Military history is filled with accounts of

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1 Stephen B. Berté Military history is filled with accounts of the devastating effects that arthropodborne disease can have on military campaigns. Although many people believe the primary cause of death and hospitalization of soldiers in a conflict is the result of hostile action, disease and non-battle injuries account for the greatest loss of personnel from military units engaged with an enemy, and much of the disease is transmitted by arthropods. Improvements in field sanitation techniques have decreased illness among deployed forces resulting from improper handling of food, water, and human waste. Arthropod-borne disease, however, is still a very real threat to our army. To deal with this threat, the U.S. Army has a corps of medical entomology officers on its preventive medicine team who deploy with the army. Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) are no exception. In this article, I give a brief summary of some of the activities in which army medical entomologists are involved as they support deployed U.S. Forces; and I focus on operations in Southwest Asia. Medical Entomology in the Military Before I discuss some of the details of entomology operational support, it is important that you know something of the nature of the entomology mission in the U.S. Army. Medical Entomologists are commissioned officers in the Army Medical Service Corps. Their overall mission is to prevent arthropod-borne disease among the soldiers and civilians who support military operations. Army entomologists plan and direct comprehensive programs to control pests and animals that affect human health and the environment. They routinely conduct surveys to determine prevalence, distribution, relative abundance, and significant habits of medically important insects and other animals, and to identify insects and other zoological specimens. Some entomologists develop and monitor insect and rodent control programs and determine the effectiveness of pest management plans and operations. Others direct pesticide monitoring service, which includes determining use levels, environmental contamination potential, as well as the movement and proper storage and disposal of pesticides. Integrated Pest Management (IPM) is emphasized at all levels of army entomology. The army also conducts medical entomology research to support the above activities through the laboratories of its Medical Research and Materiel Command. Entomologists in research assignments study such topics as the transmission of arthropod-borne disease, vector physiology, detection of pathogens in arthropods, evaluation and development of new repellents, and taxonomy of medically important arthropods. Entomologists serve in deployable entomology units and on military staffs. They prepare regulations, directives, standards, and other criteria pertaining to military medical entomology programs. Other entomologists instruct army and other Department of Defense (DoD) personnel worldwide in all aspects of medical entomology, personal protection measures, and pest management practices. At the more senior levels, entomologists serve as consultants in a staff capacity in laboratories, preventive medicine activities, Army major commands, or at the Department of Army or DoD levels. Clearly, army entomology provides a variety of challenging positions that develop officers entomology, management, leadership, and military skills. Although I focus on U.S. Army entomologists, the U.S. Navy and U.S. Air Force also have medical entomology officers who support DoD forces worldwide. In fact, entomological support may be handed off from one military service to another as troops rotate in and out of a theater of operations. Army entomologists work closely with their peers in the navy and air force and serve together on the Armed Forces Pest Management Board (AFPMB). The AFPMB comprises Army, Navy, and Air Force entomologists who provide guidance and informational resources to all DoD entomologists. Technical guides, as well as more information about DoD entomology policy and procedures, are available at 208 American Entomologist Winter 2005

2 the AFPMB web site at The AFPMB plays a key role in military entomology by providing policy and guidance on the safe and effective use of pesticides in support of military operations. It is DoD policy that the more stringent of host nation or EPA label instructions about pesticide use be followed for all DoD pest management operations. Although the DoD supply system contains a variety of pesticides, from readyto-use products for use by tactical units to conduct minor pest control operations to ultra-low volume (ULV) concentrates for use by specially trained entomological teams, pesticides must sometimes be purchased on the local economy. DoD has an approval process that includes review by a senior deployed entomologist and command surgeon, as well as by the AFPMB. Products purchased for use by U.S. forces must come with bilingual labels or have translations of labels provided with the products to ensure their proper use. The APFMB has also developed an EPA-approved pesticide applicator certification training program for military and civilian DoD personnel. Whenever some preventive medicine technicians deploy to a theater of operations before they are able to renew their certifications, army entomologists conduct DoD certification training on location. Education and Training An ongoing thread in the mission of military entomologists is education. Most of the soldiers and civilians don t fully understand the disease threat posed by arthropod vectors, and many are misinformed about the threats in their area. Most military units do not consider preventive medicine when preparing for deployment they are focused on training for the tasks that will help them accomplish their mission. As a result, obtaining supplies such as DEET, uniform-treatment kits, and insect repellent is not a top priority. Entomologists therefore find themselves giving classes during deployments on uniform treatment and the local arthropod threats to military units and civilian personnel. Because of the threat of leishmaniasis in Southwest Asia, surveillance and pest control efforts are focused on sand flies and on eliminating potential reservoirs, such as rodents and dogs. The latter animals are particularly challenging to control because many soldiers adopt stray dogs as pets. Preventive medicine personnel must reeducate units and their leadership whenever units rotate into the country to make sure they understand the danger posed by keeping stray and feral dog reservoirs close to the troops. An important training function is the conduct of DoD pesticide applicator certification training to contract pest control personnel. Although contract personnel were professionally trained and possessed state certifications for pesticide application, many did not have DoD certification. Army entomologists therefore conduct threeday pesticide certification courses at multiple locations. Army entomologists are often called upon to assist when contract pest control programs run into difficulty achieving success. A review of the contract statement of work sometimes shows that it is poorly written and unrealistic. For example, the contract may not clearly delineate the responsibilities of contractor s vector control personnel. Sometimes the contract has unrealistic wording, such as statements that the contractor is to provide a pest-free environment. This is clearly not attainable, nor does it meet the criteria of IPM. In other cases, entomologists have found that although contract personnel have proper applicator certifications, this is not always the case with their subcontractors. As a result, improper application of pesticides may occur. The vigilance of army entomologists is therefore needed to ensure that such errors are corrected to protect human and environmental health. Deployment The primary army units that provide entomological support to deployed forces are 11-person preventive medicine detachments that are deployed worldwide for contingency or humanitarian operations. These detachments are led by two officers, one of whom is an entomologist. They are equipped with a variety of entomological surveillance and control equipment, as well as vehicles to move the detachment personnel and equipment. They can be broken down into up to three teams to facilitate covering multiple simultaneous missions. The diverse training of all detachment soldiers allows preventive medicine teams to conduct a wide array of tasks in such areas as entomology, environmental monitoring, water and food quality, and waste disposal. Although the detachment is capable of conducting surveillance and control operations itself, its mission often is to provide consultative services to units that are equipped with ready-mixed pesticides with which they can conduct some basic pest control operations. The advisory and educational aspect of the detachments is critical to enabling them to operate over a wide area effectively. Entomologists serve on the staffs of deployable area medical laboratories that are responsible for protecting the health of the Army through surveillance, identification, analysis, and evaluation of radiological, nuclear, biological, chemical, and endemic disease and occupational and environmental health hazards. The laboratory staff is composed of highly skilled soldier scientists who are required to set up, operate, and maintain sophisticated analytical equipment in austere and hostile environments. The laboratory entomologists are responsible for surveillance, identification, and diagnosis of vectors and vector-borne diseases; they are well provided with advanced analytical equipment that will support a variety of polymerase chain reaction Entomologists serve on the staffs of deployable area medical laboratories that are responsible for protecting the health of the Army through surveillance, identification, analysis, and evaluation of radiological, nuclear, biological, chemical, and endemic disease and occupational and environmental health hazards. American Entomologist Volume 51, Number 4 209

3 Fig. 1. Area Medical Laboratory Vehicles (PCR), antibody, and culture-based assay systems to achieve mission success. The entomologists in these laboratories also serve as consultative and information resources for medical personnel throughout an area of operations. Army entomologists may also hold key positions as staff officers in major commands supporting deployed operations. These officers provide preventive medicine, operational planning, and consultative services for deployed units and serve as the highest level of medical entomology advice during a deployment. There is, therefore, a tiered approach to deployed support that starts with war fighter units requesting support from preventive medicine entomology detachments that are capable of conducting pest surveillance and control operations. The detachments in turn may seek additional guidance and laboratory support from more senior entomologists in army area medical laboratories or on major command staffs. The role of entomology detachments often changes as deployments mature. In the initial stages, the detachment s pest control capabilities are the primary means of supporting operations for deployed units. As bases are established that are not considered mobile and as hostilities decline, the pest control mission often transitions to civilian contractor support and the detachments missions may shift to being predominantly focused in the surveillance and consultative arenas. Army entomologists leverage information technology to assist them in accomplishing their missions. The Army Center for Health Promotion and Preventive Medicine publishes the Ultimate Preventive Medicine CD-ROM Resource Set, a comprehensive resource of preventive medicine reference material. The AFPMB s Operational Entomology Library CD-ROM is available to all deploying entomologists. These resources, combined with internet connectivity that provides and web access to deployed personnel, ensure that military entomologists have ample resources, whether they are part of an entomology team or staff officers at a higher headquarters. Army entomologists also travel as preventive medicine team members to provide technical advice and assistance to foreign governments and military services in areas where U.S. forces are not deployed and armed conflict is not occurring. As a result, army entomologists may also find themselves on trips to a wide variety of countries in such places as South and Central America, Africa, Australia, and the Far East. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Since the fall of 2001 when senior and junior officer entomologists were deployed to Kuwait and Afghanistan in support of OEF, army ento- Fig. 2. Area Medical Laboratory mobile lab in use. 210 American Entomologist Winter 2005

4 mologists have been supporting U.S. forces in the global war on terrorism. The initial deployments of entomologists coincided with combat troop deployments. The entomologists included junior officers who were deployed to Afghanistan in preventive medicine teams and a senior entomologist stationed in Kuwait, who was responsible for providing technical and consultative support in the theater of operations, which initially included countries such as Afghanistan, Pakistan, and Uzbekistan. Early in OEF, many troops were established in tents, so arthropod control was quite important. As time progressed, troops moved into more established facilities. However, whether soldiers sleep in buildings or tents, around-the-clock military operations place them in close contact with arthropod vectors, so entomologists must remain vigilant. When OIF began in 2003, the mission of the senior entomologist supporting Afghanistan operations shifted as more forces entered the region. Whereas the primary focus had been on the Stans (Afghanistan, Pakistan, Uzbekistan, etc.), it now encompasses the entire Persian Gulf area and the Horn of Africa and includes military support and humanitarian aid missions. The diversity of geography, climate, and cultures ensure that there is never a dull moment for deployed military entomologists in the region. For example, Captain Owen Price was deployed to Angola, Africa as part of a site assessment team tasked to evaluate conditions in preparation for a large humanitarian aid mission. The team s focus was broad and included interesting challenges such as malaria, the black mamba, the tsetse fly, and numerous air and water quality concerns. Personal Protective Measures (PPMs) Soldiers raised in the United States, where serious and life-threatening arthropod-borne disease is relatively uncommon, have to be educated about the difference between the disease threat levels at a backyard barbecue compared with the threat faced by an immunologically naïve soldier deployed in a country where serious arthropod-borne diseases such as malaria and leishmaniasis are endemic. Convincing soldiers to use topical repellent on a daily basis is an uphill battle in the dusty and hectic environments of OEF and OIF. Personal protective measures (PPMs) provide a potentially very effective way to prevent arthropod-borne disease. The DoD has a very effective set of PPMs that involve proper wear of the uniform, application of personal repellants to the skin and of permethrin to the uniform, as well as other precautions such as proper use of permethrin-treated insect netting in sleeping areas. Soldiers are trained in the importance of using PPMs; but as is the case with the civilian population, achieving compliance with guidance on the proper use of repellants can be a challenge. Well-meaning but misinformed relatives (and on occasion, celebrities) advocate the inappropriate use of such devices as dog flea/tick collars on soldiers and send them to deployed personnel. Army entomologists put great effort into educating troops on the proper use of effective PPMs and explain why inappropriate countermeasures such as the human use of dog flea/tick collars are not only ineffective, but dangerous. Malaria and Mosquitoes Although malaria was a potential threat in Afghanistan and Pakistan, where most U.S. forces were stationed, Colonel Dan Strickman found initially that prophylaxis was only being given in Pakistan because the threat in Afghanistan was not considered as great. Reports of initial vector threat assessment activities clearly show the unusual challenges faced by military entomologists. Site surveys were conducted to determine potential anopheline breeding areas in anticipation of the rainy season in Fig. 3. Major Jamie Blow holding boy with cutaneous leishmaniasis in Afghanistan. January and February Although there were extensive signs of wetlands north of one of the initial troop bases, they were all dry in the fall. If they were to fill, there would be good anopheline habitat within 2 km of the base. In the United States, mosquito control district operations in such circumstances would involve mapping the area and planning for surveillance and control operations when the wetlands filled with water. In Afghanistan, such operations are complicated because of the threat of land mines that makes many ground-based pest control operations impossible. As it turned out, the malaria transmission did not materialize to any great extent in Afghanistan, but the challenge created by the tactical situation was significant. Because of such situations and the often mobile nature of military operations, the army stresses the use of personal protective measures and other medical preventive measures, such as chemoprophylaxis, when they are available. The value of preventive medicine and military medical entomology in preventing disease in deployed forces was reinforced from the very start American Entomologist Volume 51, Number 4 211

5 Fig. 4. Mosquito larval surveillance in Iraq. of OIF in Preventive medicine detachments moved into Iraq with fighting forces. Captain Owen Price s detachment supported combat units moving into Baghdad and later provided preventive medicine support in and around the Sunni Triangle. Their first challenge came at the Baghdad International Airport in the spring of 2003, where heavy adult mosquito populations required rapid control procedures by the deploying unit as it passed through the area. Because their ultimate destination was farther north, the unit had four days to reduce the mosquito problem. The large open areas of the airport provided the perfect opportunity to enact a variety of control measures, the primary of which was the use of the unit s ground-based ULV sprayer, which was operated from the tactical vehicles. The unit met the challenge, conducted successful ULV operations, and moved on to the next region and mission. Although many OIF troops are located in the Tigris Euphrates valley, mosquitoes have turned out to be a much smaller problem than one might expect. Saddam Hussein s regime conducted massive swamp and marshland reclamation activities that have eliminated major mosquito breeding sites. Whereas mosquitoes may still be problematic in isolated instances, such the Baghdad airport, sand flies are by far the largest vector threat to U.S. forces and will be discussed in more detail later. OIF. The first confirmed case of leishmaniasis in OEF occurred in a soldier in the Kabul area in Because each suspected case of cutaneous leishmaniasis requires that the patient be evacuated to the United States just for diagnosis, there is strong emphasis on preventing the disease. A senior entomologist worked with environmental health technicians from a preventive medicine detachment to trap mice and bleed them. The serum was refrigerated for shipment to an army laboratory in Germany for testing against leishmaniasis, hantavirus, scrub typhus, and plague. The carcasses were sent directly to the Smithsonian Institution, which has been interested and helpful in identifying rodents in the area. (This connection was made, in part, because of the close relationship between the Smithsonian and the army s Walter Reed Army Institute of Research s Biosystematics Research Unit, which has an entomology officer conducting research in mosquito taxonomy assigned to the Smithsonian.) During the summer and early fall of 2003, sand flies were the single biggest complaint of soldiers in many areas of Iraq. They attacked in large numbers, sometimes inflicting hundreds of bites to a soldier each night. Control was difficult in all areas. In some, a combination of barrier and wall treatments had a positive impact, and the addition of air conditioning to tents and the increased use of more fixed facilities have reduced the exposure of many soldiers to sand flies. However, with 24-hour operations forcing soldiers to sleep and work out of doors during sand fly activity periods, leishmaniasis continues to be a serious medical threat. The leishmaniasis control program instituted at Tallil Air Base in Iraq is a good example of challenges Army entomologists face on deployments. On the morning of 20 March 2003, when U.S. forces invaded Iraq, among the first medical units entering the country were army preventive medicine detachments and an area medical laboratory. The laboratory established operations at Tallil Air Base on 22 March and began its mission of detecting and identifying endemic diseases that Body Lice The primary purpose of a senior army entomologist s trip into Afghanistan early in OEF was to be sure that plans were in place to properly disinfect detainee camps in a safe and effective manner. Although the DoD no longer has mass delousing equipment, it does have policies and procedures to guide delousing operations, and these procedures were put in place to provide support to detainee and displaced persons camps. Leishmaniasis Leishmaniasis is the primary arthropod-borne disease of entomological concern in OEF and 212 Fig. 5. Captain Owen Price spraying a field latrine to control filth flies. American Entomologist Winter 2005

6 Fig. 6. ULV machine in Preventive Medicine Detachment Humvee. could adversely affect the health of U.S. military personnel. Although night-time temperatures at Tallil Air Base were initially too cool to support arthropod activity, warming temperatures resulted in the collection of the first phlebotomine sand flies in mid-april, and increasing numbers were found thereafter. The severity of the leishmaniasis threat led to the development of a control plan, the goal of which was to protect all coalition forces in the vicinity of Tallil Air Base from the disease. Its four main objectives were to establish a vigorous surveillance program (detection of Leishmania parasites in sand flies, rodents, dogs, and humans) to assess risk; ensure that all U.S. military personnel had access to and used PPMs measures (DEET-containing repellents and permethrin-treated uniforms and bed nets); establish a sand fly control program; and ensure that all military personnel were informed about the risk of leishmaniasis and preventive measures required to protect themselves from the disease. A diverse team of U.S. Army, Air Force, and Navy entomologists, along with colleagues from various coalition forces (British, Italian, Dutch, and Korean) and pest control contractors were responsible for implementing the leishmaniasis control plan. A standardized sand fly trapping program was established using unbaited Centers for Disease Control miniature light traps. Traps were placed at 6:00 PM local time and collected by 8:00 AM the following day. Samples were sent back to the Walter Reed Army Institute of Research for speciation, and fluorogenic (real-time) PCR was conducted at the field laboratory to determine whether leishmaniasis parasites were present in the vectors. A total of 54,067 sand flies were collected at Tallil Air Base in 2003; the most common species collected were Phlebotomus papatasi, P. alexandri, P. sergenti, and various Sergentomyia species. Using the fluorogenic PCR assay, 1,753 pools containing 21,710 female sand flies were tested for Leishmania parasites. A conservative infection rate could be determined by assuming that only one sand fly in a pool was infected, and entomologists calculated that the minimum field infection rate was 1.58%. By mapping out the temporal and geographic distribution of all sand flies and infected sand flies, the team was able to focus control efforts in areas that were at highest risk for leishmaniasis. Sand flies were routinely captured inside sleeping/living tents, and there were no significant differences in the numbers of sand flies captured inside and outside of the tents. Air-conditioned tents had ~90% fewer sand flies than un-air-conditioned Warming temperatures resulted in the collection of the first phlebotomine sand flies in mid-april, and increasing numbers were found thereafter Fig. 7. Captain Kendra Lawrence in Baghdad. American Entomologist Volume 51, Number 4 213

7 Soldiers normally slept in shorts or shorts and t-shirt and not in their permethrin-treated uniforms. Many of the available bed nets had a mesh that was so large that sand flies could pass through it. Many soldiers did not properly use bed nets (e.g., they failed to tuck the bed net in, leaving gaps through which the sand flies could enter). Soldiers reported that insect repellents were not protecting them from the sand flies. Fig. 8. Entomologists from all three military services working together at Tallil Air Base, Iraq: (left to right) Major Douglas Burkett (U.S. Air Force), Lieutenant Colonel Russell Coleman (U.S. Army) and Lieutenant Ronald Knight (U.S. Navy). Most of the soldiers at Tallil felt that PPMs were ineffective against sand flies. Although it is easy to blame the failure of PPMs on the soldiers rather than on the personal protective items themselves tents. Male and infected female sand flies were routinely captured in air-conditioned and un-airconditioned tents. Although all military personnel were instructed to deploy to Iraq with two tubes of the military s Extended Duration Insect and Arthropod Repellent, four permethrin-treated uniforms, and an insect bed net, initial surveys conducted at Tallil Air Base indicated that >90% of units did not deploy with these personal protective items. This is a graphic example of the fact that having a sound policy on the use of personal protective measures against biting arthropods doesn t mean that soldiers will use them. Constant emphasis on, and training in, the proper use of PPMs is part and parcel of Army entomology operations. Interviews with soldiers at Tallil Air Base showed that Even when available, soldiers often did not use PPMs. Fig. 10. A soldier with hundreds of sand fly bites received in one night. Fig. 9. Lieutenant Colonel Coleman setting out light traps at Tallil Air Base Iraq. 214 (i.e., a compliance issue), the incredibly arduous climate was in large part responsible for the observed problems. Temperatures during the day reached highs of 52 oc (126 of). Even at night, temperatures were warm: between 1 July and 31 August, the coolest temperature recorded was 24 oc (75 of), and the nightly low temperature averaged >85 of. Air-conditioning was nonexistent for most soldiers for all of Soldiers therefore took whatever steps necessary to stay cool. Unfortunately, many of these steps (opening up tents, not using bed nets, sleeping in shorts on top of a sleeping bag, etc.) promoted sand fly feeding on the soldiers. Military entomologists initiated an aggressive vector control program in late April 2003 that continued through October The goal of the program was to reduce the abundance of sand flies to a level where they were not a nuisance and were American Entomologist Winter 2005

8 not transmitting leishmaniasis. Without knowledge of what the light trap threshold value would be for U.S. troops, the team decided it would attempt to reduce sand fly populations below 5/trap/night. The vector control program consisted of a combination of classic vector control techniques including residual spraying of pesticide on tents and building walls using a hand-held sprayer and lambda cyhalothrin, cypermethrin, or cyfluthrin; application of 5% carbaryl dust using backpack dusters; area spraying using an ULV sprayer to dispense resmethrin or malathion; and rodent and reservoir control using an assortment of snap traps, glue boards, and baits. The goal of the ULV spray program was to spray all inhabited areas on Tallil Air Base where sand flies were found. Spraying was conducted daily, weather permitting. When surveillance data indicated that peak sand fly activity occurred between 10:00 PM and 4:00 AM, spraying that initially started at dusk was delayed until about 11:00 PM. The efficacy of the vector control program was evaluated by trapping sand flies several times a week. Twelve trap locations were established, 10 of which were in areas that were exposed to pesticide (treated traps), and 2 traps were in areas that were not sprayed (control traps). Sand flies were collected in >94% of the traps, with an average of 60 flies collected in each trap. Although data from the light trap collections was difficult to interpret, the following are some general conclusions drawn from them: On any given night, the number of sand flies varied tremendously from trap to trap. Weather had a tremendous impact on sand fly collections; the most flies were collected when wind speed was low (<2 3 MPH). The maximum numbers of sand flies were collected on calm nights that followed several nights of windy weather. The number of flies collected positively correlated with the number of windy days preceding the calm night. Fig. 11. Soldier avoiding the heat by sleeping on the hood of his Humvee. Note his unauthorized use of flea collars on his boots in an attempt to repel sand flies. Habitat /source reduction had little if any impact on sand fly numbers. In spite of classic sand fly control dogma that states these poor-flying insects can be largely eliminated if you bulldoze or otherwise destroy their habitat and that of their primary hosts, our experience showed that habitat destruction had little impact on overall sand fly numbers. Hundreds of sand flies were often captured in a single light trap placed in the middle of heavily compacted and completely denuded tent cities with no apparent normal habitat for hundreds of meters in all directions. Because of the long incubation period of leishmaniasis (months to years in some cases), and the poor compliance with PPMs, Army entomologists believed it imperative that soldiers be educated about the threat leishmaniasis posed to them. The education program focused on providing informa- During the beginning of the control effort (May and June), there was little difference in the number of sand flies collected in the treated and control traps (control efforts did not appear to be working). Later in the season (July through September), the control traps continued to collect large numbers of sand flies, whereas the numbers collected in the treated traps were significantly reduced. Data from the light trap collections clearly showed that the program could not eliminate sand flies from any location. However, the data also show that the control effort did reduce sand fly populations over a period of months. This was presumably because the constant application of pesticides reduced the number of older sand flies in the area, which could reduce or even eliminate the transmission of leishmaniasis. Fig. 12. LTC Van Sherwood (holding sprayer wand) and his team prepare to treat uniforms with permethrin. American Entomologist Volume 51, Number 4 215

9 In addition to more routine pest challenges such as sand flies, mosquitoes, rodents, etc., military entomologists sometimes get to deal with something out of the ordinary, such as cases of ocular myiasis. Fig. 13. A case of cutaneous leishmaniasis contracted in Afghanistan tion on the disease, methods of preventing the disease, disease symptoms, and methods of treatment, to include whom to contact for diagnosis and treatment. Four methods of educating soldiers were used: Giving briefings for leaders, units, and newcomers briefings; Providing newspaper articles and posters; Placing information in their medical records; and Providing Leishmaniasis cards. Leader briefings consisted of meeting with the unit staff in an attempt to make them aware of the threat and to provide guidance on how to protect their soldiers. Unit briefings consisted of briefings to all personnel in a given unit. A standard Army medical form was placed in each soldier s permanent medical file to alert physicians who reviewed the file after a soldier returned to the United States that they had potentially been exposed to the disease. Pocket-sized laminated Leishmaniasis cards, made by the U.S. Army Center for Health Promotion and Preventive Medicine, were provided to each soldier at the air base. The cards contained information and pictures about leishmaniasis, sand flies, and personal protective measures. To date, more than 750 U.S. military personnel from Iraq have developed leishmaniasis. However, very few of them have been from Tallil Air Base, which could be attributed to the Leishmaniasis control plan used at the base. Military entomologists from all services are still deployed throughout Iraq and Southwest Asia. They continue to evaluate sand fly control measures and personal protective measures and to find that sand fly control is often elusive and frustrating. Ongoing Support Army entomologists continue to support U.S. forces in Afghanistan and are experiencing new challenges and experiences on each deployment. For example, Captain Tony Schuster traveled to eight villages in four provinces as he assisted teams from veterinary detachments providing humanitarian assistance to local farmers by treating their animals. At each village, the team worked with sheep, goats, camels, cattle, chickens, turkeys, pet birds, and the occasional dog or cat. During these trips, he collected about 2,500 ticks, lice, and ked flies, many of which he had never collected before. In addition to the new professional experience, the entomology officer on these trips had some wonderful cultural experiences. Wherever the teams went, they were hosted by village elders at meals in order to show their appreciation for the assistance the soldiers had provided. Senior entomologists deploying to Afghanistan at this time serve as the principal advisers to major command surgeons on a variety of preventive medicine issues. They are responsible for developing and implementing comprehensive public health and force health protection plans to support the command. Public health plans provide support to provincial reconstruction teams to aid in the reconstruction and development of public health services in Afghanistan, and so are focused on assistance to civilian populations. These plans include components addressing water and sanitation surveillance; instruction on sanitation, hygiene, and potable water; vector and disease surveillance; and threat assessment. In addition to broad planning activities, entomology preventive medicine officers help develop training materials for soldiers and local people about the importance of proper sanitation, hygiene, disease transmission, and water sanitation. Thus, medical entomologists continue to provide critical medical support to DoD and civilian personnel in the region. Unique Challenges In addition to more routine pest challenges such as sand flies, mosquitoes, rodents, etc., military entomologists sometimes get to deal with something out of the ordinary, such as cases of ocular myiasis. In one instance, two soldiers in Iraq reported experiencing a fly buzzing around them, followed by burning and pain in their eyes. Both reported to the camp s optometrist, who removed 15 sheep nose bot fly (Oestrus ovis L.) maggots from one soldier and 2 from the other. Fortunately, the larvae were removed before any damage occurred. In their roles as preventive medicine officers, Army entomologists are exposed to a variety of challenges, including investigations into outbreaks of gastrointestinal illnesses, something entomologists come to expect on a deployment. Captain Owen Price had to respond to food-borne illness outbreaks at a rest and relaxation facility and at a refinery. In both instances, military officials had contracted with local nationals for food and lodging. Although no negligence on the part of the Iraqis was involved, because of cultural differences, their standards of sanitation did not meet ours. Military preventive medicine personnel, including the entomologist, used Arabic translators and taught food sanitation courses. They made recommendations for improvements in sanitation to the management at both facilities. The occurrence of illness was reduced to zero in both cases. 216 American Entomologist Winter 2005

10 Operation Joint Guardian - Kosovo Army entomologists deploy to a wide variety of places. The visibility of the global war on terrorism in the news media makes it easy to forget that the Army is conducting operations in other regions at the same time. While coalition forces are present in OEF and OIF, nowhere is the integration of U.S. and coalition professionals more complete than in Kosovo. Entomologists may serve as the Preventive Medicine Officer for the Kosovo Forces (KFOR) in Pristina, Kosovo. In this capacity, their responsibilities are to provide technical guidance and expert consultation in addition to coordinating policy, plans, and programs for disease prevention, environmental public health, and force health protection for a multinational, peace-keeping National Allied Treaty Organization (NATO) force in Kosovo. Major Sonya Schleich with a Swedish public health officer in Kosovo. Entomologists also participate in civil military operations. Captain Kendra Lawrence was involved in a program to treat standing water in local Iraqi neighborhoods for mosquito larvae. She also provided preventive medicine assessments regarding sewage that backed up into a base camp and a local Iraqi community, seriously threatening the health of hundreds of soldiers and Iraqis. Her assessments of the potential health threat helped to publicize the problem and eventually led to the development of a mitigation plan. The vast diversity of the Insecta dictates that entomologists must be ready to work in a wide variety of groups of insects. This predilection for diversity ensures that entomologists serving in the Army never have a dull moment. As is evident in this brief article, Army entomologists must be jacks of all trades to succeed. Fortunately for our soldiers, our entomologists are also masters of what they do. In another region of the world, Lieutenant Colonel Sonya Schleich was privileged to work closely with a U.S. Air Force medical planner and foreign nationals, including a German veterinarian, a French health care administrator, and a Hungarian microbiologist. All of these professionals worked for a French medical doctor who was charged with monitoring and reporting all military and public health medical issues in Kosovo to the mission commander, a three-star German general. Schleich also had the opportunity to work with the Head of the National Institute of Public Health of Kosovo (NIPHK) in developing an emergency action response plan in the event of an influenza epidemic/ pandemic. Her work was a natural collaborative follow-on to the previous U.S. Preventive Medicine Officer, who had also worked with the NIPHK in the development of an emergency action response plan for avian bird flu. This is an excellent example of the continuity achieved through the careful note-taking and log books that entomologists and American Entomologist Volume 51, Number 4 all preventive medicine officers maintain to ensure uninterrupted support to our deployed soldiers. The Kosovo Forces (KFOR) are focused on environmental health and protection. As a result, Shleich was able to initiate procedures for a recycling program on the headquarters complex and monitor the efforts of other multi-national forces and base camps. For example, the Swedish component recycled everything from used metal to kitchen wastes. They used organic digesters that combined the use of a sawdust-type material with kitchen food waste and resulted in biodegradable compost used by local farmers for fertilizer. She also had the opportunity to coinspect bottled water plants in Macedonia and Greece and assist with the medical planning of a multiforce medical exercise to practice medical care for numerous simulated casualties. One of her most memorable experiences was to provide a medical threat briefing associated with food-borne illness to the commanding general and other high-ranking officials from several different nations. Major Schleich s deployment experience was very educational and provided exposure to many professional and well-educated foreign military health care professionals. Acknowledgments I thank all of the dedicated medical entomology officers who have served and are serving the U.S. Army and our nation. The following officers contributed information and photos for this article: Colonel George Korch, Colonel Thomas Logan, Colonel (Retired) Dan Strickman, Lieutenant Colonel Russell Coleman, Major Jamie Blow, Lieutenant Colonel Sonya Schleich, Captain Kendra Lawrence, Captain Robert Moore, Captain Owen Price, and Captain Tony Schuster. Colonel Stephen B. Berté is the medical entomology consultant to the U.S. Army Surgeon General (Stephen.berte@us.army.mil) 217