Plasmodium vivax malaria reemerged in the Republic of Korea in 1993 after it had been declared malaria free in 1979. Malaria rapidly increased and peaked in 2000 with 4,142 cases with lower but variable numbers of cases reported through 2011. We examined the association of regional climate trends over the Korean Peninsula relative to malaria cases in U.S. military and Republic of Korea soldiers, veterans, and civilians from 1950 to 2011. Temperatures and anomaly trends in air temperature associated with satellite remotely sensed outgoing long-wave radiation were used to observe temporal changes. These changes, particularly increasing air temperatures, in combination with moderate rains throughout the malaria season, and distribution of malaria vectors, likely supported the 1993 reemergence and peaks in malaria incidence that occurred through 2011 by accelerating the rate of parasite development in mosquitoes and increased numbers as a result of an expansion of larval habitat, thereby increasing the vectorial capacity of Anopheles vectors. High malaria rates associated with a favorable climate were similarly observed during the Korean War. These findings support the need for increased investigations into malaria predictive models using climate-related variables.
Vaccination against human papillomavirus (HPV) is recommended to prevent cervical cancer among women. Vaccinating men against human papillomavirus (HPV) can prevent penile, anal, and oral cancers, anogenital warts, and the transmission of HPV to their sexual partners. This study characterized HPV acquisition among male military members by evaluating both seroprevalence at entry into service and seroincidence of HPV infection after ten years of service. At entry, 29 of 200 (14.5%) male service members were positive for HPV serotypes 6, 11, 16, or 18. Of 199 initially seronegative for at least one of the four HPV serotypes, 68 (34.2%) seroconverted to one or more serotypes at ten years; more than one-third of these were seropositive for oncogenic HPV serotypes. This estimate of HPV seroprevalence among male military accessions is higher than that reported among U.S. civilian males. Vaccination to prevent genital warts and cancers resulting from HPV infection may decrease health care system burdens. Further analyses are warranted to understand the potential costs and benefits of a policy to vaccinate male service members.
Human papillomavirus (HPV) is the most common sexually transmitted infection among U.S. military members. The most frequent clinical manifestation of HPV is genital warts (GW). This investigation examined the annual incidence of diagnoses of GW among U.S. service members before and after the availability of the quadrivalent HPV (HPV4) vaccine in 2006. Incidence rates of GW diagnoses markedly declined among female service members in the HPV4 vaccine-eligible age range from 2007 (following introduction of the HPV4 vaccine) through 2010. In contrast, among women 25 years and older and men of all age groups, annual rates of GW diagnoses remained relatively low and stable from 2000 through 2010. The higher rates of diagnoses of GWs among female than male service members reflect the effects of routine periodic gynecologic screening. Slight increases in the incidence of GW diagnoses among men between 2010 and 2012 may in part reflect the repeal of the U.S. militarys "Dont Ask Dont Tell" policy.
In May 2010, a Symposium and Workshop entitled "Assessing Potentially Hazardous Environmental Exposures among Military Populations" was held in Bethesda, MD. Participants were particularly interested in environmental exposures that are challenging to identify and characterize and that may be associated with a delayed health impact. Speakers and discussion groups reviewed past exposures and the ability of the U.S. military to: predict, identify, quantify, and prevent or mitigate potentially harmful exposures; identify, assess, and follow up military members potentially exposed; accurately determine risks of disease or injury and actual health outcomes; and expeditiously and effectively communicate to military and other leaders needed interventions, individual risks and data to support or refute associations between exposures and health outcomes. Improvements in military capabilities and shortcomings were evaluated using reports on strategies to protect the health of deployed U.S. Forces that were published by the Institute of Medicine and National Research Council in 1999-2000. Significant improvements have occurred, but many shortcomings need attention.
Vector-borne infections (VBI) are defined as infectious diseases transmitted by the bite or mechanical transfer of arthropod vectors. They constitute a significant proportion of the global infectious disease burden. United States (U.S.) Department of Defense (DoD) personnel are especially vulnerable to VBIs due to occupational contact with arthropod vectors, immunological naiveté to previously unencountered pathogens, and limited diagnostic and treatment options available in the austere and unstable environments sometimes associated with military operations. In addition to the risk uniquely encountered by military populations, other factors have driven the worldwide emergence of VBIs. Unprecedented levels of global travel, tourism and trade, and blurred lines of demarcation between zoonotic VBI reservoirs and human populations increase vector exposure. Urban growth in previously undeveloped regions and perturbations in global weather patterns also contribute to the rise of VBIs. The Armed Forces Health Surveillance Center-Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) and its partners at DoD overseas laboratories form a network to better characterize the nature, emergence and growth of VBIs globally. In 2009 the network tested 19,730 specimens from 25 sites for Plasmodium species and malaria drug resistance phenotypes and nearly another 10,000 samples to determine the etiologies of non-Plasmodium species VBIs from regions spanning from Oceania to Africa, South America, and northeast, south and Southeast Asia. This review describes recent VBI-related epidemiological studies conducted by AFHSC-GEIS partner laboratories within the OCONUS DoD laboratory network emphasizing their impact on human populations.
The Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System Operations (AFHSC-GEIS) initiated a coordinated, multidisciplinary program to link data sets and information derived from eco-climatic remote sensing activities, ecologic niche modeling, arthropod vector, animal disease-host/reservoir, and human disease surveillance for febrile illnesses, into a predictive surveillance program that generates advisories and alerts on emerging infectious disease outbreaks. The programs ultimate goal is pro-active public health practice through pre-event preparedness, prevention and control, and response decision-making and prioritization. This multidisciplinary program is rooted in over 10 years experience in predictive surveillance for Rift Valley fever outbreaks in Eastern Africa. The AFHSC-GEIS Rift Valley fever project is based on the identification and use of disease-emergence critical detection points as reliable signals for increased outbreak risk. The AFHSC-GEIS predictive surveillance program has formalized the Rift Valley fever project into a structured template for extending predictive surveillance capability to other Department of Defense (DoD)-priority vector- and water-borne, and zoonotic diseases and geographic areas. These include leishmaniasis, malaria, and Crimea-Congo and other viral hemorrhagic fevers in Central Asia and Africa, dengue fever in Asia and the Americas, Japanese encephalitis (JE) and chikungunya fever in Asia, and rickettsial and other tick-borne infections in the U.S., Africa and Asia.
Capacity-building initiatives related to public health are defined as developing laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. These initiatives represented a major piece of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) contributions to worldwide emerging infectious disease (EID) surveillance and response. Capacity-building initiatives were undertaken with over 80 local and regional Ministries of Health, Agriculture and Defense, as well as other government entities and institutions worldwide. The efforts supported at least 52 national influenza centers and other country-specific influenza, regional and U.S.-based EID reference laboratories (44 civilian, eight military) in 46 countries worldwide. Equally important, reference testing, laboratory infrastructure and equipment support was provided to over 500 field sites in 74 countries worldwide from October 2008 to September 2009. These activities allowed countries to better meet the milestones of implementation of the 2005 International Health Regulations and complemented many initiatives undertaken by other U.S. government agencies, such as the U.S. Department of Health and Human Services, the U.S. Agency for International Development and the U.S. Department of State.
Respiratory illnesses can cause substantial morbidity during military deployments. Bordetella pertussis, Chlamydia pneumoniae, Mycoplasma pneumoniae, adenovirus, parainfluenza, and respiratory syncytial virus (RSV) are hypothesized causes.
Hepatitis E virus (HEV) has been recognized as a threat to military forces since its discovery. Although HEV seroprevalence in Afghanistan is not known, HEV infection is thought to be highly endemic in that country. This study determined the incidence of HEV seroconversion among United States (US) service members who were deployed to Afghanistan, as well as the prevalence of antibodies to HEV prior to the deployment.
In mid-May 2007, a respiratory disease outbreak associated with adenovirus, serotype B14 (Ad14), was recognized at a large military basic training facility in Texas. The affected population was highly mobile; after the 6-week basic training course, trainees immediately dispersed to advanced training sites worldwide. Accordingly, enhanced surveillance and control efforts were instituted at sites receiving the most trainees. Specimens from patients with pneumonia or febrile respiratory illness were tested for respiratory pathogens by using cultures and reverse transcription-PCR. During May through October 2007, a total of 959 specimens were collected from 21 sites; 43.1% were adenovirus positive; the Ad14 serotype accounted for 95.3% of adenovirus isolates. Ad14 was identified at 8 sites in California, Florida, Mississippi, Texas, and South Korea. Ad14 spread readily to secondary sites after the initial outbreak. Military and civilian planners must consider how best to control the spread of infectious respiratory diseases in highly mobile populations traveling between diverse geographic locations.
The United States Department of Defense Global Emerging Infections Surveillance and Response System (DoD-GEIS) conducted a review in 2008 of projects funded by DoD-GEIS at five partner overseas laboratories from 1999 through 2007. During this period, the annual overseas programming budget grew from US$1.038 million to US$21 million. The review describes the distribution of project priorities and geographic locations over the years, the types of outcomes the projects generated, and the frequency with which they involved collaboration with other public health agencies and organizations, including CDC and WHO. Areas for further program strengthening are identified.
Malaria was eradicated and the Republic of Korea (ROK) declared "malaria free" in 1979. However, in 1993, a temperate strain of vivax malaria, expressing both latent and nonlatent disease populations, re-emerged near the demilitarized zone (DMZ), rapidly spread to civilian sectors near the DMZ, and increased exponentially in ROK military, veteran, and civilian populations through 1998. Malaria among all ROK populations decreased 5-fold from a high of 4142 cases in 2000 to a low of 826 cases in 2004, before increasing again to 2180 cases by 2007. Each malaria case in the ROK is reported in the metropolitan area/province where the diagnosis is made, which may be at some distance from the area where infection occurred. Therefore, it is difficult to ascertain transmission sites since approximately 60% of vivax malaria in Korea is latent with symptoms occurring >1 month to 24 months after infection. A review of case diagnosis for civilian, veteran, and military populations shows that nearly all malaria south of Gyeonggi and Gangwon Provinces is the result of veterans exposed in malaria high-risk areas along the DMZ and returning to their hometowns where they later develop malaria. Thus, malaria currently remains localized near the DMZ with limited transmission in provinces south of Seoul and has not spread throughout Korea as previously hypothesized. This report describes the reemergence of vivax malaria cases in civilian and military ROK populations and U.S. military personnel and assesses variables related to its transmission and geographic distribution.
The Pandemic Influenza Policy Model (PIPM) is a collaborative computer modeling effort between the U.S. Department of Defense (DoD) and the Johns Hopkins University Applied Physics Laboratory. Many helpful computer simulations exist for examining the propagation of pandemic influenza in civilian populations. We believe the mission-oriented nature and structured social composition of military installations may result in pandemic influenza intervention strategies that differ from those recommended for civilian populations. Intervention strategies may differ between military bases because of differences in mission, location, or composition of the population at risk. The PIPM is a web-accessible, user-configurable, installation-specific disease model allowing military planners to evaluate various intervention strategies. Innovations in the PIPM include expanding on the mathematics of prior stochastic models, using military-specific social network epidemiology, utilization of DoD personnel databases to more accurately characterize the population at risk, and the incorporation of possible interventions, e.g., pneumococcal vaccine, not examined in previous models.
Malaria is a significant health threat to U.S. combat forces that are deployed to malaria-endemic regions. From 1979, when the Republic of Korea (ROK) was declared malaria free, malaria did not present a health threat to U.S. forces deployed to Korea until the early 1990s. In 1993, a temperate strain of vivax malaria expressing both latent (long prepatent incubation periods of usually 6-18 months after infection) and nonlatent (short prepatent incubation periods < 30 days after infection) disease reemerged near the demilitarized zone (DMZ) and once again presented a primary health threat to U.S. military populations in the ROK. Following its reemergence, malaria rates increased dramatically through 1998 and accounted for > 44% of all malaria cases among U.S. Army soldiers from 1997 to 2002. More than 60% of all Korean-acquired malaria among U.S. soldiers was identified as latent malaria. Nearly 80% of all latent malaria attributed to exposure in Korea was diagnosed in the U.S. or other countries where soldiers were deployed. These data illustrate the requirement for a comprehensive malaria education program, especially for those soldiers residing or training in malaria high-risk areas, to inform soldiers and providers of the risk of developing malaria after leaving Korea.
The Department of Defense (DoD) Global Laboratory-Based Influenza Surveillance Program was initiated in 1997 to formally consolidate and expand existing influenza surveillance programs within the DoD and in areas where DoD was working. Substantial changes in 2008 provided an opportunity to review the operation of the surveillance program as it existed during seven complete influenza seasons (1998-2005); the review was conducted in 2008. A unique aspect of the DoD program was the global reach for specimen collection and the ability to rapidly ship, process, and evaluate specimens from 27 countries. The resulting epidemiologic data combined with the culture results from >46,000 patients provided information that was shared with similar national and international programs, such as those of the CDC. Likewise, selected influenza isolates were molecularly characterized and shared with the CDC to be compared with other surveillance programs. Timeliness of the samples contributed to the information available for annual influenza vaccine selection.
Since 1997, the absence of a global, DoD public health laboratory system has been identified as a vulnerability in the U.S. militarys effort to identify and quickly respond to emerging infections. The AFHSC Division of GEIS Operations has attempted to mitigate this vulnerability by supporting initiatives such as the DoD Global Influenza Surveillance Program and the DoD Directory of Public Health Laboratory Services. AFHSC continues to be engaged in identifying and addressing diagnostics needed to protect deployed forces. The GASI and the enhanced capability for identification of MDROs and threatening influenza strains in deployed areas are recent examples of GEIS utilizing its financial resources and position as a DoD organization to coordinate the efforts of the military services and other U.S. government organizations to improve preparedness for EID agents. However, the absence of a defined, comprehensive public health system that contains surveillance systems, reference laboratories, and public health communication systems functioning in unison to provide reach back and reference laboratory support to the global MHS remains a significant gap.
Adenoviruses are frequent causes of respiratory disease in the US military population. A successful immunization program against adenovirus types 4 and 7 was terminated in 1999. Review of records in the Mortality Surveillance Division, Armed Forces Medical Examiner System, identified 8 deaths attributed to adenovirus infections in service members during 1999-2010.
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