International Medicine Jim Fike Col USAF MC FS

  • Slides: 39
Download presentation
International Medicine Jim Fike, Col, USAF, MC, FS Consultant to AF/SG, Director International Health

International Medicine Jim Fike, Col, USAF, MC, FS Consultant to AF/SG, Director International Health Specialist Program 1

Objectives Characterize Important International Diseases and Disease Prophylaxis n Medical Intelligence Research and Briefings

Objectives Characterize Important International Diseases and Disease Prophylaxis n Medical Intelligence Research and Briefings n Infectious Disease Risk Assessment Operational Examples What Sources are Available to Support Collecting Medical Intelligence/Risk? Format and Content of a Brief Water and Food Vulnerability/Safety Assessments n Q&A n Cradle of Team Aerospace! 2

Important International Diseases and Prophylaxis Specific diseases of importance vary from deployment to deployment

Important International Diseases and Prophylaxis Specific diseases of importance vary from deployment to deployment n Base preparations on information from medical intelligence preparation The three most common areas of concern are usually: n Required/recommended immunizations Malaria chemoprophylaxis recommendations Host nation medical support/evacuation plans Cradle of Team Aerospace! 3

Immunization Recommendations n Baseline immunizations to maintain readiness status, reference AFJI 48 -110 (Immunizations

Immunization Recommendations n Baseline immunizations to maintain readiness status, reference AFJI 48 -110 (Immunizations and Chemoprophylaxis) at http: //www. epublishing. af. mil/shared/media/epubs/AFJI 48 -110. pdf: Guidance on exemptions (medical and administrative, to include religious) Guidance on Do. D personnel requiring immunizations Specific immunization requirements Appendix D provides a summary (pp. 32 -33) n 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 Cradle of Team Aerospace! 4

Chemoprophylaxis n AFJI 48 -110 also has section on chemoprophylaxis (Chapter 5): Anthrax Influenza

Chemoprophylaxis n AFJI 48 -110 also has section on chemoprophylaxis (Chapter 5): Anthrax Influenza A/B Malaria Plague Traveler’s diarrhea n 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) Cradle of Team Aerospace! 5

Malaria Resources n. CDC malaria website: http: //www. cdc. gov/malar ia/ n. Malaria Site:

Malaria Resources n. CDC malaria website: http: //www. cdc. gov/malar ia/ n. Malaria Site: http: //www. malariasite. co m/index. htm n. Malaria Risk World Map: http: //gis. hhs. gov/website /mrisk 9/viewer. htm Cradle of Team Aerospace! 6

Host Nation Resources Medical Evacuation Plans Large-scale operations have plans established OEF/OIF, JTF-HOA, JTF-Bravo,

Host Nation Resources Medical Evacuation Plans 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 Do. D requirements n 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 n Cradle of Team Aerospace! 7

Medical Intelligence n “That category of intelligence resulting from the collection, evaluation, analysis, and

Medical Intelligence n “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. ” n How is medical intelligence used in healthcare operations? Medical threat analysis and management Threat-based concept development Medical Research Medical doctrine development Cradle of Team Aerospace! 8

n Don Berwick—one of the world's leading thinkers on improvement in health care and

n 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 Cradle of Team Aerospace! 9

Purpose of Communicating Medical Risks to Commanders n n n Preventing/reducing DNBI casualties through

Purpose of Communicating Medical Risks to Commanders n n n 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 Cradle of Team Aerospace! 10

What Information is Important to a Commander? n n n n Anything that could

What Information is Important to a Commander? n n n n 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) Cradle of Team Aerospace! 11

Information to Consider Discussing with Commanders Endemic or epidemic diseases, public health standards and

Information to Consider Discussing with Commanders Endemic or epidemic diseases, public health standards and capabilities, and the quality and availability of health services n Medical supplies, medical services, medical treatment facilities, and the number of trained HSS personnel n Location-specific diseases, strains of bacteria, insects, harmful vegetation, snakes, fungi, spores, and other harmful organisms n Foreign animal and plant diseases, especially those diseases transmissible to humans n Cradle of Team Aerospace! 12

Information to Consider Discussing with Commanders n n n Health problems relating to the

Information to Consider Discussing with Commanders n n n 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 Cradle of Team Aerospace! 13

Disease Risk Assessment Estimate of Operational Impact n What is the risk to US

Disease Risk Assessment Estimate of Operational Impact n What is the risk to US forces from militarily relevant diseases in a particular country? n n Consider using the AFMAN 48 -153 (Health Risk Assessment) as a resource when developing a risk assessment model prior to, or while, deployed Cradle of Team Aerospace! 14

Infectious Diseases Assessed for Country-Specific Risk n n n n n n n n

Infectious Diseases Assessed for Country-Specific Risk n n n n n n n n 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 n. Mayaro virus n. Meningococcal meningitis n. Murray Valley (Australian) encephalitis n. Omsk hemorrhagic fever n. Onyong-nyong n. Oropouche virus n. Plague n. Q fever n. Rabies n. Rift Valley fever n. Ross River virus n. Sand fly fever n. Schistosomiasis n. Sindbis (Ockelbo) virus n. Spotted fever group (tickborne rickettsioses) n. St. Louis encephalitis n. Tick-borne encephalitis (TBE) n. Trypanosomiasis - American (Chagas disease) n. Trypanosomiasis - Gambiense (African) n. Trypanosomiasis - Rhodesiense (African) n. Tuberculosis n. Tularemia n. Typhoid / paratyphoid fever n. Typhus - miteborne (scrub typhus) n. Typhus - murine (fleaborne) n. Venezuelan equine encephalitis n. Venezuelan hemorrhagic fever (Guanarito) n. West Nile fever n. Yellow fever Cradle of Team Aerospace! 15

Maximum expected rates Baseline Level of Disease (exposure) Expected disease level in troops AFMIC

Maximum expected rates Baseline Level of Disease (exposure) Expected disease level in troops AFMIC Analytic Framework Cradle of Team Aerospace! Typical severity RISK LEVEL

Typical Disease Severity Focus on days lost n Mild – n Moderate – n

Typical Disease Severity Focus on days lost n Mild – n Moderate – n 1 -7 days inpatient care, return to duty Severe – n < 72 hrs sick in quarters or limited duty Care potentially may be provided in theater >7 days inpatient care or prolonged convalescence Very Severe – ICU required, permanent disability, or fatalities Cradle of Team Aerospace!

Factors Considered in Estimating Maximum Expected Rates Asymptomatic to symptomatic ratio n Efficiency of

Factors Considered in Estimating Maximum Expected Rates Asymptomatic to symptomatic ratio n Efficiency of transmission n Tick versus mosquito Foodborne or waterborne Likelihood of encountering infectious dose n Historical data n Outbreaks Infection rates Natural epidemiology of the disease Cradle of Team Aerospace! 18

What is a show-stopper? n Total lost man-days is the key factor Short duration

What is a show-stopper? n Total lost man-days is the key factor Short duration diseases in large numbers Longer duration diseases in small numbers n Severity is also important High level of care required (ICU) High morbidity or mortality Cradle of Team Aerospace! 19

What is not a showstopper? n Diseases that are unlikely to occur in significant

What is not a showstopper? n Diseases that are unlikely to occur in significant numbers Minimal exposure (e. g. , Ebola) Very inefficient transmission (e. g. , SARS) n Very mild diseases not causing lost work Gonorrhea Cradle of Team Aerospace! 20

Operational Impact Bacterial diarrhea n. Operational impact Approaches 100% per month in worst areas

Operational Impact Bacterial diarrhea n. Operational impact Approaches 100% per month in worst areas Usually 1 -3 days SIQ n. Easy to treat with antibiotics Early treatment is essential, but often neglected Cradle of Team Aerospace! 21

Operational Impact Protozoal diarrhea Giardia, Entamoeba, others n Operational impact n 1 -10% per

Operational Impact Protozoal diarrhea Giardia, Entamoeba, others n Operational impact n 1 -10% per month in worst areas Usually 1 -3 days SIQ Often longer lasting and more severe (e. g. , giardia) n Harder to diagnose in the field Cradle of Team Aerospace! 22

Operational Impact Typhoid fever n Operational impact 1 -10% per month in worst areas

Operational Impact Typhoid fever n Operational impact 1 -10% per month in worst areas 1 -7 days of hospitalization n Typhoid vaccine has largely eliminated the problem Cradle of Team Aerospace! 23

Planning/Briefing Considerations n n n n Terrain Analysis Weather Analysis Threat Evaluation (EOB, Weapons

Planning/Briefing Considerations n n n n 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 Cradle of Team Aerospace! 24

Sources to Help in Risk Assessment Preparation Armed Forces Medical Intelligence Center http: //mic.

Sources to Help in Risk Assessment Preparation 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 Do. D Agencies (and many non-Do. D entities within the U. S. government seeking information on medical concerns) n AFMIC Products Medical Capabilities Studies – Finished intelligence studies prepared on foreign countries n n n Environmental Health Factors Diseases Civilian Health Services Military Health Services Medical Facilities World Wide Products by region, COCOM, or subject Cradle of Team Aerospace! 25

The World Health Organization is the United Nations specialized agency for health. It was

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/ Cradle of Team Aerospace! 26

About the CDC The Centers for Disease Control and Prevention (CDC) is one of

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/reference. htm Cradle of Team Aerospace! 27

 • World Facts • Geopolitical Information • Demographics • Country-specific info http: //www.

• World Facts • Geopolitical Information • Demographics • Country-specific info http: //www. cia. gov/index. html Cradle of Team Aerospace! 28

Sources of Medical Intelligence n n n Virtual Naval Hospital http: //www. vnh. org/

Sources of Medical Intelligence n n n 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 Do. D sources http: //deploymentlink. osd. mil/ https: //www. tripprep. com/scripts/main/default. asp Cradle of Team Aerospace! 29

And don’t forget some of these… http: //www. airforcemedicine. afms. mil/ http: //www. armymedicine.

And don’t forget some of these… http: //www. airforcemedicine. afms. mil/ http: //www. armymedicine. army. mil/ http: //navymedicine. med. navy. mil/ Cradle of Team Aerospace! 30

Format and Content of the Commander’s Brief – be as short as possible, without

Format and Content of the Commander’s Brief – be as short as possible, without missing pertinent information n Basic overview of the Region (tailored to prior knowledge of the area) n Geography/Topography Political situation/Cultural issues n Overview of Significant Medical Threats Endemic diseases Trends Significant disease threats Vector control issues Cradle of Team Aerospace! 31

Format and Content (cont. ) n Environmental Considerations Weather Animal and Plant threats Food

Format and Content (cont. ) n Environmental Considerations Weather Animal and Plant threats Food and Water Sources and Considerations n Local and Regional Medical Capabilities n Disaster/Mass Casualty Response Considerations Medical Evacuation Plan n Recommendations for Command Support Defined COAs (Courses of Action) PROs/CONs Risks if recommended COA not followed Cradle of Team Aerospace! 32

Vulnerabilities to food-borne and waterborne diseases Eating on the local economy n Improper food

Vulnerabilities to food-borne and waterborne diseases Eating on the local economy n Improper food procurement procedures n Chow-hall problems n Person-to-person spread in field conditions n Worldwide, the biggest potential show-stopper Cradle of Team Aerospace! 33

Water and Food Vulnerability Safety Assessments n Again – use AFMS guidance as a

Water and Food Vulnerability Safety Assessments n Again – use AFMS guidance as a primary resource AFI 48 -116 (Food Safety Program) AFI 48 -144 (Safe Drinking Water Surveillance Program) Although guidance sometimes refers to base/US assets and resources, the basic principles still apply n USAID’s Field Operating Guide (FOG) is a good resource, but estimates are based on displaced personnel/refugee populations n AFMS Knowledge Exchange (https: //kx. afms. mil) n Bioenvironmental and Public Health communities also have specific reference materials/guidebooks n Cradle of Team Aerospace! 34

Food Assessments Some food sources are already approved (see VETCOM circular 40 -1 n

Food Assessments Some food sources are already approved (see VETCOM circular 40 -1 n 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 n Care must be taken when evaluating dining facilities in other nations (to not impose 100% of the US standards if unrealistic) n Attachment 1 to AFI-48 -116 lists additional websites/resources n Cradle of Team Aerospace! 35

Water Assessments n n n MAJCOM BEEs largely responsible for their MAJCOM water programs

Water Assessments n n n 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 Cradle of Team Aerospace! 36

Unapproved Water Sources Cradle of Team Aerospace! 37

Unapproved Water Sources Cradle of Team Aerospace! 37

Preventing food-borne and waterborne diseases Absolute control over food and water n Proper field

Preventing food-borne and waterborne diseases Absolute control over food and water n Proper field sanitation and hygiene n Eating on the economy n 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 Fully-cooked meat products n Fruits and vegetables that can be peeled or washed in a safe water source n Drinking on economy not recommended unless sources are approved (less likely) n Routine vaccines (hepatitis A, typhoid) for deployed personnel n Cradle of Team Aerospace! 38

QUESTIONS? ? Contact Information: Jim Fike, Col, USAF, MC, FS Consultant to the AF/SG,

QUESTIONS? ? Contact Information: Jim Fike, Col, USAF, MC, FS Consultant to the AF/SG, Liaison to the ANG International Health Specialist Program, jim. fike@ang. af. mil (301) 836 -8536, DSN 278 -8536 Cell (301) 943 -0026 Cradle of Team Aerospace! 39