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Food and water risk assessments: empowering commanders and protecting service members.

THE EMERGENCE OF THE FOOD AND WATER RISK ASSESSMENT PROGRAM

There are inherent risks associated with the purchase and consumption of subsistence procured in some overseas locations. In many countries, food-borne diseases are endemic and exacerbated by poor hygienic practices in restaurants and other commercial catering establishments. Sanitation risks include lack of potable water and sanitizing supplies, improper sanitizing procedures, poor sanitary standards, questionable health standards among workers, a poorly trained workforce, and manual or hands-on food processing techniques. There are also risks unique to particular countries or regions such as lack of food sanitation hygiene laws and insufficient oversight by the local civilian government (regulators), lack of animal herd health monitoring programs and associated controls for endemic diseases, inadequate health care systems, improper use of pesticides and chemicals, and the lack of food vendor accountability in the event of food-borne illnesses. To reduce these risks, commercial food establishments who sell to the Department of Defense (DoD) are audited by US Army Veterinary Corps officers, ensuring compliance with regulatory, industry, and DoD requirements. When a food production facility passes a food protection audit in accordance with Military Standard 3006A (1) (MIL-STD-3006A), it is placed on the Worldwide Directory of Sanitarily Approved Food Establishments for Armed Forces Procurement. (2) The DoD food protection audit assures that set food protection (food safety and defense) benchmarks have been achieved for those establishments listed in the directory, thus reducing the risk of food-borne disease to service members and their families worldwide.

Unfortunately, the ability to purchase food from DoD-approved food sources is limited in more remote locations where US military service members are increasingly engaged. These engagements range from Beyond the Horizon exercises in Panama to foreign humanitarian assistance operations in Pakistan. While most major exercises are conducted near larger cities where DoD-approved food sources are more readily available and logistically feasible, often the main thrust of these exercises and operations is to serve the most in-need populations in rural areas where DoD-approved food sources may be unavailable or impractical. Issues surfaced when assessors applied MIL-STD-3006A to food operations in developing countries, particularly in more rural areas where local food safety practices were less stringent and often did not meet the military requirements. This resulted in Veterinary Corps officers often failing the majority of the facilities audited in developing countries, leaving commanders without realistic feeding options. Over time, this issue eroded the Veterinary Corps ability to support worldwide missions the DoD considers essential. Veterinary Corps leaders recognized that a new approach had to be crafted to support the mission and commanders while still preventing food-borne disease. This new approach is the Food and Water Risk Assessment (FWRA) program which created a framework for trained assessors to identify, assess, and communicate food-borne illness risks associated with food preparation operations, including hotel kitchens, restaurants, caterers, and military feedings operations, such as field exercises and host nation dining facilities.

Both the MIL-STD-3006A and the FWRA program are based upon the same federal food safety laws of the United States. However, while MIL-STD-3006A is coupled with a "pass/fail" audit, the FWRA program does not pass or fail an establishment, but instead identifies the level of risk to commanders. Consequently, leveraging the FWRA program is a double-edged sword that allows higher risk food operations to be considered for use but requires an increased focus on food-borne disease mitigation. The danger is that some uninformed commanders may assume that food operations contracted under the FWRA program are as safe as DoD-approved sources. Specifically, FWRAs provide commanders with the ability to determine the level of acceptable risk and keeps the assessor at the commander's side with veterinary risk mitigation expertise.

LOCAL FOOD BENEFITS AND RISKS

Service members who have served in Operations Enduring and Iraqi Freedom or other operations and exercises understand the importance of building relationships and bridging cultures. In fact, successful counterinsurgency operations hinge on building trusting relationships, a major component of which can be the sharing of local foods. While often not officially approved, consuming local foods is a reality in most deployed locations. This reality also brings profound food safety risks. Among personnel deployed to Iraq and Afghanistan between 2003 and 2004, 78.6% of troops in Iraq and 54.4% of those in Afghanistan experienced diarrhea, with 80% seeking care from their unit medic. The consumption of local foods from non-US sources was associated with the increased risk of illness. (3)

Local foods also have an impact on service members in South and Central America. A diarrhea outbreak occurred during US military training and humanitarian assistance in El Salvador in 2012. While service members frequently report getting diarrhea during short deployments, in-depth investigations like the one conducted by the Naval Medical Research Unit No. 6 (NAMRU-6) with epidemiological surveys, microscopy, and polymerase chain reaction analysis of stool samples are rarely performed. This investigation concluded that the consumption of food from on-base local vendors (relative risk (RR)=4.01 (95% confidence interval (CI), 1.53-10.5), P <.001) and arriving on base within the past 2 weeks (RR=2.79 (95% CI, 1.35-5.76), P <.001) were associated with increased risk of developing diarrheal disease. (3) Although many exercises are short in duration, local food risks must be still considered by mission planners. In these situations, FWRAs may be the most effective tool to reduce the local food risks and disease.

FOOD-BORNE ILLNESS PREVENTION CHALLENGES WITH LOCAL FOODS

One of the biggest challenges in preventing food-borne illness during smaller military operations is demonstrating to medical and nonmedical leaders the importance of command involvement in preventing disease. While the benefits of consuming local foods are visible and compelling, commanders and staffs may be unaware of objective evidence, such as the NAMRU-6 study, which examines the associations between local foods and service member disease. Even though the true burden of food-borne diseases from eating local host nation foods in unknown, leaders who believe that local food consumption is not a serious mission consideration, fail to employ FWRAs, and do not apply their risk mitigation recommendations may find their personnel and mission seriously impacted by preventable diseases. A study of acute diarrhea in US military personnel deployed to Sinai, Egypt described such mission impacts. One of every 5 individuals who became ill with diarrhea while deployed to Egypt reported being unable to work because of their illness (missing an average 2 days), and an additional 2 of 5 reported that their work performance was decreased because of their illness. Multiple episodes of diarrhea during deployment equates to a large number of lost and impacted duty days for the Warfighter, and is legitimate cause for concern. (4)

INTEGRATING DoD-APPROVED FOOD SOURCES AND FWRAs DURING MILITARY EXERCISES

Rarely is there a "silver-bullet" in the prevention of food-borne diseases, and demonstrating the effectiveness of a sound food-borne disease prevention strategy remains challenging. * Nevertheless, food-borne disease prevention through timely interventions provides the "biggest bang for the buck" by preventing more disease with fewer resources. The goal is to prevent deployed personnel from consuming higher risk local foods, if possible (Figure 1). Planners supporting service members in these developing areas must construct the safest feeding plan possible within the mission requirements. Applying an integrated risk-based intervention approach to food protection in deployed settings can significantly reduce the incidence and impact of food-borne diseases. During the August 2012 Operation Martillo in Guatemala, multiple food options were leveraged. Bottled water came from a DoD-approved source in Guatemala City, fresh fruit and vegetables came from a local supermarket, Unitized Group Rations ([dagger]) and Meals Ready to Eat ([dagger]) were served at operation sites, and occasional catered meals were provided by a local hotel restaurant. Of all these food and water sources, local restaurants (in a hotel or standalone facility) usually present the highest risk of food-borne illness. Common risks include unapproved raw materials, inadequate refrigerator or freezer space, unsanitary food preparation surfaces, and improper handling of potentially hazardous foods. Ice is one potentially hazardous food for which the risk of contributing to food-borne disease is commonly underestimated. Food service personnel often fail to recognize ice as a ready-to-eat food that is easily contaminated from improper handling (Figure 2), such as in restaurants in developing countries which make their own ice.

DoD-approved food sources provide the foundation of food protection and should be considered before higher risk local food sources. When DoD-approved food sources are unavailable, planners may turn to operational rations as the next preferred option for food safety. When a feeding plan cannot rely solely on either DoD-approved food sources or operational rations because of availability or logistic feasibility, exercise planners may request the FWRA for local food procurement.

When small numbers of troops are deployed, planners may elect to provide per diem (daily allowance for expenses). Service members usually choose where they eat (spend their per diem) and contracted meals are not required. While placing service members on per diem allows them to eat at any number of facilities, FWRAs should still be considered to lower the risk at the food operations that will likely be frequented by service members. Another option is contracting with local restaurants or caterers to provide meals (no per diem). This option requires service members to eat local foods from the contracted local food operations. Under this scenario, an FWRA is required to ensure that food protection risks are understood and mitigated.

The FWRA can roughly be divided into 2 categories: those performed on upscale hotels (often large hotel chains) that host DoD sponsored conferences in major cities, and those in support of military exercises, often outside urban areas, where in-need rural populations are located.

The bulk of FWRAs currently performed are on upscale hotels in major cities. This is certainly the case in the US Southern Command's (SOUTHCOM) area of focus where upscale hotels are routinely assessed every 6 months and maintain food protection practices arguably comparable to similar hotels in the United States. These upscale hotel assessments are largely facility-based assessments that evaluate individual hotel kitchens outside the context of larger exercises.

In contrast to urban assessments, FWRAs conducted in support of exercises in less developed areas often require assessors to evaluate higher risk moderate scale hotel kitchens and consider the complete (beyond the hotel) exercise feeding plan. Heightened water quality concerns in rural areas due to inferior water distribution systems and increased agricultural use create a need for safe bottled water sources (Figure 3). In addition to bottled water, fresh fruits and vegetables, local restaurants and caterers are assessed to build feedings plans.

Assessors who understand how each food operation impacts the overall feeding plan remain agile and able to advise contractors and commanders on less obvious risks. For example, a hotel kitchen with a moderate risk of food-borne illness when serving below its maximum capacity may present an extremely high food-borne illness risk if required to double the number of meals served. The risks of food-borne illness spikes when food operations surge to meet increased demand. The challenging task of developing the safest possible feeding plan requires assessors to consider both the overall feeding plan and the intended use of each food operation.

FWRA risk communication

Unbroken risk communication to supported commanders and service members who may encounter higher risk local foods can prevent food-borne diseases. Besides commanders and service members, other key stakeholders include the assessor and the contractor. The assessor evaluates food operation risks and assists contractors in embedding food safety requirements into statements of work. This relationship with contractors is crucial to effect the most change within the food operation. For example, statements of work can require the replacement of excessively worn cutting boards, the purchase of additional freezers to ensure ample cold storage, building and kitchen improvements, or even direct the use of thermometers.

The assessor communicates risk using the risk assessment matrix (Figure 4) contained in Field Manual 5-19. (5) Since commanders are accustomed to this risk communication tool, its use allows food-borne illness threats to be placed in the same context as other operational risks. (6) This concept must remain central to the medical planning perspective so that threats may be compared and communicated to commanders as transparently as possible. A commander can then give this information appropriate weight with other risks present on the battlefield.

FWRAs IN THE US SOUTHERN COMMAND

The US Army South (ARSOUTH) Deputy Chief of Staff, Medical administers SOUTHCOM's FWRA program. The program's success hinges on partnerships between the Army Public Health Command (USAPHC) and other SOUTHCOM organizations. Specifically, USAPHC Region-South plays a critical role not only in executing the majority of FWRAs performed, but also in maintaining a FWRA database. This success is maintained by clearly delineating roles and responsibilities within SOUTHCOM's FWRA Standard Operating Procedure (SOP). This SOP provides guidance to US military groups (MILGROUPs) within host countries, FWRA assessors, and contracting officers within SOUTHCOM.

The US military groups facilitate FWRAs by coordinating assessment schedules, in-country transportation, translators, laboratory sample shipping, and country clearance. The assessor's role is to coordinate FWRAs with the military groups, perform assessments, and submit completed documents to the ARSOUTH Command Veterinarian. Contracting officers are pivotal in ensuring that the statement of work incorporates realistic risk mitigation requirements, and supported commanders receive the risk mitigation recommendations. While other combatant commands may not yet have the mature, standardized program found in SOUTHCOM, FWRAs are being conducted regularly across the DoD.

FWRAs IN FOREIGN HUMANITARIAN ASSISTANCE OPERATIONS

Natural disasters and other humanitarian crises often occur in regions of the world where DoD-approved sources are not present or are no longer present due to the disaster. Because foreign humanitarian assistance (FHA) operations often involve a rapid response to address human suffering, establishing a formal supply (DoD-approved sources or operational rations) system or conducting sanitary food protection audits of suppliers in a timely manner may not be practical. Finally, the transient nature of FHAs limit the long-term value of the audits as the operation may be over before final approval is granted. Consequently, in FHA operations, the FWRA offers commanders a valuable alternative for providing sustainment to US service members while still ensuring force health protection, as was the case during the 2010 DoD flood relief operations in Pakistan.

FWRAs were conducted at each of 3 US base camps in Pakistan. The initial overall risk assessment for all locations was "high," primarily due to the threat of microbial contamination of food and water. However, the implementation of recommended control measures reduced the overall risk to "moderate." Several of the key recommendations were:

* Remove all ruminant meat and meat products from the menu (due to the potential risk of bovine spongiform encephalopathy).

* Increase the cooking times and temperatures to US required levels.

* Use bottled water (from a former approved source) for cooking.

* Substitution of high-risk food items on the menu with lower-risk food items which were exempt from requiring approval (for example, replace locally manufactured products with imported products from Europe).

* Chlorination of bulk water tanks used for washing dishes and cookware with monthly testing for residual chlorine (Figure 5).

* Establish mess trailers for food preparation and dining (Figure 6).

While these recommendations did not completely eliminate the risk of food-borne illness, they did reduce the overall risk to a level that was acceptable to the commander and did not negatively impact the FHA operations in Pakistan. *

COMMENT

The FWRA program expanded the Veterinary Corps officers' toolbox, allowing them to better deliver food protection expertise and broadly shape risk in local food operations. Actively mitigating risk and guiding commanders to relatively lower-risk food operations has created new challenges and opportunities. The FWRA program is transitioning to a military standard, handbook, and checklist (see extracted sample on the following page) to be released in 2013. Improvements include a consolidated and updated checklist that allows assessors to systematically evaluate food operations in the context of exercise feeding plans. Another change provides the assessor with the tools to recommend exclusion of higher risk food items (for example, unpasteurized dairy products that pose a threat of brucellosis) from food operations. These changes will facilitate the evolution of this rapidly growing program.

Probably the greatest challenge is effective risk communication. Veterinary Corps officers do an excellent job of identifying threats and assessing food protection risks, but this risk must be communicated effectively to commanders and Warfighters who will use these food operations. Additionally, as combatant commands mature their FWRA programs, great care should be taken to develop processes that do not sacrifice risk communication for convenient contracting. Specifically, food operations should not receive a pass/fail designation based on the FWRA. Rather, informed commanders must weigh the FWRA risk level assigned against mission requirements and accept or reject the risk. Contracts should only be formed after risks are accepted by supported commanders. Further, these risks should be fully reevaluated prior to any contract renewal.

While challenges exist with the FWRA program, it also provides several opportunities to improve food safety, including the latitude to provide food operations recommendations and on-site training. These training opportunities create an avenue for skilled assessors to impart their expertise. Additionally, the ability to directly engage partner nations and deliver simple and sustainable food protection training that directly effects host nation health may open the door to exercise-related training engagements apart from the FWRA program.

Even when DoD-approved food sources or operational rations are maximized and FWRAs are leveraged, deployed personnel still encounter higher risk local foods, often by choice. They must, therefore, be forearmed with enough food protection knowledge to make safer choices with local foods. Educational materials such as those available online from the USAPHC (http:// phc.amedd.army.mil/topics/foodwater/ifs/Pages/Local FoodChoicesDuringDeployment.aspx) provide realistic guidance on local food consumption to reduce foodborne diseases. (2) These diseases range from acute bouts of diarrhea from Campylobacter spp to life-long spondylodiscitis and sacroilitis from diseases such as brucellosis from unpasteurized milk.

CONCLUSION

The FWRA program has experienced rapid growth because it empowers supported commanders and assessors with essential information, meshes with counterinsurgency operations, and is especially applicable to developing countries. This empowerment is accomplished by packaging veterinary expertise into realistic risk mitigation recommendations. More than ever, assessors must understand and assist planners and contractors in assembling the safest feeding plan possible. This understanding allows assessors to engage and exercise their veterinary technical knowledge, better partner with assessed food operations, and ultimately protect Warfighters by reducing the risk of food-borne illness.

Extracted portion (Step II)
from draft Food and Water
Risk Assesment checklist.

Step-II Risk Description

* Only address items from Step I rated High or Extremely High
(Significant Risks).

1st Significant Initial Risk (SIR) - Item #: O5

* High () Extremely High

Describe SIR: Thermometers were not used to verify internal
temperatures of chicken or beef before serving. While the chefs
were very experienced with using cooking time / observation to
determine when the chicken and beef were ready, using thermometers
will verify product-specific internal temperatures were reached.

Mitigation for SIR: Assessor provided establishment a thermometer
and on-site training with meals being prepared. Training included
recalibrating thermometer in ice-water. Lead chef was receptive,
engaged, and likely to use thermometer in future. Compliance probable.

Residual Risk When Mitigated: * Low () Moderate () High
() Extremely High

Affected Product Exclusions (if not mitigated): __ * None

Reason for Exclusion: N/A


REFERENCES

(1.) Military Standard 3006A: Sanitation Requirements for Food Establishments. Washington, DC: US Dept of Defense; August 20, 2000.

(2.) United States Army Public Health Command. Worldwide Directory of Sanitarily Approved Food Establishments for Armed Forces Procurement. Available at: http://phc.amedd.army.mil/topics/food water/ca/Pages/DoDApprovedFoodSources.aspx. Accessed August 12, 2012.

(3.) Putnam SD, Sanders JW, Frenck RW, et al. Self-reported description of diarrhea among military populations in operations Iraqi Freedom and Enduring Freedom. J Travel Med. 2006;13(2):92-99.

(4.) Riddle MS, Rockabrand DM, Schlett C, et al. A prospective study of acute diarrhea in a cohort of United States military personnel on deployment to the multinational force and observers, Sinai, Egypt. Am J Trop Med Hyg. 2011;84:59-64.

(5.) Field Manual 5-19: Composite Risk Management. Washington, DC: US Dept of the Army; August 2006:1-8.

(6.) Guide for Deployed Preventive Medicine Personnel on Health Risk Management: Technical Guide 248. Aberdeen Proving Ground, MD: US Army Public Health Command; August 2001:21.

LTC Jerrod W. Killian, VC, USA

MAJ Ronald L. Burke, VC, USA

James E. Westover, Jr

LTC Killian is Chief, Clinical Operations and Command Veterinarian, US Army South, Fort Sam Houston, Texas.

MAJ Burke is Assistant Director, Division of GEIS Operations, Armed Forces Health Surveillance Center, Silver Spring, Maryland.

Mr Westover is Food Defense Specialist, US Army Public Health Command Region-South, Fort Sam Houston, Texas.

* See related article on page 51.

([dagger]) US military small unit and individual field (operational) rations

Figure 4. Risk management matrix.

Hazard                      Hazard Probability
Severity
                   Frequent (A)   Likely (B)   Occasional (C)

Catastrophic (I)    Extremely     Extremely         High
                       High          High

Critical (II)       Extremely        High           High
                       High

Marginal (III)         High                       Moderate

Negligible (IV)      Moderate        Low            Low

                                  Risk Estimate

Hazard                Hazard Probability
Severity
                   Seldom (D)   Unlikely (E)

Catastrophic (I)      High        Moderate

Critical (II)       Moderate        Low

Marginal (III)        Low           Low

Negligible (IV)       Low           Low

                         Risk Estimate

Hazard probability definitions:

Frequent--occurs very often, continuously experienced.

Likely--occurs several times.

Occasionally--occurs sporadically.

Seldom--remotely possible, could occur at some time.

Unlikely--can assume will not occur, but not impossible.

Hazard severity definitions:

Catastrophic--loss of ability to accomplish the mission or
mission failure. Example indicators: death or widespread severe
illness

Critical--significantly (severely) degraded mission capability or
unit readiness. Example indicators: multiple food-borne illness
incidences.

Marginal--degraded mission capability or unit readiness. Example
indicators: sporadic food-borne illness, loss of confidence in
food supply safety.

Neglible--little or no adverse effect on mission capability.

Source: Field Manual 5-19: Composite Risk Management (5)
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Author:Killian, Jerrod W.; Burke, Ronald L.; Westover, James E.
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2013
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