Abstract

The US military conducts missions that range from major ground combat operations to
disaster and humanitarian relief efforts. A primary goal of military medical
professionals is disease prevention, which can be made more difficult in the context of
short preparation times and prolonged deployment duration. The military uses a 6-
component approach to deployment medicine, emphasizing preparation, education,
personal protective measures, vaccines, chemoprophylaxis, and surveillance in an
attempt to prevent infectious diseases. Many of the components of military deployment
medicine are applicable to civilian disaster relief and humanitarian missions.

Topic:

 antimicrobial chemoprophylaxis
 chemoprevention
 communicable diseases
 military personnel
 vaccines
 surveillance, medical
 military deployment
 prevention

Issue Section:
Travel Medicine

Infections During Military Deployment: Overview

Historically, infectious diseases radically impact military forces and can result in
suspension or cancellation of military operations [1]. During military deployments,
there is a combination of social, physical, psychological, and environmental factors
with sudden exposure to numerous disease agents that can strain the immune
defenses of immunologically naive soldiers. However, manipulation of these and
other factors has successfully altered the ratio of disease-associated to battle-
associated deaths in the US military, from 10 : 1 during the Spanish-American War
to 1 : 1 in World War I, 0.14 : 1 in the Vietnam War, and <0.01 : 1 in the Persian
Gulf War [1].

Despite these successes, nonbattle injuries due to disease still account for the
majority of illnesses encountered by military personnel in modern warfare
campaigns, such as Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF). Although data reflecting the overall use of military medical
treatment facilities during OIF and OEF are not available, the most common
presentation to a military treatment clinic in Iraq was for infectious diseases-related
illnesses [2]. Even traditional battlefield injuries may lead to infectious diseases
complications, such as multidrug-resistant Acinetobacter baumannii-
calcoaceticus complex wound infection [3]. No matter what type of military
operation, infectious diseases are frequently encountered during deployment, but
they are associated with certain risk factors that are potentially modifiable
(tables table 1 and table 2).

Table 1

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Militarily relevant infectious diseases.

Table 1

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Militarily relevant infectious diseases.

Table 2

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Activities to modify risk of infection.

Table 2

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Activities to modify risk of infection.

The most common disabling infection during military deployment is diarrhea. A

recent outbreak included severe gastrointestinal illness due to a Norwalk-like virus
among British soldiers in OEF [4]. However, diarrheal disease that affects
deployed personnel most closely resembles traveler's diarrhea with regard to
presentation, pathogens, and prevention [2, 5,6,7–8]. Diarrheal illnesses can further
greatly impact the provision of health care if providers become ill as well [8].

Despite extensive effort by the military, vectorborne diseases have been observed
during major ground combat operations and operations other than war for centuries
and remain a problem today. Recent examples include dengue fever in Haiti,
malaria during Operation Restore Hope in Somalia and OEF in Afghanistan, and
visceral and cutaneous leishmaniasis in OEF and OIF [9,10,11–12].

Airborne- and droplet-transmitted diseases are common during military

deployments because of the physical and mental strains of deployment, close living
arrangements, and decreased personal hygiene. They include upper respiratory
tract infection, tuberculosis, and meningococcal infection [4,5–6, 13]. Eosinophilic
pneumonia was recently reported among soldiers deployed in OIF, although its
etiology and transmissibility remains unclear [14].

Zoonotic infections are also of military importance. Diseases include hantaviral

infection among US Marines who participated in a joint United States-Republic of
Korea training exercise and Q fever during OIF/OEF [15, 16]. Rabies is also of
concern, because military personnel adopt, as pets, local animals that have not
received routine animal vaccines. Bloodborne diseases could include hepatitis B,
hepatitis C, HIV infection, and infection with hemorrhagic viruses, such as Ebola
or Marburg viruses. Water exposure may transmit infections, including
leptospirosis and schistosomiasis. And finally, militaries continue to encounter
sexually transmitted infections among personnel during deployments.

Although militaries primarily engage in traditional major combat operations, they

are increasingly involved in humanitarian assistance missions. Such missions
permit extensive interaction with the local populace and environment, greatly
increasing the chance of acquiring locally endemic infectious diseases and
necessitating the management of diseases in the local populace that are not
traditionally seen in military personnel. During the US military response to the
earthquake in Pakistan in 2005, a number of local residents required treatment for
tetanus (C.K.M., unpublished data), which has not been a problem among US
military personnel since World War II. In addition, bacterial infections of wounds
obtained on the battlefield are similar to infections of wounds noted during the
early stages of natural disasters, in which resistant bacterial wound infections have
also been recognized [17, 18].

Military and civilian personnel are increasingly being faced with the same
challenges of combating infectious diseases commonly seen in the context of
modern warfare operations and humanitarian relief efforts. In this review, we
discuss a 6-component approach—preparation, education, personal protective
measures, vaccines, chemoprophylaxis, and surveillance—as it relates to the
military's attempt to modify morbidity and mortality from infectious diseases. This
same approach could also be used by civilian responses to disaster relief and
humanitarian missions.

Preparation
The major medical emphasis prior to any military deployment is preparation for
the expected infectious diseases that likely will affect deployed military personnel
[19]. This is dictated by the deployment type, duration, and location, along with the
time available for planning. A number of military Web sites (table 3) are used for
assessing deployment specific infectious diseases risks, although civilian travel
medicine Web sites frequently have comparable information. Military experts in
infectious diseases stay abreast of the pertinent outbreaks of infection and often
rely on civilian counterparts or local personnel for the most current information.

Table 3

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Military Web sites used for assessing deployment-specific infectious disease risks.

Table 3

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Military Web sites used for assessing deployment-specific infectious disease risks.

During major military deployments, standard medical assets, including equipment

and personnel, accompany military units. For example, a US Army battalion will
have one general medical officer (physician), one physician assistant, and ∼40
medics with a standard set of equipment to provide medical support to ∼1000
soldiers. Those requiring more definitive care will be referred to a combat support
hospital with intensive care capabilities and surgical assets. This strategy places
less reliance on the individual person to manage their own health care, as occurs
with traditional travelers, and instead shifts that responsibility to military health
care personnel. Preparation is primarily focused on preventing diarrheal diseases,
respiratory tract diseases and vector borne diseases. However, preparing for major
combat has its own unique requirements, because one has to treat infections in
battlefield casualties, which are actually quite similar to pathogens isolated during
natural disasters [2, 17, 18]. Prevention of wound infection focuses on appropriate
initial antimicrobial therapy, adequate surgical management, tetanus prophylaxis,
and appropriate infection control to prevent nosocomial transmission [20]. This can
prove to be very challenging in austere environments.

During stability and support operations, which are similar to civilian humanitarian
missions and natural disaster relief efforts, infectious diseases endemic to the
country play the greatest role in health care. Military doctors apply traditional
travel medicine recommendations as a backbone to the management of deploying
personnel and as a guide to preparation plans for the deployment. If deployments
are short (i.e., if they last weeks), then the focus is placed on preparing personnel
and supplies to manage acute diseases among deployed personnel and the locals
receiving care. Longer deployments require ensuring that the chronic medical
conditions among military personnel are controlled, and this necessitates different
medications, disease and chronic medical problem surveillance, and larger
quantities and a greater diversity of supplies [4].

Education
Once the pertinent infectious disease information has been determined on the basis
of type, location, and duration of deployment, education is provided to those
deploying and those responsible for their medical care. Military personnel receive a
briefing on the specific risks of the deployment country, typically in large groups.
If deployments include a limited number of people to specific regions, the
information provided is more tailored to the individual. Military preventive
medicine and infectious disease personnel provide recommendations for theater
(combat area)-specific policies (such as malaria chemoprophylaxis) that include
US Food and Drug Administration (FDA)-approved indications for use of disease-
preventing medication. Distribution and implementation of these recommendations
is handled by the theater commander, not medical personnel, under the auspices of
what is termed “force protection” (i.e., protection of all military personnel). As part
of force protection, only FDA-approved indications for medications may be
recommended. However, individual physicians have the latitude to treat individual
patients with any FDA-approved medication, regardless of FDA-approved
indication, if it is deemed medically necessary. Traditionally, commanders adhere
to the recommendations provided by their medical personnel. Even with extensive
education and the military's structure and regulations, adherence with personal
protective measures or chemoprophylaxis can be suboptimal [9].

Soldiers undergo yearly medical, dental, and ophthalmologic screening to ensure

that they are physically fit. They also undergo yearly evaluation of their
vaccinations to ensure they are up to date and prepared for rapid deployments.

Medical personnel deploying with troops are provided information addressing the
medical problems encountered during deployment, including region-specific
infectious diseases [21]. Education pertaining to the care of patients during major
ground combat operations or humanitarian missions is also available to maximize
patient care [4, 22, 23]. Management strategies of military medical personnel are
evaluated to ensure that appropriate medical care is being provided [24]. Finally, in
the theater, physicians have the capability to obtain an infectious diseases
consultation on very short notice with a dedicated, secure e-mail to an on-call
infectious diseases physician.

Personal Protective Measures

The US military places substantial emphasis on preventing disease. Prevention of
diarrheal diseases includes standard education pertaining to avoidance of high risk
exposures similar to recommendations for short-term travelers. When deployments
are of longer durations, standard army regulations are invoked, including hand-
washing stations, sanitation, and food monitoring. Traditional diarrhea rates are
worse during the early stages of conflict or when camps are transitioning with
incoming military personnel [4]. Facilities are not designed for large influxes of
personnel, and new personnel may lack local pathogen immunity. Because of this,
most deployments limit initial entry meals to meals ready to eat (MREs) and
bottled water (or other approved safe water sources). Filth fly control might modify
the risk of transmitting pathogens on food [25]. Despite measures to prevent
diarrhea, military personnel have an inability to avoid high risk exposures similar
to civilian personnel during travel [26].

Avoidance of vector exposure is another goal of personal protective measures.

However, this is not always possible, because of operational tempo and the nature
of the threat. The US military currently uses a 3-component vector personal
protective measure: topical application of 33% extended-duration N,N-diethyl-3-
methylbenzamide (DEET), treatment of field uniforms with permethrin, and proper
wear of field uniforms (pant cuffs tucked into the boots, sleeves worn down, and
undershirt tucked into the pants) [27]. During the first 2 years of OIF/OEF,
numerous personnel developed cutaneous leishmaniasis. Possible issues included
lack of use of DEET, bed netting, or permethrin-impregnated clothes. In addition,
personnel spent substantial time living outside or in living quarters that did not
include windows, screens, or air conditioning. As the war continued, increased
emphasis was placed on removal of leishmania hosts and vector living areas and
construction of infrastructure with adequate housing for military personnel.

Other preventive measures include attempts to interrupt transmission of respiratory

infections through adequate hand hygiene, avoidance of the sharing of drinking or
eating utensils, and the use of appropriate control measures (e.g., isolation) when
dealing with infected individuals. Prevention of tuberculosis exposure includes the
avoidance of high-risk individuals, who are generally non-US military contacts,
avoiding high-risk environments, and screening high-risk patients for the presence
of disease. Chest radiography examination is the primary method used to detect
active disease among this non-US military population. The utility of tuberculin
skin (PPD) testing is limited for non-US military personnel because of the
difficulty in interpreting the results with regard to false-positive and false-negative
results and logistical difficulties in providing latent tuberculosis infection therapy.
All US personnel undergo PPD testing before and after deployment (typically 2–12
weeks after redeployment), with administration of treatment as appropriate.

For cases that involve exposure to water other than drinking water, such as
leptospirosis and schistosomiasis, the most effective means of prevention is
avoidance of exposure to contaminated water. This is nearly impossible during
deployment; however, commanders will order military personnel to avoid
swimming in at-risk bodies of water. In addition, use and implementation of proper
uniforms helps to prevent infectious pathogens that can be transmitted via skin
contact, such as hookworms and lice. Beds bought from the local economy have
been associated with infestations of lice.

Prevention of diseases associated with blood and body fluid exposure pose special
challenges. All medical personnel are currently vaccinated for hepatitis B, and in
the near future, all soldiers will be vaccinated against hepatitis B if they are
deploying to a high-risk area, especially in combat zones. The hepatitis B vaccine
is available for use in deployed medical units. Military personnel are ordered not to
have sexual relationships during most deployments, but enforcement of this
regulation is somewhat difficult. HIV-infected personnel, whose infection status is
confidential, are in the US military but are not deployed to combat areas, because
US military personnel provide local donation of whole blood during severe blood
shortages.

Vaccines
The military routinely administers vaccines to all personnel at the time of entrance
to the military and provides boosters at a yearly evaluation, as necessary. Routine
vaccines include vaccines for measles, mumps, rubella, tetanus, diphtheria,
pertussis, meningococcus, influenza, polio, hepatitis A, typhoid, and varicella.
Deployment-based vaccines include Japanese B encephalitis, yellow fever,
smallpox, and anthrax, which are distributed on the basis of country of deployment
and anticipated deployment activity. Vaccines are provided stateside before
deployment; all vaccines that require boosting or that are only provided at certain
times of the year (i.e., influenza vaccine) are provided in the theater.

Several other notable vaccines are administered for specific indications only.
Hepatitis B vaccine is administered to all health care personnel and will be
provided to all military personnel in the future if they lack evidence of immunity
and are deploying to a high-risk area. Rabies immunization is not routinely given
but may be recommended on a case-by-case basis for deployments with anticipated
high-risk activities. Most large deployments establish sites in the area of
deployment that have available rabies immunoglobulin and vaccine, which can be
delivered to the health care personnel who treat the patient in the event of
exposure. Development of effective malaria and dengue fever vaccines are a high
priority for the military, but none are currently available.

Chemoprophylaxis
Chemoprophylaxis is fundamental for the prevention of certain diseases (notably,
malaria). Malaria chemoprophylaxis recommendations are determined on the basis
of the deployment risks, but the decision to implement the recommendations is
under the control of the military commander. Although substantial experience
exists in the military, there are numerous examples of malaria outbreaks associated
with nonadherence to treatment, inadequate diagnosis, or inappropriate treatment
[9, 11, 28]. The standard regimens are the same as those recommended by the
Centers for Disease Control and Prevention, including mefloquine, chloroquine,
doxycycline, primaquine, and atovaquone-proguanil (Malarone;
GlaxoSmithKline), and many are undergoing development or testing in the military
[29]. Because primaquine has not been approved by the FDA for primary
prophylaxis, it is not recommended as part of US military force protection.
Terminal prophylaxis is instituted on the basis of risks but is prescribed at an FDA-
approved dose of 15 mg base, except when higher concentrations are
recommended by a patient's physician. During the early stages of OIF, doxycycline
treatment was recommended, because the country-specific malaria data that were
available were inadequate. As information became available, chloroquine was
recommended during the second malaria season. No prophylaxis has been
recommended during subsequent malaria seasons; instead, there has been reliance
on disease surveillance. Although malaria has been diagnosed in US personnel in
Iraq, most cases were attributed to acquisition in other regions, such as South
Korea, before deployment to Iraq (C.K.M., unpublished data). This highlights the
fact that frequently deployed personnel have cumulative risks from numerous
countries that need to be considered when evaluating illnesses.

Antimicrobial agents are rarely recommended for prevention of diarrhea during

deployments, except for short, critical missions where food and water precautions
are difficult to maintain. Instead, traditional traveler's diarrhea antimicrobial
therapy is used for the treatment of deployment-associated diarrhea.

The military has long used chemoprophylaxis to prevent or abort outbreaks of

group A streptococcal and meningococcal infection during basic training at certain
basic trainee sites but not during deployments or in other military populations.
More recently, azithromycin has been evaluated for prevention of upper respiratory
tract infections in navy personnel [30]. The role of antibiotics for prophylaxis of
respiratory disease in military populations is controversial but is likely of limited
benefit in deployment settings.

Doxycycline has demonstrated ability to prevent cases of leptospirosis in US

soldiers undergoing jungle warfare training [31]. This is rarely given as a force
protection recommendation. Doxycycline may be the preferred malaria
chemoprophylaxis in regions with a high risk for both malaria and leptospirosis,
because doxycycline is the only antimalarial agent that also has antileptospiral
activity [32].

Given the high risk of HIV exposure in certain regions of the world, consideration
is given to fielding antiretroviral medications and HIV rapid diagnostic kits with
forward-deployed units. This availability allows rapid institution of postexposure
prophylaxis in those persons with high-risk exposures.

Surveillance
Surveillance is fundamental to assessing ongoing risks of infectious diseases
during deployments, but is also instrumental to maintaining the health of military
personnel after redeployment. Similar to reportable diseases in the United States,
the US military has tracking systems for key infectious diseases [33]. During
deployments, there are daily reports to the theater command, detailing select
infectious disease cases. This real-time monitoring allows prompt institution of
appropriate interventions. In addition, specialized teams with expertise in certain
aspects of infectious diseases can be brought to an area to identify possible
exposures risks and management strategies.

For deployments, military personnel undergo pre- and postdeployment medical

evaluation. This evaluation assesses medical problems that developed during
deployment, any medications or vaccinations received as a result of the
deployment, and any significant exposures, such as exposure to dust, fumes,
toxins, infectious substances, or persons. In addition, all personnel receive a PPD
before and after deployment and an HIV screening test before deployment. During
OIF/OEF, there has been a 1%–2% PPD conversion rate (C.K.M., unpublished
data).

The utility of surveillance is exemplified by the military's response to

leishmaniasis. During the initial stages of OIF and OEF, leishmaniasis was
recognized as a possible substantial threat. The US military rapidly developed and
expanded diagnostic and treatment protocols in US military health care facilities.
Sandflies were captured throughout the theater to define high-risk regions. As the
number of cases persisted, diagnostic and treatment protocols were established in
the theater to avoid unnecessary medical evacuation of US personnel for all but the
most serious cases. Personnel were given small cards with pictures of cutaneous
leishmaniasis lesions and sandflies, recommendations of how to avoid sandfly
exposure, and contact information for evaluation of suspicious lesions. In addition,
increased emphasis on personal protective measures and living infrastructure was
implemented. Rates of reported cutaneous leishmaniasis drastically decreased as
these measures were instituted [34].

Conclusions
The approach to prevention of infectious diseases during military deployments has
developed over the years to incorporate 6 components. Through emphasis on
preparation, education, personal protective measures, vaccines, chemoprophylaxis,
and surveillance, the military is trying to prevent infections during deployments.
Interventions parallel many of the general recommendations for travelers while
retaining aspects that are unique to the military. This same approach can be used
by civilians, because there is an increasing global response to humanitarian and
natural disasters that are akin to military deployments.

Acknowledgments
Potential conflicts of interest.L.K.M. and L.L.H.: no conflicts.
references
1
Smallman-Raynor
MR
, 
Cliff
AD
. 
Impact of infectious diseases on war
, 
Infect Dis Clin N Am
, 
2004
, vol. 
18
 (pg. 
341
-
68
)
Google Scholar
Crossref
Search ADS
 
2
Murray
CK
, 
Reynolds
JC
, 
Schroeder
JM
, 
Harrison
MB
, 
Evans
OM
, 
Hospenthal
DR
. 
Spectrum of care provided at an Echelon II medical unit during Operation Iraqi
Freedom
, 
Mil Med
, 
2005
, vol. 
170
 (pg. 
516
-
20
)
Google Scholar
Crossref
Search ADS
PubMed
 
3
Multidrug-resistant Acinetobacter extremity infections in soldiers
, 
Emerg Infect Dis
, 
2005
, vol. 
11
 (pg. 
1218
-
24
)
Crossref
Search ADS
PubMed
 
4
Centers for Disease Control and Prevention
Outbreak of acute gastroenteritis associated with Norwalk-like viruses among
British military personnel—Afghanistan, May 2002
, 
MMWR Morb Mortal Wkly Rep
, 
2002
, vol. 
51
 (pg. 
477
-
9
)
PubMed
 
5
Sanders
JW
, 
Putnam
SD
, 
Frankart
C
, et al. 
Impact of illness and non-combat injury during operations Iraqi Freedom and
Enduring Freedom (Afghanistan)
, 
Am J Trop Med Hyg
, 
2005
, vol. 
73
 (pg. 
713
-
9
)
Google Scholar
PubMed
 
6
Paparello
SF
, 
Garst
P
, 
Bourgeois
AL
, 
Hymans
KC
. 
Diarrheal and respiratory disease aboard the hospital ship, USNS Mercy T-AH 19,
during operation desert shield
, 
Mil Med
, 
1993
, vol. 
158
 (pg. 
392
-
5
)
Google Scholar
PubMed
 
7
Thornton
SC
, 
Sherman
SS
, 
Farkas
T
, 
Zhong
W
, 
Torres
P
, 
Jiang
X
. 
Gastroenteritis in US Marines during Operation Iraqi Freedom
, 
Clin Infect Dis
, 
2005
, vol. 
40
 (pg. 
519
-
25
)
Google Scholar
Crossref
Search ADS
PubMed
 
8
Bailey
MS
, 
Boos
CJ
, 
Vauteir
G
, et al. 
Gastroenteritis outbreak in British troops, Iraq
, 
Emerg Infect Dis
, 
2005
, vol. 
11
 (pg. 
1625
-
8
)
Google Scholar
Crossref
Search ADS
PubMed
 
9
Kotwal
RS
, 
Wenzel
RB
, 
Sterling
RA
, 
Porter
WD
, 
Jordan
NN
, 
Petruccelli
BP
. 
An outbreak of malaria in US Army Rangers returning from Afghanistan
, 
JAMA
, 
2005
, vol. 
293
 (pg. 
212
-
6
)
Google Scholar
Crossref
Search ADS
PubMed
 
10
Weina
PJ
, 
Neafie
RC
, 
Wortmann
G
, 
Polhemus
M
, 
Aronson
NE
. 
Old world leishmaniasis: an emerging infection among deployed US military and
civilian workers
, 
Clin Infect Dis
, 
2004
, vol. 
39
 (pg. 
1674
-
80
)
Google Scholar
Crossref
Search ADS
PubMed
 
11
Smoak
BL
, 
DeFraites
RF
, 
Magill
AJ
, 
Kain
KC
, 
Wellde
BT
. 
Plasmodium vivax infections in U.S. Army troops: failure of primaquine to prevent
relapse in studies from Somalia
, 
Am J Trop Med Hyg
, 
1997
, vol. 
56
 (pg. 
231
-
4
)
Google Scholar
PubMed
 
12
Trofa
AF
, 
DeFraites
RF
, 
Smoak
BL
, et al. 
Dengue fever in US military personnel in Haiti
, 
JAMA
, 
1997
, vol. 
277
 (pg. 
1546
-
8
)
Google Scholar
Crossref
Search ADS
PubMed
 
13
Emmons
EE
, 
Ljaamo
S
. 
Active tuberculosis in a deployed field hospital
, 
Mil Med
, 
1999
, vol. 
164
 (pg. 
289
-
92
)
Google Scholar
PubMed
 
14
Shorr
AF
, 
Scoville
SL
, 
Cersovsky
SB
, et al. 
Acute eosinophilic pneumonia among US military personnel deployed in or near
Iraq
, 
JAMA
, 
2004
, vol. 
292
 (pg. 
2997
-
3005
)
Google Scholar
Crossref
Search ADS
PubMed
 
15
Pon
E
, 
McKee
KT
Jr
, 
Diniega
BM
, 
Merrell
B
, 
Corwin
A
, 
Ksiazek
TG
. 
Outbreak of hemorrhagic fever with renal syndrome among U.S. Marines in Korea
, 
Am J Trop Med Hyg
, 
1990
, vol. 
42
 (pg. 
612
-
9
)
Google Scholar
PubMed
 
16
Anderson
AD
, 
Smoak
B
, 
Shupikng
E
, 
Ockenhouse
C
, 
Petruccelli
B
. 
Q fever and the US military
, 
Emerg Infect Dis
, 
2005
, vol. 
11
 (pg. 
1320
-
2
)
Google Scholar
Crossref
Search ADS
PubMed
 
17
Garzoni
C
, 
Emonet
S
, 
Legout
L
, et al. 
Atypical infections in tsunami survivors
, 
Emerg Infect Dis
, 
2005
, vol. 
11
 (pg. 
1591
-
3
)
Google Scholar
Crossref
Search ADS
PubMed
 
18
Oncul
O
, 
Keskin
O
, 
Acar
HV
, et al. 
Hospital-acquired infections following the 1999 Marmara earthquake
, 
J Hosp Infect
, 
2002
, vol. 
51
 (pg. 
47
-
51
)
Google Scholar
Crossref
Search ADS
PubMed
 
19
Ognibene
AJ
. 
Medical and infectious diseases in the theater of operations
, 
Mil Med
, 
1987
, vol. 
152
 (pg. 
14
-
8
)
Google Scholar
PubMed
 
20
Murray
CK
, 
Hospenthal
DR
, 
Holcomb
JB
. 
Antibiotic use and selection at the point of injury in tactical combat casualty care
for casualties with penetrating abdominal injury, shock, or inability to tolerate oral
agents
, 
J Spec Op Med
, 
2005
, vol. 
3
 (pg. 
56
-
61
)
 
21
Diagnosis and treatment of diseases of tactical importance to US Central
Command
, 
USACHPPM Technical Guide 273, October 2005
 
Available at: http://chppm-
www.apgea.army.mil/news/TG273OCTOBER2005FINAL.pdf. Accessed 14 June
2006
22
Crutcher
JM
, 
Beecham
HJ
, 
Laxer
MA
. 
Short-term medical field missions in developing countries: a practical approach
, 
Mil Med
, 
1995
, vol. 
160
 (pg. 
339
-
43
)
Google Scholar
PubMed
 
23
Taylor
PRP
, 
Emonson
DL
, 
Schlimmer
JE
. 
Operation Shaddock—the Australian Defense Force response to the tsunami
disaster in Papua New Guinea
, 
Med J Aust
, 
1998
, vol. 
169
 (pg. 
602
-
6
)
Google Scholar
PubMed
 
24
Riddle
MS
, 
Tribble
DR
, 
Jobanputra
NK
, et al. 
Knowledge, attitudes, and practices regarding epidemiology and management of
travelers' diarrhea: a survey of front-line providers in Iraq and Afghanistan
, 
Mil Med
, 
2005
, vol. 
170
 (pg. 
492
-
5
)
Google Scholar
Crossref
Search ADS
PubMed
 
25
Cohen
D
, 
Green
M
, 
Block
C
, et al. 
Reduction of transmission of shigellosis by control of houseflies (Musca
domestica)
, 
Lancet
, 
1991
, vol. 
337
 (pg. 
993
-
7
)
Google Scholar
Crossref
Search ADS
PubMed
 
26
Putnam
SD
, 
Sanders
JW
, 
Frenck
RW
, et al. 
Self-reported description of diarrhea among military populations in operations
Iraqi Freedom and Enduring Freedom
, 
J Travel Med
, 
2006
, vol. 
13
 (pg. 
92
-
9
)
Google Scholar
Crossref
Search ADS
PubMed
 
27
Shultz
HA
. 
Department of defense doctrine and material for protecting personnel from biting
arthropods
, 
J Trav Med
, 
2001
, vol. 
8
 (pg. 
133
-
8
)
Google Scholar
Crossref
Search ADS
 
28
Susi
B
, 
Whitman
T
, 
Blazes
DL
, 
Burgess
TH
, 
Martin
GJ
, 
Freilich
D
. 
Rapid diagnostic test for Plasmodium falciparum in 32 Marines medically
evacuated from Liberia with a febrile illness
, 
Ann Intern Med
, 
2005
, vol. 
142
 (pg. 
476
-
7
)
Google Scholar
Crossref
Search ADS
PubMed
 
29
Kitchen
LW
, 
Vaughn
DW
, 
Skillman
DR
. 
Role of US military research programs in the development of US Food and Drug
Administration-approved antimalarial drugs