International Medicine

1. International Medicine Jim Fike, Col, USAF, MC, FS Consultant to AF/SG, Director International Health Specialist Program

2. Objectives • Characterize Important International Diseases and Disease Prophylaxis • Medical Intelligence Research and Briefings • Infectious Disease Risk Assessment • Operational Examples • What Sources are Available to Support Collecting Medical Intelligence/Risk? • Format and Content of a Brief • Water and Food Vulnerability/Safety Assessments • Q&A

3. Important International Diseases and Prophylaxis • Specific diseases of importance vary from deployment to deployment • Base preparations on information from medical intelligence preparation • The three most common areas of concern are usually: • Required/recommended immunizations • Malaria chemoprophylaxis recommendations • Host nation medical support/evacuation plans

4. Immunization Recommendations • Baseline immunizations to maintain readiness status, reference AFJI 48-110 (Immunizations and Chemoprophylaxis) at http://www.e-publishing.af.mil/shared/media/epubs/AFJI48-110.pdf: • Guidance on exemptions (medical and administrative, to include religious) • Guidance on DoD personnel requiring immunizations • Specific immunization requirements • Appendix D provides a summary (pp. 32-33) • Additional immunizations based on deployed location/risks • Reporting instructions for larger operations • Based on site visit and risk assessment by aerospace medicine personnel for smaller/unit operations

5. Chemoprophylaxis • AFJI 48-110 also has section on chemoprophylaxis (Chapter 5): • Anthrax Group A Step • Influenza A/B Leptospirosis • Malaria Meningococcal • Plague Scrub typhus • Traveler’s diarrhea TB • Areas covered in other documents include • Chem warfare chemoprophylaxis • Radiation-related chemoprophylaxis • Medical RX for TB exposure • Prophylaxis involving non-biologic medications (aspirin, calcium, vitamins)

6. Malaria Resources • CDC malaria website: • http://www.cdc.gov/malaria/ • Malaria Site: • http://www.malariasite.com/index.htm • Malaria Risk World Map: • http://gis.hhs.gov/website/mrisk9/viewer.htm

7. Host Nation ResourcesMedical Evacuation Plans • Large-scale operations have plans established • OEF/OIF, JTF-HOA, JTF-Bravo, etc. • Status of Forces Agreements (SOFA) versus bilateral Memorandums of Understanding (MOUs) • Classically involve established or on-call AE resources dedicated to DoD requirements • Smaller and unit operations require plans to be established • Host nation resources need to be identified (reference upcoming med intel discussions) • Presence/absence of standing MOU/SOFA determined • Potential resources: COCOM/SG, Air Component (C-NAF)/SG, Country ODC/DAT office, US Embassy health unit, CDC, USAID

8. Medical Intelligence • “That category of intelligence resulting from the collection, evaluation, analysis, and interpretation of foreign medical, bio-scientific, and environmental information that is of interest to strategic planning and to military medical planning and operations.” • How is medical intelligence used in healthcare operations? • Medical threat analysis and management • Threat-based concept development • Medical Research • Medical doctrine development

9. Don Berwick—one of the world's leading thinkers on improvement in health care and a friend of mine—tells a story that illustrates how data on performance can mislead. He was responsible for quality assurance in a hospital. The radiology department had spectacular results. Patients waited hardly a moment. Everybody was satisfied. Why did the department do so well? Don wanted to find out and encourage the department to share its learning. "How is it," he asked the director, "that you get such good results?“ "Simple," she answered, "we make them up." BMJ  2003;326 (17 May), www.bmj.com

10. Purpose of Communicating Medical Risks to Commanders • Preventing/reducing DNBI casualties through the foreknowledge of militarily significant diseases, poisonous and venomous flora and fauna, and health-threatening environmental conditions • Increasing successful return to duty of personnel • Improving existing medical support systems and RDT&E of new medical and human factors engineering systems tailored to existing and future threats • Improving casualty modeling and projections • Reducing the severity of battle casualties by medical means through the foreknowledge of enemy weapon capabilities, employment doctrine, and wounding characteristics • Decreasing the total number of WIA and KIA through medical means by using threat-based concept development

11. What Information is Important to a Commander? • Anything that could adversely affect the health of his/her troops • But…………… • Commanders time (and attention spans) are short • You will not be able to educate your commander to the point that their understanding is as in depth as yours • Prioritize the highest risk information • Present from most important to less important • Re-emphasize key points • Give concrete advice on how the command structure can support health prevention • Provide examples of consequences of supporting your recommended courses of action (or not)

12. Information to Consider Discussing with Commanders • Endemic or epidemic diseases, public health standards and capabilities, and the quality and availability of health services • Medical supplies, medical services, medical treatment facilities, and the number of trained HSS personnel • Location-specific diseases, strains of bacteria, insects, harmful vegetation, snakes, fungi, spores, and other harmful organisms • Foreign animal and plant diseases, especially those diseases transmissible to humans

13. Information to Consider Discussing with Commanders • Health problems relating to the use of local food supplies • Medical effects of and prophylaxis against chemical and biological agents and radiation • The impact of newly developed foreign weapons systems as they relate to casualty production • An enemy force related to its state of health and fitness or its use of special antidotes • Environmental factors in an area of operations such as altitude, heat, cold, and swamps that in some way may affect the health of the command or HSS operations

14. Disease Risk Assessment • Estimate of Operational Impact • What is the risk to US forces from militarily relevant diseases in a particular country? • Consider using the AFMAN 48-153 (Health Risk Assessment) as a resource when developing a risk assessment model prior to, or while, deployed

15. Mayaro virus Meningococcal meningitis Murray Valley (Australian) encephalitis Omsk hemorrhagic fever Onyong-nyong Oropouche virus Plague Q fever Rabies Rift Valley fever Ross River virus Sand fly fever Schistosomiasis Sindbis (Ockelbo) virus Spotted fever group (tickborne rickettsioses) St. Louis encephalitis Tick-borne encephalitis (TBE) Trypanosomiasis - American (Chagas disease) Trypanosomiasis - Gambiense (African) Trypanosomiasis - Rhodesiense (African) Tuberculosis Tularemia Typhoid / paratyphoid fever Typhus - miteborne (scrub typhus) Typhus - murine (fleaborne) Venezuelan equine encephalitis Venezuelan hemorrhagic fever (Guanarito) West Nile fever Yellow fever Infectious Diseases Assessed for Country-Specific Risk • Anthrax • Argentinian hemorrhagic fever (Junin) • Bartonellosis (Oroya fever) • Bolivian hemorrhagic fever (Machupo) • Brucellosis • California group viruses • Chikungunya • Crimean-Congo hemorrhagic fever • Dengue fever • Diarrhea - bacterial • Diarrhea - cholera • Diarrhea - protozoal • Eastern equine encephalitis • Ebola hemorrhagic fever • Gonorrhea / chlamydia • HIV/AIDS • Hantavirus hemorrhagic fever with renal syndrome (HFRS) • Hantavirus pulmonary syndrome • Hepatitis A • Hepatitis B • Hepatitis E • Japanese encephalitis • Kyasanur Forest disease • Lassa fever • Leishmaniasis - cutaneous and mucosal • Leishmaniasis - visceral • Leptospirosis • Lyme disease • Malaria • Marburg hemorrhagic fever

16. Maximum expected rates Typical severity Expected disease level in troops Baseline Level of Disease (exposure) RISK LEVEL AFMIC Analytic Framework

17. Typical Disease Severity Focus on days lost • Mild • < 72 hrs sick in quarters or limited duty • Moderate • 1-7 days inpatient care, return to duty • Severe • >7 days inpatient care or prolonged convalescence • Very Severe • ICU required, permanent disability, or fatalities Care potentially may be provided in theater

18. Factors Considered in Estimating Maximum Expected Rates • Asymptomatic to symptomatic ratio • Efficiency of transmission • Tick versus mosquito • Foodborne or waterborne • Likelihood of encountering infectious dose • Historical data • Outbreaks • Infection rates • Natural epidemiology of the disease

19. What is a show-stopper? • Total lost man-days is the key factor • Short duration diseases in large numbers • Longer duration diseases in small numbers • Severity is also important • High level of care required (ICU) • High morbidity or mortality

20. What is not a show-stopper? • Diseases that are unlikely to occur in significant numbers • Minimal exposure (e.g., Ebola) • Very inefficient transmission (e.g., SARS) • Very mild diseases not causing lost work • Gonorrhea

21. Operational ImpactBacterial diarrhea • Operational impact • Approaches 100% per month in worst areas • Usually 1-3 days SIQ • Easy to treat with antibiotics • Early treatment is essential, but often neglected

22. Operational ImpactProtozoal diarrhea • Giardia, Entamoeba, others • Operational impact • 1-10% per month in worst areas • Usually 1-3 days SIQ • Often longer lasting and more severe (e.g., giardia) • Harder to diagnose in the field

23. Operational ImpactTyphoid fever • Operational impact • 1-10% per month in worst areas • 1-7 days of hospitalization • Typhoid vaccine has largely eliminated the problem

24. Planning/Briefing Considerations • Terrain Analysis • Weather Analysis • Threat Evaluation (EOB, Weapons Capabilities, etc.) • Civilian Population and Enemy Prisoners of War • Flora and Fauna • Disease Threats • Availability of Local Resources (e.g., Medical Facilities) • NBC/Asymmetrical Threats

25. Sources to Help in Risk Assessment Preparation • Armed Forces Medical Intelligence Center • http://mic.afmic.detrick.army.mil/index.htm • The Defense Intelligence Agency’s (DIA) central repository of medically-related intelligence • 24-hour service supporting all DoD Agencies (and many non-DoD entities within the U.S. government seeking information on medical concerns) • AFMIC Products • Medical Capabilities Studies – Finished intelligence studies prepared on foreign countries • Environmental Health Factors • Diseases • Civilian Health Services • Military Health Services • Medical Facilities World Wide • Products by region, COCOM, or subject

26. The World Health Organization is the United Nations specialized agency for health. It was established on 7 April 1948. WHO's objective, as set out in its Constitution, is the attainment by all peoples of the highest possible level of health. Health is defined in WHO's Constitution as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO is governed by 192 Member States through the World Health Assembly. The Health Assembly is composed of representatives from WHO's Member States. The main tasks of the World Health Assembly are to approve the WHO program and the budget for the following biennium and to decide major policy questions. About WHO http://www.who.int/en/

27. About the CDC The Centers for Disease Control and Prevention (CDC) is one of the 13 major operating components of the Department of Health and Human Services (HHS), which is the principal agency in the United States government for protecting the health and safety of all Americans and for providing essential human services, especially for those people who are least able to help themselves. Since it was founded in 1946 to help control malaria, CDC has remained at the forefront of public health efforts to prevent and control infectious and chronic diseases, injuries, workplace hazards, disabilities, and environmental health threats. Today, CDC is globally recognized for conducting research and investigations and for its action oriented approach. CDC applies research and findings to improve people’s daily lives and responds to health emergencies—something that distinguishes CDC from its peer agencies. CDC is committed to achieving true improvements in people’s health. To do this, the agency is defining specific health impact goals to prioritize and focus its work and investments and measure progress. http://www.cdc.gov/travel/ http://www.cdc.gov/travel/reference.htm

28. World Facts Geopolitical Information Demographics Country-specific info http://www.cia.gov/index.html

29. Sources of Medical Intelligence • Virtual Naval Hospital • http://www.vnh.org/ • Canadian Healthcare Services • http://www.hc-sc.gc.ca/index_e.html • Department of State • http://travel.state.gov/ • Travel Medicine Clinic • http://www.travmed.com/ • Additional DoD sources • http://deploymentlink.osd.mil/ • https://www.tripprep.com/scripts/main/default.asp

30. And don’t forget some of these… http://www.airforcemedicine.afms.mil/ http://www.armymedicine.army.mil/ http://navymedicine.med.navy.mil/

31. Format and Content of the Commander’s Brief • Brief – be as short as possible, without missing pertinent information • Basic overview of the Region (tailored to prior knowledge of the area) • Geography/Topography • Political situation/Cultural issues • Overview of Significant Medical Threats • Endemic diseases • Trends • Significant disease threats • Vector control issues

32. Format and Content (cont.) • Environmental Considerations • Weather • Animal and Plant threats • Food and Water Sources and Considerations • Local and Regional Medical Capabilities • Disaster/Mass Casualty Response Considerations • Medical Evacuation Plan • Recommendations for Command Support • Defined COAs (Courses of Action) • PROs/CONs • Risks if recommended COA not followed

33. Vulnerabilities to food-borne and waterborne diseases • Eating on the local economy • Improper food procurement procedures • Chow-hall problems • Person-to-person spread in field conditions Worldwide, the biggest potential show-stopper

34. Water and Food Vulnerability Safety Assessments • Again – use AFMS guidance as a primary resource • AFI 48-116 (Food Safety Program) • AFI 48-144 (Safe Drinking Water Surveillance Program) • Although guidance sometimes refers to base/US assets and resources, the basic principles still apply • USAID’s Field Operating Guide (FOG) is a good resource, but estimates are based on displaced personnel/refugee populations • AFMS Knowledge Exchange (https://kx.afms.mil) • Bioenvironmental and Public Health communities also have specific reference materials/guidebooks

35. Food Assessments • Some food sources are already approved (see VETCOM circular 40-1 • AF Form 977 (Food Facility Evaluation) can serve as a guide/checklist for items to review • Management and Personnel • Food • Equipment, utensils, and linens • Water, plumbing, and waste • Physical facilities • Poisonous or toxic materials • Care must be taken when evaluating dining facilities in other nations (to not impose 100% of the US standards if unrealistic) • Attachment 1 to AFI-48-116 lists additional websites/resources

36. Water Assessments • MAJCOM BEEs largely responsible for their MAJCOM water programs • Civil Engineering (CE) is also an integral part; as they are responsible for the water supply/system (as opposed to the water safety) • Routine testing requirements are established by the aerospace medicine/BEE community • Approved bottled water sources can be found at: http://vets.amedd.army.mil/vetsvcs/approved.nsf • AFI 48-144 outlines principle components of a water safety program • Attachment 1 of AFI 48-144 contains additional reference materials

37. Unapproved Water Sources

38. Preventing food-borne and waterborne diseases • Absolute control over food and water • Proper field sanitation and hygiene • Eating on the economy • Informal assessments can be done without creating an unpleasant situation where host nation is offended • Can be prohibited when necessary • Education of AF personnel to lower the risk • Fully-cooked meat products • Fruits and vegetables that can be peeled or washed in a safe water source • Drinking on economy not recommended unless sources are approved (less likely) • Routine vaccines (hepatitis A, typhoid) for deployed personnel

39. QUESTIONS?? Contact Information: Jim Fike, Col, USAF, MC, FS Consultant to the AF/SG, Liaison to the ANG International Health Specialist Program, jim.fike@ang.af.mil (301) 836-8536, DSN 278-8536 Cell (301) 943-0026