1. IRAQ Plagued by internal & external conflict
Deteriorated infrastructure
Poor sanitation
BACKGROUND: Formerly part of the Ottoman Empire, Iraq was occupied by Britain during the course of World War I; in 1920, it was declared a League of Nations mandate under UK administration. In stages over the next dozen years, Iraq attained its independence as a kingdom in A "republic" was proclaimed in 1958, but in actuality a series of military strongmen ruled the country, the latest was SADDAM Husayn. Territorial disputes with Iran led to an inconclusive and costly eight-year war ( ). In August 1990, Iraq seized Kuwait, but was expelled by US-led, UN coalition forces during the Gulf War of January-February Following Kuwait's liberation, the UN Security Council (UNSC) required Iraq to scrap all weapons of mass destruction and long-range missiles and to allow UN verification inspections. Continued Iraqi noncompliance with UNSC resolutions over a period of 12 years resulted in the US-led invasion of Iraq in March 2003 and the ouster of the SADDAM Husayn regime. Coalition forces remain in Iraq, helping to restore degraded infrastructure and facilitating the establishment of a freely elected government, while simultaneously dealing with a robust insurgency. The Coalition Provisional Authority transferred sovereignty to the Iraqi Interim Government (IG) in June Iraqis voted on 30 January 2005 to elect a 275-member Transitional National Assembly that will draft a permanent constitution and pave the way for new national elections at the end of 2005.

2. Physical Environment Topography Climate
Broad Desert Plains
Hills
Mountains
Climate
Temp extremes
122° F day
37° F night
Iraq has a land area of 434,854 sq km (167,925 sq mi), slightly larger than California. It consists of broad desert plains, hills, and mountains. The two major rivers, the Euphrates and Tigris, flow southeast across the country into the Shatt al Arab (elevation 8 feet above sea level), which discharges into the Persian Gulf. Most of Iraq's population is concentrated along these rivers.
Iraq can be divided into five geographic regions:
The Zagros Mountains region is broad, rough and stony, extending along the borders of Iran and Turkey. Numerous peaks exceed 3,281 meters (10,000 feet). Elevations above 2,500 meters are conducive to altitude sickness, which may result in headache, nausea, dizziness, loss of appetite, malaise, and shortness of breath.
The Foothills region is hilly and intersected by deep valleys containing mountain streams. Elevation varies from 215 to 1,143 meters (656 to 3,484 feet) above sea level.
The Al-Jazira Region (Arabic Island) is a plain with some hills and low mountain ranges; elevation is about 160 to 1,570 meters (490 to 4,790 feet) above sea level.
The Northern and Southern Deserts are bare plains with maximum elevation of about 910 meters (2,780 feet) in the west. A sand dune belt separates the eastern border from the Euphrates River.
The Lower Mesopotamian Plain region is composed of thick layers of sediment from the Tigris and Euphrates Rivers, and wind blown deposits. Elevation extends to approximately 30 meters (90 feet) above sea level.
The summer months are marked by two kinds of wind phenomena: the southern and southeasterly sharqi (shark-ee), a dry, dusty wind with occasional gusts to 50 miles an hour, occurs from April to early June and again from late September through November; the shamal, a steady wind from the north and northwest, prevails from mid-June to mid-September. Very dry air which accompanies the shamal permits intensive sun heating of the land surface but also provides some cooling effect. Dust storms accompany these winds and may rise to height of several thousand meters, causing hazardous flying conditions and closing airports for brief periods of time.
Dust and sandstorms occur year-round; most severe between May and October

3. Physical Environment
The extremely hot, dry, nearly cloudless summer months (May through October) produce temperatures that can reach a daily high of 50 °C (122 °F) and an extreme evening low of 3 °C (37 °F). Lower temperatures occur in the northeastern highlands. Temperature extremes can increase the potential for heat and cold weather injuries, including hypothermia, trench foot, heat exhaustion, and heat stroke.
In winter months (November through April), temperatures can reach a daily high of 43 °C (109 °F) and an extreme evening low of 4 °C (25 °F). Lower temperatures occur in the northeastern highlands.

4. Physical Environment
December through February is the wettest period of the year. Precipitation is highest in northeastern Iraq, which receives an average of 381 to 483 mm (15 to 19 in) of rain annually and snow up to 3 months a year. The highest relative humidity occurs during the wet season except in Al Basrah, which has high humidity and low rainfall year-round because of its proximity to the Persian Gulf.

5. Environmental Health Risk
Greatest short-term health risks
Ingestion of food or water contaminated with fecal pathogens.
Extreme heat, high altitude, and airborne dust and sand
Greatest long term risks are associated with air contamination and chemical contamination of food/water
Picture =Iraq street market
Key Judgments
Environmental contamination may present short- and long-term health risks to personnel deployed to Iraq.
The greatest short-term health risks are associated with ingestion of food contaminated with fecal pathogens or water contaminated with raw sewage or runoff containing fecal pathogens. The physical environment in Iraq poses additional short-term health risks from extreme heat, high altitude, and airborne dust and sand.
The greatest long-term health risks are associated with air contamination in industrial and urban areas and from chemical contamination of food or water.
Background
External and internal conflict, high population growth, and United Nations' sanctions have contributed to the degradation of infrastructure and sanitary conditions in Iraq over the past several decades. Although billions of dollars have been designated for rebuilding Iraq's infrastructure, critical deficiencies still exist in water supply and waste management.
Sources of industrial contamination include petrochemical plants, petroleum refining, iron and steel manufacturing, cement plants, power generation, textiles production, and food processing plants. The greatest concentrations of industries are in and around the cities of Al Basrah, Baghdad, Kirkuk, and Mosul. Industrial infrastructure in Iraq has deteriorated in recent years due economic sanctions and ongoing conflict. The operational status of many facilities is highly variable due to ongoing conflict.
In September of 2003, a Minister of Environment was created as part of the Iraqi Governing Council. The planned size of the ministry is 1,000 employees, but as of the end of 2004, staffing was at only 250 employees. Although the main focus of the ministry is policy development, environmental monitoring, and cross-sectoral coordination, the ministry will have a role in the enforcement and implementation of environmental regulations.

6. Infectious Disease Risk
INTERMEDIATE RISK for infectious diseases
Disease risk will adversely impact mission effectiveness unless force health protection measures are implemented

7. Infectious Diseases Foodborne and Waterborne Diseases FHP Priorities
HIGH RISK = Diarrhea, hep A, typhoid fever
INTERMEDIATE RISK = brucellosis, cholera, hep E
FHP Priorities
Deploy appropriate PM personnel and equipment
Consume food, water, ice only from US-approved sources
Operate food preparation facilities in accordance with Army doctrine
Ensure proper hand washing facilities near all latrines and dining facilities and enforce
Though improvements are being made, sanitation remains generally poor throughout the country, including major urban areas. Local food and water sources (including ice) are heavily contaminated with pathogenic bacteria, parasites, and viruses to which most US service members have little or no natural immunity. Disease surveillance is improving since Operation Iraqi Freedom but remains rudimentary. In the years prior to the operation, only a small fraction of disease was identified or reported. Diarrheal diseases can be expected to temporarily incapacitate a very high percentage of personnel within days if local food, water, or ice is consumed. Hepatitis A and typhoid fever can cause prolonged illness in a smaller percentage.
Diarrhea - bacterial
Risk Assessment:
An operationally significant attack rate (potentially over 50% per month) could occur among personnel consuming local food, water, or ice. Field conditions (including lack of handwashing and primitive sanitation) may facilitate person-to-person spread and epidemics.
Typically mild disease treated in outpatient setting; recovery and return to duty in less than 72 hours with appropriate therapy.
Risk Period: Year-round
Risk Distribution: Countrywide (including urban areas)
Typical Incubation Period: 1 to 3 days
Epidemiology Comments: In general, bacterial agents such as enterotoxigenic E. coli, Campylobacter, Shigella, and Salmonella are the most common causes of "traveler''s diarrhea" wherever sanitary conditions are significantly below US standards.
Surveillance and Survey Data: Specific surveillance data for bacterial diarrhea cases are lacking; assessment of endemicity was based primarily on the lack of overall public health infrastructure to ensure safe food and water.
Hepatitis A
An operationally significant attack rate (potentially 1-10% per month) could occur among unvaccinated personnel consuming local food, water, or ice. Field conditions (including lack of handwashing and primitive sanitation) may facilitate person-to-person spread and epidemics.
Typical case involves 1 to 3 weeks of debilitating symptoms, sometimes initially requiring inpatient care; recovery and return to duty may require a month or more.
Typical Incubation Period: 28 to 30 days (maximum range: 15 to 50 days)
Epidemiology Comments: In non-indigenous personnel, hepatitis A typically occurs after consumption of contaminated food or water. Infection also may occur through direct fecal-oral transmission under conditions of poor hygiene and sanitation. Childhood hepatitis A infections tend to be asymptomatic or have mild symptoms, while adults typically develop jaundice and other symptoms. In areas where high levels of hepatitis A virus circulate, the number of reported cases in the local population is usually low because asymptomatic childhood infections confer lifelong immunity.
Surveillance and Survey Data: Most Iraqis contract hepatitis A virus infection during childhood.
Typhoid / paratyphoid fever
A small number of cases (less than 1% per month attack rate) could occur among unvaccinated personnel consuming local food, water, or ice.
Debilitating febrile illness typically requiring 1-7 days of inpatient care, followed by return to duty.
Risk Period: Year-round; risk is elevated during warmer months.
Risk Distribution: Countrywide (including urban areas); risk is elevated in populated areas with poor sanitation.
Typical Incubation Period: 8 to 14 days (maximum range: 3 to 30 days)
Epidemiology Comments: Typhoid and paratyphoid are clinically similar, and in endemic areas typhoid typically accounts for 90 percent of cases. Asymptomatic carriers are common with typhoid and contribute to sustained transmission. In countries where hygiene and sanitation are poor or nonexistent, adult cases and outbreaks are rare because of immunity acquired in infancy or early childhood. In countries with a mixture of primitive and modern sanitation and hygiene, outbreaks of typhoid fever occur and may involve all age groups.
Surveillance and Survey Data: Specific surveillance data for typhoid cases are limited to more than 21,000 cases officially reported in 2001; assessment of endemicity was based primarily on the limited overall public health infrastructure to ensure safe food and water.
Human Outbreak Information: Though incomplete, reported outbreaks include: - January 2004, Al-Rashad area near Baghdad: Outbreak reported; no further details are available Al Amarah ( N E), southern Iraq: Unconfirmed outbreak reported in the press.
Brucellosis Risk Assessment:
Rare cases could occur among personnel consuming local unpasteurized dairy products, or having contact with livestock
Febrile illness of variable severity, potentially requires inpatient care; convalescence is usually over 7 days even with appropriate treatment.
Risk Distribution: Countrywide (including urban areas); the risk from direct animal contact is likely to be highest in rural areas where livestock are present. However, the risk from contaminated meat and animal products can occur countrywide, including urban areas.
Typical Incubation Period: 30 to 60 days (maximum range: 5 to 90 days)
Epidemiology Comments: Brucellosis is a common disease in cattle, sheep, goats, swine, and some wildlife species in most developing countries. Humans contract brucellosis through consumption of contaminated dairy products (or foods made with such products), or by occupational exposures to infected animals. Worldwide, reported cases largely underestimate the extent of the problem in both animal and human populations.
Surveillance and Survey Data: From january to August 2004, 2 cases of brucellosis had been reported in US personnel in Iraq during Though case reporting is incomplete, more than 10,000 cases officially were reported among Iraqis in The 1994 official incidence was 73 cases per 100,000 population. Because more recent surveillance data for brucellosis is unavailable, assessment of endemicity was based, in part, on the lack of overall public health infrastructure to ensure safe food and water.
A livestock immunization program began in 2000; however, the current status of the program is unknown.
Diarrhea - cholera Risk Assessment:
Rare cases could occur among personnel consuming local food, water, or ice
Most symptomatic cases are mild, with recovery and return to duty in less than 72 hours on appropriate outpatient treatment; severe cases may require 1-7 days of inpatient care, followed by return to duty
Risk Distribution: Countrywide (including urban areas); as of May 2002, the World Health Organization (WHO) considered the following provinces officially cholera endemic: Al Anbar, Al Basrah, Al Muthanna, Al Qadisiyah, An Najaf, At Ta`mim, Babil, Baghdad, Dhi Qar, Diyala, Karbala`, Maysan, Ninawa, Salah ad Din, and Wasit.
Typical Incubation Period: 2 to 3 days (maximum range: 1 to 5 days)
Epidemiology Comments: Development of symptomatic cholera requires exposure to large inoculums and typically is associated with ingestion of heavily contaminated food or water. Person-to-person spread of cholera occurs very infrequently. People with low gastric acidity (the elderly, children, or those taking antacids) are at increased risk of developing symptoms. The great majority of infections (75-95 percent depending on biotype) among healthy adults are asymptomatic. Only a small percentage of infections are severe.
Surveillance and Survey Data: In 2002, 718 cases officially were reported to WHO. A 1996 WHO report estimated the 1994 incidence at 7.8 per 100,000 population. Because of international notification requirements for cholera, cases are more likely to be reported than other types of diarrhea. However, official reports generally underestimate actual level of circulating pathogen.
Human Outbreak Information: Though incomplete, reported outbreaks include: : As of August, more than 40 cases were reported in the Basra area : More than 100 cases occurred in the Basrah area between May and September (many other cases likely occurred but were not diagnosed or reported); another small outbreak occurred in the Babylon area in October--16 cases were reported : Outbreak reportedly affected Baghdad and vicinity and spread north and northeast to cities of Dahuk, Mosul (Al Mawsil), and As Sulaymaniyah and surrounding areas. More than 1,980 cases were reported in As Sulaymaniyah alone in 1999.
Diarrhea - protozoal Risk Assessment:
A small number of cases (less than 1% per month attack rate) could occur among personnel consuming local food, water, or ice
Symptomatic cases vary in severity, with most treated in an outpatient setting; severe cases may require 1-7 days of inpatient care, followed by return to duty.
Typical Incubation Period: 7 to 28 days (maximum range: 3 to 90 days)
Epidemiology Comments: In general, Cryptosporidium spp., Entamoeba histolytica, and Giardia lamblia are the most common protozoal causes of diarrhea wherever sanitary conditions are significantly below US standards.
Surveillance and Survey Data: A limited 2002 study of animal handlers and livestock in Basra found stool samples positive for cryptosporidiosis in 5 percent of the animal handlers, 20 percent of cattle, 13.3 percent of sheep, 17.7 percent of goats and 12 percent of horses. A limited 1994 study of children under 5 years of age with gastroenteritis reported prevalences of 20 percent for Entamoeba histolytica, 13 percent for Giardia lamblia, and 9 percent for Cryptosporidium. Cyclosporiasis was diagnosed in Al Basrah in the late 1990s; this was the first time cyclosporiasis had been reported in Iraq.
Hepatitis E Risk Assessment:
Data are insufficient to assess potential disease rates. However, even under worst-case conditions, attack rates are likely to be less than 1 percent per month in exposed personnel.
Typical Incubation Period: 26 to 42 days (maximum range: 15 to 64 days)
Epidemiology Comments: Fecally contaminated drinking water is the most commonly documented source of transmission. Domestic animals, including swine, may serve as reservoirs. Hepatitis E may be transmitted by direct fecal-oral route under conditions of poor hygiene and sanitation, though secondary household cases are uncommon during outbreaks. Epidemics often occur when water sources become heavily contaminated by sewage, such as during flooding. Unlike hepatitis A, where local populations are often highly immune from childhood exposures in endemic areas, outbreaks of hepatitis E can occur among both adults and children because of low immunity in most populations.
Human Outbreak Information: Though incomplete, reported outbreaks include: - March 2004, Al Sadr city, Baghdad Governorate: More than 12,000 cases reported
Regional Data: In neighboring Saudi Arabia, seroprevalence varies from 1 to 18 percent, depending on location. Seroprevalence is approximately 6 percent in neighboring Turkey. Outbreaks have occurred in neighboring Jordan.

8. Infectious Diseases Cont.
Vector-borne Diseases
LOW RISK = Malaria, Leishmaniasis, Crimean-Congo fever, Rickettsioses, Sand-fly fever, Plague, West Nile fever
FHP Priorities
Use DEET on all exposed skin
Treat field uniforms with permethrin
Use bed nets in field conditions, treat with permethrin
Enforce malaria chemoprophylaxis as appropriate
During warmer months (typically April through November), ecological conditions support populations of arthropod vectors, including mosquitoes, ticks, and sand flies, with variable rates of disease transmission. Plasmodium vivax malaria occurs at low levels in some rural areas. In addition, a variety of other vector-borne diseases occur at low or unknown levels, which as a group may constitute a significant risk. Personnel exposed to mosquitoes, ticks, sand flies, or other biting vectors are at risk during day or night.
Expect rare cases. Use DoD Insect Repellent System

9. Infectious Diseases Cont.
Animal-contact Diseases
INTERMEDIATE RISK = Avian Influenza, Anthrax, Q-fever, Rabies
FHP Priorities
Avoid animal contact
No mascots
Report all animal bites and scratches
What not to do!
Avian Influenza H5N1
Rare cases of H5N1 influenza could occur in operational forces exposed to infected poultry flocks. The impact on scheduled operations is minimal. However, in the unlikely event that H5N1 influenza gains the ability to efficiently spread directly from person to person, initiating a human influenza pandemic, a significant number of operational forces worldwide could be affected.
Very severe illness; fatality rate higher than 50% in symptomatic cases
Anthrax Risk Assessment:
Rare cases could occur among personnel exposed to animals, animal products, or undercooked meat
Cutaneous anthrax typically requires 1-7 days of supportive care with subsequent return to duty; GI or pulmonary anthrax typically requires intensive care and each has a high fatality rate.
Risk Period: Year-round
Risk Distribution: Countrywide (including urban areas); the risk from direct animal contact is likely to be highest in rural areas where livestock are present. However, the risk from contaminated meat and animal products can occur countrywide, including urban areas.
Typical Incubation Period: 1 to 7 days (maximum range: 1 to 60 days)
Epidemiology Comments: Anthrax is a naturally occurring infection with a worldwide distribution. Cutaneous anthrax is transmitted through direct contact with infected animals or carcasses, including hides; exposure is typically occupational. Gastrointestinal anthrax is contracted through eating undercooked, infected meat. Pulmonary anthrax is extremely rare and is contracted through inhalation of spores.
Surveillance and Survey Data: Anthrax in Iraq is classified as "endemic/enzootic" in an authoritative, recently published assessment based on multiple data sources, including WHO, UN Food and Agricultural Organization (FAO), the Office of International Epizootics (OIE), and others. "Endemic/enzootic" is defined as the regular occurrence of a low number of human cases, and livestock cases per million per year, without evidence for epizootics. Occupational exposure usually involves sheep.
Q fever Risk Assessment:
Rare cases could occur among personnel exposed to aerosols from infected animals, with clusters of cases possible in some situations. Significant outbreaks (affecting 1-50 percent) can occur in personnel with heavy exposure to barnyards or other areas where animals are kept. Unpasteurized milk may also transmit infection.
Debilitating febrile illness typically requiring 1-7 days of inpatient care followed by return to duty
Since specific data are limited from this or neighboring countries, this assessment is an estimate based on overall regional conditions and disease distribution.
Risk Distribution: Primarily rural; the risk from direct animal contact is likely to be highest in rural areas where livestock are present. However, the risk from contaminated milk products can occur countrywide, including urban areas.
Typical Incubation Period: 14 to 21 days
Epidemiology Comments: Q fever is a very common disease worldwide, but it is rarely diagnosed or reported, particularly in developing countries. It causes asymptomatic infections in livestock and other animals in a global distribution. Direct contact with infected animals or exposure to environments such as barnyards or fields that are contaminated with fluids from infected animals can result in human infection. Exposure occurs primarily via the respiratory route, with an infectious dose as low as a single organism. Infective aerosols also may be associated with contaminated materials such as straw, hay, or wool. Most human infections are asymptomatic or result in mild cases; the disease is usually unrecognized and unreported. In areas where Q fever is highly endemic among animal populations, human outbreaks of febrile flu-like illness may occur, sometimes with only indirect animal contact via aerosols. Aerosols can be carried downwind for long distances, and cause human infection miles from the contaminated source. Less frequently, humans become infected through consumption of contaminated milk products.
Surveillance and Survey Data: From March 2003 to June 2004, eight US soldiers diagnosed with pneumonia during OIF had tested positive for Coxiella burnetii, the Q fever agent. It is not known if Q fever caused the pneumonia in many of the cases or was an incidental finding. Since additional country-specific data are unavailable, the endemicity assessment was based on applicable data from neighboring countries with similar conditions.
Regional Data: In neighboring Iran, a limited 1996 study found up to 27 percent seropositivity among random human serum samples.
Rabies
Risk Assessment:
Rabies risk is assessed as well above US levels due to ineffective control programs; personnel bitten by potentially infected reservoir species may develop rabies in the absence of appropriate prophylaxis. The circumstances of the bite should be considered in evaluating individual risk; bats or wild carnivores should be regarded as rabid unless proven otherwise.
Very severe illness with near 100% fatality rate in the absence of post-exposure prophylaxis.
Risk Distribution: Countrywide (including urban areas); risk of exposure to rabid animals is highest in rural areas.
Typical Incubation Period: 21 to 56 days (maximum range: 9 to 180 days)
Epidemiology Comments: Rabies is transmitted by exposure to virus-laden saliva of an infected animal, typically through bites. Theoretically, transmission may occur by scratches contaminated with the saliva of a rabid animal or by the respiratory route in caves with large numbers of infected bats. Transmission by these routes is unlikely.
Reservoir Information: Worldwide, dogs, cats, and bats are principal sources of human exposure. Coyotes, foxes, jackals, marmosets, mongooses, raccoons, skunks, and wolves also may transmit infection to humans. Chipmunks, livestock, mice, opossums, rabbits, rats, and squirrels also can be rabies-infected but rarely, if ever, transmit infection to humans.
Surveillance and Survey Data: Ninawa has the highest rate of human deaths from rabies (0.24/100,000); an average of 5 to 10 deaths per year occur here. Follow-up post-exposure prophylaxis is poor with only 76 percent of high-risk dog bites receiving the first shot and 7 percent completing the series. Though incomplete, human rabies reporting includes: : data incomplete but at least one death : 7 cases : 14 cases : 27 cases.
Jackals and foxes are the primary reservoirs, with some spillover into dogs and other domestic animals.

10. Infectious Diseases Cont.
Sexually Transmitted Diseases
INTERMEDIATE RISK = gonorrhea, chlamydia, HIV, Hep B
FHP Priorities
Avoid sexual contact
Use latex condoms if sexually active
Gonorrhea, chlamydia, and other infections are common, and may affect a high percentage of personnel who have sexual contact. HIV/AIDS and hepatitis B also occur. Though the immediate impact of HIV/AIDS and hepatitis B on an operation is limited, the long-term health impact on individuals is substantial.
Gonorrhea / chlamydia Risk Assessment:
An operationally significant attack rate (potentially 1-50% per month) could occur among personnel having unprotected sexual contact, particularly with commercial sex workers (CSW)
Typically mild disease treated in outpatient setting; rarely results in significant lost duty time.
Risk Period: Year-round
Risk Distribution: Countrywide (including urban areas)
Typical Incubation Period: 2 to 14 days
HIV/AIDS Risk Assessment:
Rare cases could occur among personnel having unprotected sexual contact, particularly with commercial sex workers (CSW)
Though initial infection is typically asymptomatic, virtually all infections result in eventual immune deficiency and death.
Surveillance and Survey Data: At the end of 2001, HIV seroprevalence among those 15 to 49 was officially estimated to be less than 0.01 percent. Transmission is primarily through men having sex with men and secondarily through heterosexual transmission.
Hepatitis B Risk Assessment:
Rare cases could occur among unvaccinated personnel having unprotected sexual contact, particularly with commercial sex workers
Approximately percent of infections are symptomatic in adults. When symptoms occur, they typically last 1 to 3 weeks and sometimes require inpatient care; recovery and return to duty may require a month or more. A chronic carrier state with eventual liver damage may occur in 1-10 percent of those infected.
Typical Incubation Period: 60 to 90 days (maximum range: 45 to 180 days)
Epidemiology Comments: Hepatitis B is transmitted through sexual contact with a carrier. Transmission also may occur through exposure to blood or body fluids of a carrier (hepatitis B surface antigen positive). The World Health Organization defines areas of high endemicity as those having a hepatitis B surface antigen prevalence of greater than 8 percent. In areas of high endemicity, maternal-child transmission at birth and in the first years of childhood sustains high carrier rates in the population.
Surveillance and Survey Data: The 2002 US Department of Health and Human Services data estimated the HBsAg rates between 2 and 7 percent in 2002.

11. Infectious Diseases Cont.
Water-contact Diseases
INTERMEDIATE RISK = leptospirosis, schistosomiasis
FHP Priorities
avoid unnecessary contact with lakes, rivers, streams, and other surface water
Tactical operations or recreational activities that involve extensive contact with surface water such as lakes, streams, rivers, or flooded fields may result in significant exposure to leptospirosis and schistosomiasis. Arid portions of Iraq without permanent or persistent bodies of surface water do not support transmission of leptospirosis or schistosomiasis. Risk is primarily restricted to areas along rivers and lakes. These diseases can debilitate personnel for up to a week or more.
Leptospirosis Risk Assessment:
Disease is assessed as present, but levels are unknown; an unknown number of cases could occur among personnel wading or swimming in bodies of water such as lakes, streams, or irrigated fields. In groups with prolonged exposure to heavily contaminated foci, attack rates can be high (up to 50%).
Debilitating febrile illness typically requiring 1-7 days of inpatient care, followed by return to duty; some cases may require prolonged convalescence.
Risk Period: Year-round
Risk Distribution: Variable; arid portions of the country without permanent or persistent bodies of surface water do not support transmission. Risk is restricted to wetter areas, including irrigated fields.
Typical Incubation Period: 4 to 19 days
Epidemiology Comments: Rodents, domestic livestock, and other animals are reservoirs for the causative agent (a spirochete) and shed the organism in their urine. Organisms remain viable in surface water or mud, particularly at temperatures at or above 22 degrees Celsius (70 F). Human infection occurs through direct contact of contaminated water or mud with abraded skin or mucous membranes. Concentrations of the organism in lakes, rivers, or other surface water may vary significantly from location to location. Transmission occurs in both rural and urban areas and may be increased during flooding.
Regional Data: Serosurveillance data from neighboring Iran indicate that leptospirosis occurs in the region.
Schistosomiasis Risk Assessment:
Data are insufficient to assess potential disease rates. Under worst-case conditions, this disease could affect 1-10 percent per month of exposed personnel.
Mild infections are generally asymptomatic. In very heavy acute infections, a febrile illness (acute schistosomiasis) may occur, especially with S. japonicum and S. mansoni, requiring hospitalization and convalescence over 7 days.
Agent/Subtype: S. haematobium
Risk Period: Seasonal (typically Apr through Nov)
Risk Distribution: Variable; Schistosoma haematobium is distributed along the entire Euphrates and Tigris (as far north as Samarra, (34-12-XXN XXE) River systems, their tributaries, irrigation canals, and marsh areas, including urban areas. An isolated focus exists in the northern Province of Ninawa in the area of Tall Kayft (36-29-XXN XXE) near the city of Al Mawsil (Mosul). Reportedly, no transmission occurs south of Ar Rifa''i district ( N E) in Dhi Qar Governorate because the delta waters are too saline for the snail intermediate hosts.
Typical Incubation Period: 14 to 42 days
Epidemiology Comments: Humans are the principal reservoir for schistosomes; humans shed schistosome eggs in urine or feces. Lakes, streams, or irrigated fields frequently are contaminated with human waste containing schistosome eggs. When water temperatures are at or above 20 degree Celsius (68 F), the eggs hatch releasing larvae. If a suitable fresh water snail species is present, the larvae penetrate the snail, and after a period of development emerge as free-swimming cercariae. Cercariae infect human hosts by penetrating skin, usually while the person is wading or swimming. Exceptionally heavy concentrations of schistosomes may occur in discrete foci, which are difficult to distinguish from less contaminated areas. In nonimmune personnel exposed to such foci, rates of acute schistosomiasis can be very high (over 50 percent).
Surveillance and Survey Data: Ar Rifa''i district in Dhi Qar Governorate reported approximately 60 cases per year in Cases do not occur south of this district because of the salinity of the water. According to the World Health Organization, from 1990 to 1994 the prevalence decreased from about 60 per 100,000 to about 20 per 100,000
There will not be a sign like this.

12. Infectious Diseases Cont.
Respiratory Diseases
INTERMEDIATE RISK = tuberculosis
FHP Priorities
Tuberculin skin test before and after deployment
Avoid close contact with local population
Though not specifically assessed, deployed US forces may be exposed to a wide variety of common respiratory infections in the local population. These include influenza, pertussis, viral upper respiratory infections, viral and bacterial pneumonia, and others. US military populations living in close-quarter conditions are at risk for substantial person-to-person spread of respiratory pathogens. Influenza is of particular concern, because of its ability to debilitate large numbers of unvaccinated personnel for several days.
Tuberculosis Risk Assessment:
Tuberculin skin test (TST) conversion rates may be elevated over baseline for personnel with prolonged close exposure to local populations
TST screening to detect latent infection may be warranted in personnel with a history of prolonged close exposure to local populations.
Risk Period: Year-round
Risk Distribution: Countrywide (including urban areas)
Typical Incubation Period: 60 to 180 days (maximum range: 60 to 365 days)
Epidemiology Comments: Transmission typically requires close and prolonged contact with an active case of pulmonary or laryngeal tuberculosis (TB), though it also can occur with more incidental contact. The likelihood of exposure to an active case varies with the overall incidence in the country and the degree of contact with the local population, particularly those living in conditions of crowding and poverty.
Surveillance and Survey Data: In the 2004 World Health Organization publication on Global Tuberculosis Control, annual incidence of active TB cases in 2002 was estimated at per 100,000 (compared to the US rate of approximately 6 per 100,000).

13. Hazardous Animals & Plants
Rabid animals snakes, centipedes, scorpions, spiders
Plants
Mole Plant, Belladonna, Strychnine
FHP Priorities
Do not handle animals
Shake out boots, clothing, & bedding
Do not touch, chew, eat, or burn unfamiliar plants
HAZARDOUS ANIMALS AND PLANTS
Several species of highly poisonous snakes (desert black snake pictured), which can be aggressive, live in the region. Consider any snake encountered as poisonous, and do not handle. Seek immediate medical attention if bitten; untreated snakebites may cause serious illness or death within 1 hour.
Although many scorpions in the region are capable of inflicting a painful sting, some, such as the Fat-tailed scorpion (pictured), are known to be life-threatening. Several species of spiders are present throughout the region. The widow spider is considered life threatening. If possible, avoid sleeping on the ground. Shake out boots, bedding, and clothing prior to use, and never walk barefoot. If bitten or stung, seek medical attention immediately.
Some regional plants have thorns, stinging hairs, or toxic resins that may puncture the skin or introduce poison into the skin causing skin irritation, rashes or infections. Avoid skin contact with plants when tactically feasible.
Contact with the smoke from the burning of some plants can also cause skin rashes and damage to your lungs.
Clean your clothing after contact with harmful plants. Decontaminate clothing by washing with soap and water.
Some regional plants may cause systemic poisoning if leaves, berries, flowers, or other plant parts are chewed or swallowed. Symptoms include dizziness, vomiting, irregular heartbeat, and delirium or hallucinations.
Strychnine (pictured) can kill.

14. SUMMARY Physical Environment Infectious Diseases = Intermediate Risk
Hazardous Animals and Plants
FHP measures are simple and effective
Use and Enforce
Will conserve the fighting strength
Protecting unit personnel from disease and non-battle injury (DNBI) is critical to maintaining operational readiness, particularly on deployments. It is a medical responsibility to identify health threats and recommend appropriate countermeasures. Use the recommendations presented here to protect your health. The recommendations are useless without emphasis and action.