Annual Report the Surgeon General United States Army Fiscal Year 1959
PREVENTIVE MEDICINE
Communicable Disease Control
Common respiratory disease and influenza.-Total Army rates for common respiratory disease and influenza declined in fiscal year 1959 from the unusual heights of the previous year's Asian influenza epidemic to levels approximating the usual respiratory disease rates. A peak of about 260 cases per 1,000 mean strength per year was reached in February and March. Although cases of proved influenza were not reported in excessive numbers, they consisted of both A and B strains.
Streptococcal disease and rheumatic fever.-Streptococcal disease rates were higher than in the past, reaching a peak in March of 19.4 cases per 1,000 mean strength per year for the total Army. Reports indicated a similar increase among civilians. The relation of this increase to improved diagnosis or to actual increased incidence is not known. The Fifth U.S. Army continued to lead all areas in incidence, but, unlike previous years, Fort Carson, Colo, did not have the highest rate among installations, partly because of the practice of giving benzathine penicillin prophylaxis to recruits and partly because of the gradual closing out of recruit training there. The highest incidence among installations was at Forts Leonard Wood and Riley in the Fifth U.S. Army Area and at Fort Dix in the First U.S. Army
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Area. In spite of the increase in incidence of streptococcal disease, there was a decrease in the rate of rheumatic fever, an indication that detection and treatment of streptococcal disease were improved. In November, an explosive epidemic of streptococcal disease, probably foodborne, occurred among personnel of the Army Security Agency in Asmara, Eritrea.
Enteric diseases.-In general, the incidence of enteric diseases was similar to that of recent years. During the Lebanon operation, however, rates increased and subsequent investigation revealed the presence of Shigella (dysentery organisms) in many returnees. It is not known how many of these individuals were infected in Europe before going to Lebanon. A high incidence of gastroenteritis and infectious hepatitis was reported among U.S. personnel in Asmara and in Saudi Arabia. In the major commands, troops in Korea continued to show the highest incidence of infectious hepatitis. An epidemic of typhoid fever occurred among immunized dependents and other personnel at an American youth camp in Germany during July and August. The source was definitely determined to be a German foodhandler who was a carrier. There was no known secondary spread of the disease.
Insectborne diseases.-In spite of large-scale epidemics of infectious encephalitis among natives of Japan, Korea, and Okinawa during the first quarter of the fiscal year, only five cases involving U.S. Army personnel were reported in those areas. Cases of malaria, yellow fever, filariasis, and other insectborne diseases were infrequent or absent. One case of kala-azar was reported from Eritrea.
Venereal disease.-Incidence remained low and control activities were satisfactory. Recurring laboratory reports of decreased sensitivity of gonococcal infections to penicillin were not reflected by increased rates.
Staphylococcal disease.-Infection with staphylococcus was not a major problem in Army medical facilities. Such infections did occur, however, and efforts were made to detect sources and to institute preventive measures, chiefly by elimination or control of carrier personnel and by improvement of sterile technique.
Rubella.-The incidence of rubella was unusually high, especially in recruit training centers, in February and March. Rates during these months were more than double the previous 5-year median.
Poliomyelitis.-Incidence of poliomyelitis among Army personnel and their dependents was low, the majority of cases in the latter group being reported from Hawaii. The occurrence of many cases of ECHO (enteric cytopathogenic human orphan) and Coxsackie virus infections
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U. S. Army Hospital, Camp Kue, Okinawa
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resembling nonparalytic poliomyelitis was demonstrated by virus isolation and serologic studies on personnel in Hawaii.
Tuberculosis.-Deletion of First Test Strength Tuberculin from the Armed Services Medical Stock List was recommended. This action was not concurred in by the Navy or the Air Force; therefore, deletion for the Army alone is being carried out.
Meningitis.-Incidence of meningitis was slightly higher during the spring of 1959 than during the same period in the previous year.
Smallpox.-An epidemic of 18 cases of smallpox among German civilians occurred in and around Heidelberg in December and January. All U.S. personnel in the involved area were revaccinated, and no cases occurred. Strict enforcement by USPHS of quarantine regulations pertaining to reentry into the United States resulted in the detention of some Americans returning during the epidemic. Among those detained were infants under 6 months. There appeared to be a reluctance in some USAREUR medical facilities to vaccinate infants of this age. This deficiency was corrected.
Epidemic hemorrhagic fever.-A marked increase in the incidence of epidemic hemorrhagic fever occurred in Korea in April and May with 20 and 11 cases, respectively, occurring among U.S. Army personnel in those two months. Clothing impregnation and insect- and rodent-control activities were increased, and provisions were made for continuing these activities at an increased tempo through fiscal year 1960.
Miscellaneous.-An epidemic of an unidentified disease resembling infectious mononucleosis was reported in December from Asmara. Approximately 90 cases occurred among U.S. military personnel and their dependents. Investigation by a representative of the Preventive Medicine Division, OTSG, failed to establish the etiology but did reveal the presence of a number of sanitary defects at the station. Despite steps to correct the defects, similar cases continued to occur in 1959.
Biological warfare.-The Communicable Disease Branch of the Preventive Medicine Division was assigned the responsibility for coordinating biological warfare activities in the Office of The Surgeon General.
Immunization activities.-The immunization regulations were revised and republished as triservice regulations. The Army version appeared in AR 40-562 on 21 July 1958, superseding AR 40-230 and SR 40-230-1. Four major changes appeared in the regulations, as follows:
1. The frequency and number of required typhoid-paratyphoid reimmunizations were reduced for personnel in CONUS, Canada, Alaska, and Hawaii.
2. First reimmunization of cholera, typhus, and plague vaccines was made part of the basic series of each vaccine, thus creating a three? instead of a two-dose series.
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98th General Hospital, Neubr?cke, Germany
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3. The use of poliomyelitis vaccine was established as a requirement for personnel under 40 years of age going overseas, and Changes 2 later established this immunization as a requirement for personnel under 40 years of age, regardless of location.
4. Tetanus-diphtheria toxoids, combined, were designated as the standard agent for these immunizing agents, and the Schick-test requirement was dropped.
Influenza vaccine.-Upon the recommendation of the Commission on Influenza of the Armed Forces Epidemiological Board, the influenza vaccine to be used in 1959-60 was modified to include newer strains (AA/1/57 instead of PR 301). Immunization of Army personnel is directed in DA Circular 40-35, dated 25 March 1959.
Adenovirus vaccine.-Two firms have been licensed to produce adenovirus vaccine, and indications are that five others will enter bids. This vaccine is expected to become available starting early in 1960.
Combined tetanus and diphtheria toxoids and pertussis and poliomyelitis vaccines.-This material has been approved by the National Institutes of Health, and authorization is being published for its procurement by nonstandard purchase for use in children under 5 years of age.
Combined tetanus and diphtheria toxoids and poliomyelitis vaccine.-The Medical Research and Development Command has been requested to investigate the possibility of developing a combined agent capable of simultaneous immunization against tetanus, diphtheria, and poliomyelitis.
Lyophilized smallpox vaccine.-Tests conducted at Walter Reed Army Institute of Research have indicated that lyophilized smallpox vaccine has a high degree of stability and effectiveness. Satisfactory packaging has been developed, and preliminary steps are being taken to standardize the vaccine.
Recruit training at Fort Carson.-As a result of The Surgeon General's recommendations made in February 1959 to the Army Chief of Staff regarding the streptococcal disease problem at Fort Carson, it was decided to eliminate recruit training at that installation. Training requirements later necessitated a temporary modification of this policy.
Occupational Health
The Army Occupational Health Program continued to expand to meet the health problems created by industrial developments and by the increasing complexity of the newer weapons systems. The responsibilities, scope, and objectives of the program were discussed both at The Surgeon General's Commanders Conference and at the Biennial Pre?
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ventive Medicine and Laboratory Officers Conference. The occupational health survey activities, including industrial hygiene, carried out by USAEHL (U.S. Army Environmental Health Laboratory), are still the most productive sources of factual data upon which to base recommendations for controlling potential health hazards in the work environment.
Occupational medicine.-Claims processed by the Veterans' Administration for loss of hearing incurred in military service now amount to more than $30 million annually. The audiometric test program initiated at Fort Dix, N.J., has shown the feasibility of testing large groups within the framework of Army administrative procedures. It is estimated that the identification of persons having defective hearing among the first 10,000 men tested at Fort Dix has resulted in a saving of $125,000. This amount represents potential claims against the Government, calculated at minimum compensation rates. Thus, the test program has more than paid for itself.
During the year, it became apparent that a lack of understanding of the true nature and magnitude of potential hazards to health in the work environment may disrupt morale and create anxiety among employees. Two riggers working in the vicinity of a radar antenna developed bizarre symptoms which they attributed to exposure to microwave energy. Investigation of the circumstances of the alleged exposure, together with prompt and thorough medical examinations of the two men, did not substantiate the claim. However, these actions materially contributed to allaying the fears and anxieties of other employees. It appeared that a thoughtless remark made in jest by a passerby to the riggers regarding the danger of working with radar created this episode.
An employee, using certain heavy metals, believed that ionizing radiation was the chief hazard associated with his work and that he was being harmed. Fortunately, correct information was given to the employees of that department which brought the situation into proper perspective and prevented further baseless fears. Because of these and similar incidents, particular effort is being made to disseminate to medical personnel accurate information regarding newer occupational health hazards as they are recognized.
Industrial hygiene.-The industrial hygiene survey activities of USAEHL continued to provide both quantitative and qualitative data regarding the work environments at class I and class II military installations. Inasmuch as it has been reported that two chromate spray operators, employed by other services, had developed carcinoma of the lung, particular attention is being given to chromate primer spray operations.
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Funds were obtained for USAEHL to develop the capability of measuring power density fields at radar installations. Many requests have been received from the field for this service. Procedures have been developed for making complete environmental health surveys at Nike sites.
Radiological hygiene.-The protection of Department of the Army military and civilian personnel against hazards to health from ionizing radiation is a dominant part of The Surgeon General's occupational health program. Although some 30,000 persons were exposed to ionizing radiation, no acute damaging exposures occurred during the year.
Among the varied sources of exposure were radium, medical and dental X-ray equipment, industrial radiography, linear accelerators, betatrons, power reactors, nuclear weapons and weapon materials, industrial and medical radioisotopes, and high-voltage X-rays.
The excellence of the control program was due to the conscientious and intelligent application of good radiological hygiene by the installations, activities, and troops utilizing such material and equipment. Through the universal use of film badges throughout the Army and from reports of overexposed badges, The Surgeon General is able to monitor continuously the results of these control programs. Periodic surveys of all sources of ionizing radiation made by representatives of The Surgeon General provide the means for furnishing direct consultation and advice to local commanders on radiological hygiene.
Each month during the year, there was an increase in the number of special problems in radiation protection requiring specific answers. The uses of radium in lensatic compasses and in emergency telephone switchboards were evaluated, and steps were taken to reduce to a minimum the use of radium in Army equipment. A policy was developed on the use of tritium in luminous paints. The single-value criterion was set for radioactivity permissible in drinking water for combat troops. Simultaneously, a workable concept was developed for the purpose of evaluating for radioactivity the quality of drinking water in the field. The design of the high-energy linear accelerator for the Quartermaster ionizing radiation facility for food irradiation was evaluated for health hazards. The problem of exposure of personnel to radiation during the on-site storage and loading of nuclear weapons was studied. A calibrator for radiation detection equipment was evaluated, and means were provided to distribute it to field units in order to give them maximum protection against health hazards.
There is every reason to expect that the number of radiation-producing materials and equipment possessed by the Army will continue
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to increase. The use of radioisotopes for research and industrial process control is expanding; the power reactor program is only beginning, and in the next few years mobile and semimobile reactors will have been built ; nuclear weapons, especially tactical weapons, are increasing in number and are being handled by more people; and development can be expected of many pieces of equipment that will use radiation as a source of energy for low-level illumination at night or to activate atomic batteries and generators. For each new development, the radiological hygiene program will have to provide thorough and practical protection for personnel that will not impede the Army mission.
Occupational vision and conservation of hearing.-These two programs, designed to provide better protection for the vision and hearing of Army personnel, continue to grow. More than 90 percent of the Army industrial installations now have occupational vision programs. Plans are being made to develop a 'package' conservation hearing program similar to that utilized so successfully in the vision program.
Safety.-To promote a more effective safety program in the AMEDS class II system, courses in safety training at New York University and Northwestern University continued to be offered to personnel of the various installations. The Automotive Crash Injury Research Program, sponsored by the Armed Forces Epidemiological Board, remained a vital part of the safety program in which the medical facilities of the various Army class I and class II installations took part.
Civil Public Health
The Civil Affairs Functional Manual on Public Health was com?pleted and approved for early publication. This manual is urgently needed and should be of great value in any possible future civil affairs or military government situation involving U.S. forces. Of some 21 projected functional manuals pertaining to civil affairs, this is be-lieved to be the first completed.
Two medical officers, one each from Walter Reed Army Institute of Research and the Army Medical Service School, attended the basic course on Civil Affairs at Fort Gordon, Ga., and two spaces in the course were made available for Army health nurses early in fiscal year 1960.
A proposed plan that delineates AMEDS support of refugees in future foreign theaters of war was prepared and forwarded to the Office of Civil Affairs for consideration by the general staff.
Recommendations made during the fiscal year for increasing AMEDS officer spaces and grades in the TOE for Civil Affairs were approved and included in TOE 41-500R.
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Environmental Hygiene
Major accomplishments in the broad field of environmental hygiene during the year included the following:
1. In coordination with DCSLOG (Deputy Chief of Staff for Logistics) and the Offices of the Chief of Engineers and The Quartermaster General, recommendations were made to the Eighth U.S. Army for the control and prevention of hemorrhagic fever.
2. Timely information was supplied to personnel for the prevention of heat and cold injuries.
3. The TOE for a new preventive medicine unit was proposed.
4. A Vector Control Detail Training course was suggested for each army area in CONUS.
5. A recommendation was made that a study be undertaken to evaluate the use of Wescodyne as a general-purpose disinfectant and to provide a basis for issuing instructions regarding its use to personnel in the field.
Entomology.-The development of insect resistance to insecticides continues to be one of the principal problems in medical entomology and requires constant surveillance of arthropod vectors in all areas of Army operation. Close coordination and cooperation is maintained through the AFPCB (Armed Forces Pest Control Board) with the World Health Organization and with Federal agencies in matters of insect-resistance testing and surveillance. During the Lebanon operations, it was found that houseflies in the area were completely resistant to chlorinated hydrocarbon insecticides; locally procured malathion gave adequate control. Mosquitoes in Okinawa have been found to be resistant to DDT, dieldrin, lindane, and chlordane, necessitating the use of malathion for control.
A fog machine and a mist-dust blower, developed by the Engineer Research and Development Laboratories, are being service tested by the 714th Preventive Medicine Company. Recommendations have been made to provide for the issue of a 2-gallon sprayer to each company, battery, or similar-sized unit, for use by vector control details, and for the sprayer to be retained by the unit if ordered into the field. Justifications for these recommendations are contained in the After Action Report of the Lebanon operations, submitted in the Essential Technical Medical Data Report from USAREUR for the fourth quarter of 1958, and in a letter from the Army Medical Service School.
Sanitary engineering.-Noteworthy among the year's accomplishments in the field of sanitary engineering were the following:
1. Evaluation of two types of small sewage-treatment plants at Nike sites.
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2. Action taken to standardize the membrane filter field kit for analyzing field water supplies.
3. Revision of DD Form 686, Bacteriological Examination of Water.
4. Study of sewage disposal from tuberculosis hospitals.
5. A staff study on developing a career field for warrant officers as environmental health assistants.
6. Advice to the Chief of Engineers on the Fort Belvoir water supply.
7. A continuing study of the infectious wastes problem, particularly in hospitals.
8. Participation in a study for the Office of Civil and Defense Mobilization of a list of sanitary items necessary for survival in nuclear warfare.
9. A continuing study on the tripartite Army water purification standard.
10. Evaluation of hydrofluosilicic acid as an additional compound to be used in water fluoridation.
11. Revision of the career progression plan for sanitary engineers.
12. Review and preparation of a scenario for a film relating to detection and decontamination of radiation in food and water.
13. Return to the Office of The Quartermaster General of the proposed 1, 5, and 10 parts per million field chlorination test kit for further study after field evaluations indicated serious limitations.
14. Studies of industrial wastes at several Army industrial plants.
Nutrition
Active interest in the field of nutrition is maintained by representation of The Surgeon General at meetings of the Interdepartmental Committee on Nutrition for National Defense and at the Master Menu Board bimonthly meetings.
The revision of TM (Technical Manual) 8-501, Nutrition, is still under revision, but publication early in fiscal year 1960 is anticipated.
Army Health Nursing
Visits by the chief of the Health Nursing Branch of the Preventive Medicine Division to 23 installations in the Military District of Washington and in the First, Second, and Third U.S. Army Areas revealed that the Army health nursing programs in all of these areas were well organized but lacked written policies pertaining to the nurse's role in relation to prevention and control of communicable disease.
The draft of the proposed manual, TM 8-272, Army Health Nursing, has been submitted to the Personnel and Training Division, OTSG,
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for publication. The proposed Army Regulations prescribing records for health nursing has also been submitted for publication.
A request for the production of a 30-minute training film pertaining to Army health nursing has been approved, and the script is being written. Also approved was a workshop for nurses in health nursing and outpatient departments to be conducted at the Walter Reed Army Institute of Research, 25-30 April 1960.
Preventive Medicine Personnel and Training
The Army Medical Service required and was authorized 74 spaces for preventive medicine officers during the fiscal year. These spaces were all filled, 40 of them being in CONUS and 34 overseas. Of these officers, 33 are Regular Army career preventive medicine officers and 9 are career reservists. The other 32 are young physicians, serving an obligatory 2-year military term, who received only a brief orientation course in military preventive medicine before their assignment. Of the 42 Regular Army and career Reserve preventive medicine officers, 34 are presently board certified.
Procurement of potential preventive medicine officers continues to be a serious problem. As in civilian life, it is difficult to attract young physicians into this field. It is apparent that the young physician, having been oriented to the individual patient throughout his training is not especially interested in the health problems of the community and has little interest in groups early in his professional life. Experience shows that it is the more mature individual who, having had an opportunity to serve in various parts of the world and having functioned as a medical administrator, develops a broad appreciation of total medical service and enters the field of public health. At the present time, there are 10 officers in various stages of career training in preventive medicine. To provide supplementary training, an Advanced Military Preventive Medicine course was established at Walter Reed Army Institute of Research. Great effort has been made to interest young physicians, both military and civilian, in a preventive medicine career in the Army. A loss of more than 30 career officers in this field is anticipated in the next 10 years. At least five officers per year must be trained in this specialty in order to maintain future personnel requirements.
It has long been realized that opportunities for training in communicable disease control, particularly that dealing with the so-called exotic diseases, have been diminishing within the military framework. Yet, it is believed that the Army must have at least a small number of experts in this field among its career officers, and various plans to meet
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this requirement are being studied. At the end of the summer of 1958, an officer was sent for 2 months to the Tropical Institute of Liberia to observe tropical diseases. The Army Medical Service is now a regular participant in the fellowships in tropical medicine offered by the Louisiana State University, and four officers each year are participating in this splendid experience in Central America. The Army space on the four-man student team, which spends 2 months in Central America four times each year, is rotated among preventive medicine specialists, internists, and laboratory officers. Negotiations are underway with the International Cooperation Administration to place a well-trained career officer on duty for 2 years with this organization in one of its field teams as an epidemiologist.
A residency training program in occupational medicine has been established at USAEHL. Approval of the American Medical Association has been requested. This program will meet, in part, the training requirements of the American Board of Preventive Medicine for certification in the subspecialty of occupational medicine. It is now possible to provide recognized training within the Army in this medical specialty at a facility engaged in solving the occupational health problems found at military industrial activities.
Sufficient entomologists (MOS 3315) were obtained by direct appointment to meet the needs during the fiscal year; requirements totaled 44, and 44 were on duty. Three career officers received postgraduate training at civilian universities, and three attended a short course in acarology at the University of Maryland. Two officers who had previously received the master of public health degree at civilian universities attended the 3-month Advanced Military Preventive Medicine Course. During the fiscal year, five entomologists attended short courses in insect and rodent control presented by the Communicable Disease Center of the U.S. Public Health Service, Atlanta, Ga.
The shortage of qualified sanitary engineers became even more acute during the year. Despite the procurement of 12 new officers, the total strength of sanitary engineers dwindled from 64 to 54 as contrasted to a total manning authorization of 80. One new Regular Army officer was commissioned, making a total of 27 as compared to an authorization of 37. Three applications for Regular Army commission were still being processed. The recruiting program by senior sanitary engineers was expanded considerably, and results to date give promise of substantially overcoming the shortage of total officers during the fiscal year. Two sanitary engineers received postgraduate training at civilian universities; five attended the Military Preventive Medicine Course at Walter Reed Army Institute of Research, and two completed the Army
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Medical Service Officer Advanced Course. Eight officers were certified by the American Sanitary Engineering Intersociety Board and named as diplomates of the American Academy of Sanitary Engineers.
A space was allocated the Health Nursing Branch for attendance at a 2-week workshop in Nursing Research at the Walter Reed Army Institute of Research, 24 February-7 March 1959. Three nurses have completed graduate training in public health and have received the degree of master of public health. The OTSG Professional Education and Training Committee approved the application of two Army health nurses to enter civilian institutions in the fall of 1959 for training in public health leading to the master of public health degree. One nurse attended the Army Medical Service Advanced Course (8-A-C4) and one attended the Preventive Medicine Orientation Course (8-A-F11), both at the Army Medical Service School. Two nurses have been selected and will attend the 41-G-F1 course, Civil Affairs, to be given at the Civil Affairs School at Fort Gordon during the first quarter of fiscal year 1960. One nurse completed the 3-month Preventive Medicine Officers Advanced Course given at the Walter Reed Army Institute of Research. At the close of the fiscal year, there were 73 nurses with a primary MOS 3431 (Army health nurse) and 11 nurses with MOS in other specialties who are assigned to health nursing programs throughout the Army.
Publications
In the field of preventive medicine, five Army regulations, five Department of the Army circulars, and two TB MED's (technical medical bulletins) were published during fiscal year 1959. Another TB MED was revised. The publications were as follows:
AR 40-562, Prevention and Control of Communicable Diseases of Man, Immunization Requirements and Procedures, 21 July 1958, and Changes 2, dated 9 March 1959.
AR 40-569, Food Service Sanitation, 25 July 1958.
AR 40-582, Evaluation and Reporting Internal Exposure to Radioactive Materials, 14 October 1958.
AR 40-583, Hazards to Health from Microwave Energy, 9 September 1958.
AR 140-123, Army Reserve: Immunization, 25 May 1959.
DA Circular 40-32, Immunizations for Oversea Travel, 14 October 1958.
DA Circular 40-33, Preventive Cold Injury, 3 November 1958.
DA Circular 40-35, Influenza Immunization 1959-60, 25 March 1959.
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DA Circular 40-36, Prevention of Heat Injury, 4 May 1959.
DA Circular 40-38, Licensing of Radioisotopes, 2 June 1959.
TB MED 257, Coccidioidomycosis (issued jointly with Navy and Air Force), 25 July 1958.
TB MED 258, Q Fever (issued jointly with Navy and Air Force), 8 October 1958.
Changes 2 to TB MED 81, Cold Injury, 13 May 1959.
