1. OPERATION IRAQI FREEDOM PREVENTIVE MEDICINE BRIEFING Presenter’s Name
Presenter’s Command
Local Contact Information
Good morning/afternoon. My name is , (JOB TITLE). The purpose of this briefing is to inform you of the medical threats of Operation Iraqi 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)

2. Most losses are the result of disease and non-battle injury.
PURPOSE
To inform personnel deploying to Iraq of:
potential health hazards
individual countermeasures
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.
It is a medical responsibility to identify health threats and recommend appropriate countermeasures.
In wars, battles, and military training, the greatest loss of forces is not caused by combat wounds.
Most losses are the result of disease and non-battle injury.

3. IRAQ
Coalition forces remain in Iraq, helping to restore degraded infrastructure and facilitating the establishment of a freely elected government. The Coalition Provisional Authority transferred sovereignty to the Interim Government on June 2004.
Location: Middle East, bordering the Persian Gulf, between Iran and Kuwait. 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.
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 have ruled the country since then, the latest being 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. The Coalition returned sovereignty to the Iraqi people in June 2004.

4. IRAQ: ENVIRONMENTAL ISSUES
Climate: Desert with mild to cool winters and extremely hot, dry cloudless summers. Severe dust and sandstorms. Northern mountains have cold winters with occasional heavy snows
Terrain: Mostly broad plains; reedy marshes along Iranian border in south with large flooded areas; Zagros mountains along borders with Iran and Turkey
Sea
Level
Meters
5000 +
0-500
Depression
Terrain
Iraq can be divided into five geographic regions:
(1) 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).
(2) 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.
(3) 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.
(4) 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.
(5) 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.
Climate
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.
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.
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.
Dust and sandstorms occur year-round, and are most severe between May and October.
Lowest point:  Persian Gulf 0 m
Highest point: Unnamed peak 3,611 m
Numerous peaks exceed 3,281 meters (10,000 feet)

5. IRAQ: ENVIRONMENTAL ISSUES
Environmental factors posing the greatest health risk:
Water contamination
Localized air pollution
Localized food contamination
Seasonal temperature extremes
Dust and sand storms (especially from May to October)

6. IRAQ: ENVIRONMENTAL ISSUES
Water Contamination
Poorly treated domestic and industrial waste
Fertilizers, pesticides, and waste oils
Sewage and
industrial effluents
Food:
Contamination of food with fecal pathogens may result from use of fertilizers derived from human or animal waste, unsanitary food preparation techniques, and improper handling of prepared food products. Even one-time exposure to fecal contamination of food may cause a variety of acute enteric infections. See the Infectious Disease Risk Assessment for further details.
Chemical contamination of food may result from pesticide and fertilizer misuse in agricultural production, deposition of particulates from industrial activities or traffic exhaust, uptake of persistent chemicals in soil, and improper processing or storage.
Grains may be contaminated with seeds containing pyrrolizidine alkaloids, a natural toxin. For example, in 1994 in Mosul, northern Iraq, consuming wheat products contaminated with toxic pyrrolizidine alkaloids from Senecio vulgaris seeds caused varying levels of liver disease resulting in hospitalizations and deaths.
Short-term exposure to very high levels of pyrrolizidine alkaloids may cause acute gastroenteritis or veno-occlusive disease. Chronic exposure to lower levels may also cause liver disease.
Fish, fruits and vegetables may be contaminated with organochlorine and organophosphate pesticides. In most cases, low-level chemical contamination of food is a concern only for long-term exposures.
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.
Water:
Inadequately treated domestic and industrial liquid and solid waste, deteriorated water treatment and distribution systems, excessive use of fertilizers and pesticides, and improper disposal of waste oils contribute to water contamination in Iraq. Sewage and industrial effluents are commonly discharged untreated into rivers, streams, and the Persian Gulf.
Consumption of water contaminated with raw sewage or runoff containing fecal pathogens may cause a variety of acute enteric infections.

7. IRAQ: ENVIRONMENTAL ISSUES
Air Contamination
Petroleum refineries, petrochemical and fertilizer plants, cement production facilities, power plants, and vehicle exhaust
Food Contamination
Fecal pathogens from waste fertilizers and unsanitary food preparation
Pesticides, insecticides and fertilizers
Seeds containing pyrrolizidine alkaloids on grains
Soil Contamination
Localized to areas surrounding industrial facilities and waste disposal sites
Air
The primary sources of air contamination are petroleum refineries, petrochemical and fertilizer plants, cement production facilities, power plants, and vehicle exhaust. Typical contaminants of concern associated with vehicle exhaust and these industries include lead, particulate matter, oxides of nitrogen, and sulfur dioxide.
Short-term exposure to nitrogen oxides, particulate matter, and sulfur dioxide above established standards presents a risk of transient acute respiratory symptoms such as coughing, wheezing, and reduced lung function, especially in asthmatic individuals.
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.
Soil
Specific information on soil contamination is unavailable for Iraq. In general, soil contamination is localized to specific areas surrounding industrial facilities and waste disposal sites. Even in such areas, significant exposure to contaminants in soil is unlikely in the absence of wind-blown dust, active digging, or migration of contaminants from soil into ground water. As a result, soil contamination usually presents a low risk to human health.

8. SAND, DUST, AND WIND (MOST COMMON 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.

9. 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

10. OIL FIELD HAZARD (OIL NOT BURNING)
Blown Well Head
Avoid area, avoid oil spray, clean
with soapy water, stay away from
well heads, don mask and evacuate
upwind, use detection equipment if available
Ruptured Storage Tanks and Refineries
Avoid area
Intact Well Head
Avoid the well head
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
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.

11. TOXIC INDUSTRIAL CHEMICALS/MATERIALS
Personnel may be exposed to harmful TICs/TIMs as a result of industrial accidents, sabotage, the intentional or unintentional actions of enemy or friendly forces.
CAUTION - There are many uncommon/unknown TIC/TIM sources.
COUNTERMEASURES
Become familiar with individual response technique, such as shelter in place, and any emergency warning systems.
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.
3. 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.”
4. 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 “

12. UNEXPLODED ORDNANCE STOP! Don't Touch DUDS can Maim or KILL!
Do not touch
Can explode at any time
No souvenirs!
STOP!
DUDS
Don't
Touch
can Maim or KILL!
What is a dud? It is an explosive device that a soldier fired, but it failed to explode due to a malfunction. The dud can still explode at any time. Some could explode just by getting close to it.
Never keep duds as souvenirs. Warn others you know not to keep dud souvenirs. If you do know about these, be certain to notify appropriate authorities. They can get the experts to come and identify whether it is hazardous or not. Remember, DO NOT TOUCH!

13. 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.

14. 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.

15. HEAT INJURY PREVENTION
Heat Cramps, Exhaustion, or Stroke
COUNTERMEASURES
Drink fluids continuously (hourly fluid intake should not exceed 1 1/2 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
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 Creatin 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!

16. 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

17. 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! Wear the Combat Arms Earplug with the green side out for gunfire and the yellow side out for steady noise.
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.

18. 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)

19. FOOD-BORNE AND WATER-BORNE DISEASES
Diseases of high risk
Diarrhea (bacterial)
Hepatitis A
Typhoid/Paratyphoid Fever
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.
Food- and water-borne diseases
Diarrhea – bacterial 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 hand washing 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 antibiotic therapy.
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.
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 hand washing 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.
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.
Even a one-time consumption of these foods or water
may cause severe illness

20. VECTOR-BORNE DISEASES
Diseases of high risk (continued)
Vector-borne (high risk as a group)
Crimean-Congo hemorrhagic fever
Leishmaniasis – cutaneous and visceral
Malaria
Plague
Rickettsioses, tick-borne (spotted fever group)
Sand fly fever
West Nile fever
Vector-borne
Crimean-Congo hemorrhagic fever Rare cases could occur among personnel exposed to ticks
Very severe illness typically requiring intensive care with fatality rates from 5-50%
CCHF also can be transmitted in the health care setting through contact with blood or body fluids.
Leishmaniasis – cutaneous A small number of cases (less than 1% per month attack rate) could occur among personnel exposed to sand flies in areas with infected rodents, dogs, or other reservoir animals. In small groups exposed to heavily infected sand flies in focal areas, attack rates can be very high (over 50%).
Cutaneous infection is unlikely to be debilitating; definitive treatment typically requires non-urgent evacuation to CONUS, with extended inpatient treatment.
Leishmaniasis – visceral Rare cases could occur among personnel exposed to sand flies in areas with infected humans, dogs, or other reservoir animals
When symptomatic, VL causes a severe febrile illness which typically requires hospitalization with convalescence over 7 days
Malaria Rare cases could occur among personnel exposed to mosquitoes
Debilitating febrile illness typically requiring 1-7 days of inpatient care, followed by return to duty. Severe falciparum cases may require intensive care or prolonged convalescence, and fatalities can occur.
Malaria risk has decreased since 1997.
Plague Disease is assessed as present, but levels are unknown; an unknown number of cases could occur among personnel exposed to rodents and fleas. Epidemic transmission may occur under conditions of crowding, with heavy rat and flea exposure and respiratory transmission.
Potentially severe illness which may require more than 7 days of hospitalization and convalescence
Rickettsioses, tickborne (spotted fever group) Disease is assessed as present, but levels are unknown; an unknown number of cases could occur among personnel exposed to ticks
Debilitating febrile illness typically requiring 1-7 days of inpatient care followed by return to duty; more prolonged and severe infections may occur with rare fatalities
Sand fly fever Disease is assessed as present, but levels are unknown; an unknown number of cases could occur among personnel exposed to sand flies. In small groups exposed to heavily infected sand fly populations in focal areas, attack rates can be very high (over 50%).
Debilitating febrile illness typically requiring 1-7 days of inpatient care followed by return to duty
West Nile fever Disease is assessed as present, but levels are unknown; an unknown number of cases could occur among personnel exposed to mosquitoes
Debilitating febrile illness typically requiring 1-7 days of inpatient care followed by return to duty; convalescence may be prolonged.
Data are insufficient to assess potential disease rates. However, even under worst-case conditions, rates are likely to be less than 1 percent per month in exposed personnel..

21. LEISHMANIASIS Caused by parasite obtained from sand fly bites
Increased risk from dusk to dawn and July through September
Symptoms
Skin (cutaneous) form - sores on skin or in nose, mouth, and throat
Internal form - fever, substantial weight loss, anemia, swelling of the spleen and liver, and possibly death
Countermeasures Prevent sand fly bites
Use the DOD Insect Repellent System
Sleep under a permethrin treated bed net
Leishmaniasis is caused by a protozoa, Leishmania species, that is obtained through the bite of infected female sand flies.
There are three forms of leishmaniasis: cutaneous or skin leishmaniasis (CL); mucocutaneous leishmaniasis (MCL), which affects the mucous membranes of the nose, mouth, and throat; and visceral leishmaniasis (VL), which affects internal organs. CL produces symptoms within a few weeks to months and includes skin sores on exposed parts of the body, usually the face, arms, and legs. CL can cause serious disability and leave permanent scars. MCL can produce lesion that produce extensive and disfiguring destruction of the mucous membranes of the nose, mouth, and throat. VL, also known as kala azar, is the most severe form and produces symptoms within several months and in rare cases, years. If left untreated, VL has a mortality rate of nearly 100%. Symptoms of VL include irregular bouts of fever, substantial weight loss, anemia, and swelling of the spleen and liver.
Preventive countermeasures include avoidance of sand fly bites by keeping otherwise exposed skin covered, wearing permethrin-treated uniforms, and using insect repellent containing DEET. Sand flies can go through most bed nets, but a bed net treated with permethrin can act as a repellent.
Sources: AFMIC, Chin, J. Control of Communicable Diseases Manual, 17th ed, APHA, and
Sand flies may be hard to see as they are very small - only about one-third the size of typical mosquitoes.

22. MALARIA Caused by parasite found in mosquitoes Increased risk:
April through November
In areas north of Baghdad
Symptoms range from none to fever, chills, sweating, headaches, muscle pains; to cerebral malaria, anemia, kidney failure that can result in death
COUNTERMEASURES:
Anti-malarial drugs (weekly mefloquine or daily doxycycline)
Prevent mosquito bites
Use the DOD Insect Repellent System
Sleep under a permethrin-treated bed net
Primaquine on redeployment
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. Some drug resistance has been seen to mefloquine in areas of Indonesia, the Philippines, and Somalia and to doxycycline in Indonesia. For those soldiers unable to take mefloquine or doxycycline, malarone is available. The information below is current at the time of this report, but should be confirmed with AFMIC prior to deployment. In the chart below, 1˚ means the primary type seen and √ means the type is present but at a lower incidence.

23. VECTOR-BORNE DISEASE COUNTERMEASURES
DOD Insect Repellent System
MAXIMUM
PROTECTION =
Permethrin On
Uniform
DEET On
Exposed
Skin
Properly
Worn
Uniform
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.
a) 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 )
b) 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.” IDA, 2-gallon sprayer, and factory permethrin treatment methods provide protection for 'over 50 launderings.'
Order and use a permethrin impregnated bed net while sleeping; many insects feed at night. NSN
a) 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.
b) 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.
c) Don’t let the net touch your skin while you sleep because insects may bite you through the netting.
d) Wash and inspect your body for insects and their bites daily, or as often as the tactical situation permits.
e) Check your clothing routinely for insects, and use the buddy system to inspect areas of the uniform not easily seen.
f) Launder your uniform routinely to remove insects you may have missed, and their eggs.
Wash and inspect your body for insects/ticks and bites daily
Launder uniform routinely to remove insects and eggs
Order a permethrin-impregnated bed net and use while sleeping

24. SEXUALLY TRANSMITTED DISEASES
Diseases of intermediate risk
Gonorrhea/ Chlamydia
Hepatitis B
HIV/AIDS
COUNTERMEASURE:
Always use condoms during sex – regardless of other measures you choose. Using latex or polyurethane condoms during each sexual encounter provides improved (not 100%) prevention against STD’s and pregnancy.
Sexually Transmitted
Gonorrhea / chlamydia An operationally significant attack rate (potentially 1-50% per month) could occur among personnel having unprotected sexual contact, particularly with commercial sex workers
Typically mild disease treated in outpatient setting; rarely results in significant lost duty time.
Hepatitis B Rare cases could occur among unvaccinated personnel having unprotected sexual contact, particularly with commercial sex workers
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. Chronic infection with liver damage may occur.
HIV/AIDS Rare cases could occur among personnel having unprotected sexual contact, particularly with commercial sex workers
Though initial infection is typically asymptomatic, virtually all infections result in eventual immune deficiency and death.
Abstinence is the only 100% effective method
for preventing sexually transmitted diseases

25. WATER CONTACT, RESPIRATORY & ANIMAL CONTACT DISEASES
Diseases of intermediate risk
Water Contact: Leptospirosis, Schistosomiasis
Avoid contact with standing water
Towel dry vigorously after exposure
Take all medications as directed
Respiratory
Tuberculosis
Use N95 respiratory protection when directed
Pneumonia
Animal-contact: Anthrax, Q-fever, Rabies
Do not feed, handle, or keep wild or stray animals
Do not tolerate the presence of rodents
Seek medical attention for animal bites or scratches
Water-Contact
Leptospirosis 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.
Human infection occurs through direct contact of contaminated water or mud with abraded skin or mucous membranes. Transmission occurs in both rural and urban areas and may be increased during flooding
Schistosomiasis Rare cases could occur among personnel wading or swimming in fecally contaminated bodies of water such as lakes, streams, or irrigated fields.
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.
Respiratory
Tuberculosis 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.
Animal-contact Diseases
Anthrax 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.
Q fever Rare cases could occur among personnel exposed to aerosols from infected animals. 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.
Rabies 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. Very severe illness with near 100% fatality rate in the absence of post-exposure prophylaxis.
Dogs, cats, and bats are principal sources of human exposure.

26. If you don’t smoke, don’t start during deployment.
PNEUMONIA
19 cases of severe pneumonia - 2 deaths
15 smokers
In the more severe cases, troops had
just started smoking on this deployment
COUNTERMEASURES:
Stay hydrated
Wash hands frequently
Use cravat or dust mask to avoid inhaling dust
Use wet mops to clean dust
Seek medical care for fever, chills & cough
A severe pneumonia case was defined as someone who was hospitalized in theater; with a chest x-ray indicative of pneumonia; with a fever, cough, or shortness of breath; and who was intubated or died.
Eosinophilia is
If you don’t smoke, don’t start during deployment.
If you do smoke, quit.

27. FOOD AND WATER-BORNE DISEASES OF INTERMEDIATE RISK
Diseases of intermediate risk (continued)
Food and water-borne
Brucellosis
avoid livestock, local dairy products
Diarrhea – cholera
Diarrhea - protozoal
Hepatitis E
Food-and Water-Borne
Brucellosis 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.
Diarrhea – cholera 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
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.
Diarrhea – protozoal 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.
Hepatitis E Disease is assessed as present, but levels are unknown; an unknown number of cases could occur among personnel consuming local food, water, or ice. Risk is increased for personnel heavily exposed during outbreaks in the local population. 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.
Fecally contaminated drinking water is the most commonly documented source of transmission. Also 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.
NO LOCAL FOOD, WATER, OR ICE!