Page 128 - Journal of Special Operations Medicine - Fall 2017

and personnel were tenants on the DoS compound and relied 20% of the warehouse service’s food items originated from
on DoS services for both feeding and living arrangements. The DLA-approved sources.
DoS had contracted a company to provide much of the com-
pound’s support functions. The contractor had further sub- Food items that originated on farms, such as produce, were
contracted the dining facility operations to a second company. first trucked in from the farm to an airport, then flown in to
Contracting and subcontracting are common practices among Kuwait and trucked to the warehouse location in Iraq. At the
government entities, including the DoS and DoD. However, warehouse, the food items underwent a wash in a 100–200
the DoS, and hence the DoS contractors, abide by different ppm solution of chlorine, then rinsed in municipal water. The
food policies and controls than those of the DoD. As a re- warehouse used International Organization for Standardiza-
sult, only approximately 20% of the DoS subcontractor’s food tion (ISO) 17025:2005 standards and filtered municipal water
sources originated with DLA-approved sources. The remain- onsite. The filtration system at the warehouse site had been
ing 80% of food sources originated through non–DLA-ap- tested twice weekly by a contracted laboratory and annually
proved vendors. against the U.S. National Primary Drinking Water Standards
(40 CFR 141.63). Food purchased by the dining facility was
The DoD, in contrast, uses only food vendors who are first vet- shipped by truck to the DoS compound. Public health officials
ted through the DLA to procure 100% of food stuffs for DoD monitored shipment receipts. The dining facility stored ship-
dining facilities. The military recognizes that disease and non- ments until the food was needed for use. The food was then
battle injury can greatly affect combat operations. The speed taken to a preparation room and sampled for microbiological
with which disease can spread, even via a single source such activity before placement on the serving line. The microbio-
as water or food, can cause battle tempo to slow or even cease logical sampling occurred in an in situ subcontractor-operated
as combatants succumb to illness. Given the importance of food laboratory. Dining facility personnel routinely collected
having a healthy fighting force and considering past negative food samples of all menu items, which were then held for 24
experiences, the DoD has come to recognize the importance of hours. Microbiological analyses then were conducted on ap-
protecting its food supply; therefore, it leverages the services proximately 6 to 10 of the collected food items.
of the DLA. The DLA audits food vendors for best practices
and performs a risk-based analysis for the selection of poten- The subcontractor used a licensed medical provider at the
tial vendors. Food shipments follow a chain of custody that dining facility to examine employees before their shifts for
includes security measures, trace-back and trace-forward sys- signs or symptoms of illness. Before the GI illness outbreak,
tems, and a system of checks and controls to mitigate not only all dining facility employees had been regularly checked and
foodborne illness but potential food tampering as well. screened daily for medical concerns such as lacerations, cuts,
open wounds, dermatological issues, fever, diarrhea, respira-
Outbreak Setting tory infections, and general overall health before their work
The outbreak of GI illness occurred on a DoS compound in shifts. In addition, handwashing surveys had been conducted
Baghdad among a combined diplomatic and military popula- biweekly whereby patrons were observed for compliance
tion. The compound population totaled approximately 1,000 with handwashing with soap and water before dining. These
personnel and comprised multinational military forces who surveys had maintained a 100% compliance rate for several
were primarily American, American diplomatic or DoS em- months before the outbreak.
ployees, and third-nation contracted employees. The popula-
tion was approximately 90% male. All personnel were older The dining facility received its water from a series of wells. The
than 18 years, the majority of the population was younger water was moved from production to consumption through
than age 40 years, and the median age was approximately 23 buried polyvinylchloride pipes. The well water was tested daily
years. at the points of production and of consumption for nine qual-
ity parameters: total and free available chlorine, pH, turbidity,
Aside from the one communal dining facility, several private electrical conductivity (salinity), presence of coliform bacteria,
food vendors sold food on the compound. Both the dining fa- hardness, alkalinity, and total dissolved solids. As mentioned,
cility and private food vendor premises had previously been the dining facility water underwent annual testing against the
inspected monthly by public health professionals. Inspec- U.S. National Primary Drinking Water Standards (40 CFR
tions conducted by military public health personnel assessed 141.63). The dining facility used the treated well water for
the hygiene of the respective facilities, the grounds, and staff; juice and soup preparation, food washing, food preparation
the safety of food preparation, serving, and storage practices; surface and device cleanings, and personal hygiene. The col-
and other factors with potential health effects. The military’s lected well water was purified by reverse osmosis and treated
main consistent finding was that most food sources supplying with chlorine.
the DoS dining facility did not originate with DLA-approved
vendors. The compound’s source of individual drinking water was pri-
marily commercial bottled water. The commercial water plant
The DoS dining facility subcontractor procured food though a was DLA approved and had been inspected annually by U.S.
warehouse service. The warehouse purchased food stuffs from Army veterinarians. The bottled water supplies consistently
a wide variety of sources, including international suppliers, lo- passed testing against the National Primary Drinking Water
cal suppliers, and a few DLA-approved sources. The main in- Standards in accordance with 21 CFR 165.
ternational suppliers originated in Turkey and the United Arab
Emirates. Other international suppliers originated, for example, There were six community-based first level Role 1 clinics,
in Kenya (avocados) and Ecuador (bananas). No requirement which provided basic health-care services. Two hospitals, one
existed for food items to have been procured from DLA- military and one diplomatic, served as the next higher level
approved sources; however, by coincidence, approximately of care. Sick-call hours at the Role 1 clinics were limited to

124 | JSOM Volume 17, Edition 3/Fall 2017