Force health protection 

Proactive, Dynamic, dedicated 

July – September 2012 

Perspectives 1 

MG Philip Volpe; COL Mustapha Debboun; Richard Burton 

The Relevance of Rabies to Today’s Military 4 

Edwin D. Cooper, BS, MT; COL Mustapha Debboun 

Vector Surveillance to Determine Species Composition and Occurrence of 12 

Trypanosoma cruzi Infection at Three Military Installations in San Antonio, Texas 

CPT Lee McPhatter; Walter Roachell, MS; Farida Mahmood, PhD; et al 

A Field-expedient Method for Detection of Leptospirosis Causative 22 

Agents in Rodents

James C. McAvin, MS; Ampornpan Kengluecha, MS; et al 

Military Entomology in Operation Enduring Freedom, 2010-2011 29

MAJ Michelle G. Colacicco-Mayhugh; LT Tony Hughes, USN; LT Ryan Larson, USN; et al

A Rapid and Inexpensive Bioassay to Evaluate the Decontamination 36

of Organophosphates 

CDR (Ret) David M. Claborn, USN; Skylar A. Martin-Brown, MS; et al 

Review of the Institute of Medicine Report: Long-term Health Consequences of 43 

Exposure to Burn Pits in Iraq and Afghanistan

Coleen P. Baird, MD, MPH 

Hospitalization and Medical Evacuation of Army Personnel Due to Toxic 48

Inhalational Exposure – Operations Iraqi Freedom and Enduring Freedom, 

2001 Through Mid 2011 

Jessica M. Sharkey, MPH 

The Impact of Attachment Style on Posttraumatic Stress Disorder Symptoms in 54

Postdeployed Military Members 

LTC Sandra M. Escolas; Rachel Arata-Maiers; 1Lt Erika J. Hildebrandt; et al 

A Review of Mechanics and Injury Trends Among Various Running Styles 62

LTC Donald L. Goss; Michael T. Gross, PhD 

Clinical And Electrodiagnostic Abnormalities of the Median Nerve in 72

US Army Dental Assistants at the Onset of Training

LTC Scott W. Shaffer; CPT Rebecca Moore; CPT Shannon Foo; et al 

Risky Business: Challenges and Successes in Military Radiation 82 

Risk Communication 

COL Mark A. Melanson; Lori S. Geckle; Bethney A. Davidson 

Summary of the Infectious Diseases and Disaster Response 88 

Conference in Abu Dhabi 

Priya Baliga, MPH; Brittany J. Tang-Sundquist; David R. F. Hajjar, JD, MPH; et al 
July – September 2012 The Army Medical Department Center & School PB 8-12-7/8/9 

By Order of the Secretary of the Army: 

Official: 

1212912 

RAYMOND T. ODIERNO 

General, United States Army 

Chief of Staff

DISTRIBUTION: Special 

Administrative Assistant to the 

Secretary of the Army 

JOYCE E. MORROW 

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of the AMEDD Community 

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

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CORRESPONDENCE: Manuscripts, photographs, official unit requests to receive 

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

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DISCLAIMER: The AMEDD Journal presents clinical and nonclinical professional 

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and technological advances; promote collaborative partnerships among Services, 

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

dialogue concerning healthcare initiatives. 

Appearance or use of a commercial product name in an article published in the 

AMEDD Journal does not imply endorsement by the US Government. 

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

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

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OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical 

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

worldwide. 

LTG Patricia D. Horoho 

The Surgeon General 

Commander, US Army Medical Command 

MG Philip Volpe 

Commanding General 

US Army Medical Department Center & School 
 July – September 2012 1

Perspectives

Commander’s Introduction

MG Philip Volpe

Among the many important responsibilities I have assumed 

as Commanding General of the US Army Medical Department Center and School (AMEDDC&S) is publication of 

military medicine’s very own professional periodical, the 

AMEDD Journal. I am pleased to present the fi rst issue of 

the Journal to be published during my tour. The AMEDD 

Journal is the only periodical published by military medicine for medical professionals to present and discuss topics 

which stimulate, enhance, and advance the science of military medicine, the primary mission of which is to ensure 

the health and combat effectiveness of our nation’s military 

force. The scope and application of such professional writing is, of course, not limited to the practice of medicine in 

the military environment. The majority of the information 

found in the pages of the AMEDD Journal is relevant, and 

often directly applicable, to the civilian world of medical 

science and healthcare delivery. Throughout the history of 

military medicine are found examples of discoveries, advancements, and developments that found immediate application in civilian healthcare, thereby benefi tting human 

society as a whole.

In 1994, The Surgeon General directed the AMEDDC&S 

to establish an Army Medical Department periodical to 

be a forum for military medical professionals to present 

and discuss current healthcare topics and issues, as well as 

combat theater experiences, for the advancement of military medical science and doctrine development. Since that 

fi rst issue in October of 1994, the AMEDD Journal has 

evolved in scope, sophistication, and presentation of its 

content. The Journal joined the ranks of the world’s most 

respected medical periodicals in 2009 when it was chosen 

by the National Library of Medicine for inclusion and indexing in MEDLINE, the nation’s premier bibliographic 

database of life sciences and biomedical information. Indicative of that recognition is the broad readership refl ected 

in its distribution. Not only is it welcomed by Army, Navy, 

Air Force, and Defense Department recipients, the Journal is also found in many civilian medical schools, libraries, and research institutions, as well as foreign military 

medical organizations and commands. The AMEDD Journal is a superb presentation of who we are and what we do 

as healthcare professionals, both on the battlefi eld and in 

garrison.

The AMEDD Journal is an invaluable clearinghouse for 

the most important healthcare information and combat experiences related to maintaining a healthy, viable, effective fi ghting force. The Journal receives manuscripts from 

across the entire spectrum of medical professionals, including highly experienced medical and dental practitioners, 

accomplished research scientists, preventive medicine and 

public health specialists, veterinarians, healthcare support 

and service specialists, and nonmedical professionals who 

contribute to healthcare delivery in various ways. The diversity of subject matter is clearly indicative of the depth 

and breadth of responsibilities and functions found in today’s military medicine.

This issue was sponsored by COL Mustapha Debboun, 

the senior medical and veterinary entomologist at the 

AMEDDC&S and Chairman of the AMEDD Journal Editorial Review Board. For the seventh consecutive year he 

has organized and assembled an outstanding collection of 

articles featuring topics related to public health, preventive medicine, and force health protection. Time and again 

throughout military history, the success or failure of battles, campaigns, and even wars has been determined by 

the health, and therefore the effectiveness, of a fi ghting 

force. There are many examples which demonstrate that 

it does not matter if a military force has the best training, 

the fi nest equipment, and the most capable leadership if the 

Warriors themselves cannot physically perform their tasks. 

Indeed, our primary mission at the Army Medical Department begins and ends with the health of the individual Soldier, from his or her fi rst day at basic training until the last 

day in the Army. Force health protection is the keystone to 

ensuring that a commander has enough healthy, effective 

Warriors where and when needed to initiate, sustain, and 

complete all operations dictated by the unit’s mission.

EDITOR’S PERSPECTIVE

One disease threat that has plagued humankind throughout history is rabies, and it remains present in one form 

or another in almost every area in the world. Even though 

the well-understood threat of rabies is the subject of repeated training throughout military units, and regulations 

are established to minimize the potential for contact with 

infected animals, it still occurs. Indeed, in 2011 a US Army 

Soldier died from rabies he acquired from a dog bite in 

Afghanistan. This occurrence, albeit rare, serves to underscore the inescapable facts that rabies exists, and it still 

kills humans who become infected if prompt notifi cation 

and treatment do not follow. This threat is even more serious to our military personnel who fi nd themselves in areas 

where rabies may be endemic, not an uncommon situation. 

Edwin Cooper and COL Debboun open this issue of the 

AMEDD Journal with an important article that reinforces 
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

the importance of understanding that the threat of rabies to 

military personnel exists, it is serious, and what is necessary to minimize the potential of contracting this pernicious disease. This article should serve as a refresher in 

what to do and, perhaps more importantly, what not to do 

in combating the horror that is rabies.

The value of the military working dog (MWD) in many environments, including garrison security, disaster recovery, 

and combat operations, is now an indisputable fact. Each 

of those dogs represents a signifi cant monetary investment 

in procurement, training, and support. Further, as clearly 

demonstrated throughout the last issue of the AMEDD 

Journal, specially trained dogs are increasingly found in 

medical treatment roles within the military, whether for 

physical assistance, in psychological and physical therapy 

settings, or as companions for emotional support. Understandably, the health of these dogs is important, not only 

because of the monetary investment, but also because dogs 

can carry diseases transmittable to humans. In their article, 

CPT Lee McPhatter and his coauthors report on their investigation of the insect vector of one such disease on military installations in and around San Antonio, Texas. As 

pointed out in their article, not only is Chagas disease a signifi cant health threat to MWDs, but it also sickens over 7 

million people worldwide, and kills approximately 21,000 

each year. Their important article is a detailed presentation 

of a well-designed, carefully executed, thorough search for 

triatomine bugs, not only in areas where they represent a 

threat to dogs being raised and trained for service in government agencies, but also in military training areas where 

the potential to infect humans is very real.

Leptospirosis is another zoonotic disease that presents a 

signifi cant threat to humans worldwide, especially in areas where military deployments may be expected, such 

as combat environments and scenes of natural disasters. 

Therefore, it is very important that medical caregivers have 

the capability to detect the Leptospira bacteria in austere 

environments, where infrastructure and transportation 

resources may be limited at best. James McAvin and his 

coauthors present their work in the development of a fi eldexpedient method to identify the presence of Leptospira

in rats, the most signifi cant reservoir of the disease causing agents. Their article is an excellent example of a carefully designed and meticulously executed research project, 

presenting the methodology and science of their research 

with clarity and detail. The results of their efforts should 

provide caregivers with the capability to detect another serious disease threat in remote, austere locations, allowing 

them to quickly narrow the fi eld of diagnostic possibilities 

in the treatment of sick personnel.

The capabilities of our fi ghting forces become increasingly 

sophisticated and effective as their training, equipment, 

and support infrastructure continue to evolve in response 

to the ever-changing nature of the enemy threat. Detection, 

identifi cation, and analysis of that threat is essential to formulating the appropriate response. The same principle applies to the threats they face from vector-borne diseases 

which can vary signifi cantly across geographic locations 

and climates. In their detailed article, MAJ Michelle Colacicco-Mayhugh and her coauthors describe the current 

structure and functioning of the US military’s entomological support in the Afghanistan theater of operations. This 

article provides excellent insight to the complex coordination and planning that is necessary to ensure that entomological resources are available when and where needed in 

the challenging, widely dispersed, fl uid, and dynamic combat environment of Afghanistan.

Organophosphates and closely related chemicals are toxic 

substances routinely introduced into our environment because they are found in a number of commercially available insecticides. However, the same substances are components of potent neurotoxic chemical warfare agents, 

such as sarin. The potential risk posed by either application has, of course, stimulated a number of approaches to 

decontamination, from simple bleach to specifi cally developed decontamination compounds. But most techniques 

to determine the effectiveness of decontamination efforts 

involve expensive equipment and trained technicians. Retired CDR David Clayborn and his colleagues from Missouri State University investigated the effectiveness of a 

relatively simple and inexpensive bioassay technique using 

measured survival of red fl our beetles to judge the level 

of toxic residue. The article is the report of their detailed, 

rigorous research project which evaluated the effectiveness 

of that approach. The results of the study are encouraging, 

demonstrating that the approach offers the potential of a 

rapid, very low expense bioassay that accurately measures 

biological toxicity of surfaces previously contaminated 

with malathion and malaoxin. This technique may be developed into an initial screening tool for fi eld environment 

applications to determine the decontamination of a variety 

of toxic environments.

In a 2010 AMEDD Journal article, Dr Coleen Baird discussed the emerging recognition of the potential hazard to 

the respiratory health of deployed personnel (and others) 

posed by open burn pits around bases in Iraq and Afghanistan. In 2011, she followed with another article investigating the questions of increased incidences of respiratory 

diffi culties among troops returning from combat deployments. The increasing interest and concern about these 

topics led to a Department of Veterans Affairs request that 

the Institute of Medicine form a committee to determine 

the long-term health effects from exposure to burn pits. In 

her latest article, Dr Baird examines the resulting report, 

describing the approach used by the study committee, and 

their fi ndings. She also discusses the responses to the report by the military and the VA in their continuing efforts 

PERSPECTIVES
 July – September 2012 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

to defi nitively understand, and potentially quantify, any 

relationships between burn pit exposure and the health of 

deployed personnel. Dr Baird’s excellent series of articles 

continue to highlight a subtle, enigmatic, but potentially 

serious threat to the health of our Warriors, both while deployed and after return.

In a complementary article, Jessica Sharkey examines the 

broad topic of all types of potential inhalational exposures 

to US military forces throughout the 10 years of Southwest 

Asia operations using records of in-theater medical treatments, medical evacuations, and postevacuation care. Her 

well-researched article develops the scope and character 

of inhalational threats, explains the diffi culties involved in 

categorizing and quantifying exposures, and presents the 

available data related to such exposures throughout the decade of deployments. Ms Sharkey’s article provides more 

insight into the diffi culty that medical science faces in its 

efforts to address health issues resulting from the broad 

range of potentially harmful inhalational contaminants.

Posttraumatic stress disorder (PTSD) has been recognized, 

under various descriptive names, as a diagnosis mode by 

medical professionals for more than a century. Mental and 

behavioral health specialists have long been involved with 

research and studies as to its causes, diagnosis, and treatment, seeking to understand how and why it affects individuals to such varying degrees. In their article, LTC Sandra 

Escolas and her coauthors describe their work exploring 

how an aspect of an individual’s ability to relate to others, 

known as attachment theory, may be a factor in how that 

individual deals with the stresses that induce PTSD, and 

infl uence his or her ability to cope with and recover from 

its symptoms. This is a carefully designed, extensively researched, meticulously conducted scientifi c study that produced statistically sound results. The insights contained in 

this important article should be of value to researchers and 

practitioners involved in the care and treatment of those 

diagnosed with PTSD.

Military personnel must maintain a high level of physical fi tness throughout their military careers, and running 

is an integral component of the fi tness regimen. Unfortunately, running all too often results in a number of injuries to the feet and legs, some of which are serious and 

debilitating. Over the last several years, various alternative running styles have been developed and promoted 

among running enthusiasts, most intended to change the 

footstrike to one believed less prone to cause injury. LTC 

Donald Goss and Dr Michael Gross conducted an extensive search and review of published information and data 

on the various styles to identify any biomechanical advantages, injury relationships, and trends associated with a 

specifi c style. Their article is a careful compilation of data 

from numerous, diverse sources, and a detailed presentation of their analysis which should be of great interest to all 

practitioners involved with lower body injury prevention 

and rehabilitation.

LTC Scott Shaffer and his colleagues return the ArmyBaylor University Doctoral Program in Physical Therapy 

to the pages of the AMEDD Journal with a report on their 

study investigating the presence of neuropathy in the wrists 

and hands of Army dental assistants at the beginning of 

their training. Since dental personnel are reported to have 

a relatively high prevalence of upper-extremity musculoskeletal disorders, this study sought to identify preexisting 

conditions which might be exacerbated by the movements 

and positions required for their work. Indeed, they found 

that fully 11% of the sample population had indications of 

abnormalities that could be predictive of future disorders 

as they pursue their occupations in dental treatment. This 

well-designed and executed research project is another example of level of professional expertise that military medicine directs towards providing only the best “care for the 

caregivers” across all of our specialties.

Radiation is a word that refl exively strikes fear in most people, primarily due to the overall lack of knowledge about 

it, combined with the exaggerated and/or false presentations of radiation exposure in popular media. The problem 

of preventing inaccurate information and distorted claims 

from causing undue anxiety and even panic is exacerbated 

by today’s instant, pervasive, and completely unregulated 

worldwide communications. COL Mark Melanson and his 

coauthors use 3 actual events of potential radiation exposure within the US Army to develop their article on the 

very important topic of communication of radiation risks. 

In this interesting and very informative article, they clearly 

explain the complexities inherent in the subject of radiation 

risk, the common misconceptions that must be addressed 

and countered, and the compounding diffi culties presented 

by addressing it within the military context. The principles 

of risk communication discussed in this article are important and widely applicable for all medical professionals in 

this dangerous era of weapons of mass destruction.

In July 2011, the Armed Forces Health Surveillance Center, the Center for Disaster and Humanitarian Assistance 

Medicine, and the US Central Command sponsored a 

major regional conference in Abu Dhabi to promote collaboration and interoperability in responding to complex 

health and humanitarian emergencies. In their thorough 

and very informative article, Priya Baliga and her coauthors describe the diversity of attendees, the genuine interest and enthusiasm demonstrated by the participants, and 

the diversity of the valuable information shared throughout 

the conference. The reader can only be encouraged at the 

apparent tone of cooperation and mutual respect demonstrated throughout, as health professionals meet and interact as colleagues rather than competitors in the common 

goal of healthier populations throughout the region. 
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

A 24-year-old Army Specialist was assigned as a cook at 

Combat Base Chamkani, Paktia Province, Afghanistan, 

from May 2010 to May 2011.1

 He was a known animal 

enthusiast and had been caring for unauthorized dogs 

in his unit’s area, in spite of General Order Number 1 

which forbade the keeping of animals in theater. Feral 

dogs have been a perennial issue throughout the combat 

theaters of Iraq and Afghanistan, as they are attracted 

to the presence of food waste at dump sites around the 

bases.2

 During an attempt to break up a dog fi ght between one of the local unauthorized dogs and a feral dog, 

the Specialist was bitten on the hand. According to reports, the Specialist told his mother that he was ordered 

to shoot the feral dog and have it sent for rabies testing. 

It has also been reported that a rabies vaccine series was 

initiated, but discontinued because the vaccine had expired. Unfortunately, there is no evidence that any animal was tested for rabies and no record of medical treatment being sought or given. The Specialist left Afghanistan in May 2011 with his unit for Germany. He later 

reported to his new assignment at Fort Drum, New York, 

in August 2011. By this time, he had started to exhibit 

neurologic symptoms. He complained of a tingling pain 

radiating down his arm on August 14, and was treated 

for tendonitis at a civilian hospital. He reportedly had 

trouble drinking on August 17 and collapsed at work on 

August 19, again seeking treatment at a civilian hospital. 

At this point, it was learned that he had received the dog 

bite in Afghanistan. This history and the symptoms led 

to the suspicion of rabies, which triggered specifi c testing at Wadsworth Center, the New York State Department of Health’s public health laboratory. Rabies virus 

antigens were detected in hair follicles of nuchal skin 

biopsy specimens by direct immunofl uorescence, and 

rabies viral RNA was found in saliva and cerebrospinal 

fl uid (CSF) by reverse transcriptase–polymerase chain 

reaction. Once rabies was identifi ed as a potential cause 

of his symptoms, a coma was medically induced as part 

of an experimental rabies treatment protocol. At the 

time of his hospitalization, rabies virus specifi c immunoglobulin M and immunoglobulin G antibodies were 

detected in his serum and cerebral spinal fl uid in laboratory testing performed by the Wadsworth Center and at 

the Centers for Disease Control and Prevention (CDC).3

Virus neutralizing antibodies were found in the serum 

at a level of 0.07 IU/mL on August 28, and by the date 

of his death on August 31, had increased to 0.50 IU/mL. 

Virus neutralizing antibody was not detected in the CSF. 

Laboratory testing at the CDC detected no rabies virus 

neutralizing antibody in the blood drawn in May 2011 

as a routine banked sample upon his return from deployment. He suffered a massive brain hemorrhage and succumbed to rabies on August 31. He was the fi rst US military member to die from rabies since the Vietnam war.1

Postmorten tests performed at the CDC established that 

the virus variant was consistent with the canine rabies 

virus found in Afghanistan.3

The Army and local health departments, in collaboration with the New York State Department of Health and 

the CDC, interviewed and provided risk assessments to 

the patient’s family members and friends, fellow travelers, health care workers, and any other personnel who 

may have interacted with the patient.3

 Any individual 

that was identifi ed as meeting the exposure criteria set 

by the Advisory Committee on Immunization Practices 

was given postexposure prophylaxis. The exposure criteria includes wound or mucous membrane exposure 

to the patient’s saliva, CSF, neural tissue, or tears.4

 The 

Army Public Health Command assembled a rabies response team to locate other members of the Soldier’s 

unit who may not have reported bites to medical providers while in theater. More individuals were identifi ed 

through medical record reviews. Any Soldier who had 

a possible animal exposure was evaluated and, where 

indicated, given postexposure prophylaxis, which typically consists of immediate administration of rabies immune globulin, followed by a series of 4 antirabies vaccinations given on days 0, 3, 7, and 14.5

 Postexposure 

prophylaxis has proven to be very effective when given 

promptly, however, rabies is considered to be universally fatal once clinical signs develop. In all, about 9,000 

personnel were evaluated to assess their risk of rabies 

exposure.1

REPORTED ANIMAL BITES

The Armed Forces Health Surveillance Center (AFHSC) 

reported 643 animal bites to US personnel in Southwest 

Asia and the Middle East combat operational theaters 

from 2001 through 2010, half of those being dog bites.6

A total of 117 personnel reported that they received some 

amount of rabies vaccine. Of the 20,522 total animal 

bites reported from US Armed Forces worldwide during that period, the majority of the reports from outside 

The Relevance of Rabies to Today’s Military

Edwin D. Cooper, BS, MT 

COL Mustapha Debboun, MS, USA
 July – September 2012 5

the current combat operational theaters were from dog 

bites.6

Rabies has been known since ancient times, with the 

fi rst basic treatment for rabies demonstrated by Louis 

Pasteur in 1885. Still, as of 2001, every 15 minutes one 

person died from rabies and over 300 were exposed.7

Most exposures to rabies worldwide are due to bites 

from canines. Worldwide, the rabies virus kills an estimated 55,000 people annually, with about 56% of the 

deaths in Asia and 44% in Africa.8

 The majority (84%) 

of these deaths occur in rural areas. In many of these 

places, there are often great diffi culties to overcome in 

the transport of medical supplies, especially those requiring cold storage. Worldwide, there is a limited supply of rabies immune globulin.9

SURVIVORS ARE EXCEPTIONS

Rabies is considered to be the infectious disease with 

the highest case-fatality ratio.10 There have been only a 

handful of recent cases in which a patient has survived 

after symptoms were exhibited, each having had circumstances that may have weighed in the patient’s favor. 

As described by Willoughby et al,11 in 2004, a girl aged 

15 received a bite on the fi nger while catching and releasing a bat from inside a building in Wisconsin. The 

fi nger was washed and disinfected with hydrogen peroxide. No medical attention was sought at the time and no 

post exposure prophylaxis was administered. A month 

later, she felt symptoms including nausea and vomiting 

and sought medical attention. Her symptoms progressed 

to include fever, salivation, and diffi culty in swallowing. Laboratory tests of serum and cerebral spinal fl uid 

showed the presence of antirabies antibodies. As part 

of a new and aggressive treatment regime, the patient 

was placed in an induced coma using ketamine, phenobarbital, and midazolam. Ribavirin and (later) amantadine were added for direct antiviral effect. After about 

2 weeks of aggressive therapy, the girl began to show 

positive effects. She was considered to be clear of transmissible rabies by day 31 of hospitalization and was discharged on day 76. The girl initially had severe neurological impairment which has progressively, albeit slowly, improved with time. It is possible that the therapy in 

this case was more successful than in other cases due to 

a possible lower dose of rabies virus, early recognition 

of the symptoms, and aggressive management. The therapy was based on a hypothesis of protecting the brain 

from injury while enabling the immune system to mount 

a response and clear the virus. This treatment regime 

has since been termed the “Milwaukee Protocol.” According to the Children’s Hospital of Wisconsin Rabies 

Registry,12 4 of 28 rabies patients treated using the Protocol have survived (as of this writing). There is debate 

among scientists concerning how many of surviving patients actually responded to the therapy, as well as to the 

appropriate advice for treatment of future patients.13

The rabies virus spreads throughout the body through the 

cells of the nervous system. It is usually introduced into 

the tissue through a bite, scratch, or mucous membranes 

from an inoculum of saliva. The virus may remain in the 

local tissue for some period of time depending on the 

depth of the wound, innervation to the area, and other 

biological factors. Upon reaching nerve cells, the virus 

spreads very quickly and effi ciently through the central 

nervous system, by fast axonal transport along neuroanatomical pathways.13 The virus travels in a retrograde 

direction through the axon toward the neuron cell body. 

The rabies virus is able to take advantage of the axonal 

transport machinery of the neuron to travel through the 

axon at speeds of 3 to 10 mm per hour.14 Once the virus has passed through the brainstem into the brain, the 

antirabies immunoglobulin is unable to reach the virus, 

because it cannot pass through the blood brain barrier. 

Neurologic symptoms are exhibited once the virus passes into the brain. After reaching the brain, the virus then 

travels outward to the salivary glands where it is available for transmission to the next victim. The rabies virus 

has evolved a unique and extremely effective mode of 

transmission, combining placement of the virus with alteration of mammalian behavior to allow it to be passed 

on to other victims.

US ARMY EXPERIENCE WITH RABIES

The Army has long recognized the threat of rabies to 

military operations. The Offi ce of The Surgeon General 

received reports in 1937 of:

...5,962 dogs, 225 cats, 18 monkeys, 1 fox, and 1 squirrel that were given single dose antirabic vaccination at 

67 Army posts during the calendar year 1937. Quarterly 

Veterinary Sanitary Reports showed that vaccination is 

practiced at 71 percent of the reporting stations.15

According to the 1937 report, the last reported human 

case of rabies in the military was in 1926. There were 8 

cases and 6 deaths reported from 1906 to 1926.15

In 1942, the Eighth Service Command Medical Laboratory was established at Fort Sam Houston, Texas.16 It 

included a food analysis branch and a virus laboratory, 

both of which were supervised and operated by veterinary personnel. The virus laboratory was mainly concerned with the study of troop health aspects of such 

diseases as typhus, Rocky Mountain spotted fever, lymphogranuloma venereum, lymphocytic choriomeningitis, rabies, ornithosis, equine encephalomyelitis, and 

St. Louis encephalitis. The various Army veterinary 
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

laboratories across the continental United States eventually combined into the Department of Defense Food 

Analysis and Diagnostic Laboratory (FADL). In 2011, 

the Army Veterinary Command was merged into the 

newly established US Army Public Health Command 

(USAPHC), and the FADL became part of the USAPHC 

Region-South. Currently, there are 2 Army laboratories 

with rabies testing capabilities, one at the USAPHC Region-South in Fort Sam Houston, and the other at the 

USAPHC Region-Europe in Landstuhl, Germany.

ANIMAL HOSTS

The primary carrier for rabies (genotype 1 of the genus Lyssavirus) worldwide is canine. This is especially 

true in urban centers of the developing world. It should 

be understood, however, that any mammal can become 

infected by the rabies virus. There are currently 9 recognized antigenic variants of the rabies virus. Each variant is associated with a specifi c species of mammal that 

commonly carries the virus within a certain region. This 

relationship is complex and the genetic characterization 

of the variants is being redefi ned as the science continues to advance. Additionally, the habitats of the host 

species are constantly changing. For example, raccoon 

rabies in the states of the US eastern seaboard has been 

slowly moving westward. With wildlife vaccination efforts in Texas, the canine variant of rabies in coyotes has 

been eliminated in Texas, but persists south of the border in Mexico. Further, it has been reported in Mexico 

that the bat variant in vampire bats has been found at 

higher elevations of the mountains due to an increase 

in average air temperature. Mongoose throughout the 

Caribbean islands, where they are an invasive species, 

are now demonstrating a unique challenge in regards to 

rabies. They have been a particular problem in Puerto 

Rico, where they not only pose a threat of rabies, but 

also threaten endangered birds through predation.17

In 1942, Fox wrote of the presence of bat rabies in Trinidad.18 He emphasized the need for inoculation of men 

and cattle, but also emphasized that rabies must be kept 

in perspective compared with other communicable diseases found in the tropics. Rabies had been recognized 

earlier in the century in cattle in Brazil and was linked 

with vampire bats. Rabies is an increasing economic issue throughout Central and South America due to the 

impact of virus transmission from vampire bats to cattle 

and other livestock. It should be noted that bat control 

efforts may inadvertently have an adverse impact by the 

decimation of collocated benefi cial bat species.19 Many 

species of bats cohabit the same roosts as vampire bats. 

Insectivorous bats are benefi cial through the feeding on 

vast numbers of insects, while many plants depend on 

the pollinating activities of fruit bats.20

BAT RABIES IN THE UNITED STATES

Bat rabies was recognized for the fi rst time in the United 

States in 1953. The son of a migrant worker from Mexico was bitten by a bat while searching for a lost ball on 

a ranch near Tampa, Florida. The bat was knocked to 

the ground by the boy’s mother, and killed by the father. 

Fortunately, the owner of the ranch knew about rabies 

in vampire bats in Mexico and insisted that the bat be 

tested for rabies. It was sent to the local public health 

laboratory and was confi rmed to be positive through 

the identifi cation of Negri bodies on microscopic examination. Further testing included inoculations of mice 

which resulted in the 5 injected mice dying with clinical 

symptoms of rabies. The bat was later identifi ed as a lactating female Florida yellow bat (Dasypterus fl oridanus 

Miller, 1902). The boy was administered postexposure 

prophylaxis and, after an initial period of illness, recovered uneventfully.21

The following year (1954), a study was undertaken at 

the US Army Veterinary Laboratory at Fort Sam Houston to investigate the prevalence of rabies in bat species throughout the southwestern United States. A total 

of 1,247 bats were collected from various sites in Texas, 

Louisiana, Arkansas, and New Mexico, including 27 

vampire bats collected from 2 sites in the northern parts 

of Mexico for comparison. The bats were necropsied 

and Sellers stained impressions of brain tissue were examined to look for the presence of Negri bodies. A portion of each brain was also injected intracerebrally into 

Swiss albino mice to isolate the viral agent. Additionally, 

serologic studies were conducted using the mouse inoculation procedure. Four species of bats, 3 from Texas 

and one from Louisiana, were shown to be naturally 

infected with rabies. This study also demonstrated that 

a high percentage of the bat brain tissues from which 

rabies virus was isolated through the use of mouse inoculation had been negative for Negri bodies.22

BAT RABIES IN CENTRAL AND SOUTH AMERICA

There has been an increase in the number of human cases of rabies transmitted by bats throughout Latin America.23 This has come at a time when canine rabies has 

begun to decline in some areas due to concerted antirabies campaigns. Of the bat cases, the majority are due 

to vampire bats. It has been surmised that the vampire 

population has increased over the past several decades 

due to increasing numbers of cattle operations throughout the region. In areas where the cattle have overgrazed 

an area and human occupations moved in, the bats simply change their food source from bovine to human, 

leading to outbreaks of rabies. Other factors involved 

include the clearing of rain forest cover, poor condition of available housing, and lack of access to health 

THE RELEVANCE OF RABIES TO TODAY’S MILITARY
 July – September 2012 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

care. In 2009, a case of rabies encephalitis in a teen aged 

male in Colombia was considered to be the fi rst case of 

bat transmitted rabies in an urban area in the region.24

The virus was found to be the antigenic variant whose 

main reservoir is the vampire bat, Desmodus rotundus 

(E. Geoffroy, 1810). The Milwaukee Protocol had been 

attempted, but was not successful due to a number of 

complicating factors.

RABIES WORLDWIDE

As shown in the Figure, rabies is present worldwide on 

all continents except Antarctica.9

 Terrestrial rabies, or 

rabies in mammals other than bats, can be found in over 

150 countries. Countries that may be referred to as “rabies free” include Australia, Guam, Iceland, Japan, Norway, Sweden, and the United Kingdom. The World Organisation for Animal Health considers a country to be 

rabies free for international trade purposes when certain 

criteria are met.25 These criteria include having a system 

for surveillance and notifi cation of rabies, effective importation procedures and other measures. There can be 

no cases of rabies acquired within the country in animals 

or man for 2 years and no cases of rabies from imported 

carnivores outside of a quarantine station. The criteria 

do not include the isolation of a bat lyssavirus, which 

can still present as rabies disease in humans. At times a 

country’s claim to be rabies free can be tenuous due to 

disease reintroduction or emergence. According to the 

World Health Organization, all of Africa and Asia, Central America, the northern half of South America, and 

the Caribbean islands are at high risk from rabies. The 

CDC has estimated the rate of possible exposure to rabies of travelers throughout the world to be in the range 

of 16 to 200 per 100,000 travelers.26 Guidelines for rabies 

treatment to include both pre- and postexposure prophylaxis are specifi cally intended for use within the United 

States. These guidelines are currently the best available 

for deployed environments around the globe, but it must 

be realized that rabies is a disease which still has many 

potential unknowns. Rabies virus is the most important 

of 11 known lyssaviruses globally.27 The other lyssaviruses cause disease which clinically resembles rabies, 

however, there is reason to question the effectiveness of 

pre- and postexposure prophylaxis based on the genetic 

distance each virus has from the rabies genotype.28

RABIES TESTING

The animal suspected of carrying rabies must be euthanized in a humane manner such that the biological 

integrity of the brain is not compromised. The head 

should be removed and transported to the laboratory in 

an insulated box with ice packs. Transportation should 

be arranged to effect the shipment of the sample to the 

laboratory as quickly as is feasible. A bat may be submitted as a whole body. The gold standard test for rabies 

in animals remains the direct fl uorescent antibody test 

The levels of the risk of rabies within countries and areas worldwide as of 2008. Source: http://www.who.int/rabies/resources/en/
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

(DFA). This test replaced the use of Sellers stain to determine the presence of Negri bodies in the mid 1960s. 

In the DFA test, brain tissue is adhered to glass slides 

in an “impression smear,” and, after fi xation in acetone, 

stained with a fl uorescent conjugate. The presence of 

punctate bodies of apple-green fl uorescence indicates a 

positive sample. The limitations of this test in an austere 

environment are the requirements for a fl uorescent microscope and cold storage capability for reagents and for 

transport of samples.

In 2008, Veterinary Laboratory Europe, now US Army 

Public Health Command Region – Europe, deployed a 

veterinary pathologist to Iraq and Afghanistan to provide rabies surveillance capabilities and training to military personnel and key local civilian veterinarians.29 The 

US military exchanged ideas and information with their 

civilian counterparts and shared their common interest 

in future coordination regarding rabies surveillance in 

Iraq and Afghanistan. In 2010, a veterinary offi cer with 

the 734th Agribusiness Development Team stationed in 

Kunar Province, Afghanistan, provided continuing education training on rabies and other topics to the private 

veterinary practitioners in Kunar.30 This was done as 

part of an effort to establish a rabies control program 

for Afghanistan.

VACCINATION PROGRAMS AND SEROLOGY 

FOR RABIES ANTIBODY

A reccurring theme in public health seems to be the need 

to reeducate the public on the need for public health programs. The safety and effi cacy of vaccines seem to be 

particularly contentious issues. In 2007, the CDC declared the United States to be free of the canine strain of 

rabies,31 indicating that the rabies variant whose natural 

hosts include dogs and coyotes is no longer considered 

enzoonotic in the continental United States. This was 

after many decades of vaccination programs through local and state health agencies across the country. At each 

stop, the US Public Health Service had to convince local community health decision-makers to allow the program to go forward, often against dissenting voices in 

the community. A modifi ed version of the Semple phenol killed virus vaccine was recommended by the US 

Army in the 1940s for use on dogs, but it required semiannual vaccination.32 Vaccine and vaccination protocols 

have greatly improved since then. It is important to understand, however, that even though the canine variant 

may no longer be enzootic, rabies variants from bats, 

raccoons, and skunks still exist in the United States, and 

there is always the risk from imported cases of rabies.

In 1988, the canine strain of rabies was spreading in 

the coyote population in Starr county, Texas.33,34 The 

epizootic was spreading through 11 other counties in 

south Texas, approaching San Antonio. A young boy 

died from rabies transmitted by a puppy, which had received the virus from a coyote. A new program was initiated by the Texas Department of Health (TDH) to vaccinate the coyote and later the fox populations through 

the use of oral bait.35 Since 1995, the FADL Diagnostic 

section has evaluated coyote and fox serum by Rabies 

Fluorescent Focus Inhibition Test (RFFIT) as a means 

of monitoring the effi ciency of vaccine baiting strategies 

in the fi eld. The use of titer information has allowed the 

TDH to adjust fl ight plans, distribution rates, and other 

variables to increase effectiveness and effi ciency. Each 

January, bait is dropped over an area of south Texas. In 

March or April, a cohort of animals is harvested and 

bled. Samples of serum are sent to the FADL for RFFIT, 

while other samples are retained by the TDH or sent on 

to the US Department of Agriculture or the CDC for 

related research. The program has greatly reduced the 

risk of transmission of rabies from coyotes and fox to 

domestic animals and humans.36

The RFFIT assay is also used by FADL to evaluate the 

titer of veterinarians, animal handlers, and other personnel with potential rabies exposures. This helps ensure 

the safety of having adequate titers of antirabies antibody, while reducing the risk of vaccine-related events 

by reducing the frequency of vaccination. A side benefi t 

is the inherent cost savings. The CDC Advisory Committee on Immunization Practices recommends that personnel with animal exposure have serum antibody titers 

tested every 2 years.4

 Those working directly with the 

rabies virus should be tested every 6 months. The FADL 

laboratory is accredited by the American Association 

for Laboratory Accreditation (A2LA) to the ISO 17025 

standard, and by COLA laboratory accreditation (http://

www.cola.org) for human antirabies antibody testing by 

the RFFIT method. The FADL laboratory tested 9,620 

samples by RFFIT assay from January 2000 through 

December 2011.

Animal travel has become a major concern for the Department of Defense. Since 1997, the FADL has offered 

the Fluorescent Antibody Virus Neutralization (FAVN) 

assay for rabies antibody testing for military working 

dogs as well as pets of service members going overseas. 

The FADL is one of only 2 laboratories in the United 

States that offer this test, the other being at Kansas State 

University. This testing has allowed the movement of animals to Hawaii, Britain, Europe, Japan, Guam, and other countries without the stress of prolonged quarantine. 

The laboratory is accredited by A2LA and the French 

Agency for Food, Environmental, and Occupational 

Health and Safety, the accreditation laboratory in Nancy, 

THE RELEVANCE OF RABIES TO TODAY’S MILITARY
 July – September 2012 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

France, which authorizes the results for international 

travel to Europe. The FADL laboratory tested 88,545 

samples by the FAVN test from 1999 through 2011.

FERAL ANIMALS SHIPPED FROM IRAQ

When US forces entered Afghanistan in 2001, General 

Order Number 1 prohibited military members from any 

contact with stray dogs. Over time, some military personnel began to ignore the order and “adopt” strays as 

pets. In June 2008, an international animal rescue group 

imported a shipment of 26 animals from Iraq to Newark, 

New Jersey.37 The 24 dogs and 2 cats were to be reunited 

with those personnel who had befriended them in theater. 

On arrival, one cat was found to be ill with neurologic 

signs. The cat was euthanized and tested negative for 

rabies. Three days later, an 11-month-old dog became 

ill. It was taken to a veterinarian and hospitalized with 

fever, diarrhea, wobbly gait, agitation, and crying. The 

dog’s condition proceeded to deteriorate until it was euthanized on June 11. Testing at the New Jersey Public 

Health and Environmental Laboratory proved positive 

for rabies. Further testing at the CDC typed the virus as 

a variant associated with dogs in the Middle East. The 

dog had reportedly lived with a Soldier in Baghdad for 

7 months and was not vaccinated for rabies before transport. None of the 24 dogs had the required valid rabies 

vaccination certifi cates. Five of the dogs had a previous 

rabies vaccination, the remaining 21 animals received 

their primary rabies vaccine upon embarking transport. 

By the time the positive rabies results were reported, the 

23 dogs and one cat were spread out to California, Colorado, Connecticut, Iowa, Kentucky, Maryland, Massachusetts, Missouri, North Carolina, Ohio, Oklahoma, 

Pennsylvania, South Carolina, Texas, Virginia, and 

Washington. State health departments in all 16 states 

were notifi ed, with the recommendation that the animals receive immediate vaccine and be quarantined for 

6 months. Additionally, postexposure prophylaxis was 

recommended for 13 individuals who were identifi ed as 

having had potential exposure to infectious saliva.37

RABIES RISK AWARENESS

Murray and Horvath38 outlined 6 components of deployment medical preparation the US military uses with the 

goal of preventing infectious diseases: preparation, education, personal protective measures, vaccines, chemoprophylaxis, and surveillance. While each component 

is critically important, education of rabies awareness is 

one in which personnel at all levels of responsibility can 

assist. The salient features of this approach are to stress 

the reasons to not pet or feed animals, especially dogs; 

avoid direct contact with animals and animal products; 

and not adopt stray animals as pets. In recognition of 

human nature and the individual’s desire to seek the 

human-animal bond, all personnel must be made fully 

aware of the risks involved in the choices they make. It is 

the responsibility of military public health professionals 

to educate service members at all levels about the risks 

to health and safety in deployed environments. Although 

all military personnel deploying overseas receive a predeployment medical threat brief which includes rabies 

risk information, additional direct emphasis stressing 

the signifi cance of rabies disease in wild animal populations should convince young Soldiers that their personal 

decisions with regard to local animals could be a matter 

of life or death.

The Global Alliance for Rabies Control (GARC) is a partnership of many international agencies with an interest 

in rabies, including the World Health Organization and 

the World Organization for Animal Health. The GARC 

has designated each September 28 as “World Rabies 

Day.” This initiative brings together many different entities to raise awareness about the impact of human and 

animal rabies, prevention strategies, and efforts toward 

elimination of this disease from its main sources. The 

World Rabies Day organization (www.worldrabiesday.

org) is a good source of information about educational 

materials in many languages for a variety of intended 

audiences. The rabies information page on the US Army 

Public Health Command website (http://phc.amedd.ar

my.mil/topics/discond/aid/Pages/Rabies.aspx) also has 

helpful educational materials for rabies risk awareness, 

including specifi c information for deployed environments. The availability of such information provides the 

opportunity for all US military personnel, wherever they 

may be, to become actively engaged in the prevention of 

contracting this universally fatal, but entirely preventable disease.

THE CHALLENGE

At the 2012 Military Health System Conference, The 

Surgeon General of the Army, LTG Patricia D. Horoho, 

acknowledged the death of the Soldier to rabies39:

Are we good enough when we lose one Soldier to a preventable illness? Last summer, an active duty Soldier 

died of rabies. Of rabies? This is the fi rst active duty rabies death in over 40 years. So my question to you is...

are we good enough? My challenge and my personal belief is that...we can be better! We must be better!

She continued to stress that the Military Health System 

must fi nd ways to infl uence behaviors of patients in the 

“white space” between the 100 minutes a year that an 

average Soldier has contact with a healthcare provider.

Rabies is an entirely preventable disease if the individual 

is informed enough to understand the importance of (1) 
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

avoiding contact in the fi rst place, and (2) seeking and 

receiving treatment if contact occurs. The consequences 

otherwise are tragic.

REFERENCES

1. Gould J. Parents blast Army response to rabies 

death. Army Times [serial online]. February 22, 

2012. Available at: http://www.armytimes.com/

news/2012/02/army-drum-rabies-death-afghanistan-parents-blast-response-022212w/. Accessed 

April 26, 2012.

2. Wanja EW. Observed Noncompliance with Implementation of Vector-Borne Disease Preventive 

Measures Among Deployed Forces. US Army Med 

Dep J. April-June 2010:56-64.

3. Imported Human Rabies in a U.S. Army Soldier - 

New York, 2011. MMWR Morb Mortal Wkly Rep. 

2011;61(17):302-305.

4. Human rabies prevention–United States, 2008. 

Recommendations of the Advisory Committee 

on Immunization Practices. MMWR Recomm 

Rep. May 18,2008;57(RR03):1-26,28. Available at: 

http://www.cdc.gov/mmwr/preview/mmwrhtml/

rr5703a1.htm. Accessed April 26, 2012.

5. Use of a reduced (4-dose) vaccine schedule for 

postexposure prophylaxis to prevent human rabies. Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm 

Rep. March 19, 2010;59(RR02):1-9. Available at: 

http://www.cdc.gov/mmwr/preview/mmwrhtml/

rr5902a1.htm. Accessed April 26, 2012.

6. Armed Forces Health Surveillance Center. Animal 

bites, active and reserve components, US armed forces, 2001-2010. MSMR. 2011;18(9):12-15. Available 

at: http://www.afhsc.mil/viewMSMR?fi le=2011/

v18_n09.pdf. Accessed April 26, 2012.

7. Rupprecht CE, Hanlon CA, Hemachudha T. Rabies 

re-examined. Lancet Infect Dis. 2002;2:327-343.

8. WHO Expert Consultation on Rabies: First Report. 

Geneva, Switzerland: World Health Organization; 

2005:13. WHO Technical Report Series 931. Available at: http://www.who.int/rabies/trs931_%20

06_05.pdf. Accessed April 26, 2012.

9. World Health Organization. Fact Sheet No. 99: Rabies. September 2011. Available at: http://www.who.

int/mediacentre/factsheets/fs099/en/index.html. 

Accessed May 2, 2012.

10. Hemachudha T, Laothamatas J, Rupprecht CE. Human rabies: a disease of complex neuropathogenetic mechanisms and a diagnostic challenge. Lancet 

Neurol. 2002;1:101–109.

11. Willoughby RE Jr, Tieves KS, Hoffman GM, et al. 

Survival after treatment of rabies with induction of 

coma. N Engl J Med. 2005;352(24):2508-2514.

12. Rabies registry. Children’s Hospital of Wisconsin 

Website. Available at: http://www.chw.org/display/

PPF/DocID/33223/router.asp.

Accessed May 1, 2012.

13. Jackson AC. Update on rabies. Res Rep Trop Med. 

2011;2:31-43.

14. Salinas S, Schiavo G, Kremer EJ. A hitchhiker’s 

guide to the nervous system: the complex journey of viruses and toxins. Nat Rev Microbiol. 

2010;8(9):645-655

15. Rabies in the Army–1937. Army Med Bull. April 

1938;44:76-78.

16. Miller EB. United States Army Veterinary Service 

in World War II. Washington DC: Offi ce of The 

Surgeon General, US Dept of the Army;1961:398-

399. Available at: http://history.amedd.army.mil/

booksdocs/wwii/vetservicewwii/chapter11.htm. 

Accessed April 23, 2012.

17. Mortality threats to birds – small Indian mongoose 

(Herpestes javanicus). American Bird Conservancy Website. Available at: http://www.abcbirds.org/

conservationissues/threats/invasives/mongoose.

html. Accessed May 1, 2012.

18. Fox LA. Mad dogs with wings. Army Med Bull. 

January 1942;60:122-127.

19. Aguiar, LMS, Brito D, Machado RB. Do current 

vampire bat (Desmodus rotundus) population 

control practices pose a threat to Dekeyser’s 

nectar bat’s (Lonchophylla dekeyseri) long-term 

persistence in the Cerrado?. Acta Chiropt. 

2010;12(2):275-282. Available at: http://www.bioone.

org/doi/abs/10.3161/150811010X537855. Accessed 

April 26, 2012.

20. Heithaus ER, Opler PA, Baker HG. Bat activity and 

pollination of Bauhinia Pauletia: plant-pollinator 

coevolution. Ecology. 1974;55(2):412-419.

21. Venters HD, Hoffert WR, Schatterday JE, Hardy 

AV. Rabies in bats in Florida. Am J Public Health 

Nations Health. 1954;44(2):182-185.

22. Burns KF, Farinacci CF, Murnane TG. Insectivorous bats naturally infected with rabies in southwestern United States. Am J Public Health Nations 

Health. 1956;46(9):1089-1097.

23. Kuzmin IV, Bozick B, Guagliardo SA, et al. Bats, 

emerging infectious diseases, and the rabies paradigm revisited. Emerg Health Threats J [serial online]. June 2011;4:7159. Available at: http://www.

eht-journal.net/index.php/ehtj/article/view/7159. 

Accessed April 26, 2012.

24. Badillo R, Mantilla JC, Pradilla G. Encefalitis rábica humana por mordedura de murciélago en un área 

urbana de Colombia. Biomédica. 2009;29:191-203.

THE RELEVANCE OF RABIES TO TODAY’S MILITARY
 July – September 2012 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

25. Rabies. In: World Organisation for Animal Health. 

Terrestrial Animal Health Code. 2011:chap 8.10. 

Available at: http://www.oie.int/index.php?id=169&

L=0&htmfi le=chapitre_1.8.10.htm. Accessed May 

2, 2012.

26. Infectious Diseases Related to Travel: Rabies. 

Centers for Disease Control and Prevention Web site. 

Available at: http://wwwnc.cdc.gov/travel/yellow

book/2012/chapter-3-infectious-diseases-relatedto-travel/rabies.htm. Accessed April 26, 2012.

27. Rupprecht CE, Turmelle A, Kuzmin IV. A perspective on lyssavirus emergence and perpetuation. 

Curr Opin Virol. 2011;1(6):662-670.

28. Hanlon CA, Kuzmin IV, Blanton JD, Weldon WC, 

Manangan JS, Rupprecht CE. Effi cacy of rabies 

biologics against new lyssaviruses from Eurasia. 

Virus Res. 2005;111(1):44-45.

29. Saturday GA, King R, Fuhrmann L. Validation and 

operational application of a rapid method for rabies 

antigen detection. US Army Med Dep J. JanuaryMarch 2009:42-45.

30. Adams L. Wednesday warfi ghter: fi ghting rabies 

in Afghanistan. DoD Live [serial online]. December 15, 2010. Available at: http://www.dodlive.mil/

index.php/2010/12/wednesday-warfi ghter-fi ghtingrabies-in-afghanistan/. Accessed May 10, 2012.

31. Compendium of Animal Rabies Prevention and 

Control, 2011. National Association of State Public 

Health Veterinarians, Inc Website; May 31, 2011. 

Available at: http://www.nasphv.org/Documents/

RabiesCompendium.pdf. Accessed April 26, 2012.

32. Carter CN. One Man, One Medicine, One Health: 

The James H. Steele Story. Self-published. 2009.

33. Slate D, Algeo TP, Nelson KM, et al. Oral rabies 

vaccination in North America: opportunities, complexities, and challenges. PLoS Negl Trop Dis. 

2009;3(12):e549.

34. Sidwa TJ, Wilson PJ, Moore GM, et al. Evaluation 

of oral rabies vaccination programs for control of 

rabies epizootics in coyotes and gray foxes: 1995-

2003. J Am Vet Med Assoc. 2005;227(5):785-792.

35. Texas oral rabies vaccination program (ORVP) 

1995-2010. Infectious disease control page. Texas 

Department of State Health Services Website. 

Available at: http://www.dshs.state.tx.us/idcu/dis

ease/rabies/orvp/information/summary/. Accessed 

May 1, 2010.

36. Baiting Statistics from the Texas ORVP. Infectious 

disease control page. Texas Department of State 

Health Services Website. Available at: http://www.

dshs.state.tx.us/idcu/disease/rabies/orvp/statistics/. 

Accessed May 1, 2010.

37. Rabies in a dog imported from Iraq-New Jersey, 

June 2008. MMWR Recomm Rep. 2008;57:1076-

1078. Available at: http://www.cdc.gov/mmwr/previ

ew/mmwrhtml/mm5739a3.htm. Accessed April 26, 

2012.

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

39. Horoho PD. Plenary remarks presented at: 

2012 Military Health System Conference; 

January 31, 2012; Oxon Hill, Maryland. Available 

at: http://www.armymedicine.army.mil/news/docs/

MHS2012PlenaryLTGHorohoArmySurgeon

General_31_JAN_12_Remarks.pdf.

Accessed April 26, 2012.

AUTHORS

Mr Cooper, an American Society of Clinical Pathologists 

Certifi ed Medical Technologist, is a Microbiologist at the 

US Army Public Health Command Region-South Food 

Analysis and Diagnostic Laboratory, Fort Sam Houston, 

Texas.

COL Debboun is Chief, Department of Preventive Health 

Services, Academy of Health Sciences, AMEDD Center 

and School, Fort Sam Houston, Texas.
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

INTRODUCTION

Chagas disease or American trypanosomiasis is caused 

by the hemofl agellate protozoan Trypanosoma cruzi 

Chagas, which was identifi ed by the Brazilian physician 

Carlos R. J. Chagas in 1909.1

 It is a serious disease that 

mainly occurs in Latin America (Mexico, Central and 

South America).2

 Currently, over 7 million people are 

infected with more than 108 million people at risk annually.2

 Of those infected, 21,000 are predicted to die 

each year.2 Trypanosoma cruzi is mainly transmitted to 

humans via infected feces of hematophagous triatomine (Hemiptera: Reduviidae: Triatominae) bugs. Human 

transmission primarily occurs when an infected bug defecates on a host during or shortly after taking a bloodmeal. Reacting to an itching sensation, the bite victim 

rubs fecal material into the bite site, which ultimately 

facilitates the transmission of the parasite. Triatomine 

bugs feed on many mammalian and avian hosts. They 

typically feed on sleeping humans at night, attacking 

wherever skin is exposed, but especially on the face. For 

this reason, the triatomine bug is often referred to as the 

“kissing bug.” Although the pathogen can also be transmitted to humans by blood transfusion,3

 congenitally,4

by oral ingestion,5

 and by organ transplantations,6,7 more 

than 80% of all human cases are caused by vector-borne 

transmission.8

In the United States, Chagas disease exists almost exclusively in animals.9

 Only 5 autochthonous insect-borne 

cases in humans have been reported in the southwestern 

United States.10,11 The fi rst autochthonous insect-borne 

case of Chagas disease in the United States was reported by Woody and Woody in 1955.11 Trypanosomes were 

discovered in the blood of a 10-month-old girl from Corpus Christi, Texas.11 One of the suggested reasons for 

the low incidence of human Chagas disease cases in the 

southwestern United States is differences in the resting 

and blood feeding (sylvatic and peridomiciliary) habitats of the insect vectors.12

Although the reported incidence of human Chagas disease in the United States is relatively low, North American strains of T. cruzi have been proven to be virulent 

among various mammals exposed to triatomine-triatomine speciesin nature.12 Some of the common mammalian species naturally infected with T. cruzi are raccoon (Procyon lotor (Linnaeus)), wood rat (Neotoma 

micropus Baird), armadillo (Dasypus novemcinctus

Vector Surveillance to Determine

 Species Composition and Occurrence of

 Trypanosoma cruzi Infection at Three

 Military Installations in San Antonio, Texas

 CPT Lee McPhatter, MS, USA Neal Lockwood, DVM, MPH

 Walter Roachell, MS Angel Osuna, BS

 Farida Mahmood, PhD MAJ Jorge Lopez, MS, USA

 Lauren Hoffman, BS COL Mustapha Debboun, MS, USA

ABSTRACT

Chagas disease, also known as American trypanosomiasis, is caused by the hemofl agellate protozoan Trypanosoma cruzi which is transmitted by blood-sucking triatomine bugs (Hemiptera: Reduviidae; Triatominae). The 

disease is endemic to south Texas, but exists almost exclusively as a zoonosis. Chagas disease has proven to be 

a serious public health threat to military working dogs. In 2007, seroprevalence of Chagas disease in military 

working dogs in San Antonio, Texas, reached 8%. A faunal survey was conducted at 3 San Antonio area military installations (Camp Bullis, Fort Sam Houston, and Lackland Air Force Base). A total of 140 triatomines 

representing 4 species (Triatoma gerstaeckeri, T. sanguisuga, T. lectularia, and T. indictiva) were collected. 

Trypanosoma cruzi infected bugs were only collected at Lackland Air Force Base, where the overall infection 

rate was 16%. The wood excavation technique developed during this study collected all life stages. Only 2 life 

stages (adult and 5th instar) were positive for T. cruzi.
 July – September 2012 13

(Linnaeus)), and domestic dog (Canis familiaris (Linnaeus)).13,14 Many dog breeds have been infected and 

suffered mortality because of this infl iction.14 Twelve 

species of triatomines are known to occur in the southern half of the United States.9

 Seven of the triatomine 

species including: Triatoma gerstaeckeri (Stal), T. indictiva Neiva, T. lecticularia (Stal), T. protracta (Uhler), T.

rubida (Uhler), and T. neotomae Neiva , T. sanguisuga

(Leconte) have been routinely collected from Texas.14

The overall infection rate in Texas has been found to be 

higher than in any other state where T. cruzi has been 

reported.12 The T. cruzi infection rate among triatomine 

vectors in Texas has been reported as more than 50%.15

Chagas disease has proven to be a signifi cant veterinary 

health threat to the military working dogs (MWDs). In 

late 2006, US Army veterinarians assigned to the Military Working Dog Center Veterinary Services, Lackland 

Air Force Base, San Antonio, TX, began to observe an 

increase of Chagas disease cases in the MWD population. Prior to this, only a few sporadic cases were identifi ed through serology and clinical diagnosis. In 2007, 

veterinarians began to see an increase in the number of 

Chagas cases diagnosed. A cross-sectional serological 

study was conducted at one of the kennel facilities. It 

was demonstrated that a seroprevalence rate of 8% (24) 

of the dogs were positive for T. cruzi antibodies (S. Baty, 

written communication, June 30, 2007). This number 

was comparable to the number reported for stray dogs 

tested along the US border with Mexico.9

 In 2009, several MWDs were returned to the Military Working Dog 

Center with reported clinical symptoms of cardiac issues 

further diagnosed as Chagas disease. These dogs were 

supporting various units deployed to the Iraq theater of 

operations. As a result of evacuating the MWDs, these 

units were left without explosive detection dogs, thus 

leaving the units more vulnerable to attacks using improvised explosive devices. These fi ndings have recently 

brought a new sense of urgency to better understand the 

Chagas disease vector. The purpose of this fi eld study 

was to (1) survey Triatoma spp. found on Lackland Air 

Force Base, Camp Bullis, Medina Annex, and Fort Sam 

Houston; (2) develop Triatoma collection techniques; (3) 

characterize Triatoma habitats; and (4) determine relative incidence of T. cruzi in fi eld collected specimens.

MATERIALS AND METHODS

Study Area

Five sites were selected based on proximity to potential 

host and habitat characteristics as indicated in the literature9,12,13,16 (Figures 1 and 2).

Site 1. Medina Woods, N29° 23′ 07.97′′ W98° 40′ 55.76′′

(Figure 1). The Medina Training area consists of 

woodland habitat (oak, mesquite forest and open range 

land) located at the northeastern edge of the Medina Annex (Figure 2A).

Site 2, The Medina Kennel, N29° 23′ 13.71′′ W98° 39′

57.46′′ (Figure 1). The Medina Kennel is a fi xed site facility that houses approximately 800 dogs (Figure 3A).

Site 3, Transportation Security Administration (TSA) 

puppy breeding program kennels (N29° 24′ 06.96′′ W98° 

37′ 07.02′′) are located on the northeastern side of Lackland Air Force Base (Figure 1). It is located south of Wilford Hall Medical Treatment Facility and is proximate to 

a wooded drainage area. Both kennel sites have several 

fl oodlights operating during the night.

Site 4, Western side of Camp Bullis, N29° 40′ 24.45′′

W98° 36′ 23.74′′ (Figure 1). Camp Bullis is located in the 

Texas Hill country. Predominate vegetation consists of 

oak, juniper, mesquite, prickly pear cactus, yucca plants, 

and open range (Figure 2B).

Site 5, Fort Sam Houston, N29° 27′ 38.28′′ W98° 25′

26.70′′ (Figure 1). The site is located on the northeastern 

side of the installation between the golf course and the 

horse stables.

Field Collection Techniques

Triatomine bugs were collected from April to August 

2011 at the study sites using 2 techniques.

 Excavation of dead wood. The wood excavation 

technique involved identifying likely triatomine 

harborage such as a sheltered position near a potential host nesting/resting location. A visual search 

was conducted at the harborage site. Sites examined 

included hollow or rotten logs, cactus plants, dead 

yucca plants, and other debris piles near burrows 

(Figure 2).

 Dog kennels surveillance. Dog kennels were inspected daily by kennel personnel and kissing bugs 

(Figure 3B) were collected using forceps and placed 

into 50 ml collection tubes with holes drilled in the 

tube cap for aeration.

Rearing, Preparation of Fecal Pools, and 

Species Identification

Specimens were maintained in the insectory by methods described by Durvasula and Taneja.17 Insects were 

blood fed in vitro using a glass blood feeder18 (Figure 

4A) and defi brinated rabbit blood (less than 7 days old) 

(Lampire, Pipersville, PA). The blood was kept at 37°C 

using Super RMT LAUDA hot water circulator (LAUDA Brinkman, Delran, NJ). Each blood fed insect was 
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

Bexar County/San Antonio, Texas

Fort Sam Houston

Lackland AFB

Camp Bullis

Figure 1. Map and aerial imagery of the 3 military installations in and around San Antonio, Texas, where 

specimens of triatomine bugs were collected, April 

through August 2011.

Offi cer Basic Course

Training Area

Forward Operating

Base Warrior

LACKLAND AFB

TSA Kennels

Medina Kennels

Medina Woods

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 July – September 2012 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

isolated individually in a 25 cm2

 cell culture fl ask, with 

canted neck and 0.2 μm vent cap (Corning Flask, Lowell, 

MA) (Figure 4B). The fl asks were kept humid in plastic 

boxes with wet paper towels. Triatomines were identifi ed using taxonomic keys by Lent and Wygodzinsky19

(Figure 5). A database was maintained for all the specimens brought into the laboratory.

Detection of T. cruzi Infection by Traditional 

Polymerase Chain Reaction

Sample collection. Fecal matter from triatomine bugs 

was collected by plastic shaft with Dacron tip wetted 

with M4RT media liquid (Remel, Lexena, KS). Dacron 

tips were placed in 2.5 mL microtubes with 500 μL aliquoted liquid media and subsequently frozen at -20oC 

until testing.

Sample processing. Aliquots used were subjected to 

one freeze/thaw cycle. From each sample, 140 μL was 

aliquoted for nucleic acid extraction. Specimen extractions were performed using the Qiagen QiaAmp Viral 

RNA Mini Kit (Qiagen Inc, Valencia, CA) according to 

manufacturer’s minispin extraction recommendation. 

Feces from a subsample of the collected bugs (uninfected/infected) were checked for the presence and absence 

of live T. cruzi by magnifi cation (×400) using a compound microscope ((Figure 4C, D) Table 1).

Primers. Primers used for amplifi cation by traditional 

PCR of T. cruzi were:

primer set TCZ1/TCZ2:

forward primer TCZ1, 5′-CGAGCTCTTGCCCACAC

GGGTGCT-3′

A B

C D

1

1

2

1

Figure 2. Collection habitat for triatomine bugs. Panel A, Medina Woods habitat; Panel B, dead Yucca plant (1) near a rodent 

burrow (2) from where triatomine bugs were collected at Camp Bullis; Panel C, hollow tree trunk with rodent nesting material 

(1); Panel D, Triatoma nymph (1) inside a hollow tree.
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

reverse primer TCZ2, 5′-CCTCCAAGCAGCGGATAG

TTCAGG-3′)20

primer set S36/S36: forward primer S35, 5′-AAATAA

TGTACGGGKGAGATGCATGA-3′

reverse primer S36, 5′-GGGTTCGATTGGGGTTGGT

GT-3′).2,21

DNA amplifi cation. The PCR was performed in 25 μl 

reaction mixtures consisting of 7.45 μl PCR grade water (Roche Diagnostics, Mannheim, Germany), 5 μl 5x 

Q-Solution (Qiagen, Valencia, CA), 5 μl GoTaq Flexi 

(Promega, Madison, WI), 1.5 mol MgCl2

, 0.5 μl deoxynucleoside triphosphates, and 0.15 μl of each primer (Integrated DNA Technologies, Coralville, IA). Reaction 

conditions (iCycler BioRad, Hercules, CA), for TCZ1/

TCZ2 primers: initial denaturation at 94°C for 5 minutes, followed by 35 cycles of amplifi cation at 94°C for 

20 seconds, 57°C for 10 seconds, and 72°C for 30 seconds, a fi nal extension at 72°C for 7 minutes, then fi -

nal hold at 4°C. Conditions for the S35 and S36 primers 

were processed under the following conditions: initial 

denaturation at 95°C for 10 minutes, followed by 35 cycles of amplifi cation at 95°C for 30 seconds, 58°C for 30 

seconds, and 72°C for one minute, then a fi nal extension 

at 72°C for 10 minutes, and held at 4°C until analysis.

The completed DNA reactions were analyzed by gel 

electrophoresis made with 2% agarose (Fischer Scientifi c, Fair Lawn, NJ) in 1X Tris-Borate-EDTA Buffer 

(Sigma-Aldrich, St Louis, MO) solution. Each sample 

set was run with a negative (without DNA) and positive 

control (with T. cruzi strain). Positive controls were acquired from the Department of Defense Food and Animal Diagnostics Laboratories at Fort Sam Houston, TX

RESULTS

A total of 140 triatomine-triatomine bugs 

representing 4 species (T. gerstaeckeri, T. 

sanguisuga, T. lectularia, and T. indictiva)

were collected during this study (Table 2). 

The most prevalent triatomines collected 

were T. gerstaekeri (49%) and T. sanguisuga (39%). Triatoma gerstaeckeri was collected at all 5 study sites, while T. sanguisuga was only collected at 3 study sites. The 

majority of T. gerstaeckeri were collected 

at Camp Bullis (37%) and Medina Kennel (35%). All life stages were collected 

for T. gerstaekeri and T. sanguisuga. Four 

life stages (adult, 5th, 4th, and 3rd instars) 

were collected for T. indictiva and only 

adult collections resulted for T. lectularia. 

Only adults were collected at both kennel 

sites. Woodland collections from Camp 

Bullis and Medina resulted in collections 

of all life stages for T. gerstaeckeri.

Of 113 specimens tested using PCR for T. 

cruzi, 16% were positive. Triatoma gerstaekeri (25%) and T. sanguisuga (8%) 

were the only species that tested positive 

for T. cruzi. Infected bugs were only collected at 3 (Medina Woods, Medina Kennel, and TSA) of the 5 collection sites. The 

TSA kennel site had the highest occurrence 

(60%) of infection. However, only 5 bugs 

were collected. Medina kennel was the site 

with the second highest occurrence (53%) 

of infection. Only 2 life stages (adult and 

5th instar) were positive for T. cruzi.

Table 1. Distribution of Trypanosoma cruzi infection in different species of 

triatomine bugs collected at 3 US military installations in San Antonio, Texas, 

April to August 2011.

Location Species PCR

Results

No.

Tested

Percentage

Infected

Visual

Validation

Camp Bullis T. gerstaeckeri Not Infected 21 – 3

T. indictiva Not Infected 11 – 1

T. lecticularia Not Infected 1 –

T. sanguisuga Not Infected 10 – 1

Totals 43 5

Ft. Sam Houston T. gerstaeckeri Not Infected 2 – 1

Totals 2 1

Lackland Air Force Base

Medina Woods T. gerstaeckeri Not Infected 11 – 3

T. gerstaeckeri Infected 2 15.4 1

T. indictiva Not Infected 1 –

T. sanguisuga Not Infected 22 – 2

T. sanguisuga Infected 3 12.0 1

Totals 39 7

Medina Kennel T. gerstaeckeri Not Infected 9 – 4

T. gerstaeckeri Infected 10 52.6 10

T. lecticularia Not Infected 1 –

T. sanguisuga Not Infected 4 –

Totals 24 14

TSA Puppy 

Kennel

T. gerstaeckeri Not Infected 2 – 2

T. gerstaeckeri Infected 3 60.0 3

Totals 5 5

Totals of tested specimens 113 31

TSA indicates US Transportation Security Administration.

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THE ARMY MEDICAL DEPARTMENT JOURNAL

COMMENT

This study provided an updated status on the distribution and infection prevalence of triatomine species on 3 

military installations in San Antonio, TX. Pippen12 conducted the last comprehensive Chagas disease survey of 

this kind in the 1960s. From 1965 to 1966, Pippen conducted an extensive Chagas disease study on Lackland 

Air Force base. He collected over 386 specimens using 

2 collection methods: wood rat dwelling inspection and 

black light trapping.12 Pippin inspected 142 wood rat 

dwellings and collected 229 triatomines, of which the 

majority were T. sanguisuga and T. gerstaekeri nymphs. 

Of the specimens collected from the wood rat dwellings, 

30% were infected with T. cruzi like organisms. While T. 

sanguisuga nymphs were the most prevalent specimens 

collected, T. gerstaekeri nymphs had a higher infection 

rate for T. cruzi.

12

The triatomine distribution in our study was similar to 

Pippins’ results. However, infection rates were different. 

This difference was most likely due to variance of collection techniques. While Pippin concentrated on wood 

rat dwellings, the majority of our specimens were collected inside the dog kennels (Figure 3). This collection 

technique appeared to be biased for adult specimens. 

Immature kissing bugs were never observed during collection at the kennel sites. Based on observed triatomine 

activity in the wood line near the kennels, we believe 

that adult kissing bugs fl ew to the kennels to feed. Furthermore, environmental conditions (short grass, roads 

between wood lines, and kennel daily cleaning regimen 

with high pressure water) at the kennel are not conducive for the establishment of triatomine colonies. Our 

results are similar to recent studies conducted in other 

areas of Texas.9,12-15 In a study conducted by Kjos et al,14

higher infection rates were observed in dog kennels in a 

domestic setting when compared to sylvan settings.

Our results indicate that the area with the highest T. cruzi infection rate is in and around the military working 

dog kennels. This is consistent with clinical observations at the MWD Center. Dogs observed at the MWD 

Center have exhibited multiple clinical signs. Canines 

affected with Chagas disease develop either acute or 

A

B

Figure 3. Dog kennel habitat at Lackland Air Force Base. 

Panel A, area between backside of dog kennels from where 

live triatomine bugs were frequently collected. Panel B, a 

triatomine bug resting on the concrete wall of a kennel.

Table 2. Distribution of species composition of triatomine bugs collected at 3 US military installations in San 

Antonio, Texas, April to August 2011.

Location Species Number Percentage

Camp Bullis T. gerstaeckeri 26 49.0

T. indictiva 12 22.6

T. lecticularia 1 1.9

T. sanguisuga 14 26.4

Total 53

Ft. Sam Houston T. gerstaeckeri 2 100

Total 2

Lackland Air Force Base

Medina Woods T. gerstaeckeri 13 27.1

T. indictiva 1 2.1

T. sanguisuga 34 70.8

Total 48

Medina Kennel T. gerstaeckeri 25 78.1

T. lecticularia 1 3.1

T. sanguisuga 6 18.8

Total 32

TSA Puppy 

Kennel T. gerstaeckeri 5 100

Total 5

Total Collected 140

TSA indicates US Transportation Security Administration.
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

chronic disease. Generally, dogs develop signs characterized by right-sided heart failure and cardiac arrhythmias.22 Acute myocarditis, such as sudden collapse and 

death of a previously normal dog was observed in one 

case. Other symptoms associated with acute cardiac 

issues include lethargy, pale mucous membranes with 

slow capillary refi ll time, weak pulse, tachyarrhythmias, and respiratory arrest. Additionally, other clinical 

symptoms in dogs that do not die suddenly will exhibit a 

generalized lymphadenopathy, diarrhea, weight loss due 

to anorexia, fever, hepatosplenomegaly caused by the 

right-sided heart failure, ascites, and some neurological 

signs characterized by pelvic limb ataxia.23 Dogs which 

overcome the acute symptoms and become chronic survivors will develop further cardiac issues to include 

arrhythmias which can be exacerbated by exercise or 

hard work on the battlefi eld. As the chronic myocarditis progresses, the heart muscle undergoes a progressive 

cardiac degeneration and dilation. The result is a bilateral enlarged heart with fl accid thin walls that exhibit 

abnormal electrical impulses and arrhythmias on an 

electrocardiograph, along with possible respiratory distress. These cases can often be confused with chronic 

dilative cardiomyopathy observed in other large breeds 

of dogs.

Effective surveillance for Chagas disease vectors is essential for the development of a control program. Few 

studies have been published regarding the ecology of 

North American Triatomines. Most research efforts 

have been conducted in endemic countries (Mexico, 

Guatemala, Brazil, and Peru) in Central and South 

America. Surveillance techniques in these areas yielded 

large numbers of triatomines. This is mainly due to the 

difference in abundance, behavior, and biology. The 

main South American species responsible for Chagas 

A B

C D

2

3

4

1

3

2

1

1

1

Figure 4. Various experimental components of T. cruzi infection procedure. Panel A, an in vitro blood feeding method using a 

hog intestine membrane (1) stretched on a glass feeder (2) and T. gerstaeckri (3) feeding through a netting (4) on defi brinated 

rabbit blood. Panel B, isolation of a blood fed nymph (1) in a cell culture fl ask (2) to obtain infected urine (3) and feces. Panel 

C, (1) contents of an infected midgut showing epimastigote stage. Panel D, (1) actively motile metacyclic trypomastigote stage 

from the feces of an infected triatomine bug.

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THE ARMY MEDICAL DEPARTMENT JOURNAL

transmission (T. infestans (Klug)) was more urban and 

cohabitated with humans. North American species are 

more elusive and mainly sylvatic. The 2 most common 

techniques cited in the literature are light trapping and 

wood rat nest excavation. These two collection methods 

rarely give a reliable indication of population size. 

The wood excavation method was the most effective surveillance technique in this study because we collected 

all life stages for 4 different Triatoma species. During 

the peak of the summer, this method proved to be consistently effective for collecting large numbers of specimens. However, this method is labor intensive and requires skill for habitat acquisition.

Possible oral transmission of Chagas disease poses a 

challenge for the control of Chagas vectors at the MWD 

Center. Conventional pesticide applications would not 

be effective due to the cleaning regimen and could possibly expose the dogs to dead or dying insects. Control 

of the reservoir hosts (rodents) in the woodland habitat 

with rodenticides could lead to secondary poisoning of 

the military working dogs.24,25

A solution to the problem would be the use of a systemic insecticide for the control of the triatomine vectors. 

Systemic insecticides attack insects directly through 

their living food sources without harming the host species, and can be impregnated into a grain bait to treat 

the rodents and any other potential reservoir hosts in the 

wooded areas around the MWD Center. Pesticides with 

low mammalian toxicity are available, and should pose 

no unreasonable threat to the military working dogs.26

Kaput Rodent Flea Control Bait (EPA Reg. No. 72500-

17) is an imidicloprid systemic bait well suited for this 

application. This product can be used in accordance with 

the Federal Insecticide, Fungicide, and Rodenticide Act,27

Section 2ee, by treating the site specifi cally as described 

on the product label.

Field collected specimens were mainly collected in habitats that included hollow logs of different species (live 

A B

C D

Figure 5. Four species of triatomine bugs that were collected during fi eld surveillance. Panel A, T. gerstaeckeri female. Panel B, 

T. sanguisuga female. Panel C, T. lecticularia male. Panel D, T. indictiva male.
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

oak and cedar) and dead dry yucca plants. Triatomines 

were rarely found in rodent nests. The most common 

habitat conditions included a hollow log over or near an 

active rodent burrow. It appeared that the kissing bugs 

entered the nest to feed, and then retreated to harborage for protection. Various arthropods are often found 

cohabitating inside the logs with the kissing bugs (scorpions, wood boring beetles, pill bugs, and centipedes). 

Acorns, rodent droppings, and nesting material were 

also indicators for positive habitat association. If fi re 

ants were present near or in the log or burrow, no kissing bugs were found. 

In summary, Chagas disease continues to pose signifi -

cant health risks to the military working dog population 

in San Antonio. In order to develop an effective control 

method, further research is warranted to understand 

both biology and ecology of local triatomine species.

REFERENCES

1. Chagas C. Nova tripanozomiase humana: Estudos 

sobre a morfologia e o ciclo evolutivo do Schizotrypanum cruzi n. gen., n. sp., ajente etiolójico de nova 

entidade mórbida do homem. Mem Inst Oswaldo 

Cruz. 1909;1:159-218. 

2. Reisenman CE, Lawrence G, Guerenstein PG, 

Gregory T, Dotson E, Hildebrand JG. Infection of 

kissing bugs with Trypanosoma cruzi, Tucson, Arizona, USA. Emerg Infect Dis. 2010;16(3):400-405.

3. Wendel S. Transfusion-transmitted Chagas disease. 

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4. Gürtler RE, Segura EL, Cohen JE. Congenital 

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5. Nobrega AA, García MH, Tatto E, Obara MT, 

Costa E, Sobel J, Araujo WN. Oral transmission of 

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Brazil. Emerg Infect Dis. 2009;15(4):653-655.

6. Chagas disease after organ transplantation–United States, 2001. MMWR Morb Mortal Wkly Rep. 

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7. Kun H, Moore A, Mascola L, et al. Chagas transmission of Trypanosoma cruzi by heart transplantation. Clin Infect Dis. 2009;48(11):1534-1540.

8. Dias JC, Schofi eld CJ. The evolution of Chagas disease (American trypanosomiasis) control after 90 

years since Chagas discovery. Mem Inst Oswaldo 

Cruz. 1999;94(suppl1):103-121.

9. Beard CB, Pye G, Steurer FJ, et al. Chagas disease 

in a domestic cycle in Southern Texas, USA. Emerg 

Infect Dis. 2003; 9(1): 103-105.

10. Herwaldt BL, Grijalva MJ, Newsome AL, et al. Use 

of polymerase chain reaction to diagnose the fi fth 

reported US case of autochthonous transmission of 

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11. Woody NC, Woody HB. American trypanosomiasis (Chagas disease); fi rst indigenous case in the 

United States. JAMA. 1955;159:676-677.

12. Pippin WF. The biology and vector capability of 

Triatoma sanguisuga Texana Usinger and Triatoma 

gerstaeckeri (Stal) compared with Rhodnius prolixus (Stal) (Hemiptera: Triatominae). J Med Entomol. 1970;7(1):30-45.

13. Burkholder JE, Allison TC, Kelly VP. Trypanosoma cruzi (Chagas) (Protozoa: Kinetoplastida) 

in invertebrate, reservoir, and human hosts of the 

lower Rio Grande Valley of Texas. J Protozol.

1980;66:305-311.

14. Kjos SA, Snowden KF, Craig TM, Lewis B, Ronald N., Olson JK. Distribution and characterization 

of canine Chagas disease in Texas. Vet Parasitol. 

2008;152(3-4):249-256.

15. Kjos SA, Snowden KF, Olson JK. Biogeography and Trypanosoma cruzi infection prevalence 

of Chagas disease vectors in Texas, USA, Vector 

Borne Zoonotic Dis. 2009;9(1):41-49.

16. Ricardo MM, Silvia BA, Carlota ME. A mass collection of triatoma ryckmani (Hemiptera: Reduviidae) from Stenocereus eichlamii (Cactaceae) 

in semiarid region of Guatemala. Rev Bio. Trop. 

2004;52(4):931-936.

17. Durvasula RV, Taneja J. Maintenance of the triatomine bugs Rhodnius prolixus and Triatoma dimidiate under laboratory conditions. In: Maramorosch M, Mahmood F, eds. Maintenance of Human, 

Animal, and Plant Pathogen Vectors. Enfi eld, New 

Hampshire: Science Publishers, Inc; 1999:139-157.

18. Rutledge LC, Moussa MA, Belletti CJ. An in vitro 

blood-feeding system for quantitative testing of 

mosquito repellents. Mosq News. 1976;36:283-293.

19. Lent H, Wygodzinsky P. Revision of the Triatominae (Hemiptera, Reduviidae), and their signifi -

cance as vectors of Chagas’ disease. Bull Am Mus 

Nat Hist. 1979;163:123-520. 

20. Ochs DE, Hnilica VS, Moser DR, Smith JH, Kirchhoff LV. Postmortem diagnosis of autochthonous 

acute chagasic myocarditis by polymerase chain 

reaction amplifi cation of a species-specifi c DNA 

sequence of Trypanosoma cruzi. Am J Trop Med 

Hyg. 1996;54(5):526-529.

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TRYPANOSOMA CRUZI AT THREE MILITARY INSTALLATIONS IN SAN ANTONIO, TEXAS
 July – September 2012 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

21. Strum NR, Degrave W, Morel CC, Simpson L. 

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of Trypanosoma cruzi cells by amplifi cation and 

kinetoplast minicircle DNA sequences: use in diagnosis of Chagas disease. Mol Biochem Parasitol.

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22. Barr SC. American trypanosomiasis. In: Greene 

CE, ed. Infectious Diseases of the Dog and Cat. 3rd 

ed. St Louis, MO: Sanders/Elsevier; 2006:676-681.

23. Barr SC. American trypanosomiasis. In: Greene 

CE, ed. Infectious Diseases of the Dog and Cat. 3rd 

ed. St Louis, MO: Saunders/Elsevier; 2006:676-

681.

24. Godfrey MER. Non-target and secondary poisoning hazards of “second generation” anticoagulants. 

Acta Zoologica Fennica. 1985;173:209-212.

25. Mbise TJ. Control of rodent fl eas using systemic 

insecticides. Int J Trop Insect Sci. 1994;15(2): 235-

239.

26. Metzger ME, Rust MK. Laboratory evaluation of 

fi pronil and imidacloprid topical insecticides for 

control of the plague vector Oropsylla montana (Siphonaptera: Ceratophyllidae) on California ground 

squirrels (Rodentia: Sciuridae). J Med Entomol. 

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27. Federal Insecticide, Fungicide, and Rodenticide 

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AUTHORS

CPT McPhatter is an Entomologist, Environmental 

Health Engineering Division, Public Health Command 

Region South, Fort Sam Houston, TX.

Mr Roachell is an Entomologist, Environmental Health 

Engineering Division, Public Health Command Region 

South, Fort Sam Houston, TX.

Dr Mahmood is an Entomologist, Environmental Health 

Engineering Division, Public Health Command Region 

South, Fort Sam Houston, TX.

Ms Hoffman is a Medical Laboratory Technician, Diagnostics Division, Public Health Command Region South, 

Fort Sam Houston, TX.

Dr Lockwood, a retired Army Veterinary Corps offi cer, 

is a public health veterinarian consultant in San Antonio, 

TX.

Mr Osuna is a Biologist, Diagnostics Division, Public 

Health Command Region South, Fort Sam Houston, TX.

MAJ Lopez is Chief, Environmental Health Engineering 

Division, Public Health Command Region South, Fort 

Sam Houston, TX.

COL Debboun is Chief, Department of Preventive Health 

Services, Academy of Health Sciences, AMEDD Center 

and School, Fort Sam Houston, TX.

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 identifi ed to 

researchers during searches for relevant information using any of several 

bibliographic search tools, including the NLM’s PubMed service.
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

Routine biosurveillance and outbreak response systems 

are important public health tools which can facilitate 

prevention of infectious diseases through early detection 

and identifi cation of pathogen emergence and mitigation 

of outbreaks through focused and timely response efforts. Rodent-borne zoonoses are a signifi cant cause of 

morbidity and mortality worldwide and rapid recognition is critical to minimizing disease transmission at the 

local level and the spread of pathogens globally.

Leptospirosis is one of the most widespread zoonotic 

diseases in the world.1-3 Genus Leptospira bacteria are 

classifi ed into 17 species and over 200 serovars comprised of pathogenic, opportunistic, and nonpathogenic 

organisms.4 Leptospira are transmitted by infected wild 

and domestic animals with rodents recognized as the 

most signifi cant reservoir. Transmission to humans is by 

contact with infected urine in water, soil, and surfaces 

and through direct contact with infected animals.

The absence of a licensed vaccine against Leptospira

and limitations in leptospirosis diagnostics and treatment drive the need for effi cacious prevention and control. Surveillance of potential sources of Leptospira

transmission serves a valuable role in leptospirosis risk 

assessment. Leptospirosis prevention is dependent on 

control of infected animals and awareness and elimination of contaminated environmental sources. To most 

effi ciently make use of fi nite surveillance resources risk 

assessment activities must be focused on likely transmission foci and the associated environment. Analyses and 

risk assessment conducted in a timely manner is critical 

to effectively implementing prevention and control resources in an outbreak or potential outbreak situation.

Disease outbreaks often occur in developing regions 

and coincide with natural disasters or in war-torn areas. It is under these conditions that rapid disease surveillance, effi cacious risk assessment, and appropriate 

and effi cient use of control resources are most critical. 

However, Leptospira reference methodology by microscopic agglutination test requires up to 3 weeks for culture incubation.5-8 As such, real-time PCR can serve as 

a valuable aid in surveillance and provides promise in 

diagnostics. Rapid and highly sensitive and specifi c molecular-based detection tests have been developed, however, these technologies are designed for use in a fi xed 

laboratory infrastructure and as such are not suitable 

for use under austere and extreme fi eld conditions.7-16

In situations of an underdeveloped, damaged, or totally 

absent infrastructure, disease surveillance must be conducted without access to laboratory facilities, electricity, 

or cold-chain resources. Disruption of transportation 

systems and power grid are some of the obstacles that 

drive the need for mobile and independently operating 

disease surveillance systems.

We have developed a highly sensitive and specifi c, thermal-stable, pathogenic Leptospira species (LPS) PCR 

detection assay formatted for use with mobile, autonomously operating, fi eld-proven, real-time PCR instrumentation.17-20 We describe a fi eld-expedient method for 

A Field-expedient Method for Detection of

 Leptospirosis Causative Agents in Rodents

James C. McAvin, MS

Ampornpan Kengluecha, MS

Ratree Takhampunya, PhD

LTC Jason H. Richardson, MS, USA

ABSTRACT

We have developed a thermal-stable, pathogenic Leptospira TaqMan PCR assay intended to support pathogen 

surveillance in reservoir populations. The assay is packaged specifi cally for use with a portable, ruggedized, 

real-time PCR thermocycler. Limit of detection was established at ≤100 fg (20 organisms). Sensitivity and 

specifi city were 100% concordant with conventional PCR results using a broad test panel of human pathogenic 

and nonpathogenic Leptospira, genetic near neighbors, and clinically signifi cant organisms. In blind testing using a panel (n=50) of pathogenic Leptospira infected and noninfected Rattus species samples, assay sensitivity 

results were 100% concordant with conventional PCR. Tests performed under fi eld conditions using wild-collected rodent kidney extracts demonstrated the mobility of the system. During fi eld evaluation, samples were 

processed and analyzed in 3 hours. Thermal stabilized reagents allowed transportation, storage, and analyses 

under ambient temperatures. The system provides a promising aid in leptospirosis control programs.
 July – September 2012 23

sensitive and specifi c detection of leptospirosis causative agents in rodents.

MATERIALS AND METHODS

Study Site. Field-evaluation was conducted at Buri Ram 

Province (14° 33′ 30′′ N, 102° 55′ 30′′ E), Thailand, 16 to 

20 August 2010. The LPS PCR assay, nucleic acid preparation reagents, and PCR instrument were transported, 

stored, and sample preparation and analyses conducted 

under ambient temperature (25°C to 33°C) and humidity 

(80%-100%) conditions. Staff and equipment and supplies were transported by a van to the fi eld site. The fi eld 

laboratory was set up and system operations confi rmed 

within 2 hours. The laboratory was established in a single room of a building without environmental control 

using 2 tabletops (each approximately 1 m2

). Sample 

preparation and analyses were conducted without provisions for spatial separation or containment.

Wild-caught Rodents. Field-evaluation of the LPS assay 

in vivo sensitivity was conducted using a test panel of 

wild-caught rodent kidney tissue extracts (n=36). Sampling was conducted for 2 nights in the rice fi eld and 

forest around the rural villages in 3 study sites (Chamni 

(14° 47′ 18′′ N, 102° 50′ 30′′ E), Khu Mueng (15° 16′ 18′′

N, 103° 0′ 6′′ E), Lahan Sai (14° 24′ 42′′ N, 102° 51′ 36′′

E) districts of Buri Ram province). In each site, rodent 

habitats were identifi ed, and small wire live-traps (14 

cm wide, 14 cm high, 30 cm long) specially fi tted for rodents were set. A mixture of banana and snail was used 

for bait. The traps were placed in the evening (between 

4 PM and 5 PM) and collected early the following morning (7 AM to 8 AM). Captured rodents were euthanized by 

carbon dioxide overdose.21 Rodent kidneys and spleens 

were aseptically removed and extract prepared as described below. Rattus rattus was the most prevalent species (subspecies identifi cation was not made). Sample 

extracts were transported on dry ice from the fi eld site 

to the Armed Forces Research Institute of Medical Sciences laboratory for confi rmation testing using a well 

established Leptospira gyrase subunit B conventional 

PCR assay.15 All animal activities were approved by the 

Institutional Animal Care and Use Committee and conducted in an Association for Assessment and Accreditation of Laboratory Animal Care International (Frederick, MD) accredited facility and in compliance with 

the Animal Welfare Act (7 USC §§ 2131-2156) and other 

federal statutes and regulations involving animals.

Preparation of Nucleic Acid Extract. Total nucleic acid 

extracts were prepared from bacterial cultures, viral 

cultures, and rodent kidney and spleen tissues using 

QIAamp DNA Mini kit, QIAamp viral RNA Mini kit 

(QIAGEN Inc., Valencia, CA), and DNA preparation 

kit (Wizard Genomic DNA Purifi cation Kit (Promega 

Corp, Wisconsin)) respectively. Leptospira DNA was 

quantifi ed using the Qubit fl uorometer (Life Technologies, Grand Island, NY) following the manufacturers’ 

instructions. Extracts were stored at -70°C.

Design of PCR Probe and Primer Oligonucleotides. The 

LPS TaqMan PCR assay primer and probe oligonucleotide sequences may be requested from the primary 

author. Oligonucleotides were designed de novo by eye 

targeting a 132 base pair (bp) sequence of the gene encoding Leptospira interrogans serogroup Australis major outer membrane protein (lipl32); GenBank accession 

number: AY609325.1. Oligonucleotide sequences of human pathogenic Leptospira species were selected considering the following guidelines:

 amplicon length=75-150 bp

 oligonucleotide length=18-30 bases

 guanine and cytosine content=30%-80%

 primer melting temperature (Tm)=63°C to 67°C

 probe Tm 8°C to 10°C higher than primer Tm

 probe placement relative to primers (proximal)

 avoidance of runs of identical nucleotides to prevent 

mismatching and nucleotide complementarities to 

prevent secondary structure (hairpin-loop) formation and oligonucleotide dimerization.

Melting temperatures were quantifi ed and the absence of 

signifi cant secondary structure formation and dimerization were confi rmed with PrimerExpress software (PE 

Applied Biosystems, Foster City, California). Primer 

and probe sequence heterology with genomic sequences 

of closely related species through diverse genera were 

validated by BLAST (Basic Local Alignment Search 

Tool) database search.23 Primer and probe synthesis and 

quality control were conducted by a commercial vendor 

(Idaho Technology, Inc, Salt Lake City, Utah). The TaqMan probe contained 2 fl uorigenic labels, a 5′ reporter 

dye (6-carboxyfl uorescein (FAM)) and a 3′ quencher dye 

(6-carboxytetramethylrhodamine (TAMRA)) (Roche 

Molecular Diagnostics, Pleasanton, California).24,25

Polymerase Chain Reaction. Wet reagent LPS PCR assay 

optimization was conducted on the “Ruggedized” Advanced Pathogen Identifi cation Device (R.A.P.I.D.) (Idaho Technology, Inc (ITI), Salt Lake City, Utah). Primers 

and probe were optimized with R.A.P.I.D. wet reagents 

and the optimum condition was 5 mmol/L MgCl2

, 400 

nmol/L primers, 100 nmol/L probe. The master mix 

contained LPS 400 nmol/L forward and reverse primers, 

100 nmol/L TaqMan probe, 200 μmol/L each dNTP, 5 

mmol/L MgCl2

, 1PCR buffer, 1stabilization buffer, 

and Taq Polymerase:Ab: Enzyme diluent (1:1:10.5).
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

The optimal LPS PCR master mix formula was used for 

LPS assay preparation and production conducted by an 

ITI proprietary process. Freeze-dried LPS PCR master 

mix reagents only required hydration and addition of 

sample template prior to analysis. Assays were prepared 

according to the manufacturer’s (ITI) instructions. A 

positive template control reaction was prepared using L 

interrogans serovar Bangkok at a total concentration of 

1 pg template. Negative template control reactions were 

prepared using PCR grade water. A R.A.P.I.D. standardized PCR thermal cycling protocol consists of an initial 

DNA denaturation at 95°C for 3 minutes, and PCR for 

45 cycles at 95°C for 0 seconds for template denaturation (sinusoidal temperature cycling) and 60°C for 20 

seconds of combined annealing and primer extension.

Linearity and Limit of Detection. The linearity of the 

LPS freeze-dried assay was assessed in order to determine the amplifi cation effi cacy and effi ciency of the 

PCR. These data were used to estimate limit of detection (LOD). The estimated value served as the starting 

point for further evaluation of LOD by replicate sample 

test. The correlation coeffi cient (R2

) of standard DNA 

concentrations was used to establish linearity. The slope 

was used to calculate amplifi cation effi cacy and effi ciency using the formulas:

Effi cacy=-1+10(-1/slope) Effi ciency=10(-1/slope)

The LOD was estimated using a standard curve produced by plotting critical threshold (Ct) values versus 

the logarithm of serial dilutions of L borgpetersenii serogroup Ballum serovar Ballum at 10 ng to 1.0 fg genomic DNA per reaction volume. The Ct values of each 

log DNA concentration were measured in 2 replicates. 

Least-squares regression analysis (performed by the 

R.A.P.I.D. software) plotted Ct as a function of DNA 

concentration. The R.A.P.I.D. software automatically 

calculated “best-fi t” of the regression and a standard 

curve was established, the linear relationship between 

ΔPCR cycle number and ΔDNA concentration. The R2

value was automatically adjusted near or at unity by the 

R.A.P.I.D. software.

The LOD was estimated as the template concentration 

at the lowest Ct value above background. The estimated LOD was used to conduct replicate sample testing 

(n=20). Replicate sample testing was conducted by 3 

operators.

Rodent extracts and Leptospira Reference Strains. A 

test panel of well characterized rodent kidney extracts 

from sample archives was prepared consisting of 30 

pathogenic Leptospira infected tissue extracts and 

20 noninfected extracts. Kidney tissue extracts were 

previously prepared and confi rmed positive for pathogenic Leptospira species by Leptospira gyrase subunit 

B conventional PCR.8

 Extracts were archived at -70°C. 

Prior to LPS assay sensitivity testing, template quality 

was confi rmed using Leptospira gyrase subunit B conventional PCR.

Validation testing of LPS PCR assay sensitivity and 

specifi city were conducted using a diverse panel of 24 

reference serovars of Leptospira species consisting of 

22 pathogenic and 2 nonpathogenic serovars (Table 1). 

Reference strains were obtained from the Department of 

Leptospirosis Laboratory, National Institute of Animal 

Health, Thailand. Cultures were grown in Ellinghausen-McCullough-Johnson-Harris medium (Difco Laboratories, Detroit, Michigan) and maintained by weekly 

subculture at 30°C following established methodology.22 Reference sample quality was confi rmed using 

Leptospira gyrase subunit B conventional PCR.

Non-Leptospira Organisms: Specifi city Test Panel.

Specifi city testing included a panel of a well characterized nucleic acid extracts consisting of non-Leptospira

genetic near neighbors, clinically signifi cant organisms, 

and R. rattus and human DNA (Table 2). Organisms 

harboring RNA genomes underwent reverse transcription to produce genomic cDNA for testing. The intent 

of cDNA testing was to confi rm exclusion of potential 

laboratory introduced crossover contaminates.

Data Analysis. Sample identifi cation and specifi cations 

were entered electronically in the R.A.P.I.D. operating 

system run protocol. Analyses and results were automatically archived. The criterion for a positive result 

was a signifi cant increase in fl uorescence over background levels, ie, Ct, defi ned by an algorithm provided 

in the R.A.P.I.D. analytical software. The Ct is defi ned 

as the fi rst PCR cycle with signifi cant fl uorescence when 

normalized against background fl uorescence. Samples 

with a Ct of ≥40 were considered negative, while samples with a mean Ct of <40 were considered positive by 

R.A.P.I.D. analyses.

RESULTS

Linearity. Linear regression analyses of the LPS freezedried assay using L borgpetersenii serovar Ballum concentrations ranging from 10 ng to 1 fg of total nucleic 

acid (2 replicates for each of eight 10-fold dilutions) 

demonstrated the robustness of the assay. Amplifi cation 

was linear from 10 ng to 100 fg of template concentration. Slope and best fi t of correlation coeffi cient (R2

) and 

error values were performed automatically by regression analyses software included in the software package of the R.A.P.I.D. operating system. Linearity was 

A FIELD-EXPEDIENT METHOD FOR DETECTION OF LEPTOSPIROSIS CAUSATIVE AGENTS IN RODENTS
 July – September 2012 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

quantifi ed at slope=3.378, R2=1.00, and error=0.0613. 

Leptospira interrogans serovar Bangkok positive template control (PTC) reaction prepared at 1 pg concentration reported fl uorescence at an average Ct value of 

31.85 corresponding with L borgpetersenii serovar Ballum 1 pg concentration average Ct value of 32.03.

Limit of Detection. The LOD was estimated at ≤100 fg or 

≤20 genome equivalent (ge) based on linear regression 

analyses results. A total of 60 replicate 

R.A.P.I.D. runs at 100 fg concentration L borgpetersenii serovar Ballum 

total nucleic acid template established 

the LOD at ≤100 fg (20 ge). Three operators running 20 replicates reactions 

each over a 2-day period achieved a 

replicate test score of 100% (60/60). 

Operator 1 mean (μ) Ct values were 

35.02, SD=0.51, and percent coeffi cient 

of variation values (CV%)=1.45 where 

n=20, SE=0.11 and 95% confi dence 

interval (CI)=34.80-35.24. Operator 2 mean Ct values 

were μ=35.38, SE=0.75, and CV%=2.11 where n=20, 

SE=0.17, and 95% CI=35.05-35.71. Operator 3 mean Ct

values were μ=35.61, SE=0.63, and CV%=1.76 where 

n=20, SE=0.14, and 95% CI=35.33-35.89.

Sensitivity and Specifi city Testing. In LPS assay sensitivity and specifi city testing with Leptospira reference 

strains, sensitivity and specifi city results were 100% 

Table 2. Results of negative control testing.

Species LPS 

Results

Human blood Negative

Rodent blood (Rattus rattus) Negative

Escherichia coli Negative

Shigella fl exneri Negative

Shigella sonnei Negative

Pseudomonas aeruginosa Negative

Klebsiella pneumoniae Negative

Enterobacter aerogenes Negative

Staphylococcus aureus Negative

Staphylococcus typhimurium Negative

Streptococcus pyogenes Negative

Bartonella doshiae Negative

Plasmodium falciparum Negative

Plasmodium vivax Negative

Japanese Encephalitis Virus (cDNA) Negative

West Nile Virus (cDNA) Negative

Tembusu Virus (cDNA) Negative

Dengue Virus Serotype 1 (cDNA) Negative

Dengue Virus Serotype 2 (cDNA) Negative

Dengue Virus Serotype 3 (cDNA) Negative

Dengue Virus Serotype 4 (cDNA) Negative

Table 1. Reference strains tested by Leptospira pathogenic spp (LPS) PCR

Serogroup Serovar Strain LPS Results*

(mean Ct)

†

Pathogenic L. interrogans

Australis Bratislava Jez Bratislava 35.44

Autumnalis Autumnalis Akiyami A 33.82

Australis Bangkok Bangkok-D92 34.50

Bataviae Bataviae Swart 35.36

Canicola Canicola Hond Utrecht IV 35.47

Djasiman Djasiman Djasiman 35.31

Hebdomadis Hebdomadis Hebdomadis 36.22

Icterohaemorrhagiae Icterohaemorrhagiae RGA 35.18

Pomona Pomona Pomona 35.12

Pyrogenes Pyrogenes Salinem 35.16

L. borgpetersenii

Ballum Ballum RATTUS SP 127 34.32

Javanica Javanica Veldrat Bataviae 46 34.89

Mini Mini Sari 34.09

Sejroe Sejroe M84 35.33

Tarassovi Tarassovi Perepelitsin 35.50

L. kirschneri

Cynopteri Cynopteri 3522 C 35.06

Grippotyphosa Grippotyphosa Moskva V 34.25

L. noguchii

Louisiana Louisiana LSU 1945 34.82

Panama Panama CZ 214 34.99

L. weilii

Celledoni Celledoni Celledoni 34.77

L. santarosai

Shermani Shermani 1342 K 35.67

L. inadai

Manhao Manhao Li 130 38.23

Nonpathogenic L. bifl exa

Semaranga Patoc Patoc I Negative 

Andamana Andamana CH 11 Negative 

L. meyeri

Ranarum Ranarum ICF Negative 

*Pathogenic Leptospira sample population (n=22) mean Ct=35.16, SD=0.89, CV%=0.78.

†Leptospira strain mean Ct value represents duplicate testing at the LOD concentration (100 fg).
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

concordant with Leptospira gyrase B conventional PCR 

analyses. (Table 1). Twenty-fi ve Leptospira reference 

strains consisting of 22 pathogenic serovars were positive by LPS assay analyses and 3 nonpathogenic serovars 

did not report fl uorescence above background. All samples were tested in duplicate at a DNA concentration of 

100 fg (1LOD). Pathogenic Leptospira sample population Ct values were μ=35.16, SD=0.89, and CV%=0.78 

where n=22, SE=0.19, and 95% CI=34.79-35.53. Nonpathogenic serovars from the panel tested at 1 pg and 

100 pg DNA concentrations (100 and 1000LOD) 

reported no fl uorescence above background. Inhibition 

of PCR was not observed at 100 pg DNA concentration 

(1000LOD) using 3 pathogenic Leptospira serovars: 

L interrogans serogroup Australis serovar Bangkok 

(Ct=15.98), L interrogans serogroup Australis serovar 

Bratislava (14.34), and L weilii serogroup icterohaemorrhagiae serovar Sarmin (Ct=33.29). A single anomalous 

result occurred, L weilii serovar Sarmin was detected at 

1 pg (Ct=39.62) but did not report fl uorescence at the 100 

fg LOD level. This result was not included in the statistical analyses because L weilii serovar Sarmin sequence is 

100% homologous with primer and probe sequences and 

as such probable experiment error is under assessment.

Archived and wild-captured rodent kidney tissue extracts tested by the LPS assay demonstrated 100% 

sensitivity compared to the Leptospira gyrase subunit 

B conventional PCR assay (Table 3). Using a test panel of 50 archived rodent tissue extracts, 30 Leptospira

infected extracts were positive by LPS assay analyses 

and 20 noninfected extracts did not report fl uorescence 

above background (Table 3). Sample preparation and 

blind testing were conducted under controlled laboratory conditions. Leptospira infected rodent extract Ct

values were μ=29.50, SD=3.31, and CV%=10.98 where 

n=30, SE=0.60, and 95% CI=28.32-30.68.

In fi eld evaluation using a test panel of 36 wild-captured 

rodent tissue extracts, 4 Leptospira infected extracts 

were positive by LPS assay analyses and 32 noninfected 

extracts did not report fl uorescence above background 

(Table 3). Sample preparation and testing were conducted under fi eld conditions. Wild-captured rodent extract 

Ct values were μ=34.34, SD=4.83, and CV%=23.36 

where n=4, SE=2.42, and 95% CI=29.61-39.07.

Specifi city Testing Using Negative Control Organisms.

Specifi city of the LPS assay was 100% concordant with 

a diverse panel of well characterized non-Leptospira

organisms (Table 2). No cross-reaction occurred with 

human or Rattus species undiluted extracts from blood 

or kidney tissue, respectively. Ten common infectious 

disease agents and Total nucleic acid extract from 10 

infectious disease agents and cDNA prepared from 7 

viruses were tested at a concentration of 1000LOD. 

No fl uorescence above background was observed for all 

non-Leptospira organisms tested.

Throughout laboratory validation testing and fi eld 

evaluation, PTC reactions reported fl uorescence at the 

expected Ct value (≈32) and negative template control 

reactions did not report fl uorescence above background.

COMMENT

Our results clearly show that the LPS assay is a robust, 

portable, highly sensitive, and specifi c test for the detection of pathogenic Leptospira species In evaluation 

with Leptospira infected rodent kidney extracts, the assay proved to be sensitive with no false negative or false 

positive results. The stability of the assay was evidenced 

by the reproducibility of PTC results. Use of the assay 

with the R.A.P.I.D. provided a highly mobile, standalone, real-time PCR analytic system for fi eld-deployed 

rodent surveillance. During fi eld evaluation, the system 

was confi gured and normal operations confi rmed in 

less than 2 hours. Sample processing and analyses were 

completed in less than 3 hours. The system is unique in 

its ability to fi ll an important public heath role as it provides rapid pathogenic Leptospira detection capability 

under austere and extreme operating conditions.

Targeting transmission risk areas and identifying preventable conditions help focus control resources. Correctly collected and interpreted data on rodent infection rate and prevalence of contaminated environment 

integrated with other key transmission indicators such 

as confi rmed leptospirosis cases (where epidemiological 

data is available), virulence of the circulating Leptospira

serovar, rodent infestations and population densities, reproduction rate, terrain and climatic conditions, provide 

for effi cacious transmission risk assessment. These data 

collected in a spatially focused and expedient manner, 

augment the predictive power of fi eld surveillance allowing decision makers to dedicate control resources 

for focused application of animal abatement measures, 

treatment of habitat, and increased public awareness. 

The value of animal and environmental surveillance is 

enhanced by fi eld-expedient detection capability.

Limitations in leptospirosis diagnostics must be addressed. Achieving a defi nitive diagnosis across both the 

acute and immune phases of leptospirosis is challenging because clinical symptoms are easily confused with 

those of other common diseases.5,26 The treatment of leptospirosis can be enhanced by rapid and highly sensitive 

diagnostics.5

 Antibiotics are most effective when started 

by day 5 of disease onset and as such early diagnosis 

A FIELD-EXPEDIENT METHOD FOR DETECTION OF LEPTOSPIROSIS CAUSATIVE AGENTS IN RODENTS
 July – September 2012 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

would be benefi cial in the treatment of leptospirosis.4

However, while rats may shed up to 108 spirochetes per 

ml of urine, leptospirosis patient sample concentrations 

present challenges in detection limit. The presence of 

Leptospira organism/DNA can vary from very low to 

high levels during the acute (2-7 days) and immune (0-30 

days) phases of the disease depending on the seriousness 

of the infection.27 Patient urine sample concentration of 

Leptospira ranges from 102

 to 104 spirochetes per ml and 

the asymptomatic urinary range is 101

 to 103 spirochetes 

per ml.28 Blood sample concentration of Leptospira

ranges from 101

 to 105 spirochetes per ml.29 Diagnosis 

of leptospirosis is usually retrospective because of the 

length of the time required for diagnosis by microscopic 

agglutination test (MAT) reference methodology.5-8 The 

MAT and other agglutination-based tests have been developed for more rapid and convenient diagnostics, however, these methods have limitations in specifi city.30 An 

approved molecular-based human diagnostic test does 

not currently exist that does not require confi rmation 

testing by Leptospira isolation and culture. Molecularbased methodologies describing direct detection from 

clinical samples are not currently well represented in 

the literature. It is our intent to transition the LPS assay 

to human diagnostic use. We will address challenges in 

achieving effi cacious PCR-based leptospirosis diagnostics by enhancing the high sensitivity and specifi city of 

the LPS assay procedurally, adapting specialized protocols to concentrate patient samples, and the development 

of extraction and PCR internal positive controls.

Our results show that the LPS TaqMan assay is a fi eldexpedient method for sensitive and specifi c detection of 

leptospirosis causative agents in rodents.

ACKNOWLEDGEMENTS

Thanks to Stuart Tyner and Panita Gosi, Department of 

Immunology, Armed Forces Research Institute of Medical Sciences (Bangkok) for providing samples and support in testing.

This work was funded by the Military Infectious Diseases Research Program, US Army Medical and Materiel Research Command, Fort Detrick, Maryland. The 

joint efforts of the Departments of the Army and Air 

Force were conducted through the Walter Reed Army 

Institute of Research and the USAF 59th Medical Wing 

Memorandum of Agreement.

DISCLAIMER

Reference to trade name, vendor, proprietary product or 

specifi c equipment is not an endorsement, a guarantee or a 

warranty by the Department of the Defense or US Armed 

Forces, and does not imply an approval to the exclusion of 

other products or vendors that also may be suitable.

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Table 3. Results of rodent kidney tissue testing

Samples No.

Samples 

No.

True Pos 

No.

True Neg LPS PCR Sensitivity gyrB PCR Sensitivity 

Archived rodent extract* 50 30 20 100% (30/30+0)(100%) 100% (30/30+0)(100%)

Wild-captured rodents† 36 4 32 100% (4/4+0)(100%) 100% (4/4+0)(100%)

*Archived rodent extract (n=30) mean Ct=29.5, SD=3.31, CV%=10.98.

†Wild-captured rodent extract (n=4) mean Ct=34.34, SD=4.83, CV%=23.36.
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

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20. Swaby JA, McAvin JC. Support of far-forward disease surveillance operations with deployable, realtime vector-borne disease agent analytic capability. 

Army Med Dept J. April-June 2008:21-24.

21. Agudelo-Flórez P, Londoño AF, Quiroz VH, Ángel 

JC, Moreno N, Loaiza ET, et al. Prevalence of Leptospira spp. in urban rodents from a groceries trade 

center of Medellín, Colombia. Am J Trop Med Hyg. 

2009;8:906-910.

22. Cole JR Jr, Sulzer CR, Pursell AR. Improved microtechnique for the leptospiral microscopic agglutination test. Appl Microbiol. 1973;25:976-980.

23. Altschul SF, Gish W, Miller W, Myers EW, Lipman 

DJ. Basic local alignment search tool. J Mol Biol. 

1990;215:403-410.

24. Wittwer CT, Herrmann MG, Moss AA, Rasmussen RP. Continuous fl uorescence monitoring of 

rapid cycle DNA amplifi cation. Biotechniques. 

1997a;22:130-131, 134-138.

25. Wittwer CT, Ririe KM, Andrew RV, David DA, 

Gundry RA, Balis UJ. The LightCycler: a microvolume multisample fl uorimeter with rapid temperature control. Biotechniques. 1997b;22:176-181.

26. Medeiros FR, Spichler A, Athanazio DH. Leptospirosis-associated disturbances of blood vessels, 

lungs and hemostasis. Acta Trop. 2010;115:155-162.

27. Wilson W, Sande M. Current Diagnosis & Treatment in Infectious Diseases. New York: Lange/

McGraw-Hill Professional Publishing; 2001.

28. Ganoza CA, Matthias MA, Saito M, Cespedes M, 

Gotuzzo E, Vinetz JM. Asymptomatic renal colonization of humans in the Peruvian Amazon by 

Leptospira. PLoS Negl Trop Dis. 2010;23:e612.

29. Bourhy P, Collet L, Clément S, Huerre M, Ave P, 

Giry C, Pettinelli F, Picardeau M. Isolation and 

characterization of new Leptospira genotypes 

from patients in Mayotte (Indian Ocean). PLoS 

Negl Trop Dis. 2010;22:e724.

30. Faine S, Adler B, Bolin C, Perolat P. Leptospira 

and Leptospirosis. 2nd ed. Melbourne, Australia: 

MediSci; 1999. 

AUTHORS

Mr McAvin is a Molecular Biologist with the 59th Medical 

Wing, Lackland Air Force Base, Texas, temporarily 

assigned to the Armed Forces Research Institute of 

Medical Sciences (AFRIMS), Bangkok, Thailand.

Ms Ampornpan is a Medical Research Technologist 

in the Diagnostic and Reemerging Diseases Section, 

Entomology Department, AFRIMS, Bangkok, Thailand.

Dr Ratree is Chief of the Molecular Biology Section, 

Entomology Department, AFRIMS, Bangkok, Thailand.

LTC Richardson is Director, Entomology Branch, Center 

for Infectious Disease Research, Walter Reed Army 

Institute of Research, Silver Spring, Maryland.

A FIELD-EXPEDIENT METHOD FOR DETECTION OF LEPTOSPIROSIS CAUSATIVE AGENTS IN RODENTS
 July – September 2012 29

Since 2001, the United States has been engaged in Operation Enduring Freedom (OEF) in Afghanistan. Although vector-borne disease in Afghanistan does not 

present as high a risk in comparison to other areas into 

which the US military deploys, such as sub-Saharan Africa, it does present suffi cient risk to adversely impact 

military operations. This article discusses the growth 

and state of US military entomological support to the 

Afghan theater of operations (ATO).

ENTOMOLOGICAL SUPPORT TO THE 

AFGHAN THEATER OF OPERATIONS

Providing entomological support to the Afghanistan theater of operations presents unique challenges to preventive medicine personnel, similar to those experienced 

in Iraq. Military and civilian infrastructure throughout 

the country remains poor, despite signifi cant buildup 

and investment since 2001. Ground logistic routes are 

limited and security concerns often restrict movement 

not essential to direct support of combat operations and 

sustainment. Access to many US military camps in Afghanistan is primarily by air, and a number of locations 

are accessible only by air. Transporting equipment and 

pesticides further complicates the challenge of this operational reality. Consistent and comprehensive vector 

surveillance and disease reporting were improved over 

the years, however, coordination and oversight are required to identify pest and vector issues.

As a result of its diverse topography and climate, Afghanistan experiences signifi cant variation in pest and vector 

issues. Each vector-related problem presents unique challenges that require careful coordination between base 

operations, preventive medicine (PM), and contracted 

vector control assets. Mosquito and sand fl y populations 

are regional and seasonal. Other pest problems, such as 

bed bugs, fl eas, wood infesting insects, fl ies, and rodents, 

are also relatively common in Afghanistan.

Over the past decade, entomological support to OEF has 

been fulfi lled jointly, with the US Army and US Navy 

providing most of the support. Until 2010, there were 

generally one or 2 Army PM detachments operating in 

Afghanistan at any given time. In addition to the medical 

entomologists with the PM detachments, there was also 

an Army or Navy entomologist assigned to the cooperative medical assistance (CMA) unit that dealt with 

various medical issues among the Afghan population. 

US forces were heavily focused in the eastern provinces 

of Afghanistan. One PM detachment generally operated split-based operations between Bagram Air Field 

and Forward Operating Base Salerno, while another PM 

detachment provided support to southern Afghanistan.1

The map shown in the Figure displays the regions and 

areas of responsibility across Afghanistan.

As in-theater operations intensifi ed in late 2009 and early 

2010, entomological support across the ATO increased 

as well. In 2009, the Navy fi elded a preventive medicine 

detachment, modeled after an Army PM detachment, to 

Kandahar Air Field, providing level III PM and entomological support (described in the Table) to the southern part of Afghanistan. In early 2010, the 12th Medical 

Detachment moved from Kandahar to western Afghanistan to provide support to that region. The Marine Expeditionary Brigade (MEB) in Helmand Province was 

replaced by a larger Marine Expeditionary Force (MEF) 

in 2010; with one Navy entomologist supporting the 

Regional Command Southwest (RC-SW). The US Air 

Force fi elded a PM detachment based on the Army model that was assigned to conduct split-based operations 

between Kabul and northern Afghanistan. In June 2010, 

the 1st Area Medical Laboratory (AML) was deployed 

to Afghanistan and positioned at Kandahar to provide 

theater-wide level IV PM and laboratory support. Along 

with other scientifi c specialists, the 1st AML deployed 

to Afghanistan with a medical entomologist.

As a result of the rapidly changing requirements for 

preventive medicine and entomological support to US 

forces in Afghanistan, there were 7 US military entomologists in the Afghan theater by midsummer 2010. 

The total included one Air Force entomologist supporting the Kabul area and northern Afghanistan; 3 Army 

entomologists—one supporting eastern Afghanistan, 

one supporting western Afghanistan, one providing 

theater support as part of the 1st AML; and 3 Navy entomologists—one supporting the southern region, one 

Military Entomology in Operation

 Enduring Freedom, 2010-2011

 MAJ Michelle G. Colacicco-Mayhugh, MS, USA CPT Susan Gosine, MS, USA

 LT Tony Hughes, MSC, USN LT Joseph Diclaro, MSC, USN

 LT Ryan Larson, MSC, USN LT James Dunford, MSC, USN
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

supporting the southwestern region, and one working 

with the CMA to support counterinsurgency operations 

by providing entomological training to local nationals, 

Afghan medical personnel, and the Afghan National 

Army.

Prior to the autumn of 2010, the role of the theater entomologist had historically been fi lled as an additional duty 

by the CMA entomologist. This model was established 

because the CMA entomologist was located at Bagram 

Air Field along with primary headquarters elements; for 

several rotations the CMA entomologist was a senior 

entomologist; and there were very few entomologists 

in theater. With the changing requirements of PM and 

entomological support in OEF in 2010, the 62nd Medical Brigade revisited the automatic assignment of the 

theater entomologist duties to the CMA entomologist. 

Ultimately, the determination was made to select the 

theater medical entomologist based on a variety of factors including location in Afghanistan (with a location at 

one of the major airfi elds (Bagram or Kandahar) being 

preferred), rank, and previous deployment experience. 

As a result, the theater entomologist duties moved from 

the CMA entomologist in Bagram to the 1st AML entomologist at Kandahar in late 2010. When the 1st AML 

redeployed from Afghanistan in June 2011, the theater 

entomologist duties moved to the entomologist assigned 

to the 155th Medical Detachment at Bagram Air Field.

ENTOMOLOGICAL SUPPORT TO 

HELMAND PROVINCE

Entomological support to US forces in RC-SW differed 

from support in the rest of the regional commands since 

the preventive medicine support for this region did not 

mirror the Army preventive medicine detachment model used in the other regions. As previously described, 

command and control in RC-SW was transferred from a 

MEB to a MEF in 2010. Therefore, the preventive medicine support to the MEF was provided by the Navy and 

included one entomologist.

Southwestern Afghanistan, including Helmand Province, is largely a desert area with expected temperature extremes, lack of rain, and sparse vegetation. The 

MILITARY ENTOMOLOGY IN OPERATION ENDURING FREEDOM, 2010-2011

The provinces, important cities, military regional commands, and NATO member country responsible for each region across 

Afghanistan.
 July – September 2012 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

Helmand River, which cuts through the province, provides a signifi cant amount of water for irrigation and 

other purposes throughout the region. The river valley 

is also a source of public health signifi cance as the environment supports the presence of Anopheline mosquito 

vectors of malaria.

In 2010 and 2011, there were 2 large bases, Camps Dwyer and Leatherneck, and a number of smaller camps 

across the region. With much of the forces stationed at 

the 2 large camps, and thousands of military personnel 

spread among disparate forward operating bases and 

outposts, there was much ground to cover. The provision of preventive medicine services involved Marine 

and Navy operations within the constraints of a large 

geographic area, inadequate infrastructure, and largescale security concerns.

Prior to 2010, the regional medical entomologist was stationed at Camp Dwyer. In 2010, after careful consideration of how to best support the region, the entomologist 

was moved to Camp Leatherneck, which was the logistics hub of Helmand Province, and the location of both 

the Defense Contract Management Activity (DCMA) 

and Logistics Civilian Augmentation Program activities 

for the region. In addition, the supervisory staff of contracted vector control was also located at Camp Leatherneck. The presence of these important groups in one 

location permitted the entomologist direct communication and increased infl uence regarding pest and vector 

control operations.

One signifi cant operational consideration for Helmand 

Province is availability of transportation. As no formal 

or modern road system exists in the province, air assets are used extensively. Locating the entomologist at 

the air logistics hub provided the capability to travel to 

many areas of the Province in support of contract oversight, large-scale pest problems, or a breakout of vectorborne diseases. It was not feasible to travel around the 

province via convoy for regularly scheduled or reactive 

support. Positioning the entomologist at another forward 

operating base in Helmand Province would have delayed 

response to vector-borne diseases and pest problems.

Camp Leatherneck is also home to the largest Preventive Medicine Detachment in Helmand Province. A very 

important component of providing PM support to Marine forces is the provision of enlisted Navy Preventive 

Medicine Technicians (PMTs). Navy PMTs are broadly 

trained in preventive medicine, including monitoring 

disease and nonbattle injury, water quality/safety, food 

preparation and storage, and pesticide application. There 

are certainly limited resources, particularly available 

environmental health offi cers and entomologists, therefore, PMTs are provided to the Marines at their various 

echelons of command. Although PMTs are certifi ed to 

apply public health pesticides and do receive baseline 

training on pests and vectors, they are not subject matter experts on pesticides, pests, and disease vectors. The 

presence of an entomologist provided synergy to PMT 

efforts, as they could be better directed in the reduction 

of pests and disease vectors. Without question, stationing an entomologist in an area where he or she can train, 

guide, and use PMT resources was important, not only 

in Helmand Province, but throughout the ATO.

MAJOR ENTOMOLOGICAL ISSUES

The entomological issues that faced US forces in Afghanistan during 2010 were not unique, however, the 

rapidly increasing US footprint in the ATO increased 

the risk of vector-borne diseases and other entomological problems among US forces. Anticipating when and 

The levels of preventive/environmental medicine support, 

compiled by the author from doctrinal publications.2

Preventive 

Medicine 

Support

Defi nition

Level I Support provided by a field sanitation team (FST) at 

the company level. The FST is responsible for establishing basic sanitation measures to prevent 

spread of diseases.

Level II Preventive medicine (PM) personnel at the brigade 

combat team level. Responsibilities include, but 

are not limited to, dining facility inspections, waste 

disposal/treatment facilities, etc; vector surveillance and control; and base camp assessments. 

The level II PM personnel provide direct support to 

the field sanitation teams within their area of operations (AO).

Level III Support provided by PM detachments. Units are typically responsible for areas that can include multiple 

level II preventive medicine units. PM detachments 

provide support to the level I and II preventive medicine assets in their AO. Their duties include, but are 

not limited to, base camp assessments, epidemiological investigations, occupational and environmental health site assessments, industrial hygiene 

surveys, and vector surveillance and control.

Level IV Support provided by the Area Medical Laboratory. 

PM responsibilities of this unit include, but are not 

limited to, supporting levels I – II preventive medicine as needed; testing samples for toxic industrial 

chemicals and materials; performing industrial hygiene surveys; performing epidemiological investigations; and performing vector testing, including 

pathogen detection and insecticide resistance 

testing.

Level V Support provided by the US Army Public Health Command and the Navy and Marine Corps Public Health 

Center. Responsibilities include, but are not limited 

to, supporting deployed level I – IV preventive medicine personnel; performing definitive testing of air, 

water, and soil samples; and performing vector 

pathogen testing. 
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

where an outbreak of vector-borne disease would occur 

was diffi cult, however, efforts to improve vector surveillance and disease reporting were made in 2010.

Vector Surveillance

From the onset of operations in the Afghanistan theater 

until 2010, the fl uid character of the operational environment and frequently shifting resource availability 

resulted in variations in the practice of vector surveillance across the ATO. In some areas, notably Regional 

Command North and Regional Command East, the level 

II PM personnel made efforts to conduct surveillance 

and submitted both sand fl ies and mosquitoes to the 

US Army Public Health Command (USAPHC) Region 

Europe for analysis. However, the majority of level II 

PM assets in theater did not conduct vector surveillance. 

Vector surveillance was typically performed by level III 

PM assets. However, in the absence of guidance as to 

the conduct of surveillance and what to do with insects 

that were collected, only about half of the level III PM 

units submitted specimens to USAPHC for analysis during the summer of 2010.

In an effort to ensure that vector surveillance was conducted properly and samples were submitted for laboratory analysis, a formal vector surveillance and testing 

program for US Forces Afghanistan (USFOR-A) was 

established in late spring 2011. Under this plan, the entomologists embedded with the level III PM units in each 

region were responsible for overseeing vector surveillance in their region and providing technical assistance as 

needed to level II preventive medicine units conducting 

vector surveillance. Sand fl ies, mosquitoes, and ectoparasites were submitted to the USAPHC for disease analysis, 

with results reported to the regional entomologists, the 

theater entomologist, and the clinical operations section 

of the medical task force for the ATO. While USAPHC 

(and its predecessor) had been conducting pathogen testing for vectors collected in the US Central Command 

(CENTCOM) area of operations for several years, formalization of the vector surveillance program in 2011 

was necessary to ensure that units across theater were 

properly collecting and submitting vectors for testing.

Vector-borne Diseases

Cutaneous leishmaniasis (CL) remains a signifi cant 

cause of disease and injury among US service members 

deployed to Afghanistan. In 2010 and 2011, CL was diagnosed among US forces primarily located in Regional 

Command South and Regional Command North. Cutaneous leishmaniasis in Afghanistan may be zoonotic 

cutaneous leishmaniasis, caused by Leishmania major

(Friedlin), or anthroponotic cutaneous leishmaniasis 

(ACL), caused by L. tropica (Wright).

The majority of CL cases in 2010 and 2011 originated 

from Camp Mike Spann in northern Afghanistan. In 

this region, L. major is the primary cause of CL. NATO 

forces have experienced outbreaks in this area several 

times over the last decade.3

 In this epidemiological cycle, 

the primary vector is Phlebotomus papatasi (Scopoli), 

and the great gerbil, Rhombomys opimus (Lichtenstein), 

serves as the reservoir.4

 The preventive medicine team 

located at Camp Mike Spann in 2010 conducted sand 

fl y surveillance and submitted samples to USAPHC-Europe for analysis. When the results were reported from 

USAPHC-Europe in early 2011, 3 of 74 pools of sand 

fl ies collected between July and September 2010 tested 

positive for Leishmania spp.

In early 2011, two cases of ACL were diagnosed in Soldiers bitten by sand fl ies in the Kandahar City area in the 

summer and fall of 2010. The Soldiers reported sleeping 

on the ground in open structures, not using N,N-diethyl3-methyl-benzamide (deet) regularly, and not using bed 

nets. In both cases, the Soldiers had lesions for several 

months before seeking treatment.

Outbreaks of malaria have been reported periodically 

among US and coalition forces since 2001.5,6 Malaria 

continued to be a problem for US forces in Afghanistan in 2010 and 2011. According to the Armed Forces 

Health Surveillance Center, 58 cases of malaria were 

reported in Afghanistan in 2010, and 91 cases in 2011.7,8

From August through December 2010, approximately 37 

cases of malaria were diagnosed in Regional CommandEast, primarily from the Jalalabad area. During this period, the level II medical treatment facility located at 

Forward Operating Base Fenty collected blood samples 

from patients diagnosed with malaria at the camp. Seventeen samples were taken and both thick and thin blood 

smears were sent to the 1st AML for speciation. Plasmodium vivax (Grassi and Feletti) was the most common (14 of 17) malaria species, however, P. falciparum 

(Welch) was identifi ed from 4 of the cases, including 2 

P. falciparum/P. vivax mixed infections. Most military 

personnel from this region who were diagnosed reported improper use of chemoprophylaxis and/or not using 

appropriate personal protective measures.

In 2010 and 2011, the malaria chemoprophylaxis policy 

for Afghanistan was governed by USCENTCOM Individual Protection and Individual/Unit Deployment 

Policy,* which required all military personnel to take 

MILITARY ENTOMOLOGY IN OPERATION ENDURING FREEDOM, 2010-2011

*Internal, limited distribution military document not readily accessible by the general public.
 July – September 2012 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

prophylaxis year-round, with primaquine for postexposure prophylaxis. Since many areas of Afghanistan experience low winter temperatures, mosquitoes are not 

active year-round. Therefore, a concern was raised in 

late 2010 that the year-round prophylaxis policy was inappropriate. In order to assess the policy and examine 

the real risk of malaria across theater, the 62nd Medical Brigade established a malaria working group in late 

2010. In the spring of 2011, the malaria working group 

recommended that CENTCOM examine changing the 

prophylaxis policy. In late 2011, the recommendation 

was accepted and the prophylaxis policy for Afghanistan was changed to require prophylaxis from March 

through November each year.

Vector Control

In 2010 and 2011, many forward operating bases and 

larger combat outposts in Afghanistan received vector 

control support from contractors. In the smaller locations without contracted vector control, the responsibility for vector control support was assumed by the entomologist assigned to the level III PM unit for the region, 

level II PM assets within the region, and the unit-level 

fi eld sanitation teams, when present and equipped.

Locations with US Contracted Vector Control

Two companies held the contracts for pest control for US 

locations in the ATO in 2010, divided into 2 areas, (1) 

the northern and eastern regions, and (2) the southwestern and western regions. It is important to note that locations that were not under US military control had different pest control contracts which were not subject to the 

USFOR-A Integrated Pest Management Plan (IPMP).*

Communication was one of the major challenges for 

successful pest control in those locations where vector 

control services were provided under a US contract. As 

indicated in the USFOR-A IPMP, military preventive 

medicine assets are responsible for public health vector surveillance, whereas pest control contractors are 

responsible for pest surveillance and large-scale vector 

control. Therefore, communication between those entities is critical in preventing vector-borne diseases among 

US forces. Communication between the pest control 

managers for the 2 contracting companies and the theater entomologist has historically been good. However, 

communication at the local level between PM assets and 

pest controllers can vary widely across the theater. In 

many instances, there was a positive 2-way fl ow of information between local PM and vector control assets. 

At the same time, communication was poor to nonexistent in some instances, leading to delayed vector control 

activities and poor follow-up on the effi cacy of vector surveillance efforts. In order to help mitigate this problem 

and ensure communication, part of the USFOR-A vector 

surveillance plan for 2011 included a clear directive for 

PM units to keep local pest control contractors informed 

of their surveillance results. While this requirement was 

previously outlined as part of the USFOR-A IPMP, mandating it as part of a fragmentary order helped ensure 

that the PM units were aware of this requirement.

Another major challenge for vector control contractors 

in the ATO was movement around the theater, especially when trying to carry pest control equipment and 

chemicals with them as they visited the geographically 

dispersed, smaller forward operating bases and combat 

outposts. To overcome this challenge, contractors wanted to establish pesticide storage facilities at key smaller 

locations to facilitate travel, increasing their ability to 

provide timely pest control services to those locations. 

Unfortunately, the language governing pesticide storage 

in the 2010 USFOR-A IPMP made it diffi cult to establish 

storage facilities at those locations. The 2010 USFOR-A 

IPMP referred to the Armed Forces Pest Management 

Board Technical Guide No. 17 9

 (TG 17) for requirements for pesticide storage facilities. The guidance in 

that publication primarily addresses the storage conditions required in garrison-based operations, outside of 

combat zones. Unfortunately, the space and facility requirements of TG 17 cannot always be met in contingency operations. The consensus of the theater and regional 

medical entomologists in the summer of 2010 was that 

the storage provisions outlined in TG 17 were largely 

impractical for most locations in the ATO.

To address the issue of pesticide storage, the theater entomologist coordinated with other entomologists to review 

the pesticide storage provisions in the 2010 USFOR-A 

IPMP. The 2010 IPMP specifi cally stated:

Permanent or semipermanent pesticide storage facilities 

will comply with design and construction guidance as 

published in the Armed Forces Pest Management Board 

(AFPMB) TG 17.

 In an effort to make the requirements more appropriate for the theater and more attainable for pest control 

contractors, the determination was made that the entire 

pesticide storage section of the USFOR-A IPMP should 

be rewritten. The revised, 2011 IPMP included clearly 

defi ned guidelines for pesticide storage facilities that are 

safe and allow contractors to store a basic load of supplies at smaller locations, increasing their ability to provide timely pest control services. The 2011 IPMP still 

*Internal, limited distribution military document not readily accessible by the general public.
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

refers to TG 17 as a guide, but the language referring to 

this reference was changed considerably to state:

all interested parties should consult the...TG 17...for additional guidance or ideas to improve storage facilities 

based on local and theater conditions.

The 2011 IPMP provided a detailed list of storage condition criteria specifi c for both permanent (larger bases/

installations) and semipermanent (small forward operating bases and combat outposts) storage facilities to 

facilitate timely and effective vector control services 

throughout the ATO.

Locations with NATO Contract Vector Control

There are several locations throughout the ATO where US 

forces live on forward operating bases where contracted 

services, including pest control, are not provided under 

US contracts. At Kandahar Air Field, the largest location 

with a signifi cant number of US forces, the pest control 

contract was managed by the NATO Maintenance and 

Supply Agency. The contractors are not required to comply with the USFOR-A IPMP, which outlines reporting 

requirements and allowable pesticides. While the contractors were not held to the USFOR-A IPMP, they had 

to meet reporting, pesticide use requirements, and quality control procedures outlined in their contract.

In 2010, the US population at Kandahar more than tripled. 

In response to this, the regional entomologist located at 

the Navy PM detachment worked with the contractor to 

foster a strong working relationship, helping to ensure 

that pest control met the spirit of the USFOR-A IPMP. 

An effort was made to ensure the insecticides in use 

were similar in active ingredient and concentration as 

those found on the AFPMB Standard Pesticides List and 

the DoD Contingency Pesticide List. This working relationship continued when the contractors were changed. 

The positive working relationship between the US Navy 

medical entomologist located at Kandahar in the summer of 2010 and the NATO pest control contractors was 

a good model for other locations in Afghanistan where 

similar situations existed.

ENTOMOLOGICAL SUPPORT TO

STABILITY OPERATIONS

Another area where entomologists played a critical role 

in the ATO was their work with organizations and units 

supporting counterinsurgency and stability operations. 

The entomologist assigned to the CMA unit had such responsibilities; however, that position was discontinued 

in mid-2011 due to theater-wide mission changes reducing MEDCAP and VETCAP operations.* The CMA 

entomologist provided training on basic vector surveillance and control techniques, following the “trainthe-trainer” concept, to Afghan nationals and medical 

personnel. The CMA entomologist also worked with 

agribusiness development teams and provincial reconstruction teams on crop pest management and related 

issues. Further, the CMA entomologist, along with regional entomologists, worked with physicians and veterinarians in regional command stability operations, 

the World Health Organization, the Afghan Ministry of 

Public Health, the National Malaria and Leishmaniasis 

Control Program, and various nongovernment organizations working to understand and prevent vector-borne 

diseases among the Afghan population. These organizations represent a wealth of knowledge and have the 

continuity and expertise to track and predict vector and 

disease outbreaks that may impact US forces. Developing and cultivating relationships with nonmilitary governmental and nongovernmental organizations working 

to improve public health across Afghanistan was a signifi cant role for both the CMA and AML entomologists 

in 2010-2011. Despite the loss of both of those positions 

in 2011, efforts by the entomologists currently in theater 

to continue to foster these relationships would be mutually benefi cial for both the Afghan population and US 

forces. Improving those lines of communication would 

continue to help reduce disease risk in the local population, and contribute to a better understanding of the 

vector-borne disease threat to coalition forces in different parts of the country.

SUMMARY

While the challenges and lessons learned from entomological support to the Afghanistan theater of operations 

in 2010 and 2011 were not novel, they provided a reminder that we often have to relearn the same lessons. 

The prevention of vector-borne diseases is one of the 

major responsibilities of deployed preventive medicine 

personnel at all levels. Given the wide variety of responsibilities placed on preventive medicine personnel, it can 

be easy to underestimate the importance of a well-designed, effective vector surveillance program. Deployed 

medical entomologists must champion the importance 

of appropriate surveillance in disease prevention to ensure that it is conducted in an effective manner. Further, 

entomologists must work closely with commanders to 

emphasize the use of personal protective measures to 

reduce the risk of vector-borne diseases.

Surveillance must be tied to responsive vector control efforts. In areas where surveillance is conducted 

by military personnel and vector control is conducted 

MILITARY ENTOMOLOGY IN OPERATION ENDURING FREEDOM, 2010-2011

*MEDCAP indicates medical civic action program. VETCAP indicates veterinary civic action program.
 July – September 2012 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

by contractors, communication between these groups 

is critical in ensuring that effective vector control efforts can be initiated as soon after the identifi cation of 

a problem as possible. It is also important that deployed 

entomologists establish relationships with the appropriate DCMA personnel so that the people responsible for 

contract enforcement have good subject matter experts 

to reach out to if and when they have questions about 

contract compliance.

While the vector-borne disease problems in Afghanistan are not as severe as in other areas to which the US 

military has been and will be deployed, there is still the 

threat of vector-borne diseases. It is important that deployed medical entomologists maintain their focus on 

prevention of those diseases while balancing other mission critical tasks.

REFERENCES

1. Gellasch CA, Calix LC. Preventive medicine support in Afghanistan during Operation Enduring 

Freedom VI. US Army Med Dept J. April-June 

2007:56-64.

2. Field Manual 4-02: Force Health Protection in a 

Global Environment. Washington, DC: US Dept of 

the Army; February 2003: sect 2-4. [This manual, 

although currently characterized by the Army as 

obsolete, is still the governing document pending 

publication of Army Techniques Publication 4-02.8

during 2013.]

3. Faulde MK, Heyl G, Amirih ML. Zoonotic cutaneous leishmaniasis, Afghanistan. Emerg Infect Dis. 

2006;12(10):1623-1624.

4. Faulde M, Schrader J, Heyl G, Amirih M. Differences in transmission seasons as an epidemiological tool for characterization of cutaneous leishmaniasis in northern Afghanistan. Acta Tropica. 

2008;105:131-138.

5. Kotwal RS, Wenzel RB, Sterling RA, Porter WD, 

Jordan NN, Petrucelli BP. An outbreak of malaria 

in US Army Rangers returning from Afghanistan. 

JAMA. 2005;293(2):212-216.

6. Armed Forces Health Surveillance Center. Update: malaria, U.S. armed forces, 2009. MSMR. 

2010;17(1):2-5. Available at: http://www.afhsc.mil/

viewMSMR?fi le=2010/v17_n01.pdf#Page=02. Accessed March 28, 2012.

7. Armed Forces Health Surveillance Center. Update: malaria, U.S. armed forces, 2010. MSMR. 

2011;18(1):2-6. Available at: http://www.afhsc.mil/

viewMSMR?fi le=2011/v18_n01.pdf#Page=02. Accessed March 28, 2012

8. Armed Forces Health Surveillance Center. Update: malaria, U.S. armed forces, 2011. MSMR. 

2012;19(1):2-11. Available at: http://www.afhsc.

mil/viewMSMR?fi le=2012/v19_n01.pdf#Page=02. 

Accessed March 28, 2012

9. AFPMB Technical Guide No. 17: Military Handbook–Design of Pest Management Facilities. Silver Spring, MD: Armed Forces Pest Management 

Board, Deputy Under Secretary of Defense (Installations and Environment); August 2009. Available 

at: http://www.afpmb.org/sites/default/fi les/pubs/

techguides/tg17.pdf. Accessed March 28, 2012.

AUTHORS

MAJ Colacicco-Mayhugh is Chief, Department of 

Vector Control, Entomology Branch, Walter Reed Army 

Institute of Research, Silver Spring, Maryland.

LT Hughes is Head, Operational Assessment Department, 

Navy Entomological Center of Excellence, Naval Air 

Station, Jacksonville, Florida.

LT Larson is Head, Fleet Support Department, Navy 

Entomological Center of Excellence, Naval Air Station, 

Jacksonville, Florida.

When this article was written, CPT Gosine was the 

Environmental Science and Engineering Offi cer, 1st 

Brigade Combat Team, 101st Airborne Division, deployed 

to Afghanistan. She is currently a doctoral student in the 

School of Global Health, University of South Florida, 

Tampa, Florida.

LT Diclaro is Head, Vector Biology Research Program, 

US Naval Medical Research Unit No. 3, Cairo, Egypt.

LT Dunford is assigned to the Entomology Section, 

Centers for Disease Control and Prevention, Atlanta, 

Georgia.

A medical entomology class at an Afghan girls school.
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

The organophosphates and closely related chemicals 

include not only important insecticides, but also potent 

chemical warfare agents (CWA) that have been used by 

militaries and terrorists alike. Important organophosphate insecticides include malathion, parathion, and chlorpyrifos which are used in a broad range of insect control 

programs from agriculture to public health. Among the 

related CWA are the neurotoxins sarin, tabun, and VX. 

Decontamination of areas containing these chemicals 

may be necessary following the inappropriate use of insecticides or following a terrorist attack with a CWA. For 

instance, in the early 1990s, several illegal applications 

of methyl-parathion, a potent agricultural insecticide, 

were used to control cockroach infestations in human 

residences in Ohio, Mississippi, Louisiana, Illinois, and 

Mississippi.1

 More than 4,500 homes were affected and 

2 children were killed. More recently, resurging bed bug 

populations in the United States led to the illegal use of 

malathion, carbaryl, and cypermethin in over 70 houses 

in New Jersey, eventually requiring varying levels of 

decontamination.2

 Similar decontaminations have also 

been required after improper termiticide applications in 

military housing.3,4 The threat to public health presented 

by inappropriately used insecticides is obvious, but the 

CWA are also of interest to people working in homeland 

security and national defense. The intentional use of 

sarin in the Tokyo subway system in 1995 is an example 

of terrorists’ use of CWA. That one event resulted in 12 

deaths and approximately 5,000 injuries, including injuries to fi rst responders.5

Decontamination of the CWA has been defi ned as the 

“process of making any person, object or area safe by absorbing, destroying, neutralizing, making harmless, or 

removing chemical...agents.”6

 Consistent with this defi -

nition, early attempts at CWA decontamination included 

washing with soap and water, absorbing with Fuller’s 

earth, and simply leaving the chemicals to weather naturally over time. Actual chemical degradation of the toxin often relied on harsh chemicals such as calcium oxide 

and chlorine dioxide. New decontaminating compounds 

have been developed that are more effective or more environmentally friendly, including organophosphorous 

acid anydrolase (a hydrolyzing enzyme), and decontaminating foam with hydrogen peroxide. Much of the 

research required to quantify CWA decontamination requires sophisticated instrumental analytical techniques 

such as liquid or gas chromatography, which involves 

expensive equipment and trained personnel.7-9 Extensive 

reviews of analytic detection and monitoring techniques 

are provided by Witkiewicz et al10 and Kientz.11 Such 

techniques are considered defi nitive but may provide 

A Rapid and Inexpensive Bioassay to Evaluate

 the Decontamination of Organophosphates

CDR (Ret) David M. Claborn, MSC, USN

Skylar A. Martin-Brown, MS

Sanjay Gupta Sagar, BS

Paul Durham, PhD

All authors state that they have no confl icts of interest involving the research reported in this manuscript and do not have investments or business with the companies mentioned. Mention of any company or product should not be seen as an endorsement by 

Missouri State University or any branch of the US military. This study was approved by the Institutional Review Board of Missouri 

State University.

ABSTRACT

An inexpensive and rapid bioassay using adult red fl our beetles was developed for use in assessing the decontamination of environments containing organophosphates and related chemicals. A decontamination protocol 

was developed which demonstrated that 2 to 3 applications of 5% bleach solution were required to obtain nearly 

complete decontamination of malathion. The bioassay was also used to screen common household cleaners as 

potential decontaminating agents, but only 5% bleach was effective at improving survival of insects on steel 

plates treated with 25% malathion. A toxic degradation product (malaoxon) was detected using gas chromatography/mass spectrophotometry; this toxin affected the decontamination effi cacy and resulted in continued toxicity to the beetles until subsequent decontaminations. The bioassay provides evidence to support the use of red 

fl our beetles as a sensitive, less expensive method for determining safety levels of environments contaminated 

with malathion and other toxins, and may have application in the study of chemical warfare agents.
 July – September 2012 37

only indirect measures of the biological toxicity. Often 

such processes document the breakdown of the target 

chemical into degradation products that are also toxic, 

though perhaps much less so than the original toxin. 

As Munnecke12 stated, “the true change in toxicity of a 

pesticide containing medium can only be measured by 

conducting pertinent in vivo bioassays....” The same is 

probably true for CWA.

An inexpensive and rapid bioassay would be a useful 

screening tool with which to assess potential decontaminating agents for subsequent, more defi nitive testing by 

chemical analysis. Such a screening test would also be 

useful in quantifying or confi rming changes in biological toxicity as a result of decontamination efforts. This 

article describes such a bioassay using an easily maintained insect colony. The bioassay is primarily intended 

to be a rapid screening tool. It is based on a previously 

published study by the fi rst author and colleagues that 

demonstrated the detoxifi cation of insecticides by certain types of paint used on ships.13 In that study, the red 

fl our beetle, Tribolium castaneum (Herbst), was used as 

a test organism on painted and unpainted steel plates 

treated with three different pesticide formulations. The 

mortality rate of beetles exposed to some of the insecticides was lower on painted steel plates when compared 

to unpainted plates. This study used a similar technique 

as a bioassay to investigate the level of decontamination 

of an organophosphate insecticide that has also been 

used as a CWA simulant.

MATERIALS AND METHODS

Development of Bioassay

The red fl our beetle (RFB) was selected as a test organism with which to develop a rapid, inexpensive, and 

sensitive bioassay for evaluation of organophosphate 

decontamination. The RFB was used because it is easy 

to rear and handle in the laboratory, and has a long history of use in insecticide tests.13 A colony of insects was 

obtained from the USDA Stored Products Laboratory 

in Manhattan, Kansas, in April 2011. The insects were 

raised in 946.4 ml canning jars on a diet of whole wheat 

fl our and baker’s yeast (10:1 mixture). The center of the 

jar lid was replaced with an unbleached coffee fi lter and 

held in place with the ring. A new colony was started 

every week by moving a few adults and a spoonful of 

fl our with larvae into a new jar with the fl our:yeast mixture. The jars were kept at room temperature (21°C to 

24°C) in a dark cabinet with an open pan of water to provide moisture. All of the insects used for these experiments were from colonies started on April 15 or April 

20, 2011. 

Unpainted steel plates (20 cm by 20 cm) were cleaned 

with ethanol and allowed to air dry. The plates were treated with a 1-ml aliquot of 25% malathion. A commercial 

formulation of 50% malathion (Spectracide, Chemsico, 

St. Louis, MO) was used as the stock solution and was 

further diluted to 25% with xylene, which was also the 

diluent in the commercial formulation. This percentage was used because greater concentrations produced 

nonuniform dispersal on the plates as evidenced by oily 

droplets after decontamination. At 25% concentration, 

the malathion could be applied uniformly and it dried 

enough to allow the insects to move freely on the surface. The 1-ml aliquot was dripped onto the plate from 

a pipette, then spread evenly with a dry, 2.54 cm wide 

nylon bristle brush, covering the surface area of one side 

of the steel plate. Applications were made under a hood 

and the plates were allowed to dry for 48 hours. The 

plates then received the fi rst decontamination. 

All decontaminations were applied with an air brush 

(Iwata Revolution, Iwata-Medea Inc, Portland, OR) to 

prevent any unintended physical removal of the malathion that might occur with a brush or other application 

technique. The propellant for the air brush was 1,1-difl ouroethane in a pressurized can. Decontaminant applications were all done in 1-ml aliquots. Potential decontaminants included:

 Standard household bleach (5% sodium hypochlorite), Clorox Bleach, The Clorox Company, Oakland, CA

 95% ethanol

 Lysol All-Purpose Cleaner (active ingredient 3.2% 

lactic acid), Reckitt Benckiser Inc, Parsippany, NJ

 Simple Green Concentrate, Sunshine Makers Inc, 

Huntington Beach, CA

 Pine Sol Concentrate (active ingredient 8.7% pine 

oil), The Clorox Company, Oakland, CA

Bleach and ethanol were both selected because they are 

commonly used for insecticide decontamination, and 

bleach is a standard decontamination agent for nerve 

agent weapons.9

 Lysol, Simple Green, and PineSol are 

common household cleaners that could be used by residents of a contaminated facility to clean an insecticidecontaminated area. Ethanol and bleach were used as decontaminants in all tests, but only one of the 3 household 

cleaners was used in each of 3 replications. The decontamination schedule is shown in Table 1.

In each replication, the plates were decontaminated 

3 times consistent with the schedule in Table 1. After 

each decontamination, the plates were allowed to dry 
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

for 48 hours before the insect bioassay was performed. 

An untreated, nondecontaminated control was used for 

each replication as well as a control that was treated 

only with 1 ml of 5% bleach and another treated with 

3⁄4 ml of the xylene diluent. In replication No. 1, Lysol 

was compared to bleach and alcohol; in replication No. 

2, Simple Green was substituted for Lysol, followed by 

Pine Sol in replication No. 3. Three to 4 plates received 

each treatment/decontamination combination in each of 

the 3 replications. A separate bioassay was run to compare the toxicity of each of these household cleaners to 

an untreated (no malathion) control.

For the bioassay, 10 RFB adults were counted into small 

disposable Petri dishes and allowed to starve overnight. 

They were observed the next day to ensure that they were 

still alive, then one side of the Petri dish with the RFB 

inside was inverted on the steel plates, exposing the insects to the treated surfaces. After one hour, the plates 

were inverted, collecting the RFB back into the Petri 

dish and the insects were observed for toxic effects. All 

of the insects in each dish were immediately observed 

and placed into one of the following 3 categories:

Category 1: Alive (moves when prodded with a probe).

Category 2: Knockdown (moribund but showing some 

movement of legs or head)

Category 3: Dead (total lack of movement even when 

prodded with a probe)

The lids were replaced on the Petri dishes and the insects 

were allowed to sit undisturbed on the bench top until they were evaluated again for toxic effects 24-hours 

postexposure. This process was performed after each of 

the 3 decontaminations. At the end of each bioassay, the 

tested insects were destroyed and not used for subsequent bioassays.

Statistical Analysis

Data were analyzed using the PROC ANOVA procedure in the SAS 9.2 software (SAS Institute Inc, Cary, 

NC). The models were used to describe the effects of 

decontamination on survival (those classifi ed as alive) 

at 1-hour postexposure and at 24-hours postexposure. 

Another category of some movement combined the 

categories of alive and knockdown. Means of survival 

and survival with knockdown were compared using the 

Tukey’s HSD (honest signifi cant difference) test.

Comparison to Standard Chemical Assay

The described steel plate assay was used to compare to 

a standard analytical process using gas chromatography/

mass spectrophotometry (GC/MS). Twelve steel plates 

were set up as in the assay as previously explained, and 

then smaller steel plates (5.08 cm by 5.08 cm) were 

placed in the center of each plate as coupons. The coupons were taped onto the larger steel plates with only 

a small edge of the laboratory tape extending onto the 

coupon. This was done to prevent treatments from contaminating the underside of the coupon. The plates and 

coupons were then treated with 1-ml aliquots of 25% 

malathion and dried for 24 hours. Four of the coupons 

were then removed, placed in glass jars, and transported 

to the chemistry laboratory at the Jordan Valley Innovation Center, Missouri State University, for analysis. At 

that time, the remaining plates with coupons received a 

single decontamination with 5% bleach identical to that 

described earlier. After 24 hours, 4 more coupons were 

removed for chemical analysis, and the remaining plates 

with coupons received a second decontamination treatment. Following another 24 hours, two of the coupons 

were removed for analysis and the last two plates with 

coupons received a third decontamination treatment. 

After another 24 hours, the bioassay was performed on 

the larger steel plates, placing the Petri dishes on treated 

(malathion) and decontaminated (bleach) areas next to 

the sites where the coupons had been removed.

Reagents and Materials. Malathion and malaoxon 

PESTANAL analytical standards were purchased from 

Sigma-Aldrich (St Louis, MO). Optima grade acetone 

was purchased from Fisher Scientifi c (Fair Lawn, NJ). 

Stock standards of 150 μg/ml and 100 μg/ml were 

freshly prepared in acetone each week and stored at 4oC 

in opaque Nalgene bottles (Fisher Scientifi c). Calibration standards (0.1 μg/ml-150 μg/ml) were also prepared weekly in acetone from the stock standards by 

serial dilution in acetone and stored at 4oC in opaque 

Nalgene bottles. 

Sample Extraction. The sample extraction procedure 

was adapted from Rogers et al.14 The coupons were removed from the treated steel plates and placed in 250 

ml glass straight-sided jars (Fisher Scientifi c) to which 

80 ml of acetone was added. The samples were then 

sonicated for 30 minutes. After sonication, 1 ml was removed from the jar and added to an autosampler vial for 

GC/MS analysis. A single extraction cycle proved to be 

suffi cient for the steel coupons.

Table 1. Application and bioassay schedule for decontamination of malathion with common household cleaners.

Day 0 25% malathion applied to plates

Day 2 First decontamination

Day 4 First bioassay; second decontamination of plates

Day 6 Second bioassay; third decontamination of plates

Day 8 Third bioassay

A RAPID AND INEXPENSIVE BIOASSAY TO EVALUATE

THE DECONTAMINATION OF ORGANOPHOSPHATES
 July – September 2012 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

GC/MS Analysis. A Varian 450 GC (Varian Medical 

Systems Inc, Palo Alto, CA), coupled to a Varian 320 

triple quadropole mass spectrometer was used for the 

analysis. The instruments were interfaced to a computer 

running Varian MS workstation version 6.9.1 for instrument control and data processing. Instrument conditions 

were similar to those used in Rogers et al.14 The column 

used for separation was a Zebon ZB-1701 with 5 mm 

Guardian guard column (Phenomenex, Torrance, CA). 

The column dimensions were 30 mm by 0.25 mm by 

0.15 μm fi lm thickness. A 1 μl sample was injected in 

splitless mode at 200oC. The GC oven was programmed 

as follows: 100oC hold for 2 minutes, increased to 180oC 

at a rate of 10oC/minute, increased to 220oC at a rate of 

5oC/minute, increased to 260oC at a rate of 20oC/minute 

and held at 260oC for 2 minutes. Total run time was 22 

minutes. Helium was the carrier gas with a fl ow rate of 

0.8 ml/minute. The mass spectrometer was operated in 

electron impact mode. The transfer line and ion source 

temperatures were set to 280oC and 230oC, respectively. 

Retention times were determined and parent ions were 

verifi ed in full scan mode. Quantifi cation and qualifi cation ions were selected and collision energies were determined experimentally by tandem mass spectrometry. 

Analyte specifi c information is shown in Table 2.

Peak areas of standards were plotted using a quadratic 

function with weighting scaled by the inverse of analyte 

concentration. A minimum of 6 points was required for 

an acceptable calibration curve. Both calibration curves 

had correlation coeffi cients of r2>0.990.

Statistical Analysis. Mean concentrations were calculated with the PROC MEANS procedure in SAS 9.2 for 

both malathion and malaoxon on the coupons. Results 

were graphed using a Microsoft Excel 2010 spreadsheet.

RESULTS

Bioassay Development

Survival on plates that did not receive an application of 

malathion or a decontaminant was not different from 

plates that received only a xylene application (0.75 ml) 

or 1 to 3 applications of 5% bleach (r2=0.01, P=.65). 

This fi nding indicated negligible toxicity of the diluent 

(xylene) and the standard decontaminant (5% bleach). 

Due to the lack of toxicity on these plates, the control 

throughout the study was subsequently defi ned as plates 

that did not receive a malathion application or any decontamination treatment, or that received only a bleach 

or xylene application. Similarly, survival on plates that 

were treated only with the decontamination agents of 

Lysol, Pine Sol, Simple Green, and ethanol was not signifi cantly different from an untreated (no malathion) 

and undecontaminated control.

Survival levels on plates treated with malathion but which 

were not decontaminated were consistent throughout the 

multiday study for each replication. The last bioassay on 

each replication was run 8 days after the initial application of malathion, but survival levels on control plates 

on the last bioassay was not different from that of the 

fi rst or second bioassays in each replication (r2=0.002, 

P=.97). This fi nding provides evidence that in the protected environment of the laboratory, malathion was not 

degraded and it remained active throughout the duration 

of the biological testing.

Table 3 displays the survival of 10 RFB confi ned for 

one hour on steel plates treated with malathion, then decontaminated with 1, 2, or 3 treatments of 5% bleach 

solution. Bleach was used as the standard decontamination treatment for this study. To monitor changes in the 

level of toxicity to each treatment, survival levels were 

measured one hour and 24 hours after initial exposure, 

and as a combined measurement of survival and knockdown (some movement) 24 hours after initial exposure. 

A means separation test indicated that the fi rst application of a decontaminant on Day 2 of the experiment did 

not result in signifi cant detoxifi cation. This fi nding was 

consistent with all 3 measures of toxicity. However, after a second application of the bleach solution on Day 4, 

survival was signifi cantly increased on the plates as 

measured by the bioassay on Day 6. This fi nding was 

also consistent with all 3 measures of toxicity. After a 

third decontamination of the plates on Day 6, the survival level as measured on Day 8 was slightly greater, but 

was not signifi cantly different from that of the second 

decontamination. Survival levels after the second and 

third decontaminations were not signifi cantly different 

from that on plates that did not receive an application 

of malathion except as measured by simple survival (not knockdown) at 24 hours. 

That measure indicated a difference in 

survival on malathion-treated plates that 

received only 2 decontaminations as compared to plates that received no malathion 

but did receive bleach applications. Of 

the 3 measures of toxicity, the measure of 

“some movement” explained the greatest 

Table 2. Analyte information for gas chromatography/mass spectrophotometry 

analysis.

Analyte MW Parent 

Ion

Retention 

time (min)

Quantifi cation 

Ion (m/z)

Qualifi cation 

Ion (m/z)

Collision 

Energy

Malathion 330.36 331 17.2 285 173 5 eV

Malaoxon 314.30 315 17.7 173 127 6 eV

MW indicates molecular weight.

m/z indicates mass to charge ratio.
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

amount of variation in the model as demonstrated by an 

r2 value of 0.70.

None of the household cleaners appeared to decrease 

toxicity, with only bleach demonstrating a decontaminating effect as demonstrated by the bioassay. Table 4 

compares the standard (5% bleach) to common household and laboratory cleaners in their capacities to decontaminate malathion. The measures of toxicity were 

the same as used earlier. All treatments for each decontaminant were combined for comparison in Table 4. 

There was decreased survival on plates treated with 

Pine Sol and Simple Green alone as compared to the 

nondecontaminated control, a fi nding that 

is inconsistent with the control studies that 

indicated no toxicity due to the decontaminating agents alone. Survival on bleachtreated plates was signifi cantly greater than 

on plates decontaminated with any of the 

other agents.

GC/MS assay

To correlate data from the bioassay experiments to the degradation of malathion, GC/

MS was used to measure the amount of malathion and malaoxon, the oxidative byproduct of the decontamination of malathion. Because malaoxon is toxic, the concentration 

of this chemical was also determined in the 

GC/MS assay. Concentrations of malathion 

and malaoxon after 0 to 3 decontaminations 

are graphically depicted in the Figure. The 

presence of malaoxon as a toxic byproduct of the oxidation of malathion continued after 1 and 2 applications of 

bleach decontaminant, but was completely removed after a third application Three decontaminations resulted 

in almost complete degradation of malathion.

COMMENT

The simple bioassay demonstrated in this study provides 

a quick screening mechanism that can be used to investigate factors affecting the decontamination of neurotoxic chemicals, particularly the organophosphates. It 

allowed the identifi cation of an effective application rate 

of bleach for use as a decontaminating agent. This is 

perhaps the greatest utility of the bioassay. When the toxic agent was 25% 

malathion, about twice as much 5% 

bleach by volume was required to signifi cantly improve survival of RFB on 

malathion treated plates. Nearly complete decontamination was obtained 

by 3 subsequent applications of bleach 

with each application being the same 

size by volume as the 25% malathion. 

This rapid assessment of effi cacy can 

be useful when putting together decontamination protocols for toxic agents, 

especially because it measures actual 

biological toxicity. Further research is 

necessary to determine if lower concentrations of the bleach decontaminant or smaller aliquots might be effective in repeated decontaminations. The 

concentration used in this study (5%) 

was very high and would not be suitable for use in many situations.

Table 3. Postexposure percentage of surviving Tribolium castaneaum after 

confi nement for one hour on 20 cm by 20 cm steel plates which had been 

treated with 1 ml of 25% malathion, then decontaminated sequentially with 

1, 2, or 3 applications (1 ml) of 5% bleach solution. 

Number of

decontamination

treatments n

Survival

1-hour

postexposure

% (SD)

Survival

24-hours

postexposure

% (SD)

Some movement*

24-hours

postexposure

% (SD)

0 36 59.7 (26.4)a 30.8 (22.9)a 30.8 (22.9)a

1 12 44.2 (28.1)a 12.5 (31.0)a 24.2 (35.0)a

2 12 82.0 (28.0)b 55.0 (40.5)b 85.8 (18.3)b

3 12 96.7 (4.5)b 80.0 (34.9)b,c 97.5 (4.5)b

Bleach only 27 97.7 (4.4)b 98.8 (3.3)c 98.8 (3.3)b

r

2 0.40 0.62 0.70

n indicates the number of steel plates that received the designated treatment.

Note: Values in a column followed by the same letter are not significantly different (Tukey 

test, P=.05).

*Combined category including insects that were alive or knocked down.

Table 4. Postexposure percentage of surviving Tribolium castaneaum after confi nement for one hour on 20 cm by 20 cm steel plates which had been treated 

with 1 ml of 25% malathion, then decontaminated sequentially with a common 

household cleaning product. 

Decontaminant n

Survival

1-hour

postexposure

% (SD)

Survival

24-hours

postexposure

% (SD)

Some movement*

24-hours

postexposure

% (SD)

No decontamination 98 8.1 (20)a 9.5 (20.0)a 30.8 (22.0)b

Pine solvent 9 3.3 (5.0)a 1.1 (3.3)a 3.3 (5.0)a

Simple Green 12 8.3 (11.0)a 1.7 (3.9)a 15.0 (23.5)a,b

Ethanol 23 3.9 (6.6)a 16.0 (25.0)a 37.8 (32.0)b

Lysol 12 18.3 (25.1)a 20.0 (26.9)a 41.7 (31.6)b

Bleach (5%) 24 61.2 (38.4)b 67.0 (39.0)b 91.7 (14.3)c

No malathion/no

decontamination 37 96.6 (7.7)b 95.2 (12.0)b 98.6 (3.5)c

r

2 0.85 0.80 0.79

n indicates the number of steel plates that received the designated treatment.

Note: Values in a column followed by the same letter are not significantly different (Tukey test, 

P=.05).

*Combined category including insects that were alive or knocked down.

A RAPID AND INEXPENSIVE BIOASSAY TO EVALUATE

THE DECONTAMINATION OF ORGANOPHOSPHATES
 July – September 2012 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

Chemical analysis of the residual toxin on 

decontaminated plates confi rmed that a 

signifi cant amount of malathion remains 

on the plates after one decontamination; 

the concentration of degradation byproducts was also increased. When 25% malathion was decontaminated with 5% bleach, 

nearly complete decontamination of the 

surface was achieved with 3 treatments, a 

fi nding consistent with both the bioassay 

and the GC/MS analysis. The presence 

of a toxic byproduct of decontamination 

(malaoxon) was demonstrated by both 

the chemical analysis and suggested by 

the bioassay, demonstrating the need for 

validated protocols for decontamination 

processes.

A rapid screening of household cleaners using the RFB bioassay failed to identify any 

additional decontaminating agent other 

than the common bleach solution already 

known to be an effective decontaminant. 

Other cleaners like Simple Green and Pine 

Sol might be useful in the physical removal 

of the agent, but do not demonstrate a reduction in toxicity of malathion as determined by the insect bioassay. The results of the bioassay, however, were 

not always straightforward. The increased toxicity on 

malathion-treated plates decontaminated with Simple 

Green and Pine Sol was unexpected. These undiluted 

substances are slightly viscous. Perhaps this physical 

characteristic impedes the insect’s movement or covers 

the spiracles leading to asphyxiation. Alternatively, the 

cleaners may break down protective characteristics of 

the insect cuticle, thereby increasing the insect’s susceptibility to the toxin. Insects exposed to plates that received only Pine Sol or Simple Green applications, but 

no malathion, did not elicit greater mortality than did 

plates that had received no application. This suggests 

that these 2 cleaners may somehow synergize the action 

of the malathion, though this possibility would require 

more research to confi rm. Another interesting fi nding 

in this screening was the lack of effi cacy of ethanol as 

a decontaminating agent against malathion. Ethanol 

has been used as a decontaminant for other insecticides, 

specifi cally organochlorines,4

 but did not show any effi cacy against an organophosphate.

The benefi ts of this bioassay include its rapidity, very low 

expense, and its actual measurement of biological toxicity. The latter is important given that analytical chemistry-based measures can quantify the breakdown of the 

target chemical, but may fail to measure the toxicity of 

degradation products. No expensive equipment is required and this bioassay could actually be performed 

in a fi eld situation with only minor modifi cations. This 

type of bioassay provides almost immediate results and 

can easily be adapted to test a variety of surfaces such as 

concrete, wood, and tile. It can also be used to study the 

impact of environmental variables such as temperature, 

humidity, and insolation on the decontamination of toxic 

chemicals. However, this bioassay does not identify the 

mode of toxic action, nor does it rule out the possibility 

of other forms of toxicity such as endocrine disruption 

or carcinogenicity. Since this bioassay does not identify 

the mechanism by which the insects are killed, it is not 

a replacement for the standard analyses involving analytical chemistry. Also, the surfaces to be tested must be 

dry. Wet surfaces lead to concentration of the toxins or 

decontaminants and wetting of the insect cuticle, both of 

which can cause inconsistent measures of toxicity. This 

phenomenon was particularly observable with the Lysol 

applications and may limit the utility of the bioassay for 

such decontaminants.

Future research using this bioassay will include investigations of decontamination effi cacy on various surface 

types, extended screening of potential decontamination 

agents, and evaluation of environmental factors such 

as temperature and humidity on decontamination processes. Although the current screening was done with 

Mean malathion and malaoxon residuals (μg/ml) on steel plates after 0, 1, 

2, or 3 applications of 5% sodium hypochlorite (bleach) solution applied with 

an air brush.
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

decontamination of an insecticide on steel plates as a 

model, this bioassay may also serve as a method to study 

the decontamination of a variety of toxic environments 

such as facilities that have been contaminated during 

inappropriate termiticide applications, chemical warfare agent attacks by terrorists or national militaries, or 

even houses contaminated by the illegal manufacture of 

methamphetamines. It would be most useful when used 

as an initial screening tool as it is not a replacement for 

the more comprehensive and expensive analytical tests.

REFERENCES

1. Clark JM, Bing-Canar J, Renninger S. Methyl 

parathion in residential properties: relocation and 

decontamination methodology. Environ Health 

Perspect. 2002;110:1061-1070.

2. DEP orders cleanup of harmful pesticides used by 

Newark fi rm to treat bedbugs [press release]. New 

Jersey Department of Environmental Protection; 

July 9, 2010. Available at: http://www.nj.gov/dep/

newsrel/2010/10_0065.htm. Accessed December 

29, 2011.

3. Calder IC, Maynard EJ, Turczynowicz LT. Aldrin 

contamination at a school in South Australia. Bull 

Environ Contam Toxicol. 1993;51:185-192.

4. Callahan RA, Frazier AR, Criscuolo D. Chlordane 

Contamination of Government Quarters and 

Personal Property-Webb AFB TX. Kelly AFB, TX: 

USAF Environmental Health Laboratory; March 

12,1970; Technical Report EHL(K) 70-7. Available 

at: http://www.dtic.mil/cgi-bin/GetTRDoc?Loca

tion=U2&doc=GetTRDoc.pdf&AD=ADA955626. 

Accessed April 3, 2012.

5. Spanjaard H, Khabib O. Chemical weapons. In: 

Levy BS, Sidel VW, eds. Terrorism and Public 

Health: A Balanced Approach to Strengthening 

Systems and Protecting People. New York, NY: 

Oxford University Press; 2003:199-212.

6. Smart JK. History of the Army chemical and 

biological decontamination-part I. CBRNIAC Newsletter. 2008;9(3):20-23. Available at: https://www.

cbrniac.apgea.army.mil/Documents/vol9%20

num3.pdf. Accessed April 3, 2012.

7. Kennedy MV, Stojanovic BJ, Shuman FL Jr. Decontamination of Organophosphorous Insecticides. 

State College, MS: Mississippi Agricultural Experiment Station; September 1970. Technical Report 

AFATL-TL-70-92.

8. Nelson C, Laughlin J, Kim C, Rigakis K, Raheel 

M, Scholten L. Laundering as decontamination 

of apparel fabrics: residues of pesticides from six 

chemical classes. Arch Environ Contam Toxicol. 

1992;23:85-90.

9. Love AH, Bailey CG, Hanna ML, Hok S, Vu AK, 

Reutter DJ, Raber E. Effi cacy of liquid and foam 

decontamination technologies for chemical warfare agents on indoor surfaces. J Hazard Mater. 

2011;196:115-122.

10. Witkiewicz Z, Mazurek M, Szulc J. Chromatographic analysis of chemical warfare agents. J 

Chromotogr. 1990;503:293-357.

11. Kientz CE. Chromatography and mass spectrometry of chemical warfare agents, toxins and related 

compounds: state of the art and future prospects. J 

Chromatogr. 1998;814:1-23. 

12. Munnecke DM. Enzymatic detoxifi cation of waste 

organophosphate pesticides. J Agric Food Chem. 

1980;28:105-111

13. Claborn DM, Tetrault GE, Arthur FH. Effectiveness of three residual insecticide formulations to 

control red fl our beetles (Coleoptera: Tenebrionidae) on painted and unpainted steel. J Entomol Sci. 

1991;26:395-400.

14. Rogers J, Hayes T, Kenny D, et al. Decontamination 

of Toxic Industrial Chemical and Chemical Warfare 

Agents on Building Materials Using Chlorine 

Dioxide Fumigant and Liquid Oxidant Technologies. 

Research Triangle Park, NC: US Environmental 

Protection Agency; February 2008. Technology 

Investigation Report EPA/600/R-08/125. Available 

at: http://oaspub.epa.gov/eims/eimscomm.getfi le?p_

download_id=502972. Accessed March 29, 2012.

AUTHORS

CDR (Ret) Claborn is an Assistant Professor of Public 

Health and Homeland Security, Missouri State University, Springfi eld, Missouri. A career US Navy medical entomologist, his last assignment was the Uniformed 

Services University of the Health Sciences, Bethesda, 

Maryland.

Ms Martin-Brown is a chemist with the Center 

for Biological and Life Sciences, Jordon Valley 

Innovation Center at Missouri State University, 

Springfi eld Missouri.

Mr Sagar is a graduate assistant in the Master of 

Public Health program at Missouri State University, 

Springfi eld, Missouri.

Dr Durham is a Professor of Biology and Director of 

the Center for Biological and Life Sciences, Jordon 

Valley Innovation Center, Missouri State University, 

Springfi eld, Missouri.

A RAPID AND INEXPENSIVE BIOASSAY TO EVALUATE

THE DECONTAMINATION OF ORGANOPHOSPHATES
 July – September 2012 43

BACKGROUND

A previous issue of the AMEDD Journal included 

an article1

 I wrote concerning solid waste disposal in 

the US Central Command (CENTCOM) area of operations. That article described how the Department of 

Defense (DoD) conducted numerous monitoring studies at Joint Base Balad (JBB), the location with the US 

military’s largest burn pit in theater. Screening health 

risk assessments, publicly released in 2008,2

 stated that 

the burn pits at JBB and other US military locations 

in Iraq posed an “acceptable health risk” based on the 

contaminant levels measured. While sampling can be 

used to identify a potential concern, it does not refute 

every concern because it cannot address all locations 

and conditions at all times. I discussed the limitations of 

the sampling efforts, including the points that sampling 

identifi es conditions at the time of sampling, and that 

burn pit sampling was intermittent while waste streams 

and meteorological conditions were variable. As waste 

streams vary, analyte concentrations would be expected 

to vary. The methodology does not incorporate particulate matter (PM) such as PM10 or PM2.5 concentrations. 

Particulate matter is a mixture, and does not have a toxicological value for use in the methodology. The list of 

analytes was not exhaustive. Screening health risk assessments indicate the general probability that a risk is 

present under very specifi c exposure conditions. This 

can be useful to make decisions regarding the need to 

take remedial actions, but is not well-suited to inform 

regarding an individual’s health risk.

To further evaluate the potential health impact of burning trash, the Armed Forces Health Surveillance Center 

conducted a retrospective cohort study3

 to compare the 

incidence rates among deployers and nondeployers for 

respiratory diseases, circulatory diseases, cardiovascular disease, ill-defi ned conditions, and sleep apnea; 

compare the responses on the postdeployment health 

assessment forms among individuals deployed to one 

of several CENTCOM locations with and without burn 

pits; and compare the rates and proportions of medical 

encounters for respiratory outcomes while assigned to 

various CENTCOM locations. To address the issue of 

particulate matter exposure, service members in Korea (where particulate matter levels are high) were also 

included, as well as a nondeployed control population. 

The main fi nding was that for nearly all health outcomes 

measured, service members from the CENTCOM locations and Korea had either similar or signifi cantly lower 

incidence rates compared to the US-based cohort. The 

exception was that personnel assigned to a deployed site 

without a burn pit had a measurably higher rate of signs, 

symptoms, and ill-defi ned conditions noted postdeployment. For health outcomes measured during the deployment period, Air Force personnel at Joint Base Balad had 

a higher proportion of respiratory encounters, yet this 

was not noted among Army members at the same location, or for military personnel at the other burn pit sites 

which were studied. The report concluded that, while 

the study had limitations, the results taken collectively 

generally showed no impact of burn pit exposure several years postdeployment. They recommended further 

improvement in the quality of individual-level exposure 

data, to include data from additional burn pit sites, and 

further investigation of possible long-term health effects. 

Strengths of the study included the ability to use comprehensive electronic medical records and the large size 

of the population for statistical analysis. As with many 

epidemiological studies, limitations are also recognized, 

for example, measures of individual exposures, some 

exposure misclassifi cation, lack of information on job 

duties, and information on smoking behavior.

Personnel are exposed to dust and ambient particulate 

matter while deployed, often in conjunction with other 

exposures such as burn pit smoke and local industrial 

emissions. Sampling data indicates variable conditions 

to include occasions where levels exceed certain health 

guidelines.4

 High levels of ambient particulate matter 

and burn pit smoke can irritate the eyes and respiratory 

passages at the time of exposure. Air pollution literature 

indicates that such exposures could cause or exacerbate 

chronic lung conditions, including chronic bronchitis 

and asthma, with effects dependant on the degree and 

duration of exposure, as well as characteristics of the 

population being exposed.5,6 The completed scientifi c 

Review of the Institute of Medicine Report:

 Long-term Health Consequences of Exposure

 to Burn Pits in Iraq and Afghanistan

Coleen P. Baird, MD, MPH
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

studies evaluating the association between environmental exposures encountered during deployment to Iraq 

and/or Afghanistan and lung health indicate a range of 

different fi ndings. These include no evidence of an association between deployment-related exposures and 

chronic respiratory conditions,3

 an association between 

specifi c lung diseases and deployment,7

 and evidence 

of increased respiratory symptoms but not a specifi c diagnosed disease.8

 Additional conditions such as acute 

eosinophilic pneumonia and constrictive bronchiolitis 

are described in case series from which epidemiologic 

associations cannot be directly estimated.9,10 Although 

all of these studies have methodological limitations that 

constrain the strength of the conclusions being drawn, 

their fi ndings warrant continued investigation.

Given the lack of clear consensus and in response to concerns expressed by military personnel, Veterans, their 

families, and Congress, the Department of Veterans Affairs (VA) asked the Institute of Medicine (IOM)* to:

Determine the long-term health effects from exposure 

to burn pits in Iraq and Afghanistan. Specifi cally, the 

committee will use the Balad Burn Pit in Iraq as an example and examine existing literature that has detailed 

the types of substances burned in the pits and their byproducts.11(p1)

APPROACH USED BY THE IOM COMMITTEE

The committee used 3 sources of information in their 

deliberations. The fi rst was the actual monitoring data 

from JBB. The report noted that while the Balad assessments were useful, information regarding the waste 

streams at particular locations was not available apart 

from general information on percentages of plastics, 

wood, metal, and other combustible and noncombustible 

items burned. They also acknowledged that the sampling 

did not include criteria pollutants such as ozone, carbon 

monoxide, and sulfur dioxide, although this was due to 

diffi culties in conducting this sampling in a deployed 

setting. They concluded that background ambient air 

concentrations of PM were high, with average concentrations above US air pollution standards, and were most 

likely derived from local sources. Dioxin compounds 

were detected at low concentrations, although high even 

when compared to polluted urban areas, and the burn pit 

was the likely source. Volatile organic compounds and 

polycyclic aromatic hydrocarbons were similar to those 

reported for polluted urban environments outside the 

United States. The report concluded that personnel were 

exposed to a mixture of combustion products from the 

burn pit and other air pollutants from local and regional 

sources, including other combustion sources, ground 

transportation, stationary power generation, the Balad 

airport, other industry, and wind-blown soil. 

The second phase of their approach involved a review 

of the monitoring data from JBB and evaluation of the 

potential health effects of compounds detected in more 

than 5% of samples, or expected to be present. There 

were 51 such compounds which were evaluated for potential cancer and noncancer health effects. These chemicals were categorized as dioxins and furans, volatile organic compounds, and particulate matter. The “potential 

health effects” associated with exposure to these chemicals at suffi cient levels were stated as:

 Neurological effects and reduced central nervous 

system functions

 Liver toxicity and reduced liver function

 Cancer (stomach, respiratory, skin, leukemia, 

others) 

 Respiratory toxicity and morbidity

 Kidney toxicity and reduced kidney function

 Blood effects (anemia, etc)

 Cardiovascular toxicity and morbidity

 Reproductive and developmental toxicity

The committee acknowledged that potential health effects associated with any single compound have “little 

predictive value” for deployed personnel at JBB. This 

determination was reached because although most of 

the detected pollutants were present at concentrations 

lower than the health-based reference values, sampling 

was limited in time. Individual exposure levels would be 

expected to vary. For example, exposure would be higher for those who worked at or near the burn pit (which 

in fact was quite large) than for those located elsewhere 

on the Balad camp. Additionally, concentration of PM 

exceeded US standards, but PM composition and characteristics can vary with the source and contributors. 

Literature on the health effects of exposure to mixtures, 

and specifi cally mixtures from burn pits is minimal.

These issues led the committee to the third aspect of their 

assessment; a review of the epidemiologic literature on 

health outcomes associated with exposure to burn pit 

emissions (military studies) and other populations with 

exposure to similar combustion sources (fi refi ghters, 

workers at municipal incinerators, residents who live 

near incinerators, and Veterans of the 1990-1991 Persian Gulf War who were exposed to smoke from oil-well 

REVIEW OF THE INSTITUTE OF MEDICINE REPORT: LONG-TERM HEALTH CONSEQUENCES

OF EXPOSURE TO BURN PITS IN IRAQ AND AFGHANISTAN

*The Institute of Medicine is the health component of the 

National Academy of Sciences. It is an independent, nonprofi t 

organization that works outside of government to provide 

unbiased and authoritative advice to decision makers and the 

public. Information: http://www.iom.edu/About-IOM.aspx.
 July – September 2012 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

fi res) to identify health outcomes potentially related to 

combustion products similar to burn pit emissions. All 

studies are known to have limitations and uncertainties, 

including the “healthy worker” effect, exposure misclassifi cation, lack of information on confounders, inadequate statistical power, disease misclassifi cation and 

publication bias. Considering these and the information 

from the studies reviewed, the committee then adopted 

the categories of association used for previous reports regarding the fi rst Gulf War and health, and Agent Orange 

and health, based on the weight of evidence. The 5 categories were suffi cient evidence of a causal relationship, 

suffi cient evidence of an association, and limited, suggestive, or inadequate evidence based on available data.

FINDINGS OF THE COMMITTEE

As noted, the report concluded that the mixture of chemicals from regional background and local sources that 

contribute to the high PM may be of the greatest concern at JBB. As previously described, the PM consists 

of windblown dusts and elemental carbon and metals 

that arise from transportation and local industrial activities.12 The committee considers the air pollution literature related to particulate matter to be relevant to military personnel deployed to the Middle East. Weese and 

Abraham4

 noted that the potential health implications of 

the PM measured in an extensive sampling event in deployed locations in the Middle East included respiratory 

and cardiovascular outcomes.

Overall, the committee concluded:

In light of its assessment of health effects that may result from exposure to air pollutants detected at JBB and 

its review of the literature on long-term health effects 

in surrogate populations, the committee is unable to 

say whether long-term health effects are likely to result 

from exposure to emissions from the burn pit at JBB. 

However, the committee’s review of the literature and 

the data from JBB suggests that service in Iraq and Afghanistan—that is, a broader consideration of air pollution that exposure only to burn pit emissions—might be 

associated with long-term health effects, particularly in 

highly exposed populations (such as those worked at the 

burn pit, or susceptible populations (for example, those 

who have asthma) mainly because of the high ambient 

concentrations of PM from both natural and anthropogenic, including military, sources. If that broader exposure to air pollution turns out to be suffi ciently high, potentially related health effects of concern are respiratory 

and cardiovascular effects and cancer.11(p7)

The committee determined that there is inadequate/

insuffi cient evidence of an association between exposure to combustion products and cancer, respiratory 

disease, circulatory disease, neurologic disease, and 

adverse reproductive and developmental outcomes in 

the population studied. The report concluded that there 

was limited/suggestive evidence of an association between exposure to combustion products and reduced 

pulmonary function in the populations studied. It was 

acknowledged that the results in the populations studied 

(fi refi ghters and people living near incinerators) may not 

be generally applicable to military personnel exposed to 

emissions from burn pits.

So what does this really mean? The report noted that no 

individual chemical constituent of the combustion products emitted at JBB was measured at levels likely to be 

responsible for adverse health effects discussed. However, the sampling had limitations and the issue of mixed 

and cumulative exposures remains. These include not 

only PM and combustion products, but other interacting 

factors such as stress, smoking, and local climatic conditions. The report identifi es the value of better exposure characterization. Individual monitoring data would 

greatly reduce misclassifi cation bias and potentially allow for an assessment of dose/response, but the burn pit 

in Balad has closed and the drawdown in troops in the 

CENTCOM area makes extensive monitoring unlikely. 

Also recommended was a prospective study on individuals who were deployed to Balad, with an attempt to 

classify the exposure into low, medium, and high. Identifying highly exposed subgroups within those deployed 

to Balad is not possible from deployment location records, but comparison of groups deployed there during 

the height of burn pit use as opposed to after initiation of 

incinerator use is another approach. Additionally, it recommended extending the study for a longer time period 

to address conditions which would not arise immediately 

due to latency. This is being accomplished. The Armed 

Forces Health Surveillance Center is repeating the prior 

study with a longer period of follow-up. This study design was very similar to the design recommended by the 

Institute of Medicine, including outcomes associated 

with proximity to exposure and outcome comparisons 

between deployed personnel who were exposed to burn 

pits and deployed personnel without such exposure. An 

independent oversight committee comprised of military 

and external experts was also recommended, and is being explored.

It was noted that pilot studies should be conducted to 

address the issues of statistical power and to develop 

design features for specifi c health outcomes. At present, 

studies are being conducted among a predeployment 

population at Fort Hood, Texas, and in a new recruit 

population at Fort Sam Houston, Texas, to assess the 

feasibility of conducting baseline spirometry at predeployment and at accession into the military. The use of 
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

screening spirometry in an asymptomatic population is 

not currently recommended.13,14 However, the rational 

for baseline testing is that military members, as a group, 

might have better lung function than the reference populations used for comparison. Traditional evaluation 

of pulmonary function determines whether test results 

are in the normal range, which is based on asymptomatic nonsmokers. If individuals have above average lung 

function at baseline, it is possible over time to drop, unnoticed, from the top to the bottom of the normal range 

without dropping below the normal range. In this case, 

changes from a baseline would be more meaningful and 

might detect impacts to pulmonary function earlier.15

It is also important to obtain smoking status for use in 

epidemiological studies, and to move towards a smokefree Army. A prospective evaluation performed by the 

Millennium Cohort Study team* found greater percentages of smoking initiation in never-smokers, smoking 

resumption in past smokers, and increased smoking in 

current smokers among service members with a history of deployment when compared to nondeployers.17

Smoking is typically raised as an issue when discussing 

respiratory health outcomes, but not merely to attribute 

health effects to another cause. The infl ammation associated particularly with new-onset smoking might make 

one more susceptible to exposures. For example, acute 

eosinophilic pneumonia, a serious but uncommon respiratory condition diagnosed in some deployed individuals, appears to be related to new-onset smoking.9

The DoD and VA have recognized the need to address 

burn pit exposure as well as other exposure effects on 

pulmonary function and disease. Additionally, organ 

systems other than the pulmonary system are affected 

by at least some of the chemicals involved with burn 

pit smoke and other airborne exposures. The DoD and 

VA now consider deployment-related airborne hazards a 

better focus than burn pits. The fi rst study by the Armed 

Forces Health Surveillance Center used locations in the 

CENTCOM area of operations (specifi cally, 2 burn pit 

sites and 2 nonburn pit sites). The selected locations 

allowed comparisons between sites where individuals 

were exposed to burn pit smoke and sites where individuals were not exposed to burn pit smoke, but were 

exposed to other pollution sources, such as particulate 

matter and pollution from local industry. The studies 

evaluated circulatory diseases, cardiovascular disease, 

signs, symptoms, and ill-defi ned conditions, as well as 

respiratory diseases. The Naval Health Research Center 

component of the study evaluated birth outcomes in infants whose mothers and fathers had been exposed before and during pregnancy, chronic multisystem illness, 

lupus, and rheumatoid arthritis. Continued follow-up 

of these cohorts will provide information regarding deployment related exposures in addition to burn pits and 

any health condition can be included in the analysis.

A number of Veterans groups have worked for recently 

introduced federal legislation that mandates a VA burn 

pit registry.18 According to Congressman Todd Akin, 

who authored the legislation:

Unfortunately the VA has struggled to help these Veterans. Creating a burn pit registry is an important step to 

help these Veterans get the care and support they need 

and that our nation has promised them.18

However, given that the IOM concluded that ambient air 

pollution may pose greater health risks than chemicals 

emitted from military burn pits, mandating a registry 

of those exposed to burn pits might not target individuals at risk of health outcomes. Registries enable medical 

follow-up and outreach efforts. A registry and subsequent studies limited to those who self-report exposure 

to burn pits may miss identifying adverse health effects 

in those exposed to wider pollution. According to the 

IOM report, there are no illnesses specifi cally associated with burn pit exposure and, therefore, no markers 

to allow for medical follow-up. However, the broader 

question of deployment-related inhalational exposures 

and health outcomes deserves continued study.

REFERENCES

1. Weese CB. Issues related to burn pits in deployed 

settings. US Army Med Dept J. April-June 2010:22-

28.

2. Vietas JA, Taylor G, Rush V, Deck A. Screening 

Health Risk Assessment, Burn Pit Exposures, Balad 

Air Base, Iraq and Addendum Report. Aberdeen 

Proving Ground, MD: US Army Center for Health 

Promotion and Preventive Medicine; May 2008. 

USACHPPM Report No. 47-MA-08PV-08/AFIOH 

Report No. IOH-RS-BR-TR-2008-0001. Available 

at: http://www.dtic.mil/cgi-bin/GetTRDoc?AD=

ADA493142&Location=U2&doc=GetTRDoc.pdf. 

Accessed March 15, 2012.

3. Epidemiological Studies of Health Outcomes among 

Troops Deployed to Burn Pit Sites. Washington DC, 

US Dept of Defense. May 2010. Available at: http://

www.af hsc.mil/viewDocument?file=100604_

FINAL_Burn_Pit_Epi_Studies.pdf.

REVIEW OF THE INSTITUTE OF MEDICINE REPORT: LONG-TERM HEALTH CONSEQUENCES

OF EXPOSURE TO BURN PITS IN IRAQ AND AFGHANISTAN

*The Millennium Cohort Study is an ongoing, longitudinal 

cohort study designed to evaluate any long-term health 

effects of military service, including deployments. Based 

at the Naval Health Research Center in San Diego, CA, it 

is the largest prospective study ever undertaken in the 

US military.16
 July – September 2012 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

4. Weese CB, Abraham JH. Potential health implications associated with particulate matter exposure in 

Southwest Asia. Inhal toxicol. 2009:21(4):291-296.

5. Pope CA III. Epidemiology of fi ne particulate 

air pollution and human health: biologic mechanisms and who’s at risk?. Environ Health Perspect. 

2000;108(suppl 4):713-723.

6. Integrated Science Assessment for Particulate 

Matter [fi nal report]. Washington, DC: US 

Environmental Protection Agency; December 

15, 2009. EPA/600/R-08/139F, EPA/600/R08/139FA. Available at: http://cfpub.epa.gov/ncea/

isa/recordisplay.cfm?deid=216546#Download. 

Accessed March 15, 2012.

7. Szema AM, Peters MC, Weissinger KM, Gagliano 

CA, Chen JJ. New-onset asthma among soldiers 

serving in Iraq and Afghanistan. Allergy Asthma 

Proc. 2010;31(5):67-71.

8. Smith B, Wong CA, Smith TC, et al. Newly reported respiratory symptoms and conditions among 

military personnel deployed to Iraq and Afghanistan: a prospective population-based study. Am J 

Epidemiol. 2009;170(11):1433-1442.

9. Shorr AF, Scoville SL, Cersovsky SB, et al. 

Acute eosinophilic pneumonia among US military personnel deployed in or near Iraq. JAMA. 

2004;292(24):2997-3005.

10. King MS, Eisenberg R, Newman JH, et al. Constrictive bronchiolitis in soldiers returning from Iraq 

and Afghanistan. N Engl J Med. 2011;365(3):222-

230.

11. Institute of Medicine. Long-Term Health Consequences of Exposure to Burn Pits in Iraq and 

Afghanistan. Washington, DC: The National 

Academies Press; 2011. Available at: http://www.

iom.edu/Reports/2011/Long-Term-HealthConsequences-of-Exposure-to-Burn-Pits-in-Iraqand-Afghanistan.aspx#. Accessed March 21, 2012.

12. Englebrecht JP, McDonald EV, Gillies R, Jayanty 

KM, Casuccio G, Gertler AW. Characterizing mineral dusts and other aerosols from the Middle East. 

Inhal Toxicol. 2009;21(4):297-336.

13. US Preventive Services Task Force. Screening 

for chronic obstructive pulmonary disease using 

spirometry: US Preventive Services Task Force 

recommendation statement. Ann Intern Med. 

2008;148:529-534.

14. Townsend MC, and the ACOEM Occupational 

and Environmental Lung Disorders Committee. 

Spirometry in the occupational health setting-2011 

update. J Occup Environ Med. 2011;53(5):569-584.

15. Townsend MC, and the ACOEM Occupational 

and Environmental Lung Disorder Committee. 

Evaluating pulmonary function change over time. 

Policies and Position Statements page. American 

College of Occupational and Environmental 

Medicine web site. Available at: http://www.acoem.

org/EvaluatingPulmonaryFunctionChange.aspx. 

Accessed March 29, 2012.

16. Ryan MAK, Smith TC, Smith B, et al. Millennium 

cohort: enrollment begins a 21-year contribution 

to understanding the impact of military service. 

J Clin Epidemiol. 2007;60(2):181-191. Available 

at: http://dodreports.com/pdf/ada519306.pdf. Accessed March 21, 2012.

17. Smith B, Ryan MAK, Wingard DL, Patterson TL, 

Slymen DJ, Macera CA. Cigarette smoking and military deployment. Am J Prev Med. 2008;35(6):539-

546.

18. Akin introduces burn pit legislation to support 

veterans-HR 3337. Congressman Todd Akin web 

site. November 3, 2011. Available at: http://akin.

house.gov/index.php?option=com_content&vi

ew=article&id=1678:akin-introduces-burn-pitlegislation-to-support-veterans&catid=31:2011-

press-releases&Itemid=88. Accessed March 29, 

2012.

AUTHOR

Dr Baird is Program Manager, Environmental Medicine, 

US Army Public Health Command, Aberdeen Proving 

Ground, Maryland.

Marines observing burn pit smoke plumes at a location in 

Afghanistan.
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

BACKGROUND

Problem Statement

Following the fi rst Gulf War (1991), concerns related to 

potential toxic inhalational exposures among military 

personnel were raised that remain unresolved. Similar 

exposure concerns during deployment have arisen as a 

result of current efforts, including military support of 

Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). During these confl icts, extensive 

intermittent ambient sampling has been conducted at 

select locations within the US Central Command area 

of operations (CENTCOM AO)1

 and questionnaires 

aimed at documenting service members’ environmental 

exposures while deployed have been completed. Some 

work has been done to characterize exposure to specifi c exposure events on a population level. However, 

research regarding the possible relationship(s) between 

deployment-associated toxic inhalational exposures and 

subsequent health outcomes is limited, due to the fact 

that quantitative, verifi able exposure information at the 

individual level is diffi cult to ascertain.

Potential Exposures

The current confl icts in Southwest Asia comprise the 

longest period of continuous armed confl ict in US history. As a result, almost all US military personnel serving since 2001 have deployed in support of these operations,2,3 typically 12 months at a time, with many service 

members deploying multiple times. As a result, concerns 

regarding environmental exposures during deployment 

have been documented frequently by deployed service 

members.4

 Helmer et al found that concern for poor air 

quality from burning trash, smoke from oil well fi res, 

and sand/dust was documented in 34%, 20%, and 16%, 

respectively, of reviewed medical records.5

 Air sampling conducted by the Department of Defense (DoD) 

in Southwest Asia areas of operation identifi ed particulate matter (PM) as a major environmental exposure 

of concern.6

 Deployment-associated sources of PM include fi ne sand and dust that was resuspended by strong 

winds or troop activities, exhaust from the engines of 

heavy machinery (gas, diesel, turbine), the industrial 

landscape that is characteristic of some locales, and potentially toxic smoke from burn pits and fi res.6

 Concern 

regarding these population level deployment-related 

exposures, as well as uncertainty regarding the health 

effect of combined exposures has highlighted the need 

for deeper understanding of individual environmental 

exposure during deployment. Gaining this understanding is complicated by the fact that personal exposure experiences vary with the unit, their mission, and location. 

Further, there may be unplanned or accidental exposures 

not refl ected in available aggregate sampling data.

Exposure Events

Large populations have potentially had inhalational exposures due to ambient conditions, localized sources 

(industry), unplanned events (releases/venting of toxic 

substances, fi res), and activities such as waste management. Available sampling data indicate that measured 

levels are rarely of acute concern, but if sustained, may 

be associated with or contribute to chronic health effects. The availability of sampling data varies, with 

most available data refl ecting ambient conditions, and 

minimal data available for unplanned incidents.

Burn Pits

In addition to naturally occurring, ambient PM, burn 

pits are being recognized as a contributing source of PM 

at many OIF and OEF deployment locations in Southwest Asia.4,7 Prior to 2010, burn pits were widely used 

as waste management tools at locations where more sophisticated methods of solid waste disposal (incinerators, 

reuse/recycling, containerized removal by contractors) 

were not feasible methods for trash disposal in the wartime environment. A burn pit is formally defi ned as:

an area, not containing...an incinerator or other equipment specifi cally designed...for burning of solid waste, 

designated for the purpose of disposing of solid waste by 

burning in the outdoor air at a location with more than 

100 attached or assigned personnel and that is in place 

longer than 90 days.8

Hospitalization and Medical Evacuation of

 Army Personnel Due to Toxic Inhalational

 Exposure—Operations Iraqi Freedom and

 Enduring Freedom, 2001 Through Mid 2011

Jessica M. Sharkey, MPH
 July – September 2012 49

Open-air burn pit use is now minimized due to the potential for both short-term and long-term health effects.

In response to concerns regarding the possible health effects brought about or exacerbated by exposure to smoke 

plumes originating from burn pits during deployment, 

several research initiatives to examine potential associations have been conducted. The Armed Forces Health 

Surveillance Center, Naval Health Research Center, and 

US Army Public Health Command conducted a series of 

evaluations that found exposure to burn pits was not associated with incidents of or worsening prevalent respiratory health diseases. However, it was acknowledged 

that, in light of study limitations, further investigation 

is needed to establish a better understanding of the relationship between exposure and outcome.9

 The Institute of Medicine* recently released the results of their 

study, Long-Term Health Consequences of Exposure to 

Burn Pits in Iraq and Afghanistan†

,

7

 which, among other 

things, concluded that it is uncertain whether exposures 

to emissions from burn pits have caused long-term 

health effects. But the report also included:

...the committee’s review of the literature and the data 

from JBB [Joint Base Balad] suggests that service in Iraq 

or Afghanistan—that is, a broader consideration of air 

pollution than exposure only to burn pit emissions—

might be associated with long-term health effects, particularly in susceptible (for example, those who have 

asthma) or highly exposed subpopulations (such as those 

who worked at the burn pit).7(p114)

Despite the current absence of defi nitive evidence citing 

a direct link between burn pit smoke exposure and longterm chronic respiratory conditions among OIF and OEF 

veterans, deployed military forces, following DoD policies, have been decreasing their reliance on burn pits.

Fires

Not surprisingly, signifi cant fi re events have been documented in the combat theaters of Southwest Asia. The 

impact on the environment included air pollutants that 

may have had potentially detrimental consequences on 

the respiratory health of exposed military personnel. 

One study conducted after the Kuwait oil well fi res at 

the end of the 1991 Gulf War found a statistically signifi -

cant positive association between the prevalence of selfreported exposure to the smoke and self-reported symptoms of asthma and bronchitis. That association did not 

hold when modeled exposure was assessed in conjunction with the same respiratory outcomes.10 Petruccelli 

et al found increased reports of respiratory symptoms 

(such as cough, shortness of breath, upper respiratory 

tract irritation) among Soldiers with potential exposure 

to the Kuwait oil fi res, a phenomenon that mostly dissipated at redeployment.11 More pertinent to the current 

confl ict is the Al Mishraq sulfur fi re that burned in Iraq 

for 3 weeks in June 2003. A retrospective cohort study 

indicated more self-reported respiratory symptoms on 

the Postdeployment Health Assessment, DD Form 2796 

(administered within 3 months of the end of deployment), among exposed personnel but did not show an 

increase of chronic respiratory conditions in association 

with exposure to the smoke plume.12

Geological Dust

An analysis conducted by Englebrecht et al13 on air 

samples collected from the CENTCOM AO implicated 

geological dust as one of the 3 main pollutants in the 

environment. The samples of interest showed generally 

expected composition, both chemical and mineralogical, 

when compared to samples from the Sahara and desert 

regions of the United States and China. However, average mass and chemical concentrations of the CENTCOM AO samples used in the analysis are as much as 10 

times greater than those seen in samples from 10 rural 

and urban sites in the US near to military bases with 

similarly dry climates. Notably, the levels detected during this sampling program’s efforts regularly exceeded 

the 24-hour standards set by the US Environmental Protection Agency.14

Exhaust and Industrial Byproducts

The operational setting in Iraq is largely desert, and industrial in nature. Existing infrastructure sources that 

contribute to air pollution include oil, cement, and fertilizer industries. The terrain of Afghanistan is mostly 

rugged mountains and desert, and environmental conditions have been described as degraded. Coupled with inherent environmental stressors of war, including factors 

like exhaust from military vehicles/heavy machinery 

and chemicals released during explosions, the extent of 

PM generated from these sources is of major concern 

regarding the respiratory health of our service members 

while deployed.15-17

Identification of Exposures Using 

Disease and Nonbattle Injury Data

Acute, high level exposures would likely affect few individuals, but are typically not refl ected by sampling due 

to their unplanned nature. While individuals may seek 

*The Institute of Medicine is the health component of the National Academy of Sciences. It is an independent, nonprofi t organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public. Information 

available at: http://www.iom.edu/About-IOM.aspx.

†The Institute of Medicine final report is discussed in detail in the article on page 43.
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

care, these occurrences 

have not been systematically evaluated. Disease and 

nonbattle injury (DNBI) is 

the term for an illness and/

or injury that is not directly 

related to enemy action 

or participation in direct 

combat. Reporting of DNBIs from deployed settings 

can be used to evaluate the 

frequency and nature of individual toxic inhalational 

exposures. They can include injuries and illnesses 

resulting from training or 

recreational activities or 

occupational and environmental exposures indirectly 

caused by military service. 

Throughout the history of 

US confl ict, DNBIs have 

contributed signifi cantly 

to decreased force strength 

and operational readiness 

of our fi ghting troops.18-20

In order to highlight the 

impact of environmental 

exposures on the individual 

Soldier across the US Army, 

the focus of this article is DNBI related to toxic substance exposures, particularly those that are inhalational 

in nature, which resulted in hospitalizations or medical 

evacuations from the combat theater from 2001 through 

mid 2011. Since medical visits which did not result in 

hospitalization are not included, the data does not refl ect 

exposures which may have been less severe.

DATA SOURCES

The DoD Standard Inpatient Data Records database stores information regarding inpatient 

medical encounters within the military health 

system. The electronic records for all hospitalizations occurring during deployment were 

accessed through the Patient Administration 

Systems and Biostatistics Activity. The US 

Transportation Command Regulating and 

Command and Control Evacuation System 

(TRAC2

ES) is a web-based data repository 

that stores information pertaining to all patient regulation and movement throughout 

DoD activities and locations.21 Specifi cally, 

TRAC2

ES contains individual health-related 

data necessary to coordinate the transition of personnel 

requiring medical evacuation from the operational environment to a location where specialized medical care 

can be provided.22 In-theater hospitalization data was 

reviewed to identify hospitalizations among active duty 

Soldiers due to toxic inhalation exposures between 2001 

and mid 2011. External cause codes were reviewed and 

available records were further refi ned to identify additional information and need for medical evacuation.

RESULTS

Toxic Substance Exposure

Disease and nonbattle injuries related to toxic substance 

exposures are specifi ed as one of the following 3 categories: poisoning by ingestion of toxic substances, poisoning by inhalation of toxic substances, or adverse systemic or skin reaction by contact with a toxic substance. 

The most commonly occurring subcategory is ingestion 

of toxic substances, followed by inhalation of toxic substances, then adverse systemic or skin reaction with a 

toxic substance. Table 1 shows the distribution for each 

toxic substance exposure category.

Hospitalizations

Demographics

The data for all US Army personnel with a history of 

OIF and OEF deployments between 2001 and mid 2011 

were eligible for capture in the query for toxic inhalation-related hospitalizations and evacuations. A total of 

100 such hospitalizations was identifi ed. The distribution of population demographics for those hospitalizations is shown in Table 2.

Causes, Trends, and Theater Distribution

Specifi c causes (identifi ed by ICD-9* codes in the primary diagnosis fi eld) that attributed to toxic inhalational 

Table 1. Distribution of in-theater (OIF and OEF) toxic substance exposures 

(DNBI) requiring hospitalization from 2001 through mid 2011.

Toxic Substance Exposure Environment When Exposed Total

Training On-Duty Unknown

Poisoning by ingestion of toxic 

substances

1 414 14 429

Poisoning by inhalation of 

toxic substances

0 95 5 100

Adverse systemic or skin 

reaction by contact with a 

toxic substance

11 45 0 56

Total 12 554 19 585

Source: DoD Standard Inpatient Data Records database

OIF indicates Operation Iraqi Freedom

OEF indicates Operation Enduring Freedom

DNBI indicates disease and nonbattle injury

Table 2. Population demographics of Soldiers hospitalized in theater due to 

toxic inhalation exposures 

from 2001 to mid 2011 

(N=100).

Category No.

Age (years)

17-19 6

20-29 62

30-39 24

40-49 6

50-59 2

Gender

Male 93

Female 7

Rank

E1-E3 25

E4-E6 64

E7-E9 1

WO1-WO5 3

O1-O3 6

O4-O1Ø 1

Component

Active Army 67

Army Reserve 20

Army National Guard 13

Source: DoD Standard Inpatient 

Data Records database

*International Classification of Diseases, Ninth Revision

HOSPITALIZATION AND MEDICAL EVACUATION OF ARMY PERSONNEL DUE TO TOXIC INHALATIONAL

EXPOSURE—OPERATIONS IRAQI FREEDOM AND ENDURING FREEDOM, 2001 THROUGH MID 2011
 July – September 2012 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

exposures consisted mostly of toxic effects of gases, 

fumes, and vapors (not otherwise specifi ed, n=22; not 

elsewhere classifi ed, n=7), and toxic effects of chlorine 

gas (n=14). These diagnoses represent 43% of all toxic 

inhalational exposure hospitalizations (N=100). As 

shown in Figure 1, the frequency of toxic inhalational 

hospitalizations increased from 2001 through 2003, 

before decreasing and remaining fairly stable between 

2004 and 2007, increased in 2008 before declining from 

2009 through mid 2011. Operation-specifi c counts indicate the majority (n=91) of toxic inhalational exposure 

hospitalizations occurred in OIF, with 9 hospitalizations 

recorded from OEF.

Evacuations

Data gathered from TRAC2ES indicated 26 air evacuations from the combat theaters of OIF and OEF between 

2001 and mid 2011 with toxic inhalational exposure listed as the cause of injury. The population demographics 

for those evacuations is presented in Table 3.

As shown in Figure 2, the frequency of evacuations for 

toxic inhalation increased from 2001 through 2004, decreased in 2005 before increasing and levelling between 

2006 and 2008, then declined in 2009 and remained 

fairly stable through mid 2011. Theater-specifi c counts 

indicate the majority of toxic inhalational exposure 

evacuations were made from OIF (n=20), with 6 evacuations recorded from OEF.

CONCLUSION

Disease and nonbattle injuries have contributed signifi -

cantly to overall morbidity and mortality associated with 

battle throughout the history of US confl ict, and the current confl icts are no exception.18,20 Based on the available 

data, poisoning by exposure to toxic 

substances, including toxic inhalations, is relatively infrequent. Some 

cases are serious enough to warrant 

in-theater hospitalization, a subset of 

which results in out-of-theater medical evacuation.

While deployed in support of OIF 

and OEF, our military personnel may 

experience toxic substance exposures that can have respiratory health 

consequences. Unfortunately, most 

of these exposures in the deployment 

environment cannot be avoided, and 

the demands of combat operations 

and wartime stressors may hinder adequate preventive measures. 

While both the acute and chronic health effects of such 

exposures are not yet fully understood, studying such a 

relationship is diffi cult due to a lack of individual exposure data. Hospitalization and medical evacuation data 

related to toxic inhalational exposures were examined 

in an effort to better understand the extent of true exposure during deployment at the individual level in an 

objective fashion. Available data indicate that the number of toxic inhalational exposures signifi cant enough 

to require hospitalization from 2001 through mid 2011 

is small relative to the number of troops who were deployed and potentially 

exposed during that time 

period. A smaller subset 

of the hospitalized service members required 

medical evacuation due 

to severe inhalational exposures. As the data used 

in this study were limited 

to those toxic exposures 

signifi cant enough to require hospitalization or 

medical evacuation, it 

represents some fraction 

of a still unquantifi ed denominator that includes 

exposures that may have 

resulted in symptoms or 

medical evaluation, but 

not hospitalization. Additionally, toxic inhalation 

exposures may affect individuals with conditions 

which make them more 

Frequency

Year

Figure 1. Yearly frequency distribution of toxic inhalation exposures requiring hospitalization (N=100) of Soldiers during Operations Iraqi Freedom and Enduring Freedom from 2001 through mid 2011. Source: DoD Standard Inpatient Data Records 

database.

Table 3. Population demographics of Soldiers evacuated from 

theater due to toxic inhalation 

exposures from 2001 to mid 

2011 (N=26).

Category No. %

Age (years)

17-19 1 3.8

20-29 14 53.8

30-39 9 34.6

40-49 2 7.7

Gender

Male 22 84.6

Female 4 15.4

Rank

E1-E3 15 57.7

E4-E6 9 34.6

O1-O3 2 7.7

Component

Active Army 16 61.5

Not annotated 10 38.5

Source: US Transportation Command 

Regulating and Command and Control Evacuation System
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

susceptible to exacerbations, such 

as asthma.23 These hospitalizations 

would most likely be coded with the 

primary condition (asthma) and not 

the precipitating exposure. Therefore, 

while available data indicate that 

acute inhalational injury of signifi -

cance is a rare event, this likely represents the “tip of the iceberg” of inhalational exposures while deployed.

The concern that the DoD has not 

truly identifi ed the full impact of 

toxic inhalational exposures during 

military operations is not new, however. In fact, some personnel have 

received treatment due to environmental exposures during deployment, 

yet systems previously available have 

not captured this information adequately. As a result, 

some very specifi c solutions have been recently developed to improve the quality of the data collected when 

exposures result in medically notable encounters. These 

efforts include the establishment of the Defense Occupational and Environmental Health Readiness SystemIncident Reporting module,* an offi cial DoD archive 

system that includes fi elds for collection of incident data, 

personnel rosters, and medical/duty status; the institution of specifi c ICD-9 causal codes for consistent reporting and surveillance; development of base camp periodic 

occupational and environmental monitoring summaries 

and incident/hazard specifi c factsheets. Additionally, 

the US Army Public Health Command’s Environmental 

Medicine Program now offers an Environmental Medicine Clinical Consult Service, the only offi cial environmental medicine level V support†

 offered through the 

Army Medical Command which provides documents 

and presents recommendations regarding diagnostics 

and/or medical documentation to address individual 

concerns associated with environmental exposures (see 

inset below). These tools facilitate more comprehensive 

evaluation, documentation, and reporting of toxic inhalational events and other environmental exposure incidents, and improve the DoD’s ability to address post 

deployment health concerns related to such exposures.

REFERENCES

1. National Research Council. Review of the 

Department of Defense Enhanced Particulate Matter 

Surveillance Program Report. Washington, DC: 

The National Academies Press; 2010. Available at: 

http://www.nap.edu/catalog.php?record_id=12911.

Accessed March 23, 2012.

2. Cavallaro G. If you haven’t deployed yet, stand by: 

search for Soldiers without a combat tour could 

result in break for multiple deployers. Army Times

[serial online]. February 24, 2008. Available at: 

http://www.armytimes.com/news/2008/02/army_

deploy_080225w/. Accessed October 27, 2011.

3. Mitchell B. Army Seeks Deployment Equality. 

Military.com News [serial online]. May 19, 2009. 

Available at: http://www.military.com/news/article/

army-seeks-deployment-equality.html. Accessed 

October 27, 2011.

4. Smith B, Wong CA, Smith TC, Boyko EJ, Gackstetter GD, Ryan MAK. Newly reported respiratory 

symptoms and conditions among military personnel 

deployed to Iraq and Afghanistan: a prospective 

population-based study. Am J Epidemiol. 2009;

170(11):1433-1442.

*https://doehrs-ih.csd.disa.mil/Doehrs/

†Level V is support provided by the US Army Public Health Command and the Navy and Marine Corps Public Health Center. Responsibilities 

include, but are not limited to, supporting deployed level I – IV preventive medicine personnel; performing definitive testing of air, water, 

and soil samples; and performing vector pathogen testing.24

Year

Frequency

Figure 2. Yearly frequency distribution of toxic inhalation exposures requiring medical 

evacuation (n=26) of Soldiers from the combat theaters of Operations Iraqi Freedom 

and Enduring Freedom from 2001 through mid 2011. Source: US Transportation 

Command Regulating and Command and Control Evacuation System

US Army Public Health Command Environmental

 Medicine Consult Service

Building E1570

Aberdeen Proving Ground-Edgewood Area, Maryland

 21010-5400

Telephone: 410-436-2714

Email: USAPHC-EMP@AMEDD.army.mil

HOSPITALIZATION AND MEDICAL EVACUATION OF ARMY PERSONNEL DUE TO TOXIC INHALATIONAL 

EXPOSURE—OPERATIONS IRAQI FREEDOM AND ENDURING FREEDOM, 2001 THROUGH MID 2011
 July – September 2012 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

5. Helmer DA, Rossignol M, Blatt M, Agarwal R, 

Teichman R, Lange G. Health and exposure concerns 

of veterans deployed to Iraq and Afghanistan. J 

Occup Environ Med. 2007;49(5):475-480.

6. Weese CB, Abraham JH. Potential Health implications associated with particulate matter exposure in 

deployed settings in southwest Asia. Inhal Toxicol. 

2009;21(4):291-296.

7. Institute of Medicine. Long-Term Health 

Consequences of Exposure to Burn Pits in Iraq 

and Afghanistan. Washington, DC: The National 

Academies Press; 2011. Available at: http://

www.iom.edu/Reports/2011/Long-Term-HealthConsequences-of-Exposure-to-Burn-Pits-in-Iraqand-Afghanistan.aspx#. Accessed March 21, 2012.

8. Department of Defense Instruction 4715.19: Use 

of Open-Air Burn Pits in Contingency Operations. 

Washington, DC: US Dept of Defense; February 15, 

2011:9.

9. Armed Forces Health Surveillance Center. Epidemiological Studies of Health Outcomes 

Among Troops Deployed to Burn Pit Sites. 

Washington, DC: US Dept of Defense; May 

27, 2010. Available at: http://www.afhsc.mil/

viewDocument?file=100604_FINAL_Burn_Pit_

Epi_Studies.pdf. Accessed March 23, 2012.

10. Lange JL, Schwartz DA, Doebbeling BN, Heller 

JM, Thorne PS. Exposures to the Kuwait oil fi res 

and their association with asthma and bronchitis 

among gulf war veterans. Environ Health Perspect. 

2002;110(11):1141-1146.

11. Petruccelli BP, Goldenbaum M, Scott B, et al. 

Health Effects of the 1991 Kuwait Oil Fires: A Survey of US Army Troops. J Occup Environ Med. 

1999;41(6):433-439.

12. Misraq Sulfur Fire Environmental Exposure Assessment, June 2003 through March 2007. Epidemiological Consultation Number 64-FF-064C-07. Aberdeen 

Proving Ground, MD: US Army Center for Health 

Promotion and Preventive Medicine. April, 2009.

13. Engelbrecht JP, McDonald EV, Gillies JA, Jayanty 

RK, Casuccio G, Gertler AW. Characterizing mineral dusts and other aerosols from the Middle East. 

Inhal Toxicol. 2009;21(4):297-336.

14. Abraham JH, DeBakey SF, Reid L, Zhou J, Weese 

CB. Does deployment to Iraq and Afghanistan affect respiratory health of US military personnel?. J 

Occup Environ Med. In press.

15. Dixon M, Fitz-Gibbon S. The environmental 

consequences of the war on Iraq [press release]. 

London, UK: The Green Party. April 2003. Available at: http://www.docstoc.com/docs/26639534/

The-Environmental-Consequences-of-the-War-onIraq. Accessed March 23, 2012.

16. El Raey M. Air quality and atmospheric pollution 

in the Arab region. Kingdom of Bahrain: United 

Nations Environment Programme – Regional Offi ce for West Asia; 2011. Available at: http://www.

un.org/esa/sustdev/csd/csd14/escwaRIM_bp1.pdf. 

Accessed September 12, 2011.

17. Mosher DE, Lachman BE, Greenberg MD, Nichols 

T, Rosen B, Willis HH. Green warriors: Army environmental considerations for contingency operations from planning through post-confl ict. Santa 

Monica, CA: RAND Corporation, 2008. Available 

at: http://www.rand.org/pubs/monographs/MG632. 

Accessed March 23, 2012.

18. Hauret KG, Taylor BJ, Clemmons NS, Block SR, 

Jones BH. Frequency and causes of nonbattle injuries air evacuated from Operations Iraqi Freedom 

and Enduring Freedom, US Army, 2001-2006. Am 

J Prev Med. 2010;38(suppl 1):S94-S107.

19. Sanders JW, Putnam SH, Frankart C, et al. Impact 

of illness and non-combat injury during Operations 

Iraqi Freedom and Enduring Freedom (Afghanistan). Am J Trop Med Hyg. 2005;73(4):713-719.

20. Wojcik BE, Humphrey RJ, Czejdo B, Hassell 

LH. U.S. Army disease and nonbattle injury 

model, refi ned in Afghanistan and Iraq. Mil Med.

2008;173(9):825-835.

21. Zouris JM, Wade AL, Magno CP. Injury and illness casualty distributions among U.S. Army and 

Marine Corps personnel during Operation Iraqi 

Freedom. Mil Med. 2008;173(3):247-252.

22. Harman DR, Hooper TI, Gackstetter GD. Aeromedical evacuations from Operation Iraqi Freedom: 

a descriptive study. Mil Med. 2005;170(6):521-527.

23. Roop SA, Niven AS, Calvin BE, Bader J, Zacher 

LL. The prevalence and impact of respiratory 

symptoms in asthmatics and nonasthmatics during 

deployment. Mil Med. 2007;172(12):1264-1269.

24. Field Manual 4-02: Force Health Protection in a 

Global Environment. Washington, DC: US Dept of 

the Army; February 2003: sect 2-4. [This manual, 

although currently characterized by the Army as 

obsolete, is still the governing document pending 

publication of Army Techniques Publication 4-02.8

during 2013.]

AUTHOR

Ms Sharkey is an Epidemiologist for the Environmental 

Medicine Program of the Occupational and Environmental Portfolio, US Army Public Health Command, Aberdeen Proving Ground, Maryland.
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

Throughout history there have been psychological effects on Soldiers and their Families during combat deployment.1

 Posttraumatic stress disorder (PTSD) is an 

anxiety disorder that may occur following an emotionally terrifying, life-threatening event or events that create psychological trauma. Events associated with onset 

of PTSD include, but are not limited to: 

military combat, violent personal assault (ie, sexual 

assault, robbery, mugging), being kidnapped or taken hostage, terrorist attack, torture, incarceration as 

a prisoner of war or in a concentration camp, natural 

or manmade disasters, and automobile accidents.2

It is estimated that 5% to 24% incidence of PTSD for the 

over 2 million American troops deployed to Iraq and Afghanistan occurred from September 2001 until October 

2009.3

 Primary characteristics of PTSD are debilitating 

fear and helplessness.4

 As such, severe PTSD symptoms 

can be detrimental to the overall life and functioning of 

the individual, with consequences at the biological, psychological, and social levels. The social implications of 

PTSD directly relate to attachment theory and the disruption of ways we relate with others in our social support system.5

 Attachment theory provides a framework 

for understanding and addressing the central problems 

of PTSD that affect psychosocial functioning: emotion 

or affect regulation, interpersonal skills, and social support behaviors.6,7

ATTACHMENT THEORY AND 

ATTACHMENT PATTERNS/STYLES

Adult attachment is an extension of the early attachment 

relationship between the infant and caregiver.8

 This relationship sets the foundation for all future attachment 

relationships and the “internal working model” of self 

and of others. The theory concentrates on secure attachments between infants and their caregivers as related 

to the development of social and emotional stability. 

Moreover, the ideal of secure attachment “assumes that 

successful navigation through the universal stages of attachment normatively provides children with a secure 

emotional attachment base, a base from which children 

competently lead the rest of their relational lives.”9

Child attachment theory was developed in the 1970s 

by Mary Ainsworth,10 who established 3 different attachment styles in children: type B or secure, type A or 

avoidant, and type C or ambivalent/resistant. A fourth 

category identifi ed by Main and Solomon11 was labeled 

as disoriented or disorganized attachment, or type A/C.8

The fi eld was further developed by Bowlby8

 who asserted 

the fi rst attachment relationship between the infant and 

caregiver (usually the mother) sets the stage for all future 

attachment relationships. In their studies of romantic love, 

Hazan and Shaver13 developed a 3-category theory of 

adult attachment based on Ainsworth’s original 3 infantparent styles. Their styles were labeled secure, avoidant, 

and ambivalent. As with the child literature, a fourth 

The Impact of Attachment Style on

 Posttraumatic Stress Disorder Symptoms

 in Postdeployed Military Members

LTC Sandra M. Escolas, MS, USA

Rachel Arata-Maiers

1LT Erika J. Hildebrandt, MS, USA

Alan J. Maiers, PsyD

Shawn T. Mason, PhD

Maj Monty T. Baker, MSC, USAF

ABSTRACT

This study examined the effects of attachment style on self-reported posttraumatic stress disorder (PTSD) symptoms 

in a population of service members (N=561). Active duty, postdeployment service members completed anonymous 

questionnaires including 2 measures of adult attachment and the PTSD checklist–military as a measure of PTSD 

symptoms. Results confi rmed the central hypothesis that attachment style was related to reported PTSD symptoms. Secure attachment style was associated with less reported PTSD symptoms and therefore may be involved in 

mechanisms associated with protection from developing PTSD after experiencing wartime trauma. Results were 

consistent when tested across continuous and dichotomous assessments that captured diagnostic criteria. This study 

demonstrates a signifi cant relationship between attachment style and PTSD symptoms within a military population, 

potentially providing the basis for future research in this area.
 July – September 2012 55

adult attachment category was added by Bartholomew.13

Bartholomew’s styles are secure, preoccupied, fearful, 

and dismissing. Conceptually, the secure and preoccupied styles are similar to Hazan and Shaver’s12 secure 

and ambivalent styles, whereas fearful and dismissing 

describes 2 different types of avoidant individuals. More 

recently, the adult attachment literature has expanded to 

look at adult attachment more succinctly as a composite 

of relationship anxiety and relationship avoidance.

Attachment style is based on how you feel about yourself and about others. In Bartholomew’s styles, secure 

describes low relationship anxiety and low avoidance, 

preoccupied indicates high anxiety and low avoidance, 

fearful depicts high anxiety and high avoidance, and dismissing characterizes low anxiety and high avoidance. 

Additionally, insecure adults may have anxious-resistant 

attachment, which means they worry that their partner 

may not love them completely, and they are emotionally 

reactive when their attachment needs go unmet. Conversely, avoidant partners appear not to care too much 

about close relationships; they are not dependent on others and others cannot be dependent on them.12 The attachment research literature shows that individuals with 

secure attachment “score higher on personality variables indicative of self-confi dence, psychological wellbeing, and functioning in the social world.”15 Securely 

attached individuals are also described as “adaptive, capable, trusting and understanding,” as well as “able to 

appraise stressful situations, cope more positively with 

them, and adjust more fl exibly to these experiences.”14

POSTTRAUMATIC STRESS DISORDER

AND SOCIAL BONDS

Interpersonal factors play a large role in the diagnosis, 

development, maintenance, and recovery from PTSD. 

From a diagnostic perspective, symptoms of social impairment include various degrees of withdrawal from 

relationships and social roles. In terms of development, 

PTSD diagnoses often result from interpersonal trauma, 

such as rape and abuse, as compared with natural disasters, or even the trauma of combat itself. As such, it 

appears that PTSD involves a dissembling of the internal 

structures of trust and attachment that allow us to connect with important others and to function normally in 

social settings as a result of this breach in social bonds 

via trauma. Regardless of the kind of traumatic experience, people with PTSD suffer extreme social diffi culty 

due to the impairment to the ability to distinguish between dangerous and normal stimuli.16 Trauma studies 

show that the biophysical, psychological, and social functioning of individuals with PTSD is comprised at neurophysiological levels in such a way that limbic systems 

for self regulating or self-calming are disrupted; rational 

thinking and action are debilitated; and interpersonal relationships as well as social bonds are often broken. It 

is important to note that social support processes are at 

play within these sequelae of PTSD and the severity of 

symptoms.17 People with PTSD have diffi culty drawing 

on social support when they need it most.18 And in turn, 

resources of social support tend to diminish as people 

with PTSD are unable to reach out for help.19 Several 

studies show that social support is an important factor in 

adjustment and functioning for Veterans with PTSD.20,21

While severity and prognosis are varied, the impact on 

military performance, family, and quality of life has precipitated signifi cant clinical and research interest.

Closely related to social support, particularly through 

the lens of attachment theory, is the experience of intimate partner relationships. Importantly, intimate partner 

relationships are also known to be an important factor 

in overall functioning for Veterans and Soldiers, if not 

for all families.22 This area of research provides a particularly informative application of attachment theory in 

light of attachment styles with adult romantic partners, 

which is considered by current attachment theory to be 

an extension of the individual attachment style established with the primary caregiver.23 Recent research 

shows that this theory is supported in its application to 

dyadic, or couple’s processes in PTSD outcomes.24-27

This growing body of research shows that PTSD is associated with insecure attachment styles.27,28 Additionally, 

recent studies have shown that marital functioning and 

couple adjustment is an important aspect for Veterans 

and Soldiers with PTSD.24,29 Two recent studies show 

that marital satisfaction plays an important role in lower symptom severity of Veterans with PTSD.30,31 This 

theoretical perspective is beginning to provide insight 

into the interpersonal factors at work in PTSD outcomes, 

making this an opportune time to further explore relationships between mechanisms of attachment and PTSD 

in recent Veterans.24-26 Posttraumatic stress disorder has 

recently been increasingly associated with attachment 

theory due to the interpersonal nature of the disorder.32

THE CURRENT STUDY

Data from a cross-sectional study were analyzed to further explore the relationship between attachment styles 

and PTSD. Of note, this study examined the relationship between PTSD symptoms and 2 different but theoretically and empirically related assessments of human 

attachment. Regarding the fi rst assessment, our fi rst 

hypothesis was that PTSD symptoms would be differentially related to each of the categorical attachment 

measure styles. We expected the higher PTSD scores to 

be associated with the fearful group and the lower PTSD 

scores to be associated with the secure group.
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

It is also hypothesized that relationship anxiety and 

relationship avoidance would predict reported PTSD 

scores with low relationship anxiety and low relationship avoidance being related to lower PTSD scores with 

the opposite being related to higher PTSD scores.

METHODS

Procedure

Data were collected as part of a quantitative, cross-sectional study looking at attachment, temperament, and 

resilience as protective mechanisms for posttraumatic 

stress. Data were collected on anonymous questionnaires distributed on Fort Sam Houston and Lackland 

Air Force Base in San Antonio, Texas, from summer 

2010 to summer 2011. In order to participate in this study, 

the participants must have been deployed for at least 

30 days or more, aged 18 years or older, and on active 

duty. The study was reviewed and received an exempt 

determination from the Brooke Army Medical Center’s 

Institutional Review Board. For this study, the independent variable was adult attachment (both the categorical attachment measure (RQ) and the continuous measure of adult attachment (see description in Attachment 

section below), and the dependent variable was PTSD 

symptoms.

Participants

Among the 561 respondents, 403 were male, 157 female, 

and one no response; 8% aged 25 years and younger, 

23% in the 26 to 30 year age range, 48.5% aged 31 to 

40 years, 21% 41 years of age and over; 69% married or 

living with a partner; 62% Army and 37% Air Force; 

54% SGT, SSG, or SFC; 23% LTs to CPTs*; 22% with 

master’s degree or higher, 30% with bachelor’s degree, 

and 44% had some college. The ethnicity of the sample 

was 12.3% Hispanic and 86.6% non-Hispanic; the racial profi le was 65.6% white, 19.6% African American; 

5.9% Asian/Pacifi c Islander, and 8% other. All participants had deployed at least once. Each participant reported personal total career deployment time. resulting 

in an average of 1.9 years (1 year, 10.8 months), ranging 

from one month to 14 years.

MEASURES

Attachment

Adult attachment was measured 2 ways: one with the 

Bartholomew and Horowitz Relationship Questionnaire,33 a 4-item categorical adult attachment variable; 

the other with the Fraley et al34 Experiences in Close 

Relationships [scales]-Revised, (ECR-R) which creates 

continuous anxiety and avoidance attachment variables. 

The conceptual relationship between the categorical 

measure of adult attachment and the continuous measure is that secure adults are low in relationship anxiety and avoidance; fearful adults are high in relationship avoidance and relationship anxiety; the preoccupied adults are low in relationship avoidance and high 

in relationship anxiety; whereas dismissing are higher 

in relationship avoidance and lower in anxiety. Shaver 

and Fraley35 further developed the relationship between 

these 2 self-report measures of adult attachment.

Experiences in Close Relationships-Revised34 is a measure of adult attachment. This is a 36-item self-report instrument designed to measure attachment-related anxiety and avoidance. Participants are asked to think about 

their close relationships, without focusing on a specifi c 

partner, and rate the extent to which each item accurately describes their feelings in close relationships, using a 

7-point scale ranging from “not at all” (1) to “very much” 

(7). Eighteen items tap attachment anxiety and 18 items 

tap attachment avoidance. Internal consistency reliability tends to be 0.90 or higher for the 2 ECR-R scales.

The Relationship Questionnaire33 is a self-report adult 

attachment measure. The measure includes a series of 

4 statements that represent secure, preoccupied, fearful, 

and dismissing adult attachment styles. Participants are 

instructed to place a checkmark next to the letter corresponding to the style that best describes themselves. 

Next they are asked to rate each of the presented relationship styles to indicate how well or poorly each description corresponds to their general relationship style 

as measured by a Likert-type scale, from “disagree 

strongly” to “agree strongly.” Test-retest reliabilities 

of the RQ subscales ranged from 0.49 to 0.71 as were 

reported by Scharfe and Bartholomew.36 Schmitt and 

colleagues9

 validated the attachment questionnaire in 

62 cultures suggesting that people worldwide fall into 

one of the 4 attachment patterns, and there are cultural 

differences that suggest societal norms infl uence one’s 

resulting attachment pattern.

Posttraumatic Stress Disorder Symptoms

The PTSD checklist–military,37 commonly known as 

the PCL-M, is a 17-item self-report inventory that assesses the severity of each DSM-IV†

-defi ned PTSD 

symptom. Each item corresponds to the DSM-IV diagnostic criteria for PTSD and is scored on a 1 (not at all) 

to 5 (extremely) scale. 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.37 The 

*SGT indicates sergeant; SSG indicates staff sergeant; SFC indicates sergeant fi rst class; LT indicates 1st or 2nd lieutenant,

CPT indicates captain.

†Diagnostic and Statistical Manual of Mental Disorders, 4th Edition38

THE IMPACT OF ATTACHMENT STYLE ON POSTTRAUMATIC STRESS DISORDER SYMPTOMS IN 

POSTDEPLOYED SERVICE MEMBERS
 July – September 2012 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

PCL is widely used in the Department of Defense and 

the Department of Veterans Affairs and has excellent 

reliability and validity.37

DATA ANALYSIS

The data analysis was conducted using SPSS version 

18 (SPSS, Inc., Chicago, IL). An analysis of variance 

(ANOVA) was used to test the fi rst hypothesis, which 

examined the relationship between the RQ and the 

PTSD scores. For further analysis, the PTSD score was 

dichotomized creating a categorical variable of low and 

high PTSD. A logistic regression was used to test the 

second hypothesis, which examines the relationship between the ECR-R and the PTSD scores. 

To test the validity of using our current measures in this 

population, we examined the relationship between the 

RQ and the ECR-R to determine the conceptual relationship between these instruments. Using this sample, our 

results were consistent with the literature. Those who 

selected the secure attachment style also rated themselves as lower avoidance and lower anxiety compared 

to fearful, preoccupied, and dismissing; fearful rated 

themselves as higher anxiety and avoidance than secure, 

preoccupied, dismissing, etc. In a separately published 

article,39 we present a more detailed discussion of the 

relationship between the RQ and ECR-R.

RESULTS

Descriptive Statistics 

The RQ is made up of 4 possible attachment styles: secure, fearful, preoccupied, and dismissing. In our sample, 

39.3% selected secure, 24% fearful, 7.2% preoccupied, 

and 29.5% dismissing as their attachment style. The 

ECR-R creates 2 measures of attachment, relationship 

anxiety and relationship avoidance. The mean scores on 

each subscale were 2.79 for anxiety and 2.79 for avoidance with standard deviations of 1.21 and 1.15 respectively. The PTSD Score on the PCL-M ranged from 17 

to 76 with a mean of 30.23 (SD=14.40). Higher scores 

on the PCL-M indicate more reported PTSD symptoms. 

13% of our sample scored 50 or over on the PCL-M 

whereas 33% of our sample scored 32 or higher. 

Attachment Style and Posttraumatic Stress Disorder

An ANOVA was conducted using the self-selected attachment style (secure, fearful, preoccupied, or dismissing) as the independent variable and the PTSD score as 

the dependent variable. Least squared difference was 

used for the follow-on contrasts. This resulted in a signifi cant ANOVA, F3,501=18.05; P<.001, and in signifi cant 

differences between all attachment styles except for the 

preoccupied and dismissing styles (Figure 1). The means 

(M) and standard deviations for the PTSD scores on the 

RQ measures resulted for secure (M=25.57, SD=10.86), 

fearful (M=37.14, SD=16.28), preoccupied (M=31.83, 

SD=14.53) and dismissing (M=30.24, SD=14.55).

In our second analysis, we examined diagnostic implications for PTSD. In order to dichotomize PTSD cases, we 

used a cutoff of 32 on the PCL score which is consistent 

with a screening threshold for this self-report measure. 

A score of greater than or equal to 32 is considered to 

have a higher sensitivity than the 50 or higher cutoff 

traditionally seen in research.40 Although there is some 

debate, researchers recommend using a cutoff score between 30 and 34 when using the PCL.41

Chi-square analysis was conducted using the dichotomous PTSD variable of low versus high PTSD severity 

score. Low PTSD severity scores included scores from 

17 to 31, whereas high PTSD severity score category included scores from 32 to 76. Twice as many individuals were classifi ed by having a low PTSD severity score 

(66.7%) as compared with those classifi ed as having 

a high PTSD severity score (33.3%). The Chi-square 

analysis resulted in signifi cant differences (χ2=40.343, 

P=.000, N=502).

Figure 2 demonstrates that secure attachment produces 

lower frequencies in the high PTSD severity category 

and the fearful style produces the greatest frequencies, 

followed by preoccupied and then dismissing. Conversely, the secure style has the greatest representation in the 

low PTSD severity category.

We predicted that individuals reporting lower relationship anxiety and avoidance would predict lower levels of PTSD scores. A t test relationship anxiety and 

Figure 1. The mean posttraumatic stress disorder scores 

plotted by attachment style.
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

relationship avoidance based on whether they were in 

the low or high PTSD severity category. This resulted 

in a t539=-7.63, P<.001 for relationship anxiety and a 

t538=-8.79, P<.001 for relationship avoidance. The low 

PTSD severity score group had a mean of 2.53, SD of 

1.10 on relationship anxiety and a mean of 2.50, SD of 

1.03 for relationship avoidance, whereas the high PTSD 

severity group had a mean of 3.33, SD of 1.26 for relationship anxiety and a mean of 3.37, SD of 1.17 for 

relationship avoidance. Our results, shown in Figure 3, 

indicate that individuals who self report low levels of 

PTSD symptoms also report signifi cantly lower levels 

of relationship anxiety and relationship avoidance than 

those who self report high levels of PTSD symptoms.

COMMENT

Adult Attachment and Service Members

Descriptive statistics showed that approximately 40% of 

our population of service members is self-classifi ed as 

securely attached individuals. The rest are self-classifi ed as one of the insecure attachment styles (ie, fearful, 

proccupied, dismissing). Research outcomes supported 

our hypotheses that securely attached individuals report 

far fewer incidences of PTSD outcomes on both categorical and continuous measures of attachment. More 

severe symptoms were associated with less functional 

attachment styles, and less severe with more functional 

styles. These fi ndings were strengthened by the consistency across the two different types of attachment measurement, one a self-reported style and the second measure a detailed description of relationship functioning. 

Thus, these outcomes provide insight into both the intrapersonal and interpersonal aspects of the attachment 

system as it pertains to this population.

Our prevalence rates of PTSD when defi ned as scoring 

50 or higher on the PCL-M (13%) were consistent with 

the prevalence rates in the literature (13%) for service 

members returning from the wars in Iraq and Afghanistan.42 Additionally, our results were consistent with the 

known relationship between attachment style and PTSD 

outcomes in other high-risk populations. These fi ndings 

have important implications to our military population at 

the individual and organizational levels. Understanding 

attachment patterns and styles among service members 

can possibly be both a protective factor and a diagnostic 

factor in mitigating the risk of PTSD and providing treatment to service members and their families. Additionally, 

attachment measures may help guide recruitment, placement, and organizational decisions for the military.

Adult attachment style may protect service members 

from developing PTSD after experiencing combat and 

combat-related experiences. Attachment theory asserts 

that “any relationship in which proximity to the other affects security is an attachment relationship”43 and therefore most all professional relationships in the military 

impact the individual attachment system. Moreover, an 

attachment relationship does not have to be a romantic 

relationship and may be any relationship such as peer 

to peer, subordinate to supervisor, leader to follower, 

or same or mixed gender relationships. By the time a 

person enters the military their propensity for certain 

attachment styles has been established and may play a 

role in how much trust is placed in new relationships 

(ie, peer to peer, leader to follower, etc). As early as basic training young trainees are assigned a battle-buddy*

and encouraged to always have their battle buddy with 

Figure 2. Attachment style plotted by dichotomous posttraumatic stress disorder score.

Figure 3. Relationship anxiety and avoidance plotted by 

dichotomous posttraumatic stress disorder score.

*Generally defi ned as the person to whom a Soldier can turn in 

time of need, stress, and emotional highs and lows who will not 

turn the Soldier away, no matter what. This person knows what 

the Soldier is experiencing because of experience with similar 

situations or conditions, either current, previous, or both.

THE IMPACT OF ATTACHMENT STYLE ON POSTTRAUMATIC STRESS DISORDER SYMPTOMS IN 

POSTDEPLOYED SERVICE MEMBERS
 July – September 2012 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

them. When assigned to a military unit, especially in a 

stressful combat environment, relationships with others 

within the unit are vital to enabling a cohesive effort 

towards a collective goal. Many view the others within 

their unit as their “military family,” and are encouraged to always have a battle buddy or a “wingman” and 

support each other, establishing positive relationships 

throughout their career in the military, and some even 

follow beyond retirement. Conversely, there are unstable 

relationships within units, sometimes causing detrimental effects, especially when individual members isolate 

themselves, inhibiting communication, and consequently harming unit cohesion and effectiveness, not only for 

themselves, but for their entire unit.43

Military personnel with secure attachments, especially 

with their respective military family, appear to experience less stress because they use social coping mechanisms. They are more apt to engage with their families 

and peers, and go to mental/behavioral health practitioners or the chaplain for assistance, all of which mitigates 

the risks to developing symptoms of PTSD. Flexibility 

allows these securely attached individuals to adapt well 

to their environment. Beyond preventing PTSD, secure 

attachment may also contribute to the reconstruction of 

comforting, health sustaining beliefs shattered by trauma, an example of what Tedschi and Calhoun44 call posttraumatic growth. Current efforts by the military have 

focused on group debriefi ngs, psychotherapy, and psychopharmocological interventions. However, additional 

efforts could be focused on making a more successful 

match between treatment approaches so that those who 

are not securely attached can receive supportive interventions that may prevent the symptoms of PTSD. Based 

on these various attachment styles, providers would be 

able to plan programs and provide interventions and 

treatments for service members in the predeployment, 

deployment, or postdeployment phases.

FUTURE DIRECTIONS

The relationship between attachment style and PTSD 

outcomes in service members clearly merits further 

inquiry. Future studies will need to explore the subcategories of the PTSD diagnosis with respect to attachment styles in order to show more specifi cally how the 

attachment system affects the disorder. More detailed 

information on these relationships can guide the development of programs and interventions, and inform the 

application of attachment related treatment to the clinical context. Additionally, longitudinal studies examining the relationship between these variables pre- and 

posttreatment and pre- and postdeployment will advance the determination of causal factors, the potential 

for change, and the effi cacy of prevention measures. For 

example, is attachment style changed by trauma or is it 

more of a risk factor? If something can be done in the 

military to help promote secure attachment in the interest of strengthening our forces, what could that be and 

how can this be undertaken within a military setting?

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15. Declercq F, Willemsen J. Distress and post-traumatic stress disorders in high risk professionals: adult attachment style and the dimensions of 

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16. van der Kolk BA. Posttraumatic stress disorder 

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MF, eds. Healing Trauma: Attachment, Mind, Body, 

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17. Guay S, Billette V, Marchand A. Exploring links 

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and post deployment social support protect against 

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24. Allen ES, Rhoades GK, Stanley SM. Hitting home: 

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THE IMPACT OF ATTACHMENT STYLE ON POSTTRAUMATIC STRESS DISORDER SYMPTOMS IN 

POSTDEPLOYED SERVICE MEMBERS
 July – September 2012 61

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37. Weathers FW, Litz BT, Herman DS, Huska JA, 

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Soc Environ. In press.

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Frueh C. Performance characteristics of the posttraumatic stress disorder checklist and SPAN in 

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Psychiatry. 2007;29:294-301.

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AUTHORS

LTC Escolas is Assistant Dean for Research and Human 

Protections Administrator, Academy of Health Sciences, 

US Army Medical Department Center and School, Fort 

Sam Houston, Texas.

Ms Arata-Maiers is a Mental Health Technician at Nix 

Specialty Health Care, San Antonio, Texas.

1LT Hildebrandt is a Social Work Intern, Department of 

Behavioral Health, San Antonio Military Medical Center, 

Fort Sam Houston, Texas.

Dr Maiers is a Clinical Psychologist, Warrior Resiliency 

Program, San Antonio Military Medical Center, Fort 

Sam Houston, Texas.

Dr Mason is Associate Director of Research Outcomes 

and Data Analytics, Wellness & Prevention, Inc, Ann 

Arbor, Michigan. He is also an Assistant Professor, 

Adjunct, Department of Psychiatry and Behavioral 

Sciences, Johns Hopkins University School of Medicine, 

Baltimore, Maryland.

Maj Baker is a Flight Commander, Behavioral Analysis 

Service, 559th Aerospace Medicine Squadron, Lackland 

Air Force Base, Texas.

US Department of Defense photo
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

The popularity of running is at an all-time high with 

nearly 500,000 people in the United States completing 

a marathon in 2009.1

 Annual running injury incidence 

has recently been reported between 19% and 79%.2

This large number of injuries has medical providers and 

coaches struggling to determine how best to advise their 

running clients to prevent injuries. Alternative running 

styles such as barefoot running, POSE running, and Chi 

running have enjoyed an increase in popularity recently. 

Proponents of these alternative running styles with a 

more anterior landing pattern claim that employing these 

techniques will reduce injuries. Little information, however, has been published comparing the mechanics and 

injury trends associated with different running styles.

OVERVIEW OF DIFFERENT RUNNING STYLES

Traditional Shod Running

A recent kinematic analysis of elite runners wearing 

shoes who participated in a half marathon indicated that 

75% of the runners were heel strikers, 24% were midfoot strikers, and 1% were forefoot strikers.3

 When runners use a rearfoot strike pattern, the knee is relatively 

extended and the ankle is in relative dorsifl exion upon 

initial contact. As the ankle moves into plantarfl exion, 

the knee fl exes and the knee extensors act eccentrically to dampen the ground reaction forces. Traditionally 

shod rearfoot strikers often take long strides, characterized by a vertical displacement of the center of mass and 

an impact peak present at approximately 10% to 12% of 

the stance phase on the vertical ground reaction force 

curve (Figure 1).4

 Runners using a rearfoot strike pattern 

in bare feet or minimalist footwear have demonstrated 

greater initial vertical loading rates than shod heel 

strikers.4,5 Runners using a rearfoot strike may require 

greater angular work at the knee6

 resulting in higher patellofemoral and tibiofemoral compressive forces7,8 and 

possibly greater risk of knee injury than other running 

styles with more anterior footstrike patterns. Advocates 

of barefoot and alternative running styles report that initial heel contact running is a relatively new phenomenon 

associated with the development of the modern running 

shoes with thicker cushioned heels in the last 30 to 40 

years. Prior to this, many believe the proportion of midfoot and forefoot strikers was much greater.

A Review of Mechanics and Injury Trends

 Among Various Running Styles

LTC Donald L. Goss, SP, USA

Michael T. Gross, PhD

ABSTRACT

Context: Running related overuse injuries are a signifi cant problem with half of all runners sustaining an injury 

annually. Many medical providers and coaches question how to advise their running clients to prevent injuries. 

Alternative running styles with a more anterior footstrike such as barefoot running, POSE running, and Chi 

running are becoming more popular. Little information, however, has been published comparing the mechanics 

and injury trends of different running styles.

Objective: The original purpose of this paper was to examine evidence concerning the biomechanics and injury 

trends of different running styles. Little to no injury data separated by running style existed. Therefore, we 

discuss the biomechanics of different running styles and present biomechanical fi ndings associated with different running injuries.

Data Sources: English language articles published in peer reviewed journals were identifi ed by searching 

PubMed, CINAHL, and SPORTDiscus databases. Nearly all of the studies identifi ed by the search were observational studies. 

Results: A more anterior initial foot contact present in barefoot or other alternative running styles may decrease 

or eliminate the initial vertical ground reaction peak or “impact transient,” possibly reducing knee joint loads 

and injuries. A more anterior foot strike, however, may increase mechanical work at the ankle and tensile 

stress within the plantarfl exors. Wearing minimal footwear may also increase contact pressure imposed on the 

metatarsals.

Conclusion: More research is needed to determine which individuals with certain morphological or mechanical gait characteristics may benefi t from alternative running styles that incorporate a more anterior initial foot 

contact with or without shoes.
 July – September 2012 63

Alternative Running Styles

Barefoot running and other alternative running styles 

have gained recent popularity, leaving many health care 

providers with questions regarding the safety and appropriateness of these techniques for various running populations. In several publications, barefoot runners exhibited a more anterior midfoot or forefoot striking pattern, 

thereby avoiding heel strike.4,9-11 A growing number of 

barefoot running advocates, teachers, and websites have 

provided barefoot running instruction since publication 

of McDougall’s 2009 book.12 Generally with habituated 

barefoot runners, stride length is shortened, stride frequency is increased, and the vertical displacement of the 

center of mass is reduced.9,13,14

One alternative running style that has gained popularity 

recently is the POSE method designed by Dr Nicolas 

Romanov.15 This running strategy involves a midfoot to 

forefoot strike pattern that minimizes contact time with 

the support surface and focuses on picking up the feet 

and not pushing off the ground as vigorously.15,16 Romanov claims that gravity causes the muscle system to 

absorb body weight on landing during POSE running, 

which then produces elastic strain energy. Romanov 

further describes that as the center of mass passes over 

the support limb, a gravitational torque occurs as extensor muscle activity ceases. The runner falls forward 

while the ground reaction forces decrease and vertical 

work against gravity is reduced. Romanov suggests that 

the foot is unweighted during terminal stance, as it is 

rapidly pulled from the ground by hamstring muscle activity to reduce lower-limb inertia and to catch up with 

the body. The focus on falling via a gravitational torque 

and pulling the foot from the ground effectively differentiates POSE running from more traditional running 

forms.

Another alternative running style that has recently gained 

popularity is Chi running. The founder of Chi running, 

Danny Dreyer, credits the origins of this running form 

to the discipline of Tai Chi.17,18 This method of running is 

described as the alignment of body, mind, and forward 

movement. Runners are instructed to avoid heel strike 

and to land with a midfoot strike pattern. The body leans 

forward slightly, and the strides are shorter with a focus 

on relaxed legs. Dreyer recommends that runners discard 

more traditional heavily padded running shoes and use 

a more minimalist running shoe that involves thin sole 

material and limited supportive features.17,19 In summary, 

barefoot, POSE, and Chi runners attempt to land with 

a midfoot or forefoot strike, take shorter strides with a 

greater frequency, and may demonstrate a reduced initial 

vertical ground reaction impact compared with 

traditional heel-toe shod runners. The original 

purposes of this review of literature were to 

examine additional evidence concerning the kinematics, kinetics, and injury trends associated 

with different running styles. Little to no injury 

data separated by running styles were found. 

Therefore, we discuss the biomechanics of different running styles and present biomechanical fi ndings associated with different running 

injuries.

DATA SOURCES

English language articles published in peer reviewed journals were identifi ed by searching 

PubMed, CINAHL, and SPORTDiscus databases. Key words used in this search included 

running, barefoot, POSE, Chi, kinematics, kinetics, injury, and running styles in various combinations. The 

authors included original research, meta-analyses, and 

review articles in the search. Only one randomized control trial was identifi ed.20 Nearly all of the studies included were observational studies. The search for manuscripts detailing aspects of Chi running in scientifi c peer 

reviewed literature yielded no results. The authors then 

resorted to using popular literature and website descriptions of the Chi running style. 

RESULTS

Running Mechanics

Traditional Shod Running

For heel strikers (approximately 80% of shod runners),3,9

the initial (impact) peak vertical ground reaction force 

at heel strike occurs during the fi rst 10% of stance21-23

or within approximately 25 milliseconds.24 This force 

is passive in nature and the anterior-posterior component of this impact is generally considered a braking 

Figure 1. Vertical ground reaction curves of 1 representative person demonstrating a rearfoot strike pattern in bare feet and shod. Reprinted from

De Wit et al4 with permission.

Time (milliseconds)

Forces (body weight)

0

1

2

3

4

0 100 50 250 150 200

Bare

Shod
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

force with the heel strike anterior to the runner’s center 

of mass. The second peak for the vertical ground reaction force occurs between 40% and 50% of the stance 

phase.25 This force is more active as the runner pushes 

off the ground and the anterior-posterior component is 

more propulsive in nature with the runner’s center of 

mass superior/anterior to the foot contact. Typical running peak vertical ground reaction forces for runners 

are between 1.5 and 3.5 times body weight.25 Vertical 

ground reaction forces increase linearly with increasing running velocity26 and increasing stride length,27-29

and decrease with a faster stride rate or cadence.30 Runners with a history of injuries may demonstrate greater 

initial peak vertical ground reaction forces than healthy 

matched runners,22,23,31 however, this point has been 

refuted.32

Cushioned running shoes are commonly prescribed for 

runners with high arches and motion control shoes are 

often recommended for low arched runners who require 

pronation control. Cushioned running shoes may attenuate the ground reaction force better for high arched 

runners33 and motion control shoes may control instantaneous loading rates better for low arched runners.34 Increased resultant joint torques at the hip and knee have 

been observed in shod runners compared with barefoot 

runners.7

 Aside from the effects of footwear modifi cations, some runners may benefi t from an altering their 

running style and learning to run with a reduced impact 

load or ground reaction force.21 However, this has not 

been widely studied to date.

Alternative Running Styles

Most habitual barefoot runners choose to land with a 

midfoot or forefoot initial foot contact to avoid greater 

initial loading rates observed with heel striking in barefeet4

 (Figure 1). While most runners attempting to run 

in bare feet or minimalist shoes will convert to a more 

anterior footstrike, McCarthy et al reported recently on 

a sample in which 50% of runners continued to demonstrate a rearfoot strike pattern 2 weeks after changing to 

the Vibram 5-fi nger shoe.5

A toe-heel-toe or midfoot contact pattern used by barefoot runners and other minimalist shoe runners who use 

this landing strategy may decrease the vertical loading 

rates and initial passive peak vertical ground reaction 

force by 15% to 33% during the fi rst 25 milliseconds 

of foot contact compared to traditional heel-toe strike 

patterns.9,35 This reduction in initial peak vertical 

ground reaction force is accomplished by prolonging 

the time needed to decelerate the runner’s vertical velocity after initial foot contact. By prolonging this period of time with a greater ankle range of motion,10 the 

vertical ground reaction force is reduced as refl ected by 

the impulse-momentum equation F=m×Δv/Δt, where

F=vertical ground reaction force, m=mass of runner,

Δv=the change in vertical velocity from initial foot contact to the velocity of zero when downward motion stops, 

Δt=the time required to change the downward velocity 

to zero.

The period of time required to change a runner’s downward velocity to zero (Δt) will likely be longer with a 

toe-heel-toe initial contact pattern than with a heel strike 

pattern. The initial vertical ground reaction force (F) will 

therefore be reduced. Another mechanism to decrease 

vertical ground reaction forces given a fi xed mass would 

be to reduce the amount of change in velocity. This can 

be accomplished by reducing the vertical height from 

which the body’s center of mass falls to the ground.36

Essentially, limiting the vertical displacement of the center of mass prior to foot contact will reduce Δv. This is 

achieved by adopting running styles in which the runner 

glides forward more and bounces up and down less.

Little research has been conducted concerning injury 

trends that are associated with barefoot or other alternative running styles. Particularly of concern to some 

medical providers are metatarsalgia and other injuries 

related to foot contact patterns, particularly in bare 

feet.37,38 Injuries caused by excessive contact pressures 

that are perpendicular to the foot-ground interface are 

governed by the equation

contact pressure=contact force/contact area

Wearing minimal footwear that has relatively thin sole 

material and no supportive features built into the shoe’s 

construction may simulate conditions of barefoot running.39 Running in bare feet or using minimal footwear 

may increase peak contact pressure, increase maximum 

ground reaction force, and reduce contact area of the 

foot, thereby increasing peak pressures imposed on the 

forefoot.40,41 For a given ground reaction force, this reduction in contact area will signifi cantly increase plantar 

contact pressure.40,42,43 A 25% to 63% reduction in plantar contact area while running in bare feet44 may counteract the 15% to 33% reduction in impact peak vertical 

ground reaction forces9,13 achieved from using a toeheel-toe strike pattern. This could result in potentially 

greater contact pressures on the more anterior portions 

of the metatarsals. High arched runners may experience 

greater risk of injurious plantar pressures in the lateral 

metatarsals,45 while low arched runners may experience 

greater medial and lateral midfoot contact pressures 

under a variety of athletic conditions.46 Concentrating 

the center of pressure on the midfoot47 also increases 

the vertical ground reaction impulse stress (forcetime) 

A REVIEW OF MECHANICS AND INJURY TRENDS AMONG VARIOUS RUNNING STYLES
 July – September 2012 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

on the metatarsals. Previous investigators have reported 

greater stride frequency with a reduced stride length for 

individuals who run in bare feet or for individuals who 

run using a midfoot or forefoot strike pattern.6,14 Greater 

peak axial strains and strain rates have been observed 

in the metatarsals than those in the tibia for barefoot 

running.48 Increased stride frequency has been associated with reduced knee and hip loading,36 however the 

shorter stride length and increased stride frequency associated with midfoot and forefoot strike patterns will 

result in more impacts per unit of time and distance, and 

potentially increased cumulative metatarsal strain compared with rearfoot strike running.

Another potential concern for injury is the increased 

moment requirement at the ankle joint associated with 

a more anterior initial foot contact. Runners who use 

a midfoot or forefoot strike pattern will require greater 

activation of the plantarfl exors during early stance phase 

to effect the deceleration and then propulsive impulses.13

This muscular activation may lead to increased mechanical work at the ankle6,14,49 and additional tensile stress 

imposed on the plantar fl exor muscles and Achilles tendon. Cole et al observed a greater magnitude and rate of 

loading in the ankle joints during the impact phase of 

barefoot running compared to shod running.50

Supporters of midfoot and forefoot strike running styles 

blame the initial peak ground reaction force and loading 

rate associated with a rearfoot strike pattern for increased 

strains that may injure the lower extremities.9,31,51 While 

the initial passive impact peak ground reaction forces 

that occur at approximately 10% to 12% stance phase are 

greater for shod heel-toe runners, the midstance active 

propulsive vertical ground reaction forces may be greater for midfoot or forefoot strikers (Figure 2).13,14 These 

greater active propulsive ground reaction forces have 

not yet been correlated with specifi c injury risk, but further investigation is warranted. 

Few scientifi c studies have evaluated the POSE running 

method. Dallam observed a decreased stride length, decreased vertical displacement of the center of mass, and 

increased oxygen cost when runners used the POSE 

method compared with traditional heel-toe running in 

a very small sample.52 Arendse analyzed 20 individual 

runners who ran on an outside track, comparing traditional heel-toe running, midfoot strike running after 

15 minutes of instruction, and POSE running after 7.5 

hours of instruction.6

 Arendse observed decreased stride 

length and decreased vertical displacement of the center 

of mass when subjects ran using the POSE method. He 

reported greater initial vertical ground reaction forces 

with heel-toe running. Arendse also observed less eccentric angular work at the knee joint and greater eccentric angular work at the ankle joint when subjects 

ran using the POSE method. This reduction in angular 

work at the knee joint is often used to promote use of 

the POSE running method. Reducing knee loading at 

the cost of increased moment demands at the ankle joint, 

however, may lead to increased Achilles tendon or other 

ankle overuse injuries. Fletcher and Romanov also observed reduced stance time, decreased vertical and horizontal displacement of the center of mass, greater knee 

fl exion angular velocity, and greater stride frequency in 

a sample of 8 runners after 7 hours of POSE running instruction.53 Again, this increase in stride frequency may 

result in potentially increased cumulative metatarsal 

strain and total ankle joint work compared with 

rearfoot strike running.

The authors were unable to fi nd any peer-reviewed biomechanical analyses of Chi running 

in the literature. In summary, POSE running, 

Chi running, barefoot running, and running 

with a forefoot or midfoot strike pattern have 

several commonalities. As shown in the Table, 

these include decreased stride length, decreased 

vertical displacement of the center of mass, and 

a possible shift from greater knee joint loading 

to greater loading at the ankle joint.

Injury Trends

Annual running injury incidence rates have 

been reported as ranging from 19% to 79%,2

with the knee joint being the most commonly 

injured anatomic region among runners.2,54 We 

Fz (percent body weight)

0 100 300 200

Time (milliseconds)

0

100

300

200

Fzmax

Fz1

Bare

Shod

Figure 2. Vertical ground reaction force curve for the stance phase of gait 

displaying the initial impact transient (Fz1) for shod runners and higher 

overall propulsive peak ground reaction forces (FZmax) in midstance for 

barefoot runners using a midfoot strike pattern. Reprinted from Divert et 

al14 with permission.
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

were unable to identify any previous work separating 

injury trends by running style. With the majority of 

modern-day shod runners employing a heel-toe landing 

style,3,9 previous injury reports may relate primarily to 

this running style. Potential causes of running related 

injuries and various mechanical observations associated 

with injuries in specifi c anatomical regions will be addressed. Finally, we discuss injury trends that may be 

related to wearing traditional running shoes or adopting 

alternative running styles.

Potential Causes

Many different potential causes have been suggested to 

explain running injuries. These potential causative factors can be organized into extrinsic and intrinsic factors. 

Extrinsic factors that may be related to running injury 

include running shoe age and training errors.54,55 Training errors may be more associated with injury incidence 

than biomechanical factors.55 Exposure to a high training 

load involving increased intensity, frequency, or running 

distance55 without adequate rest may increase the risk of 

injury,56 and modifi cation of the training schedule may 

reduce the incidence of injury.55-57 The effect of stretching on running injuries has not been determined.55,58,59

Intrinsic causes of injury include a previous history of injury,2,54 increased runner age,54 increased body mass,54,60

foot strike characteristics,23,25,31,61-63 and morphological 

characteristics such as excessive genu valgum,64 pes 

planus,31 and pes cavus feet.63 Greater instantaneous and 

average vertical loading rates have also been observed 

in runners with a history of injury.22,65

Ankle and Foot Injuries

Particular characteristics present in subjects with a history of ankle and foot injuries were more years running, 

weaker plantarfl exors, higher arches, and more inversion at touchdown.59 McCrory et al suggest that plantarfl exor insuffi ciency to control the eccentric phase of 

dorsifl exion may have contributed to the development 

of Achilles tendonopathy.59 A more rigid foot may lead 

to “compensatory overpronation” that overstresses the 

Achilles tendon. Reduced tibial external rotation moment and more medial femoral rotation has also been 

associated with injury in a group of subjects with a history of Achilles tendonopathy.61 Williams et al propose 

that this places the lateral gastrocnemius more anteriorly and the medial head of the gastrocnemius more 

posteriorly.61 They hypothesized that this shortening of 

the medial head of the gastrocnemius may have resulted 

in changes in muscular stress at the musculotendinous 

junction that may have lead to the development of Achilles tendonitis. Another possible explanation may be that 

increased internal rotation of the entire lower extremity 

is associated with increased pronation, which passively 

stretches the Achilles tendon.

Increased dorsifl exion range of motion and greater instantaneous load rates were observed in a population of 

females with a previous history of plantar fasciitis.31 Pohl 

et al state that the increased passive dorsifl exion range 

of motion is usually perceived as desirable.31 They attribute this extra motion to the fact that these previously injured subjects were patients in rehabilitation where they 

commonly receive plantar fl exor stretching exercises as 

part of their exercise prescription. Since this study was 

retrospective, the authors were unable to determine if 

the subjects had the additional range of motion prior to 

sustaining an injury or if it was acquired during the time 

the subjects spent in rehabilitation. The authors believe 

that greater instantaneous rates of loading may subject 

the plantar fascia to excessive stress.31 Two groups of investigators have documented that greater pronation and 

leg length inequality were observed in other samples of 

plantar fasciitis patients.63,66 Subotnick previously reported an association between limb length inequality 

and greater pronation.67 Warren and Jones also observed 

greater dorsifl exion and less plantar fl exion range of motion in a sample of runners with plantar fasciitis compared to controls.66 Messier and Pittala observed greater 

plantar fl exion range of motion in their sample of plantar fasciitis patients.63 They hypothesized that excessive 

sagittal plane motion may increase the amount of time 

the runner can impart a propulsive force which may lead 

to excessive plantar stresses.63 These authors also attribute greater pronation with greater midfoot stress on the 

plantar fascia for the injury.63

While the balance of running injury literature in the past 

30 years assumes a rearfoot strike pattern while wearing traditional shoes, one recent case series detailed 2 

marathon runners who sustained metatarsal stress fractures running in barefoot-simulating footwear reportedly adopting a more anterior footstrike.38 Another recent 

military study reported reduced incidence of tibial and 

Characteristics of various running styles.

TraditionalBarefoot Chi Pose

Stride length + –––

Stride frequency – +++

Impact transient + – unknown unknown

Ankle moment – + unknown +

Knee moment + – unknown –

Vertical loading 

rates + – unknown unknown

+ denotes greater. – denotes lesser.

“unknown” denotes lack of research data.

A REVIEW OF MECHANICS AND INJURY TRENDS AMONG VARIOUS RUNNING STYLES
 July – September 2012 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

femoral stress fractures as the body adapted to the increased military training demands of several cycles of 

training, but no reduction in metatarsal stress fractures 

after months of infantry training.68 This may suggest 

that the body responds differently to metatarsal stress 

compared to tibial and femoral stress.

Lower Leg Injuries

Several investigators have examined characteristics of 

individuals with lower leg injuries. Heel-toe landing 

styles have been associated with greater anterior compartment pressures than more anterior landing styles.69

This could be due to a greater activation of the dorsifl exors during initial heel contact compared to a midfoot 

or forefoot initial contact pattern where greater activation of the plantarfl exors has been observed.13 In a recent 

case series, 2 previously rearfoot striking patients with 

chronic exertional compartment syndrome avoided anterior compartment release surgeries by adopting a forefoot striking pattern.70

Comparing runners with a history of tibial stress fracture to matched controls, runners with previous tibial 

stress fractures exhibited greater peak hip adduction 

and greater rearfoot eversion angles during the stance 

phase of running.62,71 Milner and Pohl hypothesized 

that these forces may have induced a tensile stress on 

the posteromedial aspect of the tibia.62,71 These authors 

also observed greater absolute free moment for individuals who had incurred previous tibial stress fractures.51,62

Absolute free moment was defi ned as the torque acting 

between the foot and the ground at impact which may 

impose a torsional stress on the tibia.62 Similarly, greater 

pronation and velocity of pronation were observed in 

subjects with a history of shin splints.63 This increased 

pronation may increase the stress on the posterior medial tibia as increased stretching of the tibialis posterior 

imposes greater tensile stress on its proximal attachment 

site. Greater anterior-posterior braking force and vertical 

ground reaction forces were observed in another sample 

of tibial stress fracture patients.72 Zifchock et al suggest 

that high peak tibial shock may lead to injury.72 Creaby 

and Dixon, however, recently reported no differences 

in the magnitude of free moment, sagittal, or frontal 

plane vertical ground reaction forces observed in a small 

sample of military members with tibial stress fracture 

compared to matched controls.32 In a recent systematic 

review,73 Zadpoor and Nikooyan contend that greater 

vertical loading rates and not greater vertical ground 

reaction forces are more often associated with lower extremity stress fractures.22,72,74,75 Additionally, no signifi -

cant intrinsic risk factors were identifi ed in a population 

of collegiate runners with exercise related leg pain.76

Knee Injuries

Multiple intrinsic risk factors have been associated with 

increased incidence of knee injuries, particularly patellofemoral pain syndrome. Lower extremity malalignment, 

particularly increased Q-angle and excessive pronation, 

have been identifi ed as causative factors.60,64,77,78 Genu 

valgus changes patellofemoral force vector alignment. 

Increased body weight and lack of hamstring fl exibility may also be related to knee injury.60 Increased body 

weight will increase the moment demands on the knee, 

which will increase the quadriceps and hamstring force 

production demands. Hamstring tightness may elicit 

greater knee extension force production, effecting a 

greater patellofemoral compressive resultant force vector from the knee extensors. Ferber et al recently observed greater peak rearfoot inversion moment, greater 

peak knee internal rotation angle, and greater peak hip 

adduction angle in a sample of 35 women with iliotibial 

band syndrome.79 Abnormal hip mechanics such as excessive hip internal rotation or adduction possibly due to 

weakness in the hip abductors may also lead to undesirable knee mechanics and injuries.80,82 Observed gender 

differences in strength and alignment may contribute to 

the running kinematic differences and higher overuse 

knee injury incidence observed in women.80-83

Foot Morphology

In a sample of military recruits, Cowan observed higher 

odds ratios for lower extremity overuse injuries in soldiers with the highest arches.84 Messier also observed a 

similar trend with recreational athletes.63 Higher arches 

were associated with greater lower extremity injury incidence in a different sample of female athletes.85 Higher 

arches may be associated with rigid feet that do not promote shock absorption at initial foot contact. In a sample 

of 20 high arched runners, Williams et al observed more 

bony injuries and lateral injuries in the lower extremities 

(ie, 5th metatarsal stress fractures, lateral ankle sprains, 

and iliotibial band syndrome).86 They also detected more 

medial injuries, knee injuries, and soft tissue injuries in 

a sample of 20 low arched runners.86

Traditional Running Shoes

In an effort to correct undesirable and possibly injurious mechanics, many healthcare professionals prescribe running shoes with extra cushioning to provide 

shock absorption, or motion control characteristics to 

limit pronation.33,34 Cushioned running shoes may increase contact area and reduce contact pressures in 

cavus feet.44,87 Likewise, motion control shoes may increase plantar contact area, reduce tibial internal rotation, and reduce plantar contact pressures in runners 

with fl atter feet.33,44 Recently, the practice of matching 
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

foot morphology to running shoe type has been questioned.20,88,89 Even though undesirable mechanics have 

been prevented in laboratory settings by specifi c shoe 

selection and modifi cation, no well-designed studies 

have demonstrated signifi cant injury reduction by using 

this commonly used practice of shoe prescription. In the 

last decade, the results of several studies have demonstrated a correlation between injury and loading rates, 

and between injury and impact forces.22,23,31 This growing body of evidence suggests that runners who have 

developed strike patterns that incorporate relatively 

low levels of impact forces and a more moderate rate 

of pronation are at a reduced risk of incurring overuse 

running injuries. 22,23,31

Alternative Running Styles

Little to no research exists for injury patterns that may be 

associated with POSE, Chi, or barefoot running styles. 

Danny Dreyer claims that the braking forces of heel 

strike are responsible for many lower extremity overuse injuries.17-19 The authors could not fi nd any scientifi c 

manuscripts in any peer-reviewed journals to substantiate claims that Chi running is safer or superior to traditional heel-toe running mechanics in injury prevention or running economy. Dr Mark Cucuzella presented 

survey fi ndings of 2500 Chi runners in 2008. Approximately 90% of the runners had favorable impressions of 

Chi running. Unfortunately, this survey was originally 

made available to approximately 25,000 people who 

had purchased Chi running materials and only 10% responded. Theoretically, the adoption of these alternative 

running styles may shift stress from the knee joint to the 

ankle joint,6,8,50 potentially resulting in ankle and foot 

related injuries. These alternative running forms may 

be desirable if a runner has a history of knee injuries 

or knee osteoarthritis and is attempting to shift stress 

away from the knee joint. More research is needed to 

compare the mechanics of various running styles and to 

survey runners who have adopted these running styles 

for a suffi cient period of time to assess the type and severity of injuries they are experiencing.

SUMMARY

Clinicians are often faced with questions from patients 

about running shoe selection and running style. Traditional shod heel-toe strike running gait has been challenged recently by individuals who advocate a more 

anterior initial foot contact, or minimal to no footwear 

which tends to force runners to make initial contact 

more anteriorly on the foot. Decreasing or eliminating 

the initial vertical ground reaction peak or “impact transient” has been cited as a potential method to reduce 

knee joint injuries or injuries in other anatomic regions. 

This theory requires further investigation to prove its 

injury prevention claims and to insure that runners who 

adopt a more anterior strike pattern are not merely increasing their risk for foot and ankle injuries. 

Certainly more research is needed to determine ultimately which individuals with certain morphological or 

mechanical gait characteristics may benefi t from alternative running styles that incorporate a more anterior 

initial foot contact with or without shoes. Controlled 

longitudinal studies are needed to assess the utility of 

adopting alternative running styles in an effort to reduce injury rates. Laboratory research comparing the 

mechanics of various running styles is needed to quantify internal force and moment demands of the various joints in multiple planes. Additional running shoe 

research is required with large samples of experienced 

runners to examine the potential effectiveness of matching running shoes to running mechanics and not merely 

foot morphology. Unbiased injury history surveys are 

also needed to evaluate the incidence of injury associated with various running styles.

ACKNOWLEDGEMENT

No funding was received for the preparation of this 

manuscript.

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A REVIEW OF MECHANICS AND INJURY TRENDS AMONG VARIOUS RUNNING STYLES
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AUTHORS

LTC Goss is a doctoral student in the Program in Human 

Movement Science, University of North Carolina, Chapel 

Hill, North Carolina.

Dr Gross is a Professor, Program in Human Movement 

Science, Division of Physical Therapy, University of 

North Carolina, Chapel Hill, North Carolina.
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

There has been a tremendous increase during the past 20 

years in the reported cases of carpal tunnel syndrome1-3

resulting in an increased focus on occupational surveillance and screening.2

 Median mononeuropathy at or 

distal to the wrist or carpal tunnel syndrome (CTS) is 

one of a number of muscle-, tendon- and nerve-related 

disorders that affect people performing intensive work 

with their hands.1-3 Dental personnel including dentists, 

dental hygienists, and dental assistants reportedly have 

a high prevalence of upper-extremity musculoskeletal 

disorders, including CTS.4-16

In their study investigating the presence of hand problems in US Army dental personnel, Lalumandier et 

Clinical and Electrodiagnostic Abnormalities

 of the Median Nerve in US Army Dental

 Assistants at the Onset of Training

LTC Scott W. Shaffer, SP, USA

CPT Rebecca Moore, SP, USA

CPT Shannon Foo, SP, USA

CPT Nathan Henry, SP, USA

COL Josef H. Moore, SP, USA

David G. Greathouse, PhD

ABSTRACT

Purpose/Hypothesis: Dental personnel including dentists, dental hygienists, and dental assistants have been 

reported as having a high prevalence of upper-extremity musculoskeletal disorders, including carpal tunnel 

syndrome. Previous research has not involved dental assistant students at the onset of dental training. Therefore, the purpose of this study was to determine the presence of median and ulnar neuropathies in US Army 

dental assistants at the onset of their training.

Number of Subjects: Fifty-fi ve US Army Soldiers (28 female, 27 male) enrolled in the Dental Assistant (68E) 

course, volunteered to participate in the study. The mean age of the dental assistant students was 24±7.2 years 

(range 18-41 years). There were 45 right handed dental assistant students, and the mean length of time in the 

Army prior to dental training was 27 months (range 3-180 months).

Materials/Methods: Subjects were evaluated during the fi rst week of their 10-week dental assistant course. Subjects completed a history form, were interviewed, and underwent a physical examination. Electrophysiological 

status of the median and ulnar nerves of both upper extremities was obtained by performing motor and sensory 

nerve conduction studies. Descriptive statistics for subject demographics and nerve conduction study variables 

were calculated.

Results: Six of the 55 subjects (11%) presented with abnormal electrophysiologic values suggestive of median 

mononeuropathy at or distal to the wrist. Five of the subjects had abnormal electrophysiologic values in both 

hands. Five of these 6 subjects had clinical examination fi ndings consistent with the electrophysiological fi ndings. The ulnar nerve electrophysiologic assessment was normal in all subjects sampled.

Conclusions: The prevalence of median mononeuropathies in this sample of Army dental assistants at the onset of training is greater than 5% prevalence reported in previous healthy populations and is less than 26% prevalence in previous 

research examining Army dental assistants with dental work experience.

Clinical Relevance: Median neuropathy at or distal to the wrist has been reported in dental personnel including 

dentists, dental hygienists, and dental assistants, and is also prevalent in this sample of dental assistants at the 

onset of training. Further long-term prospective research involving the impact of dental practice and techniques 

for reducing upper extremity injuries in dental professionals appears to be warranted.
 July – September 2012 73

al12 stated that 45% of the dental personnel surveyed 

indicated hand problems, and 25% were determined 

to indicate a high probability of CTS. The authors concluded that Army dental personnel are at greater risk of 

developing CTS than the general public.12 Additionally, 

Lalumandier et al12 found that 73% of dental assistants 

complained of hand problems, and a number of these 

dental assistants exhibited probable or classic symptoms 

of CTS. In a separate investigation, Rice et al13 reported that symptoms associated with CTS were noted by 

75.6% of the dental workers, 11% presented diagnosed 

CTS, and 53% indicated back and shoulder pain. Individuals in the dental assistants group were found to be 

at risk for developing upper extremity symptoms, CTS 

and back pain.

Previous studies by our investigative team, which included the diagnostic gold standard of nerve conduction 

studies, also support an increased prevalence of median 

neuropathies in military dental personnel. Specifi cally, 

9 (26%) of the 35 Army dental assistants investigated 

were found to have electrodiagnostic abnormalities of 

the median nerve at or distal to the wrist (when compared to the ulnar nerve of the same hand).15 Ulnar nerve 

electrophysiological function was within normal limits 

for all subjects examined.15 This population of dental assistants was studied at the beginning and end of their 

training to become preventive dental specialists.15,16

There were no new cases of electrodiagnostic median 

nerve abnormalities and no statistically signifi cant shift 

of the nerve conduction values in the prevalence of median mononeuropathies following the 12-week training 

program.16 Several ergonomic risk factors are also associated with CTS and include repetitiveness of work, 

forceful exertions, mechanical stress, posture, temperature, and vibration.17 These risk factors may be present 

for dental personnel as dental instruments may cause 

contact stress over the carpal tunnel, and wrists may be 

held in awkward positions for prolonged periods.18

Collectively, musculoskeletal dysfunction of the upper 

extremities, to include carpal tunnel syndrome, are well 

documented in practicing dentists, dental hygienists, 

and dental assistants. There is also evidence to suggest 

that short-term dental training does not impact the electrophysiologic status of the median and ulnar nerves.16

Unfortunately, there is a paucity of information in the 

literature to document the presence of CTS or upper 

extremity musculoskeletal dysfunction in Soldiers as 

they begin their didactic and clinical training program 

to become dental assistants. The job description for the 

Army dental assistant is similar to that of a civilian dental assistant. Therefore, the purpose of this study was to 

determine the presence of clinical and electrodiagnostic 

abnormalities of the median and ulnar nerves in both 

upper extremities in this sample of Soldiers at the onset 

of their training to become dental assistants.

METHODS AND MATERIALS

All Army dental assistants participating in the October 

through December 2008 dental assistant classes (N=94) 

were approached to participate in this study. Fifty-fi ve 

participated, 33 declined, and 6 volunteered but did not 

keep their appointment for the data collection session.

Experimental procedures, risks, and subject rights were 

discussed with each individual before participation in 

the study. All subjects signed an institutionally approved 

written consent form. Individuals were excluded if they 

were pregnant. The study was approved by the Institutional Review Board of Brooke Army Medical Center, 

Fort Sam Houston, Texas.

A history, physical examination, and upper quarter neuromusculoskeletal screen were performed to determine 

the musculoskeletal status of the neck and upper extremities, and neural integrity of the median and ulnar 

nerves. These assessments were performed during the 

fi rst week of the dental assistant training program.

History

A history was taken from each patient in questionnaire 

format. The history included information pertaining to 

demographics, medical history, military background, 

work experience, hand dominance, and the amount of 

time using a computer.

Physical Examination

As part of the evaluation process, the physical (screening) examination of each participant included assessment of active range of motion, manual muscle tests, 

sensory evaluation, refl ex testing, and select special 

tests.19,20 Specifi cally, active range of motion was assessed for the cervical spine, shoulders, elbows, wrists, 

and hands. Manual muscle testing was performed for all 

major muscle groups in both upper extremities. Sensory 

assessment was determined with light touch, vibration, 

and pain/pin prick assessment of the bilateral upper extremities. Light touch and pin prick sensation included 

the bilateral C4-T1 dermatomes. Vibration sensory 

testing was conducted using the Biothesiometer (Biomedical, Newbury, Ohio). Testing was performed at the 

dorsal 1st metacarpal and distal tip of the thumbs, long 

fi ngers, and middle fi ngers. Muscle stretch refl exes (also 

known as deep tendon refl exes) were obtained from the 

biceps brachii, brachioradialis, and triceps in the upper 

extremities. Upper extremity pathological refl exes were 

assessed with the Hoffman sign.
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

Last, the special tests of Tinel’s sign of median and ulnar nerves at the wrist, Tinel’s sign of the ulnar nerve at 

the elbow, Phalen’s test, and the assessment of the radial 

pulses during positional changes of the upper extremities and neck (Adson’s maneuver) were examined.19,20

Additional special tests of the median and ulnar nerves 

were performed on both upper extremities of each subject and included the elbow hyperfl exion test (EHFT) to 

assess for ulnar neuropathy at the elbow,21 upper limb 

neural dynamic testing (ULNDT) to determine irritation 

of the cervical nerve roots or upper extremity nerves,22

and wrist ratio tests that determines the ratio of both the 

anterior-posterior and medial-lateral widths measured at 

the distal crease of the wrist.23-25

Nerve Conduction Studies

At the time of volunteer solicitation, potential subjects 

were instructed to abstain from exercising for 1 hour 

prior to testing. Skin temperature at the wrist was measured using a digital thermometer model TM99A (Cooper Instrument Corporation, Middlefi eld, Connecticut), 

and was maintained at or above 32oC. If skin temperature fell below this value, the wrist, hand, and forearm 

were rewarmed with warm towels.

The Cadwell Sierra LT electromyograph and stimulator (Cadwell Laboratories, Inc, Kennewick Washington) 

were used to measure the compound motor action potential (CMAP) and sensory nerve action potential (SNAP) 

latencies and amplitudes. The stimulating current was 

a monophasic pulse 0.1 millisecond long. The oscilloscope was set to a sweep duration of 2.0 milliseconds 

per division and a gain of 20 μV per division for the 

SNAPs. For the CMAPs, the oscilloscope was set to a 

sweep duration of 2.0 milliseconds per division and a 

gain of 5 mV per division. The fi lter settings were 10 Hz10 kHz for the motor potentials and 10 Hz-2 kHz for the 

sensory potentials. The sensory latency was measured 

at the negative peak of the SNAP, and the amplitude was 

measured from negative peak to positive peak. The motor latency was measured from the negative takeoff of 

the evoked CMAP, while the amplitude was measured 

from the baseline to the negative peak of the evoked response. The obtained results were recorded manually 

and on computer printout.

Specifi c details for performing the median and ulnar 

nerve conduction studies (NCS) were presented in a 

study by Harkins et al26 and follow procedures previously described.15,27-30 The median and ulnar nerve palmar 

and digital distal sensory latencies (DSLs), distal motor 

latencies (DMLs), and conduction velocities were obtained from both upper extremities. All NCS procedures 

included measuring the anatomic course of the nerve: 

median and ulnar palmar DSLs (8 cm), median and ulnar digital DSLs (14 cm), and median and ulnar DMLs 

(8 cm). In addition to comparing median nerve palmar 

and digital DSLs, DMLs, and conduction velocities with 

a chart of normal values, comparison studies between 

median and ulnar palmar DSLs, digit DSLs (digit 2 and 

digit 5, digit 4 median/ulnar), and DMLs in the same and 

opposite extremities were obtained. Examination of median and ulnar latencies in the same extremity and median and ulnar latencies in opposite extremities has been 

shown to assist in early electrodiagnosis of CTS.27-30

Preventive Guidelines and Exercises for the

Wrist and Hand

Upon completion of the examination, each Soldier received information regarding stretching, strengthening, 

resting, and nerve gliding techniques to assist in the prevention of future musculoskeletal injury. The exercises 

focused on the forearm, wrist, and hand. The purpose of 

providing upper extremity exercises (mobility, strengthening, and stretching) was to increase these Soldiers’ 

awareness of possible musculoskeletal problems in dental personnel. Additionally, the subjects were advised to 

incorporate these exercises into their professional dental 

assistant practice.

In an effort to ensure consistency across subjects, one 

investigator (N.H.) collected all history data, another 

(S.F.) performed the physical examinations, and a third 

(R.M.) performed all nerve conduction tests. The neural 

conduction assessment of the median and ulnar nerves 

that were performed by researcher R.M. was directly 

monitored by either investigator 4 (D.G.), 5 (S.S.), or 6 

(J.M.). Investigators 4 and 5 are board-certifi ed clinical 

specialists in clinical electrophysiology by the American Board of Physical Therapy Specialties of the American Physical Therapy Association. Investigators 4, 5, 

and 6 are or have been credentialed by the US Army to 

perform clinical electrophysiological testing (NCS and 

EMG studies).

Data Management and Analysis

Descriptive statistics for subject demographics and 

nerve conduction study variables were calculated using 

Statistical Package for Social Sciences (SPSS) software 

version 12.0 (SPSS Inc, Chicago, IL).

RESULTS

History

Fifty-fi ve subjects participated in this study (28 female, 

27 male). The age of the subjects ranged from 18 to 45 

years (mean=24±7 years). Forty-fi ve of the subjects 

were right-handed. All subjects had been in the military 

for at least 3 months with a range of 3 to 180 months 

CLINICAL AND ELECTRODIAGNOSTIC ABNORMALITIES OF THE MEDIAN NERVE

IN US ARMY DENTAL ASSISTANTS AT THE ONSET OF TRAINING
 July – September 2012 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

(mean=27 months), and had completed basic combat 

training. Three of the subjects had college degrees, 19 

had completed some college work, 31 had a high school 

diploma, and 2 had a GED. Twenty-three subjects were 

active duty Soldiers, 19 Army Reservists, and 13 Army 

National Guardsmen. One subject (No. 49) had previous 

experience as a dental assistant in a civilian setting.

The mean time the subjects spent working on a computer 

was 5 hours per week with a range of 0 to 40 hours per 

week. Fifteen of the subjects played some type of musical instrument including guitar, violin, clarinet, fl ute, 

piano, and drums. The subjects participated in sporting 

activities an average of 5 hours per week with a range 

of 0 to 30 hours.

When asked to describe their general health, 46 of the 

subjects reported being in excellent/good health and 9 

of the subjects reported fair health. None of the subjects 

reported having a history of neuropathic disease, renal 

disease, peripheral vascular disease, thyroid disease, or 

diabetes. Two subjects reported a history of having arthritis. Fifteen of the subjects responded positively to 

having a problem with their head, neck, or upper extremities during the previous 6 months prior to data collection. All other subjects denied having any musculoskeletal problems in the past 6 months.

The following information was received in response 

to specifi c questions about current pain or symptoms 

in the neck or upper extremity: dull, aching neck pain 

and in the C7-T1 dermatomes (subject 8); cramps in the 

left hand (subject 26); dull, achy pain in the left D3-D4 

fi ngers (subject 37); and numbness and tingling in both 

hands (subject 46).

A review of the subjects’ histories revealed that subjects 

8, 37, and 46 had subjective complaints suggestive of 

median or ulnar dysfunction. Otherwise, there were 

no indicators in the information obtained in the history 

suggesting median or ulnar nerve abnormalities in the 

upper extremities of these dental assistants.

Screening Examination

Active Range of Motion: Two subjects had limited active range of motion (AROM). One had limited right 

shoulder internal rotation and one had limited right elbow extension and forearm supination. All other subjects had normal AROM of the cervical spine, shoulder, 

elbow, wrist, and hands bilaterally. Cervical quadrant 

tests were determined to be normal without radicular 

symptoms in either upper extremity.

Motor Strength: All subjects were assessed to have normal (5/5) muscle strength for the neck fl exors, extensors, 

and rotators (C1-5); both upper extremities to include the 

scapula elevators, depressors, protractors, and retractors 

(C1-5); shoulder fl exors, abductors, and external/internal rotators (C5-6); elbow fl exors and extensors (C5-8); 

wrist fl exors and extensors (C6-8); fi nger fl exors and 

extensors (C7-T1); and hand intrinsics (C8-T1). All upper extremity peripheral nerves (motor components) and 

myotomes (C4-T1) were assessed during motor testing.

Sensation: Five subjects had abnormal sensation to light 

touch. Sixteen subjects had abnormal palm to tip light 

touch sensation. Eight subjects had abnormal vibration 

sensation (3 metacarpal, 3 thumb, 1 long fi nger, 1 little 

fi nger). Of the subjects with abnormal sensation, only 3 

subjects had abnormal median nerve fi ndings on electrophysiological testing (subject 37, light touch and pain; 

subject 49, palm to tip light touch; subject 20, abnormal vibration test). Otherwise, all subjects had normal 

peripheral nerves (sensory components) and C4-T1 dermatome sensory testing results for light touch, pain/pin 

prick, and vibration in both upper extremities.

Muscle Stretch Refl exes (MSRs) and Pathological Signs:

Two subjects had absent MSRs. One subject had absent 

brachioradialis (C6) MSRs bilaterally, and a second subject had an absent left brachioradialis (C6) MSR. Otherwise, all subjects displayed present and equal muscle 

stretch refl exes. Pathological signs (Hoffman) were absent in both upper extremities of all subjects.

Special Tests: Twelve subjects had positive Tinel’s tests 

(3 median nerve at the wrist; 1 ulnar nerve at the wrist; 

8 ulnar nerve at the elbow). Only one subject (No. 26) 

had a positive Tinel’s sign of the median nerve at the 

wrist and abnormal electrophysiological fi ndings in the 

median nerve. Three subjects had positive Phalen’s test 

for the median nerve. One subject had a positive EHFT. 

None of the subjects with a positive Phalen’s test for the 

median nerve or EHFT for the ulnar nerve had abnormal 

electrophysiologic fi ndings on NCS testing. Twenty subjects had positive ULNDTs for the median nerve. Only 

subject 37 had a positive ULNDT for the median nerve 

and abnormal electrophysiologic fi ndings on NCS testing. 

Forty-two subjects (76.1%) had wrist ratios (WR) ≥0.70. 

Four subjects (8, 20, 26, 37) with abnormal WR also had 

abnormal median nerve electrophysiological fi ndings.

Thoracic Outlet Tests: All subjects displayed normal radial pulses when the upper extremities were tested in the 

3 thoracic outlet syndrome testing positions.19,20
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

Other than 5 subjects (8, 20, 26, 37, 

49) who had abnormal fi ndings on 

physical examination and abnormal 

median nerve electrophysiologic 

testing, there were no diagnostic 

indicators or evidence of median 

and ulnar nerve abnormalities in 

either upper extremity of the dental assistants tested during the 

physical examination portion of the 

assessment.

Nerve Conduction Studies

The results of the nerve conduction 

studies are presented in Table 1. The 

values for these electrophysiological variables for each subject were 

compared to a chart of normal values (Table 1). This chart of normal 

values was developed in the Clinical 

Electrophysiological Laboratory of 

Texas Physical Therapy Specialists 

(New Braunfels, Texas), and revalidated at the Electrophysiological 

Laboratory, Army-Baylor University Doctoral Program in Physical 

Therapy. The chart of normal values depicted in Table 1 is similar to 

other charts of normal values.27-30

A comparison of the results of the 

study with the chart of normal values determined that 4 subjects (8, 20, 37, 46) had electrophysiologic evidence of median mononeuropathy at 

or distal to the wrist (Table 2).

Interestingly, when comparison studies between the median and ulnar palmar DSLs, digital DSLs, and DMLs 

in the same and opposite extremities, and the digit 4 median/ulnar comparison study in the same extremity were 

assessed, electrodiagnostic abnormalities of the median 

nerve at or distal to the wrist in an additional 2 subjects 

(26, 49) were revealed (Table 2).

Six of the 55 subjects (11%) presented with abnormal 

electrophysiologic values suggestive of median mononeuropathy at or distal to the wrist. Five of the subjects 

had abnormal electrophysiologic values in both hands. 

Three of the subjects (8, 20, 37) had electrophysiologic abnormalities of both the motor and sensory fi bers 

, and three (26, 46, 49) had abnormal fi ndings in only 

the sensory fi bers (Table 2). Five of the 6 subjects had 

clinical examination fi ndings consistent with the electrophysiological fi ndings. (Tables 3 and 4) The ulnar 

nerve electrophysiologic assessment was normal in all 

subjects.

COMMENT

To our knowledge, no studies have used histories, physical examinations, and NCS to assess the status of the 

median and ulnar nerves in Soldiers enrolled in a dental 

assistant course. A thorough history and physical examination are considered essential screening tools for 

detecting signs and symptoms of peripheral neuropathy.28-30,32-34 Nerve conduction measurement is often performed on the median and ulnar nerves to determine 

whether certain entrapment neuropathies are present.28-42

Nerve conduction measurement is considered the gold 

standard when assessing the electrophysiologic status of 

the peripheral nerve.28-42

Of the 55 Soldiers in the dental assistant course that 

participated in the study, 11 hands (10%) in 6 subjects 

(11%) had electrodiagnostic abnormalities of the median 

nerve at or distal to the wrist. Subject 8 was an 18-yearold right hand dominant (RHD) male who worked in 

Table 1. Mean, standard deviation, and range of values for neural conduction measurements.

Right Upper

Extremity

Left Upper

Extremity

Normal

Values

Mean SD Range Mean SD Range

Median Nerve

Motor

DML (milliseconds) 3.5 0.4 2.8-4.6 3.5 0.5 2.7-5.5 <4.2

Amp CMAP (mV) 9.0 2.2 5-16 8.7 2.9 5.0-17 >5

MNCV BE - W(m/sec) 59 4.1 50-67 59 4.1 51-67 >50

Sensory

Palmar DSL (ms) 1.9 0.2 1.6-2.4 1.9 0.2 1.5-2.9 <2.2

Palmar Amp SNAP (μV) 117 41.9 20-200 103 41.8 23-200 >15

2 Digit DSL (milliseconds) 3.0 0.2 2.5-3.6 2.9 0.3 2.5-4.0 <3.5

2 Digit Amp SNAP (μV) 31 12 15-66 28 10.5 16-55 >15

Ulnar Nerve

Motor

DML (milliseconds) 2.8 0.3 2.2-3.4 2.8 0.3 2.3-3.3 <3.6

Amp CMAP (mV) 9 2.5 5-17 8 2.3 5-14 >5

MNCV BE - W (m/sec) 64 4.1 54-73 62 4.4 51-74 >50

MNCV AE - BE (m/sec) 67 5.6 54-77 65 6.2 52-76 >50

Sensory

Palmar DSL (milliseconds) 1.7 0.1 1.5-2.1 1.7 0.1 1.5-2.1 <2.2

Palmar Amp SNAP (μV) 44 27.0 15-153 48 26.8 16-130 >10

5 Digit DSL (milliseconds) 2.8 0.2 2.5-3.5 2.9 0.2 2.5-3.2 <3.5

5 Digit Amp SNAP (μV) 23 6.8 14-52 26 10.8 12-79 >10

Glossary

AE–above elbow DSL–distal sensory latency

Amp–amplitude MNCV–motor nerve conduction velocity

BE–below elbow SNAP–sensory nerve action potential

CMAP–compound motor action potential W–wrist

DML–distal motor latency

CLINICAL AND ELECTRODIAGNOSTIC ABNORMALITIES OF THE MEDIAN NERVE

IN US ARMY DENTAL ASSISTANTS AT THE ONSET OF TRAINING
 July – September 2012 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

the fast food industry prior to joining the 

military. He regularly played the guitar 12 

hours/week and worked on the computer 

for 21 hours/week. The subject complained 

of a dull, aching pain in the bilateral C7-

T1 dermatome but had no other symptoms 

suggestive of median mononeuropathy at 

or distal to the wrist. Physical examination 

determined that the patient’s bilateral wrist 

ratios were >0.70, but otherwise there were 

no fi ndings on the physical examination 

suggestive of a median mononeuropathy. 

During NCS testing, subject 8 had bilateral 

median mononeuropathy at or distal to the 

wrist that affected both the motor and sensory fi bers.

Subject 20 was a 45-year-old RHD male 

who had been a mail carrier before entering the military and had been worked in 

the military for 8 years prior to the dental assistant course as an infantryman, 

mechanic, and vehicle operator. He had 

no symptoms including pain, numbness/

tingling, or weakness in bilateral upper 

extremities (BUE). However on physical 

examination, the subject displayed an abnormal left wrist ratio (>0.70), decreased 

vibration sensation on the right metacarpal 

area, and decreased vibration sensation on 

the left D1-D2-D3. He had bilateral median 

mononeuropathy at or distal to the wrist 

affecting both motor and sensory fi bers on 

the left and motor fi bers only on the right.

Subject 26 was a 21-year-old left hand dominant (LHD) female who had a 3-month 

history of bilateral hand cramping and a 

family history of arthritis and CTS. The subject did not 

list any previous occupations before entering the military 3 months prior to the testing session. Physical examination determined that this subject had an abnormal 

bilateral wrist ratio (>0.70), and a positive Tinel’s sign 

over the right median nerve at the wrist. The subject 

had early bilateral median mononeuropathy at or distal 

to the wrist of the sensory fi bers based on comparison 

studies. Subject 26 also had a positive Tinel’s sign of the 

right ulnar nerve at the wrist, but NCS studies of the 

right ulnar nerve were normal.

Subject 37 was a 39-year-old LHD male who has been a 

medic in the Army National Guard for 13 years. Prior to 

entering the military, subject 37 had been an ambulance 

and rescue worker. Subject 37 had a 6-month history of 

a dull, aching pain in the left D3-D4. Physical examination revealed an abnormal bilateral wrist ratio (>0.70), 

abnormal sensation to light touch and pinprick in the 

left C6 dermatome, and an abnormal bilateral ULNDT 

examination. The subject had bilateral median mononeuropathy at or distal to the wrist affecting both motor 

and sensory fi bers. The subject had normal NCS studies 

of both ulnar nerves.

Subject 46 was a 29-year-old RHD male who had no current symptoms in BUE but stated occasional numbness 

and tingling in both hands prior to joining the military 6 

months before the exam. In civilian life, the subject was 

an electrician and played the guitar approximately one 

hour per week. He had no fi ndings on physical examination to suggest a bilateral median mononeuropathy at or 

Table 2. Subjects with positive fi ndings on neural conduction comparison 

studies.

Palmar DSL* Digital DSL*

Subject Hand Median Ulnar Difference Median Ulnar Difference

8

R 2.3 1.7 0.6 3.4 2.9 0.5

L 2.3 1.7 0.6 3.4 3.0 0.4

20

R 2.2 1.6 0.6 3.2 2.7 0.5

L 2.3 1.7 0.6 3.4 2.8 0.6

26

R 2.2 1.6 0.6 3.4 2.8 0.6

L 1.9 1.6 0.3 3.1 2.8 0.3

37

R 2.4 1.9 0.5 3.5 2.9 0.6

L 2.9 1.8 1.1 4.0 2.9 1.1

46

R 2.4 1.6 0.8 3.6 2.9 0.7

L 2.2 1.8 0.4 3.3 2.7 0.6

49

R 2.1 1.6 0.5 3.5 2.9 0.6

L 1.9 1.7 0.2 3.0 3.0 0.0

DML* D4 DSL*

Subject Hand Median Ulnar Difference Median Ulnar Difference

8

R 4.6 2.8 1.8 3.6 2.8 0.8

L 4.5 2.9 1.6 3.4 3.3 0.1

20

R 4.3 2.7 1.6 3.3 2.9 0.4

L 4.3 2.7 1.6 3.6 2.6 1.0

26

R 3.7 2.7 1.0 3.3 2.8 0.5

L 3.5 2.9 0.6 3.4 2.7 0.7

37

R 4.3 2.8 1.5 3.6 3.1 0.5

L 5.5 2.9 2.6 4.3 3.1 1.2

46

R 4.2 2.6 1.6 3.6 2.9 0.7

L 3.8 2.6 1.2 3.5 2.7 0.8

49

R 4.2 2.5 1.7 3.3 2.9 0.4

L 3.6 2.6 1.0 3.0 2.8 0.2

*All units are milliseconds.

DSL indicates distal sensory latency. DML indicates distal motor latency.

Notes:

Prolonged DSL (palmar and digit) difference ≥0.6 (normal ≤0.5)

Prolonged D4 median/ulnar difference ≥0.7 (normal ≤0.6)

Prolonged median D2 DSL ≥3.7 (normal ≤3.6)

Prolonged DML difference ≥1.1 (normal ≤1.0)

Prolonged median palmar DSL ≥2.3 (normal ≤2.2)

Prolonged DML ≥4.3 (normal ≤4.2)
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

distal to the wrist. Subject 46 had a right median mononeuropathy at or distal to the wrist affecting the sensory 

fi bers (prolonged palmar DSL), and an early left median 

mononeuropathy affecting the sensory fi bers based on 

comparison studies.

Subject 49 was an 18-year-old RHD female and was the 

only soldier in the study that had prior experience and 

work history (2 years) as a civilian dental assistant. She 

had no symptoms in BUE. On physical examination, she 

had no fi ndings suggestive of median mononeuropathy, 

but had abnormal sensation to light touch of the right D5 

and a positive Tinel’s sign of the right ulnar nerve at the 

elbow. NCS studies of the right ulnar nerve were normal. 

On NCS testing, subject 49 had an early right median 

mononeuropathy at or distal to the wrist affecting only 

the sensory fi bers based on comparison studies.

Four of the 6 subjects with abnormal electrophysiological fi ndings of median mononeuropathy at or distal 

to the wrist had a wrist ratio ≥0.70. It is important to 

note that 42 subjects (76%) had an abnormal wrist ratio ≥0.70, but only 3 subjects had clinical electrophysiologic evidence of median mononeuropathy at or distal 

to the wrist and abnormal wrist ratios. There is growing 

evidence suggesting that wrist anatomy may predispose 

individuals to carpal tunnel syndrome.23-25 Specifi cally, 

3 separate studies have identifi ed that “square-shaped” 

wrists, or wrists with larger wrist ratio indexes (>0.67-

0.70), appear to be predisposed to CTS.23-25 To obtain 

the ratio both the anteroposterior (AP) and mediolateral 

(ML) widths are measured at the distal crease of the 

wrist. The wrist ratio is then calculated by dividing the 

AP width by the ML width. A 2005 study revealed that 

this measure was both reliable and sensitive for determining the presence of electrodiagnostically confi rmed 

CTS.24 Other than the wrist ratio, there were no 

other consistent physical exam fi ndings across 

subjects in this study.

In this population of Soldiers entering the dental 

assistant training program, 5 of the 6 subjects with 

electrophysiologic evidence of median mononeuropathy at or distal to the wrist had prior occupations both in the civilian and military workforce. 

Subject 8 worked in the fast food industry; subject 20 was a mail carrier (civilian) and an infantryman, mechanic, and vehicle operator in the 

military; subject 37 worked as an ambulance and 

rescue worker; subject 46 was an electrician; and 

subject 49 was the only subject in this population 

with experience as a civilian dental assistant. It 

appears that these subjects with electrophysiologic evidence of median mononeuropathy at or distal to the wrist may indeed be pre-exposed to disorders 

that affect people performing intensive work with their 

hands.1-3

Three of the subjects (8, 46, 49) had known risk factors 

for developing median mononeuropathy at or distal to 

the wrist. Subject 49 had previous civilian dental experience. Median mononeuropathies at or distal to the wrist 

have previously been reported in the dental assistant 

population.12,13,15,16 Two subjects (8, 46) played musical 

instruments (guitar), and there is evidence to support 

that guitarists are susceptible to having median mononeuropathies at or distal to the wrist.43 It is interesting to 

note that if we exclude the 3 subjects with known risk 

Table 3. Symptoms and history of subjects with electrophysiologic 

evidence of median mononeuropathy at or distal to the wrist.

Subject

(+NCS) 

Symptoms Duration of

Symptoms

Patient History

8

(R/L)

Dull, achy pain in C7-T1

dermatome bilaterally Unknown Guitar player, worked in 

fast food industry

20

(R/L) None N/A

Mail carrier; previous 

military: infantry, mechanic, 

and vehicle operator

26

(R/L)

Cramps in left hand 

intrinsics 3 months Family history of CTS and arthritis

37

(R/L)

Dull, achy pain in left 

middle/ring fi ngers 6 months Ambulance and rescue worker

46

(R/L)

No current symptoms;

N/T in hands prior to 

joining military

N/A

Family history of CTS; 

previous work history as 

electrician, guitar player

49

(R) None N/A Dental assistant; waiter

NCS indicates nerve conduction studies. CTS indicates carpal tunnel syndrome.

Table 4. Physical examination fi ndings on subjects with electyrophysiologic evidence of median monomeuropathy at or 

distal to the wrist.

Subject Dominant

Hand

+NCS Physical Exam Findings

8 RB R&L wrist ratio ≥0.70 

20 R B

Left wrist ratio ≥0.70; right 

metacarpal abnormal vibration; 

left metacarpal/thumb/long & 

little fi nger abnormal vibration

26 L B

R&L wrist ratio ≥0.70; right 

abnormal ROM; right Tinel’s 

median nerve at wrist & ulnar 

nerve at wrist 

37 L B

R&L wrist ratio ≥0.70; abnormal 

sensation left C6 dermatome; 

R&L ULNDT

46 R B no positive fi ndings

49 R R

Right abnormal palm-to-littlefi ngertip light touch; right Tinel’s 

ulnar nerve at elbow

NCS indicates nerve conduction studies. R&L indicates right and left.

ULNDT indicates upper limb neural dynamic testing.

CLINICAL AND ELECTRODIAGNOSTIC ABNORMALITIES OF THE MEDIAN NERVE

IN US ARMY DENTAL ASSISTANTS AT THE ONSET OF TRAINING
 July – September 2012 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

factors, the prevalence of median mononeuropathy at or 

distal to the wrist is reduced to 5.45%, which is consistent with previous reports on the general population.44

In a population such as the Soldiers enrolled in a dental assistant training program that were studied here, it 

is reasonable to expect that subclinical upper extremity 

mononeuropathies secondary to repetitive overuse may 

be present. In the early stages of a mononeuropathy of 

this type, many individuals with a clinically detectable 

problem are not aware that their neural function has 

been impaired.44 Atroshi et al44 examined 125 asymptomatic controls with NCS of the median nerves and 

they reported that 18% (n=23) had electrophysiological 

evidence of carpal tunnel syndrome.

Atroshi et al44 stated that the estimation of the prevalence 

of carpal tunnel syndrome in a general population may 

contribute to the early diagnosis and effective treatment 

of subjects and provide useful data for the interpretation 

of results that estimate the prevalence of carpal tunnel 

syndrome in specifi c occupational groups. Franzblau 

and Werner45-47 further suggest that performing NCS 

on individuals without symptoms of carpal tunnel syndrome is important because it permits the assessment of 

the overall relationship between the electrophysiological properties of the nerve and other clinical features of 

carpal tunnel syndrome. Although no strong evidence 

exists regarding the prevention or progression of CTS, 

it makes sense, theoretically, to identify a problem early, 

where a minor intervention, such as a resting night splint 

or ergonomic changes in the work environment, might 

rectify the dysfunction.45-47

A valuable extension of this study would be evaluation 

of these dental assistants as they progress through their 

dental health careers and to reevaluate these dental assistants in 5 to 10 years to determine whether these individuals who presented with early electrodiagnostic abnormalities of median nerve at or distal to the wrist later 

develop symptomatic carpal tunnel syndrome. Future 

research should include the development of more accurate diagnostic tests performed during the physical examination to determine the presence of median mononeuropathy at or distal to the wrist. Since the majority of 

current evidence is based on individuals already being 

symptomatic, a larger study of the general population 

would be required to more accurately determine prevalence. Last, a longitudinal study should be conducted to 

determine if there is a relationship of physical examination fi ndings as predictors for development of CTS. This 

could be developed into an occupational screening tool 

that would identify individuals at greater risk. Additional 

long-term prospective studies examining the prevalence 

and prevention of upper extremity disorders, to include 

carpal tunnel, appear to warrant further investigation.

CONCLUSION

This descriptive study examined a sample of 55 US Army 

Soldiers who were enrolled in a training program to become dental assistants for the presence of median and ulnar neuropathies. Six of the 55 subjects (11%) presented 

with abnormal electrophysiologic values suggestive of 

median mononeuropathy at or distal to the wrist. Five of 

the subjects had abnormal electrophysiologic values in 

both hands. Five of these 6 subjects had clinical examination fi ndings consistent with the electrophysiological 

fi ndings. The ulnar nerve electrophysiologic assessment 

was normal in all subjects sampled.

The prevalence of median mononeuropathies in this 

sample of Soldiers at the onset of training to become 

dental assistants is greater than 5% prevalence reported 

in previous healthy populations and is less than 26% 

prevalence in previous research examining Army dental 

assistants with dental work experience. These fi ndings 

suggest that nerve conduction comparison studies may 

provide sensitive measures and early indicators for detecting early median nerve compromise at or distal to 

the wrist. Additional prospective research is required 

to validate our fi ndings and determine the factors that 

are predictive of activity limitations and participation 

restrictions in dental assistants who develop carpal tunnel syndrome.

ACKNOWLEDGEMENT

The authors thank COL Robert Lutka, SFC Charles A. 

Aponte, SFC Heide C. Mayberry, SFC Michael C. Mason, and SSG Gerald M. Bradford (AMEDD Center and 

School, Fort Sam Houston, Texas) for their support of 

this study and their assistance in recruiting the participating Soldiers.

This research was performed in partial fulfi llment of the 

requirements of CPT Moore, CPT Foo, and CPT Henry 

for the Doctor of Physical Therapy degree, and approved 

by the Brooke Army Medical Center Institutional Review Board.

The authors have no fi nancial affi liation (including research funding) or involvement with any commercial 

organization that has a direct fi nancial interest in any 

matter included in this manuscript.
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

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AUTHORS

LTC Shaffer is Associate Professor and Program 

Director, US Army-Baylor University Doctoral Program 

in Physical Therapy, Fort Sam Houston, Texas.

CPT Moore is a staff physical therapist at Fort Benning, 

Georgia.

CPT Foo is a staff physical therapist at the Madigan 

Army Medical Center, Fort Lewis, Washington.

CPT Henry is a staff physical therapist at Fort Benning, 

Georgia.

COL Moore is a Professor, US Army-Baylor University 

Doctoral Program in Physical Therapy, Fort Sam 

Houston, Texas.

Dr Greathouse is Director, Clinical Electrophysiology 

Services, Texas Physical Therapy Specialists, New 

Braunfels, Texas. He is also an Adjunct Professor, US 

Army-Baylor University Doctoral Program in Physical 

Therapy, Fort Sam Houston, Texas.

Erratum

In the article “Reliability of Lower Quarter Physical Performance Measure in Healthy Service Members” published on pages 37-49 of the July-September 2011 issue of the AMEDD Journal, the byline entry “John C. 

Childs” is incorrect. The correct byline entry is “John D. Childs.”
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

RISK COMMUNICATION:

WHAT IT IS AND WHAT IT IS NOT

Chances are, if you asked a group of health physicists 

to defi ne risk communication, you would get a wide variety of answers. Fortunately, there is a commonly accepted defi nition of risk communication: 

Risk communication is an interactive process of the exchange of information and opinion among individuals, 

groups, and institutions. It involves multiple messages 

about the nature of risk and other messages, not strictly 

about risk, that express concerns, opinions, or reactions 

to risk messages or to legal and institutional arrangements for risk management.1

Although communication with the public is typically 

thought to be a public affairs or public relations function, the authors view risk communications as a unique 

discipline with expertise in communication that combines an understanding of science and its limitations 

with an appreciation of the psychology and sociology of 

how people, individually and collectively, process, understand, and ultimately come to accept or reject risks 

to human health.

Having provided a commonly accepted defi nition of 

risk communication, we now attempt to debunk some 

popular myths about it. First, risk communication is not 

a “quick fi x” for dealing with a crisis, nor is it an afterthought in responding to an emergency, or a panacea for 

handling public concerns. Risk communication is never 

a one-way dialogue simply “telling” the public what the 

risks are, thereby ending the matter. Nor is risk communication public affairs or public information, where the 

purpose is to convey an organization’s message, story, 

or agenda.1

 And fi nally, risk communication is never, 

ever “spin.” In its truest sense, risk communication is a 

combination of “tools” to be used when concern is high, 

and “processes” that integrate risk communication factors into the overall risk management of an issue. This 

paper outlines the use of these concepts in actual realworld situations involving radiation risk.

COMMON AND UNIQUE CHALLENGES OF 

MILITARY RADIATION RISK COMMUNICATION

Communicators of military radiation risk share all of the 

common challenges of anyone conveying radiation risks. 

First, the very nature of radiation makes communicating 

its risks very diffi cult. Although radiation is ubiquitous, 

exposure is imperceptible to the human senses, making it both unfamiliar and seemingly nefarious. Also, 

radiation risk is highly complex: radiation exposure 

at very high doses can cause immediate death clearly 

due to its effects, while at low doses it may or may not 

cause cancer years or decades after exposure (and if induced, these cancers cannot be identifi ed as radiogenic). 

Further complicating matters is the fact that radiation 

can be both an internal and external hazard, depending 

upon the radionuclide and the type of radiation it emits 

(alpha, beta, gamma, etc). The general public’s overall 

understanding about radiation is also extremely limited 

and often tainted and distorted by misrepresentation of 

Risky Business: Challenges and Successes in

 Military Radiation Risk Communication

COL Mark A. Melanson, MS, USA

Lori S. Geckle

Bethney A. Davidson

ABSTRACT

Given the general public’s overall lack of knowledge about radiation and their heightened fear of its harmful effects, 

effective communication of radiation risks is often diffi cult. This is especially true when it comes to communicating 

the radiation risks stemming from military operations. Part of this diffi culty stems from a lingering distrust of the 

military that harkens back to the controversy surrounding Veteran exposures to Agent Orange during the Vietnam 

War along with the often classifi ed nature of many military operations. Additionally, there are unique military exposure scenarios, such as the use of nuclear weapons and combat use of depleted uranium as antiarmor munitions 

that are not found in the civilian sector. Also, the large, diverse nature of the military makes consistent risk communication across the vast and widespread organization very diffi cult. This manuscript highlights and discusses both 

the common and the distinctive challenges of effectively communicating military radiation risks, to include communicating through the media. The paper also introduces the Army’s Health Risk Communication Program and its 

role in assisting in effective risk communication efforts. The authors draw on their extensive collective experience to 

share 3 risk communication success stories that were accomplished through the innovative use of a matrixed, team 

approach that combines both health physics and risk communication expertise.
 July – September 2012 83

its risks in popular culture, the news media, and by activists. Finally, society’s risk appetite has changed over 

time, with increased demands by society’s members to 

be involved in risk management decisions that personally affect them, and a decreased overall societal tolerance of risk in general (eg, demands for zero risk).

Added to this already contentious situation are the 

unique challenges of communicating military radiation risks. First, there is a latent distrust of the military 

that harkens back to the legacy of veteran exposures 

to Agent Orange during the Vietnam War. Also, many 

military operations are classifi ed, thereby serving as a 

serious barrier to open risk communication. To further 

complicate things, the military also has its own unique 

and sometimes unfamiliar radiation sources, such as nuclear weapons and depleted uranium which, because of 

its unique metallurgic properties, makes it both an ideal 

antiarmor munition and armor plating. Finally, the military is a large, diverse, bureaucratic organization with 

many stovepipe* and silo†

 components, making consistent risk communication a constant challenge.

COMPONENTS OF RISK COMMUNICATION

In the fi eld of general communication, there are 3 distinct components, normally listed in this order: messenger, message, and audience. However, in health physics, 

one typically starts with the message (what is the dose), 

then focuses on the audience (patients, workers, general 

public), and rarely, if at all, do health physicists think 

about themselves, the messengers. Conversely, in this 

paper, we deliberately choose to begin with the audience 

because, in our opinion, understanding the audience is 

the most important part of effective risk communication. 

However, as mentioned previously, it is usually considered secondarily, at best. Important information about 

the audience includes their actual concerns (not what the 

experts think are their concerns); other risks they may 

be facing; their level of understanding of science and 

their trust in both it and in scientists; their preconceptions about radiation and its risks; and other cofactors 

such as possible economic loss due to radiological contamination, potential stigma by being “contaminated or 

exposed,” and their overall perception of social justice. 

Research also shows that the human brain processes 

risk information differently when concern is high, so it 

is important to account and plan for these changes in 

message development and overall risk communication 

efforts, particularly about radiation risks.4

Next, we address the messenger, the one actually communicating the risk. Often, health physicists fi nd themselves as risk communicators because of their unique 

expertise in radiation safety. However, while this expertise is essential, the most important trait in an effective 

risk communicator is empathy.5

 This is because worried people need their emotions and perceptions about 

specifi c risks verbally and visibly acknowledged by the 

risk communicator before productive communication 

can take place. Additionally, a messenger must be open, 

honest, and sincere. Since many risk communication 

events can be quite emotionally heated, the health physicist must also be able to practice the fi ne art of defl ection and detachment, not taking any anger or hostility 

personally (which sounds easy but is very diffi cult to 

do in practice!). Other factors to consider are the ability 

to deal with uncertainty by describing what is known, 

what is not known, and what will be done to fi ll any 

data gaps; a genuine commitment to follow up; and being both willing and prepared to go the extra distance to 

address the audience’s concerns (such as offering dosimetric monitoring or bioassay sampling even when it is 

not legally required or deemed scientifi cally necessary).

Finally, we address the message. Although it’s tempting 

to merely develop messages based on a radiological assessment alone, the most effective messages are those 

that balance what the audience wants to know with what 

you need to provide (thus our focus on the audience fi rst). 

No more than 3 messages should be provided in a given 

situation, since the human brain when under stress is 

capable of processing only limited amounts of information.6

 Messages should be simple (provided in the language of the audience) and concise, but not condescending. Also, messages should always avoid the use of jargon and never include humor. The messages should be 

brief (7-12 words, if possible) and include the reemphasis 

of its clear points. Whenever possible, messages should 

be validated by credible independent third party sources, 

such as the National Council on Radiation Protection 

and Measurements or the International Commission on 

Radiological Protection for international audiences.

THE ARMY’S HEALTH RISK COMMUNICATION 

PROGRAM

Health risk communication expertise within Army Medicine is available from 2 sources. First, risk communication expertise is now available within the Communication Directorate at the Army Medical Command (MEDCOM) headquarters. This is a new skill set within the 

Directorate intended to support issues MEDCOM-wide 

and is slowly being integrated into sensitive, high-profi le 

projects throughout the Command. The subject matter 

expert (SME) provides senior-level risk communication 

*An organizational structure in which the fl ow of information is 

restricted to up and down through lines of control but is inhibited 

or prevented from moving across the organization.2

†A silo structure is one that functions almost entirely within itself, 

without interaction, communication, or cooperation with other 

components of the organization.3
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

guidance to identify and develop strategies to minimize 

communication and reputational risks, strengthen audience confi dence in Army medicine, increase risk and 

crisis communication skills level and standardize crisis communication response throughout MEDCOM, 

and improve the effectiveness of communication efforts. The SME has provided risk communication recommendations and guidance to numerous MEDCOMwide issues, including the temporary removal of dietary 

supplements, Soldier death from rabies, allegations of 

inadequate behavioral health care, use of expired blood 

products, and allegations of the use of recalled test questions in the Army’s radiology residency program. The 

risk communication SME has also provided onsite assistance to medical risk communication issues, such as 

the recent medical reevaluations of Soldiers seen by the 

forensic psychiatry team at the Madigan Army Medical 

Center. 

The second source is the Army Public Health Command’s Health Risk Communication Program (HRCP), 

established in 1989 in response to increasing demands 

from the Army and the public for a broader approach to 

public health risks. The HRCP initially focused on risk 

communication training, but the program has expanded 

and now provides technical consultative expertise to customers throughout the Department of Defense, responding to the broad spectrum of health risk communication 

issues, including radiation. The HRCP staff members 

are highly trained and seasoned health risk communicators with diverse academic backgrounds, including education, public health, and health communication.

The HRCP supports the 3 components of the risk communication process (audience, messenger, and message), 

actively gathering qualitative data (eg, surveys, focus 

groups, sensing sessions) from concerned populations 

to assist in more effective communication throughout 

an entire project. The HRCP also uses audience feedback tools (eg, focus groups) to pretest and validate risk 

communication message effectiveness, for example, 

examining if the information presented is understandable, and are there words and/or phrases that resonate 

poorly with the target audience. The HRCP can assist 

risk communication messengers, often scientifi c subject 

matter experts who rely primarily on quantitative data, 

in becoming more effective. To this end, it provides several risk communication training options: introductory, 

advanced, and specialized. Over the past decade, the 

HRCP has provided several tailored and focused training sessions to Army health physicists, the most recent 

being a 2-day workshop based upon an actual case study 

involving the potential overexposure of a Soldier to 200 

cSv. (It was determined that the Soldier’s dosimeter had 

been intentionally irradiated after the individual had 

worn it and turned it in.) The workshop included roleplaying risk communication exercises involving actors 

playing the roles of the potentially exposed Soldier, his 

wife, and a news reporter.7

 Finally, the HRCP provides 

complete support to public health crisis events, including the development and implementation of a comprehensive communication strategy, identifying and engaging key audiences, and providing on-the-ground support 

throughout the risk communication intervention to the 

evaluation phase. 

The following case studies fully illustrate the comprehensive support provided by the Army’s health risk 

communication assets.

THREE MILITARY RADIATION RISK 

COMMUNICATION SUCCESS STORIES

The fi rst radiation risk communication success story we 

present occurred in 2003, during the early phases of Operation Iraqi Freedom. High level concerns were raised 

about the safety of US troops occupying the Tuwaitha 

Nuclear Research Center, the crown jewel in Saddam 

Hussein’s nuclear weapons program, located just outside 

of Baghdad. At the time, over 4,000 Soldiers and Marines were in and around the facility which had been recently bombed during coalition operations, and vandalized and looted by local Iraqis. The decision was quickly 

made to assemble a special scientifi c team from within 

USACHPPM and expedite its dispatch to Iraq in order 

to perform a thorough fi eld assessment and communicate the risks to the US forces deployed there.8

Since it was obvious that this was a radiation risk communication intervention, a matrixed team combining 

health physics (HP) and RC expertise was formed to 

develop a response strategy. First, the deploying team 

leader was provided refresher RC training and, based 

on demographic information and communication preferences of the units on the ground, key RC messages for 

the response were developed: (a) the team was deployed 

because of Army leadership concerns about protecting 

their troops; (b) the team’s mission was to ensure the 

safety of US forces; and (c) the team was comprised of 

the Army’s foremost radiation experts. Upon arrival, the 

team leader immediately met with the deployed Soldiers 

to present the situation and explain the safety of ambient radiation levels. Once environmental samples were 

analyzed and the risk assessment was completed, it was 

determined that the Soldiers were safe (the highest upper bound dose equivalent was estimated to be 1.2 cSv, 

which is less than one fourth on the annual allowable 

dose for radiation).9

 Fact sheets were then developed 

and provided to the units and their direct leadership. 

RISKY BUSINESS: CHALLENGES AND SUCCESSES IN MILITARY RADIATION RISK COMMUNICATION
 July – September 2012 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

Complementary RC was also provided to key stakeholders at all higher echelons of command. As a direct result 

of this successful intervention, Soldier concerns were 

satisfactorily addressed and the situation never escalated to become a public affairs issue or result in congressional interest.

The second intervention occurred in early 2004, when 

members of the 442nd Military Police (MP) Company, 

New York Army National Guard, redeployed from Iraq 

and were inappropriately denied routine postdeployment 

bioassay screening for depleted uranium. Disgruntled 

about their lack of medical testing, some of the Soldiers 

approached a local paper, the New York Daily News, for 

assistance. Despite the ethical implications of becoming part of the story, the paper coordinated and funded 

the collection and analysis of urine bioassay samples 

from the Soldiers.10 The New York Daily News sent the 

samples for analysis to the Uranium Medical Research 

Centre (UMRC)(Toronto, Canada), a self-proclaimed 

independent, nonprofi t organization and alleged activist group opposed to use of depleted uranium. When 

the URMC sent the medical specimens to a nonaccredited geology laboratory, depleted uranium was detected 

(though no amounts reported) and the story immediately 

became headline news internationally and evoked widespread concern, including congressional inquiries.11,12

As in the previous case study, a matrixed team was 

quickly assembled with HP and RC expertise (a physician was also added to the team). The team immediately 

went to Fort Dix, New Jersey on a fact-fi nding mission 

to meet with and listen to Soldiers and their Families, 

a key fi rst step in effectively identifying true concerns 

and communication needs. An environmental sampling 

team was also sent to the 442nd MP Company’s base 

camp in Iraq to survey for depleted uranium (none was 

detected). Risk communication training was provided to 

the medical staff at the Fort Dix hospital and the 442nd 

Soldiers were fi nally offered bioassay testing. Even 

though not medically required, offering the option to be 

tested reinforced the critical risk communication message that the Army truly cared about Soldier welfare. 

Despite the offer, only about one fourth of the roughly 

200 Soldiers in the unit wanted to be tested (all of the 

results were consistent with natural uranium and within 

normal levels, as reported by the Centers for Disease 

Control and Prevention (CDC)).13 Once available, bioassay results were discussed with the individual Soldier, 

military Families, and healthcare providers. Briefi ngs 

were also provided to senior National Guard leadership and select members of Congress from New York. 

Once again, due to the prompt and effective response, 

all stakeholder concerns were addressed and the crisis 

was successfully resolved.

The fi nal case study event occurred in the summer of 

2007, when a medic from the Army’s 101st Airborne 

Division redeployed from Iraq. Having been to the Tuwaitha Nuclear Research Center (TNRC) during his deployment, the medic contacted the CDC to ask about 

the health risks of radiation exposure because of health 

problems he was experiencing. Fortunately, an Army 

physician, who was coincidentally doing a fellowship at 

CDC, was contacted and the matter was properly referred 

to the Army Medical Department. As with the 442nd 

MP Company, the media also became involved, though 

much later in the response than the previous case.

As before, a matrixed team of HP, RC and medical experts was assembled. A comprehensive RC strategy 

was developed to respond to all stakeholders. Support 

from senior Army leaders ensured full cooperation by 

all Army participants. Despite some initial reluctance to 

engage other recently redeployed Soldiers at Fort Campbell (home of the 101st Airborne), the natural inclination 

to “just let sleeping dogs lie” was overcome.14 Updated 

information about Tuwaitha was obtained from “boots 

on the ground” Army HP assets to augment what was 

already known about the site and provided to unit Soldiers. After interviewing the medic, RC messages were 

developed: (a) the TNRC was safe; (b) all the radioactive sources at TNRC had been properly contained and 

safely stored; (c) anyone desiring testing could provide 

a bioassay sample. Given that, preparations were made 

for the “nightmare scenario” of hundreds of individuals simultaneously wanting bioassays. As it turned out, 

however, only the medic ultimately wanted to be tested 

(his results were either below detection limits for anthropogenic radioactive sources located on the site or within 

COL Melanson, the leader of the assessment and radiation risk 

communication team, describes the situation and explains the 

safety of ambient radiation levels to deployed Soldiers at the 

Tuwaitha Nuclear Research Center outside of Baghdad, Iraq in 

2003. Photo provided by COL Melanson.
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

CDC reported dietary levels for other naturally occurring radionuclide).15 In order to assist other potentially 

concerned Soldiers, a combined HP and RC team deployed to Fort Campbell (where an onsite medical expert 

joined the team) and 3 town hall meetings were held for 

Soldiers, their Families, and members of the local press. 

By delivering the actual briefi ng prepared for the Soldiers to the assembled reporters, the team leader was able 

to tell the good news story that the Army was genuinely 

concerned and was making sure that its Soldiers were 

safe. During all of the town hall meetings, the team’s 

RC expert observed the HP’s message delivery and response to questions, and provided real-time feedback to 

enhance the process. Once again, the concerns of stakeholders were addressed and the crisis was satisfactorily 

resolved. Feedback from the initially concerned medic 

and his fellow Soldiers indicated the response was effective, and press reports were very favorable overall.16

SUMMARY AND CONCLUSIONS

Risk communication is more than just a message; it is 

both a discipline and a process. Military radiation risk 

communication shares all of the diffi culties of communicating civilian radiation risks along with its own 

unique challenges. Effective risk communicators address all three of the components of communication: 

audience, messenger, and message, specifi cally in that 

order. The Health Risk Communication Program is 

a vital corporate asset of the United States Army that 

provides unique and essential expertise to enhance risk 

communication, whatever the risk. The proper partnering of health physics and health risk communication expertise, coupled with senior leadership support, allayed 

public concerns and diffused 3 high stakes crises, despite media involvement and Congressional scrutiny in 

two of them. As illustrated in the case studies discussed, 

effective risk communication is actually achievable and 

we fi rmly believe that without it, properly responding to 

crises, actual or perceived, is impossible.

RECOMMENDATIONS

Recognizing that risk communication is a discipline and 

a process, not merely a product, is essential for success. 

All health physicists should add risk communication 

training as part of their professional development, and 

integrate risk communication into their ongoing professional practice, and not just during emergencies. Whenever possible, health physicists should seek to partner 

with competent health risk communicators in a matrixed 

team, thereby exploiting the synergy between these 2 

diverse, yet complimentary disciplines. Finally, health 

physicists should also share their risk communication 

success stories, along with their failures, so others can 

learn from their experiences.

REFERENCES

1. National Research Council. Improving Risk Communication. Washington, DC: National Academies 

Press; 1989.

2. Handy C. Understanding Organizations. New York, 

NY: Oxford University Press; 1993.

3. Rosen E. Smashing silos. Bloomberg Businessweek [serial online]. February 5, 2010. Available at: 

http://www.businessweek.com/managing/content/

feb2010/ca2010025_358633.htm. Accessed February 24, 2012.

4. Centers for Disease Control and Prevention. 

Crisis and Emergency Risk Communication 

Course. Available at: http://www.bt.cdc.gov/CERC/

overview.asp. Accessed February 21, 2012.

5. Covello PR, Peters RG, McCallum DB. The determinants of trust and credibility in environmental 

risk communication. Risk Anal. 1997;17(1):43-54.

6. Environmental Protection Agency. Communicating 

Radiation Risks: Crisis Communication for Emergency Responders. Washington, DC: Offi ce of 

Radiation and Indoor Air, US Environmental 

Protection Agency; 2007. EOA-402-F-07-008. 

Available at: http://nepis.epa.gov/Exe/ZyPURL.

cgi?Dockey=500025HA.txt. Accessed February 

21, 2012.

7. Melanson MA, Geckle LS, Kukral LC, Costanza 

M. Mystery of the X-ray overexposure: an innovative risk and media communication mentoring workshop. US Army Med Dept J. April-June 

2010:36-42.

8. Melanson MA, Matcek GJ, Goodison SG, Alberth 

DP. Assessing and communicating radiation risks 

in Iraq. US Army Med Dept J. January-March 

2004:39-43.

9. Melanson MA, Goodison S, Szrom GA, Falo GA, 

Alberth DP. Deployment radiation risks to US 

troops at the Tuwaitha Nuclear Research Center 

during the early phases of Operation Iraqi Freedom. Proceedings of the 38th Health Physics Society Midyear Meeting. McLean, VA: Health Physics 

Society;2005:171-176.

10. Editorial Staff. Protect the health of U.S. troops. 

New York Daily News. April 7, 2004. Available at: 

http://archive.truthout.org/article/new-york-dailynews-protect-health-us-troops. Accessed November 8, 2009.

11. Gonzalez J. The war’s littlest victim Daily News 

exclusive: he was exposed to depleted uranium. 

His daughter may be paying the price. New York 

Daily News. September 29, 2004. Available at: 

http://articles.nydailynews.com/2004-09-29/

news/18277829_1_urine-birth-defects-naturaluranium. Accessed February 21, 2012.

RISKY BUSINESS: CHALLENGES AND SUCCESSES IN MILITARY RADIATION RISK COMMUNICATION
 July – September 2012 87

THE ARMY MEDICAL DEPARTMENT JOURNAL

12. Moritz O. Hil stands with News in call for G.I. 

testing. New York Daily News. September 30, 2004. 

Available at: http://articles.nydailynews.com/2004-

09-30/news/18278387_1_depleted-uranium-soldier. 

Accessed February 21, 2012.

13. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey, 

2003-2004. Available at: http://www.cdc.gov/nchs/

nhanes/nhanes2003-2004/nhanes03_04.htm. Accessed February 21, 2012.

14. Melanson MA, Goodison S, Szrom F, Falo GA, 

Alberth DP. The 101st Airborne Division and the 

Tuwaitha Nuclear Research Center: a case study in 

effective post deployment radiation risk communication. Paper presented at: Annual Meeting of the 

Health Physics Society; July 15, 2009; Minneapolis, 

Minnesota.

15. Centers for Disease Control and Prevention. 

National Health and Nutrition Examination Survey, 

2005-2006. Available at: http://www.cdc.gov/

nchs/nhanes/nhanes2005-2006/nhanes05_06.htm. 

Accessed February 21, 2012.

16. Hall KM. Army: troops at Iraqi nuclear site not 

exposed to high radiation. Log Cabin Democrat

[serial online]. November 28, 2007. Available at: 

http://thecabin.net/stories/112807/loc_1128070011.

shtml. Accessed November 28, 2007.

AUTHORS

COL Melanson is the Director of the Armed Forces 

Radiobiology Research Institute, Bethesda, Maryland.

Ms Geckle is Strategic Risk Communication Specialist, 

US Army Medical Command, Fort Sam Houston, Texas.

Ms Davidson is a Risk Communicator with the Health 

Risk Communication Program, US Army Public Health 

Command, Aberdeen Proving Ground, Maryland.
88 http://www.cs.amedd.army.mil/amedd_journal.aspx

Due to the interconnectedness of the world today and the 

ease with which infectious diseases can spread globally, 

collaboration within and among countries around the 

world on pandemic planning and response is immensely 

important. One of the fi rst steps for pandemic planning 

involves identifying existing gaps in a nation’s current 

plans, and examining previous outbreaks for lessons 

learned. To identify such gaps, the World Health Organization (WHO) created a framework with 5 main components for assessing disaster and pandemic planning 

and response: surveillance, healthcare response, public 

health intervention, communication, and command.1

Assessing a country’s current pandemic planning and 

response capability can be accomplished by examining 

each of the 5 aspects of the WHO framework.1

 The fi rst 

component is surveillance. Countries need a robust surveillance system to detect emerging infectious diseases 

or potential outbreaks. However, many countries may 

lack the capacity for such a system. In resource-limited 

settings or countries recovering from a disaster, foreign 

militaries can play a key role in disease surveillance.2

Foreign militaries may have the capacity to support local civilian ministries of health in disease surveillance 

and reporting. Healthcare response focuses on ensuring 

that current hospital resources meet demands and that 

contingency plans exist for continuity of operations during an emergency. Public health intervention is important for preventing or containing the spread of disease. 

Strategic communication is also a fundamental part of 

disaster response and should occur pre-event, during the 

event, and during response and recovery phases. Finally, 

the incident command structure is an integral aspect of 

disaster response. Identifying roles and responsibilities 

of key staff and cross-training ahead of time will enable 

individuals to better respond in the event of a disaster.

The WHO framework provides a structure to assess a 

country’s pandemic response capabilities, but many 

countries around the world may lack capacity for 

effi cient and effective pandemic response. The Armed 

Forces Health Surveillance Center–Global Emerging 

Infections Surveillance and Response System (AFHSCGEIS) partners with many countries around the world to 

build sustainable public health surveillance and laboratory capacities.3

 In addition to partnering with laboratories around the world, the AFHSC, in collaboration 

with the Center for Disaster and Humanitarian Assistance Medicine* (CDHAM) and the geographic combatant commands, also works closely with partner nation militaries and local ministries to conduct training 

workshops and exercises on important topics such as 

infectious diseases and disaster response.

THE CONFERENCE

The AFHSC, collaborating with the CDHAM and the 

US Central Command, held the Infectious Diseases and 

Disaster Response Conference (IDDRC) July 11-14, 2011, 

hosted by the United Arab Emirates Armed Forces in 

Abu Dhabi. This conference promoted regional interoperability and enhanced the capability of regional countries to respond to complex humanitarian and health 

emergencies, with a particular focus on response to infectious disease-related disasters such as pandemics.

Specifi c objectives of the conference included:

a. Creating a platform for military leaders and civil 

authorities to share best practices and lessons 

learned in regards to emerging infectious diseases and disaster response;

b. Providing regional partners with current updates on global emerging infectious threats and 

surveillance improvement;

c. Assisting regional partners to understand the 

roles of the international community (international organizations, nongovernmental organizations, and regional governments) in the management of disasters; and

Summary of the Infectious Diseases and

 Disaster Response Conference in Abu Dhabi

Priya Baliga, MPH

Brittany J. Tang-Sundquist

David R. F. Hajjar, JD, MPH

Faith A. Cooper, MPA

CDR Annette Von Thun, MC, USN

*The Center for Disaster and Humanitarian Assistance Medicine is a component of the Department of Military and Emergency Medicine at 

the Uniformed Services University of the Health Sciences in Bethesda, Maryland. The Center is the Department of Defense’s focal point for 

academic aspects of medical stability operations.
 July – September 2012 89

d. Identifying national and regional opportunities 

for improvement of surveillance and regional 

coordination that will assist in the development 

of a regional response to emerging infectious 

hazards and disasters.

The conference included a total of approximately 95 distinguished participants and lecturers from the United 

Arab Emirates, the United States, Iraq, the Hashemite 

Kingdom of Jordan, Lebanon, Qatar, the Kingdom of 

Saudi Arabia, and Yemen. Individuals from each of 

the countries were invited to present on best practices 

in disaster mitigation within their countries. Subject 

matter experts from the US Department of Homeland 

Security, AFHSC, Georgetown University, the George 

Washington University, and the Carolinas Medical Center presented on topics relevant to infectious disease and 

disaster response. The conference incorporated facilitated discussions on the Sphere Project,a

 strategic communication in disaster response, and the World Health 

Organization’s International Health Regulations.4

 Attendees had the opportunity to participate in a regional 

pandemic response tabletop exercise, which identifi ed 

gaps and promoted regional communication.

During the conference workshops, participants were 

able to identify existing gaps in their current national 

and regional plans and methodologies, examine previous infectious disease outbreaks for lessons learned, 

consider possible ways to address some of the identifi ed 

gaps, and build relationships with their regional counterparts. Future interactions will fortify regional partnerships and cooperative agreements to strengthen infectious disease and disaster response within the region.

Emerging Infectious Diseases and Surveillance

The Institute of Medicine b defi nes emerging infectious 

diseases as conditions that have increased incidence in 

humans and that are clinically distinct.5

 In his lecture 

“Emerging Infectious Disease Updates,” Dr Daniel Luceyc

 presented information on newly emerging diseases 

as well as disease prevention strategies for controlling 

outbreaks. He further distinguished between emerging and reemerging infectious diseases, explaining that 

emerging infectious diseases are newly recognized 

pathogens, such as Nipah virus, Severe Acute Respiratory Syndrome (SARS), and pandemic (H1N1) 2009. 

Reemerging infectious diseases have been previously 

recognized, but are now seen in a new location, such as 

Monkeypox, West Nile virus, and Rift Valley fever.

Dr Lucey was an integral part of a response team to the 

2003 SARS epidemic in Toronto, Canada. He elaborated 

upon several measures for preventing disease transmission, including the importance of SARS assessment 

triage centers that were established in trailers outside 

of hospitals to prevent the spread of disease while still 

providing care for sick patients. Having dedicated staff 

members to deal with SARS patients, screening check 

points at all hospital entrances, and providing adequate 

personal protective equipment for patients provided further mechanisms for reducing transmission within the 

hospital.

Dr Lucey outlined 5 major contributions of the early 

21st century regarding emerging infectious diseases: (1) 

the One Health concept (collaboration of human, animal, 

and environmental health disciplines, see http://www.

onehealthinitiative.com/index.php); (2) the importance 

of international partnerships; (3) antibiotic and antiviral 

drug resistance; (4) the WHO International Health Regulations4

 (IHR), and (5) global infectious disease surveillance. Dr Lucey also mentioned the importance of 

organizations such as the AFHSC-GEIS and the WHO 

in current global surveillance efforts.

The AFHSC-GEIS laboratory surveillance network has 

been an important player in global biosurveillance of 

infectious diseases. In 2009, AFHSC-GEIS provided 

funding and oversight to a network of 39 partners at approximately 500 sites, impacting a total of 92 countries 

through active surveillance projects, capacity-building 

initiatives, or participation in training exercises.6

 Many 

of these training initiatives have been in direct support 

of the WHO IHR.7

 During the IDDRC, COL Robert Lipnickd

 and Ms Priya Baligae led a small-group session 

on the importance of the WHO IHR, and reviewed the 

framework for a member state to report a potential Public Health Emergency of International Concern (PHEIC). 

They also introduced scenarios of potential PHEICs and 

a The Sphere Project, headquartered in Geneva, Switzerland, is a voluntary initiative that brings a wide range of humanitarian agencies together to improve the quality of humanitarian assistance and the accountability of humanitarian actors to their constituents, donors, and 

affected populations. Information available at: http://www.sphereproject.org/.

b The Institute of Medicine is the health component of the National Academy of Sciences. It is an independent, nonprofi t organization that 

works outside of government to provide unbiased and authoritative advice to decision makers and the public. Information available at: 

http://www.iom.edu/About-IOM.aspx.

c Adjunct Professor, Department of Microbiology and Immunology, Georgetown University

dDirector, Communications Standards and Training Divisions, AFHSC

e Epidemiologist, AFHSC
90 http://www.cs.amedd.army.mil/amedd_journal.aspx

led discussions on the intricacies of reporting through a 

country’s ministry of health to the WHO. Further discussions deliberated upon the consequences of countries 

not disclosing a potential PHEIC to the WHO, the criteria that constitute a PHEIC and when to report, and 

complications of detecting and reporting potential PHEICs in countries with limited resources and capacities. 

Thus, infectious disease surveillance is only the fi rst 

step to overall disaster planning and response.

Disaster Planning and Response

When planning for disasters such as an infectious disease outbreak or pandemic situation, it is extremely benefi cial to have a whole of society approach to the disaster, 

including integrated planning and preparation (Figure 1). 

Mr Robert Hutchinsona

 and Ms Sharon Peyus b highlighted the importance of identifi cation of essential 

sectors in supporting relevant authorities, and the need 

for development of business continuity plans for critical sectors. They also emphasized the benefi ts of multisectoral preparedness through close interministerial 

collaboration and communication, commitment of subject matter experts, and the leveraging of resources.

In their lecture on contingency planning, they presented 

a variety of lessons learned during the US response efforts for Hurricane Katrina in 2005, the H1N1 pandemic 

in 2009, and the earthquake in Haiti in 2010. The after action report (AAR) on the H1N1 pandemic evaluated several functional areas, including emergency operations center management, information gathering and 

recognition of indicators and warnings, responder safety 

and health, critical resources logistics and release, and 

managing risk. Some of the strengths of the pandemic 

(H1N1) 2009 response, including previously conducted 

H5N1 planning and training efforts, greatly assisted 

the development and refi nement of pandemic mitigation measures. Assessment of the AAR established that 

DHS effectively communicated with state, local, territorial, and tribal government offi cials. Some of the areas 

of improvement noted in the AAR included increasing 

effi ciency of incident command/control to streamline 

a Assistant Special Agent in Charge, US Department of Homeland Security

bDirector, National Incidence Response Unit, US Department of Homeland Security

Figure 1. “The Whole of Society Approach” to disaster management. Courtesy of Robert Hutchinson and Sharon Peyus, US 

Department of Homeland Security.

SUMMARY OF THE INFECTIOUS DISEASES AND DISASTER RESPONSE CONFERENCE IN ABU DHABI
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THE ARMY MEDICAL DEPARTMENT JOURNAL

decision making, improving communication, information sharing, and strengthening partnerships.8

The US Federal Emergency Management Agency’s 

Incident Command System (ICS)9

 is a standardized, onscene, all-hazards incident management approach. In his 

lecture “Force Health Protection in Disaster Response,” 

Dr David Callaway*

 discussed the ICS, which helps 

to manage incidents through concepts such as unity 

of command, common terminology, management 

by objective, fl exible and modular organization, and 

span-of-control (Figure 2). The ICS has an systematic 

approach to managing safety of responders through 4 

functions of the safety management cycle: information 

acquisition, analysis of options, decision-making, and 

taking action. He emphasized force health protection as 

an essential element for maintaining resources to respond 

to crises through standardized processes and customized 

response, and that there is a full spectrum of requirements 

throughout the disaster and deployment cycle.

In addition to ICS and the importance of force health 

protection, Dr Callaway also spearheaded a small group 

discussion on strategic communication during a disaster, 

deemed critical during all stages of the event. He provided 2 case examples: Hurricane Katrina and the consequences of failed strategic communication, and the 

success of strategic communication during the earthquake in Haiti. During the Katrina event, the lack of a 

basic coordinating instruction, a knowledge management plan, and an overall situational awareness was the 

reason that strategic communication failed. In contrast, 

successes in Haiti were attributed to a clear strategic 

message, which allowed decentralized command and 

execution. Additionally, relationships with the press and 

nongovernmental organizations (NGOs) were fi rmly 

established prior to the earthquake. These relationships 

fostered a sense of trust between all parties involved and 

were offered as further reasons why strategic communication was so effective (Figure 3).

*Director, The Operational Medicine Institute and Assistant Professor of Emergency Medicine, Carolinas Medical Center, Charlotte, NC

Figure 2. The structure of a nominal Incident Command System (US Dept of Homeland Security).9
92 http://www.cs.amedd.army.mil/amedd_journal.aspx

Nongovernmental organizations play a key role in response to disasters. During the IDDRC, Dr David Hajjar *

 guided a small-group discussion on the Sphere 

Project and the Sphere Handbook,10 which is designed 

for use in disaster response and is applicable to natural 

disasters as well as armed confl ict. During the smallgroup discussion, Dr Hajjar presented a case study on a 

migration of Ugandans crossing the border to Tanzania 

after a pandemic outbreak resulted in violence and limited resources.

Throughout the session, discussions arose about minimum and adequate standards for conditions in refugee 

camps, when and how refugees should be persuaded 

to return to their countries of origin, and various other 

factors that must be taken into account when caring for 

individuals fl eeing a crisis (security, political situation, 

weather, health, capacity, mental state, etc). A lively 

debate surrounded the topic of adequate standards for 

camps without indulging refugees in luxuries, so they 

would still feel compelled to return to their countries 

of origin once the emergency has been resolved. The 

importance of maintaining dignity while balancing the 

desire to return home was recognized as a pervasive 

challenge in the refugee camp setting.

Best Practices in Disaster Response: Country 

Presentations

The IDDRC was designed to foster contribution by attendees. Participants from invited countries were encouraged to make presentations on best practices in disaster 

response within each of their respective countries. Dr 

Saleh Fares, a consultant for the Emergency Department 

at the Zayed Military Hospital in Abu Dhabi, presented 

“Regional Critical Infrastructure and Key Resources 

for Disaster Response” within the United Arab Emirates (UAE). The unique population of the UAE, which 

is made up of more than 80% guest workers with thousands of people crossing borders daily, makes responding 

to disasters in the country a particular challenge. One of 

the key resources Dr Fares highlighted for managing disasters in UAE was the Higher National Security Council 

National Emergency and Crisis Management Authority. 

He discussed the command structure, starting with Level 

1–the President of the UAE; Level 2–the National Security Advisor; Level 3–the Ministries of Health, Interior, 

and Environment; and Level 4–local or Emirate level. 

He shared the UAE’s national response plan to H1N1,11

including surveillance elements, case investigation and 

management, strengths, and areas for improvement. 

Strengths of the H1N1 response included adequate funding, political support, coordination of various organizations, and incorporation of past lessons learned. Areas 

for improvement included lack of a “real-time” surveillance system, limited laboratory capacity and capability, 

poor communication, and suboptimal ICS coordination.

Dr Mahmud Abdallat, representing the Preventive Medicine Department of the Royal Medical Service (RMS) 

of Jordan, lectured on Jordan’s pandemic infl uenza response. He explained that the RMS had representatives 

on the National Steering Committee, National Technical 

Committee, and National Treatment Committee for Pandemic Infl uenza Response, and that the RMS pandemic 

response plan is part of the national response plan for 

pandemic infl uenza in Jordan. This response plan encompasses the RMS surveillance system, external communications, and their internal communications, including RMS medical outpatient clinics and military units. 

These communication systems are coordinated by a senior offi cer in a designated operations room in the RMS 

directorate. Dr Abdallat also described the structure of 

teams for surveillance and treatment of pandemic infl uenza cases in RMS hospitals.

Dr Awni Abulail, also of the Jordanian RMS, gave a 

briefi ng on the RMS role in international medical assistance. Dr Abulail presented some of the capabilities of 

the main RMS hospital, King Hussein Medical Center, 

(http://www.jrms.gov.jo/Default.aspx?tabid=54), as well 

as Jordan’s fi eld hospitals and surgical teams and facilities, who have provided medical assistance to 21 locations throughout the world as part of United Nations 

Peacekeeping Forces or humanitarian aid missions.

Brigadier General Maurice Sleem, Surgeon General of 

the Lebanese Army, addressed the nature of disasters in 

Lebanon, most of which are man-made and involving 

wars. He reviewed response efforts to a major oil spill in 

the Mediterranean Sea as a result of the bombing of the 

Jiyeh power station, which caused the leakage of nearly 

15,000 tons of oil reaching areas on the Syrian coastline, and the waters of Turkey and Cyprus. The Lebanon 

Figure 3. Five elements of communicating a message. Source: 

Dr David Callaway.

*Senior Consultant, IDEAS, Inc, Kirtland, Ohio

SUMMARY OF THE INFECTIOUS DISEASES AND DISASTER RESPONSE CONFERENCE IN ABU DHABI
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THE ARMY MEDICAL DEPARTMENT JOURNAL

Ministry of Environment requested assistance from 31 

countries, 71 national and international organizations, 

and 80 NGOs in response to this disaster. The quantity of waste collected and safely stored is estimated to 

be about 200 cubic meters, however, there are still 12 

polluted sites undergoing cleanup operations along the 

shoreline of Lebanon.

Brigadier General Sleem discussed health security in relation to the response to unexploded ordnance in Lebanon 

where the Ministry of Public Health continues to provide 

emergency medicine and supplies for acute and chronic 

conditions. He shared the role of the WHO and the United Nations Children’s Fund in health security in support 

of response efforts. These organizations worked with a 

broad range of partners in Lebanon to save lives, protect 

civilians, and support basic services such as health, water, sanitation, education, and psychosocial care.

Brigadier General Sleem added that Lebanon’s National 

Committee for Disaster Management held its fi rst national conference on disaster management in November 2009, 

bringing together many key stakeholders. However, due 

to current political circumstances in Lebanon, there has 

been a delay in setting plans and policies, and in strengthening infrastructure development in the country.

Major General Dr Samir Abdullah Hasan from the Directorate of Iraqi Military Medical Services gave a presentation on the “Emergency Health Plan of the Iraqi 

Surgeon General’s Offi ce.” The Iraqi plan’s purpose is 

to establish a policy under the new democratic Iraqi law 

to protect military and civilian installations, facilities, 

and personnel in the event of a public health emergency, 

whether due to manmade or natural disaster, outbreaks 

of infectious disease, biological warfare, or terrorism. 

The plan contains elements of isolation, public health 

emergency response, quarantinable communicable diseases, and mandatory quarantine. It also addresses those 

public health emergencies that occur during religious 

events.

The Iraq Surgeon General’s offi ce has a senior military 

medical offi ce or Ministry of Defense civilian employee 

who is designated as a Public Health Emergency Offi cer 

(PHEO). The PHEO ascertains the existence of cases 

suggesting a public health emergency; investigates cases 

for sources of infection; recommends implementation of 

proper control measures; defi nes distribution of illness; 

identifi es all exposed individuals; counsels individuals 

on the course and spread of their illness; assesses facilities for purpose of closing; evacuates affected individuals; decontaminates or destroys any materials contributing to the public health emergency; shares information 

with federal, provincial, or local offi cials; notifi es applicable military channels; and reports public health emergencies to the Surgeon General and the Ministry of Defense. The PHEO is also responsible for providing written notice to all quarantined individuals, screening and 

safely disposing of corpses, and informing all affected 

individuals of control and mitigation actions to take during a public health emergency. Dr Samir listed education and training of PHEOs and commanders as one of 

the most pressing challenges faced by the Iraq Surgeon 

General’s offi ce for emergency health planning.

The country presentations were an essential element of 

the IDDRC. Through learning about country-specifi c 

approaches to controlling infectious diseases and responding to disasters, groups were better able to interact 

and have open discussions during the tabletop exercise 

(TTX) portion of the conference.

Regional Pandemic Tabletop Exercise

The UAE Regional Pandemic TTX was based on an 

outbreak of infl uenza-like illness that initially presented 

in a rural village in Thailand. The participants were divided, as much as possible, into 4 groups with representatives from all of the countries present. Each group 

was given about 3 hours to discuss the exercise before 

reconvening to present the main fi ndings of their discussion. Participants were encouraged to take the information gained from the previous days’ lectures to guide 

their TTX group discussions.

The objectives of the TTX were to: 

 Create a platform for military leaders and civil authorities to share best practices and lessons learned 

in emerging infectious disease and disaster response activities.

 Provide regional partners with current updates 

on global emerging infectious threats and surveillance.

 Assist regional partners in understanding the roles 

of the international community (international organizations, NGOs, regional governmental organizations) in the management of disasters.

 Promote regional interoperability and enhance the 

capability of host nations to respond to complex humanitarian emergencies.

 Identify national and regional opportunities for the 

improvement of surveillance and regional coordination that will assist in the development of multicountry response to emerging infectious hazards 

and disaster response.
94 http://www.cs.amedd.army.mil/amedd_journal.aspx

Sharing best practices and lessons learned throughout 

the region, each country contributed specifi c experiences and signifi cant discussion points to the exercise. In 

one group, representatives from both the UAE and Jordan noted having a national food stockpile for emergency purposes, which can feed their respective country’s 

current populations for 3 to 6 months. As part of their 

national pandemic response plan, the Jordanian government has informed retired medical personnel who, 

in case of a pandemic, may be recalled to service. The 

Jordanian plan has the capability to increase personnel 

capacity by 30% through extending normal emergency 

department shifts from 8 to 12 hours.

Timely, accurate and effective communication is critically important during disasters as it contributes to saving lives and increases the public awareness and understanding. Discussions from the breakout groups focused 

heavily on effective communication practices during 

the pandemic scenario. Participants from the UAE and 

Jordan discussed how they would strategically choose 

one government representative as a spokesperson, who 

would serve as the only source of communication between the government and the media. This trusted individual would be responsible for relaying facts, dispelling rumors, calming the public, and delivering the 

government’s messages about the pandemic. This open 

communication with the media would help inform and 

empower, building trust among the government, the media, and the public.

Another critical issue for pandemic response planning is 

that of refugees and internally displaced persons (IDPs). 

Concerns arose, such as prioritizing resources between 

refugees and citizens, focusing on high risk individuals 

within these groups, as well as exploring legal mandates 

on basic needs of refugees, communicating with the refugees’ country of origin, and enforcing border security. 

One Jordanian participant noted that during a severe crisis, schools would be closed and therefore could be used 

as a shelter to house IDPs, whereas refugees would be in 

camps and the burden would remain on the refugee fi eld 

hospitals to treat those sick individuals. It was concluded that it is essential to include neighboring countries in 

pandemic planning efforts.

Groups identifi ed 2 major gaps during their TTX discussions. First, they found the countries’ postpandemic 

planning insuffi cient. The transition to long-term recovery and the resources needed for the postpandemic 

phase was unclear. Additionally, they found that the 

role of NGOs and the UN during a pandemic in the region was vague. The groups additionally alluded to the 

relevance of the One Health concept, emphasizing the 

importance of human and animal disease surveillance 

and the integration of human and animal health in the 

control of pandemics.

One of the facilitators noted that most of the participants 

in his group consisted of high-level offi cials who have 

not previously focused on contingency plans for some of 

their critical resources. For example, contingency plans 

in many countries did not appear to address employee 

absenteeism, a phenomena that could greatly affect the 

size of the critical workforce during a pandemic situation. A concrete plan did not seem to be in place in many 

of the participating countries for securing borders and 

supporting the interior with the limited personnel and 

resources that would be expected in such a crisis. Some 

countries may not have previously planned for the ramifi cations of interrupted electricity, sanitation pickup, 

food deliveries, medical supply deliveries, etc. Although 

most of these examples represent worst-case scenarios, 

it is important for countries in the region to have these 

components incorporated into their contingency plans 

for pandemics and disasters.

CONCLUSIONS

Over the course of the 4-day conference, a number of 

common themes were brought to the forefront by the 

presentations, discussions, and tabletop exercise. Among 

these is the need to be proactive by taking steps to identify, detect and respond effectively to crises rather than 

wait for a disaster to occur and then be dependent on 

external organizations (such as the UN) to address national needs. Participating national governments understood their role as the primary responsible party for the 

wellbeing of their citizens. The attendees understood the 

value of being proactive, taking immediate action, and 

enhancing their own capacity to prepare for, respond 

to, and recover from emergency and disaster situations. 

Participants expressed their appreciation for the value of 

the multisectoral, all-hazards, whole of society approach 

and pronounced their desire to move forward with such 

a comprehensive plan.

In addition, participants exhibited a new appreciation 

for (1) the value of redundancy in emergency management procedures and methodologies; (2) the importance 

of continuity of operations and continuity of governance procedures; and (3) the critical role of effective 

coordination and information-sharing mechanisms for 

enhancing timeliness and effectiveness of their disaster 

response efforts. Finally, due to the wealth of participant 

experience and breadth of geographical representation, 

participants embraced the importance of developing 

clearly articulated and tested standard operating procedures, coupled with written mutual aid agreements and 

SUMMARY OF THE INFECTIOUS DISEASES AND DISASTER RESPONSE CONFERENCE IN ABU DHABI
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THE ARMY MEDICAL DEPARTMENT JOURNAL

procedures at the local, national, regional, and international levels.

As a result of the time shared together at the workshop, 

participants identifi ed existing gaps in their current 

national and regional plans and methodologies, examined previous infectious disease outbreaks for lessons 

learned, considered possible ways to address some of 

the identifi ed gaps, and built relationships with their regional counterparts.

The IDDRC was one of several workshops planned by 

the AFHSC, the Center for Disaster and Humanitarian 

Assistance Medicine, and US combatant commands that 

focus on emerging infectious disease outbreaks and disaster planning and response as a means of contributing to national, regional and global security.12 These engagements (workshops, conferences, tabletop exercises) 

bring together civil and military personnel to develop 

common strategies on surveillance, laboratory techniques, implementation of public health policies, use of 

vaccines, and military support for an effective pandemic 

response. The information obtained from this conference in Abu Dhabi will help to inform ongoing efforts 

to improve capacity while enhancing the capability of 

regional countries to respond to complex humanitarian 

and health emergencies.

Preparing globally to address pandemics is a signifi cant 

challenge, but the consequences of being unprepared 

could be catastrophic. Meeting this challenge will require a comprehensive, multidisciplinary approach to 

building sustainable capacity in partner nations to recognize, prevent, and respond to the threat of emerging 

and reemerging infectious diseases which are critically 

important for an effective global response. Additionally, 

future engagement strategies will be designed to focus 

on regional partnerships and cooperative agreements 

geared towards strengthening infectious disease and disaster response efforts.

ACKNOWLEDGEMENTS

The authors thank the following individuals for their 

presentations at the conference, facilitation of the tabletop exercise, and contributions to this report:

Dr Mahmud Abdallat (Jordan Royal Medical Services); 

Dr Awni Abulail (Jordan Royal Medical Services); Dr 

Yousif Al Hosani (UAE Armed Forces Medical Services Corps); Dr Charles Beadling (CDHAM); Dr David 

Callaway (Carolinas Medical Center); Mr Brian Engel 

(George Washington University Medical Faculty Associates); Dr Saleh Fares (Zayed Military Hospital); Dr 

Samir Abdullah Hasan (Iraqi Military Medical Services); Mr Robert Hutchinson (Department of Homeland 

Security); Mr John Jordan (United States Agency for 

International Development); Ms Amy Keim (George 

Washington University Medical Faculty Associates); Mr 

Chris Lafranniere (United States Central Command); 

COL Robert Lipnick (Armed Forces Health Surveillance 

Center); Dr Daniel Lucey (Georgetown University); Ms 

Daniela Macander (George Washington University Medical Faculty Associates); Mr James Marinucci (George 

Washington University Medical Faculty Associates); Ms 

Sharon I. Peyus (Department of Homeland Security); 

CAPT Kevin Russell (AFHSC); Maj Issam Sebaihi (US 

CENTCOM); Brigadier General Maurice Sleem (Lebanese Army); CDR Carlos Williams (CDHAM)

REFERENCES

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back to basics during a public health emergency: 

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2. Chretien JP, Blazes DL, Coldren RL, et al. The importance of militaries from developing countries in 

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3. Chretien JP, Blazes DL, Gaydos JC, et al. Experience of a global laboratory network in responding 

to infectious disease epidemics. Lancet Infect Dis. 

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ihr/9789241596664/en/index.html. Accessed November 10, 2011.

5. Lederberg J, Shope RE, Oaks SC Jr, eds. Emerging Infections: Microbial threats to Health in the 

United States. Washington, DC: National Academies Press; 1992. Available at: http://books.nap.

edu/openbook.php?record_id=2008&page=R1. 

Accessed March 15, 2012.

6. Russell KL, Rubenstein J, Burke RL, et al. The 

global emerging infection surveillance and response system (GEIS), a U.S. government tool for 

improved global biosurveillance: a review of 2009. 

BMC Public Health. 2011;11(suppl 2):S2.

7. Otto JL, Baliga P, Sanchez JL, et al. Training 

initiatives within the AFHSC-GEIS: support for 

IHR(2005). BMC Public Health. 2011,11(suppl 

2):S5.
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8. Infl uenza Pandemic: Lessons from the H1N1 Pandemic Should Be Incorporated into Future Planning. 

Washington, DC. US Government Accountability 

Offi ce; June 2011. Report GAO-11-632. Available 

at: http://www.gao.gov/assets/330/320176.pdf. Accessed November 3, 2011.

9. Incident Command System. The Federal Emer-gency 

Management Agency Web site. Available at: http://

www.fema.gov/emergency/nims/IncidentCom

mandSystem.shtm. Accessed November 3, 2011.

10. Humanitarian Charter and Minimum Standards 

in Humanitarian Response. 3rd ed. Rugby, United 

Kingdom: Practical Action Publishing; 2011. Available at: http://www.sphereproject.org/handbook/. 

Accessed November 3, 2011.

11. Khan G, Al-Mutawa J, Hashim MJ. Pandemic 

(H1N1) 2009, Abu Dhabi, United Arab Emirates, May 2009-March 2010. Emerg Infect Dis. 

2011;17(2):292-295.

12. COCOM Engagements page. Armed Forces Health 

Surveillance Center web site. Available at: http://

www.afhsc.mil/trainingCOCOM. Accessed November 3, 2011.

AUTHORS

Ms Baliga is an Epidemiologist at the Armed Forces 

Health Surveillance Center, Silver Spring, Maryland.

Ms Tang-Sundquist is a Project Offi cer, Center for Disaster and Humanitarian Assistance Medicine, Uniformed 

Services University of the Health Sciences, Bethesda, 

Maryland.

Mr Hajjar is Lead Consultant, IDEAS Inc, Kirtland, 

Ohio.

Ms Cooper is Program Manager, Center for Disaster and 

Humanitarian Assistance Medicine, Uniformed Services 

University of the Health Sciences, Bethesda, Maryland.

CDR Von Thun is Head, Training and Combatant Command Initiatives, Armed Forces Health Surveillance 

Center, Silver Spring, Maryland.

SUMMARY OF THE INFECTIOUS DISEASES AND DISASTER RESPONSE CONFERENCE IN ABU DHABI
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