i

PREFACE

Disease Vector Ecology Profiles (DVEPs) summarize unclassified literature on medically

important arthropods, vertebrates and plants that may adversely affect troops in specific

countries or regions around the world. Primary emphasis is on the epidemiology of

arthropod-borne diseases and the bionomics and control of disease vectors. DVEPs have

proved to be of significant value to commanders, medical planners, preventive medicine

personnel, and particularly medical entomologists. These people use the information

condensed in DVEPs to plan and implement prevention and control measures to protect

deployed forces from disease, injury, and annoyance caused by vector and pest

arthropods. Because the DVEP target audience is also responsible for protecting troops

from venomous animals and poisonous plants, as well as zoonotic diseases for which

arthropod vectors are unknown, limited material is provided on poisonous snakes,

noxious plants, and diseases such as hantavirus.

In this document vector-borne diseases are presented in two groups: those with

immediate impact on military operations (incubation period < 15 days) and those with

delayed impact on military operations (incubation period > 15 days). For each disease,

information is presented on military importance, transmission cycle, vector profiles, and

vector surveillance and suppression. 

Additional information on venomous vertebrates and noxious plants is available in the

Armed Forces Medical Intelligence Center’s (AFMIC) Medical, Environmental, Disease

Intelligence, and Countermeasures (MEDIC) CD-ROM.

Contingency Operations Assistance: The Armed Forces Pest Management Board

(AFPMB) is staffed with a Contingency Liaison Officer (CLO), who can help identify

appropriate DoD personnel, equipment, and supplies necessary for vector surveillance

and control during contingencies. Contact the CLO at Tel: (301) 295-8312, DSN: 295-

8312, or Fax: (301) 295-7473.

Defense Pest Management Information Analysis Center (DPMIAC) Services: In

addition to providing DVEPs, DPMIAC publishes Technical Information Bulletins

(TIBs), Technical Information Memorandums (TIMs), and the Military Pest Management

Handbook (MPMH). DPMIAC can provide online literature searches of databases on

pest management, medical entomology, pest identification, pesticide toxicology, and

other biomedical topics. Contact DPMIAC at Tel: (301) 295-7476, DSN: 295-7476, or

Fax: (301) 295-7483. Additional hard copies or diskettes of this publication are also

available.

Other Sources of Information: The epidemiologies of arthropod-borne diseases are

constantly changing, especially in developing countries undergoing rapid growth,

ecological change, and/or large migrations of refugee populations resulting from civil

strife. In addition, diseases are underreported in developing countries with poor public
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health infrastructures. Therefore, DVEPs should be supplemented with the most current

information on public health and geographic medicine. Users may obtain current disease

risk assessments, additional information on parasitic and infectious diseases, and other

aspects of medical intelligence from the Armed Forces Medical Intelligence Center

(AFMIC), Fort Detrick, Frederick, MD 21701, Tel: (301) 619-7574, DSN: 343-7574. 

Disease Risk Assessment Profiles (DISRAPs) and Vector Risk Assessment Profiles

(VECTRAPs) for most countries in the world can be obtained from the Navy Preventive

Medicine Information System (NAPMIS) by contacting the Navy Environmental Health

Center (NEHC) at Tel: (757) 762-5500, after hours at (757) 621-1967, DSN: 253-5500,

or Fax: (757) 444-3672. Information is also available from the Defense Environmental

Network and Information Exchange (DENIX). The homepage address is:

<http://denix.army.mil/denix/denix.html>.

Specimen Identification Services: Specimen identification services and taxonomic keys

can be obtained form the Walter Reed Biosystematics Unit (WRBU), Museum Support

Center, MRC-534, Smithsonian Institution, Washington, DC 20560 USA; Tel: (301) 238-

3165; Fax: (301) 238-3667; e-mail: <wrbu@wrbu.si.edu>; homepage:

<http://wrbu.si.edu/>.

Emergency Procurement of Insect Repellents, Pesticides and Equipment: Deploying

forces often need pesticides and equipment on short notice. The Defense Logistics

Agency (DLA) has established the following Emergency Supply Operations Centers

(ESOCs) to provide equipment and supplies to deploying forces:

For insect repellents, pesticides and pesticide application equipment: Contact

the Defense Supply Center Richmond ESOC at Tel: (804) 279-4865, DSN: 695-

4865. The ESOC is staffed seven days a week/24 hours a day. Product Manager

(804) 279-3995, DSN: 695-3995.

For personal protection equipment (bednets, headnets, etc.) and respirators:

Contact the Defense Supply Center Philadelphia ESOC Customer Assistance

Branch at Tel: (215) 737-3041/3042/3043, DSN: 444-3041/3042/3043.

Every effort is made to ensure the accuracy of the information contained in DVEPs. 

Individuals having additional information, corrections, or suggestions, are encouraged to

provide them to the Chief, DPMIAC, Armed Forces Pest Management Board, Forest

Glen Section, Walter Reed Army Medical Center, Washington, DC 20307-5001, Tel:

(301) 295-7476, DSN: 295-7476, or Fax: (301) 295-7482.

Acknowledgments: The initial draft of this DVEP was prepared by Dr. John B.

Gingrich, LTC USA (retired), Dr. Harold J. Harlan, LTC USA (retired), Dr. Peter V.

Perkins, COL USA (retired) and Dr. James H. Trosper, CDR USN (retired). Subsequent

technical reviews and recommendations were provided by DPMIAC’s LTC Richard N.
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Johnson, USA, Capt Daniel J. Mauer, USAF, Dr. Richard G. Robbins, CDR George W.

Schultz, USN, COL Harvey A. Shultz, USAR and Mr. Steven G. Wynne. Additional

reviews were provided by COL Phillip G. Lawyer, USA, Dr. Timothy H. Dickens, CDR

USN (retired), as well as by the Armed Forces Medical Intelligence Center. The cover

design is the work of Mr. J. Rees Stevenson of DPMIAC. The taxa presented in the list

of species in North Africa were reviewed by experts for the respective groups. Dr. James

E. Keirans, Georgia Southern University, reviewed the ticks. Dr. Robert E. Lewis, Iowa

State University, reviewed the fleas. COL Phillip G. Lawyer and Dr. Peter V. Perkins

reviewed the sand flies. Dr. Roy McDiarmid, National Museum of Natural History,

reviewed the snakes. MAJ Scott A. Stockwell reviewed the scorpions. Mr. James Pecor,

US Army Walter Reed Biosystematics Unit, reviewed the mosquitoes. 
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Table of Contents

I. Preface .................................................................................................................... i

II. Executive Summary ............................................................................................... 4

III. Map of Central Europe

Map of Central Balkan Region

Map of Kosovo

A. Map of Albania

B. Map of Bosnia and Herzegovina

C. Map of Bulgaria

D. Map of Croatia

E. Map of Czech Republic

F. Map of Greece

G. Map of Hungary

H. Map of Macedonia

I. Map of Poland

J. Map of Romania

K. Map of Serbia and Montenegro

L. Map of Slovak Republic

M. Map of Slovenia ( see Map of Croatia)

IV. Country Profiles

A. Albania ........................................................................................................... 45

B. Bosnia and Herzegovina ................................................................................ 47

C. Bulgaria .......................................................................................................... 48

D. Croatia ............................................................................................................ 50

E. Czech Republic .............................................................................................. 52

F. Greece ............................................................................................................ 53

G. Hungary .......................................................................................................... 54

H. Macedonia ...................................................................................................... 56

I. Poland ............................................................................................................ 58

J. Romania ......................................................................................................... 59

K. Serbia and Montenegro .................................................................................. 61

L. Slovak Republic ............................................................................................. 62

M. Slovenia .......................................................................................................... 64

V. Militarily Important Vector-Borne Diseases with Short Incubation Periods 

(<15 days)

A. Sand Fly Fever ............................................................................................. 66

B. Malaria ......................................................................................................... 70
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C. West Nile Fever ............................................................................................ 79

D. Sindbis Virus ................................................................................................. 82

E. California Group Viral Infections ................................................................. 84

F. Dengue Fever ............................................................................................... 87

G. Tick-borne Encephalitis ............................................................................... 90

H. Crimean-Congo Hemorrhagic Fever ............................................................. 95

I. Boutonneuse Fever ....................................................................................... 98

J. Rickettsialpox ............................................................................................ 100

K. Q Fever ........................................................................................................ 101

L. Tularemia .................................................................................................... 103

M. Relapsing Fever (Tick-borne) ..................................................................... 105

N. Bhanja Virus ............................................................................................... 107

O. Ehrlichiosis ................................................................................................. 108

P. Murine Typhus ............................................................................................ 108

Q. Epidemic Typhus ........................................................................................ 112

R. Relapsing Fever (Louse-borne) ................................................................... 117

S. Other Arthropod-borne Viruses .................................................................. 118

VI. Militarily Important Vector-borne Diseases with Long Incubation Periods 

(>15 days)

A. Leishmaniasis ............................................................................................. 120

B. Lyme Disease ............................................................................................. 127

VII. Other Diseases of Potential Military Significance

A. Leptospirosis .............................................................................................. 131

B. Hantaviral Disease ..................................................................................... 132

VIII. Noxious/Venomous Animals and Plants of Military Significance

A. Arthropods....................................................................................................134

1. Acari (ticks and mites) ........................................................................ 135

2. Araneae (spiders) ................................................................................ 137

3. Ceratopogonidae (biting midges, no-see-ums, punkies) ..................... 138

4. Chilopoda (centipedes) and Diplopoda (millipedes) .......................... 139

5. Cimicidae (bed bugs) .......................................................................... 139

6. Dipterans Causing Myiasis ................................................................. 140

7. Hymenoptera (ants, bees and wasps) .................................................. 141

8. Lepidoptera (urticating moths and caterpillars) .................................. 143

9. Meloidae (blister beetles), Oedemeridae (false blister beetles) and

Staphylinidae (rove beetles) ................................................................ 144

10. Scorpionida (scorpions) ...................................................................... 144

11. Simuliidae (black flies, buffalo gnats, turkey gnats) ........................... 146

12. Siphonaptera (fleas) ............................................................................ 146
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13. Tabanidae (deer flies and horse flies) ................................................. 146

B. Venomous Snakes of Central Europe ........................................................ 147

C. Medical Botany .......................................................................................... 151

IX. Selected References

A. Military Publications .................................................................................... 154

B. Other Publications ........................................................................................ 155

Figures 

Figure 1. Endemic Areas of Sand Fly Fever in Central Europe ....................................... 68

Figure 2. Life Cycle of Plasmodium the Malaria Parasite ............................................... 73

Figure 3. Anopheles, Aedes, and Culex Mosquitoes ........................................................ 78

Figure 4. Areas of Recent Outbreaks of West Nile Fever in Central Europe .................. 80

Figure 5. Endemic Areas of Louse-borne Typhus in Central Europe ............................ 115

Figure 6. Endemic Areas of Cutaneous Leishmaniasis in Central Europe .................... 122

Figure 7. Endemic Areas of Visceral Leishmaniasis in Central Europe ........................ 123

Figure 8. Life Cycle of Leishmania ............................................................................... 125

Tables

Table 1. Venomous Snakes and their Reported Distribution in Central Europe .......... 150

Table 2. Plants that Cause Contact Dermatitis in Central Europe ................................ 152

Table 3. Specific Reports of Pesticide Resistance in Central Europe ........................... 185

Appendices

 

A. Arthropod Species and their Distribution in Central Europe

A.1. Distribution of Mosquitoes in Central Europe ........................................ 169

A.2. Distribution of Sand Flies in Central Europe .......................................... 173

A.3. Distribution of Ticks in Central Europe .................................................. 174

A.4. Distribution of Fleas in Central Europe ................................................... 176

A.5. Distribution of Scorpions in Central Europe ........................................... 178

B. Vector Ecology Profiles of Tick Vectors in Central Europe .................................... 179

C. Pesticide Resistance in Central Europe .................................................................... 182

D. Sources of Snake Antivenoms ................................................................................. 189

E. Selected List of Taxonomic Papers and Identification Keys ................................... 190

F. Personal Protective Measures .................................................................................. 194

G. Bioscience and State Department Contacts in Central Europe ................................ 196

H. Glossary ................................................................................................................... 201

I. Internet Websites on Medical Entomology and Vector-borne Diseases .................. 204

J. Metric Conversion Table ......................................................................................... 207
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EXECUTIVE SUMMARY

Central European Profile 

Geography. Central Europe encompasses slightly more than 1.45 million sq km of land. 

From north to south, its topography varies from flat marshy plains along the Baltic Sea,

through open plains, rolling hills, the eastern Alps and Carpathian Mountains, the broad

upland valleys drained by the Danube River, the rugged crests and steep narrow valleys

of the Balkan Mountains, and over 2,000 Greek islands in the Aegean and Mediterranean

Seas. Each of the 16 countries in the region is geographically unique, as exemplified by 

Hungary’s broad, flat, fertile valley, bordered on one side by mountains; Romania’s

combination of mountains and rolling plains; Macedonia’s extensively rugged

mountains; and the thousands of islands of Greece. The highest peak in this region is Mt.

Musala, at 2,925 m, in the Rhodope Mountains of southwestern Bulgaria. The lowest

point is a depression at Raczki Elblaskie, at -2 m elevation, about 50 km southeast of the

Polish port city of Gdansk. Many peaks and ridges in the Alps, Carpathian and Balkan

Mountains remain snow-capped during much of the year. Central Europe is bordered on

the north by the Baltic Sea and Russia; on the east by Russia, the Ukraine, Moldova, the

Black Sea, and Turkey; on the south by the Adriatic and Mediterranean Seas; and on the

west by Germany, Austria, Italy and the Adriatic Sea. This area has been a crossroads of

trade, travel and military activity throughout recorded history. The economies of the

region are based on minerals, petroleum, coal and agriculture. Greece and Croatia have

significant fishing industries, and Greece is very important in world shipping. Tourism is

an important source of income for several Central European countries. The states that

formerly constituted Yugoslavia have suffered severe disruption of their infrastructures

and economies since 1992 because of bitter ethnic fighting, despite intervention by

international mediators and peacekeeping forces. Serbia and Montenegro, Bosnia and

Herzegovina, and Croatia have suffered the most destruction. Over half the countries in

Central Europe must import most of their energy resources, food and/or raw materials. 

Many are heavily dependent on foreign aid and foreign investment. 

Climate. The climate of Central Europe can be generally described as continental, with

cold wet winters and warm moist summers, or Mediterranean, with cool wet winters and

hot dry summers. The climate in any particular country depends on its proximity to

major mountains or large bodies of water, its elevation, and local topography. Coastal

lowlands tend to have moderate, moist conditions year-round, while steep valleys at

higher elevations tend to be cooler and drier, especially when they are on the lee side of

prevailing weather patterns. In the southernmost countries, it can be very hot in midsummer at lower elevations, especially on southeast-facing slopes. Wind and weather

patterns tend to travel from west to east across this area, but local direction, moisture

content, and temperature extremes can often be greatly modified by mountains or large

bodies of water. 
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Population and Culture. Central Europe has a population of approximately 140 million

people. Most have a long history of ethnic pride, passionate feelings, and great

awareness of their ancestry and cultural background. The ethnic make-up, religious mix

and culture of each country may vary greatly over short distances. In Bosnia and

Herzegovina, roughly 40% of the people claim to be Serbs, 38% are Muslims, and 22%

are Croats. In most Central European countries, one ethnic group accounts for more than

half the population. The people of Central Europe practice many different religions. 

About 43% are Roman Catholics, 33% are Eastern (or Russian) Orthodox, and about 6%

are Muslims (mainly of the Sunni sect). At least five Protestant denominations in

addition to Judaism and other religions are practiced by the remaining 18% of the

population. These Central European countries have become more urbanized, especially

since World War II and the collapse of Communism. All but three countries (Serbia and

Montenegro, Albania, and Slovenia) are at least 50% urbanized. Most people live on a

relatively small portion of the land, mainly in or near larger cities, which have better

access to transportation and other resources. Urban areas are concentrated along major

rivers, in fertile valleys, or near the coast. Large cities, such as Warsaw, Prague,

Bucharest and Budapest, often have many old, deteriorating buildings that are unfit for

habitation. Many cities and towns in Bosnia and Herzegovina, Croatia, and Serbia and

Montenegro have been extensively destroyed in ethnic fighting, and refugees from those

conflicts have crowded into nearby countries, severely straining their resources. Two

poorly developed and neighboring countries, Albania and Macedonia, both impoverished

and with mainly agricultural economies, have been nearly overwhelmed by the refugee

burden. This displacement, along with associated poor sanitation and crowding, provides

excellent conditions for the spread of vector-borne and infectious diseases. Before the

ethnic conflicts, population densities in Central European countries varied from a low of

81 persons per sq km in Bulgaria to a high of 131 persons per sq km in the Czech

Republic. Despite their turbulent history, the vast majority of the people in all these

countries are literate, with 11 countries having literacy rates of at least 97%. 

Sanitation and Living Conditions. Sanitation and living conditions throughout the

region are barely adequate by Western standards. Septic and sewer systems are chiefly

found in cities, and even these are often old, inadequate, and poorly maintained. Water

treatment and distribution systems are few and limited (many serve less than 1/3 of their

city), are seldom maintained, and frequent cross-connections result in contamination by

fecal matter or industrial wastes. Waste disposal is indiscriminate in many areas,

especially urban slums, where waste and refuse are sometimes piled into an empty

apartment or an empty room in an otherwise fully occupied building. Food sanitation is

poor, and vermin of various kinds are common in and near human habitations. Housing

shortages in many cities have been made worse by an influx of refugees, and several

families often share a small building. Areas with sanitary conditions degraded by civil

war have rapidly increasing rodent populations. The potential for rodent-borne and

louse-borne diseases under such crowded, unsanitary conditions is high. Many cities,

streams and rivers, and even some extensive areas of soil, have been progressively

contaminated by heavy metals and toxic chemicals as a result of decades of heavy
6

industrial activity, such as smelting, manufacturing, chemical production, and petroleum

refining. Little or no effort has been made to minimize or prevent such pollution. 

Countries with serious industrial pollution include Poland, Croatia, Bosnia and

Herzegovina, Hungary, the Czech Republic, and the Slovak Republic. 

DIARRHEAL DISEASE

Gastrointestinal infections are moderately or highly endemic throughout Central Europe

and are the principal disease threats to military personnel deployed to the region. Risk of

transmission is generally higher in rural areas and during warm months of the year in less

developed countries such as Albania, countries with declining socioeconomic standards,

and areas of Yugoslavia with degraded sanitary conditions and large refugee populations

due to civil war. It may take several years to rebuild the sanitary and public health

infrastructures destroyed during the recent conflict. Outbreaks of typhoid fever have

already been reported.

Fecal-oral transmission from person to person is common, but most infections are

acquired from the consumption of contaminated food, water or ice. Filth flies can be

important in the mechanical transmission of pathogens to food, food preparation surfaces

and utensils. Fly populations sometimes reach very high levels during the summer in

areas with poor sanitation. Strict sanitation and fly control can significantly reduce the

risk of gastrointestinal infections. Cockroaches have also been shown to mechanically

transmit gastrointestinal pathogens. 

Bacteria and viruses causing diarrheal disease include: Staphylococcus aureus,

Clostridium perfringens, Bacillus cereus, Vibrio parahaemolyticus, numerous serotypes

of Salmonella, Shigella spp., Campylobacter, pathogenic strains of Escherichia coli,

hepatitis A and E, rotaviruses and other viral species. Infection with pathogenic

protozoa, such as Entamoeba histolytica, Giardia lamblia and Cryptosporidium spp., is

common, though bacterial pathogens account for most cases of diarrheal disease. Onset

of symptoms is usually acute and may result in subclinical infections or severe

gastroenteritis. Shigella infections can produce significant mortality even in hospitalized

cases. Resistance of enteric pathogens to commonly used antibiotics can complicate

treatment. Such resistance is very common in many parts of Central Europe, and

bacterial populations with resistance to multiple antibiotics have been reported.

 

Bacillary dysentery has had a profound impact on military operations throughout history. 

Gastroenteritis was epidemic in the Mediterranean, Middle Eastern and North African

theaters during World War II. 

TICK-BORNE DISEASE* 

Tick-borne diseases are the most prevalent vector-borne diseases in Central Europe. 

Most are associated with periods of high tick activity, usually April through September,

but regional differences and seasonal patterns may occur. 
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Tick-borne encephalitis is focally distributed with its primary vector, Ixodes ricinus, in

mixed deciduous forests, extending into brushlands and meadows at the forest edge,

including suburban forests bordering cities. Antibody prevalences up to 33% in humans

and up to 92% in reservoir animals have been reported from active foci in Slovenia and

Croatia. The Central European form of tick-borne encephalitis produces a milder illness

than the Russian spring-summer encephalitis form found in Siberia, northeast China and

Korea. Most infections are subclinical. 

Lyme disease, also transmitted by Ixodes ricinus, is focally distributed throughout

Central Europe in forested areas up to 1,500 m, and is the most common tick-borne

infection in humans. Incidence of Lyme borreliosis has been increasing in the region. 

Antibody prevalences over 40% have been reported in forestry workers in Slovenia. 

Military personnel would have a high risk of exposure to these and other tick-borne

diseases. 

Tularemia, a plague-like disease caused by the bacterium Francisella tularensis, is

widely distributed in Central Europe. Infection is acquired through the bite of infected

hard ticks, by exposure to the blood or tissues of infected animals, or by consumption of

insufficiently cooked meat of infected animals. Numerous wild mammals, especially

rabbits and hares, and some domestic animals act as reservoirs.

Sporadic cases of tick-borne relapsing fever caused by Borrelia recurrentis are also

reported throughout the region. The disease is enzootic in rocky, rural areas where

livestock are tended and vector soft ticks, Ornithodoros spp., are found.

Crimean-Congo hemorrhagic fever infects domestic animals in nearly every country in

the region and is widely distributed in discrete foci in agricultural and rural areas. 

Sporadic human cases occur. The disease can be contracted by the bite of infected

Hyalomma ticks, but most human cases result from exposure to secretions or blood from

infected animals or humans. Medical workers treating patients are at high risk of

becoming infected. Clinical symptoms can be severe, with mortality rates up to 50%.

Q fever is an acute, febrile rickettsial disease contracted primarily by inhalation of

airborne pathogens or contact with secretions of infected domestic animals. 

Transmission by ticks to humans is possible but rarely, if ever, occurs. Serological

surveys indicate that Q fever is widespread throughout Central Europe and infects a wide

variety of wild mammals and domestic animals, especially goats. Military personnel

should avoid exposure to sheep, goats, cattle and other domestic animals and should not

sleep or rest in animal shelters.

Boutonneuse fever (also termed Mediterranean spotted fever) transmitted by the brown

dog tick, Rhipicephalus sanguineus, and other ixodid ticks is focally distributed,

primarily in coastal areas. The risk of infection is elevated in cities and villages with
8

high populations of tick-infested dogs. Other Rickettsia of the spotted fever group have

been isolated in several countries of Central Europe. 

Bhanja virus is transmitted primarily by Haemaphysalis ticks in enzootic areas of

Central Europe and causes a mild febrile illness in humans. Antibodies have been

detected in a wide range of mammals, especially ruminants, and in several species of

birds. Its distribution in Central Europe is unclear. Infections with Bhanja virus would

have minimal military significance. 

MITE-BORNE DISEASE*

Rickettsialpox, an acute febrile illness transmitted by mites, is caused by Rickettsia

akari, a member of the spotted fever group of Rickettsia. Clinical symptoms mimic

chickenpox and cases may be misdiagnosed. The house mouse, Mus musculus, and other

commensal rodents are reservoirs. Rickettsia akari was isolated from a patient in Croatia

in 1991; this was the first report of this disease in Central Europe in 40 years. Its

presence in other areas of Central Europe is unclear, but the potential exists for outbreaks

in the human population in areas of the former Yugoslavia disrupted by civil war. 

LOUSE-BORNE DISEASE*

Epidemic typhus in the recrudescent form of Brill-Zinsser disease has been reported

from several countries in Central Europe. During the period 1965 to 1975, 623 cases

were reported from Bosnia and 107 from Serbia. Declining sanitary and living

conditions caused by civil war in many areas of the former Yugoslavia have increased the

incidence of head and body lice. The conditions faced by refugees and displaced

persons, whether in collective centers or living independently in the community, are such

that the likelihood of louse-borne disease is high.

Sporadic cases of louse-borne relapsing fever have also been reported from the region,

and, like epidemic typhus, it is a winter disease. 

FLEA-BORNE DISEASE*

Murine typhus is a rickettsial disease similar to louse-borne typhus but milder. It is

enzootic throughout the region in domestic rats and mice and possibly other small

mammals. Infected rat fleas (usually Xenopsylla cheopis) defecate infective rickettsiae

while sucking blood. Airborne infections can occur. Sporadic human cases have been

reported throughout Central Europe. 

SAND FLY-BORNE DISEASE*

Cutaneous leishmaniasis, caused by Leishmania tropica, is present in the countries of

Central Europe that border the Mediterranean and in a band that extends into Central

Asia. Leishmania tropica is usually a parasite of man in urban environments and is

transmitted by the sand fly Phlebotomus sergenti in Greece. The disease is also found in

Albania, Bulgaria, the southern half of Romania, and in all of the newly formed countries

of the former Republic of Yugoslavia except Slovenia. Phlebotomus perfiliewi, the
9

primary vector, is very tolerant of the hot summers and cold winters characteristic of

these Central European countries. Man is the principal reservoir, but dogs have been

found naturally infected. 

Visceral leishmaniasis, caused by Le. infantum, is a less prevalent but more severe

systemic disease. It generally occurs as foci in rural areas, but the highest incidence in

Central Europe occurs in the suburbs of Athens and the Greek Isles. It is endemic in at

least part of every country in Central Europe except Poland, the Czech Republic and

Slovakia. The most common reservoirs are believed to be domestic dogs and wild

canines, primarily foxes. Phlebotomus neglectus is the putative vector in Greece, but P.

perfiliewi, P. pernicious, P. tobbi, P. simici and P. longiductus may be significant vectors

in many endemic areas of Central Europe. Transmission occurs during the warmer

months of April through October, coinciding with the activity of vector sand flies. 

Phlebotomine sand flies bite from dusk to dawn but may feed during the day if hosts

enter their resting habitat. The distribution of sand flies and the diseases they carry is

very focal because of their limited flight capabilities. 

Foci of sand fly fever occur primarily throughout the Adriatic coastal areas of Central

Europe. This disease caused significant morbidity among Allied forces in the

Mediterranean during World War II. The highest risk of transmission exists in villages

and periurban areas. Local populations are generally immune as a result of childhood

infection. The Naples, Sicilian and Toscan viruses circulate in endemic areas of Central

Europe, but the Naples type predominates. Risk of infection is highest between May and

October, when the sand fly vector, Phlebotomus papatasi, is most active. Humans are

the reservoir of this debilitating disease, although small rodents are suspected reservoirs.

MOSQUITO-BORNE DISEASE* 

There is virtually no risk of malaria in Central Europe. Malaria was eradicated from all

countries by the 1970s with the exception of Greece, which was declared malaria-free in

1986. However, indigenous transmission of malaria in Greece may have occurred as late

as 1991. The risk of transmission is greatest along the Turkish border, where

Plasmodium vivax is highly endemic. All recent cases of malaria reported in Central

Europe are imported. The number of imported cases, including drug-resistant strains of

P. falciparum, has increased since the 1990s. Several species of competent vectors exist

throughout the region, and Anopheles surveillance and control programs have been

discontinued in many countries of Central Europe. Conditions for the reestablishment of

malaria in the region are therefore favorable.

Several mosquito-borne viruses circulate in Central Europe. Serological surveys and

viral isolates from mosquitoes indicate that Sindbis and West Nile viruses are

widespread and probably enzootic in every country of the region. Europe’s largest

outbreak of West Nile fever occurred in Romania during 1996. California group

viruses usually produce a mild febrile illness with headache and are transmitted

primarily by Aedes mosquitoes. Tahyna virus is the most prevalent member of this viral
10

group in Central Europe. Cases of dengue fever have not been reported recently from

Central Europe, although outbreaks have historically occurred in Greece, Albania and

Bulgaria, where the primary vector Aedes aegypti is present. Aedes albopictus has

become established in Italy, Albania and Greece, and many are concerned about its

spread to other Mediterranean countries and its potential for involvement in arbovirus

cycles in the region.

RODENT-BORNE DISEASE

Hantaviral diseases are an emerging public and military health threat. Field rodents are

reservoirs for several closely related viruses that can be transmitted to humans exposed to

airborne pathogens from dried rodent excreta. Serological evidence of hantaviral

infection has been detected in humans and wild animals in every country of Central

Europe. At least five serotypes of hantavirus that cause clinical disease in humans are

present in the region. A severe form of the disease referred to as hemorrhagic fever with

renal syndrome is caused by the Hantaan virus and is associated with the field mouse,

Apodemus agrarius, in open field or unforested habitats. Death rates often exceed 10%. 

A milder disease, caused by the Puumala virus, is associated with the red bank vole,

Clethrionomys glareolus, in woodland or forest-steppe habitats. Dobrava-Bulgaria virus

is closely related to Hantaan virus and is associated with the yellow-necked field mouse,

Apodemus flavicollis. The Seoul serotype infects Rattus norvegicus, and risk of infection

occurs when living or working in dusty rat-infested buildings. Tula virus also circulates

in the region, but its role in human disease is unclear. Outbreaks of hantaviral disease

have frequently occurred in military personnel during field operations in the Balkans. 

Leptospirosis should be considered enzootic in most countries of Central Europe. The

spirochete is transmitted when skin or mucous membranes are contacted by water

contaminated with urine of infected domestic and wild animals, especially rats. Military

personnel would be at high risk of infection from this disease. Troops should never

handle rodents and should not sleep or rest near rodent burrows or swim or bathe in

stagnant pools or sluggish streams. 

 

CONJUNCTIVITIS

Bacterial and viral conjunctivitis is common in Central Europe and has epidemic

potential. Transmission is normally through contact with secretions of infected persons

or contaminated articles. Trachoma, caused by the bacterium Chlamydia trachomatis,

has become rare in most parts of Central Europe and most cases are imported. Eye gnats

and flies can mechanically transmit these pathogens. 

VENOMOUS ANIMALS

Only five species of venomous terrestrial snakes are found in Central Europe. Death

from snakebite in the region is extremely rare, although the toxicity of venom and

frequency of envenomization are significant. Military personnel should be thoroughly

briefed on the risk and prevention of snakebite, as well as the steps to take immediately

after snakebite. Effective antivenoms are available. Scorpions, centipedes and widow
11

spiders (Latrodectus spp.) are common in many parts of the region. Scorpion stings

rarely require hospitalization, although Latrodectus envenomization can be life

threatening. Troops should be warned not to tease or play with snakes and scorpions.

* A properly worn Battle Dress Uniform (BDU) impregnated with permethrin,

combined with use of extended duration DEET on exposed skin, has been

demonstrated to provide nearly 100% protection against most blood-sucking

arthropods. This dual use of highly effective repellents on the skin and clothing is

termed the “DoD arthropod repellent system.” It is the most important single

method of protecting individuals against arthropod-borne diseases. Permethrin can

also be applied to bednets, tents and screens to help prevent disease transmission by

insects. The proper use of repellents is discussed in TIM 36, Personal Protective

Techniques Against Insects and Other Arthropods of Military Significance. 
12

 VECTOR-BORNE DISEASES IN CENTRAL EUROPE* (+ = present; ? = uncertain)

Diseases ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

sand fly fever + ? + + + + + + + +

West Nile virus + + ? + + + + ? ? + ? +

Sindbis virus ? + ? + + + + ? ? ? ? +

California

viruses ? + ? + + ? + ? ? ? + +

tick-borne

encephalitis + + + + + + + + + + + + +

CrimeanCongo

hemorrhagic

fever

+ + + + + + + + + +

boutonneuse 

fever + + +

+

+ + + ? ? + + + +

rickettsialpox ? ? ? + ? ?

Q fever + + + + + + + + + + + +

tularemia + + + + + + + + + +

tick-borne

relapsing fever ? + + + + ?

Bhanja virus + + ? + ? + + ? + + + +

ehrlichiosis ? +

murine typhus ? + ? + + + + + +
13

Diseases ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

epidemic

typhus ? + ? ? + ? + ?

louse-borne

relapsing fever ? ? + ? ?

cutaneous

leishmaniasis + + + + + + ? + + ?

visceral

leishmaniasis + + + + + + ? + + ?

Lyme disease + + + + + ? + + + + + + +

leptospirosis + + + + + + + + + + + + +

hantavirus + + + + + + + + + + + + +

* ALB=Albania, BIH=Bosnia and Herzegovina, BGR=Bulgaria, HRV=Croatia, CZE=Czech Republic, GRC=Greece,

HUN=Hungary, MKD=Macedonia, POL=Poland, ROM=Romania, SER=Serbia and Montenegro, SVK=Slovak Republic,

SVN=Slovenia.















45

IV. Country Profiles.

 A. Albania.

1. Geography. Albania, about the size of Maryland, has a land area of 27,400 sq km,

nearly 70% of which is mountainous. The country can be divided into two geographic

regions: (1) The mountainous highland region consists of three mountain ranges. In the

north, the rugged Albanian Alps run north-south with peak elevations of 2,700 m. The

central highlands, with wide valleys and large lakes, are less rugged than the Alps, but

reach a peak elevation of 2,750 m at Mt. Majae Korabit, the highest point in the country. 

This area occasionally experiences severe earthquakes. The mountains of the southern

highland region have peaks from 2,100 to 2,400 m and continue into northern Greece. 

(2) The lowland region along the Adriatic Sea reaches 470 m elevation and generally

extends inland about 16 to 48 km, but extends further along the river valleys. Much of

the area consists of marshlands and eroded lowlands, but inland foothills have fertile

soils. The rugged terrain, occasional earthquakes, and the risk of tidal waves along the

southwestern coast are threats to humans living in Albania. 

2. Climate. Albania's climate varies geographically and seasonally. In the highlands,

cold northerly winds frequently cause frigid winters from November through March. 

Snow remains on the ground for several months and accumulates to average depths of

1,800 to 2,500 mm. Precipitation is heaviest from October through March. In the

southern highlands, mean precipitation for November through January is about 1,000

mm. In the central highlands, thunderstorms and torrential downpours are common. The

lowlands typically have mild, wet winters, with temperatures seldom falling below -8oC. 

In the lowlands, summers are hot and dry, with temperatures in July and August

frequently rising above 38oC. Cyclones are common in winter. The cold weather at high

elevations, and frequent severe storms, make much of Albania a physically demanding

place to live or work outdoors. 

Tirane (elevation 90 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 11 12 15 18 23 28 31 31 27 23 17 14

MINIMUM (°C) 2 2 5 8 12 16 17 17 14 10 8 5

Monthly Precipitation (liquid equivalent) 
46

MEAN (mm) 135 152 128 117 122 86 32 32 60 105 211 173

3. Population and Culture. Albania is mostly rural and economically undeveloped. It

is one of Europe's poorest nations. Poor soil conditions and lack of water in some areas

discourage settlement and severely limit food production. Poor nutrition makes the

population less resistant to disease and environmental stress. The rugged terrain makes

land transportation difficult and reduces access to many settlements that typically contain

70 to 100 households. The majority of the population lives on the coastal plain. Land

use includes: 21% arable, 20% crops or pasture, and 38% forests or woodlands. 

Albania’s ethnic makeup is about 95% Albanians, 3% Greeks and 2% other origins. 

Religious makeup is 70% Muslim, 20% Orthodox Christian and 10% Roman Catholic. 

The culture is traditionally male-dominated, and family, ethnic, and cultural ties are

strong. Total population 3.3 million, 37% urbanized, literacy rate 72%.

4. Water, Living and Sanitary Conditions. Albania has abundant water resources. 

Principal sources include wells, springs, lakes, rivers, and streams. Average annual

precipitation is the highest in Europe, but rainfall is unevenly distributed throughout the

year, and drought has affected water supply in the lowlands. Water from urban and rural

sources is frequently contaminated biologically and/or chemically. Even water from

treated sources is suspect because of antiquated, ineffective or poorly maintained

treatment and distribution systems. Water shortages are frequent, and broken and

cracked water and sewage lines run close together, resulting in frequent crosscontamination. This provides excellent opportunities for the spread of many water-borne

diseases and parasites. Leaking water systems assure ample breeding sites for disease

vectors. Smaller communities and urban homes not connected to municipal water

systems rely on private wells, cisterns and public fountains for water. Since these are

frequently in poor condition, they are also a source water-borne disease. Water obtained

from the karst area (limestone region with crevices and sink holes) east of Tirane lacks

the brackish taste characteristic of coastal well water, but these sources can easily be

contaminated through open karst fissures. Sanitation typically fails to meet Western

standards. Public services cannot keep pace with the increasing amount of solid waste in

urban areas. Most waste is simply dumped into the streets. Landfills are not organized

to separate hazardous from nonhazardous waste. Albania has few urban sewage

treatment systems. Rural residents rely on outdoor pit latrines and privies to dispose of

excreta. Multiple family groups frequently live in the same dwelling because of housing

shortages. This facilitates the spread of communicable diseases in a country where

health care and medicines are very limited. Many homes lack potable water, electricity,

and fuel for heating and cooking. Frequent food shortages, especially of fresh meats,

eggs, and milk, result from inadequate storage, refrigeration and distribution systems. 

Hot and cold food-handling equipment is lacking. Gastrointestinal diseases are common

due to poor sanitation and improper food handling. Large segments of the population,

especially in urban areas, depend on humanitarian aid to meet basic food needs. Like
47

many Central European nations, Albania has numerous local pollution problems caused

by industrial wastes, chemicals, or burning of low quality fuels. Sites that contain

mercury, arsenic, petroleum, or highly acidic residues pose a significant public health

threat.

B. Bosnia and Herzegovina. 

1. Geography. Bosnia and Herzegovina is slightly larger than Tennessee and covers a

land area of 51,200 sq km. It is landlocked except for a 20 km coastline on the Adriatic

Sea. It is bordered on the north mainly by Croatia, on the west and southwest by Croatia

and the Adriatic Sea, and on the east and southeast by Serbia and Montenegro. It is

primarily mountainous with several peaks exceeding 1,900 m elevation. Lowlands with

fertile soils are located in the north. The highest elevation in the country is a peak near

Maglic (southeast of Sarajevo, near the border with Serbia and Montenegro) that reaches

2,386 m. During the past 30 years, Croatia has been subject to frequent destructive

earthquakes.

2. Climate. Bosnia and Herzegovina have a continental climate that is warm in summer

and cold in winter. In Sarajevo, temperatures have reached as low as -26oC in January

and as high as 37oC in July and August. At high elevations, summers are short and cool,

and winters are long and severe. Snow is frequent and remains on the ground for several

months. Winters are mild and rainy along the Adriatic coast. 

Sarajevo (elevation 520 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 2 6 10 14 20 22 25 25 22 16 8 3

MINIMUM (°C) -5 -3 1 4 8 12 13 13 9 5 0 -4

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 58 53 74 69 81 94 67 67 76 97 81 71

3. Population and Culture. Bosnia and Herzegovina is one of the least urbanized

countries in Europe. Land use includes: 14% arable, 25% permanent crops or pasture,

and 39% forests. Religious makeup is 40% Muslim, 31% Orthodox Christian, 15%

Roman Catholic, 4% Protestant, and 1% other. The culture is traditionally maledominated, and family, ethnic, and cultural ties are strong. The civil war that began in
48

1992 has severely disrupted much of the country’s infrastructure, and many cultural and

religious institutions have been destroyed. Large numbers of displaced persons and

current reintegration efforts have significantly altered the ethnic makeup and population

density. Before the war, the population’s literacy rate was about 93%, but education has

been seriously disrupted. Total population is 3.4 million. The current literacy rate and

percent urbanized are unknown due to the civil war. 

4. Water, Living and Sanitary Conditions. Major water sources include rivers,

streams and wells. Water is perennially available throughout the country, except for the

Karst areas of the coastal and interior highlands, and the terraces and sandy tracts of the

eastern part of the northern plain. Surface water is most abundant from November

through June. Large influxes of displaced persons are straining existing water supplies. 

Prewar water treatment and supply systems were old and in poor repair. During the

conflict, these systems were extensively damaged. Lack of materials and qualified

technicians prevent their repair. In Sarajevo, Zagreb and other cities, water treatment

includes chlorination and filtration. However, inadequate supplies of treatment

chemicals and intermittent pumping due to fuel shortages have resulted in unreliable

water quality at the tap. Drinking water is frequently contaminated by fecal or industrial

wastes. Since the signing of the Dayton Agreement, peacekeeping forces and many nongovernmental organizations have been attempting to repair and improve water treatment

and distribution systems to the indigenous population. However, the damage will take

many years to repair. Bosnia and Herzegovina was one of the poorest republics in the

former Yugoslavia. Since fighting began in 1992, the country’s limited infrastructure

has collapsed. Many homes have been intentionally razed, damaged or destroyed by

fighting. The internal displacement of large portions of the indigenous population

continues to degrade the environment through the indiscriminate disposal of solid and

municipal waste. Large numbers of refugees, poor sanitation and water treatment, and

disrupted medical support have greatly increased the risk of epidemics. Soils

contaminated over decades with hazardous industrial wastes, such as PCBs, pose

additional risks to human health. 

C. Bulgaria. 

1. Geography. Bulgaria is slightly larger than Tennessee and has a land area of about

110,500 sq km. It consists of four geographic regions: (1) The Danubian Plain is a

fertile, hilly area following the course of the Danube River. It begins in the north along

the border with Romania and covers nearly one-third of the country. (2) The Balkan

Mountains, or Stara Planina (Old Mountains), border the southern edge of the Danubian

Plain and have a maximum elevation of 2,377 m. The Sredna Gora (hills) parallel the

southern edge of the Balkan Mountains. (3) South of the Balkan Mountains and the

Sredna Gora is the Thracian Plain that includes the Maritsa River Basin and the lowlands

extending inland from the Black Sea. (4) A massif, consisting of the Rila, Rhodope and

Pirin Mountains, separates the Thracian Plain from the border with Greece. Elevations
49

reach a maximum of 2,925 m at Musala in the Pirin Mountains. Bulgaria is bordered on

the north by Romania, on the west by Serbia and Montenegro and Macedonia, on the

south by Greece and Turkey, and on the east by the Black Sea. 

2. Climate. Bulgaria has a complex climate influenced by its mountains and valleys, air

masses from the Mediterranean and continental climatic zones, and the Black Sea. In the

north, summers (June through August) usually have a mean daily maximum temperature

of about 26oC, while winters (December through February) experience mean daily

minimum temperatures of about -0.3oC. Precipitation is evenly distributed throughout

the year. On the Thracian Plain, summers are long, with high temperatures and humidity. 

Here precipitation is erratic from year to year, with prolonged and severe droughts during

summer. The southern slope of the Rhodope Mountains has mild, damp winters with a

mean daily minimum temperature of approximately 0oC and hot, dry summers with a

mean daily minimum temperature of 26oC. Annual precipitation averages about 635 mm

countrywide. The coastal and plains regions receive less than this average, and the

mountains receive more than average. Temperature inversions frequently occur

throughout the uplands and the many valley basins. Black winds, named after the large

amount of dust carried by the wind, are common in winter along the Danube River Basin. 

Frequent dust storms can cause breathing difficulties and eye irritation. Risk of cold

injury exists at higher elevations in the Rhodope and Pirin Mountains. 

 Sofia (elevation 5500 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 1 4 9 16 20 24 26 27 23 17 10 4

MINIMUM (°C) -5 -3 -1 4 9 12 14 14 11 6 2 -2

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 26 28 41 61 87 73 68 64 41 65 48 49

3. Population and Culture. Bulgaria is one of Europe's most sparsely populated

countries, with approximately 81 persons per sq km. The highest population density

occurs in the Sofia River Basin and the southwestern portion of the Thracian Plain. The

least densely populated areas are located at higher elevations, particularly in the Rhodope

Mountains. Land use includes: 37% arable, 18% crops or pasture, and 35% forests or

woodlands. Bulgaria’s ethnic makeup is 85.3% Bulgarians, 8.5% Turks, 2.6% Gypsies,
50

2.5% Macedonians, and 1.1% Armenians, Russians, or other origins. Its religious

makeup includes: 85% Orthodox Christians, 13% Muslims, 0.8% Jews, 0.5% Roman

Catholics, and 0.7% others. Total population 8.2 million, 67% urbanized, literacy rate

98%. 

4. Water, Living and Sanitary Conditions. Rivers and underground waters are the

most important sources of water for industrial, agricultural and domestic uses. The

quantity and quality of water in Bulgaria are heavily influenced by the upstream impacts

of neighboring countries in the Danube basin (including the Czech Republic, Slovak

Republic, Hungary and Romania). Water supplies are problematic throughout the

country because of drought and upstream water extraction. Water rationing is common

in urban areas during summer. Industry and agriculture have priority for water and use

over half of the potable supply. Bulgaria's ground water has a high mineral content. 

Municipal water treatment systems are ineffective, distribution systems are degraded, and

demand for services exceeds the government's ability to meet water needs. From 30 to

50% of treated water is lost during distribution. Few homes in Bulgaria are hooked up to

a municipal water supply. The water in the capital city of Sofia is considered

bacteriologically safe to drink, but it has a poor taste due to a high mineral content. 

Water for domestic use in rural areas is frequently untreated and comes directly from raw

sources. Consequently, water-borne diseases are common. Pools from leaking water

systems attract and support significant populations of vector and pest species. Except in

large cities, food processing, refrigeration, and preparation standards are poor. Most

older and larger cities in Bulgaria combine wastewater and storm water in the sewer

system. Interceptors and pump stations, designed to carry flows from sewer systems,

rarely support entire cities. Transmission of food-borne pathogens is common. Effective

wastewater treatment plants with secondary treatment designed to remove nutrients

causing eutrophication have been built only in a few large cities. None of the plants

provides adequate disinfection. Over 60% of the rivers in Bulgaria are adversely affected

by partially treated domestic and industrial sewage. Rural areas depend on cesspits and

latrines. Large urban areas regularly collect garbage and trash for incineration or

disposal in landfills, while rural areas generally use small, unregulated, family dump

sites. Soils have been contaminated over decades by industrial wastes and chemicals,

and air is polluted by industrial emissions. Nuclear wastes stored at the power plant at

Kozloduy and uranium ore tailings at mines in Silen, Karandila and Bukhovo are

additional public health threats. 

D. Croatia. 

1. Geography. Croatia is slightly smaller than West Virginia and has a total land area of

56,400 sq km. It comprises three geographic regions: (1) A long, narrow coastal region

extends from the Istrian Peninsula down the Dalmatian coast to Dubrovnik and includes

more than 1,000 small Adriatic Sea islands. (2) The Dinaric Alps run northwest to
51

southeast and parallel the coastline. Several peaks in the Dinaric Alps have elevations

greater than 1,600 m. The highest elevation is 1,830 m at Dinara. (3) The Pannonian

Plain is an agriculturally rich region of northern Croatia that consists mostly of flat

plains, wide valleys, rolling hills and a few low mountains. Croatia is bordered on the

north by Hungary and Slovenia, on the west by the Adriatic Sea, on the south by Bosnia

and Herzegovina, and on the east by Serbia and Montenegro. Croatia is subject to

frequent, destructive earthquakes. 

2. Climate. Croatia's climate is warm in summer and cold in winter. In Zagreb,

temperatures reach as low as -24oC in January and as high as 37oC in July. Mountain

areas have lower winter temperatures and heavy snowfall. Summers tend to be dry and

winters mild along the Adriatic coast; however, during the winter, strong, gusty winds

known as the bora bring cold air from Central Europe for several days at a time. Annual

precipitation averages about 1,900 mm. Autumn and winter precipitation on the coast is

heavy, and the Dinaric Alps south of Dubrovnik are among the wettest areas in Europe

during winter. 

Zagreb (elevation 110 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 3 6 11 17 21 25 28 27 22 16 10 3

MINIMUM (°C) -2 -1 3 8 12 15 17 16 13 8 5 -1

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 86 104 124 132 201 157 229 201 224 198 183 112

3. Population and Culture. There are more than 490,000 displaced persons throughout

Croatia, mostly living in enclaves and refugee centers. Reintegration efforts, continued

ethnic tension, and the approaching expiration of the UN mandate have resulted in a very

dynamic population situation. This has severely strained the health care system

throughout the country. Before the civil war began in 1992, Croatia’s ethnic makeup was

78% Croats, 12% Serbs and 10% other origins. The religious makeup was 77% Roman

Catholics, 11% Orthodox Christians, and 12% Muslims, Protestant Christians and other

religious traditions. Land use includes about 21% arable, 22% crops and pasture, and

38% forests and woodlands. Fishing is a major industry in Croatia. Before the war, the
52

population was 97% literate. Total population is 4.6. million. The current literacy rate

and the percent urbanized are unknown due to the civil war. 

4. Water, Living and Sanitary Conditions. Croatia’s major water sources include

rivers, streams and wells. Water is generally available year-round, although the quantity

of surface water varies with season (most available November through June) and region

(shortages occur along the Adriatic coast). Water treatment and distribution systems

have been disrupted throughout Croatia. Water is either partly treated or not treated at

all. Damage to water distribution systems or intermittent pumping that allows back flow

contribute to unreliable water quality at the tap. Vertical pipes in the distribution system

are subject to breakage from freezing, illegal taps and sabotage. Outbreaks of food and

water-borne disease are common. Since the signing of the Dayton Agreement,

peacekeeping forces and many nongovernmental organizations have been trying to repair

and improve water treatment and distribution systems for the indigenous population. 

However, the damage in many locations is extensive and will take many years to repair. 

Since the war began in 1992, the country's infrastructure has collapsed. Waste disposal

sites are limited in urban areas. Many homes have been intentionally razed, damaged or

destroyed by fighting. Mass movement of refugees has severely degraded sanitary and

environmental conditions. The threat of vector-borne disease is high. Numerous farms

and food processing facilities have been destroyed, and nutrition is inadequate for much

of the population. Soil, water and air in many areas of Croatia are contaminated by

industrial emissions and chemicals such as arsenic, trihalomethane, PCBs, sulfates and

petrochemicals. 

E. Czech Republic. 

1. Geography. The landlocked Czech Republic covers an area of 78,800 sq km and is

slightly smaller than South Carolina. It is bordered on the north by Poland, on the west

by Germany, on the south by Austria, and on the east by the Slovak Republic. The

highest elevation is 1,602 m at Snezka; the lowest elevation is 115 m at the Elbe River. 

The country can be divided into two geographic regions, Bohemia and Moravia. The

Bohemian region in the west consists of rolling plains, hills, and plateaus surrounded by

low mountains with elevations under 1,600 m. The Plain of Polabi in central Bohemia

has fertile soils and extensive coal deposits. Moravia, the lowland region in the east, 

comprises rugged hills with an average elevation of 150 m, but becomes more rugged

and mountainous eastward. The country has numerous rivers and lakes, and many peaks

are high enough to be suitable for skiing much of the year. 

2. Climate. The Czech Republic has a temperate climate with moderate summers and

cold, humid winters. In July, temperatures have reached as high as 38oC, and in

February, as low as -24oC. There is little climatic variation in the two regions of the

country, except that the basins and lowlands are warmer and drier than mountainous

areas. Annual precipitation averages about 411 mm. Frequent morning fogs and dense

cloud cover are prevalent in the valleys and lowlands. In winter, the ground may be

covered with snow from 40 to 100 days, depending on elevation. 
53

 

Prague (elevation 260 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 0 1 7 12 18 21 23 22 18 12 5 1

MINIMUM (°C) -5 -4 -1 3 8 11 13 13 9 5 1 -3

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 18 18 18 27 48 54 68 55 31 33 20 21

3. Population and Culture. The population of the Czech Republic is concentrated in

the highly industrialized areas of northern Bohemia, northern and southern Moravia, and

in the major cities of Prague, Brno and Ostrava. The country has a skilled industrial

work force, but unemployment is rising because of limited foreign investment. Land use

includes: 41% arable, 13% crops and pasture, and 34% forests and woodlands. The

ethnic makeup includes 94% Czechs, 3% Slovaks, and 3% Poles, Germans, Hungarians

and others. Religious makeup includes 40% atheists, 39% Roman Catholics, 5%

Protestant Christians, 3% Orthodox Christians, and 13% others. Total population 10.3

million, 70% urbanized, literacy rate 99%.

4. Water, Living and Sanitary Conditions. Both surface water and ground water

sources are limited. Rural populations depend primarily on well water. Water

purification systems are inadequate in major cities, and the quality of water is declining. 

The quality of surface water is poor due to ineffective waste treatment. Even after

treatment, more than half of drinking water supplies fail to meet Czech standards. Risk

of waterborne disease is high. Although living standards fell after the recent political and

economic upheaval, they are still above most Central European standards. Less than onefifth of municipal sewage receives any treatment before release. Many towns have

inadequate or no sewage treatment plants. Sewage treatment facilities in large cities,

such as Prague, Brno and Plzen, typically exceed their capacity by 40%, and most

facilities are antiquated and function poorly. Rural populations typically dispose of

sewage in cesspools or privies. Soil, water and air in many areas of the Czech Republic

are heavily contaminated by industrial emissions and chemicals such as lead, arsenic,

cadmium, nitrates, PCBs, sulfates and petrochemicals. Local produce, such as dairy

products, meat, sausage and fish, often contains hazardous levels of one or more of these

contaminants. Soviet military occupation forces reportedly left many unexploded shells

and land mines in place on or around their former military installations. 

F. Greece. 
54

1. Geography. Greece is the third largest and the southernmost country of Central

Europe. It is slightly larger than the state of New York and has a land area of 130,800 sq

km. It is bordered on the north by Albania, Macedonia, and Bulgaria; on the west by the

Adriatic Sea; on the south by the Aegean and Mediterranean Seas; and on the east by

Turkey. The geography is mountainous and generally slopes from the northwest toward

the southeast. The Pinkos Mountain chain runs from Albania southeastward to the

Mediterranean coast. An eastern arm of this mountain chain includes the highest point in

Greece, Mt. Olympus, at 2,917 m, which is near the Aegean Sea coast. The higher

elevations in the north and northwest sometimes have temperatures low enough to pose a

risk of cold injury in persons who are not properly protected. The soil is generally very

shallow and rocky, mostly suitable for pasture or olive trees. There are rich mineral

deposits in Greece, including rare minerals like chromium. Greece possesses over 2,000

islands and has more than 120 seaports suitable for either passenger or cargo traffic, most

notably at Athens and Thessaloniki. The country is subject to severe earthquakes. 

2. Climate. Greece generally has a Mediterranean climate, with mild wet winters and

hot dry summers. Higher mountain areas can be cold in winter, sometimes reaching 

-10oC. Snow may fall anywhere in Greece, but it is seldom very heavy and never

remains on the ground more than a few hours except at higher elevations. Sea breezes

moderate temperature changes at lower elevations. 

Athens (elevation 107 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 13 14 16 20 25 30 33 33 29 24 19 15

MINIMUM (°C) 6 7 8 11 16 20 23 23 19 15 12 8

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 62 37 37 23 23 14 6 7 15 51 56 71

3. Population and Culture. Historically, Greece was a seafaring and agrarian nation. It

has become increasingly urbanized since World War II, and more than half of the

population now lives in Athens and Thessaloniki. Currently, the main industries include

tourism, shipping, fishing, agriculture, mining and petroleum refining. Land use

includes: 49% crops and pasture, 19% arable, and 20% forest or woodlands. The
55

country’s ethnic makeup is 98% Greeks and 2% other origins. Religious makeup

includes 98% Orthodox Christians, 1.3% Muslims, and 0.7% other. Unemployment due

to a depressed economy has been a problem for several years. Many Albanian refugees

have strained the country’s infrastructure, especially the economy and health care. Total

population 10.6 million, 64% urbanized, literacy rate 94%. 

4. Water, Living and Sanitary Conditions. Streams and wells are the main water

sources. Rural and mountainous inhabitants frequently depend on catching rainwater in

cisterns. Water treatment and distribution are fairly good and reliable, especially in

larger towns and cities. Desalinization of sea water is being studied as an alternative

source. Local water shortages are often due to earthquakes, which may divert the courses

of streams or cause subsurface shifts large enough to stop the flow of even a large

aquifer. Sewage is treated and trash is properly disposed of in larger towns, but in some

slum areas open dumping is common. In slums, several families may share the same

house. This is commonly the case in refugee communities, as well as in some remote

agricultural villages. Crowding and poor sanitation in these areas increases the risk of

vector-borne disease as well as transmission of food and water-borne pathogens. The

civil war in Greece after WWII damaged much of the country’s infrastructure. 

Construction of modern transportation and medical facilities has been slow. In recent

years, an influx of Albanian refugees has further strained these facilities. Air pollution

and acid rain in Athens have caused serious damage to buildings and ancient monuments.

G. Hungary. 

1. Geography. Landlocked Hungary (bordered by Slovakia on the north, Ukraine and

Romania on the east, Slovenia, Croatia, and Serbia on the south, and Austria on the

west), is slightly smaller than Indiana and has a total land area of about 93,000 sq km. It

can be divided into three geographical regions: (1) The Great Hungarian Plain accounts

for more than half of the total area and includes the lowlands east of the Danube River. 

This region has a mean elevation of approximately 90 m. (2) Transdanubia, west of the

Danube River, consists primarily of rolling foothills of the Austrian Alps and contains

Lake Balaton, Central Europe's largest freshwater lake. (3) The Northern Hill region lies

north of Budapest and extends to the Slovak border. Elevation ranges from 78 m on the

Tisza River at Hortabagy to Mt. Kekes (1,014 m) in the Matra Mountains, northeast of

Budapest. 

2. Climate. Hungary typically has hot summers from June through August and cold

winters from December through February, with little climatic variation throughout the

country. Annual extremes range from 35oC in summer to -26oC in winter. Average

annual rainfall is 640 mm, but severe droughts may occur in the east during summer. 

April through August usually is the wettest period, with much of the precipitation in the

form of heavy downpours during frequent thunderstorms. Snow generally remains on the

ground 30 to 40 days during winter. Winters can be foggy and bitterly cold when

easterly winds blow from Russia. 
56

Budapest (elevation 140 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 1 4 10 17 22 26 28 27 23 16 8 4

MINIMUM (°C) 4 -2 2 7 11 15 16 16 12 7 3 -1

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 37 44 38 45 72 69 56 47 33 57 70 46

3. Population and Culture. Except for Budapest, Hungary's population is distributed

fairly evenly throughout the country. Average population density is 111 persons per sq

km, with more than 20% concentrated in Budapest and its suburbs. Hungary's population

has been slowly declining since 1980 when it peaked at 10.7 million. Land use includes:

51% arable, 15% in crops or pasture, and 19% in forests or woodlands. Hungary’s ethnic

makeup is 90% Hungarians, 4% Gypsies, 3% Germans, 2% Serbs, and the remainder

Slovaks or Romanians. Religious makeup includes 68% Roman Catholic, 20% Calvinist,

5% Lutheran, and 7% other. Total population 10.2 million, 63% urbanized, literacy rate

99%. 

4. Water, Living and Sanitary Conditions. Water resources throughout the country

are unevenly distributed, and approximately 70% of water supplied from surface sources

comes from surrounding countries. Water shortages occur during hot, dry summers in

some lowland areas. Most groundwater resources consist of bank-filtered waters

(aquifers along the Danube and other rivers), in addition to artesian wells and karstic

waters. The Danube River and its tributaries typically flood in April, May or June. 

Ground water levels in the area between the Danube and Tisza rivers were reported in

1996 to be 3 to 5 m below average. The ground water level in the Szigetkoz area, just

north of Budapest, has been severely lowered by the diversion of the Danube by the BosNagymaros dam project in Slovakia. The flatness of the land and water level fluctuations

make the Carpathian basin susceptible to salinization. About 85% of Hungary's

population has piped, treated drinking water. However, the risk of water-borne diseases

is high because of antiquated distribution systems. Many smaller settlements throughout

the country rely on water from tanker trucks. Municipal sewage systems are outdated

and inadequate to meet the needs of the population. Although approximately half of the

homes in Hungary are connected to public sewage systems, only half of the sewage is

properly treated. In rural communities, many people rely on septic tanks, cesspools, and

privies. At least 165 million m3 of untreated wastewater is dumped into Hungarian rivers

each year. Another 439 million m3 is only partially treated. Several locations in

downtown Budapest dump untreated sewage directly into the Danube. About 33% of
57

Budapest homes are not connected to the sewer system. The majority of landfills in

Hungary do not meet minimal environmental safety standards, and hazardous wastes are

mixed with domestic wastes. The number of illegal landfills is increasing. Budapest has

a well-organized system of solid waste disposal, but collection and disposal of solid

waste in other parts of the country are inadequate. Air, soil and water pollution are

serious problems. Soils are severely contaminated at 340 decommissioned former Soviet

military bases throughout the country. Fuels, lubricants, solvents, and other unidentified

toxic materials have permeated the soil from leaking tanks or open ponds and pits. Crops

harvested from these soils are often contaminated by industrial wastes and chemicals.

H. Macedonia. 

1. Geography. Macedonia is landlocked and has a land area of 24,900 sq km. The

country is slightly larger than Vermont. It is bordered on the north by Serbia and

Montenegro, on the west by Albania, on the south by Greece, and on the east by

Bulgaria. Macedonia is characterized by high mountain ranges, with several peaks

exceeding 2,450 m elevation. The highest elevation is 2,753 m at Korab, near the

northwestern border with Albania. The lowest elevation is 50 m where the Vardar River

flows into Greece. The country has two large lakes, Ohrid and Prespa, both in the

southwest on the Albanian border. Macedonia is highly prone to earthquakes. 

2. Climate. Macedonia's climate is characterized by hot summers and autumns, and

cold winters with heavy snowfall lasting several months. Average temperatures are as

high as 41oC in July and August, and as low as -21oC in January and February. Winters

tend to be mild in the Varder Valley, which runs northwest to southeast through the

center of the country. Annual precipitation averages about 500 mm, with dry autumns

and wet springs. 

Skopje (elevation 230 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 5 8 12 19 23 28 30 30 26 19 12 7

MINIMUM (°C) -3 -3 1 5 10 13 15 14 11 6 3 -1
58

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 39 32 37 38 54 47 29 28 35 61 55 53

3. Population and Culture. Macedonia, the poorest republic in the former Yugoslavia,

is ethnically diverse and urbanized. About 40% of average household income is used to

buy food. Population density averages 79 inhabitants per sq km. Land use includes:

24% arable, 27% crops and pasture, and 39% forests and woodlands. The main

industries are mining, agriculture and tourism. Macedonia’s ethnic makeup is 65%

Macedonians, 22% Albanians, 4% Turks, 2% Serbs, and 7% Gypsies and other origins. 

The country’s religious makeup is 67% Orthodox Christians, 30% Muslims, and 3%

other. Tensions between different ethnic groups in Macedonia are far more restrained

than in other countries that were once part of Yugoslavia. Large refugee populations

immigrated to Macedonia during regional civil wars. Total population 2.1 million, 58%

urbanized, literacy rate 89%. 

4. Water, Living and Sanitary Conditions. Macedonia’s water sources include rivers,

streams and wells. Seasonal and regional shortages occur. Although some urban areas

have access to adequate water treatment and distribution systems, water quality is

unreliable in most areas of the country. Many urban homes are not connected to

municipal water systems, and rural communities rely on private wells, cisterns and public

standpipes for water. Water supplies are frequently contaminated by fecal wastes and

agricultural runoff. Macedonia has few urban sewage treatment systems, and waste

collection and disposal are generally inadequate. Rural areas rely on outdoor pit latrines

and privies to dispose of wastes. Adequate food processing and preparation measures are

poor except in large urban areas. Food-borne diseases are common. Many rural homes

lack electricity and fuel for heating and cooking. Packed-dirt floors are common in the

homes of poorer communities. Livestock are frequently housed near human living

quarters, and in winter livestock may be moved into homes. Although Macedonia does

not have the concentration of heavy industry seen in some parts of Central Europe, there

is serious localized air pollution from electrical power plants and factories that use coal. 

The most severely polluted area is Skopje, the site of most Macedonian industry. 

I. Poland. 

1. Geography. Poland, with a land area of about 304,500 sq km, is slightly smaller than

New Mexico and can be divided into four geographic regions: (1) In the far north, the

Baltic coastal plain consists of swamps and dunes that stretch across northern Poland
59

from Germany to Russia. Poland's Baltic coastline is about 700 km long. The lowest

elevation in Central Europe lies within a geological depression at Raczki Elblaskie. (2)

A belt of thousands of lakes mixed with hills constitutes the region south of the coastal

plain. (3) A great central lowlands area, most of which lies below 300 m, covers about

75% of the country. (4) In the south, the lowlands give way to the Little Poland Uplands

that vary in elevation from 200 to 500 m. The Sudeten and Carpathian Mountains reach

a peak elevation of 2,500 m and form a natural border with the former Czechoslovakia. 

The highest point in Poland is a peak of 2,499 m in the Tatry Mountains at Rysy, just

inside the border with the Slovak Republic. Poland is bordered on the north by the Baltic

Sea, Russia and Lithuania, on the west by Germany, on the south by the Czech Republic

and Slovak Republic, and on the east by Belarus and the Ukraine. 

2. Climate. Poland's climate is characterized by hot summers (June through August)

and cold winters (November through March), with more temperate conditions in the west

than in the east. The worst winter weather is caused by strong easterly winds that

produce severe winter cold. Poland's mean annual precipitation is low, ranging from 500

to 625 mm. The mountains receive about twice the amount of precipitation that falls on

the central Polish lowlands. Snow covers the ground for an average of 40 days during

winter in the north and west, and for as much as 70 days in the south and east. Floods

frequently occur in low-lying areas during the spring thaw and after summer

thunderstorms. Flooded areas can produce tremendous populations of mosquitoes and

other blood-sucking insects. 

Warsaw (elevation 110 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 0 0 6 12 20 23 24 23 19 13 6 2

MINIMUM (°C) -6 -6 -2 3 9 12 15 14 10 5 1 -3

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 27 32 27 37 46 69 96 65 43 38 31 44

3. Population and Culture. Average population density is 123 persons per sq km, but

most Poles live in major cities located in the central plains. Major urban areas include

Warsaw, Lodz, Wroclaw, Krakow, Katowice and the Baltic port cities of Gdansk and

Gdynia. Land use includes: 47% arable, 14% crops and pasture, and 29% forests or

woodlands. There are very few ethnic minorities in Poland. Poland’s ethnic makeup is

about 97.6% Polish, 1.3% German, and 1.1% others. The country’s religious makeup is
60

95% Roman Catholic and 5% other, including Orthodox and Protestant Christians. Main

industries are mineral production, coal, petroleum refining and agriculture. Poland is

located within natural land transportation routes through Europe, and the port cities of

Gdansk and Gdynia are excellent harbors on the Baltic Sea. Total population 38.6

million, 68% urbanized, literacy rate 99%. 

4. Water, Living and Sanitary Conditions. Poland has abundant surface water

resources, but extensive pollution reduces their utilization and has increased the demand

for ground water, which is becoming depleted. Water treatment and distribution systems

are unreliable, aging and poorly maintained even in major cities. More than one-third of

the treated water is lost because of leaks in the distribution system. About 10% of the

urban population and more than half of village populations lack access to water

distribution systems. More than half of rural inhabitants use wells for their water supply. 

Living conditions in Poland have deteriorated since the breakup of the Soviet Union and

subsequent social changes in eastern Europe. One-third of Poland's towns do not have

sewage-treatment plants, and those systems operating in Poland's major cities generally

are poorly constructed, aging and inadequate to meet existing needs. Less than 40% of

the country's sewage receives treatment before being discharged into waterways. 

Villages and small towns rely on septic tanks and privies. Household and industrial

wastes often end up in the same disposal site. Utilities in Poland are subject to

unscheduled outages lasting for hours or days. Serious housing shortages exist in urban

areas, forcing many families to live in small apartments. Housing is characterized by

poor maintenance and low-quality construction. Decades of poorly regulated heavy

industry have resulted in significant pollution of soil, water and air in many areas of

Poland. In the past, Poland accepted shipments of toxic and hazardous waste in return

for hard currency but lacked facilities for safe disposal. Poland generates about 100 m3

of radioactive waste annually, primarily from hospital and academic sources. 

Radioactive waste is stored in Poland's only waste site at Rozane, in Ostroleka Province. 

Traces of residual cesium (Cs-137) contamination from the nuclear accident at Chernobyl

are reported in southwestern Poland, in the eastern Sudety Mountains, the Tectonic

Foreland and the Silesian Plain. A contaminated zone stretches from the Polish-Czech

border in the Klodzko Valley to Warsaw. Cs-137 contamination has appeared in some

agricultural products. 

J. Romania. 

1. Geography. Romania is slightly smaller than Oregon and has a total land area of

230,300 sq km. It can be divided into four geographic areas: (1) Central Romania is

dominated by the Carpathian Mountains and the Transylvanian Alps that reach a peak

elevation of 2,544 m at Mt. Moldoveanu. (2) Transylvania is a hilly plateau region in the

northwest. (3) The Romanian Plain and the regions of Wallachia and Moldavia consist of

lowlands and fertile plains in the south and east. (4) The coastal plains of the Black Sea
61

and the Danube Delta lie in the country's easternmost region. Romania is bordered on

the north by the Ukraine, on the west by Hungary and Serbia and Montenegro, on the

south by Bulgaria, and on the east by Moldova, the Ukraine and the Black Sea. Romania

is prone to earthquakes and landslides, which are most severe in the south and southwest. 

Flooding is common and often severe, particularly during spring thaw and summer

thunderstorms. 

2. Climate. Romania normally has warm, sunny summers from June through August

and cold, snowy winters from November through March. Daily highs of 38oC sometimes

occur in the lowlands during July and August. Temperatures as low as -30oC have been

recorded throughout much of Romania during the winter. The climate along the Black

Sea is mild. Average annual precipitation is about 710 mm, except at higher elevations

where precipitation may exceed 1,270 mm annually. Frequent thunderstorms occur

during the wettest months of April through July. In winter, snow remains on the ground

30 to 50 days a year in the lowlands and up to 100 days a year in the mountains. Winds

blowing across the plains from the Russian steppes can cause severe droughts during dry

summers and bitter cold during winters. Cold injury is a serious health threat. 

Bucharest (elevation 90 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 1 4 10 18 23 27 30 30 25 18 10 4

MINIMUM (°C) -7 -5 -1 5 10 14 16 15 11 6 2 -3

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 46 26 28 59 77 121 53 45 45 29 36 27

3. Population and Culture. Romania's predominantly rural population is rapidly

urbanizing. The current population density is 96 persons per sq km. Most people live in

the plains in the south and east. The Danube Delta and Black Sea coastal plains are

sparsely populated. Romania’s ethnic makeup is 89% Romanians, 9% Hungarians, and

2% others. The country’s religious makeup is 70% Orthodox Christians, 6% Roman

Catholics, 6% Protestant Christians, and 18% others. Land use includes: 41% arable,

24% permanent crops and pasture, and 29% forests or woodlands. Total population 22.4

million, 55% urbanized, literacy rate 97%. 

4. Water, Living and Sanitary Conditions. Romania’s water is obtained from lakes,

rivers, reservoirs and groundwater sources. There are seasonal and regional water
62

shortages, primarily in the Black Sea coastal region and delta areas of the Prut and

Danube Rivers. Even when treated, water may be contaminated due to antiquated or

ineffective treatment and distribution systems. About 80% of the urban and 15% of the

rural population have access to piped water in their homes. Increasing urbanization is

straining the water treatment and distribution infrastructure. Interruptions in water

supply occur due to breakdowns in pressure pumps or malfunctions in the distribution

system and can result in contamination due to back siphoning. Water-borne diseases are

common. During periods of drought, urban areas without adequate reserves must ration

limited water supplies. Crowded living conditions prevail in urban areas, including

Bucharest, and interruptions in electrical and water services are common. Sanitation is

poor, and abandoned buildings are frequently used as dump sites. Less than 60% of the

urban population is connected to sewer systems. The larger cities in Romania have

designed sewer systems to handle both wastewater and storm water runoff. Interceptors

and pump stations are not effective in channeling the flow of sewer systems, and they

rarely support entire cities. Effective wastewater treatment plants have been built in only

a few of the large cities, and none of the plants provide adequate disinfection capabilities. 

Most rivers in Romania are polluted by domestic sewage and agricultural runoff. 

Households not connected to a sewer network rely on septic tanks or latrines. Soil and

air pollution are serious public health threats. Radiation hazards exist at the Cernavoda

nuclear power plant and in the town of Mioveni, Arges County, where nuclear fuel is

manufactured. 

K. Serbia and Montenegro. 

1. Geography. Serbia and Montenegro is slightly larger than Kentucky and has a total

land area of 102,200 sq km. It can be divided into three geographic areas: (1) Northern

Serbia is dominated by the Pannonian Plain, an agriculturally rich area of flat plains and

low, rolling hills. (2) The Black, Sar, and Balkan Mountains contain several peaks

exceeding 2,450 m elevation and dominate southern Serbia. The highest elevation in the

country is 2,656 m at Deravica, near the Albanian border. Wide river valleys and rolling

hills also are scattered throughout the region. (3) In the southwest, Serbia and

Montenegro has a 200-km long mountainous coastline on the Adriatic Sea. Serbia and

Montenegro is bordered on the north by Hungary and Romania, on the west by Bosnia

and Herzegovina, Croatia, and the Adriatic Sea, on the south by Albania and Macedonia,

and on the east by Bulgaria. The region is subject to destructive earthquakes. 

2. Climate. The climate is characterized by cold winters and hot, humid summers. 

Temperatures in Belgrade are as low as -25°C in January and as high as 39°C in July and

August. Snow accumulations at higher elevations last throughout the winter. The coastal

area has dry summers and mild, wet winters. The heaviest precipitation occurs along the

coast. Mean annual precipitation is 1,550 mm in Podgorica and 700 mm in Belgrade. 
63

Belgrade (elevation 100 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 3 5 11 18 23 26 28 28 24 18 11 5

MINIMUM (°C) -3 -2 2 7 12 15 17 17 13 8 4 0

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 47 46 46 54 74 96 61 55 50 55 61 55

3. Population and Culture. Average population density is 102 persons per sq km. The

highest density (179 per sq km) is in the southern province of Kosovo and the lowest (45

per sq km) is in Montenegro. Almost 10% of the population lives in and around

Belgrade. Ethnic hatred has resulted in bitter conflict between Albanians and Serbs. As

a result of civil war in the former Yugoslavia, more than 600,000 refugees have fled to

Serbia and Montenegro. The ethnic makeup of Serbia before the war was 63% Serbs,

14% Albanians, 6% Montenegrans, 4% Hungarians, and 13% from other origins. The

religious makeup was 65% Orthodox Christian, 19% Muslims, 4% Roman Catholics, 1%

Protestants, and 11% other. Demographic estimates before the civil war: total population

11.2 million, 47% urbanized, literacy rate 93%. 

4. Water, Living and Sanitary Conditions. Water sources include the Sava and

Danube rivers in addition to streams and wells. Seasonal and regional water shortages

occur, particularly in Kosovo and in Montenegro's coastal area. Water treatment and

distribution systems are unreliable; water is either partly treated or not treated at all. 

Water treatment and distribution systems in the Vojvodina region are extremely

degraded. Cities where municipal water treatment systems still operate include Subotica,

Sombor, Gornji, Milanovac and Kragujevac. Although most major cities have piped

water, nearly half of all dwellings nationwide are not connected to a central, piped water

system. The country's infrastructure has been severely degraded by civil war. 

Overcrowding and the mass movement of refugees have severely degraded sanitary and

environmental conditions and have disrupted agricultural production. Risk of vectorborne diseases is high. Serious air, water, and soil pollution threaten public health. 

L. Slovak Republic. 
64

1. Geography. Landlocked Slovakia (bordering countries include Austria, the Czech

Republic, Poland, Ukraine, and Hungary) covers an area of 49,000 sq km and is about

twice the size of New Hampshire. The country can be divided into two geographic

regions: (1) The Carpathian Mountains, which dominate northern and central Slovakia,

run in an east-west direction and reach their highest elevation of 2,655 m at Gerlachovka. 

(2) In the southern region, the Slovak lowlands extend from the foothills of the

Carpathian Mountains to the Danube River. 

2. Climate. Except for elevation, climatic conditions vary little throughout Slovakia. 

The months of December through February are cold, cloudy, and humid, with fog in lowlying areas. In February, daily temperatures have dropped to as low as -24oC. Mountains

are usually snow covered from November through April, while lower elevations rarely

have more than 150 mm of snow cover at a time. Summer is warm and wet. Extreme

heat is rare, although temperatures occasionally reach 38oC. Temperatures in

mountainous areas are as much as 10oC lower than in Bratislava. 

Bratislava (elevation 130 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 1 3 9 16 21 24 27 26 22 15 8 3

MINIMUM (°C) -5 -3 1 5 9 13 14 14 9 5 1 -3

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 46 39 40 53 65 51 70 64 50 54 69 56

3. Population and Culture. Slovakia's population is concentrated primarily in the

urban and highly industrialized areas of Bratislava, Kosice and Nitra. Most of the

Carpathian Mountain region and portions of the Danube Basin region are sparsely

populated. Land use includes: 31% arable, 20% crops and pasture, and 41% woodlands. 

The ethnic makeup is 86% Slovakians, 11% Hungarians, 1% Gypsies, and 2% other. The

country’s religious makeup is 60% Roman Catholic, 10% atheist, 8% Protestant, 4%

Orthodox Christian, and 18% other. Total population 5.4 million, 57% urbanized,

literacy rate 99%. 

4. Water, Living and Sanitary Conditions. Most drinking water comes from surface

supplies. Erosion and flooding have resulted from unsound agricultural practices and

deforestation. Rural inhabitants are dependent on well water, and many areas in Slovakia
65

experience shortages of drinking water. Even in major cities, water purification systems

are considered inadequate. Attempts to improve the quality of surface water sources fail

because of ineffective waste treatment. Sanitary conditions are below Western standards. 

Only 353 of 2,825 communities are linked to public sewers, and sewage treatment plants

have been built in only 225 towns and villages. The rural population disposes of sewage

in cesspools or privies. Consequently, the risk of food and water-borne disease is high. 

Ground and surface water is contaminated from uncontrolled industrial and municipal

discharges, agricultural runoff, and inadequate storage of hazardous wastes. Acid rain is

a severe problem in this country.

M. Slovenia. 

1. Geography. Slovenia is slightly larger than New Jersey and has a land area of 20,300

sq km. There are three distinct geographical regions: (1) The Julian Alps in the north are

among the most rugged in Europe and contain Mt. Triglav, the highest peak in the

country with an elevation of 2,864 m. (2) In eastern Slovenia, the mountains are less

rugged and decrease in elevation to about 1,000 m near Maribor. This region contains

many valleys and rivers. (3) In the southeast, Slovenia has a 40-km long coastline on the

Adriatic Sea. Slovenia is bordered on the north by Austria, on the west by Italy and the

Adriatic Sea, on the south by Croatia, and on the east by Hungary. Flooding and

earthquakes are common. 

2. Climate. Slovenia's climate is generally hot in summer and cold in winter. 

Temperatures as high as 39oC in July and as low as -28oC in February have been recorded

in Ljubljana. The coastal region typically has dry summers and mild winters. Average

annual rainfall varies from 800 mm in the east to 3,000 mm in the northwest. 

Ljubljana (elevation 360 m)

Mean Daily Temperatures (oC) 

MONTH J F M A M J J A S O N D

MAXIMUM (°C) 2 5 10 15 20 24 27 26 22 15 8 4

MINIMUM (°C) -4 -4 0 4 9 12 14 14 11 6 2 -1

Monthly Precipitation (liquid equivalent) 

MEAN (mm) 88 89 76 98 121 133 113 127 142 151 131 114
66

3. Population and Culture. Slovenia's population is dispersed in small towns. Only

two cities have populations greater than 100,000. Average population density is 97

inhabitants per sq km. Slovenia's ethnically homogeneous population has not been

involved in the bitter ethnic conflicts seen in the neighboring republics of the former

Yugoslavia. The ethnic makeup is 91% Slovenes, 3% Croats, 2% Serbs, and 4% other. 

The religious makeup is 71% Roman Catholic, 1% Lutheran, 1% Muslim, 4% atheist,

and 23% others. Land use includes: 12% arable, 31% crops and pasture, and 51% forests

and woodland. Total population 2.0 million, 50% urbanized, literacy rate 99%. 

4. Water, Living and Sanitary Conditions. Ground water and springs are the major

sources of water in Slovenia. Water is perennially available throughout much of the

country; however, shortages occur along the Adriatic coast. The quality of treated water

varies widely throughout Slovenia. Municipal water systems may include tertiary

treatment, but inadequate water treatment is common. Historically, Slovenia has been

one of the most prosperous regions of the Balkans. Infrastructure is well developed, and

sanitation in major cities is good. Garbage is collected regularly. There are housing

shortages in some urban areas. The influx of refugees, mostly from Bosnia and

Herzegovina, has strained Slovenia's limited resources. Overcrowding and poor

sanitation are common among displaced persons, and the risk of vector-borne diseases is

high in refugee populations. Industrial pollution is not as bad in Slovenia as in most

other Central European countries, though the Sava, Slovenia's largest river, is

contaminated with industrial wastes, including phenols, petroleum, and heavy metals

from the Kranj industrial basin. Agricultural chemicals contaminate surface and ground

water sources, particularly in the Celjsko Polje. Localized air pollution is a public health

problem in urban areas where soft coal and charcoal are used for heating.
67

V. Militarily Important Vector-borne Diseases with Short Incubation Periods 

(<15 days)

A. Sand Fly Fever. (Papatasi fever, Three-day fever)

The sand fly fever group of viruses (Phlebovirus, Bunyaviridae) contains at least seven

immunologically related types. Naples, Sicilian and Toscana are normally associated

with sand fly fever. The virus produces an acute febrile illness lasting 2 to 4 days and is

commonly accompanied by headache and muscle pain. There is usually no mortality nor

are significant complications associated with infections of Naples or Sicilian viruses,

although weakness and depression may persist a week or more after acute illness. 

However, Toscana virus may cause central nervous system disease in addition to fever. 

Most infections are acquired during childhood in endemic areas. The clinical disease in

children is generally mild and results in lifelong immunity to homologous strains.

Military Impact and Historical Perspective. Sand fly fever has been an important

cause of febrile disease during military operations since at least the Napoleonic Wars. In

1909, an Austrian military commission first reported that an infectious agent found in the

blood of infected soldiers caused this fever, and that the vector was the sand fly. During

World War II, sand fly fever attained importance in Allied and Axis forces in the

Mediterranean theater by incapacitating large numbers of men for periods of seven to 14

days. The disease was first recognized in US forces in North Africa in April 1943. 

Although several thousand cases were reported from 1943 to 1945 in the Mediterranean

Theater, the incidence of sand fly fever was undoubtedly underestimated. Many

thousands of cases of sand fly fever were probably recorded as fevers of unknown origin,

since most medical officers were unfamiliar with the disease and specific tests for

diagnosis were not available. In sharp contrast to World War II, there were no reports of

sand fly fever among coalition forces during the Persian Gulf War. The military

significance of sand fly fever is magnified because of its short incubation period, which

may result in large numbers of nonimmune troops being rendered ineffective early in an

operation, while endemic forces would be largely immune and unaffected.

Disease Distribution. Sand fly fever is moderately endemic along the Adriatic coast of

Albania, Bosnia and Herzegovina, Montenegro, Slovenia, Croatia and its offshore islands

as well as landlocked Serbia. In the late 1980s, over 50% of the residents of the Adriatic

island of Mljet had antibodies to the Naples virus. Similar high seroprevalences were

found on the islands of Brac and Hvar. Sand fly fever is also focally distributed

throughout Greece below 2,000 m. The incidence of sand fly fever declined in Greece

when residual insecticide spraying for malaria control was initiated in the 1960s but

increased again after spraying stopped. Consequently, seroprevalence to Phleboviruses is

higher in older age groups. Both Naples and Sicilian viruses circulate in endemic areas,

but the Naples virus predominates. Corfu, a Phlebovirus closely related to the Sicilian

virus, has been isolated from Greece. In temperate regions, the immature stages of sand
68

flies enter diapause during the winter and adult activity practically ceases. Thus, in most

areas of Central Europe, transmission of sand fly fever occurs primarily from May

through October, when sand flies are most active. See Figure 1 for the distribution of

sand fly fever in Central Europe.

Transmission Cycle(s). No vertebrate reservoir has been clearly established, but small

rodents may serve as reservoirs. Infected humans can infect sand flies and thus have an

amplifying effect during epidemics. Humans with high levels of virus in the blood more

easily infect sand flies. The principal reservoir mechanism appears to be transovarial

transmission. The virus is most efficiently replicated in the sand fly vector and

transmitted when temperatures exceed 25oC. Infected sand flies remain infective for life

and are not harmed by the virus.

Vector Ecology Profiles.

Phlebotomus papatasi is the primary vector throughout the region. Phlebotomus

perfiliewi, P. sergenti and P. major are potential vectors. Phlebotomus papatasi is

widely distributed and has been reported from Albania, Bosnia and Herzegovina,

Bulgaria, Croatia, Greece, Hungary, Macedonia, Romania, Serbia, and Slovenia. It tends

to be more rural and periurban in distribution because it utilizes warm, humid

microhabitats, usually animal burrows, for larval development. 

Phlebotomus sergenti is also present but is not as ubiquitous as P. papatasi. Phlebotomus

sergenti is distributed in virtually the same countries as P. papatasi, except for Hungary,

where its presence is uncertain. In some areas, such as Serbia, P. perfiliewi is the most

abundant species. Phlebotomus major is also widely distributed in the region, with a

range similar to that of P. papatasi. A list of sand fly species and their distribution in

Central Europe is shown in Appendix A.2.

Some P. papatasi are autogenous; that is, they are capable of producing small numbers of

eggs without a bloodmeal, at least during the first gonotrophic cycle. After a bloodmeal,

females deposit eggs, 30 to 70 at a time, in rodent burrows, poultry houses, masonry

cracks, rock crevices, leaf litter, or moist tree holes. Eggs hatch in one to two weeks, and

larvae develop in warm, moist microhabitats that provide abundant organic matter for

food. In military fortifications, larvae may live in the cracks between stacked sandbags. 

There are four larval instars, and four to eight weeks are required to reach the pupal

stage. Fourth instar larvae may diapause for weeks or months if environmental

conditions are excessively cold or dry. Alternatively, if environmental conditions

improve, diapause may be quickly broken. Pupation occurs in the larval habitat. There is

no cocoon; rather, the pupa is loosely attached to the substrate by the cast skin of the 4th

larval instar. 
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Phlebotomus papatasi feeds most intensely at dusk and dawn, with some feeding

continuing sporadically through the rest of the night. Phlebotomus papatasi and

71

P. sergenti are endophilic and follow odor plumes to their hosts. Only females suck

blood, but both sexes feed on plant sugars and nectar. Besides humans, female sand flies

feed on the blood of a variety of birds and mammals, commonly dogs, mice, voles and

hedgehogs. On humans, they feed on exposed skin around the head, neck, legs, and

arms. Female sand flies will crawl under the edges of clothing to bite skin where

repellent hasn't been applied. Sand flies feed outdoors or indoors and readily penetrate

ordinary household screening. After engorgement, P. papatasi and other sand flies rest

briefly on objects near their host, then move to gerbil burrows or other cool, moist

environments to lay eggs. They also rest in caves and other areas that are relatively cool

and shaded during the daytime.

Sand flies are weak fliers and do not travel in wind that exceeds a few kilometers per

hour. Phlebotomus papatasi may be active at low relative humidities of 45 to 60%, but

other vector species require 75 to 80% relative humidity in order to fly and feed. Sand

flies fly in short hops, which usually limits their feeding radius to about 100 to 200 m

from pupation sites. However, unengorged females may occasionally disperse as far as

1.5 km. Mating dances occur on the ground, often at dusk, with males landing first,

followed by females. 

Phlebotomus perfiliewi has a life history that is similar to that of P. papatasi. However,

it is more exophilic than P. papatasi, often living in animal shelters and other outdoor

manmade structures. Cow manure is one of its most common larval habitats. It was the

most common species found in abandoned basements and outdoor latrines in

southeastern Serbia. Several isolates of sand fly fever virus were obtained from this

species in southeastern Serbia. Phlebotomus major is also similar to P. papatasi in its

life cycle. However, it is more often found outdoors, particularly in animal shelters, and

is not as attracted to artificial lights as the other species. It commonly feeds on humans. 

At least one Phlebovirus isolate has been reported from this species in Greece. 

Vector Surveillance and Suppression. Because sand flies are small and retiring,

specialized methods are required to collect them. The simplest method is active

searching of daytime resting sites with an aspirator and flashlight, but this method is very

labor intensive. Human-landing collections are an important method of determining

which species are anthropophilic. Sticky traps (paper coated with a sticky substance or

impregnated with an oil such as castor oil, mineral oil or olive oil) are used to randomly

capture sand flies moving to or from resting places. Traps can also be placed at the

entrances of animal burrows, caves and crevices, in building debris, and in local

vegetation where sand flies are likely to rest during daytime hours. A variety of light

traps have been used to collect phlebotomines, but their effectiveness varies according to

the species being studied and the habitat. Light traps are inefficient in open desert. Light

traps used for mosquito collection should be modified with fine mesh netting in order to

collect sand flies. Traps using animals as bait have been also devised. Collection of
72

larvae is extremely labor intensive and usually unsuccessful because specific breeding

sites are unknown or hard to find and because females deposit eggs singly over a wide

area. Emergence traps are useful for locating breeding sites. Identification of sand flies

requires a microscope and some training; however, with a little experience, sorting and

identification by color and size will suffice using minimal magnification. For accurate

species identification, laboratory microscopes having 100x magnification are required.

Because of their flight and resting behavior, sand flies that feed indoors are very

susceptible to control by residual insecticides. When sand flies are exophilic or bite

away from human habitations, control with insecticides is impractical, although the

application of residual insecticides to a distance of 100 m around encampment sites may

be helpful. Some success in reducing vector populations has been achieved by

controlling the rodent reservoir or host population. Selection of encampment sites

without vegetation or rock outcroppings that harbor rodents is important. Cleanup and

removal of garbage and debris that encourage rodent infestation are necessary for longer

periods of occupation. Pets must be strictly prohibited, because any small desert rodent

and/or local dog may be infected with leishmaniasis or other infectious diseases.

Sand flies are able to penetrate standard mesh screening used on houses and standard

mesh bednets (seven threads per cm or 49 threads per sq cm). These items should be

treated with permethrin to prevent entry. Fine mesh (14 threads per cm or 196 threads

per sq cm) bednets must be used, but these are uncomfortable under hot, humid

conditions because they restrict air circulation. The use of repellents on exposed skin and

clothing is the most effective means of individual protection. Insect repellent should be

applied to exposed skin and to skin at least two inches under the edges of the BDU to

prevent sand flies from crawling under the fabric and biting. The use of personal

protective measures (see TIM 36) is the best means of preventing sand fly-borne

disease. 

B. Malaria.

Human malaria is caused by any of four protozoan species in the genus Plasmodium that

are transmitted by the bite of an infective female Anopheles mosquito. Clinical

symptoms of malaria vary with the species. The most serious malaria infection,

falciparum malaria, can produce life-threatening complications, including renal and

hepatic failure, cerebral involvement, and coma. Case fatality rates among children and

nonimmune adults exceed 10% when not treated. The other human malarias, vivax,

malariae and ovale, are not life-threatening except in the very young, the very old, or

persons in poor health. Illness is characterized by malaise, fever, shaking chills,

headache, and nausea. The periodicity of the fever, occurring daily, every other day, or

every third day, is characteristic of the species. Nonfatal cases of malaria are extremely

debilitating. Relapses of improperly treated malaria can occur years after the initial

infection in all but falciparum malaria. Plasmodium malariae infections may persist for
73

as long as 50 years, with recurrent febrile episodes. Persons who are partially immune or

have been taking prophylactic drugs may show an atypical clinical picture. Treatment of

malaria has been complicated by the spread of multiple drug-resistant strains of 

P. falciparum in many parts of the world. Current information on foci of drug resistance

is published annually by the World Health Organization (WHO) and can also be obtained

from the Malaria Section of the Centers for Disease Control and Prevention, and the

Armed Forces Medical Intelligence Center.

Military Impact and Historical Perspective. Malaria has had an epic impact on

civilizations and military operations. During World War I, in the Macedonian campaign,

the French army was crippled with 96,000 cases of malaria. In 1918, over two million

man-days were lost in the British Macedonian Army because of malaria. During World

War II, malaria caused five times as many US casualties in the South Pacific as did

enemy action. In 1942, malaria was the major cause of casualties in General Stilwell’s

forces in North Burma. There were approximately 81,000 confirmed cases of malaria in

the US Army in the Mediterranean Theater from 1942 to 1945. The average length of

hospitalization for malaria in 1943 was 17 days, representing a total of 425,000 man-days

lost during the year or the equivalent of an entire division lost for a month. In North

Africa, the most highly malarious areas during World War II were in Rabat and Port

Lyautey in Morocco, the Constantine coast area in Algeria, and the Tunis-BizerteFerryville area in Tunisia. In 1952, during the Korean War, the 1st Marine Division

suffered up to 40 cases per 1,000 marines. Battle casualties accounted for only 17% of

American hospitalizations during the Vietnam War. Many regiments were rendered

ineffective due to the incidence of malaria, and many US military units experienced up to

100 cases of malaria per 1,000 personnel per year. Elements of the 73rd Airborne Brigade

had an incidence of 400 cases of malaria per 1,000 during 1967 and early 1968. Almost

300 military personnel contracted malaria during Operation Restore Hope in Somalia. 

Malaria remains a threat to military forces due to widespread drug resistance in

plasmodia, insecticide resistance in the vectors, and the consequent resurgence of malaria

in many areas of the world.

Disease Distribution. Endemic malaria has been eradicated from most temperate

countries, but it still is a major health problem in many tropical and subtropical areas.

Worldwide, there are an estimated 250 to 300 million cases of malaria annually, with two

to three million deaths. The WHO estimates that in Africa nearly one million children

under the age of 10 die from malaria every year. Globally, P. falciparum and 

P. vivax cause the vast majority of cases. Plasmodium falciparum occurs in most

endemic areas of the world and is the predominant species in Africa. Plasmodium vivax

is also common in most endemic areas except Africa. Plasmodium ovale occurs mainly

in Africa, and P. malariae occurs at low levels in many parts of the world. In most

endemic areas the greatest malaria risk is in rural locations, with little or no risk in cities. 
74

However, in Somalia during Operation Restore Hope (1993), several malaria cases

occurred in troops who were only in Mogadishu.

There is no risk of malaria in Central Europe. By the 1970s, malaria had been eradicated

from all countries in the region except Greece, which was declared malaria-free in 1986. 

However, indigenous transmission of malaria in Greece may have occurred as late as

1991. The risk of transmission is greatest along the Turkish border, where Plasmodium

vivax is highly endemic. Malaria in Central Europe is limited to sporadic imported cases;

however, several species of competent vectors exist throughout Central Europe, and

Anopheles surveillance and control programs have been discontinued in most countries. 

Conditions for the reestablishment of malaria in the region are favorable.

The number of imported cases, including drug-resistant strains of P. falciparum, has

increased since the 1990s as more citizens of the region travel to malaria-endemic areas

for work or recreation. Poland reported 37 imported cases in 1997, mainly from Africa. 

A study of 95 cases of malaria acquired by Polish citizens overseas between 1984 and

1993 found the majority of patients had neglected chemoprophylaxis while traveling in

malaria-endemic areas. 

 

The number of foreign residents in Central Europe is increasing. Of 660 foreigners from

African countries south of the Sahara entering Czechoslovakia between 1986 and 1989,

10% were positive for P. falciparum. Nearly 75% of these were asymptomatic carriers. 

Infected mosquitoes can be accidently transported in the cabin or cargo holds of

international flights to malaria-free nations. From 1969 to 1996, 64 known cases of

“airport malaria” were acquired by persons who worked or lived near an international

airport in Europe.

Transmission Cycle(s). Humans are the only reservoir host of human malaria. 

Nonhuman primates are naturally infected by many Plasmodium species that can infect

humans, but natural transmission is rare. Female mosquitoes of the genus Anopheles are

the exclusive vectors of human malaria. Plasmodium species undergo a complicated

development in the mosquito. When a female Anopheles ingests blood containing the

sexual stages (gametocytes) of the parasite, male and female gametes unite to form a

motile ookinete that penetrates the mosquito’s stomach wall and encysts on the outer

surface of the midgut. Thousands of sporozoites are eventually released, and some of

these migrate to the salivary glands. Infective sporozoites are subsequently injected into

a human host when the mosquito takes a blood meal (Figure 2). The time between

ingestion of gametocytes and liberation of sporozoites, ranging from eight to 35 days, is 

dependent on the temperature and the species of Plasmodium. Malaria parasites develop

in the mosquito vector most efficiently when ambient air temperatures are between 25oC

and 30o C. Parasite development is prolonged during cool seasons and at high altitudes,

and may exceed the life expectancy of the vector. Adult life span varies widely
75

depending on species and environmental conditions. Longevity is an important

characteristic of a good vector. Once infected, mosquitoes remain infective for life and

generally transmit sporozoites at each subsequent feeding. Vector competence is

frequently higher with indigenous strains of malaria. This decreases the likelihood that

imported strains from migrants will become established. 
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Vector Ecology Profiles. 

Worldwide, about 70 species of Anopheles transmit malaria to man, but of these, only

about 40 are important vectors. There are a number of anopheline species that have been

malaria vectors in the recent past and are still widely distributed in Central Europe. 

Although anophelines occur throughout the region, the areas of greatest concern are

countries or provinces of the former Yugoslavia (Serbia, Montenegro, Croatia, BosniaHerzegovina, Macedonia, and Slovenia), the Czech Republic, Romania, and Greece. 

 

Potential malaria vectors in the region include: Anopheles atroparvus, An. claviger, An.

labranchiae, An. maculipennis, An. melanoon, An. messeae, An. plumbeus, 

An. pseudopictus, An. sacharovi, and An. superpictus. Appendix A.1 lists these

mosquitoes and their known distribution in Central Europe. 

 

General Bionomics. Female anopheline mosquitoes must ingest a bloodmeal in order

for their eggs to develop. Feeding activity begins at dusk for many species, although

many others feed only later at night or at dawn. Most anophelines feed on exposed legs,

although some may feed on arms, ears or the neck. Infected females tend to feed

intermittently and thus may bite several people. Eggs mature three to four days after the

bloodmeal and are deposited one at a time, primarily in clean water with or without

emergent vegetation, depending upon the mosquito species. A single female may deposit

up to 200 eggs. Mosquito larvae feed on organic debris and minute organisms living in

aquatic habitats. Oviposition sites include ground pools, stream pools, slow moving

streams, animal footprints, artificial water vessels, and marshes. Deep water (over one

meter in depth) is generally unsuitable for larval development. There are four larval

instars, and one to two weeks are usually required to reach the nonfeeding pupal stage. 

The pupa is active and remains in the water for several days to a week prior to adult

emergence. The life span of females is usually only two to three weeks, although under

ideal conditions female mosquitoes may live for two to three months. Longevity of

individual species varies. A long life span is an important characteristic of a good vector. 

The older the anopheline population is in an endemic area, the greater the potential for

transmission. Males live only a few days. Females mate within swarms of males,

usually one female per swarm. Males and females feed on plant sugars and nectar to

provide energy for flight and other activities.

Adult Feeding, Resting, and Flight Behavior. Anopheles spp. that are strongly

attracted to humans are usually more important as vectors than those species that are

strongly zoophilic. Anopheles generally fly only short distances from their breeding

sites. The flight range is the distance traveled from the breeding site over the course of

the mosquito’s lifetime. This is important when determining how far from military

cantonments or human settlements to conduct larviciding operations. Vectors that feed

and rest indoors are more susceptible to control by residual insecticides.
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Specific Bionomics:

Anopheles atroparvus was originally considered to be a race of An. maculipennis but

has been raised to species status by van Thiel. This species is a dark, short-winged form

of Anopheles that does not hibernate. It is more abundant in northern Europe, although in

Central Europe it is common along the Danube River in Romania, as well as in the

lowlands of Serbia, Montenegro and the north-central part of Serbia (near Sabac). 

Larvae are found in ground pools or slow-moving, stagnant streams with a high saline

and alkaline content. This species is more anthropophilic than An. maculipennis, but its

spotty distribution helps to account for the highly focal nature of past malaria outbreaks

in areas where it was the primary vector. Anopheles atroparvus is primarily an outdoor

feeder but occasionally enters buildings. It usually rests outdoors after feeding and is not

considered a particularly strong flier. 

 Anopheles claviger occurs in southern Bohemia in the Czech Republic, in the plains of

Serbia, the Istrian Peninsula of Slovenia, Montenegro, and in Poland. Larval stages

prefer ponds, marshes, cisterns, wells and rock pools in sunlight or shade. Adults feed on

man outdoors and domestic animals in animal sheds and outdoors. Adults chiefly rest

outdoors after feeding, but they can be collected in animal sheds. They usually fly only

200 to 300 m from larval breeding sites to attack animals, although they may be carried

greater distances on cattle as they graze or return to animal sheds. 

Anopheles labranchiae is a relatively uncommon species in Central Europe. Larvae can

be found in fresh or brackish marshes, swamps, slow-moving streams and irrigated fields. 

Larvae tolerate warm water habitats, particularly in coastal areas. Adults feed on humans

and domestic animals. They are endophilic and enter houses in large numbers. 

Anopheles labranchiae may rest indoors or outdoors after feeding. Its flight range in

Central Europe is not known.

Anopheles maculipennis occurs widely throughout the region but is rare in Greece. 

Larvae frequently occur in oxbow swamps along the Danube River. Larvae also inhabit

rice fields and freshwater and brackish marshes and lagoons. This is the dominant

Anopheles species in highland areas. Anopheles maculipennis is zoophilic and feeds and

rests in animal shelters as well as outdoors. Adults hibernate during the winter. Its flight

range is generally one to two km from breeding sites. 

In Central Europe, An. melanoon larvae develop in fresh, stagnant ground water, as well

as brackish water habitats. Although its biting habits are not well known, it is considered

to be primarily zoophilic. Consequently, it has low vector potential for malaria. 

However, it is prolific and can produce up to 500 eggs in its first gonotrophic cycle. Its

flight range is estimated to be one to two km. 
79

 Anopheles messeae is distinguished by its long wings and occurs widely in Central

Europe. It is the most abundant Anopheles species in the plains and river valleys of

Slovenia, Serbia, Montenegro and the Czech Republic. Larvae develop in ground pools

along the alluvial plain of the Danube and in low-lying coastal areas with standing water. 

This species is a marginal malaria vector due to its zoophilic feeding behavior. It feeds

and rests indoors and outdoors. Adults hibernate during the winter. Its flight range is

generally one to two km from breeding sites.

 Anopheles plumbeus is an uncommon mosquito in Central Europe. It has been reported

in the Czech Republic, Serbia and the Sava River Valley of Slovenia. Larvae inhabit

treeholes, primarily in lowlands along river valleys, which would account for this

species’ sparse distribution. Its eggs are unusual among anophelines in that there are no

floats, so the eggs hang perpendicularly in the water. This species is primarily zoophilic,

and it rarely occurs indoors. It is not a strong flier. 

Anopheles pseudopictus has been reported in the Danube River Delta where larvae

inhabit extensive shallow, stagnant waters with abundant vegetation. This species feeds

aggressively on animals indoors and outdoors, but rests outdoors. It feeds

opportunistically on man. It is considered a good flier, often traveling up to one to two

kilometers from its breeding habitat to feed. Adults hibernate in the open on vegetation. 

In Central Europe, An. pseudopictus is a poor malaria vector due to its low population

densities and short life span. Adults rarely survive three gonotrophic cycles.

 Anopheles sacharovi is a coastal species that has been reported from the Central

European countries of Greece, Bosnia, Macedonia, Serbia, and Romania. Larvae develop

in brackish ground pools and marshes. Adults of this species bite man and animals

indoors and outdoors and often rest indoors or in animal shelters after feeding. In areas

where it is abundant, An. sacharovi is considered a good malaria vector. It is known to

be a strong flier in other regions, although no specific information on its flight range has

been published for Central Europe. 

In Central Europe, the larval habitats of An. superpictus include pools associated with

muddy rivers or fast, shallow streams flowing over rocky stream beds. Vegetation may

or not be present, although sunlit streams are preferred. Adults feeds on man and animals

indoors and outdoors and rest indoors, in animal shelters or caves, or outdoors after

feeding. Anopheles superpictus is considered an efficient malaria vector, but in this

region it is an unlikely vector because of its scarcity. 

Vector Surveillance and Suppression. Light traps are used to collect night-biting

mosquitoes, but not all Anopheles spp. are attracted to light. The addition of the

attractant carbon dioxide to light traps increases the number of species collected. Traps

baited with animals, or even humans, are useful for determining feeding preferences of
80

mosquitoes collected. Adults are often collected from indoor and outdoor resting sites

using a mechanical aspirator and flashlight. Systematic larval sampling with a longhandled white dipper provides information on species composition and population

dynamics that can be used to plan control measures.

Anopheles mosquitoes have unique morphological and behavioral characteristics that

distinguish them from all other genera of mosquitoes (Figure 3). Anopheles feed on the

host with the body nearly perpendicular to the skin. Other genera of mosquitoes feed

with the body parallel or at a slight angle to the skin. These characteristics can easily be

used by inexperienced personnel to determine if Anopheles are present in an area.

Malaria suppression includes elimination of gametocytes from the blood stream of the

human reservoir population, reduction of larval and adult Anopheles mosquito

populations, use of personal protective measures such as skin repellents, permethrinimpregnated uniforms and bednets to prevent mosquito bites, and chemoprophylaxis to

prevent infection. Specific recommendations for chemoprophylaxis depend on the

spectrum of drug resistance in the area of deployment. Command enforcement of

chemoprophylactic measures cannot be overemphasized. When Sir William Slim,

British Field Marshal in Southeast Asia during World War II, strictly enforced

chemoprophylactic compliance by relieving inattentive officers, malaria attack rates

declined dramatically. During the Vietnam War, malaria attack rates dropped rapidly in

military personnel when urine tests were introduced to determine if chloroquine and

primaquine were being taken.

Many prophylactic drugs, such as chloroquine, kill only the erythrocytic stages of

malaria and are ineffective against the latent hepatic stage of Plasmodium that is

responsible for relapses. Therefore, even soldiers who take chloroquine appropriately

during deployment can become infected. Individuals who are noncompliant with the

prescribed period of terminal prophylaxis are at risk for late relapses upon their return to

the United States. During the Vietnam War, 70% of returning troops failed to complete

their recommended terminal prophylaxis. The majority of cases in military personnel

returning from Operation Restore Hope in Somalia resulted from failure to take proper

terminal prophylaxis. Application of residual insecticides to the interior walls of

buildings and sleeping quarters is an effective method of interrupting malaria

transmission when local vectors feed and rest indoors. Nightly dispersal of ultra low

volume (ULV) aerosols can reduce exophilic mosquito populations. Larvicides and

biological controls (e.g., larvivorous fish) can reduce populations of larvae at their

aquatic breeding sites before adults emerge and disperse. Insecticides labeled for

mosquito control are listed in TIM 24, Contingency Pest Management Guide. Chemical

control may be difficult to achieve in some areas. After decades of malaria control, many

vector populations are now resistant to insecticides (Appendix C. Pesticide Resistance in

Central Europe). Sanitary improvements, such as filling and draining areas of
81

impounded water to eliminate breeding habitats, should be undertaken to the extent

possible.
78
83

The proper use of repellents and other personal protective measures is thoroughly

discussed in TIM 36, Personal Protective Techniques Against Insects and Other

Arthropods of Military Significance. The use of bednets impregnated with a synthetic

pyrethroid, preferably permethrin, is an extremely effective method of protecting

sleeping individuals from mosquito bites. Buildings and sleeping quarters should be

screened to prevent entry of mosquitoes and other blood-sucking insects. The interior

walls of tents and bunkers can be treated with permethrin to control resting vectors. See

Appendix F for further information on personal protective measures. 

C. West Nile Fever. 

West Nile fever is a mosquito-borne illness characterized by fever, headache, muscular

pain, and rash. Serious complications involve the liver and nervous system. The

etiological agent, West Nile virus (WNV), is named after the district of Uganda where

the virus was first isolated. It is a Flavivirus closely related to viruses causing Japanese

encephalitis and St. Louis encephalitis. Infection with WNV is most often asymptomatic. 

The incubation period ranges from 1 to 6 days and clinically resembles a mild denguelike illness. Recovery is complete but may be accompanied by long-term muscle pain

and weakness. Permanent sequelae have not been reported. Most fatal cases have

occurred in patients over 50 years old.

Military Impact and Historical Perspective. WNV was isolated in 1937 and was one

of the earliest human arboviral infections to be documented. Undoubtedly, WNV has

been the cause of many cases classified as fevers of unknown origin in military

personnel. In view of the mild illness and the infrequent occurrence of epidemics, the

military impact of this virus is likely to be minor compared with other diseases in Central

Europe. Infection with WNV will complicate diagnoses by medical personnel, since

West Nile fever cannot be clinically distinguished from many other arboviral fevers.

Disease Distribution. WNV has been isolated in many areas of Africa, Europe, India

and Pakistan, as well as from North America in 1999. Viral isolations from vertebrate

hosts and mosquitoes, and serological surveys of humans and suspected reservoir hosts

indicate that WNV is circulating throughout Central Europe, but the incidence in humans

is unknown. A large outbreak occurred in the summer of 1996 in and near Bucharest,

Romania, with more than 800 clinical cases and a case-fatality rate approaching 10%. 

This epidemic was the first important outbreak of West Nile fever recorded in Europe. 

Several human cases of West Nile fever also occurred in the Czech Republic in July

1997, after heavy rains caused extensive floods along the Morava River. See Figure 4 for

the distribution of outbreaks of West Nile fever in Central Europe.

West Nile fever occurs during the period of maximum activity of mosquito vectors,

usually June through September. Environmental factors, including human activities that

enhance vector populations (irrigation, heavy rains followed by flooding, higher than

86

normal temperatures), increase the potential for an outbreak of this and other mosquitoborne diseases. 

Transmission Cycle(s). WNV has been isolated from numerous wild birds and

occasionally from mammals. Serological surveys have demonstrated WNV antibodies in

wild and domestic bird species, wild mammals such as lemurs, rodents and bats, and

domestic animals such as camels, horses, mules, donkeys, goats, cattle, water buffalo,

sheep, pigs and dogs. However, birds are considered to be the primary reservoir for

WNV and may reintroduce the virus during seasonal migrations. Birds usually do not

show any symptoms when infected with WNV, though illness and death have been

observed in pigeons and corvids (crows). Infections in most mammals fail to produce

viremias high enough to infect potential vectors. WNV has been isolated from several

species of mosquitoes in nature, especially Culex spp., which are recognized as the

primary vectors. WNV has also been recovered from bird-feeding ticks and mites, and

experimental transmission of WNV has been observed in Ornithodoros spp. and several

species of hard ticks. A natural bird-tick zoonotic cycle has been suggested, but the role

of ticks in the natural transmission of WNV has not been well defined. Mosquitoes are

clearly implicated in the transmission of WNV to humans. WNV replicates quickly in

mosquitoes when temperatures exceed 25oC. Infected mosquitoes can transmit WNV for

life. Experimental transmission of WNV by Aedes albopictus has been reported, and the

spread of this species from Albania and Greece to other areas of Central Europe may

increase the risk of transmission to humans.

In Europe WNV circulation exhibits rural and urban cycles of transmission. Rural foci of

WNV infections are mainly situated in wetland ecosystems (river deltas and flood plains)

and involve bird-feeding mosquitoes. Ticks may substitute as vectors and in certain dry

and warm habitats lacking mosquitoes. The urban cycle consists of domestic birds and

mosquitoes that feed on both birds and humans, primarily members of the Culex pipiens

complex. The principal cycle is rural, but the urban cycle predominated in Bucharest

during the 1996 outbreak. 

Vector Ecology Profiles. West Nile virus has been isolated from Culex pipiens (in

Bulgaria, the Czech Republic, and Romania), Culex modestus in Slovakia, and Aedes

cantans in Slovakia and Moravia. 

Aedes cantans chiefly occurs along the edges of forests or in thinned forests. This

species deposits its eggs singly or in small numbers on moist soil and wet leaf litter near

water subject to flooding. Favored oviposition sites include ground pools or ditches with

fallen leaves or sparse vegetation but without filamentous algae. Aedes cantans

overwinters in the egg stage; eggs hatch when flooded during the spring. Eggs can

remain viable for more than four years at high relative humidity. Larvae are often

associated with those of Ae. annulipes, Ae. communis, Ae. punctor and Ae. rusticus. 
87

Adults are fierce outdoor feeders on large domestic animals and humans but rarely feed

or rest indoors. Adults seldom travel far from their larval habitats to feed. 

Culex modestus has a fairly restricted habitat compared with Cx. pipiens, though the two

species show similar oviposition behavior. Larvae occur in small fishponds, marshy

areas, and swamps in south-central Europe. The development time of larval instars is

also similar to Cx. pipiens and is dependent on temperature. Adults are zoophilic and

feed and rest outdoors. Adults feed primarily on birds and waterfowl. This species often

overwinters in Phragmites reed piles or other dead vegetation around breeding sites. 

Culex pipiens is widespread and abundant throughout Central Europe. Adults usually

prefer to feed on birds but readily feed on humans and large animals like cattle and goats. 

They feed early in the evening, usually within two hours of sunset, although feeding

continues throughout the night. Adults are strong fliers and will travel three to five km 

from breeding sites to find a bloodmeal. This species is an annoying biter and produces a

high-pitched buzzing sound that can easily be heard. Members of the Cx. pipiens

complex feed and rest indoors or outdoors. Adults are more endophilic in the late fall.

Three or four days after a bloodmeal, Cx. pipiens deposits egg rafts containing 75 to 200

eggs on the water surface. Common oviposition sites include cisterns, water troughs,

irrigation spillovers, wastewater lagoons, and swamps. Eggs hatch two to four days after

deposition. Larvae of the Cx. pipiens complex generally prefer ground pools with high

concentrations of organic matter or swamps with emergent vegetation. Polluted water

from septic systems is an ideal breeding site for this complex. In Bucharest, Romania,

and nearby suburbs flooded basements are an important breeding habitat for this

mosquito. Larval development requires seven to nine days at a temperature range of 25

to 30 C. At lower temperatures, larval stages may require 15 to 20 days. The pupal

stage lasts about two days. Adults of Cx. pipiens occur from May to October in most of

Central Europe, although they may be found for another month or more in Greece, or

even year-round in highly focal areas where sewage effluent keeps breeding sites warm. 

Adults usually display two population peaks, one in May and another in September. 

Vector Surveillance and Suppression. Epidemics of West Nile fever are infrequent,

and public health officials in Central European countries can rarely justify continued

long-term surveillance for virus activity when considering other health care demands. 

Reduction of mosquito populations by ULV spraying may be useful as a means of

disease control. The most feasible long-term control strategies involve reducing vector

breeding by environmental management techniques. Personal protective measures to

prevent mosquito bites are the most practical means of avoiding infection with WNV. 

Consult TIM 13, Ultra Low Volume Dispersal of Insecticides by Ground Equipment;

TIM 24, Contingency Pest Management Guide; and TIM 40, Methods for Trapping and

Sampling Small Mammals for Virologic Testing. Also see vector surveillance and

suppression for malaria.
88

D. Sindbis Virus. 

Sindbis virus belongs to the genus Alphavirus, family Togaviridae. It is closely related to

the Western equine encephalitis complex. The incubation period is less than a week and

symptoms may include fever, headache, rash, and joint pain. Syndromes resulting from

Sindbis virus infection have been called Ockelbo disease in Sweden, Pogosta disease in

Finland, and Karelian fever in the former Soviet Union. No fatal cases have been

reported.

Military Impact and Historical Perspective. Sindbis virus was first isolated in 1952

from Culex mosquitoes collected in the village of Sindbis north of Cairo. It was

subsequently reported from Europe, Asia, sub-Saharan Africa and Australia. A role in 

human disease was recognized in 1961 when Sindbis virus was isolated from patients

with fever in Uganda. Human epidemics due to Sindbis virus were documented in South

Africa in the late 1960s, and clusters of cases with fever, arthralgia and rash have been

observed in Sweden. Although outbreaks of Sindbis virus have caused significant human

morbidity in areas of northern Europe, this disease is expected to have a minor impact on

military operations in Central Europe.

Disease Distribution. Sindbis virus is one of the most widely distributed of all known

arboviruses. Studies have demonstrated Sindbis virus transmission in most areas of the

Eastern Hemisphere. Viral isolations and serological surveys of birds, small mammals,

domestic animals and humans indicate that Sindbis virus is enzootic throughout Central

Europe. Seroprevalence found in most studies is generally low, < 3%. 

Transmission Cycle(s). A wide range of wild and domestic vertebrate species are

susceptible to infection with Sindbis virus. Most experimentally infected wild birds

easily produce viremias high enough to infect several different species of mosquitoes. 

Wild and domestic birds are considered the main enzootic reservoir. Although several

species of domestic mammals can become infected with Sindbis virus, there is no

evidence that these infections result in significant illness. Evidence implicates birdfeeding mosquitoes of the genus Culex as the vectors of Sindbis virus in enzootic and

human infections. However, viral isolations and transmission experiments have shown

that Aedes spp., which are less host specific and feed readily on both birds and humans,

may be important as vectors linking the enzootic cycle and human infection. 

Mechanisms that allow the virus to overwinter and survive between periods of enzootic

transmission have not been identified. Outbreaks of Sindbis fever epidemics in northern

Europe are believed to be caused by the introduction of the virus from Africa to Europe

by migratory birds. 

Vector Ecology Profiles. Essentially the same vectors that transmit Sindbis virus in

Russia and Scandinavia are present in Central Europe, including Culiseta morsitans,
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Culex pipiens, Cx. torrentium and Aedes cinereus. The bionomics and behavior of 

Cx. pipiens are described under West Nile. 

Aedes cinereus acts as a bridge vector between birds and humans and is widely

distributed in Central Europe. Eggs hatch rapidly after inundation with water. Larvae

generally occur in deep or partially shaded water in thinned forests, at forest edges, in

meadows or swamps bordered by shrub thickets, and in pools with little vegetation. This

species is referred to as a snow-melt mosquito, since larval habitats are often associated

with melting snow. Larval development is often extended for several weeks because of

cool water temperatures. Larvae often occur in association with Culex territans. Adults

of Ae. cinereus may be extremely numerous and are crepuscular or daytime biters. They

rest in grasses in thinned forests or at forest edges, biting humans and animals as they

enter these areas. This species usually feeds close to its larval breeding sites and rarely

travels more than 1.5 km. In the Slovak Republic, peak activity of Ae. cinereus adults

occurs in late July. 

Culiseta morsitans is widely distributed in Europe. This is mainly a forest mosquito that

prefers to feed on birds. Larval stages occur in moderately saline, shaded ground pools,

or in cool, slow-moving water that is shaded and usually contains decaying leaves at the

bottom. Normally there is one generation per year. Larval diapause in permanent bodies

of water is the principal overwintering mechanism, although diapause in the egg stage

has also been reported. This species is rare inside human habitations. Adults rest in

grass at the edges of forests and usually feed close to their larval breeding sites. They

bite wild and domestic animals, birds and, occasionally, humans.

The distribution of Culex torrentium is limited to the Czech and Slovak Republics,

Romania and Poland. This species is morphologically similar to Cx. pipiens and can only

be distinguished by examination of the male terminalia. Larvae occur in a wide variety

of natural and manmade breeding sites, including the perimeters of lakes, marshy areas,

permanent ponds and swamps bordered by Phragmites reeds, stagnant water in ditches,

and artificial containers. Larvae are often found in polluted water in association with

those of Cx. pipiens. Adults occur from May to October, with peak populations

appearing in June and July. Inseminated females overwinter. 

Vector Surveillance and Suppression. See West Nile fever and malaria. 

 

E. California Group Viral Infections.

California serogroup infections are mosquito-borne diseases characterized by a wide

spectrum of clinical manifestations, ranging from a simple febrile illness to lifethreatening encephalitis. Tahyna, the only California group virus isolated from Central

Europe, produces an influenza-like illness lasting three to five days. The onset is sudden,
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with fever, sore throat and generalized malaise. Additional symptoms associated with

Tahyna virus infection include cough, pharyngitis, conjunctivitis, headache, nausea,

generalized weakness and, rarely, meningoencephalitis or bronchopneumonia. No

residual sequelae or deaths have been recorded due to Tahyna virus infection.

Military Impact and Historical Perspective. The first California group virus was

isolated in 1943 from Aedes melanimon mosquitoes collected in Kern County, California. 

Subsequent isolations of related viruses and their association with human infections led

to the recognition that members of this serogroup were etiological agents of human

encephalitis. Tahyna virus was first isolated in 1958 from Aedes mosquitoes in

southeastern Czechoslovakia. It has now been isolated from several countries, most in

Central Europe. The military impact of Tahyna viral infections on military operations

should be minimal due to the mild nature of the illness. Distinguishing this virus from

other febrile diseases on clinical grounds would be difficult. 

Disease Distribution. Foci of Tahyna virus have been found from Finland to Tajikistan. 

The center of Tahyna virus distribution in Central Europe lies within the Pannonian plain. 

This steppe-like region contains soils with a high salt content and covers parts of Austria,

southern Czechoslovakia, Hungary, Serbia and Romania.

Transmission Cycles. A large number of vertebrate species have been experimentally

infected with Tahyna virus and examined for viremia. Viremia has been observed in

almost all mammal species tested except bats. Tahyna virus does not produce detectable

viremias in birds, amphibians or reptiles. The main amplification hosts for Tahyna virus

in Central Europe are European hares and rabbits. Under natural conditions, no clinical

manifestations have been described in animals infected with California group viruses. In

Europe, Tahyna virus appears to have a number of overwintering mechanisms. The virus

is transmitted transovarially in Aedes mosquitoes and it may overwinter in adult

mosquitoes. European hedgehogs infected with Tahyna virus and placed in hibernation

for 140 days develop a viremia subsequent to awakening that is sufficient to infect

mosquitoes.

Vector Ecology profiles. In Central Europe, Tahyna virus has been isolated from

mosquitoes of five genera. The majority of isolates have been obtained from Aedes

species, primarily Aedes vexans and Ae. caspius. The pattern of viral isolates from

mosquitoes throughout Eurasia indicates that strains of Tahyna virus utilize different

vector species in different geographical areas. 

The principal vectors of this virus in Central Europe are Ae. vexans, Ae. sticticus and Ae.

cantans. Aedes caspius is an important vector in the eastern portion of the Slovak

Republic, while Ae. cinereus has been identified as a secondary vector in Moravia, Czech

Republic. However, the virus has been isolated in the field from several other species of
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mosquitoes, as well as a number of species of Culicoides. Culiseta subochrea and Culex

modestus have been reported as vectors in southern Moravia. The virus has been isolated

from Cx. pipiens in Romania. Pools of Culicoides achrayi, C. grisescens, C. heliophilus,

C. obsoletus, C. impunctatus and C. pallidicornis have yielded two field isolations of

Tahyna virus in the Czech Republic. Since these isolates came from mass pooling of

mixed species, it is uncertain which, if any, of these biting midges are significant vectors. 

Of the four principal vectors, Ae. vexans is the most widely distributed and is present or

suspected in nearly every country in the region. Aedes cantans and Ae. sticticus have a

more central distribution. Aedes caspius has a slightly more coastal and southern

distribution, although it occurs in Poland. Culex pipiens is also widely distributed and is

probably present in every country in the region. Culex modestus and Culiseta subochrea

appear to have a more inland rather than coastal distribution. The distribution of

mosquitoes in Central Europe appears in Appendix A.1. 

Aedes caspius deposits its eggs singly or in small groups directly on the surface of

shallow, stagnant, sunlit pools with muddy bottoms and little or no vegetation. Larvae

emerge two to three days after deposition. Breeding sites colonized include isolated

stream pools, ground pools, coastal impoundment areas, inland lakes with high salinity,

and overflow water from irrigation projects. Although this species is frequently found

alone, it is sometimes associated with Uranotaenia unguiculata in freshwater habitats. 

Aedes caspius is an opportunistic feeder that attacks birds and large mammals close to its

breeding habitats. Hosts include cattle, deer, sheep, and humans. It feeds chiefly

outdoors during the daytime but may feed in the evening. Females occasionally develop

eggs autogenously after feeding only on plant nectars. 

Aedes sticticus is found in forested floodplains and river deltas and may also inhabit

forest-steppes. Like all floodwater Aedes, it overwinters in the egg stage and may

survive up to three years in a desiccated state. Larvae emerge in the spring puddles and

pools formed by melting snow or river flooding. Partially shaded puddles and ground

pools covered by fallen leaves are ideal habitats. Adults emerge in large numbers and

feed aggressively on humans and animals. Aedes sticticus feeds and rests outdoors and

will feed throughout the day but prefers the evening hours. It is a strong flier and may

travel up to 16 km from its breeding sites to find hosts. 

Aedes vexans also inhabits floodplains and river deltas and lays its eggs on the edges of

slopes and the mud of river beds where seasonal inundations occur. Larvae are also

found in ground pools, puddles, ditches, and hoofprints free of filamentous algae. Eggs

hatch at a water temperature between 14 and 16°C. Larval stages take seven to14 days to

complete their development depending on temperature. The optimal temperature range is

28 to 30°C. Adults are fierce human biters that feed and rest indoors or outdoors. They

are strong fliers and may travel 10 to 20 km from their breeding sites. 
92

Culiseta subochrea is widespread throughout the region and primarily inhabits lightly

forested plains. Females deposit approximately 200 eggs in a raft on the surface of

partially shaded pools, cisterns, ditches or containers. Breeding sites often contain

vegetation, high quantities of organic debris, and moderate salinity. Adults are

zoophilic and feed primarily on birds and large mammals. They rarely bite humans. 

Adults feed and rest outdoors, close to their larval breeding sites. Adults overwinter,

often in animal sheds. Larval diapause has been reported in northern areas of Central

Europe. 

Culex modestus often occurs in large numbers in forest-steppe, mixed forests, and

clearings in wooded areas. Larvae inhabit reed thickets around fish ponds, marshy areas

and swamps in south-central Europe. Larvae can tolerate foul water and frequently occur

in association with those of Cx. pipiens and members of the Anopheles maculipennis

complex. Egg rafts are deposited on the surface of breeding sites. Larval development is

similar to that of Cx. pipiens and is dependent on temperature. Adults are primarily

zoophilic and rest and feed outdoors during twilight and evening hours. This species

feeds on hedgehogs, birds and waterfowl near its breeding sites. However, Cx. modestus

is also a fierce human biter and may feed even in daylight. Adults are more abundant

from July through September. Adults often overwinter in Phragmites reed piles or other

dead vegetation occurring around breeding sites. 

Culex pipiens and Ae. cantans are discussed under West Nile fever. 

Vector Surveillance and Suppression. Control of larvae or adults of these species over

large areas is usually impractical or uneconomic. Floodwater mosquitoes such as 

Ae. vexans can emerge in vast numbers over such large areas that aerial dispersal of ULV

aerosols is required to reduce their populations. Vegetation frequently prevents aerially

dispersed sprays from reaching breeding sites and resting adults. Use of the DoD

repellent system is the best means of protection from these mosquitoes.

F. Dengue Fever. (Breakbone fever, Dandy fever)

Dengue is an acute febrile disease characterized by sudden onset, fever for 3 to 5 days,

intense headache, and muscle and joint pain. It is commonly called “breakbone fever”

because of the severity of pain. There is virtually no mortality in classical dengue. 

Recovery is complete, but weakness and depression may last several weeks. Dengue is

caused by a Flavivirus and includes four distinct serotypes (dengue 1, 2, 3 and 4). 

Recovery from infection with one serotype provides lifelong immunity from the same

serotype but does not confer protection against other serotypes. Dengue hemorrhagic

fever (DHF) and associated dengue shock syndrome (DSS) were first recognized during a

1954 epidemic in Bangkok, Thailand. DHF/DSS have spread throughout Southeast Asia,

Indonesia and the southwest Pacific, Latin America and the Caribbean. DHF requires
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exposure to two serotypes, either sequentially or during a single epidemic involving more

than one serotype. DHF is a severe disease that produces high mortality in children.

Military Impact and Historical Perspective. Dengue virus was first isolated and

characterized in the 1940s, but dengue fever can be identified clinically from the 18th

century. Epidemics of dengue are noted for affecting large numbers of civilians or

military forces operating in an endemic area. Outbreaks involving 500,000 to two

million cases have occurred in many parts of the world. During World War II, the

incidence of dengue was largely restricted to the Pacific and Asiatic theaters. Only

scattered cases of dengue were reported from other theaters, including North Africa. 

Campaigns in the Pacific were marked by dengue epidemics, and throughout the war the

US Army experienced nearly 110,000 cases. At Espiritu Santo in the Pacific, an

estimated 25% of US military personnel became ill with dengue, causing a loss of 80,000

man-days. Dengue was an important cause of febrile illness among US troops during

Operation Restore Hope in Somalia. In recent years dengue, especially DHF, has been

expanding throughout the world. Thirty to 50 million cases of dengue are reported

annually.

Disease Distribution. Dengue is present in nearly all tropical countries. Its distribution

is congruent with that of its primary vector, Aedes aegypti, between 40o N and 40o S

latitude. Epidemics generally coincide with the rainy season and high mosquito

populations. Increasing urbanization and discarded litter have increased breeding

habitats for dengue vectors. Transmission of dengue has not been reported in Central

Europe for many years, although dengue antibodies were found in residents of Albania

and Croatia in serological studies conducted during the late 1980s.

Transmission Cycle(s). Dengue virus is primarily associated with Aedes mosquitoes in

the subgenus Stegomyia. The virus is maintained in a human-Ae. aegypti cycle in

tropical urban areas. A monkey-mosquito cycle serves to maintain the virus in sylvatic

situations in Southeast Asia and West Africa. Mosquitoes are able to transmit dengue

virus eight to 10 days after an infective blood meal and can transmit the virus for life. 

Dengue virus replicates rapidly in the mosquito at temperatures above 25oC.

 

Vector Ecology Profiles. 

Aedes aegypti, the primary vector in most endemic areas, has been reported from the

Central European countries of Albania, Bosnia, Bulgaria, Greece and Macedonia. This

species is more common in cities or villages than in rural areas. Aedes aegypti deposits

its eggs singly or in small groups of two to 20 above the water line of its habitat. Larvae

emerge after eggs have been submerged for four or more hours. Aedes aegypti larvae

live in artificial water containers, including flowerpots, cisterns, water jugs, and tires. 

Larvae prefer relatively clean and clear water. They develop quickly in warm water,

maturing to the pupal stage in about nine days. Pupae remain active in the water
94

container until adult emergence, one to five days after pupation. Aedes aegypti rarely

disperses more than 

50 m from its breeding site, but over several days, it can disperse as far as 500 to 600 m. 

It does not fly when winds exceed five km per hour.

Aedes aegypti prefers human hosts and feeds primarily around human habitations. It is a

diurnal feeder and readily enters homes. Aedes aegypti is not attracted to light; rather, it

responds to contrasting light and dark areas presented by human dwellings. When

feeding outdoors, it prefers shaded areas. It feeds on the lower legs and ankles,

increasing its biting activity when temperatures and humidity are high. It is easily

disturbed when feeding and, because it feeds during the day, is often interrupted by the

movements of its host. This behavior results in multiple bloodmeals, often taken within

the same dwelling, which increases transmission of virus.

The increase in the transport of freight and passengers by ship and air has allowed

vectors and pathogens to spread quickly and easily over large distances. The 

introduction of Aedes albopictus to many new areas through the shipment of used tires to

recapping plants has alarmed public health officials. Aedes albopictus has been

spreading rapidly in the Mediterranean since its accidental introduction into Italy in 1990.

 It has been reported from Albania and Greece, and this important vector may spread to

other areas of Central Europe where the climate is favorable for its survival, especially

the former Republic of Yugoslavia. Its arrival in Albania from China in the mid-70s was

the first recorded infestation of Ae. albopictus outside the Oriental and Australian

regions. 

Aedes albopictus is second only to Ae. aegypti in importance as a vector of dengue. It is

more common in rural than urban areas. It has larval and adult feeding habits similar to

Ae. aegypti but is more commonly found breeding in natural containers, such as tree

holes, leaf axils, and fallen fruit husks. It is a slightly stronger flier than Ae. aegypti. 

Aedes albopictus is strongly anthropophilic but has a broader host range than Ae. aegypti.

 

Aedes caspius deposits its eggs singly or in small groups directly on the surface of

shallow, stagnant, sunlit pools with muddy bottoms and little or no vegetation. Larvae

emerge two to three days later. Breeding sites colonized include isolated stream pools,

ground pools, coastal impoundment areas, inland lakes with high salinity, and overflow

water from irrigation projects. Although this species is frequently found alone, it is

sometimes associated with Uranotaenia unguiculata in freshwater habitats. Aedes

caspius is an opportunistic feeder that attacks birds and large mammals close to its

breeding habitats. Hosts include cattle, deer, sheep, and humans. It chiefly feeds

outdoors during the daytime but may feed in the evening. Females occasionally develop

eggs autogenously after feeding only on plant nectars. If dengue outbreaks occur in

Central Europe, Ae. caspius could be a significant vector. 
95

Vector Surveillance and Suppression. Landing rate counts provide a quick relative

index of adult abundance. The number of mosquitoes that land on an individual within a

short period of time, usually one minute, is recorded. Resting collections consist of the

systematic search for dengue vectors in secluded places indoors, such as in closets and

under furniture. Resting collection studies performed with mechanical aspirators are an

efficient but labor-intensive means of evaluating adult densities. Densities are recorded

either as the number of adult mosquitoes per house or the number of adult mosquitoes

collected per unit of time. 

Several indices have been devised to provide a relative measure of the larval populations

of Ae. aegypti. The house index is the percentage of residences surveyed that have

containers with larvae. The container index is the percentage of containers at each

premise that have larvae. The Breteau index is more widely used and is the number of

positive containers per 100 premises. There is a risk of dengue transmission when the

Breteau index goes above five, and emergency vector control is indicated when the index

exceeds 100. Adult egg-laying activity can be monitored using black oviposition traps. 

Ovitraps are especially useful for the early detection of new infestations in areas from

which dengue vectors had been eliminated. 

Control of dengue fever is contingent upon reducing or eliminating vector populations. 

Ground or aerial applications of insecticidal aerosols have been relied upon to reduce

adult populations during epidemics of dengue. Many vector control specialists have

questioned the efficacy of ULV adulticiding. In some outbreaks of dengue fever, ULV

dispersal of insecticides has had only a modest impact on adult mosquito populations. 

Aedes aegypti is a domestic mosquito that frequently rests and feeds indoors and

therefore is not readily exposed to aerosols. The sides of large storage containers should

be scrubbed to remove eggs when water levels are low. Water should be stored in

containers with tight-fitting lids to prevent access by mosquitoes. A layer of oil will

prevent mosquito eggs from hatching and will kill the larvae. The elimination of

breeding sources, such as old tires, flowerpots, and other artificial containers, is the most

effective way to reduce mosquito populations and prevent dengue outbreaks. In

Singapore, passage of sanitation laws and their strict enforcement to eliminate breeding

sites reduced the house index for Ae. aegypti larvae from 25% to 1%. Proper disposal of 

trash, bottles and cans at military cantonments must be rigidly enforced. The individual

soldier can best prevent infection by using personal protective measures during the day

when vector mosquitoes are active. Wear permethrin-impregnated BDUs and use

extended-duration DEET repellent on exposed skin surfaces (see TIM 36).

G. Tick-borne Encephalitis. 

Tick-borne Encephalitis (TBE), caused by a complex of flaviviruses, actually comprises

two clinically different diseases, Far Eastern TBE, also known as Russian spring-summer

encephalitis, and Central European TBE, also known as biphasic meningoencephalitis, or
96

diphasic milk disease. Human disease of the Far Eastern subtype is usually more severe

in the acute phase and is associated with a higher rate of chronic nervous system sequelae

than the Central European subtype. Far Eastern TBE has been a significant public health

problem in central Russia since the 1930s. Case fatality rates have been as high as 40%

in endemic areas. The case fatality rate for Central European TBE ranges from 1 to 5%. 

The term TBE is used to identify the broad spectrum of clinical syndromes caused by the

virus, ranging from a simple febrile illness to severe central nervous system infection that

may be fatal. However, about 80% of serologically documented infections are

inapparent. The incubation period ranges from seven to 14 days and is followed by

fever, headache, muscle pain, nausea, vomiting and photophobia. In about 30% of

patients, the disease progresses to encephalitis, paralysis or even death. The highest

mortality and most serious neurological sequelae occur in people over 40. 

Military Impact and Historical Perspective. Illness of the Far Eastern subtype was

first described in 1937 during an epidemic in the Russian Far East. The European

subtype was clinically defined in 1948 during an epidemic in Central Bohemia. 

Although TBE virus exists in discrete foci, it is widespread throughout Central Europe,

and military personnel would experience a high level of exposure to vector ticks. TBE

should be considered a serious threat to personnel deployed to the region.

Disease Distribution. The tick-borne encephalitides occur along the southern part of the

forest belt of temperate Eurasia, from the Atlantic to the Pacific Ocean. The Far Eastern

subtype occurs in Siberia, the southern republics of the former Soviet Union, and

Northeastern China. The European subtype occurs in Europe, including Russia west of

the Ural Mountains. The largest number of cases in recent years was observed in the

Urals and in western Siberia. In the 1950s and 1960s, TBE was primarily an

occupational disease contracted by forest workers and farmers in rural areas. During the

1970s and 1980s, up to 70% of reported cases were in urban dwellers that became

infected during recreational outings in forests, usually within three to eight km of towns.

TBE is focally distributed throughout Central Europe in ecological conditions that are

favorable to the primary vector, I. ricinus, and small rodent reservoirs of the virus. Ideal

habitats include mixed deciduous forests (particularly oak) extending into brushy forest

edges and meadows, and along stream and river valleys. Enzootic areas are usually less

than 1000 m in elevation. Suburban forests and urban forested parks are frequently foci

of TBE.

Albania: Areas of greatest risk include the southern districts of Gjirokaster and Permet,

the central district of Tirane, and the eastern district of Librazhd. 

Bosnia and Herzegovina: Highest risk of transmission occurs along oak-forested river

basins, particularly around Zenica (central Bosnia), west of Tuzla (eastern Bosnia), areas
97

surrounding and to the southwest of Gorazde (southeast Bosnia), and along the Adriatic

coast between Capljina and Dubrovnic (extreme southwest Bosnia).

Bulgaria: High levels of antibodies to TBE virus have been found in goats and sheep in

central Bulgaria.

Croatia: Risk of transmission is high along oak-forested river basins, primarily in the

areas between the Drava and Sava Rivers, but is low along the Adriatic coast and on the

Adriatic islands.

Czech Republic: TBE is known locally as “Roznava disease.” Enzootic areas include

Bohemia (especially areas south of Prague and throughout the Vltava River Basin, and

near Plzen) and Moravia (particularly in the south, including the area bordered by the

cities of Brno, Breclav, and Znojmo, and areas around the northern city of Ostrava).

Hungary: Enzootic areas include western (Gyor-Sopron, Somogy, Vas, Veszprem and

Zala Counties) and northwestern (Komarom and Nograd Counties) Hungary.

Greece: TBE is focally distributed countrywide, although up to 14% of the population in

southern Greece was seropositive during the late 1980s.

Macedonia: Recent seroprevalence data are not available, although Macedonia has

historically reported the lowest incidence of TBE in the former Republic of Yugoslavia.

Poland: TBE is widely distributed countrywide, but the risk of transmission is highest in

the northeast, particularly in areas bordering Lithuania and Belarus.

Romania: Enzootic foci are concentrated in the Tulcea District and in areas of

Transylvania at the base of both the Carpathian Mountains and the Transylvanian Alps.

Slovak Republic: Elevated risk of transmission occurs in western Slovakia (including

the Zahorske lowland, the Vah River Valley, and northward to the district of Povazska,

the Low Carpathian Mountains, Tribec and Vtacnik ridges, the Nitran-Pohron area, and

the Kovacov Hills) and southern Slovakia including the Pannonian Plain. Enzootic areas

also occur in central Slovakia (including the Krupin Hills) and in eastern Slovakia 

(including the Slovak Karst and Slanske Hills).

Serbia and Montenegro: Enzootic foci are located in northeastern Serbia around

Belgrade. Additional foci exit in west and southwest Serbia.

Slovenia: Slovenia has the highest risk of TBE in the former Republic of Yugoslavia.

Persistent enzootic foci exist in the hilly and mountainous regions, as well as the plains
98

of Slovenia. TBE antibody seroprevalences in endemic areas have exceeded 30%. 

Officially, 200 to 300 cases of TBE are reported per year despite an active immunization

program. Very few cases have been reported from the Adriatic Coast.

Transmission Cycle(s). Humans acquire infection from bites of infected ticks or by

crushing infected ticks on abraded skin. Infection can also be acquired from the

consumption of raw milk or unpasteurized milk products, usually from goats. Natural

infections have been recorded in 16 species of ixodid ticks. Ixodes ricinus is the primary

vector in Central Europe and also the primary reservoir of the virus. Up to 4% of I.

ricinus have been found infected with TBE virus in the Czech Republic. The virus

overwinters in infected ticks and is passed transstadially and transovarially. Important

vertebrate hosts that amplify the virus are hedgehogs, shrews, field mice and voles. Over 

20% of some Apodemus spp. and Clethrionomys spp. have been found with antibodies to

TBE virus in enzootic areas of Central Europe. Besides small mammals, in natural TBE

foci the most frequent hosts of immature ixodid ticks are birds, especially those species

that spend large amounts of time searching for food or nesting on the ground. Avian

hosts are not important as reservoirs of TBE virus, but migrating birds disperse vector

ticks over long distances. There are reports of illness and death in dogs, calves, lambs,

goats, wild birds and rodents after natural infection.

Vector Ecology Profiles. 

The principal vector of TBE in the region is Ixodes ricinus. This is a relatively small,

three-host tick that primarily inhabits moist, dense forest biotopes, where mice and voles

are abundant. Ixodes hexagonus, I. trianguliceps, Dermacentor marginatus,

D. reticulatus, Haemaphysalis concinna, H. punctata, and H. inermis are secondary

vectors, based on occasional isolations of TBE virus. Ixodes persulcatus may occur in a

few, circumscribed areas of Central Europe. Since this species is easily mistaken for I.

ricinus, its distribution in Central Europe is uncertain. In those areas where I.

persulcatus occurs, it is a primary vector of TBE. Its life cycle is similar to that of I.

ricinus and will not be further discussed. The bionomics of vector ticks in Central

Europe is summarized in Appendix B. The known distribution of ticks in Central Europe

is presented in Appendix A.3.

Ixodes ricinus occurs widely in upland forests (consisting primarily of oaks, hornbeams,

or mixtures of these two groups) and, to a lesser degree, in lowland areas (consisting of

beech, maple, alders and mixed shrubs). In southern parts of the region, this species

occurs at higher altitudes (up to 1500 m) than in northern areas of Central Europe. This

species also inhabits weedy pastures, hedgerows, and shady gardens. Populations of I.

ricinus can persist for many years in areas that have been urbanized, especially in parks

with populations of rodents, dogs and roe deer. It is not well adapted to desiccation and

may die in a matter of weeks if humidity falls below 50 percent. However, where

humidity is high, it can survive unfed for over two years. Ixodes ricinus feeds on a wide
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range of hosts (it has been collected from over 150 species), although small terrestrial

rodents (such as Apodemus flavicollis and Clethrionomys glareolus) are the most

common hosts of immature ticks and are considered essential reservoirs for TBE virus. 

Female ticks lay 100 to 2,700 eggs, depending on the degree of engorgement. Eggs

usually hatch in July and August. There are three active stages and each requires a

bloodmeal in order for development to proceed. Larvae and nymphs usually require one

to two years to complete development. Adults commonly feed on deer, foxes, rabbits,

hedgehogs, squirrels, cattle, goats and, occasionally, humans. Large domestic animals,

particularly sheep, are important in some areas in maintaining high populations of I.

ricinus. Mating occurs before feeding or while the female is still feeding on the host. 

Females die after oviposition is completed. The complete life cycle normally requires

three years in Central Europe. In marginal habitats the life cycle can last up to six years. 

All stages of this species, including eggs, can overwinter. Unmated females diapause

during winter and become active in the spring. However, females that have mated during

the summer do not diapause and exhibit peak activity in the autumn. Ticks are active

primarily from April to October, although in southern areas they may be collected from

March to December. Transovarial and transstadial transmission of TBE is extremely

efficient in this tick. 

Dermacentor marginatus is widely distributed in Central Europe and is found in a variety

of habitats, including lowland forests, marshes and shrubby areas. This is a three-host

tick. Larvae and nymphs feed on rodents, insectivores, hares or foxes, while adults feed

on cattle, sheep, deer, other herbivores and, occasionally, humans. While larvae and

nymphs are often active during the summer, adults frequently are inactive during this

season, especially in northern areas. Larvae and nymphs are moderately resistant to

desiccation and may live unfed for several months under dry conditions. Females that

have diapaused over the winter begin laying eggs in the spring. Up to 2,500 eggs may be

laid at this time. However, females that feed in late summer or early fall detach after

seven days of feeding and lay up to 6,200 eggs. The entire life cycle is normally

completed within one year. Occasionally, diapause may be spent on the host 

Transstadial and transovarial transmission of TBE virus occurs in this species, although

not as efficiently as in I. ricinus. 

Dermacentor reticulatus (= D. pictus) has a wide distribution in Central Europe,

including Croatia, Poland, Serbia and the Slovak Republic. It is found in mixed

deciduous forests, meadows, and humid habitats along rivers, especially the Danube. 

Larvae feed on mice, voles and hedgehogs. Larvae are most abundant in June and July,

while populations of nymphs peak in August and September. Adults feed on bear, sheep,

cattle and dogs. This species overwinters primarily in the adult stage; consequently,

adults are more abundant in the spring (April through May). The life cycle typically

requires one year for completion. Development may be slower in forests than in

meadows because of lower average temperatures in the forest environment. However,
100

survival rates are greater in forests than in meadows. Transstadial and transovarial

transmission is efficient in this species. Up to 28% of infected female ticks pass TBE

virus to their progeny. 

Haemaphysalis concinna is a small tick that inhabits meadows alternating with birchaspen clearings, areas of sparse shrubs along rivers and streams, and marshy areas

overgrown with sage or ferns. Adult females engorge for three to nine days on cattle,

sheep, goats and deer. They begin laying eggs 14 to 66 days after detaching from their

hosts. Larvae emerge 39 to 114 days after oviposition. Immature ticks feed on hares,

hedgehogs and rodents. Larvae engorge for two to four days, drop off the host, and molt

into nymphs 34 to 86 days after engorgement. Adults emerge from engorged nymphs 23

to 111 days after nymphs detach. Larval and nymphal stages are more abundant in late

summer and autumn. Nymphs that emerge late in the year may go into diapause and

molt to adults the following spring; consequently, adults are more common between

April and June. Active adults can be collected through the summer and into October. In

most cases the life cycle can be completed in one year, although development may

require up to three years. Transstadial and transovarial transmission of TBE virus occurs,

but not as efficiently as in I. ricinus. 

Haemaphysalis inermis is a three-host tick that is sparsely distributed in Central Europe. 

Larvae feed on shrews, hedgehogs and small rodents. Larval ticks feed only a few hours

before detaching from their hosts. The adult stage is large and may reach up to 10 to 12

mm in length. Adults feed on deer, cattle, foxes and goats. Adults take large blood

meals over several days but produce only about 200 large eggs. TBE virus is

transstadially passed in this tick, and transovarial transmission probably occurs as well.

Haemaphysalis punctata occurs widely, but very focally, in submediterranean biotopes.

This tick is moderately resistant to aridity and inhabits shrubby growth, forests or

pastures. It is most abundant in areas of pubescent oak and dwarf shrub heath. This

species has been reported in Bulgaria, the Slovak Republic, Greece and Serbia, and

probably occurs in other countries of Central Europe. Haemaphysalis punctata is also a

three-host tick. Immature stages quest passively in grassy areas and feed on birds, voles

and hares. Larvae are most abundant in July and August, while nymphs are more

abundant from July to October. Adults feed on the same range of hosts as D. marginatus

(sheep, cattle, dogs, goats, deer, and humans), often attaching in the groin or neck area. 

This tick is frequently found in association with D. marginatus and D. reticulatus. 

Adults overwinter, become active in March and April, and begin oviposition in May and

June. However, immature stages may also overwinter. Transovarial transmission of

TBE virus is believed to occur but has not been conclusively demonstrated.

Ixodes hexagonus is a relatively large species, sometimes reaching dimensions of 1.1 by

0.7 cm when engorged. This three-host tick inhabits lowland and hilly areas below 
101

1,000 m. It frequently occurs in caves, dens and pits, where its hosts normally are found. 

Both larval and nymphal stages feed for three to seven days. All stages commonly infest

hedgehogs, foxes, martens, wolves, wild cats and dogs. Occasionally, this species infests

badgers, domestic cats and cattle. Ixodes hexagonus is a very important zoonotic vector,

but humans are reportedly not attacked. Females mate, complete engorgement, and begin

laying eggs within two weeks of fertilization. Eggs hatch in about four weeks, and the

entire life cycle may take as little as four months in Slovenia but is generally much

longer in cooler climates, requiring at least one full year. Transstadial transmission of

TBE has been demonstrated in this species. 

Ixodes trianguliceps is a common tick in grassy hills and forested mountains along the

Adriatic coast and in Serbia between 500 and 2000 m. It also occurs at lower densities in

Bulgaria, the Slovak Republic and, probably, adjacent countries. It is very resistant to

cold temperatures. In all stages, this three-host tick feeds mainly on small mammals,

such as Apodemus spp., moles, voles and shrews. It does not feed on humans and is

considered a zoonotic vector of TBE virus. Larvae occur from February to December,

with a peak of activity in October. Nymphs and adults occur sequentially from April

through October. Development can take place within a one-year period, although in

colder regions it is likely to take longer. 

Vector Surveillance and Suppression. Surveillance techniques for ixodid ticks are

discussed in TIM 26, Tick-Borne Diseases: Vector Surveillance and Control, and under

Lyme disease. Control of I. ricinus over large areas with acaricides is impractical and

environmentally unacceptable. In areas where viral transmission is endemic, personal

protective measures must be used. Regular inspection to remove ticks should be

performed as often as practical. Military personnel should not consume local dairy

products. 

A formalin-inactivated cell culture vaccine has been widely used in European countries

for many years with few side effects. A full course of vaccination includes three primary

doses, with a booster six to 12 months later. Vaccine efficacy approaches 97%; however,

the FDA has not approved a vaccine for TBE. The vaccine can be administered to U.S.

personnel only under an investigational new drug (IND) protocol. To protect US military

forces deployed to Bosnia in early 1996 as part of Operation Joint Endeavor, an

inactivated, parenteral vaccine produced in Austria was offered on a volunteer basis to

soldiers at high risk of exposure to TBE.

H. Crimean-Congo Hemorrhagic Fever. 

Crimean-Congo Hemorrhagic Fever (CCHF) is a zoonotic disease caused by a tick-borne

virus of the family Bunyaviridae. The disease is characterized by febrile illness with

headache, muscle pain and rash, frequently followed by a hemorrhagic state with

hepatitis. The mortality rate can exceed 30%. The incubation period ranges from three
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to 10 days. CCHF may be clinically confused with other hemorrhagic infectious

diseases.

Military Impact and Historical Perspective. Descriptions of a disease compatible with

CCHF can be traced back to antiquity in eastern Europe and Asia. CCHF was first

described in soldiers and peasants bitten by ticks of the genus Hyalomma while working

and sleeping outdoors on the Crimean peninsula in 1944. The virus was first isolated in

1967. Since there are no available treatment regimens of proven value and recovery from

CCHF can be protracted, military personnel with CCHF would require significant

medical resources. 

Disease Distribution. CCHF virus has the widest geographic distribution of any tickborne virus. It is enzootic in the steppe, savanna, semi-desert and foothill environments

of eastern and central Europe, Russia, parts of Asia, and throughout Africa. These are

favored habitats of xerophilous Hyalomma ticks. In the deciduous forests of Moldavia,

Ixodes ricinus, Dermacentor and Rhipicephalus species have replaced hyalommine

species due to changing practices of handling cattle herds. 

Several Eurasian CCHF epidemics have taken a great toll of human life. In recent years,

cases of CCHF have tended to be sporadic, with most reported from Bulgaria and South

Africa. Bulgaria recorded 1410 cases, primarily in agricultural workers, between 1953

and 1992. However, CCHF is underdiagnosed in many countries due to lack of

appropriate medical and laboratory services. CCHF virus is likely enzootic in widely

distributed discrete foci in agricultural areas throughout Central Europe. Vector ticks are

common on domestic animals throughout the region. Movement of domestic animals

between countries in the region is common and can easily spread the disease. The

prevalence of human antibodies to CCHF virus in most rural areas of Central Europe

ranges from 0.1 to 3%, although studies conducted in the mid-1980s revealed that up to

12% of inhabitants were seropositive in some enzootic areas of the former Republic of

Yugoslavia. An outbreak affecting 55 people occurred in the Kosovo and Montenegro

areas of Serbia in 1995. The risk of transmission is highest from April through

September. 

Transmission Cycle(s). CCHF virus has been isolated from at least 30 species of ticks. 

From experimental evidence, it appears that many tick species are capable of transmitting

the virus, but members of the genus Hyalomma are the most efficient vectors. The

aggressive host-seeking behavior of adult hyalommine ticks makes them ideal vectors. 

The highest prevalence of antibodies in wild and domestic reservoirs has been found in

many areas where Hyalomma ticks are common. Antibodies to CCHF virus are

widespread in hares and large wild and domestic herbivores in Central Europe. Domestic

ruminants generally acquire infection early in life. Viremia in livestock is short-lived

and of low intensity. Antibodies or virus have also been found in a variety of small
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mammals, including hedgehogs and rodents. Infected wild and domestic animals show

no serious signs of disease. Transovarial transmission of virus in vector ticks is an

important reservoir mechanism. The wide range of tick species from which CCHF virus

has been isolated, the diversity of life cycles and habitats of these ticks, and the uncertain

involvement of various vertebrates have contributed to a poor understanding of the

complex transmission and maintenance cycles of CCHF. 

Persons occupationally exposed to domestic animals, such as animal husbandry and

abattoir workers, have the greatest risk of infection. Humans acquire CCHF virus from

tick bites, from contamination of broken skin or mucous membranes with crushed tissues

or feces of infected ticks, or from contact with blood or other tissues of infected animals. 

CCHF virus is highly infectious, and nosocomial infection of medical workers has been

important in many outbreaks.

CCHF virus loses infectivity shortly after the death of an infected host. There is no

indication that consumption of meat processed according to normal health regulations

constitutes a hazard.

Vector Ecology Profiles. 

Hyalomma marginatum marginatum is the principal vector in Bulgaria, Albania and the

former Yugoslavia. Other vector species that act as secondary or enzootic vectors

include Boophilus annulatus, Dermacentor marginatus, Haemaphysalis punctata, Ixodes

ricinus, and Rhipicephalus bursa.

Hyalomma m. marginatum inhabits upland woods and meadows in the Sredna Gora hills,

Bulgaria, at altitudes of 340 to 550 m. In Bulgaria, this two-host tick primarily attacks

horses and cattle. It begins feeding on cattle in March, and tick populations increase

through July but then decline precipitously. This species also inhabits cattle-ranching

areas of the former Yugoslav republics, with rolling, hilly terrain from 600 to 800 m. 

This is one of the hardiest, most cold-resistant ticks in the world and can survive arid

conditions as well. Immature stages quest actively from rodent burrows or grasses and

feed primarily on small mammals (rodents, hedgehogs and hares) and birds (chiefly

rooks and magpies). Nymphs feed from five to eight days before dropping off their

hosts. After molting, adult ticks await their next host by questing from tall grasses, often

in pastures. In addition to cattle and horses, adults feed on goats, dogs, sheep and,

occasionally, humans. After feeding for 4 to 6 days, adult females drop off their hosts

and oviposit several thousand eggs. Under ideal conditions, the life cycle can be

completed in a single year, although adults often overwinter and begin laying eggs in the

spring. Under adverse conditions, the life cycle can be extended for two or more years. 

Transovarial and transstadial transmission of CCHF virus occur in this species, although

migratory birds are believed to re-introduce infected ticks each year throughout the

region. 
104

Boophilus annulatus is a one-host tick that feeds primarily on cattle and only

occasionally feeds on deer, horses and man. After feeding and mating on the host,

females drop to the ground and rest for up to a month before laying eggs. The female

dies after depositing 2,000 to 4,000 eggs over an eight to nine day period. The life cycle

typically requires less than one year but may be prolonged under adverse conditions. 

Under favorable conditions, larvae hatch after three to seven weeks and actively quest for

new hosts from the tips of grasses, often in pastures. This species is considered a

marginal, enzootic vector of CCHF virus. 

Dermacentor marginatus has been reported as a vector in Bulgaria and Moldavia in

Romania. Ixodes ricinus has been reported as a vector in Bulgaria, the former Yugoslav

republics and Moldavia, Romania. Transstadial and transovarial transmission are known

to occur in this species. Rhipicephalus bursa has been reported as a vector in Bulgaria

and Greece. Boophilus annulatus and R. sanguineus have been reported as vectors in

Bulgaria. Haemaphysalis punctata has been reported as a vector in Bulgaria and

Moldavia, Romania. 

The vector ecologies of D. marginatus, I. ricinus, and H. punctata are described under

tick-borne encephalitis. The vector ecology of R. bursa can be found under Lyme

disease. Information on these and other tick vectors is summarized in Appendix B. 

Appendix A.3 lists the distribution of ticks in Central Europe. 

Vector Surveillance and Suppression. Military personnel should conscientiously use

personal protective measures to prevent tick bites (see TIM 36). Frequent selfexamination and removal of ticks are important. Ticks should be handled as little as

possible and not crushed. Troops should not sleep, rest or work near rodent burrows,

huts, abandoned rural homes, and livestock or livestock enclosures. Close contact with

livestock and exposure to locally butchered animals should be avoided. 

An inactivated mouse-brain vaccine against CCHF has been used in eastern Europe and

the former Soviet Union. The FDA has not approved a vaccine for human use. A

purified modern vaccine will probably not be developed in view of the limited potential

demand.

I. Boutonneuse Fever. (Mediterranean tick fever, Mediterranean spotted fever,

Marseilles fever, African tick typhus, Kenya tick typhus, India tick typhus) 

This tick-borne typhus is a mild to severe illness lasting a few days to two weeks. 

Clinical symptoms begin 6 to 10 days after the bite of an infected tick and include fever,

headache and muscle pain. Boutonneuse fever is caused by Rickettsia conorii and

closely related rickettsial organisms. Different strains of R. conorii isolated from ticks

and humans indicate that this pathogen has substantial genetic and antigenic diversity. 

Rickettsia slovaca is a related pathogen found in Central Europe that causes the same
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clinical disease. The common name of this disease comes from the button-like lesions,

two to five mm in diameter, that develop at tick attachment sites. With antibiotic

treatment, fever lasts no more than two days. The case fatality rate is usually very low,

even without treatment.

Military Impact and Historical Perspective. Historically, boutonneuse fever has not

significantly interfered with military operations. Sporadic cases among combat troops

can be expected in limited geographic areas. The severity of illness will be dependent

upon the strain of R. conorii contracted. Because the spotted fevers are regional diseases,

military medical personnel newly assigned to an area may be unfamiliar with them and

diagnosis may be delayed. 

Disease Distribution. Boutonneuse fever is widespread in countries bordering the

Mediterranean, and most countries of Africa. Along the European Mediterranean coast,

the seroprevalence of boutonneuse fever varies from 4.2 to 45.3%, depending on the

geographical region. Expansion of the European endemic zone to the north is occurring 

because North European tourists vacation along the Mediterranean with their dogs, which

acquire infected ticks and are then brought home.

Boutonneuse fever is focally enzootic throughout Central Europe but is more prevalent

along coastal areas. Rickettsia conorii appears to be the more common and widespread

pathogen, particularly in coastal areas of the region, while R. slovaca is more common in

inland areas, especially Hungary, the Slovak Republic and the Czech Republic. The

incidence of boutonneuse fever appears to be increasing in the Mediterranean basin,

including the Adriatic coast of Croatia. Studies in the early 1990s found that antibodies

to R. conorii were present in 5% of the inhabitants living in coastal areas of Dalmatia,

and in 62.4% of the dogs surveyed form southern coastal Croatia. A significantly higher

seroprevalence (69.9%) was found in dogs from suburban or semirural areas than in dogs

from urban areas of Croatia (20.7%). A 1996 study of rodents collected from localities in

southwestern and south-central Slovenia found a seroprevalence of 70 to 90% in the

house mouse, Mus musculus, and the field mouse, Apodemus agrarius. The disease is

enzootic in the Black Sea coastal areas of Bulgaria and Romania and the coastal regions

of Serbia and Greece. However, a seroprevalence of over 40% was found among

inhabitants of rural villages in central Greece during 1991. Few medical reports are

available for Albania. 

Transmission cycle(s). The disease is maintained in nature by transovarial passage of

rickettsiae in ticks, primarily the brown dog tick, R. sanguineus, although almost any

ixodid tick may harbor the pathogen. Enzootic infection in dogs, rodents, hares and other

animals is usually subclinical. Transmission to humans is by bite of infected ticks. 

Contamination of breaks in the skin, mucous membranes, or eyes with crushed tissues or
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feces of infected ticks can also lead to infection. Close association with domestic dogs in

endemic areas is a risk factor for boutonneuse fever. 

Vector Ecology Profiles.

Rhipicephalus sanguineus, the brown dog tick, is the primary vector, as well as reservoir,

of R. conorii. This species is widespread throughout the region, probably occurring in

every country. Probable zoonotic vectors include Ixodes hexagonus and the flea

Archeopsylla erinacei. These zoonotic vectors frequently feed on hedgehogs and rabbits. 

All stages of ticks, including eggs, can be infected with rickettsiae, indicating that

transmission occurs both transstadially and transovarially. The primary vectors of R.

slovaca include Dermacentor marginatus, Ixodes ricinus, and Haemaphysalis punctata,

the larvae and nymphs of which infest small rodents. Possible secondary vectors include

Dermacentor reticulatus and Haemaphysalis inermis. Vector ecology profiles of D.

marginatus, D. reticulatus, H. inermis, H. punctata, and I. ricinus are presented under the

section on tick-borne encephalitis. Appendix A.3 lists the known distribution of ticks in

Central Europe.

Rhipicephalus sanguineus is a three-host tick, with larval, nymphal and adult stages

preferring to feed primarily on dogs and occasionally on humans. Larvae and nymphs of

R. sanguineus spend three to six days feeding on hosts, then drop off to molt. Males feed

on hosts for three to five days but do not produce sperm until after engorgement. After

mating on the host animal, the female feeds for seven to 15 days, then drops off the host

to lay eggs. Females of this species lay hundreds of eggs, generally in the dens of host

animals, particularly canines. Eggs may require 10 to 20 days to hatch. Adult R.

sanguineus are passive in their host-questing activity, rarely moving more than two

meters to find a host. This species requires a humid microhabitat, which can be found in

the dens of its hosts even if the area is arid. The entire life cycle may require up to two

years to complete, although one year is usually sufficient. Larval and nymphal stages

may survive months without a host.

Archaeopsylla erinacei is the only flea that is involved in the zoonotic cycle of this group

of diseases. This species has been reported from the Czech Republic, the Slovak

Republic and Greece, although it undoubtedly occurs in adjacent countries as well.

Archaeopsylla erinacei normally parasitizes hedgehogs, foxes, dogs, martens and

polecats, and only occasionally bites humans. Eggs are laid in the nesting material or

dens of the hosts. Newly hatched larvae feed on dried blood, feces, dander and other

organic debris occurring in the nest. The duration and number of larval stages can be

highly variable, depending on temperature. Pupation occurs in the same den or nesting

area inhabited by larvae. Adults emerge a short time later (usually several days),

depending on temperature and the presence of hosts. The entire life cycle may be

completed in a matter of weeks under favorable conditions. 
107

Vector Surveillance and Suppression. Personal protective measures (see TIM 36)

afford the best protection against boutonneuse fever. In endemic areas domestic dogs are

commonly infested with the brown dog tick. Troops should not be allowed to feed,

befriend or adopt local dogs as pets. 

 

J. Rickettsialpox. (Vesicular rickettiosis)

Rickettsialpox is an acute febrile illness transmitted by mites. The disease is caused by

Rickettsia akari, a member of the spotted fever group of rickettsiae. The mite bite is

painless and a skin lesion or eschar develops at the bite site within 24 to 48 hours. There

is a seven to 12 day incubation period followed by fever, malaise, headache and muscle

pain. A vesicular rash of 20 to 100 papules (two to 10 mm in diameter) appears on the

face, trunk and extremities. The palms and soles are not affected. The rash disappears in

a few days without scarring. Untreated cases recover seven to 10 days after onset of

symptoms, and death is rare. Human to human transmission does not occur.

Military Impact and Historical Perspective. The disease was recognized in New York

City in 1946, but outbreaks have been reported from Russia, Ukraine, South Korea,

South Africa and equatorial Africa. Rickettsialpox is typically a mild disease that is

easily treated with antibiotics. Most infections have occurred in crowded urban areas

with large rodent populations. It is unlikely to affect military operations, but epidemics

in civilian or refugee populations are likely when living standards are degraded by war. 

The disease may be clinically confused with chickenpox or spotted fever.

Disease Distribution. Rickettsia akari was isolated in Croatia in 1991. This was the

first report of rickettsialpox in Central Europe in 40 years. The disease has the potential

to spread and remain endemic in populations living under crowded, unsanitary conditions

in parts of the former Republic of Yugoslavia destroyed by civil war.

Transmission cycle(s). Infection with R. akari is spread through the bite of the housemouse mite, Liponyssoides sanguineus (formerly called Allodermanyssus sanguineus). 

Experimental transmission of R. akari by the tropical rat mite, Ornithonyssus bacoti, has

been demonstrated, and this species may act as a secondary vector. Transovarial passage

of rickettsiae occurs, implicating the vector as a reservoir. 

Vector Ecology Profile. Although the house mouse, Mus musculus, is the preferred

host, L. sanguineus has been collected from other commensal rodents and small wild

mammals, including the Korean vole, Microtus fortis, and jirds, Meriones spp. The mite

is a nest-dweller and leaves the host after feeding. Larvae do not feed, so transmission is

by feeding nymphs and adults of both sexes. Mites can be found in nesting materials, or

crawling along rodent runways, or on the ceilings and walls of heavily infested buildings. 

Development from egg to adult requires two to three weeks. Unfed females have been

observed to live up to 50 days.
108

Vector Surveillance and Suppression. Humans appear to be accidental hosts and are

more likely to be attacked when murine hosts are scarce or suddenly reduced by rodent

control programs. Disease outbreaks are prevented or controlled by rodent elimination in

conjunction with mite control. Nesting materials should be destroyed and rodent

harborages treated with a residual insecticide. Mites can be collected from debris and

nesting material with a Berlese funnel. 

 

K. Q Fever. (Query fever)

This is an acute, self-limiting, febrile rickettsial disease caused by Coxiella burnetii.

Onset may be sudden with chills, headache and weakness. Pneumonia is the most serious

complication. There is considerable variation in severity and duration of illness. 

Infections may be inapparent or present as a nonspecific fever of unknown origin. Acute

Q fever is self-limited and the case fatality rate in untreated acute cases is usually less

than 1%. Chronic Q fever is a serious and often fatal illness with high mortality rates. 

Illness occurs months to years after the acute infection, and endocarditis occurs in up to

10% of patients.

Military Impact and Historical Perspective. Coxiella burnetii was originally described

from Australia in 1937. In ensuing years, C. burnetii was found to have a worldwide

distribution and a complex ecology and epidemiology. Q fever first appeared among

Allied troops in 1944 and 1945, when several sharp outbreaks occurred in the

Mediterranean Theater. The disease was not recognized immediately because this

rickettsial pathogen had been reported as occurring naturally in humans only in

Queensland, Australia. The need to consider Q fever in the differential diagnosis of

primary atypical pneumonia was recognized during this period, but it took several years

for this knowledge to become widespread in field military medicine. The British Army

in the Mediterranean area experienced several localized epidemics of atypical pneumonia

characterized by a high attack rate, up to 50% of some units. This was probably Q fever,

but no serological proof was ever obtained. Three cases of Q fever were recorded in US

military personnel during the Persian Gulf War. 

Disease Distribution. Coxiella burnetii has been reported from at least 51 countries. 

Incidence is greater than reported because of the mildness of many cases. Q fever is

enzootic throughout Central Europe, with most countries reporting sporadic isolated

cases and occasional epidemics. The disease is highly enzootic in western Poland. In

1988 an epidemic was detected in the Leszno district, and 34% of 4,264 animal workers

tested positive for C. burnetii antibodies. On one farm, 32% of the cattle were

seropositive, as were 68% of workers in direct contact with infected animals and 29% of

persons drinking raw milk. Coxiella burnetii was isolated from ticks, wild mammals and

birds in close proximity to the farm. From 1992 to 1994, three additional outbreaks

occurred in different regions of Poland.
109

From 1982 to 1985, 725 cases of Q fever were reported near the town of Knezha,

Bulgaria. Romania recorded 134 sporadic cases of Q fever from 1981 to 1987. 

Seroprevalence to C. burnetii in the early 1990s varied from 1.1% of blood donors in

Strakonice and Novy Jicn districts of the Czech Republic to 19% of blood donors in

northwestern Croatia. Over 10% of sheep in enzootic areas of Slovenia were seropositive

in 1996. 

The epidemiology of Q fever has changed in many Central European countries as a result

of dramatic political and economic shifts in the early 1990s. In Bulgaria, the large state

cooperative farms collapsed and the number of cattle and sheep decreased. Individuals

began raising goats, and the consumption of raw goat milk and its products increased. 

Goats thus replaced cattle and sheep as the main source of human C. burnetii infections. 

Hundreds of cases of Q fever were reported from Bulgaria during the 1990s, including

chronic forms of Q fever with endocarditis. Goats are a threat to human health in every

Central European country where they are raised extensively. 

Since the 1980s, only sporadic cases of Q fever have been reported from different parts

of Slovakia. Better preventive measures, including control of animal movement,

veterinary surveillance, and vaccination of domestic animals, have prevented Q fever

from being a serious public health problem. Recent studies indicate that the strains of 

C. burnetii circulating among cattle in the Czech Republic and the Slovak Republic have

a low virulence in humans.

Vector Ecology Profiles. Several species of ixodid ticks transmit C. burnetii to animals

but are not an important source of human infection. Coxiella burnetii has been isolated

from Ixodes ricinus, Dermacentor reticulatus, D. marginatus, Haemaphysalis concinna,

H. punctata and H. inermis in enzootic areas of Central Europe.

Transmission Cycle(s). In nature there are two cycles of infection with C. burnetii. One

involves arthropods, especially ticks, and a variety of wild vertebrates. The most

important reservoirs are small wild rodents, but infection has also been demonstrated in

insectivores, lagomorphs, carnivores, ungulates, marsupials, monkeys, bats, birds and

even reptiles. The other cycle is maintained among domestic animals. Although humans

are rarely if ever infected by ticks, arthropods may transmit infection to domestic

animals, especially sheep and cattle. Domestic animals have inapparent infections but

shed large quantities of infectious organisms in their urine, milk, feces, and especially

their placental products. Because C. burnetii is highly resistant to desiccation, light and

extremes of temperature, infectious organisms become aerosolized, causing widespread

outbreaks in humans and other animals, often at a great distance from the place of origin. 

Dust in sheep or cattle sheds may become heavily contaminated. Once established,

animal-to-animal spread of C. burnetii is maintained primarily through airborne

transmission. Outbreaks of Q fever in humans have been traced to consumption of
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infected dairy products and contact with contaminated wool or hides, infected straw, and

infected animal feces. Coxiella burnetii may enter through minor abrasions of the skin or

the mucous membranes. Although rare, human-to-human transmission of Q fever has

occurred.

Vector Surveillance and Suppression. A satisfactory vaccine has not been developed,

and human vaccination has been hampered by the high rate of adverse reactions. 

Measures to identify and decontaminate infected areas and to vaccinate domestic animals

are difficult, expensive and impractical. Military personnel should avoid consumption of

local dairy products and contact with domestic animals, hides, or carcasses. During the

Persian Gulf War, troops were frequently exposed to domestic animals and carrion. 

Soldiers should not rest, sleep, or work in animal sheds or other areas where livestock

have been housed.

L. Tularemia. (rabbit fever, deer fly fever, Ohara disease, Francis disease)

Tularemia is caused by the bacterium Francisella (formerly Pasteurella) tularensis. 

Two biovars with differing pathogenicity cause human disease. Jellison type A, or F.

tularensis biovar tularensis, is more virulent. It can produce an untreated case-fatality

rate of five to 15% from pulmonary disease or symptoms similar to typhoid. Jellison

type B, or F. tularensis biovar palaearctica, is less virulent, and even without treatment

produces few fatalities. Tularemia may be clinically confused with typhoid fever, plague

and other infectious diseases.

Clinical manifestations vary according to the route of infection and the pathogenicity of

the bacterial strain. Usually infection produces an ulcer or papule at the site of

inoculation, with swelling of the regional lymph nodes. Early symptoms include fever,

headache, abdominal pain, cough and vomiting. Ingestion of organisms in contaminated

food or water may produce a painful pharyngitis, vomiting and diarrhea. Inhalation of

infectious material may be followed by severe pulmonary disease. Tularemia is easily

treated with antibiotics. Long-term immunity follows recovery, though reinfection has

been reported.

Military Impact and Historical Perspective. The impact of tularemia on military

operations would be minimal. Sporadic cases should be expected, but tularemia can be

epidemic when water or food supplies are contaminated.

Disease Distribution. Tularemia is focally distributed throughout Central Europe. From

1985 to 1994, 126 cases of tularemia were reported from western Slovakia, which has

been an endemic area for several decades. In April 2000, 231confirmed cases of

tularemia occurred in Kosovo, with most cases in the western area. The majority of cases

occur during the summer, primarily in occupationally exposed persons like foresters. In

Central Europe, tularemia has historically been caused by strains of F. tularensis that
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produce clinically mild disease. The first isolations of F. tularensis biovar tularensis in

Europe were reported from Slovakia in 1998. These findings significantly increased the

public health importance of tularemia in the region.

Transmission Cycles. The epidemiology of tularemia varies markedly in different

geographic regions. Francisella tularensis has been isolated from over 100 kinds of

wildlife and domestic animals and from the natural waters frequented by reservoir hosts

such as the water vole, Arvicola terrestris, and muskrats. Infection among rodent species

varies from asymptomatic disease to rapid death of an entire colony. The European

brown hare, Lepus europaeus, is a very good indicator of the presence of tularemia and

has been used routinely for the surveillance of this zoonosis in Central Europe.

The primary mode of transmission in the region is by direct contact of the skin or

conjunctivae with infected blood or tissues from hares and rodents. Other important

routes of infection include ingestion of contaminated food or water and inhalation of soil,

grain, hay or other agricultural products contaminated with the excreta of infected

animals. Rabbit meat frozen at -15°C has remained infective more than three years.

Francisella tularensis has been isolated from at least 60 species of ticks, mites, fleas,

deer flies and mosquitoes. Transovarial and transstadial transmission have been

demonstrated in ixodid ticks. Although tick-borne transmission is common in North

America, tick-borne cases have historically been infrequent in Central Europe. However,

recent studies in Slovakia indicate that tick-borne transmission of tularemia is rapidly

becoming more common. Other methods of acquiring the disease include direct

inoculation into the skin from an infected animal bite or scratch. A high percentage of

farm dogs and free-ranging dogs in Slovakia have been infected with F. tularensis. 

Laboratory infections are common. Under normal circumstances, person-to-person

transmission does not occur, although congenital infection has been reported. 

Vector Ecology Profiles.

Early isolates of the pathogen, Francisella tularensis, were made from Dermacentor

reticulatus and Ixodes ricinus in the Czech Republic and Croatia. These ticks transmit

the disease to hares, which are the primary zoonotic hosts of the disease. Other hosts for

these ticks and the pathogen include several species of field mice and voles. Strains of

Francisella tularensis have also been isolated from Dermacentor marginatus and Ixodes

trianguliceps in the Czech Republic and from Haemaphysalis concinna collected in the

western part of Slovakia. The bionomics and distribution of these vector species are

discussed under tick-borne encephalitis and summarized in Appendix B. The known

distribution of ticks in Central Europe appears in Appendix A.3. 

Vector Surveillance and Suppression. Area vector control is not necessary. The

permethrin-impregnated uniform is very effective against crawling arthropods like ticks. 
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Military personnel should not handle rodents and should avoid rodent secretions. Wild

rabbits and hares should not be hunted for food. Natural foci of the disease appear to be

stable and are unlikely to be eradicated. Live attenuated vaccines have been used

extensively in the former Soviet Union and to a limited extent in the US for occupational

risk groups, such as laboratory workers. Chemoprophylaxis is not recommended. 

M. Relapsing Fever (tick-borne). (Endemic relapsing fever, cave fever)

This is a systemic spirochetal disease characterized by periods of fever alternating with

afebrile periods. The number of relapses varies from one to 10 or more. The severity of

illness decreases with each relapse. The duration of tick-borne relapsing fever is usually

longer than the closely related louse-borne relapsing fever. A number of species of

Borrelia are responsible for the disease. The taxonomy of the pathogen is complex. The

close vector-spirochete relationship has led to the definition of most spirochete species

by their tick vectors. There is great strain variation among tick-borne Borrelia, and a

single strain can give rise to many serotypes. 

Military Impact and Historical Perspective. Although clinical symptoms of tickborne relapsing fever can be severe, impact on military personnel would be minimal due

to low incidence of the disease.

Disease Distribution. Tick-borne relapsing fever is focally enzootic throughout Central

Europe, but only sporadic human cases are reported. Transmission is most likely to

occur from April through November. Vector ticks commonly infest caves, bunkers and

tombs. 

Transmission Cycle(s). Argasid (soft) ticks of the genus Ornithodoros transmit tickborne relapsing fever. Infection is transmitted from human to human, animal to animal,

or from animal to human by the bite of infective ticks. Rodents are sources of infection

for ticks, although ticks are more important as a long-term reservoir. In some tick

species, the pathogen has been maintained naturally for years by transovarial

transmission. The rate of transovarial transmission varies greatly among tick species. 

Ticks of both sexes and all active stages transmit the pathogen by bite or by infectious

fluids exuded from pores in the basal leg segments. Spirochetes can pass into bite

wounds or penetrate unbroken skin. Exposure to infected blood of patients can cause

infections in medical personnel.

Vector Ecology Profiles. 

Ornithodoros spp. ticks are the vectors of tick-borne relapsing fever in Central Europe. 

In addition to their role in the transmission of relapsing fever, this genus is important

because it includes several species that inflict painful bites, some of which can produce

local or systemic reactions in humans.
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Most Ornithodoros ticks inhabit restricted habitats, such as rock outcroppings, caves,

dens, burrows, nests and other sheltered habitats. Some species are parasitic on livestock

and are found in stables and places where host animals rest. Adult Ornithodoros spp. 

feed at night, usually for only one to two hours. Males are slightly smaller than females

but similar in appearance. Larvae may remain attached to their hosts for protracted

periods of several days. Subsequent nymphal stages are active and require blood meals

in order to develop. Engorgement is rapid, and nymphs drop off their hosts after feeding

for brief periods. Nymphs and adults of some species feed quickly and painlessly, so

their bites may go undetected by the human host until well after the tick has detached. 

After a variable number of molts (generally four to five), adults emerge and mate. In

contrast to ixodid (hard) ticks, female Ornithodoros do not die after oviposition. Females

may live many years without a bloodmeal, but blood is required for egg development. 

Over the life span of the female, the number of eggs deposited may total several hundred,

with up to eight batches of eggs produced. A list of tick species and their distribution

appears in Appendix A.3.

Vector Surveillance and Suppression. Argasid ticks like Ornithodoros are found in the

restricted habitats of their hosts and rarely move very far. They occupy loose, dried soil

of dwellings, cracks and crevices in mud-walled animal shelters, animal burrows and

resting places, and the undersides of tree bark. They can be collected by passing soil

through a metal sieve or by blowing a flushing agent into cracks and crevices and other

hiding places. Some species are attracted by carbon dioxide, and dry ice can be used in

the collection of burrow-dwelling ticks. Ornithodoros ticks also fluoresce under

ultraviolet light. There is little seasonal fluctuation in numbers of argasids since their

microhabitats are relatively stable. Personal protective measures (see TIM 36) are the

most important means of preventing bites and diseases transmitted by soft ticks. Tents

and bedding can be treated with the repellent permethrin. Encampments should not be

established in areas infested with Ornithodoros ticks. Troops should avoid using

indigenous shelters, caves, or old bunkers for bivouac sites or recreational purposes.

Control of small mammals around cantonments can eliminate potential vector hosts. 

Rodent-proofing structures to prevent colonization by rodents and their ectoparasites is

an important preventive measure. Limited area application of appropriate acaricides,

especially in rodent burrows, can reduce soft tick populations. Medical personnel may

elect to administer antibiotic chemoprophylaxis after exposure to tick bites when risk of

acquiring infection is high. See Appendix F for personal protective measures.

N. Bhanja Virus.

Bhanja viral infection is a tick-borne disease appearing as a simple febrile illness or with

symptoms of meningitis. This pathogen is an unclassified virus in the family

Bunyaviridae.
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Military Impact and Historical Perspective. Bhanja virus was first isolated in 1954

from Haemaphysalis ticks collected on goats in India. It is unlikely to have a significant

military impact due to the high percentage of asymptomatic infections and the mild

nature of the clinical disease. Over 60% of the residents of some villages of Brac Island, 

off the Adriatic coast of Croatia, have antibodies to Bhanja virus, but no outbreaks of

febrile illness in the human population of Brac have been recorded.

Disease Distribution. Bhanja virus has been isolated from at least 15 countries of Asia,

Africa and Europe, and serological evidence indicates it may be present in at least 15

additional countries. Natural foci of the virus occur in the steppe or forest-steppe zones

of Central Asia and Europe. Bhanja virus has been isolated from Croatia’s Brac Island,

Bulgaria, the Czech and Slovak Republics, Romania, Serbia, and along the border

between Slovenia and Italy. Serological evidence indicates that the virus is also

circulating in other Central European countries. Over 90% of some goat and sheep herds

in Slovakia and Bulgaria have tested positive for antibodies to Bhanja virus. Serological

surveys indicate that the highest endemicity is along the Adriatic coast.

Transmission cycles. Isolation of Bhanja virus from mammals is rare. Antibodies to

Bhanja virus are common in domestic animals and have occasionally been found in

rodents and birds. A characteristic feature common to all natural foci of the virus is

intense pasturage of cattle, sheep or goats and abundant ticks of the genera Dermacentor

and Haemaphysalis. Serological evidence indicates that sheep play a major role in the

maintenance of the virus in Central Europe. 

In Central Europe, Bhanja virus has been isolated most often from Dermacentor

marginatus and Haemaphysalis punctata. The virus has also been isolated from

Haemaphysalis sulcata in Bulgaria and an unidentified Dermacentor species in Romania. 

The immature stages of these species may acquire their infections from small mammals;

adult ticks then transmit the virus to domestic animals.

Haemaphysalis sulcata inhabits submediterranean biotopes (both mountainous and high

plateau terrain) that encompass semi-arid or scrubby areas. At lower elevations this

species has been collected in vegetation ranging from thermophilic oak forests to beech

and pines. It has been reported from Greece, Croatia, Bulgaria and Serbia, and probably

occurs in adjacent countries. It is a small tick that feeds on hares, rodents and even small

lizards in its immature stages. The adult stage feeds primarily on goats, sheep and deer. 

Adults are abundant in fall and winter and are active the following February and March. 

They feed on their hosts for 10 to 13 days before dropping off to lay eggs. Larvae hatch

in the spring and feed for three to17 days before dropping off the host and molting into

nymphs, which are most abundant from June through August. Adults emerge from

engorged nymphs in the autumn. Larvae and nymphs that emerge too late in the autumn

to find a host may enter diapause and molt into adults the following spring. All stages
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can overwinter, although most often it is the adult stage that does so. The entire life

cycle is usually completed in one year. Vector ecology profiles for H. punctata and 

D. marginatus appear under tick-borne encephalitis. 

Vector Surveillance and Suppression. Personal protective measures (see TIM 36)

afford the best protection against the ticks that transmit Bhanja virus. Military personnel

should be especially vigilant in areas used to graze or hold sheep and goats.

O. Ehrlichiosis.

Until the 1980s, Ehrlichia spp. were known primarily as pathogens transmitted by ixodid

ticks to dogs, cattle, sheep and goats. The first well-substantiated report of a human

infection with Ehrlichia in the U.S. appeared in 1986. Since that original case report,

1,223 human cases of ehrlichiosis have been reported in the U.S. through 1997. There

are two distinct forms of human ehrlichiosis: human monocytic ehrlichiosis (HME)

caused by E. chaffeensis that infects mononuclear phagocytes, and human granulocytic

ehrlichiosis (HGE) caused by an Ehrlichia sp. closely related to E. phagocytophila and 

E. equi that infect granulocytes. Symptoms are usually nonspecific. The most common

complaints are fever, headache, nausea, and muscle and joint pain. Human deaths from

ehrlichiosis have been reported in the U.S. The first European case of acute HGE was

confirmed in Slovenia in 1996. Little is known about the distribution of ehrlichiosis in

Europe, but serological and clinical evidence of human infection reported from several

European countries suggests that HGE might exist all over Europe. Ixodes ricinus has

been implicated as the primary vector in Europe. Seroprevalence of antibodies to

Ehrlichia spp. in Europe is elevated in high-risk groups exposed to tick bites, such as

foresters. The reservoir hosts in Central Europe are unknown but, based on studies in

North America, wild rodents, deer and sheep probably play important roles in the

epidemiology of ehrlichiosis. Medical personnel should include HGE in the differential

diagnosis of febrile illnesses occurring after a tick bite in Europe. The potential for

transmission of this pathogen through blood transfusions must also be considered. 

P. Murine Typhus. (Flea-borne typhus, Endemic typhus, Shop typhus)

The infectious agent, Rickettsia typhi, causes a milder disease than does R. prowazekii,

but it still results in a debilitating illness with high fever. The incubation period ranges

from one to two weeks, and clinical symptoms may last up to two weeks in untreated

cases. Mortality is very low, and serious complications are infrequent. The disease is

easily treated with antibiotics. Absence of louse infestation, seasonal distribution, and

the sporadic occurrence of murine typhus help to differentiate it from epidemic typhus. 

Murine typhus is often unrecognized and substantially underreported in most endemic

areas.

Military Impact and Historical Perspective. Confusion in diagnosis between murine

typhus and closely related diseases may occur. Prior to World War II, murine typhus was
116

not distinguished from the epidemic form, and its importance in prior wars is unknown. 

During World War II, there were 786 cases in the US Army, with 15 deaths. Only about

a dozen cases were recorded in the Mediterranean theater. There are little available data

on the incidence of murine typhus during military operations in Korea or Vietnam. 

During the Vietnam War, murine typhus was concentrated in port cities and incidence

seemed low. However, retrospective studies indicated that a large proportion of fevers of

unknown origin experienced by Americans during that conflict were due to R. typhi. The

disease is most common in lower socioeconomic classes and increases when wartime

disruptions or mass migrations force people to live in unsanitary conditions in close

association with domestic rodents. However, murine typhus has not been a major

contributor to disease rates in disaster situations. Because of the sporadic incidence of

murine typhus, it is difficult to confidently predict the potential impact of this disease on

future military operations, although any such impact would probably be minimal.

Disease Distribution. Murine typhus is one of the most widely distributed arthropodborne infections and is endemic in many coastal areas and ports throughout the world.

Human cases occur principally in urban areas where commensal rodent infestations are

common, although infected rodents have been collected from rural villages. Sporadic

cases are reported from Central Europe. Most recent outbreaks have occurred in Greece. 

During the summer of 1985, 49 patients admitted to the Chalkis General Hospital on the

Greek island of Evia were diagnosed with murine typhus. An epidemiological study on

the island in 1993 found R. typhi in 18% of Rattus norvegicus and 4% of Xenopsylla

cheopis fleas. Antibody to R. typhi was found in the sera of 92% of the rats. Only eight

cases of murine typhus were reported from central Dalmatia, Croatia, between 1978 and

1987. However, 63% of sera from northern Dalmatian islanders had antibodies to 

R. typhi, and 62% of 231 blood donors from the northwestern part of Bosnia and

Herzegovina were seropositive. This suggests that many infections are mild or

asymptomatic. 

Transmission Cycle(s). Murine typhus is a zoonotic infection associated with domestic

rats (Rattus rattus and R. norvegicus) and vectored by their fleas and the spiny rat louse,

Polyplax spinulosa. The Oriental rat flea, X. cheopis, is the most important vector. 

Neither rodents nor their ectoparasites are affected by infection with R. typhi. 

Inoculating crushed fleas or infective flea feces into the skin at the bite site transmits

murine typhus. Scratching fleabites increases the likelihood of infection, but Rickettsia

typhi is rarely transmitted directly by fleabite. Other routes of infection are inhalation of

dry flea feces containing rickettsiae (which may remain infective for months), and

ingestion of food contaminated by rodent urine. Murine typhus is not transmitted from

person to person. The risk of transmission is year-round but peaks during the warm

months.
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Although the rat-flea-rat cycle is still the major source of human infection, murine typhus

exists in some endemic foci where commensal rodents are absent. In suburban areas of

Texas and southern California, the classic enzootic cycle has been replaced by a

peridomestic animal cycle involving free-ranging cats, dogs, and opossums and their

fleas. In the Dinaric beech-fir forest of southern Slovenia, Monopsyllus sciurorum fleas

collected from the nests of the fat doormouse, Glis glis, were found infected with R.

typhi. The widespread distribution of this sylvatic flea species of Europe and its presence

on other mammalian and avian hosts suggests that murine typhus may exist in

unrecognized enzootic cycles. 

Vector Ecology Profiles. 

The primary vector is the Oriental rat flea, X. cheopis. Cat and dog fleas,

Ctenocephalides felis and C. canis, as well as the body louse, Pediculus h. humanus, are

potential secondary vectors for humans. However, these vectors have not been

incriminated in Central European epidemics. The northern rat flea, Nosopsyllus

fasciatus, spiny rat louse, Polyplax spinulosa, and tropical rat mite, Ornithonyssus bacoti,

are vectors that maintain the enzootic cycle of the disease, although N. fasciatus has been

incriminated as the primary vector in Croatia and other areas of the former Republic of

Yugoslavia. The fleas of Central Europe are listed in Appendix A.4.

Polyplax spinulosa, the spiny rat louse, is closely associated with its rodent hosts. Female

lice attach eggs to rodent hairs and all developmental stages live exclusively on rodents. 

Lice are only transferred from rodent to rodent by body contact. These lice feed on rat

blood but do not feed on humans. 

Ornithonyssus bacoti, the tropical rat mite, lives on commensal and other rodents

throughout the region and feeds on blood and other fluids that ooze from its tiny bite

wounds. Engorged females start laying eggs within two days of feeding and continue to

lay groups of eggs for two to three days. Eggs hatch in one to two days and develop into

larvae, followed by protonymphs and deutonymphs. The entire life cycle, from egg to

adult, requires only five to six days. These mites will readily infest humans if their

rodent hosts are suddenly eliminated, or if humans live in close association with rodent

nests.

The Oriental rat flea, X. cheopis, occurs mostly in urban and periurban areas, in

conjunction with commensal rodents. Adult fleas feed exclusively on blood and utilize

blood protein for egg production. After feeding on a rodent, the female Oriental rat flea

lays several eggs (two to 15). Several hundred eggs may be laid during the entire life

span. Oviposition most often occurs on the hairs of the host, although the eggs drop off

and hatch in the nest or its environs. In locally humid environments, such as rodent

burrows, eggs may hatch in as little as two days. Larvae grow rapidly when temperature

and humidity are above 25 C and 70% R.H., living in the nest and feeding on dried
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blood, dander, and a variety of organic materials. The larval stages can be completed in

as little as 14 days (at 30 to 32 C), or as long as 200 days when temperatures drop below

15 C or when nutrition is inadequate. Mature larvae pupate in cocoons, loosely attached

to nesting material. Adult emergence may occur in as little as seven days or as long as a

year and is stimulated by carbon dioxide or host activity near the cocoon. Adult fleas

normally await the approach of a host rather than actively search for one. Fleas feed on

humans when people and rodents live close together, but man is not a preferred host. 

However, if rat populations decline suddenly due to disease or rat control programs, these

fleas readily switch to feeding on humans. The life span of adult X. cheopis is relatively

short compared to that of other flea species, often less than 40 days. Flea populations

increase rapidly during periods of warm, moist weather.

The northern rat flea, N. fasciatus, also occurs primarily where commensal rodents are

found, particularly R. norvegicus and R. rattus. It has a life cycle similar to that of the

Oriental rat flea. Nosopsyllus fasciatus lays its eggs in the nests or burrows of

commensal rodents. Larvae have the unique habit of attaching to the abdomen of an

adult flea and ingesting fecal blood as it passes from the anus of the adult. Adults of this

species rarely feed on man. Nosopsyllus fasciatus prefers cooler temperatures than 

X. cheopis. Under favorable conditions, the adult life span is just under 100 days. Adults

of both N. fasciatus and X. cheopis can survive unfed for several months. 

Vector Surveillance and Suppression. The methods of flea surveillance depend upon

the species of flea, the host, the ecological situation, and the objective of the

investigation. Fleas can be collected from hosts or their habitat. The relationship of host

density to flea density should be considered in assessing flea populations. It has been

common practice for years to use a flea index (average number of fleas per host),

especially in studies of rodent fleas. For X. cheopis, a flea index > 1.0 flea per host is

considered high. The flea index has many limitations, since only adults are considered

and then only while they are on the host. Fleas are recovered by combing or brushing the

host or by running a stream of carbon dioxide through the fur while holding the host over

a white surface. 

Flea abundance in the environment can be determined by counting the number of fleas

landing or crawling in one minute on the lower parts of the legs of the observer. The

trouser legs should be tucked into the socks to prevent bites. Flea populations can also be

estimated by placing a white cloth on the floor in buildings or on the ground in rodent

habitat and counting the fleas that jump onto the cloth. Various flea traps have been

devised. Some use light or carbon dioxide as an attractant. Sifting and flotation of

rodent nesting materials or of dust and debris from infested buildings are effective

methods of collecting fleas from the environment.
119

Control of rodents over large areas is not feasible during wartime. Control efforts should

be limited to foci adjacent to urban areas, military encampments, or other areas

frequented by military personnel. If possible, cantonment sites should not be located in

wild rodent habitat. Fleas quickly leave the bodies of dead or dying rodents in search of

new hosts. Consequently, flea control must always precede or coincide with rodent

control operations. Application of insecticidal dusts to rodent burrows is effective in

reducing flea populations, but it is very labor intensive. Fleas can be controlled by

attracting infested rodents to bait stations. The stations contain an insecticidal dust that

rodents pick up while feeding, or a rodent bait containing a systemic insecticide that fleas

ingest when taking a bloodmeal. Baiting with systemic formulations may pose

environmental risks.

Urban rodent control requires that rodent runs, harborages and burrows be dusted with an

insecticide labeled for flea control and known to be effective against local fleas. 

Insecticide bait stations can also be used. Rat populations should be suppressed by wellplanned and intensive campaigns of poisoning and concurrent measures to reduce rat

harborages and food sources. Buildings should be rat-proofed to the extent possible to

prevent rats from gaining entry. Domestic rodent control is discussed in Technical Guide

(TG) 138, Guide to Commensal Rodent Control. Insecticides recommended for flea

control are listed in TIM 24, Contingency Pest Management Guide.

Military personnel, especially those involved in rodent control, should use the personal

protective measures discussed in TIM 36, Personal Protective Techniques Against Insects

and Other Arthropods of Military Significance, and outlined in Appendix F. 

Q. Epidemic Typhus.

Epidemic typhus is a severe disease transmitted by the human body louse, Pediculus

humanus humanus. The infectious agent is the bacterium Rickettsia prowazekii. It 

causes high mortality, particularly in populations weakened by malnutrition. Case

fatality rates normally vary from 10 to 40% in the absence of specific therapy. Onset is

usually sudden and marked by fever, headache, and general pains followed by a rash that

spreads from the trunk to the entire body. Untreated cases of epidemic typhus may last

up to 3 weeks. Many humans who contract typhus retain some rickettsiae for the rest of

their lives. Under certain stressful conditions or reduced immunity, they may relapse and

develop a milder form of typhus known as Brill-Zinsser disease.

Military Impact and Historical Perspective. Epidemics of typhus have changed the

course of history. One author has stated that the louse has killed more soldiers than all

the bullets fired during conflict. In one of the worst disasters in military history, over

half of Napoleon’s army perished from epidemic typhus during the invasion of Russia in

1812. During the first year of World War I, typhus started as an epidemic in the Serbian
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Army. In six months, 150,000 people had died of the disease, including 50,000 prisoners

of war and one-third of Serbian physicians. By the end of the war and during the period

immediately following it (1917 to 1923), an estimated 30 million cases of epidemic

typhus occurred in Russia and Europe, with over 300,000 deaths. During World War II,

there were severe epidemics of typhus in some endemic areas. Large epidemics occurred

in Bucovina, northeast Romania and neighboring Moldova. From 1941 to 1944, there

were over 132,000 cases in urban areas of French North Africa. Over 91,000 cases

occurred in Egypt during the same period. Despite this incidence, US Army personnel

experienced only 30 cases of typhus with no typhus deaths in the North African-Middle

East-Mediterranean zone during the years 1942 to1945. When Allied forces landed in

Italy in 1943, a typhus epidemic in Naples was ravaging the city of one million. Death

rates reached 80%. An effective delousing campaign, chiefly using DDT, was waged. 

This marked the first time in history that an epidemic of typhus did not exhaust itself but

instead was terminated by human action. The US Army achieved a remarkable record of

low morbidity with no fatalities from epidemic typhus in World War II by taking

effective protective measures against the disease and through the work of the US Typhus

Commission established by the Secretary of War on October 22, 1942.

The development of modern antibiotics and insecticides has reduced the threat of this

disease to military forces. However, the short incubation period and severe clinical

symptoms of epidemic typhus should be of concern to medical personnel when dealing

with large concentrations of refugees and prisoners of war. Rickettsia prowazekii has the

most serious epidemic potential of all rickettsiae, and the emergence and dissemination

of body lice can be very rapid under appropriate conditions. In a refugee camp in Goma,

Zaire, all 800,000 refugees became infested within one month.

Disease Distribution. Epidemic typhus is more common in temperate regions and in the

cooler tropics above 1600 m. It is absent from lowland tropics. It usually occurs in

mountainous regions where heavy clothing is worn continuously, such as the Himalayas,

Pakistan and Afghanistan, and the highlands of Ethiopia. The incidence of epidemic

typhus has been steadily declining in the last two decades. The majority of recent cases

have occurred in Africa, primarily in Ethiopia, with most of the remainder occurring in

Peru and Ecuador. The most recent outbreak occurred in Burundi, and a small outbreak

was observed in Russia in 1997. Epidemic typhus may still be endemic in many parts of

Central Europe. Sporadic cases have been reported from Poland and Romania. From

1965 to 1975, there were 623 cases of recrudescent Brill-Zinsser disease recorded from

Bosnia and 107 cases recorded from Serbia. Up to 13% of the population in Bosnia and

Herzegovina has antibodies to R. prowazekii. Endemic areas of epidemic typhus in

Central Europe appear in Figure 5. 

Until the civil war in the former Republic of Yugoslavia, body louse infestations were

uncommon and more likely to be encountered in gypsy populations. An infestation
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reported in the Czech Republic in 1991 was the first observation of body lice in that

country since 1945. However, over five million persons in the former Republic of

Yugoslavia have been displaced by civil war. Large numbers of people are living in

crowded, unsanitary conditions. Surveys of refugee camps have found a high incidence

of head lice. Though the incidence of body lice has been low, it is expected to increase. 

The conditions faced by refugees and displaced persons, whether in collective centers or

located with host families, are such that the potential for louse-borne disease is high. 

Transmission cycle(s). The head louse, Pediculus humanus capitis, and the crab louse,

Pthirus pubis, can transmit R. prowazekii experimentally, but epidemics have always 

been associated with the body louse, P. h. humanus. Humans are reservoirs of the

pathogen and the only hosts for the lice. Transmission of the disease occurs when 

individuals wear the same clothes continuously under crowded, unsanitary conditions. 

Major epidemics have been associated with war, poverty and natural disasters. Persons

in cold climates are more likely to acquire epidemic typhus when they are unable to bathe

or change clothes for long periods of time.

 

Lice become infective five to seven days after a bloodmeal from an infected human. 

During subsequent bloodmeals, the lice defecate and rickettsiae are excreted in their

feces. Louse bites are irritating, and scratching by the host produces minor skin

abrasions, which facilitate entry of the pathogen from feces or crushed body lice. 

Rickettsia prowazekii can survive desiccation for several weeks. Louse feces are 

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extremely dry and powdery, so infection may also occur by inhalation of infective louse

feces.

The survival of R. prowazekii between outbreaks is of interest, since there is no

transovarial transmission and lice die from the infection. Individuals who recover from

the initial infection and relapse years later with Brill-Zinsser disease are considered the

primary reservoir. Lice feeding on such patients become infected. A sylvatic cycle of R.

prowazekii has been recognized in the southeastern United States, where flying squirrels

and their ectoparasites (the flea Orchopeas howardii and the louse Neohaematopinus

sciuropteri) are naturally infected. The louse is host specific, but O. howardii has an

extensive host range, which includes humans. Sporadic human cases have occurred in

houses harboring flying squirrels. The significance of this finding to the epidemiology of

epidemic typhus in other areas is not known. 

Vector Ecology Profile. Human lice spend their entire life cycle (egg, three nymphal

stages and adult) on the host. Eggs of body lice are attached to clothing at a rate of about

five to eight eggs per female per day. Lice must mate before egg laying, since females

cannot store sperm. At 29oC to 32o C, eggs hatch in seven to 10 days. The maximum

time eggs can survive unhatched is three to four weeks, which is important when

considering the survival of lice in infested clothing and bedding. A bloodmeal is

required for each of the three nymphal molts and for egg production in adults. The

nymphal stages are passed in eight to 16 days. Louse populations have the potential to

double every seven days. Adults live about two weeks and feed daily. Infestations of

lice cause considerable irritation and scratching, which may lead to skin lesions and

secondary infections. Body lice are commonly found in the seams and folds of clothing. 

Lice tolerate only a narrow temperature range and will abandon a dead host or one with a

body temperature of 40o C or above. This contributes to the spread of lice and louseborne disease. Humidity is also critical because lice are susceptible to rapid dehydration. 

The optimal humidity for survival is between 70% and 90%; they cannot survive at a

relative humidity below 40%. Human lice can survive without a host for only a few

days.

Vector Surveillance and Suppression. The incidence of head lice has been increasing

worldwide. Body louse infestations have declined with higher standards of living,

although infestations are still common in some North African populations, especially

nomads. The prevalence of body lice reflects the socioeconomic level of the society. 

The incidence of body lice has increased in some countries due to war and social change. 

Infestations with body lice are increasingly being reported among the homeless and

deprived populations in inner cities of developed nations. Military personnel should

avoid close personal contact with infested persons and their belongings, especially

clothing and bedding.
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Surveillance for body lice consists of examining individuals and their clothing for lice or

nits (eggs). The population density of body lice may be very high, but usually only a few

lice are observed on an individual. Body lice are frequently found around the waistbands

of clothing. Heavily bitten areas, such as the base of the thorax, the groin and the flanks

of the body, may become darker. This characteristic skin coloration is often referred to

as vagabond’s disease.

Dry cleaning or laundering clothing or bedding in hot water (55o C for 20 minutes) will

kill eggs and lice. Control of epidemics requires mass treatment of individuals and their

clothing with effective insecticides. The permethrin-treated BDU is extremely effective

against lice. Since lice cannot survive away from the human host, application of

insecticides to buildings, barracks or other living quarters is not necessary. Mass louse

control could be hampered by insecticide resistance. Resistance to common

pediculicides, particularly DDT and gamma BHC (lindane), is widespread in Central

Europe. Pyrethroid lotions and shampoos have been widely used in this region to control

head lice, and reports of pyrethroid resistance are increasing. Compounds such as

ivermectin, taken orally to eradicate lice, have been investigated experimentally but are

not currently registered for that use. 

Production of typhus vaccine in the United States has been discontinued, and there are no

plans for commercial production of a new vaccine. Vaccination against typhus is not

required by any country as a condition of entry.

R. Relapsing Fever (louse-borne). (Epidemic relapsing fever) 

Louse-borne relapsing fever is caused by the spirochete Borrelia recurrentis. The

symptoms and severity of relapsing fever depend on the immune status of the individual,

geographic location, and strain of Borrelia. The incubation period in an infected host

ranges from two to 14 days. The disease is characterized by a primary febrile attack

followed by an afebrile interval and one or more subsequent attacks of fever and

headache. Intervals between attacks range from five to nine days. In untreated cases,

mortality is usually low but can reach 40%. Infection responds well to treatment with

antibiotics.

Military Impact and Historical Perspective. Major epidemics of louse-borne relapsing

fever occurred during and after World War I in Russia, Central Europe and North Africa. 

After the war, relapsing fever was disseminated through large areas of Europe, carried by

louse-infested soldiers, civilians and prisoners of war. Between 1910 and 1945, there

were an estimated 15 million cases and nearly 5 million deaths. Large outbreaks were

common during and after World War II, when epidemics of louse-borne relapsing fever

in North Africa produced an estimated one million cases and some 50,000 deaths. 

During the Vietnam War, epidemics of louse-borne fever occurred in the Democratic

Peoples’ Republic of Vietnam. 
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Disease Distribution. From 1960 to 1980, louse-borne relapsing fever flourished

primarily in the Sudan and Ethiopia. Ethiopia reported the highest number of cases, an

estimated 10,000 per year. Relapsing fever is also suspected of persisting in the Peruvian

Andes and the Himalayas. Epidemics usually occur in the cold season, among poor

people with inadequate hygiene. The potential for outbreaks of relapsing fever in the

war-ravaged areas of the former Yugoslavia is high.

Transmission Cycle(s). The body louse, P. h. humanus, is the vector of B. recurrentis. 

After the louse feeds on infective blood, the spirochetes leave the digestive tract and

multiply in the insect’s body cavity and other organs. They do not invade the salivary

glands or the ovaries and are not found in the feces. Bites and fecal deposits cannot

transmit the pathogen, and transovarial transmission does not occur. Human infection

occurs when a louse is crushed and Borrelia spirochetes are released. The spirochetes

may be scratched into the skin or come in contact with mucous membranes, but there is

evidence that B. recurrentis can penetrate unbroken skin. Since infection is fatal to the

louse, a single louse can infect only one person. However, B. recurrentis can survive for

some time in a dead louse. Outbreaks of louse-borne relapsing fever require high

populations of body lice. Lice leave febrile patients in search of new hosts, and this

behavior contributes to the spread of disease during an epidemic. 

Humans are the only known reservoir for B. recurrentis. Mechanisms of survival during

non-epidemic periods are unknown. The life cycle of the body louse is less than two

months, and in the absence of transovarial transmission B. recurrentis cannot survive in

the louse population.

Vector Ecology Profile. See epidemic typhus.

Vector Surveillance and Suppression. See epidemic typhus.

S. Other Arthropod-borne Viruses.

Many enzootic arboviruses are circulating in Central Europe, but little is known about

them. Available epidemiological information indicates that they would have a minor

impact on military operations. However, medical personnel should be aware of these

arboviruses because they will frequently be treating fevers of unknown origin.

Vesicular stomatitis (VS) is a serious viral disease of cattle, horses and swine that has

caused enormous economic loss in many areas of the world. A group of related viruses

constitute the genus Vesiculovirus in the family Rhabdoviridae. Human infections with

VS virus have occurred under natural conditions during epizootics and as the result of

laboratory accidents. Most human infections occur in veterinarians and livestock

handlers who have direct contact with large domestic animals. The natural history of VS

viruses, including their endemic and epizootic patterns, is poorly understood. VS viruses
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have been isolated from a wide variety of blood-sucking insects, including mosquitoes,

black flies and biting midges. However, VS virus can seldom be isolated from the blood

of an infected animal, and viremias are usually insufficient to infect blood-sucking

arthropods. VS viruses have also been isolated from nonhematophagous Diptera, such as

eye gnats and house flies, and mechanical transmission of VS virus has been

demonstrated experimentally. A VS virus named Yug Bog Danovac has been isolated

from Phlebotomus perfiliewi in southeastern Serbia. Antibodies to this virus have been

detected in humans, but its role in human disease is unknown.

In Central Europe, Lednice (Bunyavirus, Bunyaviridae) virus has been isolated only from

Culex modestus in southern Moravia, Slovakia. Little is known about its natural history

or role in human disease. Low levels of viremia have been produced experimentally in

birds but not in the several species of mammals tested. Antibodies to Lednice virus have

been detected in wild geese and ducks in Slovakia and Romania. 

Human infection with Batai virus (Bunyavirus, Bunyaviridae) produces a fever and

occasionally a meningitis syndrome. The virus, also called Calovo virus, has been

isolated from mosquitoes in northeastern Croatia and southern Moravia, Slovakia. The

large number of field isolates from Anopheles maculipennis makes this species a

candidate for further vector studies. Available serological data indicate cattle as the

principal vertebrate host.

Uukuniemi (Uukuvirus, Bunyaviridae) virus has been isolated from Ixodes ricinus in the

Czech and Slovak Republics, Hungary and Poland. Antibodies to this virus have been

detected in humans, but its role in human disease is unknown. 

Viruses of the Kemerovo group form a distinct serogroup in the genus Orbivirus, family

Reoviridae. Two Kemerovo group viruses, Tribec and Lipovnik, isolated in Central

Europe have been incriminated as causes of human illness. Both viruses are transmitted

by ticks, and serological evidence of infection has been found in domestic animals. 

However, the complete natural cycle of these viruses and their role in human disease is

unknown. Isolations of both viruses have been reported from Slovakia and Romania. 

Lipovnik virus has been isolated from I. ricinus in Slovakia, and during the mid 1980s

antibodies to this virus were found in up to 88% of the goats and up to 30% of the

inhabitants of the Silica plateau area of the Slovak karst region. In Slovakia, antibodies

to Tribec virus were found in cerebrospinal fluid of patients with inflammatory

neurologic disorders.
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VI. Militarily Important Vector-borne Diseases with Long Incubation Periods 

 (>15 days)

A. Leishmaniasis.

This potentially disfiguring and sometimes fatal disease is caused by infection with

protozoan parasites of the genus Leishmania. Transmission results from bites of infected

phlebotomine sand flies. All vectors of leishmaniasis in the Old World are in the sand fly

genus Phlebotomus. Incubation in humans may take as little as ten days or more than six

months. Symptoms include ulcerative cutaneous lesions (cutaneous leishmaniasis or

CL), lesions in the mucosal areas of the mouth and/or nose (mucocutaneous

leishmaniasis or MCL), and internal pathological manifestations resulting in fever,

swollen lymph glands, anemia, enlargement of the liver and spleen, and progressive

emaciation and weakness (visceral leishmaniasis or VL). In Central Europe, both CL and

VL are important public health problems except in the Czech Republic, the northern two

thirds of Hungary, Poland, the northern half of Romania, and the Slovak Republic. 

CL (Baghdad boil or Oriental sore), caused by infection with Le. tropica, typically

appears as a nonhealing ulcer. The lesion usually develops within weeks or months after

a sand fly bite and slowly evolves from a papule to a nodule to an ulcer. Cutaneous

lesions may resolve quickly (two to three months) without treatment or they may become

chronic (lasting months to years) and will seldom heal without treatment. Scarring is

associated with healing. In endemic areas, such scars are common among rural and

urban populations. Life-long immunity to the infecting Leishmania species normally

results.

VL (Kala-azar, Dum Dum fever), caused by Le. infantum, is a severe form of

leishmaniasis, with as much as 95% mortality in untreated cases. It is a chronic disease

that without treatment is marked by fever (two daily peaks), weakness and, as the

parasites invade internal organs, weight loss coupled with enlargement of spleen and

liver that may resemble severe malnutrition. It should be noted that cutaneous lesions

may also be seen in human visceral leishmaniasis cases, but the chronic visceralizing

nature of the disease is the main concern. In Central Europe, VL is usually attributed to

Le. infantum. Viscerotropic Le. tropica has also been reported and was described in

veterans of the Persian Gulf war. The incubation period for VL is usually four to six
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months but may be as short as 10 days or as long as two years. By the time the disease is

diagnosed, patients have usually forgotten any contact with sand flies. In endemic

regions it is a disease of the young and old, who succumb to it disproportionately. 

Epidemics of VL often follow conditions of severe drought, famine or disruption of

native populations by wars that produce large numbers of refugees. In Sudan, between

the years 1991 and 1996, there were reports of 10,000 treated cases and an estimated

100,000 deaths from untreated cases of VL. 

Military Impact and Historical Perspective. Leishmaniasis is a persistent health

threat to U.S. military personnel because troops deploy or conduct military exercises in

locations where the disease is endemic. The potential for this disease to compromise

mission objectives is significant. Soldiers exposed to sand fly bites while deployed are

highly susceptible to infection with Leishmania tropica. Immunity among US military

personnel is essentially nonexistent, and recovery from CL does not confer immunity to

VL. In the Karum River Valley of Iraq, US forces suffered 630 cases of the disease in a

three-month period during WWII. From 1990 to 91, 12 cases of VL due to Le. tropica

were diagnosed when 697,000 allied soldiers were deployed to the Arabian Peninsula

during Operations Desert Shield and Storm. Even though no fatalities were associated

with leishmaniasis in this deployment, new lessons were learned that could affect future

military deployments. Before the Persian Gulf War, eastern Saudi Arabia was not known

to be endemic for visceral leishmaniasis, and Le. tropica was not convincingly shown to

produce visceral disease. More important, the potential for leishmaniasis to cause

intransigent post-deployment diagnostic problems and threaten blood supplies had not

been anticipated. Returnees from the Persian Gulf War were barred from donating blood

for up to two years, severely impacting blood supplies. Infection with Leishmania was

even suspected as one of the causative agents of Persian Gulf War syndrome, but

scientific evidence for this association was never established.

 

Diagnosis of leishmaniasis is difficult at best, and providing proper care for service

members who may have been exposed or infected is a long, costly and complex process. 

Treatment usually requires 20 or more days and consists of injections with pentavalent

antimony (Pentostam). Because this drug is not registered for use in the US, it must be

administered under an experimental protocol at an approved medical treatment facility. 

Estimated leishmaniasis-related costs can exceed US $17,000 per patient, with an

average of 92 lost duty days per patient. Other important but less quantifiable costs

include loss to the unit, personal distress, and delay of career progression. 

Disease Distribution. Anthroponotic (human-to-human) transmission of CL due to 

Le. tropica occurs in urban centers and rural highland villages in Albania, Bosnia and

Herzegovina, Bulgaria, Croatia, Greece, Macedonia, Romania, Serbia and Montenegro,

and Slovenia (Figure 6). The disease is widespread in areas with a temperate climate
129

(Mediterranean Basin), or a cold, arid climate (Transcaucasian region, Afghanistan, etc.). 

 

VL due to Le. infantum occurs in the Mediterranean Basin countries of North Africa, the

Middle East, southern Europe, East Africa, south-central Asia, and China. In Central

Europe, it is reported from parts of Hungary and Romania and in the countries of

Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, Macedonia, Serbia and

Montenegro, and Slovenia (Figure 7). It is not highly endemic in any of these countries. 

In Albania, Croatia and Greece, the etiological agent of VL has been incorrectly reported

as Le. donovani due to improper interpretation of the subspecies name Le. donovani

infantum, which is correctly designated as Le. infantum.


132

Transmission Cycles. In urban areas humans may serve as reservoirs of Le. tropica. In

rural areas, non-human hosts of Le. tropica may include wild and domestic rodents living

in close proximity to humans. Sand fly vectors inhabit the burrow systems of domestic 

and wild rodents, moles, hedgehogs and jerboas, and acquire infections while feeding on

these reservoir hosts. Amastigotes (the mammalian form of the Leishmania parasite)

ingested with the bloodmeal transform to a flagellated promastigote form within the gut

of the female fly. In addition to a bloodmeal, the female consumes sugar in the nectar of

nearby plants during subsequent nocturnal flights. These sugars help maintain

Leishmania infections in the flies. Promastigotes multiply within the bloodmeal in the

gut of the sand fly and undergo development to an infective form called the metacyclic

promastigote. By the time the bloodmeal is digested and the fly is ready to lay its eggs,

infective metacyclic promastigotes are ready to be transmitted to the next vertebrate host

when the sand fly feeds again (Figure 8). 

 

Infective-stage promastigotes (metacyclics) are deposited in the skin of a susceptible host

during the sand fly’s next bloodmeal. Promastigotes are engulfed by white blood cells or

macrophages, in which they transform to amastigotes. Amastigotes proliferate in the

macrophage until it ruptures and new macrophages are invaded. At the skin surface, the

tiny bite site becomes a small red papule that enlarges and ulcerates, with a raised edge of

red inflamed skin. This inflamed area is where macrophages continue to engulf parasites,

resulting in additional parasite multiplication. The ulcerated sores may become painful,

last for months and, in uncomplicated CL caused by Le. tropica, eventually heal to form

the characteristic scars seen on large numbers of people in some endemic areas of the

region. 

The incriminated vector of Le. tropica in Central Europe is P. sergenti, though P.

papatasi is a suspected vector. The form of CL known as “dry sore” is most common in

densely populated urban centers and is considered to have a human-sand fly-human

(anthroponotic) transmission cycle, with no recognized sylvatic reservoir. In recent

years, CL due to Le. tropica has been reported in rural highland villages of Central

Europe. In these foci, the disease is thought to have a zoonotic transmission cycle in

which P. caucasicus maintains transmission within a wild rodent reservoir population.

However, a sylvatic reservoir has not been identified.

The cycle of development of parasites causing VL is essentially the same as described for

CL. The differences when dealing with VL caused by Le. infantum are the species of

sand flies that vector the disease and the reservoirs for the parasite. In Central Europe,

VL is a zoonotic disease of wild canids. It has been isolated from jackals and foxes in

rural areas, as well as from feral and domestic dogs. Incidental infections occur in

humans living in close association with infected dogs. In addition to wild and domestic

canids, and man, Le. infantum has been isolated from infected rats (Rattus rattus) in

southern Saudi Arabia, expanding the list of potential reservoirs. As previously
133

mentioned, a less virulent, viscerotropic form of Le. tropica has been reported from the

Middle East.

135

Vector Ecology Profiles. The incriminated vector of Le. tropica in the region is 

P. sergenti. Suspected vectors of Le. tropica are P. alexandrei, P. papatasi and 

P. perfiliewi. Proven or suspected vectors of Le. infantum in Central Europe are 

P. caucasicus, P. longiductus, P. neglectus, P. perfiliewi, P. pernisciosus, P. simici and

P. tobbi.

Adult sand flies rest during the daytime in dark, humid, protected areas, such as rodent

burrows, rock crevices and caves. The preparation of military bunkered ground positions

in desert areas provides additional protected daytime resting sites for phlebotomine sand

flies. In urban areas, sand fly adults often rest in dark, cool, humid areas of human

habitations and animal structures. Abandoned structures and their vegetative overgrowth

often become attractive wild or domestic rodent habitats and foci of rural CL.

 

Nectar is important as a sugar source for both male and female sand flies, since sugars

are required for development of parasite infections. After a bloodmeal, eggs are

deposited in dark, humid, secluded areas. They develop into minute caterpillar-like

larvae that feed on mold spores and organic debris. The larvae go through four instars

and then pupate near larval feeding sites. Development from egg to adult requires 30 to

45 days, depending on feeding conditions and environmental temperatures. 

Phlebotomine sand fly eggs, larvae and pupae have seldom been found in nature,

although exhaustive studies and searches have been made. The adult female has been

observed to spread eggs around rather than oviposit in a single site. The larvae are

widely distributed in the environment but are probably below the ground surface in

termite mounds, rodent burrows, caves, or cracks and crevices in the soil where

temperature, humidity and mold growth provide ideal conditions for larval development. 

The dusk-to-dawn movement of adults is characterized by short, hopping flights just

above the ground surface to avoid wind. Adult sand flies generally do not travel great

distances, and most flights are believed to be less than 100 meters. Sand fly habitats in

the region range in altitude from desert areas below sea level up to 2,800 m in the

mountains. In temperate climates adult sand flies are most abundant and active in the

warmer months of April through October, especially after rains. However, species of

sand flies such as P. sergenti are tolerant of cold winters, and P. mascittii, found in

northern latitudes, will bite man in cool conditions. Both P. sergenti and P. papatasi will

bite humans either indoors or outdoors and are troublesome pest species.

Female sand flies are quiet "stealth biters" from which comes the name “papataci”

(silent gorger), and their bites may go unnoticed by military personnel. Sand flies may

also bite during the daytime if disturbed in their secluded resting sites. Areas with some

vegetation and cliffs, rock outcroppings, or other geologic formations that provide

suitable hiding places and daytime resting sites are important habitats. Exact information

on reservoirs and vectors will require more extensive study in many countries of the
136

region. Vast areas of these countries remain unsurveyed for sand fly vectors and disease. 

When searches are made, sand fly vectors are often found in areas where they were

previously unknown. 

Vector Surveillance and Suppression. See sand fly fever.

B. Lyme Disease. 

Lyme disease is also called Lyme borreliosis, tick-borne meningopolyneuritis and Lyme

arthritis. The causative agent is the spirochete bacterium Borrelia burgdorferi. At least

four genospecies of the Lyme disease spirochete have been isolated in Central Europe: B.

burgdorferi sensu stricto, B. afzelii, B. garinii and B. valaisiana (formerly group VS116). 

Borrelia afzelii and B. garinii predominate in the region. Like syphilis, the clinical

disease manifests itself in acute and chronic stages. Initially there is a highly

characteristic expanding skin lesion (erythema migrans) that develops in about 60% of

cases. Flu-like symptoms usually occur about the same time. Weeks to months after

initial infection, cardiac, neurological or arthritic symptoms and other joint abnormalities

may occur and persist for years. Different genotypes have been associated with

characteristic clinical symptoms. Borrelia afzelii prevails in skin lesions, whereas B.

garinii is associated with neurological involvement. Treatment in the late stages of

Lyme disease can be difficult, and chronic infection can be very debilitating. Early

recognition and treatment are critical.

Military Impact and Historical Perspective. Lyme disease is an emerging infection of

public health importance in many parts of the world. Since its recognition in Connecticut

during the 1970s, Lyme disease has been reported from 48 states. The development of

effective vaccines, absence of antibiotic resistance in B. burgdorferi spirochetes, and

availability of highly effective repellents should minimize the military impact of Lyme

disease. Since 1995, about 100 cases of Lyme disease have been officially reported in

US Army personnel worldwide. 

Disease Distribution. Lyme disease is the most common tick-borne infection of humans

in the temperate Northern Hemisphere, including North America, Europe and northern

Asia. Lyme-like syndromes have been reported from South America, Africa, tropical

Asia and Australia, but their epidemiology has not been clarified. Clinical and

serological evidence of Lyme disease in humans has been reported throughout Central

Europe. It is difficult to compare published results from different European labs using

different diagnostic tests. Incidence of antibodies to B. burgdorferi is correlated with

exposure to tick habitat. Nearly 40% of forestry workers in eastern Poland showed a

positive antibody response in a 1997 survey, while only 6% of the general population of

blood donors were seropositive. Nearly 35% of foresters from various regions in

Bulgaria were seropositive. The highest incidence of Lyme disease antibodies occurs in

Croatia (43%), while the lowest seroprevalence to B. burgdorferi in the region (1.1%) has
137

been reported from Greece. There are few reports in the medical literature about the

seroprevalence of Lyme disease in Albania. 

Incidence of infection has been increasing in most countries of Central Europe. In the

Czech Republic, 6,302 cases of Lyme disease were reported in 1995 and 4,192 cases

were reported in 1996. Borrelia burgdorferi was isolated from 231 patients during 1994

at the Medical Center Ljubljana, Slovenia. From 1991 to 1995, 2,357 people were

diagnosed with Lyme borreliosis in Slovakia. Even suburban areas and urban parks may

be active foci of Lyme disease. Approximately 10% of I. ricinus nymphs and adults

collected in suburban and urban wooded areas of southern Poland were infected with

Borrelia burgdorferi in 1996. In the same year, another study found that 19.2% of I.

ricinus collected from urban areas in Warsaw and 31% of I. ricinus collected from forests

near Warsaw were infected. Infection rates in I. ricinus collected from 10 localities in

Prague between 1994 and 1997 ranged from 3.6% to 11.3%.

Borrelia burgdorferi was isolated from 19% of the I. ricinus ticks collected from six

regions of Slovakia in 1993. Up to 34% of I. ricinus collected at 12 sites in the foothill

areas of Veliko Tarnovo, Bulgaria, from 1989 to 1990 were infected with Lyme disease

spirochetes. Some of the highest infection rates in the region have been recorded from

Croatia. Forty-five percent of I. ricinus collected from an enzootic region in northern

Croatia were infected, and 21% of the roe deer sampled were seropositive in northwest

Croatia. Hungary has recorded a countrywide incidence of 50 cases per 100,000. 

Transmission Cycle(s). All known primary vectors of Lyme disease are hard ticks of

the genus Ixodes, subgenus Ixodes. Infective spirochetes are transmitted by tick bite.

Nymphal ticks usually transmit the disease to humans. Transmission of the pathogen

often does not occur until the tick has been attached for at least 24 hours, so early tick

detection and removal can prevent infection. Borrelia burgdorferi has been detected in

mosquitoes, deer flies and horse flies in the northeastern United States and Europe, but

the role of these insects in Lyme disease transmission appears to be minimal. Rodents,

insectivores and other small mammals maintain spirochetes in their tissues and blood and

infect larval ticks that feed on them. Infection with more than one genotype has been

found in ticks as well as vertebrate reservoirs. Spirochetes are seldom passed

transovarially by female ticks. Small mammals vary in their relative importance as

reservoir hosts in different geographic regions. Field mice in the genera Apodemus and

Clethrionomys are the chief reservoirs across Eurasia. Experimental studies suggest that

birds are poor hosts of Lyme disease spirochetes and play an insignificant role as

reservoirs. Birds are involved in the circulation of B. burgdorferi principally as

disseminators of infected ticks to new areas. Large mammals, especially deer, are

important as hosts of adult ticks and essential to completion of the life cycle of the

vector, but are unimportant as reservoirs of the pathogen. 
138

Vector Ecology Profiles. 

Ixodes ricinus is the principal vector of Lyme disease in Europe and around the

Mediterranean Sea, although other Ixodes spp. are possible vectors. Ixodes ricinus is

either reported or suspected from every country in Central Europe. Secondary vectors in

the region include Haemaphysalis concinna, H. punctata, Dermacentor marginatus and

Rhipicephalus bursa. The vector ecology profiles of these species, except Rhipicephalus

bursa, are described in the section on tick-borne encephalitis. Consequently, only the

biology of R. bursa is discussed here. Central European tick species and their

distributions appear in Appendix A.3. The biology of tick vectors is summarized in

Appendix B. 

Rhipicephalus bursa is a medium-sized, two-host tick that is widely distributed in most

of the countries bordering the Mediterranean and occurs in nearly all biotopes of Greece

except for wet, marshy areas. It also occurs in Bulgaria and Serbia, and probably occurs

in Romania, Albania, Macedonia, Croatia and Bosnia. In Greece, immature stages of this

species appear during the autumn and winter. They may infest hares but more often

attack cattle or sheep. Larvae and nymphs attach to their hosts from three to10 days,

while adult females may attach for five to 12 days. Adults are most active during the

spring to early summer period. Adults readily feed on cattle, sheep, goats and, to a lesser

extent, dogs. Since man is rarely attacked, R. bursa is significant only in the zoonotic

cycle of Lyme disease. Adults of this species frequently attach around the anus, vulva,

udder, or scrotum of cattle. The female tick takes large bloodmeals, often increasing its

body weight by 9,000 percent. Males also engorge but increase their weight by only 100

to 200%. Females that have fully engorged produce 3,000 to 6,000 eggs. This species

has been known to reproduce parthenogenetically. 

Vector Surveillance and Suppression. There are several methods that can be used to

determine the numbers and species of ticks in a given area. These include dragging a

piece of flannel cloth over vegetation where ticks are waiting for a passing host and

collecting the ticks that attach to the cloth, collecting ticks from animal hosts or their

burrows/nests, attracting ticks to a trap using carbon dioxide (usually in the form of dry

ice), and removing ticks from a person walking in a prescribed area. Different species

and life stages of ticks are collected disproportionately by the various methods, and

techniques selected must be tailored to the species and life stage desired. These

collection procedures are discussed thoroughly in TIM 26, Tick-borne Diseases: Vector

Surveillance and Control.

Habitat modification can reduce tick abundance in limited areas. Mechanical removal of

leaf litter, underbrush, and low-growing vegetation reduces the density of small mammal

hosts and deprives ixodid ticks of the structural support they need to contact hosts. Leaf

litter also provides microhabitats with environmental conditions suitable for survival,
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such as high relative humidity. Controlled burning, where environmentally acceptable,

has been shown to reduce tick populations for six to 12 months.

Large-scale application of pesticides to control ticks is usually impractical and may be

environmentally unacceptable at military installations during peacetime. Chemical

treatment should be confined to intensely used areas with a high risk of tick-borne

disease. Liquid formulations of pesticides can be applied to vegetation at various heights

to provide immediate reduction in tick populations. Granular formulations provide

slower control and only affect ticks at ground level. Both formulations give

approximately the same level of control when evaluated over a period of several weeks. 

Consult TIMs 24 and 26 for specific pesticide recommendations and application

techniques.

Exclusion of deer and other large animals using electric or nonelectric fences has reduced

populations of Ixodes ticks that require large animals to complete their life cycle. This

technique would have limited applicability in most military situations.

The personal protective measures discussed in TIMs 26 and 36 are the best means of

protecting individual soldiers from tick bites. Clothing impregnated with permethrin is

particularly effective against crawling arthropods like ticks. Frequent body checks while

operating in tick-infested habitat are essential. Tick attachment for several hours is 

required for transmission of many tick-borne pathogens, so early removal of ticks can

prevent infection (Appendix F).

The FDA has approved LYMErix, a vaccine developed by SmithKline Beecham, for

vaccination of people ages 15 to 70. The vaccine is only about 80% effective, and it

takes three shots over a full year to build optimal immunity. It protects only against

North American strains of B. burgdorferi and is not effective against European genotypes

of the spirochete. Therefore, vaccinated individuals must still use personal protective

measures against ticks.
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VII. Other Diseases of Potential Military Significance. 

A. Leptospirosis. (Weil disease, Canicola fever, Hemorrhagic jaundice, Mud fever, 

Swineherd disease)

The spirochete bacterium Leptospira interrogans is the causative agent of this zoonotic

disease. More than 200 serovars of L. interrogans have been identified, and these have

been classified into 23 serogroups based on serological relationships. Common clinical

features are fever with sudden onset, headache, and severe muscle pain. Serious

complications can occur. Infection of the kidneys and renal failure is the cause of death

in most fatal cases. The severity of leptospirosis varies greatly and is determined to a

large extent by the infecting strain and health of the individual. In some areas of enzootic

leptospirosis, a majority of infections are mild or asymptomatic. The incubation period is

10 to 12 days after infection.

Disease Distribution. Distribution is worldwide in urban and rural areas of both

developed and developing countries. Leptospirosis is regarded as focally enzootic

throughout Central Europe, and sporadic human cases are reported from most countries

as a result of occupational exposure. Human cases of leptospirosis have been contracted

from bathing in some rivers of Central Europe. All 18 outbreaks of leptospirosis in

Romania between 1978 and 1984 occurred after swimming or bathing in rivers. An

epidemiological study in Slovakia from 1970 to 1991 found a 50% decline in the

incidence of the leptospirosis, although over 500 cases were reported from Bosnia and

Herzegovina in 1995.

Transmission Cycle(s). Numerous wild and domestic animals act as reservoirs,

including rodents, raccoons, deer, bear, boar, foxes, squirrels, swine, cattle, sheep, goats,

and horses. Cats and dogs are frequently infected but are probably insignificant as a

source of infection to humans. Dogs are a good indicator of the distribution of different

leptospiral serovars in the environment. Many small mammals are involved in the

epidemiology of leptospirosis in Central Europe. The common vole, Microtus arvalis,

and the striped field mouse, Apodemus agrarius, are important reservoirs in addition to

domestic rodents. Because of its prevalence in rodents and domestic animals,

leptospirosis has usually been an occupational hazard to farmers, sewer workers,

veterinarians, animal husbandry workers, slaughterhouse workers, and rice and sugarcane

field workers. Leptospira infect the kidneys and are transmitted in the urine of infected

animals. Humans become infected through contact of skin or mucous membranes with

contaminated water, moist soil or vegetation. Leptospira survive only in fresh water. 

Spirochetes are not shed in the saliva; therefore, animal bites are not a source of

infection. Although infected humans shed Leptospira in urine, person-to-person

transmission is rare. Infection may occasionally occur by ingestion of food contaminated

with urine from infected rats. Infection from naturally infected meat or milk is low. 

Spirochetes disappear from whole milk within a few hours.
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Disease Prevention and Control. To prevent leptospirosis, control domestic rodents

around living quarters and food storage and preparation areas. Leptospira are readily

killed by detergents, desiccation, acidity, and temperatures above 60oC. Good sanitation

reduces the risk of infection from commensal rodents. Troops should be educated about

modes of transmission and instructed to avoid swimming or wading in potentially

contaminated waters. Leptospirosis could be a problem following flooding of

contaminated streams or rivers. Vaccines have been used effectively to protect workers

in veterinary medicine, and immunization has also been used to protect against

occupational exposure to specific serovars in Japan, China, Italy, Spain, France, and

Israel. Short-term prophylaxis may be accomplished by administration of antibiotics. 

Doxycycline was effective in Panama in preventing leptospirosis in military personnel.

B. Hantaviral Disease. [Epidemic hemorrhagic fever, Korean hemorrhagic fever,

Nephropathia epidemica, Hemorrhagic nephrosonephritis, Hemorrhagic fever with renal

syndrome (HFRS), hantavirus pulmonary syndrome (HPS)]

Hantaviruses are a closely related group of zoonotic viruses that infect rodents. The

genus Hantavirus, family Bunyaviridae, comprises at least 14 viruses, including those

that cause HFRS and HPS. Syndromes in humans vary in severity but are characterized

by abrupt onset of fever, lower back pain, and varying degrees of hemorrhagic

manifestations and renal or pulmonary involvement. Depending in part on which

hantavirus is responsible for illness, HFRS can appear as a mild, moderate or severe

disease. Severe illness is associated with Hantaan virus (HTN) and Seoul virus (SEO),

primarily in Asia and the Balkans. The case fatality rate is variable but is about 5% in

Asia and somewhat higher in the Balkans. Convalescence takes weeks to months. A less

severe illness caused by Puumala virus (PUU) and referred to as nephropathia epidemica

predominates in Europe. Dobrava-Belgrade (DOB) virus has caused severe HFRS cases

in several countries surrounding Turkey, with mortality rates of up to 20%. Tula virus

(TUL) has been isolated throughout Europe and eastward to the Kirov region, Russia, but

its role in human disease is unclear. HPS, caused by several hantaviruses, has been

reported throughout North and South America. 

Military Impact and Historical Perspective. Prior to World War II, Japanese and

Soviet authors described HFRS along the Amur River in Manchuria. An epidemic of

“trench nephritis” during World War I may have been due to hantaviral infection.

Thousands of cases of this illness, considered an entirely new disease, were noted on both

sides of the front. During World War II, more than 10,000 cases of a leptospirosis-like

disease were recorded during the 1942 German campaign in Finnish Lapland. When the

snow melted, great numbers of lemmings and field mice invaded German bunkers. In

1951, HFRS was recognized among United Nations troops in Korea and has been

observed in both military personnel and civilians since then.
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Hantaviral disease is an emerging medical threat to military forces operating in many

areas of the world. Over 20 acute PUU infections were documented in US Army

personnel during a 1990 field exercise in southern Germany. Several outbreaks of

hantaviral disease occurred in1995 as a result of the civil war in the states of the former

Yugoslavia. Over 300 patients, most of them soldiers exposed in the field, were

hospitalized in the Tuzla region (northeast Bosnia) with acute hantaviral disease. 

Outbreaks also occurred around Sarajevo and Zenica. Croatia reported over 200 cases 

from several localities. A study the following year in central Croatia found 11% of

sampled rodents were infected with HTN. Over 100 cases were reported in northern

Montenegro. Hantaviral infections also occurred during the fighting in Kosovo. 

Advanced diagnostic techniques have led to increasing recognition of new hantaviruses

and hantaviral infections globally. New outbreaks with novel hantaviral strains are still

being uncovered. The distribution of new and old strains of hantaviruses presents a

complex and confusing epidemiological picture of this emerging disease, but the military

threat is significant. 

Disease Distribution. At least 200,000 cases of HFRS involving hospitalization are

reported annually throughout the world. Hantaan virus claims 40,000 to 100,000 victims

annually in China. South Korea has reported about 1,000 cases annually in recent years. 

In Central Europe, at least 4 hantaviruses (PUU, DOB, HTN and TUL) are enzootic,

primarily in rural and semirural areas. SEO virus is associated with the commensal

Norway rat and occurs in more urban areas. Most clinical cases are reported from the

Balkans. PUU infections predominate but most infections are subclinical. Prevalence of

hantaviral antibodies in endemic areas increases with age. During the 1990s, outbreaks

of Dobrava virus were reported from the Albanian southern Karst Mountain region, in

neighboring Greece, and Bosnia and Herzegovina.

Transmission Cycle(s). Virus is present in the urine, feces and saliva of persistently

infected, asymptomatic rodents. Aerosol transmission to humans from rodent excreta is

the most common mode of infection. Human-to-human transmission of HFRS is

considered rare, although viruses have been isolated from the blood and urine of patients. 

Hantaviruses have caused laboratory-associated outbreaks of infection.

Each hantavirus appears to have a single predominant murid reservoir. HTN is

commonly associated with the field mouse, Apodemus agrarius, in open field or

unforested habitats. The red bank vole, Clethrionomys glareolus, inhabits woodland or

forest-steppe environments and is a primary reservoir for PUU. DOB has been isolated

from the yellow-necked field mouse, Apodemus flavicollis, in open field and unforested

foothills. The Norway rat, Rattus norvegicus, is the reservoir for SEO worldwide. The

common European vole, Microtus arvalis, appears to be the primary reservoir of TUL. 

Hantavirus infection is not pathogenic in its rodent reservoir and produces chronic and
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probably lifelong infection. Hantaviruses may be spread by infected rodents that infest

ships, thereby reaching ports worldwide. 

The risk of transmission is highest in warm months when rodent reservoir populations are

abundant. Military personnel are exposed to infection when working, digging or sleeping

in fields infested by infected rodents. 

Disease Prevention and Control. Exclude or prevent rodent access to buildings. Store

food in rodent-proof containers or buildings. Disinfect rodent-contaminated areas with

dilute bleach or other antiviral agents. Do not sweep or vacuum rodent-contaminated

areas; use a wet mop moistened with disinfectant. Eliminate wild rodent reservoirs

before military encampments are established in fields. Do not disturb rodent droppings

or sleep near rodent burrows. Military personnel should not tame wild rodents. Rodents

frequently urinate or bite when handled. Detailed information on surveillance and

personal protective measures when working around potentially infected rodents can be

found in TIM 40, Methods for Trapping and Sampling Small Mammals for Virologic

Testing, and in TIM 41, Protection from Rodent-borne Diseases. 

VIII. Noxious/Venomous Animals and Plants of Military Significance.

A. Arthropods.

Annoyance by biting and stinging arthropods can adversely affect troop morale. The

salivary secretions and venoms of arthropods are complex mixtures of proteins and other

substances that are allergenic. Reactions to arthropod bites and stings range from mild

local irritation to systemic reactions causing considerable morbidity, including rare but

life-threatening anaphylactic shock. Insect bites can be so severe and pervasive that they

affect the operational readiness of troops in the field. Bites and their discomfort have

been a major complaint by soldiers deployed in many regions of the world.

Entomophobia, the irrational fear of insects, and the related arachnophobia, fear of

spiders, are two of the most common human phobias. The fear is usually not limited to

obvious threats, such as scorpions The anxiety produced in a fearful individual by a

potential encounter with an insect ranges from mild aversion to panic. The degree of

negative response to encounters with insects or spiders is important in assessing the

difference between common fear and true phobia. Common fear is a natural extension of

human experience and is appropriate to situations that involve potential danger or require

caution. Phobias, however, are characterized by persistent, high levels of anxiety in

situations of little or no threat to the individual. Many individuals may express a fear of

insects or spiders, but few are phobic to the extent that their ability to function in a

normal daily routine is impaired by their fear. The term delusory parasitosis refers to a
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mental disorder in which an individual has an unwarranted belief that insects or mites are

infesting his or her body or environment. This psychiatric condition is distinct from

entomophobia or an exaggerated fear of real insects. Extreme entomophobia and

delusory parasitosis require psychological treatment. 

The following groups of noxious arthropods are those most likely to be encountered by

military personnel operating in countries of Central Europe:

1. Acari (ticks and mites). Tick paralysis is a potentially fatal but easily cured affliction

of man and animals. It is almost exclusively associated with hard (ixodid) ticks and is

presumably caused by injection of neurotoxin(s) in tick saliva. The toxin, which may be

different in different species, disrupts nerve synapses in the spinal cord and blocks the

neuromuscular junctions. Worldwide, nearly 50 species of hard ticks have been

associated with tick paralysis, although any ixodid tick may be capable of producing this

syndrome. A tick must be attached to its host for four to six days before symptoms

appear. This condition is characterized by an ascending, flaccid paralysis, usually

beginning in the legs. Progressive paralysis can lead to respiratory failure and death. 

Diagnosis simply involves finding the embedded tick, usually at the base of the neck or

in the scalp. After tick removal, symptoms resolve within hours or days. However, if

paralysis is advanced, recovery can take several weeks. No drugs are available for

treatment. Ixodes ricinus and Dermacentor marginatus commonly cause paralysis in

domestic animals in Central Europe and probably in humans as well. Ixodes gibbosus

has caused paralysis in humans.

Most tick bites are painless, produce only mild local reaction, and frequently go

unnoticed. However, dermal necrosis, inflammation or even hypersensitivity reactions

may occur within a few days of tick attachment. After tick removal, a reddened nodule

may persist for weeks or months. Tick-bite wounds can become infected with

Staphylococcus and other bacteria causing local cutaneous abscesses. The bite of the

cave tick, Ornithodoros tholozani, produces deep red, crusted nodules or papules up to

1.5 cm in diameter. Tick toxicosis is a systemic reaction to tick saliva. Tickbite

anaphylaxis has rarely been reported, but studies in Australia suggest it is more common

and potentially life threatening than tick paralysis. Tick removal and other personal

protective measures against ticks are discussed in Appendix F.

Scabies is the most important disease caused by mite infestation, and infestations have

been a common feature of military campaigns. During World War I, scabies infestations

occurred at a rate of 20 per 1,000 soldiers per year among American forces in Europe. 

During World War II, nearly 100,000 cases were reported in American troops. Five

percent of the residents of London became infested with scabies during the bombing of

that city by the German Luftwaffe. During the Falklands War of 1982, scabies became

such a problem among Argentine troops that their fighting efficiency was significantly

impaired.
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Sarcoptes scabiei (family Sarcoptidae) is a parasitic mite that spends its entire life cycle

in burrows in the skin of mammals. Mite infestations cause scabies in man and mange in

other animals, including primates, horses, wild and domestic ruminants, pigs, camels,

rabbits, and dogs and other carnivores. Populations found on different host species differ

physiologically more than morphologically and are referred to as forms (those on man,

for instance, are S. scabiei form hominis). All forms are considered to be the same

species, Sarcoptes scabiei. Mites from one host species do not establish themselves on

another. Humans can become infested with scabies mites from horses or dogs, but such

infestations are usually mild and disappear without treatment. Sarcoptes mites are

common on domestic animals in Central Europe, especially stray dogs, so troops should

avoid contact with local animals. 

Scabies mites are very small, about 0.2 to 0.4 mm. Both sexes burrow in the horny layer

of the skin, but only the female makes permanent winding burrows parallel to the skin

surface. Burrowing may proceed at up to five mm per day, and the burrow may extend

over a cm in length. The female lays a few eggs in the burrow. The six-legged larvae that

hatch from the eggs three to four days after oviposition leave the burrow and move to the

hair follicles. Two nymphal stages that precede the adult are also found in the hair

follicles. The entire life cycle takes 10 to 14 days. Scabies is transmitted from person to

person by close, prolonged personal contact. Transmission is common in dormitories,

barracks and medical facilities. Mites die rapidly away from the human body.

Most mite burrows occur in the interdigital and elbow skin, but skin of the scrotum,

breasts, knees and buttocks is also affected. The face and scalp are rarely involved. In

newly infested persons, a period of three to four weeks usually elapses before

sensitization to mites and mite excretions develops. Itching is not experienced during

this period, and infestations may progress extensively before being noticed. However,

fewer than 20 mites are enough to produce intense itching, particularly at night. The

burrows often become secondarily infected with bacteria. In infested persons, an

extensive rash can cover areas where there are no mites. In immunocompromised

individuals, who do not respond to infestation by itching and scratching, mites can reach

very high populations and produce a scaly crusted skin known as Norwegian scabies. 

Sarcoptes scabiei is cosmopolitan but infestations have been declining in Central Europe. 

Scabies is not a reportable disease in most countries; thus, estimated rates of infestation

are usually inaccurate. Scabies is usually only reported when large outbreaks occur. 

Increases in the incidence of scabies appear to occur in 15 to 20 year cycles that are

related to fluctuating levels of immunity to S. scabiei in the human population. An

epidemiological study of scabies infestation in Poland during the period 1966 to 1986

recorded 1,675,213 cases. Incidence peaked in 1968 at 5,881 cases per 100,000

inhabitants and declined to 48 cases per 100,000 inhabitants by 1986. The highest

proportion of cases were individual infestations in people under the age of 20. The
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highest morbidity occurred in autumn and winter. A study in Czechoslovakia showed a

similar epidemiology, with incidence of infestation peaking in the years 1968 to 1970. 

Incidence of scabies has increased in the war-torn areas of the former Yugoslavia. 

Persons of all ages are affected, although in most developing countries infestation is

highest in poor communities and in children. Infestation is more common in

overcrowded areas with poor hygiene. 

Larvae of the mite family Trombiculidae are known variously as chiggers, harvest mites

and scrub itch mites and are parasites of mammals and birds. Over 1,500 species have

been described and about 30 of these are known to attack humans. Larvae are very small,

measuring about 0.25 mm long. Females lay eggs in damp soil. The eggs hatch into sixlegged larvae that congregate near the tips of grass and fallen leaves and attach to passing

animals that brush against the vegetation. Larvae cluster in the ears of rodents and

around the eyes of birds. On humans they most often attach where the clothing is tight, 

around the waist or genitals. Chiggers do not burrow into the skin as commonly

believed, nor do they feed primarily on blood; rather they remain on the skin surface and

use digestive fluids to form a feeding tube (stylostome) that enables them to feed on

cellular material for several days. Fully fed larvae drop to the ground to continue their

complex life cycle. In the nymphal and adult stages, these mites are believed to prey on

the eggs and larvae of other arthropods. Most temperate zone chiggers have one annual

generation. 

Chiggers do not transmit disease in Central Europe but can cause an intense itchy

dermatitis leading to pustules and sometimes to secondary infection. Species of chigger

mites are common throughout the region. Neotrombicula autumnalis is frequently

implicated in human infestations in Europe. It is commonly called the harvest mite

because the parasitic larvae are active at harvest time in summer and early autumn. It has

been responsible for mass outbreaks of dermatitis even in suburban areas and urban parks

of Central Europe. 

2. Araneae (spiders). More than 35,000 species of spiders have been described

worldwide. All spiders, with the exception of the family Uloboridae, are venomous and

use their venom to immobilize or kill prey. Most spiders are harmless because their

chelicerae cannot penetrate human skin, or they have venom of low toxicity to humans. 

Only about a dozen species have been responsible for severe systemic envenomization in

humans, although as many as 500 may be capable of inflicting significant bites. Those

that can bite humans are rarely seen or recovered for identification, so physicians need to

be able to recognize signs and symptoms of common venomous spider bites in order to

administer appropriate therapy. In Central Europe the widow spiders, Lactrodectus spp.

(family Theridiidae), and the sac spiders, Chiracanthium spp. (family Clubionidae), are

responsible for significant local and systemic effects from envenomization. 
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The brown widow, L. geometricus, and the black widow, L. mactans, are widespread

throughout the region. These are also referred to as hourglass, shoe button, or po-ko-moo

spiders. Considerable variation in coloration and markings exists between species and

between immatures and adults. Widow spiders are found in various habitats in the wild,

especially in protected places, such as crawl spaces under buildings, holes in dirt

embankments, piles of rocks, boards, bricks or firewood. Indoors, they prefer dark areas

behind or underneath appliances, in deep closets and cabinets. They commonly infest

outdoor privies, and preventive medicine personnel should routinely inspect these

structures. Widow spiders spin a crude web and usually will not bite unless provoked.

Latrodectus spp. inject a potent neurotoxin when biting. The bite itself is mild and most

patients don't remember being bitten. Significant envenomization results in severe

systemic symptoms, including painful muscle spasms, a rigid board-like abdomen, and

tightness in the chest. Mortality rates from untreated bites have been estimated at 1 to

5%. Most envenomizations respond quickly to sustained intravenous calcium gluconate.

Antivenins are commercially available and very effective.

Sac spiders of the genus Chiracanthium have a cytolytic venom that produces cutaneous

necrosis in its victims, although the necrotizing lesions are usually not as severe as those

produced by the bite of Loxosceles spp. Some species have neurotoxic components in

their venom. Over 150 species of sac spiders have been recorded worldwide. 

Chiracanthium punctorium is found in southern and Central Europe and is considered to

be Europe’s most venomous spider after the Latrodectus spp. The consequences of bites

include severe local pain, fever, swelling and redness, with a small area of necrosis at the

site of the bite.

3. Ceratopogonidae (biting midges, no-see-ums, punkies). The Ceratopogonidae is a

large family containing nearly 4,000 species. These extremely small flies can easily pass

through window screens and standard mosquito netting, although most species feed

outdoors. Their small size is responsible for the moniker "no-see-ums." Many species in

this group attack and suck fluids from other insects. Most species that suck vertebrate

blood belong to the genera Culicoides (1,000 species) or Leptoconops (about 80 species). 

In Central Europe these insects do not transmit human diseases, but they do serve as

vectors for several diseases of veterinary importance. Many species of Ceratopogonidae

are widespread in the region, but little is known about their biology. Most Central

European species of Culicoides are zoophilic. Leptoconops are more likely to be a major

nuisance to man. Blood-sucking species predominately feed and rest outdoors, entering

houses in much smaller numbers. Only females suck blood. Leptoconops are active

during the day; Culicoides may be either diurnal or nocturnal. Diurnal species of both

genera prefer early morning and late afternoon periods. Despite their small size, they

often cause local reactions severe enough to render a military unit operationally
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ineffective. In sensitive people bites may blister, exude serum, itch for several days, or

be complicated by secondary infections from scratching. Enormous numbers of these

tiny flies often emerge from breeding sites, causing intolerable annoyance.

Breeding habits vary widely from species to species. The larvae are primarily aquatic or

semiaquatic, occurring in the sand or mud of fresh, salt, or brackish water habitats,

notably salt marshes and mangrove swamps. Many species exploit specialized habitats

such as tree holes, decaying vegetation, and cattle dung. Most species remain within 

500 m of their breeding grounds. Ceratopogonidae are troublesome mainly under calm

conditions, and the number of flies declines rapidly with increasing wind speed. In

militarily secure areas, encampments should be located in the open, away from breeding

sites, to avoid the nuisance caused by these insects.

Larvae are difficult to find, but adults are easily collected while biting and with light

traps. Environmental management best controls larval stages, but this may be

impractical. Adult control typically includes applying residual insecticides to fly

harborages, treating screens and bednets with pyrethroids, and using repellents.

4. Chilopoda (centipedes) and Diplopoda (millipedes). Centipedes in tropical

countries can attain considerable size. Members of the genus Scolopendra can be over

25 cm long and are capable of inflicting painful bites, with discomfort lasting one to five

hours. Species of this genus known to bite man are most likely to be encountered in

coastal areas of the Mediterranean. Two puncture wounds at the site of attack

characterize the bite. Neurotoxic and hemolytic components of a centipede's venom

normally produce only a localized reaction, but generalized symptoms such as vomiting,

irregular pulse, dizziness and headache may occur. Most centipede bites are

uncomplicated and self-limiting, but secondary infections can occur at the bite site. 

Centipede bites are rarely fatal to humans.

Centipedes are flattened in appearance and have one pair of legs per body segment. 

Large species may have over 100 pairs of legs. They are fast-moving, nocturnal

predators of small arthropods. During the day, they hide under rocks, boards, bark,

stones and leaf litter, but occasionally they find their way into homes, buildings, and

tents. Centipedes are not aggressive and seldom bite unless molested. Most centipede

bites occur when the victim is sleeping or when putting on clothes in which centipedes

have hidden. Troops should be taught to inspect clothing and footwear when living in the

field.

Millipedes are similar to centipedes except that they have two pairs of legs per body

segment and are rounded or cylindrical instead of flattened. Millipedes are commonly

found under stones, in soil and in leaf litter. They are nocturnal and most species feed on

decaying organic matter. They are more abundant during the wet season. When
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disturbed they coil up into a tight spiral. Millipedes do not bite or sting, but some species

secrete defensive body fluids containing quinones and cyanides that discolor and burn the

skin. An initial yellowish-brown tanning turns to deep mahogany or purple-brown within

a few hours of exposure. Blistering may follow in a day or two. Eye exposure may

require medical treatment. A few species from the genera Spirobolida, Spirostreptus,

and Rhinocrichus can squirt their secretions a distance of 80 cm or more. 

5. Cimicidae (bed bugs). There are over 90 species in the family Cimicidae. Most are

associated with birds and/or bats and rarely bite humans. The common bed bug, Cimex

lectularius, has been associated with humans for centuries and is cosmopolitan in

distribution. The tropical bed bug, Cimex hemipterus, also feeds on humans and is

similar in appearance to C. lectularius. It is common in tropical areas of Asia, Africa and

Central America. Bed bug infestations are typical of unsanitary conditions, but they can

still be found in developed countries. There is little evidence that bed bugs transmit any

pathogens. Bites can be very irritating, prone to secondary infection after scratching, and

may produce hard swellings or welts. Bed bugs feed at night while their hosts are

sleeping but will feed during the day if conditions are favorable. During the day they

hide in cracks and crevices, under mattresses, in mattress seams, spaces under

baseboards, or loose wallpaper. Chronic exposure to bed bugs can result in insomnia,

nervousness and fatigue. Some studies have found a high percentage of asthmatic

patients had positive skin reactions to Cimex antigen. 

Five nymphal instars precede the adult stage. Each nymph must take a bloodmeal in

order to molt. Adults live up to one year. Bed bugs take about five minutes to obtain a

full bloodmeal. They can survive long periods of time without feeding, reappearing from

their hiding places when hosts become available. Bed bugs possess scent glands and

emit a characteristic odor that can easily be detected in heavily infested areas. Blood

spots on bedding or “bedclothes” and fecal deposits are other signs of infestation. 

Infestations of bed bugs in human habitations are uncommon in most areas of Central

Europe. In Czechoslovakia the bat bug, Cimex dissimilis, has been known to attack man

when bat colonies were removed from human dwellings. Bed bugs can be introduced

into barracks through infested baggage and belongings. In contingency situations, old

dwellings should be surveyed for these and other pests before they are occupied. Cimex

lectularius is common in poultry houses in many parts of the region and should be

avoided by military personnel. 

6. Dipterans Causing Myiasis. Myiasis refers to the condition of fly maggots infesting

the organs and tissues of people or animals. Worldwide there are three major families of

myiasis-producing flies: Oestridae, Calliphoridae and Sarcophagidae. The Oestridae

contains about 150 species known as bot flies and warble flies. They are all obligate

parasites, primarily on wild or domestic animals. Members of the genera Cuterebra and
150

Dermatobia commonly infest humans in the Americas. The Calliphoridae, known as

blow flies, are a large family composed of over 1,000 species. At least 80 species,

mostly in the genera Cochliomyia, Chrysomya, Calliphora and Lucilia, have been

recorded as causing cutaneous myiasis. The family Sarcophagidae, known as flesh flies,

contains over 2,000 species, but its only important genus in terms of myiasis is

Wohlfahrtia. 

 Myiasis is also classified according to the type of host-parasite relationship, and specific

cases of myiasis are clinically defined by the affected organ, e.g., cutaneous, enteric,

rectal, aural, urogenital, ocular, etc. Myiasis can be accidental when fly larvae

occasionally find their way into the human body. Accidental enteric myiasis occurs from

ingesting fly eggs or young maggots on uncooked foods or previously cooked foods that

have been subsequently infested. Other cases may occur from the use of contaminated

catheters, douching syringes, or other invasive medical equipment in field hospitals. 

Accidental enteric myiasis is usually a benign event, but larvae may survive temporarily,

causing stomach pains, nausea, or vomiting. Numerous fly species in the families

Muscidae, Calliphoridae, and Sarcophagidae are involved in accidental enteric myiasis. 

A common example is the cheese skipper, Piophila casei (family Piophilidae), which

infests cheese, dried meats and fish.

Facultative myiasis occurs when fly larvae infest living tissues opportunistically after

feeding on decaying tissues in neglected wounds. Considerable pain and injury may be

experienced as fly larvae invade healthy tissues. Facultative myiasis has been common

in wounded soldiers throughout military history, and numerous species of Muscidae,

Calliphoridae, and Sarcophagidae have been implicated. Species of these families are

widespread throughout Central Europe.

Myiasis is obligate when fly larvae must develop in living tissues. This constitutes true

parasitism and is essentially a zoonosis. Obligate myiasis is a serious pathology. In

humans, obligate myiasis results primarily from fly species that normally parasitize

domestic and wild animals. The sheep bot fly, Oestrus ovis, is found wherever sheep are

raised. Larvae are obligate parasites in the nostrils and frontal sinuses of sheep, goats,

camels and horses. Human ocular infestation by O. ovis is not uncommon in Central

Europe. Several cases occurred in US military personnel during the Persian Gulf War. 

Female flies are larviparous, depositing larvae while in flight directly into the human eye. 

Normally, infestations produce a painful but not serious form of conjunctivitis. 

However, larvae are capable of penetrating to the inner eye, causing serious

complications.

Wohlfahrtia magnifica (family Sarcophagidae) is an important obligatory parasite in the

wounds and natural orifices of warm-blooded animals, including humans. Female flies

deposit over 100 first-stage larvae in wounds or next to body orifices of the host. The
151

larvae mature in five to seven days before leaving the wound and dropping to the ground

where they pupate. Cases of myiasis caused by this species have been reported from

Central Europe. This fly commonly infests livestock, particularly sheep. One study in

Romania found that 80 to 95% of sheep were infested.

Myiasis is rarely fatal, but troops living in the field during combat are at a high risk of

infestation. Good sanitation can prevent most cases of accidental and facultative myiasis.

To prevent flies from ovipositing on them, exposed foodstuffs should not be left

unattended. Fruits and vegetables should be washed prior to consumption and examined

for developing maggots. Extra care should be taken to keep wounds clean and dressed. 

Avoid sleeping in the nude, especially outdoors during daytime when adult flies are

active and likely to oviposit in body orifices. At field facilities, proper waste disposal

and fly control can reduce fly populations and the risk of infestation.

The larvae of most species of flies are extremely difficult to identify. Geographic

location and type of myiasis are important clues to identity. It is particularly helpful to

rear larval specimens so that the adult can be used for identification.

7. Hymenoptera (ants, bees and wasps). Most wasps and some bees are solitary or

subsocial insects that use their stings for subduing prey. These species are not usually

involved in stinging incidents, and their venom generally causes only slight and

temporary pain to humans. The social wasps, bees and ants use their sting primarily as a

defensive weapon, and their venom causes intense pain in vertebrates.

The three families of Hymenoptera responsible for most stings in humans are the

Vespidae (wasps, hornets, and yellow jackets), the Apidae (honey bees and bumble bees),

and the Formicidae (ants). Wasps and ants can retract their stings after use and can sting

repeatedly. The honey bee stinging apparatus has barbs that hold it so firmly that the

bee's abdomen ruptures when it tries to pull the stinger out of the skin. The bee's poison

gland, which is attached to the stinger, will continue injecting venom after separation. 

Scraping the skin after a bee sting is important to remove the stinger and attached venom

sac. Honey bees and social wasps of the family Vespidae account for most stings

requiring medical treatment in Central Europe. Wild strains of honey bees may be more

aggressive than domesticated populations maintained by bee keepers. Ants can bite,

sting and squirt the contents of the poison gland through the tip of their abdomen as

defensive secretions. The components of the venom are complex and vary with the

species of ant. Formic acid is a common substance discharged as a defensive secretion. 

Some protein-feeding ants such as the pharaoh ant, Monomorium pharaonis, have been

incriminated as mechanical vectors of pathogens in hospitals.

 

Hymenoptera venoms have not been fully characterized but contain complex mixtures of

allergenic proteins and peptides as well as vasoactive substances, such as histamine and
152

norepinephrine. These are responsible for the pain at the sting site, irritation, redness of

the skin, and allergic reactions in sensitized individuals. There is no allergic crossreactivity between honey bee and vespid venoms, although cross-reactivity may exist to

some extent between different vespid venoms. Therefore, a person sensitized to one

vespid venom could have a serious reaction to the sting of another member of the vespid

family.

Reactions to stings may be grouped into two categories, immediate (within two hours) or

delayed (more than two hours). Immediate reactions are the most common and are

subdivided into local, large local, or systemic allergic reactions. Local reactions are

nonallergic responses characterized by erythema, swelling, and transient pain at the sting

site that subsides in a few hours. Stings in the mouth or throat may require medical

assistance. Multiple stings in a short period of time may cause systemic symptoms such

as nausea, malaise and fever. It generally takes 500 or more honey bee stings to kill an

adult by the toxic effects of the venom alone. Large local reactions are characterized by

painful swelling at least 5 cm in diameter and may involve an entire extremity. Systemic

reactions vary from mild urticaria to more severe reactions, including vomiting, dizziness

and wheezing. Severe allergic reactions are rare but can result in anaphylactic shock,

difficulty in breathing, and death within 30 minutes. Emergency kits should be provided

to patients who have experienced anaphylactic reactions to stings. Commercial kits are

available that include antihistamine tablets and syringes preloaded with epinephrine. 

Sensitive individuals should also consider wearing a Medic-Alert tag to alert medical

personnel of their allergy in case they lose consciousness. Venom immunotherapy for

sensitive individuals will reduce but not eliminate the risk of anaphylactic reactions. The

frequency of sting hypersensitivity is probably less than 1% of the population. The

prevalence of systemic reactions to Hymenoptera stings was 3.1% of a sample population

of the Hellenic Air Force. The study concluded that the prevalence of Hymenoptera

allergy and venom sensitization in Greece was high compared to other countries.

Delayed reactions to Hymenoptera envenomization are uncommon but usually present as

a large local swelling or, rarely, as systemic syndromes. The cause of delayed reactions

is unclear and may not always involve immunologic mechanisms.

Individuals can practice a number of precautions to avoid stinging insects. Avoid

wearing brightly colored floral-pattern clothes. Do not go barefoot in fields where bees

and wasps may be feeding at ground level. Avoid the use of scented sprays, perfumes,

shampoos, suntan lotions, and soaps when working outdoors. Be cautious around rotting

fruit, trash containers, and littered picnic grounds, since large numbers of yellow jackets

often feed in these areas. Avoid drinking sodas or eating fruits and other sweets

outdoors, since bees and yellow jackets are attracted to these items. Bees and wasps are

most aggressive around their nests, which should not be disturbed.

 
153

8. Lepidoptera (urticating moths and caterpillars). The caterpillars of certain moths

possess urticating hairs that can cause dermatitis. The hairs are usually connected to

glands that release poison when the hair tips break in human skin. The intensity of the

irritation varies with the species of moth, sites and extent of exposure, and the sensitivity

of the individual, but usually the symptoms are temporary. Hairs stimulate the release of

histamine, and resultant skin rashes last about a week. The irritation is more severe when

the hairs reach mucous membranes or the eyes, where they can cause nodular

conjunctivitis. When the larva pupates, urticating hairs can also become attached to the

cocoon, and later to the adult moth. Hairs readily become airborne. If inhaled, detached

caterpillar hairs can cause labored breathing; if ingested, they can cause mouth irritation. 

The hairs of some species retain their urticating properties long after being shed. Hairs

and setae may drop into swimming pools and irritate swimmers. 

Scratching and rubbing the affected parts of the body should be avoided to prevent

venomous hairs from penetrating deeply into tissues. Running water should be used to

wash the hairs out of the lesion. Light application of adhesive tape and stripping it away

will remove many of the hairs or spines from the skin. Acute urticarial lesions usually

respond to topical corticosteroid lotions and creams, which reduce the inflammatory

reaction. Oral histamines help relieve itching and burning sensations.

Larvae of Thaumetopoea spp. (processionary moths, Thaumetopoeidae) are common in 

Europe and the Mediterranean, although contact dermatitis from moth hairs is a limited

public health problem in Central Europe. Thaumetopoea pityocampa has produced

outbreaks of intense dermatitis in the Balkans. The brown-tailed moth, Euproctis

chrysorrhoea (Family Lymantriidae) has caused large summer outbreaks of allergic

dermatitis along the coast of Croatia and on its offshore islands. These moths are readily

attracted to artificial light in urban areas. A mature larva of the tussock moth, E.

chrysorrhoea, may have several million barbed hairs. 

9. Meloidae (blister beetles), Oedemeridae (false blister beetles) and Staphylinidae

(rove beetles). Blister beetles are moderate-sized (10 to 25 mm in length), soft-bodied

insects that produce cantharidin in their body fluids. Cantharidin is a strong vesicant that

readily penetrates the skin. Handling or crushing the beetles causes blistering within a

few hours of skin contact. There is great variation in individual susceptibility to

blistering from cantharidin. Blisters are generally not serious and normally clear within

seven to 10 days without scarring. If blister beetles are ingested, cantharidin can cause

nausea, diarrhea, vomiting, and abdominal cramps. Blisters that occur on the feet where

they will be rubbed may need to be drained and treated with antiseptics. Cantharidin was

once regarded as an aphrodisiac, and a European species of blister beetle was popularly

known as Spanish-fly. Troops should be warned against using blister beetles for this

purpose, since cantharidin is highly toxic when taken orally.
154

Approximately 1,500 species of Oedemeridae are found worldwide. They are slender,

soft-bodied beetles, five to 20 mm in length. The adults of most species feed on pollen,

so they are commonly found on flowers. These beetles also contain the vesicant

cantharidin. Although there are few references in the medical literature, blister beetle

dermatitis caused by oedemerids may be more common and widespread than currently

recognized. During a training exercise on the North Island of New Zealand in 1987, 74

of 531 soldiers developed blistering after exposure to Thelyphassa lineata. Oedemerids

are readily attracted to light. 

The Staphylinidae, commonly called rove beetles, is another family that produces a

strong vesicating substance that causes blistering. Rove beetles are active insects that run

or fly rapidly. When running, they frequently raise the tip of the abdomen, much as

scorpions do. They vary in size, but the largest are about 25 mm in length. Some of the

larger rove beetles can inflict a painful bite when handled. Many species are small (<five

mm) and can get under clothing or in the eyes. Members of the genus Paederus are

widespread throughout the world. They have a toxin, paederin, that can cause dermatitis,

painful conjunctivitis and temporary blindness after eye contact. Normally, rove beetles

must be crushed to release the vesicating agent. Like beetles in the family Meloidae,

rove beetles are attracted to light and can be a hazard to soldiers at guard posts. Rove

beetles often emerge in large numbers after rains and can cause outbreaks of dermatitis. 

A 1966 outbreak of blistering on Okinawa resulted in 2,000 people seeking medical

treatment. 

10. Scorpionida (scorpions). These arthropods have a stout cephalothorax, four pairs of

legs, a pair of large anterior pedipalps with enlarged claws, and a tail tipped with a

bulbous enlargement and a poisonous stinger. Some species carry the tail above the

dorsum of the thorax, while others drag it behind. Of over 1,500 described species

worldwide, fewer than 25, all in the family Buthidae, possess a venom that is life

threatening to humans. Scorpions inject the venom with a stinger on the tip of their

abdomen, and some species can inflict a painful pinch with their pedipalps. They feed at

night on insects, spiders and other arthropods. During the daytime, scorpions hide

beneath stones, logs or bark, loose earth or among manmade objects. In dwellings,

scorpions frequently rest in shoes or clothing. 

There are few scorpions in Central Europe. The two most widely distributed medically

important species are Buthus occitanus and Euscorpius capathicus. An additional

medically important species, the black scorpion, Androctonus crassicauda, has been

reported from Greece, but this report may be erroneous. A list of scorpions reported

from Central Europe appears in Appendix A.5. 

Most stings are to the lower extremities or the arms and hands. Among indigenous

populations, stings are more often inflicted at night, while scorpions are most actively
155

hunting for prey. Scorpion stings can occur year-round in countries such as Greece,

coastal Albania, and Bosnia and Herzegovina. However, in countries of Central Europe

with colder climates, most stings are reported during the warmer months of April to

August. 

In Albania, Greece, and the countries of the former Yugoslavia (except Slovenia) the

sting of Buthus occitanus causes localized pain, edema, occasional hospitalization and

even death in children. No scorpions of medical importance have been reported from the

Czech Republic, Hungary, Poland, the Slovak Republic or Slovenia. However, the

movement of refugees within Central Europe may have aided in the dispersal of scorpion

species to previously scorpion-free areas. 

Scorpions can sting multiple times, and when trapped, as with a person in a sleeping bag,

will readily do so, as long as the victim is active. Common places where stings are

encountered by military personnel include the boots and under or around piled clothing. 

Scorpion stings broadly affect nearly all body tissues, and they present a mixture of

hemolytic, neurotoxic and cardiotoxic effects. All stings should be considered

potentially dangerous. The severity of scorpion stings can be categorized as follows: 1)

patients with pain but no systemic findings; 2) those who, in addition to pain, have one or

two mild systemic manifestations, such as local muscle spasm, dry mouth, increased

salivation, or runny nose; 3) those who have more severe systemic manifestations but no

central nervous system manifestation or general paralysis; and 4) those who have severe

systemic reactions, including central nervous system involvement, such as confusion,

convulsions, and coma, with or without general paralysis. They may also develop

uncoordinated eye movements, penile swelling, or cyanosis. The most severe

manifestations occur in children, who are more susceptible to the effects of venom

because of their small body mass. Those with type 1, 2, or 3 manifestations can be

managed by attempting to slow the spread of the venom by applying ice, and supporting

the patient with fluids and antihistamines. However, those with type 4 manifestations

require intensive medical treatment, especially during the first 24 hours following the

sting. Antivenin therapy is important for severe cases. For this treatment to be effective,

the stinging scorpion must be captured so it can be properly identified. 

To prevent scorpion stings, military personnel should be instructed to empty boots before

attempting to put them on, carefully inspect clothing left on the ground before putting it

on, and keep sleeping bags tightly rolled when not in use. Also, troops must be cautioned

that scorpions can cause painful reactions requiring medical treatment and should never

be kept or handled as pets.

11. Simuliidae (black flies, buffalo gnats, turkey gnats). Black flies are small (three to

five mm), usually dark, stout-bodied, hump-backed flies with short wings. Despite their

appearance, black flies are strong flyers that are capable of dispersing many km from
156

their breeding sites. Only females suck blood. They can emerge in large numbers and be

serious pests of both livestock and humans. Black flies bite during the day and in the

open. Some species have a bimodal pattern of activity, with peaks of activity around

0900 h in the morning and 1700 h in the afternoon, but in shaded areas biting is more

evenly distributed throughout the day. The arms, legs and face are common sites of

attack, and a favorite site is the nape of the neck. Black fly bites may be itchy and slow

to heal. Systemic reactions, characterized by wheezing, fever or widespread urticaria, are

rare but require medical evaluation and treatment. Numerous species of anthropophilic

black flies are distributed throughout Central Europe and have been a significant source

of human discomfort. 

12. Siphonaptera (fleas). Fleabites can be an immense source of discomfort. The

typical fleabite consists of a central spot surrounded by an erythematous ring. There is

usually little swelling, but the center may be elevated into a papule. Papular urticaria is

seen in persons with chronic exposure to fleabites. In sensitized individuals, a delayed

papular reaction with intense itching may require medical treatment.

Some fleas are extremely mobile, jumping as high as 30 cm. Biting often occurs around

the ankles when troops walk through flea-infested habitat. Blousing trousers inside boots

is essential to provide a barrier, since fleas will crawl under blousing garters. Fleas may

be encountered in large numbers shortly after entering an abandoned dwelling, where flea

pupae may remain in a quiescent state for long periods of time. The activity of anyone

entering such premises will stimulate a mass emergence of hungry fleas. The most

common pest fleas encountered in Central Europe are the cosmopolitan cat and dog fleas,

Ctenocephalides felis and C. canis, the Oriental rat flea, Xenopsylla cheopis, and the

human flea, Pulex irritans. A list of ceratophyllid and pulicid species reported from this

region appears in Appendix A.4.

13. Tabanidae (horse flies and deer flies). Tabanids are large, stout-bodied flies with

well-developed eyes that are often brilliantly colored. More than 4,000 species have

been described worldwide. The larvae develop in moist or semiaquatic sites, such as the

margins of ponds, salt marshes or damp earth. The immature stages are unknown for

most species. Mature larvae migrate from their muddy habitats to drier areas of soil to

pupate. In temperate regions the entire life cycle can take two years or more to complete. 

The larvae of horse flies are carnivorous and cannibalistic, whereas deer fly larvae feed

on plant material. Consequently, deer fly populations can reach considerably higher

numbers in the same area. Deer flies, about 8 to 15 mm long, are about half the size of

horse flies, which range from 20 to 25 mm long. The most common tabanid genera

containing man-biting species are Chrysops (deer flies) and Tabanus and Haematopota

(horse flies).
157

Only female tabanids bite and take a blood meal, and nearly all species feed on

mammals. Males feed on flower and vegetable juices. Tabanids are diurnal and are most

active on warm, sunny days with low wind speeds, especially during the early morning

and late afternoon. Adults are powerful flyers with a range of several km. They are very

persistent biters, and their painful bites are extremely annoying. Tabanids lacerate the

skin with scissor-like mouthparts and ingest the blood that flows into the wound. Some

species can consume as much as 200 mg of blood. The puncture in the skin continues to

ooze blood after the fly has fed. Tabanid bites often become secondarily infected, and

systemic reactions may occur in hypersensitive individuals. The mouthparts and feeding

behavior of tabanids are well suited to the mechanical transmission of blood-borne

pathogens. Because their bites are painful, tabanids are frequently disturbed while

feeding and move readily from host to host. In Central Europe, tabanids are not vectors

of human disease but are serious pests of livestock and transmit several diseases of

veterinary importance.

Tabanids are difficult to control. Larval control is impractical, and ULV aerosols are

generally ineffective against adults. Localized control can be achieved around military

encampments using a variety of simple traps. The skin repellent DEET is only

moderately effective against these flies. 

B. Venomous Snakes of Central Europe

There are six species of venomous snakes in Central Europe, but only three of these are

widely distributed (Table 1). The two families of venomous snakes present in the region

are Colubridae and Viperidae.

Although most species of the family Colubridae are nonvenomous, there is one

venomous species in Central Europe. This species, Malpolon monspessulanus, possesses

relatively small, grooved fangs in the rear of the upper jaw. In order to envenomate a

person, it literally has to be picked up and handled. This snake is rarely encountered, and

little is known about the nature of its venom, except that it can generate an allergic

response. 

Species of Viperidae are commonly known as vipers, adders, or asps. They have heavy,

patterned bodies and triangle-shaped heads, sometimes with horns. They possess two

relatively long, hollow fangs at the front of the upper jaw. These fangs are erected during

a bite, but are folded against the palate when the mouth is shut. Five species of this

family occur in Central Europe. 

Macrovipera schweizeri, the schweizer’s, Milos, or Cyclades blunt-nosed viper, has only

been reported from Greece in Central Europe. This is a robust snake with an average

length of 0.75 to 1.15 m. It is the largest venomous snake in Europe. The head is broad
158

and triangular and distinct from the neck. This snake has a series of brown to gray spots

on its back, which are sometimes joined together. The snake tends to be almost gray in

sandy areas. This species is nocturnal and is very lethargic during the day. Although it

appears sluggish even when hunting, it can strike quickly if molested. It occurs in a wide

range of habitats, including semi-desert to high hilly areas and mountains up to 2,100 m. 

In the Greek islands, it is found in rocky river valleys, often near cultivated fields and

pastures. It is principally a ground dweller, but it can climb bushes and small trees. The

venom of this viper is only moderately toxic, but its bite is considered very dangerous

because of the size of the snake and the amount of venom that may be injected. Its bite

has killed humans as well as sheep, horses and cattle.

Vipera ammodytes, the sand viper, is widely distributed in Central Europe, with Poland

being the only country from which it has not been reported. This is a medium-sized

snake, with a length ranging from 0.6 to 0.75 m. This viper appears to have a short horn

on the tip of its nose. The head is nearly triangular and distinct from the neck. The body

is stout, with a zigzag series of dorsal dark stripes. The overall color is ash gray in males

to reddish brown in females. This snake inhabits a variety of areas, from low plains to

mountains at 2,500 m. It seeks gravelly, rocky areas with few trees and shrubs. It is

mainly a ground dweller but may climb into bushes. This species hibernates from

October to April over much of its range. It is sluggish and not aggressive, although its

hisses loudly when disturbed. Despite its sluggish behavior, it can strike very quickly. 

The sand viper has a highly toxic venom and is considered by many authors to be the

most venomous snake in Europe. Fortunately, only a small quantity of venom is injected. 

Vipera aspis, the asp viper, is found only in Slovenia. This is a small, robust species that

attains a length of 0.45 to 0.6 m. The head is triangular and distinct from the neck. The

snout is distinctly upturned but lacks a nose-horn. The back of the body appears to have

a series of transverse brownish bars, while the overall color of the snake ranges from

yellowish brown to gray or light brown. This species can tolerate very cold weather well

and remains active in temperatures as low as 5 C. It can be found in wet mountainous

regions, but it is more common in warmer, dry, hilly areas and rocky hillsides at lower

elevations. This snake hibernates from October to April. It is a diurnal species in the

spring and fall but becomes a nocturnal hunter during hot summer periods. In the

summer it remains under the cover of vegetation. Individual snakes do not travel very far

and may stay in the same locale for several years. This species is not aggressive and

often appears sluggish. It will strike only if harassed. The risk of envenomation is low,

and the venom usually produces mild to moderately toxic reactions in humans. However,

fatalities have been recorded. 

Vipera berus, the common adder, is very widely distributed and present in all countries

of Central Europe. This snake has a stout body that is slightly flattened and attains a

length of 0.5 to 0.6 m. The head is ovoid in shape and only slightly broadened toward its
159

rear. There is a distinct series of zigzag marks running down the back of the snake, but

the overall appearance of males is of a rather plain gray snake, while females are often

brown. This species has the northernmost distribution of any of the European vipers and

can tolerate the coldest environment of any of the viper species. It is found in rocky

hillsides, woods, moors, and bogs in the northern part of its range. In southern countries,

it is restricted to mountainous areas or moist lowlands. It is a good swimmer and can be

found in rivers and lakes. It flourishes in areas where there are numerous small, grounddwelling animals. This adder hibernates in winter and is active primarily from March to

September, although it may come out of hibernation for short periods during warm spells. 

It is a gregarious species, often hibernating in colonies. The common adder is not

aggressive and usually freezes when danger is sensed. It bites only when highly alarmed

or stepped upon. Its venom is not very toxic. 

Vipera ursinii, the meadow viper, is a small, moderately thick viper, with a length

ranging from 0.4 to 0.5 m. It is the smallest European viper and is found in southern

areas of Central Europe. The center of the back contains a series of dark, zigzag

blotches. The overall dorsal surface can range from yellow to greenish or light brown. 

Completely black specimens have been found in parts of its range, especially in the

former Republic of Yugoslavia. This species occurs in dry plains and flatlands with few

trees and bushes, although it can also occur in sparse woods, hillsides, and mountainous

areas up to 2,700 m. Occasionally it occurs in grasslands and even marshes. It hides in

rodent dens and small animal burrows. This species usually hibernates in colonies from

November to February. During the spring and fall it is usually diurnal, but during the hot

summer months it is a nocturnal hunter, feeding on lizards, grasshoppers and rodents. 

This snake is docile and seldom bothers humans, but it will bite if continuously

disturbed. Its venom is the least toxic of the vipers in Europe, and there are no recorded

human fatalities from its bite.

 Sources of snake antivenoms are listed in Appendix D. For additional information on

snakes and snakebite, contact DPMIAC. Also consult: Management of Snakebite in the

Field, by LTC Hamilton, section IX A . 
160

Table 1. Venomous Snakes and their Reported Distribution in Central Europe

Snake Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

COLUBRIDAE

Malpolon

monspessulanus + + + + + + + +

VIPERIDAE

Macrovipera

schweizeri

+

Vipera ammodytes + + + + + + + + + + + +

V. aspis +

Vipera berus + + + + + + + + + + + + +

V. ursinii + + + + + + + + +
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C. Medical Botany.

1. Plants that Cause Contact Dermatitis. 

Plant dermatitis is a problem of enormous magnitude. Categories of dermal injury

caused by plants include mechanical injury, immediate or delayed contact sensitivity,

contact urticaria, phototoxicity and photoallergy, primary chemical irritation, or some

combination of these. Plants causing contact dermatitis in Central Europe are listed in

Table 2.

Mechanical injury by splinters, thorns, spines, and sharp leaf edges can produce visual

impairment or fungal and bacterial infections at the site of injury. Some dried seeds are

hygroscopic and can cause severe discomfort due to swelling of the plant tissues when

lodged in the auditory canal or other body cavities.

Members of the Rhus group (poison ivy, oak, and sumac) are the most frequent causes of

acute allergic contact dermatitis. About 70% of the US population is sensitive to urushiol

in the sap of these plants. Any part of the skin surface of a sensitized individual may

react upon contact with Rhus spp. Urushiol remains active for up to one year and is

easily transferred from an object to a person, so anything that touches poison ivy

(clothing, tools, animal fur, sleeping bags) ban be contaminated with urushiol and cause a

skin reaction. Even smoke from burning plants can produce a severe allergic response. 

Barrier creams have been developed to prevent contact dermatitis in people sensitive to

urushiol, but they are only partially effective.

Contact urticaria may result from immunological or nonimmunological host responses,

although the latter is more common. Nettles, such as Urtica spp., are examples of plants

that cause nonimmunological contact urticaria. These plants have hollow stinging hairs

that inject a chemical after penetration of the skin. A burning sensation and pruritis

occur almost immediately.

A number of cultivated plants of the carrot and rue families sensitize the skin to longwave ultraviolet light (phytophotodermatitis). Within six to 24 hours of contact with the

plant and exposure to sunlight or fluorescent light, the area of contact will selectively

burn. In some cases, hyperpigmentation may persist for several months.

Some plants contain primary chemical irritants that produce skin damage resembling that

from contact with a corrosive acid. The reaction depends on the potency of the irritant. 

The most serious reactions involve the eyes. Daphne spp. and Euphorbia spp. are

examples of plants containing chemical irritants.
162

For additional information on plants causing dermatitis, contact the Armed Forces

Medical Intelligence Center, Fort Detrick, MD, (301) 619-7574, DSN: 343-7574; FAX:

(301) 619-2409 (DSN = 343).
163

Table 2. Plants that Cause Contact Dermatitis in Central Europe.

Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

Aconitum spp. + + + + + + + + + + +

Actaea spp. + + + + + + + + + +

Bryonia spp. +

Croton spp. + + + + + + + + + + + +

Daphne spp. + + + + + +

Datura spp. + + + + + +

Euphorbia spp. + + + + + + + + + + + + +

Heracleum spp. + + + + + + + + + + +

Polygonatum spp. + + + + + +

Rhus spp.

(Toxicodendron

spp.)

+ + + + + + + + + + + + +

Tamus spp. + +
164

Urtica spp. + + + + + + + + + + + +
165

2. Systemic Toxicity from Ingestion of Plants. 

Most wild plants contain toxic components, and military personnel must be instructed not

to consume local plants unless necessary for survival. Wild plants are difficult to

identify, and poisonous plants can easily be mistaken for plants with parts safe to eat. 

Military personnel will be forced by necessity to consume wild plants during survival

operations. To avoid accidental poisoning, they should be thoroughly trained to

recognize common edible plants in the region. Local inhabitants may be knowledgeable

about poisonous plants in their vicinity.

Many plants have fruiting bodies that appear edible or have attractive parts, such as the

castor bean. Some military personnel may be tempted to consume plants because they

are used locally for various purposes. Local lore may attribute medicinal qualities,

psychotropic or aphrodisiac effects to native plants. Medical personnel and combat

commanders must be aware that some troops will be tempted to experiment with native

plants. Military personnel should not chew on any part of an unfamiliar plant or use

unfamiliar plants for fuel or cooking materials.

In most cases of poisoning, care is usually symptom driven. The age and medical

condition of the patient influence toxic response and medical treatment. Special

monitoring and specific drug therapy are indicated in some instances. Because lifethreatening intoxications are rare, military medical personnel may have little experience

in management of plant poisoning. It is inappropriate to assume that the toxicity

exhibited by a single member of a genus will apply to all other species of that genus or

that all toxic members of a genus will have similar effects. Most toxic plants, regardless

of their ultimate effects, induce fluid loss through vomiting and diarrhea. This is

important when military personnel are operating in hot, arid areas. Plant toxicity varies

with the plant part, maturity, growing conditions, and genetic variation.

TG 196, Guide to Poisonous and Toxic Plants, provides information on toxic plants

common in the US that also occur in other regions of the world. It includes a list of state

and regional poison control centers. For additional information, contact the Armed

Forces Medical Intelligence Center, Fort Detrick, MD, (301) 619-7574, DSN: 343-7574;

FAX: (301) 619-2409 (DSN = 343).
166

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183

Appendix A.1. Distribution of Mosquitoes in Central Europe (+ = present; ? = uncertain).

Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

Aedes aegypti + + ? + + ?

Ae. albopictus + +

Ae. annulipes + + + + + +

Ae. behningi + +

Ae. berlandi +

Ae. cantans + + + + +

Ae. caspius + + + + + + +

Ae. cataphylla + + + +

Ae. cinereus

cinereus

+ + + + +

Ae. cinereus

rossicus

+ + +

Ae. communis + + + + +

Ae. cretinus +

Ae. cyprius + +

Ae. detritus + + + +

Ae. diantaeus + + +

Ae. dorsalis + + + + +

Ae. duplex +

Ae. echinus + +

Ae. esoensis ? +

Ae. excrucians + + + + +
Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

184

Ae. flavescens + + + +

Ae. geminus + +

Ae. geniculatus + + + + + +

A.1. Continued

Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

Ae. hungaricus +

Ae. intrudens + + + +

Ae. lepidonotus +

Ae. leucomelas + + + + +

Ae. mariae + ?

Ae. nigrinus + ? +

Ae. nigripes +

Ae. pulchritarsis + + + + +

Ae. pullatus + + + +

Ae. punctor + + + + +

Ae. refiki + + + +

Ae. riparius + + + +

Ae. rossicus +

Ae. rusticus + + + +

Ae. sticticus + + + + + +

Ae. vexans + + + + + + + + +
Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

185

Ae. zammitii +

Anopheles

algeriensis

+ + + + +

An. atroparvus + + + + + + + + +

An. cinereus

hispaniola + + +

An. claviger + + + + + + + + + + +

An. hyrcanus + + + + +

An. labranchiae + + + + + ? +

 A.1. Continued

Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

An. maculipennis + + + + + + + + + + + + +

An. marteri

marteri

+ +

An. marteri

sogdianus +

An. melanoon + + + ? + + ? +

An. messeae + + + + + + + + + + +

An. petragnani +

An. plumbeus + + + + + + + + + + +
Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

186

An. pseudopictus + +

An. sacharovi ? + + + + + ?

An. sergenti +

An. superpictus + + + + + +

Coquillettidia

buxtoni ? +

Cq. richiardii + + + + + + + +

Culex apicalis +

Cx. hortensis + + + + +

Cx. impudicus ? ?

Cx. laticinctus +

Cx. martinii + + ? + ?

Cx. mimeticus + + ?

Cx. modestus + + + + +

Cx. perexiguus +

Cx. pipiens + + + + + + + + +

Cx. pusillus +

Cx. territans + + + + + +

Cx. theileri + + + +

Cx. torrentium + ? + + +

Cx. univittatus +

Culiseta

alaskaensis

+ + + +
Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

187

Cs. annulata + + + + + + + +

Cs. fumipennis + + +

Cs. glaphyroptera + + ? + +

Cs. longiareolata + + + +

Cs. morsitans + + + + +

Cs. silvestris

ochroptera

+ + + +

Cs. subochrea + + + + +

Orthopodomyia

pulchripalpis + + +

Uranotaenia

unguiculata

+ + + + +
188

Appendix A.2. Distribution of Sand Flies in Central Europe (+ = present; ? = uncertain).

Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

Phlebotomus

alexandrei

+ + + +

P. balcanicus + + + + + + + + + ?

P. caucasicus + + + ?

P. jacusieli + ? +

P. longiductus + + + + ?

P. major + + + + + + + + +

P. mascittii + ? + +

P. neglectus + + + + + + +

P. papatasi + + + + + + + + + +

P. perfiliewi + + + + + + + + + +

P. perniciosus + + + + + + + + +

P. sergenti + + + + + ? + + + +

P. simici + + + + + + + +

P. simulus + + + + + + + + +

P. syricus +

P. tobbi + + + + + +
Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

Phlebotomus

alexandrei

+ + + +

P. balcanicus + + + + + + + + + ?

P. caucasicus + + + ?

P. jacusieli + ? +

P. longiductus + + + + ?

P. major + + + + + + + + +

P. mascittii + ? + +

P. neglectus + + + + + + +

P. papatasi + + + + + + + + + +

P. perfiliewi + + + + + + + + + +

P. perniciosus + + + + + + + + +

P. sergenti + + + + + ? + + + +

P. simici + + + + + + + +

P. simulus + + + + + + + + +

P. syricus +

189

Sergentomyia dentata + + + + + +

S. minuta + + + + + + +
Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

Phlebotomus

alexandrei

+ + + +

P. balcanicus + + + + + + + + + ?

P. caucasicus + + + ?

P. jacusieli + ? +

P. longiductus + + + + ?

P. major + + + + + + + + +

P. mascittii + ? + +

P. neglectus + + + + + + +

P. papatasi + + + + + + + + + +

P. perfiliewi + + + + + + + + + +

P. perniciosus + + + + + + + + +

P. sergenti + + + + + ? + + + +

P. simici + + + + + + + +

P. simulus + + + + + + + + +

P. syricus +

190

S. theodori +

Appendix A.3. Distribution of Ticks in Central Europe (+ = present; ? = uncertain).
191

Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

ARGASIDAE

Argas persicus + + + +

A. polonicus +

A. reflexus + +

A. vespertilionis +

Ornithodoros 

lahorensis

+ + +

O. peusi +

IXODIDAE

Boophilus annulatus + + + + + + +

D. marginatus + + + + + +

D. niveus ? + ? ? + + ?

D. reticulatus + + + + + + +

Haemaphysalis

concinna

+

H. erinacei +

H. e. taurica +

H. inermis ? + + + + + + + + + +

H. parva +

H. punctata + + + + + + + + + +

H. sulcata + + + +

Hyalomma

aegyptium

+ + +

H. detritum ? + ? + + +

H. marginatum

marginatum 

+ + + + ? + + + +

Ixodes canisuga +

I. gibbosus + + + + +
Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

192

I. hexagonus ? + + + + + + +

I. persulcatus + ? + + +

I. ricinus + + + + + + + + + + + + +

I. trianguliceps + + + + + + + +

Rhipicephalus bursa ? + + + + ? ? +

R. rossicus + + +

R. sanguineus

+ + + + + + + + + + + + +
193

Appendix A.4. Distribution of Fleas in Central Europe.

Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

CERATOPHYLLIDAE

Amalaraeus arvicolae + + + + + + + + + +

A. penicilliger + + + + + + + + + +

Callopsylla c. caspia +

C. orneacus waterstoni + +

Ceratophyllus c. affinus + + +

C. c. delichoni + +

C. c. enefdeae + + + +

C. c. farreni + + + + +

C. c. fringillae + + + + + + + + + +

C. c. gallinae + + + + + + + + +

C. c. hirundinis + + + + + + + + +

C. c. pullatus + +

C. c. rossittensis + + + + +

C. c. rusticus + + + + + + + + + + +

C. c. styx + + + + + + + +

C. c. tribulus +
194

C. c. vagabundus + +

C. emmareus borealis + + + + + +

C. e. columbae + + + + + + + +

C. e. garei + + + + + + + +

C. e. spinosus + + +

C. monopsyllus sciurorum + + + + + + + + + + +

C. rosickyiana lunatus + + +

A.4. Continued

Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

Citellophylus martinoi + + + + + + + +

C. simplex + + + + +

Dasypsyllus d. gallinulae + + + + + + + + + +

Megaaabothris m. walkeri + + + + +

M. gebiella rectangulatus + + + +

M. g. turbidus + + + + + + + + + +

Myoxopsylla m. lavarani + + + + + +

M. miriampsylla jordani +

Nosopsyllus n. consimilis + + + + +

N. n. durii +

N. n. fasciatus + + + + + + + + + + + + +

N. n. londiniensis + +

N. n. mokrzeckyi + + + + +
195

Oropsylla o. silantiewi + +

Paraceras melis + + + + + + + + +

Tarsopsylla octodecimdentata + + + + + + + + + +

PULICIDAE

Ctenocephalides canis + + + + + + + + + + + + +

C. felis + + + + + + + + + + + + +

Pulex irritans + + + + + + + + + + + + +

Xenopsylla cheopis + + + + + + + + + + + + +
196

Appendix A.5. Distribution of Scorpions in Central Europe (+ = present; ? = uncertain).

Scorpion Species ALB BIH BGR HRV CZE GRC HUN MKD POL ROM SER SVK SVN

Buthidae

Androctonus bicolor +

Androctonus

crassicanda ?

Buthus occitanus + + ? + + + +

Mesobuthus gibbosus ? + ? ? +

Euscorpiidae

Euscorpius flavicaudis +

Euscorpius capathicus + + + + +

Euscorpius germanus + + ? + + + + +

Euscorpius italicus + + ? ? + ? ?

Euscorpius +

Iuridae

Iurus dufoureius +

Panaiurus nordmanni +
198

Appendix B. Vector Ecology Profiles of Tick Vectors in Central Europe.

Species Geographic

Distribution

Potential Hosts Disease Transmission Bionomics/Habitat

Boophilus

annulatus

Bulgaria, Greece &

Serbia. 

Adults & immatures feed on

cattle, sheep, rarely horses &

man.

A minor CCHF vector. A 1-host tick. All stages of the life

cycle are normally spent on cattle.

Females lay eggs one month after

feeding and mating. Life cycle <1

year. 

Dermacentor

marginatus

Reported from

Bulgaria, Croatia,

Greece & Serbia.

Probably occurs in

other countries.

Adults feed on sheep, cattle,

dogs, deer & humans. 

Immatures feed on rodents,

hares, foxes & shrews.

Secondary vector of

CCHF, TBE, & Lyme

disease. Good vector of

spotted fever group &

Bhanja virus. 

A 3-host tick. Inhabits a wide range

of biotopes such as shrubby growth,

forests and steppes. Resists

desiccation. May diapause on its

host. Lays large number of eggs –

up to 6,200. 

Dermacentor

reticulatus

Croatia, Poland,

Serbia & Slovakia. 

Adults feed on bear, cattle,

sheep & dogs. Immatures

feed on mice, voles &

hedgehogs.

Vectors TBE. A 3-host tick that occurs along

rivers, in meadows & forests. Life

cycle usually takes 1 year. 

Overwinters primarily as adults . 

Haemaphysalis

concinna

Slovakia. Adults feed on deer and

livestock, especially cattle,

sheep & goats. Immatures

feed on hedgehogs, hares

and birds. 

Zoonotic TBE vector.

Secondary Lyme

disease vector.

Transovarial

transmission of TBE

virus occurs.

A 3-host tick. Inhabits meadows

next to woods, marshy areas &

streamsides. Engorgement is slow,

taking up to 9 days for females. 

Larvae & nymphs may diapause. 

Life cycle takes 1-3 years. 
200

 Appendix B. Continued.

Species Geographic

Distribution

Potential Hosts Disease Transmission Bionomics/Habitat

Haemaphysalis

inermis

Bulgaria, Czech

Republic, Greece,

Romania, Serbia &

Slovakia. Possibly other

former Yugoslav

republics. 

Adults feed on deer,

goats, cattle & foxes. 

Immatures feed on

hedgehogs, shrews &

other small rodents.

Zoonotic TBE A large 3-host tick. Larvae feed

only a few hours. Adults feed for

several days but often produce only

about 200 eggs. 

Hyalomma m.

marginatum

Bulgaria, Greece &

Slovakia.

Adults feed on sheep,

goats, cattle, dogs &

sometimes humans.

Immatures feed on

rodents, hares & birds.

Primary vector of

CCHF. Transovarial

transmission occurs. 

A 3-host tick. Inhabits a wide

variety of habitats & is common in

cattle pastures or feedlots. Nymphs

feed on host’s ears. This species is

often active in winter months.

Aggressive host-seeker; resistant to

climatic extremes and aridity. 

Haemaphysalis

punctata

Bulgaria, Greece, the

Czech Republic,

Slovakia & Serbia.

Adults feed on sheep,

cattle, goats, dogs, deer

& humans. Immatures

feed on birds, hares and

voles.

Transmits TBE, CCHF

& Lyme disease. Also

vectors Bhanja virus.

Transmits TBE &

CCHF transovarially. 

A 3-host tick. Inhabits shrubby

growth, pastures & forests in

submediterranean biotopes. 

Attaches at neck or groin areas of

hosts. 

Haemaphysalis

sulcata

Bulgaria, Croatia,

Greece & Serbia. 

Adults feed on goats,

sheep & deer.

Immatures feed on

hares, rodents and 

small lizards. 

Bhanja virus. A 3-host tick that inhabits scrubby

oak, beech/pine forests in mountain

& high plateaus. Adults emerge in

autumn & feed 10-13 days. Life

cycle takes 1 year. 
201

Appendix B. Continued.

Species Geographic

Distribution

Potential Hosts Disease Transmission Bionomics/Habitat

Ixodes

hexagonus

Greece, Serbia,

Slovenia, probably

Bosnia & Croatia. 

Adults & immatures

feed on hedgehogs,

martens, feral cats,

dogs, cattle &

badgers. 

Zoonotic TBE vector.

Transstadial transmission

occurs.

A large 3-host tick that lives in lowlands and

hilly areas. Has a rapid life cycle that can be

completed in 4 months to 1 year. 

Ixodes ricinus Probably all countries

of Central Europe.

Adults feed on sheep,

cattle, deer, foxes &

man. Immatures feed

on rodents, hares,

hedgehogs, foxes,

dogs & man.

Principal vector of Lyme

disease. Good vector of

TBE. Rarely vectors

CCHF. Transovarial

transmission of virus

occurs. 

A 3-host tick. Inhabits moist, dense,

oak/hornbeam forests. Poorly adapted to

desiccation. Life cycle requires 2-4 years. 

Females lay up to 2700 eggs. All stages can

overwinter.

Ixodes

trianguliceps

Bosnia, Bulgaria,

Czech Republic,

Croatia, Macedonia,

Serbia, Slovakia &

Slovenia.

Adults & immatures

feed on moles, voles

& shrews. 

Zoonotic TBE vector. A 3-host tick that lives in forested mountains

or grassy hills, often along coasts. A coldresistant tick that usually completes life cycle

in 1 year. 
202

Rhipicephalus

bursa

Bulgaria, Greece &

Serbia. 

Adults feed on swine,

cattle, sheep, rarely

horses & dogs. 

Immatures feed on

hares, cattle & sheep. 

Secondary vector of Lyme

disease. A secondary

zoonotic CCHF vector. 

A 2-host tick. H

overwinter. May 

not found during 

Rhipicephalus

sanguineus

Throughout Central

Europe. 

Adults & immatures

feed on dogs, cattle,

horses, sheep, &

sometimes man. 

Vectors spotted fever

group; possible vector of

CCHF. 

A 3-host tick. Qu

Adults attach on 

Immatures prefer 

neck. Eggs are la

Appendix C

Pesticide Resistance in Central Europe

Vector-borne diseases are an increasing cause of death and suffering in many areas of the

world. Efforts to control these diseases have been founded on the use of chemical

pesticides. However, the spread of resistance among arthropods has rendered many

pesticides ineffective, while few substitute pesticides are being developed. Resistance

has been reported to every class of insecticides, including microbial agents and insect

growth regulators.

 

Resistance is formally defined by the WHO as "the development of an ability in a strain

of some organism to tolerate doses of a toxicant that would prove fatal to a majority of

individuals in a normal population of the same species." Resistance has a genetic basis

and is the result of a change in the genetic composition of a population as a direct result

of the selection effects of the pesticide.

Early detection and monitoring are vital to resistance management. Historically,

standardized methods, test kits and insecticides were provided by WHO. The simplest

method of detecting resistance is the diagnostic dose test. The diagnostic dose is a

predetermined insecticide dose known to be lethal to a high proportion of susceptible

individuals, but that a high proportion of resistant individuals can tolerate. A list of

recommended diagnostic doses of many insecticides for a number of arthropod vectors is

available from WHO. For terrestrial and/or adult stages, the insecticide is either applied

topically or insects are exposed to a surface treated with insecticide. For aquatic stages,

insecticide is added to water at given concentrations.

New approaches use rapid biochemical tests to detect resistance and determine resistance

mechanisms. These methods permit multiple assays of a single specimen. Worldwide

application of biochemical assays will require production of standardized kits similar to

the insecticide bioassay kits supplied by WHO. The choice of method to test for
203

resistance is of great importance in order to determine resistance mechanisms. Consult

TG 189, Procedures for the Diagnostic Dose Resistance Test Kits for Mosquitoes, Body

Lice, and Beetle Pests of Stored Products. To obtain test kits and additional

recommendations for resistance testing contact:

 USACHPPM/Entomological Sciences Programs

 5158 Blackhawk Road

 Aberdeen Proving Ground, MD 21010-5422

 Tel: (410) 436-3613

 DSN 584-3613, FAX (410) 436-2037

Pesticide resistance can be classified into two broad categories: physiological and

behavioral. There are many mechanisms of physiological resistance, including reduced

penetration of insecticides through the cuticle, presence of enzymes that detoxify the

insecticide, and reduced sensitivity of the target site of the insecticide. Physiological

resistance can confer cross-resistance to structurally related insecticides of the same

chemical class or related classes. Some vector populations have acquired several

resistance mechanisms providing multiple resistance to a variety of insecticide classes. 

Many vector control programs have reached a stage where resistance is so great that few

chemical alternatives are available.

In recent years, synthetic pyrethroids have replaced widely used classes of insecticides

such as organophosphates, carbamates, and chlorinated hydrocarbons. These pyrethroids

have shown great promise for vector control due to their low mammalian toxicity and

ability to quickly immobilize and kill arthropods at low dosages. Unfortunately,

resistance has been detected in several medically important arthropods. An issue of

concern in vector control is whether DDT resistance confers cross-resistance to

pyrethroids as a result of similar resistance mechanisms. Increasing pyrethroid resistance

is of particular concern to the US military because of the widespread use of permethrin

and other pyrethroids in BDUs, bednets, and vector control programs. Studies indicate

that resistance appears rapidly in areas where treated bednets are used to control

mosquitoes.

Changes in behavior that result in reduced contact with an insecticide include a reduced

tendency to enter treated areas or an increased tendency to move away from a surface

treated with insecticide once contact is made. These are population-based changes in a

species' genetics resulting from the selection pressure of insecticide use. Avoidance

behavior is widespread but poorly understood. Some form of behavioral avoidance has

been documented for virtually every major vector species. Methods to detect and

determine behavioral resistance have not been standardized and are difficult to interpret.
204

Pesticide resistance will be an increasing problem for vector control personnel. More

than 90% of all pesticides are used for agricultural purposes. Insecticide resistance in at

least 17 species of mosquitoes in various countries has occurred because of indirect

selection pressure by agricultural pesticides. The development of organophosphate and

carbamate resistance in Anopheles sacharovi, An. hyrcanus and An. maculipennis in the

Chukurova plain and the northern area around Osmanjik in Turkey has been attributed to

the use of chemicals for agricultural pest control.

Innumerable genetic, biological and operational factors influence the development of

insecticide resistance. A pesticide use strategy that will prevent the evolution of

resistance has not been developed. Tactics to manage or delay the development of

resistance include: 1) using nonchemical methods of control as much as possible, 2)

varying the dose or frequency of pesticide application, 3) using local rather than areawide application, 4) applying treatments locally only during outbreaks of vector-borne

diseases, 5) using less persistent pesticides, 6) treating only certain life stages of the

vector, 7) using mixtures of pesticides with different modes of action, 8) using improved

pesticide formulations, 9) rotating pesticides having different modes of action, and 10)

using synergists.

Reports of resistance must be interpreted carefully. Many reports of resistance for a

vector species are based on single data sets from a single point within a country and may

be years if not decades old. Resistant populations tend to revert to susceptible status

once insecticide selection pressure has been removed. Isolated reports of resistance,

although recent, may indicate local resistance that has not become widespread. Vector

control personnel frequently assume that resistance in a particular species occurs

throughout their control area but, in reality, insecticide resistance is focal. The length of

time an insecticide has been used at a location may not be helpful in predicting the

presence of resistance. Vectors in some countries have never developed resistance to

DDT, despite decades of use in malaria control. Only appropriate resistance monitoring

can guide the vector control specialist in the selection of a suitable insecticide.
205

Table 3. Specific Reports of Pesticide Resistance in Central Europe.

Country Species/Stage Insecticide Location Date of Test

Czech Republic Pediculus humanus

capitus

bioallethrin, permethrin &

phenothrin Danube Plain & Dobrudja 1992

Czech Republic Musca domestica

adults

bendiocarb, dimethoate, DDT,

fenitrothion, propoxur,

trichlorfon

multiple locations 1976-1980

Hungary M. domestica adults &

larvae

bioresmethrin, cypermethrin,

DDT, deltamethrin, dioxacarb,

lindane, malathion,

methoxychlor, permethrin,

pyrethrin, trichlorfon 

multiple locations 1990

Hungary M. domestica adults cypermethrin, deltamethrin,

permethrin, tetramethrin multiple locations 1983-1985

Hungary M. domestica adults DDT, dichlorvos, fenitrothion,

trichlorfon multiple locations 1983-1985

Poland M. domestica adults permethrin multiple locations 1985

Romania M. domesica adults trichlorfon Timisoara 1996

Romania Anopheles messeae

adults DDT 15 localities in the DanubePlain & Dobrudja

1981-1983

Slovakia M. domesica adults permethrin Kosice 1994
206

Slovakia M. domesica adults organophosphates Kosice 1991-1992
207

Published Reports of Insecticide Resistance Testing in Central Europe.*

Hoffmann, G. 1987. [ Development of resistance in pests including ectoparasites-- 

 definition and present situation.] Zentralbl.. Bakteriol. 185: 139-153. (reviews

status of European species)

WHO. 1986. Resistance of vectors and reservoirs of disease to pesticides. Tenth report

of the WHO expert committee on vector biology and control. WHO Tech. Rep. Ser.

737: 87 pp.

 

Czech Republic

Chmela, J. and V. Rupes. 1986. [Resistance of house mice to warfarin in

Czechoslovakia.] Agrochemia 26: 244-246.

Rettich, F. 1977. The susceptibility of mosquito larvae to eighteen insecticides in

Czechoslovakia. Mosquito News 37: 252-257.

Rettich, F. 1979. The toxicity of four synthetic pyrethroids to mosquito larvae and

pupae (Diptera, Culicidae) in Czechoslovakia. Acta Ent. Bohemoslov. 76: 395-401.

 

Rupes, V., J. Ledvinka, J. Chmela and J. Pinterova. 1984. Susceptibility to DDT and

some other insecticides of head lice (Pediculus capitis De Geer) in Czechoslovakia. 

Folia Parasitol. 31: 169-175.

Rupes, V., J. Moravec, J. Chmela, J. Ledvinka and J. Zelenkova. 1995. A resistance of

head lice (Pediculus capitis) to permethrin in Czech Republic. Cent. Eur. J. Pub.

Health 3: 32-32.

Rupes, V., J. Pinterova, J. Ledvinka, J. Chmela, J. Plachy, M. Homolac and V. Pospisil. 

1983. Insecticide resistance in houseflies Musca domestica (L.) in Czechoslovakia. 

Intl. Pest Control 4: 106-108.

Hungary

Bajomi, D., J. Eross, J.K. Sasvari and A. Kis-Varga. 1990. Applications of larvicides

and toxicant baits to control the breeding of houseflies in closed poultry houses and

piggeries. Intl. Pest Control 32: 44-49.

Bajomi, D., A. Kis-Varga and J. Eross. 1989. [Current problems in fly control.

Proposals for improving the efficiency of fly control.] Parasit. Hung. 22: 115-124.
208

Farkas, R. and L. Pap. 1991. Monitoring of susceptibility to cyromazine and

diflubenzuron in house fly (Musca domestica L.) populations in Hungary. Parasit.

Hung. 24: 99-107.

Pap, L. and R. Farkas. 1991. Monitoring of susceptibility to adulticides in house fly

(Musca domestica L.) populations in Hungary. Parasit. Hung. 24: 109-123. 

Pap, L. and R. Farkas. 1994. Monitoring of resistance of insecticides in house fly

(Musca domestica L.) populations in Hungary. Pestic. Sci. 40: 245-258.

Szabo, L. 1986. Insecticide resistance of houseflies ( Musca domestica L.) in Hungary.

I. Resistance to organochlorine insecticides. Parasit. Hung. 19: 31-35.

Szabo, L. 1986. Insecticide resistance of houseflies (Musca domestica L.) in Hungary.

II. Resistance to organophosphorus insecticides. Parasit. Hung. 19: 93-103.

Szabo, L. 1986. Insecticide resistance of houseflies (Musca domestica L.) in Hungary.

III. Resistance to pyrethroid insecticides. Parasit. Hung.19: 105-117. 

Szabo, L. 1987. [Insecticide resistance of houseflies (Musca domestica L.) on pig

farms.] Magyar Allatorvosok Lapja 42: 531-536. 

Poland

Krzeminska, A., A. Gliniewcz and B. Styczynska. 1988. The assessment of resistance to

permethrin of Musca domestica L. in Poland. In: Medical and Veterinary

Dipterology. Proceedings of the International Conference, November 30-December 4,

1987, Ceske Budejovice, Czechoslovakia.

Kucirka, S., L.C. Parish and J.A. Witkowski. 1984. [Resistance to insecticides in head

lice.] Przeglad Dermatol. 71:165-169.

Romania

Bilbie. I., A. Enescu, I. Giurca, G. Nicolescu and N. Velehorschi. 1983. Laboratory and

field investigations on insecticide susceptibility of the anophelines in the previously

endemic areas of malaria in the Danube Plain and Dobrudja. Arch. Roum. Path. Exp.

Microbiol. 42: 343-351.

Cristescu, A., I. Giurca and S. Durbaca. 1980. The surveillance of the resistance in the

Cimex lectularius (Heteroptera, Cimicidae) species. Arch. Roum. Path. Exp.

Microbiol. 39:171-177.
209

Nichita, I. 1997. [Evolution of trichlorfon susceptibility in a population of flies in the

field.] Al 23-lea simpozion, Cluj-Napoca, 1997. Actualitati in patologia animalelor

domestice: lucrari stiintifice. pp. 485-489.

Nosec, I., A. Cristescu, A. Enescu, V. Tacu, I. Giurc| and G. Cristodorescu. 1978. 

[Studies of the sensitivity to the usual domestic insecticides of the Anopheles

maculipennis group and Musca domestica, Cimex lectularius and Blattella

germanica.] Bacteriol. Virusol. Parazitol. Epidemiol. 23: 183-188.

Slovak Republic

Kociscova, A. 1992. [Control of Musca domestica under regional conditions.] 

Veterinarstvi 42: 337-338.

Kociscova, A., D. Kukucka, M. Petrovsky and L. Para. 1995. The development of

resistance in the housefly (Musca domestica) and German cockroach (Blattella

germanica) after the selection with permethrin. Folia Veterinaria 39: 49-51.

Kociscova, A., and L. Para. 1995. [Efficacy of azamethiphos baits against houseflies

(Musca domestica L.).] Veterinarni Medicina 40: 17-22.

Kociscova, A., and L. Para. 1998. [The influence of monofactorial and rotational

selection pressure of insecticides on the development of resistance in the house fly

(Musca domestica L.) in animal production.] Czech J. Animal Science 43: 557-564. 

Kociscova, A., L. Para and M. Petrovsky. 1994. [The resistance of the house fly to

organophosphates in Kosice district.] Zivocisna Vyroba 39: 357-364.

Kociscova, A., L. Para and M. Petrovsky. 1995. [The possibility of suppressing Diptera

in animal production facilities, considering the current levels of resistance.]

Agrochemica Bratislava 35: 11-12.

Kociscova, A., L. Para and M. Petrovsky. 1996. [Application of pyrethrum synergized

with piperonyl butoxide against pyrethroid resistant housefly (Musca domestica L.)] 

Zivocisna Vyroba 41: 317-320.

Kociscova, A., L. Para, W.H. Robinson, F. Rettich and G.W. Rambo. 1999. Stability of

resistance to selected insecticides in wild populations of the house fly Musca

domestica (L.) under laboratory and practical conditions. Proceedings of the 3rd

International Conference on Urban Pests. Czech University of Agriculture, Prague,

Czech Republic, 19-22 July 1999. pp. 629-631.
210

* Only papers published in the 25 years prior to preparation of this document are

included. Most resistance studies in Central Europe were conducted during malaria

control programs from the 1960s through the 1970s. Many of the articles included

contain tests on insect populations that were found to be susceptible or contain

general discussions about pesticide resistance in Central Europe. 

Appendix D

Sources of Snake Antivenoms

1 Perusahaam Negara Biofarms 9, Jalan Pasteur Bandung, Indonesia

2 Behring Institut, Behringwerke AG, D3550 Marburg (Lahn), Postfach 167,

Germany. Telephone: (06421) 39-0. Telefax: (06421) 660064. Telex: 482320-02 

3 Institute of Epidemiology and Microbiology, Sofia, Bulgaria

4 Shanghai Vaccine and Serum Institute, 1262 Yang An Road (W), Shanghai, PRC

5 Commonwealth Serum Laboratories, 45 Poplar Road, Parkville, Victoria 3052,

Australia Telegram: “SERUMS,” Melbourne Telex: AA32789, Telephone: 387-1066

6 Foreign Trade Company, Ltd., Kodandaka, 46 Prague 10, Czech Republic

7 Fitzsimmons Snake Park, Box 1, Snell Park, Durban, South Africa

8 Haffkine Bio-pharmaceutical Corporation, Ltd., Parel, Bombay, India

9 Chiba Serum Institute, 2-6-1 Konodai, Ichikawa, Chiba Prefecture, Japan

10 Institut d’État des Serums et Vaccins Razi, P.O. Box 656, Tehran, Iran

11 Central Research Institute, Kasauli (Simia Hills), (H.P.) India

12 Kitasato Institute, 5-9-1 Shirokane, Minato-ku, Tokyo, Japan

13 The Chemo-Sero Therapeutic Research Institute, Kumamoto, 860 Kyushu, Japan

14 National Institute of Health, Biological Production Division, Islamabad, Pakistan. 

Telex: 5811-NAIB-PK, Telephone: 820797, 827761

15 Research Institute For Microbial Diseases, Osaka University, 3-1 Yamadoaka, Suite

565, Osaka, Japan, Telephone: (06) 877-5121

16 Institut Pasteur Production, 3 Boulevard Raymond Poincaré, 92430-Mames la

Coquette, France. Telephone: (1) 47.41.79.22, Telex: PASTVAC206464F

17 Institut Pasteur d’Algérie Docteur Laveran, Algiers, Algeria

18 Industrial and Pharmaceutical Corporation, Rangoon, Burma

19 Rogoff Medical Research Institute, Beillinson Medical Center, Tel-Aviv, Israel

20 South African Institute for Medical Research, P.O. Box 1036, Johannesburg 2000,

Republic of South Africa. Telegraph: “BACTERIA”, Telephone: 724-1781

21 Instituto Sieroterapica e Vaccinogeno Toscano “Sclavo”, Via Fiorentina 1, 53100

Siena, Italy.

22 National Institute of Preventive Medicine, 161 Kun-Yang St., Nan-Kang, Taipei,

Taiwan
211

23 Takeda Chemical Industries, Ltd., Osaka, Japan

24 Research Institute of Vaccine and Serum, Ministry of Public Health U.I. Kafanova,

93 Tashkent, USSR

25 Red Cross Society, Queen Saovabha Memorial Institute, Rama 4 Road, Bangkok,

Thailand

26 Twyford Pharmaceutical Services Deutschland, GmbH, Postfach 2108 05, D-6700

Ludwigshafen am Rhein, Germany

27 Institute of Immunology, Rockefellerova 2, Zagreb, Yugoslavia
212

Appendix E

Selected List of Taxonomic Papers and Identification Keys*

Centipedes and Millipedes

Kaczmarek, J. 1980. [Centipedes. Chilopoda.] Katalog Fauny Polski No. 36, 43pp. 

Kos, I. 1996. A review of centipedes (Chilopoda, Myripoda) of Croatia. Natura

Croatica 5: 145-154. 

Mauries, J.P., S.I. Golovatch and P. Stoev. 1997. The millipedes of Albania: recent

data, new taxa; systematical, nomenclatural and faunistical review. Zoosystema 19:

255-292.

Zapparoli, M. 1994. [Taxonomic and faunistic notes on centipedes from Greece

(Chilopoda).] Fragmenta Entomologica 26: 11-66.

Ceratopogonidae

Orszagh, I. 1976. The genus Culicoides Latr., 1809 (Diptera, Ceratopogonidae). Acta

Fac. Rerum. Nat. Univ. Comenianae Zool. Bratislava 21: 1-89.*

Szadzieweli, R. 1991. [Haematophagus biting midges of the genus Culicoides (Diptera,

Ceratopogonidae) from Poland.] Wiad. Prazyitol., Wroclaw 37: 53-56.

Cimicidae

Jablonska, J. 1964. [The species of the family Cimicidae occurring in Poland.] Pol.

Pismo Entomol., Lemberg, Breslau 34: 185-187.

Culicidae

Darsie, R. and A. Samanidou-Voyadjoglou. 1997. Keys for the identification of the

mosquitoes of Greece. J. Amer. Mosq. Cont. Assoc. 13: 247-254.*

Gaffigan, T.V. and R.A. Ward. 1985. Index to the second supplement to “A catalog of

the mosquitoes of the world (Diptera: Culicidae).” Mosq. Syst. 17: 52-63.
213

Knight, K.L. 1978. Supplement to “A catalog of the mosquitoes of the world (Diptera:

Culicidae).” Thomas Say Foundation, Entomological Society of America, Vol. 6,

107 pp.

Knight, K.L. and A. Stone. 1977. A catalog of the mosquitoes of the world (Diptera:

Culicidae). 2nd ed. Thomas Say Foundation, Entomological Society of America,

Vol. 6, 611 pp.

Maslov, A.V. 1989. Bloodsucking Mosquitoes of the Subtribe Culesitina

(Diptera:Culicidae) in World Fauna. Amarind Pub. Co. Pvt. Ltd., New Delhi, 248 pp. 

 

Ribeiro, H. and H. C. Ramos. 1999. Identification keys of the mosquitoes (Diptera:

Culicidae) of continental Portugal, Acores and Madeira. European Mosq. Bull. 3: 

 1-11. 

Samanidou-Voyadjoglou, A. and R. Darsie. 1993. An annotated checklist and

bibliography of the mosquitoes of Greece (Diptera: Culicidae). Mosq. Syst. 25: 177-

185. 

Stojanovich, C.J. and H.G. Scott. 1993. Mosquitoes of the Republics of the Former

Yugoslavia. Chester R. Stojanovich, 479 Riverside Rd., Watsonville, California. 

81pp.* 

Ward, R.A. 1984. Second supplement to “A catalog of the mosquitoes of the world

(Diptera: Culicidae).” Mosq. Syst. 16: 227-270.

Ward, R.A. 1992. Third Supplement to “A catalog of the mosquitoes of the world

(Diptera: Culicidae).” Mosq. Syst. 24: 177-230.

Other Diptera

Povolny, D. and J. Verves. 1990. A preliminary list of Bulgarian Sarcophaginae

(Diptera). Acta Entomol. Mus. Natl., Prague 43: 283-329.*

Rognes, K. 1987. The taxonomy of the Pollenia rudis species group in the Holarctic

region (Diptera: Calliphoridae). Syst. Entomol. 12: 475-502.*

Mammalia
214

Nowak, R.M. [ed.] 1991. Walker’s Mammals of the World. 5th ed., John Hopkins

University Press, Baltimore & London, 1629 pp.

Wilson, D.E. and D.M. Reeder. 1993. Mammal Species of the World: a Taxonomic

and Geographic Reference. 2nd ed., Smithsonian Institution Press, Washington, DC,

1,206 pp.

Psychodidae

Leger, N., B. Pesson, B. and G. Madulo-Leblond. 1986a. [Phlebotomines in Greece

(first part).] Bull. Soc. Pathol. Exot. 79: 386-397.*

Leger, N., B. Pesson, B. and G. Madulo-Leblond. 1986b. [Phlebotomines in Greece

(second part).] Bull. Soc. Pathol. Exot. 79: 514-524*

Lewis, D.J. 1982. A taxonomic review of the genus Phlebotomus (Diptera:

Psychodidae). Bull. Brit. Mus. Nat. Hist., Entomology Ser., 45: 1- 209.* 

Seyedi-Rashti, M.A., A. Nadim, M.A. Rashti and M.A. Sayedi. 1992. The genus

Phlebotomus (Diptera: Psychodidae : Phlebotominae) of the countries of the Eastern

Mediterranean Region. Iranian J. Pub. Hlth. 21: 11-50.*

Reptiles

Defense Intelligence Agency. 1986. The Poisonous Snakes of Europe. Washington,

D.C. 17 pp. 

Harding, K.A. and K.R.G. Welch. 1980. Venomous Snakes of the World: a Checklist. 

Pergamon Press, Oxford. 188 pp.

Poisonous Snakes of the World, a Manual for Use by U.S. Amphibious Forces. 1966. 

NAVMED P-5099, BUMED, Department of the Navy, U.S. Gov. Print. Off., 212

pp.*

Scorpions

El Hennawy, H.K. and H.K. El Hennawy. 1990. Key to scorpion families (Arachnida:

Scorpionida). Serket 2: 14-19.*
215

Sissom, W.D. 1990. Systematics, Biogeography, and Paleontology. pp. 64-136. In:

The Biology of Scorpions, G.A. Polis [ed.] Stanford University Press.*

Vachon, M. 1952. [Studies on scorpions.] Insitut Pasteur d’Algérie. Algiers, Algeria. 

481 pp. 

Siphonaptera

Adams, N.E. and R.E. Lewis. 1985. An annotated catalogue of primary types of

Siphonaptera in the National Museum of Natural History, Smithsonian Institution. 

Smithsonian Contributions to Zoology. No. 56: 1-86.

Lewis, R.E. 1967. The fleas (Siphonaptera) of Egypt. An illustrated and annotated key. 

J. Parasitol. 53: 863-885.*

Lewis, R.E. 1990. The Ceratophyllidae: currently accepted valid taxa (Insecta:

Siphonaptera). Theses Zoologicae, volume 13. R. Fricke [ed.] Koeltz Scientific

Books. Koenigstein, Germany. 267 pp.

Lewis, R.E. and J.H. Lewis. 1989. Catalogue of invalid genus-group and species-group

names in the Siphonaptera (Insecta). These Zoologicae, Volume 11. R. Fricke [ed.]. 

Koeltz Scientific Books. Koenigstein, Germany. 263 pp.

Skuratowicz, W., K. Bartkowska and G. Bachvarov. 1982. Fleas (Siphonaptera) of

small mammals and birds collected in Bulgaria. Frag. Faun. 27: 101-140.

Traub, R., M. Rothschild and J.F. Haddow. 1983. The Rothschild Collection of Fleas. 

The Ceratophyllidae: Key to the Genera and Host Relationships. With Notes on

Their Evolution, Zoogeography and Medical Importance. Privately published by M.

Rothschild and R. Traub. Distributed by Academic Press. 288 pp.

Tabanidae

Trojan, P. 1959. Keys to Polish Diptera (Tabanidae). Polski Awiazek Ent. Key Ser.

No. 27: 1-69.* 

Trojan, P. 1979. Tabanidae (Insecta: Diptera) Fauna Pol., Warsaw 8:1-309.*

Ticks (Ixodidae, Argasidae)
216

Balashov, Y. 1972. Bloodsucking ticks. Bull. Entomol. Soc. Amer. 8: 1- 376. 

Dusbabek, F. and B. Rosicky. 1976. Argasid ticks (Argasidae, Ixodoidea) of

Czechoslovakia. Pirodoved. Pr. Ustavu Cesk. Akad. Brne 10: 1-43.*

Sonenshine, D.E., C.M. Clifford, and G.M. Kohls. 1966. The systematics of the

subfamily Ornithodorinae (Acarina: Argasidae). III. Identification of the larvae of

the Eastern Hemisphere. Ann. Entomol. Soc. Amer. 59: 92-122.*

*Papers marked with an asterisk include a taxonomic key for identification of species. 

References without keys for identification usually contain a checklist of species

known from a given geographic area or a list of species collected during extensive

surveys of an area.
217

Appendix F: Personal Protective Measures

Personal protective measures are the first line of defense against arthropod-borne

disease and, in some cases, may be the only protection for deployed military personnel. 

Proper wearing of the uniform and appropriate use of repellents can provide high levels

of protection against blood-sucking arthropods. The uniform fabric provides a

significant mechanical barrier to mosquitoes and other blood-sucking insects. 

Therefore, the uniform should be worn to cover as much skin as possible if weather and

physical activity permit. When personnel are operating in tick-infested areas, they

should tuck their pant legs into their boots to prevent access to the skin by ticks,

chiggers, and other crawling arthropods. They should also check themselves frequently

for ticks and immediately remove any that are found. If a tick has attached, seek

assistance from medical authorities for proper removal or follow these guidelines from

TIM 36, Appendix IX A.

1. Grasp the tick’s mouthparts where they enter the skin, using pointed tweezers.

2. Pull out slowly and steadily with gentle force.

a. Pull in the reverse of the direction in which the mouthparts are inserted, as

you would for a splinter.

b. Be patient – The long, central mouthpart (called the hypostome) is inserted in

the skin. It is covered with sharp barbs, sometimes making removal difficult

and time consuming.

c. Many hard ticks secrete a cement-like substance during feeding. This

material helps secure their mouthparts firmly in the flesh and adds to the

difficulty of removal.

d. It is important to continue to pull steadily until the tick can be eased out of the

skin.

e. Do not pull back sharply, as this may tear the mouthparts from the body of the

tick, leaving them embedded in the skin. If this happens, don’t panic. 

Embedded mouthparts are comparable to having a splinter in your skin. 

However, to prevent secondary infection, it is best to remove them. Seek

medical assistance if necessary.

f. Do not squeeze or crush the body of the tick because this may force infective

body fluids through the mouthparts and into the wound.
218

g. Do not apply substances like petroleum jelly, fingernail polish remover,

repellent pesticides, or a lighted match to the tick while it is attached. These

materials are either ineffective or, worse, may agitate the tick and cause it to

salivate or regurgitate infective fluid into the wound site.

h. If tweezers are not available, grasp the tick’s mouthparts between your

fingernails, and remove the tick carefully by hand. Be sure to wash your

hands -- especially under your fingernails -- to prevent possible contamination

by infective material from the tick.

3. Following removal of the tick, wash the wound (and your hands) with soap and

water and apply an antiseptic. 

4. Save the tick in a jar, vial, small plastic bag, or other container for identification 

should you later develop disease symptoms. Preserve the tick by either adding some 

alcohol to the jar or by keeping it in a freezer. Storing a tick in water will not 

preserve it. Identification of the tick will help the physician’s diagnosis and 

treatment, since many tick-borne diseases are transmitted only by certain species.

5. Discard the tick after one month; all known tick-borne diseases will generally

display symptoms within this time period. 

Folklore remedies such as petroleum jelly or hot matches do little to encourage a tick to

detach from skin. In fact, they may make matters worse by irritating the tick and

stimulating it to release additional saliva, increasing the chances of transmitting

pathogens. These methods of tick removal should be avoided. In addition, a number of

tick removal devices have been marketed, but none are better than a plain set of finetipped tweezers.

Newly developed repellents provide military personnel with unprecedented levels of

protection. An aerosol formulation of permethrin (NSN 6840-01-278-1336) can be

applied to the uniform according to label directions, but not to the skin. This will impart

both repellent and insecticidal properties to the uniform material that will be retained

through numerous washings. An extended formulation lotion of N, N-diethyl-mtoluamide (deet) (NSN 6840-01-284-3982) has been developed to replace the 2 oz.

bottles of 75% deet in alcohol. This lotion contains 33% active ingredient. It is less

irritating to the skin, has less odor and is generally more acceptable to the user. A

properly worn Battle Dress Uniform (BDU) impregnated with permethrin, combined

with use of extended duration deet on exposed skin, has been demonstrated to provide

nearly 100% protection against a variety of blood-sucking arthropods. This dual strategy

is termed the DoD ARTHROPOD REPELLENT SYSTEM. In addition, permethrin may

be applied to bednets, tents, and other field items as appropriate. Complete details
219

regarding these and other personal protective measures are provided in TIM 36, Personal

Protective Techniques Against Insects and Other Arthropods of Military Significance

(1996).

Appendix G 

Bioscience and State Department Contacts in Central Europe

1. Regional Contacts. 

World Health Organization (WHO) Phone: (0045) 39-17-17-17 

Regional Office for Europe (EURO) FAX: (0045) 398-17-18-18 

8, Scherfigsvej e-mail: < postmaster@who.dk >

DK-2100 Copenhagen 0 website: < http://www.who.dk >

Denmark 

Centers for Disease Control and Prevention 

Division of Quarantine Phone: (404) 639-3311 

National Center for Infectious Diseases e-mail: < netinfo@cdc.gov > 

1600 Clifton Road, NE Website: 

Atlanta, GA 30333 <http://www.cdc.gov/travel/index.htm >

U.S.A. 

Commander 

USACHPPM-EUR Phone: (011) 49-6371-86-8540 (Germany) 

ATTN: MCHB-AE-EN, CMR 402 DSN: 486-8540 

APO, AE 09180 FAX: (011) 49-6371-86-7198 / -8958 

2. Albania. 

Ambassador Phone: [355] (42) 328-75, 335-20 

Rruga E. Labinoti 103 FAX: [355] (42) 322-22

Tirana, Albania 

PSC 59, Box 100 (A) 

APO, AE 09624 

WHO Liaison Office Phone: [355] (42) 64-270 

ATTN: WHO Liaison Officer FAX: [355] (42) 64-270

C

/o Ministry of Health e-mail: < miho@who.tirana.al > 

Tirana, Albania 
220

3. Bosnia and Herzegovina. 

Ambassador Phone: [387] (71) 445-700, 667-391, 

443 Ul. Dure Dakovica 667-389, 667-743, 667-390, 659-969, 

Sarajevo 659-992

Bosnia and Herzegovina FAX: [387] (71) 659-722

WHO Liaison Office Phone: [387] (71) 20-18-15 

ATTN: WHO Liaison Officer FAX: [387] (71) 20-18-15

Marsala Tita Str. 9/2 e-mail: < wholo@bih.net.ba > 

71 000 Sarajevo 

Bosnia and Herzegovina 

4. Bulgaria. 

Ambassador Phone: [359] (2) 980-52- 41 (through - 48) 

1 Saborna Street FAX: [359] (2) 981-89-77 

Sophia, Bulgaria 

Unit 1335 

APO, AE 09213-1335 

WHO Liaison Office Phone: [359] (2) 981-02-25 

ATTN: WHO Liaison Officer FAX: [359] (2) 987-27-92

C

/o Ministry of Health e-mail: < wholobg@who.bg > 

5, Sveta Nedelja Square 

Sofia 1000, Bulgaria 

5. Croatia. 

Ambassador Phone: [385] (1) 455-55-00 

Andrije Hebranga 2 FAX: [385] (1) 455-85-85

Zagreb, Croatia 

WHO Liaison Office Phone: [385] (1) 61-76-502 

ATTN: WHO Liaison Officer FAX: [385] (1) 61-76-504 

C

/o Institute for Health Organization 

and Economics e-mail: < b.skupnjak@wholo.hr >

WHO Collaborating Centre for 

Health Development 
221

Savska 41 

41000 Zagreb, Croatia 

6. Czech Republic. 

Ambassador Phone: [420] (2) 5732-0663, 5731-3814 

Trziste 15, 11801 FAX: [420] (2) 5732-0584

Prague 1, Czech Republic 

Unit 28129 

APO, AE 09114 

 or State Pouch: American Embassy Prague, Washington, DC 20521-5630 

WHO Liaison Office Phone: [420] (2) 2497-2486 

ATTN: WHO Liaison Officer FAX: [420] (2) 291-517

C

/o Ministry of Health e-mail: < wholocz@who.cz > 

PalackÁho n×m 4 

128 01 Prague 2 

Czech Republic 

7. Greece. 

Ambassador Phone: [30] (1) 721-2951 

91 Vasilissis Sophias Boulevard FAX: [30] (1) 645-6282

10160 Athens, Greece 

PSC 108 

APO, AE 09842-0108 

 

Consulate general, Thessaloniki 

8. Hungary. 

Ambassador Phone: [36] (1) 267-4400, after hours - 

V. Szabadsag Ter 12 269-9331, 

1054 Budapest, Hungary FAX: [36] (1) 269-9326 after hours - 269-

9339

 

 mail: Pouch: American Embassy Budapest, Washington, DC 20521-5270

WHO Liaison Office Phone: [36] (1) 331-7450 

ATTN: WHO Liaison Officer FAX: [36] (1) 269-1303

C

/o Ministry of Welfare e-mail: < wholohu@who.hu > 
222

Arany Jaanos u. 6-8 

H-1361 Budapest V, Hungary 

9. Macedonia. 

Ambassador Phone: [389] (91) 116-180 

Bul. Ilindenska bb FAX: [389] (91) 117-103

9100 Skopje, Macedonia 

 mail: American Embassy Skopje, Dept.of State, Washington, DC 20521-7120 

(pouch)

WHO Liaison Office Phone: [389] (91) 121-142 

ATTN: WHO Liaison Officer FAX: [389] (91) 121-142

C

/o Ministry of Health e-mail: < kisman@unet.com.mk > 

Vodnjanska bb 

91000 Skopje, Macedonia 

10. Poland. 

Ambassador Phone: [48] (22) 628-30-41 

Aleje Ujazdowskie 29/30 00-054 FAX: [48] (22) 628-82-98

Warsaw, Poland 

 

mail: American Embassy Warsaw, U.S. Dept. of State, Washington, DC 20521-

5010 (pouch)

 Consulate general, Krakow 

WHO Liaison Office Phone: [48] (22) 635-94-96 

ATTN: WHO Liaison Officer FAX: [48] (22) 831-08-92 

C

/o Ministry of Health and Social Welfare e-mail: < wholo@pol.pl >

Dluga 38/40 

00-238 Warsaw, Poland 

11. Romania. 

Ambassador Phone: [40] (1) 210-01-49, 210-40-42 

Strada Tudor Arghezi 7-9 FAX: [40] (1) 210-03-95

Bucharest, Romania 

 mail: American Embassy Bucharest, Dept. of State, Washington, DC 20521-

5260 (pouch)
223

branch office, Cluj-Napoca 

WHO Liaison Office Phone: [40] (1) 211-0911 

ATTN: WHO Liaison Officer FAX: [40] (1) 210-0173

Str. Pitar Mos Nos. 7-13 e-mail: < wholoro@who.eunet.ro > 

 70151 Bucharest, Romania 

12. Serbia and Montenegro. 

[ NOTE: the U.S. and Serbia and Montenegro do not maintain full diplomatic

relations. ]

Chief of Mission Phone: [381] (11) 645655 

Kneza Milosa 50 FAX: [381] (11) 645332

11000 Belgrade 

Serbia and Montenegro

mail: American Embassy, Belgrade, Dept. of State, Washington, DC 20521-

5070 (pouch), Unit 1310, APO, AE 09213-1310 

13. Slovakia. 

Ambassador Phone: [42] (7) 533-0861, 533-3338 

Hviezdoslavovo Namestie 4 FAX: [42] (7) 533-5439

81102 Bratislava, Slovakia 

WHO Liaison Office Phone: [421] (7) 373-662 

ATTN: WHO Liaison Officer FAX: [421] (7) 373-662

Limbova 3 e-mail: < wholosk@mbox.bts.sk > 

83007 Bratislava, Slovakia 

14. Slovenia. 

Ambassador Phone: [386] (61) 301-427, 301-472, 

P.O. Box 254 301-485 

Prazakova 4, FAX: [386] (61) 301-401 

1000 Ljubljana, Slovenia 

 mail: American Embassy Ljubljana, Dept. of State, Washington, DC 20521-

7140 (pouch)
224

Appendix H: Glossary

acaricide - a substance developed to kill ticks and mites.

adulticide - insecticides used to kill the adult stages of an insect.

anaphylaxis - an unusual and severe allergic reaction of an organism to a foreign protein

or other substances.

anthropophilic - the preference of insects and other arthropods to suck blood from

humans rather than from animals.

autochthonous - transmission of a disease in the place where the disease occurred.

autogenous - not requiring a bloodmeal to produce eggs.

bionomics - the ecology of an organism.

biotope - a habitat characterized by environmental conditions and its community of 

animals and plants.

campestral - relating to fields or open country.

carrier - a person or animal that harbors infectious organisms but is free of clinical

disease. Generally synonymous with reservoir.

case fatality rate - the percentage of persons diagnosed as having a specific disease who

die as a result of that illness within a given period.

cephalothorax - a body region consisting of head and thoracic segments.

cercariae - free-living stage in the life cycle of Schistosomes that emerges from snails

and

infects vertebrate hosts. 

chelicerae - a pair of appendages used as mouthparts in arachnids such as scorpions,

spiders, and ticks.

chemoprophylaxis - the administration of a chemical to prevent the development of an 

infection or the progression of an infection to active disease.

commensal - living in close association with another organism.

crepuscular - the twilight periods of dusk and dawn.

diapause - a period of arrested development and reduced metabolic rate, during which 

growth and metamorphosis cease.

diurnal - activities occurring during the daytime.

ectoparasite - a parasite that lives on the exterior of its host.

endemic - the constant presence of a disease or infection within a given geographic area.

endophagic - an arthropod that prefers to feed indoors.

endophilic - the tendency of arthropods to enter human structures.

enzootic - a disease that primarily infects animals and is present in an animal community

at all times.

epidemic - the occurrence of cases of an illness (or an outbreak) that is clearly in excess

of normal expectancy.

epizootic - an outbreak of a disease within an animal population.

eutrophic - rich in nutrients; usually applied to aquatic ecosystems.

exophagic - the tendency of an arthropod to feed outdoors.
225

exophilic - the tendency of blood-sucking arthropods to feed and rest outdoors.

facultative - not obligatory; characterized by the ability to adjust to circumstances.

family - a group of related genera.

focus (pl. foci) - a specific localized area.

genus (pl. genera) - a group of closely related species.

gonotrophic cycle - the time between feeding and oviposition.

inapparent infection - the presence of infection in a host without clinical symptoms.

incidence - the number of new cases of a specific disease occurring during a certain

period of time.

incubation period - the time interval between initial contact with an infectious agent and

the first appearance of symptoms associated with the infection.

indigenous - living or occurring naturally in a particular environment or area.

infection rate - the proportion (expressed as a percent) of a vector or host population that

is infected.

infective - an organism that can transmit an infectious agent to another individual.

instar - an insect between successive molts.

larva (pl. larvae) - the immature stage, between the egg and pupa of an insect, or the sixlegged immature stage of a tick.

larvicide - insecticides used to kill larvae or immature stages of an insect. 

larviparous - insects that deposit larvae rather than eggs on a host, food source, or other 

substrate.

maggot - legless larva of flies (Diptera).

mechanical transmission - the vector transmits the pathogen on contaminated

mouthparts, legs, or other body parts, or by passage through the digestive tract

without change.

miracidium (pl. miracidia) - ciliated, first larval stage in the life cycle of Schistosomes

that penetrates and infects a snail, undergoing further development in the snail. 

molluscicide - a chemical substance used for the destruction of snails and other molluscs.

myiasis - the invasion of human tissues by fly larvae.

night soil - human excrement used as fertilizer. 

nosocomial - originating in a hospital or medical treatment facility.

nulliparous - a female arthropod that has not laid eggs.

nymph - an immature stage of an insect that does not have a pupal stage or an eightlegged immature tick or mite.

obligate - necessary or compulsory; characterized by the ability to survive only in a 

 particular environment.

pandemic - a widespread epidemic disease distributed throughout a region or continent.

parous - a female arthropod that has laid eggs.

pedipalps - the second pair of appendages of an arachnid.

periurban - relating to an area immediately surrounding a city or town. 

prevalence - the total number of cases of a disease in existence at a certain time in a

designated area.
226

pupa (pl. pupae) - a nonfeeding and usually inactive stage between the larval and adult

stage. 

quest (questing) - the behavior of ticks waiting in search of a passing host.

refractory - a host or vector that will not permit development or transmission of a

pathogen.

reservoir - any animal, plant or substance in which an infectious agent survives and

multiplies.

rodenticide - a chemical substance used to kill rodents, generally through ingestion.

ruminants - relating to a group of even-toed mammals, such as sheep, goats and camels, 

that chew the cud and have a complex stomach.

sequelae - any aftereffects of disease. 

species complex - a group of closely related species, the taxonomic relationships of

which are sometimes unclear, making individual species identification difficult.

steppe - a vast, arid and treeless tract found in southeastern Europe or Asia.

sylvatic - related to a woodland or jungle habitat.

synanthropic - animals that live in close association with man.

synergist - a chemical that may have little or no toxicity in itself but, when combined

with a pesticide, greatly increases the pesticide’s effectiveness.

transovarial transmission - passage of a pathogen through the ovary to the next

generation .

transstadial transmission - passage of a pathogen from one stage of development to

another after molting. 

ultra low volume (ULV) - the mechanical dispersal of concentrated insecticides in

aerosols of extremely small droplets that drift with air currents.

urticaria - a reaction of the skin marked by the appearance of smooth, slightly elevated 

patches (wheals) that are redder or paler than the surrounding skin and often

associated with severe itching.

vector - an organism that transmits a pathogen from one host to another. 

vector competence - the relative capability of a vector to permit the development,

multiplication and transmission of a pathogen. 

vesicant - a blistering agent.

viremia - a virus that is present in the blood.

virulence - the degree of pathogenicity of an infectious agent.

xerophilic - tolerant of dry environments.

zoonosis - an infectious disease of animals transmissible under natural conditions from

nonhumans to humans.

zoophilic - the preference of insects and other arthropods to feed on animals other than

humans.
227

Appendix I

Internet Websites on Medical Entomology and Vector-borne Diseases

A. Primary Sites

1. The Armed Forces Pest Management Board’s website provides information about

the Board as well as Army, Navy and Air Force entomology programs. Users can

download Board publications, including Technical Information Memorandums,

Disease Vector Ecology Profiles, and Technical Information Bulletins and search the

Defense Pest Management Information Analysis Center’s literature database.

<http://www.afpmb.org/>

2. ProMED (Program for Monitoring Emerging Diseases), with current information on

disease outbreaks.

<http://www.fas.org/promed>

3. Iowa State University’s comprehensive site on medical entomology, with excellent

information and links to over 20 additional sites. 

<http://www.ent.iastate.edu/>

4. WHO disease outbreak information – emerging and communicable disease

information from the WHO and its databases. The tropical medicine databases are

the most useful for vector-borne diseases. Access can also be obtained to the Weekly

Epidemiological Record. 

<http://www.who.int/emc/index.html>

5. The Walter Reed Biosystematic Unit’s online information regarding taxonomic keys,

diseases transmitted by mosquitoes, and mosquito identification modules. 

<http://wrbu.si.edu/>

6. Centers for Disease Control and Prevention – information on the CDC’s travel alerts,

including access to country health profiles, vaccine recommendations, State

Department entry requirements, and publications. 

<http://www.cdc.gov/travel/>

7. The National Library of Medicine’s biomedical databases, especially Medline.

Provides complete references and abstracts to more than 9 million journal articles

from biomedical publications.

 <http://www.nlm.nih.gov/>
228

8. The Malaria Foundation International’s site for general resources on malaria

available through the worldwide web. Includes references, malaria advisories, and

lists of other malaria websites.

<http://www.malaria.org>

9. The WHO site for information on vector-borne diseases, including disease

distribution, information on disease outbreaks, travel alerts, WHO research programs,

and progress on control. 

<http://www.who.ch/>

10. The CDC’s site on encephalitis information, as published in the Morbidity and

Mortality Weekly Report. Includes case definition and disease outbreak information. 

<http://www.cdc.gov/epo/mmwr/other/case_def/enceph.html>

11. Information from the University of Florida’s website on mosquitoes and other biting

flies. 

<http://hammock.ifas.ufl.edu/text/ig/8804.html>

12. Information on ticks and other ectoparasites from the University of Rhode Island’s

Tick Research Laboratory. 

<http://www.uri.edu/artsci/zool/ticklab/>

13. Information on plague available from the CDC’s Morbidity and Mortality Weekly 

Report. 

<http://www.cdc.gov/epo/mmwr/other/case_def/plague.html>

14. A list of websites and servers pertaining to entomology from Colorado State

University. Over 30 websites are listed. 

<http://www.colostate.edu/Depts/Entomology/ent.html>

15. AGRICOLA is a comprehensive source of bibliographic citations covering all aspects

of agriculture and many areas of the life sciences, including medical entomology and

pest management.

< http://www.nalusda.gov/> 

16. Medical Matrix provides access to hundreds of sites for medical information, with 

 emphasis on clinical medicine. It includes 75 sites on infectious diseases.

 <http://www.medmatrix.org>
229

B. Additional Sites

1. Lyme Disease Network – information on Lyme disease, including research abstracts,

treatments for Lyme disease, newsletter, conferences, and professional resources.

<http://www.lymenet.org>

2. The USDA plant database – includes the integrated taxonomic information system.

<http://plants.usda.gov/ >

3. University of Sydney, Medical Entomology – contains mosquito keys, fact sheets,

and photos of mosquitoes. 

<http://medent.usyd.edu.au>

4. American Society of Tropical Medicine and Hygiene – information on the ASTMH’s

programs, conferences, newsletters, publications, and resources. 

<http://www.astmh.org >

5. The American Mosquito Control Association’s site containing information on

mosquito biology, AMCA programs, conferences, newsletters, publications, and

resources. 

<http://www.mosquito.org>

6. Reuters’ search engine on health news pertaining to health issues around the world. 

<http://www.reutershealth.com/>

7. The ORSTOM (now IRD) home page includes information about the organization’s

medical research program in Asia, Africa, and Latin America. Bulletins and

publications on its research are offered. 

<http://www.orstom.fr/>

8. Emory University’s website allows access to the University’s extensive database of

medical and scientific literature. 

<http://www.medweb.emory.edu/medweb/>

9. The Entomological Society of America offers information on its overall services,

including conferences, journals, references, membership, and literature available for

ordering. 

<http://www.entsoc.org>

10. Travel Health Online contains country profiles with health precautions and disease

risk summaries, general travel health advice, contacts for providers of pretravel health

services, and access to US State Department publications.
230

<http://www.tripprep.com>
231

APPENDIX J METRIC CONVERSION TABLE

Metric System U.S. Customary System

LINE`AR MEASURE LINEAR MEASURE

10 millimeters = 1 centimeter 12 inches = 1 foot

10 c entimeters = 1 decimeter 3 feet = 1 y ard

10 d ecimete rs = 1 meter 5 1⁄2 yards = 1 rod

10 meters = 1 decameter 40 rods = 1 furlong

10 d ecam eters = 1 hectometer 8 furlongs = 1 mile

10 he ctome ters = 1 kilometer 3 land miles = 1 league

AREA MEASURE AREA MEASURE

100 sq. millimeters = 1 sq. centimeter 144 sq. inches = 1 sq. foot

10,0 00 sq . centime ters = 1 sq. meter 9 sq. feet = 1 s q. yard

1,00 0,00 0 sq. m illimeters = 1 sq. meter 30 1⁄4 sq. yards = 1 sq. rod

100 sq. me ters = 1 s q. are 160 sq. rods = 1 a cre

100 ares = 1 h ectare 640 acres = 1 sq. mile

100 hectares = 1 sq. kilometer 1 sq. mile = 1 section

1,00 0,00 0 sq. m eters = 1 sq. kilometer 36 sections = 1 tow nsh ip

VOLUME MEASURE LIQUID MEASURE

1 liter = 0.0 01 c ubic me ters 4 gills (2 cups) = 1 pint

10 milliliters = 1 centiliter 2 pints = 1 q uart

10 c entiliters = 1 deciliter 4 qua rts = 1 gallon

10 d ecaliters = 1 liter

10 liters = 1 decaliter DRY MEASURE

10 d ecaliters = 1 hectoliter 2 pints = 1 q uart

10 he ctoliters = 1 kiloliter 8 qua rts = 1 peck

4 pecks = 1 bushel

WEIGHT WEIGHT

10 milligrams = 1 centigram 27 11/32 grains = 1 dram

10 centigrams = 1 decigram 16 drams = 1 ounce

10 decigrams = 1 gram 16 ounces = 1 po und

10 grams = 1 decagram 100 pounds = 1 hundred weight

10 decagrams = 1 hectogram 20 hundredw eight = 1 ton

10 hectograms = 1 kilogram

1,000 kilograms = 1 metric ton

Kitchen Measurements

3 tsp. = 1 tbsp. 5 1/3 tbsp. = 1/3 cup 2 cups = 1 pint 2 pints = 1 q uart

4 tbsp. = 1⁄4 cup 16 tbsp. = 1 cup 4 cups = 1 q uart 4 qua rts = 1 gallon

Temperature

Celsius = 5 (F-32) Fahrenheit = 9C + 32

 9 5

Conversion Table

To C onvert Into Multiply by To C onvert Into Multiply by To C onvert Into Multiply by

Ce ntimeters Inches .394 Liters Cups 4.226 M iles Feet 5,280

Feet .0328 Pints 2.113 Yards 1,760

M eters .01 Gallons .264 Kilomete rs 1.609

M illimeters 10 M illiliters 1000 Pints Liters .473

Qua rts 1.057 Qua rts .5

M eters Ce ntimeters 100 Grams Ounces .035 Gallons .125

Feet 3.281 Pounds .002 Qua rts Pints 2

Inches 39.37 Kilograms .001 Liters .946

Kilomete rs .001 Kilograms Grams 1,000 Gallons .25

M iles .0006214 Ounces 35.274 Gallons Pints 8

M illimeters 1000 Pounds 2.205 Liters 3.785

Yards 1.093 Inches Ce ntimeters 2.54 Qua rt 4

Feet .0833 Ounces Grams 28.35

Kilomete rs Feet 3281 M eters .0264 Pounds .0625

M eters 1000 Yards .0278 Kilograms .028

M iles .621 Yards Inches 36 Pounds Grams 453.59

Yards 1093 Feet 3 Ounces 16

M eters .914 Kilograms .454

M iles .0005682