Combat & Casualty Care

Q4 2016

Military Magazines in the United States and Canada, Covering Combat and Casualty Care, first responders, rescue and medical products programs and news\Tactical Defense Media

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The Walter Reed Army Institute of Research (WRAIR) is a 123-year old institution tasked with researching ways to counter threats to the health of the U.S. military. "At the WRAIR, we have two fundamental programmatic lines of effort, one of which focuses on mental health, the other on infectious diseases" said COL (Dr.) Michael Zapor, WRAIR Deputy Commander for Operations and OCID Course Director. "The Center for Military Psychiatry and Neuroscience (CMPNS) focuses on the prevention, diagnosis, and treatment of both traumatic brain injury (TBI) as well as post-traumatic stress disorder (PTSD). In contrast, the Center for Military Infectious Diseases Research (CMIDR) researches pathogens that pose a threat to the health of service members." The CMIDR is comprised of a Bacterial Diseases Branch that focuses on enteric (gastrointestinal) infections (primarily bacillary dysentery) and wound infections caused by multidrug resistant bacteria. Similarly, the CMIDR also consists of a Virus Diseases Branch that focuses of flaviviruses such as dengue. "Our researchers have made significant contributions towards the development of a number of viral vaccines including hepatitis A, the Middle East Respiratory Syndrome Corona Virus (MERS-COV), Zika, and Ebola" said COL Zapor. "Moreover, we have an entire program dedicated to researching a vaccine against the Human Immunodeficiency Virus (HIV). The Military HIV Research Program (MHRP), which is congressionally funded, has helped produce the only HIV vaccine to date proven to have any efficacy". The CMIDR also consists of a large Military Malaria Research Program (MMRP). "Malaria is the quintessential infectious disease threat to deployed service members" noted Zapor; and the MMRP has produced or improved most of the antimalarial drugs in use, as well as the only malaria vaccine with any proven efficacy". Infectious diseases research at WRAIR is supported by an Entomology Branch and insectary which breeds, infects, and maintains mosquitoes and sand flies as well as a Veterinary Services Branch that includes a vivarium where rodents, nonhuman primates, and other animals are maintained. Additionally, the WRAIR maintains a pilot bio production facility that produces vaccines and other therapeutics under good manufacturing practice (GMP) standards. In addition to its main campus in Silver Spring, Maryland, WRAIR has a number of daughter sites both in the Continental United States (CONUS), including one at Joint Base Lewis-McChord in Washington State, as well as Outside the Continental United States (OCONUS), including the Republic of Georgia, Kenya, and Thailand. In turn, the OCONUS sites have a number of smaller field sites, all arranged in a hub- and-spoke manner. "Throughout the WRAIR CONUS and OCONUS labs, research is being done in collaboration with other governments, with industry, and with academia" said Zapor. Infectious Disease Awareness The Department of Defense runs a number of tropical medicine courses, including the Military Tropical Medicine Course at the Uniformed Services University of Health Sciences (USUHS). "However, these are graduate level courses that are intended for infectious diseases specialists and other physicians for whom comprehensive training in tropical medicine is appropriate" said Zapor. "In contrast, the Operational Clinical Infectious Disease (OCID) course offered at WRAIR is designed for primary care physicians, physician assistants, medics, and corpsmen who will be deploying to regions in which certain infectious diseases are endemic." There are two different versions of the OCID course, a 5 day course taught at WRAIR and a 3 day course conducted at the requesting unit's CONUS or OCONUS base or post. Both versions share a similar curriculum consisting of lectures and a laboratory session, but the five day course has an expanded curriculum that addresses some additional pathogens and provides a little more detail. "The curriculum is continuously being adapted, both in response to emerging infectious disease threats as well as response to student feedback" noted Zapor. "We endeavor to ensure that the lectures are relevant, informative, and appropriate for the attendees". The OCID is funded by the Global Emerging Infections Surveillance (GEIS) section at the Armed Forces Health Surveillance Branch (AFHSB) and is accredited to award either 40 Continuing Medical Education (CME) credits for the 5 day course or 18 CME for the 3 day course. The OCID course is highly regarded by medical personnel in field units and there is a high demand for attendance. Iterations of the course are run year round throughout CONUS as well as OCONUS locations such as Germany, Japan, and Nigeria and deconflicting schedules can be a challenge. "We get requests from all of the Services as well as the occasional request from a non-DoD agency such as a civil police department. Requests and repeat requests for course iterations, particularly by folks pending deployment, place a demand on the limited number of course lecturers, all of whom have full time jobs and voluntarily participate as OCID faculty" remarked Zapor. According to COL Zapor the OCID is patterned like a college course with lectures by core and adjunct faculty, each of whom is selected based on his or her expertise. The curriculum is continuously reviewed and updated in order to keep it topical and relevant. "For example, because the distribution of Plasmodium (malaria) species varies geographically, malaria lectures given to those traveling to Africa may have a different emphasis than those traveling to South America. Similarly, travelers to Africa will spend more time learning about Ebola and related viruses endemic to that continent." Regardless of the course content for a particular iteration, each begins with a lecture titled "Preparing the traveler" which addresses such topics as pre-deployment vaccinations and prescriptions. Moreover, all lectures are similarly structured and begin with background information on the geographic distribution of the pathogen, its reservoir in nature, and its vector (e.g. mosquito), if any. This is followed by clinical presentation (i.e. the signs and symptoms associated with infection), how the disease is diagnosed, how infected patients are treated, and lastly, how infection may be prevented (e.g. by means of vaccination or prophylactic medications). "Unlike the other more comprehensive tropical medicine courses, the OCID course presupposes that the deployed provider will have very limited diagnostic capabilities and a limited formulary" Zapor noted. "Therefore, the OCID course emphasizes such topics as physical exam findings, empiric treatment of disease (i.e. treatment based on experience and observation rather than definitive diagnosis), and when to consider medical evacuation (MEDEVAC) of patients to a higher level of care." Diagnosis by Teleconsultation Not part of the OCID program but another resource available to deployed providers is the Army's telemedicine consultation program in infectious diseases ( This program COL Michael Zapor, PhD, MD, CTropMed, FACP, FIDSA Winter 2016/2017 | Combat & Casualty Care | 23

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