Annual Report of the Surgeon General United States Army Fiscal Year 1958
PREVENTIVE MEDICINE
Communicable Disease Control
Common respiratory disease and influenza.-Asian influenza, which had begun to assume importance in the latter part of fiscal year 1957, became the center of interest and the most significant medical problem of the first half of fiscal year 1958. Common respiratory disease and influenza rates reflected the great incidence of influenza and were higher than usual in each of the last 6 months of 1957. The October peak of 592.4 cases per 1,000 average strength per year was the highest common respiratory disease and influenza rate since the type A influenza
29
epidemic month of January 1941. Considering November through March to be the usual respiratory disease season, the October peak was the highest respiratory disease rate to occur in a nonrespiratory season month since October 1918, the peak month of the 1918-19 influenza pandemic. The 1957 rate, however, was less than half of that in 1918. Following the October peak, common respiratory disease and influenza rates declined until January and then rose to a lower, but normal, seasonal peak in February. The epidemic was characterized by a relatively low mortality due more to an absence of complications than to particularly successful treatment of complications. While the mortality rates in 1957-58 were higher than any since 1944-45, they represented relatively few deaths, the greatest monthly number being 4 in October and 6 in January. The acute respiratory illness death rate of 7.3 per 100,000 mean strength per year in January 1958 was the highest of the season. However, this rate was far smaller than the acute respiratory death rate of approximately 4,700 per 100,000 average strength per year of October 1918. The relative absence of mortality during the 1957-58 influenza epidemic was both remarkable and comforting.
Streptococcal disease and rheumatic fever.-A staff study submitted to the Army Chief of Staff in October 1957 reaffirmed The Surgeon General's analysis of the continued prevalence of streptococcal disease and its complications at Fort Carson, Colo., and urged that recruits, other than those indigenous to the Rocky Mountain area, not be sent there for training. Sufficient interest was aroused that a briefing was held at the Pentagon with all training and assignment agency representatives attending. Again in the winter months the streptococcal disease rate at Fort Carson increased to the point where another benzathine penicillin program was put into effect for all recruits between February and May of 1958. The Commission on Streptococcal Diseases, Armed Forces Epidemiological Board, conducted a seminar at Fort Carson in October 1957, which was so well received that it is planned to repeat this type of conference in the fall, with the Air Force acting as host at Lowry Air Force Base.
Although the incidence of streptococcal disease at Fort Dix, N.J., increased markedly during the first quarter of fiscal year 1958, no reason for this has been determined.
The incidence of rheumatic fever continued relatively steady throughout the year with a fairly even distribution throughout CONUS.
Enteric diseases.-These diseases occurred sporadically and in small epidemics but were not peculiar to any given area, and no new problems arose.
30
Insectborne diseases.-From July 1957 through the end of April, 188 patients were hospitalized for malaria. Although malaria is still of potential military importance, it is not a significant medical problem at this time.
Tuberculosis.-The tuberculin testing and preventive therapy program within the American Dependent School System in the Ryukyu Islands was continued. During the year, the U.S. Public Health Service reversed its long-standing recommendation for periodic chest X-ray surveys for all adults in favor of surveys of high-risk groups and more tuberculin testing. Future Army policy will be in line with these recommendations.
Poliomyelitis.-Only 2 of the 21 cases of poliomyelitis occurring among active duty Army personnel during the year were initially hospitalized in CONUS installations; all other cases occurred in oversea areas. Supplies of poliomyelitis vaccine were plentiful throughout the year. Vaccination has been mandatory only for travelers to the Marshall Islands. In a portion of the Communications Zone in France, however, all U.S. personnel were vaccinated following an outbreak of the disease in the indigenous population. In all other areas, the vaccine was available to all age groups on a voluntary basis. Department of Defense Instruction No. 6220.1, dated 8 April 1958, made it possible for the services to institute mandatory programs; triservice agreement was reached, and AR 40-562, submitted for publication in June 1958, will require poliomyelitis vaccination for all personnel under age 40 prior to travel anywhere outside CONUS. This regulation directs that a fourth dose also be given to this category of persons if more than 1 year has elapsed since the initial three-dose series.
Smallpox.-The Research and Development Division, OTSG, is sponsoring experimental studies on dried smallpox vaccine. While it is occasionally authorized for use under adequate controls, it is not considered generally acceptable at the present time.
Infectious hepatitis.-The incidence of infectious hepatitis followed a pattern similar to that of the previous year and was generally low. The highest incidence, on a rate basis, was among U.S. troops in Korea. In May and June, 22 cases were reported from Eritrea; this suggested a common-source epidemic.
Rabies.-On 28 October 1957, a 22-year-old female dependent died of rabies at William Beaumont Army Hospital, despite supposedly adequate prophylactic treatment. Both the deceased and her husband had been bitten and scratched by their unvaccinated dog on or about 23 June 1957. Following this, the provisions of paragraph 3, changes 1, AR 40-90, dated 6 August 1956, which prohibited Veterinary Corps
31
officers from administering rabies vaccine to private pets of military personnel and their dependents, were rescinded.
Staphylococcal infections.-The extent of staphylococcal infections is difficult to assess, since staphylococcal infections are varied and scattered throughout morbidity statistics and are inclined to be more prevalent among dependent personnel for whom strength figures are not readily available. More emphasis is being placed on aseptic hospital techniques. In line with this, copies of the manual entitled 'Guide for the Prevention and Control of Infections in Hospitals,' prepared jointly by the New York State Health Department and the American Public Health Association, were recommended as a reference for all hospitals.
Rubella.-During the third quarter of the fiscal year, rubella was highly prevalent, particularly among recruits, and for a time became second leading cause of noneffectiveness due to disease.
Meningitis.-The incidence of meningococcal meningitis was low, and the cases were scattered among the military population. Several young dependent children died of this disease in CONUS hospitals during the winter months.
Immunization activities.-The first lot of Asian influenza vaccine produced was a 200 CCA (chick cell agglutinating unit) product which was administered to all Army personnel in accordance with DA Circulars 40-15 and 40-17 as soon as it became available in September 1957. By December the manufacturers were able to furnish a 400 CCA vaccine, and this was used for the second dose. In oversea areas a third dose of polyvalent vaccine, carried over from fiscal year 1957, was administered following the second dose of monovalent Asian vaccine. Because the epidemic had reached most world areas before the vaccine became available, it was difficult to determine its efficacy. In an effort to inject at least 90 percent of the Army with the new influenza vaccine, DA Circular 40-24 extended the program for vaccination of recruits until 1 August 1958. It is anticipated that the fall program, covered by DA Circular 40-25, will serve as a booster dose when implemented in October 1958. The Armed Forces Epidemiological Board is studying the effects of adjuvant vaccine, but at the present time only aqueous vaccines are in use Armywide.
On 19 September 1957, the U.S. Department of Health, Education, and Welfare established standards for an adenovirus vaccine. The Surgeons General of the Army and the Navy were signatories to these
standards. At the end of this fiscal year the Supply Division, OTSG, is attempting to procure an adenovirus vaccine, bivalent, types 4 and 7, to be utilized at recruit training stations this fall. If the program
32
is instituted, a detailed surveillance program will be set up to determine the worth of the vaccine.
General.-When AR 40-562, Prevention and Control of Communicable Diseases of Man-Immunization Requirements and Procedures, replaces AR 40-230 and SR 40-230-1, the number and frequency of certain immunizations will be reduced. The new triservice regulations should be published early in fiscal year 1959.
Quarantine.-Army Regulations 40-577, a revision of AR 42-40, Quarantine Regulations for Vessels and Aircraft of the Armed Services, were submitted for publication in January. At the end of the fiscal year they were still being circulated through other governmental agencies for concurrence, even though they repeat essentially all of the Navy's General Order No. 20 which has been in effect since July 1957.
Occupational Health
Occupational medicine activities in the Army were expanded during the year to provide for a safer and more healthful working environment. Wider publicity was given the program through staff visits to military installations and through the publication of specific guidance and regulatory material. As a result, fewer individual technical inquiries were received. The survey activities of the USAEHL (U.S. Army Environmental Health Laboratory) remained one of the most effective means leading to the correction of adverse environmental conditions.
Occupational medicine.-In order to provide better medical control of the environment through the use of physicians trained in occupational medicine, action was taken to establish a residency training program in occupational medicine at the USAEHL. The proposal was approved by the Education and Training Division, OTSG, and action was taken to have the laboratory approved by the American Medical Association. This will provide a suitable institution in which to train Army medical officers in occupational medicine.
With a view to providing better control in the selection and elimination of military personnel, a pilot study was initiated to determine the feasibility of conducting an audiometric examination of all personnel upon entrance to and release from active duty. With modern electronic audiometric equipment a large number of persons can be screened rapidly. The procedure will eliminate disability compensation claims brought against the United States for alleged hearing loss while on active duty. In addition, it will provide a wealth of scientific data which will further aid in the control of environment.
33
During the year a problem arose in the handling of missile fuels and oxidizers. Several fuel handlers began to show adverse effects as a result of handling one of the exotic fuels, unsymmetrical dimethyl?hydrazine. An extensive and intensive investigation was conducted by the Chief, Occupational Health Branch, Preventive Medicine Division, OTSG, the commanding officer of the USAEHL, and one of the consultants to The Surgeon General in occupational medicine. Inasmuch as more exotic and possibly more toxic missile fuels are being developed, medical and engineering control of this hazard is becoming more necessary. The Preventive Medicine Division has established a continuing project to monitor the problem and to assist in providing a solution.
During the fourth quarter of fiscal year 1957, several individuals who had worked on the Coast Defense Light project during World War II claimed that the radiation from the searchlights had caused them to be sterile or to suffer genetic damage. A full-scale investigation revealed that there was no scientific basis for the claims. Although the lamps emit some ultraviolet rays, such radiation is weakly ionizing and will not produce genetic damage. The operating voltage of the lamps was too low to produce X-rays. This information was submitted to the Secretary of the Army and was subsequently released to the public.
Industrial hygiene.-The industrial hygiene survey activities of the USAEHL have been expanded to include larger segments of the class I system of the Army as well as the class II system. Class I installations contain many industrial-type activities on a small scale which are as important as those in the class II installations. Surveys to date show many deficiencies, most of which are correctable at no great cost.
With the increasing use of radar within the Army, there is a need for a system to measure microwave radiation and to evaluate the hazard. The design of specifications for measuring instruments has now been assigned to the USAEHL. When a suitable instrument is available, the Laboratory will be equipped to make microwave surveys.
Radiological hygiene.-The radiation health protection program has kept pace with the growing utilization of sources of ionizing radiation and is one of the most dramatically effective programs in the Army. Installations employing such sources are surveyed at approximately 18-month intervals. The procedure of followup overexposure to ionizing radiation recorded on the photodosimetry film packets issued by the Lexington Signal Depot has proved effective in causing users of sources of ionizing radiation to be more conscious of the hazard. An information copy of the message notifying the user of an overexposure is forwarded to The Surgeon General in selected cases where concern appears justified. A letter is sent to the installation requesting review of
34
the facilities and offering the technical assistance of the USAEHL. As a result, the number of overexposures throughout the Army has been reduced by approximately 75 percent.
It was discovered that some installations were employing a type of whole-body fluoroscopic device to examine employees for evidence of pilferage of Government property. This was considered to be needless exposure to ionizing radiation, and it was recommended that the procedure be discontinued. Department of Army Circular 40-3, Fluoroscopic Examination of Personnel for Evidence of Pilferage, dated 4 March 1958, states that the procedure is not to be employed without the consent of The Surgeon General.
Occupational vision and conservation of hearing.-These two programs are providing better protection for the eyes and ears of Army personnel. Hearing conservation programs have been extended to class I installations, and the occupational vision program is being expanded to include all Army installations.
Safety.-In order to provide a more effective safety program in the AMEDS class II system, selected personnel from various installations were given safety training at New York University and Northwestern University. Medical facilities at various Army class I and class II installations continued to participate in the Automotive Crash Injury Research Program sponsored by the Armed Forces Epidemiological Board.
Nutrition
Army Medical Service nutrition officers continued to assist the Interdepartmental Committee for National Defense in planning nutrition surveys. Such surveys were completed in Turkey, Libya, and Alaska, and another was started in Spain.
A representative of the Preventive Medicine Division participated in the monthly Army-Air Force Master Menu Board meetings, sponsored by the Quartermaster Corps, and in the 26th Food Research and Development Coordination meeting at Camp Lejeune, N.C., 8 May 1958.
A revision of the TM 8-501, Nutrition, was near completion and is to be published about the middle of fiscal year 1959. The manual will contain new chapters on nutritional survey techniques, mass feeding in major disasters, survival, and cultural and psychological aspects of nutrition.
Civil Public Health
A revised description of The Surgeon General's responsibility for the public health aspects of CAMG-PH (Civil Affairs and Military Gov?
35
ernment-Public Health) was published as change 2 to OTSG Administrative Letter 10-4, dated 28 October 1957. The Chief of the Civil Public Health Branch, Preventive Medicine Division, is designated as The Surgeon General's representative in CAMG medical and public health affairs.
The OCAMG (Office of the Chief of Civil Affairs and Military Government) selected the September 1955 draft of a functional manual for public health activities in CAMG as being best suited for meeting
its staff and field requirement. This manual will undergo final technical revision in OTSG and will be published by OCAMG in the CAMG field manual series in the first half of fiscal year 1959. Two other drafts, prepared in 1956 and 1957, were rejected by OCAMG because they lacked sufficient technical data.
Courses for AMEDS officers at Walter Reed Army Institute of Research and at the Army Medical Service School included instruction in CAMG-PH.
TOE's and TD's for CAMG-PH staff sections and functional teams were studied, and recommended revisions were forwarded to CONARC and OCAMG. These revisions recommended a considerable increase in AMEDS officer and enlisted personnel spaces in these units.
Environmental Hygiene
Environmental activities are broad in scope but are directed primarily toward the specialized fields of entomology, sanitary engineering, toxicology, and the special problem of physiological stress peculiar
to the military.
Entomology.-The development of insect resistance to insecticides throughout the world continues to be one of the principal problems in medical entomology and has required constant surveillance of arthropod vectors in all areas of Army operations. In cooperation with the U.S. Department of Agriculture, the Armed Forces Pest Control Board, and the World Health Organization, the Army Medical Service has developed, and furnished to entomologists in the field, test methods and procedures for detecting resistance to chlorinated hydrocarbon insecticides and malathion in flies, lice, bedbugs, mosquitoes, and roaches. Flies resistant to the chlorinated hydrocarbon have been reported from practically all of the army areas in CONUS and overseas. A report that body lice in Korea are developing resistance to lindane is of special significance. Through the Armed Forces Pest Control Board, close liaison has been maintained with the World Health Organization re?
36
garding worldwide resistance development. Continued support is being given to research in the field of insect physiology.
Six test models of the 'Outfit, Delousing' being developed by the Quartermaster Research and Engineering Command were field tested by medical units. The service test plan and questionnaire for this test were prepared in the OTSG. The increased use of organic phosphorus insecticides requires that additional emphasis be placed on safe handling of insecticides to protect operators and occupants of buildings and areas being treated. This subject was stressed at training conferences for pest control operators.
Sanitary engineering.-Noteworthy among the developments in the field of sanitary engineering during the year were the following:
New standards for automatic dishwashers which permit the purchase and use of commercially available machines.
An improved Quartermaster germicidal rinse for emergency disinfection of eating and cooking utensils as well as locally procured vegetables.
Procedures for testing and approving coin-operated vending machines.
An improved dry latrine bucket disinfectant yet to be field tested.
A more realistic chlorination policy for fixed water supplies.
A new field testing kit for chlorine residuals of 1, 5, and 10 parts per million.
Testing of commercially obtainable membrane filter kits for quick bacteriological analysis of water in the field.
A continuing study of the infectious waste problem, particularly in hospitals.
Evaluation of sewage lagoons as a means of waste disposal at military stations.
Preparation for the Office of Defense Mobilization of a list of sanitary items essential to survival in nuclear warfare.
The completion of a study of the Potomac River as a source of military water supply.
Army Health Nursing
Due to a temporary but rather critical shortage of qualified public health nurses in the Army Nurse Corps, two Army health nursing programs had to be discontinued. In all, 79 Army Nurse Corps officers were serving in general and specialized health nursing programs in the United States and overseas as of 30 June 1958.
A workshop on Army health nursing was conducted in December at the Walter Reed Army Institute of Research with 39 Army Nurse
37
and Medical Specialist Corps officers attending. One of the main tasks of the workshop was to review and revise a draft of the manual on Army health nursing.
Army health nurses also attended a short course at the U. S. Public Health Service Communicable Disease Center, Atlanta, Ga., on the epidemiology and control of milkborne disease; a 1-day workshop on exercises for ante partum patients in Washington, D. C.; and a short course on rehabilitation nursing at Peabody College, Nashville, Tenn., and the State Health Department at Austin, Tex.
Two nurses completed the requirements for master of public health degrees, and three more were recommended for such training beginning in the fall of 1958.
Several educational films relating to maternal and child health were purchased from commercial firms and were stocked in army area and oversea film libraries.
Because of the shortage of Army health nurses, a fact sheet on Army health nursing as a career was sent to the deans of accredited schools of nursing as an aid to recruiting.
Specialized Personnel
Preventive and occupational medicine.-At the end of the fiscal year, 88 Medical Corps officers were assigned to preventive medicine positions or were in training. They were distributed as follows:
| Number |
OTSG | 8 |
Walter Reed Army Institute of Research | 2 |
Army Medical Service School | 5 |
Army Environmental Health Laboratory | 5 |
ZI armies | 29 |
USARPAC (including Hawaii, Japan, Korea, and Ryukyus) | 13 |
USAREUR (including France, Germany, and Italy) | 20 |
Alaska | 1 |
Caribbean | 1 |
In training | 4 |
| Total | 88 |
Seven officers were certified by the American Board of Preventive Medicine during the fiscal year-one in occupational medicine and six in public health. This brings the total number of Medical Corps officers who are on active duty and certified by the Board to 41. Of these, 4 are certified in occupational medicine (MOS 3006) and 39 in public health (MOS 3005), with 2 certified in both. Among this group, 24 are functioning in preventive medicine positions (MOS 3005 and
38
3006), and 17 are occupying other positions, mainly in the staff and command field (MOS 3000 and 3500).
An annually recurring 3-month postgraduate course in advanced military preventive medicine at the Walter Reed Army Institute of Research received final approval, and the first class was scheduled for 15 July to 15 October 1958. Although the course is designed primarily for Medical Corps officers, the first class will consist of 5 sanitary engineers, 2 entomologists, and 1 nurse. Medical Corps officers (MOS 3005), however, will attend, beginning with the second class in the summer of 1959. This training course will serve as specialized supplementary instruction for AMEDS officer graduates of civilian schools of public health. All of the eight students of the first class will be graduates with master's degrees in public health or science. Upon proper arrangement, foreign preventive medicine officers will also be given an opportunity to attend.
One preventive medicine orientation course (course 8-AF-11) was conducted at the Army Medical Service School during the year. Twenty-one Medical Corps officers on 2-year tours of duty received this 6 weeks' training. One class is scheduled in fiscal year 1959, to meet requirements for preventive medicine officers (MOS 3005).
Two Medical Corps officers were in civilian residency training in California and New York, respectively. Two other medical officers now receiving training at civilian institutions for master's degrees in public health will enter residency training in California during the forthcoming fiscal year.
Two preventive medicine officers attended the regularly recurring 2-month course in tropical medicine conducted in Central America under the auspices of the China Medical Board and the Louisiana State University School of Medicine. This course is given four times a year.
Arrangements were completed by the OTSG with the Liberian Institute of the American Foundation of Tropical Medicine in Harbel, Liberia, for the establishment of a 2-month short course for training of selected medical officers in tropical medicine. One preventive medicine officer attended this Institute (April to July 1958). It is anticipated that this training may be offered on a continuing basis as availability of personnel and funds permits.
Preventive medicine personnel assigned to continental U.S. armies, Army Medical Service School, Walter Reed Army Medical Center, U.S. Army, Europe, and U.S. Army, Caribbean, attended the Occupational Health Course sponsored by the Army Environmental Health Laboratory, 14-18 April 1958.
39
Sanitary engineers.-Although the shortage of qualified sanitary engineer officers persisted throughout the year, the training programs for both active-duty and Reserve personnel were expanded, particularly in the fields of radiological health and industrial hygiene. At the end of the year, 61 qualified sanitary engineers (MOS 7960) of the 90 authorized were on duty. The shortage was partially relieved by the use of 9 graduate sanitarians and 6 officers trained on the job as sanitary inspectors.
Entomologists.-Sufficient entomologists (MOS 3315) were obtained by direct appointment to meet the needs. As of 30 June 1958, requirements totaled 49 and 49 were on duty. Four career officers received postgraduate training in civilian universities, and three attended a short course in acarology at the University of Maryland.
Nutritionists.-Three officers on duty were qualified nutritionists (MOS 3316). Efforts to obtain more personnel have been unsuccessful. No applications for commission in this category were received.
Change in Triservice Morbidity Reporting
Department of Defense Instruction 6010.5, dated 12 June 1957, discontinued the use of the Morbidity Report as a Department of Defense standard form. This reflected a decision at the Department of Defense level that the three medical services need not maintain current comparable data on the incidence of and mortality from all the various separate diagnostic categories of diseases and injuries. The decision permits each service to limit current detailed diagnostic information to categories that it considers to be of immediate interest, and also permits the three services to use different methods of collecting current data on morbidity and mortality according to diagnosis. (Diagnosis on individual medical records, however, will still be reported in conformity with the Joint Armed Forces Statistical Classification and Basic Diagnostic Nomenclature.)
While the DOD instruction discontinued the rather detailed requirements for morbidity and mortality data embodied in the Morbidity Report, it established a basic minimum of data pertaining to the health of military forces which each service is required to maintain and provided for an exchange among the three medical services of such data regarding personnel cared for under cross-servicing arrangements.
Representatives of the Preventive Medicine and Medical Statistics Divisions, OTSG, are designing a current summary report for Army use to replace the Morbidity Report. This new report will be in use early in fiscal year 1959.
