Annex Q to CJFLCC Opord



1. (U) Situation

a. (U) General

(1) (U) Purpose. This Appendix provides a concept of operations, assigns tasks, and gives guidance for developing the health service support (HSS) for 4ID operations.

(2) (U) Applicability. Commands listed in Annex A, (Task Organization) this OPORD.

b. (U) Enemy Forces. Refer to Annex B, (Intelligence), this OPORD.

c. (U) Friendly Forces. Refer to Annex A, (Task Organization), this OPORD.

d. (U) Assumptions

(1) (U) Adequate aeromedical evacuation support will be available throughout the operation.

(2) (U) Adequate Class VIIIA/B materiel is available, and methods of resupply are adequate. Units will use a combination of unit supply and throughput to manage stock levels.

(3) (U) Adequate civilian medical facilities are not available.

(4) (U) Medical support, to some degree, will be provided to the host nation, Private Volunteer Organizations, and Non-Government Organizations.

e. (U) Limitations

(1) (U) Civilian medical resources and facilities in the AO are extremely limited and they can provide limited health service support.

(2) (U) Limited organic air MEDEVAC.

2. (U) Mission. 4ID medical units will provide combat health services in support of Division operations during Phases III - V to promote the health and provide medical treatment of combat fighting forces to minimize the effects of wounds, injuries, diseases, environmental hazards, and combat stress.

3. (U) Execution

a. (U) Concept of Support:

(1) (U) Transition to Phase III: Seize the Initiative (D-3 to D+10):

(a) (U) Organic medical assets will provide medical services for their assigned units. The 62d MSC will provide area medical coverage for those units with no organic medical support operating within the 4ID AO. The 62d MSC will attach one FST to each BCT NLT D-10. FSTs will remain attached until the end of Phase IV. BSMCs will ensure the FST is included in the BCT movement order and provide all required support once attached.

(b) (U) Unit Movement Coordinators will ensure that vehicles and key medical equipment are placed into the movement order ISO offensive operations.

(c) (U) The 62d MSC will establish one CSH into AO4 to be established in the Division Support Area (DSA), with the Sustainment Brigade and 62d MSC subordinate units. Level III requirements in the DSA will include augmented medical teams (Head/Neck, Renal/Hemo, Infectious Diseases, Specialty Care, Min Care). 62d MSC is prepared to establish additional level III capability ISO of 4ID operations.

(d) (U) All medical units will deploy from the TAA with 100% Class VIIIA and 5 DOS.

(e) (U) One FSMT will support each BCT for air MEDEVAC from the BSAs to the DSA.

(f) (U) All medical units will ensure that communication equipment is mission capable and ensure effective communication with higher level medical support prior to leaving the TAA.

(g) (U) Endstate for Phase III is the establishment of one CSH in AO4, area medical coverage for the DSA and units without organic medical capabilities, and organic medical units established in the BSAs. FSTs are operational with BSMCs. Air ambulances from 2-4 GSAB are operating ISO of BCTs; Air ambulances from the 21st AVN are prepared to augment DIV MEDEVAC assets. The 44th MDSC has augmented the 62d MSC with one ground ambulance company for evacuation to level III in the Corps area. Lines of Communication are established with the 44th MDSC for resupply and future coordination.

(2) (U) Phase IV: Offense - Decisive Operation (D+10 to D+30):

(a) (U) BSMCs and the 62d MSC will establish ambulance exchange points (AXPs) to facilitate patient transfer during combat operations.

(b) (U) 62d MSC will establish resupply procedures for Class VIIIA/B to the BSMCs.

(c) (U) BSMCs and FSTs are ready to receive, treat, stabilize casualties, and facilitate patient transfer to level III facilities.

(d) (U) 62d MSC is prepared to provide distributed combat health support up to level III for IDP and EPW medical services.

(e) (U) Endstate is synchronization of Medical Battlefield Operating Systems (BOS) and CHS established in AO4. FSTs are returned to original units in the 62d MSC and incorporated into CSHs.

(3) (U) Phase V: Establish Security and Restore Essential Services (D+30 to On Order):

(a) (U) General. Once combat operations end and control of the battle space occurs, the health services change focus from combat health support to humanitarian assistance for the local populace and preventive / supportive care of the U.S. / Coalition forces. CHS transition focus of health care services from resuscitative surgery / evacuation to medical assessment, definitive surgical care and long term critical and nursing care. This includes different equipment required to care for long term critically ill patients.

(b) (U) The 62d MSC is prepared to provide specialty teams (Preventive Medicine, Veterinary, Public Health, etc.) to restore essential health services in assigned communities.

(c) (U) FSTs are functioning in the CSHs with equipment loaded and prepared to deploy for contingency medical operations within 24 hour notice.

(d) (U) 62d MSC provides distributed combat health support up to level III for IDP and EPW medical services.

b. (U) Medical Battlefield Operating Systems:

(1) (U) Hospitalization. See Tab 1 (Hospitalization).

(2) (U) Preventive Medicine. See Tab 2 (Force Health Protection). Command emphasis is required to prevent heat, sun, and cold induced injuries. Water sources within the area of operations are considered non-potable unless approved for use by U.S. medical personnel. Use of iodine water purification tablets is not sufficient to render local groundwater safe due to the presence of multiple chemical contaminants. Subordinate and attached units will establish water surveillance programs, field sanitation operations, and execute detailed surveillance programs as outlined in Tab 2.

(3) (U) Blood. See Tab 3 (Blood / Class VIIIB). Medical units with holding capability will deploy with 60 units of PRBCs as long as cold chain management is maintained. Blood will be pushed prior to offensive operations to ensure that medical units are prepared to treat casualties.

(4) (U) Medical Logistics. See Tab 4 (Medical Logistics / Class VIIIA)

(5) (U) Veterinary Services. The 62d MSC will provide veterinary teams as necessary to promote food safety, food security, and quality assurance; provide veterinary medical care for military working dogs; and, provide veterinary preventive medicine services to prevent foodborne illnesses and diseases while inspecting rations and approving food sources.

(6) (U) Laboratory Services. The medical laboratory function is performed in the level III facilities to analyze, identify, and diagnose microorganisms in the treatment of patients and the prevention of disease. The level III medical laboratory manages blood stocks and blood components for distribution in coordination with health service logistics to the BSMCs.

(7) (U) Dental Services. Dental services are organic to the BSMCs as dental sections. Dental services are provided in the CSH and on a Theater basis from the 44th MDSC. All dental trauma and other head related injuries will be treated by the CSH, as the dental sections at the BSMC level do not have dental surgery capability.

(8) (U) Combat Stress Control. Combat stress control is a leadership responsibility. Subordinate and attached medical units will implement stress control measures, to include surveying forces to identify stressors and excess stress, and developing a program for the prevention, treatment, and return to duty of combat stress reaction casualties. The 62d MSC will provide stress control teams and medical expertise to BCTs as necessary.

(9) (U) Patient Movement

(a) (U) Evacuation and medical regulation of patients from AO4 to the Corps level III facilities is the responsibility of the 62d MSC.

(1) (U) Evacuation is a unit responsibility from point of injury to a casualty collection point or healthcare facility. Non-4ID Friendly casualties brought to a 4ID medical unit within AO4 will be placed into the medical regulation system and the G-1 will be notified to coordinate with non-4ID or coalition units for further patient evacuation and regulation. EPW casualties will be evacuated to the nearest EPW site with medical assets. NBC casualties will be decontaminated prior to entering healthcare facilities and MEDEVAC vehicles.

(b) (U) Evacuation of patients within 4ID’s AO will be coordinated with the DIV SURG, G-1, and the Theater Patient Movement Requirements Center (TPMRC).

(10) (U) Theater Evacuation Policy. The Theater Evacuation Policy is seven days for the combat zone and a combined total of fifteen days for the combat zone and the communication zone. Evacuate all patients to the nearest medical unit. Medical units will exercise further MEDEVAC as required. The 62d MSC will coordinate evacuations out of AO4.

(11) (U) Area Medical Support. Each medical company is assigned an AO to ensure all personnel receive adequate medical care. Within each company AO, the treatment platoon (with its treatment, dental, x-ray, laboratory, and patient-holding capability) forms the core of the company’s medical support. Ambulances and AXPs are established throughout the AO to facilitate patient movement to medical facilities or further evacuation to level III facilities. Each BSMC is responsible for their assigned BCT area and the 62d MSC will provide area medical coverage in the DSA and to all units without organic medical capability.

(12) (U) Command, Control, and Communication. See Tab 6. Combat Health Support (CHS) is the 62d MSC's responsibility. The Division Surgeon works in coordination with the 62d MSC Commander and Brigade Surgeons to provide guidance and planning for force health protection, future medical operations, and medical resources.

c. (U) Host Nation Support. Host nation medical facilities are inadequate for US service members and will not be used unless approved by the CFLCC Surgeon.

d. (U) Enemy Prisoners Of War (EPW), Civilian Internees (CI), and Detained Persons (DET). Initial Treatment of EPWs will comply with the provisions of the Geneva Conventions and will consist of procedures necessary to stabilize them for transfer to military medical facilities control. Seriously wounded, injured, or sick EPW are segregated from U.S. and coalition patients and evacuated from the combat zone through channels as soon as possible under appropriate security measures. Emergency and life saving care is authorized for local nationals. After stabilization, coordinate patient’s release with local health authorities.

e. (U) Tasks

(1) (U) Division Surgeon Section (DSS)

(a) The DSS plans, coordinates, and synchronizes 4ID's CHS. The DSS is also responsible for coordinating relationships of organic medical units and medical units/elements under operational control (OPCON) or attached to the division for general support (GS) or direct support (DS).

(b) (U) Plan patient care systems to support the health service support needs of the 4ID forces. Provide health service support planning and operating guidance to subordinate and attached units.

(c) (U) Exercise technical authority for subordinate and attached units for all allocated medical resources to ensure effective use to meet the health service support mission. Establish the Division Surgeon's Operations Center (DSOC) to manage and monitor the wartime patient care systems to support the health service support needs of the 4ID forces.

(d) (U) Plan and ensure medical supply (Class VIIIA / B) support is established and maintained in support of the BCTs’ health service support mission.

(e) (U) Develop and coordinate mutually supporting military Health Service Support plans to provide the most effective and efficient casualty management, and return-to-duty the maximum number of military casualties.

(f) (U) Monitor patient evacuation to level III medical care facilities.

(g) (U) Develop and implement reporting matrix for medical operations.

(2) (U) Sustainment Brigade Surgeon and BCT Surgeon Sections (BSS)

(a) (U) Push requirements to the appropriate section for action including the DSS on all emergency requests and critical requirements.

(b) (U) Execute reporting matrix IAW paragraph 4.d. below.

(3) (U) 62d Medical Support Command

(a) (U) Establish and maintain patient care systems to support the health service support needs of the 4ID forces (CHS level I through CHS level III care) IAW the Medical BOS.

(b) (U) Maintain interoperable and dedicated CHS communications systems.

(c) (U) Establish level III medical capability in Yevlakh.

(d) (U) Attach FSTs to BCTs through Phase IV.

(e) Establish MED LOG accounts and distribution system with SIMLM and BMSOs for medical supply flow (Class VIIIA/B) in 4ID.

(f) Establish AXPs with BSMCs in the BSAs. Push ground MEDEVAC assets forward into BSAs ISO combat operations.

(g) Provide area medical coverage for DSA and units without organic medical assets.

(h) (U) Be prepared to provide medical support to Enemy Prisoners of War (EPW) temporary holding facilities, EPW patient evacuation systems, and to the EPW internment camps.

f. (U) Coordinating Instructions

(1) (U) 4ID medical units will communicate and coordinate issues through BSS' to the DSS level.

(2) (U) Division medical elements will include in their supporting plans the details of medical planning as follows:

(a) (U) Medical support concept to include command and control lines.

(b) (U) Identification of significant environmental factors, special sanitary measures to include food and water discipline, and available preventive medicine support units and facilities.

(c) (U) Communications channels and frequencies used by medical personnel.

(e) (U) Ensure accompanying supplies include nerve agent antidote and treatment kits.

(f) (U) Be prepared to manage mass casualties.

(3) (U) HSS requirements, which exceed capabilities, should be passed formally through channels to the 4ID DSS.

4. (U) Administration and Logistics

a. (U) The CFLCC has identified the 44th MDSC (326th MED LOG Co) as the Single Integrated Medical Logistics Manager (SIMLM) for Class VIIIA. Requesting organizations will furnish necessary fund citations for support. All units must provide Class VIII requirements list to its higher level of support to facilitate stock replenishment until demand history is established for 4ID.

b. (U) Chain of support flows from the 326th MED LOG Co (SIMLM) in vicinity Tblisi to the 354 MED LOG Co in vicinity DSA. All BMSOs will establish accounts with the 354 MED LOG Co. Medical units will maintain the basic load of medical equipment and material prescribed in Tab 5 (Medical Logistics (Class VIIIA)), of this Appendix.

c. (U) Medical Material Disposition

(1) (U) Captured medical supplies and equipment will not be destroyed. Units having custody of enemy supplies and equipment will turn them into the supporting medical facility.

(2) (U) Recaptured medical supplies will be turned into the nearest Medical Treatment Facility for determination on its further use.

5. (U) Command and Control

a. (U) Command

(1) (U) The Division Surgeon has technical authority for medical operations within 4ID. The 62d MSC has command and control (C2) responsibility for all medical units above BCT level and will augment BAS and BSMC units with ground MEDEVAC, air MEDEVAC (Forward Support MEDEVAC Teams, or FSMTs), and Forward Surgical Team (FST) assets.

(2) (U) The 62d MSC will C2 the medical BOS throughout AO4 to include hospitalization / surgery (level III), preventive medicine, veterinary, laboratory services, blood, dental services, health logistics, combat stress control, patient evacuation / regulation, and area medical support for areas outside the BSAs and those units without organic medical capabilities.

b. (U) Control

(1) (U) Medical communications and information will be transmitted via normal unit communications channels/networks.

(2) (U) 62d MSC will ensure that medical elements have sufficient communication capability and have accessibility to medical specific systems.

(3) (U) Reports

(a) (U) MEDSTAT and SITREP (Medical) reports are due IAW 4ID TACSOP. 62d MSC and divisional medical companies will use Medical Regulating Reports (MEDREGREP) to report bed availability; to identify patients requiring beds, and movement to another facility, and designate/assign beds at another facility.

(b) (U) Blood reports are due in accordance with Tab 3.

(c) (U) Weekly Disease Non-Battle Injury (DNBI) Surveillance Summaries are due in accordance with Tab 2 (Force Health Protection) and the 4ID TACSOP.

Signature Block

Tabs

1 — Hospitalization

2 — Force Health Protection

3 — Blood / Class VIIIB

4 — Medical Logistics / Class VIIIA

TAB 1 TO APPENDIX 6 TO ANNEX I TO 4ID OPORD (U)

HOSPITALIZATION (U)

1. (U) Purpose. To describe the concept for hospital employment (level III) in support of operations given in the basic plan and document requirements and capabilities for hospital beds in the 4ID AO.

2. (U) Concept of Support. Level III will be established at TAAs and unit support areas. Aeromedical evacuation will be the link to medical facilities at the DSA for inter-theater patient evacuation.

3. (U) Requirements

a. (U) The 62d MSC will establish one CSH in AO4 in the DSA, with the Sustainment Brigade and 62d MSC subordinate units. Level III requirements in the DSA will include augmented medical teams. 62d MSC is prepared to establish additional level III capability ISO of 4ID operations.

b. (U) Based on casualty estimates, the division peak bed requirements are 365 beds during Phase IV operations.

4. (U) Capabilities

a. (U) Once established in the DSA, the level III capabilities will include: Head/Neck, Renal/Hemodialysis, Infectious Diseases, Specialty Care, Mininal Care.

b. (U) 62d MSC will maintain the capability to employ non-committed level III assets ISO 4ID operations.

5. (U) Assessment. This plan is supportable.

6. (U) Coordinating Instructions

a. (U) The DSS will monitor communications for mission sensitive, critical information and assistance.

b. (U) Each BSS will maintain contact with the DSS to ensure reporting and information is timely and accurate.

TAB 2 TO APPENDIX 6 TO ANNEX I TO 4ID OPORD (U)

FORCE HEALTH PROTECTION (U)

1. (U) Purpose. To provide the concept of operations, define the threat, and assign tasks for force health protection support for 4ID AO.

2. (U) Definitions and Assumptions

a. (U) The climate of the AO varies significantly by season. Winters are cold with heavy snowfall and subfreezing temperatures occurring during December through March. Spring and fall are relatively mild, while summers are dry and hot.

b. (U) Public health problems in the AO present a concern for 4ID personnel. Food and waterborne diseases are the number one cause of illness in the area. Unsanitary conditions in and around populated areas (e.g. dense urban areas and IDP camps) have made diarrheal diseases a principle concern.

c. (U) A limited risk of malaria exists in parts of Azerbaijan, Georgia, and Armenia.

d. (U) There is a slight risk of Diphtheria-Tetanus, primarily in areas of Georgia and Azerbaijan where people are inadequately immunized.

e. (U) Dengue fever, leishmaniasis, and plague are other diseases carried by insects in the AO.

f. (U) Heat and cold injuries are possible depending on the season.

3. (U) Concept of the Operations. Preventive medicine countermeasures will provide basic protection for deployed CFLCC forces. Medical personnel will make reports detailing the status of Force Health Protection (FHP) programs to commanders after conducting the requisite inspections or surveys. Ideally, preventive and veterinary medicine specialists conduct these surveys. The health risks of specific environmental health issues are to be assessed, and recommendations for individual/unit protection made only after a thorough analysis.

a. (U) Preventive medicine priorities for subordinate units are:

(1) (U) Priority 1. Water Surveillance

(a) (U) All water sources are to be considered non-potable until tested and approved by preventive medicine personnel. Survey, sample, and analyze raw water sources and production water every day and report findings to supported units. Record and promptly report sample results of water surveillance to quartermaster water personnel and to the DIV Surgeon's Office.

(b) (U) Determine quartermaster water unit locations.

(c) (U) Ensure that water point personnel understand Free Chlorine residual requirements of two parts per million at the point of distribution of water.

(2) (U) Priority 2. Food Service Sanitation. Medical personnel assisted by preventive medicine personnel will oversee all aspects of food service in the field to include, but not limited to, food handling practices, transportation of food items, preparation and serving, messing facilities and equipment, galley waste disposal, and food service training.

(3) (U) Priority 3. Waste Disposal

(a) (U) Proper waste disposal is essential in prevention of diseases caused by flies, rats, and other vermin that live and breed in waste disposal sites.

(b) (U) Field sanitation teams will oversee all field operations that generate large amounts of wastes each day.

(c) (U) Human waste, the wastes associated with bathing, kitchen operations, and organic and inorganic garbage, all require preventive medicine personnel oversight.

(d) (U) Be prepared to dispose of chemical and biological waste caused by chemical and biological warfare agents.

(4) (U) Priority 4. General Preventive Medicine Support

(a) (U) Monitor disease and non-battle injuries at Level I-III facilities to detect trends, which could indicate a breakdown in sanitation or preventive measures. Results of medical monitoring should be evaluated at each level of command. Unusual results detected at any level should be brought to the attention of appropriate preventive medicine and command officials.

(b) (U) Evaluate and provide appropriate recommendations to improve sanitation of food service operations and facilities, troop housing, water supplies, industrial hygiene, and other environmental problems within the supported area.

(c) (U) Evaluate waste (solid waste, liquid waste) storage and disposal to reduce communal rodent and insect problems. Tasks include the following:

(1) (U) Evaluate hazardous waste, and medical infectious waste storage and disposal.

(2) (U) Provide field sanitation training support.

(5). (U) Immunizations. 4ID personnel will comply with required immunization requirements as outlined in the CFLCC OPORD.

(a) (U) All routine vaccines will be kept up-to-date including tetanus, typhoid, polio, diphtheria, hepatitis A, and anthrax. Subordinate units will screen all deploying 4ID personnel to ensure vaccinations are current.

(b) (U) Hepatitis B. Immunization is recommended for medical personnel who may have contact with body fluids. Immunizations in support of the host nation, Private Volunteer Organizations, and Non-Government Organizations will be coordinated through the 4ID DIV Surgeon and CFLCC Surgeon.

b. (U) Report preventive medicine issues through medical channels to the 4ID DIV Surgeon, who will report to the CFLCC Surgeon and CFLCC MOC.

c. (U) Preventive Medicine Policies

(1) (U) Provide specific guidance to the Joint Force Health Protection Working Group (through 4ID DIV Surgeon and CFLCC Div Surgeon channels) on the health surveillance systems and programs.

(2) (U) Provide assistance in the control of water-borne diseases.

(3) (U) Provide assistance in the control of arthropod and rodent-borne diseases including technical consultation, entomological surveillance, and reinforcement of unit organic pest management capabilities.

(4) (U) Provide assistance and guidance in the placement and construction of food service facilities, field showers, and latrines.

(5) (U) Provide assistance in the control of food-borne diseases by monitoring food service operations and providing guidance to commanders.

(6) (U) Provide assistance in the control of excessive occupational/environmental exposures to such hazards as radiation, toxic gases, noise, and climatic extremes.

(7) (U) Provide policy guidance and monitoring compliance for immunization and drug prophylaxis activities.

(8) (U) Provide assistance to intelligence analysts in evaluating elements of the medical threat.

(9) (U) Provide guidance in developing plans for wash-down/de-snailing retrograde operations and agricultural pest inspection points during airhead/port operations reload.

(10) (U) Provide medical intelligence in-briefings and out-briefings for incoming and outgoing personnel at all aerial and seaports of debarkation.

d. (U) Subordinate medical units will provide laboratory services in support of preventive medicine personnel.

e. (U) Concept of Veterinary Operations. Within the AO, veterinary assets must inspect and approve all bulk food sources, including both non-U.S. sources as well as U.S. Government prepackaged, acquired, or produced foods. Food production facilities located in the AO must be inspected periodically and approved by military veterinary authorities for continued usage.

(1) (U) Veterinary preventive medicine assets within the JOA are responsible for periodic inspection and sanitary approval of food preparation and handling techniques in food production facilities.

(2) (U) When non-U.S. military personnel are involved in food preparation and handling, the CFLCC Surgeon (communication through 4ID DIV Surgeon office) is responsible for setting health standards for the hiring of these employees as well as establishing standards of health to be maintained for continued employment. Medical and veterinary preventive medicine assets must ensure implementation of these standards, verify continued state of good health of these employees, and ensure that proper food handling standards are being taught to these employees. All food handlers must obtain food-handling certificates, issued by military preventive medicine assets.

(3) (U) Local subsistence items will be kept to a minimum and will be inspected and tested by veterinary personnel prior to procurement.

(4) (U) Traveler’s diarrhea can be caused by viruses, bacteria, or parasites, which are found throughout the region and can contaminate food or water. Making sure food and drinking water are safe is paramount to force health protection.

(5) (U) The prevention of endemic animal/zoonotic diseases, hospitalization and evacuation policy for working dogs and other government owned animals will be in accordance with CFLCC Surgeon guidance. A veterinary officer will examine any animal that is to be sent to the United States from the AO.

(6) (U) MSC Veterinary components will coordinate for any additional requirements through the CFLCC Joint Medical Operations Center.

4. (U) Health Threat

a. (U) Food and Water-Borne Diseases. Food and waterborne diseases are major causes of illness. These conditions can be caused by viruses, bacteria, or parasites, which are found throughout the AO.

(1) (U) Typhoid Fever is a bacterial infection transmitted through contaminated food or water, or directly between people. Drinking only bottled or boiled water and eating only thoroughly cooked food reduces the risk of infection.

(2) (U) Cholera is an acute intestinal infection caused by a bacterium. Infection is acquired by ingesting contaminated water or food. The best method of prevention is to follow the standard food and water precautions. Individuals with severe cases should receive medical attention immediately.

(3) (U) Hepatitis A is a viral infection of the liver transmitted by fecal contamination; through direct person-to-person contact; from contaminated water, ice, or shellfish; or from fruits or uncooked vegetables contaminated through handling. No specific therapy is available, but immunization is effective in preventing illness.

b. (U) Insect-Borne Diseases. Many diseases are transmitted through the bite of infected insects such as mosquitoes, flies, fleas, ticks, and lice. Personnel must protect themselves from insect bites by wearing proper clothing, using bed nets, and applying the proper insect repellent. Mosquito activity is most prominent during the hours between dusk and dawn.

(1) (U) Malaria is a serious parasitic infection transmitted to humans by the mosquito.

(2) (U) Dengue Fever is primarily an urban viral infection transmitted by mosquito bites. The illness is flu-like and prevention is important since no vaccine or specific treatment exists.

(3) (U) Leishmaniasis is a parasitic disease transmitted by the bite of some species of sand flies. The disease most commonly manifests either in a cutaneous (skin) form or a visceral (internal organ) form. One or more skin sores that develop weeks to months after a person is bitten by infected sand fleas characterize cutaneous leishmaniasis.

(4) (U) Plague can be acquired by the bite of rodent fleas, by direct contact with infectious materials, or by inhalation of infective respiratory droplets. Initial signs and symptoms are flu-like with swollen lymph nodes.

c. (U) Person-to-Person Diseases

(1) (U) Human immunodeficiency virus (HIV) which causes Acquired Immunodeficiency Syndrome or AIDS is found primarily in blood, semen, and vaginal secretions of an infected person. The human immunodeficiency virus is spread by contact with an infected person, by needle sharing among injecting drug users, and through transfusions of infected blood and blood clotting factors. Treatment has prolonged the survival of some HIV infected persons, but there is no known cure or vaccine available.

(2) (U) Hepatitis B is a viral infection of the liver. Primarily, Hepatitis B is transmitted through activities, which result in the exchange of blood or blood-derived fluids and/or through sexual activity with an infected person. The primary prevention consists of either vaccination and/or reducing intimate contact with those suspected of being infected.

(3) (U) Meningococcal Disease (bacterial meningitis) is a bacterial infection in the lining of the brain or spinal cord. Repository droplets spread this when an infected person sneezes or coughs on you.

d. (U) Other Diseases

(1) (U) Schistosomiasis is an infection that develops after the larvae of a flatworm have penetrated the skin. Water treated with chlorine or iodine is virtually safe, and salt water poses no risk. The risk is a function of the frequency and degree of contact with contaminated fresh water for bathing, wading, or swimming. It is often difficult to distinguish between infested and non-infested water; therefore, swimming in fresh water in rural areas should be avoided.

(2) (U) Rabies is a viral infection that affects the central nervous system. The virus is introduced by an animal bite. The best prevention is not to handle animals that are suspect. Any animal bite should receive prompt attention.

(3) (U) Avian influenza is a viral infection that affects the respiratory system (causing fever, cough and flu-like illness) and can cause death in a high percentage of infected individuals. Contact with infected birds (e.g. ducks, chickens, turkeys, geese and other water fowl) is the main mode of transmission. Person-to-person transmission has not been confirmed as a major mode of disease acquisition. The best prevention is to avoid contact with birds/fowl and to wash hands thoroughly and frequently with soap and water or alcohol-based cleaning solutions (particularly after suspected exposure). Individuals with respiratory symptoms should seek medical care promptly. Medical personnel and contacts of patients with respiratory symptoms should adhere to strict hand and respiratory hygiene measures (frequent hand washing, covering coughs/sneeze, appropriate use of respiratory masks, and limiting exposure to infected patients)

e. (U) Vector Control

(1) (U) The control or eradication of animal and insect vectors of disease, and the application of pesticides to control these vectors may be required. Integrated pest management should be part of any pest control program, but must be directly supervised by trained Preventive Medicine (PM) personnel. Accordingly, all pest control operations will be coordinated through the servicing Preventive Medicine unit.

(2) (U) Personal protective measures are the first line of defense for military personnel in the field. The combined use of permethrin to impregnate the uniform and DEET for application to the skin offers unprecedented levels of protection from blood-sucking arthropods. Proper instruction in the use of these repellents, uniform wear, bed netting, and appropriate command emphasis to ensure compliance will provide better than 90% protection.

(3) (U) Shelters should be designed to ensure minimal entry of insects, arthropods, and rodents. This can be achieved through the appropriate disposal of waste, proper preparation of food, decreasing the amount of standing water, and the use of screens and bed nets.

5. (U) Tasks. The number one goal for Commanders and Preventive Medicine personnel is to maintain the health of the troops and employ resources efficiently and effectively to maximize disease and injury prevention efforts. The following tasks are essential in accomplishing this mission:

a. (U) Ensure clean water.

b. (U) Appropriate use of personal protective measures.

c. (U) Epidemiological services.

d. (U) Ensure safe sanitation.

e. (U) Vector control.

f. (U) Provide minimum diagnostic capabilities.

g. (U) Provide disease and injury prevention, to include comprehensive troop education programs.

6. (U) Coordinating Instructions

a. (U) The DSS will coordinate with the CFLCC Joint Force Health Protection Working Group to standardize, coordinate, execute, and monitor all aspects of deployment health surveillance within the AO.

b. (U) Preventive Medicine personnel will effect direct liaison with quartermaster water purification and distribution units within their geographical area of support.

c. (U) Preventive medicine units must effect direct liaison with veterinary units to coordinate the evaluation of ice plants and potable water plants, and to assist in pest management operations in and around food storage and distribution points.

d. (U) Preventive medicine units must provide direct liaison with MTFs in the AO to facilitate and ensure collection of information to prepare Health Reports and Situation Reports (SITREPS).

TAB 3 TO APPENDIX 6 TO ANNEX I TO 4ID OPORD (U)

BLOOD / CLASS VIIIB (U)

1. (U) Purpose: To provide guidance for the management and procurement of Class VIIIB.

2. (U) Assumptions: Ample Blood will be available and modes of supply are maintained.

3. (U) Execution:

a. (U) Concept of the Operation:

(1) (U) Medical companies and Forward Surgical Teams initial deployment blood requirement issue is 60 units Packed Red Blood Cells (PRBCs) type Group O, Rh positive and negative mix.

(2) (U) ID tags and cards will only be used to identify Rh negative patients so that they may receive Rh negative PRBCs. Priority of Rh negative PRBCs will be transfused to Rh negative females if there is a shortage of Rh negative blood. If a female patient has no ID tag or card then ONLY Group O, Rh negative PRBCs will be given.

(3) (U) Planning factors and guidance: 4.00 units PRBCs for each surgical patient. 15 lbs of ice / collins box / day. Use of thermostabilizers are preferred when power generation is stable and consistent.

(4) (U) Transportation: Blood will be transported by the most expeditious means, preferably by military air. Maximize the use of air ambulance for delivery (backhaul) to forward units.

b. (U) Tasks:

(1) (U) BSMCs will maintain direct coordination with the Brigade Medical Supply Officer (BMSO) for all blood requirements.

(2) BMSOs submit daily blood Report (BLDREP) to their supporting level III CSH.

(3) The CSH will maintain adequate supplies of blood products and coordinate with the 62d MSC for resupply.

(4) The 62d MSC will coordinate with the 44th MDSC as the Class VIIIA / B SIMLIM for medical resupply.

c. (U) Coordinating Instructions: The BLDREP is submitted by the BSMC regarding requirements and use of blood as of 0800Z to be received by the BMSO NLT 0900Z hours. The BMSOs will forward BLDREP to the CSH for further submission to the Joint Blood Program Office. Emergency requisitions will be processed priority 03.

d. (U) Communications: All blood reports and requests will have an IMMEDIATE precedence and be classified as Confidential.

TAB 4 TO APPENDIX 6 TO ANNEX I TO 4ID OPORD (U)

MEDICAL LOGISTICS / CLASS VIIIA

1. (U) Purpose: To provide guidance for the management and procurement of medical materiel.

2. (U) General:

(1) (U) The Army serves as the Single Integrated Medical Logistics Manager (SIMLM) for the JOA. Each Medical Logistics (MED LOG) activity in the JOA will support US services and attached coalition forces with Class VIIIA in their respective AOs.

(2) (U) Class VIIIA flows into theater from the USA Medical Material Command Europe (USAMMCE) to the SIMLM (44th MDSC, 326th MED LOG SPT CO) located in vicinity Tblisi. The 44th MDSC exercises overall directive authority for CHS logistics in the JOA as directed by CFLCC.

(3) (U) The SIMLM, 326th MED LOG SPT CO, assumes the responsibility for planning and executing the health service logistics support for CFLCC. The SIMLM ensures Class VIIIA requisitions are received, processed, and distributed forward.

(4) (U) The SIMLM establishes procedures for initial requirement requisitions and issue of CHS supplies / materials to supported units. Additional CHS line items are added based on utilization rates or as supported by documented demand requirements. Emergency CHS supply requirements that are not satisfied by the established supply points, are passed to USAMMCE.

(5) (U) All Class VIIIA requisitions are submitted via TAMMIS Customer Assistance Module (TCAM). Brigade Medical Supply Offices (BMSOs) will ensure connectivity to the 62d MSC and the 62d MSC will ensure connectivity to the SIMLM. The 62d MSC will utilize the 10th MLMC to fix technical problems with TCAM within the 4ID AO.

(6) (U) Routine Requisitions of Class VIII Supplies. BCTs request Class VIII supplies from their supporting BMSO utilizing the CHL functional module of TCAM. Those requisitions that are not filled are passed to the MED LOG CO in the DSA using TAMMIS or TCAM. If the requested items are available for issue, a materiel release order is printed and the requested supplies are prepared for shipment. For items not available for issue, the requests are passed to the next higher level of supply in the Corps. The MED LOG CO forwards status to the unit on items shipped and on those requests that were not filled. Shipment of medical materiel from the MED LOG CO is coordinated with SUST BDE and the Division Movement Control Office (MCO). Shipments may be sent through medical backhaul using returning medical transportation when possible. Shipments of Class VIII supplies to medical platoons of the BCTs are shipped to the supporting BMSO. The BMSO will coordinate with the BSB support operations section for delivery of Class VIII supplies from the BSA to forward deployed medical elements.

(7) (U) Emergency Requisitions. Emergency requisitions from medical units in the BCTs are submitted to the supporting BMSO under priority 03. When the BMSO is unable to fill the request, the requisition is forwarded through the MEDLOG CO and the DIV SURG Section is informed. The DIV SURG Section will direct cross-level issues between division medical elements as necessary and track open emergency requisitions. All emergency requests received by the MEDLOG CO are processed immediately for shipment by the most expedient transportation available. The MEDLOG CO immediately passes all emergency requests not filled to the next higher level. The HSMO of the DIV SURG Section has the responsibility of monitoring all emergency requisitions not filled by the MED LOG CO.

3. (U) Execution:

a. (U) Concept of Support:

(1) (U) Phase III: Seize the Initiative (D-3 to D+10):

(a) (U) MED LOG activities will ensure medical units deploy the TAA with 100% Class VIIIA and 5 DOS on-hand. Coordination is made to receive open requisitions once units are established within AO4. The MSC will provide area MED LOG coverage for those units with no organic medical materiel support operating within the 4ID AO. BMSOs will ensure the FSTs have provided a reorder list and coordinated with the MED LOG CO for medical-surgical resupply.

(b) (U) MED MAINT personnel will ensure that all customer equipment is returned to the unit. All medical equipment must be fully operational and meet 10/20 standards prior to leaving the TAA.

(c) (U) MED LOG activities will ensure their ordering systems are loaded with the appropriate TCAM updates and can communicate with their higher level of support. All units are instructed to backup and batch save Class VIII systems daily and keep hard copy records of demand history. Communications equipment is tested and mission capable to ensure effective communication with higher level medical support prior to leaving the TAA.

(d) (U) MED LOG activities will forward consolidated customer lists by DODAAC, UIC, POCs, and APCs to the MED LOG CO and the HMSO in DIV SURG Section. Accounts and signature cards must be complete and validated prior to departing the TAA.

(2) (U) Phase IV: Offense - Decisive Operation (D+10 to D+30):

(a) (U) BMSOs and the 62d MSC will establish Lines of Communication to facilitate Class VIII distribution. The primary means of distribution will be provided by the 62d MSC or SUST BDE pushing Class VIII LOG packs forward to the BSAs. As supplies move forward, MED LOG units will coordinate with the receiving customer and establish a timeframe of delivery to ensure supplies are received.

(b) (U) BMSOs are responsible to coordinate for receipt of Class VIII within the BSAs if not delivered directly to the BMSO warehouse.

(c) (U) BMSOs are responsible for coordinating new locations with the MED LOG CO if the BSA changes locations.

(3) (U) Phase V: Establish Security and Restore Essential Services (D+30 to On Order):

(a) (U) Transition from CHS to HN / IDPE / NGO Class VIII support.

(b) (U) Reconstitute DIV medical unit Class VIII stocks.

c. (U) Reporting: MED LOG reports will be submitted IAW TACSOP and CFLCC Reporting Matrix.

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