SAPPORO, Japan — The soldiers live in cramped quarters, sleeping on bunks and cots mere inches apart. They use common dining and bathroom facilities.

In their spare time, they play cards and share snacks, even drinks. Strangers are greeted with handshakes, and over a single day, some doorknobs will get turned by hundreds of palms.

And it’s human nature for people to touch their own eyes, noses and mouths without a second thought. But a cough or sneeze in the wrong direction can trigger a chain reaction the Army is diligently fighting to prevent — not only in war zones but also in large field exercises such as North Wind.

In Hokkaido’s deep snow and wicked wind, dressing warmly just isn’t enough. The influenza bug can bite in any weather.

Flu outbreaks crop up routinely and can spread rapidly on droplets, with deadly consequences. There hasn’t been a pandemic in more than four decades, but medical experts say it’s just a matter of time.

"The question is not if another will occur, but when," said Dr. Eric Morgan, an Army lieutenant colonel, family-practice physician and deputy commander for clinical services at the Brig. Gen. Crawford F. Sams U.S. Army Health Clinic on Camp Zama. "The flu is one of the top 10 killers in the U.S. right now — there are 36,000 deaths a year. It’s nothing to take lightly."

Just as troops are flown to Afghanistan and Iraq from all over the world, the same long-distance air travel is necessary to get participants to events like North Wind. While the majority flew in from Kentucky, support elements represent National Guard units around the United States. That can exacerbate flu concerns because of the time spent in an aircraft’s confined spaces.

Major outbreaks at Army basic training have stopped platoons in their training tracks, according to Morgan. Officials are working to avoid that at North Wind.

‘Nobody wants another Orient Shield’

In February 2008, U.S. Army Japan’s Orient Shield exercise at Nagano was on the verge of being shut down after 65 soldiers — about 20 percent of the American forces there — fell ill with the flu. It’s unclear how many Japanese troops became sick.

Morgan, called in from Camp Zama to assist, thought the cases could top 100 and that it might even reach the local community.

It’s possible someone brought the virus in during travel, he said, or it might have latched onto a soldier during one of the social exchange events. No one knows for sure. But the outbreak transpired over a 10-day stretch.

Doctors and medics used an armory to isolate sick soldiers and essentially hit the entire camp population with Tamiflu, the anti-viral drug.

"That helped dramatically slow it down and contain it. There were no more new occurrences," Morgan recounted. "But it could have spread further if people started traveling."

The exercise proceeded as planned, but dozens of soldiers couldn’t participate.

"It was hitting people and hitting them very hard," Morgan recalled. "There were some reductions in training events, but it did not curtail it."

The Nagano episode was a wake-up call for USARJ medical leaders.

"Last year got our attention," said Col. Marilyn Brew, the U.S. Army Medical Activity-Japan commander. "Nobody wants another Orient Shield."

This year, soldiers got reminders about regular hand washing, maintaining distance in close quarters, and cough and sneeze etiquette — using the inside of a sleeve or elbow instead of the hands.

Before an exercise, sanitary inspections of dining and bathroom facilities are conducted and food handlers face medical screenings before making the trip, according to Col. Thomas Little, an environmental science officer and commander of the U.S. Army Center for Health Promotion and Preventive Medicine-Pacific at Camp Zama.

"So far this year, we have not identified any influenza type A," Brew said. "People have been really diligent taking the preventive steps and following our recommendations. It’s those little things that can make all the difference in the world."

At North Wind 2009, officials also created a little more space for U.S. and Japanese troops. There are now four per tent instead of up to eight, which had been the case in previous exercises.

"We’re trying to make it a habit instead of a practice," said Capt. Eric Rhodes, chief of the Pacific center’s field preventive medicine division at Zama. "That reduces the opportunity for communicable diseases to spread."

Immunizations act as ‘body armor’

Japan Ground Self-Defense Force troops taking part in North Wind received flu vaccinations. They’re mandatory for U.S. servicemembers.

"Immunizations are your body armor," Morgan said. "It’s not perfect, but you can reduce the damage being done.

"There can be side effects. A couple of days later, people sometimes feel bad. … [But] that does not compare to the flu itself. A flu shot does not lay you up in bed."

The Defense Department ordered 3.44 million doses of vaccine for this flu season, including 1.8 million doses of the intranasal vaccine Flumist. Only the injectable vaccine was sent to Central Command personnel, including those in Iraq and Afghanistan.

For young healthy adults who receive an annual flu vaccination, a recent Department of Defense study suggests, injections may be a better choice than Flumist.

"However, further studies in young adult groups that have not been highly vaccinated with influenza vaccine are needed," said Lt. Col. Wayne E. Hachey, director of preventive medicine and surveillance for the Defense Department’s health affairs office. "In addition, further studies comparing vaccine effectiveness in years when vaccine strains don’t match circulating strains well are also needed."

He said studies in young children suggest disparities in vaccine success, which could be affected by different population dynamics, immunization history and seasonal changes in circulating influenza strains.

"Although these findings should be considered for future military policy decisions on influenza vaccination," Hachey said, "they are only one part of a very complicated decision-making process."

Stars and Stripes reporter Jeff Schogol contributed to this story.

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