International Medicine

1

International Medicine

Jim Fike, Col, USAF, MC, FS

Consultant to AF/SG, Director

International Health Specialist Program

2Cradle of Team Aerospace!

Objectives

Characterize Important International Diseases and Disease Prophylaxis

Medical Intelligence Research and BriefingsInfectious 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


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 immunizationsMalaria chemoprophylaxis recommendationsHost nation medical support/evacuation plans


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 immunizationsSpecific immunization requirementsAppendix D provides a summary (pp. 32-33)

Additional immunizations based on deployed location/risks

Reporting instructions for larger operationsBased on site visit and risk assessment by aerospace medicine personnel for smaller/unit operations


Chemoprophylaxis

AFJI 48-110 also has section on chemoprophylaxis (Chapter 5):

Anthrax Group A StepInfluenza A/B LeptospirosisMalaria MeningococcalPlague Scrub typhusTraveler’s diarrhea TB

Areas covered in other documents includeChem warfare chemoprophylaxisRadiation-related chemoprophylaxisMedical RX for TB exposureProphylaxis involving non-biologic medications (aspirin, calcium, vitamins)


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


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


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 managementThreat-based concept developmentMedical ResearchMedical doctrine development


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


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


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)


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


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


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


Infectious Diseases Assessed for

Country-Specific Risk 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

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

Cradle of Team Aerospace!

Baseline Level of Disease

(exposure)

Maximum expected

rates

Expected disease level in troops

Typical severity

RISK LEVEL

AFMIC Analytic Framework

Cradle of Team Aerospace!

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


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


What is a show-stopper?

Total lost man-days is the key factorShort duration diseases in large numbersLonger duration diseases in small numbers

Severity is also importantHigh level of care required (ICU)High morbidity or mortality


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


Operational ImpactBacterial diarrhea

Operational impactApproaches 100% per month in worst areasUsually 1-3 days SIQ

Easy to treat with antibioticsEarly treatment is essential, but often neglected


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


Operational ImpactTyphoid fever

Operational impact1-10% per month in worst areas

1-7 days of hospitalization

Typhoid vaccine has largely eliminated the problem


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


Sources to Help in Risk Assessment Preparation

Armed Forces Medical Intelligence Centerhttp://mic.afmic.detrick.army.mil/index.htmThe Defense Intelligence Agency’s (DIA) central repository of medically-related intelligence24-hour service supporting all DoD Agencies (and many non-DoD entities within the U.S. government seeking information on medical concerns)

AFMIC ProductsMedical Capabilities Studies – Finished intelligence studies prepared on foreign countries Environmental Health Factors Diseases Civilian Health Services Military Health Services

Medical Facilities World WideProducts by region, COCOM, or subject


About WHO

WHO's goal is the attainment by all peoples of the highest possible level of health

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.

http://www.who.int/en/


About the CDCThe 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


http://www.cia.gov/index.html

• World Facts• Geopolitical Information• Demographics• Country-specific info


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


http://www.airforcemedicine.afms.mil/

http://www.armymedicine.army.mil/

http://navymedicine.med.navy.mil/

And don’t forget some of these…


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


Format and Content (cont.)

Environmental ConsiderationsWeather

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


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


Water and Food Vulnerability Safety Assessments

Again – use AFMS guidance as a primary resourceAFI 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


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 PersonnelFoodEquipment, utensils, and linensWater, plumbing, and wastePhysical facilitiesPoisonous 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


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


Unapproved Water Sources


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 offendedCan be prohibited when necessaryEducation 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


QUESTIONS??

Contact Information:

Jim Fike, Col, USAF, MC, FSConsultant to the AF/SG, Liaison to the ANGInternational Health Specialist Program, [email protected](301) 836-8536, DSN 278-8536Cell (301) 943-0026

Documents

International Medicine