DoD Policy Research Articles

A Review of Force Health Protection Aspects of Lyme Disease in the U.S. Military.

Lyme disease (LD) is an underrated threat to the military that negatively impacts mission readiness. Lyme disease has traditionally been thought to only be a risk in an operational context, where training or deployments are frequently conducted in heavily wooded environments. However, this view diminishes risks posed by many off-duty outdoor recreational activities. Furthermore, although the Army introduced a permethrin factory-treated Army Combat Uniform in 2012, permethrin retention and subsequent protection have been shown to decrease significantly after 3 months of wear. Thus, although LD is a known health risk that threatens unit readiness, beyond using treated uniforms there has been little progress at the unit level to address this threat. Focusing on a narrative review of LD and its impact on U.S. military force health protection, sources included DoD websites and policies, government press releases and information papers from sources like the CDC and FDA, and scholarly peer-reviewed journals with full-text access from the online databases EBSCOhost, MEDLINE, SCOUT, and Google Scholar. Searches included the following key words: LD and military, Army, etiology, epidemiology, incidence, treatments, post-treatment LD, and chronic LD. Articles were selected for review based on the relevance of their abstracts and titles. Although the incidence of LD appears to be increasing among service members, it is difficult to attribute this increase to military-related duties. Also, despite ongoing LD research specifically conducted and funded by the DoD, there are limited data on the mitigating effects of force education and permethrin-treated uniforms on the LD threat. Therefore, it is reasonable to conclude that LD negatively impacts military readiness and monetary costs diverted from other priorities. Lyme disease poses a genuine threat to the health and careers of service members and is an often-overlooked disruptor to military operations. Simple, feasible prevention strategies that are tailored to high-risk geographic regions can be emphasized by military units to reduce the incidence of on-duty and off-duty cases. Additionally, there remains a critical need for new preventative and diagnostic measures for LD.

An ontology‐based digital test and evaluation master plan (dTEMP) compliant with DoD policy

AbstractTest and evaluation (TE) planning is a critical part of systems engineering. However, it has not received as much attention from digital engineering efforts as early‐stage design and analysis. Digital engineering has the potential to reduce the risk and effort associated with TE, while leveraging existing digital capabilities to add value. One aspect in particular that may benefit from such attention is the Department of Defense's Test and Evaluation Master Plan (TEMP). The purpose of the TEMP is to identify the key processes with respect to the TE of a product, and to specify the roles and responsibilities of key personnel and organizations. Concerns have been raised regarding the document‐based nature of the TEMP and the increased risk and reduced reward that this entails. In this paper, we investigate the potential benefits of digitalizing the TEMP and outline an incremental approach for achieving this. We also present a set of ontologies, collectively known as the Digital TEMP (dTEMP), and investigate potential benefits and limitations by applying the dTEMP to an example test program.

Comparison of Tobacco Product Prices at Fort Liberty Army Installation and Surrounding Community Areas, 2021.

High rates of tobacco use persist in the U.S. military, with 18.4% of service members smoking cigarettes in 2018. The Department of Defense's (DoD) 2017 policy required that tobacco retailers on military installations set tobacco product prices equal to the most common community price, including tax, but there is limited evidence confirming whether local retailers are adhering to this policy. We examined tobacco product pricing in tobacco retailers on- and off-post at the largest U.S. Army installation, Fort Liberty, and Cumberland County, North Carolina. Between June and August 2021, we collected data on tobacco product availability, price, and promotions from retailers on Fort Liberty (n = 14) and a random sample of off-post retailers within 10 miles of installation gates (n = 52). We calculated the mode, mean, and median price of each product, plus the difference in these prices at on- and off-post retailers. We used Welch's t-test to test differences in mean prices between on- versus off-post retailers. The mode, mean, and median prices of cigarette packs and cartons were lower on-post than off-post (eg, $0.51-$0.55 cheaper for Marlboro cigarette packs on-post). However, the mode, mean, and median prices of smokeless tobacco products and little cigars were higher on-post than off-post (eg, $0.82-$0.89 more costly for Swisher Sweets 2-packs on-post). Results highlight the need for continued enforcement to ensure compliance with the 2017 DoD policy. Comprehensive policy action to reduce tobacco price disparities on- and off-post is critical to reducing high rates of tobacco use among service members. Despite the implementation of the 2017 DoD pricing policy, some tobacco products remain cheaper at tobacco retailers on-post compared to off-post retailers. Our results highlight the need for greater routine surveillance to increase implementation of the policy-particularly for cigarettes-to reduce high rates of tobacco use among service members.

Cold Habituation Does Not Alter Thermal Responses or Manual Dexterity During Prolonged Cold Air Exposure

Background: Habituation is a pattern of cold acclimatization characterized by attenuated cold defense responses, including a reduction in peripheral vasoconstriction and subsequent increase in skin temperature (TSk) as well as a decrease in shivering thermogenesis. Habituation is achieved through repeated reductions in TSk, rather than deep body core temperature (TC), via exposure to prolonged cold air or brief cold-water immersion. Due to improvements in TSk, enhanced manual dexterity and peripheral cold injury risk reduction are purported benefits of cold habituation. Warfighters frequently operate in cold climates and experience decrements in manual dexterity and strength. These functional losses can negatively impact mission critical tasks and training exercises; however, the effectiveness of cold habituation as a potential countermeasure to alleviate the deleterious effects of prolonged cold exposure on peripheral temperatures, thermal comfort, and hand function is unclear. Purpose: To evaluate the influence of eight consecutive cold air exposures on the thermal (TC and TSk), perceptual (thermal comfort and sensation), and functional (manual dexterity and strength) responses to cold air. We hypothesized that TSk would be higher and perceptual responses and manual dexterity improved, following repeated cold exposure. Methods: Eight young adults (6 M/1 F/1 FTM; 21 ± 2 years; %BF 24.5 ± 7.0) underwent a 2-h cold air exposure (8 °C, ~50% RH) on 8 consecutive days wearing minimal clothing. On Day 0 (baseline exposure ~1 week prior) and Days 1 and 8 of repeated exposure, TC was recorded continuously via a telemetry pill used as a rectal suppository. Extremity (Thand and Tfinger) and mean weighted TSk (MWTSk) from 8 skin sites were recorded continuously. Thermal comfort (TC) and thermal sensation (TS) were recorded at 20 min intervals. Expired gases were collected at 20 min intervals and used to calculate metabolic heat production (MHP). Manual dexterity was assessed using the Purdue Pegboard and Minnesota Manual Dexterity Test (MMDT), and hand strength were measured before and at the end of cold exposure. Results: TC changed across time ( p < 0.05) but did not differ between days ( p > 0.05). MWTSk, Thand, and Tfinger decreased across time ( p < 0.05) but also did not differ between days ( p > 0.05). Mean and minimum whole-body TS and TC were not different between days ( p > 0.05). MHP increased across time ( p < 0.05) but did not differ between days ( p > 0.05). Purdue Pegboard, MMDT task performance, and hand strength did not differ between days ( p > 0.05). Conclusion: Eight consecutive days of cold air exposure does not augment extremity skin temperature, thermal comfort, or manual performance during prolonged cold conditions. Supported by U.S. Army Medical Research and Development Command, Military Operational Medicine Research Program; author views not offcial US Army or DoD policy. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Increase in Plasma S100B Concentration Is Associated With Decrements in Spatial Processing During Acute High-Altitude Exposure

Vasogenic edema consequent to blood-brain barrier (BBB) permeability may contribute to cognitive performance decrements during acute exposure to high altitude. S100B is a putative marker of BBB permeability, but S100B responses to high altitude are poorly characterized and the relation to cognitive performance is unknown. To test the hypothesis that S100B increases upon ascent to high altitude and that increase is associated with changes in cognitive performance, 41 healthy Soldiers (mean±SD; age=26±5yr) were tested at their baseline residence (SL, 331m), transported to Taos, NM (2845m), then immediately hiked (n=21) or were driven (n=20) to a high-altitude (HA, 3600m) facility. Plasma S100B was measured at 06:00 throughout the study; twice at SL and again after the first night at HA (16h exposure). The automated neuropsychological assessment metric (ANAM) was administered four times at SL and once at HA to assess sustained attention, working memory, spatial processing, computation, executive function, and reaction time. ANAM performance was assessed using throughput scores, a metric considering both response speed and accuracy. The last SL morning assessment and the HA morning assessment (19h exposure) were used to generate ΔANAM scores. Correlations between ΔS100B and ΔANAM scores were significant for 1 of 9 modules, simultaneous spatial processing (SPD; r=-0.401; p=0.009). S100B increased (5.3%, p=0.02) from SL to HA while SPD scores decreased (8.2%, p=0.05). Using the reliable change index (RCI) to dichotomize individuals into those demonstrating a decrease in performance that exceeded measurement error and day-to-day variability (responders; RCI <-1.64; n=7) and those who did not (non-responders; RCI >-1.64; n=34) revealed that responders experienced a greater increase (+12.3%, p=0.01) in S100B from SL to HA relative to non-responders (+3.4%, p=0.14) Findings suggest that acute exposure to 3600m may increase BBB permeability, as indicated from plasma S100B concentrations, and the increased BBB permeability may be mechanistically associated with spatial processing decrements. Funding: USAMRDC, PRMRP. Authors’ views not offcial U.S. Army or DoD policy. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Imparied insulin sensitivity in the early hours following either active or passive ascent to 3600m is associated with acute mountain sickness susceptibility

Reduced insulin sensitivity (a higher glucose level for the same insulin concentration) at baseline residence (BLR) has been associated with increased susceptibility to acute mountain sickness. (AMS) at high altitude (HA). The objective of this study was to determine whether fasting blood glucose (GLU), lactate (LAC) and insulin (INS) were impacted during an active versus passive ascent to 3600m in AMS-susceptible and AMS-resistant individuals. We hypothesized that insulin sensitivity would be reduced at BLR in the AMS-susceptible cohort based on previous research. To test this hypothesis, 78 active-duty Soldiers were tested at baseline residence (BLR), transported to Taos, New Mexico (2,845m), then hiked (n=39) or were driven (n=39) to 3600m, and stayed for four days. AMS-C was assessed using the Environmental Symptoms Questionnaire (ESQ) at HA twice on day 1, five times on days 2 and 3 and once on day 4. If AMS-C was ≥0.7 at any timepoint, individuals were categorized as AMS-susceptible (AMS+, n=33); others categorized as resistant (AMS−, n=45). Fasting rested blood GLU and LAC responses collected at 06:00 were measured using a blood gas analyzer and serum INS responses were measured using an ELISA assay at BLR, HA2 (14-h post-ascent), HA3 (38-h post ascent), and HA4 (62-h post ascent). An additional sample for blood GLU and LAC was collected on HA1 at 18:00 (2-h post ascent). As expected, the active compared to passive ascent group demonstrated an increase (p<0.05) in GLU (113.6±14.3 vs. 101.9±15.1) and LAC (2.56±0.93 vs. 1.73±0.78) on HA1 most likely due to sympathetic stimulation following active ascent. However, differences in fasting GLU and LAC between ascent groups did not persist on HA2 through HA4. There were also no ascent group differences INS in any of the conditions. Fasting GLU levels on HA2 were higher in the AMS+ vs. AMS− cohorts (99.8±9.8 vs 95.3±7.9 mg/dl; p<0.05) but fasting INS levels on HA2 did not differ between cohorts (9.8±5.4 vs.7.1±3.4 mIU/ml; p>0.05) indicating impaired insulin sensitivity in those susceptible to AMS early in the HA exposure. There were no differences, however, in GLU and INS levels between AMS+ vs. AMS− cohorts on BLR, HA3 or HA4. Fasting LAC also demonstrated no differences in any of the conditions in the active vs. passive ascent groups or AMS+ vs. AMS− cohorts. In conclusion, the increase in blood GLU and LAC at HA1 following active compared to passive ascent was expected. Contrary to our hypothesis, however, a reduction in insulin sensitivity was not found in AMS-susceptible individuals at BLR but was found at 14-h post ascent to 3600m and quickly resolved thereafter. The inability to effectively utilize glucose as an O2-effcient fuel in the early hours of HA exposure may contribute to AMS symptoms. USAMRDC. Authors’ views not offcial U.S. Army or DoD policy. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Elevated sympathoadrenal response following active ascent to 3,600m is not associated with acute mountain sickness

Previous reports have suggested an increase in plasma epinephrine (EPI) and either an increase, no change or decrease in norepinephrine (NE) following acute (< 4 h) exposure to high altitude (HA). In addition, previous research has demonstrated an exercise-induced increase in EPI and NE during exercise initiated following arrival at HA. Last, some but not others have reported an association between increased sympathoadrenal activity and acute mountain sickness (AMS). We hypothesized that elevated sympathoadrenal activity induced from active ascent on foot to 3,600m may contribute to the development of AMS. Thirty-seven Soldiers (mean ± SD; 6 women; age=25.5±4.9 years) were tested at their baseline residence (BLR; Fort Bliss, TX, 1,190m), transported to Taos, NM (2,845m), then hiked (n=18) or were driven (n=19) to the HA data collection site where they resided for four days (68hrs). AMS Cerebral Factor Score (AMS-C) was determined using the Environmental Symptoms Questionnaire (ESQ-III) recorded twice at HA on day 1 (HA1), five times on days 2 (HA2) and 3 (HA3) and once on day 4 (HA4). If AMS-C was ≥0.7 on any measurement occasion, individuals were categorized as AMS-susceptible (AMS+, n=11) others were AMS-resistant (AMS─, n=26). Plasma EPI (pg/ml) and NE (pg/ml) were measured from venous blood draws at 06:00 at BLR, a non-fasted blood draw at 18:00 following ascent on HA1, and subsequent fasted blood samples at 06:00 on each morning at HA (HA2, HA3, HA4). AMS-susceptibility was not associated with the EPI or NE response in any condition so both cohorts were combined. The EPI response to active vs. passive ascent was similar with an increase (p<0.05) from BLR (28.0±26.8) to HA1 (47.5±40.3) followed by a subsequent decrease (p<0.05) from HA1 to HA2 (28.0±18.6) through HA4 (25.4±16.9). NE, however, increased (p<0.05) only in the active ascent group from BLR (413±216) to HA1 (729±281) and remained stable from HA1 through HA4 (644±192). The passive ascent group demonstrated no change in NE from BLR (327±126) to HA1 (413±181) through HA4 (466±144). NE levels were similar (p>0.05) in the active vs passive ascent group at BLR but higher (p<0.05) in the active ascenders on HA1 through HA4. In conclusion, contrary to our hypothesis, the sympathoadrenal response to HA was not impacted by AMS susceptibility but active ascent induced a greater NE response following ascent and throughout the duration of the HA stay. USAMRDC. Authors’ views not offcial U.S. Army or DoD policy. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Pro- and Anti-Inflammatory Responses Following Active and Passive Ascent to 3600 m

Lowlanders who develop acute mountain sickness (AMS) following rapid ascent to high altitude (HA) demonstrate increased levels of both pro-inflammatory (tumor necrosis factor α (TNFα), Interleukin (IL)- 1β, IL-6, IL-8, and IL-17α) and anti-inflammatory biomarkers (IL-10 and IL-1 receptor agonist; IL-1ra). Whether ascending by self-locomotion (i.e., active ascent) modulates these pro- and anti-inflammatory cytokine responses at HA is unknown. We hypothesized a greater pro-inflammatory response in the AMS-susceptible group following active ascent. To test this hypothesis, 78 healthy Soldiers (mean±SD; age, 26±5yr) were tested at baseline residence (BLR), transported to Taos, NM (2845m), then hiked (n=39) or were driven (n=39) to HA (3600m), and stayed for 4 days. AMS-Cerebral factor score (AMS-C) was assessed using the Environmental Symptoms Questionnaire (ESQ) at HA twice on day 1 (HA1). If AMS-C was ≥0.7 at either assessment, individuals were categorized as AMS-susceptible (AMS+; n=24); others were AMS-resistant (AMS−; n=54). Fasting blood samples were taken at 06:00 at BLR, HA2, HA3 and HA4 and analyzed to determine cytokine (TNFα, IL-1β, IL-6, IL-8, IL-10, IL-17α, and IL-1ra) responses following the initial hypoxic insult. Blood values (pg/mL) were log-transformed and adjusted for plasma volume changes from BLR to HA. The active group expended a greater ( p<0.05) amount of energy (745±435 kcal) than the passive group (55±10 kcal) during ascent. There were no differences in biomarkers between ascent groups, so data were combined. In the AMS-susceptible group, IL-17α increased ( p<0.05) from BLR to HA2 (63.3±8.8 to 73.1±8.8, p=0.002) and remained increased at HA3 (70.1±8.8) and HA4 (73.1±8.8). In the AMS-resistant group, IL-17α did not change from BLR to any of the days at HA. Independent of AMS susceptibility, the anti-inflammatory marker IL-1ra increased from BLR to HA2 (63.5±11.4 to 89.9±11.4, p=0.013) and then fell back down to BLR values on HA3 (70.4±11.4, p=0.560) and HA4 (71.8±11.4, p=0.537). When all days were combined, TNFα (+15%, p=0.036), IL-6 (+50%, p=0.042), and IL-10 (+36%, p=0.040) were increased in the AMS-susceptible compared to the AMS-resistant group. IL-1β and IL-8 did not change ( p>0.05) from BLR to any time point at HA in either group. In conclusion, both a robust pro- (TNFα, IL-6, IL-17α) and anti-inflammatory (IL-10) response occurred at HA in those susceptible to AMS most likely due to inflammation following the initial hypoxic insult followed quickly by an anti-inflammatory response. However, ascent strategy on HA1 had no impact on pro- or anti-inflammatory cytokines on days 2-4 at HA. Authors’ views not offcial U.S. Army or DoD policy. Funding: USAMRDC. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Pioglitazone does not affect exogenous glucose oxidation or metabolic clearance rate during steady-state aerobic exercise at high altitude

Background: Hypoxia-induced insulin insensitivity decreases exogenous glucose oxidation and metabolic clearance rate (MCR, proxy for peripheral glucose uptake) in native lowlanders exercising during the initial hours of high-altitude (HA) exposure compared sea level. These data suggest that administering an insulin sensitizing drug before HA exposure may increase exogenous glucose oxidation rate by stimulating peripheral glucose uptake. Objective: To compare the effects of pioglitazone (PIO) and placebo (PLA) on exogenous glucose oxidation and MCR during steady-state aerobic exercise at HA. We hypothesized that exogenous glucose oxidation and MCR would be higher with PIO than PLA. Methods: Using a randomized, crossover design, native lowlanders (n = 7 males, mean ± SD, age: 23 ± 6 y, body mass: 84 ± 11 kg) consumed 145 g (1.8 g/min) of glucose while performing 80-min of metabolically-matched (1.43 ± 0.16 VȮ2 L/min) treadmill exercise at HA (460 mmHg) after being administered PIO (15 mg) or PLA (microcrystalline cellulose pill) daily for five days. Substrate oxidation and glucose turnover were determined using indirect calorimetry, oral 13C-glucose and [6,6-2H2]-glucose primed, continuous infusions. Results: Exogenous glucose oxidation rate was not different between PIO (0.31 ± 0.03 g/min) and PLA (0.32 ± 0.09 g/min). Total carbohydrate oxidation with PIO (1.65 ± 0.22 g/min) was the same as PLA (1.68 ± 0.32 g/min). There were no treatment effects on glucose rate of appearance (PIO: 2.46 ± 0.27, PLA: 2.43 ± 0.27 mg/kg/min) disappearance (PIO: 2.19 ± 0.17, PLA: 2.20 ± 0.22 mg/kg/min), and MCR (PIO: 1.63 ± 0.37, PLA: 1.73 ± 0.40 mL/kg/min). Conclusion: These data do not support our hypothesis that exogenous glucose oxidation during exercise at HA can be restored through the short-term administration of PIO. Findings from this study may suggest that hypoxia-induced insulin resistance may be a symptom and not the primary etiology of dysregulated glucose metabolism during acute HA exposure. Supported by MOMRP; authors’ views not offcial US Army or DoD policy. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Reappraising the Use of Systemic Immunomodulators for Psoriasis and Eczema in the Military.

Psoriasis and atopic dermatitis are chronic, immune-mediated skin disorders that are disqualifying for entrance into the military. Both conditions can cause difficulty wearing body armor and other protective equipment when poorly controlled, limiting a service member's ability to train and deploy worldwide. In addition, these conditions may be exacerbated by military service because of increased exposure to austere environments, extreme temperatures, stress, skin injury, bug bites, and vaccinations Service members have limited treatment options because of restrictions on systemic medications that can be used while deployed. Newer systemic medications-in particular, biologics and oral immunomodulators-have evolved to be both extremely effective and safe. We review more recent treatment options for psoriasis and atopic dermatitis in the context of DoD's regulations guiding entry and retention of personnel with psoriasis and eczema and make recommendations regarding updating DoD policy for systemic treatment options. A literature search was performed using PubMed, Embase, and Ovid with the last search done in the fall of 2023 from all years to date. These articles were further screened based on inclusion and exclusion criteria. In total, 25 articles were included in this review. An Internet search was also performed on the DoD's regulations guiding entry and retention of personnel with psoriasis and eczema. In addition, we examined medical requirements for deployment to the U.S. Central Command and U.S. European Command. Currently, U.S. Central Command and U.S. European Command do not allow the use of medications with special storage and handling requirements on deployments. Newer biologics are safe and efficacious but require refrigeration, although other immunomodulators like deucravacitinib and apremilast are oral pills and do not have cold-storage requirements. However, the use of biologics in austere environments may be feasible because of increased intervals between dosing and the ability to store refrigerated medical supplies in most deployed environments. For military service members with psoriasis, risankizumab and deucravacitinib are excellent options given their favorable safety and efficacy profiles. Of the biologics available for atopic dermatitis, dupilumab is the safest and effective systemic medication available. The Janus kinase inhibitors have also demonstrated excellent efficacy in treating atopic dermatitis, but more safety data are needed because of potential adverse events to include heart-related events, blood clots, and cancers. Systemic treatments have evolved to become highly specific for both eczema and psoriasis. These newer biologics and immunomodulators may be compatible with use in the deployed setting, especially those that have long dosing intervals and proven efficacy and safety. Of the biologics, dupilumab and risankizumab offer the best efficacy, safety, and dosing intervals for atopic dermatitis and psoriasis, respectively. Deucravcitinib is a recently FDA-approved oral immunomodulator for psoriasis that has an excellent safety profile and efficacy. Allowing the use of these medications on deployments will enable more people with moderate to severe psoriasis and eczema to join and remain in the military while receiving effective treatment.

Expanding Global Health Engagement through Multilateral Security Organizations.

Many countries around the world employ defense capabilities in support of global health engagement (GHE) through bilateral and multilateral organizations. Despite this, there does not appear to be a strategic approach and implementation plan for U.S. DoD GHE in support of and through multilateral organizations. The purpose of this research is to identify which security multilateral organizations are engaged in GHE, as well as how and why. These findings could inform an interoperable approach for doing so going forward. A systematic review was conducted to develop a list of multilateral security organizations and agreements which engage in GHE, or could potentially play a role in GHE. Of the 3,488 agreements and organizations identified, 15 met the inclusion criteria. Among them, 87% (13/15) of the multilateral organizations are regional and 13% (2/15) are international, all established between 1948 and 2020. The 15 organizations cover all DoD Geographical Combatant Commands. Among them, 20% (3/15) are a legally binding alliance, 73% (11/15) have a treaty, and 7% (1/15) have a diplomatic partnership. Twenty percent (3/15) have an explicit intent to improve health in either their mission statement or as part of their goals, priorities, and/or objectives. Eighty percent (12/15) engage in at least two GHE domains outlined in DoD Policy, 67% in three (10/15), and 47% in all four (7/15). The most common domain is humanitarian assistance and foreign disaster response at 100% (15/15) and least common is Nuclear, Chemical, and Biological Defense Programs at 53% (8/15). Although there is high demand for GHE, resourcing to enable implementation has not been prioritized. Therefore, multilateral organizations continue to support what is funded (e.g., disaster response) versus prioritizing capacity building or modifying authorities and appropriations to match demand. It is also worth noting most organizations included in this review support the European theater aligning to historical defense priorities, versus emerging threats in the Indo-Pacific region. Identifying a forum within these multilateral institutions to convene GHE policy makers and practitioners is a logical next step. The forums could guide and direct priorities, devise solutions, and implement best practices. Near term efforts could include GHE financing, governance, assurance, and technical assistance within and across multilateral institutions. Recent efforts highlight growth in both interest and action to support the variety of GHE activities regionally and internationally. As the United States seeks to reinforce multilateral institutions and uphold the international and rules-based order, employing GHE through multilateral cooperation could buttress efforts. Now is a perfect time given the sustained interest in global health, amplified value of allies and partners, and renewed emphasis placed on multilateral cooperation for the DoD to design a multilateral GHE strategy and seek Congressional support to resource it accordingly.

Opioid-Related Trends inActive Duty Service Members During the Coronavirus Disease 2019 Pandemic.

The USA is experiencing an opioid epidemic. Active duty service members (ADSMs) are at risk for opioid use disorder (OUD). The Coronavirus disease 2019 (COVID-19) pandemic has disrupted health care and introduced additional stressors. The Military Healthcare System Data Repository was used to evaluate changes in diagnosis of OUD, medications for OUD (MOUD), opioid overdose (OD), and opioid rescue medication. ADSMs ages 18-45 years enrolled in the Military Healthcare System between February 2019 and April 2022 were included. Joinpoint Trend Analysis Software calculated the average monthly percent change over the study period, whereas Poisson regression compared outcomes over three COVID-19 periods: Pre-lockdown (pre-COVID-19 period 0) (February 2019-February 2020), early pandemic until ADSM vaccination initiation (COVID-19 period 1 [CP1]) (March 2020-November 2020), and late pandemic post-vaccination initiation (COVID-19 period 2 [CP2]) (December 2020-April 2022). A total of 1.86 million eligible ADSMs received care over the study period. Diagnoses of OUD decreased 1.4% monthly, MOUD decreased 0.6% monthly, diagnoses of opioid OD did not change, and opioid rescue medication increased 8.5% monthly.Diagnoses of OUD decreased in both COVID-19 time periods: CP1 and CP2: Rate ratio (RR) = 0.74 (95% CI, 0.68-0.79) and RR = 0.72 (95% CI, 0.67-0.76), respectively. MOUD decreased in both CP1 and CP2: RR = 0.77 (95% CI, 0.68-0.88) and RR = 0.86 (95% CI, 0.78-0.96), respectively. Adjusted rates for diagnoses of opioid OD did not vary in either COVID-19 time period. Opioid rescue medication prescriptions increased in CP1 and CP2: RR = 1.09 (95% CI, 1.02-1.15) and RR = 6.02 (95% CI, 5.77-6.28), respectively. Rates of OUD and MOUD decreased, whereas rates of opioid rescue medication increased during the study period. Opioid OD rates did not significantly change in this study. Changes in the DoD policy may be affecting rates with greater effect than COVID-19 pandemic effects.

Medical Evaluation Readiness Information Toolset (MERIT): Developing a Data-driven Decision Support Tool to Augment Complex Clinical Decisions.

Medical readiness continues to be a significant concern for the military. DoD policy directs medical authorities to refer service members to the Disability Evaluation System (DES) when the course of further recovery is relatively predictable or within 1 year of diagnosis, whichever is sooner. The Medical Evaluation Readiness Information Toolset (MERIT) is an application that leverages artificial intelligence within a clinical decision support tool to provide clinicians with predictions of a service member's likelihood of referral to the DES for the top 24 medical conditions that result in separation from the service, which represent more than 90% of all referral cases to the DES since 2000. Data spanned 19 years and contained records for over 3 million army service members. The MERIT team incorporated a novel approach using a Gamma window function to weight recent medical data more than older medical data in the creation of a "Disease Severity Index" (DSI) that summarized the progression of a health deterioration process per medical condition code. Time-dependent medical encounter data were aggregated into an individual-level DSI. The identified features including the DSI were used in logistic regression and random forest models to predict whether a service member is likely to be referred to the DES. Models were constructed for each of the top 24 unfitting medical conditions. MERIT produced a set of high-performing classification models with area under the receiver operating characteristics curves across all conditions exceeding 0.919 using logistic regression for all conditions. This project demonstrated with a high degree of accuracy that MERIT, using a combination of ICD codes and personnel records, can be used to develop an individual risk profile for each service member.

Rocket noise models for the US Department of Defense

Accurate rocket noise prediction models are critical to support growing space defense programs. Potential deficiencies in the NASA SP-8072 model developed in the 1970s have been identified, but their impacts on accurate predictions are currently unknown. Cross-validationcomparisons to full-scale rocket measurements are needed to identify and quantify errors and to improve accuracy. This paper will review the DoD programs and policies that motivate rocket noise modeling requirements, summarize the current models in use, discuss some of the potential deficiencies of the models, and propose a roadmap for establishing confidence in models for official DoD use.

Ventilatory And Cardiovascular Acclimatization Remains Unchanged Following Active Versus Passive Ascent To 3600 m

PURPOSE: Sympathetic stimulation, induced by intense endurance exercise, may alter the process of ventilatory and cardiovascular acclimatization. The purpose of this study was to examine the magnitude and time course of ventilatory and cardiovascular acclimatization following active and passive ascent to 3600 m. METHODS: Forty-one healthy unacclimatized Soldiers (n = 41, mean ± SD; age = 26 ± 5 yr; body weight = 83.5 ± 11.6 kg; VO2max = 47.9 ± 5.5 ml · kg−1 · min−1) were tested at sea level (SL) in Ft. Leonard Wood, MO, flown to Taos Ski Valley, NM (2845 m) where they arrived around 1400 m, and then either hiked (n = 21; 5.0 km, 15.5% mean grade) or were driven (n = 20; 30-min drive) to a high altitude (HA) ski patrol facility located at 3600 m. Energy expenditure during ascent was measured with an ankle accelerometer. Portable real-time capnography was used to measure end-tidal carbon dioxide partial pressure (PETCO2) after 10 min of sitting at SL, after 19 h (HA2), 43 h (HA3), and 67 h (HA4) at HA. Mean arterial blood pressure (MAP), heart rate (HR), and pulse arterial oxygen saturation (SpO2) were measured at the same time (~0900) as PETCO2 RESULTS: The active group expended a greater (P < 0.05) amount of energy (745 ± 435 kcal) than the passive group (55 ± 10 kcal) during ascent. There were no differences between groups in terms of ventilatory and cardiovascular acclimatization so data were combined. Resting PETCO2 (mmHg) decreased (P < 0.05) from SL (37.5 ± 3.35) to HA2 (33.5 ± 3.71), remained stable from HA2 to HA3 (33.8 ± 3.73) and decreased further (P < 0.05) from HA3 to HA4 (30.8 ± 4.9). Resting MAP and HR, respectively, increased (P < 0.05) from SL (89.9 ± 6.9 mmHg; 65.7 ± 9.8 bpm) to HA2 (100.0 ± 7.2 mmHg; 78.7 ± 10.1 bpm), MAP decreased (P < 0.05) but HR remained unchanged from HA2 to HA3 (96.9 ± 7.1 mmHg; 78.5 ± 15.4 bpm), and both stayed consistent from HA3 to HA4 (98.1 ± 7.1 mmHg; 80.1 ± 12.9 bpm). Resting SpO2 (%) decreased (P < 0.05) from SL (97.6 ± 1.3) to HA2 (88.7 ± 3.1), increased (P < 0.05) from HA2 to HA3 (89.7 ± 2.9), and remained unchanged from HA3 to HA4 (89.1 ± 3.2). CONCLUSION: Ventilatory and cardiovascular acclimatization occurred at HA but sympathetic stimulation and increased metabolic rate due to the active ascent did not change the magnitude or time course of either of these processes. Authors’ views not official U.S. Army or DoD policy. Funding: USAMRDC

Dynamic Relationship Between Heart Rate And Core Temperature During Exercise-heat Stress And Iced Sheet Cooling

Athletes, military personnel, and others who perform physical work in the heat are at risk for exertional heat illness due to the combined presence of high ambient temperature and elevated metabolic heat production. Cooling with iced sheets is an immediate treatment used by the military and others to rapidly decrease body temperature in a field setting. Physiologically, increases in core temperature (Tc) and heart rate (HR) contribute to the cardiovascular strain associated with exercising in the heat. This increased HR is linked to the combination of metabolic (exercise) and thermal (environmental) requirements for systemic blood flow (i.e. cardiac output). Mechanisms include both autonomic neural and local influences of temperature on the heart. PURPOSE: To quantify the dynamic response of HR to changes in Tc during exercise in the heat and subsequent iced sheet cooling. We hypothesized that for a given Tc, HR would be higher during increases in Tc compared to during decreases in Tc. METHODS: Nine healthy (n = 8 males) volunteers (age 25 ± 6 y, ht 176.9 ± 9.7 cm, wt 86.6 ± 15.9 kg, body surface area 2.03 ± 0.2 m2) participated in a exercise-heat stress protocol consisting of up to 180 minutes of treadmill walking (3.5 mi·hr-1, 5% grade, in 40 °C, 30% RH). Volunteers then lay supine and underwent iced-sheet cooling (ISC) (bed sheets placed in 5-gallon ice buckets with 2/3 ice, 1/3 cool water; rotated out with pre-soaked sheets every 3 min) until Tc decreased to ≤38.0 °C. Individual changes in HR during both exercise and cooling were compared at Tc = 38.2 and 38.6 °C using 2-way analysis of variance. RESULTS: HR was significantly higher for a given Tc when Tc was increasing during exercise compared to when it was decreasing during cooling. For example, during exercise, HR was 150 ± 13 bpm at Tc = 38.2 °C and 157 ± 9 bpm at Tc = 38.6 °C, while during cooling, HR was 96 ± 10 bpm at Tc = 38.2 °C and 104 ± 14 bpm at Tc = 38.6 °C (both p < 0.01). CONCLUSION: These data confirm the efficacy of iced-sheet cooling for decreasing cardiovascular strain associated with heat-related events. The fact that cooling resulted in lower HR for a given Tc suggests that exercise associated autonomic reflexes predominated over direct effects of temperature on sinus node control of HR. Supported by USAMRDC; author views not official US Army or DoD policy.

Active Ascent Does Not Alter Cognitive Performance Compared To Passive Ascent To 3600 m

PURPOSE: Cognitive performance is known to decrease following acute exposure to high altitude (HA) but it is unknown whether active ascent affects that response. The purpose of this study was to examine changes in cognitive performance following active and passive ascent to 3600 m. METHODS: Forty-one healthy unacclimatized Soldiers (n = 41, mean ± SD; age = 26 ± 5 yr; body weight = 83.5 ± 11.6 kg; VO2max = 47.9 ± 5.5 ml · kg−1 · min−1) were tested at sea level (SL) in Ft. Leonard Wood, MO, flown to Taos Ski Valley, NM (2845 m) where they arrived around 1400 and then either hiked (n = 21; 5.0 km, 15.5% mean grade) or were driven (n = 20; 30-min drive) to a HA ski patrol facility located at 3600 m where they resided for the next 4 days. Energy expenditure during ascent was measured using an ankle accelerometer (Actical, Respironics, Inc.). Six cognitive modules (simple reaction time (SRT), match to sample (M2S), mathematical processing (MTH), procedural reaction time (PRO), simultaneous spatial processing (SPD) and simple reaction time 2 (SR2)) were administered using the Automated Neuropsychological Assessment Metrics in the morning (~0900) four times at SL, and following ~19 h at HA (HA2), and ~ 43 h at HA (HA3). All cognitive modules demonstrated no difference between the third (am) and fourth (pm) administrations at SL so the 3rd administration was used for the baseline record. RESULTS: The active group expended a greater (P < 0.05) amount of energy (745 ± 435 kcal) than the passive group (55 ± 10 kcal) during ascent. There were no differences in cognitive performance between groups so data were combined. The SRT decreased (P < 0.05) from SL (203 ± 28) to HA2 (192 ± 34) and increased (P < 0.05) from HA2 to HA3 (204 ± 29). PRO decreased (P < 0.05) from SL (97.5 ± 13.7) to HA2 (91.2 ± 14.9) and increased (P < 0.05) from HA2 to HA3 (96.1 ± 11.3). The SRT2 decreased (P < 0.05) from SL (195 ± 29) to HA2 (179 ± 46) and remained unchanged from HA2 to HA3 (188 ± 34). There were no changes in M2S, MTH, and SPD from SL to HA2 or HA3. CONCLUSION: Active compared to passive ascent did not impact cognitive performance at HA but reaction time whether simple, procedural, or repeated decreased on HA2. Both SRT and PRO recovered on HA3 but SR2, a measure of cognitive fatigue, did not recover. Authors’ views not official U.S. Army or DoD policy. Funding: USAMRDC

Changes In Leukocyte Distribution And T-cell Reactivity During Initial Military Training

PURPOSE: Physiological stressors present during initial military training (IMT) may increase risk of illness and infection by suppressing immune function. This study aimed to improve insight into those relationships by characterizing changes in markers of innate and adaptive immune function during IMT. METHODS: Sixty U.S. Army infantry recruits (97% male) provided fasted blood and saliva samples at the beginning (PRE; week 0) and end (POST; week 22) of IMT. Peripheral leukocyte distribution was measured by flow cytometry, and T-cell and innate cell reactivity were measured by mitogen (anti-CD3/CD28 or lipopolysaccharide (LPS))-stimulated cytokine profiles in 48-hr whole blood culture. Latent reactivation of Epstein-Barr virus (EBV), varicella-zoster virus (VZV), and herpes simplex virus 1 (HSV1) was measured in saliva by qPCR. RESULTS: Lymphocyte percentage increased (+28%) while granulocytes (-15%) and monocytes (-13%) decreased PRE to POST (all P < 0.01). This lymphocytosis was driven by an increase in natural killer cells (+19%), and accompanied by decreases in B-cells (-9%) and T-cells (-5%; all P < 0.01). Within T-cell subsets, terminally differentiated CD4+ (+22%) and CD8+ (+30%) cells increased while those of effector memory CD4+ cells (-11%), effector memory CD8+ cells (-54%) and central memory CD8+ cells (-15%) decreased (all P ≤ 0.02). T-cell production of most measured cytokines following anti-CD3/CD28 stimulation increased from PRE to POST (P < 0.05). Conversely, stimulation with LPS resulted in reduced production of most measured cytokines (P < 0.05). Prevalence of EBV reactivation was higher POST (n=30) relative to PRE (n=19; P = 0.01), but neither VZV nor HSV1 reactivation was observed at either time point. CONCLUSION: Lymphocytosis, maturation of CD4+/CD8+ T-cell subsets, and heightened T-cell reactivity at POST collectively suggests an appropriate immune response to pathogen challenges during IMT. Though EBV reactivation was increased at POST, no evidence of VZV or HSV1 reactivation, which are more common during severe stress, was observed. Findings suggest that EBV reactivation during IMT was likely appropriately controlled in recruits and that immune-competence was relatively uncompromised at the end of IMT. Supported by USAMRDC. Authors’ views not official DoD or Army policy

The Recruitment, Enlistment, and Deployment of HIV-Positive Military Service Members: An Evaluation of South African and U.S. National, Alongside International, Policies.

Since its detection in the early 1980s, HIV and AIDS have claimed 32.7 million lives. The HIV epidemic continues to plague the world with its most devastating effects felt in Eastern and Southern Africa. The exposure, vulnerability, and impact of HIV have been prominent among military personnel due to environmental, demographic, and socioeconomic characteristics. Policies have been developed to mitigate its exposure, vulnerability, and impact on the military. However, there are disparities across these policies, especially on recruitment, enlistment, and deployment. These contentions inspired this evaluation, which was designed to provide vital information and insights for militaries developing new HIV policies, for example, the Ghana Armed Forces (GAF). Content analyses of key documents and secondary resources from South Africa (SA), the USA, and the United Nations and International Labour Organizations were undertaken. The key documents evaluated included HIV and AIDS policies of the SA National Defence Force (SANDF), the U.S. DoD, UN Department of Peacekeeping Operations, and International Labour Organization (ILO); national HIV and AIDS policies; and legislations of SA and the USA. The SANDF policy permits the recruitment of HIV-positive applicants while the U.S. DoD policy does not. Mandatory pre-employment health assessments including HIV testing is conducted for prospective applicants. Again, discrimination against persons living with HIV (PLHIV) is discouraged by national policies and legislations of both countries and the ILO policy. At the same time, the SA national policy permits discrimination based on requirement of the job.On deployment, the SANDF policy explicitly permits deployment of HIV-positive service members, while the U.S. DoD policy cautiously does so. Both policies support mandatory pre-deployment health assessments in line with the UN peacekeeping policy and medical standards even though voluntary confidential HIV counseling and testing is recommended by the UN. All HIV-positive service members are retained and offered treatment and care services; however, the U.S. DoD policy retires unfit service members after 12 months of consecutive non-deployment. Further, the UN policy repatriates service members with pre-existing medical conditions and pays no compensation for death, injury, or illness, which is due to pre-existing medical conditions or not mission-related. First, the contents of the military policies are not very diverse since most militaries do not enlist or deploy PLHIV except few countries including SA. Implementation and interpretation is however inconsistent. Some militaries continue to exclude PLHIV despite the existence of policies that permit their inclusion. Second, discrepancies exist among the military policies, national legislations, and international policies. The UN policy is not coherent and empowers the military to exclude PLHIV. Also, potential costs to be incurred, in the form of compensation and repatriation, seem to be a major factor in the decision to deploy HIV-positive service members. Harmonization of military HIV policies to ensure uniform standards, interpretation, and implementation and the coherence of the UN policy are essential to guide countries developing new policies, for example, GAF.

Waste Flow, Recycling, and Greenhouse Gas Emissions: a Case Study of the Comparative Environmental Impact of Recycling Approaches on a College Campus

Municipal solid waste flow was modeled and measured at the U.S. Naval Academy to understand not only the movement of waste, but also the policies and economic incentives that have led to the current waste management plan at the Academy. The study contains four primary thrusts: regulatory policies, waste production and recycling levels, collection and sorting processes, and disposal and material recovery. Waste hauling data for a one-year period in 2017-2018 showed that the institution generated approximately 300 tons of total waste each month and recycled approximately 11-15% of that waste. From directly measuring waste across campus, approximately 36% of the non-recyclable waste stream contains recyclable materials. Most recyclable materials that ended up in the non-recyclable waste stream were plastics and cans, and came from academic spaces. However, a test academic space that gave access to waste bins only conjoined with recycling bins showed a substantial reduction in recycling infiltrating the non-recyclable waste stream. The study also shows how the handling of waste has evolved over recent years. Since the mid-2000s, the Academy has shifted to relying on contractors to sort and transport waste. Currently, five private contracting agencies are utilized in the waste flow stream after materials leave the Academy. To assess environmental impact, a life cycle assessment model was constructed based on the movement of waste to estimate the possible effects of the current recycling program on carbon equivalent emissions. The results indicate that current practices result in over 500 metric tons of carbon equivalent savings over the long-term during the one-year measurement period. The model also shows that by reducing recycling infiltrates into the waste stream, an additional 1000 metric tons of carbon equivalent savings are possible. Economic incentives were evaluated at each of the four sections of the waste process model, and analysis suggests that focusing on behavioral change strategies at the waste generation and initial collection and sorting levels holds the best promise for increasing levels of recycling, reducing landfilled waste, and reducing net carbon emissions in accordance with DOD policy goals.