Armed Forces Health Surveillance Center Research Articles

Exertional rhabdomyolysis: an analysis of 321 hospitalised US military service members and its relationship with heat illness

IntroductionExertional rhabdomyolysis is a syndrome of muscle breakdown following exercise. This study describes laboratory and demographic trends of service members hospitalised for exertional rhabdomyolysis and examines the relationships with heat...

775. The Burden of Arboviral Infection in the Military Health System, 2011-2019

BackgroundTravel-related arboviral infections are important preventable, emerging infectious diseases, with an estimated annual global toll of US$950 million. We investigated the burden of arboviral infections in the military health system (MHS).MethodsKAPOS (Deployment and Travel Health: Knowledge, Attitudes, Practices, and Outcomes Study) is a multi-cohort study evaluating the burden of travel-associated diseases in the MHS. The MHS Data Repository was searched for International Classification of Diseases (ICD)-9/10 codes for arboviral infection in military beneficiaries receiving care in military treatment facilities (direct care) or civilian centers (purchased care) for fiscal years 2011-2019. Diagnostic codes were classified as Dengue, Chikungunya, Zika, or other arboviral infection. 755 outpatient charts in the direct-care system were randomly selected for diagnostic validation using Armed Forces Health Surveillance Center case definitions, and review of travel history, medical comorbidities, and pre-travel counseling.Results11,066 unique-patient ICD codes for arboviral infections were identified; 6356 (57.4%) were direct care; 4710 (42.6%) were purchased care; 889 (8.0%) were inpatient. Median age was 31 years; 5110 (46.2%) were active duty. The most frequent ICD codes for arboviral infection were Japanese encephalitis virus (JEV) (n=4483), dengue (DENV) (n=1786), yellow fever (YF) (n=230), Zika virus (ZIKV) (n=217), West Nile virus (WNV) (n=171), and chikungunya virus (CHIKV) (n=91). DENV codes were confirmed in 166/249 (66.7%) charts; CHIKV in 23/41 (56.1%), and ZIKV in 15/129 (11.6%). No cases of JEV were confirmed in 171 encounters; all codes referred to JEV vaccine administration. 173/204 (84.8%) of confirmed arboviral cases did not undergo pre-travel counseling.ConclusionArboviral infections constitute a substantial burden of preventable infections within the MHS. Dengue contributed the largest burden of arboviral infection when corrected for accuracy. Coding for ZIKV and JEV likely overestimated the burden of these diseases in the MHS. Low rates of pre-travel counseling among patients with confirmed, non-endemic arboviral infections represent an opportunity for increased emphasis on travel counseling and insect-avoidance precautions.Disclosures All Authors: No reported disclosures

Environmental Exposures and Asthma in Active Duty Service Members.

Reports of respiratory symptoms, including asthma and hyper-reactive airway disease, have been more numerous in the media and medical literature since active duty service members (SM) began to support campaigns in South West Asia (SWA). Numerous environmental exposures have been reported and this review assesses the available evidence surrounding exposures, confounding conditions, and attempts to develop screening mechanisms. While particulate matter exposures and particularly exposure to burn pits have garnered much attention, a 2010 Armed Forces Health Surveillance Center report and 2011 Institute of Medicine publication did not identify a link between exposure to particulate matter with SM respiratory disease. The "Study of Active Duty Military for Pulmonary Disease related to Environmental Deployment Exposure," (STAMPEDE) and STAMPEDE II have not identified effective forms of routine screening and these and other sources point to the importance of other factors in SM respiratory disease. These include higher than anticipated rates of tobacco use in deployed settings, impacts of obesity, recurrence of childhood asthma, and of confounding conditions such as Paradoxical Vocal Fold Motion. As with the general population, a complex set of clinical inputs and environmental exposures surround asthma and similar respiratory processes in SM. Concrete relationships and mechanisms for assessment continue to be assessed and refined, but clear associations and pathways have remained elusive.

Resuscitation of Hypotensive Traumatic Brain Injured Animals With Spray-Dried Plasma Does Not Adversely Alter Physiology and Improves Blood-Brain Barrier Function.

According to the Defense and Veterans Brain Injury Center and the Armed Forces Health Surveillance Center, the number of soldiers who have sustained a traumatic brain injury (TBI) has risen dramatically over the past decade. Studies have shown that brain damage can be exacerbated if blood loss occurs (often occurring in polytrauma). As blood supply is critical for brain function and survival, TBI patients must be properly resuscitated to maintain blood volume, blood pressure, and cerebral perfusion. Recent studies have suggested that blood loss can damage the vascular endothelium and enhance blood-brain barrier (BBB) permeability. Brain endothelial cells and the tight junctions between them are key structural components of the BBB. As the BBB is critical for isolating the brain from potential pathogens and for regulating the influx of molecules into the brain, evaluation of resuscitation fluids for their efficacy to improve BBB function has clinical relevance. Although whole blood and fresh frozen plasma (FFP) contain the essential coagulation factors, ions, and other factors, the transport and storage of these products in remote, austere environments can be challenging. The use of spray-dried plasma (SDP) has several advantages including storage at ambient temperature, can be readily reconstituted before use, and infectious materials can be inactivated during the drying process. In this study, we compared FFP and SDP for their effects on blood pressure, cerebral blood flow, BBB integrity, and markers of endothelial cells and tight junction proteins, in TBI animals with blood loss. All procedures were reviewed and approved by the UTHealth animal welfare committee. Sprague Dawley rats received controlled cortical impact brain injury followed by removal of 25% blood volume. Animals were resuscitated 40 minutes later with either FFP or concentrated SDP (Resusix) Heart rate and blood pressure were monitored continuously using catheters implanted into the femoral artery. Cerebral perfusion was assessed using a scanning laser Doppler device. Twenty-four hours after the injury and resuscitation with either FFP or SDP, BBB integrity were monitored by measuring the amount of Evans Blue dye in the injured brain following its intravenous administration. As this dye is excluded from the uninjured brain, its presence in the injured brain is an indicator of BBB breakdown. In addition, von Willebrand Factor immunohistochemistry was used to examine endothelial cell loss, whereas claudin-5 immunohistochemistry was used to assess the loss of tight junctions, in FFP- and SDP-resuscitated TBI animals. Our results show that post-TBI resuscitation with FFP and SDP had similar influences on cardiovascular physiology and cerebral perfusion. Resuscitation with SDP after TBI was found to decrease BBB permeability as indicated by reduced Evans Blue dye extravasation, and increased levels of von Willebrand Factor and claudin-5, as compared to resuscitation with FFP. These preclinical results show that resuscitation with SDP may be superior to FFP, and support the further evaluation of this product as a resuscitation fluid for polytrauma patients with TBI.

Medical Redeployment in Soldiers With and Without Medical Deployment Waivers.

Historically, disease and nonbattle injuries (DNBI) have caused more casualties during military operations than enemy combatants. Recent deployments to U.S. Central Commands (USCENTCOM) area of operation (AOR) have demonstrated similar outcomes. Intuitively, appropriate medical standards for our deploying Soldiers should result in no greater redeployments rates for those Soldiers who are waived for various medical conditions. However, no formal study has been published on redeployment rates of Soldiers with medical deployment waivers. The objective of this report was to evaluate the redeployment rates of Soldiers with and without medical waivers. A matched retrospective cohort study design was used in this study. Data were obtained from USCENTCOM, Army Central Command, Transportation Command, and the Armed Forces Health Surveillance Center. All U.S. Soldiers deploying to USCENTCOM's AOR with a medical deployment waiver during the calendar years of 2008-2013 were eligible for inclusion into the exposure group of this study. Soldiers with a medical deployment waiver were matched 1:5 to Soldiers without a medical deployment waiver. The Soldiers with a medical deployment waiver and their matched counterparts were then subdivided into 5 strata on the basis of their diagnosis. A McNemar's χ2 test was performed to calculate risk ratios (RRs) per strata and for the group as a whole. The overall risk of being medically evacuated because of DNBI for all medical deployment waivers was an RR of 2.03 (CI: 1.74, 2.36). The greatest risk of being medically evacuated because of DNBI was from the group of Soldiers on a waiver for neurological conditions with an RR of 3.81 (CI: 1.99, 7.30). The RR of medical evacuation because of DNBI was increased and statistically significant for all strata (p < 0.05). There is a statistically significant increased RR of Soldiers with a Modification of the Operational Order waiver being medically redeployed for a DNBI reason from USCENTCOM's AOR from 2008 to 2013 compared with their matched peers without a waiver. The results of this study provide Commanders with additional information when making decisions regarding Soldier deployment.

The Relationship Between Enlistment Body Mass Index and the Development of Obstructive Sleep Apnea in the U.S. Military.

The incidence of obstructive sleep apnea (OSA) in the military has risen dramatically. OSA is considered "service connected" and compensable by the Veterans Administration. The association between body mass index (BMI) (kg/m(2)) measured at initial enlistment and development of OSA has yet to be assessed. Data were obtained from the Defense Medical Surveillance System, the Armed Forces Health Surveillance Center, U.S. Department of Defense, Silver Spring, Maryland (inclusive dates:1993-2012; release date: December 2013). A study population of 550,000 randomly-selected active duty enlisted personnel was followed retrospectively from January 1, 2008, through December 31, 2012, or until diagnosis with OSA, separation from the military, or death occurred. The main exposure of interest was BMI recorded at time of enlistment. Adjusted hazard ratios for enlistment BMI were calculated using BMI of 23 to 23.9 as reference. Exponentially increasing risk for OSA was observed as BMI increased. The heaviest individuals (BMI > 35) were at the highest risk (hazard ratio: 3.93; 95% confidence interval [CI]: 3.35-4.62) for developing OSA. Enlistment BMI's role in developing OSA may be valuable in designing screening tools and preventive interventions in higher-risk groups, as well as prompt further consideration in the realm of military enlistment policy.

Incidence of Norovirus-Associated Medical Encounters among Active Duty United States Military Personnel and Their Dependents.

BackgroundNorovirus is a leading cause of gastroenteritis episodes and outbreaks in US military deployments, but estimates of endemic disease burden among military personnel in garrison are lacking.MethodsDiagnostic codes from gastroenteritis-associated medical encounters of active duty military personnel and their beneficiaries from July 1998–June 2011 were obtained from the Armed Forces Health Surveillance Center. Using time-series regression models, cause-unspecified encounters were modeled as a function of encounters for specific enteropathogens. Model residuals (representing unexplained encounters) were used to estimate norovirus-attributable medical encounters. Incidence rates were calculated using population data for both active duty and beneficiary populations.ResultsThe estimated annual mean rate of norovirus-associated medically-attended visits among active duty personnel and their beneficiaries was 292 (95% CI: 258 to 326) and 93 (95% CI: 80 to 105) encounters per 10,000 persons, respectively. Rates were highest among beneficiaries <5 years of age with a median annual rate of 435 (range: 318 to 646) encounters per 10,000 children. Norovirus was estimated to cause 31% and 27% of all-cause gastroenteritis encounters in the active duty and beneficiary populations, respectively, with over 60% occurring between November and April. There was no evidence of any lag effect where norovirus disease occurred in one population before the other, or in one beneficiary age group before the others.ConclusionsNorovirus is a major cause of medically-attended gastroenteritis among non-deployed US military active duty members as well as in their beneficiaries.

Enhancing the Department of Defense's Capability to Identify Environmental Exposures Into the 21st Century.

Military service members come in contact with a wide range of hazardous substances especially during deployment. The identification of service member's with potential exposures to infectious diseases and environmental toxic substances has been a problem for the U.S. military almost since the formation of the services and continues to be an issue today. In June and July of 2013, the Armed Forces Health Surveillance Center sponsored two meetings to address the need by the Department of Defense to perform retrospective exposure analysis that would support military force health protection efforts. The first meeting included medical professionals who were familiar with health problems that followed potential environmental or infectious disease exposures but that the military health system was unprepared to address. The second group was composed of technical experts who were asked to suggest potential material and nonmaterial solutions to address the needs of the military public health community. This supplement to Military Medicine includes the outcome of these two meetings, descriptions of some of the Department of Defense biorepositories including the large serum repository housed at Armed Forces Health Surveillance Center and discussion of additional topics related to the establishment and use of biorepositories that would support public health practice in the 21st century.

Maximizing the Utility of the Serum Repository With Current Technologies and Recommendations to Meet Future Needs: Report of the Technical Panel.

The Department of Defense Serum Repository (DoDSR) of the Armed Forces Health Surveillance Center (AFHSC), Silver Spring, Maryland, has over 55 million specimens. Over 80% of these specimens are linked to individual health data. In response to Congressional and Department of Defense (DoD) concern about toxic exposures of deployed Service members and rapidly developing laboratory capabilities that may identify those exposed, the AFHSC hosted two panels in 2013. The first, the Needs Panel, focused on assessing the needs of the DoD that may be met using the current DoDSR and an enhanced repository. The second panel, the Technical Panel, focused on identifying the emerging laboratory technologies that are or will be available to DoD public health workers and researchers. This report summarizes the recommendations of the Technical Panel, to include identified gaps in the ability of the current DoDSR to address questions of interest to the DoD, the availability of laboratory technology to address these needs, and the types and quality of specimens required from Service members possibly exposed.

Maximizing the Capabilities of the DoD Serum Repository to Meet Current and Future Needs: Report of the Needs Panel.

In June 2013, the Armed Forces Health Surveillance Center, Silver Spring, MD, hosted two panels of civilian and military public health and laboratory professionals to address medical surveillance and primary care needs of the Department of Defense (DoD) that might be met by a biorepository that contained specimens that would be suitable for testing using emerging laboratory technologies. The first panel, the "needs panel," was asked to identify capabilities that were needed by the Military Medicine community to better perform their jobs but were either not presently available or not supported by specimens archived in the current DoD Serum Repository (DoDSR). A second panel, the "technology panel," considered whether current technology existed to support the needs identified by the first panel. This report summarizes the findings of the needs panel, to include recommendations regarding both current capabilities using the DoDSR and possible future capabilities.

A Brief Description of the Operation of the DoD Serum Repository.

Beginning in 1985, the United States military has consistently maintained repositories of frozen human serum for force health protection reasons. The separate repositories created by the Army, Navy, and Air Force during the startup of their human immunodeficiency virus (HIV) screening programs were fully combined by 1996, along with the Defense Medical Surveillance System, to form the DoD Serum Repository (DoDSR). Currently comprised of 450,000 square feet of storage space at a constant -30 degrees Celsius, the DoDSR, operated by the Armed Forces Health Surveillance Center (AFHSC), receives approximately 2 million new serum specimens per year as a result of current HIV screening programs and pre- and post-deployment serum collection. Following initial testing for HIV when required, each specimen remains frozen until needed for clinical testing or a public health study, and its physical location is carefully tracked. Certain militarily-relevant research studies occur, though the serum from a specific individual is never allowed to be fully exhausted. AFHSC maintains careful control over the repository, utilizing a scientific review board to determine which requests for serum will be granted. As of 2012, only 0.42% of all of the frozen specimens in the DoDSR had been thawed for any type of use. The addition of new specimen processing capacity and significant changes to policy would be required if more of the specimens were to be used to answer relevant epidemiological, operational, or medical research questions.

Increased Risk of Functional Gastrointestinal Sequelae After Clostridium difficile Infection Among Active Duty United States Military Personnel (1998–2010)

Some acute enteric infections are associated with the development of functional gastrointestinal disorders, most commonly irritable bowel syndrome but also other functional and organic gastrointestinal sequelae. Clostridium difficile infection has increased in incidence and severity, however, few studies have evaluated functional disorders after this infection. We evaluated the epidemiology and sequelae of C difficile in the US military population by using the US Department of Defense's Armed Forces Health Surveillance Center Defense Medical Ecounter Database. We then performed a retrospective cohort study of 891 active-duty US military personnel who developed C difficile from 1998to 2010 and 3231 matched subjects who had not been exposed to C difficile. Subjects were identified based on International Classification of Diseases, 9th revision, Clinical Modification codes for C difficile disease. C difficile was associated independently with increased rate ratios (RRs) for incident irritable bowel syndrome (RR, 6.1; 95% confidence interval [CI], 2.9-12.9), gastroesophageal reflux disease (GERD) (RR, 1.9; 95% CI, 1.4-2.6), dyspepsia (RR, 3.3; 95%, 1.4-7.7), and constipation (RR, 2.2; 95% CI, 1.3-3.7). Approximately 14.1%of subjects with C difficile later were identified with one of these functional gastrointestinal disorders (FGDs), compared with 6% of controls. Community- and health care-associated Cdifficile were associated at similar rates with these sequelae. Patients were at increased risk for FGDs within 3 months of a Cdifficile episode, with one additional case of FGD developing for every 12 diagnoses of C difficile. The incidence of community- and health care-associated C difficile has increased in the US military population from 1998 through 2010. As for other gastrointestinal infections, C difficile disease is associated with clinically relevant functional sequelae in this military population.

Description and utilization of the United States department of defense serum repository: a review of published studies, 1985-2012.

Specimens in the United States Department of Defense (DoD) Serum Repository have accumulated in frozen storage since 1985 when the DoD began universal screening for human immunodeficiency virus. Use of the stored serum for health research has been carefully controlled, but the resulting publications have never been systematically identified or described. The Armed Forces Health Surveillance Center (AFHSC) information systems and open (online) sites were used as data sources. Through 2012, the repository contained 54,542,658 serum specimens, of which 228,610 (0.42%) have been accessed for any purpose. Between 2001 (the first year that comprehensive, digital records were available) and 2012, 65.2% of all approved requests for serum were for healthcare or public health investigations, but greater than 99% of all shipped samples were for research. Using two different methods – a structure search of PubMed and an exhaustive online search based on records from AFHSC – we identified 76 articles published between October 1988 and March 2013 that covered a multitude of infectious diseases, injuries, environmental exposures and mental health conditions through analysis of antibodies, biological metabolic, signaling and regulatory substances, Vitamin D, organochlorines, dioxin, omega-3-fatty acid, and portions of human deoxyribonucleic acid. Despite its operational and scientific value, it appears that the DoD Serum Repository has been underutilized. Changes to policy and increased capacity for specimen processing could increase use of the repository without risking privacy or the availability of specimens for the healthcare of individual service members in the future.

Gonorrhea surveillance in Ghana, Africa.

We face the specter of global transmission of highly resistant Neisseria gonorrhoeae. The U.S. Department of Defense's Armed Forces Health Surveillance Center has engaged many military and civilian partners (including Ghana) in a sexually transmitted infections (STI) program to address emerging needs in STI surveillance. We implemented gonorrhea surveillance in Ghana to fill the gap in knowledge regarding gonorrhea prevalence and antimicrobial resistance characterization in Ghana. Gonorrhea surveillance was conducted from June 2012 to March 2013 as one of the AFHSC surveillance network partners at two Ghana Armed Forces (GAF) military clinics. The population encompassed a convenience sampling of patients presenting with STI symptoms. Urine was taken for nucleic acid amplification testing (NAAT). A urethral or cervical/vaginal specimen was obtained for culture and antibiotic susceptibility testing. 13/220 (6%) specimens tested were positive by culture (7 of which were confirmed); and 39/213 (18%) specimens tested were positive by NAAT. Positive results were biased toward men. Cultures were resistant to ciprofloxacin, penicillin and tetracycline and sensitive to cephalosporins. This investigation provides data on gonorrhea prevalence and resistance profiles in Ghana hitherto poorly characterized. We note significant resistance to fluoroquinolones without the presence of resistance yet to the cephalosporins.

Strengthening malaria prevention and control: integrating West African militaries' malaria control efforts. The inaugural meeting of the West African Malaria Task Force, April 24-26, 2013, Accra, Ghana.

From April 24 to 26, 2013, the Armed Forces Health Surveillance Center and the U.S. Africa Command cosponsored the inaugural meeting of the West Africa Malaria Task Force in Accra, Ghana. The meeting's purpose was to identify common challenges, explore regional and transcontinental collaborations, and to share knowledge about best practices in the fight against malaria in West Africa. Military representatives from Benin, Burkina Faso, Ghana, Liberia, Niger, Nigeria, Senegal, and Togo participated in the Task Force; various U.S. Government agencies were also represented, including the Department of Defense, the Centers for Disease Control and Prevention, and the Agency for International Development. African nation participants presented brief overviews of their military's malaria prevention and control measures, surveillance programs, diagnostic capabilities, and treatment regimens emphasizing gaps within existing programs. Representatives from U.S. agencies discussed activities and capabilities relevant for the region, challenges and lessons learned regarding malaria, and highlighted opportunities for enhanced partnerships to counter malaria in West Africa. This article summarizes the major conclusions of the Task Force meeting, identifies relevant focus areas for future Task Force activities, and outlines opportunities for further inclusion of West African militaries to improve regional malaria surveillance and control efforts.

Epidemiologic modeling in the Department of Defense: capability and coordination opportunities.

INTRODUCTION Epidemiological models increasingly help to guide preparation for and response to public health emergencies. For example, the Secretary’s Advisory Council on Public Health Preparedness, in the U.S. Department of Health and Human Services (HHS), formed a smallpox modeling working group in 2002 to guide national bioterrorism planning. The White House consulted modeling groups supported by the National Institutes of Health to assess pandemic mitigation strategies when the influenza A(H5N1) and influenza A(H1N1)pdm09 strains emerged. In the United Kingdom, authorities used modeling results in establishing control measures during the 2001 foot-and-mouth disease outbreak. Real-time biosurveillance systems model epidemiologic patterns to identify possible disease outbreaks. Epidemiologic models also facilitate evaluation of epidemic control measures once used, such as HIV treatment as a prevention strategy. The U.S. National Strategy for Pandemic Influenza Implementation Plan, issued in 2006, requires the HHS, in coordination with the Department of Defense (DoD) and Department of Homeland Security, to establish a “modeling center with real-time epidemic analysis capabilities” to support policyand decision-makers. This center is currently under development in the HHS Office of the Assistant Secretary for Preparedness and Response/Biomedical Advanced Research and Development Authority (ASPR/BARDA). Within the DoD, various organizations support or conduct epidemiologic modeling, and could constitute part of the interagency network centered within HHS. However, in workshops held by the Armed Forces Health Surveillance Center (AFHSC) or the DoD Global Emerging Infections Surveillance and Response System (DoD-GEIS; now part of the AFHSC) in 2005–2010, and by U.S. Northern Command (USNORTHCOM) in 2005, participants noted that the DoD lacks formal procedures for coordinating across these programs. As a result, DoD decision-makers sometimes have received conflicting results from different models or modeling efforts, with no procedures in place to reconcile conflicts or ensure transparency of methods, assumptions, and data across efforts. As a step toward improved epidemiologic modeling capabilities and coordination in the DoD, the AFHSC convened the DoD Epidemiologic Modeling Coordination Working Group (WG) in February 2013 in an effort to identify, coordinate, and assess current DoD efforts, and provide recommendations for improving them.

A retrospective cohort study on the influence of UV index and race/ethnicity on risk of stress and lower limb fractures

BackgroundLow vitamin D status increases the risk of stress fractures. As ultraviolet (UV) light is required for vitamin D synthesis, low UV light availability is thought to increase the risk of vitamin D insufficiency and poor bone health. The purpose of this investigation was to determine if individuals with low UV intensity at their home of record (HOR) or those with darker complexions are at increased risk of developing stress fractures and lower limb fractures during U.S. Army Basic Combat Training (BCT).MethodsThis was a retrospective cohort study using the Armed Forces Health Surveillance Center data repository. All Basic trainees were identified from January 1997 to January 2007. Cases were recruits diagnosed with stress fractures and lower limb fractures during BCT. The recruit’s home of record (HOR) was identified from the Defense Manpower Data Center database. The average annual UV intensity at the recruits’ HOR was determined using a U.S National Weather Service database and recruits were stratified into low (≤3.9); moderate (4.0-5.4), and high (≥5.5) UV index regions. Race was determined from self-reports.ResultsThe dataset had 421,461 men and 90,141women. Compared to men, women had greater risk of developing stress fractures (odds ratio (OR) = 4.5, 95% confidence interval (95%CI) = 4.4-4.7, p < 0.01). Contrary to the hypothesized effect, male and female recruits from low UV index areas had a slightly lower risk of stress fractures (male OR (low UV/high UV) = 0.92, 95%CI = 0.87-0.97; females OR = 0.89, 95%CI = 0.84-0.95, p < 0.01) and were at similar risk for lower limb fractures (male OR = 0.98, 95%CI = 0.89-1.07; female OR = 0.93, 95%CI = 0.80-1.09) than recruits from high UV index areas. Blacks had lower risk of stress and lower limb fractures than non-blacks, and there was no indication that Blacks from low UV areas were at increased risk for bone injuries.ConclusionsThe UV index at home of record is not associated with stress or lower limb fractures in BCT. These data suggest that UV intensity is not a risk factor for poor bone health in younger American adults.

SAGES Update: Electronic Disease Surveillance in Resource-Limited Settings

The Suite for Automated Global Electronic bioSurveillance (SAGES) is a collection of modular, flexible, open source software tools for electronic disease surveillance in resource-limited settings. SAGES software development, funded by the US Armed Forces Health Surveillance Center, continues as we add new international collaborators.

Racial Differences in the Incidence of Acute Low Back Pain in United States Military Service Members

An epidemiological study. To determine the effect of race on the incidence of acute low back pain, resulting in a health care encounter in active duty military service members. Although racial differences in the incidence of low back pain have been documented in previous studies, currently no consensus exists on the relative risk between these groups. A query was performed using the Armed Forces Health Surveillance Center database for the International Classification of Diseases, Ninth Revision code for low back pain (724.20). A total of 12,399,276 person-years of data were analyzed and stratified by age, race, and sex. Incidence rates were calculated and compared using the multivariate Poisson regression analysis. A total of 467,950 cases of low back pain resulted in a visit to a health care provider in our population, with an overall incidence rate of 37.74 per 1000 person-years. Asians/Pacific Islanders had the lowest incidence rate of 30.7 and blacks had the highest with 43.7. Female sex and older age were also significant risk factors but with significantly different effect sizes between racial groups. Native Americans/Alaskan Natives demonstrated the greatest effect of age on low back pain incidence rates, with a 126% increase between the youngest and oldest age groups compared with a 36% difference in whites. Race, sex, and age were all found to be significant risk factors for acute low back pain. The highest rates were identified in blacks followed by whites, Hispanics, and American Indian/Alaskan Native, and the lowest rates were identified in Asians/Pacific Islanders. Significant differences in the effect of sex and age were identified between the different racial groups.

Tropical Medicine Training in the Department of Defense

OVERVIEW With increased emphasis by the Department of Defense (DoD) on stabilization of the peace, including medical stability operations, deployment to tropical environments will not decrease in the foreseeable future. Although every medical provider should have some training in the recognition of tropical diseases, a growing need exists for providers with advanced training in the diagnosis, treatment, and prevention of these illnesses. Too often, all providers are incorrectly assumed to possess detailed knowledge about these conditions rarely seen in the continental United States. Tropical medicine practitioners must be knowledgeable in relevant aspects of infectious diseases, preventive medicine, parasitology, and entomology. They must be competent in the diagnosis of tropical diseases, including the application of laboratory and radiologic techniques in austere settings. Critically, they must understand the impact of tropical diseases on deployed military personnel and endemic communities alike. The DoD offers several courses in tropical medicine that vary in length, scope, detail, and target audience. Here we seek to increase awareness of the availability and scope of these courses. This list is not exhaustive and excludes locally produced courses and courses that focus on a single area of tropical medicine. The courses described herein include the Masters of Tropical Medicine and Hygiene (MTM&H) at the Uniformed Services University of the Health Sciences (USU), the Masters of Public Health (MPH) with a concentration in Tropical Public Health (TPH) at USU, the Training in Tropical Medicine and Travelers’ Health Course at USU, courses within the U.S. Military Tropical Medicine (MTM) program, the Global Medicine Course, the Walter Reed Army Institute of Research (WRAIR) Tropical Medicine Course, the Military Medical Humanitarian Assistance Course (MMHAC), and the training program offered by the Armed Forces Health Surveillance Center (AFHSC) and USU.