April – June 2013 

Perspectives 1 

MG Philip Volpe; COL Mustapha Debboun; Richard Burton 

Contributions of the Global Emerging Infections Surveillance and Response 7 

System Network to Global Health Security in 2011 

CDR David L. Blazes, USN; et al 

US Army Public Health and Veterinary Support in Japan Following the 19 

Tōhuku Earthquake and Tsunami, March-April 2011 

Nolan A. Watson 

Diet, Physical Activity, and Bone Density in Soldiers Before and After Deployment 25 

1LT Ashley R. Carlson; MAJ Martha A. Smith; MAJ (Ret) Mary S. McCarthy 

Addressing Cancer Clusters in the US Army 31 

Jessica M. Sharkey; Veronique D. Hauschild

The Effects of Attachment Style on Sleep in Postdeployed Service Members 35 

LTC Sandra M. Escolas; 1LT Erika J. Hildebrandt; et al 

Considerations Regarding a Burn Pit Registry 46 

Coleen P. Baird, MD, PhD 

The Health Hazard Assessment Process in Support of Joint Weapon System Acquisitions 53 

Timothy A. Kluchinsky, PhD; et al 

1991 Gulf War Exposures and Adverse Birth Outcomes 58 

Bengt Arnetz, MD, PhD; et al 

Efficacy and Duration of Three Residual Insecticides on Cotton Duck and Vinyl Tent 66 

Surfaces for Control of the Sand Fly Phlebotomus papatasi (Diptera: Psychodidae) 

Abdel Baset B. Zayed, PhD; et al 

Evaluation of Imidacloprid-Treated Traps as an Attract and Kill System for 73 

Filth Flies During Contingency Operations 

LT James C. Dunford, USN; et al 

Field Evaluation of Commercial Off-the-Shelf Spatial Repellents Against the Asian 80 

Tiger Mosquito, Aedes albopictus (Skuse) and the Potential for Use During Deployment 

Aaron M. Lloyd, MS; et al 

A Long-Term Survey of Indian Meal Moths in a Dry Goods Warehouse Using 87 

Monitoring Traps With Pheromone Lures 

Choe Hyon Chong, PhD 

Complications of Male Circumcision Treated at a Military Hospital in Afghanistan 93 

LTC Jennifer M. Gurney; et al 

Quarantine and Isolation: A Primer for Military Leaders 98 

MAJ Joseph B. Topinka 

The Battle of Yellow Jack: A Comparative Look at Preventive Medicine During the 103 

American Civil War 

COL Barry F. Graham 

Military Quantitative Physiology, A New Volume in the Borden Institute 107 

Textbooks of Military Medicine Series 

COL (Ret) Brian Lukey 

The Military commitment to Public Health 
April – June 2013 The Army Medical Department Center & School PB 8-13-4/5/6 

By Order of the Secretary of the Army: 

Official: 

1304616 

RAYMOND T. ODIERNO 

General, United States Army 

Chief of Staff

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LTG Patricia D. Horoho 

The Surgeon General 

Commander, US Army Medical Command 

MG Philip Volpe 

Commanding General 

US Army Medical Department Center & School 
 April – June 2013 1

Perspectives

COMMANDER’S INTRODUCTION

MG Philip Volpe

Throughout history, battles, campaigns, and even wars 

have been won and lost due to a factor having nothing 

to do with force organization, combat doctrine, fi re and 

maneuver, superior weapons, inspired leadership, or 

logistics support, but rather because of the collective 

health of the single essential element, the Warfi ghters. 

Field commanders had long struggled with the loss of 

combat effectiveness due to the ravages of diseases and 

other debilitating physiological problems among their 

forces. There were few answers as to causes, and even 

fewer for remedies, until the second half of the 19th 

century when, as COL Stephen Craig explained in the 

AMEDD Journal in 2006:

Bacteriology, developed by Koch, Pasteur, and others, 

and the nascent science of immunology were establishing a foundation for public health practice that was being 

effectively applied by innovative physicians in state and 

metropolitan public health departments.1

Army medical leaders were also recognizing that these 

new approaches to explaining the causes and prevention 

of diseases were potentially of great value to military 

capabilities and readiness. In 1893, The Army Surgeon 

General, BG George Sternberg, established the fi rst 

Army Medical School. However, the purpose of the 

school was not to teach medicine and surgery. As BG 

Sternberg wrote to Daniel Lamont, the US Secretary of 

War:

There is no need to teach medicine and surgery to graduates of our medical colleges, but there are certain duties of an Army medical offi cer—for which the college 

course has not prepared them—which are more important than the clinical treatment of individual cases of 

disease and injury.... A special education is needful to 

prepare a military man to undertake the protection of the 

public health. The course at the army medical school will 

prepare him to cope with the questions of practical sanitation that will be presented to him at every turn in his 

military career.2

That profound insight in 1893 established that the tenets 

of public health were basic to military medicine. From 

that beginning, the science and practice of public health 

disciplines in the military have become recognized as 

essential to the achievement of a relevant and ready force 

and the sustainment of combat power. That evolving realization has resulted in top-down emphasis, policies, 

and regulations to institutionalize public health as an 

integral part of garrison management and the planning 

and execution of training and operational deployments. 

The creation of the US Army Public Health Command 

in 2011 formally established public health as a distinct, 

major component of the Army Medical Department.

The scope of AMEDD’s commitment to public health is 

impossible to convey in a few short paragraphs, or even 

an entire issue of the AMEDD Journal. Fortunately, for 

each of the past 7 years, COL Mustapha Debboun, Chief 

of the Academy of Health Sciences Department of Preventive Health Services, has assembled articles from 

preventive medicine and public health professionals for 

a dedicated issue of the Journal, providing exposure for 

the diversity and complexity of their responsibilities and 

their work. That continues with this eighth issue, with 

articles covering a spread of public health and force 

health protection concerns, from extensive research 

studies and surveillance, to solutions for problems and 

threats. As with those past issues, this AMEDD Journal

clearly conveys the breadth and depth of this vital work 

and vigilance that are never-ending, mostly behind the 

scenes. Because of the preventive and environmental 

nature of their work, the success of the Army’s public 

health professionals is often not noticed in our everyday 

lives, but it is absolutely refl ected in an absence of disease and injury, and the improved health of us all. For 

this, these medical professionals have truly earned our 

respect and gratitude, both for what they have done and 

what they will do to protect our most valuable asset, the 

Warriors who defend our nation and our way of life.

1. Craig SC. The evolution of public health education in the US Army. US Army Med Dep J. April-June 2006:7-17.

2. Annual Report of the Army Surgeon General, 1893. Washington, DC: US War Department; 1893:15.
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

EDITOR’S PERSPECTIVE

As the understanding of the value of information relating 

sicknesses, diseases, and deaths to geographic locations 

and time expanded and matured, the United States has 

increasingly regarded the threat of wide-spread, uncontrolled diseases as a national security concern. Following 

World War II, the military took the lead in implementing 

world-wide disease and vector surveillance and analysis, initially for its own strategic purposes, but also to 

complement the growing initiatives and activities across 

the civilian public health sectors. Quantum leaps in the 

sophistication of analysis, communications, and data 

management have made such disease surveillance an 

indispensable tool for both military and civilian public 

health professionals throughout the world. The Defense 

Department (DoD) established the Global Emerging Infections Surveillance and Response System (GEIS) in 

1997 to centralize coordination of surveillance efforts of 

the overseas DoD medical research laboratories. Over 

the years, the GEIS network has expanded to include 

international collaborations with various agencies and 

organizations in numerous countries. In an excellent article providing insight into the capabilities, scope, and 

value of the functions performed by GEIS, Navy CDR 

David Blazes and his team of coauthors detail the extensive activities and accomplishments of the GEIS network for one year, 2011. Their article clearly conveys the 

enormity, gravity, and especially the importance of the 

work that GEIS has done, and will do in the future.

The world was stunned at the destruction and loss of life 

suffered by Japan following the earthquake and tsunami 

which struck the main island of Honshu in March 2011. 

As happens for most major disasters, an international relief effort was quickly mobilized, with the military leading the way. The US has considerable military resources 

located in Japan, and the rapid employment of those 

assets in partnership with Japanese forces was clearly 

evident in the media coverage. However, the immediate 

and sustained involvement of the US military preventive 

medicine, veterinary, and radiological defense personnel 

was largely overlooked, a normal circumstance for these 

public health professionals who perform their important 

functions in the background of large operations. Nolan 

Watson’s article reveals this aspect of disaster response 

that was absolutely essential for execution of the US 

military’s contingency plans. Ranging from immediate 

water and food sampling and analysis, to evacuation of 

military personnel’s pets from Japan, to extensive radiological sampling and testing following the nuclear reactor malfunctions, these professionals provided the US 

and Japanese authorities with almost continuous data vital to their decisions and planning. Mr Watson’s article 

is not only an eye-opening presentation of what these 

military personnel do, but their dedication and pride in 

their work is clearly evident, a well-deserved tribute to 

the military public health professionals upon whom we 

all depend, whether we realize it or not.

The nutrition needs of recruits and combat Soldiers, primarily infantry, have been studied for years, and military nutrition programs and fi eld rations are tailored to 

those needs. However, scant attention has been given to 

the nutrition requirements of deployed personnel who do 

not normally experience the same physical activity and 

stress levels of those involved in combat operations. 1LT 

Ashley Carlson and her coauthors investigated the diet, 

physical activity, and bone mineral density of a group 

of combat service support Soldiers before and after deployment to detect any indicators that their nutrition 

needs may be different. Their article clearly describes 

the carefully designed study, presents the data, and discusses it within the context of results from similar studies of combat Soldiers. This is an interesting fi rst look at 

whether there may be value in tailoring nutrition to specifi c populations in varying deployment environments.

In this time of nearly unrestricted access to information, 

often of suspect accuracy, and nearly universal connectivity among individuals, sometimes a bit of information is interpreted and/or applied incorrectly, but that 

interpretation is spread without further investigation or 

verifi cation, and sometimes achieves a life of its own. 

This may be particularly true with subjects of health and 

illness, as uninformed, unverifi ed, and incomplete opinions and statements can easily fuel a sense of paranoia 

and fear, especially when the subject is cancer. Occasionally, however, such information may indeed be accurate, and fears justifi ed. Jessica Sharkey and Veronique 

Hauschild have contributed an article which discusses 

how the US Army Public Health Command (USAPHC) 

deals with one area of such concern, the cancer cluster. 

The Centers for Disease Control and Prevention have 

formally defi ned cancer clusters, and have established a 

set of scientifi cally-based guidelines to evaluate reports 

to determine if a cancer cluster investigation is indeed 

warranted. The guidelines include carefully established 

criteria with which to judge the reported cancers, including frequency, the type(s) of cancer involved, the 

geographic area, and the time period of the onsets. Their 

article is a succinct, clearly presented explanation of how 

the US military addresses reports of perceived concentrations of cancer cases which ostensibly may be related 

to environmental or other external conditions.

The central component of The Army Surgeon General’s 

System for Health initiative is the Performance Triad 

PERSPECTIVES
 April – June 2013 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

of activity, nutrition, and sleep. Activity and nutrition 

as part of good health have long been promoted both in 

health literature and the public media. In recent years, 

researchers have increasingly been examining sleep as 

an equally valuable counterpart of an overall healthy 

lifestyle. One aspect of sleep research looks at the quality of the sleep to be as important as the quantity, and 

the factors that affect sleep quality. Army medicine is 

currently involved in several ongoing sleep research 

projects and collaborative efforts. LTC Sandra Escolas 

and her team of researchers examined the sleep of postdeployed military service members from the perspective of an individual’s ability to relate to others, known 

as attachment theory, and how it may affect the type of 

sleep, quality and quantity, that an individual experiences. This excellent article reports the results of their 

carefully designed, extensively researched study, and 

how those results correlate with the literature of civilian 

studies in this area. This is an important contribution to 

the growing area of research into sleep as an essential 

component of one’s overall health.

Dr Coleen Baird has contributed two earlier articles to 

the AMEDD Journal exploring various aspects of how 

exposure to burn pits may affect the long-term health 

of military and civilian personnel deployed to combat 

theaters. She has kept us current on the potential hazards, the research, the fi ndings and conclusions, and the 

responses of military and veterans’ healthcare agencies. 

Her article in this issue discusses the most recent legislative action which places burn pit exposure into a category on par with radiation exposure from World War 

II tests, Agent Orange exposure, and the 1991 Gulf War 

undiagnosed symptoms and diseases. The Department 

of Veterans Affairs maintains a registry for personnel 

potentially exposed to environmental hazards in each 

of those circumstances. New legislation effective January 10, 2013, directs the establishment of a registry for 

those potentially exposed to toxic chemicals and fumes 

from open burn pits during deployments. Such registries 

are important because they allow personnel to be listed 

as eligible for medical assistance should their exposure 

lead to illness. Such symptoms and diseases often do 

not present for a number of years following exposure, 

at which time it may be diffi cult to verify eligibility and 

receive care. Dr Baird’s article is an excellent and informative presentation which synopsizes burn pit exposure 

actions to date, explains the registries, and details what 

was involved in the creation of this registry dedicated to 

potential victims of those exposures.

The Consumer Products Safety Commission is charged 

with ensuring that the public in the United States is protected from unreasonable risks of injury or death from 

use of the thousands of products under their jurisdiction. 

The military has a similar responsibility to those who 

use the thousands of items that are specifi cally developed and procured for use by military service personnel 

and civilians, especially weapon systems. In 1981, The 

Army Surgeon General established the Health Hazard 

Assessment Program (HHA) to evaluate the potential 

health effects of operating military weapon systems. 

Following the DoD-wide adoption of the HHA concept in 1983, the Army HHA was formally established 

in what is now the USAPHC. In their article, Dr Timothy Kluchinsky and his team use the responsibilities of 

the HHA in the testing of joint weapon systems under 

development to describe the parameters that USAPHC 

must consider and evaluate, the standards that must be 

applied, and the various other considerations that are 

involved in their work. This article is a detailed, informative discussion of another very important function of 

Army medicine that works quietly and effi ciently in the 

background, and is vital to protect our Warfi ghters from 

preventable, unnecessary injury, or worse.

In 2011, Dr Hikmet Jamil, Dr Bengt Arnetz, and a team 

of researchers contributed a report of their study of the 

health effects on Iraqi civilians and military personnel 

resulting from environmental exposure to multiple biologic and chemical substances during the 1991 Gulf War. 

Dr Arnetz and Dr Jamil return to the AMEDD Journal

with another team of researchers to report the results 

of a second study concerning environmental exposures 

during that confl ict. The focus of this research effort 

was the relationship of such exposures and adverse birth 

outcomes among Iraqis. As in their previous study, the 

research was complicated by several factors including 

availability of specifi c exposure data, sample selection 

after a period of intervening years, and the availability 

of proper comparison groups. There were also a number of cultural factors to consider since data collection 

involved direct interviews to discuss often sensitive issues. Therefore, this group of experienced researchers 

had to carefully design and plan the study to mitigate the 

recognized defi ciencies, strictly follow the plan during 

data collection, and meticulously examine and analyze 

that data to account for nonrelevant infl uences or corrupting factors. The results of their study are presented 

in a clear, organized manner that completely supports 

their conclusion. Their work is an example of important 

research that should stimulate further investigation into 

this side effect of warfare, which may have broader applications for similar peacetime exposures to comparable substances.

As we have learned from hard experience over the last 

110 years, some of the most pernicious threats to our 
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

Soldiers are posed by the smallest of adversaries—mosquitoes, ticks, sand fl ies, fl eas, mites, and other arthropods—which cause problems directly through bites and 

irritation, and, more importantly, vector some of the most 

virulent disease pathogens that affl ict humans and other 

mammals. The battle to counter those threats is neverending, pursued not only by the best resources of the US 

military, but also by governments, foundations, and corporations worldwide. Some of the arthropod threats are 

regional, perhaps existing in areas of low human population density, thus lowering the priority for attention 

from meager public health resources available in most 

undeveloped countries. However, for the US military, 

the challenge of preparing for such threats is exacerbated by the potential of deploying forces to virtually any 

location on the globe, so military medical professionals 

must always be prepared to address any of the potential 

arthropod threats, often on very short notice. Research 

across the spectrum of threats, therefore, is constant. 

Dr Abdel Zayed and a diverse team of researchers have 

investigated effi cacy of residual insecticides against an 

arthropod pest of the desert environment that is particularly diffi cult to control, the Old World sand fl y, a source 

of signifi cant nuisance bites and an important vector of 

cutaneous leishmaniasis. Their article reports the results 

of the study examining the effectiveness and duration 

of 3 residual insecticides on the 2 types of tent materials used in the current combat theaters, cotton duck 

and vinyl. The study involved several environmental 

parameters to which each material/insecticide combination was exposed, and data was gathered over a period 

of months. This interesting article is another excellent 

example of a well designed, professionally executed scientifi c study that yielded positive, usable results for the 

improved protection of our Warfi ghters.

Another group of arthropods that can cause serious illness and even death among humans are fi lth fl ies. Unchecked, their ability to transmit viral, bacterial, and protozoal pathogens, including dysentery and cholera, can 

rapidly degrade the combat capability of a fi ghting force. 

Such fl ies populate almost every climate and geographic 

area, including the deserts of the world, often in great 

numbers. There are many measures employed to control 

fi lth fl ies, including aggressive sanitation controls, insecticides, and baited traps. All of those measures have 

limitations, especially within deployed environments. 

Baited traps, in particular, while initially very effective 

at collecting large numbers of fl ies, quickly lose effectiveness as the containers fi ll and additional fl ies cannot enter. In their article, Navy LT James Dunford and 

his collaborators describe a research project conducted 

by the Navy Entomology Center of Excellence in which 

they investigated increasing the kill potential by placing 

a coating of residual insecticide on the outside surface of 

the trap to deliver a lethal dose to those fl ies who land, 

but do not enter the trap container. While such a concept may seem fairly straightforward, the complexity of 

collecting valid, robust data and the parameters which 

must be considered for a fi eld research project quickly 

complicate its planning and execution. Because of the 

comparative purpose of the data collected at the various 

locations and times, planning and design are especially 

crucial, and collection of data and maintenance of the 

traps must follow the plan exactly. Although each of two 

collection periods were roughly one week in length, the 

team collected an enormous amount of fl ies and attendant data, and then had to carefully organize and analyze everything. The article clearly demonstrates the 

thoroughness, attention to detail, and dedication of those 

involved in fi nding answers for threats to our health and 

well-being.

Since the development of the fi rst truly effective topical 

insect repellent by the US Army in 1946 (deet (N,Ndiethyl-3-methyl benzamide)), the use of such a repellent has been the fi rst line of personal defense against 

biting insects. Over the years, many commercial topical 

products of varying effectiveness have been developed 

and marketed, but the more effective of those still share 

some measure of cosmetic disadvantages, including oily 

residue, unpleasant smell, and/or dermal irritation. Additionally, there is the inherent inconvenience of application, and reapplication, especially when heavy perspiration or water immersion in encountered. Although the 

US military has for years required use of a personal protection measure system which includes deet application 

to exposed skin, surveys show that actual use of deet, 

even when the hazards of vector borne diseases in the 

area are understood, has been confi rmed by only around 

50% of deployed military personnel. The commercial 

market has encountered similar ambivalence towards 

the use of topical repellents, and has pursued development of repellent devices that do not require application 

to either skin or clothing, collectively known as spatial 

repellents. In another research effort by the Navy Entomology Center of Excellence, Aaron Lloyd and his team 

of researchers evaluated 4 commercial, off-the-shelf 

consumer spatial repellent products for effectiveness as 

an insect repellent, as well as reliability, suitability for 

the tactical environment, and supportability. Their article describes another excellently designed and executed 

fi eld research project, requiring precision and attention 

to detail to ensure that the resulting data and derived 

conclusions solidly support the conclusions. Although 

the currently available products may not be completely suitable for combat applications, this research study 

could lay the foundation for the concept of individual 

PERSPECTIVES
 April – June 2013 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

Soldier spatial repellent devices, and stimulate further 

research and development in this area.

Arthropods not only cause harm to human health with 

bites, venom, and as disease vectors, they also can be severely destructive to the food chain, not only for humans, 

but for many grazing animals. This has been recognized 

throughout history, as records from ancient civilizations 

describe locust infestations destroying fi elds of crops 

throughout regions, caterpillars stripping crops and forests, and, in more recent times, insect infestations rendering entire stores of grain and other food products inedible. The US military procures, transports, and stores 

huge amounts of food products at locations throughout 

the world. Protection of those products in transport and 

especially in storage is a challenge requiring constant 

surveillance monitoring and immediate corrective actions. Dr Choe Hyon Chong has contributed an article 

describing actions by Army public health professionals 

in the Republic of Korea to optimize control measures 

for the Indian meal moth, a persistent and greatly harmful pest involved in the destruction of stored dry food 

products in many areas of the world. The focus of this 

research project were the Army’s food storage warehouses. His article describes a well-conceived approach 

to fi rst understanding the dynamics and parameters of 

the infestations at the specifi c location of concern, followed by application of the most effective control measures at the optimum times for their use. The plan began with period of surveillance trapping to determine 

the moth’s seasonal cycles at various locations in the 

warehouse, then implementation of control treatments, 

and continued surveillance to evaluate the results. In addition to active control measures, the researchers were 

able to recommend changes to warehouse management 

policies and procedures, as well as physical changes to 

the warehouse itself, both of which complemented the 

control treatments, resulting in a much more effi cient 

overall control program. Dr Choe’s article is an excellent 

example of the nature of many public health studies and 

projects. To be truly effective, many such studies require 

an extended timeline, careful planning, patience and attention to detail in execution, and vigilance to events 

and changes in the study environment.

The US military routinely conducts medical assistance 

missions into developing countries around the world, 

usually providing medical capabilities for the population 

that may be scarce, or nonexistent, in those areas. Such 

missions serve many purposes, the highest of which is 

the humanitarian benefi ts for the patients served, but the 

military medical personnel greatly benefi t from encounters with health problems and conditions which they 

may never actually experience within more developed 

societies, such as the United States and Europe. These 

experiences could be invaluable during operational deployments with units into remote, undeveloped areas 

where the local populace may have never seen a trained 

healthcare professional, much less any medical equipment. Over time, the local people realize that their new 

neighbors, the deployed forces, do in fact have the capability to offer them medical care rarely available in their 

area, and reluctance to seek assistance fades, especially 

when they face a medical emergency. At that time, they 

may present conditions or illnesses similar to those encountered during medical outreach missions, unfamiliar but to the most experienced medical personnel. In 

their article, LTC Jennifer Gurney and her colleagues 

describe one such condition encountered on several 

occasions in Afghanistan, and how the Army combat 

support hospital was able to respond. Circumcision of 

young male children, even infants, is a common practice in that country. Unfortunately, it is usually practiced 

absent any local medical capabilities, neither in training 

nor facilities or equipment. As should be expected, the 

results of such practice can be devastating, causing lifelong deformation and often permanent injury to the urinary and reproductive systems of the children. Over the 

years of US presence, Afghans have been bringing such 

injured boys to our military facilities to receive care for 

this injury. LTC Gurney et al present the case studies 

of 2 boys, one infant and one aged 4 years, who were 

severely injured during the traditional, primitive, local 

procedure in the village. Both children required unique 

reconstructive surgery and several days of inpatient care 

to resolve their injuries. The article clearly depicts the 

knowledge, skills, resourcefulness, and total dedication 

to patient care that is inherent in our military medical 

professionals. It is an eye-opening source of experiencebased advice, ideas, and hints about how to successfully 

contend with this injury which is rarely seen among the 

US populace. This article should be must-reading for all 

military medical personnel preparing for deployment 

into the third world environment, whether with an operational unit, or with a medical assistance mission.

An understanding of the transmissibility of disease dates 

back many centuries, as indicated in early religious 

writings describing rules for isolating lepers. Examples 

of mandated separation of the healthy from the sick can 

be found in the Roman empire. The formal system of 

quarantine began years later as port cities imposed rules 

restricting personnel to remain aboard newly arriving 

ships for a period of time to provide the opportunity to 

detect any diseases that may be among them. Of course 

we have come a long way in our ability to detect diseases, understand the mechanisms of infection and transmission, anticipate outbreaks and the potential scope 
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

of their spread, and institute preventive action, including vaccinations and sanitation and hygiene measures. 

However, legally imposed quarantine and isolation remain tools for public health authorities when a disease 

outbreak threatens to overwhelm other control measures 

and spread unchecked. The same option is available to a 

military commander as the responsible authority for the 

health and safety of the military installation, facility, or 

organization under his or her command. The military 

commander may isolate and quarantine personnel and 

property on a military installation when a threat is imminent. Such action may be implemented either to prevent 

military personnel from contracting a disease that is infecting the civilian population in the area, or to quickly 

contain spread of serious disease detected among military personnel aboard the installation. In either case, the 

commander must understand the various options available before the imposition of involuntary quarantine may 

be required, and must clearly understand the governing 

rules and regulations for such actions. MAJ Joseph 

Topinka has contributed an excellent article clearly and 

succinctly providing a thorough, detailed overview of 

the legal aspects of a military commander’s authority in 

such situations. The breadth of a commander’s authority 

as well as the limitations are clearly explained, and the 

references list provides a ready source for locating the 

specifi c directives, instructions, and orders pertaining to 

these situations. This article is an ideal primer to introduce a military commander or staff to this complex and 

unusual responsibility. As MAJ Topinka states so well 

in closing his article, “Considering the potential magnitude of an epidemic or other medical crisis, the value 

of understanding the laws, regulations, and guidance in 

this article cannot be overstated.”

The Spanish philosopher George Santayana wrote in 

1905, “Those who cannot remember the past are condemned to repeat it.”* That well-known (but too often 

misquoted) maxim is applicable in almost every facet 

of human existence, and medicine is no exception. It is 

especially applicable in the area of public health, where 

so much of the benefi ts to health and well-being have 

been obtained by constant attention to environmental 

and sanitation standards and practices, most of which 

are conducted in the background of daily life. Unfortunately, from that perspective, another old adage is also 

too often proven true—out of sight, out of mind. It has 

been proven time and again that a reduction in emphasis or resources involved in public health activities will 

eventually result in a decline in the health of those residing in the area. COL Barry Graham’s excellent, absorbing article describes a classic sequence of events 

occurring during the American Civil War that clearly 

proves and emphasizes these points. His article focuses 

on two very different approaches in addressing one of 

the scourges of the period, yellow fever, and the tragic 

results. The differences between Union Army actions in 

occupied New Orleans, Louisiana, and New Bern, North 

Carolina, could not have been more stark, and the resulting differences in yellow fever infections and death were 

dramatic. Compounding the tragedy is the fact that the 

success in suppressing yellow fever in New Orleans preceded the epidemic in New Bern by 2 years, and had been 

recognized and publicized throughout the Union states. 

Unfortunately, the actions that led to the success was 

not given any emphasis within the Union Army, and the 

deadly New Bern epidemic of 1864 was the result. However, the observant reader of COL Graham’s article will 

quickly recognize an even greater tragedy from failure 

to “remember the past.” As he points out, only 11 people 

died of yellow fever in New Orleans between 1862 and 

1865 under Union Army occupation. After occupation 

ended and civil authority resumed in 1866, 185 people 

died; in 1867 there were 3,107 deaths; and more than 

4,000 died of yellow fever in 1878. Indeed, the people of 

New Orleans were immediately “condemned to repeat” 

the past because it had been so quickly forgotten.

The AMEDD Journal is pleased to present COL (Ret) 

Brian Lukey’s introduction of a new volume of the Borden Institute’s Textbook of Military Medicine Series, 

Military Quantitative Physiology. COL (Ret) Lukey provides an informative overview of the book, and describes 

its contents as the most complete amalgamation of many 

years of research into the physiology of military operational medicine printed to date. His presentation should 

stimulate interest in this book as an extremely valuable 

resource for medical practitioners and researchers involved in helping Warfi ghters contend with the physiologic stressors of the military operational environment.

PERSPECTIVES

*Santayana G. The Life of Reason. New York, NY: C Scribner’s 

Sons; 1905:82.
 April – June 2013 7

ABSTRACT

In its 15th year, the Global Emerging Infections Surveillance and Response System (GEIS) continued to make 

signifi cant contributions to global public health and emerging infectious disease surveillance worldwide. As a division of the US Department of Defense’s Armed Forces Health Surveillance Center since 2008, GEIS coordinated a 

network of surveillance and response activities through collaborations with 33 partners in 76 countries. The GEIS 

was involved in 73 outbreak responses in fi scal year 2011. Signifi cant laboratory capacity-building initiatives were 

undertaken with 53 foreign health, agriculture and/or defense ministries, as well as with other US government entities and international institutions, including support for numerous national infl uenza centers. Equally important, a 

variety of epidemiologic training endeavors reached over 4,500 individuals in 96 countries. Collectively, these activities enhanced the ability of partner countries and the US military to make decisions about biological threats and 

design programs to protect global public health as well as global health security.

BACKGROUND

The mission of the US Department of Defense’s (DoD) 

Armed Forces Health Surveillance Center Global 

Emerging Infections Surveillance and Response System 

(AFHSC-GEIS) Division is to develop, implement, support, and evaluate an integrated global emerging infectious disease (EID) surveillance and response system 

that contributes to enhancement of US forces’ health, 

the military health system, and the global public health 

community. Force health protection of US and allied service members remains the strategic focus of our efforts. 

Equally important and well-aligned with its primary focus of global public health security is the recognition 

that adequate health allows for country-level security, 

and thus regional stability—one of the stated strategic 

goals of the DoD.

During fi scal year (FY) 2011, AFHSC-GEIS supported 

a network of 33 partners in 76 countries (shown in Figure 1) contributing to global EID surveillance and capacity building efforts. Key partners continued to be the 

5 DoD overseas research laboratories:

 US Naval Medical Research Unit Number 2 

(NAMRU-2) (Hawaii)

 NAMRU-3 (Egypt)

 NAMRU-6 (Peru)

 Armed Forces Research Institute of Medical

Sciences (AFRIMS) (Thailand)

 US Army Medical Research Unit-Kenya 

(USAMRU-K)

These laboratories operate regional disease surveillance 

networks centered in Cambodia, Egypt, Peru, Thailand, 

and Kenya, respectively. Additionally, support was provided to DoD reference laboratories at the Naval Health 

Research Center (NHRC), the Walter Reed Army Institute of Research, and at the USAF School of Aerospace 

Medicine to conduct disease surveillance in military and 

nonmilitary associated populations. A key goal of the 

network continued to be the enhancement of host-country capacity in support of integrated disease surveillance 

as mandated by the World Health Organization’s (WHO) 

International Health Regulations (2005) (IHR (2005)).1

The strategic goals through which AFHSC-GEIS 

achieves its mission provide a holistic approach to public health, and constitute the foundation of our global 

surveillance efforts across all EID surveillance goals 

including: (1) surveillance and response; (2) training 

Contributions of the Global Emerging

 Infections Surveillance and Response System

 Network to Global Health Security in 2011

CDR David L. Blazes, MC, USN; Jennifer L. Bondarenko; MAJ Ronald L. Burke, VC, USA; Kelly G. Vest, DVM, DrPH, MPH; 

COL Mark M. Fukuda, MC, USA; LCDR Christopher L. Perdue, MED, USPHS; Alice Y. Tsai, MPH; Alaina C. Thomas, 

MSPH; Ruvani M. Chandrasekera, MPH; LT Jennifer A. Cockrill, MS, USPHS; CAPT Annette M. Von Thun, MC, USN; 

Priya Baliga, MPH; COL Mitchell Meyers, MC, USA; Miguel Quintana, PhD; LTC Eyako K. Wurapa, MC, USA; Moustafa 

M. Mansour, PhD; Erica Dueger, DVM, PhD; LT Chadwick Y. Yasuda, MSC, USN; Claudio F. Lanata, MD; Gregory C. Gray, 

MD, MPH; Karen E. Saylors, PhD; Lucy M. Ndip, PhD; Sheri Lewis, MPH; CAPT Patrick J. Blair, MSC, USN; Col Paul A. 

Sjoberg, BSC, USAF; LTC Stephen J. Thomas, MC, USA; COL Emil P. Lesho, MC, USA; COL Max Grogl, MS, USA; LCDR 

Todd Myers, MS, USPHS; CPT Damon Ellison, MS, USA; LTC Kathryn K. Ellis, MC, USA; MAJ Matthew L. Brown, MS, 

USA; Randall J. Schoepp, PhD; G. Dennis Shanks, MD, MPH; Grace E. Macalino, PhD; Angelia A. Eick-Cost, PhD, ScM; 

CAPT Kevin L. Russell, MC, USN; Jose L. Sanchez, MD, MPH
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

and capacity building; (3) research, innovation and integration; and (4) assessment and communication of 

value added. This article provides a summary of the accomplishments for each of these in FY2011 and presents 

future challenges being addressed by our network. We 

also update AFHSC-GEIS system accomplishments of 

FY2009 which were previously published,2

 and further 

evaluate contributions of this network towards global 

health security in 2011.

SURVEILLANCE AND RESPONSE INITIATIVES

As surveillance and response activities are central to the 

overall mission of the AFHSC-GEIS, human and animal disease surveillance activities were supported in 76 

countries. Outbreak response is an integral part of partner collaborations with host country health systems, and 

in FY2011, network partners assisted in a total of 73 investigations and outbreak response efforts, shown in Table 1. The most salient of these investigations included:

1. NAMRU-3’s response to a large outbreak of over 

1,500 dengue-like cases in Yemen’s west coast October 2010-January 2011, leading to its fi rst chikungunya case confi rmation and successful Aedes aegypti

(L.) vector control implementation.3,4

2. NAMRU-3’s response to a request from the Egyptian 

Ministry of Health for the conduct of a retrospective 

freezer study of human samples to determine whether Egypt was the main source of a very large foodborne outbreak in Germany from May to July 2011. 

The outbreak affected over 4,000 patients and was 

associated with a Shiga toxin-producing enterohemorrhagic Escherichia coli (Migula) O104:H4. No evidence from any of the samples in this retrospective 

study demonstrated the outbreak strain.

3. USAMRU-K’s diagnostic and entomologic assessment support for a dengue serotype 3 outbreak among 

the African Union Mission in Somalia military peacekeepers and civilians in northeast Kenya along the 

Kenya-Somalia border, September to October 2011.

A number of country-specifi c surveillance programs 

also achieved notable accomplishments in FY2011, including the following highlights. Researchers from AFRIMS conducting acute febrile illness surveillance in 

Nepal detected the fi rst known chikungunya infections 

in the country and defi ned the genetic diversity among 

hantaviruses in Nepal.5

 The researchers also identifi ed 

enteroaggregative E.coli and Campylobacter spp. as the 

CONTRIBUTIONS OF THE GLOBAL EMERGING INFECTIONS SURVEILLANCE AND

RESPONSE SYSTEM NETWORK TO GLOBAL HEALTH SECURITY IN 2011

Figure 1. AFHSC-GEIS network and major laboratories, fi scal year 2011. Note: GEIS partner countries are shaded gray.

Glossary:

AFRIMS – Armed Forces Research Institute of Medical Sciences NMRC – Naval Medical Research Center

LRMC – Landstuhl Regional Medical Center USAFSAM – USAF School of Aerospace Medicine

NAMRU – Naval Medical Research Unit USAMRU-K – US Army Medical Research Unit-Kenya

NHRC – Naval Health Research Center USAPHC – US Army Public Health Command

NMCPHC – Navy & Marine Corps Public Health Center WRAIR – Walter Reed Army Institute of Research
 April – June 2013 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

two most commonly isolated enteric pathogens from a 

cohort of Nepalese children aged less than 2 years. Investigators from USAMRU-K have continued to expand 

their acute febrile illness and arbovirus surveillance 

program throughout Kenya and identifi ed strains of 

Crimean-Congo hemorrhagic fever virus in Hyalomma 

spp. ticks,6

 as well as 9 additional as yet unidentifi ed 

mosquito-borne arboviruses isolated in cell culture.

Surveillance projects supported by AFHSC-GEIS utilizing the DoD Serum Repository were vital in identifying infectious disease exposures during deployments 

and other military service. A study conducted by the 

AFHSC and NHRC investigated the seroprevalence of 

and seroconversion to 7 respiratory pathogens among 

service members deployed to Afghanistan from 2004 to 

2007.7

 The study found that 30.1% of service members 

seroconverted to at least one pathogen and Bordetella 

pertussis (Bergey et al) seroconversion was 2 to 4 times 

higher than that reported for the general US population. 

A second Serum Repository-based study found a Q fever incidence of 4.2 cases per 1,000 person-years among 

Army veterinary offi cers from 1989 to 2008 (K.G.V., 

unpublished data). Preliminary fi ndings indicate that 

13.8% of these Army veterinary offi cers were seropositive upon entry into the military. Thus, Coxiella burnetii

(Derrick) (the causative agent of Q fever infections) appeared to be common among veterinarians that enter the 

military. This estimate was similar to seroprevalence estimates of 22.2% among civilian counterparts reported 

in a 2006 study among US veterinarians, the only other 

large, well-studied veterinary population to date.8

Country and pathogen-specifi c prevalence studies were 

conducted by several partner laboratories. Surveillance 

for sexually transmitted infections was conducted in 

Djibouti (NAMRU-3), Kenya, and Peru, retrospectively 

focusing on Neisseria gonorrhoeae (Neisser) antibiotic 

resistance and Chlamydia trachomatis (Busacca) prevalence in high-risk civilian (commercial sex workers, men 

who have sex with men) and local military populations.9

Large, enteropathogen-focused cross-sectional studies 

involving over 3,500 stool samples conducted in those 

3 countries demonstrated that norovirus was the most 

common viral etiology found among US military personnel at Camp Lemonier, Djibouti, whereas Shigella spp. 

Table 1. AFHSC-GEIS outbreak response actives (listed by partner) during fi scal year 2011.

Partner Number of

Outbreaks

Countries Pathogens/Conditions

AFME 2 Kenya, USA Adenovirus, Rift Valley fever

AFRIMS 4 Cambodia, Nepal Cholera, influenza 

NAMRU-2 3 Cambodia Dengue, leptospirosis, malaria

NAMRU-3 4 Egypt, Pakistan, 

Yemen Crimean-Congo hemorrhagic fever, Dengue, E. coli

NAMRU-6 21 El Salvador, Peru 

A. baumanii, Bell's Palsy, dengue, E. histolytica, gastroenteritis, influenza, 

K. pneumonia, leishmaniasis, leptospirosis, pneumonic plague, rabies 

(animal), tuberculosis, varicella,

NASA 3

Afghanistan, Botswana, Kenya, 

Namibia, Somalia, 

South Africa

Crimean-Congo hemorrhagic fever, dengue, Rift Valley fever 

NHRC 11 Costa Rica, USA Adenovirus, group A beta-hemolytic streptococci, influenza, norovirus, 

pneumonia

USAPHC 1 USA Group A beta-hemolytic streptococci

USAPHCR-Europe 4

Afghanistan, 

Germany, United 

Kingdom

E. coli, influenza, rabies

USAFSAM 1 USA Norovirus

USAMRIID 1 Kenya Rift Valley fever

USAMRU-K (& GVF) 15 Cameroon, Kenya, 

Somalia

Acute febrile illness, cholera, dengue, transboundary animal diseases of 

regional concern, yellow fever

WRAIR 3 Kenya, Peru, USA Crimean-Congo hemorrhagic fever, Orthobunyavirus spp., Rift Valley fever

Glossary:

AFME – Armed Forces Medical Examiner USAFSAM – USAF School of Aerospace Medicine

(formerly Armed Forces Institute of Pathology) USAMRIID – US Army Medical Research Institute of Infectious Diseases

AFRIMS – Armed Forces Research Institute of Medical Sciences USAMRU-K – US Army Medical Research Unit-Kenya

GVF – Global viral forecasting USAPHC – US Army Public Health Command

NAMRU – Naval Medical Research Unit USAPHCR – US Army Public Health Command Region

NASA – National Aeronautics & Space Administration WRAIR – Walter Reed Army Institute of Research

NHRC – Naval Health Research Center
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

were the most prevalent bacterial pathogen in Kenya,10

and Campylobacter spp. the most frequently identifi ed 

bacterial pathogen associated with diarrhea in Peru.11

Acute diarrheal diseases continued to represent one of 

the largest disease and nonbattle injury threats in the US 

military. The study fi ndings will aid military planners in 

defi ning more specifi c preventive and treatment countermeasures for US forces deployed to these areas.

Several antimicrobial-resistant organism surveillance 

initiatives were undertaken to inform and improve treatment options and policies for military service members 

both in the United States and in deployed settings. Antimalarial resistance surveillance efforts by NAMRU-2 

detected an unexpectedly high rate of Plasmodium falciparum (Welch) multidrug resistance gene amplifi cation 

in the south-central region and on the eastern border of 

the country; a fi nding which may represent evidence of 

the regional spread of mefl oquine resistance in Southeast Asia. In Egypt and Jordan, NAMRU-3 scientists established hospital-acquired infection (HAI) surveillance, 

which has since found that ≈70% of E. coli isolates in 

that region were producers of extended-spectrum betalactamase (ESBL), an enzyme that confers resistance to 

many common penicillin and cephalosporin antibiotics, 

and about 50% of Staphylococcus aureus (Rosenbach) 

isolates were resistant to methicillin. A similar HAI 

surveillance effort by NAMRU-6 scientists in Peru 

documented similar, or even higher rates, of methicillin resistant S. aureus and ESBL-producing Klebsiella 

pneumonia (Schroeter). 

In the United States, the DoD’s Multidrug-resistant Organism Repository and Surveillance Network, initially 

established in June 2009, continued to provide the military health system with a unique centralized pathogen 

identifi cation and resistance profi ling resource for advanced characterization of multidrug resistant organisms. Over 300 isolates were characterized by pulsefi eld gel electrophoresis which resulted in identifi cation 

of the emergence of colistin-resistant Acinetobacter, 

vancomycin-resistant Enterococcus, and the fi rst report 

of a New Delhi metallo-beta-lactamase isolate in the 

military health system. These identifi cations were performed as part of the DoD’s component of the Infectious 

Diseases Society of America’s global ESKAPE (Enterococcus faecium (Orla-Jensen), S. aureus, Klebsiella

spp., Acinetobacter baumannii (Bouvet and Grimont), 

Pseudomonas aeruginosa (Schroeter) and Enterobacter

spp.) genomics project, which receives isolates from 13 

military medical treatment facilities, fi ve of which are 

from war zones in Iraq and Afghanistan.12

Investigators from NHRC continued to monitor antibiotic resistance of group A Streptococcus, a persistent 

respiratory bacterial pathogen in recruits and advanced 

CONTRIBUTIONS OF THE GLOBAL EMERGING INFECTIONS SURVEILLANCE AND

RESPONSE SYSTEM NETWORK TO GLOBAL HEALTH SECURITY IN 2011

Figure 2. Sequenced infl uenza subtype A(H1N1)pdm09, subtype A(H3N2) and subtype B strains, DoD laboratories, by country, 

2010-2011. Pie charts represent distribution of the 3 infl uenza subtypes within the countries indicated.

H1 – A(H1N1)pdm09 subtype H3 – A(H3N2) subtype

B – B subtype
 April – June 2013 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

individual training units at 9 US military medical treatment facilities serving these trainees. Moderate resistance was seen against erythromycin and clindamycin. 

In addition, an important infl uenza-related collaboration 

between NAMRU-6, USAF School of Aerospace Medicine, NHRC, and the Walter Reed Army Institute of 

Research led to the identifi cation of an A(H1N1)pdm09 

virus subclade possessing a reemergent HA D222N mutation that was found to be associated with increased 

respiratory illness severity among patients in Ecuador, 

Mexico, and Washington, DC.13

In the Middle East, scientists at the Global Disease Detection Regional Center of the US Centers for Disease 

Control and Prevention partnered with NAMRU-3 staff 

and regional medical offi cials to conduct severe acute 

respiratory illnesses (SARI) surveillance at 22 hospitals in 6 countries 

(Egypt, Jordan, Djibouti, Yemen, Oman, 

and Qatar). This effort, named the Eastern Mediterranean Acute Respiratory 

Infection Surveillance network in September 2011, is expanding to 8 additional hospitals in Iraq and Afghanistan. Its 

main objectives include: (1) establishing and monitoring baseline trends for 

SARI; (2) describing the seasonality of 

infl uenza in each country; (3) providing 

an early warning system for epidemics; 

and, (4) monitoring high-risk patients 

(very young, old, and those with comorbidities) who may be at greater risk of 

SARI.

Partnering with National Infl uenza 

Centers (NICs) in South America, the 

US Army Public Health Command Region-South initiated military participation in national respiratory surveillance 

programs in El Salvador, Guatemala, 

and Honduras, while USAMRU-K established a regional genetic sequencing 

capability at the Kenya NIC to support 

infl uenza surveillance network activities in 4 partner countries (Kenya, 

Uganda, Tanzania, and Cameroon). The 

AFHSC-GEIS continued to support a 

comprehensive worldwide effort in infl uenza surveillance that monitors circulating strains and subtypes, and contributes to the yearly evaluation of seasonal 

and pandemic vaccines. A geographical 

summary of isolates sequenced is provided in Figure 2. 

FY 2011 outbreak response and disease surveillance 

efforts have contributed to the understanding of infectious diseases pertinent to the DoD as well as to partner 

countries. Through effective data collection and timely 

reporting, the AFHSC-GEIS partner network continued to provide disease situational awareness to inform 

decision-makers on prevention, treatment, and outbreak 

response actions to address force health protection and 

global disease burdens.14

CAPACITY BUILDING AND TRAINING INITIATIVES

The AFHSC-GEIS supported a broad array of capacity 

building projects in coordination with US military, foreign military and civilian government offi cials. Major 

laboratory capacity-building initiatives were undertaken 

Table 2. Major laboratory capacity building initiatives, by geographic region,

fi scal year 2011.

Geographic Region

(Supporting DoD

Laboratory)

Major Laboratory Capacity

Building Initiative

Countries

Supported

Southeast Asia 

(AFRIMS, NAMRU-2)

NIC and military influenza lab 

equipment, reagent & training support; EID laboratory 

diagnostics and disease 

surveillance systems

Bhutan, Cambodia, Lao 

People’s Democratic Republic, 

Nepal, Thailand, Vanuatu & 

Solomon Islands 

Far East

(AFRIMS)

NIC and military influenza 

lab equipment & reagent 

support; EID laboratory 

proficiency and equipment 

support; disease surveillance systems

Philippines

East & Central Africa 

(USAMRU-K)

NIC and VHF lab equipment, reagent and training 

support; EID laboratory 

diagnostics

Cameroon, Kenya, Tanzania, 

Uganda

West Africa (NAMRU-3, USAMRIID)NIC and MoH influenza lab 

equipment, reagent and 

training support; VHF lab diagnostics & military EID lab 

diagnostic testing capacity

Burkina Faso, Cote d’Ivoire, 

Djibouti, Ghana, Liberia, Libya, 

Nigeria, Sierra Leone

North Africa, Middle 

East, Southwest 

Asia (NAMRU-3, 

WRAIR)

NIC lab equipment, reagent 

and training support

Afghanistan, Bahrain, Egypt, 

Jordan, Qatar, UAE, Yemen

Central Asia

(NAMRU-3, University of Florida, 

USAMRIID)

EID and influenza lab equipment, reagent and training 

support

Azerbaijan, Georgia, Mongolia

Europe (NAMRU-3, 

PHCRE, University 

of Florida)

Military and academic influenza lab equipment, reagent and training supportBulgaria, Poland, Romania, 

Ukraine

North, Central, South 

America (NAMRU-6, 

PHCRS)

NIC and MoH influenza lab 

equipment, reagent and 

training support; leishmania 

military reference lab equipment, reagent and training 

support

Argentina, Bolivia, Colombia, 

Ecuador, El Salvador, Guatemala, Haiti, Honduras, Mexico, 

Nicaragua, Panama, Paraguay, 

Peru, Venezuela

Glossary:

EID – Emerging infectious diseases PHCRE – Army Public Health Command Region-Europe

MOH – Ministry of health PHCRS – Army Public Health Command Region-South

NIC – National influenza center VHF – Viral hemorrhagic fever
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

with 48 foreign health, agriculture, and defense ministries, as well as with other US government entities and 

international institutions, including numerous NICs 

and other country-specifi c and regional EID reference 

laboratories worldwide, as shown in Table 2. The objective of the GEIS capacity-building strategy continued to 

be improvement of the ability of deployed US military 

forces and partner governments to effectively engage 

in biosurveillance activities through enhanced laboratory and human resource capacities, as well as improved 

electronic disease surveillance systems.

The AFHSC-GEIS partners made signifi cant enhancements to laboratory capacities by providing equipment to 

host country reference laboratories in Afghanistan, Bulgaria, Burkina Faso, Cote d’Ivoire, Egypt, Ghana, Kenya, 

the Republic of Georgia, Tanzania, and the Ukraine. In 

addition to the training that is normal with new equipment, basic and advanced training in laboratory methods and biosafety were commonly performed by our 

network partners in other countries such as Cambodia, 

Lao People’s Democratic Republic, and Sri Lanka. A 

signifi cant capacity building engagement by NAMRU-3 

included the conduct of training and provision of supplies and equipment to enhance EID laboratory diagnostic, vector surveillance, safety, and biomedical capacity 

in Afghanistan. This resulted in the analysis of nearly 

3,000 clinical samples and 8,000 arthropods and enabled 

this country to better implement its health policy obligations under the WHO’s IHR (2005).

1

 Additionally, collaborations between the Naval Medical Research Center 

and NAMRU-6 resulted in the establishment of a DoD 

Clinical Laboratory Improvements Program (CLIP)-certifi ed and College of American Pathologists-accredited 

laboratory to support the diagnosis of infectious diseases 

among US personnel stationed in the Latin American 

region. The USAMRU-K and Walter Reed Army Institute of Research scientists were also directly involved in 

similar improvements that will eventually lead to CLIP 

accreditation of DoD laboratories in Kenya and Afghanistan, respectively.

Many signifi cant contributions were made to the enhancement of electronic disease surveillance systems 

through the AFHSC-GEIS network. Scientists from 

AFRIMS, in collaboration with Royal Thai Army (RTA) 

medical offi cials, continued support for the Unit-Based 

Surveillance (UBS) tool with integration of components 

of the Suite for Automated Global Electronic bioSurveillance (SAGES). The program included training of approximately 600 personnel and expansion to 113 reporting units in 16 surveillance clinics/hospitals throughout Thailand. The diligent, effi cient efforts of the Thai 

members of the AFRIMS and RTA medical team who 

worked on the UBS project were recognized with presentation of the prestigious RTA Innovation Award in 

September 2011, the only medical project to earn such 

an honor. Additionally, NAMRU-6 and NAMRU-2 assisted the Peruvian and Cambodian military forces, respectively, with installation of SAGES disease surveillance capacity.

The AFHSC supported training activities for over 4,500 

individuals from 96 countries as shown in Table 3. Overall, 203 training events were conducted in 42 countries. 

A total of 3,691 (81%) trainees from 49 countries were 

directly supported by AFHSC-GEIS funded partners. 

Signifi cant expansion of training initiatives has occurred 

since our FY 2009 report.15 One of the highlights in this 

area is the University of Florida’s Certifi cate Program in 

Emerging Infectious Disease Research which enrolled 

30 students, 22 of whom completed the program in FY 

2011. Another highlight is the Uniformed Services University of the Health Sciences (USUHS) Tropical Medicine Program which supported 39 US military medical 

students and physicians in FY2011. During the training 

program which involved tropical medicine practical experiences in Kenya, Peru, and Thailand, US military 

tropical medicine practitioners obtained the practical 

experience they needed to recognize, diagnose, and treat 

US military personnel, coalition partners, and civilians 

during deployments.

Military-to-military partnerships and surveillance exchanges among global network partners and foreign 

military counterparts, shown in Table 4, continued to be 

an area of high interest and priority for AFHSC-GEIS in 

FY2011. Military partnerships in 20 countries resulted 

in a number of collaborative response activities that supported foreign military partners as well as multinational 

peacekeepers in joint exercises and missions. Specifi c 

efforts included electronic surveillance systems and disease reporting support, outbreak training and response 

support, laboratory capacity building, and computerized 

data analysis and training capacity.

RESEARCH, INNOVATION, AND INTEGRATION 

INITIATIVES

The AFHSC-GEIS continued to introduce innovative 

methods in disease surveillance activities, mainly through 

a variety of research efforts targeted to improve timely 

and accurate surveillance. These included advanced 

characterization of pathogens to better understand genetic variability across strains, improvements in diagnostic 

products, and evaluation of diagnostic and transportation 

media in forward deployed settings. Consideration was 

given to how proposed research and innovation activities 

are adding value to standard surveillance.

CONTRIBUTIONS OF THE GLOBAL EMERGING INFECTIONS SURVEILLANCE AND

RESPONSE SYSTEM NETWORK TO GLOBAL HEALTH SECURITY IN 2011
 April – June 2013 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

In collaboration with the Joint Project Executive Offi ce 

for Biological and Chemical Defense, AFHSC-GEIS 

supported expansion of an infl uenza detection panel 

for use by the Joint Biological Agent Identifi cation and 

Diagnostic System (JBAIDS). Funding was provided to 

achieve US Food and Drug Administration (FDA) 510K 

clearance for a fi eld-expedient fi ve-target assay (Infl uenza A, Infl uenza B, Infl uenza A/H1, Infl uenza A/H3, 

and Infl uenza A/H1/2009 (swine lineage)).16,17 After 

completing clinical studies and receiving FDA clearance 

for the JBAIDS Expanded Infl uenza Panel in September 

2011, panel kit deliveries to forward deployed US Central Command sites and Navy large deck ships started 

in November 2011, allowing for more timely access to 

novel strains that may be needed in support of WHO’s 

Global Infl uenza Surveillance and Response System 

vaccine development efforts.18,19

The AFHSC-GEIS continued to support historical analyses of infl uenza pandemics among military populations 

in an attempt to inform current epidemic risk and identify 

potential patterns of spread. Continued analysis of the 

1918 pandemic mortality among Australian, British, Canadian, New Zealand, and US forces was conducted by 

collaborators at the Australian Army Malaria Institute 

and AFHSC in FY 2011.20-22 Epidemiologic research 

examining the genetic variability of human adenovirus 

(HAdv) strains, prospective surveillance for vaccine-targeted HAdv-4 and HAdv-7 strains, and early detection 

Table 4. Military-to-military partnerships in 20 countries, fi scal year 2011.

Country Collaborative Focus Collaborative Area of Exchange

Afghanistan Human resource development Laboratory capacity

Burkina Faso Avian influenza surveillance Laboratory and disease reporting capability

Cambodia Influenza sentinel surveillance Influenza laboratory capacity and electronic reporting

Cameroon Influenza sentinel surveillance Sentinel site support and data sharing collaboration

Cote d'Ivoire Avian influenza surveillance Laboratory and disease reporting capability

Ecuador EID surveillance Electronic surveillance system and outbreak training support, laboratory capacity for antimicrobial resistance testing

El Salvador Influenza sentinel surveillance Influenza surveillance capability

Ghana Avian influenza and sentinel surveillance Laboratory and disease reporting capability

Guatemala Influenza sentinel surveillance Influenza surveillance capacity

Honduras Influenza sentinel surveillance Influenza surveillance capacity

Kenya Malaria and influenza surveillance Laboratory capacity, microscopy training, electronic surveillance 

system, sentinel site support and data sharing collaboration

Liberia Malaria and other FVBI vector surveillance Vector collection training laboratory capacity

Nigeria Malaria surveillance Laboratory and disease reporting capability, microscopy training, 

electronic surveillance system

Paraguay EID surveillance Electronic surveillance system

Peru EID surveillance, outbreak response, ILI surveillance, enterics surveillance, hospital acquired 

infection surveillance, antimicrobial resistance, 

TB diagnosis and reporting

Electronic surveillance system and outbreak training support, laboratory capacity for antimicrobial resistance testing

Philippines Influenza sentinel surveillance Influenza laboratory capacity

Poland Influenza sentinel surveillance & EID laboratory 

capability

Influenza laboratory capacity

Singapore Influenza sentinel surveillance Influenza surveillance capacity

Tanzania Malaria and influenza sentinel surveillance Laboratory capacity, microscopy training and influenza surveillance 

capacity

Thailand Influenza sentinel surveillance and outbreak 

detection

Laboratory capacity and outbreak training support

Glossary:

EID – Emerging infectious diseases FVBI – Febrile and vector-borne infections

ILI – Influenza-like illness TB – Tuberculosis

Table 3. Statistics for AFHSC-GEIS funded training 

initiatives by geographic area, fi scal year 2011

US Combatant

Command

Training

Initiatives

Countries Trainees*

Africa Command 55 17 1,668

Central Command 74 18 1,310

European Command 15 15 496

Northern Command 16 10 376

Pacific Command 20 22 462

Southern Command 23 14 233

Total 203 96 4,545

*If exact fi gures are not known, esƟ mates of number of trainees 

are provided.
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

of vaccine breakthrough infections continued to be implemented by scientists at the Lovelace Respiratory Research Institute and NHRC. Retrospective (2006-2011) 

characterization of over 500 vaccine-targeted HAdv-4 

and HAdv-7 strains was also achieved with identifi cation 

of a new genomic variant of HAdV-4, tentatively designated HAdv-4a6 and exhibiting a novel Xho I profi le, 

from a case of infl uenza-like illness in a recruit at the 

Marine Corps Recruit Depot, San Diego in 2006.

Diagnostic tools were also developed and improved 

for several other pathogens in FY2011. A novel fl uorescence resonance energy transfer-based reverse transcriptase polymerase chain reaction (RT-PCR) assay to 

simultaneously diagnose and speciate Leishmania spp. 

was developed and validated by NAMRU-6, and NAMRU-3 developed the capacity to conduct RT-PCR for the 

rapid quantitative detection of Plasmodia spp. in blood 

from humans. Preliminary results from experiments in 

the standardization and validation study phases have 

provided results concordant with those obtained from 

a previously established PCR test. This work is being 

expanded to a rapid quantitative multiplex RT-PCR for 

the simultaneous detection of P. falciparum, P. vivax 

(Grassi and Filetti), P. malariae (Grassi and Filetti), and 

P. ovale (Grassi and Filetti) and will be evaluated for use 

in malaria diagnostics.

Timely processing of samples is important to any surveillance activity. To this end, AFHSC-GEIS supported 

efforts in the development of new specimen collection 

methods and rapid diagnostic assays. The 65th Medical Brigade at the Brian Allgood Army Community 

Hospital in Seoul, Republic of Korea (RoK), conducted 

a validation study of a 12-pathogen respiratory virus 

multiplex assay and used the assay to characterize viral 

diseases during a US-RoK joint exercise. Investigators 

at the San Antonio Military Medical Center (SAMMC) 

developed and fi eld tested a simple fi lter-card diagnostic system for leptospirosis, a disease spread to humans 

from the urine of infected animals by bacteria that can 

survive in the environment for weeks to months. Likewise, and in support of norovirus shipboard surveillance 

efforts, scientists at the Naval Environmental Preventive Medicine Unit Number 2 validated the use of FTA 

Elute (Whatman, Inc, Florham Park, NJ) fi lter paper as 

a medium for stool sample transport as an alternative 

to viral transport medium currently provided in surveillance kits, eliminating the need for cold chain and thereby alleviating logistical obstacles which have prevented 

ships from participating in such surveillance. Preliminary validation testing suggests there is no decrease in 

PCR detection when samples are collected and stored 

on FTA Elute fi lter paper compared to classic methodology of sample acquisition and storage. Once validation 

is complete, this method can be integrated in other norovirus surveillance efforts in the US military.

Transportation media for handling multidrug resistant 

bacteria were also evaluated by SAMMC. Two swab 

types at 2 time points and 3 temperatures were assessed 

to see if bacteria were viable after varying parameters 

possibly associated with transporting isolates. This 

study found that swabs held at room temperature had 

the highest chance of yielding bacteria with both swabs 

held for as long as one or 4 weeks. Finally, in an entomological surveillance study to evaluate presence and 

population size of Ae. aegypti in 3 countries around the 

Red Sea, investigators found that RNAlater (Life Technologies Corporation, Grand Island, NY), a commercial 

tissue storage reagent, is a viable medium to transport 

nucleic acid from virus-infected mosquitoes, especially 

from countries lacking liquid nitrogen. The method provides fl exibility in the delay of sample transportation 

and, above all, does not compromise results.

Integration of surveillance efforts is a complex and challenging task, one that requires constant adaptation and 

adjustment. The AFHSC-GEIS continued its efforts 

to integrate disease specifi c surveillance activities to 

develop a more robust surveillance network, generating comparable data across regions. Standardization of 

malaria surveillance protocols across DoD partners on 

3 continents was initiated and acute gastroenteritis surveillance was established among recruit and shipboard 

populations. These efforts have helped to improve the 

quantifi cation of the burden of illness and will serve as a 

platform for development of malaria/enteric diagnostics. 

These and similar efforts will serve to enhance DoD’s 

capacity to conduct therapeutic and/or prophylactic 

drug studies as well as better inform vaccine developers 

and other stakeholders.

ASSESSMENT AND COMMUNICATION OF

VALUE ADDED INITIATIVES

Assessment of fi ndings and timely communication of 

their importance and public health impact are key components of effective surveillance programs. This communication is essential for keeping public health leaders and offi cials properly informed so they can, in turn, 

make recommendations and enact measures that reduce 

disease risk and prevent or respond to disease outbreaks. 

Surveillance fi ndings are routinely provided to the respective health, agriculture, and defense ministries of 

host countries, and all AFHSC-GEIS partners are highly encouraged to present and publish their fi ndings. 

CONTRIBUTIONS OF THE GLOBAL EMERGING INFECTIONS SURVEILLANCE AND

RESPONSE SYSTEM NETWORK TO GLOBAL HEALTH SECURITY IN 2011
 April – June 2013 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

In FY2011, participants in the network published 152 

manuscripts in peer-reviewed journals and delivered 136 

posters and oral presentations at scientifi c conferences. 

The importance of these papers and presentations in describing the risk regarding disease transmission and severity, as well as disease prevention, is best exemplifi ed 

by the selection of 2 NAMRU-6 articles by the Peruvian 

Society of Emerging and Tropical Infections in 2011 as 

important infectious disease articles in Peru.23,24

Surveillance fi ndings and information were also communicated to DoD leadership and the public health community through the development and publication of disease prediction models. In FY2011, USUHS collaborated 

with investigators in the ROK and AFRIMS to develop 

and refi ne ecological niche models for predicting mosquito densities and Japanese encephalitis transmission. 

The information obtained from these models was used 

by the DoD Joint Preventive Medicine Policy Working 

Group for their Japanese encephalitis vaccination policy 

review. The models also contributed to disease transmission risk assessment products such as VectorMap, an 

example of which is shown in Figure 3.

The AFHSC-GEIS is also responsible for assessing disease surveillance fi ndings from across the network as a 

whole. Through review of these programs, the AFHSC 

and its partners detected a decrease in vaccine effectiveness for the live-attenuated vaccine, especially with 

regards to the A(H1N1)pdm09 vaccine component.25

These fi ndings were presented at the annual FDA’s Vaccine and Related Biological Products Advisory Committee (VRBPAC) meeting in February 2011, prior to 

the decision on seasonal infl uenza vaccine production 

for the United States and the northern hemisphere. Subsequent studies of the serologic responses among vaccinated recruits found modest differences between the 

live-attenuated and inactivated vaccines.26 More importantly, the later studies also found evidence of decreased 

antibody-mediated immunity against the currently circulating A(H1N1)pdm09 infl uenza strains in 2011 when 

compared to 2009 strains, possibly due to genetic drift 

which could have negative implications during subsequent infl uenza seasons if there is signifi cant mismatch 

with circulating A(H1N1) strains.26

The assessment and communication of the aforementioned surveillance activities, as well as those in the 

preceding subsections of this article, play a critical role 

in protecting military and global public health. As discussed earlier, assessing the meaning of surveillance 

fi ndings and conveying the importance of these fi ndings 

Figure 3. VectorMap mosquito distribution overlays for determining locations where vectors are present and risk of disease 

transmission to US forces. Each maroon dot represents a location of vector population data, including vector species.
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

to the global community are key requirements for promoting public health. By effectively communicating 

this information to public health leaders, AFHSC-GEIS 

continued to support informed decision making in support of global public health.

CONCLUSIONS AND CHALLENGES 

In its 15th year of existence, the AFHSC-GEIS continued to make signifi cant contributions to global public 

health and emerging infectious disease surveillance 

worldwide. Signifi cant progress was attained in maturation, standardization, and unifi cation of worldwide EID 

surveillance and response initiatives in FY2011 through 

support of the 4 strategic goals outlined earlier. Routine program evaluation through quarterly assessment 

of project milestones and metrics was implemented in 

accordance with previously-established, nationally recommended public health response guidelines.27 Expansion and standardization of genetic and molecular-based 

testing platforms (for example, PCR-based assays and 

genomic sequencing capability) was coordinated across 

the network of partners as recommended in our FY2009 

capacity building report,28 and expansion of electronic 

surveillance systems, such as SAGES, was undertaken. 

Collectively, these activities enhanced the ability of 

partner countries and the US military to make decisions 

about biological threats and design programs to protect 

both global public health and global health security.

Standardization of methodological approaches to EID 

surveillance continued to be a challenge. As part of our 

AFHSC-GEIS strategy, establishment of disease-specific or pillar-specifi c steering committees for respiratory 

infections, febrile and vector-borne infections, malaria, 

enteric infections, and sexually-transmitted infections 

was accomplished in FY2011. Similar committees were 

established in FY2012 to guide efforts in antimicrobial 

resistance surveillance and capacity building. Strategic 

guidance for each of these committees were formulated, including goals, objectives, and external review 

functions.

The greatest challenge to our work continued to be the 

provision of meaningful and sustainable host country 

infrastructure and human resource capacity to ensure 

full compliance with IHR (2005)1

 competencies as outlined previously in the AFHSC-GEIS FY2009 outbreak 

response report.14 The AFHSC-GEIS disease surveillance network is positioned to detect the emergence of 

new and reemerging human and zoonotic pathogens29; 

however, we must continue to provide innovative and 

cost effective approaches to disease surveillance in 

these times of fi scal constraint. For example, recognizing that zoonoses constitute over 70% of EIDs, increased 

zoonotic surveillance efforts will be undertaken in future years in order to develop local capacity focusing on 

high-risk populations at the human-animal interface.

There are various other challenges AFHSC-GEIS faces 

in conducting timely and effective disease surveillance. 

Optimizing collaborations within the DoD and other US 

government agencies to minimize duplication of efforts 

continues to be a priority. Establishment of data sharing agreements between and among countries within 

the network is another major challenge. AFHSC-GEIS 

hopes to address these challenges by the introduction of 

a “disease surveillance dashboard” that aims to maintain sovereignty of data, while making useful information available to decision makers in a timely fashion. 

The importance of health security cannot be overemphasized and the role that military public health offi cials 

play continues to require clarifi cation in many settings.

ACKNOWLEDGEMENTS

We thank the numerous individuals who perform surveillance as part of the AFHSC-GEIS global network, 

including all individuals in the health, agriculture, and 

defense ministries of our partner nations whose efforts 

have contributed to the success of the network. We also 

express our appreciation to the AFHSC staff, especially 

Dr Luther Lindler and Dr Julie Pavlin, for their assistance with manuscript edits and editorial suggestions.

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 April – June 2013 17

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mutation associated with severe clinical outcomes 

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JF. Determinants of mortality in naval units during 

the 1918-19 infl uenza pandemic. Lancet Infect Dis. 

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et al. Epidemiology of infl uenza-like illness in the 

Amazon basin of Peru, 2008-2009. Infl uenza Other 

Respi Viruses. 2011;4(4):235-243.

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al. Arboviral etiologies of acute febrile illnesses 

in western South America, 2000-2007. PLoS Negl 

Trop Dis. 2011;4(8):e787.

25. Myers CA, Faix DJ, Blair PJ. Possible reduced 

effectiveness of the 2009 H1N1 component of 

live, attenuated infl uenza vaccine. Clin Infect Dis. 

2011;53(2):207-208.

26. Faix DJ, Hawksworth AW, Myers CA, et al. Decreased serologic response in vaccinated military 

recruits during 2011 correspond to genetic drift in 

concurrent circulating pandemic A/H1N1 viruses. 

PLoS One. 2012;7(4):e34581.

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Health Organization Press; 2001.
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

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RESPONSE SYSTEM NETWORK TO GLOBAL HEALTH SECURITY IN 2011

28. Sanchez JL, Johns MC, Burke RL, et al. Capacity-building efforts by the AFHSC-GEIS program. 

BMC Public Health. 2011;11(suppl2):S4.

29. Burke RL, Kronmann KC, Daniels CC, et al. A 

review of zoonotic disease surveillance supported 

by the Armed Forces Health Surveillance Center. 

Zoonoses Public Health. 2012;59(3):164-175.

AUTHORS

CDR Blazes is Associate Professor, Tropical Public Health, 

Uniformed Services University of the Health Sciences, Bethesda, 

Maryland.

Ms Bondarenko is Program Manager, Division of GEIS 

Operations, Armed Forces Health Surveillance Center, Silver 

Spring, Maryland.

MAJ Burke is Division of GEIS Operations, Armed Forces 

Health Surveillance Center, Silver Spring, Maryland.

Dr Vest is Deputy Chief of Staff, Operations, Armed Forces 

Health Surveillance Center, Silver Spring, Maryland.

COL Fukuda is DoD Liaison to PMI, Southeast Asia, Armed 

Forces Health Surveillance Center, Silver Spring, Maryland.

LCDR Perdue is Lead Coordinator, Capacity Building and 

Disease Surveillance, Division of GEIS Operations, Armed 

Forces Health Surveillance Center, Silver Spring, Maryland.

Ms Tsai is a Junior Epidemiologist and ORISE Fellow, Division 

of GEIS Operations, Armed Forces Health Surveillance Center, 

Silver Spring, Maryland.

Ms Thomas is a Junior Epidemiologist and ORISE Fellow, 

Division of GEIS Operations, Armed Forces Health Surveillance 

Center, Silver Spring, Maryland.

Ms Chandrasekera is HJF Epidemiologist, Enterics & ARO 

Programs Division of GEIS Operations, Armed Forces Health 

Surveillance Center, Silver Spring, Maryland.

LT Cockrill is an Epidemiologist, Capacity Building and Disease 

Surveillance, Division of GEIS Operations, Armed Forces 

Health Surveillance Center, Silver Spring, Maryland.

CAPT Von Thun is the former Head, Training and COCOM 

Initiatives, Division of GEIS Operations, Armed Forces Health 

Surveillance Center, Silver Spring, Maryland.

Ms Baliga is a Healthcare/Research Analyst, Dynamics Research 

Corporation, Arlington, Virginia.

COL Meyers is Chief, Medical Plans and JUSMAG Liaison, 

Armed Forces Research Institute of the Medical Sciences, 

Bangkok, Thailand.

Dr Quintana is with the Diagnostics Section, Public Health 

Services Laboratory, USAPHC Region-South, Fort Sam Houston, 

Texas.

LTC Wurapa is Director, Department of Emerging Infectious 

Diseases, US Army Medical Research Unit-Kenya, Nairobi.

Dr Mansour is Research Science Advisor and GEIS Coordinator, 

US Naval Medical Research Unit No. 3, Cairo, Egypt.

Dr Dueger is Director, GDDRP-Egypt, US Naval Medical 

Research Unit No. 3, Cairo, Egypt.

LT Yasuda is a Microbiologist, US Navy Environmental & 

Preventive Medicine Unit No. 6, Joint Base Pearl Harbor, 

Hawaii.

Dr Lanata is Science Advisor, US Naval Medical Research Unit 

No. 6, Lima, Peru.

Dr Gray is Professor and Chair, Department of Environmental 

and Global Health, College of Public Health and Health 

Professions, University of Florida, Gainesville, Florida.

Dr Saylors is Director, Behavioral Sciences, Global Viral & 

Metabiota, San Francisco, California.

Dr Ndip is Microbiology Specialist and Head of Service, Teaching, 

and Research, Laboratory for Emerging Infectious Diseases, 

Department of Biochemistry and Microbiology, University of 

Buea, Cameroon.

Ms Lewis is Project Manager, SAGES, Johns Hopkins University 

Applied Physics Laboratory, Laurel, Maryland.

CAPT Blair is Research and Development Liaison Offi cerSoutheast Asia, US Naval Medical Research Unit No. 2, 

Singapore.

Col Sjoberg is Chair, Public Health and Preventive Medicine 

Department and Associate Dean for Public Health, US Air Force 

School of Aerospace Medicine, Wright-Patterson Air Force Base, 

Ohio.

LTC Thomas is Director, Virus Diseases Branch, Walter Reed 

Army Institute of Research, Silver Spring, Maryland.

COL Lesho is Director, Bacterial Diseases Branch, Walter Reed 

Army Institute of Research, Silver Spring, Maryland.

COL Grogl is Director, Division of Experimental Therapeutics, 

Walter Reed Army Institute of Research, Silver Spring, 

Maryland.

LCDR Myers is Director, Identifi cation Diagnostic Laboratory, 

US Naval Medical Research Center, Silver Spring, Maryland.

CPT Ellison is Chief, Immunology Section, DPALS, Landstuhl 

Regional Medical Center, Landstuhl, Germany.

LTC Ellis is Chief, Epidemiology Section, USAPHC RegionEurope, Landstuhl, Germany.

MAJ Brown is Chief, Laboratory Section, William Beaumont 

Army Medical Center, Fort Bliss, Texas.

Dr Schoepp is Chief, Applied Diagnostics Branch, Diagnostics 

Systems Division, US Army Medical Research Institute of 

Infectious Diseases, Fort Detrick, Maryland.

Dr Shanks is Director, Australian Army Malaria Institute, 

Gallipoli Barracks, Enoggera, Queensland, Australia.

Dr Macalino is Deputy Director, HIV/STI Program, Infectious 

Disease Clinical Research Program, Rockville, Maryland.

Dr Eick-Cost is Special Studies Lead, Epidemiology and 

Analysis Division, Armed Forces Health Surveillance Center, 

Silver Spring, Maryland.

CAPT Russell is Director, Armed Forces Health Surveillance 

Center, Silver Spring, Maryland.

Dr Sanchez is Leader, STI Pillar Activities, Division of GEIS 

Operations, Armed Forces Health Surveillance Center, Silver 

Spring, Maryland.
 April – June 2013 19

BACKGROUND

This article is a brief summary of the activities of the 

Public Health Command Region – Pacifi c and the Japan 

District Veterinary Command following the March 11, 

2011 earthquake, tsunami, and nuclear reactor explosion 

in northeastern Japan.

The information used in this article was primarily gathered by the Special Army Medical Command Response 

Capability-Medical History Team (SMRC-MHT) based 

at Fort Sam Houston, Texas, which consists of historians 

from the Army Medical Department Center of History 

and Heritage’s Offi ce of Medical History. Team members for the Japan 2011 mission were an active duty military historian and the author. In Japan, the Commander, 

Public Health Command Region-Pacifi c (PHCR-PAC), 

and the Commander, Japan District Veterinary Command (JDVC),* provided invaluable insight and information. They were also extremely helpful in assisting the 

SMRC-MHT members in travel and conducting interviews with personnel.

During the week July 9 through July 15, 2011, the SMRC-MHT traveled to Camp Zama, Japan and recorded 

the activities of the PHCR-PAC and the JDVC related 

to the March 2011 earthquake, tsunami, and resulting 

nuclear crisis. Information concerning immediate disaster response and the later formal Army and United 

States Forces–Japan (USFJ) support during Operations 

Tomodachi, Pacifi c Passage, and Pacifi c Homecoming† 

was also collected.

The team was able, through discussion, interviews, and 

personal interaction, to develop a greater understanding of the challenges faced by and achievements of the 

Soldiers and civilians of the PHCR-PAC and the JDVC. 

Trained through simulated disasters and performing 

constant travel related to testing and support, the personnel of these units were prepared to operate under 

unusual circumstances. Although these organizations 

operated within a joint environment during the recovery 

and support efforts, the focus of this document is US 

Army operations.

EVENT 1: EARTHQUAKE

We’d feel earthquakes every now and then because we 

get quite a few every year, but it started off just a normal 

earthquake, and then it got bad and cars were shaking 

and alarms were going off and people were screaming.

SPC Donald Lewis, PHCR-PAC

On Friday, March 11, 2011, a magnitude 9.0 earthquake, 

one of the largest in recorded history, struck off the 

northeastern (Tohoku) coast of the main Japanese island 

of Honshu, near the city of Sendai. Initial reactions were 

for safety and accountability at various levels. Communication was diffi cult due to power and telephone line 

damage. Additionally, the size of the units’ regions of 

responsibility further hampered accountability efforts. 

Internet connectivity remained to varying degrees, and, 

in many cases, contact was made through Skype and Facebook social networking sites when government telephone lines were inoperable. Contact was established 

with all personnel before midnight, March 11.

The PHCR-PAC normally tests a wide variety of environmental and industrial samples during routine, steadystate operations. After the earthquake, one of its fi rst 

tasks was to test Camp Zama’s water supply. The tremors had shaken water pipes and agitated visible sediment 

which concerned the residents of Camp Zama. Initial 

testing confi rmed that there was no danger, and after 

US Army Public Health and Veterinary Support

 in Japan Following the Tōhoku Earthquake

 and Tsunami, March-April 2011

Nolan A. Watson

*When information for this article was collected, PHCR-PAC and the JDVC were under separate command structures. On July 22, 2011, 

the US Army Veterinary Command was deactivated and all Department of Defense veterinary services were assumed by the Army Public 

Health Command. In Japan, the JDVC was integrated into the Camp Zama-based PHCR-PAC. On August 31, 2011, the JDVC was reconstituted as Public Health Command District-Japan. The PHCR-PAC includes 3 veterinary command districts: Japan, Guam, Hawaii.

†Operation Tomodachi included both humanitarian assistance (direct) and consequence management (indirect) support of the Japanese 

people through combined US and Japanese military aid and assistance following the actual disaster events, and was continuing when this 

article was written (January 2012). Operation Pacifi c Passage refers to the voluntary departure of military family members from Japan. 

Operation Pacifi c Homecoming is the converse of Operation Pacifi c Passage, with voluntary departees returning to Japan.
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

approximately 24 hours of rumors and misinformation 

about storing water, fears abated and the issue subsided.

During the early hours of recovery following the fi rst 

event, the JDVC* shifted to emergency operations. Power outages and potential structural damage posed immediate food safety concerns, including the primary US 

military storage and staging food warehouses on Honshu. Food inspectors called, drove, or walked as needed 

(sometimes for miles) to reach all affected facilities and 

conduct refrigeration failure procedures and evaluate the 

potential affect on food safety of any physical damage.

Within 24 hours of the earthquake, after initial food and 

animal facility assessments at 10 sites supported by the 

Zama, Yokosuka, and Misawa branches, the Veterinary 

Services Branches began preparing installation command channel messages. The messages addressed food 

safety during power outages and provided continued 

refrigeration failure information and support to government food facilities.

Military Working Dog kennels, stray facilities, and installation boarding and care kennels were contacted to 

determine physical status and address any animal injury/care issues. An increased food surveillance laboratory testing program was initiated due to increased 

food sanitation-related concerns. The Misawa Veterinary Services Branch and its Veterinary Treatment 

Facility (VTF) at Misawa Air Base near the northern 

tip of Honshu lost power, heat, and telecommunications 

while dealing with snow and freezing temperatures. Its 

personnel labored to continue operations under extreme 

adverse conditions for the next 2 weeks.

EVENT 2: TSUNAMI

The tsunami was the major cause of damage from the 

3/11 events. When I traveled through Sendai, there was 

some building damage from the earthquake, but the tsunami damage was incredible and absolute, sparing almost nothing in its wake.

COL Michael Brumage, Commander, PHCR-PAC

As the tremors and aftershocks from the large earthquake continued while decreasing in magnitude, another 

threat appeared. The earthquake caused a vast tsunami 

along the east coast of Japan, which was particularly 

damaging to the Sendai area and roughly 400 km of 

the Tohoku coast, obliterating many towns and cities 

in the affected area, resulting in approximately 20,000 

deaths. Breaking through a lowered coastline caused by 

the earthquake, the waters crushed countless walls and 

buildings, and damaged the Fukashima Daiichi nuclear 

power plant. Personnel from the Yokosuka Veterinary 

Services Branch (animal care, JDVC food inspectors, 

and a JDVC noncommissioned offi cer assigned to the 

Navy Food Management Team) stationed on Yokosuka 

Naval Base had to withdraw for a short time due to fears 

of the tsunami, which fortunately crested at 2 m near 

Yokosuka, rather than the height of 9 m near Sendai, approximately 160 km to the north. In the tsunami’s aftermath, PHCR-PAC provided support in testing water 

supplies, air samples, and other items for radiological, 

biological, and chemical contaminants to assure the 

safety of the working environment where US personnel 

were assisting the Japan Self-Defense Force.

The tsunami also directly and indirectly impacted Japanese commercial food plants normally audited by the 

JDVC. The JDVC’s immediate post-tsunami actions included communicating with those plants and determining the physical damage, power supply, proximity to affected areas, and state of operations. This was essential 

to determining food safety decisions for USFJ.

Concurrent with the other contingency actions, search 

and rescue (SAR) dogs from the United States, the United Kingdom, and Australia required veterinary support 

to be allowed entry into Japan, a rabies-free country, to 

assist in recovery efforts. The strict animal quarantine 

requirements of the Japanese government were met 

largely through the efforts of the JDVC.

US ARMY PUBLIC HEALTH AND VETERINARY SUPPORT IN JAPAN FOLLOWING

THE TŌHOKU EARTHQUAKE AND TSUNAMI, MARCH-APRIL 2011

*The JDVC consisted of 5 Veterinary Service Branches supporting 

34 installations, the 7th Fleet (USN), the 5th Air Force, USFJ, and 

the US Embassy. The branches were Misawa (supporting 2 installations), Zama (supporting 8 installations, 5th Air Force, US Embassy, and USFJ Headquarters), Yokosuka (supporting 8 installations/sites and the 7th Fleet), Iwakuni (supporting 4 installations/

sites and 7th Fleet units at Sasebo), and Okinawa (supporting 15 

installations and the III Marine Expeditionary Force).

The March 11, 2011 earthquake and tsunami devastated the 

northeast coastline of the Japanese island of Honshu. The 

area around the city of Sendai, pictured here, was especially 

hard hit. Photo courtesy of the US Army.
 April – June 2013 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

EVENT 3: CRITICALLY DAMAGED NUCLEAR REACTOR

I didn’t really think it touched home for most of the personnel here on what the seriousness of the situation was, 

until the incident with the nuclear reactor started up and 

then it became real.

CPT Brian E. Vencalek, PHCR-PAC

Monday, March 14, brought more challenges as requests 

for assistance and support increased, and the situation 

at the Fukashima Daiichi power plant came under close 

scrutiny. The condition of the nuclear reactors at the 

power plant continued to deteriorate, and public concern in connection with a potential nuclear accident was 

greatly heightened. Rumors had detrimental effects on 

PHCR-PAC operations. While Facebook aided communication immediately following the initial events, it now 

impeded progress as its postings spread and heightened 

unfounded fears. Similarly, American news media compounded anxiety and fear by incessantly publicizing 

possible nuclear concerns. Community-level risk communication became a de facto mission of PHCR-PAC.

In order to fi eld questions and assist with their expertise at a higher level, some health physics personnel at 

PHCR-PAC were detailed to the US Army-Japan and 

Joint Security Forces–Japan staffs. Also, PHCR-PAC 

was later augmented with health physics personnel from 

the Army Public Health Command’s Army Institute of 

Public Health (AIPH), who arrived in Japan before any 

other military radiation detection unit. As the tempo increased within PHCR-PAC, the newly formed operations 

cell increased from an operations offi cer and one noncommissioned offi cer to several personnel with varying 

augmentations, all working very long hours over the 

next month. Fortunately, a training exercise prior to the 

events had demonstrated the value and need for a larger 

operations department, and such a plan was in place.

When reactor Unit #3 at the Fukashima nuclear power 

plant exploded on March 14, new fears emerged, and PHCR-PAC dispatched teams to collect data to determine 

the effects of the explosion and measure the amount of 

possible radioactive contamination. The teams collected 

air and water samples from Army bases in the Kanto 

Plain (Tokyo area) as well as from areas where US 

personnel were working in the vicinity of Sendai. Coordination and cooperative testing was conducted with 

the US Air Force Radiation Assessment Teams, which 

arrived in Japan one week after the AIPH team. Also, 

Occupational and Environmental Health Surveillance 

Assessment teams were sent for an extended time to the 

Sendai Airport area where US and Japanese Forces were 

concentrated during humanitarian relief operations.

POSTDISASTER OPERATIONS

Japan District Veterinary Command

The JDVC became concerned that Military Working Dogs 

might require preventive radiologic protection with administration of potassium iodine or KI tablets. The JDVC

addressed those concerns to the USFJ Surgeon, then 

worked with the Department of Defense (DoD) Military 

Working Dog Veterinary Service to determine a dosage 

and dosing scheme. The JDVC then quickly coordinated 

with the US Army Medical Department Activity, Japan,

to obtain the medications and fi nalize the dosage plan, 

in case it was needed. Dosage and methods of dispersal 

were quickly identifi ed and relayed, but fortunately the 

need to administer the medications did not materialize.

The VTFs at Camp Zama, Yokosuka, Yokota, and Misawa began to experience increased visitation by military dependents, steadily at fi rst, then increasing very 

rapidly. Dependents and DoD civilians had concerns 

for their safety and were voluntarily leaving Japan, but 

all pets had to receive health certifi cations before they 

could depart. The stream of people increased and often 

nearly overwhelmed the staff of the VTFs. The workload reached particularly high levels after offi cial notifi cation of voluntary assisted departures for dependents 

and their pets was announced, and Operation Pacifi c 

Passage began on March 22. This operation involved the 

examination, certifi cation of health, and transportation 

of over 2,700 pets.

The VTFs succeeded through the dedication and fl exibility of their personnel. Supplemental personnel were 

primarily available food inspectors from the Yokosuka 

and the Camp Zama Veterinary Service Branches. But 

there were also enthusiastic volunteers, such as Military 

Working Dog handlers, and a newly arrived JDVC Animal Health Technician destined for the Sasebo VTF who 

A US Army public health specialist from the Institute of Public Health, Aberdeen Proving Ground, MD, checks radiation 

levels at the Sendai Airport, Japan, on March 27, 2011. 

Photo courtesy of the Department of Defense.
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

had not yet processed from arrival. A surgeon waiting 

with his pet in the Misawa VTF line expressed a wish 

to help and was given a stethoscope and a crash course 

on animal physical exam basics, and put to work in an 

exam room. Very long days and nights combined with 

some emotional military dependents to add to the challenges faced by the VTF staffs.

The JDVC developed and initiated a novel program for 

radiological surveillance that continues today. The program information was requested by the Department of 

Veterinary Science at the AMEDD Center and School 

(AMEDDC&S) for instructional purposes. Supplemented with additional radiation meters received from 

AMEDDC&S and USAPHC Veterinary Services, the 

program provided daily radiological surveillance monitoring of up to 68 different animal and food related facilities and conveyances on 14 different installations for all 

military service branches within USFJ, with over 7,000 

readings as of July 2011. The monitoring provided assurances to commands and the public of no health threat 

to installation level food supplies from radiation. Health 

physicists from PHCR-PAC reviewed the data daily and 

confi rmed the absence of a health threat, and provided 

supplemental equipment training and refi ned the JDVCdeveloped program. They were also essential in facilitating JDVC efforts with additional handheld radiological 

monitoring equipment that was vital to the program.

With the public announcement of radiological contamination of Japanese food products, JDVC immediately 

initiated working relationships with the Government of 

Japan (GoJ) to receive testing results; Defense Logistics 

Agency and the Defense Commissary Agency personnel 

regarding normally exempt product origin; and the Food 

and Drug Administration (FDA) representative who had 

been dispatched to the US Embassy in Japan. The JDVC 

food inspectors also began conducting surveys at the installation level. The results were rapid responses to USFJ 

and JDVC to provide assurances that contaminated 

products had not reached USFJ installations. Command 

channel messages were sent with each newly researched 

product announcement. Although time consuming, it 

was very important to ensure announcements and news 

media events addressed food safety concerns.

The Commander, JDVC, described the food inspection 

mission in detail:

By the next Monday after the quake, we initiated conducting commercial food plant assessments. Within 10 

days, we had recommended suspension of the fi rst commercial food plant previously approved for DoD procurement due to proximity of the primary damage sites and 

our inability to reach them. Within 15 days of 3/11, we 

had fi nished our initial evaluation with additional suspension recommendations, and worked with USAPHC 

Veterinary Services, DoD Veterinary Services Activity, 

FDA, USDA [US Department of Agriculture], ASD/HA 

[Assistant Secretary of Defense/Health Affairs], USFJ, 

etc, with the result being an historical ALFOODACT 

[all food activities alert] 004-2011 issued on April 1, 

2011, with suspension of DoD food procurement from 

13 different prefectures, with a few individual plant exceptions, due to concerns of compromised food safety 

from radiological, seismic activity damage, and resupply/transportation or power outages resulting in potential 

microbiological, chemical, physical, or radiological contamination. JDVC then developed an enhanced auditing 

program fi rst enacted later in April 2011 that included 

sending a team with a CWO [chief warrant offi cer] 640A, 

veterinarian, and 68R food inspectors to the plants to conduct onsite radiological surveillance, bioluminescence 

surveillance, determination of raw ingredient origins, 

HAACP [hazard analysis and critical control points] 

and production/processing methodology reassessment, 

etc. We also gathered onsite water and food product 

samples for microbiological [tested by the JDVC Food 

Surveillance Laboratory], chemical [DoD food analysis 

and diagnostic laboratory], and radiological [food, FDA 

US based laboratory; water, AIPH testing]. In addition, 

JDVC met with GoJ [agencies] to obtain GoJ and prefectural radiological testing results, to discuss radiation 

testing methodologies, and to determine complementary 

efforts to avoid any needless duplication. This will be an 

ongoing mission for the next 2 years [estimated], with 

continued surveillance for several years to come.

LTC Margery Hanfelt, Commander, JDVC

Although JDVC served as the food safety lead and primary responder for all USFJ during Operation Tomodachi, it was not spared from other tasks. The JDVC 

faced part two of the dependent animal care mission, 

Operation Pacifi c Homecoming, when returning family 

members required documentation to expedite bringing 

their pets back into Japan. Working with the GoJ, this 

effort was accomplished in a short amount of time. The 

accomplishment was made possible through meticulous 

record-keeping and an atmosphere of great trust between the JDVC and the GoJ. The JDVC also enacted a 

“hotline” connecting veterinary teams with GoJ Animal 

Quarantine Service offi cials at Narita Airport, and received pets at designated US military installation sites.

Public Health Command Region–Pacific

We were getting a lot of people who were engineering 

and veterinary specialties fi lling in, trying to do as best 

as they possibly could. But it was many, many long days. 

I think that the fi rst day we got off was about 60 days 

after the actual earthquake.

MAJ William Whitaker, PHCR-PAC

US ARMY PUBLIC HEALTH AND VETERINARY SUPPORT IN JAPAN FOLLOWING

THE TŌHOKU EARTHQUAKE AND TSUNAMI, MARCH-APRIL 2011
 April – June 2013 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

The testing site distance and monitoring schedule (every 4 hours during the fi rst weeks) added to logistics 

issues within PHCR-PAC. For the remainder of March 

and through most of April, teams and trucks were almost continuously en route to testing sites, performing a 

test, or returning with data for interpretation. Assisting 

in testing were augmentees from the 296th Army Band, 

the 78th Signal Battalion, and the 441st Military Intelligence Battalion. Personnel within PHCR-PAC were 

also trained outside of their normal scope of duties to 

assist in the monitoring mission. Additional assistance 

for PHCR-PAC missions was also later received from 

USAPHC, and the 9th Area Medical Laboratory based 

at Aberdeen Proving Ground, MD.

The operations cell of PHCR-PAC grew as it received 

assistance for its staff members. Long hours increased 

as the unit gathered and disseminated information to 

USARJ and USAPHC. The public health section of the 

BG Crawford F. Sams Hospital (Camp Zama) also continued to work closely with PHCR-PAC, providing information and testing requests.

A small testing team was sent to the operations center 

at Ishinomaki near the Sendai Airport. The US military used Ishinomaki Camp, near the devastated area 

of Sendai, as a staging area. From there, Army, Marine 

Corps, and Air Force personnel supported the Japanese 

Ground Self-Defense Force as it provided humanitarian 

relief and rescue operations. Because of the proximity of 

the destruction and the large congregation of personnel, 

the PHCR-PAC team monitored for potential hazards. 

The team provided particulate matter sampling of the 

air, water, and soil. Heavy metal and vapor air sampling 

was conducted, as well as water quality analysis.

Housing areas for US military personnel and their dependents were also of primary interest for testing. These 

testing areas included Camp Zama; the nearby Sagamihara Housing Area, Sagami Depot, and Atsugi Naval Air 

Station; Yokohama’s North Dock facilities; and Hardy 

Barracks (downtown Tokyo). Reaching the Yokohama 

North Dock and Hardy Barracks areas was diffi cult because of constant heavy traffi c congestion and the maze 

of streets. Yet dedicated drivers, mostly Japanese civilians, successfully navigated the city streets to transport 

Soldiers to the areas requiring testing.

Not surprisingly, operations during the heavy sampling 

period of March, April, and May 2011 increased dramatically. The logistics of the sampling and survey mission, 

including translation and continually providing information, were complex. Similarly, the materials required 

for collecting the samples and their transport presented 

more challenges. “Normal” operations for PHCR-PAC 

before the disasters required numerous testing items 

and transport at great expense. Such expenses increased 

substantially as the monitoring efforts expanded. Material gathered by air, water, and soil sampling arrived at 

either the Camp Zama or USAPHC laboratories for testing. Some of the materials were shipped to contractors to 

perform the testing. Many of the Japanese vendors were 

sympathetic and offered free supplies or discounts.

NONCOMBATANT EVACUATION OPERATION

Operation Pacifi c Passage was the fi rst true test of existing plans for the noncombatant evacuation operation 

(NEO) from Japan in the event of catastrophe or the outbreak of hostilities on the Korean peninsula. Spouses, 

dependents, US or other foreign national civilian employees, and pets presented a signifi cant challenge. It is 

understandable that some people were eagerly seeking 

transit due to the unstable environment. As military personnel and family members pondered courses of action, 

a town hall meeting was called at Camp Zama where 

USFJ and garrison command leadership fi elded questions and concerns. One issue was the care of personally 

owned animals (pets). Noting the extreme concern, the 

Commander, USARJ agreed that pets could be a part of 

the voluntary departure.

Ultimately, NEO was not activated, but voluntary leave 

paid by the government was approved. This action eased 

many dependents’ minds, but also signifi cantly increased the workload for VTFs. Though most of the dependents and civilians opted to stay in Japan, a number 

decided to leave. Volunteers helped to bridge the gap for 

animal care in the manner of feeding and walking. Also, 

military exchanges sometimes provided complimentary 

water and pet carriers. Navy personnel assisted in movement of the pets to the Narita airport near Tokyo. Cooperation continued at the Narita airport as the airport 

staff and the airlines allowed more animals on aircraft 

and eased their travel and storage through the airport. 

The environment of cooperation was necessary as many 

of the dependents had small children, compounding the 

already stressful situation.

Denver International Airport and Seattle-Tacoma (SeaTac) International Airport were the receiving hubs for 

voluntary departees. Family members then had to fi nd 

passage to other parts of the United States. For some, an 

additional day would be necessary to arrange further 

transportation. Logistic support was provided by local 

USMC reserve units and Army and Air Force personnel. 

Strollers were provided for the large number of young 

children and the American Red Cross provided showering and baby changing stations.
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

After 4 to 8 weeks, many of the dependents returned 

to Japan. Operation Pacifi c Return, the reverse of Operation Pacifi c Passage, went smoothly. The ease of the 

transition in connection with the movement of pets was 

largely due to JDVC’s interactions with the GoJ. The 

time for animal entry into Japan was signifi cantly reduced due to their good working relationship. The JDVC 

maintained the required documentation and addressed 

all questions that satisfi ed GoJ’s requirements.

CONTINUED EFFECTS

I guess we’re at the new normal....We still have some 

families slowly coming back, so we, I think, have gone 

to more of what it used to be, where you just got a regular 

full day of work.

SFC April Smith, JDVC

More than 2 weeks after the March 11 earthquake, concerns about food procurement continued. Radiologic 

contamination was the most notable concern, but refrigeration and other storage and transportation issues related to the earthquake and its aftermath remained. Veterinary food inspection teams, redirected to assisting in the 

animal care mission, “re-tooled” to their original function and began another phase of recovery. Although the 

food safety inspection was an existing mission before 

the earthquake, it has greatly expanded due to new challenges presented by the unfolding disasters. Newer technology, such as bioluminescent technology to quickly 

determine some surface contaminations at food production plants, is now used to aid the inspection process.

The Public Health Command District-Japan (PHCD-J) remains busy with food inspection issues. On August 7, 

2011, ALFOODACT 010-2011 was issued initiating removal of suspensions of procurement of food products 

from those designated areas in Japan. Implementation 

by PHCD-J of those suspension removals will require 

approximately 2 years of effort. The PHCD-J also established a comprehensive walk-through program for food 

inspectors at the facility level, which includes radiological and bioluminescence surveillance, surveillance food 

laboratory testing, and other legacy food inspection programs. Radiological surveillance of food facilities and 

conveyances will continue for several years.

PHCR-PAC continues to monitor and plot data in connection with air, water, and soil quality, in addition to 

sustained examination of biological, radiological, and 

chemical threats. Its laboratory has received additional 

equipment to perform testing and has gained additional 

personnel to assist in daily operations. Ambient radiation readings to a minute degree have increased within 

the tested areas, however, such readings pose no threat 

to personnel.

CONCLUSION

The Soldiers and civilian personnel of Public Health 

Command Region – Pacifi c and the Public Health Command District-Japan (formerly JDVC) were able to rapidly alter daily operations from a garrison structured 

organization to support fi eld operations and the myriad 

of challenges in connection with what became a de facto 

partial NEO. Although no exercise can fully prepare any 

unit for such a disaster, extensive planning was invaluable in reacting to and contending with the ceaseless 

demands for assistance and information. The events 

and actions solidifi ed a solid and cohesive working relationship between the PHCR-PAC and JDVC leaders and 

staffs, and provided a “proof of concept” for the Army 

Public Health Command.

Planning and readiness exercises for future Public Health 

Command District-Japan operations include updating 

NEO plans to be more realistic in refl ecting actual requirements and capabilities, as evidenced by events experienced by the JDVC. Organizational changes and protocols ensuring improved coordination with the GoJ to 

create and emplace procedures during similar emergencies are in staffi ng. Part of the JDVC’s success was the 

product of its management of information and prompt 

identifi cation of incorrect sources. A disaster preparedness exercise conducted 2 months prior to the March 11 

earthquake is credited with particularly benefi cial results. Key among the lessons learned from that exercise 

were the need for a robust operations cell with dedicated 

personnel and communications assets, implementation 

of which was an essential element in the success of the 

emergency reaction to such an unprecedented disaster 

event.

US ARMY PUBLIC HEALTH AND VETERINARY SUPPORT IN JAPAN FOLLOWING

THE TŌHOKU EARTHQUAKE AND TSUNAMI, MARCH-APRIL 2011

AUTHOR

Mr Watson is a historian with the Offi ce of Medical History, US Army Medical Department Center of History and 

Heritage, Fort Sam Houston, Texas.
 April – June 2013 25

Since 2001, over 2 million US military personnel have 

deployed to Iraq or Afghanistan.1

 Many of these Warfighters have been deployed multiple times for deployments lasting over 9 months. The demands placed on 

Soldiers during deployments are physically challenging 

and require them to maintain a high level of physical fi tness.2

 In garrison settings, Soldiers typically participate 

in scheduled physical fi tness routines and have access 

to dining facilities and many other food sources. The 

variability in mission requirements during deployments 

may limit routine exercise regimens and food intake, 

otherwise available in garrison.3

 Additionally, the hot 

and dry climates associated with deployments promote 

dermal calcium losses, and, when combined with inadequate dietary intake of calcium and vitamin D, subject 

military personnel to decreased bone density and place 

them at risk for musculoskeletal injuries.4

Bone-related injuries and stress fractures are a major problem in the military and affect the health and 

readiness of Soldiers.5

 Risk factors for bone-related 

injuries include increasing age, female gender, smoking, inadequate calcium intake, poor fi tness level, and 

overtraining.5

 Previous studies have examined the impact of sustained operating environments3,6 similar to 

deployments, on bone mineral density (BMD) in infantryman and have presented contradictory results. Nindl 

et al3

 observed an increase in bone mineral content of 

the whole body and trunk, whereas Casez et al6

 found 

an increase in BMD of the tibia and a decrease in BMD 

of the spine.6

 More recent studies have investigated the 

effect of deployment on physical activity and body composition. Sharp et al7

 determined that a 9-month deployment negatively impacted aerobic capacity, upper body 

power, and BMD. Lester et al8

 noted an improvement in 

upper and lower body strength and a reduction in aerobic performance. Collectively, these results suggest that 

physical activity, particularly load bearing, may positively impact bone health; however, a deployed setting 

with inadequate food and rest and periods of prolonged 

work may negatively impact BMD. Since most studies 

have investigated infantry Soldiers and recruits, levels 

of BMD and physical fi tness of combat service support 

Soldiers during deployment are unclear; so it remains 

unknown if long-term deployments impact bone density 

in this population.

Nutrient losses from environmental factors combined 

with inadequate diet subject military personnel to bonerelated injuries.3

 It is well known that calcium and vitamin D are important nutrients related to bone metabolism; however, other nutrients such as protein, fat, vitamin K, sodium, magnesium, and phosphorus may play 

a role in maintaining bone density as well.9

 Previous 

data from the National Health and Nutrition Examination Survey10 which indicated age-associated changes in 

calcium intake suggest Soldiers aged 18 to 40 years may 

not be consuming the recommended amounts of bonerelated nutrients, predominantly calcium. Etzion-Daniel 

et al11 examined nutrient consumption by female Israeli 

Diet, Physical Activity, and Bone Density in

 Soldiers Before and After Deployment

1LT Ashley R. Carlson, SP, USA

MAJ Martha A. Smith, SP, USA

MAJ (Ret) Mary S. McCarthy, AN, USA

ABSTRACT

Purpose: To investigate diet, physical activity, and bone mineral density (BMD) in combat service support Soldiers before and after deployment, and to determine if any components of diet or physical activity impacted BMD.

Design: Fifty-three Soldiers participated in the study. The BMD of the femoral neck and lumbar spine were measured 

using dual-energy x-ray absorptiometry. Diet was assessed using the Block Food Frequency Questionnaire. Physical 

activity was assessed using the Baecke Habitual Physical Activity Questionnaire.

Results: The BMD of the spine (0.79%; P=.03) increased signifi cantly during deployment. Reported physical activity 

at work (-10.76%; P=.01) decreased and vitamin K intake increased (37.21%; P=.01). Soldiers did not meet the dietary 

reference intake for vitamin D and exceeded the dietary reference intakes for all other nutrients. No signifi cant relationships were observed between change in diet or physical activity and change in BMD.

Conclusion: Due to the small sample size, we could not determine if deployment impacted BMD, diet, or physical activity in combat service support Soldiers. Future research should focus on investigating the association between lower levels 

of physical activity, inadequate diet, and decreased BMD in larger military populations.
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

Defense Forces Soldiers during Army basic training and 

found vitamin D (49%-61%) and calcium (24%-31%) 

intakes to be well below the military dietary reference 

intakes (MDRIs).12 Other studies suggest that intake of 

vitamin D and calcium greater than the MDRI may reduce the risk of fracture in Soldiers13,14; however, most 

studies focus on female recruits13-16 and do not consider 

males or deployment settings. Collectively, these results 

suggest that female Soldiers do not consume suffi cient 

calcium and vitamin D during basic training. However, 

the consumption levels of bone-related nutrients in combat service support Soldiers in garrison and deployment 

settings have not been considered and are unknown.

At present, the interactions between dietary intake, 

physical activity, and BMD in combat service support 

Soldiers during long-term deployments have not been 

investigated. The purpose of this study was to investigate dietary intake, physical activity, and BMD in combat service support Soldiers before and after a 12-month 

deployment to Iraq. Furthermore, researchers wanted to 

determine if any components of diet or physical activity 

impacted BMD throughout the study period.

SUBJECTS AND METHODS

Fifty-three US Army Soldiers were recruited from the 

62nd Medical Brigade, Joint Base Lewis-McChord, 

Washington. Volunteers were eligible to participate if 

they were active duty male or female Army Soldiers 

aged at least 18 years, were in good physical and mental 

health, and scheduled to deploy to Iraq in 2007. Pregnant 

Soldiers were excluded. The study was a prospective, 

descriptive, longitudinal design with repeated measures 

that took place at the Madigan Army Medical Center 

in Tacoma, Washington. Lifestyle factors, anthropometrics, diet, physical activity, and BMD were collected 

before and after the 12-month deployment to Iraq. Baseline measurements were taken within 30 to 60 days of 

deployment. Postdeployment measurements were taken 

within 60 days of each Soldier’s return from Iraq.

DATA COLLECTION

All dependent variables were documented at baseline and 

after the 12-month deployment. Height was measured at 

baseline to the nearest 0.1 cm using a Harpenden stadiometer. Body weight was measured at both time points 

using a calibrated electronic scale and measured to the 

nearest 0.1 kg with volunteers wearing the Army physical fi tness uniform (t-shirt, shorts, and socks). Body 

mass index (BMI) was calculated as weight (kg) divided by height2

 (m2).17 Age, ethnicity/race, and lifestyle 

habits (family history of bone abnormalities, history of 

eating disorders, alcohol use, and tobacco use) were collected using a demographic survey.

Bone mineral density of the (L1-L4) spine and femoral 

neck were measured by a trained, certifi ed technician 

using dual energy x-ray absorptiometry (Lunar Prodigy 

Densitometer, GE Healthcare, Madison, WI).

Physical activity was measured using the Baecke Habitual Physical Activity Questionnaire. This tool was validated on male and female subjects with similar age and 

activity level of study participants, and was designed to 

assess physical activity during work, leisure, and sports 

activities.18 The baseline survey assessed activity during the previous year, whereas the postdeployment survey assessed activity during deployment. Work activity 

was designed to measure frequency of sitting, standing, walking, lifting, fatigue, and sweating. Questions 

involving sports were designed to measure frequency, 

type, and duration of activity for up to 4 different sports, 

while leisure activities included frequency of sports 

participation, television watching, walking, and riding 

a bicycle during off-duty hours. The work and leisure 

subscales were scored from 1 to 5 on a Likert scale 

(1=never; 5=always/very often). The sport score was 

determined by assigning values to certain sports based 

on their frequency and intensity.18 Overall, physical activity was determined by adding work, leisure, and sport 

codes and was described on a scale of 1 to 15 (1=low, 

7.5=moderate; 15=high).

The previously validated 2010 Block Food Frequency 

Questionnaire (FFQ, NutritionQuest, Berkeley, CA) 19

was administered to estimate usual and customary intake of 110 food items. Respondents reported how often (in the past year) they typically consumed each food 

(never, a few times per year, once per month, 2-3 times 

per month, once per week, 2 times per week, 3-4 times 

per week, 5-6 times per week, or everyday), and what 

their usual intake was on those days. Individual portion 

sizes were estimated by pictures provided to enhance 

accuracy of quantifi cation. The questionnaire also contained questions about overall consumption of foods 

from each food group, beverage intake, and use of vitamin supplements. All completed questionnaires were 

analyzed by NutritionQuest. Ten nutrients (energy, protein, fat, carbohydrate, calcium, vitamin D, phosphorus, 

magnesium, sodium, vitamin K) were included in the 

analysis for this study. All nutrients were calculated as 

the sum of daily intake from food. Due to the outdated 

MDRIs12 typically used for military personnel, energy 

was compared to the Department of Agriculture’s dietary guidelines20 for Americans’ estimated energy 

intake for males and females aged 18 to 25 years with 

a moderate physical activity level. All other nutrients 

were compared to the Institute of Medicine’s dietary reference intakes (DRIs).21

DIET, PHYSICAL ACTIVITY, AND BONE DENSITY IN SOLDIERS BEFORE AND AFTER DEPLOYMENT
 April – June 2013 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

STATISTICAL ANALYSIS

Study completers were defi ned as 

those participants who completed both 

baseline and postdeployment measurements. Statistical analysis was 

performed using the SPSS Inc Statistical Package (version 18.0, SPSS Inc, 

Chicago IL). Descriptive statistics using means±standard deviations were 

used to describe all data. Independent 

t tests were used to compare those 

who completed the study and those 

who did not. Dependent variables 

were analyzed using a 2-tailed, paired 

samples t test to compare differences 

in means between baseline and postdeployment. Pearson’s correlations 

were used to compare relationships 

between changes in physical activity, changes in dietary nutrients, and 

changes in BMD. Statistical test signifi cance (alpha) was set at P≤.05.

RESULTS

Nineteen of 53 (36%) study participants returned after deployment to complete all data 

points. One Soldier did not provide baseline 

data, another did not provide baseline FFQ data, 

and 32 Soldiers did not return for postdeployment measurements. No signifi cant differences 

were observed in age, height, weight, BMI or 

gender between those who completed the study 

and those who did not. Demographic data are 

presented in Table 1. Twelve male and 7 female 

Soldiers were study completers. Age ranged 

from 18 to 36 years, with a mean of 23.13±3.4 

years. Height ranged from 149 cm to 193 cm 

with a mean of 173.19±10.8 cm. Weight ranged 

from 54 kg to 95 kg with a mean of 73.27±12.3 

kg. The BMI ranged from 20.07 to 28.49, with 

a mean of 24.26±2.4. Thirteen Soldiers were 

white, 3 African American, 2 Hispanic, and 

one Pacifi c Islander. At baseline, 4 Soldiers reported tobacco use, 10 indicated alcohol use, 3 

noted family history of bone disease, 2 a history of stress fracture, and none a history of 

eating disorder. During deployment, 4 Soldiers 

began using tobacco and only 2 Soldiers reported alcohol use. No stress fractures were experienced by either gender during deployment.

Changes in anthropometrics and BMD from 

baseline to postdeployment are presented in Table 2. No signifi cant differences were observed 

in weight or BMI. Bone mineral density of the spine increased signifi cantly from baseline to postdeployment 

(0.79%; P=.03). It is possible that 

this increase may have been related 

to bone growth during deployment, 

since bone accrual may still be taking 

place in many of these young Soldiers. 

In contrast to the increase in BMD of 

the spine, no signifi cant differences 

were seen in BMD of the femoral 

neck (-0.87%; P=.09) from baseline 

to postdeployment. However, it is important to note that even though there 

were no statistically signifi cant results, 

47% of subjects did experience a clinically signifi cant (2% change) decline 

in BMD of the femoral neck.

Reported work, sport, and leisure 

activity before and after deployment 

is presented in Table 2. A signifi cant 

decrease in physical activity at work 

(-10.76%; P=.01) was observed. No 

signifi cant differences were observed 

Table 1. Demographic characteristics 

at baseline (N=19).

Demographic Data Baseline 

Age (years)a 23.13±3.4 

Genderb 12 male 

7 female 

Height (cm)a 173.19±10.8 

Weight (kg)a 73.27±12.3

BMI (kg/m2)

a 24.25±2.4

Ethnicity/Raceb

Caucasian 13

African American 3

Hispanic 2

Pacific Islander 1

Lifestyle Habitsb

Tobacco use 4

Alcohol use 10

Family history of bone 

disease 3

History of stress fracture 2

History of eating disorder 0

Notes:

a: Expressed as means±SD

b: Number of participants

Table 2: Anthropometrics, BMD, physical activity, and dietary intake from 

baseline to postdeployment in study completers (N=19).

Anthropometrics Baseline

(Mean±SD)

Postdeployment

(Mean±SD)

Change

(%)a P valueb

Weight (kg) 73.27±12.3 73.52±12.3 0.34 0.76

BMI (kg/m2

) 24.25±2.4 24.40±2.9 0.62 0.59

Bone Mineral Density

Femur BMD (g/cm2) 1.15±0.14 1.14±0.14 -0.87 0.09

Spine BMD (g/cm2) 1.26±0.14 1.27±0.14 0.79 0.02*

Physical Activity 

Work 2.51±0.35 2.24±0.40 -10.76 0.01*

Sport 2.53±0.79 2.55±0.81 0.79 0.91

Leisure 2.51±0.65 2.58±0.80 2.79 0.71

Overall 7.55±1.35 7.37±1.40 -18.01 0.61

Dietary Intake

Energy (kcal) 3231±2215 3009±1609 -6.86 0.48

Protein (g) 117±90 113±113 -3.94 0.73

Carbohydrate (g) 409±252 387±198 -5.46 0.56

Fat (g) 120±99 120±74 -0.16 0.98

Calcium (mg) 1150±707 1183±431 2.9 0.75

Magnesium (mg) 427±260 413±164 -3.44 0.71

Sodium (mg) 5152±3968 5355±2600 3.95 0.73

Phosphorus (mg) 1722±1104 1847±760 7.25 0.32

Vitamin K (mcg) 208±171 286±287 37.21 0.01*

Vitamin D (IU) 179±126 185±96 3.13 0.81

Notes:

a: Percent change (%)=(Post-Pre)÷Pre100.

b: P values were derived from the paired samples t test

*P≤.05 was considered signifi cant.
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

in sport or leisure activity. After combining work, leisure, and sport activity into one score, no signifi cant 

differences were observed in reported physical activity. 

Furthermore, the overall physical 

activity score during deployment 

was 7.37. Based on a scale of 1 to 15, 

this can be categorized between low 

and moderate.

Data for dietary intake before and 

after deployment is presented in 

Table 2. A signifi cant increase was 

observed in reported vitamin K intake (+37.21%; P=.01) from baseline to postdeployment. No other 

signifi cant dietary changes were observed. However, after comparing 

nutrients to the DRIs, it was found 

that vitamin D intake of males and 

females were 33% and 28% of the 

DRI, respectively. Conversely, calcium intake met the DRI in both 

males (130%) and females (99%). 

All other nutrients (energy, protein, 

carbohydrate, fat, magnesium, sodium, phosphorus, vitamin K) exceeded the DRIs as shown in Table 3.

Pearson’s correlations revealed no signifi cant relationships between changes in dietary nutrients or physical activity and change in BMD of either site (P≥.05). 

These results are shown in Table 4.

COMMENT

After a 12-month deployment to Iraq, there was a significant increase in spine BMD. Additionally, there was a 

signifi cant increase in reported vitamin K intake, and a 

signifi cant decrease in physical activity at work in combat service support Soldiers. However, overall diet and 

physical activity remained unchanged. No signifi cant 

relationships were observed between changes in any dietary nutrients or physical activity and change in BMD 

during the study period. These results may not be representative of all combat service support Soldiers due 

to the small sample size. Furthermore, diet may vary 

among Soldiers during deployment based on location 

and availability of food options from the dining facility, fast food restaurants, and fi eld rations. Physical activity may also vary among Soldiers depending on unit 

missions, available exercise facilities, and scheduling 

of routine physical fi tness regimens. Therefore, caution 

must be taken when interpreting these results.

The increase in spine BMD observed in this study 

differs from the fi ndings of Sharp et al,7

 who noted a 

signifi cant decrease in BMD (-0.8%; P≤.01) of infantry Soldiers following a 9-month deployment; Nindl et 

al3

 who detected a decrease in bone mineral content in 

infantry Soldiers; and Casez et al6

who found a signifi cant decrease 

in spine BMD of infantry grenadiers (-2.1±0.4%) and tank drivers 

(-1.2±0.4%). The increase in BMD 

of the spine observed in this study 

may represent normal bone kinetics in young adults, suggesting that 

deployment did not have a negative 

impact on BMD as we anticipated.

The reported level of physical activity (7.37±1.4) observed in this 

study may not be comparable to that 

of infantry Soldiers; specifi c job requirements and duties make it diffi cult to compare results with previous studies.3,6,7 Due to the nature of 

deployment and logistical challenges, it was not feasible to conduct 

specifi c and repeated measures 

DIET, PHYSICAL ACTIVITY, AND BONE DENSITY IN SOLDIERS BEFORE AND AFTER DEPLOYMENT

Table 3. Dietary intake of male (n=12) and female 

(n=7) Soldiers during deployment compared to the 

Institute of Medicines’s DRIsa.

Postdeployment

(Mean±SD)

DRI %DRIb

Energy (kcal)c Male 3381±1686 2800 121

Female 2373±1346 2200 108

Protein (g) Male 129±53 56 230

Female 85±39 46 185

Carbohydrate (g) Male 420±203 130 323

Female 329±192 130 253

Fat (g)d Male 141±78 108 131

Female 85±54 77 110

Calcium (mg) Male 1297±408 1000 130

Female 990±428 1000 99

Magnesium (mg) Male 450±172 420 107

Female 349±139 320 109

Sodium (mg) Male 6120±2712 1500 408

Female 4045±1902 1500 270

Phosphorus (mg) Male 2096±770 700 299

Female 1421±559 700 203

Vitamin K (μg) Male 269±169 120 224

Female 316±252 90 351

Vitamin D (IU) Male 197±111 600 33

Female 165±65 600 28

Notes:

a - Dietary reference intake

b - %DRI=(Mean÷DRI)×100

c - Energy for moderately active males and females aged 18 

to 25 years derived from the US Dept of Agriculture.

d - Represents 35% of total energy based on the Acceptable 

Macronutrient Distribution Range (20%-35%).

Table 4: Pearson correlation coeffi cients 

between change in BMD and change in 

physical activity and diet variables.

Dietary Intake Femur BMD Spine BMD

Energy (kcal) 0.269 0.074

Protein (g) 0.256 0.077

Carbohydrate (g) 0.121 0.057

Fat (g) 0.267 0.013

Calcium (mg) 0.157 0.157

Magnesium (mg) 0.13 0.038

Sodium (mg) 0.18 -0.078

Phosphorus (mg) -0.32 0.051

Vitamin K (μg) -0.114 0.262

Vitamin D (IU) 0.022 0.165

Physical Activity

Work -0.02 0.176

Sport 0.015 -0.247

Leisure 0.151 0.004

BMD indicates bone mineral density.

Any P≥.05 was considered signifi cant.
 April – June 2013 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

of physical activity as seen in these studies. However, 

one study by Lester et al8 assessed self-reported physical activity in a similar manner and found a decrease in 

reported physical fi tness during deployment, which is 

similar to the signifi cant decrease in reported physical 

activity at work observed here. Long-term research investigating duration, intensity, and type of physical activity beyond what was studied here may be benefi cial 

in determining the consequences of decreased physical 

activity during deployment and BMD. Furthermore, the 

low to moderate level of self-reported physical activity 

observed here is of concern, and may potentially impact 

the maintenance of physical fi tness standards required 

to sustain mission readiness.

Surprisingly, reported intake of vitamin K signifi cantly 

increased from baseline to postdeployment; however, 

overall diet including calories, protein, carbohydrates, 

fat, calcium, magnesium, sodium, phosphorus, and vitamin D did not signifi cantly change. Current literature 

is lacking on the implications of vitamin K intake and 

bone health; however, one previous study demonstrated 

a relationship between low vitamin K intake and lower 

BMD or higher fracture risk in women.22 In our study, 

the increase in vitamin K intake was not related to BMD 

of either site. It is unknown if Soldiers consumed more 

vitamin K containing foods while deployed, or if they 

were taking a vitamin supplement containing vitamin K. 

More research is needed to determine vitamin K intake 

of deployed Soldiers and its relationship to BMD.

In this study, female Soldiers consumed 99% of the DRI 

for calcium, which differed from previous fi ndings of 

lower intakes of calcium in female military personnel.11

In contrast, both male and female Soldiers consumed 

only one-third of the DRI for vitamin D, agreeing with 

previous observations.11 Changes in dietary calcium and 

vitamin D intake during deployment was not correlated 

with changes in BMD. When interpreting these results, 

the long-term implications of low vitamin D intake on 

BMD must be considered.

All other nutrients measured (energy, protein, carbohydrate, fat, magnesium, sodium, phosphorus, vitamin K) 

exceeded the DRIs, which may place Soldiers at risk for 

other health conditions beyond what was studied here.

Since Soldiers must maintain a high level of physical 

fi tness2

 and weight17 in order to meet military standards, 

these results may be of concern to military commanders 

and health professionals.

This study has multiple strengths and limitations. The repeated measures design and the use of valid and reliable 

tools to assess diet, physical activity, and BMD added 

strength to the study. However, the major limitation of 

the study was the small sample size, typical of military 

studies because high attrition rates are common due to 

the highly mobile population. Additionally, the study 

was descriptive, therefore no comparisons with a nondeployed control group were included. Further, physical activity and dietary intake were self-reported, which 

may have resulted in reporting bias. Many male Soldiers 

commented on eating more food than what was offered 

in the questionnaire, which may have resulted in underreporting. Lastly, no midpoint measures were obtained, 

making it unclear if BMD, physical activity, and diet 

were affected at any time during deployment.

CONCLUSION

During a 12-month deployment to Iraq, combat service 

support Soldiers experienced an increase in BMD of the 

spine. Additionally, Soldiers indicated an increase in vitamin K intake, and a decrease in physical activity at 

work; however, overall physical activity and diet were 

not affected. No components of diet or physical activity 

were related to changes in BMD; however, Soldiers reported a physical activity level less than moderate, and 

a vitamin D intake below the DRI. Reported intakes of 

all other nutrients met or exceeded the DRIs. Due to the 

small sample size, we could not conclusively determine 

if deployment impacted BMD, diet, or physical activity 

in combat service support Soldiers. Military commanders and dietitians should promote routine physical fi tness and nutrition education during deployment when 

unit level training is not feasible. Furthermore, military 

dietitians are needed in both deployment and garrison 

settings to prevent both overnutrition and undernutrition, mitigate future health conditions, and maintain the 

mission readiness of Soldiers.

ACKNOWLEDGEMENTS

This study was approved by the Madigan Army 

Medical Center Institutional Review Board. Grant 

funding was provided by the TriService Nursing 

Research Program. Informed consent was obtained 

from each Soldier prior to participation in the study.

We thank LTC Lori Sigrist, MAJ Kerryn Story, Dr 

Suzy Weems, and Dr Travis Harvey for their assistance and expertise in writing this manuscript. 

We also thank associate investigators 1LT Britain 

Seaburn and 1LT Elizabeth Thompson for their efforts, Dr Raywin Huang for his statistical expertise, 

and the faculty of the US Military-Baylor Graduate 

Program in Nutrition and the staff of the Madigan 

Army Medical Center Nutrition Care Division for 

their assistance.
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

REFERENCES

1. Causes of medical evacuations from Operations 

Iraqi Freedom, New Dawn (OND) and Enduring 

Freedom (OEF), active and reserve components, 

US Armed Forces, October 2001-September 2010. 

MSMR. 2011;18(2):2-7.

2. Army Regulation 350-1: Army Training and Leader 

Development. Washington, DC: US Dept of the 

Army; December 2009 [with change 1, August 

2011].

3. Henning PC, Park BS, Kim JS. Physiological decrements during sustained military operational stress. 

Mil Med. 2011;176:991-997.

4. Nindl BC, Leone CD, Tharion WJ, Johnson RF, 

et al. Physical performance responses during 72 

hours of military operational stress. Med Sci Sports 

Exerc. 2002;34:1814-1822.

5. Stress fractures, active component, US armed forces, 2004-2010. MSMR. 2011;18(5):8-11.

6. Casez JP, Fischer S, Stussi E, et al. Bone mass at 

lumbar spine and tibia in young males-impact of 

physical fi tness, exercise, and anthropometric parameters: a prospective study in a cohort of military recruits. Bone. 1995;17:211-219.

7. Sharp MA, Knapik JJ, Walker LA, et al. Physical 

fi tness and body composition after a 9-month deployment to Afghanistan. Med Sci Sports Exerc.

2008;40:1687-1692.

8. Lester ME, Knapik JJ, Catrambone D, Antczak 

A, Sharp MA, Burrell L, Darakjy. Effect of a 13-

month deployment to Iraq on physical fi tness and 

body composition. Mil Med. 2010;175:417-423.

9. Vicente-Rodriguez G, Ezquerra J, Mesana MI, et al. 

Independent and combined effect of nutrition and 

exercise on bone mass development. J Bone Miner 

Metab. 2008;26:416-424.

10. Mangano KM, Walsh SJ, Insogna KL, Kenny AM, 

Kerstetter JE. Calcium intake in the United States 

from dietary and supplemental sources across adult 

age groups: new estimates from the National Health 

and Nutrition Examination survey 2003-2006. J 

Am Diet Assoc. 2011;111:687-695.

11. Etzion-Daniel Y, Constantini N, Finestone AS, et 

al. Nutrition consumption of female combat recruits in army basic training. Med Sci Sports Exerc.

2008;40(suppl11):S677-S684.

12. Army Regulation 40-25: Nutrition Standards and 

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

June 2001.

13. Friedl KE, Evans RK, Moran DS. Stress fracture and military medical readiness: bridging basic and applied research. Med Sci Sports Exerc.

2008;40(suppl11):S609-S622.

14. Lappe J, Cullen D, Haynatzki G, Recker R, Ahlf R, 

Thompson K. Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Back Musculoskelet Rehabil. 

2008;23:741-749.

15. Evans RD, Antczak AJ, Lester M, Yanovich R, 

Israeli E, Moran DS. Effects of a 4-month recruit 

training program on markers of bone metabolism. 

Med Sci Sports Exerc. 2008;40(suppl11):S660-

S670.

16. Anderson NE, Karl JP, Cable SJ, et al. Vitamin D 

status in female military personnel during combat 

training. J Int Soc Sports Nutr. 2010;7:1-5. Available at: http://www.jissn.com/content/pdf/1550-

2783-7-38.pdf. Accessed January 18, 2013.

17. Army Regulation 600-9: The Army Weight Control 

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

2006.

18. Baecke JA, Burema J, Frijters JER. A short questionnaire for the measurement of habitual physical 

activity in epidemiological studies. Amer J Clin 

Nutr. 1982;36:936-942.

19. Block G, Woods M, Potosky A, Clifford C. Validation of a self-administered diet history questionnaire using multiple diet records. J Clin Epidem. 

1990;43:1327-1335.

20. US Department of Agriculture and US Department 

of Health and Human Services. Dietary Guidelines 

for Americans, 2010. 7th Edition. Washington, DC, 

US Government Printing Offi ce, 2010.

21. Otten JJ, Hellwig JP, Meyers LD, eds. Dietary 

Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: The National 

Academies Press; 2006.

22. Feskanich D, Weber P, Willett WC, Rockett H, 

Booth SL, Colditz GA. Vitamin K intake and hip 

fractures in women: a prospective study. Am J Clin 

Nutr. 1999;69:74-79.

AUTHOR

1LT Carlson is Staff Dietitian, Nutrition Care Division, 

Madigan Army Medical Center, Tacoma, Washington.

MAJ Smith is Chief, Nutrition Care Division, Brian 

Allgood Army Community Hospital/121st Combat 

Support Hospital, Yongsan Garrison, Seoul, Republic of 

Korea.

MAJ (Ret) McCarthy is the Senior Nurse Scientist, Center 

for Nursing Science and Clinical Inquiry, Madigan Army 

Medical Center, Tacoma, Washington.

DIET, PHYSICAL ACTIVITY, AND BONE DENSITY IN SOLDIERS BEFORE AND AFTER DEPLOYMENT
 April – June 2013 31

When subject matter experts in the Environmental 

Medicine Program of the US Army Public Health 

Command (USAPHC) are alerted to a reported “cluster” of cancer cases with a potential environmental exposure, the decision process determining whether the 

reported situation warrants a cancer cluster investigation should follow the scientifi c guidelines set forth by 

the Centers for Disease Control and Prevention (CDC) 

for investigating clusters of health events. However, in 

reality, the high degree of concern and lack of trust 

among those perceiving and reporting the existence 

of such a cluster have often been driving factors in the 

decision to proceed, with the associated commitment 

of time and resources. It should be noted that, to date, 

none of the resulting investigations have confi rmed 

the existence of an identifi ed group of cancers that is 

causally linked or related to military specifi c operations or hazards. To ensure clarity of and confi dence 

in the process, proper risk communication is often one 

of the most important elements in the process of investigating a purported cancer cluster. This article provides 

background and information regarding the procedures 

that are used to scientifi cally evaluate a potential cancer cluster while ensuring proper risk communication is 

accomplished.

BACKGROUND

To date, several published studies have shown higher 

rates of cancer in the US military when compared to 

the general population. This fi nding was described by 

Zhu et al, who found signifi cantly higher incidence 

rates of breast and prostate cancers in both white and 

African American service members when compared to 

data from the National Cancer Institute.1

 Using US national incidence rates as a reference, Yamane found signifi cantly higher rates of cervical, prostate, and vulvar 

cancers among active duty Air Force personnel.2

 When 

compared to age-specifi c rates in the general population, 

Rennix et al reported signifi cantly elevated incidence of 

breast cancer in enlisted Army women aged 35 years or 

younger.3

Given the results discussed earlier, it is unsurprising 

that there be concern regarding an increased risk of cancer among US Army benefi ciaries. Soldiers and Army 

civilians alike may attribute clusters of cancer to occupational and/or environmental exposures related to 

military service or presence on a military installation. 

Examples of large-scale military investigations of potential cancer clusters include investigation of skin and 

respiratory cancers associated with exposure to mustard 

agents during World War II testing programs,4-6 various 

cancers due to ground water contamination involving 

contaminants like benzene and volatile organic compounds at Camp LeJeune, NC,7,8 the risk of developing 

cancer after exposure to Agent Orange in the Vietnam 

War,9-13 and risk of cancer mortality after exposure to radiation during nuclear weapons testing.14,15 Examples of 

smaller-scale investigations of potential cancer clusters 

completed by the USAPHC include those presented in 

the Table.

Because these are small investigations of limited numbers of cancer cases, they cannot be evaluated as a 

quantifi ed epidemiological investigation. Instead, the 

approach recommended by the CDC has been used.

APPROACH

Defining the Problem

In cases that have been investigated by USAPHC, concerns are raised by anecdotal reports of small numbers of persons who have been diagnosed with cancer. 

Addressing Cancer Clusters in the US Army

Jessica M. Sharkey, MPH

Veronique D. Hauschild, MPH

Potential cancer clusters investigated by the US Army Public 

Health Command.

Cancer Presumed Environmental 

Cause/Risk Factor Conclusions

Acute myelocytic 

leukemia 

Potential burnpits 

(volatile organic 

compounds), benzene 

Unrelated cases; 

latency–timeframe 

between disease and 

exposure of concern 

are too short to be 

supported by science.

Breast cancer Unknown workplace 

(building) hazards 

Unrelated cases/no 

connections; limited 

exposure time

Brain cancer Unknown environmental 

cause associated with 

location (installation) 

Unrelated types of 

cancers; no unique 

or related exposure 

experiences

Thyroid cancer Radiation source in work 

environment (unknown 

and/or irradiated mail)

Inadequate evidence of 

exposure of concern
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

Regardless of the potential relationship of the cancer 

to an external environmental exposure, these cases involve people with a serious medical condition. Proper 

risk communication and empathy, discussed later in this 

article, are critical elements, even at the earliest interactions. Part of the initial communications should ensure 

an understanding of what constitutes a cluster, as well as 

the investigative process that will be used.

According to the CDC:

A cancer cluster is defi ned as a greater-than-expected 

number of cancer cases that occur within a group of people in a geographic area over a period of time.16

The hallmark characteristics of particular cancers often 

vary from patient to patient, making cancer cluster investigation a diffi cult task. However, the CDC has established several criteria a group of cancer cases must meet 

in order to be considered a cluster16: 

 a greater-than-expected frequency; 

 a single type of cancer, or multiple types of cancer that have been scientifi cally linked to the same 

cause; 

 a carefully defi ned geographic area from which the 

cases are derived; and 

 a clearly defi ned time period during which the cases occurred.

It is important to acknowledge that a group of cancer 

cases meeting all the cluster criteria previously identifi ed may be a product of chance, inaccurate designation 

of expected cases, inconsistent case defi nitions between 

actual cases and expected cases, as well as known or 

unknown causes of cancer. Use of the specifi c guidelines described in the following sections help identify 

and minimize such instances.

Specific Investigation Guidelines 

Although every investigation has unique challenges that 

require some fl exibility to account for intricacies of the 

particular health outcome of concern or the amount of 

resources and information available, the CDC guidelines17 suggest a 4-stage systematic approach, portrayed 

in the Figure, when managing an investigation of a possible cancer cluster. Each stage includes a major component of conducting a comprehensive investigation, from 

initial contact to fi nal response.

Stage 1: Initial Contact and Response

Per CDC recommendations, the fi rst thing that should 

be accomplished is the collection of all available information regarding the potential cluster through initial 

contact with the reporting individual or entity. Crucial 

information includes type(s) of cancer involved, suspected environmental exposure(s) of importance, geographic boundaries, and the time over which cases occurred. Detailed contact and demographic information 

for those involved should also be recorded. In addition 

to obtaining as much information as possible, communicating initial impressions with the concerned party 

is also appropriate; different types of cancer outcomes, 

cancer cases occurring in older individuals, and brief 

exposure and latency periods are less indicative of true 

cancer clusters. However, a single type of cancer that is 

rare and occurs in an unusual segment of the population 

warrants further investigation.

Stage 2: Assessment

During the assessment phase, a comparison of observed 

versus expected occurrence is reviewed in order to determine if cases exist in excess of normal conditions. 

First, a case defi nition must be established, including 

geographic and time restrictions. A suitable reference 

group must then be selected to represent the expected 

occurrence. If the threshold of expected occurrence is 

not exceeded but there appears to be an argument for biologic plausibility or much public health interest, investigators must use their best judgment when deciding if 

further investigation is warranted. If these efforts refl ect 

a greater-than-expected occurrence, further investigation, case validation in particular, should be conducted. 

If case validation confi rms an excess in occurrence, a 

fi eld investigation should be conducted in order to further defi ne epidemiologic characteristics of the potential 

cancer cluster. At this time, an in-depth review of available literature and databases should be done so that the 

likelihood of an exposure-outcome relationship can be 

evaluated. If the complete assessment results indicate an 

excess without a probable environmental exposure, or 

if the excess is not confi rmed, the investigation should 

be concluded at this point. If the complete assessment 

yields information suggesting epidemiologic and biologic plausibility in a greater-than-expected occurrence 

of cancer cases, the investigation should proceed to the 

next step.

Stage 3: Major Feasibility Study

The third stage of a cluster investigation focuses on determining if an epidemiologic study designed to assess 

the relationship between environmental exposure(s) 

and cancer outcome(s) is feasible. The major feasibility study should include a more detailed literature review focused on scientifi cally established causes for the 

type(s) of cancer involved, considerations for resources 

needed, determination of proper data collection on cases and controls as well as appropriate data analysis techniques, and an assessment of the levels of concern from 

ADDRESSING CANCER CLUSTERS IN THE US ARMY
 April – June 2013 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

all stakeholders. The information gathered during this 

phase may suggest that a major etiologic investigation 

is not needed, in which case a report of fi ndings should 

be written and the investigators should relay all relevant 

information to everyone involved. The major feasibility 

study may also indicate that an etiologic investigation is 

warranted, and therefore, investigators should proceed 

to the next step.

Stage 4: Etiologic Investigation

If the fi rst 3 stages indicate, an etiologic investigation should be performed to evaluate the link between 

health outcome(s) and possible exposure(s). The information gathered during the fi rst 3 phases of the cluster 

investigation should serve as a guide for developing an 

appropriate research protocol. Ultimately, the purpose 

of such a study is to gain public health knowledge and 

determine if any associations can be found between the 

cancer(s) and environmental exposure(s) of concern. 

Whether or not rates are determined to be greater-thanexpected indicating a true cluster of cancer cases, the 

results of the etiologic investigation should be relayed 

to all stakeholders to ensure that any concerns that the 

suspected cluster may have generated are addressed.

Health Risk Communication

Risk communication is defi ned as a science-based approach for communicating effectively in high-stakes, 

emotionally charged, controversial situations. In most 

cancer cluster investigations, risk communication has 

played a major role. The 3 fundamental challenges of effective risk communication are: (1) ensuring stakeholders pay attention to what you have to say; (2) convincing stakeholders to believe what you tell them; and (3) 

delivering the message in such a way that stakeholders 

remember what you have said long enough for them to 

act on it. Effective risk communication not only helps 

to establish good working relationships with stakeholders and engage organization leaders in active participation, but it also creates rapport and credibility with 

concerned community members, which can minimize 

undue concerns and ease challenges inherent in potential cancer cluster investigations. In a world where perception equals reality and risk perception often does not 

match risk reality, lack of trust in the source of information being provided, a lack of scientifi c understanding, distortion of the facts by media outlets, misconceptions about the truth the public may hold, and fear of 

the unknown greatly reinforce the need for effective risk 

communication.18,19

Clearly, cancer is a serious, high-stakes, and emotionally 

charged issue. Given risk perceptions and assumptions 

that may exist, particularly among Soldiers and benefi -

ciaries due to higher rates of cancer in the military when 

compared to the general population, risk communication 

should always be part of the overall cancer investigation 

process. Within the USAPHC, the Health Risk Communication Program serves as the Army’s center of risk 

communication expertise for both the Department of the 

Army and the entire Department of Defense. This program can be used to assist with cancer investigations.

RECOMMENDATIONS AND CONCLUSIONS 

Army personnel concerned about potential clusters of 

cancer should review the guidelines described above. 

These concerns should not be ignored as proper risk 

communication at the earliest stages can help to ensure 

that accurate information is understood in later stages of 

Prepare summary 

report and close 

the case.

4. Etiologic 

Investigation

2. Assessment

3. Major Feasibility Study:

Does the major feasibility 

study suggest that an etiologic 

investigation is warranted?

1. Initial Contact and Response: 

Does initial information 

suggest further evaluation 

(eg, rare disease, plausible 

exposure, plausible clustering)?

Preliminary Evaluation:

Is there an apparent cluster? 

OR, if there is no excess, does 

the data suggest an occurrence 

of biological and public health 

importance?

Case Evaluation:

Are all cases verifi ed and an 

excess confi rmed?

Occurrence Evaluation:

Is there an epidemiological and 

biologic plausibility relationship 

between exposure and disease?

YES

YES

YES

YES

NO

NO

NO

NO

NO

YES

Process diagram for Centers for Disease Control and Prevention guidelines for investigations of clusters of health events.
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

a technical investigation. Assumptions should be avoided and rapid collection of necessary information will 

facilitate a successful investigation. In many cases, support from subject matter experts and risk communication specialists such as from the USAPHC can be useful 

to both bolster technical confi dence and minimize perception of bias.

REFERENCES

1. Zhu K, Devesa SS, Wu H, Zahm SH, et al. Cancer incidence in the U.S. military population: comparison with rates from the SEER program. Cancer 

Epidemiol Biomarkers Prev. 2009;18(6):1740-1745.

2. Yamane GK. Cancer incidence in the U.S. Air 

Force: 1989-2002. Aviat Space Environ Med. 

2006;77(8):789-794.

3. Rennix CP, Quinn MM, Amoroso PJ, Eisen EA, 

Wegman DH. Risk of breast cancer among enlisted 

Army women occupationally exposed to volatile 

organic compounds. Am J Ind Med. 2005;48:157-

167.

4. Pechura CM, Rall DP, eds. Veterans at Risk: The 

Health Effects of Mustard Gas and Lewisite. Washington, DC: National Academies Press; 1993.

5. Hurst CG, Smith WJ. Chronic effects of acute, lowlevel exposure to the chemical warfare agent sulfur mustard. In: Somani SM, Romano JA Jr, eds. 

Chemical Warfare Agents: Toxicity at Low Levels. 

Boca Raton, FL. CRC Press; 2001:245-260.

6. Hurst CG, Smith WJ. Health Effects of Exposure 

to Vesicant Agents. In: Romano JA Jr, Lukey BJ, 

Salem H, eds. Chemical Warfare Agents: Chemistry, Pharmacology, Toxicology, and Therapeutics. 

Boca Raton, FL. CRC Press; 2008:293-312.

7. Issues Related to Past Drinking Water Contamination at Marine Corps Base Camp Lejeune. Washington, DC: US Government Accountability Offi ce; 

June 12, 2007. Report GAO-070933T.Available at: 

http://www.gao.gov/products/GAO-07-933T. Accessed February 4, 2013.

8. Lin A. Warning: don’t drink the water: an examination of appropriate solutions for veterans exposed to contaminated water at Marine 

Corps Base Camp Lejeune. Veterans Law Rev. 

2012;4:85-130. Available at: http://www.bva.

va.gov/docs/VLR_VOL4/AuthorsCopies3-Al

lisonLin.PDF. Accessed February 4, 2013.

9. Institute of Medicine. Veterans and Agent Orange. 

Washington, DC: National Academies Press; 2010.

10. Frumkin H. Agent Orange and cancer: an overview 

for clinicians. CA Cancer J Clin. 2003;53:245-255.

11. The Selected Cancers Cooperative Study Group. 

The association of selected cancers with service in 

the US military in Vietnam. I. Non-Hodgkin’s lymphoma. Arch Intern Med. 1990;150(12):2473-2483.

12. The Selected Cancers Cooperative Study Group. 

The association of selected cancers with service in 

the US military in Vietnam. II. Soft-tissue and other sarcomas. Arch Intern Med. 1990;150(12):2485-

2892.

13. The Selected Cancers Cooperative Study Group. 

The association of selected cancers with service in 

the US military in Vietnam. III. Hodgkin’s disease, 

nasal cancer, nasopharyngeal cancer, and primary 

liver cancer. Arch Intern Med. 1990;150(12):2495-

2505.

14. Thaul S, Page WF, Crawford H, O’Maonaigh H. 

The Five Series Study: Mortality of Military Participants in U.S. Nuclear Weapons Tests. Washington, DC: National Academies Press; 2000.

15. Watanabe KK, Kang HK, Dalager NA. Cancer 

mortality risk among military participants of a 

1958 atmospheric nuclear weapons test. Am J Public Health. 1995:85(4):523-527.

16. Cancer Clusters. Centers for Disease Control and 

Prevention Website. February 15, 2012. Available 

at: http://www.cdc.gov/nceh/clusters/default.htm. 

Accessed December 11, 2012.

17. CDC (Centers for Disease Control and Prevention). 

Guidelines for Investigating Clusters of health 

Events. MMWR Recomm Rep. 1990;39(RR-11):1-16. 

Available at: http://www.cdc.gov/mmwr/preview/

mmwrhtml/00001797.htm. Accessed February 4, 

2013.

18. Rothman AJ, Kiviniemi MT. Treating people with 

information: an analysis and review of approaches 

to communicating health risk information. J Natl 

Cancer Inst Monogr. 1999;25:44-51.

19. Slovic P. Perception of Risk. Science. 1987;236

(4799):280-285.

AUTHORS

Ms Sharkey is an Epidemiologist for the Environmental 

Medicine Program of the Occupational and Environmental Portfolio, US Army Public Health Command, Aberdeen Proving Ground, Maryland.

Ms Hauschild is an Environmental Scientist for the Injury Prevention Program of the Epidemiology and Disease 

Surveillance Portfolio, US Army Public Health Command, Aberdeen Proving Ground, Maryland.

ADDRESSING CANCER CLUSTERS IN THE US ARMY
 April – June 2013 35

INTRODUCTION

In the fi eld of social work and the related social and 

psychological sciences, there is a renewed interest in 

the application of attachment theory to a variety of biopsychosocial outcomes and populations.1

 Similarly, 

there is a surge of interest in sleep hygiene, sleep behaviors, and the overall implications of good sleep for 

human development and optimal performance, particularly within special populations, such as military service 

members.2

 More recently, these two areas of research 

have merged to shed light on the underpinnings of both 

positive and negative sleep symptoms and behaviors. 

The recent literature on attachment style suggests a positive relationship between secure attachment, lower levels of anxiety and depression, and good sleep hygiene.3

Although our understanding of this attachment relationship is still nascent, there is no doubt that the factors of 

anxiety, depression, and sleep hygiene have a strong impact on well-being and performance outcomes in highstress populations, such as military service members.4

Additionally, recent research suggests that aspects of 

secure attachment experiences in veterans, such as the 

perception of unit support, can mitigate mental health 

outcomes and sleep problems.5

 This study is the fi rst to 

investigate the direct relationship between attachment 

style and sleep behaviors in a population of active duty 

service members.

ATTACHMENT THEORY: ATTACHMENT STYLE

The attachment theory of John Bowlby6

 has been a seminal foundation to understanding human growth and 

development for several decades.7

 Bowlby’s theory has 

informed the way social workers, psychologists, psychiatrists, and counselors have conceptualized healthy 

development from infancy, through childhood, and 

across the lifespan.8

 Attachment theory, while infl uential to the behavioral sciences and clinical practice from 

its inception in the 1950s, has continued to expand its 

contribution in the fi eld to the present day.9

 The idea of 

“a secure base” has become a central framework for understanding the breadth of the human experience—the 

development of the “self,” human behavior in relationship to important “others” from birth to death, and how 

this system of attachment impacts the totality of our experience from the biopsychosocial perspective.10

According to Bowlby:

Attachment theory regards the propensity to make intimate emotional bonds to particular individuals as a basic 

component of human nature, already present in germinal 

form in the neonate and continuing through adult life 

into old age.6(p120-121)

Bowlby describes how an internal system, called a “working model,” exists as a biological function in the human 

nervous system as a result of developmental experiences 

with our primary caregiver. He further explains that this 

working model not only establishes the system by which 

we relate to important others, but it is also the system 

by which a person understands the “self.”8

 Bowlby describes the attachment relationship as a back-and-forth 

dynamic between care-giving and care-seeking, and the 

nature of this exchange shapes who we are and how we 

relate to important others, particularly in close, intimate 

relationships and social bonds.9

The Effect of Attachment Style on

 Sleep in Postdeployed Service Members

LTC Sandra M. Escolas, MS, USA

1LT Erika J. Hildebrandt, MS, USA

Alan J. Maiers, PsyD

Maj Monty T. Baker, MSC, USAF

Shawn T. Mason, PhD

ABSTRACT

This study examined the effects of attachment style on subjective sleep outcomes in a population of service 

members (N=561 (403 male, 157 female)). Active duty, postdeployment service members completed questionnaires including two measures of adult attachment and two measures of subjective sleep. Results confi rmed the 

central hypothesis: secure attachment style is associated with better sleep, followed by dismissing, fearful, and 

preoccupied, respectively. Gender differences were also found for prevalence of attachment style patterns. This 

is the fi rst study incorporating attachment style and sleep outcomes within a military population, and provides 

the basis for future research in this area.
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

Bowlby6 outlines the 3 basic patterns of attachment that 

were fi rst described by his protégé and colleague Mary 

Ainsworth.11,12 The fi rst pattern, “secure” attachment, describes a confi dent individual and a caregiver who is responsive and supportive, particularly when the individual is fearful. This confi dence combined with suffi cient 

support and protection allows the individual to explore 

the world feeling secure. The second pattern, “anxious 

resistant” attachment, describes an individual who is 

uncertain if his or her caregiver will be responsive in 

times of need or danger. Due to his or her uncertainty 

regarding the caregiver, this individual will tend to cling 

to the caregiver and also be too anxious to explore the 

world freely. The third pattern is “anxious avoidant” attachment that describes an individual who believes that 

he or she will be refused support and protection from his 

or her caregiver, and therefore does not seek closeness or 

protection through close bonds with others.6,9

We now know through extensive longitudinal studies 

that these patterns of attachment, described as attachment styles, are, for the most part, stable and enduring 

across the lifespan.7

 The working model that informs 

how we understand ourselves in relation to important 

others, and our attachment style and behaviors towards 

these others, persists throughout development. As such, 

our attachment style determines how we interact with 

peers, how we interact in romantic relationships, and 

how we perceive and approach the world more broadly.8

As a result of continued research, we have learned that 

our attachment systems become “activated” and are particularly salient for us in times of threat.9

 As such, attachment styles inform the way we cope with stress, and how 

we engage with our important interpersonal support systems, especially when we need help and protection. As 

a result, attachment style also impacts some of our most 

important physical and mental health outcomes, such as 

levels of anxiety and depression, and quality of sleep.13

ATTACHMENT STYLE AND SLEEP

A growing body of recent literature in the area of attachment and health outcomes reveals an important relationship between attachment style and quality of sleep across 

the lifespan.14 Just as the attachment literature reveals a 

positive relationship between secure attachment styles 

and good health, sleep research reveals that quality sleep 

is essential to human development and functioning from 

infancy to older adulthood.15 Beyond rest and restorative 

factors, sleep also integrates learning and memory, and 

provides resources for emotion-regulation/self-regulation that is necessary for coping with stress.16 It is not 

surprising then that quality sleep has been found to have 

a strong relationship with a wide array of physical and 

psychological health outcomes including metabolism,17

body mass index,18 self-regulation and self-control,16

and depression and anxiety.13 Conversely, sleep disruptions and sleep disorders are directly associated with 

and symptomatic of several mental health conditions in 

children and adults, such as posttraumatic stress disorder (PTSD),19 depression and other mood disorders, and 

anxiety.20

In addition to the separate fi ndings, there are also conjoint fi ndings between attachment styles, sleep, and important health outcomes and performance behaviors.3

Neurological studies reveal that the anatomy of the attachment system in the brain overlaps the anatomy of 

REM sleep, which is essential to overall healthy sleep.21

It is important to note that regular sleep patterns in infancy and childhood have been a core standard by which 

we measure overall healthy development in the early 

years of life.22 Early sleep patterns appear to be interconnected with the early attachment experiences, which 

are largely dependent on the mother’s, or caregiver’s, 

attachment style.23 As such, attachment style and sleep 

have been conceptualized as a transactional system of 

early development that informs later developmental outcomes and life experiences.24 Researchers have identifi ed relationships of early childhood attachment styles 

and sleep patterns/disruptions with academic functioning24; adolescent depression25; childhood and adolescent 

trauma, PTSD, and anxiety.22

ATTACHMENT STYLE, SLEEP, AND

MILITARY SERVICE MEMBERS

There is a growing body of research conducted with 

military service members in the area of attachment 

style within the context of trauma, specifi cally PTSD.27

Importantly, it has been found that PTSD in combat veterans is associated with insecure attachment styles.28

Several studies have also shown that the attachment 

measures of marital functioning and couple adjustment 

are salient for veterans and Soldiers with PTSD.29,30

Two recent studies show that the attachment measure 

of marital satisfaction plays an important role in lower 

symptom severity for veterans with PTSD.31,32

There is also a new and growing body of research in the 

area of sleep quality and sleep disruptions with veterans and service members. It has been found that sleep 

disturbances are a common factor among veterans with 

major diagnoses, such as PTSD, traumatic brain injury 

(TBI), and anxiety disorders.4

 The attachment variable 

of perceived unit support may be helpful in reducing 

sleep diffi culties in this population.5

 These fi ndings 

speak to the transactional model of attachment style and 

sleep with respect to health outcomes for veterans. The 

possible impact of secure attachment and good sleep as 

THE IMPACT OF ATTACHMENT STYLE ON SLEEP IN POSTDEPLOYED SERVICE MEMBERS
 April – June 2013 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

mediating variables in major diagnoses such as PTSD, 

TBI, anxiety, and depression suggest the need for further research in this area. As such, this study examined 

the relationship between attachment style and sleep in a 

population of service members.

HYPOTHESES

1. The fi rst set of hypotheses examined the relationship between the two adult attachment measures.

a. Those who endorse secure and dismissing attachment styles will report less relationship 

anxiety as compared with fearful and preoccupied attachment styles. By contrast, those 

who endorse preoccupied and fearful attachment categories will report more relationship 

anxiety as compared with secure and dismissing attachment styles.

b. Those who endorse secure and preoccupied 

attachment categories will report less relationship avoidance as compared with fearful 

and dismissing attachment styles. By contrast, 

those who endorse fearful and dismissing attachment categories will report higher avoidance scores as compared with secure and preoccupied attachment styles.

c. It is expected that there will be no gender differences on attachment categories.

These hypotheses are in line with other fi ndings between 

these two types of adult attachment measures, and consistent with the literature on adult attachment patterns.

2. The second set of hypotheses examined the relationships between two measures of attachment style and 

two measures of sleep.

a. It is predicted that individuals who endorse 

secure attachment styles (secure attachment 

category, low relationship anxiety, and low 

relationship avoidance) will have more regular sleep routines as compared with insecure 

attachment styles (dismissing, preoccupied, 

fearful attachment styles, high relationship 

anxiety, and high relationship avoidance).

b. It is also predicted that individuals who endorse secure attachment styles (secure attachment category, low relationship anxiety, and 

low relationship avoidance) will have less 

sleep activity as compared with insecure attachment styles (dismissing, preoccupied, 

fearful, high relationship anxiety, and high 

relationship avoidance).

c. We predicted these relationships between 

secure attachment styles and good sleep outcomes to stand irrespective of gender.

Again, these hypotheses are consistent with the extant 

literature on attachment styles and sleep outcomes in 

nonmilitary populations.

METHOD

Participants

Among the 561 respondents, 403 were male, 157 were 

female, and one with no response on the gender selection. The ethnicity of the sample was 12.3% Hispanic 

and 86.6% non-Hispanic, and the racial profi le was 

65.6% Caucasian, 19.6% African American, 5.9% 

Asian/Pacifi c Islander, and 8% “Other.” In terms of age, 

8% were 25 years and younger, 23% were in the 26-30 

year age range, 48.5% were in the 31-40 year age range, 

and 21% were 41 years and over. With respect to marital 

status, 69% were married or living with a partner, and 

the remaining 31% were never married/single/divorced/

no partner. The branch of service and rank demographic 

were 62% Army and 37% Air Force; 54% SGT, SSG or 

SFC and 23% LT to CPT. This population was well educated, with 22% having a master’s degree or higher, 30% 

with a bachelor’s degree, and 44% having some college. 

All participants had deployed at least once. Participants 

self -reported how long they have been deployed in their 

career, resulting in an average of 1.90 years (1 year, 10.8 

months) with a range from one month to a maximum of 

14 years of total time deployed.

Procedure

Data were collected as part of a quantitative, cross-sectional study examining 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 May 2010 to 

June 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 exemption determination from the Brooke Army Medical Center Institutional Review Board. For this study, the independent 

variables were 2 measures of adult attachment (one categorical and one continuous measure) and the dependent 

variables were 2 measures of sleep: activity-level sleep 

and rhythmicity sleep. Additionally, the relationship between the 2 adult attachment measures was examined in 

hypotheses 1. The categorical measure of attachment was 

the independent variable (secure, fearful, preoccupied, 
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

and dismissing) and the continuous 

measure was the dependent variable 

(relationship related anxiety and relationship related avoidance).

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 

al Experiences in Close Relationships 

[scales]-Revised,34 which creates 2 

continuous anxiety and avoidance 

attachment variables. Figure 1 illustrates the hypothetical relationship 

between the 2 measures.

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 refl ect on 

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.34

Mean scores range from 1 to 7 on each dimension and 

higher scores suggest higher levels of relationship anxiety and relationship avoidance with overall scores ultimately mapping onto a categorical quadrant to delineate 

an individual attachment style, as shown in Figure 1.

Relationship Questionnaire33 is a self-report adult attachment measure which includes a series of 4 statements 

that represent secure, preoccupied, fearful, and dismissing adult attachment styles. Participants are instructed 

to read the statements and indicate which is most consistent with how they view themselves. Next, the volunteers are asked to rate each of the above relationship 

styles to indicate how well or poorly each description 

corresponds to their general relationship style on 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, with the assistance of over a hundred 

colleagues, 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.37 Responses from this 

assessment are presented as one of 4 

categorical outcomes that are indicative of the attachment style reported 

by the participant (Figure 1).

Sleep

Permission to use the Dimensions 

of Temperament Survey Revised38

(DOTS-R) measure was granted by 

Dr Michael Windle (oral communication, March 27, 2009). The DOTS-R 

is a 54-item questionnaire for adults 

that measures 10 temperament dimensions: (1) activity level-general, 

(2) activity level-sleep, (3) approachwithdrawal, (4) fl exibility-rigidity, (5) 

mood quality, (6) rhythmicity-sleep, 

(7) rhythmicity-eating, (8) rhythmicity-daily habits, (9) distractibility, and 

(10) persistence. Two subscales of this assessment were 

selected for use as they relate to sleep; activity level 

sleep and rhythmicity sleep. Activity level sleep was 

created by summing 4 items that describe the amount of 

activity when in bed (for example: I move a great deal 

in my sleep; I move a lot in bed)—less sleep activity 

is associated with better sleep. Rhythmicity sleep was 

created by summing 6 items that describe the regularity in sleep activities (for example: I wake up at different times; I usually get the same amount of sleep each 

night)—more stable, routine rhythmicity is associated 

with better sleep. Windle and Lerner38 reported internal consistency coeffi cients (Cronbach α) for a sample of 

300 young adults corresponding to the 10 factors listed 

above:

(1) 0.84 (2) 0.89 (3) 0.85 (4) 0.78 (5) 0.89

(6) 0.78 (7) 0.80 (8) 0.62 (9) 0.81 (10) 0.74

DATA ANALYSIS

The data analysis was conducted using SPSS version 

18 (SPSS, Inc., Chicago, IL). A multivariate analysis 

of variance (MANOVA) was used to test the fi rst hypothesis, which examined the relationship between the 

2 adult attachment measures. The independent variable 

is the categorical measure of adult attachment (the Relationship Questionnaire (RQ) attachment category) 

and the dependent variable is the continuous measure 

of adult attachment (the Experiences in Close Relationships Revised (ECR-R) attachment-related anxiety and 

attachment-related avoidance scores). A MANOVA was 

also used to test the second set of hypotheses, which 

examines the relationship between the RQ and the sleep 

variables. The least squared differences (LSD) method 

was used for the follow-on contrasts comparing the 

THE IMPACT OF ATTACHMENT STYLE ON SLEEP IN POSTDEPLOYED SERVICE MEMBERS

Figure 1. Representation of the relationship of the 4 attachment categories (secure, dismissing, fearful, preoccupied) 

to attachment related anxiety and avoidance. For example: low avoidance+high 

anxiety=preoccupied attachment; high 

avoidance+low anxiety=dismissing attachment. Adapted from Fraley35 with 

permission.

Secure Preoccupied

Low

Avoidance

High

Avoidance

High

Anxiety

Low

Anxiety

FearfulAvoidantDismissingAvoidant
April – June 2013 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

attachment categories of secure, fearful, preoccupied, 

and dismissing. Separate stepwise regressions were 

used to examine the relationships between the 2 attachment dimensions of relationship anxiety and relationship avoidance with the 2 sleep measures of activity 

level sleep and rhythmicity sleep. Regarding the third 

set of hypotheses, a χ2

 test was used examine gender 

differences on the categorical measure and an analysis 

of variance (ANOVA) was used to search for gender differences on the continuous measure of adult attachment 

and the sleep measures.

RESULTS

Descriptive Statistics

The RQ is made up of 4 possible attachment categories; 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 2.7932 for anxiety and 

2.7891 for avoidance with SDs of 1.20544 and 1.14693 

respectively. The two measures of sleep, activity level 

sleep and rhythmicity sleep, resulted in means of 10.84 

and 14.76 with SDs of 3.40 and 3.99 respectively. Higher 

scores on sleep activity indicate more sleep activities or 

lower quality of sleep, whereas higher scores on sleep 

rhythmicity indicate more sleep regularity or better 

quality of sleep.

Attachment Style Categories and Relationship Anxiety

The overall MANOVA, using the RQ as the independent variable and the ECR-R as the dependent variable, 

resulted in a signifi cant fi ndings for RQ and anxiety, 

F3,505=28.91, P=.000, and a signifi cant fi nding for RQ 

and avoidance, F3,505=22.60, P=.000. The means (M) and 

SDs for the RQ measures on anxiety resulted in secure 

(M=2.37, SD=1.00), fearful (M=3.49, SD=1.3), preoccupied (M=3.40, SD=1.09) and dismissing (M=2.66, 

SD=1.4). The secure attachment category was associated with signifi cantly less anxiety, then fearful, preoccupied, and dismissing. Fearful was associated with significantly more anxiety than secure and dismissing, but not 

preoccupied. Preoccupied was found to be signifi cantly 

more associated with relationship anxiety than secure 

and dismissing, but not fearful. Dismissing was found 

to have signifi cantly more relationship anxiety than secure, but signifi cantly less relationship anxiety than preoccupied and fearful. Thus, with respect to relationship 

anxiety, the results were as predicted in the hypotheses: 

secure and dismissing have lower levels of relationship 

anxiety, and preoccupied and fearful have higher levels 

of relationship anxiety. Moreover, relationship anxiety 

was associated most highly with fearful and preoccupied 

attachment categories, with meaningful signifi cance 

levels for all groups (Figure 2).

The means and standard deviations for the RQ measures 

on avoidance resulted in secure (M=2.35, SD=0.93), 

fearful (M=3.34, SD=1.2), preoccupied (M=2.72, 

SD=0.90), and dismissing (M=2.96, SD=1.148). Secure 

was signifi cantly less associated with avoidance as compared with both fearful and dismissing, though not signifi cantly different from preoccupied. Fearful was signifi cantly more associated with avoidance as compared 

with secure, preoccupied, and dismissing. Preoccupied 

was more associated with avoidance as compared with 

secure, though not signifi cantly so, and is signifi cantly 

less associated with avoidance as compared with both 

fearful and dismissing. Dismissing is signifi cantly more 

associated with avoidance as compared with secure, and 

signifi cantly less associated with avoidance as compared 

with fearful, though not signifi cantly different from preoccupied. These results support the hypothesis that fearful and dismissing are more associated with relationship 

avoidance than secure and preoccupied (Figure 3).

Attachment Style Categories and Sleep

A MANOVA was performed using the categorical measure of attachment style (secure, fearful, preoccupied 

and dismissing) as the independent variable and the 2 

sleep measures as the dependent variables; sleep rhythmicity and activity level sleep. The model resulted in 

signifi cant fi ndings for attachment category with activity level sleep, F3,509=10.71, P=.000 (Figure 4), though 

the fi ndings for rhythmicity sleep were not signifi cant, 

F3,509=2.01, P=.111 (Figure 5). The LSD method was 

Figure 2. Relationship anxiety (mean) plotted against adult 

attachment categories. MANOVA yielded signifi cant differences of relationship anxiety among the categories:

F3,505=28.91, P=.000. Line segments show confi dence intervals at the 95% level for relationship anxiety means.
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

used for the follow-on contrasts. Among the activity 

level sleep variables, secure was found to be signifi cantly different from fearful and preoccupied, fearful from 

secure and dismissing, preoccupied from secure and 

dismissing, and dismissing from fearful and preoccupied. According to our sample, individuals who endorse 

secure attachment styles have the lowest sleep activity levels, followed in order by dismissing, fearful, and 

preoccupied. Although the overall F score was not signifi cant for the rhythmicity sleep variable, the LSD was 

conducted. The only signifi cant difference was found 

for secure and fearful individuals. Secure individuals 

report more regular sleep activities followed by dismissing, fearful and preoccupied.

Attachment-Related Anxiety and Sleep

Two stepwise multiple regressions were conducted to analyze the relationship between attachment-related anxiety and avoidance with activity level sleep and rhythmicity sleep. Fraley39 recommends using multiple linear 

regression for analyzing ECR-R data. The independent 

variables and the dependent variables are signifi cantly 

correlated with each other as shown in the correlation 

matrix presented in the Table.

The fi rst regression had attachment-related anxiety 

and avoidance entered as predictors and activity level 

sleep entered as the dependent variable. The stepwise 

regression excluded attachment-related avoidance 

from the equation leaving attachment-related anxiety as the only predictor for activity level sleep (ACT_

Sleep=9.66+0.433ECR_Anxiety). The results of the 

regression indicated the predictor explained 2.4% of the 

variance (R2=0.024, F1,540=13.06, P=.000). The second 

regression used relationship anxiety and relationship 

avoidance as predictors for rhythmicity sleep. This 

stepwise regression excluded relationship anxiety from 

the equation, leaving relationship avoidance as the only 

predictor for rhythmicity sleep. (RHY_Sleep=16.624-

0.667ECR_Avoidance). This regression analysis found 

that relationship avoidance predicts 3.6% of the variance 

for rhythmicity sleep (R2=.036, F1,548=20.733, P=.000).

Gender Differences in Attachment Style and Sleep

Although gender differences are not widely reported on 

attachment style categories in the general population, 

THE IMPACT OF ATTACHMENT STYLE ON SLEEP IN POSTDEPLOYED SERVICE MEMBERS

Figure 5. Rhythmicity sleep (mean) plotted against adult attachment categories. MANOVA did not yield signifi cant differences of rhythmicity sleep means among the categories:

F3,509=10.71, P=.111. However, LSD follow-on contrasts 

showed a signifi cant difference between secure and fearful 

attachment categories and rhythmicity sleep. Line segments 

show confi dence intervals at the 95% level for rhythmicity 

sleep means.

Figure 3. Relationship avoidance (mean) plotted against 

adult attachment categories. MANOVA yielded signifi cant 

differences of avoidance means among the categories:

F3,505=22.60, P=.000. Line segments show confi dence intervals at the 95% level for avoidance means.

Figure 4. Activity level sleep (mean) plotted against adult 

attachment categories. MANOVA yielded signifi cant differences of activity sleep means among the categories:

F3,509=10.71, P=.000. Line segments show confi dence intervals at the 95% level for activity sleep means.
 April – June 2013 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

we examined gender differences within our military 

population in the interest of parity. A χ2

 test was used 

on the categorical measure which resulted in χ2=11.120, 

P=.011 (Figure 7). An ANOVA was used to fi nd gender 

differences on the continuous measure of adult attachment (relationship anxiety F=1.412, P=.24, relationship avoidance F=.004, P=.95) and the sleep measures 

(sleep activity F=.88, P=.349; sleep rhythmicity F=1.26, 

P=.26).

Although the ANOVA suggested there were no signifi -

cant differences on sleep outcomes by gender, the χ2

 test 

revealed important gender differences on 

attachment style categories. Specifi cally, 

female respondents had a smaller proportion of secure and dismissing attachment 

styles and a greater proportion of preoccupied and fearful attachment styles as 

compared with male respondents. Most 

remarkably, female respondents were far 

more vulnerable to fearful attachment 

styles as compared with men (by close to 

15%).

COMMENT

The fi ndings from this study are consistent 

with the related literature on attachment 

and sleep in nonmilitary populations; secure attachment may be associated with 

better sleep.3

 Additionally, this study offers a preliminary sketch of the attachment 

style types that may be found within a military population; nearly 40% of this population endorses secure attachment and 30% 

dismissing. Therefore, a full 70% of this 

population endorses attachment styles that are associated with greater resilience.22 Our fi ndings regarding attachment styles support the idea that secure attachment 

styles afford less relationship anxiety as compared with 

dismissing, fearful, and preoccupied attachment styles. 

These fi ndings also highlight the particularly compelling differences between dismissing attachment styles 

and fearful and preoccupied ones. Dismissing attachment styles are perhaps more resilient than preoccupied 

and fearful ones as they are also associated with less 

relationship anxiety. Regarding attachment style and 

sleep behaviors, our fi ndings provide further support 

Correlations for relationship anxiety, relationship avoidance, and the sleep measures. Cell information shows correlations, signifi cance level, and number of responses within each attachment 

category of relationship anxiety and relationship avoidance, and the 2 sleep measures of activity 

sleep and rhythmicity sleep.

ACT_SLEEP RHY_SLEEP ECR_ANXIETY ECR_AVOIDANCE

ACT_SLEEP Pearson Correlation 1 -0.268* 0.153* 0.143*

Sig. (2-tailed) 0.000 0.000 0.001

N 553 553 543 542

RHY_SLEEP Pearson Correlation -0.268* 1 -0.173* -0.191*

Sig. (2-tailed) 0.000 0.000 0.000

N 553 561 551 550

ECR_ANXIETY Pearson Correlation 0.153* -0.173* 1 0.603*

Sig. (2-tailed) 0.000 0.000 0.000

N 543 551 551 550

ECR_AVOIDANCE Pearson Correlation 0.143* -0.191* 0.603* 1

Sig. (2-tailed) 0.001 0.000 0.000

N 542 550 550 550

*Correlation is signifi cant at the 0.01 level (2-tailed). Percentage

Attachment Category

Figure 6. Percentage of respondents by gender per adult attachment category. A 24 χ2

 test (χ2 =11.120, P=.11) shows signifi cant differences between 

attachment category percentages and endorsements by gender.
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

for the idea that secure attachment styles afford better 

sleep; secure attachment styles are associated with uninterrupted and sound sleep, and perhaps more regular, 

routine sleep activities. As seen earlier, secure attachment, followed by dismissing attachment styles, enjoy 

better sleep as compared with fearful and preoccupied 

attachment styles. Interestingly, gender differences were 

found with respect to prevalence of attachment style between gender groups. Moreover, women had a greater 

prevalence of fearful and preoccupied attachment styles 

(less resilient) and men had a greater prevalence of secure and dismissing attachment styles (more resilient). 

These fi ndings have important implications specifi c to 

our military population.

Our fi ndings for attachment style, relationship anxiety, and sleep outcomes provide some insight into the 

resiliency versus risk profi le for service members. Secure attachment is associated with lower levels of anxiety, depression, and fewer sequelae of trauma, such 

as PTSD.28 Similarly, low relationship anxiety affords 

greater interpersonal and social support in addition to 

other protective resources,22 whereas high relationship 

anxiety not only impedes access to these protective 

factors but also promotes further risk factors, such as 

isolation.40 Of course, better sleep is associated with improved outcomes in a plethora of areas from work performance to physical and mental health.16 Thus, secure 

and dismissing attachment styles may be more resilient, 

especially considering the potential stressors and demands of military service and the active duty military 

context, which includes individual work performance 

expectations, military group and cultural expectations, 

and lifestyle necessities. Moreover, active duty service 

members must achieve an overall biopsychosocial level 

of fi tness in order to thrive, despite constant variability 

and change, unique teamwork expectations (horizontal 

relationships), and leadership pressures via chain-ofcommand (vertical relationships). Active duty service 

members must endure constant change both at work and 

at home, where intimate and familial relationships are 

also challenged by extended separations, moving locations, and a continued sense of uncertainty about the 

future. As such, individual attachment styles may be 

more salient for military personnel as compared with 

their civilian counterparts. Additionally, female service 

members may be more vulnerable to less resilient attachment styles as compared with male service members, a difference that is not conspicuous in the general 

population. Perhaps female service members are simply 

more likely to endorse fearful and preoccupied attachment patterns as compared with men in the military due 

to gender expectations and identity formation within 

the culture (such as hypermasculinity and invincibility). 

The lack of signifi cant differences in sleep outcomes by 

gender, despite these differences in attachment patterns, 

suggests a possible confl ict with subjective measures of 

attachment and other constructs, perhaps in the area of 

self-concept, within this population. While these gender differences within the military population require 

further investigation, these fi ndings provide a basis for 

continued consideration.

APPLICATIONS

Attachment styles, relationship styles, and sleep patterns 

are important considerations for military service members who can be addressed at various levels of intervention, from the individual, couples, family, and community to the larger system and culture. For example, attachment styles may be helpful to individual assessment 

protocols and clinical interventions for anxiety, depression, PTSD, problems with sleep, and other intrapersonal problems, perhaps even substance abuse. Military 

healthcare providers, particularly social workers, can 

work to bolster secure attachment patterns through the 

process of the therapeutic relationship. Moreover, secure 

attachment styles can be developed with time and effort through stable, corrective relationships and alternative support fi gures, a process known as “earned secure 

attachment.”41 Conversely, relationship factors may be 

used to assess internal resources of individual wellness 

and resilience in service members. For example, clinicians may alternately take a more strengths-based approach to working with secure individuals on their presenting concerns. Attachment factors may also provide 

insight into interpersonal problems that can have an 

impact on signifi cant family relationships, professional 

relationships, and performance outcomes for service 

members. Again, appropriate attachment-related interventions may be useful to address these interpersonal 

and social concerns. Providers may help service members develop self-awareness of their personal attachment pattern by refl ecting on early, seminal attachment 

experiences, and current interpersonal dynamics. Couples and family issues are particularly salient for service 

members who tend to rely, perhaps more strongly, on 

their marriage and family relationships for support and 

well-being as compared with their civilian counterparts. 

Thus, social workers can work to improve attachment 

style patterns in military couples and families in the interest of greater resilience and positive outcomes for service members, their signifi cant relationships, and their 

families.

At the community level, military cadres, squadrons, 

and units may benefi t from cultivating secure attachment behaviors within their groups—both horizontally between peers and vertically between commanders 

THE IMPACT OF ATTACHMENT STYLE ON SLEEP IN POSTDEPLOYED SERVICE MEMBERS
 April – June 2013 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

and their unit members—as compared with traditional 

fear-based norms and contingencies. As such, cultivating secure attachment styles, secure relationship styles, 

and also healthy sleep behaviors may be essential to future training programs for service members, and not far 

afi eld from the current emphasis on buddy systems, unit 

cohesion, family-friendly unit environments, and resiliency training. Finally, individual and group attachment 

and relationship patterns may be an important consideration to the military at the organizational level.42 These 

factors may be essential to both individual and group 

potentialities for certain performance outcomes, those 

based on a deep-seeded trust in others and the world-atlarge. Moreover, secure attachment styles may provide 

a sense of personal safety that is necessary for optimal 

performance within the military system and culture.

LIMITATIONS

There are several limitations to our study that warrant 

attention. First, the data were not longitudinal assessments of participants across time points and were based 

upon self-reported data. Second, we collected a convenience sample of Army and Air Force service members, 

and it is unknown how well our fi ndings generalize to 

other military personnel. With respect to methods used 

for this study, one central limitation must be considered 

and improved upon in future studies: the measures for 

sleep outcomes were embedded in a larger questionnaire designed to assess temperament and not sleep per 

se. Future studies of this kind may fi nd more nuanced 

and sensitive results from an instrument designed and 

validated to measure sleep outcomes, such as the Pittsburgh Sleep Questionnaire (http://www.sleep.pitt.edu/

content.asp?id=1484), or even objective sleep measures 

taken within the sleep laboratory. With respect to fi ndings, the regression analyses depict signifi cant relationships between sleep measures and attachment style although the magnitude of accounted variance is small. 

Relationship anxiety is found to predict activity sleep, 

such as waking and movement, whereas relationship 

avoidance is found to predict rhythmicity sleep, such 

as bedtime routines and consistent hours. In dealing 

with military populations, several factors may moderate 

these effects, which include situational factors such as 

variability of schedules, presence of interfering factors 

such as health factors including physical or emotional 

pain and changes in sleep environments; the potential 

use of sleep aides, and the study’s undetermined nature 

of the quality of sleep such as sleep duration, physical 

restoration and integrity of sleep architecture. Limitations notwithstanding, our study makes several important contributions. To our knowledge, this was the fi rst 

study to assess the relationship between attachment and 

sleep in military personnel.

FUTURE DIRECTIONS

The present data provide preliminary support for the 

importance of understanding an individual’s attachment 

style within the context of the military. Further research 

should also examine the relationship between attachment, sleep symptoms, and combat stress. A better understanding of factors contributing to development and/

or maintenance of attachment patterns and sleep behaviors could mitigate the consequences of combat stress 

and PTSD in addition to other concerns. With respect 

to internal demographics, the literature in the area of 

attachment style does not show established gender differences with respect to overall attachment measures 

and outcomes. However, future studies may continue to 

parse potential gender differences in the relationships 

between attachment styles, relationship anxiety, and 

sleep outcomes among service members. This same approach may also apply to observations of other discrete 

groups within the military, such as age, culture, rank, 

branch of service, or occupational specialty, as these 

important intrapersonal factors may show signifi cant 

differences on salient attachment and sleep measures. 

For example, does attachment style and position or rank 

of the patient have an impact on perceived outcomes of 

treatment? Or, are secure attachment styles easier (that 

is, more compliant) or actually better (more effective, 

more resilient) with respect to military training and organization? If so, can we increase secure attachment 

through systematic methods and within the requisite 8 

to 10 sessions of therapy as it stands? Can we increase 

secure attachment through leadership styles and policies? Linking attachment theory with clinical practice 

has posed a long-standing question: what practice approach best supports and enhances mechanisms of secure attachment? Future studies must address these important questions that arise from across the spectrum of 

behavioral healthcare fi elds that serve the total military 

system, its personnel, and families.

ACKNOWLEDGEMENTS

We thank LTC Candy Wilson, LT Adam Barnett, Kathleen Garrahan, and Philip Throne, in addition to our 

many research volunteers.

This article is based on data taken from a larger 

study including measures of posttraumatic stress and 

temperament.

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AUTHOR AFFILIATIONS

LTC Escolas: Burn Center Executive Offi cer, US Army 

Institute of Surgical Research, San Antonio Military 

Medical Center, Joint Base SA Fort Sam Houston, Texas.

1Lt Hildebrandt: Social Work Intern, Department of 

Behavioral Health, San Antonio Military Medical Center, 

Joint Base SA Fort Sam Houston, Texas

Dr Maiers: Clinical Psychologist, Warrior Resiliency 

Program, San Antonio Military Medical Center, Joint 

Base SA Fort Sam Houston, Texas.

Maj Baker: Behavioral Analysis Service, 559th Aerospace 

Medicine Squadron, Joint Base SA Lackland, Texas.

Dr Mason: Associate Director, Research Outcomes and 

Data Analytics, Wellness & Prevention, Inc, Ann Arbor, 

Michigan. Also, Adjunct Associate Professor, Department 

of Psychiatry and Behavioral Sciences, Johns Hopkins 

University School of Medicine, Baltimore, Maryland. 

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

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

Inclusion in the MEDLINE database ensures that citations to AMEDD Journal content will 

be identifi ed to researchers during searches for relevant information using any of several 

bibliographic search tools, including the National Library of Medicine’s PubMed service.
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

The issue of health concerns potentially associated with 

open burning to dispose of trash (burn pits) remains a 

concern. Both the Senate and the House of Representatives passed legislation, signed into law on January 10, 

2013,1,2 requiring the Department of Veterans Affairs 

(VA) to establish a registry of those exposed. The burn 

pit issue has been discussed in 2 earlier articles in the 

AMEDD Journal.

3,4 The fi rst article3

 discussed the environmental sampling and health risk assessment—including the implications and limitations—conducted at 

Joint Air Base Balad, the location of the largest burn pit 

in Iraq. The second article4

 discussed a review of the potential long-term health risks associated with burn pits 

conducted by the Institute of Medicine (IOM) of the National Academy of Sciences.5

 The review was conducted 

at the request of the Department of Veterans Affairs to 

address the potential for subsequent health conditions 

among Veterans. While neither the health risk assessment nor the IOM review identifi ed specifi c health concerns, the plausibility was acknowledged and a variety 

of stakeholders remain concerned that there are health 

implications. These stakeholders called for the creation 

of a “burn pit registry,” a list of all military personnel 

exposed to burn pits.6,7 This article discusses how such 

a registry might be established and some of the implications involved.

BACKGROUND OF THE HEALTH RISK ISSUE

Before incinerators or alternate forms of waste disposal 

became available, open-air burn pits were used by the 

US military to dispose of solid waste during Operations 

Enduring Freedom and Iraqi Freedom.3

 The Department 

of Defense (DoD) defi nes a burn pit as:

...an area, not containing a commercially manufactured 

incinerator or other equipment specifi cally designed and 

manufactured for [the] 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

At some deployment locations, burn pit emissions likely 

contributed to the total burden of pollutants to which deployed personnel were exposed and may have included 

particulate matter, volatile organic compounds, metals, 

and polycyclic aromatic hydrocarbons.9

 However, exposure to burn pit emissions likely varied by the size and 

location of the burn pit, as well as meteorological conditions. Technical guidance for fi eld waste management 

was available, specifying that “engineers will manage 

the disposal of all categories of wastes (except medical 

waste) in a theater of operations.”10(p4) The guidance suggests burial, or segregation and recycling when possible.10 However, disposal of collected recycled material 

was impractical for many locations in an active theater 

of combat. For this reason, in areas without host nation or 

contractor support, burning was considered a preferred 

alternative, but only for short periods until incinerators 

became available. Landfi lls are a method also suggested, but there is some risk in transporting trash from the 

base to a distant location. At many camps, establishing 

the burn pit downwind (140 m downwind of personnel 

and living areas, if possible) as recommended, would 

minimize exposure. Additionally, individual exposure 

would vary by location, type of duty, and activities; for 

example, a guard at a burn pit site versus an individual 

who spent most time indoors while deployed. Some base 

camps were large and incinerators were purchased, but 

logistical issues concerning contracts for personnel to 

use and maintain the incinerators delayed their use. This 

included Joint Air Base Balad (JBB), a very large base 

camp in Iraq with as many as 25,000 people at its peak 

base loading. In the United States, it is estimated that 

each person generates 4 to 6 pounds of solid waste per 

day. By 2008, it was estimated that JBB was generating 

several hundred tons per day.3

More waste was generated during this confl ict in comparison to previous operations due to the almost universal use of bottled drinking water in a desert climate, 

increased capability to purchase items from internet 

sites, which use a lot of packaging, and the omnipresent 

personal electronic devices that are usually discarded 

if nonfunctional. Additionally, Styrofoam packaging 

was heavily used in dining facilities and carry-out food 

sources. I observed attempts to have service members 

segregate food from Styrofoam plates and plastic tableware at dining hall exits in Afghanistan, which produced 

spotty success at best. Joint Base Balad was one of the 

camps where incinerators were available at a site that 

Considerations Regarding a Burn Pit Registry

Coleen P. Baird, MD, MPH
 April – June 2013 47

was generating a considerable volume of waste, but, for 

reasons discussed earlier, did not become operational 

until 2008. To address health concerns at JBB in 2008 

prior to the activation of the incinerators, preventive 

medicine personnel conducted air sampling for targeted 

expected emissions to include particulate matter, volatile organics, metals, polycyclic aromatic hydrocarbons, 

and polychlorodibenzodioxins/furans (dioxins and 

furans).9

 The burn pit at JBB covered 10 acres, but not 

all areas were burning at the same time. Sampling locations were selected to represent typical and maximum 

exposure levels for the general population. The samples 

were collected over multiple 24-hour periods to account 

for some of operational and meteorological variability 

in exposure levels. A total of 163 samples were collected resulting in 4,811 individual analyte results. The 

data from the sampling effort was used in a quantitative screening human health risk assessment. Using this 

methodology, both noncancer and cancer risks were “acceptable” or “safe” as per the Environmental Protection 

Agency classifi cation of the level of potential exposure 

to each individual analyte. A “moderate” operational 

risk from particulate matter and a potential for shortterm, reversible noncancer effects were noted. The Defense Health Board (DHB), an independent board comprised of experts from private industry and universities, 

reviewed the conclusions of the initial screening health 

risk assessment.11 The DHB agreed with the conclusion 

that no long-term health effects should be expected due 

to dioxin or the analytes measured and used in the risk 

assessment. However, that statement did not dismiss the 

potential for long-term health risk. Conclusions regarding long-term risk were limited by the short term and intermittent nature of the sampling event, and because not 

all possible contaminants of concern were sampled.4

 It 

was not feasible to test for some contaminants due to the 

diffi culty of using certain equipment in a fi eld setting.

The military gave additional emphasis to burn pits in 

2009, and the Multinational Coalition, Iraq, issued specifi c guidance on burn pits with checklists in an environmental standard operating procedure. As discussed 

in the IOM report,5

 Congress also became interested 

in military burn pit use and safety in 2009, and held 

hearings including testimony from both military offi cials and Veteran’s groups. These hearings discussed 

the screening health risk assessment, and Veterans and 

other medical and environmental professionals who 

served in Iraq testifi ed about the presence of noxious 

smoke on the base at Balad. Some individuals “attributed a range of medical problems to smoke from burn 

pits, including asthma, joint pain, cancer, nausea and 

vomiting, burning lungs, and Parkinson’s disease.”5(p13)

Respiratory symptoms by redeploying personnel were 

also discussed. Bills were introduced in 2009 and 2010 

to sharply curtail the use of open-air burn pits, and HR 

2647, the National Defense Authorization Act for Fiscal 

Year 2010, prohibited the use of burn pits for hazardous 

and medical waste except in conditions where there is 

no alternative, as well as placing a number of other requirements on the DoD related to burning trash.5

 The 

DoD published a directive on the use of open air burn 

pits in contingency operations in 2011.8

In 2010, the Veterans Benefi ts Administration published a training letter for claims examiners addressing, 

among other things, environmental hazards in Iraq and 

Afghanistan, particularly burn pits. It listed all chemicals detected in burn pit sampling regardless of whether 

they were detected at levels below health concern levels.12 Also in 2010, the VA asked the IOM to examine the 

long-term health consequences of exposure to burn pits 

in Iraq and Afghanistan.5

In 2011, the IOM committee concluded that:

...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 than 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.5(p7)

Although the IOM recommended a broader consideration of air pollution, SB 3202 (The Dignifi ed Burial of 

Veterans Act of 2012)1

 mandating the establishment of 

an open pit burn registry was signed into law (Public 

Law No. 112-2601) on January 10, 2013. Title II, §201 of 

the Act specifi es that:

Not later than one year after the date of enactment of this 

Act, the Secretary of Veterans Affairs [SVA] shall

(A) establish and maintain an open burn pit registry for 

eligible individuals who may have been exposed to 

toxic chemicals and fumes caused by open burn pits;

(B) include any information in such registry that the 

SVA determines necessary to ascertain and monitor 
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

the health effects of the exposure of members of the 

Armed Forces to toxic airborne chemicals and fumes 

caused by open burn pits;

(C) develop a public information campaign to inform 

eligible individuals about their eligibility, including 

how to register and the benefi ts of registering; and 

(D) periodically notify individuals about signifi cant developments in the study and treatment of conditions 

associated with exposure to toxic airborne chemicals 

and fumes caused by open burn pits.1

The law also requires the Secretary of Veterans Affairs 

(SVA) to enter into an agreement with an independent 

scientifi c organization (such as the IOM ) to develop, 

within 2 years after establishment of the registry, a report which assesses the effectiveness of the actions taken by the Secretary to collect and maintain information 

on the health effects of exposure, recommendations to 

improve collection and maintenance of such information, and using established and previously published epidemiological studies, recommendations regarding the 

most effective and prudent means of addressing medical 

needs of eligible individuals with respect to conditions 

likely to result from exposure to open burn pits. There 

is also a requirement for an update to the report 5 years 

following the original report that assesses whether and 

to what degree the registry is current and scientifi cally 

up-to-date. This is similar to the current process in the 

Agent Orange Registry.13 This bill also requires the DoD 

to cooperate with the Secretary of Veteran’s Affairs, and 

provide all possessed or obtainable data relevant to the 

reports.

WHAT DOES THIS ACT REALLY MEAN?

To address the eligibility requirement, it will be necessary to identify individuals who were “exposed.” The 

Act defi nes an “eligible individual” as:

any individual who, on or after September 11, 2001

(A) was deployed in support of a contingency operation 

while serving in the Armed Forces; and

(B) during such deployment, was based or stationed at a 

location where an open burn pit was used.1

Accordingly, anyone at a location with an open burn pit 

regardless of their location relative to the burn pit would 

be eligible. Further, the Act defi nes “open burn pit” as 

follows:

The term “open burn pit” means an area of land located 

in Afghanistan or Iraq that

(A) is designated by the Secretary of Defense to be used 

for disposing solid waste by burning in the outdoor 

air; and

(B) does not contain a commercially manufactured incinerator or other equipment specifi cally designed and 

manufactured for the burning of solid waste.1

Where other methods of waste management were not 

available, open burning of trash was a common occurrence to limit accumulation that would attract vermin 

and potentially create a public health hazard. If a listing 

of locations where trash was burned, along with where 

and when incinerators were instituted, was generated 

and provided to the Deployment Manpower Data Center, base camp rosters for relevant time periods could 

be generated. However, this assumes or implies that all 

individuals assigned to a base camp with a burn pit were 

exposed to “airborne toxic chemicals and fumes,” and 

without further information would consider them all 

equally exposed. In reality, in ideal situations, a burn pit 

site is selected with a consideration of prevailing winds, 

and located such that most personnel would be upwind 

of the burning. Considering all individuals at locations 

with burn pits equally exposed could result in misclassifi cation, as well as an inability to assess dose-response 

trends if the registry information is used for epidemiological purposes.

The second requirement authorizes the Secretary of 

Veterans Affairs to determine what information should 

be included in the registry to monitor the health effects 

of those included. This could include physical examinations with specifi c testing, periodic self-report of all 

or specifi c conditions, or as of yet undetermined information. Self-reported exposure information could also 

be collected in an attempt to classify exposure level, 

although this is not necessarily a valid measure of actual exposure.14,15 The public information campaign to 

inform eligible individuals about their eligibility, how to 

register, and the benefi ts would be easily accomplished, 

once the eligibility was established, as the VA has done 

for a number of other exposures or conditions.16 The VA 

must also periodically notify individuals about signifi -

cant developments in the study and treatment of conditions associated with these exposures. According to 

the Department of Veterans Affairs Offi ce of Public 

Health, the VA currently maintains several health registry evaluation programs to track the health of Veteran’s 

exposed to environmental hazards during military service. These are included in the Ionizing Radiation Registry17 which addresses radiation exposure, most notably 

from atomic weapons use and testing in World War II; 

the Agent Orange Registry13 which addresses herbicide 

exposure in the Vietnam War; and the Gulf War Registry18 which is not related to a specifi c exposure but 

covers undiagnosed symptoms and illnesses following service during the 1990-1991 Gulf War, Operation 

CONSIDERATIONS REGARDING A BURN PIT REGISTRY
 April – June 2013 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

Desert Shield, Operation Desert Storm, Operation Iraqi 

Freedom, and Operation New Dawn. Note that the last 

2 listed operations are the recent and ongoing confl icts. 

The VA also maintains the Depleted Uranium Follow-up 

Program19 which addresses all confl icts included in the 

Gulf War Registry and service in Bosnia with potential 

depleted uranium exposure, and the Toxic Embedded 

Fragments Registry20 for Veterans who have or likely 

have an imbedded metal fragment. These registries differ in terms of what is offered or included, and Veterans 

can be eligible for one or several, and do not need to be 

enrolled in VA health care to be included. The information from the evaluations is maintained in VA databases 

and is part of the VA medical record. However, the registry examinations are not compensation examinations, 

nor do they serve as a claim for VA benefi ts. For some 

of these registries, actual exposure data is lacking. One 

possibility for a burn pit registry would be the expansion 

of eligibility for the Gulf War Registry18 specifi cally to 

include participation in Operation Enduring Freedom 

(Afghanistan). In this way, eligible participants would 

be added to the currently existing registry and the information gathered on members might be modifi ed to 

address burn pit concerns. The model for the registry is 

most likely to be the Agent Orange Registry.13 Created 

in 1978 due to concerns of Vietnam veterans that their 

exposure to the herbicide mixture (colloquially called 

Agent Orange because it was stored in drums with orange stripes) was causing health problems, it was the 

fi rst VA registry. Registrants received an examination 

and a series of baseline tests. No specifi c test for exposure is conducted, and there is no way to determine if 

any specifi c illness or symptom is “caused” by Agent 

Orange exposure. However, those who enrolled receive 

the “Agent Orange Review,” a newsletter which provides 

information regarding developments related to Agent 

Orange.21 This information includes health conditions 

identifi ed as service-connected to Agent Orange exposure or service in Vietnam based on recommendations 

in a review by the IOM.

The Act requires the SVA to enter into an agreement 

with an independent scientifi c organization (such as the 

IOM) to develop reports which assess the effectiveness 

of the actions taken, generate recommendations to improve the collection and maintenance of the information, 

and use established and previously published epidemiological studies to evaluate “conditions that are likely 

to result from exposure to burn pits.” These reports 

would be due at 2 and 5 years following enactment of 

the bill, which occurred January 10, 2013. In all likelihood, the requirement for reports from an independent 

scientifi c organization will parallel the current relationship between VA and IOM to assess the potential health 

implications of exposure to Agent Orange. In 1991, Congress passed the Agent Orange Act of 1991 (Pub L No. 

102-4, 105 Stat 11, February 6, 1991) which directs the 

SVA to request that the IOM perform a comprehensive 

evaluation of scientifi c and medical information regarding the health effects of Agent Orange. The fi rst comprehensive review was conducted in 1994 and updates 

have been published every 2 years. These reports review 

the available scientifi c evidence regarding the “statistical association” between exposures to dioxin and other 

chemicals in the herbicide and various health outcomes. 

Statistical association means that reviewed studies have 

demonstrated a statistical association—a statistically 

signifi cant association between the disease and exposure. The categories of fi ndings following review are 

noted in the Table. The limited/suggestive evidence category is used when bias and chance could not be ruled 

out, and this category is often used when at least one 

high quality health study shows a positive association, 

but other studies produce confl icting results. This category is often suffi cient for presumption; examples from 

the Agent Orange presumptions include prostate cancer 

and type –II diabetes.23

Since the original report, 14 diseases have been considered presumptively related to service in Vietnam.24 This 

means that individuals who served on land in Vietnam 

from 1962 to 1975 are eligible for “service connection” 

for these diseases and are eligible for compensation without “proving” an association between an exposure during 

their time of service and these diseases. Some of the more 

recent additions, such as ischemic heart disease, prostate 

cancer, and type-2 diabetes are common in aging populations irrespective of exposure. According to Samet et 

al,24 estimates from fi scal year (FY) 2010 noted that VA 

now provides disability compensation to approximately 

3 million veterans and 342,000 benefi ciaries (survivors 

of those who died as a result of their condition), at a cost 

of $41 billion annually. Costs have increased from $19 

billion in FY 2000 to an estimated $43 billion in FY 2010. 

This is because the Vietnam veterans have aged, the list 

of diseases which qualify for Agent Orange compensation has lengthened, and Gulf War veterans have become 

ill and fi led claims in the 20 years since that confl ict. The 

Gulf War registry compensates Gulf War Veterans with 

“medically unexplained illness” and some infectious diseases (ie, leishmaniasis).25 If a condition is diagnosed, it 

is no longer “medically unexplained.”

The DoD and the VA recognized the need to address 

burn pit exposure as well as other exposure effects on 

pulmonary function and disease. Joint meetings and 

symposiums were held in 2011 and 2012. It has been 

considered that organ systems other than the pulmonary 
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

system may be affected by some of the chemicals emitted with burn pit smoke at suffi cient levels, although 

there is no sampling to indicate that these levels have occurred.9

 Additionally, there are other potential airborne 

exposures, such as particulate matter.5,26 The DoD and 

VA now consider deployment-related airborne hazards 

a more appropriate focus than burn pits. A joint action 

plan addressing those hazards is now being prepared by 

the 2 agencies.

The fi rst studies by the US Armed Forces Health Surveillance Center used sites in the Central Command area 

of operations.27 Four sites, two with burn pits and two 

without burn pits, were chosen to allow comparisons between sites where individuals were potentially exposed 

to burn pit smoke and individuals who were not exposed 

to burn pit smoke, but were potentially exposed to other 

pollution sources such as particulate matter and pollution from local industry. The studies evaluated cardiovascular diseases, signs, symptoms, respiratory diseases, 

and ill-defi ned conditions. The main fi nding was that for 

nearly all health outcomes measured after personnel returned from deployment, the incidence for these health 

conditions was either lower or about the same as for 

those who had not deployed or those who had deployed 

outside the area of a documented open air burn pits. One 

exception was for personnel deployed to a site without 

a burn pit (Camp Arifjan, Kuwait) where a measurable 

increase in the rate of signs, symptoms and ill-defi ned 

conditions was noted. For health outcomes occurring 

during the deployment period, Air Force personnel at 

Joint Base Balad had a higher proportion of respiratory 

encounters. However, this was not noted among Army 

personnel at the same location or service members at the 

other burn pit sites that were studied. The overall fi ndings when examining populations of personnel exposed 

to burn pit smoke indicate no substantial or consistent 

effect of possible exposure to smoke at the bases examined in these analyses when compared to other deployed 

personnel. These studies have a number of strengths and 

some limitations. Depending on the individual studies, 

strengths included the use of comprehensive electronic 

medical records to examine postdeployment medical 

visits and hospitalizations, the ability to evaluate many 

different health outcomes, and large populations which 

allowed for high power to detect fi ndings. Some limitations included an inability to adjust for confounding 

exposures such as smoking, lack of individual exposure 

data, and limited population data, and short follow-up 

time at the time of the study. The choice of comparison 

group in this study, US-based military personnel, may 

not be an ideal comparison group as those not deployed 

may be ineligible for deployment due to medical conditions, potentially making rates of disease higher in this 

nondeployed population. This is known as the “healthy 

warrior” effect.28 Because of the likelihood of some exposure misclassifi cation which may limit the detection 

of slight increases in risk and other limitations inherent 

in the data, the DoD is cautious of the interpretations of 

these fi ndings and continues to examine the possibility 

Categories of evidence for disease presumption in association with Agent Orange.

Category of Evidence Evidence Requirements Presumption

Examples 

Estimated Population

Prevalence

Sufficient evidence of an 

association

Multiple, high quality studies with statistically significant findings after chance, 

bias, and confounding are ruled out.

B-cell leukemia 

Chloracne 

Low

Limited/suggestive evidence of an 

association

Evidence is suggestive of an association 

but is limited because chance, bias, and 

confounding could not be ruled out with 

confidence. May be one positive (statistically significant) study.

Prostate cancer

Diabetes

High, increasing with 

age 

Inadequate/insufficient evidence to 

determine whether an association 

exists 

Available epidemiological studies are of 

insufficient quality, consistency, or statistical power to permit a conclusion regarding the presence or absence of an 

association due to confounding, inadequate exposure assessment, or failure 

to address latency. 

1994 assessment for type II 

diabetes, moved to limited/

suggestive in 2000.

Bladder and other cancers 

Hearing loss and “eye problems” recently added.

High for diabetes, 

Variable for cancers

High for hearing and 

vision problems with 

aging 

Limited/suggestive evidence of no 

association

Requires several adequate studies which 

cover the full range of human exposure 

to fail to show an association and, even 

then, category is valid only for the conditions/exposures/length of observation 

in those studies.

One single health outcome: 

spontaneous abortion after 

paternal exposure to dioxin.

Sufficient evidence of a causal 

association 

This category reflects consideration of the 

“Hill Criteria”22 concerning causation.

Has not been used for Agent 

Orange.

CONSIDERATIONS REGARDING A BURN PIT REGISTRY
 April – June 2013 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

that there may be a limited number of service members 

who may have experienced, or may eventually experience adverse health effects after exposure to burn pit 

smoke.29 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. These studies are currently underway.

Although there has not been conclusive evidence of 

disease associated with burn pit exposures, Veterans’ 

groups support a registry, noting that “a registry will 

enable Veterans to receive healthcare specifi c to their 

special needs and will enable VA to research further 

causes of these illnesses.”7

 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. 

While it may be true tha 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 sources. According to 

the IOM report,5

 there are no illnesses specifi cally associated with burn pit exposure and therefore no specifi c 

markers for medical follow-up. However, the IOM report 

also concluded that the broader question of deploymentrelated inhalational exposures and health outcomes deserves continued study.

REFERENCES

1. Dignifi ed Burial and Other Veterans’ Benefi ts 

Improvement Act of 2012, Pub L No. 112-260 

(2013). Available at: http://legiscan.com/US/text/

SB3202/2011. Accessed January 30, 2013.

2. Kime P. Burn pit registry for veterans signed into 

law. Marine Corps Times. January 10, 2013. Available at: http://www.armytimes.com/news/2013/01/

military-burn-pit-legislation-signed-011013w/. Accessed February 8, 2013.

3. Weese, Coleen B. Issues related to burn pits in 

deployed settings. Army Med Dept J. April-June 

2010:22-28.

4. Baird, Coleen P. Review of the Institute of Medicine Report: Long-Term Health Consequences of 

Exposure to Burn Pits in Iraq and Afghanistan. 

Army Med Dept J. July-September 2012:42-48.

5. 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-Health-Consequencesof-Exposure-to-Burn-Pits-in-Iraq-and-Afghani

stan.aspx#. Accessed January 30, 2013.

6. Toxic exposures impact Iraq, Afghanistan veterans, 

families and survivors. DAV Mag. 2010;52(6):14-18. 

Available at: http://magazine.dav.org/library/pdf/

magazine_201006.pdf. Accessed February 9, 2013.

7. Barker S. Statement before the Committee on Veteran’s Affairs, Subcommittee on Health, US House 

of Representatives, with Respect to HR 1460, HR 

3016, HR 3245, HR 3279, HR 3337, HR 3723, HR 

4079 April 16, 2012. Veterans of Foreign Wars website. Available at: http://www.vfw.org/VFW-in-DC/

Congressional-Testimony/HVAC-Healthcare-SubCommittee-Hearing/. Accessed February 8, 2013.

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. 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 January 30, 2013.

10. Technical Bulletin 593: Guidelines for Field 

Waste Management. Washington, DC: US Dept 

of the Army; September 15, 2006. Available at: 

http://armypubs.army.mil/med/dr_pubs/dr_a/pdf/

tbmed593.pdf. Accessed February 8, 2013.

11. President, Defense Health Board. Memorandum: Defense Health Board Findings Pertaining to the Health Risk Assessment of Burn Pit 

Exposures, Balad Air Base, Iraq, DHB 2008-05. 

Washington, DC: US Dept of Defense; June 26, 

2008. Available at: http://www.health.mil/dhb/

recommendations/2008/BaladHealthRiskAssess

mentBoardFindingsRecommendation.pdf.

Accessed February 8, 2013.

12. Mayes BG. Training Letter 10-03, Environmental 

Hazards in Iraq, Afghanistan, and other Military 

Installations. Washington, DC: Dept of Veterans 

Affairs; April 26, 2010. Available at: http://forums.

military.com/eve/forums/a/tpc/f/8280047191001/

m/9740039052001. Accessed February 5, 2013.

13. Agent Orange registry health exam for veterans. 

US Dept of Veterans Affairs Website. Available at: 

http://www.publichealth.va.gov/exposures/agentor

ange/registry.asp. Accessed February 4, 2013.

14. Glass DC, Sim MR. The challenges of exposure assessment in health studies of Gulf War 

veterans. Philos Trans R Soc Lond B Biol Sci. 

2006;361(1486):627-637.

15. Mancuso JD, Ostafi n M, Lovell M. Postdeployment evaluation of health risk communication after 

exposure to a toxic industrial chemical. Mil Med. 

2008:173(4):369-374.
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

16. Environmental health registry evaluation for veterans. US Dept of Veterans Affairs Website. Available at: http://www.publichealth.va.gov/exposures/

registry.asp. Accessed February 4, 2013.

17. Exposure to Radiation during Military Service. 

US Dept of Veterans Affairs Website. Available 

at: http://www.publichealth.va.gov/exposures/radia

tion/military-exposure.asp. Accessed February 4, 

2013.

18. Gulf War exposures. US Dept of Veterans Affairs 

Website. Available at: http://www.publichealth.

va.gov/exposures/gulfwar/hazardous_exposures.

asp. Accessed February 4, 2013.

19. Depleted uranium follow-up program. US Dept of 

Veterans Affairs Website. Available at: http://www.

publichealth.va.gov/exposures/depleted_uranium/

followup_program.asp. Accessed February 19, 

2013.

20. Toxic embedded fragments. US Dept of Veterans 

Affairs Website. Available at: http://www.public

health.va.gov/exposures/toxic_fragments/index.

asp. Accessed February 4, 2013.

21. Publications and reports on Agent Orange. US Dept 

of Veterans Affairs Website. Available at: http://

www.publichealth.va.gov/exposures/agentorange/

resources.asp. Accessed February 4, 2013.

22. Bradford Hill A. The environment and disease: association or causation?. Proc R Soc Med. 

1965;58:295-300.

23. Veterans’ diseases associated with Agent Orange. 

US Dept of Veterans Affairs Website. Available at: 

http://www.publichealth.va.gov/exposures/agentor

ange/diseases.asp. Accessed February 4, 2013.

24. Samet JM, McMichael GH III, Wilcox AJ. The use 

of epidemiological evidence in the compensation of 

veterans. Ann Epidemiol. 2010;20(6):421-427.

25. Benefi ts, Compensation, Post-Service, Gulf War. 

US Dept of Veterans Affairs Website. Available at: 

http://www.benefits.va.gov/compensation/claimspostservice-gulfwar.asp. Accessed February 4, 

2013.

26. Weese, CB, Abraham JH. Potential health implications associated with particulate matter exposure in 

Southwest Asia. Inhal Toxicol. 2009;21(4):291-296.

27. Epidemiological Studies of Health Outcomes 

among Troops Deployed to Burn Pit Sites. Silver 

Spring, MD: Armed Forces Health Surveillance 

Center; May 2010. Available at: http://www.afhsc.

mil/viewDocument?file=100604_FINAL_Burn_

Pit_Epi_Studies.pdf. Accessed February 8, 2013.

28. Haley RW. Point bias from the “healthy-warrior effect” and unequal follow-up in three government 

studies of health effects of the Gulf War. Am J Epidemiol. 1998;148(4):315-323.

29. Summary of Evidence Statement: Chronic Respiratory Conditions and Military Deployment. 

Aberdeen Proving Ground, MD: US Army Public Health Command; 2011. Factsheet 64-018-111. 

Available at: http://phc.amedd.army.mil/PHC%20

Resource%20Library/Chronic_Respiratory_Con

ditions_and_Military_Deployment.pdf. Accessed 

February 8, 2013.

AUTHOR

Dr Baird is Program Manager, Environmental Medicine, 

US Army Public Health Command, Aberdeen Proving 

Ground, Maryland.

CONSIDERATIONS REGARDING A BURN PIT REGISTRY
 April – June 2013 53

The Army Surgeon General established the Health Hazard Assessment (HHA) Program in 1981 to evaluate the 

potential health effects of operating military weapon 

systems. The Department of Defense Directive 5000.1* 

issued in 1983 directed all uniformed services to consider HHA as an integral part of their respective materiel 

acquisition processes. Army Regulation 40-10,

1

 which 

formally established the Army HHA Program, was 

published in October 1983. In 1995, The Army Surgeon 

General designated the US Army Center for Health promotion and Preventive Medicine, which evolved into the 

US Army Public Health Command (USAPHC) in 2011, 

as the lead agent of HHA with the primary goal of identifying and eliminating or controlling health hazards 

associated with the life cycle management of weapons, 

equipment, clothing, training devices, and other materiel systems. This article focuses exclusively on the HHA 

process for joint weapons systems being acquired by the 

US Army (Figures 1-3). For the purposes of this discussion, the term “weapon system” does not include the 

nonweapon-related aspects of vehicles or platforms such 

as engines, transmissions, chassis components, etc.

The HHA Program recently began assessing Joint weapon systems as a member of the Army Weapons System 

Safety Review Board (AWSSRB). The AWSSRB provides safety and occupational health consultation to the 

Joint Weapon Safety Working Group†

 which advises the 

Assistant Secretary of Defense for Research and Engineering and the Deputy Under Secretary of Defense for 

Installations and Environment regarding the conduct of 

effi cient and effective joint weapon system reviews. The 

HHA Program typically evaluates the following 5 hazards when assessing joint weapon systems:

1. Impulse noise

2. Blast overpressure

3. Chemical substances 

4. Recoil

5. Musculoskeletal trauma (lift and carry)

IMPULSE NOISE

Definition

Impulse noise is generally and in its most basic sense 

considered to be a high-level, short duration pressure 

wave disturbance of less than 0.5 seconds at levels that 

can immediately cause acoustical trauma.

Data Requirements, Initial Recommendations, 

Comments

Collect impulse noise data in accordance with Military 

Standard (MIL-STD) 1474D, Requirement 4,2(p35) at all 

personnel-occupied areas (operator, crew, passenger, and 

maintenance personnel). Collect appropriate data to determine the 140 dB noise contour. The MIL-STD-1474D

The Health Hazard Assessment Process in

 Support of Joint Weapon System Acquisitions

Timothy A. Kluchinsky Jr, DrPH

Charles R. Jokel

John V. Cambre

Donald E. Goddard

Robert W. Batts Jr.

*Obsolete, replaced by the DoD Directive 5000.01 series effective May 12, 2003.

†The charter of the Joint Weapons Safety Working Group was 

signed on October 11, 2012.

Figure 1. XM25 Counter Defi lade Target Engagement System. Photo provided by USAPHC.
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

requirements may differ from those described in local 

test operations procedures, and the HHA project offi cer 

can help resolve the discrepancies.

Provide system operations information to fully characterize daily impulse noise exposures for all affected personnel. Operational information for components (such as cartridges or ancillary equipment) should include a listing of 

the weapon systems with which the materiel is used, and 

any acoustically signifi cant attributes of their use. For example, provide model designations for rifl es using a new 

cartridge, and describe pertinent silencer, muzzle brake, 

and barrel length characteristics for the rifl es listed. Operational information for weapon systems that may be 

fi red in different ways during the course of a day should 

also be provided. For example, it should be specifi ed what 

shooter positions (prone, kneeling, standing, from a foxhole, etc) are anticipated for a rifl e system, and the mix of 

fi ring conditions (azimuth, elevation, charge) anticipated 

for a howitzer or mortar should be specifi ed.

Assessments may sometimes be done by analogy in lieu 

of obtaining data. There is little benefi t in redoing an 

assessment if the materiel under investigation incorporated only changes applied to an older design that did 

not affect acoustics. In such a case, we often just apply 

the original conclusions for the older design. However, 

even in such cases, the situation should be reviewed because there could be new medical criteria that must be 

applied to the old data.

Eliminate impulse noise associated with materiel and 

support design to the maximum extent feasible to reduce the reliance upon hearing protection devices for 

hearing conservation; reduce aural signatures; reduce 

the range of detectability.

All personnel exposed to hazardous noise must wear 

hearing protective devices (HPDs). Department of the 

Army Pamphlet 40-5013

 lists HPDs approved for Army 

use. The devices must be fi tted for size by properly 

trained personnel (if preformed earplugs or helmets), 

adequately maintained, and properly worn.

Double hearing protection consisting of approved earplugs in combination with an ear muff, headset, or 

noise-attenuating helmet may be used to increase fi ring 

allowances.

Additional use restrictions (fi ring allowances or doctrinal use practices) may also apply in order to mitigate the 

hazard.

Health Effects

Elevated sound levels can cause trauma to the hearing 

mechanism. The mechanical damage caused by the 

acoustic trauma may cause permanent hearing loss. This 

can also be accompanied by ringing (tinnitus) in the ears.

Medical Criteria

Impulse noise greater than 140 peak decibels is considered 

hazardous.2,3 Repeated, unprotected exposure to hazardous impulse noise will cause permanent hearing loss.

BLAST OVERPRESSURE

Definition

An instantaneous change in air pressure, typically emitted by an explosive device when it detonates, that imparts mechanical energy to contacted objects.

Data Requirements, Initial Recommendations, 

Comments

Conduct blast overpressure testing on the materiel in 

accordance with the guidance for Blast Overpressure 

Analysis and Test Operations Procedure (TOP) 4-2-

831.4,5 After the test is completed, send the properly formatted data and a description of the test to the USAPHC 

for analysis.

Health Effects

Blast waves encountering human tissue yield mechanical stresses that can injure if they are of suffi cient intensity and/or frequency. Although many organs are 

susceptible to injury, the eardrum and air containing organs such as the heart, lungs, esophagus, stomach, and 

intestines are particularly vulnerable. Possible negative 

health outcomes include mild, transient cognitive dysfunction, visceral injury, and death. Although it was 

previously thought that the absence of eardrum rupture 

could indicate sparing of damage to the viscera, this 

THE HEALTH HAZARD ASSESSMENT PROCESS IN SUPPORT OF

JOINT WEAPON SYSTEM ACQUISITIONS

Figure 2. M777A2 Howitzer in Afghanistan. Photo provided 

by USAPHC.
 April – June 2013 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

notion has recently been challenged. Blast overpressure 

injury risk is related to the mechanics of the pressure 

wave and the physical properties of the tissue contacted. 

Medical Criteria

Extensive study by the Army Medical Research and Material Command has yielded an algorithm that describes 

the relationship between the intensity of a blast recorded 

by a blast test device and lung injury.6

 This algorithm 

resides within the Blast Overpressure Health Hazard 

Assessment software used by the USAPHC to assess the 

risk of lung injury to Soldiers exposed to blast. Due to 

the complexity of factors found in the blast environment 

and variations in the intensity and pulse duration of blast 

waves, it is not possible to express blast overpressure injury risk as a simple numeric threshold value. However, 

as a general rule, risk of blast injury to visceral organs is 

considered to be minimal when the blast falls under the 

Z limit described in MIL-STD-1474D.

2

CHEMICAL SUBSTANCES

Definition

For the purposes of this discussion, chemical substances 

are those substances that are released as a gas, vapor, 

fume, or smoke as a result of fi ring a weapon system. 

They do not include combustion products or other chemicals that are released from vehicles or other ancillary 

equipment associated with the system.

Data Requirements, Initial Recommendations, 

Comments

Provide detailed information on the chemical composition of any propellants to the USAPHC for a defi nitive 

HHA on weapon combustion products. Sampling for 

weapon combustion hazards should follow test guidelines in TOP 2-2-614.7

Provide the material safety data sheets (MSDS), composition, purpose, and quantity of any miscellaneous 

chemicals used in the operation and maintenance of the 

materiel to the USAPHC. Provide MSDSs to users and 

maintainers, including information on specifi c use, handling, storage, and disposal requirements in appropriate 

technical manuals.

Eliminate or reduce the number of miscellaneous toxic/

hazardous chemicals used by design or substitution to 

the maximum extent feasible. The Army Institute of 

Public Health’s Toxicity Evaluation Program performs 

toxicity clearances and evaluations for chemicals used 

by the Army. 

Health Effects

Weapon combustion products are a primary source of 

potential toxic gas exposures. Soldiers can suffer a variety of health effects based upon the physical form of the 

chemical, route of entry, and duration of exposure.

Depending on the duration and level of exposure, Soldiers can suffer a variety of health effects resulting in a 

range of outcomes from performance decrement to death. 

Irritants or corrosive chemicals can cause infl ammation, 

burns, or blisters, fi brogenic materials lead to a loss of 

lung function, allergic reactions can lead to asthma-type 

diseases, or dermatitis. Carcinogenic materials can cause 

cancers in affected organs or tissues, possibly leading to 

death. Poisonous chemicals can lead to cell death, and 

asphyxiants will affect the body’s ability to use oxygen.

Medical Criteria

Health-based exposure limits for chemical substances 

adhere to guidelines published by the Occupational 

Safety and Health Administration Permissible Exposure 

Limits,8

 American Conference of Governmental Industrial Hygienists Threshold Limit Values,9

 or military 

unique criteria outlined in MIL-STD-1472G.

10 These 

limits formulate a level of exposure that the typical 

worker can experience during a lifetime without adverse 

health effects. The risk determination process considers 

levels of exposure for a traditional 8-hour workday in 

a 40-hour work week, time weighted average concentrations for 15-minute exposure durations, and a ceiling 

limit that should not be exceeded during any part of the 

workday exposure.

RECOIL

Definition

Recoil is a specifi c type of mechanical shock that occurs when the reactive force from discharge of a fi rearm 

propels the weapon backwards and imparts mechanical 

force to the point of contact with the Soldier’s body. The 

magnitude of recoil force delivered to the user is dependent upon several factors including the design of the 

weapon and fi ring technique.

Figure 3. M3 Carl Gustaf Recoiless Rifl e. Photo provided by 

USAPHC.
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

Data Requirements, Initial Recommendations, 

Comments

Data requirements for recoil are currently being developed. It is anticipated that data requirements will necessitate conducting a weapon kinetics study, similar to 

that described in TOP 3-2-504.11 Specifi c data items required to assess the risk of musculoskeletal injury from 

recoil will likely include measurements of weapon acceleration, weapon speed, and displacement along the 

axis of the weapon that aligns with the anatomical point 

of contact with the operator. In addition, the data items 

described in TOP 3-2-504 to calculate recoil energy will 

be needed: weights of weapon, propellant, and bullet. 

Required information about the mission scenario includes a description of the intended operators (gender), 

the anticipated number of rounds fi red on a typical training day, duration of training, and the anticipated total 

number of rounds fi red on a training activity.

This assessment, like other musculoskeletal assessments, 

will employ a systems approach. Exposure to recoil 

force will be evaluated within the context of the other 

items in the Soldier’s ensemble. The Soldier, uniform, 

personal protective equipment and other equipment carried on his/her body will be assessed as a unitary system 

that considers the interactions between all components. 

Therefore, recoil assessment will also require a description of wearable items such as individual body armor. 

Finally, since fi ring technique infl uences recoil transmission, descriptions as to how the weapon is held and 

fi ring postures will be required.

Until specifi c medical criteria dictate otherwise, initial 

recommendations to mitigate injury include enforcing 

the fi ring limitations described in the Table, as found in 

TOP 3-2-504.11 This includes limiting exposures from 

shoulder-fi red weapons to less than 60 ft-lbs (81.4 J) of 

recoil force.

Health Effects

Exposures to mechanical recoil force that occur as a 

consequence of normal use of a weapon can result in 

soft tissue injury such as contusion or laceration. High 

dosages of force directed at the anterior shoulder may 

also produce tendonitis, focal bursitis, nerve injury, or 

fracture of the clavicle. Due to the fact that there is little 

opportunity to alter the anatomical contact point with 

a shoulder-fi red weapon, repeated exposures may increase the probability and/or severity of operator injury. 

Common symptoms of injury include pain, superfi cial 

ecchymosis or deep tissue hematoma, whereas signs of 

injury include pain, minor reduction in active range of 

motion of the shoulder, or slight decrement in lifting 

capacity probably secondary to trauma of the anterior 

shoulder tissues.

Medical Criteria

Currently, no medical criteria have been identifi ed for 

recoil exposures. Personal factors that increase susceptibility to injury include the thickness of soft tissues 

(particularly the thickness of the pectoral muscles overlying the more vulnerable soft tissues in the pocket of 

the shoulder). Therefore, anthropometrically smaller individuals with ectomorphic body types are at higher risk 

of injury. The Table displays the TOP 3-2-50411 recommended design standards for fi ring limitations for test 

weapons.

The validity of these design criteria as a basis for medical 

criteria for HHA has not been substantiated. A preliminary study conducted by Blankenship et al12 questioned 

applying the fi ring limits proposed by TOP 3-2-50411 for 

the 45 to 60 ft-lb (61 to 81.4 J) range as medical criteria 

while shooting a shoulder-fi red weapon with a shoulder 

covered only by a uniform. They recommended additional studies to obtain the data needed to develop a 

more defi nitive characterization of recoil exposure.

MUSCULOSKELETAL TRAUMA (LIFT AND CARRY)

Definition

Obviously, every item in the Army inventory has weight, 

including weapon systems. Musculoskeletal trauma may 

occur if excessive weight is lifted by a Soldier either 

once or over a series of repetitions.

Data Requirements, Initial Recommendations, 

Comments

Identify the physical demands of the task and lifting requirements (manual or mechanical lift) and determine 

warning label requirements in accordance with MILSTD-1472G10 for each of the system components.

Provide data for analysis as identifi ed on the HHA Lifting Analysis Worksheet to support the completion of an 

HHA on this potential health hazard concern.

Apply the design guidance for effi cient handling contained in paragraphs 5.8.6.3 and 5.9.11 of MIL-STDTHE HEALTH HAZARD ASSESSMENT PROCESS IN SUPPORT OF

JOINT WEAPON SYSTEM ACQUISITIONS

Firing limitations for test weapons.11

Computed Recoil Energy Limitations on Rounds

Less than 20.34 ft-lb (20.3 J) Unlimited firing

15 to 30 ft-lb (20.3 to 40.7 J) 200 rounds/day/man

30 to 45 ft-lb (40.7 to 61.0 J) 100 rounds/day/man

45 to 60 ft-lb (61.0 to 81.4 J) 25 rounds/day/man

Greater than 60 ft-lb (81.4 J) No shoulder firing
 April – June 2013 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

1472G10 to the materiel design to the maximum extent 

feasible. Place emphasis on heavy items that require 

manual lift/adjustment.

Health Effects

A potential source of exposure to musculoskeletal trauma 

is the lift/carry of heavy components or equipment. Some 

components may require multiple personnel to lift, carry, 

and/or install. Manual handling and lifting are a major 

cause of work-related lower back pain (LBP) and impairment, and shoulder or arm pain. The LBP can occur by 

direct trauma, a single exertion (overexertion), or as a 

result of multiple exertions (repetitive trauma). The LBP 

and impairment are also associated with other work-related factors such as pushing and pulling activities, extreme 

postures such as forward fl exion, and cyclic loading.

Medical Criteria

Although medical criteria for musculoskeletal injury 

from lifting and carrying do not exist, human performance design criteria from paragraph 5.8.6.3 of MILSTD-1472G10 can be applied. This standard considers 

various factors that are related to manual material handling injury risk such as gender, lift height, lift frequency, object mass, object size, carry distance, and lift team 

composition. Each of these should be considered when 

requiring Soldiers to perform lift, carry, and push and 

pull tasks during use of the materiel and its components.

Each item required to be manually lifted/carried should 

be labeled with their weight and lifting requirements 

according to paragraph 5.8.6.3.12 of MIL-STD-1472G.

10

Hoist and lift points shall be provided and clearly labeled where mechanical or power lift is required.

SUMMARY

Since 1981, the Army’s HHA Program has provided an 

invaluable service to combat developers and materiel 

program managers by providing recommendations designed to eliminate or control health hazards associated 

with materiel and weapon systems. The program has 

consistently strived to improve its services by providing 

more meaningful and effi cient assistance to the acquisition community. In the uncertain fi scal times ahead, the 

Army’s HHA Program will continue to provide valuable 

and cost-effective solutions to mitigate the health risks 

of weapon systems.

REFERENCES

1. Army Regulation 40-10:Health Hazard Assessment 

Program in Support of the Army Acquitision Process. Washington, DC: US Dept of the Army; July 

27, 2007.

2. Military Standard (MIL-STD) 1474D, Department 

of Defense Design Criteria Standard: Noise Limits. 

Washington DC: US Dept of Defense; 1997.

3. Department of the Army Pamphlet 40-501: Hearing 

Conservation Program. Washington, DC: US Dept 

of the Army; December 10,1998.

4. Technical Information Paper No. 88-001-0411, Program Guidance for Blast Overpressure Analysis. 

Aberdeen Proving Ground, MD: US Army Public 

Health Command; April 12, 2011.

5. Test Operations Procedure (TOP) 4-2-831, Use of 

Blast Test Device (BTD) During Auditory Blast 

Overpressure Measurement. Aberdeen Proving 

Ground, MD: US Army Developmental Test Command; August 12, 2008.

6. Stuhmiller JH, Ho KH, Vander Vorst MJ, Dodd 

KT, Fitzpatrick T, Mayorga M. A model of blast 

overpressure injury to the lung. J Biomech. 

1996;29(2):227-234.

7. Test Operations Procedures (TOP) 2-2-614: Toxic 

Hazards Test for Vehicle and Other Equipment. 

Aberdeen Proving Ground, MD: US Army Developmental Test Command; October 31, 2003.

8. Occupational Safety & Health Administration. 29 

CFR, Subpart Z, Part 1910.1000: Air Contaminants. Washington, DC: US Dept of Labor; March 

17, 2010. 

9. Threshold Limit Values for Chemical Substances 

and Physical Agents and Biological Exposure Indices. Cincinnati, OH: American Conference of Governmental Industrial Hygienists; February 1, 2013. 

10. Military Standard (MIL-STD) 1472G, Department 

of Defense Design Criteria Standard: Human Engineering. Washington DC: US Dept of Defense; 

January 11, 2012.

11. Test Operations Procedure (TOP) 3-2-504, Safety 

Evaluation of Hand and Shoulder Weapons. Aberdeen Proving Ground, MD: US Army Developmental Test Command; March 1, 1977.

12. Blankenship K, Evans R, Allison S, Murphy M, 

Isome H. Shoulder-fi red Weapons with High Recoil 

Energy: Quantifying Injury and Shooting Performance. Natick, MA: Army Research Institute of 

Environmental Medicine; May 2004. Accession 

Number ADA425518.

AUTHORS

The authors of this article are with the US Army Public 

Health Command, Aberdeen Proving Ground, Maryland, 

in the following positions:

Dr Kluchinsky is Manager, HHA Program.

Mr Jokel is a Noise Control Engineer.

Mr Cambre is an Industrial Hygienist.

Mr Goddard is an Ergonomist.

Mr Batts is an Industrial Hygienist.
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

BACKGROUND

Exposures to chemical (Ch) and nonchemical (NCh) 

(psychosocial factors) environmental stressors have in 

some, but far from all studies been associated with nonoptimal pregnancy outcomes.1-7 Nonchemical environmental exposures such as violence and socioeconomic 

strain have also been associated with adverse birth 

outcomes.5,8,9 Prenatal exposure to air pollutants such 

as sulphur dioxide, nitrogen dioxide, fi ne (diameter≤2.5 

μm) and coarse (diameter≤10 μm) particulate matter 

might contribute to suboptimal birth outcomes through 

a range of mechanisms, including infl ammatory reactions in the lung, contributing to systematic release of 

proinfl ammatory cytokines, DNA adduct formation, 

and lipid peroxidation.5,10

Prior studies of reproductive health effects from exposure to war confl icts have reported an increased prevalence of severe congenital anomalies, neural tube defects, 

perinatal mortality and preterm delivery, and decreased 

birth length and weight.11-15 The 1991 Gulf War (GW) is a 

more recent example of sustained war with severe implications for Iraqi civilians in terms of complex environmental exposures. Studies of reproductive effects from 

the GW have predominantly concerned United Kingdom 

and US veterans reporting an increased risk for spontaneous abortions and congenital birth defects.16,17 A small 

study of civilians residing in Kuwait during the early 

phase of the confl ict reported an increased prevalence of 

children with low birth weight and stillbirth.18

Studies of reproductive risks from war typically lack detailed exposure information. However, the US General 

Accounting Offi ce reported that during the GW up to 21 

reproductive environmental hazards, such as depleted 

uranium and smoke from oil-burning fi res, were dispersed into the environment.16,19 In studies of GW veterans, “exposure” was defi ned simply as “deployment 

to the Gulf region.” 20 A void of reliable environmental 

exposure data limits our ability to assess war-related environmental reproductive risks. Major shortcomings of 

reproductive health studies from war are the lack of (a) 

samples based on random selection, (b) Ch-specifi c and 

NCh-specifi c exposure data, and (c) proper comparison 

groups.

Reproductive health effects studies from war characterized by intense and sustained exposure to environmental 

1991 Gulf War Exposures and

 Adverse Birth Outcomes

Bengt Arnetz, MD, PhD, MPH, MScEpi

Alexis Drutchas, MD

Robert Sokol, MD

Michael Kruger, MA

Hikmet Jamil, MD, DIH, PhD, MSc

ABSTRACT

We studied 1991 Gulf War (GW)-related environmental exposures and adverse birth outcomes in Iraqis. A random cross-sectional sample of 307 Iraqi families that immigrated to the United States responded to a structured 

interview covering socioeconomics, lifestyle, environmental exposures, and birth outcome. Data per each family was collected either from the man or the woman in the respective family. The respondents were divided into 

those that resided in Iraq during and following the GW (post-GW, n=185) and those that had left before (preGW, n=122). The primary outcome was lifetime prevalence of adverse birth outcomes, ie, congenital anomalies, stillbirth, low birth weight, and preterm delivery and its relationship to GW exposures. Mean number of 

adverse birth outcomes increased from 3.43 (SD=2.11) in the pre-GW to 4.63 (SD=2.63) in the post-GW group 

(P<.001). Mean chemical (Ch) and nonchemical (NCh) environmental exposure scores increased from pre-GW 

scores of 0.38 units (SD=1.76) and 0.43 (SD=1.86), respectively, to post-GW scores of 5.65 units (SD=6.23) and 

7.26 (SD=5.67), P<.001 between groups for both exposures. There was a signifi cant dose-response relationship 

between Ch environmental exposure (P=.001), but not NCh exposure, and number of adverse birth outcomes. 

Exposure to burning oil pits and mustard gas increased the risks for specifi c adverse birth outcomes by 2 to 4 

times. Results indicate that Gulf War Ch, but not NCh exposures are related to adverse birth outcomes. Pregnancies in women with a history of war exposures might benefi t from more intensive observation.
 April – June 2013 59

pollutants, such as the GW, might also contribute mechanistic understandings to studies of sustained but lowintensity urban exposures in general.

OBJECTIVES

The objectives of this cross-sectional study were to determine whether adverse birth outcomes for fathers or 

mothers exposed to the GW are worse than for non-GW 

exposed persons.

The following hypotheses were tested:

1. Exposure to the GW is associated with increased 

risk for adverse birth outcomes.

2. Participants residing in Iraq during the GW report higher exposures than those that had left 

before the outbreak of the war.

3. There is a dose-response relationship between 

Ch and/or NCh exposures and adverse birth 

outcomes.

4. Specifi c environmental exposures, such as 

smoke from burning oil wells, are predictive of 

increased adverse birth outcome risks.

METHODS

Setting

In 2005, an elaborate community-based project was initiated to identify Iraqis residing in the region of metropolitan Detroit, Michigan, which has one of the largest populations of Iraqi immigrants and refugees in the 

country. The project was announced in Arabic and English using several means of communication, such as the 

Arabic radio and television. Flyers with project information were distributed at various Arab and ChaldeanAmerican community centers as well as faith-based 

facilities, convenience stores, restaurants, gas stations, 

hair salons, and community centers. The local Iraqi directory was also used to identify potential participants.

Participants

This recruitment drive resulted in a list of 5,490 addresses from which a random sample of 411 (7.5% of the entire 

sample) was selected for study inclusion. This allowed 

for a statistical power of 0.90, with a 2-sided P=.05 to 

detect a 30% difference between the 2 groups in the total number of adverse birth outcomes, assuming a mean 

of 1.5 adverse birth outcomes in the non-GW exposed 

group. The inclusion criteria were that participants were 

Iraqi-born and aged 18 years or older at the time they 

emigrated from Iraq. We chose one person from each 

household, irrespective of gender, based on the fi rst eligible person we contacted in that household. Of 411 addresses selected, 44 had no residents who fi t the study 

criteria. Of a total of 367 eligible candidates, 17 (4.6%) 

declined participation. The reasons were lack of time 

(n=9), lack of interest in the study (n=7), or no reason 

provided (n=1). A total of 350 qualifi ed families, each 

represented either by a man or woman, representing a response rate of 95%, accepted to take part in the study. Of 

these, 43 did not attempt a pregnancy during the period 

of interest, leaving a fi nal study group of 307 persons.

Participants who came to the United States from Iraq 

before 1991, and thus not exposed to the Gulf War, were 

classifi ed as “pre-GW.” Those arriving in 1991 or later 

who had been exposed to the Gulf War were classifi ed 

as “post-GW.”

Variables

The survey instrument used was initially created through 

a joint effort of the Iowa Persian Gulf Study Group and 

the Centers for Disease Control and Prevention to evaluate a broad range of health concerns among US Gulf 

War veterans, and was adopted and used in studies of 

Iraqi civilians and military.21-23

Data Source

Data was collected using the structured interview carried out in Arabic, typically in the participant’s home, 

by a team of female and male Iraqi-born obstetric and 

gynocology specialists.

Exposure Assessment

The respondents were asked in detail about their GWrelated exposures. The GW-specifi c environmental Ch 

and NCh factors included agents reported to be associated with symptoms of the “Gulf War Syndrome” reported by many GW veterans.24 Questions began with 

the following stem: “During the Gulf War did you have 

direct contact with any of the following exposure?” The 

respondents were asked about the following 16 environmental exposures (Ch):

 Smoke from oil burning fi res

 Exhaust from heaters or generators

 Diesel or other petrochemical fumes

 Burning trash or burning feces

 Diesel or other petroleum fuel on their skin

 Chemical agent resistant compounds (such as paint)

 Other chemicals such as solvents or petroleum 

substances

 Depleted uranium

 Direct skin contact with pesticides (creams, sprays, 

fl ea collars)

 Pesticides on clothing or bedding
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

 Nerve gas

 Mustard gas or other blistering agents

 Food contaminated with smoke or oil or other 

chemicals

 Local food other than food provided by the armed 

forces

 Bathe in or drink water contaminated with smoke 

oil or other chemical

 Bathe or swim in local ponds, rivers, or the Persian 

Gulf

Respondents were also asked to respond about their experiences with 9 war-related NCh (stress exposures):

 Exposure to dead animals

 Hearing chemical alarms

 Scud missiles exploding in the air or on the ground 

within one mile

 Artillery, rockets or mortars (anything other than 

Scud missiles) explosions within one mile

 Subjected/exposed to small arms fi re

 Seeing dead bodies

 Seeing maimed or seriously injured people

 Witness someone dying

 Any other war-related exposure the participant 

deemed to be harmful or stressful

These exposures were considered to be of suffi cient severity to fulfi ll the exposure criterion A for posttraumatic stress syndrome in the Diagnostic and Statistical 

Manual for Mental Health Disorders.

25

The Ch environmental score was calculated by aggregating respondent’s answers to the 16 environmental 

questions. For each specifi c Ch measure, the exposure 

status variable was multiplied by exposure duration 

(none, less than 5 days, 6 days to 30 days, more than 31 

days: coded as 0, 1, 2, and 3 respectively) to calculate 

the cumulative exposure Ch dose. The cumulative NCh 

stress scale scores were created using the same method. 

This allowed us to calculate the respective doses of Ch 

and NCh exposures.

The mean Ch environmental exposure was 3.56 units 

(SD=5.68, SE=0.32). The actual maximum Ch exposure 

score observed was 29 of a theoretical high of 48. Based 

on the mean, Ch exposure scores above 3.56 was classifi ed as high exposure, and below as low exposure. The 

mean for the NCh exposure scale was 4.58 (SD=5.68, 

SE=0.32) and an actual maximum of 23 (theoretical 

high of 27). An NCh exposure above 4.58 was classifi ed 

as high exposure and below 4.58 as low exposure. The 

Cronbach α for both scales was greater than 0.75.

OUTCOMES

Adverse birth outcomes were classifi ed as congenital 

anomalies, stillbirth, low birth weight, and preterm delivery. Stillbirth was defi ned as fetal death at 20 weeks 

gestation or greater; low birth weight as less than 2,500 

grams; and preterm delivery as delivery of the fetus before 37 weeks gestation.

Since the primary outcome was cumulative numbers of 

adverse birth outcomes, the 4 adverse birth outcome categories were combined into a composite adverse birth 

outcome scale score. In addition, each of the 4 adverse 

birth outcomes was separately analyzed against Ch and 

NCh exposure histories.

We examined reproductive health effects as a function 

of (a) whether respondents reported having lived in Iraq 

or not during the war, and (b) using the more complex 

Ch and NCh exposure scales. We used both specifi c adverse birth outcomes and aggregate adverse outcomes 

when determining the exposure-outcome association.

STATISTICAL ANALYSES

Nonpaired student’s t test was used to compare mean 

Ch and NCh exposures in the pre- and post-GW groups, 

respectively, as well as comparing scores across both 

groups on the adverse birth outcome scale. Student’s t

test was also used for comparing mean number of each 

of the 4 adverse birth outcomes by GW status. Levene’s 

test for equality of variance was checked for all these 

comparisons, and the appropriate t statistics were used. 

Mann-Whitney U tests were also used to compare groups. 

Both tests yielded the same results, therefore only student’s t tests are reported. The Ch and NCh scale scores 

were analyzed with one-way ANOVA. The Duncan 

multiple-range test was used to determine which of the 

total adverse birth categories were different from one 

another. Multiple linear regression analysis was used to 

study the relationship between dependent factors and 

independent Ch and NCh exposure scales, while controlling for gender, ethnicity (Arabic versus Chaldean), 

education, and smoking status. We checked the normal 

P-P plot of regression of standardized residuals. Stepwise logistic regression analysis was used to determine 

the relative contribution of each of the individual environmental items in the Ch scale, classifi ed as either present or absent, on each of the 4 adverse birth outcomes. 

There was no signifi cant association between NCh and 

outcomes after controlling for Ch and demographics. 

Consequently, those results are not reported.

Data was analyzed with SPSS for Windows v19.0 (SPSS 

Inc, Chicago, Ill). A P<.05 (2-tailed) was considered 

statistically signifi cant.

1991 GULF WAR EXPOSURES AND ADVERSE BIRTH OUTCOMES
 April – June 2013 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

RESULTS

Table 1 depicts the characteristics of the study participants by post-GW and pre-GW exposure status.

Figures 1 and 2 show participants’ mean total number 

of adverse birth outcomes as a function of self-reported 

Ch and NCh exposures. There was a signifi cant association between increasing Ch exposures and number of 

adverse birth outcomes.

Figure 3 depicts participants’ aggregate Ch and NCh exposure scores versus the period of immigration. Both 

Ch and the NCh scores were signifi cantly higher in the 

post-GW group.

Table 2 reveals that the prevalence of specifi c adverse 

birth outcomes by period of immigration to the United 

States is different only for those exposed to the GW, regardless of whether the child was born in Iraq or the 

United States.

Table 3 reports pregnancy outcomes following adjustment for demographics and smoking. The Ch environmental exposure scale explained 2.1% of the variance 

in total adverse birth outcomes. NCh exposures did not 

remain in the model once Ch exposure was added.

Participants with a history of high Ch environmental exposures were more than twice as likely to report adverse 

birth outcomes as compared to the low Ch exposure 

group (odds ratio 2.04 (95% CI, 1.12-3.74)). The ethnicity of the respondent (Chaldean versus Arab) was not 

associated with birth outcomes.

Table 4 depicts the odds ratio between each of the 4 adverse birth outcomes and specifi c war-related environmental exposures. Exposures to smoke from burning oil 

wells, water contaminated with petrochemical products, 

and mustard gas were all related to a signifi cantly increased risk in the reporting of adverse birth outcomes.

COMMENT

These results support our fi rst hypothesis that the prevalence of adverse birth outcomes is higher in participants 

having been exposed to the GW as opposed to participants that had left Iraq before the war. As hypothesized, 

both Ch and NCh exposures were higher in those residing in Iraq during the GW. However, counter to our hypothesis, only Ch, not NCh exposures, exhibited a doserelationship association with adverse birth outcomes.

Stillbirth exhibited the largest systematically increased 

risk when comparing the post-GW to pre-GW groups. 

Exposure to burning oil wells and water and food 

contaminated with petrochemical products during the 

GW appeared to be especially related to reproductive 

risks. This supports our last hypothesis that certain environmental exposures are more closely associated with 

adverse birth outcomes.

The current study supports the notion that war per se 

is a risk factor for adverse birth outcomes.11,12,14-20 One 

possible environmental culprit revealed in our fi ndings 

could be the documented exposure to up to 21 potential 

reproductive toxicants in persons residing in Iraq during 

Table 1. Demographic characteristics of study participants.*

Demographic Characteristic

(N=307)

Post-GW

(n1=185)

%n1

Pre-GW

(n2=122)

%n2

P value

Education - more than high school 56.8 69.2 .40

Smoker 30.0 39.3 .11

Employed 40.0 73.3 .00

Female respondents 48.4 38.5 .10

Covered by health insurance 76.3 60.7 .01

Income – higher than $10,000 39.1 14.9 .01

*The data includes both female and male respondents. Each male 

respondent reported the outcome of pregnancy of his wife. Single men 

and women were excluded from participation in the survey.

Figure 1. Total number of adverse birth outcomes in relationship to the chemical environmental exposure scale score. For 

the trend, P<.01.
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

the GW.5,16 The dose-response relationship between Ch 

exposure and adverse birth outcomes further supports 

the hypothesis that GW is associated with adverse birth 

outcomes. Theoretically, it is possible that nonchemical 

exposures, that is, stress in the post-GW group, contributes to our fi ndings of an increased risk for adverse birth 

outcomes by means of increased levels of the stress hormone cortisol. However, our fi ndings do not support this 

theory since NCh exposures were not related to adverse 

birth outcomes after controlling for Ch exposures and 

other sociodemographic risk factors.8,26,27

These fi ndings extend previous studies conducted in 

populations exposed to war, such as in Darfur, Kuwait, 

Bosnia and Herzegovina, and the September 11, 2001 

terrorist attacks, as well as nonwar-related exposures 

in communities that suffer high rates of environmental exposures, such as certain urban and immigrant 

communities.12,18,28,29

The percentage of stillbirth in the current study was 

higher; 216 per 1,000 births in women exposed to the GW 

versus 60 per 1,000 births among nonexposed women, as 

compared to offi cial Iranian 1995 statistics citing 24 per 

1000 in 1995.30 During the war in Darfur from 2003 to 

2007, a stillbirth rate of 29 per 1,000 births was reported 

for the Wad Medani Hospital in Central Sudan.28 Furthermore, Makhseed et al reported an increased percentage of low birth-weight babies in the Maternity Hospital 

of Kuwait during Iraq’s invasion of Kuwait from 1991 

and 1992, as compared to before 1991.18

Our fi nding of an association between Ch exposure and 

preterm delivery is in line with the report by Fatusić et 

al,12 who found an increased rate of preterm delivery during the war in Bosnia and Herzegovina, as compared to 

pregnancy outcomes after the confl ict had subsided.12,18

However, none of the prior war studies classifi ed type of 

Ch and NCh exposures.

With regard to specifi c exposure culprits, air pollution as 

well as ovarian and uterine irradiation in nonwar community settings has been associated with an increased 

risk of nonoptimal pregnancy outcomes.31,32 External exposures to pesticides, both occupational and residential, 

Figure 2. Total number of adverse birth outcomes in relationship to the nonchemical environmental (stress) exposure scale 

score. For the trend, P<.01.

Figure 3. Chemical environmental (all environmental) and 

nonchemical (all stress) exposure scales presented as functions of the period of the study participants’ immigration to 

the United States relative to the 1991 Gulf War.

1991 GULF WAR EXPOSURES AND ADVERSE BIRTH OUTCOMES
 April – June 2013 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

have been linked to stillbirth.26,27 Nonchemical related 

stress, as measured through maternal salivary cortisol 

and self-reports, has been associated with shorter pregnancies, although not necessarily preterm birth in a 

sample of nonwar-exposed persons.26

There are a number of limitations to the study that 

should be considered. The original survey was designed 

to cover a range of exposures and health outcomes, not 

just reproductive health. We lacked objective exposure 

and birth outcome measures. We also asked subjects 

to report on birth outcomes and exposures a number 

of years after the GW. This could attenuate true associations. Participants could also be unaware about personal exposures to “invisible” agents such as depleted 

uranium. Finally, the age of the participants when they 

were pregnant and the birth order of children remain unknown, factors that could possibly play some role.

CONCLUSION

The prevalence of adverse birth outcomes is increased 

in participants who resided in Iraq during the Gulf 

War as opposed to those that had left prior to the GW. 

Moreover, there is a dose-response relationship between 

war-related environmental exposures and total number 

of adverse birth outcomes. Certain chemical exposures 

appear to be more closely related to adverse birth outcomes. The study points to the importance of considering reproductive risks in pregnant mothers with a history of exposure to war.

ACKNOWLEDGEMENT

This study was supported in part by Award R01MH085793 

from the National Institute of Mental Health, National 

Institutes of Health (NIH), Bethesda, MD (Dr Arnetz, 

Dr Jamil), and by Award 1R34MH086943-01 from the 

National Institute of Mental Health, NIH (Dr Arnetz). 

Data collection was supported by a grant from Pfi zer Inc, 

New York.

The authors have no competing fi nancial interests.

The content of this article is solely the responsibility of 

the authors and does not necessarily represent the offi cial 

views of the National Institute of Mental Health, nor the 

National Institutes of Health.

This study was approved by the Wayne State University 

School of Medicine Investigative Review Board.

REFERENCES

1. Calafat A, Weuve J, Ye X. Exposure to bisphenol a and other phenols in neonatal intensive care 

unit premature infants. Environ Health Perspect. 

2009;117(4):639-644.

2. McEwen B, Tucker P. Critical biological pathways 

for chronic psychosocial stress and research opportunities to advance the consideration of stress 

in chemical risk assessment. Am J Public Health. 

2011;101(suppl1):S131-S139.

3. Stillerman K, Mattison D, Giudice L, Woodruff T. 

Environmental Exposures and Adverse Pregnancy 

Outcomes: A Review of the Science. Reprod Sci. 

2008;15(7):631-650.

4. Wisborg K, Kesmodel U, Henriksen T, Olsen S, 

Secher N. Exposure to tobacco smoke in utero and 

the risk of stillbirth and death in the fi rst year of 

life. Am J Epidemiol. 2001;154(4):322-327.

5. Shah PS, Balkhair T. Air pollution and birth 

outcomes: a systematic review. Environ Int. 

2011;37(2):498-516.

6. Pearce MS, Glinianaia SV, Ghosh R, et al. Particulate matter exposure during pregnancy is associated with birth weight, but not gestational age, 1962-

1992: a cohort study. Environ Health. 2012;11:13.

Table 2. Specifi c adverse birth outcomes by date of occurrence and GW exposure category.*

Adverse Pregnancy Outcome Post-GW

(n1=185)

%n1

Pre-GW

(n2=122)

%n2

P Value

Stillbirth - before 1991 11.6 11.1 1.00

Stillbirth - after 1991 21.6 6.0 .00

Congenital anomaly - before 1991 0.0 0.0 N/A

Congenital anomaly - after 1991 2.1 0.0 .30

Low birth weight - before 1991 1.6 2.6 .68

Low birth weight - after 1991 7.4 3.4 .21

Preterm delivery - before 1991 3.2 0.9 .26

Preterm delivery - after 1991 3.4 7.4 .21

*The data includes both female and male respondents. Each male 

respondent reported the outcome of pregnancy of his female partner.

Table 3. Chemical and nonchemical exposure predictors of 

aggregate number of adverse birth outcomes.

Variable Standardized

β

t P value R2

Step 1

Gender (ref=mena

) -0.183 -2.797 .006

Smoker (smokera

) 0.021 -1.437 .750

Education (less than 

high schoola

)

-0.086 -1.437 .152

Ethnicity (Araba,b) -0.185 -2.957 .003 0.112

Step 2

Chemical exposure 

scale scores

0.229 2.852 .005

Nonchemical exposure 

scale scores

0.024 0.296 .767 0.054

Total explained variance, R2= 0.166

Notes:

a. Ref indicates reference category.

b. Iraqi Arab vs Iraqi Chaldeans
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

7. Ghosh R, Rankin J, Pless-Mulloli T, Glinianaia S. Does the effect of air pollution 

on pregnancy outcomes differ by gender? a systematic review. Environ Res. 

2007;105(3):400-408.

8. Hobel C, Goldstein A, Barrett E. Psychosocial stress and pregnancy outcome. Clin Obstet Gynecol. 2008;51(2):333-348.

9. Koubovec D, Geerts L, Odendaal H, Stein D, 

Vythilingum B. Effects of psychologic stress 

on fetal development and pregnancy outcome. Curr Psychiatry Rep. 2005;7:274-280.

10. Walters DM, Breysse PN, Wills-Karp M. 

Ambient urban Baltimore particulate-induced airway hyperresponsiveness and infl ammation in mice. Am J Resp Crit Care. 

2001;164(8):1438-1443.

11. Arias E, MacDorman M, Strobino D, Guyer 

B. Annual summary of vital statistics. Pediatrics. 2002;112:1215-1230.

12. Fatusic Z, Kurjak A, Grquic G, Tulumovic 

A. The infl uence of the war on perinatal 

and maternal mortality in Bosnia and Herzegovina. J Matern Fetal Neonatal Med. 

2005;18(4):259-263.

13. Kang DS, Kahler LR, Tesar CM. Cultural 

aspects of caring for refugees. Am Fam Physician. 1998;57(6):1245-1256. Available at: 

http://www.aafp.org/afp/1998/0315/p1245.

html. Accessed January 28, 2013.

14. Seeds J, Peng T. Does augmented growth 

impose an increased risk of fetal death? Am J Obstet Gynecol. 2000;183:316-323.

15. Stellman SD, Stellman JM, Sommer J. Health and 

reproductive outcomes among American Legionnaires in relation to combat and herbicide exposure 

in Vietnam. Environmental Res. 1988;47:150-174.

16. Doyle P, Maconochie N, Davies G. Miscarriage, 

stillbirth and congenital malformation in the offspring of UK veterans of the fi rst Gulf War. Int J 

Epidemiol. 2004;33:74-86.

17. Kang H, Mahan C, Lee K, Magee C, Mather S, Matanoski G. Pregnancy outcomes among U.S. women 

Vietnam veterans. Am J Ind Med. 2000;38:447-454.

18. Makhseed M, el-Tomi N, Moussa MA, Musini 

VM. Post-war changes in the outcome of pregnancy in maternity hospital, Kuwait. Med War. 

1996;12(2):154-167.

19. Bem H, Firyal B-R. Environmental and health consequences of depleted uranium use in the 1991 Gulf 

War. Environ Int. 2004;30:123-134.

20. Cowan D, DeFraites R, Gray G, Goldenbaum M, 

Wishik S. The risk of birth defects among children of Persian Gulf War veterans. N Engl J Med. 

1997;336(23):1650-1656.

21. Dempsey B, Day A. The identifi cation of implicit 

theories in domestic violence perpetrators. Int J 

Offender Ther Comp Criminology. 2011;55(3):416-

429.

22. Jamil H, Nassar-McMillan S, Lambert R. The aftermath of the Persian Gulf War: mental health 

issues among Iraqi-American veterans. Ethn Dis. 

2005;15(1 suppl1):S1-S105.

23. Jamil H, Nassar-McMillan S, Lambert R, Wang 

Y, Ager J, Arnetz B. Pre- and post-displacement 

stressors and time of migration as related to selfrated health among Iraqi Immigrants and refugees in southeast Michigan. Med Confl Surviv. 

2010;26(3):207-222.

24. Bullman T, Kang H. The effects of mustard gas, 

ionizing radiation, herbicides, trauma and oil 

smoke on military personnel: the results of veteran 

studies. Annu Rev Public Health. 1994;15:69-90.

25. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, 

DC: American Psychiatric Association; 2000.

26. Jones A, Godfrey K, Wood P, Osmond C, Goulden 

P, Phillips D. Fetal growth and the adrenocortical 

response to psychological stress. J Clin Endocrinol 

Metab. 2006;91(5):1868-1871.

Table 4. Statistical relationships of specifi c adverse birth outcomes to 

environmental-specifi c exposures.

Adverse Birth

Outcome

Reported Environmental

Exposures

Odds

Ratio

95% CI P Value

Congenital birth 

defects

Diesel and other petrochemical fumes

17.00 1.50; 192.76 .021

Low birth weight Contact with/exposure to 

smoke from oil well fires

3.00 1.25; 7.18 .017

Exhaust from generators/

kerosene heaters

2.59 1.01; 6.69 .063

Contaminated water in local pond, river or the Gulf

3.87 1.30; 11.58 .028

Pre-term birth Contact with/exposure to 

smoke from oil well fires

3.26 1.34; 7.92 .012

Exhaust from generators/

kerosene heaters

3.50 1.38; 8.87 .013

Drinking water contaminated by smoke, oil or other 

chemicals

3.33 1.27; 8.74 .022

Contaminated water in local pond, river or the Gulf

4.12 1.37; 12.38 .022

Stillbirth Contact with/exposure to 

smoke from oil well fires

2.38 1.32; 4.27 .005

Exhaust from generators/

kerosene heaters

2.84 1.48; 5.44 .002

Diesel fumes/other petrochemical fumes

2.60 1.24; 5.45 .014

Burning trash/feces 2.91 1.154; 7.331 .028

Mustard gas 2.548 1.24; 5.23 .013

Ingested food contaminated by smoke, oil, or other 

chemicals

2.20 1.28; 3.78 .013

Note: CI indicates confidence interval.

1991 GULF WAR EXPOSURES AND ADVERSE BIRTH OUTCOMES
 April – June 2013 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

27. De Weerth C, Buitelaar J. Physiological stress reactivity in human pregnancy - a review. Neurosci 

Biobehav Rev. 2005;29:295-312.

28. Elhassan E, Mirghani O, Adam I. High maternal mortality and stillbirth in the Wad Medani 

Hospital, central Sudan, 2003-2007. Trop Doct. 

2009;39(4):238-239.

29. Lederman S, Rauh V, Weiss L, et al. The effects of the World Trade Center events on birth 

outcomes among term deliveries at three lower 

Manhattan hospitals. Environ Health Perspect. 

2004;112(17):1772-1778.

30. Cousens S, Blencowe H, Stanton C, Chou D, 

Say L, Lawn JE. National, regional, and worldwide estimates of stillbirth rates in 2009 with 

trends since 1995: a systematic analysis. Lancet. 

2011;377(9774):1319-1330.

31. Dolk H, Armstrong B, Lachowycz K. Ambient air 

pollution and risk of congenital anomalies in England. Occup Environ Med. 2010;67(4):223-227.

32. Signorello LB, Mulvill JJ, Green DM, et al. Stillbirth and neonatal death in relation to radiation 

exposure before conception: a retrospective cohort 

study. Lancet. 2010;376(9741):624-630.

AUTHOR AFFILIATIONS

Dr Arnetz: Department of Family Medicine and Public 

Health Sciences, Wayne State University School of Medicine, 

Detroit, Michigan; Wayne State University Institute for 

Environmental Health Sciences, Cardiovascular Research 

Institute, and Department of Public Health Sciences, 

Uppsala University, Uppsala, Sweden.

Dr Drutchas: Department of Family Medicine and Public 

Health Sciences, Wayne State University School of 

Medicine, Detroit, Michigan.

Dr Sokol: C.S. Mott Center, Department of Obstetrics and 

Gynecology, Wayne State University School of Medicine, 

Detroit, Michigan.

Mr Kruger: C.S. Mott Center, Department of Obstetrics 

and Gynecology, Wayne State University School of 

Medicine, Detroit, Michigan.

Dr Jamil: Department of Family Medicine and Public 

Health Sciences, Wayne State University School of 

Medicine, Detroit, Michigan.
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

Sand fl y control is essential for reducing the risk of human infection with Leishmania parasites, the etiological agents of visceral and cutaneous leishmaniasis (VL, 

CL, respectively). Across the Middle East and north 

Africa, phlebotomine sand fl ies occur in large numbers 

and with such a widespread distribution that transmitted 

Leishmania parasites cause an average of 350,000 cases 

of CL annually, representing 12% of the global burden.1

Despite this sizeable number, CL in that region is believed to be largely underreported and thus expected 

to be even more prevalent. Even in the absence of CL, 

large sand fl y populations have produced biting rates 

in excess of 1,000 bites per night on military bases in 

Iraq. The impact of this quantity of bites signifi cantly 

degrades the quality of life and operational readiness of 

deployed personnel.2

Confl icts with Soviet invaders, Taliban, and tribal 

groups have resulted in the destruction of the Afghan 

public health infrastructure, and mass migration of displaced persons, some with prior infection, from rural to 

urban areas where living conditions are inadequate. As 

a result, the incidence of CL in Afghanistan has been 

increasing for several decades and the increased presence of sand fl ies is conducive to greater numbers of CL 

cases.3

 Kabul’s population is presently estimated at 3.9 

million people, up from about one million in 1980 just 

after the Soviet invasion.4

 As of 2002, there were an estimated 200,000 CL cases in Kabul alone.5

 Such large 

numbers of CL cases put deployed service members at 

increased risk of infection.

Integrated methods of sand fl y control in desert environments include insecticide applications, habitat modifi cation (destruction of mammal reservoirs and their 

burrows), use of personal protective measures, such as 

insecticide-treated bed nets (ITNs), and topical- and 

clothing-applied arthropod repellents.6

 Ultra low volume 

Efficacy and Duration of Three Residual

 Insecticides on Cotton Duck and Vinyl Tent

 Surfaces for Control of the Sand Fly

 Phlebotomus papatasi (Diptera: Psychodidae)

Abdel Baset B. Zayed, PhD Barry D. Furman, PhD

CDR David F. Hoel, MSC, USN Jerome A. Hogsette, PhD

Reham A. Tageldin, MSc Ulrich R. Bernier, PhD

Emaldeldin Y. Fawaz, MSc

ABSTRACT

This study evaluated the toxicity and duration of 3 residual insecticides against the Old World sand fl y, Phlebotomus papatasi, an important vector of cutaneous leishmaniasis, on 2 types of tent material used by the US military 

in Afghanistan and the Middle East. Vinyl and cotton duck tent surfaces were treated at maximum labeled rates of 

lambda-cyhalothrin (Demand CS, Zeneca Inc, Wilmington, DE), bifenthrin (Talstar P Professional, FMC Corporation, Philadelphia, PA) and permethrin (Insect Repellent, Clothing Application, 40%), then subsequently stored in 

indoor, shaded spaces at room temperature (60%-70% relative humidity (RH), 22°C-25°C), and under sunlight and 

ambient air temperatures outdoors (20%-30% RH, 29°C-44°C). Insecticide susceptible colony fl ies (F110) obtained 

from the insectary of US Naval Medical Research Unit No. 3, Cairo, Egypt, were exposed to treated tent surfaces 

for 30 minute periods twice monthly for up to 5 months, then once monthly thereafter, using the World Health Organization cone assay. Lambda-cyhalothrin treated cotton duck tent material stored indoors killed P. papatasi for 8 

months, while the complementary sun-exposed cotton duck material killed adult fl ies for 1 month before the effi cacy 

dropped to less than 80%. Sand fl y mortality on permethrin- and bifenthrin-treated cotton duck decreased below 

80% after 2 weeks’ exposure to sunlight. Shade-stored permethrin and bifenthrin cotton duck material killed more 

than 80% of test fl ies through 5 months before mortality rates decreased substantially. Vinyl tent material provided 

limited control (less than 50% mortality) for less than 1 month with all treatment and storage regimes. Lambda-cyhalothrin-treated cotton duck tent material provided the longest control and produced the highest overall mortalities 

(100% for 8 months (shaded), more than 90% for 1 month (sunlight-exposed)) of both cotton duck and vinyl tents.
 April – June 2013 67

(ULV) space sprays, thermal fogging, 

and residual insecticide treatments 

comprise the chemical control methodologies for sand fl y control, and are 

used by military preventive medicine 

personnel to provide quick relief from 

biting insects.7,8 Insecticide treatment 

of immature sand fl ies is not practical, as large areas must be treated with 

backpack sprayers, and larval habitat 

is in many cases unknown. Rapid control of biting, adult female sand fl ies 

is more practical and critical to both 

reduction of nuisance biting and disease risk. Adult 

control is partly reliant upon space sprays and residual 

insecticide treatment of surfaces on which the fl ies rest. 

Habitat modifi cation, useful in some circumstances for 

long-term sand fl y control, requires continuous monitoring and environmental manipulation, is expensive and 

time consuming, and in general is only applicable for 

bases which will be in place for many years. Habitat 

modifi cation is not useful for decreasing biting insect 

pressure on more temporary bases, most often cost prohibitive, and in some cases illegal if protected wildlife is 

present or the host-nation will not allow it.9

Ultra low volume space spraying is the standard Department of Defense (DoD) response for control of biting 

sand fl ies. Some measure of control has been achieved 

with space spraying in the Middle East, however, ULV 

applications are not successful in providing long-term 

biting relief and effective disease control.10,11 Adult populations rebound quickly despite a lack of evidence that 

indicates resistance development to adulticides in Egypt. 

No documented instances of sand fl y resistance exists in 

the Middle East or Afghanistan.2,12

Residual insecticide treatment of sand fl y resting areas, 

especially on surfaces that shelter humans, offers longer 

lasting protection from biting sand fl ies than does ULV 

space spraying or application of topical and clothing 

repellents. Further, the residual insecticide treatments 

are simple to implement, due to the presence of insecticides and application equipment typically available to 

deployed preventive medicine personnel. As with ITNs, 

a surface treated with insecticide can deliver a lethal 

dose to host-seeking insects that rest on those surfaces. Advantages of residual insecticide applications over 

space spray measures (ULV and thermal fog) include 

long-term protection from a single treatment, serendipitous use of human odors as a means to draw sand fl ies 

toward treated surfaces, and savings in manpower and 

insecticide costs associated with not needing to perform 

repeated, nonresidual space spraying.7

Presently, over 180,000 US and NATO 

personnel are now serving in Leishmania-endemic areas in Afghanistan and 

the Middle East. Many of these troops 

are quartered in temporary shelters, 

often in tents (Figure 1). Recent model 

tents provide better protection from the 

environment than older tents because 

they are equipped with better fl ooring, 

screened windows and doors, and are 

often air conditioned. Cotton duck material was used for military tents several decades ago, but modern tents are 

constructed of vinyl due to improved protection from 

sunlight, wind, dust, and rain. Greater numbers of deployed personnel are now living in modular or hardened 

quarters than were at the beginning of Operations Enduring Freedom and Iraqi Freedom, when troops were 

originally quartered in tents lacking air conditioning 

or fl ooring, or simply slept under open sky. This may 

explain, in part, the increase of CL cases in Iraq and 

Afghanistan at the start of those wars, with a subsequent 

drop in the number of cases through the present.13 In 

situations where tents are used in place of buildings or 

containerized modules, “rubber” (vinyl) tents are most 

often used by deployed forces as command posts, dining 

facilities, administrative spaces, medical clinics, and for 

billeting in both permanent bases and smaller forward 

observation bases. Although cotton duck tenting is seldom used currently, it was the DoD tent mainstay prior 

to the introduction of vinyl tents and is still commonly 

used by rural populations and in refugee centers. Cotton duck liners are still present in the supply system 

along with general purpose, Tent, Extendable Modular 

Personnel (TEMPER), and Arctic tents that do not have 

vinyl surfaces.14

This study was designed to evaluate the effi cacy and longevity of 3 insecticides, stocked by DoD and available 

to deployed forces, used as residual treatments on cotton 

duck and water-repellent vinyl tent material. Colonized 

(susceptible) Phlebotomus papatasi (Scopoli) sand fl ies 

were exposed for 30 minutes to treated tent material every second week for 20 weeks, then once monthly, encompassing an 8-month period using the World Health 

Organization (WHO) cone bioassay in an attempt to 

determine which of 3 DoD-stocked pyrethroid insecticides was most useful for killing these fl ies and how 

long they lasted on cotton and vinyl tent surfaces before 

retreatment became necessary. This research is intended to benefi t people living or working in tents who are 

concerned about protecting themselves from biting sand 

fl ies and Leishmania infection in desert environments 

common to much of the Middle East and Afghanistan.

Figure 1. Vinyl extendable modular 

personnel tents used for transitional billeting, Kuwait, August, 2009.
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

MATERIALS AND METHODS

Sand Flies

A laboratory population of P. papatasi sand fl ies was 

used to study the effectiveness of insecticide-treated 

tent material. The fl ies (F110) were reared in the Vector 

Biology Research Program insectary, US Naval Medical 

Research Unit No. 3 (NAMRU-3), Cairo, Egypt. Flies 

were colonized by the procedure of Modi and Tesh,15 at 

27°C±2°C, 80%±10% RH, and a light:dark photo period of 12:12 throughout their development. Adults were 

offered 30% sugar solution daily, and provided blood 

meals on hamster, Pachyuromys duprasi Lataste for egg 

production. Three to fi ve-day old sand fl y females were 

used in this study.

Insecticides

Three insecticides were applied to tent materials at their 

highest labeled rates for residual fl y control: Demand 

CS (9.7% lambda-cyhalothrin, National Stock Number 

(NSN) 6840-01-428-6646) (Zeneca Inc, Wilmington, 

DE), Talstar P Professional (7.9% bifenthrin, NSN 6840-

01-525-6888) (FMC Corporation, Philadelphia, PA) and 

Insect Repellent, Clothing Application (40% permethrin, 

NSN 6840-01-334-2666). Although classifi ed and used 

as a repellent in the DoD supply system, permethrin is 

also an insecticide and is formulated for adult mosquito 

control as a ULV spray. The insecticides were chosen 

based on recommendations from the Armed Forces Pest 

Management Board’s “Standard Pesticides Available 

to DoD Components” list* and are used by preventive 

medicine personnel and pest control contractors.

Insecticide Stock Solution Preparation

Demand CS was mixed at the rate of 12 mL per 3.79 L 

(one gal) of water to produce a 0.03% solution for application to 92.9 m2

 (1,000 sq ft) of surface area. The 

resultant applied surface concentration was 1.2 μg/cm2

lambda-cyhalothrin. Talstar P Professional was mixed at 

the rate of 30 mL per 3.79 L of water to produce a 0.06% 

solution for application to 92.9 m2

 of surface area and 

produced a surface concentration of 1.9 μg/cm2

 bifenthrin. Insect Repellent, Clothing Application was mixed 

at the rate of 75 mL active ingredient per 3.79 L of water to produce a 0.5% solution, designed specifi cally for 

thorough treatment of 4 combat uniforms (half the rate 

of the 150.8 mL bottle developed for use with a 7.57 L 

(2-gal) sprayer). Cotton duck tent material was sprayed 

3 times, producing a moist and darkened surface without runoff, as recommended by the label. This treatment 

produced a surface concentration of approximately 94 

μg/cm2

, or 3⁄4 of the recommended cotton battle dress 

uniform fi nished concentration of 125 μg/cm2

.

Tent Material and Applications

Vinyl and cotton duck tent material were used for this 

study. Vinyl tent material was obtained from a desert 

TEMPER tent (NSN 8340-01-185-2628). These tents are 

comprised of 13.5 oz polyester duck and are standard 

use tenting for deployed US forces. The material is naturally water-repellent and is factory treated with a fl ame 

retardant. Due to the fl ame retardant fi nish, insecticide 

application on vinyl tenting is not recommended.14 However, we chose to treat vinyl tenting with insecticide to 

determine if any residual protection could be obtained. 

The cotton duck tent material was collected from a Tent, 

General Purpose, Medium (NSN 8340-543-7788) made 

from 9.85 oz cotton duck. In preparation for testing, the 

vinyl tent material was washed with soap and water. 

The cotton duck tent material was dry cleaned twice at a 

commercial cleaner using perchloroethylene to remove 

any insecticide residues from prior treatment.

Environmental treatments included shade-stored and 

sunlight-exposed treated tent. Shade-stored (sun protected) cotton duck and vinyl tent was kept on shelves 

inside the Vector Biology Research Program’s storage 

locker. Air conditioning resulted in consistent temperatures ranging from 22°C-25°C for the duration of the 

study. Sunlight-exposed test material was set on the roof 

of the Vector Biology Research Program building from 

June 2, 2009, through February 25, 2010, and exposed to 

temperatures ranging from 9°C-44°C.

Insecticides were applied with a 3.79 L compressed air 

sprayer (NSN 3740-00-191-3677) at a pressure of 50 psi 

to 55 psi while wearing appropriate personal protective 

equipment (vented goggles, half-face respirator with 

organic vapor cartridges, long sleeve shirt, neoprene 

gloves), to simulate insecticide application under fi eld 

conditions using equipment and insecticides readily 

available to military personnel. Tent material was cut 

into 30.5 cm by 61 cm strips, representing 1/500 of a 

92.9 m2

 treatment area (per label directions) (Figure 2). 

These two 1,860.5 cm2 strips were sprayed with 1/500 

of 3.79 L of solution (7.4 mL of fi nished product). To 

calibrate, 3.79 L of tap water was added to the 3.79 L 

sprayer, pressure brought to 50 to 55 psi with the nozzle inserted in a 100 mL graduated cylinder, and water 

sprayed until 7.4 mL of water was collected. Three replications averaged one second to obtain the required 7.4 

mL sample. During tent treatment, the nozzle was swept 

the length of 61 cm in one second to produce the desired 

concentration. At an application distance of 30.5 cm to 

38.1 cm, the fan nozzle covered a width of slightly more 

than 30.5 cm, the width of test strips. Both vinyl and 

*http://www.afpmb.org/sites/ default/fi les/pubs/standardlists/dod_pesticides_list.pdf

EFFICACY AND DURATION OF THREE RESIDUAL INSECTICIDES ON COTTON DUCK AND VINYL TENT 

SURFACES FOR CONTROL OF THE SAND FLY PHLEBOTOMUS PAPATASI (DIPTERA: PSYCHODIDAE)
 April – June 2013 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

cotton tent material were treated on horizontal concrete 

surfaces and allowed suffi cient time to air dry before 

packaging and shipping. Samples were treated at the US 

Department of Agriculture facility in Gainesville, FL, 

individually bagged in laminated cambric sample bags 

(Hubco, Hutchinson, KS), wrapped in duck 5 inch W 

stretch wrap, fi lm extensible (Lowe’s Home Improvement), and shipped to NAMRU-3. Testing commenced 

about a month after tent treatment, the time necessary 

to clear samples from airport inspectors and prepare the 

laboratory for sand fl y testing.

Bioassays

These assays followed the method described by WHO,16 

in which 4 WHO plastic cones were fastened to the 

treated tent liner. A batch of 60 fl ies per tent type/insecticide combination was tested, in 4 replicates of 15 

non–blood-fed female sand fl ies per cone. All fl ies were 

held in the cones for 30 minutes. After exposure, fl ies 

were placed in 150-ml plastic cups (15 individuals per 

cup), with a 30% sucrose solution provided, and maintained in a climatic chamber for 24 hours at 27°C±2°C 

and 80%±10% RH. Percentage mortality was scored 

after 24 hours, according to WHO cone assay criteria.16

All tests were performed with the same tent material/insecticide combination tent samples. Cone test sites were 

randomly selected on the same treated tent samples 

throughout the study.

RESULTS

Cotton Duck, Sunlight-Exposed

Lambda-cyhalothrin applied at maximum fl y control 

rates produced the highest level of mortality in sand fl ies. 

Sand fl y mortality remained above 80% for 4 weeks 

(93.3% mortality at week 4) before dropping off quickly 

to 65% at week 6, and declining to 41.6% at week 8 

when testing was stopped. Permethrin-treated cotton 

duck killed 78.3% of test fl ies on week 2, declined to 

65% mortality on week 4, and slowly receded to 33.3% 

morality on week 10 when testing was stopped. Bifenthrin-treated cotton duck killed 91.6% of test fl ies on 

day 0, 66% on week 2, and fell to 40% on week 6 at 

which time testing ended (Figure 3).

Cotton Duck, Shade-Stored

Shade-stored (sun-protected) cotton duck was kept on 

shelves inside the Vector Biology Research Program’s 

storage locker. Air conditioning was kept between 22°C25°C for the duration of the study. Lack of high temperatures with no sun exposure greatly extended the 

life of insecticides. Lambda-cyhalothrin treated cotton 

duck continued killing 100% of all test fl ies through 

the end of week 38, providing complete protection well 

into 8 months. Permethrin-treated cotton duck provided 100% mortality for test fl ies through week 8, killed 

86.6%, 91.6%, and 90% of fl ies on weeks 10, 12, and 

14 respectively, and killed all fl ies between weeks 16 and 24. Mortality then 

rapidly dropped off to 10% on week 28 

and fi nally 5% on week 32, when testing stopped. Bifenthrin provided 100% 

control of test fl ies through 6 weeks, 

killed between 90% and 96.6% of fl ies 

between weeks 8 and 16, and killed all 

test fl ies between weeks 18 and 22 before mortality rates dropped off quickly 

to 18.3%, 13.3%, and 15% on weeks 26, 

30, and 36, respectively. Time-mortality rates of sand fl ies exposed to shadestored, insecticide-treated cotton duck 

tenting is shown in Figure 4.

Figure 2. Vinyl tent strips (61 cm by 30.5 cm) used for residual 

insecticide effi cacy studies against the sand fl y Phlebotomus 

papatasi, a vector of cutaneous leishmaniasis in Afghanistan 

and the Middle East.

120

100 96.7 93.3100

78.3

91.7

80

100

ty

Lambda

Permethrin

Bifenthrin

65

41.7

65 60

46.7

66.7

41.7 40 40

60

rcent Mortalit

30

20

40

Per

0

Week 0 Week 2 Week 4 Week 6 Week 8

Time

Figure 3. Mortality rates of Phlebotomus papatasi to lambda-cyhalothrin-, permethrin-, and bifenthrin-treated, sunlight-exposed cotton duck tenting after initial 

treatment, May-July 2009.
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

Vinyl, Sunlight-Exposed

TEMPER (vinyl) tenting treated with candidate insecticides did not 

produce high mortality 

rates beyond the initial 

test day (day 0), and 

treatment effi cacy wore 

off quickly. Sunlightexposed, Lambda-cyhalothrin-treated vinyl 

killed 94% of test fl ies 

on day 0, 18.4% on week 

2, and 17.5% on week 

4 when testing ended. 

Permethrin-treated vinyl 

killed 12.2% of test fl ies 

on day 0, 2.4% on week 

2, and none on week 4, 

effectively ending that 

test. Bifenthrin-treated 

vinyl killed 10.2% of test fl ies on day 0, 37.5% on 

week 2, and 11.1% on week 4 at which time testing 

ended. Time-mortality rates of sand fl ies tested on 

sunlight-exposed, insecticide-treated vinyl tenting 

is shown in Figure 5.

Vinyl, Shade-Stored

Vinyl tenting treated with insecticide and stored 

on shelves in work space conditions (no sunlight, 

22°C-25°C ambient temperatures) provided higher 

mortality in sand fl ies than did sunlight-exposed 

vinyl tenting (Figure 5). Lambda-cyhalothrintreated vinyl killed all test fl ies on day 0 and 59% 

on week 2 before falling off to 37.5% on week 4, 

the fi nal test date. Permethrin-treated vinyl killed 

29.3% of test fl ies on day 0, 11.1% on week 2, and 

10% on week 4, when testing ended. Bifen-thrintreated vinyl killed 11.1% of test fl ies on 

day 0, 26.1% on week 2, and 6.5% on 

week 4, the fi nal test date. Time-mortality 

rates of sand fl ies tested on shade-stored, 

insecticide-treated vinyl tenting is shown 

in Figure 6.

COMMENT

The application of residual insecticides 

on insect resting surfaces is an important 

component of programs designed to protect humans from disease-carrying arthropods. In troop deployment situations, 

displaced persons, or refugee camps, or on 

short-term contingencies or emergencies 

in which minimal preparation is afforded 

Figure 4. Mortality rates of Phlebotomus papatasi to lambda-cyhalothrin-, permethrin-, and bifenthrin-treated, shade-stored cotton duck tenting after initial treatment, May 2009-June, 2010.

Notes:

*Week 28 result for permethrin only. Week 26 results of lambda-cyhalothrin and bifenthrin included in 

week 28 chart (no data on week 28).

**Week 30 results for lambda-cyhalothrin and bifenthrin. Permethrin result for week 32 included in 

week 30 graph (no data on week 30).

***No week 36 data for permethrin.

100 96.7 100 100 100 100 100 100 100 100 100 100

93.3 95

100

80

100

120

ty 40

60

80

ercent Mortalit

Lambda

Permethrin

Bifenthrin

10

5

18.3

13.3 15

0

20

40 Pe

Week 0 Week 8 Week 16 Week 22 Week 28* Week 30** Week 36***

Time

Figure 5. Mortality rates of Phlebotomus papatasi to lambda-cyhalothrin-, permethrin-, and bifenthrin-treated, sunlight-exposed vinyl 

tenting after initial insecticide application, May-June, 2009.

94

40 37.5

50

60

70

80

90

100

cent Mortality

Lambda 

Permethrin 

Bifenthrin 

18.4 17.5

12.2

2.4 0

10.2 11.1

0

10

20

30

Week 0 Week 2 Week 4

Perc

Time

Figure 6. Mortality rates of Phlebotomus papatasi to lambda-cyhalothrin-, permethrin-, and bifenthrin-treated, shade-stored vinyl tenting after initial insecticide application, May-June, 2009.

120

100

80

100

ty

Lambda 

Permethrin 

59

37 5 40

60

cent Mortali

Bifenthrin 

37.5

29.3 26.7

11.1 10

26.1

6.5

20

40

Per

0

Week 0 Week 2 Week 4

Time

EFFICACY AND DURATION OF THREE RESIDUAL INSECTICIDES ON COTTON DUCK AND VINYL TENT 

SURFACES FOR CONTROL OF THE SAND FLY PHLEBOTOMUS PAPATASI (DIPTERA: PSYCHODIDAE)
 April – June 2013 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

those tasked to respond, residual insecticide application 

to berthing and work spaces takes on increased importance. It has been found that in high temperature, low 

humidity desert climates common to North Africa, the 

Middle East, and much of Afghanistan, DoD-stocked 

residual insecticides can provide long-term protection 

from sand fl ies if applied to shaded, indoor surfaces.2,6

Lambda-cyhalothrin, permethrin, and bifenthrin are 

the active ingredients in many commonly used insecticides in the United States and overseas, and are often 

used as residual sprays for controlling arthropod pests. 

Our results indicated that cotton duck tent material unquestionably provides a better substrate for insecticide 

retention than does vinyl tent material, and will provide 

much longer protection against biting sand fl ies with 

both indoor and outdoor (sunlight-exposed) treatments. 

Lambda-cyhalothrin, a second generation pyrethroid 

insecticide, has an alpha-cyano group side chain that 

provides additional stability to the compound against 

ultraviolet degradation and hydrolysis,17 whereas permethrin and bifenthrin lack this side chain and are more 

susceptible to environmental photodegradation.18 Also, 

lambda-cyhalothrin formulated as Demand CS is microencapsulated, which provides further protection against 

environmental degradation. The permethrin and bifenthrin test products were not microencapsulated. Residual treatment of shade-stored, cotton duck tenting 

with lambda-cyhalothrin, (which is representative of a 

scenario involving the interior walls of a tent in a fi eld 

setting), provided the longest duration of control of P. 

papatasi, a common sand fl y vector of CL throughout 

most of the aforementioned region. Under this regimen, 

all exposed sand fl ies were killed throughout 38 weeks 

of bioassay testing, although the end point was set at 6 

months (26 weeks).

Effective and extended control (greater than 80%) was 

produced by permethrin on shade-stored cotton duck 

through 24 weeks of testing. The effi cacy dropped rapidly to 10% on week 28 and then to 5% on week 32, 

when testing was discontinued. Bifenthrin also provided 

greater than 80% test fl y mortality through 22 weeks, 

then decreased suddenly on week 26, similar to results 

obtained with permethrin. We concluded that all 3 products are useful as long lasting residuals on cotton tenting, 

provided indoor surfaces were treated. However, while 

both permethrin and bifenthrin provided satisfactory 

control under such conditions, our results clearly indicate that when available for indoor use on cotton duck 

tenting, lambda-cyhalothrin is the best choice.

Cotton duck tent treated with all test products and exposed to sunlight provided high levels of mortality for 

only about a month, after which effi cacy dropped quickly. Availability of cotton duck military tents is now the 

exception rather than the rule. Cotton duck tents are 

sometimes found in material storage buildings on bases 

and are being replaced with vinyl tents when they reach 

the end of their service life. However, there are nonvinyl 

TEMPER tents, arctic tents, and tent liners used by the 

armed forces. Once residual treatment has been applied, 

any of the three aforementioned nonvinyl products could 

provide useful protection against biting sand fl ies, especially in temperate climates with short sand fl y seasons, 

such as is common in Afghanistan.

Insecticide-treated vinyl tenting exposed to direct sunlight provided no noteworthy protection against host 

seeking P. papatasi. The effi cacy of lambda-cyhalothrin 

dropped from 94% on day 0 to 18.4% on week 2 and 

17.5% on week 4 when testing was discontinued. Just 

over 30 days had elapsed from the time of insecticide 

application to the beginning of the test, day 0. The 94% 

kill rate on day 0 demonstrated that the insecticide application had worked, albeit for a very short while once 

lambda-cyhalothrin was exposed to sunlight. In contrast, sunlight-protected lambda-cyhalothrin-treated vinyl tent killed all test fl ies on day 0 and 59% on week 

2 before falling off to 37.5% on week 4, the fi nal test 

date. Although protection was less than desirable during 

weeks 2 and 4 (less than 80%), some short-term protection against biting sand fl ies was obtained and will supplement other personal protective measures in the fi eld 

(N,N-Diethyl-3-methyl benzamide (deet) skin repellent, 

permethrin-treated bed nets and uniforms). Permethrin 

and bifenthrin-treated vinyl tenting failed to control 

more than 30% of test fl ies at any point in time (days 0, 

14, 30), regardless of exposure to sunlight.

The Armed Forces Pest Management Board Technical 

Guide No. 3614 does not recommend treating vinyl TEMPER tenting with insecticide. The fi re retardant added 

to an already water-repellent vinyl surface impedes the 

uptake of insecticide, as clearly seen from these tests. 

However, some protection is gained for approximately 

a month if the interior surfaces of a TEMPER tent are 

treated with lambda-cyhalothrin. In areas where biting 

pressure is very high and bites can exceed several hundred per night, the added value of treating the inside of 

TEMPER tents for short deployments is obvious.2

Our results indicated that, at best, lambda-cyhalothrintreated vinyl tent provided minimal control (from 100% 

control on day 0 to approximately 35% control on day 

30) of host-seeking P. papatasi under shaded conditions (no direct sunlight exposure). Permethrin- and 

bifenthrin-treated vinyl surfaces offered no appreciable 
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

protection against host seeking sand fl ies. Nonvinyl tent 

material, if available as cotton duck tent liners or tent 

surfaces, can greatly aid in protection against sand fl ies 

under hot, sunlight-exposed and cooler, shaded conditions. All 3 insecticides gave excellent protection (greater than 90%) for at least 5 months when used indoors. 

Under short deployment conditions (less than 30 days), 

Demand CS will enhance proven personal protective 

measures (deet skin repellent, permethrin-treated bed 

nets) against biting sand fl ies when applied to the interior surfaces of vinyl tents.

REFERENCES

1. World Health Organization. Cutaneous Leishmaniasis [online]. Geneva, Switzerland: World Health 

Organization Press; 2007. WHO/CDS/NTD/

IDM/2007.3. Available at: http://whqlibdoc.who.

int/hq/2007/WHO_CDS_NTD_IDM_2007.3_eng.

pdf. Accessed December 13, 2012.

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

of phlebotomine sand fl ies on US military operations at Tallil Air Base, Iraq: 1. background, military situation, and development of a “Leishmaniasis 

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

662.

3. Reithinger R, Mohsen M, Aadil K, Sidiqi M, Erasmus P, Coleman PG. Anthroponotic cutaneous 

leishmaniasis, Kabul, Afghanistan. Emerg Infect 

Dis. 2009;9:727-729.

4. Afghanistan Statistical Yearbook 2010/11 [online]. 

Kabul, Afghanistan: Government of Afghanistan 

Central Statistics Organization; 2012. Available at: 

http://cso.gov.af/en/page/4725. Accessed December 

13, 2012.

5. World Health Organization. Cutaneous leishmaniasis, Afghanistan. Wkly Epidemiol Rec.

2002;77(29):246. Available at: http://www.who.int/

docstore/wer/pdf/2002/wer7729.pdf. Accessed December 13, 2012.

6. Alexander B, Maroli M. Control of phlebotomine 

sand fl ies. Med Vet Entomol. 2003;17:1-18.

7. Robert LL, Perich MJ. Phlebotomine sand fl y 

(Diptera: Psychodidae) control using a residual 

pyrethroid insecticide. J Am Mosq Control Assoc.

1995;11:195-199.

8. Perich MJ, Hoch AL, Rizzo N, Rowton ED. Insecticide barrier spraying for the control of sand fl y 

vectors of cutaneous leishmaniasis in rural Guatemala. Am J Trop Med Hyg. 1995;52:485-488.

9. Robert LL, Perich MJ, Sclein Y, Jacobson RL, 

Wirtz RA, Lawyer PG, Githure JI. Phlebotomine 

sand fl y control using bait-fed adults to carry the 

larvicide Bacillus sphaericus to the larval habitat. 

J Am Mosq Control Assoc. 1997;13:140-144.

10. Maroli M, Khoury C. Current approaches to the 

prevention and control of leishmaniasis vectors. 

Vet Res Commun. 2006;30(suppl1):49-52.

11. Orshan L, Szekely D, Schnur H, Wilamowski A, 

Garler Y, Bitton S, Schlein Y. Attempts to control 

sand fl ies by insecticide-sprayed strips along the periphery of a village. J Vector Ecol. 2006;31:113-117.

12. Tetreault GE, Zayed AB, Hanafi HA, Beavers GM, 

Zeichner BC. Susceptibility of sand fl ies to selected 

insecticides in North Africa and the Middle East. J 

Am Mosq Control Assoc. 2001;17:23-27.

13. Aronson NE. Leishmaniasis in relation to service 

in Iraq/Afghanistan, US armed forces, 2001-2006. 

MSMR. 2007;14(1):2-5. Available at: http://afhsc.

mil/viewMSMR?fi le=2007/v14_n01.pdf. Accessed 

December 14, 2012.

14. AFPMB Technical Guide No. 36: Personal Protective Measures Against Insects And Other Arthropods Of Military Signifi cance. Washington, DC: 

Armed Forces Pest Management Board; October 

2009. Available at: http://www.afpmb.org/sites/de

fault/fi les/pubs/techguides/tg36.pdf. Accessed December 13, 2012.

15. Modi, GB, Tesh RB. A simple technique for mass 

rearing Lutzomyia longipalpis and Phlebotomus 

papatasi (Diptera: Psychodidae) in the laboratory. 

J Med Entomol. 1983;20:568-569.

16. World Health Organization. Guidelines for testing 

mosquito adulticides for indoor residual spraying 

and treatment of mosquito nets. Geneva, Switzerland: World Health Organization Press; 2006. 

WHO/CDS/ NTD/WHOPES/GCDPP/2006.3. 

Available at: http://whqlibdoc.who.int/hq/2006/

WHO_CDS_NTD_WHOPES_GCDPP_2006.3_

eng.pdf. Accessed December 14, 2010.

17. He LM, Troiano J, Wang A, Goh K. Environmental 

chemistry, ecotoxicity, and fate of lambda-cyhalothrin. Rev Environ Contam Toxicol. 2008;195:71-91.

18. World Health Organization. Data Sheet on Pesticides No. 51. Permethrin. Geneva, Switzerland: 

World Health Organization Food and Agriculture 

Organization; 1984. VBC/DS/84.51. Available at: 

http://www.inchem.org/documents/pds/pds/pest

51_e.htm. Accessed December 14, 2012.

AUTHOR AFFILIATIONS

Dr Zayed - NAMRU-3, Cairo, Egypt; Dept of Zoology, Faculty 

of Science, Al-Azhar University (Girls Branch), Cairo.

CDR Hoel - CDC Detachment, Navy and Marine Corps 

Public Health Center, Atlanta, Georgia.

Mr Fawaz and Ms Tageldin - NAMRU-3, Cairo, Egypt.

Dr Furman - Dept of Biology, San Jacinto College, Pasadena, 

Texas.

Dr Hogsette and Dr Bernier - US Dept of Agriculture Center 

for Medical, Agricultural, and Veterinary Entomology, 

Gainesville, Florida.

EFFICACY AND DURATION OF THREE RESIDUAL INSECTICIDES ON COTTON DUCK AND VINYL TENT 

SURFACES FOR CONTROL OF THE SAND FLY PHLEBOTOMUS PAPATASI (DIPTERA: PSYCHODIDAE)
April – June 2013 73

Adult fi lth fl ies pose a health risk to humans by mechanically transmitting a wide variety of viral, bacterial, and 

protozoal pathogens.1

 Species in the families Muscidae, 

Calliphoridae, and Sarcophagidae are of particular interest to military vector control specialists because of 

their ability to rapidly degrade troop health through mechanical transmission of enteric pathogens such as the 

causal agents of dysentery and cholera.2-4 Additionally, 

signifi cant populations create a nuisance that can degrade mission readiness of deployed personnel. Baited 

fl y traps have been used in many fi lth fl y management 

programs as surveillance devices but seldom as control 

devices in the United States due to the offensive odor 

of attractants. They are used as control devices in other 

parts of the world but the large number of traps required 

to suppress adult fl y populations, their associated odors, 

and the maintenance necessary to keep these traps operational make them impractical for fl y control in the 

United States.5

Fly traps are an integral part of a fi lth fl y management 

program for US military forces deployed overseas.4

Traps with baits such as Flies Be Gone* (Combined 

Distributors, Inc, Jackson, NJ) that capture fl ies in a 

bag may not be optimal for success during contingency 

operations because the traps fi ll quickly and additional 

fl ies cannot be captured. Also, this trap is not designed 

to be reused and is typically discarded after a single 

use. There are reusable fl y traps in the military supply 

system, such as the Fly Terminator Pro trap†

 (Farnam 

Companies, Inc, Phoenix, AZ), that consistently capture 

large numbers of fl ies in fi eld trials.6

 However, this trap 

must also be routinely emptied and rebaited for maximum effectiveness.

An alternative to the physical capture of fl ies alone is the 

“attract and kill” insect control strategy.7,8 This strategy 

Evaluation of Imidacloprid-Treated Traps as an

 Attract and Kill System for Filth Flies During

 Contingency Operations

LT James C. Dunford, MSC, USN Kelly R. Dunford, PhD

CDR David F. Hoel, MSC, USN LCDR Craig A. Stoops, MSC, USN

LT Jeffrey C. Hertz, MSC, USN CDR Daniel E. Szumlas, MSC, USN

LT David B. England, MSC, USN Jerry A. Hogsette, PhD

ABSTRACT

Two fi eld trials were conducted to evaluate if fi lth fl y trap effi cacy was increased by augmentation with an 

insecticide application to the trap’s exterior. Four Fly Terminator Pro traps (Farnam Companies, Inc, Phoenix, 

AZ) baited with Terminator Fly Attractant (in water) were suspended on polyvinyl chloride pipe framing at a 

municipal waste transfer site in Clay County, Florida. The outer surfaces of 2 traps were treated with Maxforce 

Fly Spot Bait (Bayer Environmental Science, Research Triangle Park, NC) (10% imidacloprid) to compare 

kill rates between treated and untreated traps. Kill consisted of total fl ies collected from inside traps and from 

mesh nets suspended beneath all traps, both treated and untreated. Each of 2 treated and untreated traps was 

rotated through 4 trap sites every 24 hrs. In order to evaluate operational utility and conservation of supplies 

during remote contingency operations, fl y attractant remained in traps for the duration of the fi rst trial but was 

changed daily during the second trial (following manufacturer’s recommendations). In addition, 1⁄2 strength 

Terminator Fly Attractant was used during the fi rst trial and traps were set at full strength during the second 

trial. Flies collected within the traps and in mesh netting were counted and identifi ed. Three species, Musca 

domestica (L.), Chrysomya megacephala (F.), and Lucilia cuprina (Wiedemann), comprised the majority of 

samples in both trials. The net samples recovered more fl ies when the outer surface was treated with imidacloprid, however, treated traps collected fewer fl ies inside the trap than did untreated traps for both trials. No 

signifi cant statistical advantage was found in treating Fly Terminator Pro trap exteriors with Maxforce Fly Spot 

Bait. However, reducing manufacturer’s recommended strength of Terminator Fly Attractant showed similar 

results to traps set at full strength. Treating the outer surfaces may improve kill of fl y species that do not enter 

the trap. Terminator Fly Attractant was also found to be more effective if traps were not changed daily and left 

to hold dead fl ies for longer periods.

*National Stock Number (NSN): 3740-01-523-0708

†NSN: 3740-01-561-9678
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

combines visual and/or chemical attractants with insecticides to lure target insects to traps and expose them to 

a lethal dose of insecticide before they can escape. Thus, 

if a trap is full and cannot physically capture additional 

fl ies, the fl ies that alight on the trap receive a lethal dose 

of insecticide, increasing the trap kill beyond what can 

be physically held in the trap. Some of these systems 

have been previously evaluated against fi lth fl ies with 

varying degrees of success, but additional research is 

needed to determine the residual effi cacy and environmental degradation of the specifi c insecticides used in 

attract and kill systems.9

Treating a fi lth fl y trap with an insecticide may not result in increased kill. Some plastic trap materials might 

be diffi cult to treat with residual insecticides because 

water-based insecticides often leave little residue on the 

surfaces of water-repellent plastics. Also, some commonly used pyrethroid insecticides have high excitoirritancy properties that may negate the impact of the 

trap’s attractants,10 lessening the trap’s effectiveness. 

Several newer insecticides contain attractants, such as 

Maxforce Fly Spot Bait (Bayer Environmental Science, 

Research Triangle Park, NC) (active ingredient 10% imidacloprid), a sugar-baited fl y insecticide. Imidacloprid is 

a member of a new class of insecticides (neonicotinoids), 

and has been shown to have exceptional potency with 

generally low toxicity to mammals, birds, 

and fi sh.11

In contingency and rapid deployment military operations, vector control personnel 

must reduce fl y numbers quickly with a 

minimal amount of material and equipment. 

The ability to store large amounts of vector 

control supplies is frequently hindered by 

limited storage space, and manpower necessary to routinely service and maintain trapping mechanisms is often limited during 

contingency operations. Ideally, the effectiveness of fi lth fl y traps could be enhanced 

by treating them with insecticides available 

to preventive medicine personnel. If this is possible, it 

would better serve to protect human health from fi lth 

fl y-borne diseases not only during military fi eld operations, but also in natural disaster operations and in refugee camps, both of which are increasingly involving US 

military assistance. The objectives of this study were to 

examine various application techniques using 2 fl y control products to improve overall kill, including:

 Evaluate the effi cacy and selectivity of fl y species 

captured using a fi lth fl y trap augmented with a fl yspecifi c insecticide under fi eld conditions.

 Determine whether the addition of insecticide to 

the exterior of this trap increases fl y kill over traps 

used without insecticide.

 Compare fl y capture and kill totals of traps in which 

Terminator Fly Attractant was not changed versus 

attractant changed daily.

 Determine if reducing the manufacturer’s recommended strength to conserve supplies would result 

in satisfactory kill.

MATERIALS AND METHODS

Traps and Toxicant

The Fly Terminator Pro trap, shown in the mounting assembly in Figure 1, was selected for the fi eld trials because of its simplistic design, durability characteristics, 

and demonstrated effi cacy.6

 The Fly Terminator Pro is a 

reusable, fairly inexpensive, (one gallon) trap capable of 

capturing large numbers of fi lth fl ies and is baited with 

a potent chemical attractant (Terminator Fly Attractant). 

We chose Maxforce Fly Spot Bait* (10% imidacloprid) 

for our insecticide because it is a sugar-baited fl y insecticide with quick knockdown potency that might prove 

useful in attract and kill systems.

Trap Design

Four Fly Terminator Pro traps were placed on an Aframe structure consisting of 2.54 cm polyvinyl chloride (PVC) pipe joined with 25.4 

cm tie bands into a pyramid arrangement with the trap opening 

set approximately 50 cm below 

the apex of the pyramid and the 

trap bottom suspended approximately 50.8 cm above ground as 

shown in Figure 1. Traps were 

sheltered from rain with a circular 30.5 cm diameter aluminum 

pan. White tulle mesh netting 

was secured to the PVC pipes 

with binder clips to capture dead 

or moribund fl ies that came into 

contact with imidacloprid on the 

outer surface of the traps.

Field Site and Trap Positions

The fi eld site was located at the Rosemary Hill Solid 

Waste Management Facility, located 16 km west of Green 

Cove Springs, Clay County, Florida (UTM 17 428643E; 

33 18906N). Four trap sites were located around the 

fenced perimeter of the waste transfer building, which 

is on an earthen mound about 10 m above the surrounding landscape. Each trap site varied slightly with respect 

EVALUATION OF IMIDACLOPRID-TREATED TRAPS AS AN ATTRACT AND KILL SYSTEM

FOR FILTH FLIES DURING CONTINGENCY SETTINGS

*NSN: 6840-01-555-9369

Figure 1. Fly trap and stand. Pyramid arrangement enabled use of the rain shield 

while keeping the trap at a useful height 

and minimizing ant contamination.
 April – June 2013 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

to environmental parameters, and each site was at least 

20 m from the nearest trap site at the 4 corners of a square 

confi guration as illustrated in Figure 2. Site 1 was located in partial shade closest to the waste transfer building 

where it was sheltered from the wind. Site 2 was located 

in a fairly open area between oleander bushes. Site 3 was 

surrounded by oleander and somewhat sheltered from 

the wind, while Site 4 was free of vegetation, received 

the greatest effects of the wind, and was not shaded.

Experiment Design

Insecticide application and trapping design comparisons 

for Trials 1 and 2 are shown in Table 1. For Trial 1, the outer surfaces of 2 of the 4 traps were treated with Maxforce 

Fly Spot Bait formulated at the label rate (16 fl oz insecticide per gallon (473 mL/3.79 L) of water, prepared at the 

start of the trial) and applied with a one liter trigger-grip 

spray bottle until runoff at the beginning of each trial. 

The interior of each trap was also baited with Terminator 

Fly Attractant at 1⁄2 the manufacturer’s recommended 

strength (0.5 fl oz/gal (14.8 mL/3.70 L) water). The bait 

was not refreshed during the trial. Treated and untreated 

traps were placed in an alternating design at sites 1-4, 

left at the site for 24 hours, and then rotated clockwise to 

the next site. This was done daily for 7 days from June 

18 through June 25, 2008. Following precipitation events, 

the outer surfaces of 2 treated traps were re-treated with 

Maxforce Fly Spot Bait on June 19 and June 23 using the 

same mixture on both dates. Dead fl ies were collected 

from the netting daily (9 AM to 11 AM) and the contents of 

each trap was collected on June 25. A subset of either 1⁄4 

or 1⁄2 of the total trap catch was collected when the trap 

catch exceeded transfer container capacity.

The second fi eld trial was conducted from July 29 

through August 8, 2008. Traps were placed in the fi eld 

and rotated as previously described. The outer surfaces 

of 2 traps were treated daily from July 29-31, and August 4-7 with Maxforce Fly Spot Bait, formulated and 

applied as described earlier, with new mixtures prepared 

on July 29 and August 4. Each trap was baited interiorly 

with Terminator Fly Attractant at full strength per manufacturer label (1 fl oz/gal (29.8 mL/3.79 L) water) and 

emptied and refreshed with a new mixture of attractant 

daily from July 29-31 and August 4-7. Dead fl ies were 

collected from the traps and netting from 9 AM to 11 AM. 

Temperature, relative humidity, and rainfall events were 

recorded daily during both trials.

Collection and Processing of Samples

For both trials, trap contents were emptied into collection pans and fl uid was discarded. Netting samples were 

placed in vials. All trap and netting samples were returned to the Navy Entomology Center 

of Excellence (NECE) laboratory at the 

Naval Air Station Jacksonville, Florida, 

and stored in a freezer at -29°C until 

counting and specimen identifi cation 

could be accomplished. A subset from 

throughout the entire catch (either 1⁄4 or 

1⁄2 depending on total trap catch) of fl ies 

taken from within the traps was subsequently counted and specimens were 

identifi ed to species. The total number 

of specimens counted and identifi ed 

was then multiplied by the respective 

number of times that original samples 

were divided (either by 1⁄4 or 1⁄2). Dipterans occurring in small numbers (fewer 

than 25) were not identifi ed to species. 

Other insect orders occurred only in 

very low numbers relative to dipteran 

species and there was no attempt to 

Figure 2. Plan view of fl y trap positioning scheme at the 

Rosemary Hill Solid Waste Management Facility.

Covered Building

Open Area

Table 1. Experimental design and test dates of Trials 1 and 2, Rosemary Hill

Solid Waste Management Facility, Clay County, Florida (17 428643E; 33 18906N).

Trial 1

June 18-25, 2008

Trial 2

July 29-August 8, 2008

Interior trap bait (Terminator Fly Attractant) concentration in water

0.5 fl oz/gal (1⁄2 

manufacturer’s 

recommendation)

1 fl oz/gal (full manufacturer’s recommendation)

Interior bait refresh Not refreshed during 

entire trial

July 29, 30, 31

August 4, 5, 6, 7*

Exterior bait (Maxforce Fly 

Spot Bait) preparation 

dates (label concentration, 

16 oz/gal water)

June 18 July 29 and August 4

Exterior trap surface bait 

treatments June 18, 19, 23 July 29, 30, 31August 4, 5, 6, 7*

Collections

Traps–June 25

Nets–Daily during each 

visit

Traps–July 30, 31,

August 1

Nets–August 5, 6, 7, 8

Trap rotation Rotated clockwise each 

daily visit

Rotated clockwise each 

daily visit

*No traps were set August 1, 2, 3.
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

identify those specimens beyond order. Voucher specimens were placed in the NECE insect collection.

Data Analysis

The effects of independent variables (treated/untreated 

and net/trap) on the number of fl ies captured were assessed using a mixed model repeated measures ANOVA 

with data normalized via log (n+1) transformation before analysis (Proc MIXED, SAS 9.2; SAS Institute Inc., 

Cary, NC). Further analyses (slice option within Proc 

MIXED, SAS 9.2) were conducted to determine the effects of trap device and insecticide application, and their 

interaction on fl y kill.

RESULTS

It is estimated that nearly 20,000 fl ies were collected 

during this study. Three species, Musca domestica (L.) 

(Muscidae), Chrysomya megacephala (F.) (Calliphoridae), and Lucilia cuprina (Wiedemann) (Calliphoridae), 

comprised the majority of species collected from the 

trap units as show in Figure 3. A small number of other 

dipteran species, including the stable fl y Stomoxys calcitrans (L.) and eye gnats (Chloropidae), were collected 

in very low numbers relative to the 3 majority species, 

but no attempt was made to estimate their numbers. The 

only nondipteran readily observed in or around the traps 

was the metallic green histerid beetle (Saprinus sp.), 

which was likely attracted to the fermenting combination of attractant and fl ies inside the trap. Analyses were 

conducted only on the 3 dominant fl y species previously 

listed (M. domestica, C. megacephala, and L. cuprina). 

There was no signifi cant effect on total fl ies killed due to 

the position of traps, other than traps located in sheltered 

positions which did not receive the effects of wind. Site 4 

was located in an open, 

hillside area and received 

the greatest effects from 

wind. Flies that were 

dead in the netting were 

likely dislodged during 

stronger winds, therefore 

skewing downward the 

numbers collected in the 

netting at Site 4.

Field Trial 1

An estimated 18,289 of 

the dominant fl y species were collected from 

the trap units in the fi rst 

fi eld trial; 17,260 were 

captured from the traps 

and 1,029 captured from 

the nets (Table 2 and Figures 3-6). Chrysomya megacephala (53.2%) was the most abundant fl y collected, 

followed by M. domestica (39.1%) and L. cuprina (7.7%). 

There were signifi cant differences in the fl y kill rate for 

the untreated vs. treated trap units (F=49.74; df=1,28; 

P<.0001), with untreated trap units capturing an estimated 13,126 fl ies, approximately 3 times more than 

the imidacloprid-treated traps (n=5,163 fl ies). When 

counting trap interior fl y catches, no signifi cant difference was found in fl y numbers between the treated and 

untreated traps (F=3.82, df=1,28; P=.0608). However, 

there were signifi cantly more fl ies (n>1,000) collected 

in nets under the imidacloprid-treated traps than fl ies 

(n<10) collected from nets positioned under the untreated traps (F=218.40, df=1,28; P<.0001).

Field Trial 2

A total of 983 fl ies were collected from the trap units 

in the second fi eld trial, shown in Figure 3 and Table 2, 

nearly 20 times fewer fl ies than were estimated collected in the fi rst fi eld trial. A comparable number of fl ies 

were recovered from the nets (n=488) and traps (n=495), 

with M. domestica (82.2%) and C. megacephala (5.5%) 

being the most and least abundant fl y species collected, 

respectively. Overall, untreated and imidacloprid-treated trap units differed signifi cantly in the fl y kill rate 

(F=40.44; df=1,44; P<.0001). As with Trial 1, there was 

no signifi cant difference in the number of fl ies recovered inside the imidacloprid-treated and untreated traps 

(F=2.40, df=1,44; P=.1285), while signifi cant differences were found between the number of fl ies collected 

in nets under the imidacloprid-treated traps (n=479) and 

fl ies collected from nets positioned under the untreated 

traps (n=9) (F=55.42, df=1,28; P<.0001). Interestingly, 

EVALUATION OF IMIDACLOPRID-TREATED TRAPS AS AN ATTRACT AND KILL SYSTEM

FOR FILTH FLIES DURING CONTINGENCY SETTINGS

Table 2. The proportion of the 3 primary fl y species, Musca domestica, Chrysomya megacephala,

and Lucilia cuprina (with total number of fl ies from each category in parentheses), attracted and 

killed by the untreated and treated Terminator® Pro traps during fi eld Trials 1 and 2 (data not logtransformed).

Fly species

(N)

Treated trap

contents (n)

Untreated trap

contents (n)

Net below

treated trap (n)

Net below

untreated trap (n)

Total (n)

Trial 1

M. domestica 6.9% (1268) 27.5% (5024) 4.7% (852) 0.02% (4) 39.1% (7148)

C. megacephala 14.9% (2724) 37.8% (6912) 0.5% (91) 0.01% (2) 53.2% (9729)

L. cuprina 0.8% (148) 6.5% (1184) 0.4% (80) 0% (0) 7.7% (1412)

Total % (18,289) 22.6% (4,140) 71.7% (13,120) 5.6% (1,023) 0.03% (6)

Trial 2

M. domestica 7.1% (70) 34.1% (335) 40.1% (394) 0.9% (9) 82.2% (808)

C. megacephala 0.8% (8) 3.0% (29) 1.7% (17) 0% (0) 5.5% (54)

L. cuprina 0.8% (8) 4.6% (45) 6.9% (68) 0% (0) 12.3% (121)

Total % (983) 8.7% (86) 41.6% (409) 48.7% (479) 0.1% (9)
 April – June 2013 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

similar fl y counts were obtained from nets under imidacloprid-treated traps (n=479) and from the interior of 

untreated traps (n=409).

COMMENT

Depending on how often trap baits are changed, treating the exterior surface of Fly Terminator Pro traps with 

Maxforce Fly Spot Bait (10% imidacloprid) may not increase overall effectiveness in an attract and kill system. 

Although more fl ies were collected from nets placed 

under imidacloprid-treated traps than untreated traps, 

untreated Fly Terminator Pro traps collected more fl ies 

than the combined totals from interior of treated traps 

and their nets during both fi eld trials, nullifying the signifi cance of the number of dead fl ies collected from the 

netting. However, it is possible that a signifi cant number 

of moribund fl ies were able to escape the netting before 

dying or were displaced by wind or other environmental 

1268

5024

2724

6912

148

1184

0

1000

2000

3000

4000

5000

6000

7000

M. domestica 

C. megacephala 

L. cuprina 

Treated Untreated

Total 

Number 

of Flies 

Captured

Figure 3. Trial 1, trap data for trap exteriors, untreated and treated with imidacloprid as indicated.

Total 

Number 

of Flies 

Captured

Treated Untreated

Figure 4. Trial 1, net data for trap exteriors, untreated 

and treated with imidacloprid as indicated.

70

335

8 

29

8 

45

0

50

100

150

200

250

300

350

M. domestica 

C. megacephala 

L. cuprina 

Treated Untreated

Total 

Number 

of Flies 

Captured

Figure 5. Trial 2, trap data for trap exteriors, untreated and treated with imidacloprid as indicated.

Figure 6. Trial 2, net data for trap exteriors, untreated and 

treated with imidacloprid as indicated.

Total 

Number 

of Flies 

Captured

Treated Untreated
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

factors before being collected. In addition, the top portion (lid and handle) of the Fly Terminator Pro traps was 

not treated, and many fl ies were observed resting on 

those surfaces during the study, perhaps not receiving a 

lethal dose of imidacloprid.

Factors that should be evaluated before implementing 

fl y control methodologies include desired longevity or 

severity of a fl y problem. Environmental conditions and 

overall purpose will also dictate trap set-up and required 

maintenance regimens. For longer durations and larger 

fl y populations, the Fly Terminator Pro traps containing 

attractant and dead fl ies become more appealing to fi lth 

fl ies, especially to calliphorid fi lth fl ies, the longer it is 

left in traps. There were fewer fl ies taken during the second trial (N=983) when the trap attractant was changed 

daily than during the fi rst trial (N≈18,000) when attractant was left in place unchanged. There is likely a 

synergistic effect of attractant with dead and decaying 

fl ies to attract yet more fl ies to the trap. Numerous C. 

megacephala were observed fl ying around the inside of 

the trap after 2 to 3 days during the fi rst fi eld trial, and 

more C. megacephala were ultimately captured within 

the traps compared to M. domestica, as shown in Table 

2. In contrast, when the trap contents were changed and 

refreshed daily during the second fi eld trial, the majority of fl ies collected inside and outside of the traps were 

M. domestica. This could be attributed to seasonal infl uences and overall population numbers but could also 

be due to house fl y behavior and physiology (they may 

land on the outside of the trap before entering and receive a lethal dose of imidacloprid before entering the 

trap itself). For short durations (less than 2 days), the 

application of spot bait to the surface of fl y traps may increase the effectiveness of control efforts. Maxforce Fly 

Spot Bait is a wettable powder and will be washed away, 

especially from plastic surfaces, following precipitation 

events, making retreatment necessary.

Facility employees commented that fl y populations were 

low during the the second fi eld trial and they did not consider them a nuisance during that period. A major point 

of contention for these highly attractive traps is whether 

more fl ies are being attracted to a given area than would 

otherwise be found there; thus pre- and postsurveys of 

fl y populations using Scudder grids and similar methods 

should be made in future studies. However, our assumptions before conducting these trials were that (1) adult fl y 

populations were fairly uniform for a given location during summer months in North Florida, and (2) fl y traps 

attract from a relatively short distance, maybe 30 m to 

50 m (oral communication, J. A. Hogsette). No insecticides were applied by county or landfi ll personnel during 

these trials. Temperatures and rainfall were typical for 

north Florida during our trial dates, so we assume that 

neither weather nor human activities at Rosemary Hill 

Solid Waste Management Facility impacted fl y populations during June, July, and August 2008.

These data indicate that there is potential for combining existing fi lth fl y control products to create a more 

effi cacious attract and kill system, however, expected 

fl y population and control thresholds must fi rst be determined for a given area where fi lth fl y control is warranted. Although overall kill could be increased by treating 

the outer surface of Fly Terminator Pro traps, based on 

these data, treating the surfaces must occur daily, especially in areas with high humidity and precipitation. This 

may not be practical for some fl y control programs, especially under contingency circumstances, where available manpower may be limited. Several variables should 

be more closely examined, such as the residual longevity of the insecticide on the outer surfaces of the traps 

(to include plastic and paper label on trap) in both hydric 

and xeric environments, and which kinds of surfaces are 

more prone to environmental effects such as precipitation, humidity, and dust accumulation. Trap placement 

(such as spacing, distance from area requiring control) 

and maintenance (emptying contents and treating outer 

surface daily vs weekly) to create and maintain an effective barrier should also be addressed. During this study, 

we found that using only 1⁄2 of the manufacturer’s recommend strength of Terminator Fly Attractant coupled 

with changing traps weekly instead of daily, provided 

suffi cient kill under resource-limited contingency settings, and resulted in greatly increased fl y kill over full 

strength attractant-baited traps that were changed daily 

per manufacturer’s recommendations. Future studies 

could include biological assays to evaluate attractant activity of different lures and currently marketed baits.

One of the goals of the Navy Entomology Center of 

Excellence and the Deployed War Fighter Protection 

Program is to develop and evaluate user friendly and 

economically feasible traps capable of selectively sampling fi lth-breeding fl ies. Field conditions for personnel 

deployed during contingency operations are often less 

favorable than garrison conditions, thus smaller, lighter, 

low maintenance traps are preferred, such as, for example, the Florida Fly-Baiter12-16 which combines visual 

attraction and cords treated with Maxforce Fly Spot Bait 

(10% imidacloprid insecticide, with attractants 0.1% 

muscalure ((Z)-9-tricosene) and 89.9% sugar). Additional research and testing should attempt to identify and 

adapt available or novel chemical attractants to augment 

trap effi cacy and selectivity. Because few, if any, studies 

EVALUATION OF IMIDACLOPRID-TREATED TRAPS AS AN ATTRACT AND KILL SYSTEM

FOR FILTH FLIES DURING CONTINGENCY SETTINGS
 April – June 2013 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

of this type have been conducted to date, this study 

should provide additional insight into the feasibility of 

attract and kill fi lth fl y systems for use in integrated fl y 

management programs, and can be used as a stepping 

stone for similar studies leading to the development of 

better fl y management systems in the future.

ACKNOWLEDGEMENTS

This study was conducted by the Navy Entomology Center of Excellence (NECE), Naval Air Station Jacksonville, Florida, as part of its mission in developing fi eldexpedient vector control technologies and techniques to 

better protect deployed Warfi ghters from insect-borne 

diseases. Financial, technical, and fi eld support was provided by the Department of Defense’s Deployed War 

Fighter Protection Program and the US Department of 

Agriculture’s Center for Medical, Agricultural and Veterinary Entomology. The authors thank Graham White, 

George Schoeler, Todd Walker, Muhammad Farooq, Andrew Beck, and Peter Obenauer for critical reviews of 

this manuscript. Statistical analyses were performed by 

Peach State Statistical Consulting. We also thank the personnel of the Rosemary Hill Solid Waste Management 

Facility for allowing access to the facility, and NECE 

personnel Duane Flemmings, Daniel Courtney, Jason 

Forrester, and Adam Strong for assistance in the fi eld.

REFERENCES

1. Graczyk TK, Knight R, Gilman RH, Cranfi eld 

MR. The role of non-biting fl ies in the epidemiology of human infectious diseases. Microbes Infect. 

2001;3:231-235.

2. Sanders JW, Putnam SD, Riddle MS, Tribble DR. 

Military importance of diarrhea: Lessons from the 

Middle East. Curr Opin Gastroen. 2005;21:9-14.

3. Thornton SA, Sherman SS, Farkas T, Zhong W, 

Torres P, Jiang X. Gastroenteritis in US Marines 

during Operation Iraqi Freedom. Clin Infect Dis. 

2005;40:519-525.

4. . AFPMB Technical Guide No. 30 Filth Flies: Significance, Surveillance and Control in Contingency 

Operations. Silver Spring, MD: Armed Forces Pest 

Management Board; October 2011.

5. Miller RW, Rutz DA, Pickens LG, Geden CJ. Evaluation of traps and the parasitoid Muscidifurax 

raptor (Girault and Sanders) to manage house fl ies 

and stable fl ies on dairy farms. J Agric Entomol. 

1993;10:9-19.

6. Geden CJ, Szumlas DE, Walker TW. Evaluation 

of commercial and fi eld-expedient baited traps for 

house fl ies, Musca domestica L. (Diptera: Muscidae). J Vector Ecol. 2009;34:99-103.

7. Michaelakis A, Mihou AP, Koliopoulos G, Couladouros EA. Attract-and-kill strategy. Laboratory 

studies on hatched larvae of Culex pipiens. Pest 

Manag Sci. 2007;63:954-959.

8. El-Sayed AM, Suckling DM, Byers JA, Jang EB, 

Wearing CH. Potential of “lure and kill” in longterm pest management and eradication of invasive 

species. J Econ Entomol. 2009;102:815-835.

9. Geden CJ. 2006. Visual targets for capture and 

management of house fl ies, Musca domestica. J 

Vector Ecol. 2006;31:152-157.

10. Hougard JM, Duchon S, Darriet F, Zaim M, Rogier 

C, Guillet P. Comparative performances, under laboratory conditions, of seven pyrethroid insecticides 

used for impregnation of mosquito nets. B World 

Health Organ. 2003;81:324-333.

11. Tomizawa M, Casida JE. Neonicotinoid insecticide 

toxicology: Mechanisms of selective action. Annu 

Rev Pharmacol. 2005;45:247-268.

12. Hoel DF, Obenauer P, Burrus R, Dunford J, Hertz 

J, Diclaro J, Cope S. Forging the future of Navy entomology at the University of Florida. Wing Beats. 

2008;19:4-10.

13. Diclaro JW, Pereira R, Koehler P. Development 

of the University of Florida fi lth fl y death device. 

Florida Pest Pro. October 2009:12-14.

14. Koehler PG, Diclaro J, Pereira RM. Large fi lth fl y 

management. Florida Pest Pro. May 2010:10-12.

15. Diclaro II JW, Cohnstaedt LW, Pereira RM, Allan 

SA, Koehler PG. Behavioral and physiological response of Musca domestica to colored visual targets. J Med Entomol. 2012;49:94-100.

16. Diclaro JW, Hertz JC, Welch RM, Koehler PG, 

Pereira RM. Integration of fl y baits, traps and cords 

to kill house fl ies (Diptera: Muscidae) and reduce 

annoyance. J Entomol Sci. 2012;47:56-64.

AUTHOR AFFILIATIONS

LT Dunford and CDR Hoel: Navy and Marine Corps 

Public Health Center Detachment, Centers for Disease 

Control and Prevention, Atlanta, Georgia.

LT Hertz: 3rd Medical Battalion, 3rd Marine Logistics 

Group, Okinawa, Japan.

LT England: Naval Medical Center Portsmouth, Virginia.

Dr Dunford: Centers for Disease Control and Prevention, 

Atlanta, Georgia.

LCDR Stoops: Navy and Marine Corps Public Health 

Center Detachment, Center for Medical, Agricultural, 

and Veterinary Entomology, Gainesville, Florida.

CDR Szumlas: Walter Reed Military Entomology 

Research Program, Naval Medical Research Center, 

Silver Spring, Maryland.

Dr Hogsette: Mosquito and Fly Research Unit, Center 

for Medical, Agricultural, and Veterinary Entomology, 

Gainesville, Florida.
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

Humans have used repellents to protect themselves 

from pestiferous blood-feeding insects since prehistoric 

times. The most probable primitive repellent is the use of 

smoke to mask kairomones (odors from humans who are 

attractive to host-seeking mosquitoes) and provide relief 

from insect biting pressure. A personal protective measures (PPM) system that includes the use of repellents 

is vital to efforts in reducing transmission of vectorborne diseases (VBDs) to military personnel. Prior to 

World War I when synthetic repellents were introduced, 

natural plant oils were the principal means of protection 

against pestiferous insects.1

 Today, the most commonly 

used repellents are topically applied products, or topical 

repellents. Topical repellents constitute a wide array of 

chemicals ranging from natural botanicals such as citronella to synthetically derived N,N-Diethyl-3-methyl 

benzamide (deet). However, the use of topical repellents 

is often complicated by an unpleasant smell, oily residue, 

and dermal irritation. Furthermore, studies to improve 

the longevity of topically applied repellents have shown 

a loss in effi ciency due to transdermal absorption.2

 To 

improve user acceptance, additional repellent application methods should be evaluated for effi cacy.

The spatial action of repellents is not a novel concept,3

but their use among the military has been sporadic at 

best. Although fi eld evaluations of ThermaCELL (The 

Schawbel Corp, Bedford, MA) have shown the capability 

to repel biting insects up to 90% for 6 hours,4

 no spatial 

repellents have been issued a National Stock Number or 

approved for use by the Department of Defense (DoD).5

Currently recommended PPM for military members is 

effective when used properly but has largely been unsuccessful in theater due to limited availability, improper use, and troop concerns with dermal exposure.

The Navy Entomology Center of Excellence (NECE), 

Naval Air Station, Jacksonville, Florida, evaluates and 

Field Evaluation of Commercial Off-the-Shelf

 Spatial Repellents Against the Asian Tiger

 Mosquito, Aedes albopictus (Skuse), and the

 Potential for Use During Deployment

Aaron M. Lloyd, MS

Muhammad Farooq, PhD

LT Joseph W. Diclaro, MSC, USN

Daniel L. Kline, PhD

Alden S. Estep, BS

ABSTRACT

The Testing and Evaluation Department of the US Navy Entomology Center of Excellence (NECE), Naval Air Station, 

Jacksonville, Florida, is dedicated to the evaluation of novel equipment and vector control techniques to provide guidance 

on effective protection measures against human pathogens transmitted by blood-feeding arthropods. Personal protective 

measures (PPM), to include repellents, are part of a series of techniques that contribute toward reducing human-vector 

contact for globally and domestically deployed military forces. However, improper PPM use and limited availability has 

created vulnerabilities, causing troops to purchase spatial repellent products that are not approved by the Department of 

Defense. In order to ensure the most effective products are available, NECE has evaluated the spatial repellency response 

of Aedes albopictus (Skuse) to 4 commercial off-the-shelf (COTS) spatial repellents to provide technical guidance on 

proper use and effectiveness. The COTS products evaluated ThermaCELL, OFF! Clip On, Lentek Bite Shield, and Bug 

Button Mosquito Eliminator. A Biogents Sentinel (BGS) trap was placed in 5 locations with a spatial repellent device 

suspended at the level of the BGS trap opening over 4 of them (the fi fth was control). Each trap catch was collected every 12 hours, at which time the spatial repellent device was rotated to the next position. Using this method, each spatial 

repellent device and control was rotated across each of the 5 locations a total of 6 times. Spatial repellent effi ciency was 

evaluated by comparing the total number of mosquitoes collected in the BGS traps during a 12-hour period. The number 

of adult mosquitoes repelled by the ThermaCell spatial repellent was signifi cantly more than other spatial repellents with 

the exception of OFF!. These data indicate that COTS products using repellent insecticide rather than botanicals are more 

effective at deterring Ae. albopictus from biting a host.
 April – June 2013 81

tests novel techniques or equipment used for preventing VBDs. Commercial off-the-shelf (COTS) spatial 

repellents are being purchased and used by troops, raising product awareness and popularity. The increase in 

product use among troops has initiated spatial repellent 

testing at NECE to provide technical guidance for proper use and product effectiveness. In this article, results 

from the spatial repellent evaluations and their potential 

role for use by the military are discussed.

MILITARY PERSONAL PROTECTIVE MEASURES

As Peterson states, “War and disease truly are deadly 

comrades.”6

 It is common knowledge that insect-vectored diseases have devastated military campaigns 

throughout history. The Napoleonic campaigns alone 

were crippled by plague, typhus, and yellow fever, literally rewriting military history. Military campaigns 

create a situation of immunologically naive populations 

in a concentrated area, exposure to foreign pathogens, 

and societal stress promoting the perfect storm for a 

disease epidemic among troops. Due to post-World War 

II advancements in medical entomology and military 

medicine, insect-vectored pathogens have had a smaller impact on war. However, deployed troops still face 

VBD threats that have been both deadly and debilitating to the mission. In 2003, 80 of 225 Marines deployed 

to Liberia for 10 days fell ill to malaria.7

 Korzeniewski 

and Olszanski8

 reported a 1% leishmaniasis infection 

rate among US service members during operation Iraqi 

Freedom. In 2009, the US Navy deployed multiple teams 

to Key West, Florida, to provide operational assistance 

against dengue outbreaks. The continued occurrence of 

illness caused by VBDs threatens operational readiness 

of the military and exposes a gap in protection for US 

troops. However, this gap in protection is not from a lack 

of instruction or understanding of how to protect troops 

against vectors and diseases, but rather an apparent reluctance, or outright refusal, of some individual personnel to fully comply with the PPM guidelines.

Currently, the DoD promotes an insect repellent system 

that outlines 3 protection strategies: (a) deet application 

to exposed skin, (b) treatment of uniforms with permethrin, and (c) proper wear of uniforms to maximize 

coverage. This insect repellent system is required by the 

DoD when exposure to VBDs is likely. In addition, the 

DoD requires use of additional PPM such as permethrin 

treated bed nets.5

 This system will provide maximum 

protection only when components are used properly.

User acceptability of PPM is a constant challenge to 

its effectiveness. Sanders et al9

 reported that responders in a 2004 study of personnel returning from Iraq 

and Afghanistan indicated that a majority (51.2%) never 

used deet, even though most (68.5%) knew that deet was 

readily available. Of those that did use deet, only 14.6% 

reported using it more than occasionally. Many fail to 

follow the DoD PPM guidelines for several reasons: 

Manufacturer provided specifi cations and information for some current commercially available spatial repellent products.

Product Type Cost per

Unit

Area 

Covered

Batteries Butane Length of 

Use

Mosquito Biting 

Flies

Tick Comments

ThermaCELL* Allethrin $29.99 225 sq ft No Yes 4 hours Yes Yes No

Length of use is per 

insecticide pad. 

Butane cartridge 

lasts 12 hours.

ThermaCELL

Lamp Allethrin $31.99 225 sq ft No Yes 4 hours Yes Yes No

Length of use is per 

insecticide pad. 

Butane cartridge 

lasts 12 hours.

OFF! Clip On* Metafluthrin $10.00 Personal

space Yes No 12 hours Yes No No Odorless

OFF! Lamp Allethrin $15.00 225 sq ft No No 4 hours Yes No No Candle used as 

heat source.

Bite Shield 

Clip On* 30% Geraniol $29.99

15 ft radius,

2000 sq 

ft indoors

Yes No 120 hours Yes Yes Yes

Also repels lice, 

fleas, and fire 

ants.

Bite Shield 

wrist bands 20% Geraniol $5.99 Personal

space No No 120 hours Yes Yes Yes

Also repels lice, 

fleas, and fire 

ants.

Bug Button* Natural oils† $1.00 Personal 

space No No 220 hours Yes Yes Yes

Also repels lice and 

many stinging 

insects.

Flowtron

FD-15

Citronella oil 

fragrance $24.95 See comment Yes No 30 days Yes Yes No

Manufacturer does 

not specify area 

covered

*Product evaluated in this study.

†Citronella oil, Phillipine geranium oil, Indonesian lemongrass oil
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

underestimating the risk of vectors and the diseases 

they transmit; improper use of insecticide treated bed 

nets and uniforms; and lack of trust in military issued 

deet. The lack of knowledge among personnel regarding 

regional vector threats and proper use of PPM can be addressed with additional training from their commands. 

However, command emphasis on proper use of insecticide treated bed nets, permethrin 

treated uniforms, and personal repellents is sometimes ineffective.10 

In addition, even when command 

emphasis is excellent, personnel 

are concerned with the short and 

long-term exposure of some PPM 

components. Kitchen11 reported that 

personnel expressed concerns for 

their safety when using deet largely 

because of dermal sensitivities, unpleasant odors, and plasticizing effects. The required daily PPM use 

is an additional hurdle that further 

complicates the situation.12

Additional tools should be added 

to the vector control toolbox to improve PPM strategies. Ideally, there 

should be a vector control component that is easily deployed, tactical, 

and requires minimal user participation. Product development, however, can take years of research and 

millions of dollars before something 

reaches the end user. Therefore, 

products that are currently available 

to the general public should be tested and evaluated for 

military use. Due to the popularity among outdoorsmen 

in the civilian market, commercially available spatial 

repellents have drawn the attention of DoD personnel 

for use against biting arthropods. The NECE initiated 

spatial repellent device testing and evaluation studies in 

Jacksonville, Florida, after careful evaluation of commercially available products and trends of use by DoD 

personnel.

SPATIAL REPELLENT DEVICE TESTING AND 

EVALUATION

Nolen et al13 defi ned a spatial repellent as a compound, 

dispensed into the atmosphere of a 3 dimensional space, 

which inhibits the ability of host-seeking insects to locate a target. A repellent that is dispersed to protect a 

defi ned space can be distributed in several ways, including plastic or paper strips,15-17 coils,18 candles,19 fan 

emanators,20,21 and heat generating devices.4,22 In addition, commercially available spatial products currently 

on the market using repellent insecticides* or natural 

oils have shown effectiveness. Overall, reports have 

shown that repellent insecticides provide the most protection, but natural oils have also shown spatial repellency that warrants proper testing and evaluation.14,23,24

The Table presents a sample of the many spatial repellent products available to the end user, underscoring the 

diffi culty involved in choosing an 

effective spatial repellent device for 

protection. Military end users are 

personnel who deploy both domestically and globally. It is our mission 

to provide guidance on safe and effective VBD prevention.

To fi nd the best available spatial repellent devices and determine if any 

are suitable for military use, NECE 

evaluated 4 spatial repellent devices 

currently available on the market. 

The objective of this study was to 

determine the effi cacy of COTS 

spatial repellents against Aedes albopictus (Skuse) (Asian Tiger Mosquito) and evaluate their durability 

for potential military use. Originally 

from Southeast Asia, the Ae. albopictus (Skuse) is established in 20 

countries and has been reported in 

more than 50 worldwide.25,26 This 

container-breeding species is a daytime biter and competent vector of 

many pathogens including dengue 

and chikungunya viruses. 

The COTS devices evaluated (Figure 1) were: ThermaCELL; OFF! Clip On (S.C. Johnson & Son, Inc, Racine 

WI); Lentek Bite Shield (Koolatron, Brantford, Ontario, 

Canada); and Bug Button Mosquito Eliminator (Evergreen Research, Inc, Golden, CO). Biogents Sentinel 

traps (BGS traps) (Biogents AG, Regensburg, Germany) 

(Figure 2) were used to provide maximum artifi cial host 

attraction to container-breeding mosquitoes that are 

considered as primary vectors of dengue and chikungunya viruses.27-30

In a suburban neighborhood in Clay County, Florida, a 

single BGS trap was placed in each of 5 separate locations 20 m apart with a spatial repellent device suspended 

*An insecticide with aromatic properties that repel insects from 

reaching their intended target. The insecticide repellents used 

in this study incorporate an inert absorbent pad impregnated 

with an insecticide with evaporative emissions repulsive to Ae. 

albopictus, discouraging them from approaching the protected 

individual.

A

C D

B

Figure 1. Marketing imagery of COTS spatial repellent devices tested in this study:

A - ThermaCELL Mosquito Repellent

(http://www.hermacell.com)

B - OFF! Clip On (http://www.off.com)

C - Lentek BIte Shield

(http://www.koolatron.com)

D - Bug Button Mosquito Eliminator

(http://www.bugbutton.com)

FIELD EVALUATION OF COMMERCIAL OFF-THE-SHELF SPATIAL REPELLENTS AGAINST THE ASIAN TIGER 

MOSQUITO, AEDES ALBOPICTUS (SKUSE), AND THE POTENTIAL FOR MILITARY USE DURING DEPLOYMENT
 April – June 2013 83

THE ARMY MEDICAL DEPARTMENT JOURNAL

from a shepherd’s hook holder 0.30 m above the trap 

opening of each of 4 of them (Figure 3). The fi fth BGS 

trap was control, without a suspended repellent device. 

The BGS traps were started between 6:30 AM and 7:00 AM

with continual operation until 7:00 PM to 7:30 PM to obtain a 12 hour diel collection period. Each trap catch was 

collected every 12 hours, at which time the spatial repellent device was rotated to the next position. Using this 

method, each spatial repellent device (and control) was 

rotated across each of the 5 locations a total of 6 times. 

To ensure consistent operation among the devices, repellents were changed according to manufacture recommendations and power sources (butane, batteries) were 

changed daily. An analysis of variance was performed 

on the female mosquitoes collected in the BGS traps during this study with the null hypothesis of no signifi cant 

difference between any of the treatments. The means 

were compared using a t test at 95% confi dence interval. 

Operational notes were recorded throughout the study 

to document reliability of the devices during fi eld use.

There were 867 female Ae. albopictus collected during 

this study. As shown in Figure 4, The number of adult 

mosquitoes repelled by the ThermaCELL spatial repellent was signifi cantly greater than other spatial repellents 

with the exception of OFF! Clip On (P>.001). When 

compared to the control trap, ThermaCELL reduced 

trap capture by 76% and the OFF! Clip On reduced trap 

capture by 64%. The spatial repellent device using natural oils, Bug Button, did not signifi cantly reduce trap 

capture when compared to the control trap. However, 

statistically the Lenteck Bite Shield performed as well 

as the OFF! Clip On and reduced trap capture by 43%. 

These data indicate that COTS devices using repellent 

insecticide rather than botanicals are more effective at 

deterring Ae. albopictus from biting a host.

SPATIAL REPELLENT DEVICE RELIABILITY

The ThermaCELL spatial repellent device operated 

without failure throughout this study. There are no batteries needed to power the device, but due to an internal 

heat generator, the device gets hot. In addition, this device requires timely user monitoring to change the insecticide pad every 4 hours and the butane cartridge every 12 hours for continuous operation. Furthermore, the 

manufacturer recommends that the device remain horizontal (not attached to the user) making it diffi cult for 

mobility. Use of this device by military members could 

cause logistical issues with resupply of insecticide pads 

and butane. A potential heat signature from the device 

is also a tactical concern.

The OFF! Clip On was less sturdy. During this study, 

one device failed due to the fan contacting the housing 

of the unit. This device can be carried directly on the 

user, facilitating mobility. It uses batteries as the power 

source and the insecticide pad lasts 12 hours, reducing 

the amount of attention needed when operating. The 

housing is a bright blue color, reducing the ability to 

blend in with the uniform, and the fan is audible during 

operation. Use of this device by military members could 

cause logistical issues with resupply of insecticide pads 

and batteries. The sounds produced by the fan and the 

color of the housing are also a potential tactical concern.

The Lentek Bite Shield device is sturdy but it was the 

least reliable of all the devices tested. Two devices failed 

requiring replacement during this study. This device 

uses batteries as the power source, its repellent cartridge 

lasts 120 hours, and it can be carried directly on the 

user, facilitating mobility. However, the batteries seem 

to drain quickly, causing the fan to slow and reducing 

the amount of repellent being dispersed. The housing 

is white, reducing the ability to blend in with the uniform, and the fan is audible during operation. Use of 

this device by military members could cause logistical 

challenges with resupply of batteries, and the sounds 



Figure 2. One of the Biogents Sentinel traps placed at each of 

the 5 positions during the spatial repellent device study. The 

trap acted as an artifi cial host for the Ae. albopictus mosquito, using attractant and a 12 volt battery powered system to 

mimic convection currents created by a human body (green 

arrows). The mosquitoes enter the trap through the center 

opening (red arrow) and are trapped for collection.
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

produced by the fan along with the color of the housing 

are potentially a tactical concern.

The Bug Button Mosquito Eliminator is a sturdy, solid 

disk providing easy set up and maintenance for the user. 

The manufacturer claims 220 hours of protection and 

the device can be carried directly on the user, maximizing mobility. There are no logistical concerns with this 

device making it easily deployable in theater. However, 

the bright yellow color of the disk does not allow the 

device to blend in with military uniforms.

SUMMARY

The DoD insect repellent system outlines all necessary 

measures to provide maximum personal protection 

against vector-borne diseases. However, lack of consistent participation by military personnel highlight a 

disconnect between PPM availability and what personnel will use. Even though deet was developed shortly 

after World War II, it continues to be the “gold standard” 

of topical repellents. Other personal repellents listed in 

government supply systems and those available to civilians present some of the same drawbacks mentioned 

earlier (dermal irritation, unpleasant odors, oily residue) 

that cause DoD personnel to avoid using deet. There is 

a need for an additional PPM that is simple to use and 

does not require dermal application. In theory, spatial 

repellents should be able to meet these requirements, 

but the logistical and reliability issues of currently 

available devices complicate their utility in a deployed 

environment, and would likely result in reduced use by 

personnel.

In NECE’s spatial repellent study described in this article, it was determined that spatial repellent devices using 

repellent insecticides are the most effi cient at protecting 

against Ae. albopictus, an important vector of dengue 

and chikungunya viruses.31 Overall, the ThermaCELL 

spatial repellent device was the most effective device 

and is suitable for fi eld use. Results from this study show 

that this device could potentially reduce biting pressure 

by 76%, providing a level of protection that will reduce 

VBD risk among personnel. This device works well for 

stationary situations where supplies are easily obtained 

and tactical issues are not a priority. However, this device is not ideal for use during deployments, highlighting a need for the development of a military grade spatial repellent device. Logistical and tactical concerns 

outlined in this article should be addressed. Future studies should be conducted to develop a military-specifi c 

spatial repellent device. The ideal device should be versatile (indoor/outdoor), portable, tactical, easily deployable, and contain repellent insecticides that vaporize at 

ambient temperatures.

The Navy Entomology Center of Excellence continues 

to test and evaluate spatial repellents and has partnered 

with the Walter Reed Army Institute of Research to 

2

4

8

12

6

10

0

Mean Number of Female Ae. albopictus Captured Daily

Spatial Repellent Device Test Item

Figure 4. Mean number of female Ae. albopictus mosquities

captured daily by traps protected by each spatial repellent 

device over entire study period. The control trap capture 

is considered to be the 100% baseline. The percentages 

shown for each device are calculated against the control 

trap capture total.

FIELD EVALUATION OF COMMERCIAL OFF-THE-SHELF SPATIAL REPELLENTS AGAINST THE ASIAN TIGER 

MOSQUITO, AEDES ALBOPICTUS (SKUSE), AND THE POTENTIAL FOR MILITARY USE DURING DEPLOYMENT

A

B

C

D

Figure 3. Photos of each of the 4 test items suspended over the 

BGS Sentinel trap using rope and shepherd hooks:

A - ThermaCELL Mosquito Repellent

B - OFF! Clip On

C - Lentek BIte Shield

D - Bug Button Mosquito Eliminator
 April – June 2013 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

expand the idea of using spatial repellents to protect 

deployed forces. Additional PPMs should be made 

available to military personnel to expand the tools for 

VBD protection. With resolution of supportability and 

reliability challenges, these devices can provide protection to our military members, especially in stationary 

deployment situations.

ACKNOWLEDGEMENT

Financial support for this project was provided by the 

Armed Forces Pest Management Board Deployed WarFighter Protection Research Program.

We thank HM1 Jason Francona, HM1 Paul Groseclose, 

HM3 Darius Davis, and the other preventative medicine 

technicians at the Navy Entomology Center of Excellence, Naval Air Station, Jacksonville, Florida, whose 

expertise and dedication were vital to the success of the 

project and this article.

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products: effi cacy for military and general public 

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3. Schreck CE, Gilbert IH, Weidhaas DE, Posey KH. 

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4. Alten B, Caglar SS, Simsek FM, Kaynas S, Perich MJ. Field evaluation of an area repellent system (ThermaCELL) against Phlebotomus papatasi

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Armed Forces Pest Management Board; October 

2009. Available at: http://www.afpmb.org/sites/de

fault/fi les/pubs/techguides/tg36.pdf. Accessed December 13, 2012.

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7. Whitman TJ, Coyne PE, Magill AJ, et al. An outbreak of Plasmodium falciparum malaria in US 

Marines deployed to Liberia. Am J Trop Med Hyg. 

2010;83(2):258-265.

8. Korzeniewski K, Olsanski R. Leishmaniasis among 

troops of stabilization forces in Iraq. Int Marit 

Health. 2004;55(1-4):155-163.

9. Sanders JW, Putnam SD, Frankart C, et al. Impact 

of illness and noncombat injury during operations 

Iraqi Freedom and Enduring Freedom (Afghanistan). Am J Trop Med Hyg. 2005;73(4):713-719.

10. Vickery JP, Tribble DR, Putnam SD, et al. Factors associated with the use of protective measures against vector-borne diseases among troops 

deployed to Iraq and Afghanistan. Mil Med.

2008;173(11):1060-1067.

11. Kitchen LW, Lawrence KL, Coleman RE. The 

role of the United States military in the development of vector control products, including insect 

repellents, insecticides, and bed nets. J Vector Ecol. 

2009;34(1):50-61.

12. Debboun M, Strickman D, Klun JA. Repellents and 

the military: our fi rst line of defense. J Am Mosq 

Control Assoc. 2005;21(4):4-6.

13. Nolen JA, Bedoukian RH, Maloney RE, Kline DL, 

inventors; US Dept of Agriculture, owner. Method, 

apparatus and compositions for inhibiting the human scent tracking ability of mosquitoes in environmentally defi ned three dimensional spaces. US 

patent 6,362,235. March 26, 2002.

14. Kline DL, Bernier UR, Posey KH, Barnard DR. 

Olfactometric evaluation of spatial repellents for 

Aedes aegypti. J Med Entomol. 2003;40(4):463-467.

15. Obispo Argueta TB, Kawada H, Takagi M. Spatial 

repellency of metofl uthrin-impregnated multilayer 

paper strip against Aedes albopictus under outdoor 

conditions, Nagasaki, Japan. Med Entomol Zool. 

2004;55(3):211-216. Available at: http://naosite.

lb.nagasaki-u.ac.jp/dspace/bitstream/10069/16931/

1/110003820563.pdf. Accessed January 15, 2013.

16. Kawada H, Maekawa Y, Takagi M. Field trial on 

the spatial repellency of metofl uthrin-impregnated 

plastic strips for mosquitoes in shelters without 

walls (beruga) in Lombok, Indonesia. J Vector 

Ecol. 2005;30(2):181-185.

17. Kawada H, Temu EA, Minjas JN, Matsumoto O, 

Iwasaki T, Takagi M. Field evaluation of spatial repellency of metofl uthrin-impregnated plastic strips 

against Anopheles gambiae complex in Bagamoyo, 

Coastal Tanzania. J Am Mosq Control Assoc. 

2008;24(3):404-409.

18. Jensen T, Lampman R, Slamecka MC, Novak RJ. 

Field effi cacy of antimosquito products in Illinois. 

J Am Mosq Control Assoc. 2000;16(2):148-152.

19. Müller G, Junnila A, Kravchenko VD, Revay EE, 

Butler J, Schlein Y. Indoor protection against mosquito and sand fl y bites: a comparison between citronella, linalool, and geraniol candles. J Am Mosq 

Control Assoc. 2008;24(1):150-153.

20. Zollner G, Orshan L. Evaluation of metofl uthrin 

fan vaporizer device against phlebotomine sand 

fl ies (Diptera:Psychodidae) in a cutaneous leishmaniasis focus in the Judean desert, Israel. J Vector 

Ecol. 2011;36(suppl1):S157-S165.
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

FIELD EVALUATION OF COMMERCIAL OFF-THE-SHELF SPATIAL REPELLENTS AGAINST THE ASIAN TIGER 

MOSQUITO, AEDES ALBOPICTUS (SKUSE), AND THE POTENTIAL FOR MILITARY USE DURING DEPLOYMENT

The Asian Tiger Mosquito,

Aedes Albopictus (Skuse)

21. Lloyd AM, Farooq M, Estep AS, Diclaro J, Hoel 

DF, Kline DL. Evaluation of commercial repellents 

against Aedes albopictus for potential military use 

during deployment. Paper presented at: 78th Annual Meeting of the American Mosquito Control 

Association; February 29, 2012; Austin, Texas.

22. Collier BW, Perich MJ, Boquin GJ, Harrington SR, 

Francis MJ. Field evaluation of mosquito control 

devices in southern Louisiana. J Am Mosq Control 

Assoc. 2006;22(3):444-450.

23. Moore SJ, Debboun M. History of insect repellents. 

In: Debboun M, Frances SP, Strickman D. Insect 

Repellents: Principles; Methods and Uses. Boca 

Raton, FL: CRC Press; 2007:1-10.

24. Kongkaew C, Sakunrag I, Chaiyakunapruk N, Tawatsin A. Effectiveness of citronella preparations 

in preventing mosquito bites: systematic review of 

controlled laboratory experimental studies. Trop 

Med Int Health. 2011;16(7):802-810.

25. Aranda R, Eritja R, Roiz D. First record and establishment of the mosquito Aedes albopictus in Spain. 

Med Vet Entomol. 2006;20:150-152.

26. Global Invasive Species Database [database online]. Auckland, New Zealand: Invasive Species 

Specialist Group. Available at: http://www.issg.org/

database/welcome/. Accessed January 15, 2013.

27. Ritchie SA, Moore P, Carruthers M, et al. Discovery of a wide spread infestation of Aedes albopictus

in the Torres Strait, Australia. J Am Mosq Control 

Assoc. 2006;22(3):358-365.

28. Meerhaus WH, Armistead JS, Arias JR. Field comparison of novel and gold standard traps for collecting Aedes albopictus in northern Virginia. J Am 

Mosq Control Assoc. 2008;24(2):244-248.

29. Farajollahi A, Kesavaraju B, Price DC, et al. Field 

effi cacy of BG-sentinel and industry-standard 

traps for Aedes albopictus (Diptera: Culicidae) 

and West Nile virus surveillance. J Med Entomol. 

2009;46(4):919-925.

30. Ball TS, Ritchie SA. Evaluation of BG-Sentinel 

trap trapping effi cacy for Aedes aegypti (Diptera. 

Culicidae) in a visually competitive environment. J 

Med. Entomol. 2010;47(4):657-663.

31. Enserink, M. A mosquito goes global. Science. 

2008;320:864-866.

AUTHORS

Mr Lloyd is the Operations Supervisor for the Pasco 

County Mosquito Control District, Odessa, Florida. 

When this article was written, he was a contract research 

entomologist in the Field Evaluations Division, Navy 

Entomology Center of Excellence, Naval Air Station, 

Jacksonville, Florida. 

Dr Farooq is contract agricultural engineer in the Spray 

Engineering Division, Navy Entomology Center of 

Excellence, Naval Air Station, Jacksonville, Florida. 

LT Diclaro is assigned to the US Naval Medical Research 

Unit No. 3, Cairo, Egypt. When this article was written, 

he was the head of the Operation Assessment Department, 

Navy Entomology Center of Excellence, Naval Air 

Station, Jacksonville, Florida. 

Dr Kline is a research entomologist in the Mosquito and 

Fly Research Unit, US Dept of Agriculture, Agricultural 

Research Service, Center for Medical, Agricultural, and 

Veterinary Entomology, Gainesville, Florida.

Mr Estep is a contract biological technician in the Field 

Evaluations Division, Navy Entomology Center of 

Excellence, Naval Air Station, Jacksonville, Florida.
 April – June 2013 87

Stored product pest infestation is a worldwide problem. 

Economic losses of stored products due to stored product pests can amount to 9% in developed countries and 

to more than 20% in developing countries.1

 Damage by 

stored product pests include not only the economic loss, 

but also the ineffi cient availability of products; potential 

health issues such as respiratory and skin allergic reactions due to insect hairs, molts, or waste; and excessive 

use of chemical pesticides that often presents health and 

environmental concerns. Further, loss of the facility’s 

reputation and customers’ trust can result.

The Indian meal moth, Plodia interpunctella (Hübner), 

is widely considered to be one of the most economically 

important stored dry food pests.2

 This species is tolerant 

to a wide range of temperature. Indian meal moths live 

everywhere in the world, except in the Arctic and Antarctic regions. In temperate regions, it can easily survive 

over years in food manufacturing plants or warehouses, 

especially when there are no effi cient pest management 

plans. Larvae or eggs stay dormant during cold months 

(below 13°C) and begin development when the temperature rises.3,4 Female moths lay eggs when the temperature is between 13°C and 35°C.5

 In Korea, it was determined that Indian meal moths can produce 5 to 6 generations per year in dry vegetable storage areas.6

 Also, the 

species uses an extremely wide range of dry products as 

the food source. Larvae eat almost every type of stored 

products of both animal and plant origins, with a preference for oil seeds and pet foods.7

 Female moths prefer oil 

products for their oviposition sites, so the newly hatched 

larvae can easily fi nd food sources.8

 They are also facultative scavengers as they feed on dead cadavers of their 

species and other small terrestrial arthropods.5

 Indian 

meal moths often disperse to the outside and stay on 

lawns around the buildings, although the food source 

outside facilities is unknown.9

 Furthermore, they have 

developed resistance to common pesticides.7

Changes in the numbers of Indian meal moths were 

monitored using glue-board traps with pheromone 

lures in a US military commissary distribution center in the Republic of Korea (ROK), from July 2007 

to February 2010. The survey was conducted to discover the pattern of spatial and seasonal aggregations of Indian meal moths in the warehouse and to 

evaluate pest controls and warehouse management.

MATERIAL AND METHODS

The Warehouse, Cleaning Practice, and Pest Control

The warehouse is a central distribution center, located in 

the US Army Garrison Yongsan, ROK. As the facility 

receives, stores, and distributes food and other products 

into many US military installations in the ROK, successful pest management is critical to prevent the spread 

of infested commodities to other commissaries, retail 

outlets, and warehouses. The warehouse encloses 79,897 

m2

, and the interior height is 6.1 m. Half of the building was constructed in 1962, and the other half added in 

1988. The warehouse receives an average of 25 containers per week.

The cleaning schedule in 2007 was monthly fl oor mopping and weekly sweeping. It increased to weekly fl oor 

mopping and daily sweeping in 2008 and 2009, as numerous moths were captured on pheromone traps in 

2007. Phosphate pesticides were applied as an immediate 

remedy when active growths of Indian meal moths were 

detected in August 2007 (space fogging), June 30, 2008 

(residual spraying), and June 13, 2009 (residual spraying). 

Pest control dates were determined by trapping data, and 

types of pesticides and treatment methods were advised 

by the garrison Department of Public Works.

Trapping

The glue-board type of pheromone trap with attractant 

for Indian meal moths, 4 related moths (almond moth 

(Cadra cautella (Walker)), raisin moth (C. fi gulilella 

(Gregson)), Mediterranean fl our moth (Ephestia kuehniella Zeller), tobacco moth (E. elutella (Hübner))), and 

the cigarette beetle (Lasioderma serricorne (Fabricius)) 

was used (IMM+4 and CB lures, STORGARD Traps; 

Trécé Inc, Adair, Oklahoma). Pheromone lures were replaced every 60 days in accordance with the manufacturer’s specifi cations.

A Long-term Survey of Indian Meal Moths in

 A Dry Goods Warehouse Using Monitoring

 Traps With Pheromone Lures

Choe Hyon Chong, PhD
88 http://www.cs.amedd.army.mil/amedd_journal.aspx

Traps were placed on the fl oor underneath pallet rack 

frames, as stored product pests tend to move close to 

surfaces such as fl oors, walls, or ceilings to fi nd resting 

areas.10,11 The traps were placed in storage areas for vulnerable food products such as raisins, corn meal, grain, 

snacks, cereals, and pet food.12

The trapping period began on July 25, 2007, and ended 

on February 2, 2010. The number of traps and intervals 

of monitoring varied as the program progressed. Seventeen traps were installed in July 2007, and 13 traps were 

added near cereal and pet food storage areas in August 

2007 (Figure 1). These traps were replaced with 19 traps 

on August 14, 2007 (after a pest control treatment in 

the warehouse) (Figure 2). The monitoring interval was 

as short as 2 days in the beginning (July to September 

2007), and extended to 5 to 10 days from October to 

December 2007. Twenty traps were used from April 23 

to December 8, 2008 (Figure 3). For the fi nal phase, 14 

traps were placed on April 28, 2009 and removed on 

February 2, 2010 (Figure 4). Monitoring intervals were 

extended in 2008 and 2009, as the numbers of collected 

samples were smaller than in 2007. They were checked 

every 7 to 10 days during warmer months (April to October) and every 20 to 30 days during cold months (November to February).

Data Analysis

Raw data of the numbers of Indian meal moths collected on each date cannot represent the changes of pest 

population sizes, as they were measured with different 

numbers of traps and monitoring intervals. Therefore, 

trap captures were converted to monthly and daily average trap captures. Monthly average trap capture or the 

number of Indian meal moths collected per trap during a 

month was calculated using the following formula:

total Indian meal moths collected during a month

number of traps

Daily average trap capture or the numbers of Indian 

meal moths collected per day per trap was calculated 

using the formula:

total Indian meal moths collected between 2 monitoring dates

number of traps

The data in the following discussion are stated as 

mean±standard error.

In order to detect aggregations of moths, total number 

of samples collected on each trap were calculated. Also, 

the data was tested with one-way analysis of variance 

(ANOVA) using Excel version 2007 (Microsoft Inc, 

Redmond, WA). The null hypothesis: the trappings were 

random without being infl uenced by trap locations. The 

alternate hypothesis: the trappings were infl uenced by 

trap locations.

The traps collected Indian meal moths as well as cigarette beetles and other crawling pests.* Data for cigarette beetles and other arthropods are excluded in this 

study as they were collected much less frequently.

RESULTS AND COMMENT

Occurrence and Abundance

Indian meal moths were detected in the warehouse from 

April to November during each year’s survey periods, 

with a tendency of increase toward summer and decrease 

toward winter (Figures 5, 6, 7). This result is consistent 

with previous studies for the Indian meal moth life cycle 

in the ROK.4,13

As shown in the Table, monthly average trap captures 

reached their peaks from June to September. In 2009, a 

peak was detected at the end of October, when numerous individuals were collected for a short period after 

replacement of pheromone attractants. As illustrated in 

Figure 7, the number of collected specimens dropped 

abruptly afterwards.

Daily average trap captures peaked during August and 

September 2007 (Figure 5), September 2008 (Figure 6), 

June and November 2009 (Figure 7). After September, 

the collections decreased, possibly due to reduced temperature, daylight, and humidity.7

The results allowed the prediction of effi cient pest control 

periods in the warehouse. Pesticide applications should 

be performed from May to June, immediately after active growths are detected in the warehouse. Control by 

chemicals in July or August should be carefully planned, 

as they are not likely to kill many larvae that are probably growing inside stored products. Pest control after 

September is unnecessary and a waste of resources, because the population naturally decreases.

Vulnerable Sites in the Warehouse

As shown in Figures 8, 9, and 10, numbers of trapped 

specimens were more aggregated in storage areas for 

pet foods, cereals, crackers, candy bars, and rice. Such 

items are typically preferred by Indian meal moths as 

food and oviposition sites.7,8 Storage for cereals and pet 

foods are located by the partition wall, which provides 

shelter to Indian meal moths.11

A LONG-TERM SURVEY OF INDIAN MEAL MOTHS IN A DRY GOODS WAREHOUSE

USING MONITORING TRAPS WITH PHEROMONE LURES

*Most common: centipedes (Chilipoda spp) and roll bugs (Armadillididae spp). However, at most one or 2 crawling pests per trap 

were captured in a year. In total, less than 15 crawling pests captured in all the warehouse traps in any year of the survey.
 April – June 2013 89

THE ARMY MEDICAL DEPARTMENT JOURNAL

Based on one-way ANOVA test, aggregations were signifi cant in 2007 and 2008, at 95% confi dence interval: 

F=4.32, df=15, P=1.73E-07 for 2007; F=2.94, df=19, 

P=3.1E-05 for 2008. However, it was insignifi cant in 

2009: F=1.68, df=12, P=.08.

Evaluation of Pest Control Treatments

Changes of trapped Indian meal moths before and after a 

pest control application were negligible in 2007 (Figure 

5), however, they were evident in 2008 and 2009 (Figures 6 and 7). In 2007, daily mean captures continued to 

increase until September, despite a space fogging with 

residual pesticide that was applied in August. In 2008, 

population growths diminished immediately after the 

pest control treatment in June, but were sporadically active from July through November. In 2009, populations 

were retarded after the control in June, and there were 

only a few low peaks afterwards.

Figure 1. Locations of attractant baited traps placed in the warehouse in July 2007 (A), and early August 2007 (B).

Figure 2. Locations of attractant baited traps placed in the 

warehouse on August 14, 2007, following a pest control treatment.

Figure 3. Locations of attractant baited traps which were in 

place in the warehouse from April 23 to December 8, 2008.

Figure 4. Locations of attractant baited traps placed in the 

warehouse from April 28, 2009 to February 2, 2010.
90 http://www.cs.amedd.army.mil/amedd_journal.aspx

The fi ndings discussed above suggest that pest control 

probably cannot be effective when population growths 

are vigorous. In 2007, when the daily average trap capture was over 4, the number of moths collected by traps 

stayed at same level (Figure 5). However, pest controls 

at the early stage of pest development resulted in reduced 

pest populations. In 2008 and 2009, when pest control 

treatments were planned, daily trap capture was approximately 1.50 (consistent with the threshold indicated in 

Armed Forces Pest Management Board Technical Guide 

2714), detected moth numbers decreased after pest control treatments (Figures 6, 7).

Reduction of Pest Populations

In general, detected numbers of Indian meal moths fell 

over the years of the survey. The average number of Indian meal moths collected per day per trap during the total 

surveyed period was highest in 2007 (1.64±0.11). They 

were reduced by nearly one-half in 2008 (0.71±0.05) 

and in 2009 (0.72±0.09) as shown in the Table. Daily 

average trap captures often exceeded 4.0 in 2007, but 

barely reached 2.0 in 2008 and 2009 (Figures 5, 6, 7). 

The glue board traps used to monitor female moths 

also actively attracted males. As a result, males collected were not available as mates.

Data on the trapped Indian meal moths were an effective educational tool. Presentation of the data resulted in improvements in warehouse management 

while the survey was underway. The warehouse 

cleaning schedule was enhanced in 2008. The loading docks, which are often open during operating 

hours, were equipped with screens as physical barriers to prevent entrance of pests from the outside. 

Fans were operated near the vulnerable commodities 

during summer months, which possibly lowered temperature, distracted movements of the moths, and dispersed commodity odors.10

CONCLUSION

The following benefi ts of long-term monitoring were 

realized:

 More effi cient pest control was available with reduced amounts of use, as trappings demonstrated 

aggregated sites and seasons.

 Monitoring traps raised awareness among employees, which resulted in positive changes in warehouse management.

 Trapping combined with enhanced warehouse management and effi cient pest control reduced the risk 

of Indian meal moths in the warehouse.

ACKNOWLEDGEMENT

I thank William Sames (Armed Forces Pest Management Board), Terry Klein (65th Medical Brigade), Kenneth McPherson (US Environmental Protection Agency), 

Mack Fudge and Jason Pike (US Army Public Health 

Command (UASPHC)), Julio Montero (1st Medical Brigade), and Sangho Lee (US Army Medical Research Institute of Chemical Defense) and for their technical assistance in providing critical reviews of this manuscript

I thank Marivic Brown, Brian Kim, and Laura Ray 

(UASPHC); Nicole Chevalier (Army Medical Department Center & School); Lester Leanna, Tracy Brown, 

and Thomas Honadel (106th Medical Detachment); David Engelskirchen (DoD Veterinary Service); and Abida 

Shoyeb (Defense Commissary Agency) for their advice 

and support for this program. I thank DoD Veterinary 

Service food inspectors Dong Shin, Kattie Dwyer, Han 

Pan, and Saudinetra Paynewood for their invaluable help 

A LONG-TERM SURVEY OF INDIAN MEAL MOTHS IN A DRY GOODS WAREHOUSE

USING MONITORING TRAPS WITH PHEROMONE LURES

Figure 5. Average (mean±SE) daily trap captures of Indian meal 

moths during 2007. Note:  indicates pest control treatment in 

the warehouse.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

2007 2007

Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15

Daily Average Trap Capture

Figure 6. Average (mean±SE) daily trap captures of Indian meal 

moths during 2008. Note:  indicates pest control treatment in the 

warehouse.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

2008 28

3.0

2.5

2.0

1.0

1.5

0.5

0.0

Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec 15

Daily Average Trap Capture
 April – June 2013 91

THE ARMY MEDICAL DEPARTMENT JOURNAL

as they conducted monitoring, maintained traps, and 

communicated with warehouse managers.

I also thank John C. Kirk and Ralph E. Buckner (Defense 

Commissary Agency), Enrique G. Blanco (Department 

of Public Works, Yongsan), and Yi Songchu and Kim 

Chonil (US Army Installation Management CommandKorea) for their support of the suvey effort.

REFERENCES

1. Pimentel D. World resources and food losses to 

pests. In: Gorham JR, ed. Ecology and Management of Food-Industry Pests. Arlington, VA: AOAC 

International; 1991:5-11.

2. Phillips TW, Berberet RC, Cuperus GW. Post harvest integrated pest management. In: Francis FJ, ed. 

Encyclopedia of Food Science and Technology. 2nd 

ed. New York, NY: Wiley; 2000; 2690-2701. Available at: storedproducts.okstate.edu/Publications/

EFST061899WP.doc. Accessed January 16, 2013.

3. Johnson JA, Woodford PL, Gill RF. Development 

thresholds and degree-day accumulations of Indian 

meal moth (Lepidoptera: Pyralidae) on dried fruits 

and nuts. J Econ Entomol. 1995;88:734-741.

4. Na JH, Rhyoo MI, Sone J. A phenology model 

for seasonal occurrence of Plodia interpunctella 

(Lepidoptera: Pyralidae) in stored product storage. 

J Asia Pac Entomol. 2000;3(2):77-81.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

2007 200

Raisins 

Cereal 

Dog Food Dog Food Dog Food 

Crackers Crackers Crackers Crackers Crackers 

Cereal Cereal 

Rice Rice 

Corn Meal Corn Meal Corn Meal Corn Meal Corn Meal 

Average Trap Capture

Figure 8. Average (mean±SE) trap capture of Indian meal moths 

for each trap location during 2007.

Figure 7. Average (mean±SE) daily trap captures of Indian meal 

moths during 2009. Note:  indicates pest control treatment in 

the warehouse.

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2009

2.0

1.8

1.6

1.2

1.0

1.4

0.8

0.6

0.2

0.4

0.0

April 15

May 15

June 15

July 15

August 15

September 15

October 15

November 15

January 15, 2010

December 15

Daily Average Trap Capture

Number of Indian meal moths captured by month. Occurrences that disturbed the collection process are explained 

in footnotes.

Year

(No. 

Traps)

Month Surveyed Days: 

Period

Total Trap 

Capture

(Average 

Collection Per 

Trap Per Day, 

Mean±SE)

2007

Jul 15a

: 25 Jul-10 Aug 817 

Aug 15b

: 14-31 Aug 652 

Sep 28a

: 5-28 Sep 1,003

Oct 22: 1-22 Oct 353

Nov 34: 23 Oct-26 Nov 98

Dec 22a

: 5-27 Dec 0 

Total 136 2,923

(1.64±0.11)

2008

Apr 10a

: 20-30 Apr 7

May 28: 1-28 May 218

Jun 26b

: 29 May-24 Jun 293

Jul 25: 5-30 Jul 534

Aug 27: 1-27 Aug 521

Sep 30: 28 Aug-26 Sep 896

Oct 14a,d

: 27 Sep-10 Oct 194

Nov 35: 22 Oct-27 Nov 896

Dec 9a

: 1-9 Dec 14

Total 204 3,573

(0.71±0.05)

2009

May 30a

: 28 Apr-28 May 368

Jun 9b

: 29 May-17 Jun 252

Jul 20: 8 Jul-28 Jul 267

Aug, Sep 56c

: 29 Jul-30 Sep 573

Oct 20d

: 9-20 Oct 243

Nov 40c

: 21 Oct-10 Dec 20

Dec, Jan, Feb 53c

: 11 Dec-2 Feb 2

Total 228 1,393

(0.72±0.09)

Notes:

a. Placement and/or replacement of traps

b. Pest control treatment

c. Lack of manpower

d. Shortage of traps
92 http://www.cs.amedd.army.mil/amedd_journal.aspx

5. Rees D. Insects of Stored Products. Collingwood, 

Victoria, Australia: CSIRO Publishing; 2004.

6. Na JH, Ryoo MI. The infl uence of temperature on 

development of the Indian meal moth (Lepidoptera: 

Pyralidae) on dried vegetable commodities. J 

Stored Prod Res. 2000;36(2):125-129.

7. Mohandass S, Arthur FH, Zhu KY, Thorne JE. 

Biology and management of Plodia interpunctella (Lepidoptera: Pyralidae) in stored products. J 

Stored Prod Res. 2007;43:302-311.

8. Nansen C, Phillips TW. Ovipositional responses of 

the Indian meal moth, Plodia interpunctella (Hubner) (Lepidoptera: Pyralidae) to oils. Ann Entomol 

Soc Am. 2003;96:524-531.

9. Campbell JF, Mullen MA. Distribution and dispersal behavior of Trogoderma variabile and Plodia 

interpunctella outside a food processing plant. J 

Econ Entomol. 2004;97:1455-1464.

10. Silhacek D, Murphy C, Arbogast RT. Behavior and 

movements of Indian meal moths during commodity infestation. J Stored Prod Res. 2003;39:171-184.

11. Nansen C, Phillips TW, Sanders S. Effect of height 

and adjacent surfaces on captures of Indianmeal 

moth (Lepidoptera: Pyralidae) in pheromone-baited traps. J Econ Entomol. 2010;97:1284-1290.

12. MIL-STD-904C: Department of Defense Standard 

Practice–Detection, Identifi cation, and Prevention 

of Pest Infestation of Subsistence. Washington, DC: 

US Dept of Defense; July 15, 2010:5.

13. Na JH, Ryoo MI. Effects of temperature on the 

life history of Indian meal moth (Lepidoptera: 

Pyralidae) on Brown rice [In Korean with English 

abstract]. Korean Journal of Applied Entomology. 

1998;37:143-149.

14. Armed Forces Pest Management Board Technical 

Guide 27. Stored-Product Pest Monitoring Methods. Washington, DC: Armed Forces Pest Management Board; 2005. Available at: http://www.afpmb.

org/sites/default/files/pubs/techguides/tg27.pdf. 

Accessed January 9, 2013.

AUTHOR

Dr Choe is an entomologist with the 106th Medical 

Detachment (Veterinary Service Support), US Forces 

Korea.

A LONG-TERM SURVEY OF INDIAN MEAL MOTHS IN A DRY GOODS WAREHOUSE

USING MONITORING TRAPS WITH PHEROMONE LURES

0.0

0.5

1.0

1.5

2.0

2.5

3.0

2008

Raisins 

Cereal 

Dog Food Dog Food Dog Food 

Crackers Crackers Crackers Crackers Crackers 

Cereal Cereal 

Rice Rice Rice 

Corn Meal Corn Meal Corn Meal Corn Meal Corn Meal 

Average Trap Capture

Figure 9. Average (mean±SE) trap capture of Indian meal moths 

for each trap location during 2008. Average Trap Capture 0.0

0.5

1.0

1.5

2.0

Raisins Raisins 

Cereal 

Pet Food Pet Food Pet Food 

Crackers Crackers 

Cereal Cereal 

Rice 

Sugar 

Corn Meal 

2009

Figure 10. Average (mean±SE) trap capture of Indian meal moths 

for each trap location during 2009.
 April – June 2013 93

Circumcision is a common surgical procedure, performed on approximately 30% of males worldwide.1

 The 

prevalence of circumcision throughout different regions 

of the world is variable. The World Health Organization 

estimates a near universal prevalence rate in predominantly Muslim areas of southwest Asia.1

 A wide variety 

of practitioners with unverifi ed capability or skills may 

perform this procedure, particularly in rural areas. Complications of the procedure occur and are more common 

when practitioners lack adequate training and supplies.2

The management of these complications may be beyond 

the capabilities of the practitioner performing the initial 

procedure, often leading patients to seek help at other 

nearby medical facilities. The inset “Circumcision in Afghanistan” on page 97 describes the common practice in 

that country today. We describe 2 patients who recently 

presented to a US Army combat support hospital in rural 

Afghanistan and review the management of the complications encountered following attempted circumcision.

CASE 1

A child, aged approximately 4 years, was presented by 

his father for the complaint of persistent bleeding from 

the site of circumcision, reportedly performed by a local practitioner approximately 10 days prior. The child’s 

father reported that bleeding at the surgical site had persisted, despite ash being applied to the wound. No fever, 

nausea, or vomiting were reported and the child was 

reportedly eating and voiding normally. Examination 

confi rmed the patient to be afebrile. His only wound involved the distal penis, which when cleansed revealed an 

excessive removal of foreskin, exposing approximately 

1.5 cm of the penile shaft circumferentially (Figure 1). 

Evidence of recent bleeding and clot formation was apparent. The patient’s father was counseled regarding the 

proposed plan of care, which included admission, placement of a urethral catheter, and surgical debridement in 

the operating room to fully examine the wound.

The child was taken directly to the operating room for 

debridement of the wound while under general anesthesia and after administration of a deep dorsal penile block 

and circumferential ring block. The wound was cleansed, 

hemostasis obtained, and the wound was dressed with 

gauze dressings soaked in 5% solution of mafenide acetate (Sulfamyalon). He was provided pain control and 

returned to the ward with the Foley catheter in place. 

The next day, the patient’s father was counseled regarding the plan to close the wound primarily, if possible. 

Coverage with split thickness skin graft was also discussed by the surgical team in the event that penile skin 

was inadequate to close the wound without tension.

The operation was performed by fi rst placing simple stay 

sutures to assist with retraction of the skin and avoiding 

unnecessary use of forceps. The skin proximal to the 

Complications of Male Circumcision Treated

 at a Military Hospital in Afghanistan

LTC Jennifer M. Gurney, MC, USA

MAJ Nicholas Jaszczak, MC, USA

MAJ Jennifer H. Perkins, MC, USA

COL Sarah L. Lentz-Kapua, MC, USA

COL Douglas W. Soderdahl, MC, USA

COL Evan M. Renz, MC, USA

ABSTRACT

Circumcision of male infants and children is a common ritual in Afghanistan. As in many other developing 

countries, there are few safeguards relating to the procedure, particularly in rural areas. Performance of ritual 

circumcision may result in complications requiring treatment beyond the capabilities of the practitioner performing the initial procedure. It is not uncommon for local nationals to seek care at deployed military medical 

facilities for a wide variety of problems, and complications related to attempted circumcision are no exception. 

We describe 2 such cases recently presented to a US Army combat support hospital in rural Afghanistan for 

surgical treatment of the unintended consequences of male circumcision. We offer a review of the most common complications associated with circumcision and treatment options for each. It is valuable for the surgeon 

operating at the military medical hospital in remote areas of the world to be familiar with the management of 

the most common complications of circumcision.
94 http://www.cs.amedd.army.mil/amedd_journal.aspx

wound was undermined with curved 

scissors until approximately 4 cm 

of skin was freed circumferentially 

(Figure 2). Hemostasis was easily maintained with the 

use of dilute epinephrine irrigation fl uid and needle-tip 

Bovie electrocautery. Great care was exercised to remain 

in the plane between the skin and the underlying Buck’s 

fascia to avoid any additional injury to the tissue.

Once free of the subcutaneous attachments, the proximal 

skin edge was reapproximated to the subcoronal penile 

skin adjacent to the glans. A series of 4-0 chromic sutures were used in interrupted fashion to reapproximate 

the skin and close the circumferential defect (Figure 3). 

The previously placed Foley catheter served as a penile 

scaffold to allow hands-free manipulation of the phallus 

during the repair. Once the repair was completed, the 

wound and glans were dressed with Bacitracin ointment 

and sterile dressing of Kerlix. The patient recovered 

quickly from the procedures and demonstrated little 

pain overall.

The patient’s Foley catheter remained 

in place for 3 days. He was able to 

void spontaneously soon after removal. On postoperative day 5, the wound was healing well 

and the patient was discharged home with his father.

CASE 2

A male infant was presented to our hospital by his father 

who reported bleeding and swelling at the site of circumcision performed on his son several days prior. No 

other symptoms were reported except that there was no 

evidence that that infant had voided recently. The child 

was generally calm, except during the focused examination. Exam revealed the patient to be afebrile and healthy 

overall except at the site of the penile wound. There was 

a dark coagulum surrounding the circumcision site and 

the urethral meatus was not visible (Figure 4). To ensure 

a proper examination, the patient’s father was counseled 

about the need to move to the operating room to debride the wound and perform a surgical repair, if possible. 

Once the patient was under the effects of anesthesia and 

COMPLICATIONS OF MALE CIRCUMCISION TREATED AT A MILITARY HOSPITAL IN AFGHANISTAN

Figure 1 Excessive removal of foreskin

Figure 4. Coagulum with ash over partially amputated glans Figure 5. Partially amputated glans 

and transected urethra

Figure 6. Repair of glans and residual 

hypospadias

Figure 2. Retraction and undermining 

of residual skin

Figure 3. Reapproximation of skin to 

corona
 April – June 2013 95

THE ARMY MEDICAL DEPARTMENT JOURNAL

after a penile block was administered, the wound was 

cleansed and gently debrided, revealing the glans had 

been partially amputated in an oblique manner as part of 

the attempted circumcision (Figure 5). The urinary meatus was barely visible at ventral surface near the base of 

the amputated glans. A 6 Fr urinary catheter was placed 

through the residual urethra without diffi culty revealing 

ample clear urine. The glans was gently debrided and 

the transected surface appeared healthy, allowing for reapproximation of the glans tissue to resemble a normal 

glans structure, albeit with residual hypospadiac meatus 

(Figure 6). The repair was performed with 4-0 chromic 

suture. The wound was dressed with Bacitracin ointment while leaving the Foley catheter in place.

Whether or not the patient had distal hypospadias prior 

to the circumcision is unknown, but such a preexisting 

condition would partially explain the fi ndings at presentation. The patient tolerated the procedure and remained 

on the ward with Foley catheter in place for 6 days to 

allow the transected distal urethra to heal. The urinary 

catheter was removed and patient voided spontaneously 

without diffi culty. He was discharged home on postoperative day 7.

COMMENT

Commonly used circumcision techniques include the 

use of the Gomco clamp, Plastibell, Mogan clamp, and 

a variety of freehand methods. Regardless of the technique used, a wide range of complications can be seen 

following the procedure, usually divided into acute and 

late complications. As with any complications of circumcision, the prevalence is diffi cult to estimate when 

performed in a nonmedical setting. Acute complications 

include bleeding, infection, urinary retention, excessive 

skin removal, and partial amputation. Late complications include inadequate removal of skin, skin bridges, 

chordee, epidermal inclusion cyst, urethrocutaneous fi stula, and meatal stenosis.3-6

Bleeding is most commonly encountered at the time of 

surgery or in the immediate postoperative period. Usually, such bleeding can be easily controlled with direct 

pressure. Bleeding that is still not controlled can be 

treated with topical hemostatic adjuncts including dilute 

lidocaine with epinephrine, thrombin, fi brin glue, and 

bipolar cautery. Infection is the next most common complication and usually responds well to local wound care 

and antibiotics, although the clinician should be aware 

that serious necrotizing infections have been reported. 

When urinary retention occurs following circumcision, 

the clinician should be aware that this has been associated with the initiation of a systemic infection and sepsis.

Separation of the remaining penile skin from the excision 

margin due to excessive skin removal may occur acutely. 

These wounds should be treated with local wound care 

and be allowed to heal by secondary intention without 

a need for skin grafting. After initial skin removal, the 

proximal edge often retracts and the resultant appearance is that excessive skin has been removed. Reapproximate the skin ends should be attempted, even if this 

is not possible circumferentially. This often facilitates 

healing by secondary intent and provides partial skin 

coverage. The clinician must reevaluate the remaining 

distal foreskin of these patients closely to avoid scar formation that could result in phimosis or penile chordee.

By far, the most dramatic and serious of the acute complications seen is partial or complete amputation of the 

glans. Best results are obtained through primary repair 

of these injuries if possible. A Foley catheter should be 

inserted into the urethra to identify the urethra and to 

serve as a handle for intraoperative manipulation. The 

primary goal is to promote long term nonobstructed 

voiding which is achieved by focusing on the meatus. 

This may require a ventral incision and spatulation of a 

neomeatus to allow for voiding and decrease the risk of 

meatal stenosis. This will result in a functional hypospadic patient, however, reconstructive options can be 

entertained. The Foley catheter should remain in place 

for 1 to 2 weeks to stent the repair and prevent meatal 

stenosis.

Several complications related to circumcision may present in delayed fashion. Inadequate removal of skin may 

result in phimosis. Depending on the degree of scarring 

and amount of remaining excess skin, this may result 

in a medical threat to the child or simply a cosmetic 

consideration. Revision circumcision may be performed 

after careful consultation with the parents of the risks 

and benefi ts. Glanular adhesions are another commonly 

seen complication. These result from a minor injury to 

the glans during the procedure with resulting scar forming between the glans and the cut edge of the foreskin. 

These skin adhesions may tether the penis and result in 

pain or curvature with erection. They may be treated 

by simple surgical division. Another occasionally seen 

complication is an epidermal inclusion cyst. This occurs when a portion of epidermis rolls under skin that is 

primarily closed. Treatment is surgical excision if they 

become large or infected.

Finally, late complications can be seen related to urethral injury. It is important to remember the superfi cial 

location of the penile urethra. Surrounded by a minimal amount of corpus spongiosum, the penile urethra 
96 http://www.cs.amedd.army.mil/amedd_journal.aspx

is at increased risk for injury during penile procedures, 

including creation of a urethrocutaneous fi stula. Treatment involves formal delayed repair of the urethra and 

possible coverage by other tissue such as tunica vaginalis or dartos.

Meatal stenosis can be caused by direct irritation of the 

meatus that is no longer protected by the prepuce, or by 

surgical injury that results in tissue ischemia and scarring. Irritation may be secondary to mechanical trauma 

or from contact with ammonia in a urine soaked diaper 

which leads to meatitis and meatal ulcers. Treatment 

with meatotomy may be indicated if signifi cant obstruction to urine fl ow occurs.

The above examples illustrate complications of circumcision currently being seen at military hospitals in Afghanistan. The deployed military surgeon may be called upon 

to assist with many similar problems. It is valuable for 

the surgeon operating at the military hospital to be familiar with the management of the common complications 

related to circumcision and other procedures performed 

in developing countries. A list of experience-based considerations and recommendations for management of 

circumcision-related complications is provided below.

REFERENCES

1. Weiss H, Polonsky J, Bailey R, Hankins C, Halperin D, Schmid G. Male Circumcision: Global 

Trends and Determinants of Prevalence, Safety and 

Acceptability. Geneva, Switzerland: World Health 

Organization; 2007. Available at: http://whqlibdoc.

who.int/publications/2007/9789241596169_eng.pdf. 

Accessed February 20, 2013.

2. Bailey RC, Egesah O, Rosenberg S. Male circumcision for HIV prevention: a prospective study of 

complications in clinical and traditional settings 

in Bungoma, Kenya. Bull World Health Organ. 

2008;86(9):669-677.

3. Baskin LS, Canning DA, Snyder HM, Duckett JW. 

Treating complications of circumcision. Pediatric 

Emerg Care. 1996;12(1):62-68.

4. Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: a systematic review. BMC Urol. 

2010;Feb 16;10:2.

5. Neulander E , Walfi sch S, Kaneti J. Amputation of 

distal penile glans during ritual circumcision – a 

rare complication. Br J Urol. 1996;77(6):924-925.

6. Lerman SE, Liao JC. Neonatal circumcision. Pediatr Clin North Am. 2001;48(6):1539-1557.

COMPLICATIONS OF MALE CIRCUMCISION TREATED AT A MILITARY HOSPITAL IN AFGHANISTAN

KEY POINTS TO CONSIDER

 Given the ages of the patients and the nature of the lesions, all examinations and procedures should be 

done in the operating room.

 Placement of an age appropriate small caliber urethral catheter is prudent as it helps localize the urethra 

and may serve as an adjunct for manipulation of the penis during the procedure

 Use of stay sutures minimizes unnecessary tissue handling during reapproximation. A small stay suture 

through the glans can also be used for penile manipulation.

 Use of a deep dorsal penile block with circumferential ring block allows for decreased narcotic use in 

postoperative pain relief. If available, a caudal anesthetic block is optimal for pain.

 Using a weight-based infi ltration of Marcaine at the base of the glans, injected down to the fascia followed 

by a subcutaneous ring of local anesthesia. Local anesthetic with epinephrine should not be used for this 

purpose due to risk of vasoconstriction induced ischemia.

 Bipolar cautery is helpful in preventing injury to fragile tissues.

 The primary goal is to ensure unobstructed voiding from a patent meatus.

 Reattachment of a transected glans should be attempted only if there is adequate postoperative support and 

trained personnel to deal with potential ischemia and sloughing.

 A postoperative urethral catheter can easily be managed using a double diaper technique (cut a small hole 

in the inner diaper and place the catheter through the hole to drain in the outside diaper, thus separating 

urine from stool).

 Post skin excision appearance is often deceiving and patients often do well without any sequelae if the cut 

skin edges are reapproximated after proximal skin mobilization.

 A 5 French pediatric feeding tube can be used when an appropriate size Foley catheter is not available; it 

can be secured to the glans with suture as required.
 April – June 2013 97

THE ARMY MEDICAL DEPARTMENT JOURNAL

7. Doyle D. Ritual male circumcision: a brief history. 

J R Coll Physicians Edinb. 2005;35:279-285.

AUTHORS

LTC Gurney is Chief of General Surgery, Department of 

Surgery, Landstuhl Regional Medical Center, Germany.

MAJ Jaszczak, Department of Surgery, Brooke Army 

Medical Center, Fort Sam Houston, TX 

MAJ Perkins Department of Surgery, Womack Army 

Medical Center, Fort Bragg, NC

COL Lentz-Kapua is Assistant Chief of Pediatrics, Tripler 

Army Medical Center, Honolulu, Hawaii.

COL Soderdahl, Department of Urology, Brooke Army 

Medical Center, Fort Sam Houston, TX

COL Renz, Clinical Directorate, US Army Institute of 

Surgical Research, Fort Sam Houston, TX. Associate 

Professor, Surgery, Uniformed Services University of 

the Health Sciences, Bethesda, MD

CIRCUMCISION IN AFGHANISTAN

Male circumcision is one of the oldest surgical procedures known, most often performed due to cultural or 

religious beliefs. Since the 19th century, the procedure has generally been justifi ed for medical reasons. Most 

commonly, circumcision involves complete removal of the foreskin (prepuce) thereby exposing the entire 

glans of a fl accid penis.7

 Muslims comprise the largest religious group in Afghanistan and circumcision is 

regarded as a tradition originating from the Prophet, and therefore benefi cial. It is believed that more than 

80% of the males in Afghanistan are circumcised.7

Although not regarded as absolutely necessary, most parents bring their preschool aged boy to either the 

local “barber”, or, if available, to a “doctor” at a local clinic to perform his circumcision. In the southern 

provinces of Afghanistan, it is estimated that the village barber provides the service of circumcision for 70% 

to 85% of the boys. Traditionally this man has 4 tasks in the village: to cut hair, perform circumcisions, and 

to be the drummer and alternately guitarist at village gatherings. When the boys are aged between 3 and 7 

years, the father will make arrangements to meet with the barber. The barber’s kit includes 2 essential items: 

a sharp knife and a bag of ash. He performs his task in the middle of the village. The child is placed on the 

lap of the father, the penis is exposed, the glans is pushed inward as the foreskin is pulled away and then it 

is quickly cut with the sharp knife. A poultice of ash is then placed on the bleeding edge of the foreskin to 

achieve hemostasis. The barber is paid in trade by the family with harvested crops, small livestock, or other 

bartered services.

The other 10% to 15% of boys not serviced by the barber are taken to the local doctor, who is typically a 

well-educated male who owns and operates the village drugstore, often considered the village clinic. This 

practitioner performs the circumcision rite in the clinic. The child is generally provided a mild sedative and 

anesthetic, likely a narcotic, and the doctor then pushes down on the glans while pulling up on the foreskin 

and amputates the excess foreskin with a sharp scissors. The exposed edges of the foreskin are stitched to 

the coronal ring of the glans and the child is sent home with follow-up appointment scheduled for one week 

later. According to Mr Shafi q Mubarak, Afghan cultural advisor, the procedure performed at the “clinic” 

generally costs the family about 700 Pakistani Rupees, the equivalent of US $8, a large sum of money for 

much of the populace.

Erratum

In the January-March 2013 issue of the AMEDD Journal, the article “Heatstroke in a Military Working Dog,” 

contains the following incorrect sentence on page 35, left column, fi rst paragraph:

There was no evidence of bloat on abdominal radiographs, and thoracic radiographs showed diffuse pulmonary disease (acute respiratory distress syndrome/acute lung injury, pneumonia, noncardiogenic pulmonary edema were ruled out).

The correct sentence is:

There was no evidence of bloat on abdominal radiographs, and thoracic radiographs showed diffuse pulmonary disease, which could have been caused by acute respiratory distress syndrome/acute lung injury, 

pneumonia, or noncardiogenic pulmonary edema, none of which could be ruled out.
98 http://www.cs.amedd.army.mil/amedd_journal.aspx

The Centers for Disease Control and Prevention (CDC) 

Offi ce of Public Health Preparedness and Response 

(PHPR) website contains a section that addresses the 

issue of a zombie apocalypse (http://www.cdc.gov/phpr/

zombies.htm). The CDC’s Zombie Preparedness campaign “began as a tongue-in-cheek campaign to engage 

new audiences” with emergency preparedness messages. As Dr Ali Kahn, the PHPR Director, notes: “If 

you are generally well equipped to deal with a zombie 

apocalypse you will be prepared for a hurricane, pandemic, earthquake, or terrorist attack.” The campaign, 

and indeed the very idea of a zombie invasion, certainly 

translates well into a discussion about quarantine and 

isolation. One only has to watch Hollywood zombie 

movies such as Night of the Living Dead, 28 Days Later, 

or the critically acclaimed American Movie Channel 

series The Walking Dead to realize the importance of 

quarantine and isolation rules and the hazards of not 

following those rules (such as turning into a zombie). 

While I do not foresee a world-wide zombie pandemic 

like that described in Brook’s World War Z1

 coming to a 

military installation near you, epidemics and pandemics 

of equal impact are a reality in today’s highly mobile 

society. This article provides an overview of governing 

quarantine and isolation authorities that both military 

and federal civilian leaders should understand. Such understanding is important to ensure the military mission 

is maintained in the face of a medical emergency that 

could quickly spread installation-wide or further.

FEDERAL VS STATE AUTHORITY

Historically, there has been tension between state and 

local governments and the federal government regarding 

the exercise of public health power. In 1824, that tension was demonstrated in the case of Gibbons v Ogden

(22 US 1 [1824]) dealing with a water navigation rights 

dispute between New York State and the Federal government. The US Supreme Court voided the New York State 

law since the Commerce Clause of the US Constitution 

specifi cally granted Congress the power “to regulate 

Commerce with foreign nations, and among the several 

States....”2

 Chief Justice Marshall specifi cally stated that 

“quarantine and health laws...are considered as fl owing 

from the acknowledged power of a State to provide for 

the health of its citizens.”3

 In 1902, in the case of Jacobson v Massachusetts (197 US 11 [1905]), an immigrant 

failed to comply with a town’s vaccination order in the 

face of a smallpox outbreak in Cambridge, Massachusetts. Justice Harlan, delivering the opinion of the court 

in support of the order, agreed that the Constitution guarantees individual liberties but he looked to the principles 

of the social compact laid down “for the common good, 

for the protection, safety, prosperity and happiness of the 

people, and not for the profi t, honor or private interests of 

anyone man, family or class or men.”4

The cases support the general police powers of the states 

under the 10th Amendment of the US Constitution. This 

power gives the states the authority to declare and enforce isolation and quarantine areas within their borders. 

Although there is variation among states’ approaches to 

compelled isolation and quarantine, generally, the governor is the person authorized to declare a public health 

emergency that may trigger the isolation/quarantine restrictions. Most states have enacted isolation and quarantine statutes based on the Model State Emergency 

Health Powers Act.5

 This model act is designed to be 

legislatively passed in part or in its entirety by the states. 

The model act attempts to provide a comprehensive 

framework for state emergency health powers including 

isolation and quarantine. An understanding of the model 

and how a state has applied it, or not, is critical for leaders in command or on military installations within the 

geographical boundaries of a particular state.

Gibbons v Ogden and Jacobson v Massachusetts are two 

of the most important cases in public health law supporting state’s rights, but they do not undercut the federal 

government’s authority to quarantine under certain circumstances. In fact, at the federal level, the United States 

Surgeon General, with the approval of the Secretary of 

Health and Human Services (HHS), is authorized by 42 

USC §264 (2010) to make and enforce quarantine regulations “necessary to prevent the introduction, transmission, or spread of communicable diseases” including 

“apprehension, detention, or conditional release of individuals.” These powers are implemented through 42 CFR 

§§70.2, 70.5, and 70.6 (2002) which allow the Director of 

Quarantine and Isolation:

 A Primer for Military Leaders

MAJ Joseph B. Topinka, JAG, USA
 April – June 2013 99

the CDC to take reasonably necessary measures 

to prevent the spread of diseases between states 

if local efforts are “insuffi cient.” They further 

codify the authority of the Secretary of HHS to 

require permits for interstate travel by certain 

infected persons, and to order their detention.

MILITARY AUTHORITY

Like state and local leaders, a commander is responsible for maintaining the health and safety 

of the military installation, facility, or organization under his or her command. This is particularly key to a military commander who, by 

virtue of his or her position possesses authority 

to maintain health and safety, may isolate and 

quarantine personnel and property on a military 

installation when a threat is imminent, and take 

action that is reasonably likely to limit the threat. 

Actions taken by commanders in response to a 

public health crisis are based on the nature of the outbreak and applicable laws, regulations, and policies. In 

addition, since a military installation may be under exclusive federal control,* the military commander has 

broad authority to wield public health powers to protect 

lives and property under his or her command. It should 

be noted that determining which military commander 

has the appropriate authority can be a challenge that requires early coordination and agreement. A proper understanding of the defi nition of military commander as 

described in Department of Defense Instruction (DoDI) 

5200.086

 may help in making that determination.

Military commanders have many tools for containing 

contagious diseases, use of which should be considered 

before initiating involuntary isolation or quarantine. 

These tools carry few legal consequences and minimize 

the cost and inconvenience associated with more drastic measures. Such tools include voluntarily isolation or 

quarantine, closing facilities such as schools or child care 

centers, cancelling large public gatherings, encouraging telecommuting, promoting health measures such as 

frequent hand washing, and distributing surgical masks 

and hand sanitizers. Should involuntary isolation or 

quarantine on a military installation become necessary, 

DoD guidance does apply.7

 However, the decision process to implement said guidance should consider similar 

actions taken by neighboring local and state authorities 

to ensure continuity with the greater community.

DoDI 6200.037

 provides guidance for involuntary quarantine. It permits a military commander, in consultation 

with the command’s public health emergency offi cer, to 

declare a public health emergency within the scope of 

his or her authority. Upon doing so, the commander may 

then implement relevant emergency powers to achieve 

the greatest public health benefi t while maintaining operational effectiveness. These emergency powers are broad 

and include authority to isolate or quarantine military and 

civilian personnel on the installation if it is understood 

that isolation or quarantine might prevent the spread of 

a communicable disease. Executive Orders 132958

 and 

133759

 list qualifying communicable diseases and the 

list includes: cholera, diphtheria, infectious tuberculosis, plague, severe acute respiratory syndrome, smallpox, 

yellow fever, and viral hemorrhagic fevers. Interestingly, 

infl uenza (fl u) is on the list; albeit it is infl uenza caused 

by novel or reemergent infl uenza viruses that are causing, or have the potential to cause, a pandemic.

The military commanders’ emergency powers include 

authority to limit or terminate access to the installation 

or facility. Commanders can order military personnel to 

submit to testing and physical examination. They can 

require nonmilitary personnel to submit to a physical 

examination and/or testing as necessary for diagnosis. 

Commanders can require vaccination or treatment to 

prevent the transmission of a communicable disease. 

Military members who violate a commander’s directive 

may be subject to disciplinary action in accordance with 

the Uniform Code of Military Justice.†

 Nonmilitary personnel are subject to federal statutes including 18 USC 

*Not all military installations are exclusively federal jurisdictions. 

Where jurisdiction is concurrent, coordination with state and local 

governments is not only critical, but legally required.

Camp E. A. Perry, Georgia, yellow fever detention (isolation) compound 

(1888). Photo courtesy of the National Library of Medicine.

†The Uniform Code of Military Justice (UCMJ), a federal law (64 

Stat. 109, 10 USC, chap 47) is the judicial code which pertains 

to members of the United States military. Under the UCMJ, military personnel can be charged, tried, and convicted of a range of 

crimes, including both common-law crimes (eg, arson) and military-specifi c crimes (eg, desertion).
100 http://www.cs.amedd.army.mil/amedd_journal.aspx

§1382 (Entering military, naval, or Coast Guard Property) and 50 USC §797 (Penalty for violation of security 

regulations and orders). Various administrative sanctions are also available to commanders.

ISOLATION AND QUARANTINE DEFINED

It is important to defi ne the terms quarantine and isolation. People frequently confuse the terms, and their confusion could lead to improper implementation of preventive safety measures on an installation. DoDI 6200.037

defi nes both terms:

Quarantine

The separation of an individual or group that has been 

exposed to a communicable disease, but is not yet ill, 

from others who have not been so exposed, in such a 

manner and place to prevent the possible spread of the 

communicable disease.7(p41)

Isolation

The separation of an individual or group infected and/or 

suspected to be infected with a communicable disease 

from those who are healthy in such a place and manner to 

prevent the spread of a communicable disease.7(p40)

Similar defi nitions have recently been added to the Federal Quarantine, Inspection, Licensing regulation of 42 

CFR 70 et sec.* They are similar to those in the previously mentioned Model State Emergency Health Powers 

Act.5

 Unfortunately, not all states have the same quarantine and isolation defi nitions, resulting in confusion, 

especially for the military installation geographically 

located in a jurisdiction with a defi nition that is different from that found in DoDI 6200.03.

7

When teaching, to clarify the difference between the 2 

terms to military public health offi cials, I use the CDC’s 

Zombie Preparedness Campaign and use zombie analogies. Using the Hollywood genre, if a zombie bites a person, the bitten person should be quarantined as the person 

has been exposed to a communicable disease, but is not 

yet ill. However, if the person presents with pain and discoloration of the infected bite area, fever, chills, slight dementia, vomiting, acute pain in the joints, heart stoppage, 

zero brain activity, and then reanimation (as envisioned 

by Brooks10), it is time to isolate the person. My students 

never forget the difference between the defi nitions.

DoD QUARANTINE AND ISOLATION PROCEDURES

According to DoDI 6200.03,

7

 quarantine and isolation shall be accomplished through the least restrictive means available and shall be terminated when no 

longer necessary to protect the public health. Places of 

quarantine must be maintained in a safe and hygienic 

manner, and the installation commander is required to 

provide adequate food, clothing, medical care, and other 

necessities to those in isolation or quarantine. Obviously, 

there is a signifi cant logistical aspect to support these 

procedures. In addition, there are specifi c due process 

rights afforded to individuals which are similar but not 

exactly the same as those rights afforded in the Model 

Act.5

 Specifi cally, the public health emergency offi cer 

is required to furnish written notice of the reason for 

the quarantine and plan of examination, testing, and/or 

treatment. For anyone subject to quarantine who contests 

the reason for quarantine, the public health emergency 

offi cer must provide an opportunity for that person to 

present information supporting an exemption or release 

from quarantine. The commander or designee†

 shall review the information for determination of the case. The 

reviewing offi cial shall exercise independent judgment 

and promptly render a written decision on the need for 

quarantine of the person. A personal anecdote: during 

several emergency preparedness exercises, I drafted 

such notices without example or reference. I normally 

use formats similar to those used by the state and local 

jurisdictions surrounding the military installation. They 

can usually be modifi ed for DoD purposes with little effort while still looking similar to the state and local formats. These similarities help reduce confusion among 

the military and civilian populations who are living in 

the area surrounding an installation.

*77 Federal Register 30729 (Dec 26, 2012): 75880-75884.

†The commander may designate a senior offi cer or employee of the command who was not previously involved in any factual determination concerning the person being considered for quarantine/isolation.

Emergency isolation hospital at Camp Funston, Fort Riley, 

Kansas, in 1918 for Soldier victims of the infl uenza pandemic 

that killed millions of people worldwide between 1918 and 

1920. Courtesy of the National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, DC. 

(NCP1603)

QUARANTINE AND ISOLATION: A PRIMER FOR MILITARY LEADERS
 April – June 2013 101

THE ARMY MEDICAL DEPARTMENT JOURNAL

ISOLATION AND QUARANTINE OUTSIDE OF A 

MILITARY INSTALLATION

In general, military personnel cannot enforce isolation 

or quarantine orders imposed by either the US Surgeon 

General or by state or local governments. Doing so 

would involve the application of police powers, which is 

proscribed by the Posse Comitatus Act (18 USC §1385 

(1878)). This statute prohibits the use of Army personnel 

for law enforcement purposes. Enforcement of an isolation or quarantine order issued by someone other than 

an installation commander is the responsibility of federal law and/or local law enforcement offi cials.

There are several exceptions to the Posse Comitatus 

Act. For example, Congress enacted a statutory exception in the Insurrection Act (10 USC §§331-335 (1807)). 

The Insurrection Act authorizes the president to use federal military forces to suppress domestic violence that 

hinders execution of state or federal law, or otherwise 

deprives citizens of their constitutional rights. Federal 

courts have created 2 common law exceptions to the 

Posse Comitatus Act, which are commonly referred to 

as the “military purpose doctrine” and the “indirect assistance doctrine.” The fi rst exception, military purpose 

doctrine, allows the use of military personnel in a law 

enforcement capacity when the operation has a specifi c 

military purpose. As a result, military personnel may be 

used in a law enforcement capacity on a military installation or to protect military personnel or property. The 

second exception, indirect assistance doctrine, allows 

for the use of federal military personnel in a passive role 

that only indirectly aids law enforcement, such as the 

use of military facilities or equipment by civilian law 

enforcement personnel. Since the Posse Comitatus Act 

only prohibits the use of federal military personnel in a 

law enforcement activity, the statute’s prohibitions do 

not apply to members of the National Guard when in 

Title 32 status (primarily state active duty).* However, 

Posse Comitatus does apply to National Guard personnel in Title 10, Federal status (full-time duty in the active 

military service of the United States).* Thus, National 

Guard members serving in a nonfederal status can be 

used to enforce a quarantine order that is issued outside 

of a military installation.

Finally, it is important to understand that pursuant to 

DoD Directive (DoDD) 3025.18,

11 a commander at any 

level, especially an installation commander, can provide immediate assistance to save lives, prevent human suffering, or mitigate great property damage under 

imminently serious conditions. “Immediate response 

authority” is based in the belief that local and state authorities may not be able to immediately respond in suffi cient numbers to an emergency incident that requires 

saving lives, preventing human suffering, and mitigating great property damage. This authority is used only 

under unique conditions, when guidance cannot be obtained from higher headquarters on a timely basis, due 

to an attack on the United States or other emergency 

circumstances. Under these circumstances, DoD component personnel may apply DoD resources during Defense Support of Civil Authorities operations11 in the 

following order of priority only:

1. To save human life.

2. To mitigate human suffering.

3. To protect essential US governmental capabilities, 

such as continuity of the US government.

4. Protecting US governmental offi cials.

5. Prevention of loss or destruction of federal property, 

and restoration of essential federal functions.

6. To preserve or restore services of state and local 

government.

This authority should be exercised sensibly and with 

prudence. Beyond the situations listed, nonlaw enforcement assistance should only be provided in compliance 

with the Robert T. Stafford Emergency Disaster and 

Assistance Act (42 USC §§5121-5206), implemented by 

DoDD 3025.18.

11 The Stafford Act authorizes the President to declare a major disaster or emergency if an event 

is beyond the combined response capabilities of the affected state, territorial, and local governments. Following a declaration, the President may direct any federal 

agency to use its resources in support of state and local assistance efforts. If an emergency involves an area 

or facility for which the federal government exercises 

exclusive or primary responsibility and authority, the 

President may unilaterally direct the provision of emergency assistance.

The guidance and information contained in this article 

should ensure that military commanders and federal 

civilian leaders are legally well-prepared for a zombie 

apocalypse (or lesser medical catastrophe) in terms of 

quarantine and isolation authorities. The task of synchronizing federal responsibilities and authorities with 

state and local authorities, and with military commanders’ responsibilities under DoDI 6200.03,

7

 can be confusing and daunting. Considering the potential magnitude of an epidemic or other medical crisis, the value 

*http://www.arng.army.mil/SiteCollectionDocuments/Publications/News%20Media%20Factsheets/ARNG_Factsheet_May_06%20

ARNG%20fact%20Sheet.pdf 
102 http://www.cs.amedd.army.mil/amedd_journal.aspx

of understanding the laws, regulations, and guidance in 

this article cannot be overstated.

ACKNOWLEDGEMENT

I thank Ms Ida Agamy for her assistance in drafting 

and review of this article.

REFERENCES

1. Brooks M. World War Z. New York: Crown Publishing; 2006.

2. US Const Art I, §8, cl 3.

3. Gibbons v Ogden, 22 US 1, 205 (1824).

4. Commonwealth v Alger, 7 Cush 53, 84 (Mass 1851). 

Cited by: Jacobson v Massachusetts 197 U.S. 11, 

27 (1905).

5. Model Laws. The Centers for Law and the Public 

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

healthlaw.net/ModelLaws/index.php. Accessed 

December 19, 2012.

6. Department of Defense Instruction 5200.08: Security of DoD Installations and Resources and the 

Physical Security Review Board (PSRB). Washington, DC: US Department of Defense; December 10, 

2005 [Change 1, May 19, 2010]:4-5.

7. Department of Defense Instruction 6200.03: Public Health Emergency Management Within the Department of Defense. Washington, DC: US Department of Defense; March 5, 2010 [Change 1, June 

1, 2012].

8. Executive Order 13295: Revised List of Quarantinable Communicable Diseases. 68 Federal Register 

17255 (April 9, 2003). Available at: http://www.gpo.

gov/fdsys/pkg/FR-2003-04-09/pdf/03-8832.pdf. 

Accessed January 22, 2013.

9. Executive Order 13375: Amendment to Executive 

Order 13295 Relating to Certain Infl uenza Viruses 

and Quarantinable Communicable Diseases. 70 

Federal Register 17299 (April 5, 2005). Available 

at: http://www.gpo.gov/fdsys/pkg/FR-2005-04-05/

pdf/05-6907.pdf. Accessed January 14, 2013.

10. Brooks M. The Zombie Survival Guide, Complete 

Protection from the Living Dead. New York: Three 

Rivers Press; 2003:3. 

11. Department of Defense Directive 3025.18: Defense 

Support of Civil Authorities. Washington, DC: US 

Dept of Defense; December 29, 2010 [Change 1, 

September 21, 2012]. Available at: http://www.dtic.

mil/whs/directives/corres/pdf/302518p.pdf. Accessed December 21, 2012.

AUTHOR

MAJ Topinka is an Assistant Professor in the US 

Military-Baylor University Graduate Program in Health 

and Business Administration, and is the Legal Instructor 

at the Army Medical Department Center and School 

Leader Training Center, Fort Sam Houston, Texas.

American Soldiers in communicable disease quarantine confi nement, 8th Evacuation Hospital, Casablanca, 

North Africa (1943). Photo courtesy of the National Library of Medicine.

QUARANTINE AND ISOLATION: A PRIMER FOR MILITARY LEADERS
 April – June 2013 103

The US Army is an organization built upon what is often 

described as “tribal lore.” Tribal lore is a concept whereby the elders of the tribe imbue the lessons learned from 

past trials, tribulations, and experiences to the younger 

members of the tribe. In tribal societies, this feat is accomplished through storytelling, observation and emulation. In short, tribal lore at its most basic foundation 

is the application of best practices and lessons learned. 

The modern US Army employs the same techniques, albeit in a codifi ed and structured, methodological manner, 

through the after action review process and ultimately 

the creation of doctrine and Army regulations.

The current Army Regulation 40-51

 specifi es:

The overall objectives of fi eld preventive medicine are 

to provide commanders with healthy and fi t deployable 

forces; to sustain the health and fi tness in any military 

operation; and to prevent casualties from DNBI [disease 

and nonbattle injuries] and stress reactions.1(p4)

But what did the Army do before the implementation of 

Army-wide policies and regulations concerning preventive medicine? History is replete with examples of what 

the Army did or, more often than not, failed to do. One 

need only look a mere 150 years in the past to fi nd prime 

examples.

During the American Civil War, the most costly of all 

American confl icts, it is estimated that over twice as 

many Union Soldiers died of diseases (250,152) than 

were killed in action (110,070).2

 Clearly, preventive 

medicine, or the lack thereof, played a key role in the 

composition and disposition of the Union Forces during 

the American Civil War. An example of that fact is the 

story of how two Union commanders, during two different years in two separate theaters of war, approached the 

same task of executing preventive medicine programs to 

thwart yellow fever, resulting in two completely different outcomes.

MG Benjamin Butler, a politically appointed general 

with no formal military training, arrived to take control 

of the fallen Confederate city of New Orleans, Louisiana, on May 1, 1862. Occupying and controlling the 

rebellious, former Confederate shipping hub would be 

a daunting task for Butler and his Union forces requiring the full range of public administration tasks, not the 

least of which was dealing with annual scourge of yellow fever.3(pp36,37) Yellow fever was colloquially known 

as “Yellow Jack,” a name derived from the age-old 

nautical tradition requiring arriving ships with known 

health problems to fl y the all-yellow international maritime signal fl ag for the letter “Q” to signify that a contagious disease was present on the ship. That ship and 

its crew were then under quarantine until cleared by the 

port authority medical staff.4

Yellow fever was the most mysterious and terrifying of 

all southern diseases. It is typifi ed by fever, jaundice, 

headaches, bleeding from the nose and mouth and in its 

fi nal stages, vomiting of a dark, coffee ground-like material which was actually half digested blood. Fatality rates 

for those affl icted with this malady ranged up to 50%. 

Those who did survive a yellow fever outbreak were rewarded with life time immunity to the disease. The fever 

appeared annually throughout the coastal regions of the 

south during the late summer months and had the potential kill hundreds, or even thousands, especially the 

unacclimatized. For this reason, yellow fever was often 

known locally as “the strangers’ disease.” The fear of 

this disease had major psychological impacts upon the 

northern Soldiers of Butler’s command who marched 

into the streets of New Orleans in 1862.3(pp3,15) It appears 

that many in Butler’s command were more afraid of yellow fever than they were of any Confederate Soldier.

The cause of yellow fever was still unknown in 1862. 

Not until the groundbreaking work of Army physician 

MAJ Walter Reed in the early 20th century would the 

medical community understand that yellow fever was 

actually spread through the bites of the Aedes aegypti 

mosquito.5

 The conventional medical wisdom of the mid 

19th century medical community held that yellow fever 

was spread through unsanitary conditions and the unhealthy, bad air created by those conditions. In fact, this 

theory is partially true. Unsanitary conditions created 

havens for the mosquitoes, and thereby perpetuated the 

spread of the deadly disease. Based upon the perceived 

The Battle of Yellow Jack: A Comparative

 Look at Preventive Medicine During the

 American Civil War

COL Barry F. Graham, USA
104 http://www.cs.amedd.army.mil/amedd_journal.aspx

impact yellow fever would have on his command and 

the need to do something about it, Butler devised a plan 

to establish a proactive campaign to battle the conditions of Yellow Jack. He believed that if he eradicated 

the conditions required for Yellow Jack, meaning the 

bad air, he could then control the disease. Butler’s plan 

was simple and straightforward. First, he consulted not 

only with his assigned Union Army medical staff, but 

more importantly with the local doctors. By virtue of 

location, the local physicians had experience in dealing 

with the annual yellow fever outbreaks, although many 

of were initially reluctant to assist.3(p38)

Butler implemented a 2-pronged, simultaneous attack 

on yellow fever in New Orleans. His strategy included a 

strict quarantine of any vessels arriving in New Orleans 

and a comprehensive fi eld sanitation program to rid the 

city of bad, unhealthy air. A ship quarantine station was 

established some 70 miles south of the city, manned by 

Union troops and local physicians with orders to detain 

and quarantine for 40 days any vessel thought to be 

infected with yellow fever. In a rather Draconian step, 

Butler threatened the local physicians with execution 

in the event that any infected ship was allowed though 

the blockade. Simultaneously, Butler employed a literal 

army of local workers and Soldiers to work around the 

clock executing a wide range of fi eld sanitation efforts to 

remove standing, stagnant water, trash, and human and 

animal waste products throughout the city. The northern 

press praised Butler’s initiatives, with Harper’s Weekly 

stating that “he will probably demonstrate before the year 

is out that yellow fever, which has been the scourge of 

New Orleans, has been merely the fruit of native dirt and 

that a little Northern cleanliness is an effectual guarantee against it.” 3(p38) In 1863, Harper’s Weekly published a 

cartoon of a scrub brush and soap wielding Butler standing in front of an approving Abraham Lincoln. Butler’s 

efforts ultimately had the results that he sought; only 2 

cases of yellow fever death resulted in New Orleans in 

all of 1862 and, more importantly, the paralyzing fear of 

yellow fever which once strangled the northern troops as 

they entered New Orleans was mitigated under Butler’s 

Union control.3(p38) Butler’s efforts had controlled the 

disease as well as the fear that it created. Butler’s actions had a long-term impact of the Crescent City, with 

only 11 yellow fever deaths occurring in New Orleans 

between 1862 and 1865. However, after civil authority 

was returned to the civilians of New Orleans in 1866, 

185 people died of yellow fever. That number soared to 

3,107 deaths in 1867. Over 4,000 died of yellow fever in 

New Orleans during the sweeping epidemic of 1878, including noted Confederate General John Bell Hood, his 

wife, and one of his 11 children.6

Butler’s fundamental but effective preventive medicine 

program had proved successful in New Orleans. However, the scene 2 years later and 965 miles away in New 

Bern, North Carolina, was a different story altogether. 

The eastern North Carolina community of New Bern is 

a low lying town, surrounded by swamps and marshy 

land. The summer of 1864 had been characteristically 

wet and humid, bringing with it swarms of the ubiquitous southern mosquitoes. Since its occupation by 

Union forces in 1862, New Bern had become a military 

hub, crowded with troops and the trappings of an army 

of occupation. MG Butler himself, as he approached the 

town in 1864, described New Bern as having “an awful 

stench” and further observed that the sanitation ditches 

in the Union camps were never fi lled in or covered, and 

the camps were moved when the smell of human excrement made the location of the camp unbearable.7

 Unlike 

Butler’s command in New Orleans 2 years earlier, BG 

Innis Palmer’s command had taken virtually no preventive medicine steps that did anything to thwart a yellow 

fever outbreak. In fact, the lack of Union camp sanitation 

plans and poor Union camp discipline, combined with a 

long, hot, wet summer, obviously had the opposite effect, 

actually setting the stage for a yellow fever epidemic.

When yellow fever did strike New Bern in 1864, it began 

very quietly and without much fanfare. History reports 

that SGT Mason Rogers of the Fifteenth Connecticut 

was the fi rst yellow fever casualty of 1864, succumbing 

to the ravages of the disease on September 9, 1864. Union 

surgeon Dr Hubert V. C. Holcombe, who had spent time 

in Vera Cruz, Mexico, before the war and was well acquainted with the symptoms of yellow fever, reported the 

death and his suspicion about a yellow fever outbreak up 

the Union chain of command. None of the other Union 

physicians had ever personally observed a yellow fever 

outbreak. That was about to change. Medical Director 

for the Department of North Carolina, Dr D. W. Hand, 

initially denied the existence of yellow fever within the 

command and is even reported to have scolded Holcombe for trying to create a stir. When presented with 

overwhelming medical evidence of the disease, Dr Hand 

fi nally relented and acknowledged the existence of yellow fever and reported the fi ndings to his superior, BG 

Innis Palmer. Dr Hand received treatment in kind from 

BG Palmer and was subjected to scorn and ridicule, while 

being accused of ignorance of southern diseases.3(p106)

Finally, in the face of increasing sickness within the 

command, both Palmer and Hand were forced to accept 

that yellow fever had indeed struck New Bern. However, the District of North Carolina chain of command 

kept the outbreak from the press for fear of creating a 

THE BATTLE OF YELLOW JACK: A COMPARATIVE LOOK AT PREVENTIVE MEDICINE

DURING THE AMERICAN CIVIL WAR
 April – June 2013 105

THE ARMY MEDICAL DEPARTMENT JOURNAL

panic amongst both the Union troops and the North 

Carolina population. Palmer and Hand’s efforts proved 

fruitless, since history records that Union sailors as far 

south as Beaufort, South Carolina, knew of the outbreak 

of symptoms of yellow fever even before Sergeant Rogers’ death.3(p106) Because of cover-up and initial inaction, 

the District of North Carolina and the Union garrison at 

New Bern were forced into a reactive rather than proactive scenario with regard to dealing with the yellow 

fever outbreak.

When fi nally spurred to action, Union forces in New 

Bern executed with a vengeance in an attempt to thwart 

the spread of yellow fever. Union offi cials enacted a 

strict quarantine system and burned pine branches and 

barrels of tar in the streets to “purify the air.” Buildings 

thought to be infected with yellow fever were burned 

to the ground, and as many healthy Soldiers as possible 

were given furlough or transferred to “healthy” locations inland to prevent their infection, although some 

units remained in place to maintain law and order, implement sanitation measures and care for the sick.3(p107)

By October 1864, the plague had hit its peak and Union 

forces were so decimated by the disease that Union offi cials ordered the newly formed and untrained First 

North Carolina Colored Heavy Artillery to move rapidly 

to New Bern to assist with sanitation operations. It was 

believed that that the locally raised black troops would 

be immune to yellow fever and thus fare better in New 

Bern. The First North Carolina reportedly spread 200 

loads of lime around the dwellings of New Bern making the city appear to be blanketed in snow. Likewise, 

the First North Carolina cut down and burned over 500 

cords of woods as well as 200 barrels of turpentine.7(p24) 

However, contrary to the conventional medical thought 

of the day, the locally raised Soldiers of the First North 

Carolina were not completely immune to yellow fever; 

58 Soldiers fell sick with the disease, and 15 of them 

died. The fi rst frost of November 1864 brought an end 

to the epidemic. However, the total cost to Union forces 

was 763 Soldiers sickened by yellow fever and 303 died. 

Additionally, 16 medical personnel were sickened by 

the disease, 8 of whom died.3(p107) In 1864, yellow fever 

caused more casualties to the Department of North Carolina than the Confederate Army. In addition, historians 

estimate that the civilian death toll from the outbreak in 

and around New Bern numbered well over 1,000.7(p26)

The net result of the yellow fever outbreak in New Bern 

was that the Union Army’s Department of the Southeast fi nally published strict standing orders, based largely upon the horrors of the New Bern epidemic. These 

orders required district level commanders to maintain 

sterling camp sanitation standards (including the very 

liberal use of lime), the quarantine of all Confederate 

deserters and refugees, and to keep the results of New 

Bern quiet to avoid a panic amongst the Soldiers, the 

civilian population and the press.3(p107)

Based upon the historical facts concerning these separate preventive medicine operations, what lessons can 

be learned that apply for commanders in the 21st century? How did actions, or inactions, by each command 

ultimately impact the operational capability of the commands, and what were the long-term implications?

Dr Lion Poles of the Kaplan Medical Center (Rehovot, 

Israel) provides an excellent, simple, 12-step model for 

biological event consequent management consisting of 

the following logical steps8

:

1. Preparation

2. Detection

3. Diagnosis/event confi rmation

4. Containment

5. Management of the population at risk

6. Triage

7. Management of the sick

8. Handling of the deceased

9. Dealing with high risk zones

10. Investigative actions

11. Political aspects

12. Determining the end of the event

When overlaid upon the Poles 21st century biological contingency model described above, we can easily 

see that Butler’s preventive medicine campaign closely 

followed that model, beginning with step one. Butler’s 

concerns regarding the future impact of yellow fever 

on his command drove him to prepare his Soldiers, 

his command, and the city of New Orleans for an epidemic. First and foremost, Butler did an excellent job 

of assessing the situation and devising a strategy. He 

relied upon and was greatly assisted by local expertise, 

which formed the foundation of his plan to suppress the 

outbreak of yellow fever in 1862. Next he implemented 

his 2-pronged preventive medicine strategy designed to 

detect the sources for the disease—incoming ships and 

unsanitary conditions. Butler’s strategy of containment 

kept infected ships out of New Orleans via his quarantine stations, while his sanitation teams rid the city of the 

conditions that perpetuated the disease, effectively containing the conditions that supported its spread. These 

proactive actions allowed Butler to manage the population at risk, and to keep New Orleans free of a yellow 
106 http://www.cs.amedd.army.mil/amedd_journal.aspx

fever epidemic in 1862. Butler’s actions negated the need 

to apply the other steps in the Poles’ model because the 

proactive actions of his command effectively stopped 

the disease through 1865. Butler’s actions maintained 

the health of the command and the city in general while, 

perhaps more importantly, eradicating the paralyzing 

fear of yellow fever that gripped the Union Soldiers and 

the residents of New Orleans. As a commander, he kept 

his forces healthy and preserved combat strength for 

other operational requirements.

MG Butler’s success in New Orleans in 1862 provided 

the Union Army with an effective model and means for 

dealing with the ravages of yellow fever in southern climates. The details of Butler’s actions in New Orleans 

were well known in the northern press and broadcast 

throughout the Union. However, Civil War Army planners and commanders alike failed to recognize the utility of the preventive medicine successes that Butler’s 

command had achieved in New Orleans and failed to 

standardize any proven preventive medicine tactics, 

techniques, and procedures across the Union Army. The 

1864 debacle in New Bern provides proof and illustrates 

the consequences of this failure.

Because the Department of North Carolina failed to prepare for a yellow fever epidemic and were slow to detect, diagnosis, or acknowledge the outbreak, the Union 

command found itself thrust rapidly into the throes of 

a growing epidemic and was forced to execute all the 

steps of the Poles model at an expedited, feverish rate. 

The debacle of New Bern in 1864 probably could have 

been avoided; well over 1,000 lives, both military and 

civilian, saved; and combat power sustained had Union 

military commanders recognized, acknowledged, and 

publicized the lessons MG Butler had learned and applied in New Orleans only 2 years earlier. Unfortunately, 

the US Army of the 1860s had yet to develop the selfcritical after action review and lessons learned culture 

that is institutionalized today.

When examining preventive medicine requirements and 

best practices, today’s commanders have the benefi t of 

a codifi ed and time-tested preventive medicine biological strategy as presented in Army Regulation 40-5.

1

 The 

regulation gives straightforward, clear guidance for any 

commander in regard to his or her role in protecting the 

health and safety of the Soldiers and civilians residing 

on the installation:

Installation commanders are responsible for resourcing 

and implementing the preventive medicine components 

of installation infrastructure and services in coordination with the director of health services and the chief of 

preventive medicine services. Installation commanders 

provide the safe and healthy living and work environments and services such as drinking water, food, safe 

worksites, and recreational activities. Preventive medicine personnel provide the medical oversight and monitoring of installation infrastructure and services that may 

pose health threats. They provide the technical advice 

and assistance to installation commanders to minimize 

risks from such threats.1(p17)

Commanders today have the benefi t of both historical 

hindsight and fully developed, time-tested biological 

contingency management models, as well as the expertise of preventive medicine professionals at the installation. However, commanders at all levels must still exercise their responsibility to fully and regularly engage and 

empower those preventive medicine personnel in order 

to be fully prepared for any biological contingency.

REFERENCES

1. . Wash- Army Regulation 40-5: Preventive Medicine

ington, DC: US Dept of the Army; 2007.

2. Davis B. The Civil War, Strange & Fascinating 

Facts. New York, NY: Fairfax Press; 1960:215.

3. Bell AM. Mosquito Soldiers; Malaria, Yellow Fever 

and the Course of the American Civil War. Baton 

Rouge, LA: Louisiana State University Press; 2010.

4. Bryant D. Quarantine fl ag. Maritime Professional 

wWebsite. January 2012. Available at: http://www.

maritimeprofessional.com/Blogs/Maritime-Mus

ings/January-2012/Quarantine-fl ag.aspx. Accessed 

December 6, 2012.

5. Frierson JG. The yellow fever vaccine: a history. Yale 

J Biol Med. 2010;83(2):77-85. Available at: http://

www.ncbi.nlm.nih.gov/pmc/articles/PMC289

2770/. Accessed December 7, 2012.

6. Hall A. Spoons butler, yellow jack and the crescent 

city. 2010. Available at: http://deadconfederates.

com/?s=yellow+jack. Accessed December 5, 2012.

7. Muniz ML. The yellow fever epidemic of 1864. 

The Palace. 2011;10(6):15-16. Available at: http://

www.tryonpalace.org/pdfs/palace_magazine_

summer_2011.pdf. Accessed December 5, 2012.

8. Poles L. Principles of contingency planning for an 

unusual biological event. In: Sherner J, Shoenfeld 

Y, eds. Terror and Medicine: Medical Aspects of 

Biological, Chemical, and Radiological Terrorism. 

Lengerich, Germany: Pabst Science Publishers. 2003. 

Available at: http://www.pabst-science-publishers.

com/index.php?33&backPID=33&begin_at=43&tt_

products=27. Accessed February 23, 2013.

AUTHOR

COL Graham is an Academic Year 2013 Fellow at the US 

Army War College, Carlisle Barracks Pennsylvania.

THE BATTLE OF YELLOW JACK: A COMPARATIVE LOOK AT PREVENTIVE MEDICINE

DURING THE AMERICAN CIVIL WAR
 April – June 2013 107

For as long as there has been a US Army, it has been challenged with maintaining performance effectiveness—fueling (feeding) and maintaining hydration of individuals 

and large groups in challenging environments, and dealing with stressors such as fatigue and uncompensable 

heat. Modern problems introduced by technology such 

as lasers and improvised explosive devices also make the 

military the go-to place for research and information that 

relate to civilian issues, such as commercial laser eye 

safety standards or blast risks from automobile airbags.

The US Army Medical Research and Materiel Command and the Borden Institute have produced the fi rst 

summary of Army physiological research in a new volume of the Textbooks of Military Medicine series. Military Quantitative Physiology: Problems and Concepts 

in Military Operational Medicine is edited by COL 

(Ret) Karl Friedl and Dr William Santee, who together 

have more than 60 years of accumulated experience 

in solving problems in military physiology. Recruiting 

world-renowned experts, they assembled a wide-ranging 

compilation of the most military-pertinent operational 

medicine research efforts, with potentially far-reaching 

implications for civilian medicine as well.

The book effectively captures the state of knowledge resulting from more than a century of organized research 

efforts in areas vitally important to Soldier health and 

performance. The efforts extend from the Civil War, 

when teams of researchers were sent to Union Army 

camps to gather information from thousands of Soldiers 

on anthropometry, lifting strength, pulmonary function, 

and other physiological factors. While reminding us of 

the rich history of military physiological research, the 

book also helps determine the directions of future study.

A logical question from both those providing funds and 

leaders over the years has been “are we there yet?” If 

this research has been going on for more than a century, 

shouldn’t we have all the answers we need? How much 

more can we learn about how we rest, feed, exercise, 

and train Soldiers? The book makes clear the continuous process of evolving better information and interventions, as science and technology advancements provide 

new opportunities to optimize health and performance 

of our Soldiers, in addition to how much more needs to 

be done.

Only in the past decade have we had the computing 

power and information technology to convert this information into useful predictive models for medical planners, commanders, and Soldiers. Unfortunately, the book 

could not capture the rapidly advancing work in computational biology that is now harnessing years of research 

fi ndings in the form of decision support tools. The sophistication of those tools is rapidly increasing; they will 

soon support applications on every smartphone.

The book contains 12 chapters written in an easy-to-read 

format by 28 world-renowned subject matter experts 

presenting practical information directly applicable 

to helping the Soldier. Many scientists have dedicated 

their lives to mitigating the deleterious effects of common stressors for military personnel, and humankind 

in general, to improve quality of life and human performance. The book is the fi rst to highlight the Army’s 

pivotal research from devoted biomedical scientists, 

clinicians, and modelers who developed useful computational physiology models. Addressing important life 

science problems related to training, eating, resting, and 

protection, these cutting-edge models have resulted in 

enhanced systems to augment decision-making in new 

and complex situations.

The book addresses numerous areas of interest, including 

prediction of human limits; modeling the physiological 

A New Volume in the Borden Institute

Textbooks of Military Medicine Series

Military Quantitative Physiology:

Problems and Concepts in Military Operational Medicine

Karl E Friedl, PhD, and William R. Santee, PhD, Editors

COL (Ret) Brian Lukey, USA
108 http://www.cs.amedd.army.mil/amedd_journal.aspx

and medical effects of exposure to environmental extremes; measurement and prediction of sleep and performance in the operational environment; performancemaintaining and performance-enhancing drugs and 

food components; psychosocial factors in harsh and remote environments; nutrition and military performance; 

water requirements and Soldier hydration; evaluation of 

the thermal environment; protection of the skin; blast 

injury; load carriage; and injury control.

Each chapter is a well-written, comprehensive summary 

of quality research on a pertinent stressor and contains 

numerous references to more detailed studies. The research has immediate and long-term, dual-use (military 

and civilian) applications. For example, the US Army 

Research Institute of Environmental Medicine hydration tables are used worldwide in efforts to prevent heat 

injuries caused by inadequate water intake. Future refi nements with personalized monitors that signal individual water needs, perhaps through a wearable system, 

should provide further protection of health and optimize 

performance.

Individual chapters capture an entire body of literature 

and experience in interesting and specifi c military problems. For example, Chapter 5, “In Vivo Diagnostics and 

Metrics in the Assessment of Laser-Induced Retinal Injury,” represents the culmination of 40 years of research 

on laser eye safety by Bruce Stuck and colleagues. The 

Army initiated this program when lasers were a new 

technology, realizing the importance that an understanding by Soldiers of the medical effects (especially on the 

retina) would play in the safe and effective employment 

of these emerging systems. With the termination of this 

research program and retirement of the key experts, it is 

especially important to have this summary of the issues 

that drove this research for national security purposes, 

from aviation safety concerns to health hazards of new 

tactical lasers. This research has been foundational in 

national standards for laser safety and contributed to 

current international treaties on blinding lasers.

Other chapters contain similar summaries by the Army’s 

established experts: COL (Ret) Wayne Askew discusses 

the area of fi eld nutrition research which provided the 

scientifi c basis for modern fi eld feeding concepts and 

rations, such as the First Strike Ration; Dr Jim Stuhmiller presents blast model research that helps acquisition managers evaluate safety concerns for current and 

future high-powered weapons systems; MAJ (Ret) Joe 

Knapik describes load carriage research that has led to 

the current designs of load handling systems including 

rucksacks that accommodate gender differences in anthropometry and strength; and Dr Bill Santee discusses 

thermal strain modeling that provides modern tools to 

prevent heat injury and maximize Soldier effectiveness 

in the heat.

I highly recommend this book to every clinician and 

medical researcher involved in helping our Soldiers mitigate the effects of military operational stressors. Active 

duty military medical personnel may obtain one complimentary book directly from the Borden Institute using 

an online order form (http://www.cs.amedd.army.mil/

borden/BordenOrder.aspx). The book may be purchased 

either through the Borden Institute (202-512-1800) or the 

Government Printing Offi ce (http://bookstore.gpo.gov/).

AUTHOR

COL (Ret) Lukey is the former Research Area Director 

for the Military Operational Medicine Research Program, 

US Army Medical Research and Materiel Command. He 

is currently with the Henry M. Jackson Foundation at the 

711th Human Performance Wing, Wright Patterson Air 

Force Base, Ohio.

MILITARY QUANTITATIVE PHYSIOLOGY

A NEW VOLUME IN THE BORDEN INSTITUTE TEXTBOOKS OF MILITARY MEDICINE SERIES
SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international 

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