior to ROVR’s fielding, the Veterinary Medical Standardization Board had developed an approved 

formulary for all veterinary clinics. The most current 

version of the formulary was provided to the ROVR program developers, but changes were being incorporated 

into the formulary concurrent with ROVR development. 

This resulted in omission of new additions to the formulary when ROVR was initially fielded. Consequently, a 

clinic could not use a formulary-approved pharmaceutical which was not included in the ROVR inventory, even 

though it was in stock at the facility. It could only be 

used after it was added to the ROVR inventory in a future system update.

A ROVR help desk was created prior to launching the 

program to assist users with any issues that arose. Sites 

can submit requests to the help desk either electronically 

or telephonically. A configuration board subsequently reviews the request, and if approved, submits it to the vendor for implementation. The process has been fine-tuned 

and response tickets are now being addressed within 1 

to 4 hours as opposed to the initial 8 to 12 hours. Rules 

FIELDING THE REMOTE ONLINE VETERINARY RECORD, A VETERINARY ELECTRONIC HEALTH RECORD

TO IMPROVE PATIENT CARE AND PRACTICE MANAGEMENT

Appointment statistics for US Army Public Health Command District Joint Base Lewis-McChord, June 1–30, 2014, as 

obtained from the Remote Online Veterinary Record.

Facility Monthly

Capacitya Percentageof Capacityb

Kept No 

Show

Cancelled

by Facility

Cancelled

by Owner

Clinical Encounters

per Day:

Mean Value

Beale Air Force Base 360 30% 109 4 5 13 5.32

Fairchild Air Force Base 24 233% 56 1 2 4 2.73

Fort Richardson 360 112% 402 28 13 78 19.61

Fort Wainwright 540 41% 219 10 8 36 10.68

Joint Base Lewis-McChord 1200 45% 542 45 1 86 26.44

Mountain Home Air Force Base 360 51% 185 7 3 17 9.02

Naval Air Station Lemoore 360 52% 186 9 1 12 9.07

Naval Air Station Whidbey Island 540 39% 212 24 9 24 10.34

Naval Base Kitsap-Bangor 540 41% 224 13 1 46 10.93

Presidio of Monterey 24 504% 121 7 0 10 5.90

Travis Air Force Base 360 79% 284 23 3 20 13.85

a. Monthly capacity is a function of the facility tier level, number of examination rooms, and expected number of days open per month.

b. Percentage of capacity=kept appointments/monthly capacity
January – March 2015 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

have also been created for “pass through” incidents, allowing tickets that meet certain rule to go straight to the 

ROVR support team for immediate resolution. Examples include tickets pertaining to creating new accounts, 

a user changing facilities, or inactivating accounts.

To date there have been several new builds to streamline 

the program and fix reported issues. As of October 2014, 

a majority of the missing formulary inventory items 

have been added for use by clinics. Another significant 

change is the eNOTE function now contains canine dental images to more clearly document oral issues. Additional template forms such as phone consultations are 

being added on a regular basis to meet user demand.

Future Directions

Although establishment of the ROVR help desk and 

similar efforts have helped to address many of the issues with ROVR, additional work is still necessary. For 

example, while the connectivity issues have been eased 

with upgrades to operating systems and changes to network routing, they are not yet fully resolved. In addition 

to the previously mentioned improvements to local network infrastructure, other potential solutions currently 

under consideration include development of regional 

servers to reduce demand on the main server and function as back-ups, and creating the ability to store patient 

data locally to be uploaded to the server later when a 

network connection would not be required.

Another improvement currently under development involves patient care in a deployed setting. The ROVR 

was launched for a 30-day trial in theater with the 72nd 

Medical Detachment Veterinary Service Support (VSS) 

unit beginning in mid-July 2014. During this trial period, only MWDs were tracked in the system since a 

method for tracking contracted dogs in ROVR had not 

yet been created. Over the course of the trial, users were 

directed to keep a log documenting what went well with 

the application and any issues they encountered. While 

the trial found several benefits to using ROVR such as 

record portability and enhanced access to full medical 

records, the evaluation ultimately concluded that ROVR 

was not ready for use in the deployed environment due 

to several limitations (LTC N. Chevalier, 72nd VSS 

Commander, email, October 31, 2014). Most of the limitations resulted because ROVR was created for garrison 

veterinary facilities, and many of the assumptions for 

garrison did not apply in the deployed environment. For 

example, ROVR has a standard inventory based on the 

Veterinary Medical Standardization Board (VMSB) formulary which is supported by the VSCF prime vendor 

program. However, in the deployed environment, medications are procured from Medical Logistics instead of 

directly from a civilian prime vendor. This means that 

most of the medications used in theater are human medications which are not approved in the VMSB formulary, 

and consequently not found in the ROVR inventory.

Another issue was related to the ROVR designation of 

the 72nd VSS as a single entity under the name “OEF 1 

Vet Det.” This was done partly to maintain operational 

security so MWDs could not be traced to specific forward operating bases or areas of operation. However, 

this designation caused the program to assume that all 

veterinary teams were collocated in the same facility, 

which was not the case. The ROVR inventory is designed to assume that all items are located within that 

one facility, not spread across several locations. This 

made it extremely difficult to track what actually was 

available and used. Solutions to these deployment-related issues are currently under investigation.

Conclusion

With the fielding of ROVR, the VSCF is better able 

to globally manage the military’s veterinary practices 

and has access to more reporting capabilities. It is anticipated that as the application matures and evolves, a 

greater dataset for epidemiology and disease control 

will be available. Additional future developments to 

this program should include the capability of uploading 

radiographic images for real time consultation, as well 

as interface capabilities with external third parties such 

as laboratories allowing automatic entry of test results 

into the program, thus eliminating another manual entry 

function of the user.

The ultimate goals of creating the global program are 

to create a more cost efficient practice, allow for passive and active disease surveillance for MWDs and 

DoD beneficiary owned animals, and to determine the 

best practice management for different diagnoses. As 

the program continues to mature and the dataset grows 

larger, the possibilities for use of this program have only 

begun to emerge.

References

1. Department of Defense Directive 6400.04E: DoD 

Veterinary Public and Animal Health Services. 

Washington, DC: US Dept of Defense; 2013.

2. HEALTHeSTATE, LLC. Our Remarkable Story. 

Available at: http://www.healtheforces.com/ourstory/. Accessed October 26, 2014.

3. Havas KA, Burkman K. A comparison of the serological evidence of Coxiella burnetii exposure 

between military working dogs and feral canines 

in Iraq. Mil Med. 2011;176:1101-1103.
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

4. Moore GE, Burkman KD, Carter MN, Peterson 

MR. Causes of death or reasons for euthanasia in 

military working dogs: 927 cases (1993-1996). J 

Am Vet Med Assoc. 2001;219:209-214.

5. Burkman KD, Moore GE, Peterson MR. Incidence 

of zoonotic diseases in military working dogs serving in Operations Desert Shield and Desert Storm. 

Mil Med. 2001;166:108-111.

6. Day MJ, Breitschwerdt E, Cleaveland S, et al. Surveillance of zoonotic infectious disease transmitted 

by small companion animals. Emerg Infect Dis [internet]. 2012;18(12). Available at: http://wwwnc.cdc.

gov/eid/article/18/12/12-0664_article. Accessed 

October 26, 2014.

7. Glickman LT, Moore GE, Glickman NW, Caldanaro RJ, Aucoin D, Lewis HB. Purdue University-Banfield National Companion Animal Surveillance Program for emerging and zoonotic diseases. 

Vector Borne Zoonotic Dis. 2006;6(1):14-23.

Authors

CPT Hunter is the Veterinary Chief, Joint Base Elmendorf-Richardson (JBER) Branch, Public Health Command District Joint Base Lewis-McChord, JBER Alaska.

LTC Burke is the Veterinary Public Health Instructor for 

the First Year Graduate Veterinary Education Program, 

Joint Base Lewis-McChord, Washington.

FIELDING THE REMOTE ONLINE VETERINARY RECORD, A VETERINARY ELECTRONIC HEALTH RECORD

TO IMPROVE PATIENT CARE AND PRACTICE MANAGEMENT
January – March 2015 67

The First Year Graduate Veterinary Education (FYGVE) 

program was initiated in August of 2010. The year-long 

rotating internship is intended to provide exposure 

and reinforcement of those skills necessary for success in providing military veterinary medical services 

to the Department of Defense (DoD)1 in accordance 

with Army Regulation 40-905.

2

 First year internship 

programs exist in the Army Medical Corps and Army 

Dental Corps, but those are primarily clinically-focused. 

The FYGVE program includes public health and leadership tracks, in addition to clinical medicine. The duty 

requirements of a new Veterinary Corps officer (VCO) 

are diverse and challenging. Frequently, new officers are 

placed at isolated, single veterinarian duty sites, including Marine, Navy, and Air Force installations that may 

be located hundreds of miles from their peers or chain 

of command. These officers not only must be confident 

in their clinical abilities, but also must be prepared to 

manage Soldiers and civilians and oversee the procurement and protection of food for the installation. These 

diverse requirements are not adequately addressed in 

the typical veterinary school curriculum. The FYGVE 

program was conceived as a way to give a new VCO the 

best opportunity to succeed. This article is a retrospective review of the FYGVE program at Joint Base LewisMcChord (JBLM) from October 2012 until June 2013, 

as experienced by three of the interns. It details how the 

program affected readiness and the ability to excel in 

the following areas of emphasis: animal medicine, food 

protection, public health, and leadership/management.

Background

Proper mentorship is critical to the development of new 

veterinarians as they transition from the role of student 

to doctor. New graduates often search for mentors as 

they enter the work force. A licensed veterinarian is legally able to treat any species of animal, but there are far 

more clinical situations than could ever be covered in a 

4-year postbaccalaureate curriculum. This is especially 

true for the new VCO, whose responsibilities range from 

the full medical and surgical support of military working dogs (MWDs) and privately owned animals (POAs) 

of eligible beneficiaries, to advising hospital and installation commanders of matters of public health, to overseeing the procurement of safe food for all of the DoD 

(through the commercial sanitation audit program), to 

having responsibility for the financial success of the 

veterinary clinic. In addition, the young veterinarians 

are commissioned as captains in the US Army, thereby 

becoming not only a Soldier, but a leader as well. Attendance at the 3-month long Basic Officers Leadership 

Course, including a Veterinary Corps specific “vet track” 

component, is meant to provide new officers with a solid 

foundation of knowledge, However, it only paints a limited picture of the complete VCO. The day-to-day job 

functions are unveiled through the FYGVE program and 

then solidified throughout the officer’s next assignment. 

The typical FYGVE program has 4 to 6 interns overseen 

by 2 FYGVE cadre, one boarded in veterinary preventive medicine and the other in a clinical medicine specialty (eg, surgery, internal medicine). While this article 

presents a review of the program at one site (JBLM), it 

is important to note that execution of FYGVE programs 

varies greatly between sites. The locations of all FYGVE 

programs are shown in the Figure. At JBLM, the interns 

split time between clinical medicine and public health 

rotations. Interns spent from 2 to 6 weeks in any rotation, 

but there was flexibility allowing for schedule changes 

for follow up on clinical cases or commercial sanitation 

audits, as needed. Interns could elect to schedule their 

own patient rechecks from 8 am to 9 am, with the official rotation starting at 9 am. This flexibility allowed interns to follow up on their own clinical cases even when 

they had moved on to the public health rotation. While 

this was not a requirement, the continuity it provided 

was very useful from a learning perspective. The interns 

found the opportunity to conduct their own rechecks 

helpful for their professional development as clinicians.

Joint Base Lewis-McChord First Year Graduate

 Veterinary Education: Observations and

 Lessons Learned

CPT Aimee Hunter, VC, USA

CPT Teresa Villers, VC, USA

CPT Lauren Seal, VC, USA

David Galloway, DVM
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

Animal Medicine

The FYGVE program provides animal medicine mentorship by a board certified veterinary 

clinical instructor while practicing in a referral 

level veterinary hospital. The specialist is typically certified in small animal internal medicine, 

small animal surgery, radiology, or emergency/

critical care. The JBLM site had an internal medicine instructor. The clinical instructor provided 

guidance during daily case round discussions, 

continuing education through monthly case presentations and journal rounds, as well as providing clinical credentialing in both medicine and 

surgery. Each FYGVE site has a Veterinary Center (VETCEN) as the animal medicine platforms. 

The VETCENs are the highest tier installation 

veterinary medical facility in the Army Public 

Health Command. The centers are equipped and 

staffed for routine to referral-level animal medical care and have an animal medical training capability. The JBLM VETCEN was fully staffed, 

including 2 full-time civilian animal care technicians who were hired specifically to support the 

FYGVE program. This staffing allowed the interns to 

see a busy clinic schedule consisting of six 30-minute 

sick call appointments scheduled from 9 am to 12 noon, 

or ten 30-minute wellness appointments scheduled from 

9 am to 3 pm. The interns had the option of keeping any 

patients that required extensive workup or care for the 

afternoon. Equipment was up-to-date and readily available for use, providing hands-on experience with ultrasound, digital radiographs, in-house blood work, cytology, and endoscopy. This type of staffing and equipment 

is not typical of the average smaller military veterinary 

facilities, providing the interns the opportunity to learn 

as much as possible from a clinical perspective during 

their FYGVE year.

The confidence gained through mentorship by a clinical specialist has proven invaluable during the first assignment following FYGVE, typically as the officer-incharge (OIC) of a veterinary treatment facility (VTF). 

Leaving the program clinically credentialed in medicine 

and surgery allows the new VTF section OIC to be fully 

functional upon arrival. In the US Army, a VCO must be 

“credentialed” prior to performing surgery and advanced 

workups without direct supervision on governmentowned animals (GOAs) or POAs. The FYGVE program 

allows new officers to be credentialed prior to arriving 

at their first assignment, so they are able to start surgeries and advanced workups immediately. The key to 

gaining clinical proficiency and independence is continuous learning through repetition. The JBLM VETCEN 

maintains a heavy caseload, which allows interns to 

learn something new each day. That knowledge base 

was further solidified through case discussions with the 

clinical instructor and peers at the end of each day. Interns also had the opportunity to work up complicated 

POA cases, including providing a patient with 24-hour 

care. However, it was understood that interns, not enlisted veterinary technicians, provided overnight care for 

hospitalized POA patients that the intern elected to keep 

in-house. This experience was important because it conveyed to interns that Soldiers, whose primary responsibility is GOA care, should not be used for tasks that are 

not priority missions without due consideration of the 

task’s impact on overall mission accomplishment. This 

lesson in mission priorities promotes an understanding 

of better Soldier care and utilization by their leaders.

The MWD population at JBLM offered each intern the 

opportunity to work with MWDs at least once monthly. These encounters typically involved completion of 

semiannual exams, vaccinations, and health certificates 

for travel. Occasionally, a FYGVE intern was called in 

for a MWD emergency, such as a splenic torsion or uncontrolled seizing. In these instances, all interns were 

given the opportunity to be involved through provision 

of overnight critical care case management and followon case discussion. Each intern also completed animal 

facility inspections, including the MWD kennel and 

Child Development Center classroom pet care.

JOINT BASE LEWIS-MCCHORD FIRST YEAR GRADUATE VETERINARY EDUCATION:

OBSERVATIONS AND LESSONS LEARNED

C

D

E

F

G

H

B

A

Site Start Site Start

A Ft Belvoir FY10 E Ft Hood FY12

B Ft Bragg FY11 F Ft Campbell FY13

C Joint Base Lewis-McChord FY11 G Ft Benning FY13

D Ft Carson FY12 H Camp Pendleton (USMC) FY16

Locations of current FYGVE sites and the year each program began. 

Camp Pendleton, California, will be implemented in FY16.
January – March 2015 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

At JBLM, interns did not complete deployment records 

for MWDs, nor execute any of the monthly record reviews, although a didactic session was performed. The 

preparation and maintenance of records is extremely important to a VCO, especially when assigned to a location 

without the assistance of an experienced enlisted veterinary technician. This would have been a very beneficial 

hands-on task to perform during FYGVE, especially 

since the implementation of the Remote Online Veterinary Record (ROVR), an online record keeping system 

that links all military veterinary facilities.* (Note: the 

hands-on component of record preparation and management is now a requirement in the current FYGVE curriculum.) Now that record reviews must be completed 

both on ROVR and in the Veterinary Service application portal, the FYGVE would also provide an excellent 

opportunity to create and teach a universal method to 

complete monthly record reviews.

One concern about the animal medicine component to 

the FYGVE program is the difference between what is 

available during the program compared to what will be 

available to VCOs at their next duty location. The fully 

equipped and staffed VETCEN imparted false expectations to some interns as to what would be waiting for 

them at their next assignment. The JBLM VETCEN 

has full surgical capability, radiology, ultrasound, and 

ophthalmic exam equipment. It is also fully staffed with 

civilian and military veterinary personnel to assist with 

the very large and demanding clinical mission. Interns 

found different levels of staffing and equipment at their 

next assignments. It is understood that different clinics 

have different capabilities, however, it would be useful if 

the FYGVE curriculum specifically addressed the continuum of care across veterinary facility tiers and levels 

of care. This information should include treatment alternatives under resource constraints and case-based discussions of referral/evacuation procedures that ensure 

VCOs are working within Army Veterinary Medicine 

Standardization Board guidelines. This area of training 

will be addressed in future years with required rotations 

to smaller VTFs, which will be more indicative of the 

resources interns will have at their next assignment. All 

follow-on assignment locations were also experiencing 

staffing shortfalls, resulting in clinical inefficiencies not 

encountered at the JBLM VETCEN. On the positive 

side, having completed the FYGVE experience, the interns felt they were better equipped than their peers who 

did not complete the program to deal with staffing shortfalls and other unexpected adversities during their first 

assignment. They also knew to reference Army regulations and how to obtain the resources that allow them to 

perform their animal health mission and prevent Soldier 

burnout in the process.

Public Health/Food Mission

The FYGVE program provided additional mentorship through a public health instructor. The instructor 

worked with the Public Health Command District and/or 

Region Food Safety Officer, a Veterinary Corps warrant 

officer highly specialized in the areas of food safety and 

defense, to ensure each intern quickly achieved phase 

2 Commercial Sanitary Audit certification. Similar to 

animal medicine credentialing, this certification is required to complete food protection audits without supervision and is very important at the intern’s next duty 

site. An Acceptable Commercial Sanitary Audit rating 

by a VCO is required before an off-installation food establishment can be listed in the Worldwide Directory 

of Sanitarily Approved Food Establishments for Armed 

Forces Procurement.

3

 This listing is necessary to sell to 

the DoD. For continued listing as an approved source, 

these facilities must be audited by a VCO in accordance 

with Military Standard 3006A.

4

 Compliance with this 

standard ensures that facilities are producing safe and 

wholesome food to minimize the risk of food-borne 

illness to service members and their families. Interns 

transitioned from staff auditors to lead auditors, becoming competent in performing food protection audits and 

correctly reporting commercial sanitation audit findings. 

This allowed a smooth transition to performing sanitary 

audits at their next assignment, as well as helping to prepare interns to volunteer for and complete Food and Water Risk Assessments (FWRA) outside the continental 

US in accordance with Military Standard 3041.

5

 These 

FWRAs are conducted when there are insufficient DoD 

approved food sources to support short-term exercises. 

Veterinary Corps officers advise commanders of risks, 

as well as risk mitigation, regarding a particular food establishment.6

 A benefit of the JBLM site is a very large 

audit mission. Each intern completed numerous audits, 

an average of 15 different facilities each compared to 

an average of 9 audits per intern at other FYGVE sites 

during the 2013 FYGVE year. New VCOs outside of 

FYGVE may only perform 5 audits their first year. This 

increased audit load improves competency and more 

importantly confidence to better execute this mission at 

the next duty site where there is likely less opportunity 

for face to face mentorship.

Many public health topics were discussed during weekly 

FYGVE public health classes. Topics included zoonotic 

diseases, installation rabies board policy, bite reports, 

foreign animal diseases, response to refrigeration failures, the human-animal bond, and inspection of operational rations (eg, meals ready-to-eat). Though these *See related article on page 61.
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

are broad topics, classes provided important resources 

that interns have frequently applied at current assignments. These classes directly led to the creation of rabies advisory boards at two sites, improved bite report 

standards, and improved communication on animal displays (such as petting zoos) on military bases. At JBLM, 

interns also completed the ServSafe program (National 

Restaurant Association, Washington, DC), which is accredited by the American National Standards Institute 

Conference for Food Protection. The ServSafe program 

is very useful for gaining knowledge of proper preparation and storage of food to reduce risk of foodborne 

illness. It gave the interns greater baseline knowledge 

of food safety, a topic that receives limited instruction 

in most veterinary school curricula. The interns recommended that this be added as a formal part of the 

FYGVE program.

Areas in public health for which interns felt less prepared upon reaching their first assignment included 

the Installation Food Vulnerability Assessment (IFVA) 

program, IFVA team development and its annual briefing to the installation commander in accordance with 

the US Army Food and Water Vulnerability Assessment 

Guide,* approved sources tracking for temporary vendors such as food trucks on the installation, the role of 

Veterinary Services in Moral, Welfare, and Recreation 

special events, and involvement of Veterinary Services 

in installation emergency support plans. Additionally, 

although interns were given a brief didactic introduction to the Installation Support Plan, (the program 

during which VCOs perform sanitary inspections of 

the commissary, post exchange (PX), and shoppettes), 

no sanitary inspections were performed as part of the 

FY13 FYGVE program at JBLM. However, as part of 

their responsibilities, the former interns are required 

to complete sanitary inspections regularly at their new 

duty sites. The FYGVE program now requires an IFVA 

component with a mock briefing to the installation commander and a requirement of performing 5 commissary 

and 5 PX/shoppette visits.

Leadership/Management

The development of leadership skills and management 

ability is a core aspect of the FYGVE curriculum. The 

leadership training that the interns received at JBLM 

provided the knowledge base and confidence to reach 

out to leaders in other commands and organizations on 

their respective installations. A number of the interns 

reached out to base commanders immediately upon 

reaching their follow-on assignment and now collaborate with a variety of commands and organizations on 

the installation. However, interns felt that the handson component of the leadership curriculum needed 

improvement. The leadership component of the program 

has changed greatly since the FY13 FYGVE year. Now, 

there is a leadership rotation and concrete benchmarks 

for interns to achieve. This rotation includes positions 

such as veterinary branch executive officer and intern 

class leader, as well as the completion of typical VCO 

organizational, leadership, and administrative tasks.

A unique aspect of the JBLM program was a leadershipfocused book club. Interns read several books throughout the course of the year and then met for discussion. 

This was a very enjoyable and beneficial component of 

the program that has since been implemented at other 

FYGVE sites. Of interest is the fact that during the FY13 

cycle for FYGVE at JBLM, all interns, cadre members, 

and the regional commander were female. That unique 

situation made discussions regarding women in leadership roles especially relevant and beneficial to participants of this FYGVE iteration.

An area of leadership training phase that the interns felt 

could be improved was counseling and development of 

subordinates. FYGVE interns were not afforded participation in integrated roles of leadership such as rating 

Soldiers, dealing with challenging situations, writing 

awards, etc. Though each intern was given the opportunity to issue a positive counseling statement to a Soldier of his or her choice, there was no opportunity to 

witness or contribute to developmental or disciplinary 

counseling. This would be difficult to implement since 

interns do not directly supervise any Soldiers and the 

privacy of the individual counseled must be respected. 

“Praise in public and correct in private” limited interns’ 

experiences with these matters. Instead, group discussions of hypothetical scenarios and role playing were 

implemented to serve as an introduction to real world 

problems. Interns felt that this area should have received 

more emphasis during officer professional development, 

since Soldier development is one of the most important 

parts of a VCO’s job as he or she assumes a clinic section OIC or branch chief position.

Similarly, management of civilian employees was covered in a couple of one-hour training sessions, but did 

not prepare interns for the administrative burden of rating, rewarding, reprimanding, and counseling civilian 

employees. Interns also did not receive a thorough introduction to the responsibilities and roles of employees 

within the Veterinary Services Central Fund (VSCF), 

the nonappropriated fund (NAF) entity that oversees 

the fiscal management of military veterinary facilities, separate from the operational chain of command. 

This group assists with reviewing income statements 

and general business management. The VSCF and the 

JOINT BASE LEWIS-MCCHORD FIRST YEAR GRADUATE VETERINARY EDUCATION:

OBSERVATIONS AND LESSONS LEARNED
January – March 2015 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

NAF Civilian Personnel Advisory Center assists with 

civilian hiring/disciplinary matters as well as other human resources functions. The process for hiring civilian 

employees is an important topic that was not discussed 

during the FY13 iteration, which was unfortunate because all interns were faced with vacant positions upon 

arrival at their next duty site. It would have been beneficial to hold multiple teleconferences geared specifically 

towards FYGVE interns to better prepare interns for 

veterinary clinic manager level tasks. Teleconferences 

with VSCF did occur, however, they were of limited 

benefit to FYGVE interns as they were often focused on 

detailed topical instruction for specific employee positions, a discussion far too specific to be beneficial to the 

new VCO.

Perhaps the most significant advantage of the FYGVE 

year from a leadership/management perspective was the 

provision of resources for the future. Examples of counseling statements and annual evaluations were provided 

for future use. Regulations regarding specific circumstances were cited for interns to review. In addition, being stationed at a site where branch, district, and regional public health commands were located gave interns an 

excellent opportunity to be exposed to several types of 

leadership styles. Not only were the instructors 100% 

dedicated to preparing the interns for success in their future assignments, the chain of command also was fully 

engaged all the way through the regional command level. The authors strongly believe that identification and 

placement of the right people in the FYGVE instructor 

positions will continue to have a major positive effect on 

interns who participate in the program. Without cadre, 

district, and regional commanders who care about the 

program and the young officers in it, the goals of the 

program will not be realized.

Relationship Building

While the obvious benefits of the FYGVE program such 

as number of commercial audits, clinical credentialing, 

caseload, and inspections are quantifiable, all 3 interns 

felt that the most beneficial aspects involved building 

relationships with fellow interns, instructors, and noncommissioned officers. Working with peers enabled 

each intern to identify their strengths and weaknesses, 

and they were then able to work with each other to build 

on both. The bonds created during the FYGVE program 

have also translated into excellent working relationships 

with numerous Public Health Command personnel. Former interns now have contacts around the Veterinary 

Corps for questions, concerns, and advice, ranging 

from former instructors, intern-mates, food inspectors, 

warrant officers, etc. Though the FY13 JBLM interns 

have gone to their separate assignments, they continue 

to use their FYGVE colleagues as sources of perspective and knowledge as they encounter unique situations 

at their individual duty sites. The bond they now share 

after spending their first year in the Army together is 

perhaps the most unexpected advantage gained through 

participation in the program. A solid foundation of clinical competency allows the new VCO to focus more appropriately on veterinary treatment facility management, 

mission accomplishment, and leading Soldiers.

Summary

The FYGVE program provided a solid foundation to 

smooth the transition from veterinary student to Veterinary Corps officer. Not only did the program provide 

resources and exposure to vital areas of the mission, it 

also produced a network among interns and their instructors. This network was critical to their success as 

they assumed their next assignments. Interns left the 

experience with increased confidence and competency 

in clinical medicine, public health, and food safety. Improvements in the leadership/management track are already being added to the program. At the end of each 

internship year, an extensive after action report (AAR) 

is conducted. The AARs solicit feedback from interns 

and cadre alike. Many of the improvements added to the 

program have come directly from these retrospective 

reviews On the other hand, interns expressed concern 

about the direction for the future of the program and the 

effect of possible budget cuts.

This article presents the positive aspects and concerns 

expressed by 3 FYGVE interns about their internship 

experience during the FY13 iteration. Upon completion 

of the program at JBLM, all interns moved into the role 

as officer-in-charge of a veterinary treatment facility. 

Current duty sites for the intern authors are Kings Bay 

Submarine Base, Redstone Arsenal, and Fort Bliss. The 

intern assigned to Fort Bliss moved into the role of 

Chief of Veterinary Services for the Fort Bliss Branch 

a year after completion of the internship. This role 

includes oversight of 4 Veterinary Treatment Facilities 

that span 2 states. More than a year after completion, 

all interns agree that the FYGVE program provided a 

background that was integral to their success at their 

current duty stations.

References

1. Torring EH, Mey W. US Army Veterinary Corps 

First Year Graduate Veterinary Education Program. 

US Army Med Dep J. January-March 2014:39-41.
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

2. Army Regulation 40-905: Veterinary Health Services. Washington, DC: US Dept of the Army; 2006.

3. Worldwide Directory of Sanitarily Approved Food 

Establishments for Armed Forces Procurement. 

Aberdeen Proving Ground, MD: US Army Public Health Command: 2014. Available at: http://

phc.amedd.army.mil/topics/foodwater/ca/Pages/

DoDApprovedFoodSources.aspx. Accessed December 9, 2014.

4. MIL-STD-3006C: Sanitation Requirements for 

Food Establishments. Washington, DC: US Dept 

of Defense; June 1, 2008. Available at: http://quick

search.dla.mil/qsDocDetails.aspx?ident_num

ber=208822. Accessed December 9, 2014.

5. MIL-STD-3041: Requirements for Food and Water 

Risk Assessments. Washington, DC: US Dept of 

Defense; May 15, 2013. Available at: http://quick

search.dla.mil/qsDocDetails.aspx?ident_num

ber=279433. Accessed December 9, 2014.

6. Killian JW, Burke RL, Westover JE. Food and water risk assessments: empowering commanders and 

protecting service members. US Army Med Dep J. 

January-March 2013:63-68.

Authors

CPT Hunter is the Chief of Veterinary Services, Fort 

Bliss Branch, US Army Public Health Command District Carson, Fort Bliss Texas.

CPT Villers is the Veterinary Officer-in-Charge of the 

Veterinary Section, US Army Public Health Command 

District Fort Gordon, Redstone Arsenal, Alabama.

CPT Seal is Veterinary Officer-in-Charge of the Veterinary Section, US Army Public Health Command District 

Fort Gordon, Naval Submarine Base Kings Bay, Georgia.

Dr Galloway is the FYGVE Program Manager in the 

Office of The Army Surgeon General, Falls Church, 

Virginia.

JOINT BASE LEWIS-MCCHORD FIRST YEAR GRADUATE VETERINARY EDUCATION:

OBSERVATIONS AND LESSONS LEARNED
January – March 2015 73

Traumatic brain injury (TBI) and other blast-related injuries are likely to be an enduring legacy of Operations 

Iraqi Freedom and Enduring Freedom.1,2 Improvised 

explosive devices were the primary causes of exposure 

to blast energy and projectile material. The primary scientific and operational challenges to understanding and 

mitigating blast exposure risks have been the lack of data 

on the long-term sequelae from individual blast exposures, as well as lack of information regarding the relationship between relatively minor, cumulative exposures 

and brain injury symptoms. Several studies to date have 

shed light on these issues but with conflicting results.3-8

Primarily due to the wars in Iraq and Afghanistan, a 

great deal has been learned about mechanism of injury 

and pathophysiologic effects of blast-induced TBI.5,6,9-12

There have been several animal and human studies documenting metabolic, molecular, cellular, and systemic 

effects from the primary blast injury along with several 

theories of injury mechanism.3,5,7 Regardless of mechanism, these injuries are typically at the chemical and/

or microscopic level which are impossible to appreciate with the diagnostic modalities available in a combat 

environment and therefore cannot definitively be determined in that setting.5

McCrea et al 13 argued that it is difficult at best to determine in the combat setting that confusion after a blast 

event is due to brain injury or psychological trauma. 

Thus, many Soldiers may meet the diagnostic criteria 

for mild TBI (MTBI) symptoms without having suffered any physiologic injury. Further, Walker et al 14

states that loss of consciousness at the time of injury is 

an important factor in determining risk for long-term 

sequelae, and that immediate evaluation by a provider 

is key to clarifying later diagnoses. There is typically a 

significant time gap in combat for these types of injuries 

between point of impact and a thorough medical evaluation. The lack of physical injuries that can be readily 

observed in the operational setting have made it necessary in many instances to diagnose MTBI on the basis of 

exposure history as recalled by the service member and 

subjective complaints. Many of these symptoms such 

as being dazed, loss of consciousness, memory deficits, 

fatigue, increased sensitivity to noise and light, insomnia, irritability, decreased concentration, and anxiety 

Associations Between Operationally Estimated

 Blast Exposures and Postdeployment

 Diagnoses of Postconcussion Syndrome and

 Posttraumatic Stress Disorder

MAJ Jonathan L. Saxe, SP, USA

Christopher L. Perdue, MD, MPH

Abstract

Traumatic brain injuries and other blast-related injuries have been identified as the signature injury of the wars 

in Iraq and Afghanistan. Some operational units in Iraq, especially those responsible for clearing roadways, 

were exposed to hundreds of blast incidents and thousands of individual doses of concussive energy during 

their lengthy deployments. Using operational records maintained by a single command element, the researchers 

conducted a retrospective cohort study evaluating the association between estimated individual exposures to 

blasts and the risk for postconcussion syndrome (PCS) and posttraumatic stress disorder (PTSD). Tactical 

records documented all of the relevant details of the subjects’ exposures to blasts during their missions. During 

the study period there were 313 blasts involving 418 service members resulting in 4,250 blast person events. Of 

that population, 12.9% were diagnosed with PCS, 8.6% with PTSD, and 5.3% with both. This study suggests 

that estimating the total individual dosage to concussive forces through physical evidence at the scene could 

be a useful predictor of future brain-disorder diagnoses. Those in vehicles sustaining heavy blast damage are 

at increased risk of being diagnosed with PTSD with a rate ratio of 2.79 (95% CI, 1.27-6.13) and PTSD in 

conjunction with PCS with a rate ratio of 4.10 (95% CI, 1.63-10.28). Standardization of the data collection 

method for blast incidents and additional follow-up studies could lead to the development of better ways of 

monitoring operational risk factors for negative health outcomes, plans to intervene in order to minimize health 

risks, and establish customized follow-up protocols based on specific dosage thresholds.
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

are shared with acute stress reactions and PTSD.15,16

Hoge et al 6 argues that there are many psychological 

phenomenon that may produce an apparent alteration in 

consciousness. These factors make it extremely difficult 

for providers in theatre to make informed prognostic decisions, which in turn can have a significant effect on a 

unit’s mission readiness resulting from unfavorable Soldier health outcomes.

With these findings in mind, there has been an effort to 

study the relationship of MTBI, PCS, and PTSD. Hoge 

et al 6 found MTBI and PTSD to be strongly associated 

with 40% of Soldiers meeting criteria for PTSD who 

had a history of loss of consciousness. This finding is 

supported in further investigation by Wilk et al.17 A 

study by Meares et al 18 further clarifies a strong role 

for psychological comorbidities in contributing to a 

symptom-complex that appears to be PCS. Bryant 15 addresses possible physiologic sources of PTSD in patients 

with MTBI, noting that the prefrontal cortex is often injured in MTBI patients. These findings makes differentiating the long-term effects of MTBI more difficult and 

may further confound the clinical course of PCS/PTSD, 

in that distinguishing one diagnosis from the other becomes more challenging.

Soldiers who self-reported exposure to blasts perceived 

themselves to have poorer health, missed more workdays, and were more symptomatic than Soldiers who 

were not exposed to blasts.6 A study by Sim et al,19

though specific to the nonblast injuries, supports the 

concept that, on average, concussions result in shortterm injuries (impaired reaction time, attention deficits, 

memory dysfunctions, and cognitive processing delays) 

that resolve differentially over time. However, Vagnozzi 

et al 20 demonstrated lingering neurometabolic sequelae due to concussion among civilian athletes. Further, 

Trudeau et al 16 speculated that the physiologic sequelae 

produced specifically by blast-induced MTBI could be 

more permanent and result in prolonged PCS. This is 

supported by the finding by Terrio et al 2 that Soldiers 

who had a documented TBI were more likely to report 

post concussive symptoms upon redeployment (7.5%) 

than those who did not (2.3%).

With all of the challenges surrounding surveillance, diagnosis, and treatment of blast-related exposures and health 

outcomes, there is a rational need for better tools to collect information in operational settings. A tactical tool 

for measuring blast dosimetry with information readily 

available on the battlefield and transforming this data 

into predictive values for the development of long-term 

injury would be invaluable. This study is unique in that 

we compared individual operational exposure data to the 

development of PCS and PTSD in an effort to define cumulative exposure estimates that may lead to operational 

decisions aimed at reducing the likelihood of PCS/PTSD.

Method

This retrospective cohort study, approved through the 

Iraq Deployed Combat Clinical Research Team and the 

human subject review board at the Brooke Army Medical Center, Texas, included data for personnel assigned 

to 3 companies of combat engineers deployed to Iraq between (approximately) October 2006 and January 2008. 

Those 3 companies were chosen because of the similarity of their missions, geographic proximity in northern 

Iraq, and their shared command. Permission to use tactical records for the purposes of this study was provided 

by the brigade commander at that time.

Tactical records documented all of the relevant details of 

the subjects’ exposures to blasts during their missions. 

A variable number of subjects were engaged in tactical 

route clearance missions nearly every day of the deployment, though blasts did not occur on every mission. 

Only missions during which a blast occurred received 

documentation and was therefore suitable for inclusion 

in the study. Subjects traveled only by military armored 

vehicle (not by foot) during missions. During a mission, 

vehicles moved in convoys in single-file formations, 

normally resulting in exposure of a single vehicle during an explosion, though occasionally 2 vehicles were 

affected. Missions during which a blast occurred were 

described in detail in narrative documents, spreadsheets, 

photos, and digital drawings that were provided to the 

research team on the classified network. Data needed for 

this study were manually abstracted by the primary author from those files in a format and level of detail that 

was considered unclassified.

Data included the vehicle order during the mission, the 

relationship of the vehicles to the blast, seat-assignment 

of each subject, and the level of damage to the vehicle as 

a result of the blast. The exact date of the blast event was 

considered classified, so the temporal relationships between blasts were transformed into the number of days 

from the beginning of data collection (the day of the 

first mission in which a blast occurred). Possible seatassignments included the driver, front passenger, gunner 

(located in a turret protruding through the roof of the 

vehicle) or a rear passenger on either the same side or the 

opposite side of a documented blast. Not every vehicle 

had a gunner or rear passengers.

Vehicles directly in line with the explosion were considered “targeted,” and thus the passengers of that vehicle 

were targeted as well. Precise proximity of a targeted 

ASSOCIATIONS BETWEEN OPERATIONALLY ESTIMATED BLAST EXPOSURES AND POSTDEPLOYMENT

DIAGNOSES OF POSTCONCUSSION SYNDROME AND POSTTRAUMATIC STRESS DISORDER
January – March 2015 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

vehicle to a blast and the estimated size of the blast were 

not consistently available. Blast intensity was estimated 

by classifying the level of damage to each vehicle on a 

4-point scale based on the information available in the 

tactical records. After “no damage,” minor damage included paint or glass chips, blown-off external accessories or a flattened tire, but with no structural damage 

to the wheel or drive system. Moderate damage included visible cracks through one or more layers of glass, 

dents in the exterior armor, or damage to the wheel or 

drive system which sometimes left the vehicle inoperable. Heavy damage included penetration of the passenger cabin or damage to the engine block or chassis and 

meant that the vehicle was no longer drivable.

The blast intensity was used to estimate individual exposures in one of 3 models based on the blast damage 

assessment of the vehicle. In the simplest model, a blast 

dose was assigned to each individual present on a mission consistent with the level of damage to the vehicle 

in which they traveled on a scale of 0 to 3, 3 being the 

highest. Subjects in a vehicle that was not directly targeted (eg, all of the other vehicles in the convoy), as well 

as those in a targeted vehicle that suffered no damage, 

were assigned a blast intensity of zero.

Because gunners were partially external to the vehicle 

cabin, the “gunner model” postulated the he was exposed at a level above that of the other passengers. The 

gunner model classified exposures on a scale of 0 to 4 

based on the amount of damage to the vehicle, but with 

the gunner receiving one point higher than any other 

passenger in the same vehicle. Finally, the “laterality 

model” took into account the position of each person in 

the vehicle in relationship to the blast. Those in a gunner 

position or ipsilateral with respect to source of the blast 

were considered to be more exposed (by a value of one) 

than those contralateral to the blast. The laterality model 

described blast exposures on a scale of 0 to 7. For each 

individual, the cumulative “blast intensity score” (BIS) 

for the entire deployment was the sum of all individual 

exposures under each of the models.

Diagnoses of PTSD and PCS were determined using 

data from the Defense Medical Surveillance System 

(Armed Forces Health Surveillance Center, www.afhsc.

mil). A confirmed diagnosis was one or more healthcare encounters during which PTSD (ICD-9-CM code 

309.81) or PCS (ICD-9-CM code 301.2), respectively, 

were documented as the primary diagnosis during the 

365 days following deployment. Also included were 

subjects with 2 or more encounters with the diagnosis of 

PTSD or PCS in a secondary field. For PCS, diagnoses 

were excluded if, during the year following deployment, 

the healthcare record indicated that the subject suffered 

a concussion or other head injury requiring medical 

treatment, that is, a postdeployment incident.

Crude risk ratios and 95% confidence intervals were 

calculated using standard formulas. Bivariate and multivariate logistic regression models using SAS 9.0 (SAS 

Institute Inc, Cary, NC) were used to conduct sensitivity 

testing of our 3 observational models. We examined the 

relationships between the cumulative BIS, sex, age, the 

total number of times a subject was on a mission during 

which a blast occurred, and (independent of the BIS) the 

total number of times a subject was in a targeted vehicle.

Results

Over the study period, 477 service members were assigned to route clearance missions. The population was 

similar to other combat arms units with 99% male, 92% 

enlisted, and 72% aged 18 to 30 years. Other demographic and socioeconomic data were not available in 

this study, and the individuals themselves were never 

contacted by the study team.

During 366 days of observation, there were 313 blasts 

resulting in 4,625 individual potential exposure events 

(ie, the number of people in convoys multiplied by the 

number of blasts). In the final data set, 59 service members were excluded because their identification numbers 

were incorrectly transcribed during data collection and 

they could not be matched to health care record in the 

Defense Medical Surveillance System. Soldiers dropped 

from the study had a distribution of blast exposures that 

was consistent with those who were retained (data not 

shown). After the exclusions, the data included 418 service members with 313 blast events and 4,250 potential 

exposures. A total of 278 subjects were present in vehicles that appeared to have been directly targeted during 

a blast, resulting in 940 individual blast exposures.

Accumulation of blast incidents over the course of the 

study period on a relative time scale from the beginning of observations was well distributed. More blasts 

occurred during the first half of the deployment, but 

deployed personnel were at risk for blast exposures for 

most of the deployment. Further, blasts resulting in vehicle damage were also evenly distributed throughout the 

study period. Sixty blasts caused minimal vehicle damage and exposed 210 Soldiers; 50 blasts caused moderate 

vehicle damage and exposed 157 Soldiers; and 8 blasts 

caused heavy vehicle damage that affected 28 Soldiers.

Outcomes of PCS and PTSD were not evenly distributed 

among the population as shown in Table 1. Enlisted Soldiers had higher rates of PCS and PTSD at 13.8% and 
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

9.1%, respectively, than did officers at 3% for both PCS 

and PTSD. Those aged 30-34 years had the highest rate 

of PCS and PTSD at 22.6% and 14.5%, respectively, as 

well as the highest rate of diagnoses with both (11.3%). 

The crude risk ratio (CRR) for developing PCS for those 

aged 30-34 years was 1.5 (95% confidence interval 

(CI), 0.87-2.37), for developing PTSD was 1.46 (95% 

CI, 0.70-3.06), and for developing both PCS and PTSD 

together was 3.92 (95% CI, 1.88-8.18). There were no 

other statistical significant risks for the other age groups 

in this study.

Soldiers on more than one mission during which a blast 

occurred (regardless of their individual or cumulative 

blast exposure) had a CRR for the diagnosis of PCS of 

2.69 (95% CI, 1.10-6.55), as shown in Table 2. Being in 

a targeted vehicle at least once increased that risk to 2.9 

(95% CI, 1.41-5.97). Being present during more than one 

targeted blast resulted in a slight lower, but still significant, risk of developing PCS. Being in any blast during 

which the vehicle experienced heavy battle damage did 

not predict a diagnosis of PCS in the postdeployment 

period.

Developing PTSD was not significantly associated with 

being on missions during which blasts occurred; nor 

was it associated with being in a targeted vehicle as a 

single event. However, PTSD was strongly associated 

with being in more than one targeted blast (CRR 4.54; 

95% CI, 1.56-13.2), which became somewhat less pronounced with increasing numbers of exposures. Being 

in a vehicle that received heavy damage from a blast 

was also highly correlative with a diagnosis of PTSD 

during the 12 months following deployment (CRR 4.10; 

95% CI, 1.63-10.28).

Sensitivity analysis of the blast models was crudely 

evaluated by establishing sequentially increasing cut-off 

values between “not exposed” and “exposed” based on 

the cumulative blast intensity score derived from the 

battle damage assessments. The crude rate ratios for 

diagnosis of PCS for the 3 blast intensity models (any 

targeted incident, simple, gunner, or complex) are consistent across various cutoff values for blast intensity 

scores, suggesting that no model was particularly better 

at predicting outcomes. The data for those models are 

presented in Tables 3, 4, and 5.

Comment

In our opinion, the best data is derived from the targeted 

exposures. Soldiers in vehicles targeted 2 to 3 times and 

those in vehicles sustaining heavy battle damage show 

a strong correlation to being diagnosed with PTSD, and 

an even stronger correlation to PCS together with PTSD. 

Furthermore, the confidence intervals overlap for the 

risk ratios in diagnosis of PCS, PTSD, and both PCS/

PTSD together for each given level of exposure. Our 

data, therefore, suggests that there is no significant difference in the risk of diagnosis between PCS, PTSD, and 

both PCS/PTSD together per given exposure level after 

a Soldier has been targeted more than once. This may be 

indicative of the similarities between these 2 diagnoses, 

given the difficulties in distinguishing one from the other since there are no readily available objective markers 

for what may be their instigating injury (MTBI) as well 

as their similar clinical pictures. This data supports the 

Hoge et al research in that PCS and PTSD are strongly 

associated.6

Our study indicates Soldiers aged 30-34 years are more 

likely to be diagnosed with both PCS and PTSD. Soldiers in this age range are more likely to have been previously deployed but typically remain in positions with 

high exposure to blasts. These Soldiers may have some 

residual injuries/illnesses from their previous combat 

experiences that are reflected in this finding.

ASSOCIATIONS BETWEEN OPERATIONALLY ESTIMATED BLAST EXPOSURES AND POSTDEPLOYMENT

DIAGNOSES OF POSTCONCUSSION SYNDROME AND POSTTRAUMATIC STRESS DISORDER

Table 2. Crude Risk Ratios (CRR) for Levels of Blast Exposure

Exposure PCS

CRR

(95% CI)

PTSD

CRR

(95% CI)

Both

CRR

(95% CI)

>1 mission 2.69

(1.10-6.55)

1.70

(0.68-4.25)

2.74

(0.65-11.52)

Targeted at least once 2.90

(1.41-5.97)

1.76

(0.83-3.77)

3.19

(0.96-10.6)

>1 targeted blast 2.63

(1.49-4.61)

2.02

(1.04-3.93)

4.54

(1.56-13.2)

>2 targeted blasts 2.83

(1.69-4.73)

2.33

(1.24-4.38)

4.43

(1.77-11.09)

>3 targeted blasts 2.83

(1.74-4.61)

1.80

(0.96-3.40)

3.40

(1.51-7.65)

Any blast resulting

in heavy BDA

1.74

(0.82-3.71)

2.79

(1.27-6.13)

4.10

(1.63-10.28)

Table 1. Crude Risk Ratios (CRR) for Diagnoses by Demographic Groups.

Age

(years)

Any PCS Any PTSD Both

CRR 95% CI CRR 95% CI CRR 95% CI

<25 Ref Ref Ref

25-29 0.62 0.31-1.23 0.55 0.23-1.33 1.58 0.69-3.60

30-34 1.54 0.87-2.73 1.46 0.70-3.06 3.92 1.88-8.18

35-39 0.19 0.03-1.35 0.28 0.04-2.02 0.48 0.06-3.62

>39 0.19 0.03-1.35 0.28 0.04-2.02 0.48 0.06-3.62

Service

Status

Enlisted 4.54 0.65-31.8 3.00 0.42-21.2 1.80 0.25-13.0

Officer Ref Ref Ref

Note: Ref indicates reference population on which all calculations 

are based.
January – March 2015 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

There appears to be an association between blast exposure and the diagnosis of PCS and PTSD. This relationship appears to remain fairly constant despite not only 

an increasing number of exposures but also an increasing exposure intensity score. This denies us the ability 

to estimate a level of blast exposure with field expedient 

methods that may lead to operational decisions aimed at 

reducing the likelihood of PCS/PTSD. The investigators 

surmise this may be secondary to the fact that there are 

fewer subjects as blast intensity scores increase. There 

simply may have been too few subjects at the higher levels of exposure to clarify the subtle differences. It may 

also be due to our imprecise way of measuring blast 

dose. Perhaps a more scientific approach is required here 

by first incorporating blast pressure sensors, correlate 

vehicle damage to blast sensor readings, and use that 

data in a similar study. Our negative results could further be secondary to our method of collecting outcome 

data. We collected data only on those who met criteria 

for PCS and PTSD and did not imply diagnosis based 

on symptom complexes. Alternatively, we could have 

developed a case definition where subjects would meet 

criteria for our study if they were diagnosed with several of the symptoms of PCS or PTSD, such as headache, 

tinnitus, concentration deficit, and photophobia. This 

alternative may have eliminated some error resulting 

from the difficulty with which PCS and PTSD are diagnosed and distinguished. Finally, cumulative blast exposure simply may not result in injury in the same way as 

single, large exposures. This may have correlation to the 

findings that loss of consciousness is very important in 

determining long term sequelae.12,14 Unfortunately, we 

did not include this vital piece of information as we did 

not have access to the deployment medical records. Our 

study would suggest that using readily available field 

exposure data may not be an accurate way to predict 

blast dose to the Soldier. Furthermore, the development 

of PCS and PTSD may not be as strongly related to blast 

dose as it is to other injuries or experiences.

These observations bring to light some limitations of 

this study, including the facts that the estimate of blast 

intensity was not validated independently with physical or biomechanical measurements; we were unable to 

evaluate other combat and noncombat exposures that 

contribute to PCS and PTSD; we did not have access to 

longitudinal health records during the deployment; and 

recorded health histories prior to deployment were not 

assessed.

Conclusion

Our study provides evidence that blast exposure and 

particularly being targeted in a blast are predictive of 

the development of PCS and further, for those targeted 

more than one time, PCS in conjunction with PTSD. 

Those in vehicles sustaining heavy battle damage are 

at an increased risk of being diagnosed with PTSD 

and PCS in conjunction with PTSD. Finally, Soldiers 

with previous deployments may be more likely to be 

Table 5. Sensitivity Analysis of Complex Model.

Cumulative

Intensity

Score

PCS

CRR

(95% CI)

PTSD

CRR

(95% CI)

Both

CRR

(95% CI)

>0 2.90

(1.41-5.97)

1.76

(0.83-3.77)

3.19

(0.96-10.6)

>1 2.55

(1.35-4.80)

2.28

(1.07-4.89)

3.19

(0.96-10.6)

>2 2.30

(1.31-4.03)

1.77

(0.91-3.44)

3.00

(1.13-7.99)

>3 2.35

(1.37-4.40)

2.16

(1.11-4.20)

3.67

(1.38-9.77)

>4 2.29

(1.37-3.84)

1.69

(0.90-3.16)

2.36

(1.01-5.50)

>5 2.61

(1.57-4.35)

1.66

(0.89-3.10)

2.91

(1.25-6.76)

>6 2.12

(1.30-3.47)

1.35

(0.71-2.55)

2.12

(0.94-4.76)

Table 4. Sensitivity Analysis of Gunner Model.

Cumulative

Intensity

Score

PCS

CRR

(95% CI)

PTSD

CRR

(95% CI)

Both

CRR

(95% CI)

>0 2.22

(1.25-3.96)

1.77

(0.89-3.50)

2.08

(0.83-5.20)

>1 1.71

(1.04-2.84)

1.14

(0.61-2.13)

0.97

(0.43-2.20)

>2 1.90

(1.16-3.12)

1.31

(0.69-2.47)

1.71

(0.76-3.86)

>3 1.82

(1.09-3.03)

1.68

(0.87-3.23)

2.32

(1.02-5.27)

>4 2.32

(1.39-3.88)

1.69

(0.83-3.43)

2.89

(1.26-6.62)

>5 2.63

(1.53-4.52)

1.34

(0.55-3.26)

2.44

(0.94-6.29)

>6 2.42

(1.27-4.62)

1.27

(0.41-3.87)

2.20

(0.69-6.99)

Table 3. Sensitivity Analysis of Simple Model.

Cumulative

Intensity

Score

PCS

CRR

(95% CI)

PTSD

CRR

(95% CI)

Both

CRR

(95% CI)

>0 2.36

(1.34-4.15)

1.61

(0.84-3.09)

2.42

(0.97-6.07)

>1 2.02

(1.22-3.32)

1.29

(0.69-2.42)

1.94

(0.86-4.37)

>2 2.24

(1.37-3.66)

1.33

(0.68-2.61)

2.09

(0.92-4.75)

>3 1.97

(1.13-3.44)

1.24

(0.54-2.85)

2.33

(0.95-5.70)

>4 2.19

(1.17-4.09)

1.37

(0.51-3.65)

2.43

(0.87-6.79)

>5 1.24

(0.42-3.60)

0.60

(0.09-4.15)

1.00

(0.14-7.05)
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

diagnosed with both PCS and PTSD. According to our 

data, the development of these diagnoses does not show 

a linear trend with increasing number of targeted exposures or increasing blast intensity estimates. We are, 

therefore, unable to delineate an exposure threshold that, 

if maintained, may decrease the incidence of PCS/PTSD, 

and above which commanders and providers may make 

informed, operational decisions regarding mission risk.

References

1. MacGregor A, Shaffer R, Corson K, et al. Prevalence and psychological correlates of traumatic 

brain injury in Operation Iraqi Freedom. J Head 

Trauma Rehabil. 2010;25(1):1-8.

2. Terrio H, Brenner L, Warden D, et al. Traumatic 

brain injury screening: preliminary findings in a 

US Army brigade combat team. J Head Trauma 

Rehabil. 2009;24(1):14-23.

3. Ahmed F, Kamnaksh A, Kovesdi E, Long J, Agoston D. Long-term consequences of single and multiple mild blast exposure on select physiological 

parameters and blood-based biomarkers. Electrophoresis. 2013;34(15):2229-2233.

4. Calabrese E, Du F, Garman R, et al. Diffusion tensor imaging reveals white matter injury in a rat 

model of repetitive blast-induced traumatic brain 

injury. J Neurotrauma. 2014;31(10):938-950.

5. Elder G, Mitsis E, Ahlers S, Cristian A. Blast-induced mild traumatic brain injury. Psychiatr Clin 

North Am. 2010;33(4):757-781.

6. Hoge C, McGurk D, Thomas J, Cox A, Engel 

C, Castro C. Mild traumatic brain injury in U.S. 

Soldiers returning from Iraq. New Engl J Med. 

2008;358(5):453-463.

7. Kamnaksh A, Kwon S, Kovesdi E, et al. Neurobehavioral, cellular, and molecular consequences of 

single and multiple mild blast exposure. Electrophoresis. 2012;33(24):3680-3692.

8. Polusny MA, Kehle SM, Nelson NW, Erbes CR, 

Arbisi PA, Thuras P. Longitudinal effects of mild 

traumatic brain injury and posttraumatic stress 

disorder comorbidity on postdeployment outcomes 

in National Guard Soldiers deployed to Iraq. Arch 

Gen Psychiatry. 2011;68(1):79-89.

9. Warden D. Military TBI during the Iraq and 

Afghanistan wars. J Head Trauma Rehabil. 

2006;21(5):398-402.

10. French L, Parkinson G. Assessing and treating veterans with traumatic brain injury. J Clin Psychol. 

2008;64(8):1004-1013.

11. Courtney A, Courtney M. A thoracic mechanism 

of mild traumatic brain injury due to blast pressure 

waves. Med Hypotheses. 2009;72(1):76-83.

12. Jorge R, Acion L, White T, et al. White matter abnormalities in veterans with mild traumatic brain 

injury. Am J Psychiatry. 2012;169(12):1284-1291.

13. McCrea M, Pliskin N, Yoash-Gantz R, et al. Official position of the military TBI task force on the 

role of neuropsychology and rehabilitation psychology in the evaluation, management, and research of 

military veterans with traumatic brain injury. Clin 

Neuropsychol. 2008;22(1):10-26.

14. Walker W, McDonald S, Ketchum J, Nichols M, 

Cifu D. Identification of transient altered consciousness induced by military-related blast exposure and its relation to postconcussion symptoms. J 

Head Trauma Rehabil. 2013;28(1):68-76.

15. Bryant R. Disentangling mild traumatic brain 

injury and stress reactions. New Engl J Med. 

2008;358(5):525-527.

16. Trudeau D, Anderson J, Barton S, et al. Findings 

of mild traumatic brain injury in combat veterans 

with PTSD and a history of blast concussion. J Neuropsychiatry Clin Neurosci. 1998;10(3):308-313.

17. Wilk J, Herrell R, Wynn G, Riviere L, Hoge C. 

Mild traumatic brain injury (concussion), posttraumatic stress disorder, and depression in US Soldiers involved in combat deployments: association 

with postdeployment symptoms. Psychosom Med. 

2012;74(3):249-257.

18. Meares S, Shores E, Marosszeky J, et al. Mild traumatic brain injury does not predict acute postconcussion syndrome. J Neurol Neurosurg Psychiatry. 

2008;79(3):300-306.

19. Sim A, Terryberry-Spohr L, Wilson K. Prolonged 

recovery of memory functioning after mild traumatic brain injury in adolescent athletes. J Neurosurg. 2008;108(3):511-516.

20. Vagnozzi R, Signoretti S, Lazzarino G, et al. Temporal window of metabolic brain vulnerability to 

concussion: a pilot 1H-magnetic resonance spectroscopic study in concussed athletes--part III. 

Neurosurgery. June 2008;62(6):1286-1295.

Authors

MAJ Saxe is a General Surgery Physician Assistant at 

the Evans Army Community Hospital, Fort Carson, 

Colorado.

Dr Perdue is the US Public Health Service Chief, Division of International Health Security, Office of Policy 

and Planning, Assistant Secretary for Preparedness and 

Response, Department of Health and Human Services, 

Washington, DC.

ASSOCIATIONS BETWEEN OPERATIONALLY ESTIMATED BLAST EXPOSURES AND POSTDEPLOYMENT

DIAGNOSES OF POSTCONCUSSION SYNDROME AND POSTTRAUMATIC STRESS DISORDER
January – March 2015 79

Posttraumatic Stress Disorder

Although recently there has been much publicity about 

posttraumatic stress disorder (PTSD) in the national media, PTSD is not a new phenomenon. In the last century, 

PTSD was called war neurosis, soldier’s heart, shell 

shock,1 combat fatigue and battle fatigue.2 According to 

the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) the diagnostic criteria for PTSD includes experiencing or witnessing events that involved 

actual or perceived death or injury to self or others in 

which the exposed individual responded with intense 

fear, horror, or helplessness.3 Symptoms of PTSD include: initial stressor (exposure to a violent event); persistent re-experiencing of the event while awake or in 

the form of nightmares; avoidance of stimuli associated 

with the event; alterations in affect and emotional detachment; and alterations in arousal and reactivity such 

as sleep disturbances and hyper-vigilance. The diagnosis of PTSD requires the symptoms remain for a month 

or longer and the “disturbance must cause clinically significant distress or impairment in social, occupational, 

or other important areas of functioning.”3

Posttraumatic stress disorder is a continuous concern 

for the Departments of Defense (DoD) and Veterans Affairs (VA), especially for service members associated 

with combat operations, including their families. However, determining the overall prevalence rate of PTSD 

is not an easy task. In a critical review of the combatrelated PTSD prevalence estimates, the authors reported a range of 2% to 17% point prevalence rate of US 

military veterans since the Vietnam War.4 In a study on 

service members serving in theater for Operations Iraqi 

Freedom (OIF) and Enduring Freedom (OEF), it was reported that 14% of the 1,965 survey responders met the 

criterion for PTSD.5 If the survey responders are representative of the currently over 2.5 million troops who 

have been deployed in support of OIF and OEF,6 this 

would indicate that approximately 350,000 will have 

PTSD.

All military personnel do not develop PTSD, and many 

studies have focused on the risk and protective factors to 

determine methods of protecting those at greatest risk. 

Factors that have a possible role in the risk of developing PTSD include “age and education at the time of deployment, gender, race, early conduct problems, intelligence, childhood adversity, family history of psychiatric disorder, pre-deployment psychological and physical 

health, poor social support after trauma, and personality 

pathology.”4(pp9-10) To our knowledge, this article is the 

first descriptive study on temperament and PTSD in a 

military sample.

Temperament

In the 20th century, child psychologists Thomas and 

Chess studied infant and child development. They stated that, “Temperament can be equated to the term behavioral style. Each refers to the “how” rather than the 

“what” (abilities and content) or the “why” (motivations) 

of behavior. In this definition, temperament is a phenomenological term and has no implications as to etiology or 

Temperament Dimensions and Posttraumatic

 Stress Symptoms in a Previously Deployed

 Military Sample

LTC Sandra M. Escolas, MS, USA

Hollie D. Escolas, BA

Abstract

This study examines the effects of temperament on self-reported posttraumatic stress disorder (PTSD) symptoms from a convenience sample of US military service members (N=559). Previously deployed active duty 

service members completed anonymous questionnaires that included demographics, temperament, and PTSD 

measures. This study also examines demographic variables such as age, gender, ethnicity, race, education, and 

marital status, and service-related variables such as branch, grade, and years of military service for moderating 

effects. Results suggest a relationship between the temperament dimensions and PTSD symptoms in that the 

temperament dimensions of low mood quality, high levels of activity generally and during sleep, and low flexibility were found to predict high levels of self-reported PTSD symptoms. This is the first study incorporating 

temperament as a predictor of PTSD within a military population and provides the basis for future research in 

this area.
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

immutability. On the contrary, like other characteristics 

of the organism—whether it be height, weight, intellectual competence, or perceptual skills—temperament is 

influenced by environmental factors in its expression 

and even in the nature as development proceeds.”7(p9)

Based on the classic infant temperament styles established by Thomas, Chess, and colleagues, temperament 

may be viewed as a continuum from “very easy” to 

“very difficult.” They identified 9 trait-dimensions of infant temperament which include: (1) activity level; (2) 

rhythmicity; (3) approach-withdrawal; (4) adaptability; 

(5) threshold of responsiveness; (6) intensity of reaction; 

(7) quality of mood; (8) distractibility; and (9) attention 

span and persistence. These results came from their 

1950s New York Longitudinal Study8 (NYLS). The temperament dimensions are used to categorize infant temperament as “easy,” “difficult,” or “slow-to-warm up.”7-9

“Easy” babies are defined by “regularity, positive approach responses to new stimuli, high adaptability to 

change, and mild or moderately intense mood that is 

preponderantly positive.” “Slow-to-warm up” babies are 

characterized “by a combination of negative responses 

of mild intensity to new stimuli with slow adaptability after repeated contact...mild intensity of reactions, 

whether positive or negative, and by less tendency to 

show irregularity of biological functions.”7 “Difficult” 

infants are defined by “irregularity in biological functions, negative withdrawal responses to new stimuli, 

nonadaptability or slow adaptability to change, and intense mood expressions which are frequently negative.”7

Results of the NYLS reported 40% of the infants in the 

study were classified as “easy,” 15% “slow-to-warm up” 

and 10% “difficult.” With 65% of the infants accounted 

for, the remaining 35% did not neatly fit into one of the 

categories and were classified as mixed.7,9 Temperament 

is generally considered relatively stable from infancy 

throughout maturation and adult life.11-16 “Most current temperament researchers would agree with Buss 

and Plomin’s (1984) notion that early onto genetic appearance, moderate stability, and distinctive biological manifestations are key ingredients of a definition 

of temperament.”17(p14) In essence, temperament can be 

considered “as one’s general style of behavior.”15

The theoretical relative stability of temperament establishes the connection between the child and adult temperament literature. Windle and Lerner15 developed 10 

adult temperament dimensions: (1) activity level-general; 

(2) activity level-sleep; (3) approach-withdrawal; (4) flexibility-rigidity; (5) mood quality; (6) rhythmicity-sleep; 

(7) rhythmicity-eating; (8) rhythmicity-daily habits; (9) 

distractibility; and (10) persistence. The principle here is 

that measuring a person’s temperament in adulthood would 

result in very similar styles to their childhood temperament. As with Thomas and Chess’s temperament dimensions, these adult temperament dimensions do not measure 

performance ability or motivations for behavior but places 

the emphasis on how people behave. For example, activity level-general refers to an overall measure of how much 

a person moves, whereas activity level-sleep refers to the 

amount of movement a person has while asleep or in bed. 

Approach-withdrawal indicates the initial response a person has when being presented with new people, items, or 

circumstances. The flexibility-rigidity indicates how long 

it takes for a person to accommodate to changes in their 

environment. Mood quality is the degree to which a person overtly displays their mood such as smiling or laughing. The 3 rhythmicity dimensions for sleeping, eating and 

daily habits indicate how regular a person is in maintaining their daily schedules in order to function. The distractibility dimension indicates the degree to which a person 

can be distracted from a task at hand. The final dimension, 

persistence, refers to the amount of time a person will continue with a given task or activity.18

PTSD and Temperament

A limited but growing number of studies have investigated the role of temperament in the development of 

PTSD and anxiety disorders in children and adult populations. Using the terrorist attacks of September 11, 2001, 

(9/11) as a pivotal event, Lengua and colleagues found 

preattack anxiety levels, as a measure of temperament, 

were associated with children reporting a higher level 

of postattack posttraumatic stress (PTS) symptoms.19 It 

was not that children were directly exposed to the 9/11 

attacks but that they witnessed the events and heard the 

commentary on television. Otto and colleagues found 

that “on the day of the attacks adults watched a mean 

of 8.1 hours of television coverage, and their children 

watched a mean of 3.0 hours.”20 Results such as these 

were used to support the belief that children may develop PTSD through media exposure of a traumatic event. 

A distinction is made for adults and children; the exposure to a traumatic event via any visual media is not applicable for adults “unless work related” such as combat 

medics or civilian first responders.19

Additional studies of traumatic events support the idea 

that indirect exposure is sufficient to induce PTSD, at 

least in vulnerable populations such as children.21 Temperament is considered to be relatively stable and this stability helps to predict how children will manage and react 

to their environments.22 For example, children exposed 

to traumatic domestic violence were found to be more resilient when characterized with an easy temperament.23

TEMPERAMENT DIMENSIONS AND POSTTRAUMATIC STRESS SYMPTOMS

IN A PREVIOUSLY DEPLOYED MILITARY SAMPLE
January – March 2015 81

THE ARMY MEDICAL DEPARTMENT JOURNAL

The Current Study

Data from a cross-sectional study was analyzed to examine the relationship between temperament and PTSD.

Methods

Procedure

Data were collected from a convenience sample of service 

members using anonymous self-reporting questionnaires. 

Demographics information and measures for PTSD and 

temperament were included. Subjects were recruited from 

gathering places such as the post or base exchanges and 

classrooms from Joint Base San Antonio (JBSA), which 

includes Fort Sam Houston and Lackland Air Force Base 

in San Antonio, Texas. The subjects completed the voluntary 15 to 20 minute questionnaire and returned it to the 

study personnel who had provided the questionnaire. The 

data were collected from summer 2010 to summer 2011. 

As PTSD rates have been steadily increasing since deployments to Iraq and Afghanistan began, we included only 

previously deployed service members in our subject pool 

to examine the relationship of temperament dimensions to 

the development of self-reported PTSD symptoms in this 

population. Criteria for participation included a deployment of at least 30 days, aged 18 years or older, and on 

active duty at the time the questionnaire was completed. 

Due to the lack of collecting personally identifiable data 

and the anonymous nature of the questionnaire, this study 

received an exempt determination from the Brooke Army 

Medical Center Institutional Review Board.

Participants

The participants included 559 service members recruited 

from JBSA. The demographics and service-related characteristics are described in Tables 1 and 2. Demographics 

include age, gender, ethnicity, race, education, and marital status. Service-related characteristics include branch 

of service, grade, and years of military service.

Measures

Two measurement tools included in the questionnaire 

package were the PTSD Checklist-Military (PCLM)24 and Dimensions of Temperament Survey–Revised 

(DOTS-R).15

PCL-M

The PCL-M24 is a 17-item self-report inventory that is 

widely used in DoD and VA with excellent reliability and 

validity. The PCL-M assesses the severity of each DSMIV3

 defined PTSD symptom. Each item corresponds to 

DSM-IV diagnostic criteria for PTSD and is scored on a 

1-5 scale (1-not at all; 5-extremely). Previous research on 

the PCL-M indicated mean scores of 64.2 (SD=9.1) for 

PTSD subjects and 29.4 (SD=11.5) for non-PTSD subjects.

Table 1. Demographics of Study Participants.

Number

(N=559)

%N

Age Group (years)

25 or less 45 8.0%

26-30 126 22.5%

31-40 271 48.5%

41 or over 117 20.9%

Gender

Male 401 71.7%

Female 157 28.1%

Ethnicity

Hispanic 69 12.3%

Non-Hispanic 484 86.6%

Race

Caucasian/White 358 64.8%

African American 107 19.5%

Asian/Pacific Islander 33 5.9%

Other 48 8.8%

Civilian Education*

Some HS, GED, HS Diploma 20 3.6%

Some College, AAS, BA/BS 407 72.8%

MA/MS, Professional, PhD 125 22.5%

Marital Status

Never married 81 14.5%

Currently married or living with a partner 378 67.6%

Currently separated or divorced 93 16.6%

*HS-High School; GED-General Educational Development;

AAS-Associate’s Degree; BA/BS-Bachelors Degree;

MA/MS-Master’s Degree; PhD-Doctorate Degree

Table 2. Service Related Characteristics of 

Study Participants.

Number

(N=559)

%N

Branch of Service

US Army 345 61.7%

US Air Force 206 36.9%

US Navy 6 1.1%

US Coast Guard 2 0.4%

Grade (combined services)

E1-E4 29 5.2%

E5-E7 305 54.6%

E8-E9 20 3.6%

WO1-WO4 9 1.6%

O1-O3 129 23.1%

O4-O5 40 7.2%

O6-above 8 1.4%

Years of Military Service

2 or less 8 1.5%

3 to 4 43 7.8%

5 to 7 72 13.1%

8 to 10 113 20.5%

11 to 14 120 21.8%

15 to 20 138 25.0%

21 or more 57 10.3%
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

DOTS-R

The DOTS-R15 is a revision of the initial Dimensions 

of Temperament Survey developed by Lerner and colleagues25 to assess temperament factors. The DOTS-R, a 

54-item questionnaire, measures 10 adult temperament dimensions: (1) activity level-general; (2) activity level-sleep; 

(3) approach-withdrawal; (4) flexibility-rigidity; (5) mood 

quality; (6) rhythmicity-sleep; (7) rhythmicity-eating; (8) 

rhythmicity-daily habits; (9) distractibility; and (10) persistence. The internal consistency coefficients (Cronbach’s 

alpha) reported by Windle and Lerner were .84, .89, .85, 

.78, .89, .78, .80, .62, .81, and .74, respectively, for the 10 

listed factors demonstrating acceptable reliability of this 

instrument.15,26

Data Analysis

Data analysis was conducted using SPSS Version 19 

(IBM Corp, 2010). Pairwise deletion was used to control for missing data so that the respondent was dropped 

from the analyses that involved only the variables that 

have missing values. Linear regressions were used for 

data analyses using the “enter” method which enters all 

variables at the same time. The first linear regression 

analysis was used to determine which temperamental 

factors would be associated with PTSD scores. All 10 

temperament dimensions were entered into the model 

and regressed on the total PTSD score. The second linear regression was conducted in which the temperament 

factors plus demographics and service-related characteristics were used to predict PTSD score.

Results

In the first regression analysis (Model 1), all 10 temperament factors were entered into a linear regression 

as independent variables; 4 of the 10 temperament dimensions were found to be significant predictors of the 

PTSD score: mood quality, activity level-sleep, flexibilityrigidity, and activity level-general. This regression analysis determined that temperament dimensions predict 

36% of the variance for a PTSD score. Mood quality 

was found to be the strongest predictor, responsible 

for 26% of variance in PTSD scores. The remaining 

significant variables (activity level-sleep, flexibilityrigidity, and activity level-general) only accounted an 

additional 10% of the variance in the PTSD score. 

Therefore, mood quality is the best predictor of selfreported PTSD symptoms. Table 3 presents the descriptive statistics for the temperament dimensions 

and the PTSD measure.

The second regression analysis (Model 2) was conducted to determine if the effects found in the first 

regression equation remained after adding the demographic and service-related variables. Mood 

quality, activity level-sleep, flexibility-rigidity and activity level-general remained significant predictors after 

adding the demographic variables and service-related 

variables. Rhythmicity-sleep and rhythmicity-daily habits of the temperament dimensions, age and race of the 

demographic variables, and branch of the service related 

variables were also found to be significant in this second 

model. However, the addition of all these variables into 

the model only increased the variance accounted for by 

3%. The regression models are shown in Table 4.

Comment

Using self-report measures, the temperament dimensions appear to be related to PTSD symptomology. The 

mood quality temperament dimension was found to be 

the strongest predictor of self-reported PTSD score followed by activity level-sleep, flexibility-rigidity and activity level-general. The inverse relationship indicates 

that individuals reporting higher mood quality reported 

lower PTSD symptom scores. This result is similar to 

that reported by Miller27 in that the personality construct of positive and negative emotionality was related 

to PTSD. Personality constructs like positive and negative emotionality have been found to be closely related 

to dimensions of temperament identified in early childhood and infancy, and that these constructs remain stable 

throughout adulthood.27 Changes in sleep and restlessness are consistently listed symptoms for PTSD within 

the DSM-IV. Gellis et al28 studied sleep disturbances in 

service members with a positive PCL-C screen for PTSD 

and found a “positive relationship between depression 

and nightmares” with disturbed sleep. Measures of the 

mood quality dimension, including other temperament 

factors, have been demonstrated to be relatively stable 

over a lifespan. This is a reflection of the individuals’ 

temperaments and not affective symptoms associated 

with PTSD. The contrary is plausible however, and 

further investigations with a within-subjects design of 

TEMPERAMENT DIMENSIONS AND POSTTRAUMATIC STRESS SYMPTOMS

IN A PREVIOUSLY DEPLOYED MILITARY SAMPLE

Table 3. Descriptive Statistics for Temperament Dimensions and 

Posttraumatic Stress Disorder Measure.

N Minimum Maximum Mean SD

Activity Level General 559 7 28 18.12 4.47

Activity Level Sleep 551 3 16 10.83 3.41

Approach-Withdrawal 559 8 28 18.74 3.47

Flexibility-Rigidity 559 5 20 14.39 3.00

Mood Quality 559 5 28 22.30 4.91

Rhythmicity-Sleep 559 2 24 14.76 4.00

Rhythmicity-Eating 559 3 20 13.14 3.70

Rhythmicity-Daily Habits 559 2 20 11.77 2.95

Distractibility 559 5 20 12.23 2.79

Persistence 559 2 12 8.57 1.65

PTSD Score 547 17 76 30.21 14.33

Valid N listwise 543
January – March 2015 83

THE ARMY MEDICAL DEPARTMENT JOURNAL

pre- and postdeployment measures of temperament may 

elaborate the relationship quantitatively.

Research suggests that PTSD disposition in the military 

may be based on predisposing factors including gender, 

age at trauma, race, education, previous trauma, general 

childhood adversity, psychiatric history, reported childhood abuse, and family psychiatric history.29,30 Some 

of these factors, such as race, were only significant in 

certain populations. Others such as general childhood 

adversity had more uniform predictive effects and predicted PTSD more consistently.

One limitation of our study is the relatively small sample 

size and limited military occupational specialties. Our 

modest sample size yielded some significant findings, 

but the ideal population sample would include a larger 

number of personnel with a variety of occupations to 

represent the entire spectrum of military members to include but not be limited to combat ready infantry, mechanized cavalry, medical personnel, logisticians, and ordinance personnel, among others. Our sample was derived from installations within Joint Base San Antonio, 

Texas, where the primary missions are basic training, 

medical education and training, and health care delivery.

A second limitation could result from the use of a selfreport instrument. The use of self-reporting surveys/

screening tools are commonly thought 

to be biased, however, social science 

depends on these tools. Brener and 

colleagues reviewed over 100 studies of self-reported questionnaires 

for validity and determined that they 

are “accurate when individuals understand the questions and when there is 

a strong sense of anonymity and little 

fear of reprisal.”31 Any bias in selfreporting may result from participants 

completing the questionnaires in noncontrolled environments, such as at a 

food court, at home or workspace, either alone or in the presence of others, 

which may cause reluctance in providing honest answers.32

It is important to note that the DSM-IV 

has been updated to a newer version 

(DSM-V33), however, the PTSD measure used in this study is based upon 

the DSM-IV criteria and for consistency we used the DSM-IV criteria for 

this study. In our opinion, this does not 

reflect on the results being presented.

Conclusion

Our results indicate the need to increase research in the 

area of temperament/PTSD to determine if people with 

certain temperaments may be more vulnerable to PTSD. 

If this is the case, efforts to develop and provide protective/preventative measures before exposure to traumatic 

situations may be considered. In addition, perhaps the 

most vulnerable could be assigned to a military occupation that is supportive of “goodness of fit” between temperament and occupation, and even minimize exposure 

to traumatic situations.7,9 This information is important 

for the well-being of our military service members and 

should continue to be studied.

Future Directions

Both findings and limitations to this study provide insight into future directions for research into the relationship between temperament and PTSD. To the authors’ 

knowledge, this was the first study of temperament and 

PTSD within a military sample. Its replication would 

strengthen the initial findings. Additional cross-sectional designs may benefit from a more inclusive model of 

the variation in PTSD symptoms to control for known 

moderators and risk factors not measured in the study, 

such as trauma intensity, peritrauma fear, and combat 

exposure.30,32 These findings may help clinicians take 

into account a patient’s unique temperament when treating personnel affected by PTSD.

Table 4. Regression Models Predicting Posttraumatic Stress Disorder Score.

Model 1 Model 2

Variable B SE β B SE β

(Constant) 58.14 5.57 50.94 7.43

Activity Level General 0.43 0.13 0.13, P<.001 0.44 0.13 0.14, P<.001

Activity Level Sleep 0.79 0.16 0.19, P<.001 0.81 0.16 0.19, P<.001

Approach-Withdrawal -0.05 0.18 -0.01 -0.08 0.18 -0.02

Flexibility-Rigidity -0.78 0.19 -0.16, P<.001 -0.71 0.20 -0.14, P<.001

Mood Quality -0.89 0.12 -0.30, P<.001 -0.84 0.12 -0.28, P<.001

Rhythmicity-Sleep -0.35 0.18 -0.09 -0.44 0.18 -0.12, P<.05

Rhythmicity-Eating -0.17 0.19 -0.04 -0.06 0.19 -0.01

Rhythmicity-Daily Habits -0.45 0.23 -0.09 -0.49 0.23 -0.10, P<.05

Distractibility -0.08 0.21 -0.02 -0.12 0.21 -0.02

Persistence 0.19 0.35 0.02 0.34 0.35 0.04

Age 1.46 0.66 0.09, P<.05

Gender 1.21 1.16 0.04

Race 1.13 0.55 0.07, P<.05

Ethnicity -1.31 1.60 -0.03

Branch of Service -1.79 0.50 -0.13, P<.001

Marital Status 0.91 0.70 0.05

Education -0.18 0.57 -0.02

Rank Combined -0.06 0.34 -0.01

Adjusted R2 0.357 0.385

F for model (df) 31.15(10,532), P<.001 19.37 (18,511), P<.001

B indicates the unstandardized coefficient.

β indicates standardized coefficient.
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

Acknowledgements

This research was supported in part by an appointment 

to the Student Research Participation Program at the 

US Army Institute of Surgical Research, administered 

by the Oak Ridge Institute for Science and Education 

through an interagency agreement between the US Department of Energy and US Army Medical Research and 

Materiel Command. We thank Dr James Aden for his 

help and support on processing the statistics and LTC 

Mann-Salinas for her help with the revision process.

References

1. Crocq MA, Crocq L. From shell shock and war 

neurosis to posttraumatic stress disorder: a history 

of psychotraumatology. Dialogues Clin Neurosci.

2000;2(1):47-55.

2. Shively SB, Perl DP. Traumatic brain injury, shell 

shock, and posttraumatic stress disorder in the 

military--past, present, and future. J Head Trauma 

Rehabil. May-Jun;2012;27(3):234-249.

3. American Psychiatric Association. 309.81 Posttraumatic Stress Disorder. In: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association: 

1994:424-429.

4. Richardson LK, Frueh BC, Acierno R. Prevalence 

estimates of combat-related post-traumatic stress 

disorder: critical review. Aust N Z J Psychiatry. 

2010;44(1):4-19.

5. Tanielian T, Jaycox LH, Schell TL, et al. Invisible 

Wounds: Mental Health and Cognitive Care Needs 

of America’s Returning Veterans. Santa Monica, 

CA: RAND Corporation; 2008.

6. RAND Corporation. Invisible Wounds of War 

Project [internet]. 2013. Available at: http://www.

rand.org/multi/military/veterans.html. Accessed 

December 14, 2013.

7. Thomas AT, Chess S. Temperament and Development. New York, NY: Brunner/Mazel; 1977.

8. Thomas A, Chess S, Birch HG. Temperament and 

Behavior Disorders in Children. New York, NY: 

New York University Press; 1968.

9. Thomas A, Chess S. Genesis and evolution of behavioral disorders: from infancy to early adult life. 

Am J Psychiatry.1984;141(1):1-9.

10. Thomas A, Chess S, Birch HG. The origin of personality. Sci Am.1970;223(2):102-109.

11. Buss AH, Plomin R. Temperament: Early Developing Personality Traits. Hillsdale, NJ: L Erlbaum; 

1984.

12. Goldsmith HH, Buss AH, Plomin R, et al. Roundtable: what is temperament? Four approaches. Child 

Dev. 1987;58(2): 505-529.

13. Rothbart MK, Derryberry D. Development of individual differences in temperament. In: Lamb ME, 

Brown AL, eds. Advances in Developmental Psychology. Hillsdale, NJ: Erlbaum; 1981:37-86.

14. Green J, Bax M, Tsitsikas H. Neonatal behavior 

and early temperament: a longitudinal study of 

the first six months of life. Am J Orthopsychiatry.

1989;59(1):82-93.

15. Windle M, Lerner RM. Reassessing the dimensions 

of temperamental individuality across the life span: 

the Revised Dimensions of Temperament Survey 

(DOTS-R). J Adolesc Res. 1986;1:213-230.

16. Saudino KJ. Behavioral genetics and child temperament. J Dev Behav Pediatr. 2005;26(3):214-223.

17. Zentner M, Bates JE. Child temperament: an integrative review of concepts, research programs, and 

measures. Eur J Dev Sci. 2008;2(1/2):7-37.

18. Windle M. Revised dimensions of temperament 

survey (DOTS-R): Simultaneous group confirmatory factor analysis for adolescent gender groups. 

Psychol Assess. 1992;4(2):228-234.

19. Lengua LJ, Long AC, Smith KI, Meltzoff AN. 

Pre-attack symptomatology and temperament as 

predictors of children’s responses to the September 11 terrorist attacks. J Child Psychol Psychiatry. 

2005;46(6):631-645.

20. Otto MW, Henin A, Hirshfeld-becker DR, Pollack MH, Biederman J, Rosenbaum J. Posttraumatic stress disorder symptoms following media 

exposure to tragic events: impact of 9/11 on children at risk for anxiety disorders. J Anxiety Disord.

2007;21(7):888-902.

21. Martinez-Torteya C, Anne Bogat G, von Eye A, Levendosky AA. Resilience among children exposed 

to domestic violence: the role of risk and protective 

factors. Child Dev. 2009;80(2):562-577.

22. Rothbart M, Bates J. Temperament. In: Eisenberg 

N, Damon W, Richard LM, eds. Handbook of Child 

Psychology: Vol. 3, Social, Emotional, and Personality Development. 6th ed. Hoboken, NJ: John Wiley & Sons Inc; 2006;99-166.

23. Cloitre M, Morin NA, Linares OL. Children’s resilience in the face of trauma [internet]. New York 

University Child Study Center; 2010. Available at: 

http://www.education.com/reference/article/Ref_

Childrens_Resilience/. Accessed December 9, 2014.

24. Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD Checklist (PCL): reliability, 

validity, and diagnostic utility. Abstract presented 

at: 9th Annual Meeting of the International Society 

for Traumatic Stress Studies; October 1993; San 

Antonio, TX. Available at http://www.pdhealth.

mil/library/downloads/PCL_sychometrics.doc.

Accessed July 10, 2013.

TEMPERAMENT DIMENSIONS AND POSTTRAUMATIC STRESS SYMPTOMS

IN A PREVIOUSLY DEPLOYED MILITARY SAMPLE
January – March 2015 85

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25. Lerner RM, Palerno M, Spiro A III, Nesselroade 

JR. Assessing the dimensions of temperament 

individuality across the life span: the dimensions of temperament survey (DOTS). Child Dev. 

1982;53(1):149-159.

26. Windle M. Temperament and social support in 

adolescence: interrelations with depressive symptoms and delinquent behaviors. J Youth Adolesc.

1992;21(1):1-21.

27. Miller MW. Personality and the development and 

expression of PTSD. PTSD Res Q. 2004;15(3):3. 

Available at: http://www.ptsd.va.gov/professional/

newsletters/research-quarterly/V15N3.pdf. Accessed December 18, 2014.

28. Gellis LA, Gehrman PR, Mavandadi S, Oslin DW. 

Predictors of sleep disturbances in Operation Iraqi 

Freedom/Operation Enduring Freedom veterans 

reporting a trauma. Mil Med. 2010;175(8):567-573.

29. Trickey D, Siddaway AP, Meiser-Stedman R, Serpell L, Field AP. A meta-analysis of risk factors for 

post-traumatic stress disorder in children and adolescents. Clin Psychol Rev. 2012; 32(2):122-138.

30. Boscarino JA, Kirchner HL, Hoffman SN, Sartorius J, Adams RE, Figley CR. The New York 

PTSD risk score for assessment of psychological 

trauma: male and female versions. Psychiatry Res. 

2012;200(2-3):827-834.

31. Brener ND, Billy JO, Grady WR. Assessment 

of factors affecting the validity of self-reported 

health-risk behavior among adolescents: evidence 

from the scientific literature. J Adolesc Health.

2003;33(6):436-457. Cited by: Center for Health 

and Safety Culture. Validity of Self-Report Survey 

Data [internet]. January 2011. Available at: http://

www.minnetonka.k12.mn.us/TonkaCares/RwR/

Documents/Validity%20of%20Self%20Report.

pdf. Accessed July 24, 2013.

32. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull.

2003;129(1):52-73.

33. American Psychiatric Association. Diagnostic and 

Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association. 

2013.

Authors

LTC Escolas is Chief, Burns and Trauma Research, US 

Army Institute of Surgical Research, San Antonio Military Medical Campus, San Antonio, Texas.

Ms Hollie Escolas is currently pursuing her Master of 

Arts in Counseling at theUniversity of Texas at San Antonio. She is a research volunteer at the US Army Institute of Surgical Research through the Oak Ridge Institute for Science and Education.
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

Anonymous estimates indicate that up to 30% of veterans 

returning from combat operations in Iraq and Afghanistan meet screening criteria for various psychological 

problems.1,2 Fewer than half of Soldiers who meet anonymous screening criteria for a behavioral health problem 

report these problems during Post-Deployment Health 

Assessment (PDHA) screening.3 Furthermore, Soldiers 

who met anonymous screening criteria for a behavioral 

health problem were significantly less willing to honestly 

report these problems during PDHA screening.

Rates of Soldiers identified as having behavioral health 

problems during non-anonymous screening mandated 

by the Department of Defense (DoD) are less than half 

the anonymous estimate.3 Furthermore, among Soldiers 

identified during DoD-mandated screening as having a 

behavioral health problem, less than 10% received treatment for these problems within the first year following 

their return from combat operations.1

Stigma and barriers to care are 2 factors with empirical 

support that help explain why Soldiers with behavioral 

health problems are reluctant to report these problems 

during DoD-mandated screening.1,2,4 Stigma concerns 

Soldier beliefs that others (eg, leaders and/or fellow unit 

members) might think less of them for seeking treatment. Barriers to care include Soldier perceptions that 

certain obstacles make accessing available treatment 

services difficult (eg, getting time off work, scheduling 

an appointment).

This retrospective evaluation explores anonymous Unit 

Behavioral Health Needs Assessment (UBHNA) data 

in order to identify predictors of Soldier willingness 

to honestly report problems and seek treatment during PDHA screening.* Special emphasis was given to 

identifying organizational factors that unit leaders and 

behavioral health officers might be able to influence in 

order to encourage honest reporting of mental health 

problems during an upcoming PDHA screening and 

subsequent treatment seeking when indicated.

Method

Periodic use of anonymous surveys to evaluate rates of 

behavioral health problems is common among deployed 

units.5 The UBHNA survey is an anonymous survey 

used by behavioral health officers to assist unit commanders with combat stress control planning.6,7 Consisting of 6 pages that query 7 content areas (ie, demographics, deployment experiences, work environment, training, behavioral health, family, and survey satisfaction), 

the UBHNA survey is a compilation of free, open-source 

scales previously validated on a military population (eg, 

the 17-item Posttraumatic Stress Disorder Checklist, the 

9-item Patient Health Questionnaire for depression).2,8-10

Key capabilities of the UBHNA include estimates of 

Soldiers meeting screening criteria for behavioral health 

problems (ie, depression, posttraumatic stress disorder 

(PTSD), and suicidal ideation), stigma and barriers to 

care concerns, and a variety of unit climate characteristics (eg, leadership, cohesion, mission readiness).

Large-sample norms established at 3 different time 

points (pre-, during-, and postdeployment) for nearly 

every item on the UBHNA are used as a rough gauge of 

Predicting Willingness to Report Behavioral

 Health Problems and Seek Treatment

 Among US Male Soldiers Deployed to

 Afghanistan: A Retrospective Evaluation

LTC Ronald J. Whalen, MS, USA

Abstract

This retrospective evaluation explores anonymous survey data to identify predictors of Soldier willingness to 

report and seek treatment for behavioral health problems during screening mandated by the Department of 

Defense (DoD). After controlling for stigma and barriers to care concerns, Soldiers with high (+1SD) combat 

exposure and high (+1SD) levels of posttraumatic stress symptoms were significantly more willing to report 

these symptoms during DoD-mandated screening. Furthermore, Soldiers who perceived that their unit leaders 

took action on anonymous Unit Behavioral Health Needs Assessment survey findings were significantly more 

likely to report a willingness to disclose behavioral health problems and seek treatment for the same. Performance improvement considerations are discussed.

*Restricted access: https://www.rto.wrair.army.mil/bhr.html
January – March 2015 87

unit behavioral health at each phase in the deployment 

cycle. Behavioral health officers are trained to use the 

UBHNA to provide anonymous estimates of behavioral 

health problems within a particular unit, provide feedback in relation to established norms, and make recommendations on ways to improve unit behavioral health.

Like the Mental Health Advisory Team reports that informed the creation of the UBHNA,5,6 this study uses 

a conceptual framework that is based on the Soldier 

Adaptation Model (SAM).11 The SAM consists of 3 domains: stressors, moderators, and strains.

Stressors include workplace conditions that tax the 

physical or psychological fitness of Soldiers (eg, combat 

exposure, austere living conditions). Moderators “are attitudes and circumstances that increase or decrease the 

impact of stressors (eg, leadership climate).”12 Finally, 

strains are potential outcomes (eg, depression, PTSD) 

following exposure to stressors and moderators.

While there is a strong dose-response relationship between combat exposure and psychological problems 

like PTSD, unit leaders have limited ability to moderate levels of combat exposure. The UBHNA, however, 

can help unit leaders identify behavioral health interventions which are designed to help Soldiers cope with 

known risk factors (eg, seeking evidenced-based treatment for PTSD).

In late June 2011, the task force commander responsible 

for approximately 750 Soldiers assigned to an infantry 

battalion requested a UBHNA survey which was conducted in July 2011. The unit deployed to Afghanistan in 

January of 2011 and conducted counterinsurgency operations in the eastern province from January 2011 until 

December 2011. This was the second year-long deployment to Afghanistan for this unit in 3 years. In November of 2011, approximately one month prior to PDHA 

screening, a second iteration of the UBHNA survey was 

conducted on this same task force by the same 2-man 

combat stress control team collocated within the unit’s 

battalion aid station.

The study sample consisted of Soldiers assigned to an 

infantry battalion performing combat operations in Afghanistan. There were 6 subordinate (company) commands within the battalion, four of which were infantry 

companies consisting of approximately 100 Soldiers, a 

headquarters company with a scout platoon, and a support company responsible for meeting the logistic needs 

of the battalion. Three of 4 infantry companies occupied 

their own combat outposts within the battalion’s area 

of operations, while the battalion staff/headquarters 

company, logistic support company, and an infantry 

company all shared a common forward operating base 

in the eastern region of Afghanistan. Female Soldiers 

were excluded from this analysis given known gender 

differences in healthcare utilization rates,13-16 and too 

few female participants (n=4).17 Analysis of the UBHNA 

survey data was authorized under a protocol approved 

by the Joint Combat Casualty Research Team, Bagram, 

Afghanistan.

Measures

Willingness to Honestly Report Behavioral Health 

Problems and Seek Treatment. Two items were added 

to the standard UBHNA survey that explored Soldier 

willingness to honestly report symptoms on an upcoming PDHA, as well as willingness to seek treatment if 

screening indicated (or Soldiers believed) they had a 

behavioral health issue.3 Using a scale ranging from 1 

(strongly disagree) to 5 (strongly agree), Soldiers were 

asked to indicate how much they agreed with the following statements: “I feel comfortable honestly reporting 

any behavioral health problems during the postdeployment screening,” and “If screening results indicate or I 

believe I have an ongoing behavioral health issue, I will 

seek treatment.”

Combat Exposure. Five items on the UBHNA survey query combat exposure levels. Two of the 5 items 

(“How often were you in serious danger of being injured or killed?” and “How many times did you engage 

the enemy in a firefight?”) used a scale ranging from 0 

(never) to 3 (many times). The remaining 3 items were 

dichotomous (eg, “Were you responsible for the death of 

an enemy combatant?”). A dichotomous sum score was 

created from all 5 items (α=.34).

Posttraumatic Stress Disorder Checklist (PCL): Anonymous rates of posttraumatic stress disorder (PTSD) were 

estimated using a cut-off score of 50 or higher on the 

PCL.* The PTSD Checklist (PCL) was first developed 

by researchers within the Veterans Administration.18

Overall Cronbach’s alpha for the PCL have ranged from 

0.87 to 0.97 in research conducted across a broad spectrum of trauma-related research.19 A continuous scale 

of PCL symptom levels was used for this retrospective 

evaluation (α=.93).

Patient Health Questionnaire-8 (PHQ-8): The PHQ-8 

used for this retrospective study constitutes a modification to the PHQ-9, a validated screen for depression 

widely used throughout the DoD for both research and 

clinical purposes.20-22 Because one item from the PHQ-9 

*Restricted access: https://www.rto.wrair.army.mil/bhr.html
88 http://www.cs.amedd.army.mil/amedd_journal.aspx

is used to estimate both depression and suicidal ideation, the item 

measuring suicidal ideation was removed from the scale and used as 

an independent predictor of willingness to report behavioral health 

problems and/or seek treatment 

(see Suicidal Ideation below).

Soldier responses were measured 

using a scale ranging from 0 (not 

at all) to 3 (nearly every day). Sum 

scores were produced using the 

8 remaining items of the PHQ-9 

(α=.87).

Suicidal Ideation (SI): Estimates of 

SI were taken from a single item 

on the PHQ-9 (ie, “Over the LAST 

4 WEEKS, how often have you 

been bothered by...thoughts that 

you would be better off dead, or of 

hurting yourself in some way”). A 

scale ranging from 0 (not at all) to 

3 (nearly every day) was used to 

measure Soldier responses. Scores 

on this item were treated as a continuous variable.

Stigma: Six items on the UBHNA 

survey query Soldier perceptions 

of stigma concerning behavioral healthcare. All stigma 

items were preceded by the following stem: “Rate each 

of the possible concerns that might affect your decision to receive behavioral health counseling or services.” Soldiers evaluated all 6 items using a scale ranging 

from 1 (strongly disagree) to 5 (strongly agree). Sample 

stigma items include: “Members of my unit might have 

less confidence in me,” and “It would harm my career.” 

A sum score was created using all 6 items (α=.93).

Barriers to Care: Four items on the UBHNA survey query Soldier perceptions of barriers to care.All items were 

preceded by the following stem: “Rate each of the possible concerns that might affect your decision to receive 

behavioral health counseling or services.” Soldiers evaluated all 4 items using a scale ranging from 1 (strongly 

disagree) to 5 (strongly agree). A composite variable 

was created by summing all 4 items (α=.76).

UBHNA Survey Follow-up: Five items were added to the 

standard UBHNA survey to evaluate Soldier perceptions of unit leader use of the July 2011 UBHNA survey findings.23,24 All 5 items employed a 5-point scale 

ranging from 1 (strongly disagree) 

to 5 (strongly agree).

Three items queried perceptions of 

survey-based actions (ie, feedback, 

problem identification, and visible 

action) taken by unit leaders following the July UBHNA survey to improve the psychological wellbeing 

of their Soldiers (eg, “In the PAST 

3 MONTHS: I believe my unit used 

the July 2011 survey results to identify issues for improvement”). A 

sum score was generated across all 

3 survey-based actions (α=.84).

Linear regression was used to 

evaluate predictors of Soldier willingness to honestly report behavioral health problems during PDHA 

screening. A series of 3 statistical 

models were used to predict Soldier 

willingness to honestly report problems during an upcoming PDHA. 

Model 1 included strain indices for 

mental health problems (adjusted 

for rank and combat exposure levels) which would logically predict 

the perceived need to report problems and/or seek treatment. Model 

2 included established moderators 

of Soldier willingness to report problems and/or seek 

treatment (eg, stigma), as well as an exploration of routine unit climate variables found on the UBHNA (eg, 

leadership, cohesion, morale) and items added as part of 

a UBHNA survey follow-up. Finally, Model 3 examined 

the interaction between combat exposure and PTSD 

symptoms when predicting Soldier willingness to report 

problems and/or seek treatment in the event that either 

differed as a function of this interaction. Soldiers who 

arrived after July (n=7) or failed to provide an arrival 

date (n=9) were removed from analysis. All analyses 

were performed using IBM SPSS (Ver 21).

Results

Table 1 describes the demographic characteristics of 

this sample. The majority of Soldiers were young males 

(≤24 yrs), enlisted (64%), and serving their first deployment (69%). Seventeen percent of Soldiers met criteria 

for PTSD, 15% reported some level suicidal ideation in 

the past month, while only 3% met criteria for depression—rates comparable to during- and postdeployment 

norms reported elsewhere.2,3 Among sources of mental health services received during the past year, 14% 

Table 1. Demographic Characteristics of 

Sample.

Variable UBHNA

No. (%N)

(N=150)*

Age (years)

18-24 81 (54.0)

25-29 40 (27.0)

≥30 29 (19.0)

No. of prior deployments

0 102 (69.0)

1 41 (28.0)

≥2 5 (3.4)

Rank

Enlisted 95 (64.0)

Noncommissioned officers 42 (28.0)

Officers 11 (7.0)

Psychological disorders

Posttraumatic stress disorder 26 (17.3)

Depression 4 (2.7)

Suicidal ideation 22 (14.8)

Any problem 39 (26.0)

Source of mental health services

received in the past year

Mental health professional

at a military facility

21 (14.0)

General medical doctor

at a military facility

11 (7.3)

Military chaplain 16 (10.7)

Medic in unit 16 (10.7)

Soldier in unit (excluding medic) 22 (14.8)

*Exact numbers vary due to missing data.

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THE ARMY MEDICAL DEPARTMENT JOURNAL

of Soldiers sought services from a 

mental health professional. While 

representative of US Army infantry 

battalions, the demographic characteristics of this sample differs in important ways from the sample used 

to create UBHNA during deployment norms; namely, this was an allmale sample of younger, more junior 

ranking Soldiers relative to the UBHNA sample.*

Table 2 presents χ 2 findings related 

to the 6 stigma items, 4 barriers to 

care items, and willingness to report mental health problems and 

seek treatment during mandated 

PDHA screening. Replicating findings reported elsewhere,4,20 Soldiers 

with any behavioral health problem 

were significantly more likely to 

endorse all stigma items and 3 of 4 

barriers to care items than Soldiers 

who screened negative. Unlike previously reported findings, however, 

Soldiers with a current behavioral 

health problem did not differ in 

their willingness to honestly report 

behavioral health problems on the 

PDHA.3

Table 3 presents bivariate correlations between outcome 

and predictor variables. There was a strong (positive) 

bivariate correlation between willingness to seek treatment and willingness to report behavioral health problems (r=0.75, P<.001). Weak (positive) correlations exist 

between perceptions of survey-based action and willingness to report problems (r=0.30, P<.01) and seek treatment (r=0.23, P<.05). There was no correlation between 

combat exposure levels and willingness to report problems or seek treatment. Depression symptoms (PHQ-8) 

were weakly (negatively) correlated with willingness to 

seek treatment (r=-0.15, P<.01). Neither PTSD symptoms 

nor SI symptoms were correlated with either outcome.

Table 4 presents fully standardized multivariate findings 

for a series of 3 models predicting willingness to honestly report behavioral health problems during PDHA 

screening. Model 1 is the baseline model that accounts 

for rank; combat exposure; and PTSD (PCL), depression (PHQ-8), and SI symptoms, none of which predicted willingness to honestly report behavioral health 

problems. Model 2 introduces individual-level perceptions of stigma, barriers to care, leader actions with respect to the July UBHNA survey findings, as well as 

prior treatment from a behavioral health professional 

in the past year. Results from this model indicate that 

when controlling for all other variables, officers (β =.92, 

P<.05) were significantly more willing to honestly report behavioral health problems relative to enlisted Soldiers. Furthermore, Soldiers who perceived that their 

unit leaders took any action on the July UBHNA survey findings were significantly more willing to report 

behavioral health problems (β =.12, P<.01). Finally, 

Model 3 includes a positive interaction between combat 

exposure and PTSD symptoms (PCL) when predicting 

willingness to honestly report behavioral health problems (β =.01, P<.05). Figure 1 is a plot of the interaction between combat exposure and PCL scores when 

predicting willingness to report problems. Soldiers with 

high PCL scores did not differ in their willingness to 

report mental health problems as a function of combat 

exposure. However, Soldiers with high (+1 SD) combat 

exposure and low (-1 SD) PCL scores were significantly 

less willingness to report behavioral health problems.

Table 2. Stigma, Willingness to Honestly Report Behavioral Health Problems and 

Seek Treatment (N=130).*

Survey Item Any Problem† χ2 P

I don’t know where to get help. Negative (n=94) 8.54 .074

Positive (n=36)

I don’t have adequate transportation. Negative (n=94) 15.16 .004

Positive (n=36)

It is difficult to schedule an appointment. Negative (n=94) 12.85 .012

Positive (n=36)

There would be difficulty getting time off work for 

treatment.

Negative (n=94) 16.46 .002

Positive (n=36)

It would harm my career. Negative (n=94) 34.14 .000

Positive (n=36)

Members of my unit might have less confidence in me. Negative (n=94) 20.93 .000

Positive (n=36)

My unit leadership might treat me differently. Negative (n=94) 19.67 .000

Positive (n=36)

I would be seen as weak. Negative (n=94) 30.17 .000

Positive (n=36)

My visit would not remain confidential. Negative (n=94) 23.24 .000

Positive (n=36)

My leaders discourage the use of behavioral health 

services.

Negative (n=94) 24.58 .000

Positive (n=36)

I feel comfortable honestly reporting any behavioral 

health problems during the postdeployment screening.

Negative (n=94) 5.32 .256

Positive (n=36)

If screening results indicate or I believe I have an ongoing behavioral health issue, I will seek treatment.

Negative (n=94) 6.58 .160

Positive (n=36)

*Data exclude missing values, because not all respondents answered every question.

†Any problem includes posttraumatic stress disorder, depression or suicidal ideation.

*Restricted access: https://www.rto.wrair.army.mil/bhr.html
90 http://www.cs.amedd.army.mil/amedd_journal.aspx

Table 5 presents fully standardized multivariate findings for willingness to seek treatment if PDHA screening indicates (or Soldiers believed) they had a behavioral 

health problem. Beginning with Model 1, only combat 

exposure (β =-.23, P<.05) was negatively correlated 

with willingness to seek treatment. After including 

stigma, barriers to care, prior treatment from a behavioral health professional, and perceptions of any leader 

actions to address the July UBHNA survey findings 

(Model 2), we see that officers (β =.90, P<.05) were 

significantly more willing to seek treatment relative to 

enlisted Soldiers. Conversely, Soldier perceptions that 

unit leaders took any survey-based action was positively 

correlated with willingness to seek treatment (β =.09, 

P<.01). Finally, the interaction between combat exposure and PCL scores (Model 3) was not significant.

Comment

Collectively, these findings continue to highlight the 

dose-response relationship between combat exposure 

and behavioral health problems like PTSD. When evaluating the interaction between combat exposure and 

Table 3. Correlation Matrix for all Outcome and Predictor Variables (N=134).a

Range M SD RPT WTX CBT PCL PHQ8 SI STG BTC ACT MHP

RPT – Willing to Report

Problems

1-5 3.58 1.10 1.00

WTX – Willing to Seek

Treatment

1-5 3.69 0.99 0.75b 1.00

CBT –Combat Exposure 0-5 2.93 0.95 -0.11 -0.18 1.00

PCL – PTSD Symptoms 17-85 35.06 14.64 0.02 -0.04 0.46 1.00

PHQ8 – Depression

Symptoms

0-24 7.76 5.49 -0.09 -0.15c 0.51 0.71b 1.00

SI – Suicidal Ideation 0-4 0.24 0.64 0.06 -0.00 0.41 0.35c 0.46b 1.00

STG – Stigma 6-30 14.81 6.65 -0.09 -0.16 0.41 0.44b 0.51c 0.39b 1.00

BTC – Barriers to Care 4-20 7.75 3.26 -0.03d -0.10 -0.13 0.29c 0.41d 0.25 0.64b 1.00

ACT – Visible Action 0-12 4.66 2.81 0.30c 0.23d -0.13b -0.14 -0.13 -0.03 -0.21 -0.01 1.00

MPH – Mental Health

Professionale 0-1 NA NA 0.02 0.10 0.16 0.31c 0.16 0.12 0.09 -0.04 -0.20 1.00

aData exclude missing values, because not all respondents answered every item.

bP<.001 cP<.01

dP<.05 eDichotomous variable: 1=Yes (n=21) indicates received services from a mental health professional at a military facility in the Past Year; 0=No (n=113).

Table 4. Standardized Linear Regression Findings for Willingness to Report Behavioral Health Problems (N=120).

Willingness to Honestly Report Behavioral Health Problems

Variable Est SE t P Est SE t P Est SE t P

Model 1

(R2=0.07, F6,113=1.42, P=.21)

Intercept -0.08 0.13 -0.64 .521 -0.15 0.13 -1.13 .263 -0.21 0.13 -1.61 .110

Noncommissioned officer 0.13 0.22 0.58 .565 0.16 0.22 0.73 .469 0.17 0.21 0.82 .416

Officer 0.71 0.44 1.62 .108 0.92 0.43 2.14 .035 1.01 0.42 2.37 .019

Combat exposure -0.20 0.11 -1.77 .080 -0.18 0.12 -1.61 .111 -0.19 0.11 -1.69 .094

Posttraumatic stress symptoms (PCL) 0.02 0.01 1.63 .106 0.02 0.01 1.69 .093 0.01 0.01 1.42 .160

Depression symptoms (PHQ-8) -0.05 0.03 -1.72 .088 -0.04 0.03 -1.32 .190 -0.03 0.03 -1.19 .236

Suicidal ideation 0.17 0.19 0.90 .372 0.21 0.19 1.11 .268 0.24 0.19 1.26 .210

Model 2

(∆R2=0.10, F4,109=2.16, P=.05)

Stigma -0.01 0.02 -0.52 .603 -0.01 0.02 -0.57 .569

Barriers to care 0.02 0.04 0.58 .566 0.01 0.04 0.33 .743

Any survey-based action 0.12 0.04 3.33 .001 0.12 0.04 3.34 .001

Mental health treatment (Past Year) 0.28 0.29 0.98 .329 0.27 0.28 0.97 .335

Model 3

(∆R2=0.04, F1,120=6.30, P=.05)

Combat Exposure X PCL 0.01 0.01 2.11 .037

PHQ-8 indicates Patient Health Questionnaire-8. PCL indicates postraumatic stress disorder checklist

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THE ARMY MEDICAL DEPARTMENT JOURNAL

PTSD symptoms, we see that Soldiers’ willingness to 

report behavioral health problems increases as both 

combat exposure and PTSD symptoms increase.

However, Soldier willingness to seek treatment for a behavioral health problem identified during PDHA screening varied only as a function of combat exposure—as 

exposure levels increased, willingness to seek treatment 

decreased.

Clearly, Soldiers weighted other factors as more important than behavioral health symptoms levels when 

contemplating their willingness to seek treatment. The 

Soldier Adaption Model continues to have conceptual 

relevance here, in that it allows researchers to explore 

possible moderators of combat exposure—willingness 

to seek treatment relationship. Soldiers who perceived 

that their unit leaders took visible action on prior UBHNA survey findings were significantly more willing to 

report behavioral health problems during PDHA screening; so too for willingness to seek treatment if PDHA 

screening indicated (or Soldiers believed) they had a 

behavioral health problem. These exploratory findings 

suggest multiple benefits stemming from leader actions 

to improve the (psychological) command climate of their 

unit in response to UBHNA survey findings. Not only 

do perceptions of survey-based actions predict Soldier 

willingness to participate in future UBHNA surveys,24

survey-based actions by unit leaders appears to encourage both honest reporting and treatment seeking among 

their subordinates.

Given the nonrandom (convenience) sampling methods 

used in this retrospective study, findings reported here 

may not generalize beyond this unit. Furthermore, no 

attempt was made to verify whether unit leaders actually had taken survey-based action in response to the 

July UBHNA survey. Finally, these data did not allow 

for assessment of actual reporting during PDHA relative 

to Soldier intentions to report captured by the November 

UBHNA.

These findings merit replication. Future studies should 

examine the relative contribution of various forms of 

UBHNA survey follow-up (eg, feedback, problem identification, visible action) when predicting Soldier willingness to report problems and/or seek treatment. Finally, 

the ability to track actual treatment-seeking would add 

an important element missing in this retrospective study.

Acknowledgement

This study was approved by the Joint Combat Casualty 

Research Team, Bagram, Afghanistan.

References

1. Hoge CW, Auchterlonie JL, Milliken CS. Mental 

health problems, use of mental health services, 

and attrition from military service after returning 

from deployment to Iraq or Afghanistan. JAMA. 

2006;295(9):1023-1032.

2. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to 

care. N Engl J Med. 2004;351(1):13-22.

Table 5. Standardized Linear Regression Findings for Willingness to Report Behavioral Health Problems (N=120).

Willingness to Seek Treatment for a Behavioral Health Problem

Variable Est SE t P Est SE t P Est SE t P

Model 1

(R2=0.10, F6,113=2.04, P=.07)

Intercept -0.11 0.11 -0.98 .331 -0.20 0.11 -1.72 .088 -0.24 0.12 -2.08 .040

Noncommissioned officer 0.21 0.19 1.06 .292 0.22 0.19 1.13 .260 0.23 0.19 1.21 .231

Officer 0.75 0.38 1.97 .052 0.90 0.38 2.40 .018 0.97 0.38 2.57 .011

Combat exposure -0.23 0.10 -2.31 .023 -0.20 0.10 -1.95 .054 -0.20 0.10 -2.01 .047

Posttraumatic stress symptoms (PCL) 0.01 0.01 1.42 .159 0.01 0.01 1.12 .265 0.01 0.01 0.89 .377

Depression symptoms (PHQ-8) -0.04 0.02 -1.53 .130 -0.02 0.03 -0.80 .426 -0.02 0.03 -0.69 .493

Suicidal ideation 0.01 0.17 0.05 .964 0.02 0.17 0.15 .885 0.04 0.17 0.25 .802

Model 2

(∆R2=0.08, F4,109=2.37, P<.05)

Stigma -0.01 0.02 -0.46 .648 -0.01 0.02 -0.50 .622

Barriers to care -0.00 0.03 -0.10 .918 -0.01 0.03 -0.31 .760

Any survey-based action 0.09 0.03 2.76 .007 0.09 0.03 2.75 .007

Mental health treatment (Past Year) 0.49 0.25 1.95 .054 0.48 0.25 1.94 .055

Model 3

(∆R2=0.03, F1,120=4.12, P<.05)

Combat Exposure X PCL 0.01 0.01 1.69 .095

PHQ-8 indicates Patient Health Questionnaire-8. PCL indicates postraumatic stress disorder checklist
92 http://www.cs.amedd.army.mil/amedd_journal.aspx

3. Warner CH, Appenzeller GN, Grieger T, et al. Importance of anonymity to encourage honest reporting in mental health screening after combat deployment. Arch Gen Psychiatry. 2011;68(10):1065-1071.

4. Kim PY, Thomas JL, Wilk JE, Castro CA, Hoge 

CW. Stigma, barriers to care, and use of mental 

health services among active duty and National Guard Soldiers after combat. Psychiatr Serv. 

2010;61(6):582-588.

5. Bliese PD, Adler AB, Castro CA. Research-based 

preventive mental health care strategies in the military. In: Adler AB, Bliese PD, Castro CA, eds. Deployment Psychology: Evidence-based Strategies 

to Promote Mental Health in the Military. Washington, DC: American Psychological Association; 

2011:chap 4.

6. Cox AL, Castro CA. The mental health needs assessment. In: Human Dimensions in Military Operation: Military Leaders’ Strategies for Addressing 

Stress and Psychological Support. Brussels, Belgium: NATO Science and Technology Organization; 2006. Available at: http://ftp.rta.nato.int/pub

lic//PubFullText/RTO/MP/RTO-MP-HFM-134///

MP-HFM-134-07.pdf. Accessed December 30, 

2014.

7. Army Field Manual 6-22.5: Combat and Operational Stress Control Manual for Leaders and Soldiers. 

Washington, DC: US Dept of the Army; 2009.

8. Britt TW. The stigma of psychological problems in 

a work environment: evidence from the screening 

of service members returning from Bosnia. J Appl 

Soc Psychol. 2000;30(8):1599-1618.

9. Bliese PD, Wright KM, Adler AB, Cabrera O, Castro CA, Hoge CW. Validating the primary care 

posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with Soldiers 

returning from combat. J Consult Clin Psych. 

2008;76(2):272-281.

10. Prescott MR, Tamburrino M, Calabrese JR, et al. 

Validation of lay-administered mental health assessments in a large Army National Guard cohort. 

Int J Methods Psychiatr Res. 2014;23(1):109-119.

11. Bliese PD, Castro CA. The Soldier Adaptation 

Model (SAM): applications to peacekeeping research. In: Britt TW, Adler AB, eds. The Psychology of the Peacekeeper: Lessons from the Field. 

Westport, CT: Praeger Press; 2003:185-203.

12. Harmon SC, Hoyt TV, Jones MD, Etherage JR, 

Okiishi JC. Postdeployment mental health screening: an application of the soldier adaptation model. 

Mil Med. 2012;177(4):366-373.

13. Mackenzie CS, Gekoski WL, Knox VJ. Age, gender, and the underutilization of mental health services: the influence of help-seeking attitudes. Aging Ment Health. 2006;10(6):574-582.

14. Luxton DD, Skopp NA, Maguen S. Gender differences in depression and PTSD symptoms 

following combat exposure. Depress Anxiety. 

2010;27(11):1027-1033.

15. Maguen S, Cohen B, Cohen G, Madden E, Bertenthal D, Seal K. Gender differences in health service utilization among Iraq and Afghanistan veterans with posttraumatic stress disorder. J Womens 

Health (Larchmnt). 2012;21(6):666-673.

16. Maguen S, Ren L, Bosch JO, Marmar CR, Seal 

KH. Gender differences in mental health diagnoses among Iraq and Afghanistan veterans enrolled 

in Veterans Affairs health care. Am J Public Health. 

2010;100(12):2450-2456.

17. Whalen RJ. Promoting survey-based action by U.S. 

Army unit leaders in Afghanistan: a case study. Mil 

Behav Rev. In press.

18. Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD Checklist (PCL): Reliability, 

validity, and diagnostic utility. Paper presented at: 

9th Annual Meeting of the International Society for 

Traumatic Stress Studies; October 1993; San Antonio, TX. Available at: http://www.pdhealth.mil/

library/downloads/pcl_sychometrics.doc. Accessed 

December 30, 2014.

19. Keen SM, Kutter CJ, Niles BL, Krinsley KE. 

Psychometric properties of the PTSD checklist 

in a sample of male veterans J Rehabil Res Dev. 

2008;45(3):465-474.

20. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to 

care. N Engl J Med. 2004;351(1):13-22.

21. Lowe B, Unutzer J, Callahan CM, Perkins AJ, 

Kroenke K. Monitoring depression treatment outcomes with the patient health questionnaire-9. Med 

Care. 2004;42(12):1194-2001.

22. Pinto-Meza A, Serrano-Blanco A, Penarrubia 

MT, Blanco E, Haro JM. Assessing depression 

in primary care with the PHQ-9: can it be carried out over the telephone? J Gen Intern Med. 

2005;20(8):738-742.

23. Thompson LF, Surface EA. Promoting favorable 

attitudes toward personnel surveys: the role of follow-up. Mil Psychol. 2009;21(2):139-161.

24. Whalen RJ. Promoting favorable attitudes toward 

(behavioral health) surveys: the role of follow-up 

revisited. Mil Psychol. In press.

Author

LTC Whalen is an Assistant Professor, Counseling Services, Department of Family Medicine, Uniformed 

Services University of the Health Sciences, Bethesda, 

Maryland

PREDICTING WILLINGNESS TO REPORT BEHAVIORAL HEALTH PROBLEMS AND SEEK TREATMENT

AMONG US MALE SOLDIERS DEPLOYED TO AFGHANISTAN: A RETROSPECTIVE EVALUATION
January – March 2015 93

A 63-year-old female with stage I poorly differentiated 

ductal carcinoma of the left breast, tumor tissue positive 

for both estrogen and progesterone receptors, was treated with lumpectomy followed by 4 cycles of adriamycin 

and cyclophosphamide. Following a course of adjuvant 

radiation, she was started on hormonal therapy with an 

aromatase inhibitor, anastrozole. After 18 months of 

hormonal therapy, the patient developed recurrent hotflashes and facial flushing. These symptoms were only 

partially relieved with venlafaxine. She also developed 

recurrent atypical chest pain and mid-epigastric pain, 

occurring intermittently during her treatment, several 

times per week for 4 to 5 five years. At the initial time 

of this complaint, she underwent a thorough cardiac 

workup, including a gated exercise treadmill test with 

thallium based nuclear medicine imaging showing a 

normal electrocardiogram, normal ejection fraction, but 

with imaging concerning for anterolateral ischemia. A 

follow-up left heart catheterization was consistent with 

moderate one-vessel coronary artery disease involving 

the first diagonal branch of the left circumflex coronary 

artery. Cardiology felt this was not contributing to her 

chest pain and no intervention was undertaken. As the 

initial episode of chest pain occurred shortly after starting alendronate for osteopenia, her treating physicians 

believed they may be related and changed this medication to intravenous zoledronic acid. Despite resolution of 

her symptoms for a few weeks, her symptoms returned. 

She was then evaluated by gastroenterology and a thorough workup including liver specific enzymes, lipase, 

esophageal and gastric biopsies, abdominal imaging 

including ultrasound, computed tomography, and upper 

endoscopy were all normal. She was treated empirically 

with dicyclomine and omeprazole.

Her symptoms worsened with new complaints of dysphagia along with continued vasomotor symptoms. She 

underwent a barium swallow showing a delay at the aortic arch and distal esophagus; repeat upper endoscopy 

and abdominal CT were both normal. Esophageal dilatation was performed and she was started on empiric 

medical treatment for esophageal spasms with a calcium 

channel blocker and as needed sublingual nitroglycerin. 

Her symptoms improved significantly with this medication regimen, but never totally resolved. Approximately 

one year later, she had a syncopal episode with a repeat 

unremarkable cardiac workup including electrocardiogram, transthoracic echocardiogram, and holter monitor, 

and the event was attributed to vasovagal syncope. Her 

hot-flashes, chest pain, and mid-epigastric pain continued intermittently with further workup unremarkable 

including a negative HIDA scan and negative repeat 

upper endoscopy. A gastric emptying scan did reveal 

significant delayed gastric emptying, but pro-motility 

agents failed to improve her symptoms.

Four years after her initial complaints of intermittent 

atypical chest pain, abdominal pain, and vasomotor 

symptoms, a repeat abdominal CT revealed an enlarging 2.3cm by 2.3 cm soft tissue mass noted within the 

mesentery adjacent to the duodenum with internal calcifications. Given the location of the tumor and concomitant vasomotor symptoms, the diagnosis of carcinoid 

syndrome was entertained. A subsequent serum chromogranin A was elevated at 52 ng/ml (reference normal 

<34 ng/ml) and a 24-hour urine 5-HIAA was elevated at 

15 mg/24 hrs (reference range 0-6 mg/24 hrs). A PETCT showed uptake in the lesion of concern, as well as 

focal hypermetabolic activity at the cecum without a 

clear anatomic correlate. An octreoscan confirmed radiotracer uptake in the soft tissue mass adjacent to the 

duodenum, a new liver lesion with uptake, and a single 

focus of uptake within the mediastinum without a clear 

anatomic correlate. She underwent a right hemicolectomy with liver wedge resection. Pathology confirmed 

metastatic carcinoid tumor in the distal ileum, mesoappendix, and liver.

Within one month after resection, she developed recurrent chest pain, diarrhea, and hot-flashes. Repeat chromogranin A levels were 159.2 ng/ml. Further workup 

with a postoperative octreoscan showed a new liver 

A Heart Gripping Case:

 Carcinoid Heart Disease

Capt John P. Magulick, MC, USAF

Maj Frederick L. Flynt, MC USAF

LtCol Kevin E. Steel, MC, USAF

LTC Nathan M. Shumway, MC, USA
94 http://www.cs.amedd.army.mil/amedd_journal.aspx

lesion with radiotracer uptake and continued mediastinal uptake without a clear anatomic correlate. A gated 

cardiac CT showed a 1.5 cm soft tissue mass splaying 

the left anterior descending and the first diagonal branch 

coronary arteries, shown in Figures 1 and 2, with no discernible tissue plane between the mass and the ventricle. 

Cardiac MRI confirmed the mass at the bifurcation of 

these coronary arteries as well, with apparent continuity 

with the myocardium. She was evaluated by cardiothoracic surgery at our institution and this lesion was felt 

to be unresectable. She sought a second opinion at an 

outside institution and surgical resection of the tumor 

was performed. The patient noted immediate relief of 

her chest pain, flushing and diarrhea after the surgery 

and her chromogranin levels declined. She has been followed for one year since with serial PET scans and chromogranin levels without signs of definitive recurrence.

Carcinoid tumors are a heterogeneous group of neuroendocrine tumors whose clinical characteristics and 

behavior vary based on the primary site of origin, as 

each is derived from different precursor cells. Based 

on SEER data, most carcinoid tumors originate from 

the small bowel or appendix, and 80% of small bowel 

primary carcinoids are found in the ileum, as in our 

patient.1 Given their location, small bowel carcinoid 

tumors commonly present with vague abdominal complaints as they must grow quite large to cause obstructive symptoms, and diagnosis is often delayed for years. 

Hence, the majority of patients present with metastases 

at diagnosis, most commonly to the liver and regional 

lymph nodes. Our patient presented in a similar fashion, 

with epigastric abdominal pain for several years prior to 

being diagnosed with metastatic disease.

Carcinoid syndrome, characterized by intermittent 

flushing, diarrhea and wheezing, is present in 5% to 

7% of carcinoid tumors originating in the small bowel.2

Carcinoid heart disease, occurring in more than 50% of 

patients with carcinoid syndrome,3,4 usually manifests 

as right heart failure and valvular regurgitation secondary to valve and endocardial fibrosis. However, it is important to note cardiac metastases are included in the 

spectrum of carcinoid heart disease. Cardiac metastases 

are rare, though when they occur, carcinoid syndrome 

or metastatic disease to the liver is present a majority 

A HEART GRIPPING CASE: CARCINOID HEART DISEASE

Figure 1. CT Coronary showing a 1.5 cm soft tissue mass splaying the left anterior descending and the first diagonal 

branch coronary arteries.
January – March 2015 95

THE ARMY MEDICAL DEPARTMENT JOURNAL

of the time. In our review of the literature, only 

slightly more than 20 cases of cardiac metastases were reported since 1980, the majority 

originating from the ileum. A case series of 74 

patients with carcinoid by Pellika et al. found 3 

(4%) patients had metastases to the heart, all of 

which originated from the ileum and were associated with carcinoid syndrome.5

 In another 

case series by Pandya et al, of 11 patients with 

myocardial metastases, 9 (82%) had ileal primary tumors, and all 11 had hepatic metastases 

and carcinoid syndrome.6 Two other cases of 

cardiac metastases were found, both presenting 

as carcinoid syndrome and found to have small 

bowel primary tumors in the presence of extensive metastasis, including the heart.7,8 Several 

cases of carcinoid heart disease without valvular involvement have been documented. Overall, 

these cases are similar to our case with respect 

to the extensive metastases and ileal primary, 

though this is one of only 2 cases presenting 

with angina.

Cardiac metastases can also occur in the absence of hepatic metastases as noted in 4 case reports, though only 

one originated from the small bowel. In one case, a carcinoid tumor of the heart was discovered incidentally on a 

CT scan for suspected pancreatitis and was subsequently 

found to have a pancreatic mass 6 months later, which 

was thought most likely to be the primary.9 There were 

no manifestations of carcinoid syndrome or evidence of 

liver metastases. Another presented with symptoms of 

carcinoid syndrome and was found to have cardiac metastases along with a mass in the pancreatic head.10 No 

hepatic involvement was discovered based on imaging 

and laparotomy findings. A third case involved a patient 

with known bronchial carcinoid, status post resection, 

who presented with symptoms of heart failure and was 

found to have diffuse infiltration of the myocardium 

with carcinoid tumor in the absence of valvular disease 

or hepatic metastases.11 Another case is one of a patient 

with appendiceal carcinoid who developed cardiac arrest 

and at autopsy was found to have carcinoid infiltration 

of the a patient with myocardium.12 One case describes 

carcinoid heart disease involving the interventricular 

septum, presenting with palpitations and paroxysmal 

atrial fibrillation.13 Finally, one case describes a patient 

with metastatic carcinoid inducing coronary vasospasm 

with associated inferior ST-segment elevations.14

Based on the results of our literature review, cardiac 

metastases are most common in the presence of small 

bowel carcinoid tumors and hepatic metastases, though 

cardiac metastases without hepatic involvement have 

been demonstrated, and they may be more common 

than what is reported. It is also important to recognize 

cardiac metastases can occur in the absence of carcinoid 

syndrome, and as the sole manifestation of carcinoid 

heart disease. Furthermore, these metastases can cause 

symptoms of heart failure in the absence of valvular 

disease, cardiac arrest, arrhythmias, or angina by mass 

effect, as noted in our case. Hence, while cardiac metastases are rare in patients with carcinoid tumor, they 

should be considered in the differential for any patient 

presenting with cardiac-related complaints and a history 

of carcinoid tumor.

References

1. Modlin IM, Sandor A. An analysis of 8305 cases of 

carcinoid tumors. Cancer. 1997;79:813-829.

2. Moertel CG, Sauer WG, Dockerty MB, Baggenstoss AH. Life history of the carcinoid tumor of the 

small intestine. Cancer. 1961;14:901-912.

3. Lundin L, Norheim I, Landelius J, Oberg K, Theodorsson-Norheim E. Carcinoid heart disease: relationship of circulating vasoactive substances to 

ultrasound-detectable cardiac abnormalities. Circulation. 1988;77(2):264-269.

4. Patel C, Moses M, Escarcega RO, Bove AA. Carcinoid heart disease: current understanding and 

future directions. Am Heart J. 2014;167(6):789-795.

5. Pellikka PA, Tajik AJ, Khandheria BK, et al. 

Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients. Circulation. 

1993;87:1188-1196.

Figure 2. 3D CT Coronary showing a 1.5 cm soft tissue mass splaying the 

left anterior descending and the first diagonal branch coronary arteries.
96 http://www.cs.amedd.army.mil/amedd_journal.aspx

6. Pandya UH, Pellikka PA, Enriquez-Sarano M, Edwards WD, Schaff HV, Connolly HM. Metastatic 

carcinoid tumor to the heart: echocardiographicpathologic study of 11 patients. J Am Coll Cardiol. 

2002;40:1328-1332.

7. Sivasankaran S, Sonn AT, Venesy DM, et al. 

Metastatic Cardiac Carcinoid. Tex Heart Inst J. 

2007;34:132-133.

8. Davis G, Birbeck K, Roberts D, Nagvi N. Nonvalvular myocardial involvement in metastatic carcinoid disease. Postgrad Med J. 1996;72:751-752.

9. Hennington MH, Detterbeck FC, Szwerc MF, 

Fidler ME. Invasive carcinoid tumor of the heart. J 

Surg Oncol. 1997;66:264-266.

10. Penz M, Kurtaran A, Vorbeck F, Oberhuber G, Raderer M. Case 2: myocardial metastases from a carcinoid tumor. J Clin Oncol. 2000;18(7):1596-1597.

11. Goddard MJ, Atkinson C. Cardiac metastasis from 

a bronchial carcinoid: report of a case presenting 

with diffuse thickening of the left ventricular wall. 

J Clin Pathol. 2004;57:778-779.

12. Patel S, Heetun M, Gurjar SV, Szakacs S. A rare 

case of intra-cardiac metastasis from an appendiceal carcinoid tumour without liver metastases. Int 

J Colorectal Dis. 2009;24:993-994.

13. Yan AT, Gupta P. Deva D, Choi R, Kirpalani A. an 

unusual case of metastatic carcinoid tumor in the 

interventricular septum. J Cardiovascular Med. 

2014 (Epub ahead of print).

14. Eapen D, Clements S, Block P, Sperling L. metastatic carcinoid disease inducing coronary vasospasm. Tex Heart Inst J. 2012;39(1):76-78.

Authors

Capt Magulick is a Gastroenterology Fellow, San Antonio Uniformed Services Health Education Consortium, 

Brooke Army Medical Center, San Antonio, Texas.

Maj Flynt is Associate Program Director, Hematology/

Medical Oncology, San Antonio Uniformed Services 

Health Education Consortium, Brooke Army Medical 

Center, San Antonio, Texas.

LtCol Steel is Program Director, Cardiology, San Antonio Uniformed Services Health Education Consortium, 

Brooke Army Medical Center, San Antonio, Texas.

LTC Shumway is Program Director, Hematology/Medical Oncology, San Antonio Uniformed Services Health 

Education Consortium, Brooke Army Medical Center, 

San Antonio, Texas.

A HEART GRIPPING CASE: CARCINOID HEART DISEASE
January – March 2015 97

Evaluation of the Anxiolytic Effects of Asiatic Acid, a Compound from

Gotu kola or Centella asiatica, in the Male Sprague-Dawley Rat

Valdivieso DA, Kenner C, Lathrop K, Lucia A, Stailey O, Bailey H, Padrón G, Johnson AD, Ceremuga TE

US Army Graduate Program in Anesthesia Nursing

Purpose: Commonly used herbal remedies may have significant interactions on the administration of anesthesia. 

The purpose of this study was to investigate the anxiolytic and antidepressant effects of Asiatic acid and its 

potential modulation of the γ-aminobutyric acid (GABAA) receptor.

Participants: Fifty-four male Sprague Dawley rats were divided into 5 groups.

Methods: Fifty-four male Sprague Dawley rats were divided into 5 groups: vehicle (DMSO), Asiatic acid (AA), 

midazolam, or a combination of flumazenil with AA or midazolam with AA, and injected intraperitoneally 30 

minutes prior to testing. All animals received equivalent intraperitoneal volumes consisting of 2 separate 1 ml 

injections, for a total volume of 2 ml. The rats were tested on the Elevated Plus Maze (EPM) for 5 minutes. 

All testing occurred between 3 pm and 9 pm over 4 consecutive days to control for the circadian rhythm of the 

animals. Data was analyzed using a 2-tailed multivariate analysis of variance (MANOVA) and a LSD post hoc 

test.

Results: Analysis of the ratio of open-arm time to total time in the EPM showed significant increases in time 

spent in the open arms by the rodents in the midazolam with AA group compared to the vehicle group, AA 

group, midazolam group, and flumazenil with AA group. Analysis of mobility in the EPM showed significant 

decreases in the mobility of rodents in the AA, midazolam, and the midazolam with AA group compared to 

the vehicle group. In addition, significant differences in levels of mobility were found between the flumazenil 

with AA group and the midazolam with AA group. Differences between the AA group and the midazolam with 

AA group were not statistically significant. Analysis of mean maximum speed in the EPM showed significant 

decreases in the speed of rodents in the AA and midazolam with AA group compared to the vehicle group.

Conclusion: There is possible synergistic or additive effect between AA and Midazolam, with AA action at 

unidentified receptor sites such as the central motor centers and peripheral neuromuscular junctions. Further 

studies are recommended to determine the efficacy of prolonged treatment for anxiety and depression as well 

as using additional anxiety tests such as light-dark exploration and open field test in the rat model.

Value/Relevance: The findings from this research are significant and relevant to nursing for several important 

reasons. It is imperative for healthcare providers to be knowledgeable about both traditional and alternative 

medicines to effectively anticipate possible interactions and administer safe anesthesia care perioperatively. 

Understanding psychological and physiologic effects of commonly used herbal medications such as Asiatic 

acid is important to explore their potentially therapeutic effects by reducing the untoward effects and morbidity 

associated with anxiety and also to avert any potential interactions.

Abstracts of Podium Presentations from the

 4th Annual Academy of Health Sciences

 Graduate School Research Day

The following research abstracts were presented on December 10, 2014, as part of the 4th Annual US Army 

Academy of Health Sciences Graduate School Research Day at Joint Base San Antonio Fort Sam Houston, Texas.

Presentation of this abstract was selected as the best of the podium presentations at the 4th Annual Academy of 

Health Sciences Graduate School Research Day.
98 http://www.cs.amedd.army.mil/amedd_journal.aspx

Patient-Centered Medical Home Models and the Impact on

Primary Care Practice within the Veterans Health Administration

Tansey KA

US Army-Baylor University Graduate Program in Health and Business Administration

Purpose/Hypothesis: Patient-centered medical home (PCMH) models have been touted as a way to enhance 

primary care provider efficiency, improve access to care, and significantly affect quality of care. Multiple pilot 

studies have been performed with variable results. The Veterans Health Administration has invested over $700 

million to date transitioning all of their primary care clinics to this model, making it the largest integrated 

health system in the United States to do so. However, since they are still in the transitional process, the return 

on investment has yet to be fully determined. The aims of this literature review are to examine the changes the 

PCMH model has had on care for veterans in the United States and to determine if the transition to the PCMH 

model has proven beneficial to date.

Participants/Data Description: A literature review was performed per the methods detailed below.

Design/Methods/Materials: In order to perform a complete literature review on this topic, 4 separate search 

engines were utilized through the Baylor University library online: OneSearch Beta 2.0, CINAHL with Full 

Text, Wiley Online Library, and MEDLINE via EBSCO host. Articles included in the original searches included 

those that used the phrases “medical home model” and “primary care,” as well as “veterans.” Articles without 

original data, such as historical or review articles, were excluded. After application of exclusion criterion, a total 

of 23 articles were accepted for review.

Findings/Results: Five overarching themes emerged from the literature regarding outcomes from PCMH 

model implementation in the primary care clinics of the VHA: mental and behavioral health implications; 

homelessness, emergency care usage, and avoidable hospitalization; effect on and opportunities for patients 

with chronic illnesses; staff adjustments to structural changes and continuity of care; and financial impact.

Conclusions: The aims of this literature review were to examine the outcomes the PCMH model has had on care 

for veterans in the United States, and to determine if the transition to the PCMH model has proven beneficial 

to date. Based on the literature reviewed, the implementation of the PCMH model within the Veterans Health 

Administration has experienced positive and negative outcomes to the organization and staff, however, patient 

outcomes seem to be solely positive. The overarching goals of the PCMH model may not be met to date, 

but results since the onset of the transition are trending towards increasing access to primary care providers, 

decreasing improper utilization of emergency department care, improving utilization among veterans in special 

population groups, and increasing profitability.

Value/Relevance: The Veterans Administration’s investment has not achieved its desired goals to date; however, 

the trends over time are promising and should continue to be monitored for long-term outcomes of PCMH 

transition. Lessons learned from studies involving structural changes and staff or cultural attitudes throughout 

this transition may be useful for other healthcare organizations considering transitioning to a PCMH model.

ABSTRACTS OF PODIUM PRESENTATIONS FROM THE 4TH ANNUAL

ACADEMY OF HEALTH SCIENCES GRADUATE SCHOOL RESEARCH DAY

Presentation of this abstract was selected for third place among the podium presentations at the 4th Annual Academy of Health Sciences Graduate School Research Day.

Prospective Musculoskeletal Injury Rates Among Different Categories of Soldiers

Shaffer SW, Teyhen DS, Butler RJ, Williams AM, Prye J, Goffar SL, Kiesel KB, Rhon DI, Plisky PJ

US Army-Baylor University Doctoral Program in Physical Therapy

This abstract was published in the Journal of Sports and Orthopaedic Physical Therapy (January 2015; Volume 

45, No. 1, pages A37-A38).

Presentation of the above cited abstract was selected for second place among the podium presentations at the 4th 

Annual Academy of Health Sciences Graduate School Research Day.
January – March 2015 99

THE ARMY MEDICAL DEPARTMENT JOURNAL

Long-term Outcomes Among Patients Enrolled in Pre-diabetes Management

With Registered Dietitians at a Large Academic Military Teaching Hospital

Henry C, Stankorb SM, Salgueiro M

Brooke Army Medical Center

Purpose/Hypothesis: If left unmanaged, pre-diabetes may progress to diabetes. Diabetes increases overall 

medical costs with a host of diabetes-related complications. Therefore, efforts to prevent progression of prediabetes may result in substantial health savings. The purpose of this review was to examine the conversion 

rate from pre-diabetes to diabetes for 3 years following initial enrollment in a pre-diabetes education and 

management program.

Participants/Data Description: Records included in this retrospective review were those of patients with an 

International Classification Coding (ICD-9) indicating diagnosis of pre-diabetes during calendar years 2008 

through 2010. Records were included from individuals aged 17 or more years who attended the pre-diabetes 

group education program.

Design/Methods/Materials: Retrospective chart review using the M2 datamart to query medical records of 

patients meeting the above criteria. The following data was extracted for all identified individuals: gender, 

height, weight, age, body mass index (BMI), and A1C at the time point closest to the scheduled baseline 

appointment (±90 days). Patient’s medical records were queried for BMI and A1C for 3 consecutive years 

after the initial visit anniversary (±90 days). Lastly, a query of the records for each patient was conducted to 

determine if they received an ICD-9 which indicated conversion from pre-diabetes to diabetes within the 3-year 

time frame.

Findings/Results: A total of 332 records was used in this retrospective performance improvement study. A 

slightly higher proportion of subjects were male (54.2%) and the average participant was aged 57.1±12.5 years 

at baseline. The mean BMI following the initial pre-diabetes education from year one through year three ranged 

between 30.0-31.5 kg/m2 and the A1C mean was 6.0% to 6.1%. Of the patients with pre-diabetes who attended 

the pre-diabetes education, 24% were documented as converting to diabetes. The rate of conversion from 

pre-diabetes to diabetes was greatest during the first year with 9.3% converting. Each following year the rate 

of conversion decreased with only 6.3% converting during year three. There were no statistically significant 

differences in baseline characteristics and A1C between those who converted and those who did not.

Conclusions: The 3-year 24% conversion rate observed in this project was higher than the 14% rate observed 

at a similar time frame in the lifestyle intervention arm of the Diabetes Prevention Program (DPP). Given 

that nearly a quarter of patients converted from pre-diabetes to diabetes over 3 years, the overall pre-diabetes 

management program may not be optimized to achieve the desired result of delaying progression to diabetes 

over longer periods of time.

Value/Relevance: With the current scrutiny surrounding military budgets, optimizing programs that can reduce 

costs and resources, such as shared medical appointments, are essential. Cost effectiveness data from the DPP 

show that although a lifestyle intervention requires more initial resources, the cost per case of diabetes delayed 

or prevented offers a net cost savings over the long term.
100 http://www.cs.amedd.army.mil/amedd_journal.aspx

Implications of Early and Guideline Adherent Physical Therapy

for Low Back Pain on Utilization and Costs

Childs JD, Fritz JM, Wu SS, Flynn TW, Wainner RS, Kim FS, Robertson E, George SZ

US Army-Baylor University Doctoral Program in Physical Therapy

Purpose/Hypothesis: Initial management decisions following a new episode of low back pain (LBP) are thought 

to have profound implications for healthcare utilization and costs. The purpose of this study was to evaluate 

the impact of a patient’s status on both timing and adherence to clinical practice guidelines. We also sought to 

determine if the precedent seen in civilian payer environments favoring early physical therapy referral regardless 

of guideline adherence would be observed in the Military Health System (MHS).

Participants/Data Description: Patients with a new consultation to a primary care provider for standard diagnosis 

of LBP from January 1, 2007, to December 31, 2009, were identified from the MHS Management Analysis and 

Reporting Tool (M2).

Design/Methods/Materials: Descriptive statistics, utilization, and costs were examined on the basis of timing 

of referral and adherence to practice guidelines (early + adherent, delayed + nonadherent, etc) over a 2-year 

period. Utilization outcomes were compared using adjusted odds ratios with 99% confidence intervals.

Findings/Results: 821,723 continuously-eligible patients with a primary care visit for LBP who were aged 

between 18 and 60 years at the index visit were considered, with 753,450 unique patients eventually included 

in the analysis. Mean age was 36.9 years (SD=12.5), with 42.2% being female. Physical therapy was used by 

14.9% (n=122,723) of patients, with 24.0% (n=17,175) receiving early physical therapy that was also adherent 

to recommendations for active treatment. Early referral to guideline adherent physical therapy was associated 

with significantly lower utilization of advanced imaging, lumbar spinal injections, lumbar spine surgery, use of 

opioids, and 60% lower total LBP-related costs during the 2-year follow-up period.

Conclusions: Cost savings from early guideline adherent physical therapy may have important implications for 

designing optimal care process models.

Value/Relevance: Future research is necessary to examine which patients with LBP benefit most from early 

access to physical therapy and determine strategies for routinely providing early guideline adherent care.

Social Media: How Hospitals Use it and Opportunities for Future Use

Richter JP, Muehlstein D, Wilks C

US Army-Baylor University Graduate Program in Health and Business Administration

The paper for which this abstract was prepared was published in the Journal of Healthcare Management

(November-December 2014; Volume 59, No. 6, pages 447-461).

Influence of Pain and Prior Injury on Musculoskeletal Injury Occurrence:

A Prospective Review of a Large Military Cohort

Teyhen DS, Shaffer SW, Butler RJ, Goffar SL, Kiesel KB, Rhon DI, Plisky PJ

Office of The Surgeon General of the Army

This abstract was published in the Journal of Sports and Orthopaedic Physical Therapy (January 2014; Volume 

44, No. 1, pages A39-A40).

ABSTRACTS OF PODIUM PRESENTATIONS FROM THE 4TH ANNUAL

ACADEMY OF HEALTH SCIENCES GRADUATE SCHOOL RESEARCH DAY
January – March 2015 101

THE ARMY MEDICAL DEPARTMENT JOURNAL

The poster was selected as best of the presentations as part of the 4th Annual Research Day held December 10, 2014, at the Graduate School, Academy of Health Sciences, AMEDD Center & School, Joint Base San Antonio Fort Sam Houston, Texas.
102 http://www.cs.amedd.army.mil/amedd_journal.aspx School, Academy of Health Sciences, AMEDD Center & School, Joint Base San Antonio Fort Sam Houston, Texas. The poster selected for second place among the presentations as part of the 4th Annual Research Day held December 10, 2014, at the Graduate 

WINNING POSTERS PRESENTED AT THE 4TH ANNUAL

ACADEMY OF HEALTH SCIENCES GRADUATE SCHOOL RESEARCH DAY
January – March 2015 103

THE ARMY MEDICAL DEPARTMENT JOURNAL

The poster selected for third place among the presentations as part of the 4th Annual Research Day held December 10, 2014, at the Graduate School, Academy of Health Sciences, AMEDD Center & School, Joint Base San Antonio Fort Sam Houston, Texas.
104 http://www.cs.amedd.army.mil/amedd_journal.aspx

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