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Deployment Preventive Medicine Measures
Name Command Contact Information Good morning/afternoon. My name is , (JOB TITLE). The purpose of this briefing is to inform you on the medical threat in _____________________(SPECIFIC COUNTRY) or Operation Enduring Freedom. This briefing is meant to help you, and the unit leaders, accomplish the mission by giving you information on anticipated health hazards, the impact they will have on the heath of our deployed soldiers, and what actions can be taken to minimize the effects of these hazards. This briefing is unclassified. Prepared by: U.S. Army Center for Health Promotion and Preventive Medicine (800) / DSN /(410)

AGENDA Purpose Background Review of Guide to Staying Healthy
Preparation for Deployment Deployment Post Deployment Summary Conclusion

PURPOSE Inform Deploying Personnel (Military and Civilian) of the Potential Health Hazards and the Individual Countermeasures Necessary to Assure Personal Safety and Health Protecting personnel from environmental, safety, and occupational health hazards is critical to maintaining operational readiness. Commanders are responsible for implementing an effective Force Health Protection (FHP) program. Identifying health threats and recommending appropriate countermeasures is a medical responsibility.

BACKGROUND US Forces are mobilizing and deploying in support of Operation Enduring Freedom Environmental, safety, and occupational health hazards are a potential medical threat to deployed personnel Throughout history, DNBI resulting from medical threats (including, but not limited to, heat, cold, and disease) have accounted for more losses to fighting forces than combat-related injuries. Despite considerable advances in the technology of war, the medical threat still presents a significant danger to our forces. For example: Operation Just Cause, Republic of Panama, Many US personnel suffered heat prostration/injuries due to a lack of acclimatization and a shortage of drinking water. Airborne personnel jumped into the mangrove swamps around Panama City without adequate amounts of water to drink. Each individual only had one canteen of water. The water in these swamps is brackish (salt) water; therefore, the personnel could not refill their canteens and treat the water with iodine tablets. Unit combat lifesavers cut off the tops of 500 cubic centimeter (cc) IV solution bags and had the individuals drink the solution to relieve the heat effects. Operation Desert Shield/Operation Desert Storm in Saudi Arabia, At ports and other large troop concentration areas, sanitation safeguards were nonexistent or poorly controlled. In order to get to showers, soldiers had to pass through areas where human waste was leaking from outdoor latrines (some were positioned too closely). These conditions along with other sanitation problems, contributed to many cases of Shigella (a diarrheal disease). Operation Restore Hope in Somalia, In the process of upgrading and moving a unit to a new location, a US unit selected an area that had been occupied by a coalition force. The assumption was made that because these forces had found the area suitable that it would probably accommodate the unit’s soldiers. After expending considerable time and resources on construction of facilities in the area, the unit contacted the surgeon to assist in dealing with a fly problem. When the PVNTMED team arrived, they quickly discovered that the source of the flies was a dump adjacent to the site into which Somalis were discharging raw sewage. The solution was to relocate the unit to another area. Haiti. US personnel did not employ personal protective measures against arthropodborne diseases. They failed to correctly use the insect repellent, permethrin, and bed nets. Failure to use these protective measures contributed to a dengue fever rate of over 30 percent among febrile hospitalized soldiers. Historical accounts of wars, battles, and military training consistently relate that the greatest loss of forces was not caused by combat wounds – rather the majority of losses were the result of disease and non-battle injury (DNBI).

GUIDE TO STAYING HEALTHY
Unfold YOUR Guide to Staying Healthy Personal Protective Measures (PPM) – Individual Countermeasures Reference Guide for this Briefing Briefly discuss the Guide to Staying Healthy When emphasizing and practicing good personal protective measures (PPM’s), including but not limited to measures associated with nutrition, personal hygiene, and occupational and personal safety, we can reduce, or even eliminate DNBI. The result of practicing these measures, in combination with field preventive medicine (PVNTMED) support and quality health care, is maximum force readiness – capable of successfully achieving the military mission. This guide is for use by all active/reserve component military, civilian, retiree, and contractor personnel. Any individual who trains and prepares for, or participates in any type of military operation should keep and refer to this guide.

PREPARING TO DEPLOY Medical, Dental & Vision Screening (Soldier Readiness Processing) Prepare clothing and gear and personal hygiene items Complete Pre-deployment Health Assessment (DD Form 2795) Immunizations and chemoprophylaxis Begin malaria chemoprophylaxis two weeks prior to deployment (when directed by medical authority) Complete soldier readiness processing Ensure uniforms, chemical protective clothing, 2 pair of prescription military spectacles (if required), protective masks (with prescription lens inserts, if required ), protective eyewear (i.e. Ballistic Laser Protective Spectacles (BLPS) or Special Protective Cylindrical System (SPECS), contact lenses (if operationally required e.g. Apache contact lens program), and other gear are in good condition and fit properly Practice putting on/removing clothing, masks, and gear: ensure clothing items, hair, etc. do not interfere with proper wear Ensure uniforms are treated with insect repellent (permethrin), mark treatment date and method of treatment on the uniform Apply permethrin to uniforms with the Individual Dynamic Absorption (IDA) kit (good for the life of the uniform) or aerosol spray (reapply after sixth wash) Preferred or special types/brands of personal hygiene items may not be available at all locations; if you need medications or hygiene items which may not be available through normal supply systems, obtain a 6-month supply, or enough for the duration of the operation (include pre-/post-deployment) Complete DD Form 2795 prior to deployment Receive all directed immunizations During medical screening, discuss prescribed medications with the examiner; obtain at least 90-day supply of medications

ADDITIONAL PACKING ITEMS:
PREPARING TO DEPLOY ADDITIONAL PACKING ITEMS: Cotton underwear (10 changes) Birth control supplies Personal Hygiene Products Anti-fungal cream/powder & shower shoes Insect repellent, sunscreen, eye and hearing protection, lip balm, skin lotion Birth control (condoms, birth control pills) Hygiene products include unscented wet wipes, hand sanitizer gel/lotion, and feminine hygiene items Shower shoes, anti-fungal powders/creams etc… will help prevent athlete’s foot and Jock Itch. If you need medications or hygiene items which may not be available through normal supply systems, obtain a 6-month supply, or enough for the duration of the operation

PREPARING TO DEPLOY FEMALE CONSIDERATIONS
Birth control pills Feminine Hygiene Products (non-deodorant tampons, sanitary napkins, panty liners; menstrual cramp reliever) Yeast infection medication (two courses of vaginal treatment) Portable Urinary Device For use by female personnel to reduce time needed to urinate and resolve privacy issues when latrines are not available (convoys, field operations) NSN: Birth control (condoms, birth control pills) (if using birth control pills, continue as prescribed to regulate menstrual cycles and avoid problems resulting from inconsistent use) Hygiene products include unscented wet wipes, hand sanitizer gel/lotion, and feminine hygiene items Portable Urinary Device (PUD) (optional unit/indiv purchase) PUD NSN is PUD is for use by female personnel to reduce time needed to urinate and resolve privacy issues when latrines are not available (convoys, field operations) If using birth control pills, continue as prescribed to regulate menstrual cycles and avoid problems resulting from inconsistent use

DEPLOYMENT HEALTH CARE
Know where to seek health care when deployed May or may not be through same channels as your home station Maintain your health and seek care whenever an illness or injury occurs Information About Your HEALTH CARE While Deployed. It is important that you know where to seek health care while deployed. This may or may not be through the same channels as your home station. Ask your chain of command for more information. While deployed, you must maintain your health and seek care whenever an illness or injury threatens your ability to complete your tasks. Your unit is depending on you. It is always better to seek care early so that your problems can be documented appropriately and taken care of immediately.

PREVENTIVE MEDICINE COUNTERMEASURES
Medical Tests – All Personnel PPD – Purified Protein Derivative (TST – Tuberculin Skin Test) Within 12 months prior to deployment AND At time of redeployment AND Again between 3-6 months after redeployment HIV – Human Immunodeficiency Virus Required every 2 years. Serum collection before deployment will be tested regardless of date of last test. G6PD - Glucose-6-Phosphate Dehydrogenase Prior to taking Primaquine (anti-malarial drugs are contra-indicated for G6PD deficient individuals) Reference: Army Personnel Policy Guidance, Chapter 7 The following areas are considered low threat areas for tuberculosis. Personnel who have deployed only to these locations do not require TB skin testing upon redeployment: (1) Canada, Greenland, Iceland; (2) Cuba (Note: Personnel involved in detainee operations are required to undergo screening for LTBI IAW this memorandum); (3) Chile, Costa Rica, French Guiana; (4) British Isles; (5) Norway, Sweden, Finland, Denmark, France, Belgium, Netherlands, Luxembourg, Monaco, Switzerland, Austria, Germany, Czech Republic, Italy, Greece, Cyprus; (6) Australia, New Zealand; (7) Lebanon, Libya, Jordan, United Arab Emirates, Oman, Qatar; (8) Libya Redeploying soldiers will have a tuberculin skin test (TST) performed at the time of redeployment and again between 3 and 6 months after redeployment. The first test will identify soldiers who were infected with Mycobacterium tuberculosis during the early period of a deployment. The 3-6 month test will identify individuals who were infected with M. tuberculosis late during a deployment, but whose skin test is falsely negative at the time of redeployment. Three months is a sufficient period for those with recent infection to develop a positive TST reaction. Based upon medical capabilities in a theater of operations, deployed medical assets may administer and read TSTs for personnel who are scheduled to redeploy within 10 days. As appropriate, deployed medical assets will document the date and results of the TST in block 9p, "PPD", on DD Form 2766, Adult Preventive and Chronic Care Flowsheet. Home stations and processing stations that receive redeploying personnel will assess the need to complete TST testing. If a test was completed within 10 days prior to redeployment additional testing is not required at this time; assure that tests and results are documented in health records and MEDPROS. If a TST was not performed prior to redeployment (or if documentation is insufficient), a TST will be performed at the processing or home station ASAP after arrival. Home and processing stations will assure that TSTs are administered and read IAW reference g and that testing data are documented in health records and in MEDPROS. For personnel who have a negative TST result at the time of redeployment, an additional TST will be administered at least 3 months but not later than 6 months after redeployment.

IMMUNIZATION REQUIREMENTS
All Personnel Hepatitis A Typhoid Tetanus-diphtheria Yellow fever Meningococcal Influenza Measles, Mumps, Rubella (MMR) Polio Selected Personnel Hepatitis B (medics, MPs, firefighters, combat lifesavers) Rabies (occupational risk of exposure) Pneumococcal (asplenic personnel) Anthrax (as directed from higher) Smallpox (as directed from higher) Reference: Confirm requirements with medical authority or OPORD

MALARIA CHEMOPROPHYLAXIS
Anti-Malaria Medication (as directed) Take anti-malaria medication as directed by your health care provider Malaria kills at least 1 million people each year worldwide (World Health Organization) Risk for malaria varies within any country based on a number of factors of which temperature and elevation are the most important. Your local medical authority will determine if malaria is a threat in your specific location and provide appropriate countermeasures. The area/country you are deploying to and your medical condition will determine the type of drug prescribed by your health care provider

Failure to apply PMM increases the risk of mission failure
FIELD SANITATION TEAM Field Sanitation Teams (FST) train unit personnel in Preventive Medicine Measures (PMM) and advise the commander and unit leaders on implementation of unit-level PMM. Know who the members of your Field Sanitation Team are PRIOR to deployment The FST can assist in preventing medical threats to your health Deploy with all FST equipment FIELD SANITATION TEAM TASKS Unit FSTs serve as advisors to the commander on individual and unit Preventive Medicine Measures (PMM) that prevent DNBI. To assess the medical threat (disease/illness risk), the team members must be able to perform the following tasks: Inspect water containers and trailers. Disinfect unit water supplies. Check unit water supply for chlorine. Inspect unit field food service operations. Inspect unit waste disposal operations. Control arthropods, rodents, and other animals in unit area. Train unit personnel in use of individual PMM. Monitor status of PMM in unit. Assist in selection of a unit bivouac site. Supervise the construction of field sanitation devices. Monitor unit personnel in the application of individual PPM. NOTE All unit leaders should be able to perform these tasks. Failure to apply PMM increases the risk of mission failure

PERSONAL PROTECTIVE MEASURES
Wash hands frequently Do not rub eyes or inside of nose with bare finger(s) Bathe/shower regularly (field expedients will do); use unscented products Wear shower shoes to prevent athlete’s foot Dry thoroughly after showering Sleep head-to-toe if billeted in common areas Wear clean, dry uniforms; change socks daily and uniform at least weekly Do not wear nylon or silk undergarments; cotton undergarments are more absorbent and allow the skin to dry Seek prompt medical care if problem exists Using basic Personal Protective Measures (PPM’s) and good personal hygiene can significantly reduce the threat of becoming a casualty of and/or spreading infectious disease (meningitis, flu, tuberculosis, colds); becoming pregnant or contracting sexually transmitted diseases (STD’s) (HIV, chlamydia, herpes); and reduce personal discomfort during deployment ***During the recent disaster support, athlete’s foot was a common problem. Keeping feet dry and clean is critical.

ORAL HEALTH Deploy with: Brush twice-daily Floss daily
Toothbrush Dental Floss Fluoride Toothpaste Brush twice-daily Daily in difficult tactical environments Floss daily Seek medical attention at the onset of any dental problems ORAL HEALTH Dental disease is a common problem during deployments due to the challenge of maintaining good oral hygiene. You should deploy with toothbrush, dental floss, and fluoride toothpaste. Daily flossing and twice-daily brushing of teeth is the best way to ensure prevention of periodontal disease and to decrease your risk of problems such as trench mouth and tooth decay. In difficult tactical environments, teeth should be brushed at least once a day. Seek medical attention immediately at the onset of any dental problems.

SPIRITUAL HEALTH Maintain personal prayer/meditation
Obtain and read wholesome religious/spiritual literature Attend religious/spiritual group discussions/studies Process anger, fear, anxiety & guilt through personal & group spiritual/religious activities Keep in touch with spiritual advisors/chaplains Spiritual Resiliency allows a soldier the inner peace that brings great strength in times of crisis. Maintaining personal prayer/meditation keeps a soldier ready for action. Reading additional spiritual literature in times of stress broadens the soldier’s perspective and adds a fresh perspective to existing devotional practices. Group meetings strengthen a soldier’s resolve to “Keep the Faith” and allows for fellowship. When soldiers gather together to study and discuss their faith, they find a continuity in their feelings and support in their times of need. Spiritual mentors provide the wisdom of experience and learning that are needed in times of stress.

NUTRITION Drink fluids regularly (hourly fluid intake should not exceed 1.5 quarts, daily fluid intake should not exceed 12 quarts) Maintain weight; do not avoid food or attempt weight loss during a deployment Work in cold weather can increase energy needs by 10-25% Operations in high-altitude areas can increase energy needs by 50% or more Food and water play a major role in sustaining your health, performance and morale. As little as a 2% decrease in body weight due to water loss can significantly DECREASE performance. You must consume fluids continuously even when you don’t feel thirsty since thirst sensation is a poor indicator of the need for fluids. Energy needs typically increase in the field environment due to higher physical demands. To ensure optimum physical and mission performance, you should consume enough food to relieve hunger and avoid weight loss. Maintain your weight; do not avoid food or attempt weight loss during field operations. Energy needs can vary based on individual body size, weight, and level of fitness. Climate can also affect energy requirements, for example: Work in cold weather can increase energy needs by 10-25% Operations in high-altitude areas can increase energy needs by 50% or more To maximize physical performance and aid your body’s ability to heat/cool, you must consume adequate amounts of food and fluids each day.

If you don’t smoke, don’t start during a deployment.
SMOKING March – August 2003: 19 cases of severe pneumonia in service members deployed to Southwest Asia 16 smokers, 8 began smoking during this deployment Two pneumonia deaths January 2004: 2 new severe cases of pneumonia Both began smoking during this deployment If you don’t smoke, don’t start during a deployment. If you do smoke, quit.

STRESS Operational stressors Different types and intensities
Recognize the symptoms of depression Seek or encourage help Take steps to reduce operational stress Stress, fatigue and depression can weaken the body, making you more susceptible to DNBI. Deployment is stressful to everyone, however, you can reduce the symptoms of stress by: Operational stressors: Change of food and/or fluid intake, Longer work hours, Carrying heavy gear, High operations tempo (OPTEMPO), Psychological stress Different types and intensities Be aware that stressors are different or may be intensified for personnel who are: Exposed to or observe human suffering and death Distracted by worries about home or family Working in high OPTEMPO/continuous operations Recognize the symptoms of depression in yourself and your buddies Change of/or withdrawn behavior, Excessive tiredness or insomnia, Change in appetite, Feelings of despair, Talking or listening to a friend/buddy, Seek help and/or encourage your buddies to seek help Take steps to reduce operational stress: Maintain physical fitness, Stay informed, Sleep when the mission and safety permit, Sleep/rest in areas away from generators and other noises, Avoid or ensure proper use of over-the-counter medications, Avoid alcohol and tobacco products, Remain in contact with family and friends through letters, , phone, audio/video tapes. Stress can be intensified for personnel who are exposed to or observe human suffering and/or death

IMPROVE RESISTANCE TO STRESS
Fear and physical signs or symptoms of stress are normal reactions before and during combat or other dangerous/life-threatening situations Talk about what is happening with your buddies Learn ways to relax quickly Quickly integrate new replacements If you must join a new group, be active in establishing friendships Give each other moral support Care for your buddies and work together Fear and physical signs or symptoms of stress are normal reactions before and during combat or other dangerous/life-threatening situations. You should not let fear or stress keep you from doing your job. Talk about what is happening with your buddies, especially during after-action debriefings. Learn ways to relax quickly. Integrate new replacements into your group and get to know them quickly. If you must join a new group, be active in establishing friendships. Give each other moral support. Care for your buddies and work together to provide everyone food, water, sleep, and shelter, and to protect against heat, cold, poor sanitation, and enemy action.

CARBON MONOXIDE Carbon monoxide (CO) is a colorless, odorless, and tasteless gas produced by engines, stoves, and gas/oil heaters. CO replaces oxygen in the body, causing headache, sleepiness, coma, and death. COUNTERMEASURES Keep sleeping area windows slightly open for ventilation and air movement. DO NOT sleep in vehicles with the engine running or use engine exhaust for heat. DO NOT park vehicles near air intakes to tents, trailers, or environmental control units. Carbon monoxide is a silent killer that strikes with little or no warning. Exposure to carbon monoxide (exhaust gas) will result in headache, dizziness, loss of muscular control, drowsiness or coma. Permanent brain damage or death can result from severe exposure. Any device that burns combustible material can present a hazard to personnel. Ensure all such devices are in proper working order and operated by qualified and licensed personnel. Include carbon monoxide poisoning recognition and response training for all personnel. Prohibit sleeping in vehicles with engines running and ensure proper venting of areas where carbon monoxide may accumulate. Be aware of the potential for carbon monoxide poisoning from use of stoves/heaters in poorly ventilated space Carbon monoxide is a colorless, odorless, tasteless gas that results from combustion without enough oxygen. Large amounts of this gas can build up and kill you when there is not proper ventilation for engines, stoves and heaters. Many soldiers have gone to sleep with motors running and have died from carbon monoxide poisoning. Signs/symptoms progress slowly. At the onset, they may go unnoticed because carbon monoxide is colorless, tasteless, and odorless. Headache, tiredness, excessive yawning, confusion, followed by unconsciousness, and eventually death. A cherry-red coloring to the tissues of the lips, mouth, and inside the eyelids occurs very late in CO poisoning--when the patient is very near death. Do not use unapproved commercial off-the-shelf heaters. Check with your unit Safety Officer.

COLD INJURY PREVENTION
Hypothermia, Frostbite, Chilblains COUNTERMEASURES When possible, remain inside warming tents/buildings and drink warm, uncaffeinated liquids for relief from the cold If working outside or on guard duty, insulate yourself from the ground and wind. Rotate duty as frequently as mission allows. Properly wear the Extended Cold Weather Clothing System Seek immediate medical attention if you experience loss of sensitivity in any body part Anyone from a general to a private can get a cold weather injury if the conditions are right. However, some soldiers are more susceptible than others. Soldiers who have had a cold injury in the past are much more likely to develop a cold injury sooner, or a more severe cold injury in the future. Adequate nutrition is required to fuel your body’s metabolism to produce heat. Generally calories per day is sufficient. More calories are required when working in a cold environment than when in garrison. Dehydration will cause the body’s natural defense mechanisms to fail and cause the soldier to be much more susceptible to cold injuries, especially hypothermia. Overactivity can lead to sweating and wet clothing which can create conditions for immersion syndrome or hypothermia. Underactivity can lead to decreased body heat production. Use the buddy system – personnel who have had previous cold injuries are especially susceptible to new or more serious injuries You should receive annual unit training on prevention of cold injury

COLDER C: Keep clothing Clean O: Avoid Overheating.
L: Wear clothing Loose and in layers D: Keep clothing as Dry as possible E: Examine clothing (holes, tears, broken fasteners) R: Repair or replace damaged clothing Insulation depends on the amount of air trapped within the garment and properties of the material. For a given weight, a thicker material will trap more air and be a better insulator. When clothing is dirty, the material tends to be packed down, which compromises insulation. Wearing clothing ensembles in multiple layers allows insulation to be adjusted to changes in environment or workload as well as to the individual's own needs and preferences. Layered clothing is especially important for soldiers whose duties require them to frequently move in and out of heated shelters, or to periodically undertake vigorous physical activity. Physically active people sweat even in extremely cold weather. If sweat cannot evaporate, it will accumulate, wet the clothing, and ultimately compromise insulation. Sweat will be able to evaporate if clothing allows ventilation. Proper clothing will be made of material that water vapor can pass through, and will allow the wearer to unzip and open the clothing periodically to increase ventilation. Sweat evaporation will be compromised when clothing is dirty. Notify your first-line supervisor if you have had a previous cold injury. Use the buddy system.

WIND CHILL TEMPERATURE
Skin: Exposed skin is more likely to develop frostbite, therefore cover skin. Avoid wet skin (common around the nose and mouth). Inspect hands, feet, face and ears frequently for signs of frostbite. Clothing: Soldiers must change into dry clothing at least daily and whenever clothing becomes wet, and must wash and dry feet and put on dry socks at least twice daily. Nutrition: 4500 calories/day/soldier. Equivalent to 3 meal packets in meal-cold weather (MCW) or 3-4 MRE’s. Hydration: 3-6 Liters (canteens)/day/soldier. Warm, sweet drinks are useful for re-warming. Camouflage: Obscures detection of cold injuries; Not recommended below 10°F. Responsibilities: Soldiers are responsible for preventing individual cold injuries. Unit NCO’s are responsible for the health and safety of their troops. Cold injury prevention is a command responsibility. WET SKIN CAN SIGNIFICANTLY DECREASE THE TIME FOR FROSTBITE TO OCCUR

HEAT INJURY PREVENTION
Heat Cramps, Exhaustion, or Stroke COUNTERMEASURES Drink fluids continuously (hourly fluid intake should not exceed 1.5 quarts, daily fluid intake should not exceed 12 quarts) Maintain acclimatization Protect yourself from exposure to sunlight and wind Maintain good physical condition Establish work/rest schedules Wear proper clothing Participate in training Avoid over-the-counter medications, alcohol, tobacco, and caffeinated beverages since any of these can cause or increase the effects of dehydration or solar radiation (sunburn) injury. Avoid Dietary supplements which include EPHEDRA (ripped fuel/metabolife) or Creatine which increase susceptibility to heat injuries. Follow work/rest guidance for water consumption (urine color should be light with no strong odor) Use the buddy system – personnel who have had previous heat injuries are especially susceptible to new or more serious injuries You should receive annual unit training on prevention of heat injury. Heat injuries are preventable!

H: Heat category – WBGT Index E: Exertion level (prior 3 days)
A: Acclimatization T: Tables – Water/Work/Rest REMEMBER Water requirements are not reduced by any form of training or acclimatization. Regardless of their physical condition, however, soldiers who are required to deploy on short notice to hot environments, will arrive incompletely acclimatized. Adequate acclimatization will require several days to achieve. During this initial acclimatization period, soldiers must be provided copious quantities of water and carefully supervised to prevent excessive heat exposure. If possible, work tasks should be regulated using work-rest cycles tailored to the soldiers’ physical capacity by direct medical oversight. Avoiding heat casualties requires that soldiers drink enough water to replace what they lose. In hot environments, soldiers do not drink enough water to voluntarily maintain hydration. This phenomenon has been called "voluntary dehydration", although there is nothing willful about it. In hot environments, thirst is not stimulated until plasma osmolarity rises 1-2% above the level customarily found in temperate climates. Consequently, if thirst is used as the guide to drinking, soldiers will maintain themselves at a level that is 1-2% dehydrated relative to their usual state. If soldiers are to fully replace the water they lose in their daily activities and eliminate voluntary dehydration, they must understand the need to drink even though they are not thirsty and leaders must enforce water drinking discipline. Even in the face of a clear understanding of the importance of water and hydration, soldiers may decide that water drinking creates problems that outweigh its importance. For example, soldiers may not drink before going to sleep to avoid having to wake up and dress to urinate or they may not drink before convoys if no rest stops are planned. Units which have soldiers who do not drink because they do not have opportunities to urinate have a leadership problem.

Hydration is the most important element in a plan to prevent heat casualties. Full hydration is critical to the prevention of heat casualties because it is essential to maintain both blood volume for thermoregulatory blood flow and sweating. Both are reduced by dehydration. Consequently, the dehydrated soldier has less ability to maintain body temperature in the heat. Water requirements are not reduced by any form of training or acclimatization. Exercises to teach soldiers to work or fight with less water are fruitless and dangerous. Units which have soldiers who do not drink because they do not have opportunities to urinate have a leadership problem. Unit leaders must reinforce of hydration by planning for all aspects of adequate hydration: elimination as well as consumption. In hot environments, water losses can reach 15 liters per day per soldier. Complete replacement requires realistic estimates of potable water requirements, an adequate water logistic system and soldiers who understand and act on their water requirement. Water for hygiene will be needed in addition to water for drinking. There is no advantage to carbohydrate/electrolyte beverages beyond their palatability which may encourage drinking. They should not be the sole source of water as they can be mildly hypertonic.

SUNBURN Prevent overexposing skin and eyes to solar radiation and wind
COUNTERMEASURES Use sunscreen and lip balm Use protective eyewear Limit exposure Cover nose and mouth to limit drying Using sunscreen which contains para amino benzoic acid (PABA) or other chemicals capable of blocking ultraviolet radiation (at least 15 Sun Protection Factor) and covering exposed skin will prevent most sunburns. In cold weather, use alcohol-free sunscreen lotion (Sunscreen Prep, NSN ). The use of protective eyewear (Sunglasses, Polarized, NSN ) or goggles that block at least 90% of ultraviolet radiation helps to prevent snow blindness. Not all commercially available sunglasses block enough solar radiation to protect against snow blindness. Chapped lips and skin can be prevented through the use of lip balm (Cold Climate Lipstick, Antichap, NSN ) and limiting exposure of skin to the environment. Skin moisturizing lotion may help the skin retain water. Covering the nose and mouth using a balaclava or scarf will limit the drying of mucous membranes. Sunburn reduces soldier readiness and increases the likelihood of skin cancer.

HIGH ELEVATIONS High Altitude-elevations over 6,000 feet
High Altitude illnesses can kill Stage ascents over time Environmental conditions are more severe at higher elevations Lower oxygen levels (“thin air”) Colder temperatures, high winds, low visibility Ice, snow, rocks, avalanches Remain well hydrated High Altitude: During operations at elevations over 6,000 feet: Personnel must adapt to higher elevations by ascending (climbing upwards) slowly to avoid serious illness or death -- which can occur quickly if suddenly exposed to high altitudes Staged or graded ascent improves personal performance and reduces DNBI while adapting to higher elevations; personnel can maintain acclimatization only by remaining at altitude (acclimatization is lost after returning to lower elevations) Personnel with altitude sickness who continue to ascend are at risk for more serious illness or death, and must get immediate medical treatment and/or move to a lower altitude Prepare for other DNBI threats, including: Environmental conditions, including greater threat of cold weather injury due to wind chill from mountain winds: solar radiation injuries (sunburn, snow blindness) from increased sunlight and reflection from snow and rock surfaces Prepare for other DNBI threats including: Accidents resulting from: reduced physical capability and dehydration; increased effort needed to perform duties; physical and psychological effects of altitude sickness Terrain injuries (falls, avalanches, lightning) Carbon monoxide poisoning from lower oxygen content of air when using of stoves/heaters in poorly ventilated space Be observant of the common symptoms of mountain sickness: headache, nausea, vomiting, dizziness, fatigue, irritability, and coughing. Seek medical attention immediately in you experience any of these symptoms.

SAND, DUST, AND WIND (NUMBER ONE COMPLAINT)
Sand, wind, and dust cause health problems, particularly to skin, eyes, throat and lungs High winds create flying object hazards which may not be visible in blowing sand or dust Wash daily, especially body areas that collect dust and sand Protect lips with lip balm and use moisturizing skin lotion on your hands to prevent cracked, chapped fingers Shield your face with cloth materials to protect from blowing dust and sand Protect your eyes Sand, wind, and dust cause health problems, particularly to skin, eyes, throat and lungs. Take care of problems early to avoid infection. Dry air, dust and wind dry out the nose and throat and can also cause nosebleeds, coughing and wheezing. Cracked, chapped fingers reduce manual dexterity. Body areas (such as ears, armpits, groin, elbows, knees, feet, and the area under breasts) that collect dust and sand are susceptible to chafing, abrasion and infection. High winds can turn tent pegs and loose objects into flying missiles (which may not be visible in blowing sand). Take a daily sponge bath, using an approved water source. Wash your face and eyelids several times per day. Carry at least two pairs of glasses and a copy of your prescription. Do not wear contact lenses; AR prohibits contact lens use in environments where exposure to smoke, toxic chemical vapors, sand, or dust occurs. Breathe through a wet face cloth, or coat the nostrils with a small amount of petroleum jelly to minimize drying of mucous membranes. Protect your lips with lip balm. Shield your face with cloth materials to protect from blowing dust and sand. Wear goggles to protect your eyes from wind, dust and sand or when traveling in open vehicles. Wear gloves and use moisturizing skin lotion to protect your hands.

Sand Storm about to consume a camp.

HEARING CONSERVATION Loud noise causes permanent hearing loss
COUNTERMEASURES Have your hearing protection with you at all times and use it Be sure your ear plugs, noise muffs or helmets fit properly and are in good condition Avoid noise or limit time around noise to only critical tasks Combat Arms Earplug NSN Loud noise from heavy vehicles, construction equipment and tools, weapons, vehicles and aircraft causes permanent hearing loss! Protect your ears. Wear the hearing protection you have been given! Be sure your ear plugs, noise muffs or helmets fit properly and are in good condition! High-intensity noise PERMANENTLY injures the hearing mechanism. Individuals with a noise-induced hearing loss may be unaware of the loss and may not have any communication problems when in quiet listening situations. However, in noisy environments such as combat, hearing becomes significantly more difficult and can adversely impact communication and mission readiness. It is essential that you use properly fitted hearing protection during military operations. Exposure to high-intensity noise may cause hearing loss that can adversely affect your combat effectiveness and individual readiness. Good hearing is essential to mission success. If you are a dismounted soldier, the Combat Arms Earplug (NSN ) will protect you from the impact noise of weapons fire while only slightly interfering with voice communications and detection of combat sounds such as vehicle noise, footfalls in leaves, and the closing of a rifle bolt. While not as effective as the Combat Arms Earplug in preserving your ability to hear important mission-related sounds, noise muffs or standard earplugs are very effective at preventing noise-induced injury. If you are a member of vehicle or helicopter crews, your combat vehicle crew or aircrew helmets have built-in hearing protectors. Authorized wear IAW AR 670-1 If you have to raise your voice to be understood, it is too noisy. Put on hearing protection.

Vision Ready is Mission Ready!
VISION CONSERVATION Preventive Measures and Eye Protection Contact lens use is prohibited for use in environments where exposure to smoke, toxic chemical vapors, sand, or dust occurs If required, maintain 2 pair of glasses and 1 protective mask insert Use eye protection when in any potentially eye hazardous environment Safety goggles or spectacles with side shields* Chemical splash goggles* Personal protective equipment (safety eyewear) is worn by the individual service member. Impact resistant safety eyewear comes in either goggle or spectacle form and should meet the American National Standards Institute Z (ANSI Z87.1) specifications. Face shields are designed to provide secondary protection to both the wearer’s eyes and face. When the half-face respirator Personal Protective Equipment (PPE) is utilized in a chemically hazardous environment, the chemical goggle should be utilized to protect the eyes. Chemical goggles have indirect venting. Chemical goggles meet ANSI Z87.1 impact resistance standards. In a chemical hazard environment, face shields serve as only secondary protectors and should be used only in conjunction with Z87.1 chemical goggles. Face shields are designed to provide secondary protection for the wearer’s face and neck. With regard to biological hazards, according to Title 29 Code of Federal Regulations (CFR) Part (Bloodborne Pathogens Standard), masks in combination with eye protective devices, such as goggles or glasses with solid side shields or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials [OPIM] may be generated and eye, nose, or mouth contamination can be reasonably anticipated. (According to OSHA’s interpretation, glasses utilized solely to protect the eyes from bloodborne pathogens or OPIM are not required to meet ANSI Z87.1 impact standards and may be normal dress glasses prescribed by an eye care provider, but they must have solid side shields. OSHA refers to solid side shields as non-perforated or non-fenestrated shields that can be permanent or add on. Vision Ready is Mission Ready! *(ANSI Z87.1 approved)

MOUTH GUARDS Use This Lose These OR Points to Emphasize Orally
If you play sports, you may need a Mouth Guard (MG) MGs will protect your teeth against fractures and loss from sports injuries Custom-made MGs offer the best protection Protective Benefits of Mouthguards Reduce tooth fractures & dislocations Protect against intraoral soft tissue lacerations & bruises Protect against jaw fractures by absorbing energy from traumatic blows to the chin Prevent upward & backward displacement of mandibular condyle (Johnsen & Winters, Dent Clinics N Amer 35:657-66, 1991) May protect against brain concussions by cushioning shock from a blow to the jaw & preventing transmission of the shock through the TMJ to the skull (Blum & Kranz, J Dent Children 49:22-24, 1982)

FOODBORNE AND WATERBORNE DISEASES
Typhoid Fever Chemicals/Pesticides Heavy Metal Poisoning Diarrhea Cholera Hepatitis A and E COUNTERMEASURES Do not consume any food, ice, water, or beverage (to include bottled water) that have not been approved by the U.S. military Assume all non-approved food, ice, and water is contaminated The diseases of greatest risk during ANY deployment, in both rural and urban areas, are bacterial diarrhea, hepatitis A and typhoid fever, associated with contaminated food, water, and ice. Do not consume any food, water, or beverages (to include bottled water) that have not been approved by the U.S. military. Assume all non-approved food, ice, and water is contaminated. Water and food items available in this region, including dairy products, fish, fruits, and vegetables, may contain unsafe levels of pesticides, chemical fertilizers, bacteria, and viruses. Contamination with human or animal waste is widespread. Even a one-time consumption of these foods or water may cause severe illness. See GTA for appropriate countermeasures. Personnel should only eat food prepared by US military food service personnel; when not available, maximize the use of meals, ready to eat (MREs), T-Rations, or other similarly prepackaged foods. Commanders and unit leaders must be sensitive to Host Nation customs as local hosts may consider refusal to eat their foods an insult. The risk of experiencing a foodborne illness must be weighed against the impact on relationships with Host Nation personnel. Personnel should only consume water that has been treated to US military standards and inspected by PVNTMED personnel. Commanders and unit leaders must ensure that personnel carry their own supply of water purification material (iodine tablets, calcium hypochlorite ampoules, or Chlor-Floc). Bottled water does not guarantee purity; personnel should only drink US-approved and properly bottled water. Even a one-time consumption of these foods or water may cause severe illness

Hanging meat – unknown location
NOT AN APPROVED SOURCE

FOOD CONTAMINATION Metals Industrial chemical runoff
Arsenic Chromium Cadmium Lead Pesticides Insecticides Fertilizers Industrial chemical runoff Hazardous waste dumping Untreated sewage Human waste Animal waste Chemical contamination of food may result from the use of untreated sewage or industrial effluents for fertilization or irrigation of crops, deposition of particulates from industrial activities, uptake of persistent chemicals in soil, pesticide and fertilizer misuse in agricultural production, and improper processing or storage. Vegetables, fruits, and seafood may be contaminated with heavy metals such as cadmium and lead, and produce may be contaminated with organochlorine or organophosphorus pesticides. Short-term exposure to high levels of cadmium may cause acute health effects, including persistent vomiting, nausea, choking, abdominal pains, diarrhea, and headaches, which may be followed by renal failure and cardiopulmonary collapse. Long-term exposure to lower levels of cadmium may cause delayed health effects, including kidney disease, bone pain, adult rickets, osteoporosis, hypertension, and decreased sperm production. Short-term exposure to high levels of lead may cause acute health effects including peripheral nerve damage, kidney damage, anemia, male sterility, and hypertension. Long-term exposure to lower levels of lead may cause delayed health effects including central nervous system damage, particularly in children Short-term exposure to very high levels of organochlorine insecticides may cause acute health effects including central nervous system excitation and seizures, respiratory depression, and gastrointestinal upset, and may be fatal in extreme cases. Long-term exposure to very low levels of organochlorine insecticides presents a minimal risk to human health. Organophosphorus insecticides have very high acute toxicity. Organophosphorus insecticides primarily affect the nervous system, and short-term exposure to very high levels may cause nausea, abdominal pain, difficulty breathing, coma, and death. Long-term exposure to very low levels of organophosphorus insecticides presents a minimal risk to human health.

PERSONAL PROTECTIVE MEASURES
MAXIMUM PROTECTION = Permethrin On Uniform DEET On Exposed Skin Properly Worn Uniform Utilize the DOD Insect Repellent System: Clothing is the first direct line of personal defense against insects and ticks. Proper wearing of the field uniform is essential to minimize skin exposure. Tuck the pant leg into the boot. This forces non-flying pests such as ticks, chiggers, stinging ants, and spiders to climb up the outside of the pant leg. Pests have less access to the skin and are more likely to be seen. Be sure to tuck undershirt into the pants. Sleeves should be worn down. Wear headgear to help protect the head and face. In areas heavily infested with flying pests, a head net can be used over the cap or helmet. Use both skin and clothing repellents. They are safe and effective. Always follow label directions. Use standard military DEET insect repellent on the exposed skin (NSN ). OR Use new SunSet DEET insect repellent and sunscreen on exposed skin (NSN ). OR Camouflage Face Paint (CFP) w/DEET (NSN ) Use standard military permethrin insect clothing repellent on the uniform; either Individual Dynamic Absorption Kit (IDA)(NSN ) or Aerosol Spray (NSN ). Treat uniform with permethrin prior to deploying. The IDA Kit treatment provides protection for 50 launderings (see paragraph 8) . The Aerosol spray treatment lasts through 5-6 launderings, so periodic retreatments will be necessary. Regardless of the treatment method, permethrin leaves no odor in the uniform.” The change in the most recent version of the TG36 regarding persistence of the permethrin treatment is justified on the AFPMB's website at: This "Change Log" states that the change "clarified that the IDA, 2-gallon sprayer, and factory permethrin treatment methods provide protection for 'over 50 launderings' rather than the 'life of the uniform'. The change was made to increase precision of the guidance because the life of a uniform can vary from a few months on deployments to about 2 years under garrison conditions, and the frequency of washing varies from soldier to soldier and with the conditions under which the uniform is used." DOD Insect Repellent System YOU NEED TO KNOW… Dry cleaning removes permethrin from the uniform

INSECT REPELLENTS FOR SKIN AND CLOTHING
DEET lotion Permethrin Individual Dynamic Absorption Kit (IDA) Treatment lasts for for over 50 launderings NSN NSN Apply a thin coat of long-lasting DEET insect repellent lotion (NSN ) to all EXPOSED skin. Avoid eyes, lips, and any damaged skin (sunburn, poison ivy, abrasions). Product contains 33-percent DEET. Because of it’s unique long-lasting formulation, one application lasts from 6-12 hours or more, depending on the climate. Reapply as necessary in accordance with label directions. Product is non-greasy and has low odor. Does NOT affect seal of the protective mask. Does NOT affect the infrared signature of the individual. Does NOT damage field uniform fabrics (cotton, polyester), nylon, wool. If also using sunscreen, apply sunscreen first to allow it to bind to the skin. If possible, allow 30 minutes for complete binding before then applying the DEET. The military formulation, which is made by 3M Corporation, is also sold commercially as Ultrathon® UPDATE NOTE: DO NOT RE-TREAT THE UNIFORM: one treatment is effective in preventing mosquito bites through the fabric for the over 50 launderings. DO NOT TREAT THE UNDERWEAR OR THE CAP. REMEMBER THAT DRY-CLEANING WILL COMPLETELY REMOVE PERMETHRIN. Aerosol spray can Treatment lasts through 5-6 washes NSN Apply a thin coat to EXPOSED skin One application lasts up to 12 hours

OTHER INDIVIDUAL COUNTERMEASURES
Wash and inspect your body for insects/ticks and bites daily Use buddy system to check clothing routinely Launder uniform routinely to remove insects and eggs Order a permethrin-impregnated bed net for use while sleeping Otherwise, treat a bed net before use by spraying the outside of the net with permethrin Tuck edges under cot or sleeping bag Don’t let net touch your skin while you sleep NSN Order and use a permethrin impregnated bed net while sleeping; many insects feed at night. NSN Otherwise, treat a bed net before use by lightly spraying the outside surface of the net with permethrin aerosol prior to setting it up. Permethrin will help prevent insects from being able to gain entry or bite through the net. Once the permethrin-treated bed net has dried, erect net so that there are no openings. Tuck edges of the net under your mattress pad or sleeping bag. Do not allow the net to drape on the ground. Don’t let the net touch your skin while you sleep because insects may bite you through the netting. Wash and inspect your body for insects and their bites daily, or as often as the tactical situation permits. Check your clothing routinely for insects, and use the buddy system to inspect areas of the uniform not easily seen. Launder your uniform routinely to remove insects you may have missed, and their eggs.

TICK REMOVAL PROCEDURES
Use fine-tipped tweezers to grasp mouthparts Grasp mouthparts against skin surface Pull back slowly and steadily with firm tension Avoid squeezing tick Wash wound and apply an antiseptic If a tick is found attached to the body, seek assistance from medical authorities for proper removal, or follow these guidelines: Grasp the tick’s mouthparts against the skin, using pointed tweezers. Pull back slowly and steadily with firm force. Pull in the reverse of the direction in which the mouthparts are inserted, as you would for a splinter. BE PATIENT. The long, central mouthpart is inserted in the skin. It is covered with sharp barbs, sometimes making removal difficult and time consuming. Most ticks secrete a cement-like substance during feeding. This material helps secure their mouthparts firmly in the flesh, adding to the difficulty of removal. It is important to continue to pull steadily until the tick can be eased out of the skin. DO NOT pull back sharply, as this may tear the mouthparts from the body of the tick, leaving them embedded in the skin. If this happens, do not panic. Embedded mouthparts are comparable to having a splinter in your skin. Mouthparts alone cannot transmit disease because the infective body of the tick is no longer attached. However, to prevent the chance of secondary infection, it is best to remove them. Seek medical assistance if necessary. DO NOT squeeze or crush or crush the body of the tick because this may force infective body fluids through the mouthparts and into the wound site. DO NOT apply substances such as petroleum jelly, finger nail polish, finger nail polish remover, repellents, pesticides, or a lighted match to the tick while it is attached. These materials are either ineffective, or worse, might agitate the tick and cause it to force more infective fluid into the wound site. Following removal of the tick, wash the wound (and your hands) with soap and water and apply an antiseptic.

HAZARDOUS ANIMALS COUNTERMEASURES
Rabies: wild dogs, cats, and other animals Hantavirus: infected rodent feces and urine Ticks, fleas, mites: carried by rodents Rodents: contaminate food, damage equipment COUNTERMEASURES Do not feed, handle, or keep wild or stray animals as pets or mascots Do not tolerate the presence of rodents Maintain a high state of sanitation Avoid inhaling dust when cleaning unoccupied areas (avoid dry sweeping) Seek medical attention for animal bites or scratches Never attempt to feed, handle, or keep wild or stray animals as pets or mascots. Bats, raccoons, skunks, foxes, and feral dogs and cats can transmit rabies and cause other DNBI. Avoid contact with domestic (cats, dogs), farm, or wild animals. Discourage their presence by properly disposing of trash and eliminate food consumption and storage in living areas. Rodents should not be tolerated within the unit area. Hantavirus is a disease that may result from the inhalation of dust contaminated by infected rodent feces or urine. Rodent feeding and nesting activities can also contaminate food supplies or damage materials and equipment. DNBI associated with rodents can be avoided by following a number of preventive measures. Maintain a high state of sanitation throughout the unit area and frequently remove trash and eliminate water sources. Exclude rodents from entering unit areas by sealing openings 1/4-inch or greater in exterior walls. Avoid inhaling dust when clearing or cleaning previously unoccupied areas. Mist these areas with water or, preferably, a disinfectant solution of 3-oz liquid bleach per 1-gal water, prior to sweeping or mopping. Promptly remove any dead rodents from the area. Use disposable gloves or plastic bags over the hands when handling dead rodents or other animals. Place all dead animals into a plastic bag prior to disposal. Use the DOD Insect Repellent System to protect yourself from ticks, fleas, and mites which may be carried by rodents. Animals may transmit diseases through biting or scratching. Seek immediate attention if bitten or scratched by any animal.

BACKGROUND PICTURE …Camel Spiders – this picture fools the eye
BACKGROUND PICTURE …Camel Spiders – this picture fools the eye. There are actually two spiders in this picture. One is holding on to the rear of the other making them look twice as big as they really are. The camel spider is really only about 4-5 inches long. The point is, as intriguing as some animals might be … Don’t play with them. All spiders are venomous! FOREGROUND PICTURE – better perspective

VENOMOUS ANIMALS COUNTERMEASURES
Snakes: Pit vipers, cobras, adders, asps, and kraits Bees, wasps, hornets, and ants Spiders, centipedes, and scorpions COUNTERMEASURES Avoid bees, hornets, wasps, ants, and spiders Assume ALL snakes are poisonous Do not attempt to handle or capture any snakes Shake out clothes, shoes, and bedding before use Wear foot protection at all times (no barefoot) Bring proper medication if allergic to bites/stings Highly poisonous pit vipers and cobras can be found in almost every habitat in the CENTCOM region. They are well-camouflaged and when cornered or stepped on, these snakes are remarkable for the speed with which they strike. Their bites are responsible for many deaths throughout the region. Untreated snakebites can cause convulsions, paralysis, hemorrhage and death. If a snakebite occurs, transport the victim immediately to a medical facility; proper treatment of a snakebite can only be provided by a physician. The best preventive measure is to assume that all snakes are poisonous: NEVER attempt to handle or capture any snake. Stings from bees, wasps, hornets, and ants are common. These insects use their stingers to aggressively defend their nests or colonies. Allergic reactions to insect venom in some individuals can be potentially life threatening. Avoid bee, ant, wasp, and hornet nests. Do not use aftershave or cologne in the field since these can attract flying, stinging insects. Individuals that are allergic to insect stings should carry proper medication with them at all times. Spiders, scorpions, and centipedes hide in protected places. Favored sites are under rocks, wooden boards, in old tires, utility boxes, tentage, laundry piles, and debris piles. Their venom affects the nervous system. Antivenin must be administered as soon as possible after the sting/bite occurs. Always watch where you put your hands and feet. Shake out clothes, shoes, and bedding before use and avoid sleeping on the ground. Wear foot protection at all times. Seek the assistance of medical personnel for insect, spider, centipede, and scorpion stings/bites.

HAZARDOUS PLANTS Plant resins cause contact dermatitis
Poisonous roots, stems, leaves, and fruit Weeds and stinging nettles Thorny shrubs and trees TOXIC PLANT RESINS AND DERMATITIS POISONOUS FRUIT Poison Ivy COUNTERMEASURES Be prepared to encounter hazardous plants throughout the region. Plants that can cause injuries come in all sizes, from small weeds to huge trees, including some grasses, shrubs, and vines. 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. Wear foot protection at all times. Contact with the smoke from the burning of these plants can also cause skin rashes and damage to your lungs. In the region, there are some plants with stems, leaves, fruit, roots and/or bark that are toxic to the skin. Contact with plant resins, either from touching these plants, inhaling or touching the smoke from burning plants, or exposure to contaminated animal fur, clothing or equipment can cause allergic dermatitis or respiratory distress. Promptly washing skin with running water (avoid use of soap and alcohol swabs) after exposure may greatly lessen dermatitis. Although barrier creams have been developed to prevent contact dermatitis, the most effective protective measure is to avoid contact with poisonous plants. Clothing is your best protection. Reexposure is risked unless plant resins are washed (hot water and soap) from contaminated clothing or equipment. Some poisonous fruits may resemble common edible fruits. 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. Don’t chew on any part of an unfamiliar plant and never use unfamiliar plants for fuel or cooking materials. Ask medical personnel for assistance in identifying hazardous plants. Lethal Citron Avoid touching unfamiliar plants Use clothing as protective barrier Rinse skin promptly after exposure Wash clothing after contact Never eat any part of unfamiliar plant Thorny Acacia THORNY PLANTS

ENVIRONMENTAL CONSIDERATIONS
Consider environmental aspects of operations What was the area originally used for? Properly manage hazardous material Properly dispose of hazardous and medical waste Prevent oil and fuel spills Clean vehicles at proper locations Respect cultural and historical property Protect natural resources and the terrain Other things to consider: Consider environmental aspects of operations. Properly manage hazardous material. Properly dispose of hazardous and medical waste Prevent oil spills. Clean vehicles at proper locations. Respect cultural and historical property. Protect natural resources and the terrain.

ENVIRONMENTAL CONSIDERATIONS
Hazardous Materials Hazardous Waste Medical Waste Refueling Points Spill Response Wastewater Discharge Decon Sites Latrines Burn pits Laundry and Bath Fuel Storage POL Storage Generators Special Wastes Burial Sites Before establishing your AO or area of operations, you should carefully analyze terrain and your mission to determine the best location to establish your field site (field hospital/medical operations). Consider your mission, analyze terrain and consider where operations such as fuel points, hazardous materials storage, wastewater are best stored, maintained and managed. Review the directives given by your OPORD, FMs and TMs and also look at your local regulations including Installation Spill Contingency Plans (ISCP) if on an installation. Key areas you need to consider when planning are: hazardous materials - where stored and security, hazardous waste – storage, security, & transport, medical waste – storage, security, & transport, refueling points - secondary containment, spills, security, spill response for all areas, wastewater discharges – runoff, decon sites - runoff and disposal, latrines – disposal, burn pits - aerosolized contaminants, laundry and bath – wastewater Fuel storage and security- spill containment and management, POL - used oil storage and management, spill containment and management, security, Generators – security, refueling, noise barriers, Special wastes include: batteries - disposal Flameless ration heaters- storage, security, and disposal burial sites - natural conservation, endangered species, security

ENVIRONMENTAL AIR POLLUTION
Location of Air Pollution Sources Burning or Damaged Buildings Open Burning/Waste Disposal Vehicle/Generator Exhaust Contaminants Dust, Silica, Asbestos, Lead Organic Vapors and Organic Gases Industrial Facilities Air contaminants will vary with each situation. The potential to be exposed to air contaminants should be lessened by simple measures as ensuring that appropriate precautions are taken when entering burning or damaged building (respirators, if necessary); by limiting open burning of waste as a means of disposal, or if necessary, locating troops away from any any open burning that releases toxins. Also, vehicle and generator exhaust venting indoors or too close to air intakes can cause death from carbon monoxide poisoning. During cold weather situations, vehicles must be warmed up outside away from air intakes. Typical contaminants from many of these sources of particulates, asbestos, lead, and organics. In addition, seasonal conditions, such as the use of power plants during the winter months and seasonal dust storms in desert conditions are all contributors to air pollution.

OIL FIELD HAZARDS (OIL BURNING)
Burning Trench See/Feel-Wall of fire and black smoke, low visibility, intense heat, sulfur-oily smell Danger-Toxic smoke, gases, fumes, darkness, intense heat Do This-Avoid burning fields, trenches, facilities, move upwind if possible, avoid intense heat, avoid contact with oil/oil spray, use sand to clean skin and clothing, close up vehicles Burning Storage Tanks See/Feel-Burning pools of oil around well heads and tanks Danger-Sudden expansion of fires, range finders/IR won’t work well Blown Well Head See/Feel-Intense blow torch fire from well heads

OIL FIELD HAZARD (OIL NOT BURNING)
Blown Well Head See/Feel-Violent jet and spray of oil, pools of oil, rotten egg smell Danger-Sudden ignition of oil, oil spray, toxic gases and fumes, projectiles from well head, discharging weapons may ignite oil and gas Do This-Avoid area, avoid oil spray, clean with soapy water, stay away from well heads, don mask and evacuate upwind, use detection equipment if available Intact Well Head See/Feel-Pipes and valves, may be surrounded by sand bags Danger-Undetonated charges which may explode Do This-Avoid the well head

OIL FIELD HAZARD (OIL NOT BURNING)
Ruptured Storage Tanks and Refineries See/Feel-Pools of oil and oily smell Danger-Sudden ignition of oil and fumes Do This-Avoid Oil Filled Trenches See/Feel-Oily smell Danger-Sudden ignition of oil Do This-Proceed cautiously NOTE: Igniting Oil and Gas is EXTREMELY Dangerous. It is a Command decision to ignite oil or gas that is not burning. This should only be done under strict supervision.

TOXIC INDUSTRIAL CHEMICALS/MATERIALS
OCONUS threat exists from accidental or intentional release of TICs/TIMs. CAUTION - There are many uncommon/unknown TIC/TIM sources in an OCONUS setting. Become familiar with individual response technique, such as shelter in place, and any emergency warning systems (if applicable). Make sure other unit members are also aware. Protective measures are chemical specific – rely on trained personnel for recommendations. There is no one size fits all protective measures – this includes MOPP gear. We live in a technological world and the technology is based on the use of chemicals. Many of these are health and medical threats to individuals and the mission, however, some are more threatening than others. The key is that “The dose makes the poison” and minimizing exposure minimizes risk. Simple rules to remember for any soldier – deployed or not are: Never inspect or open unknown chemical containers. Never mix chemicals without knowledge that it is okay to do so – this includes disposal. There is no one size fits all protection against every industrial chemical. Always call in a specialist when in doubt. Not all exposures result in immediate health conditions – if you have been exposed, be aware of your overall feeling of wellness. 2. The Universe of Chemicals information is provided to show a comparison of the amounts/types of chemicals groupings used and a small example of different classification areas [production, regulated, military chemical warfare agents (CWAs), etc.]. Basically, this info states that the classification/use/regulation of TICs/TIMs should always be a consideration/concern to the health of the soldier and mission completion.

TOXIC INDUSTRIAL CHEMICALS / MATERIALS
Example Catastrophic Toxicological or Physical Hazards for Industrial Sites, Balkan States Personnel deployed in support of missions ranging from war to operations other than war may be exposed to harmful chemicals as a result of industrial accidents, sabotage, or the intentional or unintentional actions of enemy or friendly forces. International Task Force - 25 (1996): “..there is a hazard from the release of industrial chemicals in a military situation. Toxic industrial chemicals (TICs) are legitimate articles of commerce, are widely produced and traded, and are available worldwide. It is highly likely that forces will encounter TICs in their military missions throughout the world.” Field Manual 3-4-1: “Toxic industrial material (TIM) hazards, previously considered insignificant during wartime, increase greatly in significance when manufactured, stored, distributed, or transported in close proximity to fixed site operations. Deliberate or inadvertent release significantly increases hazards to the indigenous population and U.S. forces “

OCCUPATIONAL HEALTH PRE-DEPLOYMENT
Current Industrial Hygiene review of operations Engineering controls Supply of required Personal Protective Equipment (PPE) Hazard Communication (HAZCOM) training Personal Protective Equipment training Current medical surveillance Prior to deployment units should insure that all of their operations have been reviewed by the installation or unit’s Industrial hygienist or preventive medicine section to ensure that all potential hazards have been identified and control strategies identified. The reviews should be conducted as the operations will be preformed in the field. The unit should ensure that all hazard controls are in good working order and all damage is repaired. Such as any ventilation system to remove toxic gas are in working order and remove the required amount of air, or welding screen that prevent exposure to welding flash have all parts and don’t have any holes. The unit should have all the required PPE identified in the Industrial Hygiene reviews The PPE is a device that the you wear that act as a protective barrier between the individual and the hazard. The PPE includes hand protection, such as gloves; body protection such as aprons, and coveralls; head protection such as hard hats and hoods; face protection such as face shields; eye protection such as safety glasses, and goggles; and respiratory such as respirators. More then the other methods of control PPE depends on the individuals to use them them correctly, therefore there needs to be a program to back up the use of these PPE devices. The programs need to includes training, selection, care, storage and maintenance guidelines and in some cases medical surveillance to ensure that the personnel can wear them without doing harm to themselves. All unit members should have received a current hazard communication briefing and MSDS sheets for all hazardous chemical are available. All personnel should have received training on the PPE that they are required to use. The training should include as a minimum training on what the PPE is used for how to properly use, maintenance, and storage the equipment. Ensure that all unit personnel have received any required medical surveillance such as audiograms and medical opinions for respirator use (if required)

OCCUPATIONAL HEALTH DEPLOYMENT
Occupational Health Hazards Use your applicable control strategies Elimination or substitution Engineering control Work Practices and administrative controls Personal Protective Equipment Follow the PPE program requirements For the most part you will be exposed to the same occupational health hazards in your deployed location that you faced in your garrison location. However sometimes during your deployment some of your procedures, materials, or environment conditions may change from what you normally encounter in your garrison location. The change in these conditions may result result in additional hazards or exchange of old hazards for different hazards. In most cases these changes were anticipated and control strategies are all ready in place or changes do not change the type of control strategies that are already used. However, if you believe this is a hazard and you don’t have a method of protection available then you should contact your supporting preventive medicine office/unit for an evaluation. In most cases the hazard control strategies that you used in your normal garrison location will work in you deployed location. The control strategies are listed in order of preference listed below. Additionally, in most cases, control strategies will be used in combination. Elimination or substitution is the preferred method it is where you change the operation or the hazardous materials used to remove or eliminate the hazard. For example if you have a lead exposure hazard when spray painting then you can change the paint you use so that they are all lead free paints, or if you have an organic solvent exposure problem when clean parts you change the type of cleaning agents that you use to clean parts by substituting a non-organic solvent. Engineering controls is the second preferred method and is where you design and install a system to control or eliminate the hazard. An example is the use of ventilation to control exposures to dusts, gases, vapors or mist in the air, such as a paint booth or a flexible duct for welding. Work practice or administrative controls are work procedures put in place that when used reduce or eliminate the hazard, an example is when we perform maintenance on vehicle brakes and clutches we wet them down with water, water and soap solution, or solvents to prevent the asbestos dust from becoming airborne. Personnel protective equipment or PPE, is the least preferred method, but the one that is used the most to control the hazards. In some case there is no other way to control the hazard or other control methods do not completely control the hazard, therefore PPE is used in combination with the other methods to help with their effectiveness. Finally, if you use PPE, make sure that you follow all the requirements in your program, such as cleaning, storing and maintaining the equipment, to it ensure that it gives you the required protection.

FIELD FACILITIES CONTROL OF HAZARDOUS EXPOSURES
Garrison facilities include engineering controls to control chemical exposures In the field, additional efforts are needed to provide the same level of control for these occupational exposures Install and use safety countermeasures In garrison shops and motor pools, local exhaust ventilation is provided to control exposures to carbon monoxide and other chemical exposures such as solvents. These controls are just as important in the field but require additional efforts by the soldier to install and use them. In some cases, the control strategies that are used in the garrison site will need to be modified or changed to meet the conditions and resources that are available at the deployment site. Part of the pre-deployment preparations should be developing alternate control strategies and making sure they are available for use. However in some cases preventive medicine will need to de contracted to review the new conditions and recommend alternate control strategies.

OCCUPATIONAL HAZARDS Exhaust from engines and fuel space heaters
Gases from weapons firing Solvents used to clean weapons Chemicals and metals from painting vehicles and equipment Greases and oil from vehicle maintenance repair Detergents used to clean equipment Fuels and refueling operations Weapon systems: radiation energy, shock, vibration, noise Service members should always be aware that material safety data sheets (MSDS) accompany stores of toxic chemicals when units are deployed, and they serve as an immediate reference in cases of exposure or injury. Once a unit is deployed and set up, these MSDS should be kept as part of the unit's SOP when handling the specified chemicals/materials. Carbon monoxide. See CO Slide Bore/gun gases. Use onboard vehicle ventilation systems. Keep bore evacuator well maintained. Try to keep some air movement in gun emplacements or in protected batteries. Solvents, greases, and oils. Use safety Stoddard solvent. Never substitute one solvent for a better one; for example, never use benzene or fuel in place of Stoddard. Wear coveralls, if available, and rubber gloves. Wash or change clothing often, especially when soiled by chemicals or fuel. Always follow label instructions for use and safety precautions. Use ventilation systems in areas where fumes are present or when conditions and materials dictate.

DEPLETED URANIUM (DU) Depleted uranium (DU) is used in armor-piercing munitions and in enhanced tank armor protection DU can cause adverse health effects if it enters your body (inhaled, ingested, fragments). COUNTERMEASURES Receive Depleted Uranium Awareness Training Assume a DU contamination zone of 50 meters around actively burning fires involving any armored combat vehicles As with all battlefield debris-do not touch or move the object Notify authorities of the location of any debris Exercise standard field hygiene, to include washing hands and face No additional protective measures are required for handling unfired DU munitions other than those required for all munitions What is depleted uranium? Depleted uranium is what is left over when most of the highly radioactive types (isotopes) of uranium are removed for use as nuclear fuel or nuclear weapons. The depleted uranium used in armor-piercing munitions and in enhanced armor protection for some Abrams tanks is also used in civilian industry, primarily for stabilizers in airplanes and boats. What makes depleted uranium a potential hazard? Depleted uranium is a heavy metal that is also slightly radioactive. Heavy metals (uranium, lead, tungsten, etc.) have chemical toxicity properties that, in high doses, can cause adverse health effects. Depleted uranium that remains outside the body can not harm you. A common misconception is that radiation is depleted uranium's primary hazard. This is not the case under most battlefield exposure scenarios. Depleted uranium is approximately 40 percent less radioactive than natural uranium. Depleted uranium emits alpha and beta particles, and gamma rays. Alpha particles, the primary radiation type produced by depleted uranium, are blocked by skin, while beta particles are blocked by the boots and battle dress utility uniform (BDUs) typically worn by service members. While gamma rays are a form of highly-penetrating energy , the amount of gamma radiation emitted by depleted uranium is very low. Thus, depleted uranium does not significantly add to the background radiation that we encounter every day. When fired, or after "cooking off" in fires or explosions, the exposed depleted uranium rod poses an extremely low radiological threat as long as it remains outside the body. Taken into the body via metal fragments or dust-like particles, depleted uranium may pose a long-term health hazard to personnel if the amount is large. However, the amount which remains in the body depends on a number of factors, including the amount inhaled or ingested, the particle size and the ability of the particles to dissolve in body fluids.

CAVES Rabies from bat bites Tick-borne – Relapsing Fever
Histoplasmosis from bat guano Confined Space Issues Poor air exchange/ventilation Asphyxiant gasses and/or low oxygen level Ordnance/munitions Other hazardous chemicals and materials stored in the caves Personnel operating in caves in Afghanistan (or other countries) can face health risks from infectious disease or environmental conditions. Rabies exposure from bat bites is the primary risk. Caves in some locations in Afghanistan may have significant bat populations. Bites or any direct contact with bats where a bite cannot be ruled out warrant treatment as a potential rabies exposure. In the absence of a bite, the risk of acquiring rabies in caves is extremely remote. In rare instances, rabies may have been transmitted to humans by the airborne route in caves with very large bat populations (millions of bats). Do not handle dead bats. Never pick up a bat with bare hands since an infectious agent may have caused its death. If a dead bat must be handled, wearing heavy work gloves should minimize the risk of disease transmission because of an accidental scratch from the bat's teeth or by contamination of existing scratches or abrasions on a worker's hands. Histoplasmosis can be contracted by inhalation of fungal spores found in bat guano. Avoid contacting or disturbing bat guano deposits. Histoplasmosis is spread through the air. If soil containing the histoplasmosis fungus is disturbed, the fungus spores get into the air. People can breathe in the spores and get histoplasmosis. The disease is not spread from person to person. Histoplasmosis symptomatic infection usually presents as a flu-like illness with fever, cough, headaches, and myalgias. Some patients fail to recover and develop chronic pulmonary infection or widespread disseminated infection (affecting mucosal surfaces, liver, spleen, adrenal gland and meninges). Vector borne diseases such as tick borne relapsing fever also may be a risk in some locations. Caves and bunkers may harbor ticks that transmit relapsing fever. This disease is potentially present throughout Afghanistan. Relapsing fever is associated with caves, and is known as “Cave Fever”. Caves are also a confined space hazard. Caves may have a dangerous lack of ventilation in deep or confined spaces, particularly in areas where damage has restricted air movement and air exchange. Potentially toxic materials or substances brought into caves, such as fuels, ammunition, or other chemicals could present a greater hazard within confined spaces.

AIRBASE CONTAMINATION
Soil and ground water contamination as a result of poor storage management, accidental releases, and improper waste disposal techniques Kerosene, diesel fuel, gasoline, heating oil, lubricants, organic solvents, PCBs, heavy metals, rocket propellants, and de-icing compounds Volatile organic compounds evaporating from soil and ground water may accumulate in the airspace inside of tents or buildings constructed over contaminated areas Former Soviet Union: Potential Environmental Health Risks at Airbases Soil and ground water at many former Soviet airbases are contaminated with toxic industrial chemicals (TICs) as a result of poor storage management, accidental releases, and improper waste disposal techniques. Personnel exposed to such environmental contaminants at these facilities may experience adverse health effects. Similar contamination has been reported at other former Soviet airbases. Petroleum products such as kerosene, diesel fuel, gasoline, heating oil, and lubricants) from POL storage facilities associated with these airbases typically account for the largest volume of contamination. Other potential contaminants include organic solvents (such as methylene chloride, trichloroethene, toluene, benzene, methyl ethyl ketone, carbon tetrachloride,and tetrachloroethene), polychlorinated biphenyls (PCBs), heavy metals, and de-icing compounds containing ethylene glycol. In addition, airbases that supported Soviet rocket or missile forces may be contaminated with chemicals from solid or liquid propellants. Potential Routes of Exposure Unprotected personnel are most likely to be exposed to soil and ground water contaminants through inhalation (particulates and volatiles) or dermal contact. Personnel engaged in soil excavation or other activities that involve direct contact with soil or ground water are at increased risk of exposure. Volatile organic compounds evaporating from soil and ground water may accumulate in the airspace inside tents or buildings constructed over contaminated areas. Personnel working in contaminated confined, and poorly ventilated areas, such as excavated trenches, may be exposed to high level of volatile organic vapors. If uncontaminated water sources are unavailable, the ingestion of contaminated ground water may be another significant source of exposure.

AIRBASE CONTAMINATION
Personnel exposed to these contaminants may experience adverse health effects COUNTERMEASURES Consult with preventive medicine personnel prior to engaging in soil excavation or other activities that involve direct contact with soil or ground water (example: construction of defensive positions) Do not work or bivouac over contaminated areas or in potentially contaminated buildings Exercise standard field hygiene (wash after contact) Seek medical care if you experience: eye, nose, and throat irritation; headaches, dizziness, weakness, loss of coordination, confusion, blurred vision, or nausea Potential Adverse Health Effects Short-term exposure to high concentrations of petroleum products through inhalation of vapors may cause irritation to the eye, nose, and throat, headaches, dizziness, weakness, restlessness, incoordination, confusion, blurred vision, and nausea. Long-term inhalation exposures may result in vomiting, diarrhea, insomnia, headache, dizziness, and anemia. Direct contact with petroleum products may result in slight to severe skin and eye Irritation. Short-term exposure to high concentration s of volatile organic solvents occurs primarily through inhalation and may cause irritation to the skin,eyes,nose and mucous membranes,dizziness,irritability,confusion,weakness,sleepiness,headache,nausea,and vomiting. Long-term inhalation exposures may result in shallow and rapid respiration, ventricular irregularities, unconsciousness, and death in extreme cases. Many organic solvents, including benzene, trichloroethene, and carbon tetrachloride, are confirmed or suspected human carcinogens. PCBs, heavy metals, and ethylene glycol are potential airbase contaminants but are unlikely to present a significant inhalation hazard. Dermal contact with PCBs or ethylene glycol may irritate the skin and eyes. Ingesting water contaminated with these substances may cause adverse health effects. PCBs are classified as probable human carcinogens.

POST DEPLOYMENT Complete Post-Deployment Medical Health Assessment (DD FORM 2796) Receive post-deployment preventive medicine briefing Receive post-deployment screening, testing, and follow-up Continue malaria chemoprophylaxis for four weeks after departure or as directed Malaria terminal prophylaxis with daily primaquine for 14 days after departure as directed Complete the Post-Deployment Health Assessment (DD FORM 2796) to assess your state of health after deployment and to assist health care providers in identifying and providing present and future medical care to you. Receive post-deployment preventive medicine briefing MALARIA: Continue malaria chemoprophylaxis for 28 days AFTER departure from malaria area. Terminal prophylaxis for areas with relapsing malaria (Plasmodium vivax or avale): IN ADDITION to chloroquine, mefloquine, or doxycyline, begin use of primaquine 15mg/day after final departure from malaria area and CONTINUE daily for 14 days. If you become sick after you return home, tell your physician that you were deployed.

POST DEPLOYMENT Continue to seek counseling from Chaplain or medical personnel Homecoming Stress Don’t expect things to be exactly the same, especially if long deployment Ease back into roles; don’t rush it Children may be withdrawn Spouse may be moody or depressed Financial and property issues may require immediate attention Returning from deployment can be festive and cheerful; however a homecoming can quickly turn into a stressful event for personnel and their families who are not alert to the impact of changes or events that occurred during their separation.

SUMMARY Review of Guide to Staying Healthy Preparation for Deployment
Medical Threat Post Deployment We have reviewed the Guide to Staying Healthy, how to prepare for deployment, the medical threat and countermeasures to those threats, and post deployment actions. Please keep the GTA as a reference throughout your deployment. Remember, you can contact your local Preventive Medicine Unit, Medical Authority, or USACHPPM if you require additional information on medical threats.

CONCLUSION Health threat awareness and implementation of associated countermeasures discussed in the briefing are critical to all military missions (including combat, support, and sustaining base military and civilian forces). Apply this information during all phases of military operations, including training, pre-deployment, deployment, and post-deployment.

U.S. Army Center for Health Promotion and Preventive Medicine
Contact Your Local Preventive Medicine Service or Medical Support Unit for Additional Information Prepared by: U.S. Army Center for Health Promotion and Preventive Medicine (800) / DSN /(410)

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