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Observed noncompliance with implementation of vector-borne disease preventive measures among deployed forces.

BACKGROUND

Due to the nature of military operations, US Soldiers are exposed to various diseases not commonly experienced by the general population. Service members deploy to various parts of the world, usually in developing countries, where infectious diseases continue to be a leading cause of mortality and morbidity. Among the major concerns are vector-borne diseases such as malaria, leishmaniasis, trypanosomiasis, dengue fever, and other arboviral infections. Other diseases that are potential sources of concern for deployed military are parasitic helminthes. In disease endemic areas, the local population may not manifest these diseases but remain as reservoirs. Service members who occupy such areas could easily get the infections due to lack of prior exposure to these diseases. (1) Also, multiple deployments to different disease-endemic regions may confound diagnosis, prevention, and treatment due to repeated exposure to different parasite species. This may result in the reintroduction of parasites in areas where they had formerly been eradicated, and thereby burden the health care system.

The US military has mechanisms in place to ensure that disease and nonbattle injuries (DNBI) are prevented by continuously searching for better ways of protecting the Warfighter. Some of the active preventive programs include medical threat assessment and risk communication, use of vaccines and chemoprophylaxis, and research and product development. In the area of vector-borne disease prevention, personal protective equipment consisting of use of topical insect repellent, N, N-diethyl-3-methyl benzamide (deet) and proper wear of permethrin treated uniforms remain the first and most effective line of defense. The continuous search for safer and more effective arthropod repellents for skin and clothing applications, development of more effective insecticide treated bed nets, dissemination of information and training materials, and timely vector assessment and control is testimony to the importance that US military medical community places on force health protection (FHP).

The military also ensures that preventive medicine (PM) detachments are part of the deployed force. The PM detachments perform continuous checks on food facility sanitation, air quality monitoring, water safety, and general sanitation. They conduct surveillance of vectors of medical importance to assess disease threat, determine pest population, and recommend management and control. This is important since it not only facilitates vector control but also puts in place integrated pest management practices in order to reduce pesticide use. Historically, DNBI have been reported as causing more casualties than combat, and "seriously degrading the mission" more than combat-related injuries. From the time of Napoleon who lost over 80% of his half million Soldiers to DNBI during the French invasion of Russia in 1812 (2) to the most recent US military operations in Liberia, Somalia, Iraq, and Afghanistan, noncombat related injuries continue to reduce military efficiency. (3) Many of the disease infections were attributed largely to noncompliance with recommended disease preventive measures. (4)

Units deploying for combat operations are expected to be fully prepared to execute their mission successfully. Consequently, commanders take time to ensure that personnel are trained on all equipment and maneuvers to be used during combat prior to deployment in accordance with the Army training and evaluation program manuals. In the area of combating vector-borne diseases, supplying personal protective materials and training on recommended PM measures have to some extent been part of the predeployment preparation process. The outcome of this preparation has been a reduction in the rates of DNBI as reported for Operation Iraqi freedom (OIF) and Operation Enduring Freedom (OEF) when compared to Operations Desert Shield and Desert Storm. (5) However, despite the numerous FHP resources available to individual service members, US forces continue to be plagued by numerous vector-borne diseases that could easily be prevented if proper personal protective equipment is used as recommended.

OBSERVED CONCERNS

This report covers the period of the author's deployment with the 926th Medical Detachment (PM) to the Iraq theater from July 2007 to September 2008. During this period, failure by individual Soldiers as well as gross failure by leadership to enforce implementation of simple PM recommendations were rampant. Following are some of the aspects of noncompliance to implement vector-borne disease preventive measures that were observed at the Contingency Operating Base (COB) Speicher and Forward Operating Base Q-West.

Many of the Soldiers wore physical training shorts and tee-shirts in the evenings and remained outdoors for extended periods of time for various recreation activities. Also, due to high temperatures, physical training was conducted in the early hours of the morning or evening. Both periods coincide with the peak biting periods for sand flies and mosquitoes.

We created a questionnaire, shown at Figure 1, to gather initial information about the existing environmental conditions, knowledge of preventive measures, and availability and use of preventive materiel when responding to a unit's complaints of arthropod bites or request for pest control. From the responses to the questionnaires, we concluded that there was a marked distinction in the level of knowledge about personal preventive measures and availability of protective equipment (PPE) between the Active Army and Reserve (USAR) units.

Availability of PPE was noticeably less among USAR units. More than 75% of the USAR units deployed without treated uniforms and did not have any Individual Dynamic Absorption Application (IDAA) kits for uniform treatment. Also, over 50% of these units had not been issued deet but had other types of arthropod repellents that were bought from the post exchange or were sent to them by family members. Some of the most commonly used repellents included OFF! Deep Woods Insect Repellent Spray (S.C. Johnson & Son, Inc, Racine, WI) containing 23.8% deet; OFF! FamilyCare Insect Repellents pump-spray containing 5% to 15% deet; and Cutter (Spectrum Brands, Inc, Atlanta, GA) family Insect repellent containing 7% deet. Among Active Army units, approximately 50% of the units did not have permethrin-treated uniforms, although they had been issued the IDAA kits. Furthermore, more than 75% of the Soldiers did not know how to use the kits. About 75% of units had deet but more than 50% of the Soldiers did not use it as recommended for various reasons, such as safety concerns. Almost 90% of all units deployed without bed nets.

One of the greatest challenges involved waste disposal. At COB Speicher, food waste was dumped at the burn pit and left overnight. Much unburned food was left outside the pit attracting many wild and feral animals. Rotting food waste also provided good breeding habitat for flies. Waste was not separated and heaps of tires, metal, plastic, and wood littered the landfill, providing breeding sites for mosquitoes and habitat for snakes, scorpions, rodents, and small mammals. In turn, rodent and other small mammals' burrows provided breeding ground for sand flies. Thousands of birds flocked the area for food and shelter and posed serious problems for aircraft, especially during landing, since this area was close to the flight line.

Wild and feral animals were a major problem on COB Speicher. Food waste left in open bins close to the Soldiers' central housing units (CHUs) attracted animals. To compound this issue, Soldiers continuously fed dogs, cats, birds, and foxes, thereby encouraging them to remain in close proximity to human habitation. Foxes, cats, and sometimes dogs were observed sleeping under CHUs during the day and wandering in search of food in the evenings with no fear of humans (Figures 2 and 3). Some Soldiers adopted dogs and cats as pets, and on occasion kittens were found hidden in Soldiers' CHUs. Some Soldiers also released animals from traps set by the civilian vector control contractor, thereby frustrating efforts to remove animals from living areas. This also exposed these individuals to possible bites and scratches because trapped animals exhibited highly aggressive behavior.

Rodents were attracted to the living and work areas as a result of poor food storage and disposal. Trash bins filled with food waste were oftentimes left open. Soldiers complained of mice gnawing on their fingers and toes while they slept, a consequence of rodent-human cohabitation. Also, the rodents attracted snakes to these areas. Since most of the buildings had numerous openings due to bombings and other acts of war, exclusion was almost impossible. Large numbers of plastic tamper-proof rodent bait stations (a) containing 0.005% Brodifacoum anticoagulant rodenticide (b) placed around most buildings reduced mice numbers but could not eliminate the problem because there was an unremitting supply of new rodents from surrounding farms. The result was an incredibly high number of rodents, demonstrated by the large amount of rodent droppings as shown in Figure 4.

Birds were another vector control problem. Large numbers of pigeons, sparrows, and other species of birds were common both inside and outside of buildings. Bird droppings and feathers accumulated inside and outside of many occupied and unoccupied structures. Mechanical removal of birds by shooting with a pellet rifle (.22 caliber) (c) or trapping with bird traps (d) was mostly used to reduce the population. Unfortunately, when removed from one building, the birds migrated to another building, and their control was almost impossible. To compound this control problem, Soldiers put up bird feeding stations and continuously provided food and water to birds. This attracted more birds, as well as other animals, to these feeding stations that were often close to living and work areas.

Filth fly and other types of fly infestation were common occurrences. Dining facility entrances without adequate mesh screening and/or air curtains had serious fly problems. Soldiers left doors open allowing fly movement into and out of food serving areas. Also food waste bins outside the dining areas were not emptied and cleaned daily (or when filled), leaving food waste to rot, which in turn created fly breeding habitats. Fly traps (Fly Terminator Pro, Farnam Companies Inc, Phoenix, Arizona) (e) with a fly attractant (f) placed outside the dining facility could not eliminate flies altogether.

Sanitation was not properly practiced, especially around most of the living and work areas. Grass and shrubbery were not removed from around tents and hard structures. The vegetation served as habitat for rodents, scorpions, snakes, and sand flies. Buildings, tents, and storage containers were poorly maintained and had large openings that facilitated rodent and other animal entry. Discarded piles of wood waste, old sand bags, and other barrier materials provided habitat for scorpions, snakes, and rodents around buildings.

Infestation from the common bed bug, Cimex lectularius Linnaeus (Hemiptera: Cimicidae), was observed among US forces, contractors, and third country nationals (TCNs). Bed bugs, which are part of reemerging pests, especially in developing

countries, were to a lesser extent a problem among US service members. Infestations were more common among civilian employees, especially the TCNs. Soldiers complained of sand fly bites which we confirmed to be caused by bed bugs. Unfortunately, many Soldiers lacked education/information on bed bug infestation or what to do if infested.

IMPLICATIONS

Soldiers continued to complain of arthropod bites and sometimes sought medical treatment due to dermatitis, secondary infection, or allergic reactions to bites. During this period, sand flies tested for leishmania parasite infection were all negative. However, some Soldiers became infected with cutaneous leishmaniasis indicating the presence of the parasite in this region. Although there were only 2 reported cases of cutaneous leishmaniasis and no cases of malaria in the 2 locations during this period, malaria and leishmania remain significant medical problems for US personnel deployed worldwide. Over 500 cases of cutaneous leishmaniasis were reported among US Soldiers in the first year of OIF. (6) Four cases of visceral leishmaniasis were reported among US personnel deployed to Iraq 7 and 38 cases of malaria reported in US personnel deployed to eastern Afghanistan from 2002 to 2004.6 Even in the absence of diseases, annoyance pests could negatively affect morale and performance.

[FIGURE 2 OMITTED]

Pesticides were often used to control disease vectors that were above the recommended threshold of 25 female anopholine mosquitoes or 15 female phlebotomine sand flies per trap per night. Pesticide application frequency was, on average, one to 2 applications per week during peak periods. Due to the nature of sand fly habitat, control of immature forms was very difficult, and adult control through fogging was the most applicable method. Two of the most commonly used insecticides were Scourge (aa) (Bayer CropScience LP, Montvale, NJ) containing 4% resmethrin and 12% piperonyl butoxide, and Anvil 10+10 ULV (bb) (Clarke Inc, Roselle, Illinois) with 10% 3-Phenoxybenzyl-(1RS, 3RS; 1RS, 3SR)-2,2-dimethyl -3-(2-methylprop-1-enyl) cyclopropanecarboxylate. We observed that repeated pesticide applications were always required to bring down sand fly numbers. This may be partly due to the harsh climatic conditions where pesticides were rapidly degraded, ineffective application methods in targeting precise microhabitats, (8) or already developed pesticide resistance as a result of chemical use in agricultural and other pest control needs by the host nationals. Selection pressure may result in development of insecticide resistance due to persistent pesticide applications. This phenomenon has been reported for most vectors of human diseases and classes of pesticides. (9,10) Continuous monitoring of insecticide resistance emergence in disease vectors is therefore necessary in military operations where chemical control is constantly used.

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

Scorpion stings were mostly from less poisonous scorpion species, although we found some of the medically important scorpion genera, Androctonus and Leiurus (Buthidae) and Hemiscorpius (Liochelidae) in this region. Stings were mostly on the legs. All individuals who were stung were wearing shorts and tee-shirts. Many of these cases required hospitalization for observation. Serious cases of scorpion stings have been reported elsewhere during OIF and OEF deployments. In 2006, a US Army entomologist in Kuwait was stung by the deadly scorpion Androctonus crassicauda and had to be airlifted for medical treatment. (11) This scorpion sting report is not an isolated incident. From 2005 to 2006, 9 cases of snakebites and 85 cases of scorpion stings and spider bites were reported among 3,265 Soldiers deployed to Iraq and Afghanistan. (12)

Filth flies are not only nuisance pests but are also important in mechanical disease transmission and may act as intermediate hosts for a number of helminthes. (13,14) Flies in dining facilities frequently came into contact with food. This can enhance mechanical transmission of disease pathogens. Flies play a significant role in the spread of diarrheal diseases that contribute to reduced military effectiveness during deployments. Cases of gastroenteritis associated with Norovirus, Shigella, and Eschericia coli (Migula), Castellani and Chalmers (Gamma Proteobacteria: Entorobacteriaceae) have remained a problem among deployed forces. In a study conducted in 2003 at Doha, Qatar, on US Soldiers during rest and recuperation leave, 70% of Soldiers reported at least one episode of diarrhea while 54% reported multiple incidences during deployment to Iraq and Afghanistan. Among these individuals, 43% reported a decline in performance for 2 days, while 17% indicated they had to take bed rest for 2 days due to a diarrhea episode. (15) A study in 2004 found that 66% of US Soldiers in Iraq experienced diarrhea, with 50% reporting more than one episode. (16)

Fly larvae sometime invade human organs and tissues, a condition referred to as myiasis. Fly larvae in the human eyes results in ophthalmomyiasis or ocular myiasis. Common cause of ocular myiasis is deposition of the sheep nasal bot fly (Oestrus ovis Linnaeus (Diptera: Oestridae)) or human bot fly (Dermatobia hominis Linnaeus (Diptera: Oestridae)) larvae in the cornea of the human eye. Ocular myiasis patients complain of red watery eyes, swollen conjunctiva, and sometimes a sensation of foreign body in the eye. One case of ocular myiasis occurred on Contingency Operating Base Speicher in March 2008. A male Soldier reported to the optometry clinic complaining of painful, watery eyes and a feeling of "sand in his eyes." He reported that a day before this visit, a fly had hit his eye while it was buzzing around his face. The optometrist observed and removed 4 small worms from over the cornea of his left eye. Antibiotic and antihistamine drops were prescribed and the patient was asked to report back after 2 days. He did not return for his follow-up appointment. The worms were sent to the base entomologist for identification. They were identified as the first instar larvae of the sheep nose bot fly. This case accounts for the second report of O. ovis ocular myiasis in the northernmost part of Iraq. Bot fly ocular myiasis cases from Iraq have been reported from the Baghdad area with only one other case reported north of Baghdad at Mosul. (17) Other cases have been reported elsewhere in Iraq (18) and Afghanistan. (19) Ocular myiasis is not only medically important but is also traumatizing to the affected individual.

Large numbers of birds roosting in buildings constitute health hazards. Bird nests harbor ectoparasites such as pigeon fleas (Ceratophyllus columbae Gervais (Siphonaptera: Ceratophyllidae)), chicken mites (Dermanyssus gallinae De Geer (Acarina: Dermanyssidae)), ticks (Argas reflexus Fabricius (Acari: Argasidae)), and biting lice. Although these parasites may not transmit diseases, their bites could cause allergic reaction and discomfort. (20) Bird droppings attract filth flies and may carry disease pathogens. Soil contaminated with bird droppings accumulated over a long period of time may contain spores of the fungi Histoplasma capsulatum Darling (Ascomycetes: Onygenaceae) or Cryptococcus neoformas (San Felice) Vuillemin (Tremellomycetes: Tremellaceae). Inhalation of these spores may cause diseases such as Histoplasmosis and Cryptococcosis. Although these diseases are mild in healthy individuals, they may become fatal in a person with a compromised immune system.

Cohabitation of rodents and humans may potentially expose individuals to various rodent diseases. Worldwide, rodents transmit over 35 diseases. Mice may transmit diseases to humans through their bites, droppings, and urine. Rat bite fever is an infectious bacterial disease caused by Streptobacillus moniliformis Levaditi, Nicolau, and Poincloux (Fusobacterales: Fusobacteriaceae) and Spirillum minus Carter (Spirochaetales: Spirillaceae) and transmitted mostly through bites and scratches from rats and mice. Eating food contaminated with mice urine or feces could cause salmonelosis or leptospirosis. Rodents carry ectoparasites such as fleas. Bites from fleas infected with the bacterium Yersinia pestis (Lehmann & Neumann), Van Loghem (Enterobacteriales: Entorobacteriaceae) cause plague, a disease that caused millions of deaths in Europe during the Middle Ages (21) and is still endemic in some countries. (22)

Close association of humans with feral and wild animals could potentially expose service members to zoonotic diseases. Over 75% of emerging and reemerging pathogens are reported to be zoonotic. (23) Feral dogs and other canids that roam the military camps in search of food may transmit numerous disease pathogens to humans. Of importance are diseases such as rabies, helminthes, and bacterial and fungal infections. (24) Close contact with dogs and cats may facilitate transmission of ectoparasites which may cause prurities and secondary infection from scratching. (25) Bites from fleas could potentially transmit diseases. Of all the diseases transmitted from animals to humans, rabies is the most severe. It has worldwide distribution and causes over 55,000 deaths every year. (26)

Although bed bugs do not transmit diseases, their bites may cause allergic reactions that could range from pruritic papules (27) to hemorrhagic vesicular lesions and urticaria. (28) Bed bug infestation may result in loss of sleep due to persistent biting and itching, ultimately affecting an individual's quality of life and combat readiness. Repeated bites may cause individuals to become constantly agitated and nervous, resulting in substantial psychological problems. (29)

RECOMMENDATIONS

The first line of defense against vector-borne diseases and annoying arthropods is the proper use of personal protective measures (PPM). It is the responsibility of the individual service member to implement recommended PPM. Soldiers must educate themselves on the importance of the use of PPM. Strict adherence to PPM will only occur when service members understand the serious consequences of noncompliance. This knowledge will promote development of confidence in the effectiveness of the personal protective equipment, thereby minimizing the disease threat.

Commanders at all levels have direct responsibility for the protection of the health of Soldiers under their command. It is, therefore, imperative that unit leaders receive aggressive training on importance of PPE use and remain informed of all possible medical threats in various regions. Proper PPE use should be included as a required training task in the mission essential task list and should be part of predeployment training. Distribution of PPE to service members should be completed early in the predeployment phase whenever possible. Unit leadership should ensure that Soldiers are educated and motivated on the importance of PPM and are equipped with all required resources. They should remain vigilant, continuously emphasize the use of PPM, and perform unscheduled welfare visits to Soldier living quarters to ensure compliance. When possible, unit leadership should minimize unnecessary outdoor activity at dusk and dawn when disease vectors are most active. Also, trousers and long-sleeve shirts may give better protection than shorts and tee-shirts during physical training. Deet should be applied to exposed skin at all times.

Proper sanitation must be continuously emphasized. Unit leadership should enforce proper waste disposal. Waste bins should be emptied and cleaned daily or when filled. Segregation of waste at the source to allow proper burning should be enforced. Food storage or consumption in living areas should be discouraged and pest breeding habitats should be eliminated where possible. Leaders should enforce the US Army 5th Corps General Order Number 1 (GO-1) (March 19, 2003), with all its modifications, as it pertains to the adoption of wild and feral animals as pets and mascots and feeding or caring of these animals. GO-1B prohibits "adopting as pets or mascots, caring for, or feeding any type of domestic or wild animal." Individuals who keep or feed animals, regardless of their rank or position, should be subject to discipline under the Uniform Code of Military Justice * as specified in GO-1. Entrances to food service facilities should be equipped with adequate mesh screening and/or air curtains. Holes and cracks in the walls, doors, and windows should be sealed through the use of materials available on the base. Vegetation should be cleared and debris removed from around living and work areas.

At higher command levels, authorities should ensure that all mandatory PPE is available to deploying personnel. The responsibility of acquiring PPE should not be left entirely to individual units. It should be distributed through a centralized process such as central issue facility, rapid fielding initiative (RFI), or other means that ensure that every unit receives all required resources before deploying. This is more so for mobilized USAR units which had more difficulty obtaining PPE than did Active Army units. Similar findings have been reported elsewhere among military services and branches of each service. (31) In a study within the Army, 40% of Active Army and Army National Guard personnel reported receiving issued deet compared with 21% of personnel from the USAR. Marked differences were observed in numbers of personnel having at least 3 permethrin-treated uniforms. The USAR units fared poorly with only 6.2% of personnel having 3 permethrin-treated uniforms, compared to 54% of personnel in the Active Army units. (32,33) The basis for this difference should be established and efforts made to ensure that all deploying personnel receive recommended PPE. If for any reason equipment cannot be issued to Soldiers before they deploy, RFI teams may be forward-deployed, and it may be advantageous to preposition required PPE in different locations in theater.

CONCLUSION

The military continues to commit considerable resources to FHP. Because of this, the Department of Defense FHP effort has made massive strides in combating environmental health threats during contingency operations, especially in disease endemic regions. However, despite this success, military personnel continue to be plagued by preventable diseases not related to combat. We observed poor implementation of PPM among individual Soldiers as well as serious failure by commanders at all levels of responsibility to emphasize the use of PPM. This indicates the need for reevaluation of current regulations, such as GO-1 and Army Regulation 40-5 (34) which specifies the responsibilities of individual Soldiers and commanders in the implementation of PPM. Governing regulations and orders should clearly spell out disciplinary consequences for failure to strictly adhere to the use of required PPM. Military leadership should ensure that leaders at all levels face serious consequences if they fail to enforce use of PPM. Leaders should understand that they are responsible for the health of their troops and that they will be held accountable for DNBI among Soldiers under their command. It is therefore imperative that unit leaders strictly enforce PPM use and lead by example. Command discipline is indispensable. In the words of then Lieutenant General Sir William Slim, the commander of the British XIV Army in Burma during World War II:
   Good doctors are no use without good discipline. More
   than half the battle against disease is fought not by
   doctors, but by regimental officers. (35)


General Slim sacked commanders who failed to enforce malaria prophylactic treatment. His aggressive leadership resulted in the enforcement of malaria chemo-prophylactic drug use, which dramatically reduced the number of malaria cases among his troops. This demonstrates that combined efforts from military policy makers, the medical community, leadership at every level of command, and the individual Soldier are needed to combat DNBI among deployed US forces.

REFERENCES

(1.) Robert LL. Malaria Prevention and Control in the United States Military. Med Trop. 2001;61(1):67-76.

(2.) Bellamy RF, Llewellyn CH. Preventable casualties. Rommel's haw, Slim's edge. Army Mag. 1990;40:5256.

(3.) Sanders JW, Putnam SD, Frankart C, et al. Impact of illness and noncombat injury during Operation Iraqi Freedom and Enduring Freedom (Afghanistan). Am J Trop Med Hyg. 2005;73(4):713-719.

(4.) Kotwal RS, Wenzel RB, Sterling RA, Porter WD, Jordan NN, Petruccelli BP. An outbreak of malaria in US Army Rangers returning from Afghanistan. JAMA. 2005;293(2):212-216.

(5.) Wojcik BE, Humphrey RJ, Czejdo B, Hassell LH. US Army disease and nonbattle injury model, refined in Afghanistan and Iraq. Mil Med. 2008;173(9):825835.

(6.) Update: cutaneous leishmaniasis in US military personnel, southwest/central Asia, 2002-2004. MMWR Morb Mortal Wkly Rep. 2004;53(12):264-265.

(7.) Myles O, Wortmann GW, Cummings JF, et al. Visceral leishmaniasis: clinical observations in 4 US army soldiers deployed to Afghanistan or Iraq, 20022004. Arch Intern Med. 2007;167(17):1899-1901.

(8.) Seyedi-Rashti MA, Nadim A. Attempt to control zoonotic cutaneous leishmaniasis in the Isfahan area, Iran. Proceedings of the 9th International Congress on Tropical Medicine and Malaria. Athens, Greece: 14-21 October 1973:135.

(9.) Fonseca-Gonzalez I, Cardenas R, Quinones ML, McAllister J, Brogdon WG. Pyrethroid and organophosphates resistance in Anopheles (N.) nuneztovari Gabaldon populations from malaria endemic areas in Colombia. Parasitol Res. 2009;105 (5):1399-1409.

(10.) Foil LD, Coleman P, Eisler M, et al. Factors that influence the prevalence of acaricide resistance and tick borne diseases. Vet Parasitol. 2004;125(1-2):163 181.

(11.) Scully S. Army scorpion expert in Kuwait stung by insect, irony. Armed Forces Press Service. November 2, 2006. Available at: http://www.defense.gov/news/ newsarticle.aspx?id=1999. Accessed March 24, 2010.

(12.) Shiaud DT, Sanders JW, Putnam SD, et al. Self reported incidence of snake, spider, and scorpion encounters among deployed US military in Iraq and Afghanistan. Mil Med. 2007;172(10):1099-1102.

(13.) Graczyk TK, Knight R, Tamang L. Mechanical transmission of human protozoan parasites by insects. Clin Microbiol Rev. 2005;18:128-132.

(14.) Graczyk TK, Knight R, Gilman RH, Cranfield MR. The role of nonbiting flies in the epidemiology of human infectious diseases. Microb Infect. 2001;3:231-235.

(15.) Sanders J, Putnam S, Riddle M, Tribble et al. The epidemiology of self-reported diarrhea in Operations Iraqi Freedom and Enduring Freedom. Diagn Microbiol Infect Dis. 2004;50(2):89-93.

(16.) Aronson NE, Sanders JW, Moran KA. Emerging infections: in harm's way: infections in deployed American military forces. Clin Infect Dis. 2006; 43 (8): 1045-1051.

(17.) Gregory A, Andrew R, Schaltz S, Laubach H. Ophthalmomyiasis caused by the sheep bot fly Oestrus ovis in northern Iraq. Optom Vis Sci. 2004;81 (8):586-590.

(18.) Dunbar J, Cooper B, Hodgetts T, et al. Emerging infections: an outbreak of human external ophthalmomyiasis due to Oestrus ovis in southern Afghanistan. Clin Infect Dis. 2008;46(11):124-126.

(19.) Stacey MJ, Blanch RJ. A case of external ophalmomyiasis in a deployed UK Soldier. J Roy Army Med Corps. 2008;154(1):60-62.

(20.) Haag-Wackernagel DH, Spiewak R. Human infestation by pigeon fleas (Ceratophyllus columbae) from feral pigeons. Ann Agr Environ Med. 2004;11 (2):343-346.

(21.) Diseases from Rodents. Centers for Disease Control and Prevention website. Available at: http:// www.cdc.gov/rodents/diseases/index.htm. Accessed July 29, 2009.

(22.) World Health Organization. Fact Sheet No. 267: Plague. Available at: http://www.who.int/ mediacentre/factsheets/fs267/en/index.html. Accessed July 28, 2009.

(23.) Taylor LH, Latham SM, Woolhouse ME. Risk factors for human disease emergence. Philos Trans R Soc LondB Biol Sci. 2001;356:983-989.

(24.) Dalimi A, Sattari A, Motamedi GH. A study on intestinal helminthes of dogs, foxes and jackals in the western part of Iran. Vet Parasitol. 2006;142(1 2):129-133.

(25.) Skerget M, Wenisch C, Daxboeck F, Krause R, Haberl R, Stuenzner D. Cat or dog ownership and seroprevalence of ehrlichiosis, Q fever, and cat-scratch disease. Emerg Infect Dis [serial online]. 2003;9(10):1337-1340.

(26.) World Health Organization. Fact Sheet No. 99: Rabies. Available at: http://www.who.int/ mediacentre/factsheets/fs099/en/index.html. Accessed July 17, 2009.

(27.) Elston DM, Stockwell S. What's eating you? Bed bugs. Cutis. 2000;65:262-264.

(28.) Thanakaram S. Bullous eruption due to Cimex lectularius. Clin Exp Dermatol. 1999;24:241-242.

(29.) Bed bug re-emergence occurring. EPI--News [serial online]. Reno, Nevada: Washoe County District Health Dept;2007;27(17). Available at: https:// www.washoecounty.us/repository/files/4/Vol% 2027%20No%2017-12-31-07%20Bed%20Bug.pdf. Accessed March 23, 2010.

(30.) 64 Stat. 109, 10 USC, chap 47.

(31.) Coleman RE, Burkett DA, Putnam JL, et al. Impact of phlebotomine sand flies on US military operations at Tallil Air Base, Iraq: background, military situation, and development of a leishmaniasis control program. J Med Entomol. 2006;43(4):647-662.

(32.) Gambel JM., Brundage JF, Kuschner RA, Kelly PW. Deployed US Army soldier's knowledge and use of personal protection measures to prevent arthropod-related casualties. J Trav Med. 1998;5:217-220.

(33.) Gambel JM, Brundage JF, Burger RJ. Survey of US Army soldier's knowledge, attitudes, and practices regarding personal protection measures to prevent arthropod--related diseases and nuisance bites. Mil Med. 1998;163:695-701.

(34.) Army Regulation 40-5: Preventive Medicine. Washington, DC: US Dept of the Army; May 25, 2007.

(35.) Slim WJ. Defeat Into Victory. London: Cassell and Company; 1956:180.

(a.) National Stock Number (NSN) 3740-01-423-0737

(b.) NSN 6840-01-508-6085

(c.) NSN 1005-01-544-1044

(d.) NSN 3740-01-542-9963

(e.) NSN 3740-01-561-9678

(f.) NSN 3740-01-561-9732

(aa.) NSN 6840-01-359-8533

(bb.) NSN 6840-01-474-7706

* The Uniform Code of Military Justice (UCMJ), a federal law, (30) is the judicial code which pertains to members of the United States military. Under the UCMJ, military personnel can be charged, tried, and convicted of a range of crimes, including both common-law crimes (eg, arson) and military-specific crimes (eg, desertion).

CPT Elizabeth W. Wanja, MS, USA

CPT Wanja is Chief, Department of Immuno-diagnostics, Division of Entomology, Walter Reed Army Institute of Research, Silver Spring, Maryland.
Figure 1. The 926th Medical Detachment (PM) questionnaire used for
vector assessment and control requests.

Unit Name:                    Phone#:                            DATE:
Unit Commander:               SGM/1st Sergeant/Detachment SGT
COB/FOB:
Building Number:        LSA:                                     GRID:
Complaint:
GENERAL CONDITIONS
                                                           YES      NO
                                             Total

a. Branches cut back at least 2 feet from
   roof, ledges or other access ways?
b. No debris allowed accumulating for
   greater than 72 hours?
c. No vegetation around buildings/tents
d. * No standing water, or suspected
   animal burrows in/around site?
e. No hollow Sidewalks or walkways?

More than 2 "NO" marks, equal high risk
(* Denotes critical issues equal to 2 "No")

STRUCTURAL CONDITIONS

a. If dropped ceiling, are all tiles
   securely in place, present, good
   repair?
b. Windows closed at all times, or
   approved screening present?
c. * Walls free of holes greater than 1/4
   inch in diameter?
d. Floors extend to meet the walls with no
   gaps?
e. * Floors free of cracks/holes greater
   than 1/4 inch.
f. Doors hung properly, with no gaps
   greater than1/4 inch?
g. If "No" are door sweeps or seals
   installed and in good repair?

More than 2 "N0" marks, equal high risk
(* Denotes critical issues equal to 2 "No")

SANITARY CONDITIONS
                                             Total         YES      NO
a. Garbage cans cleaned adequately at
   least daily or when filled up?

b. Garbage bags present/used?
c. Dirty or soiled linen kept in approved
   containers.
d. * Area free of live pets or mascots of
   any kind?
e. Rodent traps checked daily?
f. Fly traps removed once 70% full?
g. * Food stored/consumed only in
   approved areas?
h. * Food (including drink mixes) stored
   in hard plastic/metal containers?
i. * No evidence of rodents (droppings,
   gnawing, rubmarks)?

More than 2 "N0" marks, equal high risk
(* Denotes critical issues equal to 2 "No")

EDUCATION/PREVENTIVE MEASURES

a. * Acting Field Sanitation Team
   certified and appointed (on orders)?
b. Proper wear of the uniform IAW FM
   21-10 enforced?
c. Uniforms treated with permethrin?
d. # of treated uniforms /soldier
e. Use of deet enforced?
f. # of deet tubes issued?
g. Other types of insect repellents?
h. Repellents obtained from?
i. Education of Arthropods of military
   importance posted/provided?
j. Time PT conducted?
k. PT uniform?
l. Evening/nonduty hour uniform?

More than 2 "N0" marks, equal high risk
(* Denotes critical issues equal to 2 "No")

ASSESSMENT TOTAL
                                             Total
Input the total number of "Yes"/"No"
observations from above.

FINDINGS

Circle all that apply
                                                           YES      NO
Area IS / IS NOT at risk of infestation
due to RODENTS/SNAKES/SCORPIONS/
MOSQUITOES/SAND FlIES/OTHER.

If other, specify:

Inspector Name:                              Rank/Grade    Phone
Signature:
Representative Name:                         Rank/Grade    Phone
Follow up inspection date:
COPYRIGHT 2010 U.S. Army Medical Department Center & School
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2010 Gale, Cengage Learning. All rights reserved.

Article Details
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Author:Wanja, Elizabeth W.
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:1USA
Date:Apr 1, 2010
Words:5619
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