Transcript Agile Acquisition Corona Fall 2001

International
Medicine
Jim Fike, Col, USAF, MC, FS
Consultant to AF/SG, Director
International Health Specialist Program
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Objectives
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Characterize Important International Diseases and
Disease Prophylaxis
Medical Intelligence Research and Briefings
Infectious Disease Risk Assessment
Operational Examples
What Sources are Available to Support Collecting
Medical Intelligence/Risk?
Format and Content of a Brief
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Water and Food Vulnerability/Safety Assessments
Q&A
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Important International
Diseases and Prophylaxis
Specific diseases of
importance vary from
deployment to deployment
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Base preparations on
information from medical
intelligence preparation
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The three most common
areas of concern are
usually:
Required/recommended
immunizations
Malaria chemoprophylaxis
recommendations
Host nation medical
support/evacuation plans
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Immunization
Recommendations
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Baseline immunizations to maintain readiness status,
reference AFJI 48-110 (Immunizations and
Chemoprophylaxis) at http://www.epublishing.af.mil/shared/media/epubs/AFJI48-110.pdf:
Guidance on exemptions (medical and administrative, to
include religious)
Guidance on DoD personnel requiring immunizations
Specific immunization requirements
Appendix D provides a summary (pp. 32-33)
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Additional immunizations based on deployed
location/risks
Reporting instructions for larger operations
Based on site visit and risk assessment by aerospace
medicine personnel for smaller/unit operations
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Chemoprophylaxis
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AFJI 48-110 also has section on chemoprophylaxis
(Chapter 5):
Anthrax
Influenza A/B
Malaria
Plague
Traveler’s diarrhea
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Group A Step
Leptospirosis
Meningococcal
Scrub typhus
TB
Areas covered in other documents include
Chem warfare chemoprophylaxis
Radiation-related chemoprophylaxis
Medical RX for TB exposure
Prophylaxis involving non-biologic medications
(aspirin, calcium, vitamins)
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Malaria Resources
CDC
malaria website:
http://www.cdc.gov/malar
ia/
Malaria Site:
http://www.malariasite.co
m/index.htm
Malaria Risk World Map:
http://gis.hhs.gov/website
/mrisk9/viewer.htm
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Host Nation Resources
Medical Evacuation Plans
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Large-scale operations have plans established
OEF/OIF, JTF-HOA, JTF-Bravo, etc.
Status of Forces Agreements (SOFA) versus bilateral
Memorandums of Understanding (MOUs)
Classically involve established or on-call AE resources
dedicated to DoD requirements
Smaller and unit operations require plans to be established
Host nation resources need to be identified (reference
upcoming med intel discussions)
Presence/absence of standing MOU/SOFA determined
Potential resources: COCOM/SG, Air Component (CNAF)/SG, Country ODC/DAT office, US Embassy health unit,
CDC, USAID
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Medical Intelligence
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“That category of intelligence resulting from the
collection, evaluation, analysis, and interpretation of
foreign medical, bio-scientific, and environmental
information that is of interest to strategic planning
and to military medical planning and operations.”
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How is medical intelligence used in healthcare
operations?
Medical threat analysis and management
Threat-based concept development
Medical Research
Medical doctrine development
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Don Berwick—one of the world's leading thinkers
on improvement in health care and a friend of
mine—tells a story that illustrates how data on
performance can mislead. He was responsible for
quality assurance in a hospital. The radiology
department had spectacular results. Patients
waited hardly a moment. Everybody was satisfied.
Why did the department do so well? Don wanted
to find out and encourage the department to share
its learning.
"How is it," he asked the director, "that you get
such good results?“
"Simple," she answered, "we make them up."
BMJ 2003;326 (17 May), www.bmj.com
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Purpose of Communicating
Medical Risks to Commanders
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Preventing/reducing DNBI casualties through the
foreknowledge of militarily significant diseases, poisonous and
venomous flora and fauna, and health-threatening
environmental conditions
Increasing successful return to duty of personnel
Improving existing medical support systems and RDT&E of
new medical and human factors engineering systems tailored
to existing and future threats
Improving casualty modeling and projections
Reducing the severity of battle casualties by medical means
through the foreknowledge of enemy weapon capabilities,
employment doctrine, and wounding characteristics
Decreasing the total number of WIA and KIA through medical
means by using threat-based concept development
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What Information is
Important to a Commander?
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Anything that could adversely affect the health of his/her
troops
But……………
Commanders time (and attention spans) are short
You will not be able to educate your commander to the
point that their understanding is as in depth as yours
Prioritize the highest risk information
Present from most important to less important
Re-emphasize key points
Give concrete advice on how the command structure can
support health prevention
Provide examples of consequences of supporting your
recommended courses of action (or not)
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Information to Consider
Discussing with Commanders
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Endemic or epidemic diseases, public health
standards and capabilities, and the quality and
availability of health services
Medical supplies, medical services, medical
treatment facilities, and the number of trained HSS
personnel
Location-specific diseases, strains of bacteria,
insects, harmful vegetation, snakes, fungi, spores,
and other harmful organisms
Foreign animal and plant diseases, especially those
diseases transmissible to humans
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Information to Consider
Discussing with Commanders
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Health problems relating to the use of local food
supplies
Medical effects of and prophylaxis against chemical
and biological agents and radiation
The impact of newly developed foreign weapons
systems as they relate to casualty production
An enemy force related to its state of health and
fitness or its use of special antidotes
Environmental factors in an area of operations such
as altitude, heat, cold, and swamps that in some way
may affect the health of the command or HSS
operations
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Disease Risk Assessment
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Estimate of Operational Impact
What is the risk to US forces from militarily relevant
diseases in a particular country?
Consider using the AFMAN 48-153 (Health Risk
Assessment) as a resource when developing a risk
assessment model prior to, or while, deployed
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Infectious Diseases Assessed for
Country-Specific Risk
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Anthrax
Argentinian hemorrhagic fever (Junin)
Bartonellosis (Oroya fever)
Bolivian hemorrhagic fever (Machupo)
Brucellosis
California group viruses
Chikungunya
Crimean-Congo hemorrhagic fever
Dengue fever
Diarrhea - bacterial
Diarrhea - cholera
Diarrhea - protozoal
Eastern equine encephalitis
Ebola hemorrhagic fever
Gonorrhea / chlamydia
HIV/AIDS
Hantavirus hemorrhagic fever with renal syndrome (HFRS)
Hantavirus pulmonary syndrome
Hepatitis A
Hepatitis B
Hepatitis E
Japanese encephalitis
Kyasanur Forest disease
Lassa fever
Leishmaniasis - cutaneous and mucosal
Leishmaniasis - visceral
Leptospirosis
Lyme disease
Malaria
Marburg hemorrhagic fever
Mayaro
virus
Meningococcal
meningitis
Murray Valley (Australian) encephalitis
Omsk hemorrhagic fever
Onyong-nyong
Oropouche virus
Plague
Q fever
Rabies
Rift Valley fever
Ross River virus
Sand fly fever
Schistosomiasis
Sindbis (Ockelbo) virus
Spotted fever group (tickborne rickettsioses)
St. Louis encephalitis
Tick-borne encephalitis (TBE)
Trypanosomiasis - American (Chagas disease)
Trypanosomiasis - Gambiense (African)
Trypanosomiasis - Rhodesiense (African)
Tuberculosis
Tularemia
Typhoid / paratyphoid fever
Typhus - miteborne (scrub typhus)
Typhus - murine (fleaborne)
Venezuelan equine encephalitis
Venezuelan hemorrhagic fever (Guanarito)
West Nile fever
Yellow fever
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Maximum
expected
rates
Baseline
Level of
Disease
(exposure)
Expected disease
level in troops
AFMIC Analytic
Framework
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Typical
severity
RISK
LEVEL
Typical Disease Severity
Focus on days lost
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Mild
< 72 hrs sick in quarters or limited duty
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Moderate
Care potentially
may be
provided
in theater
1-7 days inpatient care, return to duty
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Severe
>7 days inpatient care or prolonged convalescence
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Very Severe
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ICU required, permanent disability, or fatalities
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Factors Considered in Estimating
Maximum Expected Rates
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Asymptomatic to symptomatic ratio
Efficiency of transmission
Tick versus mosquito
Foodborne or waterborne
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Likelihood of encountering infectious dose
Historical data
Outbreaks
Infection rates
Natural epidemiology of the disease
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What is a show-stopper?
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Total lost man-days is the key factor
Short duration diseases in large numbers
Longer duration diseases in small numbers
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Severity is also important
High level of care required (ICU)
High morbidity or mortality
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What is not a showstopper?
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Diseases that are unlikely to occur in significant
numbers
Minimal exposure (e.g., Ebola)
Very inefficient transmission (e.g., SARS)
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Very mild diseases not causing lost work
Gonorrhea
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Operational Impact
Bacterial diarrhea
Operational
impact
Approaches 100% per
month in worst areas
Usually 1-3 days SIQ
Easy
to treat with antibiotics
Early treatment is
essential, but often
neglected
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Operational Impact
Protozoal diarrhea
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Giardia, Entamoeba, others
Operational impact
1-10% per month in worst areas
Usually 1-3 days SIQ
Often longer lasting and more severe (e.g., giardia)
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Harder to diagnose in the field
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Operational Impact
Typhoid fever
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Operational impact
1-10% per month in worst areas
1-7 days of hospitalization
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Typhoid vaccine has largely eliminated the problem
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Planning/Briefing
Considerations
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Terrain Analysis
 Weather Analysis
 Threat Evaluation (EOB, Weapons Capabilities, etc.)
 Civilian Population and Enemy Prisoners of War
 Flora and Fauna
 Disease Threats
 Availability of Local Resources (e.g., Medical
Facilities)
 NBC/Asymmetrical Threats
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Sources to Help in Risk
Assessment Preparation
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Armed Forces Medical Intelligence Center
http://mic.afmic.detrick.army.mil/index.htm
The Defense Intelligence Agency’s (DIA) central repository
of medically-related intelligence
24-hour service supporting all DoD Agencies (and many
non-DoD entities within the U.S. government seeking
information on medical concerns)
AFMIC Products
Medical Capabilities Studies – Finished intelligence studies
prepared on foreign countries
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Environmental Health Factors
Diseases
Civilian Health Services
Military Health Services
Medical Facilities World Wide
Products by region, COCOM, or subject
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The World Health Organization is the United
Nations specialized agency for health. It was
established on 7 April 1948. WHO's objective, as
set out in its Constitution, is the attainment by all
peoples of the highest possible level of health.
Health is defined in WHO's Constitution as a state
of complete physical, mental and social well-being
and not merely the absence of disease or infirmity.
WHO is governed by 192 Member States through
the World Health Assembly. The Health Assembly is
composed of representatives from WHO's Member
States. The main tasks of the World Health
Assembly are to approve the WHO program and the
budget for the following biennium and to decide
major policy questions.
About WHO
WHO's goal is the
attainment by all
peoples of the
highest possible
level of health
http://www.who.int/en/
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About the CDC
The Centers for Disease Control and Prevention (CDC) is one of the 13 major operating
components of the Department of Health and Human Services (HHS), which is the
principal agency in the United States government for protecting the health and safety
of all Americans and for providing essential human services, especially for those
people who are least able to help themselves.
Since it was founded in 1946 to help control malaria, CDC has remained at the forefront
of public health efforts to prevent and control infectious and chronic diseases, injuries,
workplace hazards, disabilities, and environmental health threats. Today, CDC is
globally recognized for conducting research and investigations and for its action
oriented approach. CDC applies research and findings to improve people’s daily lives
and responds to health emergencies—something that distinguishes CDC from its peer
agencies.
CDC is committed to achieving true improvements in people’s health. To do this, the
agency is defining specific health impact goals to prioritize and focus its work and
investments and measure progress.
•http://www.cdc.gov/travel/
•http://www.cdc.gov/travel/reference.htm
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• World Facts
• Geopolitical Information
• Demographics
• Country-specific info
http://www.cia.gov/index.html
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Sources of Medical
Intelligence
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Virtual Naval Hospital
http://www.vnh.org/
Canadian Healthcare Services
http://www.hc-sc.gc.ca/index_e.html
Department of State
http://travel.state.gov/
Travel Medicine Clinic
http://www.travmed.com/
Additional DoD sources
http://deploymentlink.osd.mil/
https://www.tripprep.com/scripts/main/default.asp
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And don’t forget some of these…
http://www.airforcemedicine.afms.mil/
http://www.armymedicine.army.mil/
http://navymedicine.med.navy.mil/
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Format and Content of the
Commander’s Brief
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Brief – be as short as possible, without missing
pertinent information
Basic overview of the Region (tailored to prior
knowledge of the area)
Geography/Topography
Political situation/Cultural issues
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Overview of Significant Medical Threats
Endemic diseases
Trends
Significant disease threats
Vector control issues
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Format and Content (cont.)
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Environmental Considerations
Weather
Animal and Plant threats
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Food and Water Sources and Considerations
Local and Regional Medical Capabilities
Disaster/Mass Casualty Response Considerations
Medical Evacuation Plan
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Recommendations for Command Support
Defined COAs (Courses of Action)
PROs/CONs
Risks if recommended COA not followed
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Vulnerabilities to food-borne
and waterborne diseases
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Eating on the local
economy
 Improper food
procurement procedures
 Chow-hall problems
 Person-to-person spread
in field conditions
Worldwide, the biggest potential show-stopper
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Water and Food Vulnerability
Safety Assessments
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Again – use AFMS guidance as a primary resource
AFI 48-116 (Food Safety Program)
AFI 48-144 (Safe Drinking Water Surveillance
Program)
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Although guidance sometimes refers to base/US
assets and resources, the basic principles still apply
 USAID’s Field Operating Guide (FOG) is a good
resource, but estimates are based on displaced
personnel/refugee populations
 AFMS Knowledge Exchange (https://kx.afms.mil)
 Bioenvironmental and Public Health communities
also have specific reference materials/guidebooks
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Food Assessments
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Some food sources are already approved (see VETCOM
circular 40-1
AF Form 977 (Food Facility Evaluation) can serve as a
guide/checklist for items to review
Management and Personnel
Food
Equipment, utensils, and linens
Water, plumbing, and waste
Physical facilities
Poisonous or toxic materials
Care must be taken when evaluating dining facilities in other
nations (to not impose 100% of the US standards if unrealistic)
Attachment 1 to AFI-48-116 lists additional websites/resources
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Water Assessments
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MAJCOM BEEs largely responsible for their
MAJCOM water programs
Civil Engineering (CE) is also an integral part; as
they are responsible for the water supply/system (as
opposed to the water safety)
Routine testing requirements are established by the
aerospace medicine/BEE community
Approved bottled water sources can be found at:
http://vets.amedd.army.mil/vetsvcs/approved.nsf
AFI 48-144 outlines principle components of a water
safety program
Attachment 1 of AFI 48-144 contains additional
reference materials
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Unapproved Water Sources
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Preventing food-borne
and waterborne diseases
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Absolute control over food and water
Proper field sanitation and hygiene
Eating on the economy
Informal assessments can be done without creating
an unpleasant situation where host nation is offended
Can be prohibited when necessary
Education of AF personnel to lower the risk
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Fully-cooked meat products
 Fruits and vegetables that can be peeled or washed in a safe
water source
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Drinking on economy not recommended unless
sources are approved (less likely)
Routine vaccines (hepatitis A, typhoid) for deployed
personnel
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QUESTIONS??
Contact Information:
Jim Fike, Col, USAF, MC, FS
Consultant to the AF/SG, Liaison to the ANG
International Health Specialist Program,
[email protected]
(301) 836-8536, DSN 278-8536
Cell (301) 943-0026
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