Military Preventive Medicine

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Section 1

Intro to Preventative Medicine

What are the activities of Preventive Medicine found within military operations?

1) Cleanliness

2) Field Hygiene

3) Environmental Sanitation

4) Force Protection

What is the bridge that helps provide a strong relationship between the Command Staff & Military Medicine?

Preventative Medicine

Preservation of health cannot be accomplished via medical channels only.

1) Commander Responsibility

2) Legal & Regulatory basis

What is Preventative Medicine?

The anticipation, prediction, identification, surveillance, evaluation, prevention & control of disease and injuries

*What are the goals of Military Preventative Medicine?

1) Maintain health & operational performance of the force

2) Prevent disease, injury, & disability

* What are the foci of Military Preventative Medicine?

1) Safety orientation

2) Pro-active health programs

3) Trauma/sports injuries & communicable disease control (vs. chronic diseases)

What are some of the major contributions Preventative Medicine has provided to modern society?

1) Hospital isolation wards

2) Medical Surveillance (US Weather Bureau)

3) Identifying vectors in disease transmission

4) Water sanitation (Chlorination)

5) Vaccine Development (Yellow fever, Hep A & B)

Section 2

Medical Threat Assessment

*What is a medical threat?

*Composite of all ongoing or potential enemy actions and environmental conditions that will reduce combat effectiveness through wounding, injuring, causing disease or performance degredation

(During preparation for deployment, it is critical that commanders at strategic & operational levels acquire an estimate of the medical threat for the mission)

What is the driving force behind Force Health Protection (FHP)?

RISK (must accurately identify threats depending on who, what, where, & when)

What are the "Person Factors" that estimate risk (Who & What)?

1) Number

2) Demographics

3) Health Status

4) Psychosocial profile

5) Training

6) Equipment

7) Activity Level

What are the "Place Factors" that estimate risk (Where)?

1) Global position

2) Development & Stability

3) Terrain

4) Climate

5) Biomass

6) Enclosures

What are the "Time Factors" that estimate risk (When)?

1) Year/Season

2) Time of Day

3) Duration

This is raw data that MAY BE of interest to planners

Medical information

This is analyzed and interpreted data THAT IS of interest to planners

Medical intelligence

What is the significance of medical intelligence?

Operational level- develop health service support strategies

What are the "Strategic Sources" of MEDICAL intelligence?

National Committee for Military Intelligence (NCMI) is the single authoritative producer of medical and technical intelligence on foregin health threats and other medical intelligence issues to protect and advance US interests worldwide

What are the "Tactical Sources" of MEDICAL intelligence?

S2/G2/J2 and special Military Intelligence units in combat zone

* What does the NCMI provide?

1) Trends and Forecasts (Indications & Warnings)

2) Health risk/Hazard assessments

3) Health services assessment

4) Facility Database

* What does the NCMI NOT provide?

1) Recommend medical treatment protocol

2) Approved/Authorized prophylaxis

3) Medical Policy

4) Medical doctrine

What is the focus of the NCMI Risk Assessment?

What the commander needs to know

- What percentage of personnel are likely to be affected by a disease?

- How many days will likely be lost per case?

* What are the assumptions underlying the National Committee for Military Intelligence (NCMI) risk assessment?

1) A healthy US military force (routine vaccines, but no immunity to most tropical diseases)

2) Field conditions (e.e tents, crowding, field sanitation, and vector exposure)

3) Access to local economy

4) Minimal contact with household-type exposure in the local population

* What is the Risk Level Matrix?

A tool that can be used to determine level of risk during an activity using levels of disease severity & levels of disease expectance in troops

What is residual risk?

Risk remaining after known threats have been mitigated

Section 3

Medical Surveillance

Describe the historical significance of Disease & Non-Battle injuries (DNBI)

DNBI can have a rapid and widespread impact on the effectiveness of military organizations (Look at the Civil War)

*This is the ongoing collection and analysis of health data dissemination of information

Medical surveillance

*What are the three generic "purposes" of medical surveillance?

1) Identify public health problems

2) Stimulate public health interventions

3) Suggest hypotheses for epidemiological research

* What are the important public health "functions" of medical surveillance?

1) Detection of epidemics

2) Identification of significant events

3) Detection of changes in disease agents

4) Plans & Priorities for interventions

5) Projection of future health problems

*What do these important public health "functions" of medical surveillance serve as?

An early warning system

*What are the "objectives" of medical surveillance?

1) Determine extent of disease occurence (Baseline rates and trends)

2) Detect and monitor outbreaks

3) Indentify contacts & administer prophylaxis

4) Increase knowledge of disease processes

5) Generate hypotheses about disease etiology

What are the two types of surveillance?

1) Passive

2) Active

This type of surveillance is described as the following:

1) Provider Based

2) Mandated reporting

3) Most frequently used (local, state, public health systems, DoD)

Passive Surveillance

This type of surveillance is described as the following:

1) Health agency or PM based

2) Periodic field visits by project staff

3) Involves interviews, record reviews, pre-generate reports, etc

Active Surveillance

What are the advantages of "passive" surveillance?

1) Inexpensive

2) Easy to develop initially

3) Allows for internal comparisons

What are the drawbacks of "passive" surveillance?

1) Quality

2) Can miss local outbreaks
- Underreporting
- May miss a widespread problem if it is an internal system

What are the advantages of "active" surveillance?

1) Generally more accurate

2) Local outbreaks identified

What are the drawbacks of "active" surveillance?

1) More expensive

2) Difficult to develop initially

What is the TRISERVICE reportable events list?

1) Selected communicable and environmental diseases of military importance

2) Heat and cold injuries

3) Outbreak. generalized

There is a long list of diseases/events in the TRISERVICE reportable events. What diseases/events are NOT included in this list?

1) HIV/AIDS

2) Suicides

3) Occupational injuries/illnesses

~These are reported through other mechanisms

Describe the comprehensive military medical surveillance process

1) Threat/risk assessments

2) Hospital admission rates

3) Reportable medical events

4) DNBI rates

Section 4

Communicable Disease Control

What are the 3 levels of prevention?

1) Primary

2) Secondary

3) Tertiary

This level of prevention is prior to exposure to disease source; remove causes

Primary prevention

What is included in Primary prevention?

1) Health promotion/education

2) Nutrition/diet supplementation

3) Adequate housing, recreation, agreeable working conditions

4) Immunizations

5) Environmental sanitation

6) Protection against occupational hazards

This level of prevention occurs after exposure, but prior to the onset of symptoms or complications of the disease?

Secondary prevention

What is included in Secondary prevention?

1) Screening (cholesterol, BP, HIV, PKU, PAP, Mammogram, colonoscopy > 50 years old)

2) Case finding > 40 physicals***

3) Chemoprophylaxis (rabies, needle stick HIV, post exposure prophylaxis such as anthrax)

This level of prevention limits disability after irreversible changes have resulted from disease

Tertiary prevention

What is included in Tertiary prevention?

1) Environmental adaptations to home and/or work

2) Education, counseling support to assist individual and family to adapt

3) Employment to the maximum possible extent

4) Work therapy programs (OT/PT)

5) Sheltered workshops, group homes

What is the Epidemiological Triad?

1) Host (should consider Age, Sex, Race, Occupation, Genetics)

2) Agent (consider Biological, Chemical, Physical, Nutritional, Virulence)

3) Environment (Temperature, Altitude, Food, Crowding, Water)

This is defined as the period of time during which an infectious agent may be transferred from an infected person or animal to a susceptible host

Communicable period

This is defined as the time interval between exposure to the agent and the onset of clinical illness

Incubation period

What are the 3 types of disease transmission?

1) Direct Transmission

2) Indirect Transmission

3) Airborne Transmission

What are the types of Direct Transmission?

1) Person-to-Person spread
- Direct contact (touching, kissing, sexual activity)

2) Droplet spread
- Large droplets from the source (sneezing, coughing, singing)
- Travel short distance (less than 1 meter)
- NOT suspended in air

What are some examples of diseases that result from person to person spread?

1) Chlamydia, Herpes, HIV

2) Scabies, Syphilis

3) Impetigo

What are some examples of disease that are spread from droplet spread?

1) Meningococcus

2) Mumps

What are the types of Indirect transmission?

1) Vehicle Borne
- Food and Water (Single exposure, multiple exposure, continuous exposure)
- Fomite (contaminated object such as a tie or stethoscope)

2) Vector Borne
- Arthropods
o Mechanical (Roaches and Flies land on feces and then crawl on your food)
o Biological (Biting insects)

What are some examples of diseases that result from vehicle borne transmission?

1) Salmonella, Hepatitis A
2) Cholera, Norovirus

What are some examples of diseases that result from vector borne transmission?

1) Malaria, Dengue
2) Lyme disease, Tick-borne encephalitis

Describe Airborne transmission

1) Aerosolized droplet nuclei

2) Small dust particles

3) Less than 5 um in size

4) Carried by air currents

What are some example of diseases caused by Airborne Transmission?

1) TB, Measles, Varicella

2) SARS, Influenza

This is the continuous presence of disease within a given "geographic" area. It is also the background or "expected" rate of a disease in an area

Endemic

This is an increased occurrence of a disease in a community or region which is clearly in excess of normal expectancy

Epidemic

This is a global or extensive epidemic

Pandemic

What are the determinants of disease outbreaks?

1) Infectivity & virulence of an agent

2) Susceptible population

3) Efficiency of transmission

4) Timely identification

5) Effectiveness of control measures

T or F. Determinants of disease outbreaks are depended on the balance between the number of susceptible persons and the number immune to a disease

True

This is the resistance of a group to invasion and spread of an infectious agent, based on the resistance to infection of a high proportion

Herd immunity

(If a large enough proportion of the group is immune, the entire group is protected)

What are the various prevention & control measures for communicable disease?

• Immunizations
• Medication prophylaxis
• Contact investigation
• Practices/Procedures/Inspections
• Education & Behavior modification
• Communicable disease reporting
• Vector & animal control
• Environmental sanitation
• Disease surveillance
• Outbreak investigation
• Quarantine & Isolation

This applies to Healthy (Asymptomatic) patients,it is during the Incubation period, the patient can stay Home, and there is minimal enforcement (Police PRN)

Quarantine

Why don't we like to use quarantine?

Because it results in loss of personal freedoms

This is used for Sick (symptomatic) patients, during the Communicable period, they are admitted to Hospital as a common standard precaution

Isolation

What is the single most effective way to prevent disease in deployed troops?

Access to clean potable water

Section 5

Diseases of Military & Public Health Importance

This is a disease that will have a significant impact on a unit's ability to complete its mission

Show-Stopper

What is the key factor of a show stopper?

Total lost soldier-days
- Short duration diseases in large numbers
- Longer duration diseases in small numbers

Describe how severity can play a role in diseases that are considered show-stoppers

1) There can be a high level of care required (ICU)

2) High morbidity/high mortality

What is not a show stopper?

1) Diseases that are unlikely to occur in significant numbers
- Minimal exposure (Ebola/anthrax)
- Very inefficient transmisson (Hantavirus pulmonary syndrome)

2) Very mild disease not causing lost work (gonorrhea)

What are the major exposure categories of infectious diseases in a military setting?

1) Food/Water borne

2) Vector Borne

3) Water contact

4) Soil contact

5) Animal contact

6) Sexual contact

7) Respiratory transmitted

Worldwide, what is the biggest potential show stopper?

Food and Water Borne diseases

How is the military exposed to Food and Water Borne diseases?

1) Eating on the local economy

2) Improper food procurement procedures

3) Dining facility problems

4) Person-to-person spread in field conditions

What is the most common Food and Water Borne disease?

Bacterial diarrhea (early treatment is essential)

Can we often identify the organism that caused bacterial diarrhea if a lab is present?

Yes

What population is viral diarrhea most common?

Adults

Of the causes of viral diarrhea, what is the most common virus?

Norovirus

T or F. Hepatitis A (HAV) and Hepatitis E (HEV) are Food and Water Borne diseases

True

Both HAV and HEV will leave soldiers sick for 30 days or more. Which one has a vaccine?

Hepatitis A (HAV)

**There is no vaccine for Hepatitis E (HEV)

T or F. Parasitic/Protozal diarrhea is common

False

T or F. It is easy to diagnose Parasitic/Protozal diarrhea in the field

False

What is the longest lasting and most severe cause of Parasitic/Protozal diarrhea?

Giardia

What are the methods for preventing food & water-borne diseases?

1) Absolute control over food and water

2) Proper field sanitation and hygiene

3) Eating on the economy
- Can be prohibited when necessary
- Education to lower the risk

4) Routine vaccination (Hepatitis A, typhoid)

What are the major exposure categories of infectious diseases in a military setting?

1) Food/Water borne

2) Vector Borne

3) Water contact

4) Soil contact

5) Animal contact

6) Sexual contact

7) Respiratory transmitted

In "some" areas, what is the biggest potential show stopper?

Vector Borne (Mosqutoes, Sand flies, Ticks, Mites, Flies)

What are some major vector borne causes of diseases that have operational impact?

1) Malaria (Night mosquito, Rural)

2) Dengue Fever (Day mosquito, Urban)

What is the most severe case of Malaria?

Falciparum

What is the vaccine and specific treatment for Dengue fever?

There isn't one

What do the following vector borne disease have in common:

1) Chikungunya

2) Rift Valley Fever

3) Yellow Fever

4) Japanese encephalitis

They are all mosquito borne infections

What do the following vector borne disease have in common:

1) Leishmaniasis (disease of the tropics)

2) Bartonellosis

3) Sand Fly Fever

They are all Sand fly-borne disease

What do the following vector borne diseases have in common:

1) Crimean-Congo hemorrhagic fever

2) Tick-borne encephalitis

They are tick-borne diseases

What do the following vector borne diseases have in common:

1) Murine typhus

2) Plague

They are flea borne disease

What vector causes scrub typhus?

Mites

What vector causes Endemic typhus?

Louse

How are vector borne diseases prevented?

1) Personal protective measures (PPM) such as Permetherin and bed netting
- The "only" protection in most cases
- "Always" the first line of defense

2) Chemoprophylaxis and vaccines (malaria pills, yellow fever vaccine)

What is one of the largest vulnerabilities of contracting a vector borne disease?

Neglect of PPM

Is vector control practical in the places we deploy to?

NO

* Who is responsible for enforcing PPM and prophylaxis?

The COMMAND!

What are the major exposure categories of infectious diseases in a military setting?

1) Food/Water borne

2) Vector Borne

3) Water contact

4) Soil contact

5) Animal contact

6) Sexual contact

7) Respiratory transmitted

With regards to water contact diseases, do you have to drink the water to get sick?

No

What type of field operations may involve getting wet (and possibly sick)?

1) Fording rivers, streams

2) Crossing rice paddies

3) Recreational exposure

4) Flooding

This is a disease caused by a spirochete that can penetrate skin or mucous membranes. It is shed by animals (particularly rodents) in urine and we get it from water sources

Leptospirosis

This is a disease that is caused by a parasitic worm (flat worm or fluke) that has free swimming larvae which can penetrate the skin. It causes chronic infection, also acute fever similar to dengue

Schistosomiasis

What is the main way for preventing water contact diseases?

1) Avoid swimming, bathing, or washing in stagnant pools or sluggish streams

2) Protective clothing

3) Survey bodies of water

What are the major exposure categories of infectious diseases in a military setting?

1) Food/Water borne

2) Vector Borne

3) Water contact

4) Soil contact

5) Animal contact

6) Sexual contact

7) Respiratory transmitted

How is the military vulnerable to diseases from soil contact?

1) Sleeping on the ground

2) Breathing in the dust

How can soil contact spread diseases?

Pathological organisms, particularly viruses can be suspended in dust

What is the main disease caused by contact with the soil?

Hantaviral diseases (Very severe---require ICU)

How are soil contact diseases prevented?

1) Avoid setting up camp in heavily rodent-infested areas

2) Rodent control where feasible
- Use traps ans eliminate possible nesting sites & food sources

3) Minimize dust inhalation
- use of masks
- wet down roads and floors if feasible
- No sleeping on bare ground

What are the major exposure categories of infectious diseases in a military setting?

1) Food/Water borne

2) Vector Borne

3) Water contact

4) Soil contact

5) Animal contact

6) Sexual contact

7) Respiratory transmitted

Although most Soldiers have limited contact to diseases that are spread by animals, which Soldiers have a higher risk?

1) SOF

2) MPs

3) Veterinarians

How are regular Soldiers often times exposed?

Mascots (must be controlled by the command)

What diseases are associated with animal contact?

1) Rabies (which is a significant threat if bitten/exposed to Saliva) --It is nearly always fatal

2) Anthrax

3) Q-Fever

What part of the body does rabies virus affect?

The Central Nervous System

What kind of animal is the major vector for rabies in developing countries?

Dogs

What kind of animal is the major vector for rabies in the United States?

Wild animals (Skunks, Raccoons, Bats, and foxes)

What is the prevention for rabies?

1) Avoid all strange or wild animals

2) No mascots or pets

3) Immunization: pre and post exposure wound cleaning

Does pre exposure vaccination eliminate the need for post exposure vaccination?

No

Ok so exacerbates respiratory diseases in deployed settings?

1) Overcrowding

2) Close contact with locals

Most respiratory diseases in deployed settings are NOT show stoppers but a few are, what are they?

1) Influenza (definite show stopper) --> routine vaccination is essential and required

2) Meningococcal meningitis (Rare but severe)

How are respiratory diseases prevented?

1) Avoid overcrowding

2) Proper ventilation in enclosed spaces

3) Proper hygiene and sanitation with strict hand washing for disease control

4) Isolation of cases if necessary

5) Vaccination appropriate and required in some cases

STDs rates are historically high in troops. But are STDs show stoppers?

No

What are the STDs that can cause a high impact?

1) HIV

2) Hepatitis B (part of routine vaccinations now)

How are STDs prevented?

1) Education
- Abstinence
- Condoms
- Hepatitis B vaccine for high risk

2) Command climate determines success

Section 6

Introduction to Humanitarian Operations

This is a human disaster that follows war & civil strife, characterized by:

1) Displacement of large populations

2) Near total loss of existing infrastructure

3) Continuing concerns for personal security

"Persons of Concern"

Complex Emergency

What are persons of concern?

Those leftover from a complex emergency

1) Refugees

2) Internally Displaced Person (IDP)

This person is described as the following:

1) Cross the border out of their country

2) Entitled to protection under UN and international law

Refugee

This person is described as the following:

1) Move but do not cross their border

2) Not afforded protection under the law, and therefore more difficult to assist

Internally Displaced Person (IDP)

What are the 5 leading causes of death in humanitarian emergencies?

1) Diarrhea & dehydration

2) Measles

3) Malaria

4) Acute Respiratory Infections

5) Malnutrition (only non-infectious cause of death)

Who are the most vulnerable individuals in a given population during disaster?

1) Children (orphaned/unaccompanied)

2) Women (head of household, Pregnant/Lactating, Victims of sexual violence)

3) Elderly/Disabled

What are the phases of an emergency?

Developing Country Model:
o Acute Emergency Phase
• High crude mortality rates (CMR)
• High case fatality rates (CFR)
• Outbreaks of communicable diseases
• Severe malnutrition

- Developed Country Model:
o High war-related trauma
o Malnutrition in the elderly

What are the 10 essential emergency relief measures?

(ICE PIPE PRO)


1) Institute a diarrhea control program

2) Coordinate activities

3) Establish primary care medical treatment (based on local population)

4) Provide adequate food - 2100 kcals/person/day; equitable distribution; target supplemental and therapeutic feeding programs

5) Immunization against measles & provide Vitamin A supplements (prevent measles)

6) Provide elementary sanitation & clean water - 3-5 L/person/day

7) Establish disease surveillance and a health information system

8) Provide adequate shelter & clothing

9) Rapid health assessment

10) Organize human resources

What are the advantages to military involvement in humanitarian operations?

1) Speed

2) Security

3) Transportation

4) Logistics

5) C3

6) Self-sufficiency

7) Specialty units (Engineers, Civil Affairs, PM),

8)Deployable field hospitals

9) MEDEVAC

What are the disadvantages to military involvement in humanitarian operations?

1) Medical training (oriented towards combat, not disaster victims)

2) Logistics (supplies not appropriate for disaster)

3) Focus (short-term)

4) Political (extension of the US government, never purely humanitarian)

5) Expense (Ethiopian airlift)

Section 7

Medical Response to Chemical Terrorism

What are the physical properties of Nerve Agents?

1) Clear, colorless liquids

2) Tasteless, most are odorless

3) Volatility (Persistence is inversely related to volatility. The more volatile a substance is, the less persistent it is and vice versa)
-GB (Sarin) > GD (Soman) > GA (Tabun) > GF >>VX

4) Penetrate skin and clothing

What is the MOA for Nerve agents?

Inhibits Enzyme (AChE) Acetylcholine Esterase
- Does not destroy Ach


- Then, then excess ACh continues to stimulate organs (organ overstimulation)

As a result of organ over stimulation, what would you expect to see in a patient that has been exposed to nerve agents?

D-D-U-M-B-B-B-E-L-S

1) Diarrhea

2) Diaphoresis

3) Urination

4) Myosis

5) Bronchorrhea

6) Bronchospasm

7) Bradycardia

8) Emesis

9) Lacrimation

10) Salivation

What are the heart rate effects of Nerve Agents?

May be high, low or normal

1) Muscarinic (Vagal) decreases HR

2) Nicotinic (Ganglionic) increases HR

3) Hypoxia: (decrease oxygen) increase HR

What is the FIRST and MOST important step in managing patients with nerve agent exposure?

Protect self/ Medical Facility

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