Force Health Protection Research Articles

Assessing the Feasibility of Using a Multiplex Serological Assay to Conduct Serosurveillance for Malaria Exposure in Deployed Military Personnel.

Reproducibly assessing malaria exposure is critical for force health protection for military service members deployed to malaria-endemic regions as well as for civilians making public health decisions and evaluating malaria eradication efforts. However, malaria disease surveillance is challenged by under-reporting, natural immunity, and chemoprophylaxis, which can mask malaria exposure and lead to an underestimation of malaria prevalence. In this study, we determined the feasibility of using a serosurveillance-based approach to measure Anopheles vector exposure, Plasmodium sporozoite exposure, and blood-stage parasitemia using a multiplex serological panel. We tested post-deployment samples obtained from U.S. service members returning from regions with malaria risk to assess the potential of this serosurveillance panel. The results identified that some service members had anti-CSP antibody levels comparable to those found in endemic populations, suggesting exposure to sporozoites while those individuals were on chemoprophylaxis. We also observed isolated cases of anti-MSP1 levels that were as high as those observed in endemic populations and in CHMI studies, suggesting possible cases of clinical or subclinical parasitemia. The study demonstrated the feasibility of implementing a multiplex serology approach for conducting serosurveillance for Anopheles vector exposure and Plasmodium parasite exposure in samples collected following military deployments and its potential to support public health policies.

Leptospirosis Risk Assessment in Rodent Populations and Environmental Reservoirs in Humanitarian Aid Settings in Thailand.

Leptospirosis, a global zoonotic disease caused by Leptospira spp., presents high morbidity and mortality risks, especially in tropical regions like Thailand. Military personnel deployed in endemic areas, such as during the Cobra Gold Joint exercise, face heightened exposure. This study assessed Leptospira's prevalence in rodents and environmental reservoirs at military training sites from 2017 to 2022. A surveillance program was conducted at Engineering Civil Assistance Program (ENCAP) training sites using real-time PCR, dark-field microscopy, and 16S rRNA gene sequencing to detect Leptospira in rodents and environmental samples. Results showed a 1.3% infection rate in rodents (15 of 1161), while Leptospira was detected in 10.2% of water samples (42 of 413) and 23.1% of soil samples (30 of 130). Diverse Leptospira interrogans strains circulated among rodents, and three groups of naturally circulating Leptospira strains were detected in environmental reservoirs. These findings underscore Leptospira's survival and transmission potential within exercise sites, informing Force Health Protection (FHP) decisions. By integrating pre-exercise data on primary hosts and environmental reservoirs with historical local outbreak records and research on risk factors, this study identifies key areas for public health intervention and potential mitigation strategies.

Application of Pan-Viral Metagenomic Sequencing on United States Air Force Academy Wastewater to Uncover Potential Causes of Acute Gastroenteritis.

Wastewater surveillance is an important technique to monitor public health and is being studied extensively for pandemic prevention, force health protection and readiness, and as a potential early warning system for chem-bio defense. Wastewater surveillance has traditionally relied on techniques such as quantitative PCR or targeted sequencing, both of which are microbe- or disease-specific tools. Newer pan-viral metagenomics strategies may provide higher specificity for pathogens of interest, resulting in a lower false negative rate and reduced sequencing of undesired background nucleic acids. One such system, VirCapSeq-VERT, has been developed to targetall vertebrate virus pathogens; until recently, its application has been limited to clinical samples. The objective of this study was to use VirCapSeq-VERT to interrogate wastewater samples from the U.S. Air Force Academy (USAFA), Colorado Springs, Colorado, to determine its utility in assessing complex samples and its potential application in public health surveillance. Biweekly samples were analyzed from February 2022 through May 2023. Samples were collected from the wastewater treatment facility at USAFA before treatment and stored at -20 °C until total nucleic acid (tNA: DNA and RNA) extraction. tNA was then subject to the probe-based capture system, VirCapSeq, and run through a collection of public bioinformatics pipelines to identify captured viral pathogens and perform phylogenetic analysis. It was determined by the USAFA IRB that the study was non-human subject research and was deemed exempt. In total, 68 families of viruses were identified, comprising thousands of individual strains. This study focused on viruses responsible for gastrointestinal dysfunction as a test of the use of the VirCapSeq-VERT to identify human pathogenic viruses within a complex and highly enriched biological sample. Four enteric viruses dominated the wastewater samples, with Adenoviridae most prevalent before the cadet winter recess (December 17, 2022-January 4, 2023) and Astroviridae most abundant thereafter. Although gastroenteritis outbreaks at USAFA are commonly attributed to norovirus because of clinical presentation and the acute nature of the illness-often diagnosed and treated without confirmatory stool testing-this virus was not found in high prevalence in these wastewater samples. Among adenoviruses, F serotype 41 predominated, suggesting a role in gastrointestinal infections among the cadet population. Phylogenetic investigation of adenovirus and norovirus exposed common variants with seasonal distributions. These findings may prompt correlational studies to assess the clinical predictive capability of VirCapSeq-VERT and to determine the utility of wastewater monitoring as an outbreak early warning system.

The Central Role of the Global Emerging Infections Surveillance Program in Supporting Force Health Protection.

The Global Emerging Infections Surveillance (GEIS) program is the only Department of Defense (DoD) organization that coordinates global surveillance for emerging infectious diseases that affect US military forces operating in the United States or foreign locations. Since 1997, the GEIS program has focused on surveilling pathogens likely to affect military operations and the health of service members. The foundation of the GEIS program is the long-standing, mutually beneficial relationships between the DoD overseas laboratories and their host-country partners and militaries. Through centralized programmatic support, the GEIS program provides the infrastructure needed for a rapid and scalable response to emerging threats. The GEIS program continues to enhance and evolve its initiatives to provide timely, reliable information to decision-makers in the DoD. The GEIS program has been and will continue to be a vital source of actionable biosurveillance information during infectious disease events of global public health concern.

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.

Toxicity reference values for force health protection: Provisional occupational exposure guidelines

Force Health Protection programs in the U.S. Air Force endeavor to sustain the operational readiness of the warfighters. We have previously identified hundreds of chemical substances of interest and toxicity reference value (TRV) knowledge gaps that constrain risk based-decision-making for potential exposures. Multiple approaches to occupational TRV estimation were used to generate possible guideline values for 84 compounds (18% of the substances of interest). These candidate TRVs included values from international databases, chemical similarity (nearest neighbor) approaches, empirical adjustments to account for duration differences, quantitative activity relationships, and thresholds of toxicological concern. This present work describes derivation of provisional TRVs from these candidate values. Rodent bioassay-derived long-term worker Derived No-Effect Levels (DNELs) were deemed presumptively the most reliable, but only 19 such DNELs were available for the 84 substances with TRV gaps. In the absence of DNELs, the quality of the approaches and consistency among candidate values were key elements of the weight of evidence used to select the most suitable guideline values. The use of novel nearest-neighbor approaches, empirical adjustment of short term TRVs, and occupational exposure bands were found to be options that would allow occupational TRV estimation with reasonable confidence for nearly all substances evaluated.

Toxicity reference values (TRVs) for force health protection: Gap identification and TRV prediction

The mission of the Force Health Protection (FHP) program of the U.S. Air Force (USAF), sustaining the readiness of warfighters, relies on determinations of acceptable levels of exposure to a wide array of substances that USAF personnel may encounter. In many cases, exposure details are limited or authoritative toxicity reference values (TRVs) are unavailable. To address some of the TRV gaps, we are integrating several approaches to generate health protective exposure guidelines. Descriptions are provided for identification of chemicals of interest for USAF FHP (467 to date), synthesis of multiple TRVs to derive Operational Exposure Limits (OpELs), and strategies for identifying and developing candidate values for provisional OpELs when authoritative TRVs are lacking. Rodent bioassay-derived long-term Derived No Effect Levels (DNELs) for workers were available only for a minority of the substances with occupational TRV gaps (19 of 84). Additional occupational TRV estimation approaches were found to be straightforward to implement: Tier 1 Occupational Exposure Bands, cheminformatics approaches (multiple linear regression and novel nearest-neighbor approaches), and empirical adjustment of short term TRVs. Risk assessors working in similar contexts may benefit from application of the resources referenced and developed in this work.

Burden of Submicroscopic Plasmodium Infections and Detection of kelch13 Mutant Parasites in Military and Civilian Populations in Papua New Guinea.

Malaria remains a major public health problem in Papua New Guinea (PNG) and an important force health protection issue for both PNG and Australian Defence Forces. To investigate the malaria burden in the military and civilians residing on military bases, a cross-sectional survey was conducted in April 2019 at three military bases in Wewak, Manus Island, and Vanimo, PNG. A total of 1,041 participants were enrolled; 235 military personnel from three bases and 806 civilians from Wewak and Vanimo. Polymerase chain reaction (PCR) revealed an overall high prevalence of Plasmodium infection in both the military and civilians. Among the military, the infection prevalence was significantly higher in Wewak (35.5%) and Vanimo (33.3%) bases than on Manus Island (11.8%). Among civilians, children (<16 years old) had significantly higher odds of being PCR positive than adults (≥16 years old). At Wewak and Vanimo, Plasmodium vivax accounted for 85.4%, 78.2%, and 66.2% of infections in military, children, and adult populations. Overall, 87.3%, 41.3%, and 61.3% of Plasmodium infections in the military, children, and adults, respectively, were detected only by PCR, not by microscopy (submicroscopic [SM] infections). Children had a significantly lower proportion of SM infections than adults and Papua New Guinea Defence Force personnel. Infection status was not associated with hemoglobin levels in these populations at the time of the survey. Mutant kelch13 (C580Y) parasites were identified in 5/68 Plasmodium falciparum-infected individuals. The survey results indicate extensive malaria transmission on these bases, especially in Wewak and Vanimo. More intensified interventions are required to reduce malaria transmission on PNG military bases.

Risc management: the medical support system in contemporary armed conflict

Introduction. Contemporary armed conflicts are characterized by a multifaceted blend of combat strategies, encompassing conventional and unconventional weaponry, regular and irregular forces, terrorist actions and acts of organized crime, indiscriminate violence and outside international law.&#x0D; Material and methods. A retrospective bibliographic study was conducted on the evolution of combat strategies employed by the U.S. Armed Forces, NATO member countries, and international UN Peacekeeping Operations over the past 25 years.&#x0D; Results. The way of organizing and providing medical assistance in local military conflict differs from the principles governing medical support in major armed conflicts. The staging of the treatment system and the evacuation of the wounded follows a crucial time-based framework known as the '10-1-2(+2)' rule: "10"– immediate measures to stop bleeding within 10 minutes of the injury; "1" – evacuation to the medical treatment facility capable of performing resuscitation and stabilizing vital functions.; "2" – timely transfer to a medical formation equipped for Damage Control Surgery and Resuscitation within 2 hours of the injury; "+2" – performing the surgical intervention, stabilization of vital functions, and diagnostic preparations for strategic evacuation within 4 hours of the injury.&#x0D; Conclusions. Resulting from the specific particularities of the local military conflict, the planning of medical support as well as the complex of treatment and evacuation measures, force health protection, medical logistics, require adaptation to the real tactical and medical situation created.

Force Health Protection Education: A Pilot Approach to Applying Military Frameworks to Service Member Health Education.

Ensuring Force Health Protection (FHP) is one of the most critical priorities in the DoD; however, there is no systematic approach for individual service members to address their own FHP. This paper outlines the FHP Education workshop, a model program fielded at 3rd Special Forces Group, Fort Bragg, NC, which applies military processes, principles, and frameworks to teaching special operations forces operators and enablers how to address their own FHP by identifying and mitigating threats to health and performance in the military operational environment. The FHP Education workshop has the potential to be a well-received and impactful program that offers a proactive, whole of person, community-based preventive system aligned with the Total Force Fitness framework to enable individual service members to conduct FHP.

Characterizing Methods for Surveying Partner Nation Medical Capabilities.

Medical capability surveys provide information about how U.S. forces can coordinate with partner nations to leverage partners' capabilities to deliver care to sick or injured U.S. service members. Rotating forces routinely conduct these surveys. Currently, medical capability surveys are conducted based on individual unit requirements and personnel expertise and stored locally on component-specific sites or individual computers. The lack of a systematic approach and a centralized survey depot may undermine the ability to access previous surveys, leading to redundant surveys and conflicting information, and may have critical implications for force health protection. Partner nation facilities could have capabilities that may be leveraged to care for U.S. service members when U.S. medical care is unavailable. A lack of understanding of medical capabilities at partner nation facilities may undermine the ability to plan missions that mitigate risks. This paper presents the results of 12 semi-structured focus groups with representatives from the U.S. Africa Command Surgeon's office, the U.S. Transportation Command Patient Movement Requirements Center-East, and 9 U.S. Africa Command service components, sub-unified commands, and force providers. The focus group discussions considered questions on the following four topics: (1) methods for conducting surveys, (2) guidance about how to conduct surveys, (3) nodes of care and ancillary services included in surveys, and (4) how medical capability surveys are used to inform medical planning. The team conducted thematic analysis to identify emergent themes and subthemes. The team identified five primary, overarching themes: (1) guidance for conducting medical capability surveys, (2) methods and tools for conducting surveys, (3) content and focus of medical capability surveys, (4) archiving and sharing surveys, and (5) uses of medical capability surveys. Implementing guidance and standardized templates for conducting medical capability surveys could improve the accuracy and completeness of surveys. Templates would likely increase the likelihood that surveyors collect relevant information on key medical capabilities. Training, along with guidance and templates, would provide a common understanding of how to conduct surveys. The lack of a DoD Global Health Engagement collaborative depot for storing and sharing surveys may undermine the ability to access previous surveys to inform future surveys and, thereby, results in inefficiencies in how surveys are conducted. The DoD should consider establishing a collaborative depot for medical capability surveys along with guidance or requirements for uploading surveys. Guidance, templates, training, and a collaborative depot could improve the effectiveness and efficiency of medical planning and thereby increase mission readiness.

TriService Nursing Research Program: A critical component to support military nursing science

TriService Nursing Research Program: A critical component to support military nursing science

0299 The Effects of Chronic Sleep Restriction on Calorie and Macronutrient Intake

Abstract Introduction Chronic sleep restriction (CSR) has been associated with increased calorie intake and increased consumption of fats and carbohydrates, with inconsistent changes in protein. However, the majority of studies have either been observational field studies with no sleep intervention, or laboratory-based studies where food availability may not have reflected participants’ real-world choices. We hypothesized that calorie, fat, and carbohydrate intake would increase during a week of imposed CSR compared to a week of sleep satiation (SS) among individuals living in their home environment. Methods Twelve healthy participants (6 females) kept a fixed sleep-wake schedule, with a constant waketime, at home for four weeks (actigraphy confirmed compliance). During weeks one and three, participants maintained 9 hours in bed. During weeks two and four, participants were randomly assigned to experimental weeks of 5 and 9 hours of time-in-bed in a crossover design. Participants documented their food consumption during both experimental weeks using a picture-based meal logging application (MealLogger). Intake of calories and macronutrients were classified by two blinded evaluators. Descriptive statistics were calculated in SAS (Cary, NC). Results Participants averaged 4.43 ± 0.33 (SD) hours of sleep per night during CSR compared to 7.42 ± 0.42 hours during SS. Participants consumed a daily average of 1812 ± 672 kilocalories, 71 ± 31 grams of total fat, 217 ± 69 grams of carbohydrates, and 84 ± 40 grams of protein during CSR, compared to 1682 ± 514 kilocalories, 68 ± 23 grams of total fat, 198 ± 61 grams of carbohydrates, and 77 ± 32 grams of protein during SS. Conclusion Preliminary descriptive findings suggest that, on average, participants consumed more calories, from an increase in consumption of each macronutrient group, during a week of sleep restriction compared to a week of sleep satiation. Further analysis is needed to determine whether these differences are statistically different and to identify when calories were consumed in each of the experimental conditions. Support (If Any) Supported by the Force Health Protection Program of the Office of Naval Research (SAA2402925-1, Contract Award no. N0001418IP00050) and the NASA Airspace Operations and Safety Program, System-Wide Safety.

The Lived Experience of Military Women With Chronic Pain: A Phenomenological Study.

ABSTRACTIntroductionChronic pain, a persistent or recurrent pain lasting more than 3 months, is a widespread problem among military women due to combat-related injuries and post-deployment stressors. Risk factors associated with chronic pain include gender, mental health, post-traumatic stress disorder, and prior physical or military sexual trauma. The most common prevalence of chronic pain is musculoskeletal (e.g., low back and neck), migraine, osteoarthritis, and fibromyalgia. Following deployment, 25% of military women are at risk for chronic pain. Military women are prescribed opioids for pain at a higher rate than men and are at risk for prescription opioid addiction. The unique medical needs of military women, including chronic pain, are poorly understood by health care providers and need to be addressed to achieve full integration into the military. The purpose of this study was to explore a typical day for military women living with chronic pain by examining the participants’ daily life experiences.Material and MethodsUsing van Manen’s approach, 13 active duty, retired, and veteran women were interviewed to explore these lived experiences. The study was approved by the Institutional Review Board at the University of San Diego.ResultsEight themes emerged from an analysis of the participants’ experiences: (1) chronic pain is a frustrating, persistent, daily, and an hourly struggle; (2) resilience in living with chronic pain is the new normal; (3) mission first and the impact of invisible pain; (4) self-care management and internal locus of control with nonpharmacological therapies; (5) pain accepted and managed to improve quality of life; (6) coronavirus disease 2019 (COVID-19) diminished social interactions; (7) pain of sexual trauma is not reported; and (8) disparities in health care due to self-perception of provider bias as pain is not understood.ConclusionsThe study generated new knowledge in Force Health Protection, ensuring (1) a fit and operational readiness force; (2) pre- to post-deployment care for women warriors; and (3) access to health care. The study findings supported previous research and could help direct future research into nursing, medicine, and allied health treatments for military and veterans’ gender-specific health care, education, and training. Furthermore, the military women in this study provided insight into the need for future research to explore unconscious gender bias, health disparities, and a raised awareness of military women living with chronic pain. Findings from this study merit further exploration using other qualitative research methodologies including mixed methods.

Describing mRNA Vaccine Technology for a Military Audience.

Vaccine technology has improved substantially since the first smallpox vaccine, developed more than 200years ago. As technology improves, vaccines can be produced more safely and reliably for many different pathogens. A recent breakthrough saw the first full deployment of mRNA vaccines to fight a pandemic. Despite the technological and logistical feat of developing a viable vaccine in an abbreviated time frame, there have been many questions about this new approach to vaccine development. The current review will provide descriptions about different types of vaccines as well as answers to some common questions about mRNA vaccines. The purpose is to provide military medical professionals with the information needed to better convey the importance and function of these new vaccines to service members. There were no explicit inclusion or exclusion criteria for articles describing mRNA vaccine technology. References included here were intended to illustrate important principles or empirical evidence in demonstrating the safety, efficacy, and function of mRNA vaccines. The review describes three different types of vaccines: whole-pathogen, subunit, and nucleic acid. Each vaccine type has different implications for the development and production of a vaccine line. For example, whole-pathogen and subunit vaccines often require growing significant amounts of the vaccine sample in laboratory before the material can be incorporated into the vaccine. Nucleic acid vaccines instead provide cells the opportunity to produce key proteins without needing to reproduce the virus and attenuate it in a laboratory setting. This approach has a notable advantage of speed in moving from genome sequencing to vaccine production, but it also creates some potential confusion. The discussion covers three questions with regard to this confusion. First, was the vaccine developed too quickly? Speed here is a byproduct of the new technology and unprecedented government interdepartmental cooperation. No steps were skipped in development or production. Second, does the vaccine modify DNA? No, the mRNA vaccines never enter the cell nucleus and therefore cannot modify DNA. The discussion clarifies how mRNA enters cells and produces the key proteins required to stimulate an immune system response. Third, how long will immunity last? Because mRNA vaccines are new, long-term immunity cannot be projected without significant further study. Still, the discussion does cover issues in determining vaccine efficacy in clinical laboratory trials versus field effectiveness in the real world. These mRNA vaccines are the newest and most sophisticated defensive tool military medicine has against emerging biological threats. Evolving dangers, such as synthetic biology and engineered pathogens, further enhance the importance of having defensive countermeasures that can be rapidly deployed in response. Current evidence suggests high safety and effectiveness for a biological countermeasure, decades in the making, and military medical personnel should feel confident using and recommending this technology to ensure force health protection.

Modeling a Lossy Dieletric Polymer-based Thermoacoustic High Power Microwave Directed Energy Exposure Detection System.

Presented are design considerations for a potential detection and measurement technique that could provide operational awareness of high power microwave (HPM) directed energy weapon exposure for force health protection applications, leveraging thermoacoustic (TA) wave generation as the field interaction mechanism. The HPM electromagnetic frequency (EMF) regime, used in applications in both the counter-materiel and non-lethal counter-personnel design space, presents real-time personnel exposure warning challenges due to the potentially wide variation in time and frequency domain characteristics of the incident beam. As with other EM-thermal interactions, the thermoacoustic wave effect provides the potential to determine EM energy and power deposition without the need to measure ambient field intensity values or overload-sensitive EMF survey equipment. Following measurement of relevant EM, thermal, and elastic material property values, a carbon-filled polytetrafluoroethylene (CF-PTFE) lossy dielectric medium subject to pulsed HPM was computationally modeled using the commercial finite element method multi-physics simulation software package COMSOL. The simulation was used to explore the impacts of various material properties on TA signal output as a function of simulated incident field power density, EM frequency, and pulse length, thereby informing the selection of system components for the further development of a full TA-based HPM detection chain.

A Hierarchy of Medical Countermeasures Against Biological Threats.

Emerging biological threats represent a serious challenge for force health protection (FHP). Against a novel biological threat, medical countermeasures are the first line of defense. However, as exposed by global pandemic conditions, there are significant complications when administering medical countermeasures against novel threats. One such limitation involved the lack of any guiding structure to discuss and deliberate upon the relative value of employing different countermeasures either alone or in tandem. For example, both personal protective equipment and prophylactic medication can provide some protection, but how are individual protections weighed against operational capabilities and FHP initiatives? The goal of this review is to provide a hierarchical organizing structure to the different medical countermeasures available in response to emerging biological threats. This review used no explicit inclusion or exclusion criteria for its literature review. References are provided for illustrative purposes to represent different components of the medical hierarchy. The hierarchy presented here is organized around a resource-durability structure that functions as a push-pull mechanism. Specifically, lower levels of the hierarchy require more resources to sustain FHP conditions while also providing less durable protection. These countermeasures require continual reapplication, and so resources become conceived as much in time and effort to apply as in exhaustible supplies. Higher-order countermeasures require less resources investment as a single application can provide weeks, months, or years of protection. Moreover, higher-order protections are less likely to interfere with military operational capabilities, which further support their classification as superior countermeasures to sustain FHP. The five levels of the hierarchy are presented here as follows, organized from lowest to highest value as a medical countermeasure: (1) Sanitization, (2) personal protective equipment, (3) prophylaxis, (4) vaccines, and (5) optimized immune system. Rationale and descriptions identify how each higher-order countermeasure is superior to its lower-order counterparts while noting that optimizing FHP will likely require employing multiple countermeasures at different levels. The discussion concludes with an overview as to how different countermeasures were employed to various degrees during a novel global pandemic. Identifying medical countermeasures is important to optimizing FHP. Different countermeasures have different advantages, and the hierarchy distinguishes between inferior and superior countermeasures through the push-pull style mechanism of resource-durability assessment. Future deployment and development should focus on superior countermeasures to maximize medical protections and operational readiness while understanding the relative value and complications inherent with different countermeasures.

Antimicrobial Susceptibility of Neisseria gonorrhoeae in Adult Patients Seeking Care at Military Hospitals in Thailand From 2014 to 2020.

The effective dual antibiotics ceftriaxone (CRO) and azithromycin (AZM) have successfully treated Neisseria gonorrhoeae (GC) infection, however, the CRO- and AZM-resistant strains have been sporadically detected globally and in Thailand. Furthermore, there are no currently antimicrobial susceptibility profiles of the GC isolates obtained from soldiers reported in Thailand. Hence, this is the first study to describe the antimicrobial susceptibility profiles of GC isolates obtained from predominately soldiers who seeking care at Military Camp Hospitals, in Thailand from 2014 to 2020. A total of 624 symptomatic gonococcal samples were received from 10 military hospitals during 2014-2020. They were collected from urethral swabs and inoculated into selective media. The suspected GC isolates were subcultured and presumptively identified using conventional microbiology techniques. Antimicrobial susceptibility test was performed by Etest to determine minimal inhibitory concentration (μg/mL) against AZM, benzylpenicillin, cefepime, cefixime, ceftriaxone (CRO), ciprofloxacin, spectinomycin, and tetracycline using the criteria outlined in the Clinical and Laboratory Standards Institute guidelines. This study was approved by Institutional Review Board, Royal Thai Army Medical Department under protocol number S036b/56 and Walter Reed Army Institute of Research, and Silver Spring, MD under protocol number WR #2039. A total of 624 samples were collected from symptomatic gonococcal infectious patients with 91.5% (571/624) of samples obtained from soldiers. Of those, 78% (488/624) were identified as GC and 92% (449/488) of them were isolated from soldiers. All GC samples collected were susceptible to CRO (first-line treatment) with only one GC isolate identified as non-susceptible to cefepime and three isolates identified as non-susceptible to AZM. The recommended dual treatment of GC infections with CRO and AZM is currently an effective empirical treatment for patients who are seeking care at military hospitals in Thailand. Nevertheless, cefepime is a fourth-generation cephalosporin with documented high activity against GC strains equal to other "third-generation" cephalosporins such as CRO. Due to the active duty of military personnel, they concerned about the confidentiality and frequently seek treatment at civilian clinics. Additionally, due to the availability of antibiotics over the counter in Thailand, many choose the option to self-medicate without a physician's prescription. These could be subsequently driven the gradual increase of multidrug-resistant gonococcal strains throughout the country. Thus, the GC surveillance would be needed for further Force Health Protection and public health authorities in response to the drug-resistant GC threats.

Pandemic Impacts on Cluster B Personality Disorders in the U.S. Navy: A Case Study in Context.

ABSTRACTThis paper is a brief description of the impact that the SARS-CoV-2 global pandemic has had on both mental health and U.S. Navy policies through the narrative of a deployed enlisted sailor, medically evacuated from Japan. Although the introduction of vaccines and loosening of state-specific mandates have signaled a slow return to our “normal,” pre-pandemic, way of life, there is now an opportunity to look back and understand how the situation impacted the presentation and outcome of certain cases. We believe that the sailor presented introduces a discussion about the impacts of heightened restrictions on some personality types. As the pandemic has continued to impact and reshape every facet of force health protection, we believe that understanding the impact of public health orders on individuals with specific personality disorders or traits will help us provide care and leadership counsel going forward. The discussion within our case report provides insight and an opportunity for healthcare providers to reflect.

Vitamin D Deficiency in the Military: It's Time to Act!

Vitamin D is critically important to numerous physiologic functions, including bone health. Poor vitamin D status is a common but underrecognized problem that predisposes the military population to stress fracture and completed fracture. This has significant implications for force health protection, warfighter readiness, attrition, and cost. Despite this, vitamin D deficiency is still underdiagnosed and undertreated in the military. This is a major hindrance to military readiness and one that could easily be modified with awareness, prevention, and early treatment. In this commentary, we review the literature on vitamin D deficiency and critically examine the current status of policies and clinical practice related to vitamin D in the military health system. We offer several practical recommendations to increase awareness and readiness while decreasing musculoskeletal injury and the associated costs.