<rss xmlns:a10="http://www.w3.org/2005/Atom" version="2.0"><channel><title>Health.mil Articles RSS Feed</title><link>https://www.health.mil/RSS/Articles</link><description>This feed consists of Articles related to Military Health.</description><language>en</language><item><guid isPermaLink="false">{11635EF7-39C1-45F5-A315-960E7E302A5B}</guid><link>https://www.health.mil/News/Articles/2024/03/01/MSMR-Flu-Vaccine-Effectiveness</link><title>Mid-Season Influenza Vaccine Effectiveness Estimates Among DOD Populations: A Composite of Data Presented at VRBPAC—the Vaccines and Related Biological Products Advisory Committee—2024 Meeting on Influenza Vaccine Strain Selection for the 2024-2025 Influenza Season</title><description>&lt;p&gt;Each March, the Vaccines and Related Biological Products Advisory Committee of the U.S. Food and Drug Agency meets to review and discuss data on influenza strain circulation and vaccine effectiveness estimates for the current influenza season.&lt;sup&gt;1&lt;/sup&gt; The committee then makes recommendations on the selection of strains for the influenza vaccines to be developed for the following influenza season. &lt;/p&gt;&lt;p&gt; The Department of Defense participates in the VRBPAC meeting by presenting mid-season influenza data from the DOD’s global influenza surveillance, VE, and phylogenetic analyses, in addition to antigenic characterization of circulating viruses. DOD VE analyses are conducted among both service member and non-service member beneficiary populations to complement U.S. population VE estimates.&lt;sup&gt;2&lt;/sup&gt; &lt;/p&gt;&lt;p&gt; Timing of these analyses is dependent upon the timing of peak activity for each season. Typically, mid-season estimates cannot be generated until February, to allow for adequate testing and sufficient case numbers to provide a reliable sample size for analysis.&lt;/p&gt;&lt;p&gt; These DOD VE analyses represent a joint effort between the Defense Health Agency's Defense Centers for Public Health in Falls Church and Dayton and the Naval Health Research Center. The combined assessment of data from these organizations provides the DOD, FDA, and U.S. Centers for Disease Control with comprehensive mid-season information on how well the influenza vaccines are working for force health protection and the broader military health population. &lt;/p&gt;&lt;p&gt; &lt;em&gt;MSMR&lt;/em&gt; anticipates publishing these findings annually, in February or March, to disseminate this information more widely to interested individuals and public health agencies. &lt;/p&gt;&lt;h2&gt;Author Affiliations&lt;/h2&gt;&lt;p&gt;Epidemiology and Analysis Branch, Armed Forces Health Surveillance Division, Defense Health Agency: Dr. Eick-Cost, Ms. Hu; Defense Centers for Public Health–Dayton, Defense Health Agency: Mr. Thervil, Ms. DeMarcus &lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions, nor policies of the Defense Health Agency or the Department of Defense. &lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;U.S. Food and Drug Administration. Vaccines and Related Biological Products Advisory Committee May 16, 2024 Meeting Announcement. &lt;a rel="noopener noreferrer" href="https://www.fda.gov/advisory-committees/advisory-committee-calendar/vaccines-and-related-biological-products-advisory-committee-may-16-2024-meeting-announcement" target="_blank" title="Click on the link to access the FDA's webpage announcing the 2024 VRBPAC meeting"&gt;https://www.fda.gov/advisory-committees/advisory-committee-calendar/vaccines-and-related-biological-products-advisory-committee-may-16-2024-meeting-announcement&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;McLean HQ, Petrie JG, Hanson KE, et al. Interim estimates of 2022-23 seasonal influenza vaccine effectiveness–Wisconsin, October 2022-February 2023. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2023;72:201-205.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Mar 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{5A39060B-FD0E-40C6-B0D5-ADDCA5340C5B}</guid><link>https://www.health.mil/News/Articles/2024/03/01/MSMR-Flu-Vaccine-TRICARE-Beneficiaries</link><title>2023-2024 Mid-Season Influenza Vaccine Effectiveness Against Laboratory-Confirmed Ambulatory Influenza: DOD TRICARE Beneficiaries</title><description>&lt;p&gt;The DOD Global Respiratory Pathogen Surveillance Program&lt;sup&gt;1&lt;/sup&gt; used a matched case-test negative control study design to determine VE estimates against ambulatory influenza among DOD TRICARE beneficiaries. Specimens were collected from October 1, 2023 to February 17, 2024 among individuals with an influenza-like illness medical encounter, then analyzed either at the United States Air Force School of Aerospace Medicine or Landstuhl Regional Medical Center. An ILI encounter was defined as presenting with a fever (≥100.4°F) and cough, fever (≥100.4°F) and two or more additional symptoms (fatigue, body aches, sore throat, headache, sinus congestion, shortness of breath, chills, runny nose, loss of taste or smell, acute respiratory distress) or a physician-diagnosed ILI. The study excluded service members, who were evaluated separately by the Armed Forces Health Surveillance Division. &lt;/p&gt;&lt;p&gt; Cases were individuals with a laboratory-confirmed positive influenza specimen, while controls were those with a specimen testing negative for influenza. An attempt was made to match each case to four controls by the month of specimen collection, but due to control availability, some analyses only had one case to three controls. Vaccination status was determined by utilizing the Aeromedical Services Information Management System or self-reporting through DODGRPSP questionnaires. Individuals were considered vaccinated if they received the vaccine at least 14 days prior to specimen collection, with exclusions for vaccines received within 14 days. Adjusted ORs and 95% CIs were calculated via multivariable logistic regression, adjusting for age group and geographic region. Adjusted VE estimates were computed as (1 - aOR) x 100. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-8-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-8-Table.ashx?h=472&amp;w=1200&amp;hash=917F4DEEB4B0D9B0E122E06F13903A5EC24D616D" style="width: 1200px; height: 472px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt; The study identified 158 cases and 479 controls. Adjusted VE estimates for all DOD beneficiaries showed 35% effectiveness (CI: 4, 56) against overall influenza, 32% (CI: -8, 57) against overall influenza A, 40% (CI: -15, 69) against influenza A(H1N1)pdm09, 54% (CI: -31, 84) against influenza A(H3N2), and 67% (CI: 17, 87) against influenza B. For children, the adjusted VE estimate was 43% (CI: 0, 67) against overall influenza, while for adults it was 52% (CI: 11, 74) against overall influenza. &lt;/p&gt;&lt;p&gt; VE estimates suggest statistically significant, low to moderate protection against overall influenza among all DOD TRICARE beneficiaries and adults, as well as against influenza B among all DOD TRICARE beneficiaries. VE estimates against overall influenza for children, overall influenza A for all DOD TRICARE beneficiaries, influenza A(H1N1)pdm09, and influenza A(H3N2) for all DOD TRICARE beneficiaries indicate low to moderate protection, but these results did not reach statistical significance. &lt;/p&gt;&lt;h2&gt;Reference&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Kwaah B, Gruner WE, DeMarcus L, et al. Surveillance trends for SARS-CoV-2 and other respiratory pathogens among US military health system beneficiaries, 27 September 2020–2 October 2021. &lt;em&gt;MSMR&lt;/em&gt;. 2022;29(7):2-10.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Mar 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{B1F37938-F201-46F4-85F7-BE7879FE5DEC}</guid><link>https://www.health.mil/News/Articles/2024/03/01/MSMR-Flu-Vaccines-Ambulatory-Infections</link><title>Mid-Season Influenza Vaccine Effectiveness Against Laboratory-Confirmed Ambulatory Influenza: U.S. Active Component Service Members</title><description>&lt;p&gt;This Surveillance Snapshot provides an overview of the 2023-2024 mid-season analysis of influenza VE against medically-attended ambulatory influenza infections among active component service members. Data from the Defense Medical Surveillance System, the NHRC’s respiratory surveillance program, and standardized laboratory data provided by the Defense Centers for Public Health–Portsmouth were used for this analysis.&lt;sup&gt;1,2&lt;/sup&gt; A case test-negative study design was implemented among the population of ACSMs from all services who were tested for influenza between December 1, 2023 and February 23, 2024—the period of peak influenza activity for the season. &lt;/p&gt;&lt;p&gt; Cases were defined as individuals with a positive influenza result from a rapid antigen, reverse transcription polymerase chain reaction or culture influenza assay. Test-negative controls were individuals with a negative influenza result from a RT-PCR or culture influenza assay. Crude odds ratios were calculated and multivariate logistic regression was used to calculate adjusted ORs (adjusted for sex, age category, prior vaccination [any influenza vaccine in previous 5 years], and month of diagnosis) and 95% confidence intervals. VE estimates were defined as (1 - OR) x 100. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-7-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-7-Table.ashx?h=468&amp;w=1200&amp;hash=F2846E7101D270C5CD166184C4BC7762841240B9" style="width: 1200px; height: 468px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt; There were 3,540 cases—2,794 A (any subtype), 246 A(H3N2), 119 A(H1N1)pdm09, 751 B (any type)—and 16,411 TNCs. TNCs were more likely vaccinated (85.4%) than cases (82.5%). VE varied by influenza type (Table). Statistically significant VE was found against any influenza case with an adjusted VE of 21% (95% CI: 13, 29) and influenza A (any subtype) with an adjusted VE of 26% (95% CI: 18, 34). The VE point estimate against influenza A(H1N1)pdm09 and A(H3N2) showed effectiveness, but did not reach statistical significance (23% [95% CI: -23, 51] and 28% [95% CI: -1, 49], respectively). This mid-season assessment did not find the vaccine to be effective against influenza B ambulatory infections (-5% [95% CI: -30, 15]). &lt;/p&gt;&lt;p&gt; The results of this analysis show low protection of the 2023-2024 seasonal influenza vaccines against medically-attended influenza A infections that resulted in ambulatory care visits among ACSMs. As these estimates were obtained during the middle of the influenza season, VE estimates and CIs may change when data from the full season are available and sample sizes increase. &lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Rubertone MV, Brundage JF. The Defense Medical Surveillance System and the Department of Defense serum repository: glimpses of the future of public health surveillance. &lt;em&gt;Am J Public Health&lt;/em&gt;. 2002;92(12):1900-1904. doi:10.2105/ajph.92.12.1900 &lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.med.navy.mil/Naval-Medical-Research-Command/R-D-Commands/Naval-Health-Research-Center/Core-Research/Operational-Infectious Diseases/respiratory-surveillance-2023-2024" target="_blank" title="Click on the link to access the Naval Health Research Center's Core Research website"&gt;https://www.med.navy.mil/Naval-Medical-Research-Command/R-D-Commands/Naval-Health-Research-Center/Core-Research/Operational-Infectious Diseases/respiratory-surveillance-2023-2024&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Mar 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{C5277A65-0777-4A4A-8A3E-8460DB75CCB0}</guid><link>https://www.health.mil/News/Articles/2024/03/01/MSMR-Flu-Vaccines-Hospitalizations</link><title>2023-2024 Mid-Season Influenza Vaccine Effectiveness Against Laboratory-Confirmed Influenza Hospitalizations: U.S. Active Component Service Members</title><description>&lt;p&gt;This Surveillance Snapshot provides an overview of the 2023-2024 mid-season analysis of influenza VE against influenza hospitalizations among ACSMs. Data from the DMSS and standardized laboratory data provided by DCPH–Portsmouth were utilized for this analysis.&lt;sup&gt;1&lt;/sup&gt; A cohort study design was implemented among the population of ACSMs in service at any time between September 1, 2023 and February 14, 2024. &lt;/p&gt;&lt;p&gt;The outcome was defined as a laboratory-confirmed influenza-positive result (rapid antigen, RT-PCR, or culture influenza assay) with an indication that the individual was hospitalized, or a hospitalization record with the first or second diagnostic International Classification of Diseases, 10th revision code for influenza (J09-J11). Person-time started at the beginning of the surveillance period or entry into active component service (whichever came last) and was censored at either the occurrence of the outcome, end of the surveillance period, or leaving active component or military service (whichever came first). Person-time and outcomes were stratified by vaccination status. Person-time and outcomes occurring prior to vaccination and up to 13 days post-vaccination were defined as unvaccinated. Person-time and outcomes occurring at least 14 days after vaccination were defined as vaccinated. Analyses were conducted for laboratory-confirmed influenza hospitalizations alone and then combined with hospitalization records for influenza. Incidence rates per 100,000 person-years (p-yrs) were calculated and a Poisson regression model was used to calculate adjusted incidence rate ratios (adjusted for sex, age category, prior vaccination [any influenza vaccine within previous five years], and month of diagnosis) and 95% CIs. VE was defined as (1 - OR) x 100. &lt;/p&gt;&lt;p&gt;There were 47 laboratory-confirmed influenza hospitalizations among ACSMs during the study period. An additional 17 influenza hospitalization records were identified using the encounter data. For both outcomes, the incidence rate of influenza hospitalization among unvaccinated ACSMs was twice the rate of vaccinated ACSMs (lab-confirmed only: 1.0 vs. 0.5 per 100,000 p-yrs; lab-confirmed and hospitalization records: 1.4 vs. 0.7 per 100,000 p-yrs) (Table). Likewise, the adjusted analysis resulted in VE estimates of 46% (95% CI: 2, 70) and 54% (95% CI: 12, 72) for the laboratory-confirmed only and laboratory-confirmed with hospitalization records, respectively. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-6-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-6-Table.ashx?h=395&amp;w=1200&amp;hash=FC050BEF256F1C518033F23571D0F49D562A7A0B" style="width: 1200px; height: 395px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;The results of this analysis show moderate protection against hospitalization for influenza among ACSMs from the 2023-2024 seasonal influenza vaccines. Although the number of outcomes are small, the analysis still reached statistical significance and provides data supporting the use of influenza vaccines among typically healthy ACSMs to prevent influenza hospitalizations. &lt;/p&gt;&lt;h3&gt;Reference&lt;/h3&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Rubertone MV, Brundage JF. The Defense Medical Surveillance System and the Department of Defense serum repository: glimpses of the future of public health surveillance. &lt;em&gt;Am J Public Health&lt;/em&gt;. 2002;92(12):1900-1904. doi:10.2105/ajph.92.12.1900&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Mar 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{D1A39BC0-2248-4D50-A4B6-81040DC8C9C6}</guid><link>https://www.health.mil/News/Articles/2024/03/01/MSMR-HIV-Incidence-Snapshot</link><title>Surveillance Snapshot: A Comparison of the Rate of HIV Incidence in the Active Component U.S. Military with the U.S. Population in 2021</title><description>&lt;p&gt;The 2022-2025 National HIV/AIDS Strategy to end the HIV epidemic by 2030 includes an implementation plan that directs the Department of Defense (DOD) to “continue to implement interventions, testing, education, and training on the prevention of transmission of HIV infection as described in DODI [DOD Instruction] 6485.01, DHA-PI [Defense Health Agency-Procedural Instruction] 6025.29, and DHA-PI 6485.01.”&lt;sup&gt;1,2&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;The annual crude rate of new HIV infections in the U.S. military between 2018 and 2023 was 21 per 100,000 population,&lt;sup&gt;3&lt;/sup&gt; much higher than the estimated 11.5 per 100,000 in the U.S. general population in 2021.&lt;sup&gt;4&lt;/sup&gt; A comparison of U.S. military and general population rates of HIV infection, adjusted for relevant confounding variables, has not been published, neither for U.S. military HIV incidence rates among different races and ethnicities. This Surveillance Snapshot presents a comparison of U.S. active component military and general population HIV incidence rates in 2021,&lt;sup&gt;4&lt;/sup&gt; the most recent year for which stratified U.S. data were available, using indirect standardization by sex, age, and race and ethnicity. &lt;/p&gt;&lt;p&gt;There were 174 observed cases of HIV in the U.S. military in 2021 who self-identified their race and ethnicity as Black, Hispanic, or White, compared to an expected number of 335 based on U.S. population rates,&lt;sup&gt;5&lt;/sup&gt; resulting in an overall standardized morbidity ratio of 0.52 (Table). The rate of HIV in the active component U.S. military was 48% lower than the U.S. general population rate after adjusting for sex, age, and race and ethnicity. SMR estimates stratified by race and ethnicity were similar for non-Hispanic Black and White service members (0.59 and 0.60, respectively) but lower for Hispanic service members (SMR=0.32). SMRs for racial and ethnic groups other than White, Black, and Hispanic cannot be presented because U.S. general population rates have not been not published for additional groups.&lt;sup&gt;4&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-4-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-4-Table.ashx?h=718&amp;w=1200&amp;hash=CF2D84DD4C4523949923E38659012CD4CEC6587C" style="width: 1200px; height: 718px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Since the U.S. military requires HIV testing at least biennially,&lt;sup&gt;6&lt;/sup&gt; it is unlikely that significant numbers of cases in the U.S. military are being missed, whereas infected individuals might be undiagnosed for longer periods of time in the general population if untested, leading to underestimates in younger populations. &lt;/p&gt;&lt;p&gt;The findings from this Snapshot may help to contextualize lower use (24%) of HIV pre-exposure prophylaxis in 2021 among those in the U.S. military with indications for its use, published in this issue of the &lt;em&gt;MSMR&lt;/em&gt;,&lt;sup&gt;7&lt;/sup&gt; compared to those at risk in the general population (30%). The lower adjusted U.S. military rate of HIV infection may be due to unmeasured behavioral or other factors rather than increased use of PrEP. These findings are consistent with the presence of a selection bias (or ‘healthy warrior effect’) resulting from the exclusion of HIV-infected individuals from entry into service,&lt;sup&gt;8&lt;/sup&gt; as some of those with higher-risk sexual behaviors would have already been infected. Despite the lower adjusted rate of HIV infection in the U.S. military, HIV remains a threat to force health protection due to its costs, health consequences, and impact on military readiness.&lt;sup&gt;9&lt;/sup&gt; &lt;/p&gt;&lt;h2&gt;Author Affiliations&lt;/h2&gt;&lt;p&gt;Uniformed Services University Department of Preventive Medicine and Biostatistics: Dr. Mancuso; Epidemiology and Analysis Branch, Armed Forces Health Surveillance Division, Defense Health Agency: Dr. Mabila &lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions, nor policies of the Uniformed Services University of the Health Sciences, the Defense Health Agency, or the Department of Defense. &lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;The White House. &lt;em&gt;National HIV/AIDS Strategy for the United States 2022-2025&lt;/em&gt;. Accessed Jul. 9, 2023. &lt;a rel="noopener noreferrer" href="https://files.hiv.gov/s3fs-public/NHAS-2022-2025.pdf" target="_blank" title="Click on the link to access the National HIV/AIDS Strategy document"&gt;https://files.hiv.gov/s3fs-public/NHAS-2022-2025.pdf&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;The White House. &lt;em&gt;National HIV/AIDS Strategy Federal Implementation Plan&lt;/em&gt;. Updated Aug. 21, 2023. Accessed Nov. 4, 2023. &lt;a rel="noopener noreferrer" href="https://www.hiv.gov/federal-response/national-hiv-aids-strategy/implementing-national-hiv-aids-strategy" target="_blank" title="Click on the link to access the implementation plan for the National HIV/AIDS Strategy"&gt;https://www.hiv.gov/federal-response/national-hiv-aids-strategy/implementing-national-hiv-aids-strategy&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Update: routine screening for antibodies to human immunodeficiency virus, U.S. Armed Forces, active and reserve components, January 2018-June 2023. &lt;em&gt;MSMR&lt;/em&gt;. 2023;30(9):2-10. &lt;/li&gt;    &lt;li&gt;Centers for Disease Control and Prevention. Estimated HIV Incidence and Prevalence in the United States 2017-2021. Updated May 23, 2023. Accessed Nov. 4, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-28-no-3/index.html" target="_blank" title="Click on the link to access the CDC's HIV Surveillance Report website"&gt;https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-28-no-3/index.html&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Inskip H, Beral V, Fraser P, Haskey J. Methods for age-adjustment of rates. &lt;em&gt;Stat Med&lt;/em&gt;. 1983;2(4):455-466. doi:10.1002/sim.4780020404&lt;/li&gt;    &lt;li&gt;Under Secretary of Defense for Personnel and Readiness. DOD Instruction 6485.01: Human Immunodeficiency Virus (HIV) in Military Service Members. Department of Defense. Updated Jun. 6, 2022. Accessed Nov. 4, 2023. &lt;a rel="noopener noreferrer" href="https://www.esd.whs.mil/portals/54/documents/dd/issuances/dodi/648501p.pdf" target="_blank" title="Click on the link to access the Department of Defense's HIV Instruction document"&gt;https://www.esd.whs.mil/portals/54/documents/dd/issuances/dodi/648501p.pdf&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Mancuso JD, Ahmed AE. Coverage of HIV pre-exposure prophylaxis (PrEP) in the active duty U.S. military, 2023. &lt;em&gt;MSMR&lt;/em&gt;. 2024;31(3):13-16. &lt;/li&gt;    &lt;li&gt;Office of the Under Secretary of Defense for Personnel and Readiness. Department of Defense Instruction 6130.03, Volume 1. Medical Standards for Military Service: Appointment, Enlistment, or Induction. Department of Defense. Updated Nov. 16, 2022. Accessed Jul. 7, 2023. &lt;a rel="noopener noreferrer" href="https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/613003_vol1.PDF?ver=7fhqacc0jGX_R9_1iexudA%3D%3D" target="_blank" title="Click on the link to access the Department of Defense's Medical Standards for Military Service document"&gt;https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/613003_vol1.PDF?ver=7fhqacc0jGX_R9_1iexudA%3D%3D&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Cavanaugh JS, Murray CK, Chang D, Ake JA. The purpose and impact of the U.S. military HIV research program. &lt;em&gt;JFQ&lt;/em&gt;. 2023;110(3rd quarter):69-74.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Mar 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{B7AE5D32-51B4-4BA1-A181-A39EE255ADF2}</guid><link>https://www.health.mil/News/Articles/2024/03/01/MSMR-HIV-PrEP</link><title>Coverage of HIV Pre-Exposure Prophylaxis Within the Active Duty U.S. Military, 2023</title><description>&lt;p&gt;Estimates of HIV pre-exposure prophylaxis coverage in the U.S. military, defined as the proportion of the persons taking HIV PrEP out of the estimated number of persons who had indications for it, have never been published. The objective of this study was to provide an estimate of HIV PrEP coverage comparable to U.S. civilian estimates. The population with indications for HIV PrEP was obtained from the Department of Defense 2018 Health Related Behaviors Survey, a stratified random sample of members of all military service branches. The military PrEP coverage estimate of 31.6% in 2023 was lower than the national U.S. estimate of 36.0% in 2022. Among the military population of men who have sex with men, an estimated 24.6% of service members had indications for PrEP, similar to the national estimate of 24.7%. MSM comprised 66% of all military service members with HIV PrEP indications, compared to 40% in the U.S. general population. The U.S. military should continue deliberate, sustained, and effective actions to address sexual health inequities among MSM, aligned and coordinated with societal efforts including improved coverage of HIV PrEP to prevent HIV transmission. &lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;Coverage of HIV PrEP among active duty military service members with indications for its use increased to 31.6% in 2023, which was lower than the national U.S. estimate of 36.0% in 2022. Men who have sex with men constituted 66% of all U.S. military service members with HIV PrEP indications. &lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;HIV PrEP may be underutilized within the U.S. military despite its effectiveness in preventing HIV transmission and its resultant improvements in morbidity, health care costs, and impacts on deployability and attrition. Men who have sex with men are the most important group for which the military should promote HIV PrEP use. &lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;Despite effective interventions to diagnose, treat, and prevent the transmission of the human immunodeficiency virus (HIV), 36,136 new infections occurred in the U.S. in 2021.&lt;sup&gt;1&lt;/sup&gt; Male-to-male sexual contact accounted for 67% of these infections, and 56% of those infected were ages 13 to 34, 40% were non-Hispanic Black, and 29% were Hispanic. Among the important interventions to prevent HIV transmission is pre-exposure prophylaxis with emtricitabine and tenofovir disoproxil fumarate or other approved regimens. &lt;/p&gt;&lt;p&gt;PrEP has been shown to be safe, as well as demonstrating an average effectiveness of 75% in reducing risk of HIV transmission among patients at high risk for HIV acquisition, although its effectiveness may be more or less than 75% depending on patient adherence.&lt;sup&gt;2&lt;/sup&gt; Since 2011,&lt;sup&gt;3&lt;/sup&gt; the use of PrEP has been recommended for this purpose among persons at high risk for HIV transmission by the U.S. Centers for Disease Control and Prevention.&lt;sup&gt;4&lt;/sup&gt; It is a critical component of the National HIV/AIDS Strategy for the United States&lt;sup&gt;5&lt;/sup&gt; and the Ending the HIV Epidemic in the U.S. initiative.&lt;sup&gt;6&lt;/sup&gt; Despite its importance in HIV prevention, the CDC estimated that only 36.0% of persons for whom HIV PrEP use was indicated were actually taking it in 2022,&lt;sup&gt;7&lt;/sup&gt; although this figure had increased from 12.6% in 2017.&lt;sup&gt;8&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;U.S. Department of Defense policy offers HIV PrEP in accordance with CDC guidance and as directed in national objectives.&lt;sup&gt;9,10&lt;/sup&gt; A prior study found that, from February 2014 to June 2016, an estimated 769 active duty service members had taken HIV PrEP, out of an indirectly estimated (using civilian data) population of 12,000 with indications.&lt;sup&gt;11&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;PrEP coverage in the U.S. military, defined as the proportion of the persons taking PrEP out of the estimated number of persons with indications for PrEP, has never been directly estimated using military data. An updated estimate of 4,495 service members taking PrEP in 2023 is provided in this month’s issue of &lt;em&gt;MSMR&lt;/em&gt;.&lt;sup&gt;12&lt;/sup&gt; The objective of this study was to provide a direct estimate of the denominator, or population of service members with PrEP indications, to provide an estimate of PrEP coverage comparable to U.S. civilian estimates. &lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;The population at risk was obtained from the DOD 2018 Health Related Behaviors Survey, which is comparable to the active duty population in 2023.&lt;sup&gt;13&lt;/sup&gt; The HRBS study population was a stratified random sample of members of all military service branches—Army, Navy, Air Force, Marine Corps, and Coast Guard.&lt;sup&gt;14&lt;/sup&gt; Of 199,996 invited eligible active duty service members, the overall weighted response rate was 9.6%.&lt;sup&gt;14&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;This study employed a total sampling frame of 1,357,219 active duty service members, and this was segmented into 50 strata based on the interaction of service branch (five categories), pay grade (five categories), and sex. All analyses were performed using SAS 9.4 (SAS Institute Inc., Cary, NC). Analyses accounted for survey weights to generate estimates representative of the active duty U.S. military population. &lt;/p&gt;&lt;p&gt;Estimates of the total U.S. military population of men who have sex with men, intravenous drug users, and sexually-active heterosexual men and women were obtained using HRBS questions 4 and 48 (MSM), 40c (IVDUs), and 46, 48, 49 (sexually-active heterosexuals).&lt;sup&gt;14&lt;/sup&gt; Estimates of the population of MSM who had indications for PrEP were also obtained from the HRBS, using the same methods used previously by CDC.&lt;sup&gt;15&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;MSM were considered as having indications for PrEP if they reported sex with two or more men in the past 12 months and any condom-less sex or a sexually-transmitted infection within the past 12 months (HRBS questions 46, 47, 54).&lt;sup&gt;14&lt;/sup&gt; Estimates of the population of IVDUs and heterosexual men and women with indications for PrEP were obtained by multiplying these populations from the HRBS by the proportion estimated to have indications for PrEP among civilian populations in 2018,&lt;sup&gt;15&lt;/sup&gt; as no similar questions pertaining to these indications for these groups were included in the HRBS. Estimates of MSM, heterosexual, and IVDU risks were independent of one another. &lt;/p&gt;&lt;p&gt;Both stratified and aggregate estimates of PrEP coverage in the U.S. active duty military are reported. Methods used to obtain national civilian estimates have been described previously.&lt;sup&gt;7,15&lt;/sup&gt; Institutional review was performed by the Uniformed Services University of the Health Sciences, Bethesda, MD. &lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;p&gt;As seen in the table, there were an estimated 38,341 MSM, 9,599 IVDUs, and 1,138,259 sexually-active heterosexual men and women in the active duty U.S. military population. These three subpopulations comprised, respectively, 2.8%, 0.7%, and 83.9% of the total estimated active duty population of 1,357,219 estimated by the HRBS (data not shown).&lt;sup&gt;14&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-2-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-2-Table.ashx?h=568&amp;w=1175&amp;hash=488175642587DC6A99E4CF3172F10968629A93F6" style="width: 1175px; height: 568px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Among MSM, 9,441 (24.6%) reported one or more indications for PrEP. There were also an estimated 1,776 IVDUs, 1,908 heterosexual men, and 1,106 heterosexual women with PrEP indications. These results generated an estimate of 14,231 total service members with PrEP indications. As 4,495 active duty service members were estimated to have been prescribed PrEP in 2023,&lt;sup&gt;12&lt;/sup&gt; this resulted in an estimated PrEP coverage of 31.6%. Of note, 66% of military service members with HIV PrEP indications were MSM, compared to only 40% of the U.S. population. The corresponding figures from the U.S. general population are also shown in the Table. &lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;This report estimates that PrEP coverage among active duty U.S. military service members in 2023 was 31.6%. The DOD estimate of PrEP coverage of 31.6% in 2023 was lower than the 2022 national U.S. estimate of 36.0%. Among those with PrEP indications, MSM comprised 66% of U.S. service members but only 40% of the U.S. population. The difference between these populations is largely attributable to the larger proportion of males in the U.S. military. &lt;/p&gt;&lt;p&gt;The comparison of PrEP coverage may be limited by demographic differences, with the military comprised of a younger and more racially and ethnically diverse population than the U.S. as a whole.&lt;sup&gt;16&lt;/sup&gt; Differences in health-related and other behaviors between these populations may also limit these comparisons.&lt;sup&gt;14&lt;/sup&gt; Additionally, the low response rate and the ‘healthy warrior effect’ may limit comparisons between military and civilian populations in this study due to selection bias.&lt;sup&gt;14&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;As with any self-reported data, health behaviors may have been misclassified due to concerns about social desirability, stigma, or other factors. The proportions of IVDUs and sexually-active heterosexual service members could not be directly estimated because the HRBS does not contain the necessary data for these calculations, which may have resulted in misclassification. For example, the CDC considers only those IVDUs who “have injected any assessed drug during the past 12 months and used a needle that had previously been used by another person” as having an indication for PrEP.&lt;sup&gt;15&lt;/sup&gt; The estimate of U.S. military members who were IVDUs was obtained from a question that also included other illegal drug use not limited to injection (e.g., cocaine, LSD, ecstasy, PCP), with no assessment of needle reuse.&lt;sup&gt;14&lt;/sup&gt; The U.S. military also performs routine testing for IV and other illegal drug use. These factors likely resulted in an overestimation of both service members who were IVDUs and those who had indications for PrEP, although this would have had only a small impact on the results of this report. &lt;/p&gt;&lt;p&gt;Similarly, the CDC only considered heterosexuals as having indications for PrEP if they “reported sex with two or more opposite sex partners and either 1) sex with an HIV-infected partner or 2) any condom-less sex in the last four weeks and sex with a high-risk partner in the past 12 months.”&lt;sup&gt;15&lt;/sup&gt; High-risk partners were defined as “persons who inject drugs or (for women) male partners known to also have sex with men (behaviorally bisexual).” This information on the behaviors of heterosexual service members and their sexual partners’ risk factors was likewise not available from the HRBS nor any other military source. Both national and DOD estimates may underestimate the heterosexual population with PrEP indications due to changing indications for PrEP in the 2021 U.S. Public Health Service and CDC guidelines, as neither included the new indication of a bacterial sexually-transmitted infection within the past six months.&lt;sup&gt;4,7&lt;/sup&gt; Similar to the CDC’s estimates, the groups studied in this report may not be mutually exclusive, resulting in a small overestimation in both estimates for the total population with PrEP indications. There is an expected small underestimation of the total active duty population prescribed PrEP, as it excludes activated Guard and Reserve service members. &lt;/p&gt;&lt;p&gt;Most importantly, service members may have sought HIV PrEP beyond direct or private sector health care provided by the Military Health System, instead seeking it at a local health department or privately-funded clinic serving the MSM community. If such care was not reimbursed by the military, the DOD would have no record of it, resulting in underestimates of HIV PrEP coverage in this report. &lt;/p&gt;&lt;p&gt;HIV degrades military readiness through the direct and indirect costs of HIV-associated health care and through deployment limitations and attrition of personnel with critical military occupational skills and experience.&lt;sup&gt;18,19&lt;/sup&gt; This study suggests that HIV PrEP use in the active duty military remains lower than in the U.S. population, and may be underutilized. This difference in use may be due to health care system factors, cultural factors, or demographic and behavioral differences between the U.S. military and civilian populations, although differences due to misclassification of PrEP use due to non-DOD health care utilization or other biases cannot be excluded. It further suggests that MSM in the U.S. military have similar behaviors resulting in HIV PrEP indications as MSM in the civilian population. &lt;/p&gt;&lt;p&gt;The high proportion (66%) of MSM among those with indications for HIV PrEP in the U.S. military suggests that this is the most important group in which the military should promote PrEP use. The U.S. military should continue deliberate, sustained, and effective actions to address sexual health inequities among MSM, commensurate and coordinated with societal efforts, that include improved HIV PrEP coverage to prevent HIV transmission. &lt;/p&gt;&lt;h2&gt;Authors’ Affiliation&lt;/h2&gt;&lt;p&gt;Uniformed Services University Department of Preventive Medicine and Biostatistics: Dr. Mancuso and Dr. Ahmed &lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions, nor policies of the Uniformed Services University of the Health Sciences, the Defense Health Agency, or the Department of Defense. &lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Centers for Disease Control and Prevention. HIV Surveillance Report: Diagnoses of HIV Infection in the United States and Dependent Areas, 2021. Centers for Disease Control and Prevention. Updated May 2023. Accessed Jul. 9, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-34/index.html" target="_blank" title="Click on the link to access the CDC's 2021 HIV Surveillance Report"&gt;https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-34/index.html&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Murchu EO, Marshall L, Teljeur C, et al. Oral pre-exposure prophylaxis (PrEP) to prevent HIV: a systematic review and meta-analysis of clinical effectiveness, safety, adherence and risk compensation in all populations. BMJ Open. 2022;12(5):e048478. doi:10.1136/bmjopen-2020-048478 &lt;/li&gt;    &lt;li&gt;Centers for Disease Control and Prevention. Interim guidance: preexposure prophylaxis for the prevention of HIV infection in men who have sex with men. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2011;60(3):65-68. &lt;/li&gt;    &lt;li&gt;US Public Health Service. &lt;em&gt;Preexposure Prophylaxis for the Prevention of HIV Infection in the United States–2021 Update: A Clinical Practice Guideline&lt;/em&gt;. Accessed Jul. 9, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf" target="_blank" title="Click on the link to access the U.S. Public Health Service's HIV PrEP Clinical Practice Guideline"&gt;https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;The White House. &lt;em&gt;National HIV/AIDS Strategy for the United States 2022-2025&lt;/em&gt;. Accessed Jul. 9, 2023. &lt;a rel="noopener noreferrer" href="https://files.hiv.gov/s3fs-public/NHAS-2022-2025.pdf" target="_blank" title="Click on the link to access the National HIV/AIDS Strategy document"&gt;https://files.hiv.gov/s3fs-public/NHAS-2022-2025.pdf&lt;/a&gt;  &lt;/li&gt;    &lt;li&gt;Division of HIV Prevention. Ending the HIV Epidemic in the U.S. Centers for Disease Control and Prevention. Updated Jun. 9, 2023. Accessed Jul. 9, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/endhiv/index.html" target="_blank" title="Click on the link to access the CDC's Ending the HIV Epidemic in the U.S. initiative document"&gt;https://www.cdc.gov/endhiv/index.html&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Centers for Disease Control and Prevention. Core indicators for monitoring the Ending the HIV Epidemic Initiative (preliminary data): National HIV Surveillance System Data Reported Through March 2023; and preexposure prophylaxis (PrEP) data reported through December 2022. &lt;em&gt;HIV Surveillance Data Tables&lt;/em&gt; 2023;4(2). June 2023. Accessed Jul. 9, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/hiv/library/reports/surveillance-data-tables/vol-4-no-2/index.html" target="_blank" title="Click on the link to access the CDC's HIV Surveillance Data Tables through March 2023"&gt;https://www.cdc.gov/hiv/library/reports/surveillance-data-tables/vol-4-no-2/index.html&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Centers for Disease Control and Prevention. &lt;em&gt;HIV Surveillance Data Tables (early release): Core Indicators for Monitoring the Ending the HIV Epidemic Initiative: Data Reported Through December 2019. Centers for Disease Control and Prevention&lt;/em&gt;. Updated Mar. 2020. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/hiv/pdf/library/reports/surveillance-data-tables/vol-1-no-1/cdc-hiv-surveillance-tables-vol-1-no-1.pdf" target="_blank" title="Click on the link to access the CDC's HIV Surveillance Data Tables through December 2019"&gt;https://www.cdc.gov/hiv/pdf/library/reports/surveillance-data-tables/vol-1-no-1/cdc-hiv-surveillance-tables-vol-1-no-1.pdf&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Defense Health Agency. Defense Health Agency Procedural Instruction 6025.29: Provision of Human Immunodeficiency Virus (HIV) Pre-Exposure Prophylaxis (PrEP) for Persons at High Risk of Acquiring HIV Infection. Department of Defense. Updated Dec. 20, 2019. Accessed Nov. 19, 2023. &lt;a href="/Reference-Center/DHA-Publications/2019/12/20/DHA-PI-6025-29" target="_blank" title="Click on the link to access the Defense Health Agency's HIV PrEP Instruction document"&gt;https://www.health.mil/Reference-Center/DHA-Publications/2019/12/20/DHA-PI-6025-29&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;The White House. &lt;em&gt;National HIV/AIDS Strategy Federal Implementation Plan&lt;/em&gt;. Updated Aug. 21, 2023. Accessed Nov. 4, 2023. &lt;a rel="noopener noreferrer" href="https://www.hiv.gov/federal-response/national-hiv-aids-strategy/implementing-national-hiv-aids-strategy" target="_blank" title="Click on the link to access the implementation plan for the National HIV/AIDS Strategy"&gt;https://www.hiv.gov/federal-response/national-hiv-aids-strategy/implementing-national-hiv-aids-strategy&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Blaylock JM, Hakre S, Okulicz JF, et al. HIV preexposure prophylaxis in the U.S. military services–2014-2016. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2018;67(20):569-574. doi:10.15585/mmwr.mm6720a1 &lt;/li&gt;    &lt;li&gt;Eick-Cost AA, Mabila SL, Ying S. Surveillance snapshot: HIV pre-exposure prophylaxis (PrEP) prescriptions in the active component of the U.S. Military, 2023. &lt;em&gt;MSMR&lt;/em&gt;. 2024;31(3):17. &lt;/li&gt;    &lt;li&gt;Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy. &lt;em&gt;2021 Demographics: Profile of the Military Community&lt;/em&gt;. Department of Defense. Accessed Dec. 18, 2023. &lt;a rel="noopener noreferrer" href="https://download.militaryonesource.mil/12038/MOS/Reports/2021-demographics-report.pdf" target="_blank" title="Click on the link to access the full Department of Defense 2021 Demographics Profile of the Military Community document"&gt;https://download.militaryonesource.mil/12038/MOS/Reports/2021-demographics-report.pdf&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Meadows SO, Engel CC, Collins RL, et al. &lt;em&gt;2018 Department of Defense Health Related Behaviors Survey (HRBS)&lt;/em&gt;. RAND Corporation. Accessed Aug. 28, 2022. &lt;a rel="noopener noreferrer" href="https://www.rand.org/pubs/research_reports/RR4222.html" target="_blank" title="Click on the link to access the full 2018 Health Related Behaviors Survey report"&gt;https://www.rand.org/pubs/research_reports/RR4222.html&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Smith DK, Van Handel M, Wolitski RJ, et al. Vital signs: estimated percentages and numbers of adults with indications for preexposure prophylaxis to prevent HIV acquisition–United States, 2015. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2015;64(46):1291-1295. doi:10.15585/mmwr.mm6446a4 &lt;/li&gt;    &lt;li&gt;Military OneSource. &lt;em&gt;2019 Demographics Profile of the Military Community&lt;/em&gt;. Department of Defense; Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy (ODASD [MC&amp;FP]). Accessed May 15, 2021. &lt;a rel="noopener noreferrer" href="https://download.militaryonesource.mil/12038/MOS/Reports/2019-demographics-report.pdf" target="_blank" title="Click on the link to access the full Department of Defense 2019 Demographics Profile of the Military Community document"&gt;https://download.militaryonesource.mil/12038/MOS/Reports/2019-demographics-report.pdf&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Hoover KW, Zhu W, Gant ZC, et al. HIV Services and outcomes during the COVID-19 pandemic–United States, 2019-2021. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2022;71(48):1505-1510. doi:10.15585/mmwr.mm7148a1 &lt;/li&gt;    &lt;li&gt;Cavanaugh JS, Murray CK, Chang D, Ake JA. The Purpose and Impact of the U.S. Military HIV Research Program. &lt;em&gt;Joint Force Quarterly&lt;/em&gt;. 2023;110(3rd quarter):69-74. &lt;/li&gt;    &lt;li&gt;Under Secretary of Defense for Personnel and Readiness. DOD Instruction 6485.01: Human Immunodeficiency Virus (HIV) in Military Service Members. Department of Defense. Updated Jun. 6, 2022. Accessed Nov. 4, 2023. &lt;a rel="noopener noreferrer" href="https://www.esd.whs.mil/portals/54/documents/dd/issuances/dodi/648501p.pdf" target="_blank" title="Click on the link to access the Department of Defense HIV Instruction document"&gt;https://www.esd.whs.mil/portals/54/documents/dd/issuances/dodi/648501p.pdf&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Mar 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{C2FF1E8C-D8C1-436D-B277-659DF341B0A3}</guid><link>https://www.health.mil/News/Articles/2024/03/01/MSMR-HIV-PrEP-Prescription-Snapshot</link><title>Surveillance Snapshot: HIV Pre-Exposure Prophylaxis (PrEP) Prescriptions Within the Active Component of the U.S. Military, 2023 </title><description>&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-3-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-3-Table.ashx?h=1407&amp;w=400&amp;hash=5148351FFEC8B6E8BAD889252A0E276FCE0AD1C1" style="width: 400px; height: 1407px; float: right; margin-top: 5px; margin-bottom: 10px; margin-left: 35px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;HIV Pre-Exposure Prophylaxis is a highly effective medicine for preventing HIV when used as prescribed, reducing the risk of HIV from sex by around 99% and the risk of HIV from injection drug use by at least 74%.&lt;sup&gt;1&lt;/sup&gt; The Department of Defense follows the U.S. Centers for Disease Control and Prevention HIV PrEP guidelines for identification of individuals eligible for HIV PrEP and their evaluation and monitoring.&lt;sup&gt;2&lt;/sup&gt; This Surveillance Snapshot was created to determine the number of active component service members prescribed PrEP during 2023. &lt;/p&gt;&lt;p&gt;Data from the Defense Medical Surveillance System were used for this analysis.&lt;sup&gt;3&lt;/sup&gt; The population was restricted to ACSMs who received a PrEP prescription between January 1, 2023 and December 31, 2023. A PrEP prescription was defined as a record in the Pharmacy Data Transaction System or Theater Medical Data Store medication files within DMSS containing the drug name Truvada, Descovy, Emtricitabine, Tenofovir, Apretude, or Cabotegravir. Records with the names Disoproxil, Viread, or Emtricitabine or listing a therapeutic class of 081808 (antiretrovirals) were excluded, as those are HIV treatment medications. Additionally, a prescription record was excluded if an individual had a diagnosis of chronic hepatitis B or HIV on or before the prescription date, or a needlestick diagnosis within 30 days before or after the prescription date. &lt;/p&gt;&lt;p&gt;An individual was counted once during the surveillance year. Counts were summarized by pharmacy type, demographic characteristics, service-related variables, and self-assessed sexually-transmitted infection risk (defined from the Periodic Health Assessment if completed within one year prior to the prescription date) (Table). &lt;/p&gt;&lt;p&gt;There were 4,495 ACSMs with a prescription for HIV PrEP in 2023 (Table). The majority of prescriptions (79%) were obtained directly from a military clinic. The demographic groups with the highest numbers of prescriptions were 25-29 year olds (1,307), males (4,155), non-Hispanic Whites (1,772), and single, never married (2,865) ACSMs. In evaluating service-related characteristics, the highest number of prescriptions were among Army and Navy service members (1,526 and 1,452, respectively), enlisted (1,664 junior and 1,695 senior), communications/intelligence occupations (1,287), stationed in the U.S. (3,483), and in service for 3-10 years (2,164). The majority of service members with a prescription had a self-assessed risk for a STI (46%), but this information was unknown for 31% of the total PrEP recipients. &lt;/p&gt;&lt;p&gt;These data provide an overview of ACSMs receiving HIV PrEP in 2023 and can be used to further evaluate subpopulations within the ACSM population that may have a missed opportunity for receiving HIV PrEP. &lt;/p&gt;&lt;h2&gt;Authors’ Affiliation&lt;/h2&gt;&lt;p&gt;Epidemiology and Analysis Branch, Armed Forces Health Surveillance Division, Defense Health Agency: Dr. Eick-Cost, Dr. Mabila, and Dr. Ying &lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions, nor policies of the Defense Health Agency or the Department of Defense. &lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Centers for Disease Control and Prevention. Pre-Exposure Prophylaxis (PrEP). Accessed Feb. 26, 2024. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/hiv/risk/prep/index.html" target="_blank" title="Goes to CDC site"&gt;https://www.cdc.gov/hiv/risk/prep/index.html&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Health Agency. Defense Health Agency Procedural Instruction 6025.29: Provision of Human Immunodeficiency Virus (HIV) Pre-Exposure Prophylaxis (PrEP) for Persons at High Risk of Acquiring HIV Infection. Department of Defense. Updated Dec. 20, 2019. Accessed Feb. 26, 2024. &lt;a href="/Reference-Center/DHA-Publications/2019/12/20/DHA-PI-6025-29" target="_blank" title="Click on the link to access the Defense Health Agency's HIV PrEP Procedural Instruction"&gt;https://www.health.mil/Reference-Center/DHA-Publications/2019/12/20/DHA-PI-6025-29&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Rubertone MV, Brundage JF. The Defense Medical Surveillance System and the Department of Defense serum repository: glimpses of the future of public health surveillance. &lt;em&gt;Am J Public Health&lt;/em&gt;. 2002;92(12):1900-1904.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Mar 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{D33876D4-A041-4528-B83B-C740C64FE8EF}</guid><link>https://www.health.mil/News/Articles/2024/03/01/MSMR-RMEs</link><title>Reportable Medical Events at Military Health System Facilities Through Week 5, Ending February 3, 2024</title><description>&lt;p&gt;Reportable Medical Events are documented in the Disease Reporting System internet by health care providers and public health officials throughout the Military Health System for the monitoring, control, and prevention of the occurrence and spread of diseases of public health interest or readiness importance. These reports are reviewed by each service’s public health surveillance hub. The DRSi collects reports on over 70 different RMEs, including infectious and non-infectious conditions, outbreak reports, STI risk surveys, and tuberculosis contact investigation reports. A complete list of RMEs is available in the &lt;em&gt;2022 Armed Forces Reportable Medical Events Guidelines and Case Definitions&lt;/em&gt;.&lt;sup&gt;1&lt;/sup&gt; Data reported in these tables are considered provisional and do not represent conclusive evidence until case reports are fully validated. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-9-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-9-Table.ashx?h=1528&amp;w=1225&amp;hash=EA3987C8E01E2B7BBACFA09843C90CA6C67596AF" style="width: 1225px; height: 1528px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Total active component cases reported per week are displayed for the top five RMEs for the previous year. Each month, the graph is updated with the top five RMEs, and is presented with the current month’s (January 2024) top five RMEs, which may differ from previous months. COVID-19 is excluded from these graphs due to changes in reporting and case definition updates in 2023. &lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-9-Figure.ashx?h=635&amp;w=1225&amp;hash=5B3ACCBCFD0ADF2AA2D7DEF72A0A09435A45CBF4" style="width: 1225px; height: 635px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="This graph comprises five lines on the horizontal, or x-, axis that depict case counts for the five most frequent reportable medical event conditions among active component service members during the past 52 weeks. Chlamydia remains the most common reportable medical condition, with counts consistently around 300 cases per week. Gonorrhea is generally the second-most common reported condition, averaging approximately 80 cases per week. Syphilis is typically the third-most common condition, averaging approximately 20 cases per week, but was supplanted by cold weather injuries, which rose dramatically in the first two weeks of 2024 to become the third-most common RME, slightly ahead of syphilis. Norovirus, which was generally the fourth-most frequent RME in 2023, is the fifth-most reported medical event on the graph, consistently around 20 cases per month."&gt;&lt;/p&gt;&lt;p&gt;For questions about this report, please contact the Disease Epidemiology Branch at the Defense Centers for Public Health–Aberdeen. Email: &lt;a href="mailto:dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mil" title="Click to send an email to the Disease Epidemiology Branch at the Defense Centers for Public Health"&gt;dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mil&lt;/a&gt; &lt;/p&gt;&lt;h2&gt;Authors' Affiliation&lt;/h2&gt;&lt;p&gt;Defense Health Agency, Disease Epidemiology Branch, Defense Centers for Public Health–Aberdeen &lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Armed Forces Reportable Medical Events. Accessed Feb. 28, 2024. &lt;a href="/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines" target="_blank" title="Click on the link to access the full AFHSD Guidelines and Case Definitions for Armed Forces Reportable Medical Events"&gt;https://health.mil/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Department of Defense Active Duty Military Personnel by Rank/Grade of Service. Accessed Feb. 28, 2024. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the Defense Manpower Data Center list of reports"&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Armed Forces Strength Figures for January 31, 2023. Accessed Feb. 28, 2024. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the Defense Manpower Data Center list of reports"&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Navy Medicine. Surveillance and Reporting Tools–DRSI: Disease Reporting System Internet. Accessed Feb. 28, 2024. &lt;a rel="noopener noreferrer" href="https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI" target="_blank" title="Click on the link to access Navy Medicine's Disease Reporting System Internet public website"&gt;https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Mar 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{ACEBAF9E-5062-43C5-86C8-BE37C37EE396}</guid><link>https://www.health.mil/News/Articles/2024/03/01/MSMR-Tobacco-Nicotine-Use</link><title>Tobacco and Nicotine Use Among Active Component U.S. Military Service Members: A Comparison of 2018 Estimates from the Health Related Behaviors Survey and the Periodic Health Assessment</title><description>&lt;p&gt;This study compared estimates of the prevalence of and risk factors for tobacco and nicotine use obtained from the 2018 Health Related Behaviors Survey and Periodic Health Assessment survey. The HRBS and the PHA are important Department of Defense sources of data on health behavior collected from U.S. military service members. While their collection methods differ, some survey questions are similar, which provides an opportunity to compare survey estimates. Active duty service members consistently reported a much lower prevalence of all types of tobacco and nicotine use on the PHA compared to the HRBS: cigarettes (11.1% vs. 18.4%), e-cigarettes (7.3% vs. 16.2%), chewing tobacco (9.7% vs. 13.4%), any tobacco or nicotine use (25.3% vs. 37.8%), and use of two or more tobacco or nicotine products (5.8% vs. 17.4%). Associations between tobacco and nicotine use as well as demographic and other behavioral variables were fairly similar, including age, sex, education, race and ethnicity, rank, and alcohol use. The associations with service branch, body mass index, and sleep were inconsistent. This results of this study suggest that the PHA can provide timely information on trends in military tobacco and nicotine use over time, but much higher estimates from the confidential, voluntary HRBS reported in this study suggest that the command-directed PHA may substantially underestimate the prevalence of all types of tobacco and nicotine use. &lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;U.S. service members consistently reported much lower prevalence of use of tobacco and nicotine on the PHA compared to the HRBS. The command-directed PHA may provide timely information on trends and risk factors for tobacco and nicotine use but substantially underestimates their use. &lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;The use of tobacco and nicotine remains an important threat to the health and readiness of U.S. military service members. Both the HRBS and the PHA provide unique and valuable information for military policy guidance on force health protection and readiness, and they should be used in tandem.&lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;The HRBS is a confidential, cross-sectional survey sponsored by the Department of Defense for better understanding of the health behaviors of all military branches. The HRBS was most recently conducted in 2018 by the RAND Corporation (Santa Monica, CA). Despite its utility in monitoring health-related behaviors in the U.S. military over time, the HRBS is limited by a low response rate, increasing the probability of bias.&lt;sup&gt;1&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;The periodic health assessment is an annual, standardized health assessment throughout the military services to “assess currency of individual medical readiness requirements,” in accordance with DOD Instructions 6025.19 and 6200.06.&lt;sup&gt;2,3&lt;/sup&gt; The PHA collects some survey items similar to the HRBS, including questions on smoking and tobacco and nicotine product use.&lt;sup&gt;3&lt;/sup&gt; As the PHA must be reviewed by a health care provider, often in a direct, personal encounter,&lt;sup&gt;3&lt;/sup&gt; its data may not be reported accurately due to service member concerns about negative career consequences, or other social desirability misclassification biases.&lt;sup&gt;4&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;In 2015 the prevalence of cigarette use reported in the HRBS within the active duty population (13.8%) declined for the first time to a point lower than the general U.S. population (15.1%).&lt;sup&gt;5-8&lt;/sup&gt; In contrast, the prevalence of electronic cigarette (e-cigarette) use—also known as vaping—was higher in the U.S. military (12.4%) than in the general U.S. population (3.5%).&lt;sup&gt;5,9&lt;/sup&gt; Particularly notable was the much higher prevalence of e-cigarette use among the 17-24 year old age group in the military (22.8%) compared to the general population (5.2%). The most recently published HRBS results from 2018 indicate substantial increases in overall cigarette use (18.4%) and e-cigarette use (16.2%) compared to 2015.&lt;sup&gt;1&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;A comparison of these two data sources could be helpful in determining the validity and utility of both data sources both for surveillance purposes and public health guidance. Furthermore, such a comparison could obviate the need for questions in the HRBS that are already covered in the PHA, if the two data sources are found to provide similar information.&lt;sup&gt;1&lt;/sup&gt; This study compares estimates of prevalence and risk factors for tobacco and nicotine use among active duty U.S. service members that were self-reported in 2018 in the HRBS and the PHA.  &lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;The 2018 HRBS study design included population-based stratified random sampling and non-responsive weights, which were utilized to make the analytic sample obtained from the study representative of the eligible service member population.&lt;sup&gt;1&lt;/sup&gt; Publicly available data from the 2018 HRBS, the most recent data released, were utilized to create a sampling frame of 1,357,219 active component service members, which was segmented into 50 strata, based on the interaction of service branch (five categories), pay grade (five categories), and sex. Of 199,996 invited eligible active duty service members, 17,166 responded to the survey request, with an overall weighted response rate of 9.6%.&lt;sup&gt;1&lt;/sup&gt; Sampling weights by post-stratification were used to represent the population. The low response rate of HRBS increases risk of selection bias and bias due to unobserved data. To increase representativeness, HRBS used SAS 9.4 to produce summary statistics, with confidence interval estimates computed using the Wald method.&lt;sup&gt;1&lt;/sup&gt; Missing data among respondents was addressed via imputation methods such as predictive mean matching to impute binary, ordinal, and continuous variables, and polytomous regression to impute categorical data.&lt;sup&gt;1&lt;/sup&gt; &lt;/p&gt;&lt;p&gt; All PHAs completed (n=854,579) during calendar year 2018 by ACSMs in the Army, Navy, Air Force, Marine Corps, and Coast Guard were queried from the Defense Medical Surveillance System (DMSS). &lt;/p&gt;&lt;p&gt;HRBS and PHA questions assessing tobacco and nicotine use, demographic characteristics, and other exposures were reviewed. The questions that assessed tobacco and nicotine use were very similar, as shown in Table 1. Tobacco and nicotine use outcomes were assessed for five types of single product use within the past 30 days: cigarettes, chewing tobacco or snuff, cigars (cigars, cigarillos, or little cigars), tobacco use in a pipe or hookah, and electronic cigarettes (‘e-cigarettes’ or ‘vaping’). The use of any tobacco or nicotine product use and two or more forms of any single tobacco or nicotine product use were also assessed. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-1-Table-1" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-1-Table-1.ashx?h=576&amp;w=1200&amp;hash=4BC78C597E6C48128DB1333419BF2E7D7028FBC9" style="width: 1200px; height: 576px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;In both surveys, demographic information (age, sex, race and ethnicity, branch of service, rank, education); body mass index; and health-related behaviors such as sleep (average hours of sleep in a 24-hour period over the last 30 days) and alcohol use (usual number of drinks containing alcohol on day[s] the service member drank in the last 30 days) were collected similarly. The assessment of sexually-transmitted infection risk defined by the HRBS included self-reporting of an STI (such as gonorrhea, syphilis, chlamydia, HPV, or genital herpes) within the past year. In contrast, the PHA defined STI risk by one or more of the following: a new sex partner in the past three months; more than one sex partner in the last 12 months; sexually active women less than 25 years of age; inconsistent use of latex condoms; men who have sex with men; sexual contact with person(s) with known STIs or risk of STI; exchanged money or drugs for sex; or injected drug use. &lt;/p&gt;&lt;p&gt;HRBS estimates were generated using sample weights to generate representative active component population estimates, as previously reported,&lt;sup&gt;8&lt;/sup&gt; while PHA data were reported using unweighted estimates. Relative frequency analyses were performed to describe the distribution of respondents’ demographics and health behaviors in both surveys. The prevalence estimates of tobacco or nicotine use classification groups were reported. The standard errors and CIs for weighted HRBS estimates were computed using the Taylor series method. Adjusted odds ratios of tobacco or nicotine product use and 95% CIs were calculated using logistic regression, reported separately for the HRBS and PHA; sample weights were again used for HRBS (i.e., weighted logistic regression) but not PHA analysis. Statistical significance was set at 0.05 for all statistical tests. SAS statistical software 9.4 (SAS Institute, Cary, NC) was used in all analyses. &lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-1-Table-2" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-1-Table-2.ashx?h=1487&amp;w=1200&amp;hash=ED76F9AE5A5B8D7DC197F6A1FF721B34C702E4A8" alt="Click on the table to access a 508-compliant PDF version" style="width: 1200px; height: 1487px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-1-Table-3-pt-1" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-1-Table-3.ashx?h=1510&amp;w=1200&amp;hash=E92A87CAD3E6B78540AEF8948EA31103417AEF1A" alt="Click on the table to access a 508-compliant PDF version" style="width: 1200px; height: 1510px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-1-Table-3-pt-2" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-1-Table-3-sheet-2.ashx?h=1510&amp;w=1200&amp;hash=ED09AE14CD08797386903689D9350536AAD9D943" style="width: 1200px; height: 1510px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-1-Table-3-pt-3" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-1-Table-3-sheet-3.ashx?h=1586&amp;w=600&amp;hash=9AB5D7572BA264D940FCBDD7787F9765886EE946" style="width: 600px; height: 1586px; float: left; margin-top: 5px; margin-right: 35px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;A total of 17,166 (9.6% weighted response among those invited) and 854,579 (64% of the active component population) respondents from the HRBS and the PHA, respectively, were included in the analysis (Table 2). PHA response distributions compared to the HRBS were lower for respondents who were: under age 25; of junior or enlisted ranks; in the Navy or Marine Corps; overweight; and with education levels of high school or less. Notably, compared with PHA respondents, HRBS respondents reported shorter sleep duration (5 hours or less per night: 30.3% vs. 11.3%) and more frequent alcohol use (three or more times per week: 30.2% vs. 15.4%). &lt;/p&gt;&lt;p&gt;Service members consistently reported a much lower prevalence of all types of tobacco and nicotine use in the PHA than in the HRBS (Table 3), for: cigarettes (11.1% vs. 18.4%), e-cigarettes (7.3% vs. 16.2%), cigars (2.8% vs. 10.0%), pipes or hookahs (1.5% vs. 5.2%), and chewing tobacco (9.7% vs. 13.4%). PHA estimates were also lower for any tobacco or nicotine use (25.3% vs. 37.8%) and use of two or more tobacco or nicotine products (5.8% vs. 17.4%). &lt;/p&gt;&lt;p&gt;Tobacco and nicotine use associations with demographic and behavioral variables were mostly similar between the two data sources. Prevalence for all types of tobacco and nicotine use was highest in youngest service members and decreased with age; of note, prevalence among 17 to 24 year olds was much higher in the HRBS for both cigarette use (23.1% vs. 13.7%) and e-cigarette use (27.9% vs. 12.5%). Prevalence of all types of tobacco or nicotine use was higher among men than women, except for pipe and hookah use, which was higher among women. Service members who were enlisted, at increased STI risk, used more alcohol, or had lower education levels had generally a higher prevalence of all types of tobacco or nicotine use. &lt;/p&gt;&lt;p&gt;Non-Hispanic Black service members had the lowest prevalence of cigarette, e-cigarette, and chewing tobacco use but highest prevalence of pipe or hookah use (8.0%) and high levels of cigar use (10.2%). Hispanic service members had the highest prevalence of e-cigarette (17.3%) use and high levels of cigarette use (18.1%). These findings were generally consistent between the data sources. &lt;/p&gt;&lt;p&gt; Some associations between demographic and behavioral factors and tobacco or nicotine use were inconsistent between the two data sources. Among the services, Marines had the highest use of all types of tobacco or nicotine, but otherwise associations between services varied by type of product used and the data source. For example, prevalence of cigarette use among Navy service members (20.4%) was higher than among Army service members (18.0%) according to HRBS data, but the relationship was reversed for the PHA—estimated prevalence in the Navy (10.1%) was lower than in the Army (14.6%). Associations of hours of sleep per night were also inconsistent with some types of tobacco or nicotine use. Much of the apparent “under-weight” BMI heterogeneity between the two data sources was likely due to the small numbers of HRBS respondents, leading to unstable estimates. &lt;/p&gt;&lt;p&gt;Table 4 shows the relationship between each demographic and behavioral factor and the different types of tobacco or nicotine use after adjusting for all other factors, which resulted in generally similar associations as seen in Table 3. HRBS data demonstrated statistically significant decreases in adjusted odds of any tobacco or nicotine use among service members who were female, older, officers, with higher education levels, had more hours of sleep per night, of a race or ethnicity other than Non-Hispanic White, and with lower alcohol use levels. The findings from PHA data were similar, but with even stronger negative associations between any use and female sex, service, officer rank, and increased education level. In contrast, negative associations of slightly lower magnitude were seen in the PHA data for increasing age, while positive associations of slightly lower magnitude were seen for alcohol use. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-1-Table-4-pt-1" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-1-Table-4.ashx?h=1534&amp;w=1225&amp;hash=A5687B2E59532A9D24C91CE4B6F9EB8977721262" style="width: 1225px; height: 1534px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h2&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-1-Table-4-pt-2" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-1-Table-4-sheet-2.ashx?h=1492&amp;w=1225&amp;hash=E3A218AC998754FD443CE5A480F3214308F7C791" style="width: 1225px; height: 1492px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/h2&gt;&lt;h2&gt;&lt;a href="/Reference-Center/Reports/2024/03/01/MSMR-Article-1-Table-4-pt-3" target="_blank" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/March/Article-1-Table-4-sheet-3.ashx?h=1530&amp;w=600&amp;hash=64292A27DAAC20A9673B42258015871176064515" style="width: 600px; height: 1530px; float: right; margin-top: 5px; margin-bottom: 10px; margin-left: 35px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/h2&gt;&lt;h2&gt; &lt;/h2&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;Service members consistently reported much lower prevalence for all types, and combinations, of tobacco or nicotine use in the PHA compared to the HRBS. As reported elsewhere, HRBS data trends from 2015 to 2018 indicate increased prevalence of cigarette use (13.8% to 18.4%) and e-cigarette use (12.4% to 16.2%) in the U.S. military.&lt;sup&gt;5,1&lt;/sup&gt; Highest prevalence for both types of tobacco or nicotine use was among 17-24 year olds, whose cigarette use increased from 19.3% to 23.1%, and e-cigarette use rose from 22.8% to 27.9%.&lt;sup&gt;5&lt;/sup&gt; Factors demonstrating generally strong associations with most or all types of increased tobacco and nicotine use included younger age, male sex, enlisted rank, lower education level, greater amounts of alcohol use, increased STI risk, and Marine Corps service. While associations between tobacco or nicotine use and demographic and behavioral variables were mostly similar in the two surveys, there were some inconsistent associations with branch of service. &lt;/p&gt;&lt;p&gt;The HRBS-obtained prevalence of cigarette use in the U.S. military was lower in 2015 than the prevalence in the general U.S. population reported by the U.S. Centers for Disease Control and Prevention,&lt;sup&gt;5,9&lt;/sup&gt; but HRBS-obtained prevalence then increased in 2018 to exceed the U.S. population (18.4% vs. 13.7%, respectively).&lt;sup&gt;10&lt;/sup&gt; In contrast, the 2018 prevalence of cigarette use in the U.S. military estimated from PHA data (11.1%) was lower than U.S. population prevalence. As the methods employed in obtaining HRBS data were more similar to those used by the CDC for civilian data than in PHA data capture, HRBS data were preferentially utilized for the remainder of military and civilian comparisons. The prevalence of e-cigarette use also remained much higher in the U.S. military than in the U.S. population (16.2% compared to 3.2%),&lt;sup&gt;10&lt;/sup&gt; as in 2015.&lt;sup&gt;5&lt;/sup&gt; “Any smoking” was higher among service members than in the U.S. population (37.8% vs. 19.7%), as was use of two or more tobacco or nicotine products (17.4% vs. 3.7%).&lt;sup&gt;9&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;Among 17-24 year olds in the U.S. military there was a much higher prevalence (23.1%) of cigarette use found than in the U.S. 18-24 year old population (7.8%).&lt;sup&gt;10&lt;/sup&gt; The U.S. military also had a much higher prevalence of e-cigarette use in the 17-24 age group (27.9% vs. 7.6% in the U.S. population). Any smoking was higher among 17-24 year old service members than in the U.S. population (45.7% vs. 17.1%), as was use of two or more tobacco or nicotine products (25.7% vs. 4.1%). The prevalence of e-cigarette use among U.S. high school students (20.8%) in 2018 was closer to the prevalence among the youngest U.S. service members (27.9%), compared to the U.S. population of the same age (7.6%), but U.S. high school student cigarette use (8.1%) was much lower than cigarette use by youngest U.S. service members (18.4%).&lt;sup&gt;11&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;The findings in this study are generally similar to the findings of the 2015 HRBS, but the differences between the military and civilian populations are of greater magnitude.&lt;sup&gt;5&lt;/sup&gt; The 7.3% prevalence estimate of e-cigarette use among ACSMs from the PHA data in this study was similar to the 9% prevalence among active and reserve service members previously reported, also using 2018-2019 PHA data.&lt;sup&gt;12&lt;/sup&gt; Similar to this study, in 2018 the prevalence of e-cigarette use among U.S. Air Force recruits increased to 15.3%, although prevalence of cigarette and other tobacco or nicotine product use decreased in that study but increased in this study.&lt;sup&gt;13&lt;/sup&gt; This study also found similar factors associated with higher prevalence of tobacco or nicotine use, as reported in previous military studies, including younger age, male sex, enlisted rank, lower education levels, greater alcohol use, and Army or Marine Corps service.&lt;sup&gt;5,14&lt;/sup&gt; Similar associations have also been found among the general U.S. population.&lt;sup&gt;10&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;The most important strengths of this study are the large sample sizes, multiple data sources to assess the burden of tobacco and nicotine use in the U.S. military, and the comparability between the two sources due to similar survey questions. The stratified random survey design of the HRBS is also a contributing strength, as it provides estimates representative of the entire U.S. military population. &lt;/p&gt;&lt;p&gt;This work also has several important limitations. Tobacco and nicotine use have been highly dynamic in both the U.S. general and military populations in recent years, and trends have likely changed since 2018; the release of the 2024 HRBS should allow further assessment of these trends. The weighted response rate for the 2018 HRBS was low (9.6%), which could introduce selection bias into these estimates if participating service members differed from those not participating&lt;sup&gt;1&lt;/sup&gt;; this type of volunteer bias in survey literature generally leads to healthier participants, however, so tobacco and nicotine use estimates obtained through HRBS data utilization would have been expected to underestimate prevalence, not overestimate it.&lt;sup&gt;15&lt;/sup&gt; Likewise, the 64% of service members for whom PHA data were available may have differed from those for whom data were unavailable, but because how those service members differed is unknown, the impact of this difference on prevalence estimates is unknown. &lt;/p&gt;&lt;p&gt; A more important source of PHA underestimation is introduction of misclassification bias if participants did not provide accurate information on their tobacco and nicotine use, which could occur due to social desirability bias, perceived stigma of tobacco and nicotine use, or other perceived negative consequences of divulging tobacco and nicotine use behaviors to other military personnel during a required military exam documented on an official form.&lt;sup&gt;16&lt;/sup&gt; The much lower prevalence for all types of tobacco and nicotine use in PHA data compared to the HRBS suggests this misclassification may lead to substantial bias and underestimates of the burden of tobacco and nicotine use. &lt;/p&gt;&lt;p&gt;Some misclassification may be non-differential; for example, the smaller aORs for age and alcohol use using PHA data compared to HRBS data suggest bias towards the null and possible non-differential misclassification. The more extreme aORs in the PHA data for other variables such as Naval service, sex, rank, and education compared to HRBS data do suggest possible differential misclassification, which could occur if service members who were female, officers, higher educated, and serving in the Navy were more affected by social desirability, stigma, or perceived negative consequences due to reporting tobacco and nicotine use.&lt;sup&gt;4&lt;/sup&gt; The assessment of other health behaviors such as alcohol use, drug use, and sexual practices may also be biased (particularly in the PHA) due to perceived stigma and potential for negative career consequences.&lt;sup&gt;17&lt;/sup&gt; The magnitude of this misclassification bias may be associated with the amount of stigma and potential consequences perceived for each behavior, so further research should consider and study their possible associations. &lt;/p&gt;&lt;p&gt;Tobacco and nicotine use remain an important threat to the health of U.S. military service members, resulting not only in short- and long-term health consequences, but also billions of dollars in health care and lost productivity costs,&lt;sup&gt;8&lt;/sup&gt; decreased fitness,&lt;sup&gt;18&lt;/sup&gt; and higher rates of premature discharge.&lt;sup&gt;19&lt;/sup&gt; Military tobacco and nicotine control policies and interventions must be guided by accurate and timely surveillance to ensure interventions are effective and responsive to dynamic societal, cultural, and economic forces that affect tobacco and nicotine use. &lt;/p&gt;&lt;p&gt;This study suggests that the PHA can provide timely information on trends in military tobacco and nicotine use over time, but much higher estimates in this study obtained from the confidential, voluntary HRBS also suggest that the command-directed PHA, which is part of a service member’s permanent record, may substantially underestimate the prevalence of all types of tobacco and nicotine use. Additionally, the more extreme differences between some types of service members suggest that this misclassification may be differential. This issue could potentially result in biased, and thereby invalid, associations with these demographic and behavioral risk factors, such as service members who are female, officers, higher educated, or serve in the Navy. &lt;/p&gt;&lt;p&gt;These differences also suggest that HRBS tobacco and nicotine use questions should not be discontinued, as some have suggested,&lt;sup&gt;1&lt;/sup&gt; since its data may be more valid than the PHA. The HRBS, on the other hand, suffers from a lack of timeliness, as it is only performed every three to six years, with its data lagging several years. Both data sources provide uniquely valuable information to guide military force health protection and readiness policy, and they should be used in tandem. Further research is needed to assess the validity of PHA data, not only for tobacco and nicotine use but other important health behaviors and outcomes as well. &lt;/p&gt;&lt;h2&gt;Disclaimers&lt;/h2&gt;&lt;p&gt;The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions, nor policies of the Uniformed Services University of the Health Sciences, the Defense Health Agency, or the Department of Defense. &lt;/p&gt;&lt;h2&gt;Acknowledgments&lt;/h2&gt;&lt;p&gt;The authors would like to thank Ms. Jessica H. Murray, MPH for the PHA data analysis presented in this report. &lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Meadows SO, Engel CC, Collins RL, et al. 2018 &lt;em&gt;Department of Defense Health Related Behaviors Survey (HRBS); Results for the Active Component&lt;/em&gt;. RAND Corporation; 2021. Accessed Aug. 28, 2022. &lt;a rel="noopener noreferrer" href="https://www.rand.org/pubs/research_reports/RR4222.html" target="_blank" title="Click on the link to access the full 2018 HRBS report"&gt;https://www.rand.org/pubs/research_reports/RR4222.html&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Office of the Under Secretary of Defense for Personnel and Readiness. DOD Instruction 6025.19: Individual Medical Readiness Program. Department of Defense. Updated Jul. 13, 2022. Accessed Dec. 24, 2023. &lt;a rel="noopener noreferrer" href="https://www.esd.whs.mil/portals/54/documents/dd/issuances/dodi/602519p.pdf" target="_blank" title="Click on the link to access the full Department of Defense Individual Medical Readiness Instruction document"&gt;https://www.esd.whs.mil/portals/54/documents/dd/issuances/dodi/602519p.pdf&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Office of the Under Secretary of Defense for Personnel and Readiness. DOD Instruction 6200.06: Periodic Health Assessment (PHA) Program. Department of Defense. Updated Sept. 8, 2016. &lt;a rel="noopener noreferrer" href="https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/620006p.pdf" target="_blank" title="Click on the link to access the Department of Defense Periodic Health Assessment (PHA) Program document"&gt;https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/620006p.pdf&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Nelson JP, Pederson LL, Lewis J. Tobacco use in the Army: illuminating patterns, practices, and options for treatment. &lt;em&gt;Mil Med&lt;/em&gt;. 2009;174(2):162-169. doi:10.7205/milmed-d-01-2008 &lt;/li&gt;    &lt;li&gt;Keltner CH, Kao TC, Ahmed A, Mancuso JD. E-cigarette and dual product use as an emerging health threat to the US military. &lt;em&gt;Tob Prev Cessat&lt;/em&gt;. 2021;7:43. doi:10.18332/tpc/135516 &lt;/li&gt;    &lt;li&gt;Grier T, Knapik JJ, Canada S, Canham-Chervak M, Jones BH. Tobacco use prevalence and factors associated with tobacco use in new U.S. Army personnel. &lt;em&gt;J Addict Dis&lt;/em&gt;. Jul 2010;29(3):284-293. doi:10.1080/10550887.2010.489445 &lt;/li&gt;    &lt;li&gt;Smith B, Ryan MA, Wingard DL, et al. Cigarette smoking and military deployment: a prospective evaluation. &lt;em&gt;Am J Prev Med&lt;/em&gt;. 2008;35(6):539-546. doi:10.1016/j.amepre.2008.07.009 &lt;/li&gt;    &lt;li&gt;Institute of Medicine of the National Academies. &lt;em&gt;Combating Tobacco Use in Military and Veteran Populations&lt;/em&gt;. The National Academies Press; 2009. &lt;a rel="noopener noreferrer" href="http://www.nap.edu/catalog/12632/combating-tobacco-use-in-military-and-veteran-populations" target="_blank" title="Click on the link to access the full National Academies consensus study report on military tobacco use"&gt;http://www.nap.edu/catalog/12632/combating-tobacco-use-in-military-and-veteran-populations&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Phillips E, Wang TW, Husten CG, et al. Tobacco product use among adults–United States, 2015. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2017;66(44):1209-1215. doi:10.15585/mmwr.mm6644a2 &lt;/li&gt;    &lt;li&gt;Creamer MR, Wang TW, Babb S, et al. Tobacco product use and cessation indicators among adults–United States, 2018. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2019;68(45):1013-1019. doi:10.15585/mmwr.mm6845a2 &lt;/li&gt;    &lt;li&gt;Gentzke AS, Creamer M, Cullen KA, et al. Vital signs: tobacco product use among middle and high school students–United States, 2011-2018. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2019;68(6):157-164. doi:10.15585/mmwr.mm6806e1 &lt;/li&gt;    &lt;li&gt;Gill AA, Alford B, Balmer J, et al. Use of electronic cigarettes among U.S. military service members–prevalence and associated risk factors. &lt;em&gt;Subst Abus&lt;/em&gt;. 2022;43(1):1300-1307. doi:10.1080/088970 77.2022.2095075 &lt;/li&gt;    &lt;li&gt;Little MA, Fahey MC, Wang XQ, et al. Trends in tobacco use among young adults presenting for military service in the United States Air Force between 2013 and 2018. &lt;em&gt;Subst Use Misuse&lt;/em&gt;. 2021;56(3):370-376. doi:10.1080/10826084.2020.1868517 &lt;/li&gt;    &lt;li&gt;Lin J, Zhu K, Hoang PK, et al. Electronic cigarette use and related factors among active duty service members in the U.S. military. &lt;em&gt;Mil Med&lt;/em&gt;. 2020;185(3-4):418-427. doi:10.1093/milmed/usz267 &lt;/li&gt;    &lt;li&gt;Andreeva VA, Salanave B, Castetbon K, et al. Comparison of the sociodemographic characteristics of the large NutriNet-Sante e-cohort with French census data: the issue of volunteer bias revisited. &lt;em&gt;J Epidemiol Community Health&lt;/em&gt;. 2015;69(9):893-898. doi:10.1136/jech-2014-205263 &lt;/li&gt;    &lt;li&gt;Cantrell J, Hair EC, Smith A, et al. Recruiting and retaining youth and young adults: challenges and opportunities in survey research for tobacco control. &lt;em&gt;Tob Control&lt;/em&gt;. 2018;27(2):147-154. doi:10.1136/tobaccocontrol-2016-053504 &lt;/li&gt;    &lt;li&gt;Beltran RM, Schuyler AC, Blair CS, et al. “That’s kind of like the big struggle right now is can we get PrEP?”: facilitators and barriers to PrEP uptake among active duty gay and bisexual men. &lt;em&gt;Sex Res Social Policy&lt;/em&gt;. 2023;20(2):413-425. doi:10.1007/s13178-021-00622-6 &lt;/li&gt;    &lt;li&gt;Feinberg JH, Ryan MA, Johns M, et al. Smoking cessation and improvement in physical performance among young men. &lt;em&gt;Mil Med&lt;/em&gt;. 2015;180(3):343-349. doi:10.7205/MILMED-D-14-00370 &lt;/li&gt;    &lt;li&gt;Klesges RC, Haddock CK, Chang CF, Talcott GW, Lando HA. The association of smoking and the cost of military training. &lt;em&gt;Tob Control&lt;/em&gt;. 2001;10(1):43-47. doi:10.1136/tc.10.1.43&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Mar 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{7DD7F830-E0EB-4F86-BF81-F064495811B5}</guid><link>https://www.health.mil/News/Articles/2024/02/01/MSMR-Letter-to-Editor</link><title>Letter to the Editor: TRADOC Policy Does Not List Sickle Cell Trait as a Risk Factor for Cold Injury</title><description>&lt;p&gt;We read with great interest the “&lt;a href="/News/Articles/2023/11/01/Cold-Weather-Injuries" title="Opens MSMR article"&gt;Update: Cold Weather Injuries Among the Active and Reserve Components of the U.S. Armed Forced, July 2018-June 2023&lt;/a&gt;.”&lt;sup&gt;1&lt;/sup&gt; While the update provides valuable insight into the relative number of cold weather injuries incurred by military personnel across the last five years, the authors incorrectly stated that the latest 2023 update to Training and Doctrine Command (TRADOC) Regulation&lt;sup&gt;2&lt;/sup&gt; recognizes sickle cell trait as a risk factor for cold injury. Current TRADOC policy does suggest SCT screening, driven at least in part by an increased risk of exercise collapse associated with sickle cell trait, exertional rhabdomyolysis, and blood clots in austere hot and hypoxic environments.&lt;sup&gt;2&lt;/sup&gt; Yet, no specific policy language exists linking the presence of SCT to the risk or occurrence of cold weather injuries.&lt;/p&gt;&lt;p&gt;SCT is a condition that involves the presence of a mutation on 1 of 2 genes that form red blood cells, while the complementary gene remains unmutated. Because it is typically a benign carrier condition, SCT does not disqualify carriers from military service. Very little data currently exist to support a convincing link between cold weather injuries including hypothermia, freezing injury, or non-freezing cold injury and the presence of SCT. Data from the early 1950s suggests the incidence of frostbite in a small subset of African Americans, who present day tend to disproportionately carry SCT at a rate of 73.1 cases per 1,000 compared to 6.9 in Hispanics and 3.0 in non-Hispanic Whites,&lt;sup&gt;3&lt;/sup&gt; did not appear greater in those with SCT compared to non-SCT controls.&lt;sup&gt;4&lt;/sup&gt; This very limited sample by no means speaks to a lack of association between SCT and cold injury or cold thermoregulatory adjustments. Undoubtedly there is a profound need to further leverage epidemiological data to improve our understanding of cold injury risk in those with SCT. Additionally, human experimental data is needed to determine if cold thermoregulation in those with SCT uniquely varies from those without SCT, perhaps predisposing them to vascular injury, neurallymediated cold pain,&lt;sup&gt;5&lt;/sup&gt; or diuresis-induced hypercoagulation.&lt;/p&gt;&lt;h2&gt;Authors’ Affiliation&lt;/h2&gt;&lt;p&gt;Thermal Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, MA&lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The views, opinions, and findings contained in this article are those of the authors and should not be construed as an official United States Department of the Army position, or decision, unless so designated by other official documentation. This article is approved for public release, and distribution is unlimited.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Armed Forces Health Surveillance Branch. &lt;a href="/News/Articles/2023/11/01/Cold-Weather-Injuries"&gt;Update: cold weather injuries, active and reserve component, U.S. Armed Forces, July 2018–June 2023&lt;/a&gt;. &lt;em&gt;MSMR&lt;/em&gt;. 2023;30(11):2-11.&lt;/li&gt;    &lt;li&gt;Headquarters, Department of the Army, Training and Doctrine Command. TRADOC Regulation 350-29: Prevention of Heat and Cold Casualties. Jun. 15, 2023.&lt;/li&gt;    &lt;li&gt;Naik RP, Smith-Whitley K, Hassell KL, et al. Clinical outcomes associated with sickle cell trait: a systematic review. &lt;em&gt;Ann Intern Med&lt;/em&gt;. 2018;169(9):619-627. doi:10.7326/M18-1161&lt;/li&gt;    &lt;li&gt;Ellenhorn Mj, Weiner D, U.S. Army Medical Research and Development Board. &lt;em&gt;Report No. 81: Sickle Cell Trait and Frostbite&lt;/em&gt;. Army Medical Research Laboratory; 1952. &lt;a rel="noopener noreferrer" href="https://apps.dtic.mil/sti/pdfs/ADB213334.pdf" target="_blank" title="Click on the link to access the Army Medical Research and Development Board report"&gt;https://apps.dtic.mil/sti/pdfs/ADB213334.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Zappia KJ, Guo Y, Retherford D, et al. Characterization of a mouse model of sickle cell trait: parallels to human trait and a novel finding of cutaneous sensitization. &lt;em&gt;Br J Haematol&lt;/em&gt;. 2017 Nov;179(4):657-666. doi:10.1111/bjh.14948&lt;/li&gt;&lt;/ol&gt;&lt;h2&gt;In Reply&lt;/h2&gt;&lt;p&gt;We thank Dr. Seeley and Dr. Castellani for their interest and careful review of the November 2023 &lt;em&gt;MSMR&lt;/em&gt; article “Update: Cold Weather Injuries Among the Active and Reserve Components of the U.S. Armed Forces, July 2018–June 2023.” The editorial team acknowledges the error in interpreting the addition of “sickle cell trait as a risk factor” as an explicit association with cold injuries in the June 2023 update of the TRADOC Regulation on Prevention of Heat and Cold Casualties. We appreciate Dr. Seeley and Dr. Castellani bringing this to our attention. A correction to the original report has been published.&lt;/p&gt;</description><pubDate>Thu, 01 Feb 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{FEDD5F09-30FE-4F07-BF9B-5EC070CBF5AA}</guid><link>https://www.health.mil/News/Articles/2024/02/01/MSMR-Marine-RAP</link><title>A Summary of the U.S. Marine Recruit Assessment Program Procedures and Survey from 2003 to 2021</title><description>&lt;p&gt;The Recruit Assessment Program is a cross-sectional, baseline survey of U.S. Marine recruits administered at Marine Corps Recruit Depot, San Diego. This report presents RAP study procedures and survey content that was administered to 229,015 participants between 2003 and 2021. Self-reported data were collected on recruit demographics, physical and mental health, adverse life experiences, lifestyle and risky behaviors, and substance use. In 2013, the survey was updated to remove questions with other linkable and reliable sources and those with low completion rates and low relevance to Marine health research; the removal of these items allowed for the addition of instrument measures for major depression, post-traumatic stress disorder, anger, and resilience with no significant change to overall survey length. Average completion rates are approximately 95%. Multiple studies have shown the utility of RAP data collected thus far as a robust data repository of pre-service health and behavioral measures.&lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;By surveying Marine recruits within days of arrival, RAP can more accurately obtain information on their lives and experiences prior to military service. RAP establishes a comprehensive profile of a recruit, creating a robust resource that takes into consideration each recruit’s unique history when assessing future experiences and concerns.&lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;The purpose of the RAP survey is to increase understanding of how pre-service exposures may affect a recruit’s health and readiness while in service, and thereby inform policy decisions that protect Marines’ mental and physical health while sustaining military readiness. RAP data can also be linked to other military data sources to assess how past experiences influence future decisions, behaviors, and outcomes that may affect operational health and readiness. Utilization of this additional level of information aids policy and intervention improvement efforts.&lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;A major limitation in military health research is the inability to account for events that occurred prior to military service. A Presidential Review Directive,&lt;sup&gt;1&lt;/sup&gt; Institute of Medicine reports,&lt;sup&gt;2&lt;/sup&gt; and military advisory boards have emphasized the need for collection of baseline health data for pre-existing health conditions and risks.&lt;sup&gt;3,4&lt;/sup&gt; To further investigate concerns related to pre-service health and behavioral measures and military health and career progression, the Recruit Assessment Program was developed by the Naval Health Research Center.&lt;/p&gt;&lt;p&gt;RAP was implemented in June 2001 among male recruits at the Marine Corps Recruit Depot, San Diego.&lt;sup&gt;5&lt;/sup&gt; While initially established with the goal of automating recruit enrollment within the electronic medical record system, RAP has evolved to focus on assembling a comprehensive profile of U.S. Marine recruits’ experiences prior to military duty. &lt;/p&gt;&lt;p&gt;The RAP survey consists of measures of Marine recruits’ pre-service health and behaviors not collected elsewhere. Collected during recruit training, RAP contributes to the understanding of a Marine recruit’s pre-service mental, physical, social, and behavioral health, and it can inform prevention and intervention strategies for adverse outcomes such as sexual assault and military attrition.&lt;sup&gt;6,7&lt;/sup&gt; RAP provides baseline data for health risk assessments during general service in the Marine Corps, as well as those associated with operational deployments and within military occupational specialties. The ever-changing demographics of Marine recruit populations emphasize the need for self-reported, autonomous, baseline data to properly account for pre-service exposures when assessing the effects of military life.&lt;/p&gt;&lt;p&gt;Marine recruit training is a 13-week process, during which a recruit leaves civilian life and adapts to a Marine Corps lifestyle. Training takes place at MCRD, Parris Island, South Carolina, or at MCRD, San Diego, California. Thus far, RAP has collected data exclusively on recruits at MCRD San Diego, where each receiving company of 250 to 645 Marine recruits are offered the opportunity to complete a RAP survey. &lt;/p&gt;&lt;p&gt;This report summarizes survey administration and content for the RAP versions 4 and 5 (2003-2021), the predominant versions that provided 87.7% of all RAP data collected. The survey has gone through multiple revisions, with the first version in 2001 (n=17,424),&lt;sup&gt;5&lt;/sup&gt; versions 2 and 3 in 2002 (n=14,673),&lt;sup&gt;8,9&lt;/sup&gt; version 4 in 2003-2013 (n=134,761),&lt;sup&gt;8&lt;/sup&gt; followed by version 5, currently in use (n=94,254). Prior reports have provided detailed reviews of survey versions 1 through 3.&lt;sup&gt;5,8-10&lt;/sup&gt; Survey approval was obtained by the U.S. Marine Corps Survey Office. All data were collected voluntarily from participants who provided informed consent, with the approval of the Institutional Review Board at the NHRC.&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;h3&gt;Survey Content&lt;/h3&gt;&lt;p&gt;Survey content was developed utilizing standardized survey instruments in combination with subject matter expert and stakeholder recommendations. Approximately 32% of the content in version 4 was removed from version 5, with new content in version 5 comprising 13% (Table 1). Removal of version 4 questions that had other linkable and reliable sources, low completion rates, or low relevance to Marine health stakeholders allowed the addition of instrument measures for major depression, post-traumatic stress disorder, anger, and resilience.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/02/01/MSMR-Article-1-Table-1" title="Opens PDF of article table 1"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-1-Table-1.ashx?h=1505&amp;w=1200&amp;hash=A3ABDCCFC0ECB43B195F9E0E4A78093B54DE8BE7" style="width: 1200px; height: 1505px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h3&gt;Demographics&lt;/h3&gt;&lt;p&gt;Demographic data collected include date of birth, most recent home location, race and ethnicity, education, marital status, handedness, height, and current and past year weights. Family demographic data include familial structure, education, and ability to provide essential needs. Military demographic data collected include prior service, reason for joining, and parental military service.&lt;/p&gt;&lt;h3&gt;Health&lt;/h3&gt;&lt;h4&gt;Physical Health&lt;/h4&gt;&lt;p&gt;Physical health questions were adapted from the Seabee Survey of Health Conditions,&lt;sup&gt;11&lt;/sup&gt; the 12-Item Short Form Survey (SF-12),&lt;sup&gt;12&lt;/sup&gt; and the 36-Item Short Form Survey (SF-36).&lt;sup&gt;13&lt;/sup&gt; Specific health symptoms surveyed, ranging from chronic cough to muscle aches, were reduced from 23 to 16 questions in versions 4 and 5, respectively.&lt;/p&gt;&lt;h4&gt;Mental Health&lt;/h4&gt;&lt;p&gt;Version 4 included SF-36 questions about reasoning and problem-solving, forgetfulness, attention, and concentration within the past year.&lt;sup&gt;13&lt;/sup&gt; Version 5 included the following validated instrument measures: the 8-item Patient Health Questionnaire depression scale&lt;sup&gt;14&lt;/sup&gt;; the Primary Care PTSD Screen for DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) (PC-PTSD-5)&lt;sup&gt;15&lt;/sup&gt;; the 7-item Pearlin Mastery Scale&lt;sup&gt;16&lt;/sup&gt;; and one question assessing self-perception of resilience.&lt;sup&gt;17&lt;/sup&gt;&lt;/p&gt;&lt;h4&gt;Medical Care&lt;/h4&gt;&lt;p&gt;Version 4, but not version 5, included questions about medical care during the past five years such as care received, reasons for recommended preventive care (e.g., medical or dental checkup), hospitalizations, and prescription use.&lt;/p&gt;&lt;h3&gt;Life Experiences&lt;/h3&gt;&lt;h4&gt;Lifestyle and Risky Behaviors&lt;/h4&gt;&lt;p&gt;Multiple questions focus on lifestyle habits, as well as risky behaviors, including diet, sleep, television, schooling, driving safety, sexual activity, emotional behavior, social support, and religious activities. Age at first sexual intercourse, condom use, and sexually transmitted infection diagnoses were ascertained in both versions. Questions about anger were expanded to include the Dimensions of Anger Reactions (DAR-5) scale.&lt;sup&gt;18,19&lt;/sup&gt;&lt;/p&gt;&lt;h4&gt;Adverse Experiences&lt;/h4&gt;&lt;p&gt;Ten standardized questions on adverse childhood experiences were included in the survey,&lt;sup&gt;20&lt;/sup&gt; in addition to questions about adverse experiences throughout life as well as in the past year (e.g., self-harm, attack, rape, arrest, etc.). Questions about attention-deficit/hyperactivity disorder were reduced in version 5. Three questions on traumatic brain injury, adapted from the Post Deployment Health Assessment, were added in version 5.&lt;sup&gt;21&lt;/sup&gt; Past occupational exposures were collected for participants who had worked in a position for more than one month.&lt;/p&gt;&lt;h4&gt;Substance Use&lt;/h4&gt;&lt;p&gt;Questions about tobacco use were adapted from prior military health surveys such as the Seabee Health Study&lt;sup&gt;11&lt;/sup&gt; and the National Health Survey of Persian Gulf War Era Veterans.&lt;sup&gt;22&lt;/sup&gt; Questions specific to cigarettes focused on age at first use, cessation attempts, last use, and typical use. Use of pipes, hookahs, cigars, and smokeless tobacco products were also surveyed. Detailed questions about alcohol use, age at first use, frequency, quantity, and behavior were included with the Cut, Annoyed, Guilty, and Eye&lt;sup&gt;23&lt;/sup&gt; instrument and 3-item Alcohol Use Disorders Identification Test (AUDIT)-C.&lt;sup&gt;24&lt;/sup&gt; Version 5 also included the full 10-item AUDIT.&lt;sup&gt;25&lt;/sup&gt;&lt;/p&gt;&lt;h3&gt;Survey Administration&lt;/h3&gt;&lt;p&gt;RAP was designed to be a self-reported, paper and pencil-based survey that could be completed within 45 minutes, administered in various induction settings, and generalizable to a culturally diverse population.&lt;sup&gt;9&lt;/sup&gt; Once a week, Drill Instructors led receiving recruits into an auditorium-style classroom, where blank RAP survey booklets were placed at each seat. &lt;/p&gt;&lt;p&gt;To allow for autonomy, DIs were not present during the survey’s introduction, when recruits were provided an approximately 15-minute verbal briefing on RAP and their option for voluntary participation. NHRC researchers presented slides reviewing the survey’s “Consent to Participate in Research” section, addressing: 1) voluntary participation, 2) benefits and risks, 3) data confidentiality and security, and 4) if desired, guidance for study withdrawal. Version 5 included options for consent to use of the data in future research beyond the RAP protocol purview, along with a Health Insurance Portability and Accountability Act authorization for permission to link to protected health information.&lt;/p&gt;&lt;p&gt;Following each briefing, recruits were given time to independently review the consent forms and discuss questions or concerns with the research team. Once the allotted hour for survey completion passed, recruits returned their surveys and were dismissed to their DIs. All recruits returned their survey, whether completed or not.&lt;/p&gt;&lt;h3&gt;Survey Processing&lt;/h3&gt;&lt;p&gt;Surveys were processed at NHRC. Surveys without consent or with consent withdrawn were destroyed. Surveys with consent were scanned using Teleform software (OpenText Corporation, Waterloo, Ontario, Canada) and entered into the RAP SQL database. A sample of 3-5% of surveys were manually checked for accuracy.&lt;/p&gt;&lt;p&gt;SAS version 9.4 (SAS Institute, Cary, NC) was used to manage and prepare the final analytic RAP database. Self-reported identifiers (e.g., Social Security number, date of birth, name) were verified with Defense Manpower Data Center records and entered if necessary. Implausible outliers for variables such as age, height, and weight were set to ‘missing.’ Survey versions were cleaned separately, prior to consolidation in a final analytic dataset, as they differed in question order, response options, skip patterns, and study domains. Questions from different survey versions were standardized when possible, with raw variables retained.&lt;/p&gt;&lt;p&gt;Historically, participation rates were calculated from denominators generated from DMDC records, which were prone to misclassification. In 2012, participation rate accuracy was improved by documenting the total numbers of recruits present.&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;h3&gt;Participants&lt;/h3&gt;&lt;p&gt;From 2003 through 2021, 229,015 recruits completed the survey; 134,761 participants completed version 4 (2003-2013) and 94,254 completed version 5 (2013-2021). DMDC demographic data were utilized to verify 99.6% of participants as Marine service members. Peaks in enrollment count mirrored peak recruitment periods, with highest participation in June. The average number of participants enrolled was approximately 12,000 recruits per year, with a high of 17,198 (7.51%) enrolled in 2005 and a low of 5,945 (2.60%) in 2020, when survey administration was paused from April through August due to the COVID-19 pandemic. As MCRD San Diego exclusively enrolled male Marine recruits until March 2021, RAP version 5 was the first to include female participants (n=109).&lt;/p&gt;&lt;h3&gt;Completion Rates&lt;/h3&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-1-Figure.ashx?h=969&amp;w=1250&amp;hash=A206B52971C2EA74744F28CC13DC2112EF24DEE7" style="width: 1250px; height: 969px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This figure comprises two separate bar charts, each oriented along the y-, or vertical axis. The two charts graphically represent the completion rates of selected questions from versions four and five of the Marine Recruit Assessment Program (or RAP) survey. The first graph, depicting version four of the RAP survey, comprises 188 discrete vertical bars, each of which represents a separate survey question. The second graph, which depicts version five, comprises 176 vertical bars representing 176 questions. Both charts demonstrate a gradual decline of completion rates over the course of the survey, but only a small number of questions in both versions had less than a 91 percent completion rate: only seven questions in version four, and 12 in version five. No question represented in the figure has less than an 87 percent completion rate. Notably, the reorganization of the survey resulted in markedly lower completion rates for occupational exposure questions in version five, with nine of the 12 questions with less than 91 percent completion within that domain—although none of those nine questions had below an 89 percent completion rate. The reorganization of the survey resulted in much better completion rates for questions relating to “family’s ability to provide” in version five, which in version four provided the questions with the two lowest response rates—one at 88% and the other at 87 percent; in version five, however, completion rates for “family’s ability to provide” questions rose within the section, from 93 percent to 94 percent. “Other tobacco use” questions had markedly lower rates of completion in version five, with a question about tobacco pipe use completed the least frequently, but response rates immediately rose to above 95 percent in the following section, on Alcohol use."&gt;&lt;/p&gt;&lt;p&gt;Average participation rates were 88.1% between 2012 and 2021, with a high of 97.8% in 2017, which decreased in 2020 and 2021 to 74.4% and 69.3%, respectively, due to implementation of guidelines for COVID-19 pandemic restrictions on movement. Average completion rates for individual survey questions were 94.5% and 95.3% for versions 4 and 5, respectively, and accounted for skip questions (Figure). The minimum completion rate was approximately 87% for both surveys. Completion rates for the final question declined to 89.9% and 88.2% for the final questions of versions 4 and 5, respectively.&lt;/p&gt;&lt;p&gt;Lower completion rates were observed in both surveys for questions not applicable to most participants (e.g., SF-12 questions about general health; use of tobacco products other than cigarettes, such as pipes; past occupational exposures). Marine recruits are a young and healthy population less likely to suffer from physical health issues that limit daily activities. Approximately 28% of participants reported themselves to be smokers, with a 97% completion rate in version 4 for smoking habit questions, and only 94% for pipe and cigar questions, which declined to 96% and 89%, respectively, in version 5. Completion rates were lower for questions discussing sensitive topic areas, although some improved after survey question reordering, specifically familial ability to provide essential needs (87.9%, version 4; 94.1%, version 5), family medical history (95.8-98.2%, version 4), prior health care provision (88.7-89.5%, version 4), alcohol use (91.4-96.5%, version 4; 95.3-99.5%, version 5), and risky behaviors (91.2-94.9%, version 4; 96.3-98.5%, version 5).&lt;/p&gt;&lt;h3&gt;RAP Publications&lt;/h3&gt;&lt;p&gt;RAP has demonstrated its capacity as a cross-sectional, individual resource&lt;sup&gt;26,27&lt;/sup&gt; that is also readily linkable to other data sources for longitudinal assessment of military health research (Table 2).&lt;sup&gt;6,7,26,28-36&lt;/sup&gt; Past RAP studies have successfully linked with data from the DMDC,&lt;sup&gt;6,26,33&lt;/sup&gt; PDHAs,&lt;sup&gt;28&lt;/sup&gt; the Naval Criminal Investigative Service Consolidated Law Enforcement Operations Center,&lt;sup&gt;7&lt;/sup&gt; and Department of Defense Medical Mortality Registry&lt;sup&gt;33&lt;/sup&gt;; as well as other self-reported epidemiological data such as the RAP II,&lt;sup&gt;30,34&lt;/sup&gt; a follow-up survey for deployed RAP participants, and the Millennium Cohort Study, the largest self-reported, longitudinal military cohort study.&lt;sup&gt;36&lt;/sup&gt; More importantly, the study domains included in RAP surveys have demonstrated relevancy to military outcomes of interest, through findings from prior literature.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/02/01/MSMR-Article-1-Table-2" title="Opens PDF of article table 2"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-1-Table-2.ashx?h=1297&amp;w=1200&amp;hash=8B8A6A4C6601D4194023B0835631FEC753DF4BA0" style="width: 1200px; height: 1297px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;RAP data are proven to complement personnel data, which may not be as candid due to their collection during assessment for military duty. RAP data should be evaluated within the context of certain limitations. Currently, RAP administration is limited to MCRD San Diego and does not represent recruitment for the eastern U.S. Thus far, research studies using RAP data are limited to male participants, as MCRD San Diego did not include female recruits until 2021. Inherent limitations of self-reported, paper-and-pencil survey studies include low participation rates, misreporting of sensitive topics, and resource-intensive administration. Lastly, the lengthy RAP survey is administered during a strenuous time in a recruit’s career, which can increase respondent fatigue. Although question completion rates decreased nearer the survey’s end, they remained high, however, at 87%. &lt;/p&gt;&lt;p&gt;SME and stakeholder reviews have guided survey revisions that will allow future research on pre-service mental health and psychosocial factors as predictors for retention, mental health care provision, and suicide ideation and completion. Ongoing survey content considerations include media use, marijuana use, diversity and inclusion, sexual orientation, and women’s reproductive health. The ever-changing demographics of Marine recruit populations emphasize the need for resources such as RAP, which continues to evolve with changing needs for military operational health and readiness. &lt;/p&gt;&lt;h2&gt;Author Affiliations&lt;/h2&gt;&lt;p&gt;Military Population Health Directorate, Naval Health Research Center, San Diego, CA: Lt Col Rohrbeck; Leidos, Inc.: Dr. Khodr, Dr. McAnany, Mr. Haile, Ms. Perez&lt;/p&gt;&lt;h2&gt;Acknowledgments&lt;/h2&gt;&lt;p&gt;We greatly acknowledge the support of additional Recruit Assessment Program team members: Lauren Jackson, BS, and Lani Pinon, BS. The contributions from Cynthia LeardMann, MPH to study procedure development, data management, and survey content have been integral to RAP operations. We thank MCRD San Diego and its Drill Instructors for facilitating and supporting ongoing administration of this study. Most importantly, we thank the U.S. Marine recruits who voluntarily participate in RAP and provide their invaluable time and information.&lt;/p&gt;&lt;h2&gt;Disclaimers&lt;/h2&gt;&lt;p&gt;Lt Col Rohrbeck is a military service member. This work was prepared as part of official duties. Title 17, U.S.C. §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C. §101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. Report 23-31 was supported by the Military Operational Medicine Research Program under work unit 60002.&lt;/p&gt;&lt;p&gt;The views expressed in this article are those of the authors and do not necessarily reflect the official policy nor position of the Department of the Navy, Department of Defense, or the U.S. Government.&lt;/p&gt;&lt;p&gt;This study protocol was reviewed and approved by the Institutional Review Board of the Naval Health Research Center, in compliance with all applicable Federal regulations governing human subject participant protection. Research data were derived from an approved Naval Health Research Center Institutional Review Board protocol NHRC.2000.0003.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;National Science and Technology Council Presidential Review Directive 5: A National Obligation: Planning for Health Preparedness for and Readjustment of the Military, Veterans, Their Families After Future Deployments. 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Risk factors associated with suicide completions among US enlisted marines. &lt;em&gt;Am J Epidemiol&lt;/em&gt;. 2017;186(6):668-678. doi:10.1093/aje/kwx117&lt;/li&gt;    &lt;li&gt;Bauer LJ, Jacobson IG, Phillips CJ. &lt;em&gt;Effects of Deployment on Risky Health-Related Behaviors Among U.S. Marines. Technical Report 20-17&lt;/em&gt;. Naval Health Research Center; 2020. &lt;a rel="noopener noreferrer" href="https://apps.dtic.mil/sti/pdfs/AD1105965.pdf" target="_blank" title="Click on the link to access the NHRC technical report"&gt;https://apps.dtic.mil/sti/pdfs/AD1105965.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Williams D, Yea JC, Zhu Y. &lt;em&gt;Summary of Recruit Assessment Program Survey Prediction of Military Personnel Outcomes. Technical Report 21-75&lt;/em&gt;. Naval Health Research Center; 2021. &lt;a rel="noopener noreferrer" href="https://apps.dtic.mil/sti/citations/AD1158054" target="_blank" title="Click on the link to access the NHRC technical report"&gt;https://apps.dtic.mil/sti/citations/AD1158054&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Reed-Fitzke K, LeardMann CA, Wojciak AS, et al. Identifying at-risk marines: a person-centered approach to adverse childhood experiences, mental health, and social support. &lt;em&gt;J Affect Disord&lt;/em&gt;. 2023;325:721-731. doi:10.1016/j.jad.2023.01.020&lt;/li&gt;    &lt;li&gt;MacGregor AJ, Dougherty AL, Khodr ZG, et al. Pre-service and early career predictors of new-onset alcohol misuse in male U.S. marines. In preparation.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Thu, 01 Feb 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{A1B9ACA2-78F7-40D5-9D30-1E00B66CF370}</guid><link>https://www.health.mil/News/Articles/2024/02/01/MSMR-RMEs</link><title>Reportable Medical Events at Military Health System Facilities Through Week 1, Ending January 6, 2024</title><description>&lt;p&gt;Reportable Medical Events are documented in the Disease Reporting System internet by health care providers and public health officials throughout the Military Health System for monitoring, controlling, and preventing the occurrence and spread of diseases of public health interest or readiness importance. These reports are reviewed by each service’s public health surveillance hub. The DRSi collects reports on over 70 different RMEs, including infectious and non-infectious conditions, outbreak reports, STI risk surveys, and tuberculosis contact investigation reports. A complete list of RMEs is available in the 2022 Armed Forces Reportable Medical Events Guidelines and Case Definitions.&lt;sup&gt;1&lt;/sup&gt; Data reported in these tables are considered provisional and do not represent conclusive evidence until case reports are fully validated.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/02/01/MSMR-Article-5-Table" title="Opens PDF of RME table"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-5-Table.ashx?h=1529&amp;w=1250&amp;hash=3B52CD7E572FDFF6517F59EACC4AF2CFB643EC18" style="width: 1250px; height: 1529px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Total active component cases reported per week are displayed for the top five RMEs for the previous year. Each month, the graph is updated with the top five RMEs, and is presented with the current month’s (December 2023) top five RMEs, which may differ from previous months. COVID-19 is excluded from these graphs due to changes in reporting and case definition updates in 2023.&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-5-Figure.ashx?h=510&amp;w=1200&amp;hash=A0438167D0768E728546F3AC4B116530A5629BA1" style="width: 1200px; height: 510px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This graph comprises five lines on the horizontal, or x-, axis that depict case counts for the five most frequent reportable medical event conditions among active component service members during the past 52 weeks. Chlamydia remains the most common reportable medical condition, with counts consistently around 300 cases per week. Gonorrhea is generally the second-most common reported condition, averaging approximately 80 cases per week. Syphilis is generally the third-most common condition, averaging approximately 20 cases per week. All three most-frequently reported medical events declined in the final two weeks of 2023 but rose again in the first week of 2024. Norovirus was generally the fourth-most frequent RME in 2023, and rose slightly as well in the first week of 2024. As with sexually-transmitted infections, cold weather injuries, the fifth-most reported medical event on the graph, declined in the last two weeks of 2023, but plateaued in the first week of 2024."&gt;&lt;/p&gt;&lt;p&gt;For questions about this report, please contact the Disease Epidemiology Branch at the Defense Centers for Public Health–Aberdeen. Email: &lt;a href="mailto:dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mil" title="Click on the link to access DCPH-Aberdeen's email address"&gt;dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mil&lt;/a&gt;&lt;/p&gt;&lt;h2&gt;Authors' Affiliation&lt;/h2&gt;&lt;p&gt;Defense Health Agency, Disease Epidemiology Branch, Defense Centers for Public Health–Aberdeen&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Armed Forces Reportable Medical Events. Accessed Sep. 6, 2023. &lt;a href="/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines" target="_blank" title="Click on the link to access AFHSD's RME guidelines"&gt;https://health.mil/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Department of Defense Active Duty Military Personnel by Rank/Grade of Service. Accessed Feb. 28, 2024. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the Defense Manpower Data Center's monthly reports"&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Armed Forces Strength Figures for January 31, 2023. Accessed Feb. 28, 2024. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the Defense Manpower Data Center's monthly reports"&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Navy Medicine. Surveillance and Reporting Tools–DRSI: Disease Reporting System Internet. Accessed Feb. 28, 2024. &lt;a rel="noopener noreferrer" href="https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI" target="_blank" title="Click on the link to access Navy Medicine's Disease Reporting System Internet site"&gt;https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Thu, 01 Feb 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{A8140D51-D809-43D8-B242-B2AAD6FB66C6}</guid><link>https://www.health.mil/News/Articles/2024/02/01/MSMR-Space-Force</link><title>Surveillance Snapshot: Demographics of the Space Force Active Component, U.S. Armed Forces, November 2023</title><description>&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/02/01/MSMR-Article-3-Table" title="Opens PDF of demographics table"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-3-Table.ashx?h=741&amp;w=400&amp;hash=0D0741FC4D5F9E286C95D5E43A4D3C34C74DD84C" style="width: 400px; height: 741px; float: left; margin-right: 15px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;This Surveillance Snapshot provides the first summary of the demographic composition of active component Space Force service members, as of November 2023. This Snapshot is intended to inform future &lt;em&gt;MSMR&lt;/em&gt; illness and injury surveillance reports about this population.&lt;/p&gt;&lt;p&gt;The U.S. Space Force was established in December 2019 to secure the United States’ interests in, from, and to outer space.&lt;sup&gt;1&lt;/sup&gt; The Space Force is a separate and distinct branch of the armed services, although it is organized under the Department of the Air Force. The Space Force provides space capabilities to the joint forces by managing space launch operations and maintaining a global satellite surveillance network that provides in-theater secure communications, as well as weather and navigation information, for military operations, in addition to threat warning.&lt;/p&gt;&lt;p&gt;The Armed Forces Health Surveillance Division began receiving personnel and demographic information about Space Force members from the Defense Manpower Data Center in 2023. As of November 2023, there were 8,938 active component members of the U.S. Space Force (Table). The majority were male (81.1%), non-Hispanic White (62.3%), and possessed a bachelor’s degree or higher (57.9%). The largest proportion of service members within 5-year age categories were classified as 25-29 years (23.8%) and 30-34 years (21.1%). There was a roughly even proportion of junior officers (25.9%) and senior officers (23.5%), while there were more senior enlisted (29.7%) than junior enlisted (20.9%) members.&lt;/p&gt;&lt;p&gt;The Space Force bases with the highest percentages of active component Space Force members assigned were Schriever SFB, CO (18.7%), Peterson SFB, CO (15.6%), Vandenberg SFB, CA (9.4%), Buckley SFB, CO (8.4%), and Los Angeles SFB, CA (7.4%). Roughly half of the 8,938 Space Force members were missing an occupation code as of November 2023. Of those with a valid occupation code, the most common occupations were Operations Staff Officers (42.3%) and Procurement and Production Officers (18.2%) (data not shown).&lt;/p&gt;&lt;p&gt;Active component Space Force members are demographically similar to other active component service members: The majority are males and non-Hispanic White.&lt;sup&gt;2&lt;/sup&gt; The data presented in this report suggest, however, that Space Force members are, on average, older and more highly educated than the overall active component.&lt;sup&gt;2&lt;/sup&gt; In 2022, 34.2% of all ACSM were aged 24 years or younger and 34.9% held a bachelor’s degree or higher, compared to 21.3% of Space Force members aged 24 years or younger and 57.9% with a bachelor’s degree or higher. These findings may be used to help interpret future &lt;em&gt;MSMR&lt;/em&gt; illness and injury surveillance reports on the Space Force.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;United States Space Force. About the Space Force. Accessed Jan. 19, 2024. &lt;a rel="noopener noreferrer" href="https://www.spaceforce.mil/About-Us/About-Space-Force" target="_blank" title="Click on the link to access the U.S. Space Force's website"&gt;https://www.spaceforce.mil/About-Us/About-Space-Force&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;McQuistan AA, Dreyer E, Mabila SL. Surveillance snapshot: mid-year populations by sex, age, and race and ethnicity of active component service members of the U.S. Armed Forces, 2018–2022. &lt;em&gt;MSMR&lt;/em&gt;. 2023;30(12):12. &lt;a href="/News/Articles/2023/12/01/MSMR-MidYear-Populations" target="_blank" title="Click on the link to access the MSMR report"&gt;https://www.health.mil/News/Articles/2023/12/01/MSMR-MidYear-Populations&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Thu, 01 Feb 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{E3D90BB7-725C-4B9F-9A06-CAEF52FD69C3}</guid><link>https://www.health.mil/News/Articles/2024/02/01/MSMR-Uterine-Fibroids</link><title>Incidence and Health Care Burden of Uterine Fibroids Among Female Service Members in the Active Component of the U.S. Armed Forces, 2011–2022</title><description>&lt;p&gt;Uterine fibroids are the most common benign tumors of the &lt;span tabindex="0" class="TooltipLink"&gt;&lt;span class="TooltipContent"&gt;&lt;a href="javascript:void(0);"&gt;&lt;span class="visiblyHidden"&gt;Click to close&lt;/span&gt;&lt;span class="cancelButton"&gt;&lt;/span&gt;&lt;/a&gt;&lt;span class="DefinitionTerm"&gt;uterus&lt;/span&gt;Also known as the womb, the uterus is the female reproductive organ where a baby grows. &lt;/span&gt;uterus&lt;/span&gt; among women of reproductive age, disproportionally affecting non-Hispanic Black women compared to other races and ethnicities. This report is an update of a 2011 &lt;em&gt;MSMR&lt;/em&gt; report that examined uterine fibroids among female active component service members in the U.S. Armed Forces from 2001 to 2010. Incident uterine fibroids were identified for this report from inpatient and outpatient medical encounter data from 2011 to 2022. Health care burden was estimated utilizing uterine fibroid-related inpatient and outpatient diagnostic and procedure codes. Crude incidence rates and incidence rate ratios were calculated to compare rate differences between subpopulations. A total of 16,046 new uterine fibroid cases were identified, with an incidence rate of 63.5 cases per 10,000 person-years (95% confidence interval: 62.5-64.5). The highest incidence rates were observed among service women 40 years and older, non-Hispanic Black women, and those who served in the Army. Health care burden analysis showed that, even with increases in medical encounters and individuals affected, the numbers of hospital bed days declined over time. The decline in uterine fibroid-related hospital bed days could be attributed to early diagnoses and minimally-invasive treatments. Continued promotion of uterine fibroid awareness can potentially help further reduce uterine fibroid-related impacts on military readiness.&lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;Uterine fibroid-related medical encounters and individuals affected increased over time from 2011 to 2022, but the number of hospital bed days decreased from 699 days in 2011 to 625 days in 2022. This decrease in bed days could be attributed to the early detection of uterine fibroid cases and increased accessibility of non- or less invasive treatments. &lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;With the growth of medical encounters and individuals affected over time, the decline in uterine fibroid-related hospital bed days shows that early diagnoses and minimally-invasive treatments can effectively reduce uterine fibroid-related health care burdens and minimize impacts on military readiness.&lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;Uterine fibroids are the most common benign tumors of the uterus among women of reproductive age, disproportionally affecting Black women compared to other races and ethnicities.&lt;sup&gt;1,2&lt;/sup&gt; A systematic review by Guiliani et al. found high prevalence of uterine fibroids detected by ultrasound among U.S. Black and White women, 80% and 70% respectively, by the age of 50.&lt;sup&gt;2&lt;/sup&gt; Guiliani et al. reported that Black women were more likely to have uterine fibroids at younger ages, or larger fibroid sizes, compared to their counterparts. In a more recent study, Huang et al. found that, besides Black women, Asian-Chinese women were also disproportionately affected by uterine fibroids.&lt;sup&gt;3&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;In addition to race and ethnicity, other risk factors of uterine fibroids reported in the literature include older age, early menarche, obesity, stress, hypertension, nulliparity, late &lt;span tabindex="0" class="TooltipLink"&gt;&lt;span class="TooltipContent"&gt;&lt;a href="javascript:void(0);"&gt;&lt;span class="visiblyHidden"&gt;Click to close&lt;/span&gt;&lt;span class="cancelButton"&gt;&lt;/span&gt;&lt;/a&gt;&lt;span class="DefinitionTerm"&gt;menopause&lt;/span&gt;A point in time 12 months after a woman's last period. This transitional period begins between ages 45 and 55.&lt;/span&gt;menopause&lt;/span&gt;, and family history.&lt;sup&gt;2,4-6&lt;/sup&gt; Many studies have focused on the disproportionally high incidence of uterine fibroids among Black women and identified potential risk factors including lack of fruit, vegetable or fiber intake, vitamin D deficiency, obesity, life stressors, in addition to limited access to care.&lt;sup&gt;7-9&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Approximately 30% of women with uterine fibroids experience symptoms such as profound bleeding, anemia, pelvic pressure or pain, in addition to others.&lt;sup&gt;2&lt;/sup&gt; Many different treatments are available for symptomatic uterine fibroids.&lt;sup&gt;10&lt;/sup&gt; Recommended treatment for each patient is determined based upon number, size, and location of the tumors, as well as the patient’s desire for maintaining fertility.&lt;sup&gt;11&lt;/sup&gt; Recently, with growing interest among women for non-surgical treatments, more minimally-invasive methods, including uterine artery embolization, high intensity focused ultrasound, microwave ablation, and radiofrequency ablation, have become available.&lt;sup&gt;12&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Due to the prevalence of uterine fibroids and advanced treatments associated with it, annual direct and indirect costs in the U.S. are estimated to be as high as $34.4 billion.&lt;sup&gt;2&lt;/sup&gt; In addition to health care costs, symptomatic uterine fibroids can also cause loss of work days or work productivity.&lt;sup&gt;13&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Regardless of the high prevalence and potential impacts of uterine fibroids, women have continued to delay seeking medical attention due to lack of knowledge or awareness.&lt;sup&gt;14&lt;/sup&gt; During the past 10 years, researchers began examining any associations between hair products used by Black women and their risk of developing uterine fibroids or uterine cancer,&lt;sup&gt;15,16&lt;/sup&gt; which helped raise uterine fibroid awareness. Marsh et al.&lt;sup&gt;11&lt;/sup&gt; found, however, that only half of women experiencing fibroid-related symptoms without clinical diagnosis had heard of uterine fibroids. Marsh et al. also found that lack of awareness was more prevalent among low-income women or racial minorities. Since many uterine fibroids are discovered by chance, through routine pelvic exams,&lt;sup&gt;4&lt;/sup&gt; continuing to raise awareness is important, for encouraging women who are experiencing symptoms to consult health care providers.&lt;/p&gt;&lt;p&gt;This report is an update of a 2011 &lt;em&gt;MSMR&lt;/em&gt; report,&lt;sup&gt;17&lt;/sup&gt; published as a Surveillance Snapshot, that provided numbers, rates, and demographic characteristics of uterine fibroids as well as uterine fibroid-related health care among female service members in the active component of the U.S. Armed Forces. The 2011 report identified higher rates of uterine fibroids among non-Hispanic Black women among all age groups.&lt;sup&gt;17&lt;/sup&gt; The 2011 report also showed a declining trend of &lt;span tabindex="0" class="TooltipLink"&gt;&lt;span class="TooltipContent"&gt;&lt;a href="javascript:void(0);"&gt;&lt;span class="visiblyHidden"&gt;Click to close&lt;/span&gt;&lt;span class="cancelButton"&gt;&lt;/span&gt;&lt;/a&gt;&lt;span class="DefinitionTerm"&gt;hysterectomy&lt;/span&gt;A partial or total surgical removal of the uterus. It may also involve removal of the cervix, ovaries, Fallopian tubes, and other surrounding structures. &lt;/span&gt;hysterectomy&lt;/span&gt; treatments among patients.&lt;/p&gt;&lt;p&gt;This report aims to confirm whether similar trends to those discerned in 2011 persisted from 2011 to 2022 among female service members. This report also assesses possible procedural delays due to the coronavirus disease pandemic related to new gynecological ultrasound guidance published by the International Society of Ultrasound in Obstetrics and Gynecology,&lt;sup&gt;18&lt;/sup&gt; following COVID-19 guidelines for non-emergent surgical procedures developed by the American College of Surgeons.&lt;sup&gt;19&lt;/sup&gt; During the COVID-19 pandemic, health care providers were more likely to offer fibroid patients less invasive procedures that could be performed in an outpatient setting or required no more than 1 overnight hospital stay.&lt;sup&gt;20&lt;/sup&gt;&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;The study population of this report included all female service members serving in the active component of any branch of the U.S. Armed Forces during the surveillance period, from January 1, 2011 through December 31, 2022. Data were queried from the Defense Medical Surveillance System. Uterine fibroid cases were determined based on outpatient and inpatient administrative health records from both direct and &lt;span tabindex="0" class="TooltipLink"&gt;&lt;span class="TooltipContent"&gt;&lt;a href="javascript:void(0);"&gt;&lt;span class="visiblyHidden"&gt;Click to close&lt;/span&gt;&lt;span class="cancelButton"&gt;&lt;/span&gt;&lt;/a&gt;&lt;span class="DefinitionTerm"&gt;Purchased Care&lt;/span&gt;The TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.&lt;/span&gt;purchased care&lt;/span&gt;.&lt;/p&gt;&lt;h3&gt;Case definition&lt;/h3&gt;&lt;p&gt;International Classification of Diseases, 9th/10th revision diagnostic codes were used to define uterine fibroid cases (Table 1). Female service members with either one inpatient or outpatient medical encounter with a uterine fibroid case-defining code in the primary diagnostic position, or a case-defining code in the secondary diagnostic position paired with an associated symptom code in the primary diagnostic position, were considered as uterine fibroid cases. The date of the first case-defining inpatient or outpatient medical encounter was used as the incident date, and service members were counted once per lifetime. Service members with a case-defining encounter prior to the surveillance period were deemed ineligible and excluded from this report.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/02/01/MSMR-Article-2-Table-1" title="Opens PDF of article table 1"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-2-Table-1.ashx?h=851&amp;w=1200&amp;hash=CC54801DFF8A04F255322E65825804FFE05FD7C0" style="width: 1200px; height: 851px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h3&gt;Health care burden&lt;/h3&gt;&lt;p&gt;To precisely measure health care burdens associated with uterine fibroids, only inpatient or outpatient medical encounters with a case-defining code in the primary diagnostic position were included. Uterine fibroid-related procedures were identified using ICD-9/ICD-10 procedural codes as well as the Current Procedural Terminology codes (Table 1). Procedures were then categorized into three groups: Hysterectomy, Myomectomy, and Other. Total numbers of medical encounters, individuals affected, hospital bed days, as well as numbers and percentages of uterine fibroid-related treatment procedures were utilized to quantify the health care burdens of uterine fibroids in the U.S. Armed Forces.&lt;/p&gt;&lt;h3&gt;Time-censoring calculations &lt;/h3&gt;&lt;p&gt;For each eligible service member’s person-time calculations, the most recent of two dates—either military enrollment or the beginning of the surveillance period, January 1, 2011—was used as the starting time. Time was then censored at the earliest of three dates: date of uterine fibroid diagnosis, date of separation from active component or military service, or end of the surveillance period, December 31, 2022.&lt;/p&gt;&lt;h3&gt;Statistical analysis&lt;/h3&gt;&lt;p&gt;Incident cases of uterine fibroids by key demographic variables were determined. Crude incidence rates were calculated as incident uterine fibroid diagnoses per 10,000 person-time (p-years) with 95% confidence intervals. Based on the IRs, the least at-risk subgroup of each demographic variable was selected as the reference group. Incidence rate ratios were then calculated. All analyses were conducted using SAS Enterprise Guide (version 8.3).&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;p&gt;The study population included female service members who served in the active component, from January 1, 2011 through December 31, 2022. Among 586,252 eligible female service members, a total of 16,046 new onset uterine fibroid cases were identified, for an IR of 63.5 per 10,000 p-years (95% CI: 62.5-64.5). Among all new onset cases, 97% (n=15,578) were outpatient cases.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/02/01/MSMR-Article-2-Table-2" title="Opens PDF of article table 2"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-2-Table-2.ashx?h=694&amp;w=1200&amp;hash=401D2994C8B9EB4CA80987698B2F8DECB100BDDB" style="width: 1200px; height: 694px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;As shown in Table 2, the highest incidence rates of uterine fibroids were observed among service women aged 40 years and older (IR: 276.6 per 10,000 p-yrs, 95% CI: 268.9-284.2), non-Hispanic Black women (IR: 150.5 per 10,000 p-yrs, 95% CI: 147.3-153.6), and those serving in the Army (IR: 85 per 10,000 p-yrs, 95% CI: 83-87). Incidence rate ratio analysis revealed that non-Hispanic Black women were almost five times more likely to develop uterine fibroids than their non-Hispanic White counterparts. Service women aged 40 years and older were 29 times more likely to be diagnosed with uterine fibroids than those under 25 years of age (Table 2). Table 2 also demonstrates a trend of increasing uterine fibroids with increased ages of service women.&lt;/p&gt;&lt;p&gt;When examining uterine fibroid cases by both age and race and ethnicity, incidence rates of uterine fibroids among non-Hispanic Black service women were consistently higher than among other races and ethnicities, for all age groups (Figure 1). The incidence rate differences between non-Hispanic Black women and other races and ethnicities augmented with increasing age.&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-2-Figure-1.ashx?h=653&amp;w=1200&amp;hash=481C4CC05A497B4B7FFAA8D6E7AF1F7FB9F83AB4" style="width: 1200px; height: 653px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="This graph presents four lines, each oriented on the x-, or horizontal, axis. Each line represents a race or ethnicity category: White, non-Hispanic; Black, non-Hispanic; Hispanic; and Other. Each line connects five data points along the x-, or horizontal, axis that represent five discrete age groups: under 25, 25 to 29, 30 to 34, 35 to 39, and 40 and older. The y-, or vertical, axis charts the incidence rate per 10,000 person-years for uterine fibroids among active component female service members. The graph illustrates that rates are lowest for White, non-Hispanic women, rising gradually with age to approximately 150 per 10,000 person-years for women ages 40 and over. Hispanic and Other women evince a similar pattern, at slightly higher rates, with Hispanic women ages 40 over evincing rates at approximately 225 per 10,000 person-years. Rates among Black, non-Hispanic women are markedly higher even at the 25 to 29 age range, already at 100 per 10,000 person-years, and rise steadily to 600 per 10,000 person-years for women ages 40 and over."&gt;&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-2-Figure-2.ashx?h=715&amp;w=1200&amp;hash=80C7D6FC70B2EFC308A827AD4CCC47238F0DA05D" style="width: 1200px; height: 715px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This graph combines pairs of vertical bars oriented along the y-, or vertical, axis with a trend line oriented along the x-, or horizontal, axis. The 12 pairs of vertical bars represent Medical Encounters for uterine fibroids and Individuals Affected for each year from 2011 to 2022. Initially, medical encounters are generally double the number of individuals affected each year, which increase gradually over the surveillance period, from approximately 2,500 medical encounters and 1,200 individuals affected in 2011 to approximately 6,750 medical encounters and 2,750 individuals affected in 2022. During the same period, the horizontal trend line for hospital bed days shows an overall decline, with annual variations, from over 700 bed days in 2011—with a high of 900 bed days in 2014—to approximately 625 in 2022."&gt;&lt;/p&gt;&lt;p&gt;As shown in Figure 2, health care burden analysis revealed that both numbers of medical encounters and individuals affected increased over time, with medical encounters showing a steeper upward slope. From 2011 to 2022, annual numbers of medical encounters increased from 2,496 to 6,585, while the numbers of individuals affected rose from 1,208 to 2,994, with a slight decrease of both medical encounters and individuals affected in 2020, followed by elevations in 2021 and 2022. During the surveillance period, the total number of female service members also increased substantially, from 193,211 in 2011 to 228,145 in 2022. Regardless of the increase of both medical encounters and individuals affected, the total number of bed days declined gradually after peaking at 911 days in 2014, from 699 days in 2011 to 625 days in 2022.&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/February/Article-2-Figure-3.ashx?h=658&amp;w=1200&amp;hash=8D632971B295306B0A12076710AE9608143288CA" style="width: 1200px; height: 658px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This graph presents three lines oriented along the x-, or horizontal, axis, each of which connects 11 points that represent every year from 2011 to 2022. The y-, or vertical, axis provides the percentages of total uterine fibroid-related procedures each year that were constituted by Hysterectomies, Myomectomies, or Other medical or surgical procedures. In 2011, exactly 50 percent of uterine fibroid-related procedures were hysterectomies, but after 2012 that percentage has steadily declined, to just under 20 percent in 2022. The percentage of myomectomies has remained relatively stable, between 20 and 25 percent. Other medical or surgical procedures have steadily increased from 28 percent in 2011 to 55 percent in 2022."&gt;&lt;/p&gt;&lt;p&gt;The percentage of hysterectomies declined consistently, from 50% in 2011 to 17% in 2022 (Figure 3). While fibroid-related myomectomy treatments tended upward over the surveillance period, from 22% to 28%, the speed of the increase was relatively low. A higher speed of increase was observed (from 28% to 55%) among other fibroid-related treatments including uterine artery embolization and hysteroscopy dilation and curettage (D&amp;C, hysteroscopy) (data not shown).&lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;This report summarizes counts, incidence rates, and treatment trends of uterine fibroids among female service members in the active component of U.S. Armed Forces from 2011 to 2022. The same pattern of highest incidents among older non-Hispanic Black female service members reported in the 2011 report&lt;sup&gt;17&lt;/sup&gt; was observed in this analysis. This report also found non-Hispanic Black women more likely to develop uterine fibroids at a younger age, confirming existing literature.&lt;sup&gt;2,4,17&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Potential associations between uterine fibroids and Black women include use of certain hair products, insufficient nutrition, vitamin D deficiency, obesity, life stressors, in addition to limited access to care.&lt;sup&gt;7-9,15&lt;/sup&gt; While the chance of obesity in the military is low, and all service members have access to health care, individual lifestyle factors such as hair product use and fruit, vegetable and vitamin consumption among Black female service members is likely comparable to their civilian counterparts. Additionally, the military is regarded as a stressful work environment. These associated factors may contribute to similar patterns in the military population.&lt;/p&gt;&lt;p&gt;Among all incident cases identified from 2011 to 2022, 97% were outpatient cases, which was elevated from the 92% outpatient cases in the 2011 &lt;em&gt;MSMR&lt;/em&gt; report.&lt;sup&gt;17&lt;/sup&gt; This result could be attributed to increased public awareness of uterine fibroids&lt;sup&gt;14-16&lt;/sup&gt; that resulted in more women with mild symptoms seeking medical diagnoses during outpatient visits.&lt;/p&gt;&lt;p&gt;During the surveillance period, both medical encounters and numbers of individuals affected increased gradually, following similar trends observed in the 2011 report.&lt;sup&gt;17&lt;/sup&gt; The current report did observe a slight decrease, however, of medical encounters and individuals affected in 2020, followed by elevations in 2021 and 2022. That slight decrease could be attributed to the overall decline in primary care due to overwhelmed and strained health care systems during the COVID-19 pandemic.&lt;/p&gt;&lt;p&gt;Despite the increase of medical encounters and individuals affected over time, in this report hospital bed days showed a consistent downward trend, differing from the 2011 report.&lt;sup&gt;17&lt;/sup&gt; This report also identified a significant decline in invasive procedures, and an increase in other procedures, which explain the reduction in hospital bed days. It is possible that early detection of uterine fibroid cases combined with access to non- or less invasive treatments such as UAE and D&amp;C, hysteroscopy have reduced uterine fibroidrelated hospital bed days over time. A more rapid decrease of hospital bed days was also observed in 2019-2020, which could be attributed to procedural delays or the preference of less invasive procedures during the COVID-19 pandemic.&lt;sup&gt;18,20&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;This report has some limitations. The severity of uterine fibroid cases could not be categorized due to lack of specific medical information such as tumor size, location, and numbers. Additionally, DOD Instruction 6130.0321 defines history of chronic pelvic pain and abnormal uterine bleeding as accession-limiting. As a result, the data for those under 25 years old could be skewed. Lastly, the case definition did not include individuals with a diagnosis of abnormal uterine bleeding if there was no diagnosis of uterine fibroids in the primary or secondary diagnostic position. Consequently, use of this more specific case definition may have underestimated incidence of uterine fibroids within this population.&lt;/p&gt;&lt;p&gt;This report reassessed trends last reported in 2011, to provide an updated general assessment of the impact of uterine fibroids among female service members in the active component of the U.S. Armed Forces. Additionally, this report examined potential COVID-19-associated procedural delays in treatment. While the total number of cases during the surveillance period increased over time, a concurrent reduction of hospital bed days demonstrates a better approach for disease management, contributing to reduced costs of uterine fibroid-related medical care and lost work days.&lt;/p&gt;&lt;p&gt;Even with  universal health care access, non-Hispanic Black service women continue to be disproportionally affected by uterine fibroids. This finding indicates that the higher incidence of uterine fibroids among non-Hispanic Black women are not primarily caused by health care accessibility. Additional, well-designed research is needed to further examine any genetic, behavioral, or environmental risk factors for uterine fibroids among this subpopulation.&lt;/p&gt;&lt;h2&gt;Authors' Affiliation&lt;/h2&gt;&lt;p&gt;Epidemiology and Analysis Section, Armed Forces Health Surveillance Division, Defense Health Agency, Silver Spring, MD: Dr. Nieh, Dr. Mabila&lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The opinions and assertions expressed herein are those of the authors and do not reflect the official policy nor position of the Department of Defense or the U.S. Government.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Wallach EE, Vlahos NF. Uterine myomas: an overview of development, clinical features, and management. &lt;em&gt;Obstet Gynecol&lt;/em&gt;. 2004;104(2):393-406. doi:10.1097/01.AOG.0000136079.62513.39&lt;/li&gt;    &lt;li&gt;Giuliani E, As-Sanie S, Marsh EE. Epidemiology and management of uterine fibroids. &lt;em&gt;Int J Gynaecol Obstet&lt;/em&gt;. 2020;149(1):3-9. doi:10.1002/ijgo.13102&lt;/li&gt;    &lt;li&gt;Huang D, Magaoay B, Rosen MP, et al. Presence of fibroids on transvaginal ultrasonography in a community-based, diverse cohort of 996 reproductive-age female participants. &lt;em&gt;JAMA Netw Open&lt;/em&gt;. 2023;6(5):e2312701. doi:10.1001/jamanetworkopen.2023.12701&lt;/li&gt;    &lt;li&gt;De la Cruz MS, Buchanan EM. Uterine fibroids: diagnosis and treatment. &lt;em&gt;Am Fam Physician&lt;/em&gt;. 2017;95(2):100-107. &lt;/li&gt;    &lt;li&gt;Paul EN, Grey JA, Carpenter TJ, et al. Transcriptome and DNA methylome analyses reveal underlying mechanisms for the racial disparity in uterine fibroids. &lt;em&gt;JCI Insight&lt;/em&gt;. 2022;7(20):e160274. doi:10.1172/jci.insight.160274&lt;/li&gt;    &lt;li&gt;Yang Q, Ciebiera M, Bariani MV, et al. Comprehensive review of uterine fibroids: developmental origin, pathogenesis, and treatment. &lt;em&gt;Endocr Rev&lt;/em&gt;. 2022;43(4):678-719. doi:10.1210/endrev/bnab039&lt;/li&gt;    &lt;li&gt;Kant AK, Graubard BI. Ethnicity is an independent correlate of biomarkers of micronutrient intake and status in American adults. &lt;em&gt;J Nutr&lt;/em&gt;. 2007;137(11):2456-2463. doi:10.1093/jn/137.11.2456&lt;/li&gt;    &lt;li&gt;Catherino WH, Eltoukhi HM, Al-Hendy A. Racial and ethnic differences in the pathogenesis and clinical manifestations of uterine leiomyoma. &lt;em&gt;Semin Reprod Med&lt;/em&gt;. 2013;31(5):370-379. doi:10.1055/s-0033-1348896&lt;/li&gt;    &lt;li&gt;Vines AI, Ta M, Esserman DA. The association between self-reported major life events and the presence of uterine fibroids. &lt;em&gt;Womens Health Issues&lt;/em&gt;. 2010;20(4):294-298. doi:10.1016/j.whi.2010.03.009&lt;/li&gt;    &lt;li&gt;Hartmann KE, Fonnesbeck C, Surawicz T, et al. &lt;em&gt;Management of Uterine Fibroids—Comparative Effectiveness Review No. 195. AHRQ Publication 17(18)-EHC028-EF&lt;/em&gt;. Agency for Healthcare Research and Quality; 2017. doi:10.23970/AHRQEPCCER195&lt;/li&gt;    &lt;li&gt;Marsh EE, Al-Hendy A, Kappus D, et al. Burden, prevalence, and treatment of uterine fibroids: a survey of U.S. women. &lt;em&gt;J Womens Health (Larchmt)&lt;/em&gt;. 2018;27(11):1359-1367. doi:10.1089/jwh.2018.7076&lt;/li&gt;    &lt;li&gt;Krzyzanowski J, Wozniak S, Szkodziak P, et al. Minimally invasive treatment options for uterine fibroids: state-of-the art 2021. &lt;em&gt;Ginekol Pol&lt;/em&gt;. 2022;93(3):242-247. doi:10.5603/GP.a2021.0202&lt;/li&gt;    &lt;li&gt;Hasselrot K, Lindeberg M, Konings P, et al. Investigating the loss of work productivity due to symptomatic leiomyoma. &lt;em&gt;PLoS One&lt;/em&gt;. 2018;13(6):e0197958. doi:10.1371/journal.pone.0197958&lt;/li&gt;    &lt;li&gt;Ghant MS, Sengoba KS, Vogelzang R, et al. An altered perception of normal: understanding causes for treatment delay in women with symptomatic uterine fibroids. &lt;em&gt;J Womens Health (Larchmt)&lt;/em&gt;. 2016;25(8):846-852. doi:10.1089/jwh.2015.5531&lt;/li&gt;    &lt;li&gt;Wise LA, Palmer JR, Reich D, et al. Hair relaxer use and risk of uterine leiomyomata in African-American women. &lt;em&gt;Am J Epidemiol&lt;/em&gt;. 2012;175(5):432-440. doi:10.1093/aje/kwr351&lt;/li&gt;    &lt;li&gt;Chang CJ, O'Brien KM, Keil AP, et al. Use of straighteners and other hair products and incident uterine cancer. &lt;em&gt;J Natl Cancer Inst&lt;/em&gt;. 2022;114(12):1636-1645. doi:10.1093/jnci/djac165&lt;/li&gt;    &lt;li&gt;Armed Forces Health Surveillance Center. Uterine fibroids, active component females, U.S. Armed Forces, 2001-2010. &lt;em&gt;MSMR&lt;/em&gt;. 2011;18(12):10-13.&lt;/li&gt;    &lt;li&gt;Bourne T, Leonardi M, Kyriacou C, et al. ISUOG consensus statement on rationalization of gynecological ultrasound services in context of SARS-CoV-2. &lt;em&gt;Ultrasound Obstet Gynecol&lt;/em&gt;. 2020;55(6):879-885. doi:10.1002/uog.22047&lt;/li&gt;    &lt;li&gt;American College of Surgeons. COVID 19: Elective Case Triage Guidelines for Surgical Care. Updated Mar. 27, 2020. Accessed Jan. 24, 2024. &lt;a rel="noopener noreferrer" href="https://www.facs.org/media/wfjhq0jw/guidance_for_triage_of_nonemergent_surgical_procedures.pdf" target="_blank" title="Click on the link to access the American College of Surgeons guidelines"&gt;https://www.facs.org/media/wfjhq0jw/guidance_for_triage_of_nonemergent_surgical_procedures.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Kisilevzky N, Lipman C. Uterine fibroid embolization in time of Covid-19. &lt;em&gt;Clin J Obstet Gynecol&lt;/em&gt;. 2020;3:79-80. doi:10.29328/journal.cjog.1001053&lt;/li&gt;    &lt;li&gt;Office of the Under Secretary of Defense for Personnel and Readiness. &lt;em&gt;DOD Instruction 6130.03, Volume 1. Medical Standards for Military Service: Appointment, Enlistment, or Induction&lt;/em&gt;. Updated Nov. 16, 2022. &lt;a rel="noopener noreferrer" href="https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/613003_vol1.PDF?ver=7fhqacc0jGX_R9_1iexudA%3D%3D" target="_blank" title="Click on the link to access the Defense Department's medical standards"&gt;https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/613003_vol1.PDF?ver=7fhqacc0jGX_R9_1iexudA%3D%3D&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Thu, 01 Feb 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{7EB44B81-CF7F-4E2E-B7F9-394688F1F66A}</guid><link>https://www.health.mil/News/Articles/2024/01/25/Ask-the-Doc-What-are-the-New-Rules-for-Blood-Donations</link><title>Ask the Doc: What are the New Rules for Blood Donations?</title><description>&lt;p&gt;Dear Doc,&lt;/p&gt;&lt;p&gt;I really want to help my fellow service members and community by donating blood, but I’m confused about some of eligibility changes and how safe the donation procedure is. Also, if I can’t donate blood—what can I do to help the cause?&lt;/p&gt;&lt;p&gt;U.S. Marines Corps Pvt. 1st Class O. Positive&lt;/p&gt;&lt;p style="padding: 0in; border: none;"&gt;&lt;strong&gt;__________________________________________________________________________&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;Dear Private,&lt;/p&gt;&lt;p&gt;What a great attitude you have about donating blood. January is Blood Donor Awareness Month. There have been some eligibility changes recently, and there are definitely other ways you can help if you’re unable to or do not want to donate blood. I found two experts to weigh in on your questions: Rick Lumzy, the public affairs/donor recruitment branch chief of the Armed Services Blood Program Division, and former U.S. Navy Blood Program Director Lt. Cmdr. Jeffrey Hebert. Here’s what they had to say.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Lumzy: &lt;/em&gt;&lt;/strong&gt;&lt;em&gt;Every drop of blood you donate to the &lt;a href="/Military-Health-Topics/Health-Readiness/ASBP" target="_self" title="opens ASBP on Health.mil"&gt;Armed Services Blood Program&lt;/a&gt; has the potential to help someone in need. Blood donations are crucial for our family members, retirees, and service members deployed globally. Your contribution directly supports those facing life-threatening conditions.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;Donating blood is a safe and simple procedure, and our experienced staff is dedicated to making your experience comfortable.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;Blood saves lives, and just a few minutes of your time can give years to another person. Whether at home or in combat, blood is needed to treat severe injuries and illnesses. At our hospitals, blood is used to make sure a mother and baby can survive complications during childbirth. In wartime, blood transfusions ensure our sailors, soldiers, Marines, and airmen can make it back home.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;Our donors are screened using the same rules for blood collection that our civilian counterparts do, which ensures that our blood and blood products are safe and effective for patient care.&lt;/em&gt;&lt;/p&gt;&lt;h2&gt;&lt;em&gt;Donor Eligibility Changes&lt;/em&gt;&lt;/h2&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Lumzy: &lt;/em&gt;&lt;/strong&gt;&lt;em&gt;The Food and Drug Administration requirements (or eligibility) for blood donation change over time and are based on rigorous analysis of scientific data to inform blood safety initiatives. For example, many people in the past have been found ineligible to donate blood due to spending time living in Europe during the 1980’s and 1990’s. This was due to a concern that the outbreak of “mad cow disease” (known officially as variant Creutzfeldt-Jakob disease) in certain European countries could possibly affect the safety of the blood supply, and there was no way to test for it. However, blood donation in Europe did not stop, and after decades of studying and tracking, transmission of this disease by blood transfusion was impossibly rare. The &lt;a href="/News/Articles/2022/11/09/Mad-Cow-Blood-Donor-Ban-Lifted" target="_self" title="opens Health.mil article"&gt;FDA lifted the ban fully in 2022&lt;/a&gt;.As we are a worldwide military force, this has greatly increased the number of donors who qualify to donate blood.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;Similarly, the &lt;a href="/News/Dvids-Articles/2023/12/02/news459746" target="_blank" title="opens Health.mil article"&gt;individualized donor assessment was updated&lt;/a&gt; by the FDA due to a changed understanding of how blood safety is affected by personal behaviors. What matters most is the individual and whether or not they are engaged in behavior that can affect the safety of his blood. Every single blood donation is tested to ensure the donor is free of disease and as long as the donor engages in healthy lifestyle habits, the donation can be used to bring life to a person in need.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Hebert:&lt;/em&gt;&lt;/strong&gt;&lt;em&gt; Most healthy individuals over the age of 17 and weighing 110 pounds or more can donate blood. Weight, health history, and recent travel may affect your eligibility, so please check with your local ASBP blood donor center for more information. Your willingness to donate is vital, and we encourage you to review the eligibility criteria to ensure a smooth donation process.&lt;/em&gt;&lt;/p&gt;&lt;h2&gt;&lt;em&gt;If You Can’t Donate or You’re Deferred&lt;/em&gt;&lt;/h2&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Lumzy: &lt;/em&gt;&lt;/strong&gt;&lt;em&gt;Unfortunately, not everyone is eligible to donate blood. This can be a heartbreaking moment for someone who is motivated to do something for others. Being disqualified from donating is called a “&lt;a href="/News/Dvids-Articles/2023/12/02/news459746" target="_self" title="opens Health.mil article"&gt;deferral&lt;/a&gt;” and it can be temporary, indefinite, or permanent.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;Temporary deferrals are usually based on travel history or physiological conditions such as low iron in the blood. These are the easiest type of deferral since the potential donor can come back at a later time or ask about donating a different blood product, such as plasma or platelets.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;Indefinite and permanent deferrals exist to protect the safety of the blood supply, but it does not mean that there is something wrong with the donor. In these cases, the best thing to do is to find a different way to support the ASBP. You could do something as simple as finding a friend and motivating them to donate blood, volunteering to help at a blood drive, or even hosting your own blood drive.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Hebert:&lt;/em&gt;&lt;/strong&gt;&lt;em&gt; If donating blood isn’t possible at this time, we want you to know there are other meaningful ways to get involved. Your time and efforts are just as valuable. Consider volunteering with us—your dedication can create a lasting impact; help with refreshments, tell others about the blood drive, talk. We can also help you coordinate an ASBP blood drive in collaboration with your unit or community. Every effort counts, and together, we can make a significant difference.&lt;/em&gt;&lt;/p&gt;&lt;h2&gt;&lt;em&gt;Donating Blood Can Save Three Lives&lt;/em&gt;&lt;/h2&gt;&lt;p&gt;&lt;strong&gt;&lt;em&gt;Lumzy:&lt;/em&gt;&lt;/strong&gt;&lt;em&gt; When you donate a unit of blood, it is actually a mixture of different components: red blood cells that carry oxygen, platelets that fix ‘holes’ and are the first responders to injury, and plasma, which contains special proteins to help stop bleeding. We can either keep everything together to make a product called “whole blood,” or process the donation into separate components.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;There are also some pretty cool technologies that allow our donor centers to collect one or two components of blood but not the others. In either case, these separate components of blood can be used to save three lives.&lt;/em&gt;&lt;/p&gt;&lt;p style="padding: 0in; border: none;"&gt;&lt;strong&gt;&lt;em&gt;Hebert:&lt;/em&gt;&lt;/strong&gt;&lt;em&gt; Whether you have blood type A, B, AB, or O, your blood can make a difference. Your generosity can provide a lifeline for those in need. To schedule your ASBP donation appointment, find a nearby blood donation center.&lt;/em&gt;&lt;/p&gt;&lt;p style="padding: 0in; border: none;"&gt;&lt;em&gt;&lt;strong&gt;__________________________________________________________________________&lt;/strong&gt;&lt;/em&gt;&lt;/p&gt;&lt;p&gt;Private,&lt;/p&gt;&lt;p&gt;I hope these answers let you know you are highly valuable as a blood donor or equally in another role in a blood drive, and the rules for donating blood have become more flexible than they once were. Blood saves lives. You can save lives.&lt;/p&gt;&lt;p style="padding: 0in; border: none;"&gt;As always, take care out there.&lt;/p&gt;</description><pubDate>Thu, 25 Jan 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{9A0AF80C-13CE-4416-BC18-5563C07E7BD5}</guid><link>https://www.health.mil/News/Articles/2024/01/19/Military-Health-System-Stabilization-Rebuilding-Health-Care-Access-is-Critical-to-the-Wellbeing-of-our-Patients</link><title>Military Health System Stabilization: Rebuilding Health Care Access is ‘Critical to the Wellbeing of our Patients’</title><description>&lt;p&gt;The Department of Defense is on a mission to get the right people into the right military hospital or clinic at the right time— both medical staff and patients. &lt;/p&gt;&lt;p&gt;On Dec. 6, 2023, the Deputy Secretary of Defense signed a memo directing the stabilization of the Military Health System. The memo requires that the MHS add capacity to reattract patients and beneficiaries, improve access to care in military hospitals and clinics, and increase opportunities to sustain military clinical readiness for medical forces.&lt;/p&gt;&lt;p&gt;There is a clear need to stabilize the MHS. The realignment of medical personnel, coupled with a volatile health care economy in the past three years, created challenges to care for beneficiaries and affected the ability to efficiently generate and sustain medically ready and ready medical forces.&lt;/p&gt;&lt;p&gt;“Coming out of COVID-19, there were capacity constraints across all health systems in both the United States and peer nations,” said Dr. David J. Smith, the deputy assistant secretary of Defense for Health Readiness Policy and Oversight, who is leading a task force charged with implementing the memo’s directives. “Health-seeking behaviors changed as well as the demands on the war fighters and readiness ... health systems worldwide could not keep up.”&lt;/p&gt;&lt;p&gt;Aligning with the recently released &lt;a href="/Reference-Center/Publications/2023/12/15/MHS_Strategic_Plan_FY24_29" target="_self" title="opens Health.mil publication"&gt; MHS Strategy&lt;/a&gt; for fiscal years 2024 through 2029, the memo primarily addresses the need for the MHS to continue providing medically ready forces and ready medical forces while simultaneously delivering quality care to beneficiaries. Doing so effectively, “requires a stable, predictable workforce sufficiently staffed, trained, and routinely available to provide health care to our beneficiaries,” as stated in the memo. &lt;/p&gt;&lt;p&gt;“A big piece of this memo was about providing that stability: creating more stability for our staff so that they can provide more stability for our patients,” said Smith. “This leads to better access to care and more clinical capabilities.”&lt;/p&gt;&lt;p&gt;Rarely have issues in the MHS become so front-and-center. Recognizing the lasting impacts of the COVID-19 pandemic and reorganization, the Under Secretary of Defense for Personnel and Readiness began relying heavily on the Military Health System Executive Review Board to oversee and implement major improvement projects. Moreover, the board began referring issues up to the seniormost military and civilian leadership in the DOD through the Deputy Secretary’s Workforce Council.&lt;/p&gt;&lt;p&gt;“The board is chaired by the Under Secretary of Defense for Personnel and Readiness, with official representation from the Army, Navy, Air Force, joint staff, and Marine Corps ... all of the major components of the United States DOD.” Smith said. “This is so important to our senior leadership, as we are actively discussing and updating this effort at the Deputy’s Workforce Council, the most senior governance forum in the department covering personnel issues.”&lt;/p&gt;&lt;p class="pf0"&gt;“This is a massive commitment of time from our senior-most leadership because we know that medical is critical to the war fight.” Smith said, then added, in reference to the four-years long reorganization of the MHS, “The Department has undergone a tremendous transformation to deliver more effective and efficient health care. This is critical to the wellbeing of our patients and the wellbeing of our families."&lt;/p&gt;&lt;p&gt;The reorganization realigned all military clinics and hospitals from the U.S. Army, U.S. Navy, and U.S. Air Force to the Defense Health Agency. Doing so leverages economies of scale and standardizes care for our warfighters and beneficiaries in the long-term, but the transition was enormous. Smith said that the organization has been characterized as the largest reorganization and transformation in the DOD since the establishment of the U.S. Air Force in 1947. Major transitions often take time to stabilize and realize improvements, especially for organizations as large and diverse as the MHS.&lt;/p&gt;&lt;h2&gt;Upcoming Steps to Stabilize the MHS&lt;/h2&gt;&lt;p&gt;The Department will prioritize military and civilian staffing and uniformed personnel management at military hospitals and clinics, incorporating the memo’s guidance into programming and planning activities. The focus is increasing medical personnel delivering care at military hospitals and clinics to optimize capacity for beneficiaries and mission requirements. “The [Secretary’s] goal of taking care of our people is about investing in our workforce,” Smith said, and that is exactly what the Deputy Secretary’s memo does in the short and long term.&lt;/p&gt;&lt;p&gt;First and foremost, by June 30, 2024, the Under Secretary of Defense for Personnel and Readiness will complete a comprehensive review of all medical manpower and staffing. The review will inform how best to increase capacity to improve access to care for service members, their families, and all MHS beneficiaries while maintaining and improving our readiness capabilities.&lt;/p&gt;&lt;p&gt;The memo also directs the Department to rethink policies on the assignment of military medical personnel to hospitals and clinics. In the short term, there will be a limited redistribution of medical personnel to boost capacity at a few key locations and will begin no later than July 1, 2024, “to stabilize health care delivery and mitigate risk to operational forces and missions.”&lt;/p&gt;&lt;p&gt;“We’ll begin PCSing [permanent change of station] a number of health care professionals,” said Smith. “From there, we're going to a phased progression of assigning these providers to military hospitals and clinics.”  Assigning military medical forces primarily to military hospitals and clinics will provide more predictability and continuity for patients and increase capacity for day-to-day health care.&lt;/p&gt;&lt;p&gt;“Another big change will be on civilian personnel staffing,” Smith said. “We are going to implement authorities allowing us to recruit and retain our civilian employees better. This will include facilitating paying our civilian employees at rates commensurate with the [Department of Veterans Affairs] and the private sector.”&lt;/p&gt;&lt;p&gt;As Smith stated, one critical, key initiative is implementing the authorities under chapter 74 of &lt;a rel="noopener noreferrer" href="https://hr.nih.gov/benefits/pay/title-38-pay#:~:text=Title%2038%20is%20a%20special,in%20certain%20health%20care%20occupations." target="_blank" title="opens NIH.gov"&gt;title 38&lt;/a&gt; to improve pay for civilian health care personnel. The Department recognizes that we need to be a more competitive employer and pay civilian health care personnel at rates equal to the Departments of Veterans Affairs and Health and Human Services.   &lt;/p&gt;&lt;h2&gt;Boosting Staff to Bring Back Beneficiaries&lt;/h2&gt;&lt;p&gt;The DOD wants to reattract our beneficiaries back to military hospitals and clinics where possible. Many have turned to the private sector for health care as fewer military and civilian personnel were available to deliver care in the Department’s hospitals and clinics. The Department also recognizes that burnout in health care workers is a serious challenge in the United States. Recruiting and making more medical personnel available at military hospitals and clinics reduces burnout, improving the workplace environment and enhancing the experience of care for patients.&lt;/p&gt;&lt;p&gt;“If we have more people in military hospitals and clinics, we won't be burning out people as much. We also know that burnout is correlated with the experience of care for our beneficiaries,” Smith said. “In doing so, we can reattract beneficiaries to MHS.”&lt;/p&gt;&lt;p&gt;Based on an economic model that optimizes the future state of the MHS around our warfighters and military families, the memo directs, “reattracting at least 7 percent of available care from the private sector back to MTFs on average.” Reattracting 7% of patients from the private care system is an ambitious yet realistic goal given the time it takes to close gaps in medical personnel staffing. For patients, coming back to military hospitals and clinics should be easy and limit any out-of-pocket costs.&lt;/p&gt;&lt;p&gt;“We want to bring beneficiaries back to the MHS  ... and truly make the MHS the place you want to receive care,” Smith added. “We are going to rebuild that capacity first to earn trust from our beneficiaries.”&lt;/p&gt;&lt;p&gt;The Departments does not plan to ask any patients to change their health plan or their doctor. The goal is to make the MHS more accessible to make getting care at military hospitals or clinics the easiest, simplest choice.&lt;/p&gt;&lt;p style="line-height: normal;"&gt;“We remain focused on readiness and health care for all our beneficiaries,” stated Dr. Lester Martínez-López, the DOD assistant secretary for health affairs, in the strategic plan. “The two are inseparable: When our people take care of people, we increase the readiness of the total force. I look forward to this work, knowing that it will lead to a stronger MHS capable of meeting the challenges we inevitably face.” His message to the MHS is this, “I hear you. I know we have serious issues, and we have a plan to fix our situation. I am asking for your support during the time it will take to make the changes we need.”&lt;/p&gt;&lt;p style="line-height: normal;"&gt;Ultimately, the MHS exists to support the military and the nation. Doing so is the highest calling, and the Deputy Secretary’s memorandum stabilizes and makes whole the MHS to provide better access to care for the DOD’s 9.6 million beneficiaries in the United States and around the world.&lt;/p&gt;&lt;p&gt;To learn more about this effort, check &lt;a href="/"&gt;health.mil&lt;/a&gt; and &lt;a rel="noopener noreferrer" href="https://www.tricare.mil" target="_blank" title="goes to TRICARE"&gt;tricare.mil&lt;/a&gt; and follow our &lt;a href="/Military-Health-Topics/MHS-Toolkits/Social-Media"&gt;social media channels&lt;/a&gt; for regular updates.&lt;/p&gt;</description><pubDate>Fri, 19 Jan 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{7A454183-4137-45B6-9237-E382858E8196}</guid><link>https://www.health.mil/News/Articles/2024/01/01/MSMR-Content-Analysis</link><title>A Content Review of Articles Published in the Medical Surveillance Monthly Report, 2019–2023</title><description>&lt;p&gt;In continuous publication since 1995, the &lt;em&gt;Medical Surveillance Monthly Report &lt;/em&gt;serves as the official peer-reviewed journal of the Armed Forces Health Surveillance Division and the Defense Health Agency Public Health Directorate. This monthly publication provides evidence-based estimates of the incidence, distribution, impact, and trends of illness and injury among U.S. military service members and associated populations. &lt;em&gt;MSMR&lt;/em&gt; reports present data, public health information, and original research with direct relevance to the operational fitness of military members or Military Health System beneficiaries’ health, safety, and well-being.&lt;/p&gt;&lt;p&gt;This editorial provides a bibliometric summary and thematic analysis for articles published in &lt;em&gt;MSMR&lt;/em&gt; over a 5-year period, from January 2019 through December 2023. The bibliometric summary provides annual metadata on most-read articles and journal impact, while the thematic content analysis reviews published article data to quantify the populations of focus and primary study outcomes or topics of interest, which are further grouped into major thematic categories, corresponding to the International Classification of Diseases chapter subjects. For analytic summaries described in full and brief reports as well as Surveillance Snapshots, the data sources utilized to study the main outcome were also reviewed.&lt;/p&gt;&lt;h2&gt;Summary Data&lt;/h2&gt;&lt;p&gt;From January 2019 through December 2023, &lt;em&gt;MSMR&lt;/em&gt; published a total of 248 articles. Full reports (n=166), Surveillance Snapshots (n=33), and brief reports (n=17) were the predominant content types, followed by a range of other articles including editorials (n=10), outbreak reports (n=7), case reports (n=6), and historical perspectives (n=5). Less-employed article types included letters to the editor (n=2), notice to readers (n=1), and Images in Health Surveillance (n=1).&lt;/p&gt;&lt;p&gt;The annual number of published articles declined over the past five years, from 58 articles in 2019 to 44 articles in 2023 (Figure). Notably, a summary of Reportable Medical Events for Department of Defense service members and other MHS beneficiaries returned to MSMR in 2023; however, the eight summary reports published in 2023 were not included for this content review. Sentinel RME summaries were regular features of &lt;em&gt;MSMR&lt;/em&gt; until 2010.&lt;sup&gt;1&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-4-Figure.ashx?h=486&amp;w=850&amp;hash=C0B640BE16BA0752AB6EDA3D8DE2F07D6BAAB1C7" style="width: 850px; height: 486px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This graph combines vertical bars oriented to the y-axis and a single trend line oriented along the horizontal, or x-, axis. Five vertical bars, each denoting a year from 2019 through 2023, chart the number of articles published that year in MSMR. The trend line along the x-axis charts the number of PubMed LinkOut clicks for the corresponding period. The number of articles published in MSMR have declined gradually, from 58 in 2019 to 44 in 2023. Over the same period, the number of PubMed LinkOut clicks increased, rising markedly from 2,271 in 2019 to 2,968 in 2020, and even more the following year, to 3,856 in 2021. LinkOut clicks have nearly leveled out since then, increasing to 4,160 over the next two years."&gt;&lt;/p&gt;&lt;p&gt;The population of interest in the majority of articles (n=206; 83.1%) focused on service members (active component, reserve component, or former service members), while 9.6% (n=24) of articles centered on both service members and non-service member beneficiaries, and 5.6% (n=14) were limited to non-service member beneficiaries; four articles did not include a particular population of interest (e.g., environmental sampling data).&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/01/01/MSMR-Article-4-Table-1" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-4-Table-1.ashx?h=1007&amp;w=775&amp;hash=F737ECB33317203D18B4D48888D2808E6C36232D" style="width: 775px; height: 1007px; float: right; margin-top: 0px; margin-bottom: 15px; margin-left: 25px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h2&gt;Content Themes&lt;/h2&gt;&lt;p&gt;The content themes for each &lt;em&gt;MSMR&lt;/em&gt; article published over the 5-year period were reviewed and then grouped into major thematic categories corresponding to ICD chapter subjects. Content themes not aligned to a chapter subject group were classified into separate categories, described in Table 1. Among the 248 total articles published in &lt;em&gt;MSMR&lt;/em&gt; from 2019 to 2023, 42 (16.9%) articles provided a summary of total health care burden and provision, rather than one specific thematic topic. Each year, the &lt;em&gt;MSMR&lt;/em&gt; publishes an annual compendium of burden of disease reports that groups diagnoses to inform readership of the major drivers of health care provision within the MHS.&lt;sup&gt;2&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;While injuries, musculoskeletal diseases, and mental health disorders are the categories of medical conditions associated with most medical encounters and greatest numbers of hospital bed days reported among active component service members in 2022,&lt;sup&gt;2&lt;/sup&gt; infectious and parasitic diseases (n=73, 29.4%) represented a substantial majority of publication topics identified in the 5-year content theme review, described in Table 1. Additionally, maternal conditions contributed to approximately 13% of all hospital bed days for active component female service members in 2022,&lt;sup&gt;2&lt;/sup&gt; but no articles were published for service women on the topics of pregnancy, childbirth, and the puerperium, or for certain conditions originating in the perinatal period.&lt;/p&gt;&lt;p&gt;Publication themes discussing contact with health services or procedures (‘Z-codes’) represented 24 (9.7%) of all articles; the majority of these were related to immunization (n=14, 5.6%) (Table 1). Other topics associated with health service contacts or procedures (n=10, 4.0%) included women’s health issues related to contraception use, infertility, menstrual suppression, or cervical cancer screening (n=5) as well as men’s health issues related to vasectomy or testosterone replacement therapy (n=2) (data not shown).&lt;/p&gt;&lt;h2&gt;Data Sources&lt;/h2&gt;&lt;p&gt;The methods of each article were manually reviewed to classify the data source of the major outcome of interest that was described in full and brief reports as well as Surveillance Snapshots (n=216). Six data source categories were assessed for each article, including: 1) administrative inpatient and ambulatory records, 2) laboratory results, 3) pharmacy prescriptions, 4) RME records, 5) survey data, and 6) all other data. Many articles included more than one data source for the major outcome of interest, and each of those data sources were classified independently. Since immunization records may be stored in a range of service-specific data systems, or as administrative records, those data were included in the ‘other data’ source category. Data outside of the main outcome of interest that were related to covariate or dependent variable analyses were not assessed.&lt;/p&gt;&lt;p&gt;Almost 30% (n=61) of full and brief reports and Surveillance Snapshots combined more than one data source for analysis of an outcome of interest. Administrative data for clinical conditions from inpatient and ambulatory records, based on ICD diagnoses, contributed to a substantive majority of articles (n=150, 69.4%), followed by laboratory data (n=44, 20.4%), RME records (n=42, 19.4%), then other data sources (n=45, 20.8%). Survey data (n=14, 6.5%) and pharmacy records (n=9, 4.2%) contributed to a smaller proportion of analyses. The largest proportion of other sources from articles with ‘other data’ source classifications included immunization records (n=12), chart reviews (n=8), and medical evacuation records (n=7) (data not shown).&lt;/p&gt;&lt;h2&gt;Bibliometric Summary&lt;/h2&gt;&lt;p&gt;The articles published to the &lt;em&gt;MSMR&lt;/em&gt; website hosted by health.mil garnered a total of 274,518 unique page views from 2019 to 2023, with a median of 296 unique page views per article. Four articles received over 10,000 web page views, with "Testosterone Replacement Therapy Use Among Active Component Service Men" exceeding all other articles during the 5-year period for maximum unique views (n=41,167) (Table 2). The publication date of that article, March 1, 2019, corresponds with a 2018 report from the U.S. Department of Veterans Affairs Office of the Inspector General that documented health care providers’ poor adherence to guideline recommendations for the diagnosis and treatment of men with hypogonadism.&lt;sup&gt;3&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/01/01/MSMR-Article-4-Table-2" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-4-Table-2.ashx?h=614&amp;w=1250&amp;hash=BB41D8C75E16F3ECFEFCBF8E9C35E0C574DD5C9D" style="width: 1250px; height: 614px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;The National Center for Biotechnology Information LinkOut service routinely tracks the number of clicks from the &lt;em&gt;MSMR&lt;/em&gt; publisher icon in PubMed’s abstract listing to the journal’s open access, full text articles on health.mil.&lt;sup&gt;4&lt;/sup&gt; The LinkOut clicks from &lt;em&gt;MSMR&lt;/em&gt; abstracts on PubMed in 2023 remained relatively stable compared to 2022 (Figure), but over the 5-year publication period &lt;em&gt;MSMR&lt;/em&gt;’s LinkOut clicks almost doubled, from 2,271 to 4,160. The far greater number of total page views of articles hosted on the &lt;em&gt;MSMR&lt;/em&gt; health.mil website compared to LinkOut clicks from PubMed indicates a significant readership originating from the AFHSD journal home page.&lt;/p&gt;&lt;p&gt;&lt;em&gt;MSMR&lt;/em&gt; also tracks CiteScore metrics from Scopus, which are based on the number of citations to articles published by a journal over four years, divided by the number of the same document types indexed in Scopus and published during those respective four years.&lt;sup&gt;5&lt;/sup&gt; The &lt;em&gt;MSMR&lt;/em&gt; CiteScore has continually increased over the past three years, from 0.7 in 2020 to 1.9 in 2022.&lt;/p&gt;&lt;h2&gt;Future Direction&lt;/h2&gt;&lt;p&gt;While &lt;em&gt;MSMR&lt;/em&gt; will continue to maintain full text, open access to articles through publication on the journal website in 2024, the full text access from the PubMed abstract display will begin linkage to PubMed Central. This full text archival process will potentially expand readership to a larger academic community, while standardizing and improving historic archival links to PubMed. The journal will also continue to track CiteScore metrics from Scopus. The improvement of the CiteScore metric in recent years corresponds with the increasing number of PubMed LinkOut clicks over the same period, which may be further bolstered by full text archival processes to PubMed Central during 2024.&lt;/p&gt;&lt;p&gt;Biosurveillance remains a high-priority mission for the DOD, with DHA Public Health prioritizing capabilities to support a better biodefense posture in 2023 and beyond.&lt;sup&gt;6,7&lt;/sup&gt; &lt;em&gt;MSMR&lt;/em&gt; welcomes new submissions accordant with the 2023 DOD Biodefense Posture Review, which outlines significant reforms for a resilient force to deter use of bioweapons, rapidly respond to natural outbreaks, and minimize global risk of laboratory accidents.&lt;sup&gt;8&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Just one-fifth of the analytic reports (i.e., full reports, brief reports, Surveillance Snapshots) published in &lt;em&gt;MSMR&lt;/em&gt; from 2019 to 2023 were supported by laboratory capabilities. Critical topics such as antimicrobial resistance, wastewater surveillance, and other environmental threats were presented but are likely under-represented, as sustaining and strengthening U.S. deterrence of the biothreat environment, including naturally occurring, accidental, and deliberate biological threats, is a recently heightened priority.&lt;sup&gt;7&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;A substantial number of articles published from 2019 to 2023 employed dual or multi-sourced data approaches, typically combining laboratory, RME, or administrative records; pharmacy records, however, contributed to relatively few full and brief reports and Surveillance Snapshots. Pharmacosurveillance offers a different and useful perspective for public health capabilities, supporting surveillance for empirical treatment in the absence of laboratory confirmation often corresponding with lags in illness reporting. While laboratory records available within the MHS are usually limited to results generated from military hospitals and clinics, the Pharmacy Data Transaction Service offers a comprehensive data source for DOD beneficiaries with prescription orders originating from military hospitals and clinics, mail order, and retail-dispensed facilities.&lt;sup&gt;9&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;The low number of outbreak reports and case reports published over the last five years also indicates an unrealized opportunity to broaden content from clinicians in addition to each of the Public Health Defense Centers engaged in local force health protection. Additionally, increased publication of editorials, letters to the editor, and notices to readers may offer another venue for publishing efforts by the Army, Navy, and Air Force to enable a healthy, ready Force.&lt;/p&gt;&lt;p&gt;As we usher in a new year that will see the start of &lt;em&gt;MSMR&lt;/em&gt;’s 30th year of production, our editorial staff continues to welcome new submissions, especially those aligned with DHA Public Health’s strategic position for meeting the needs of the MHS, the military services, and the Combatant Commands, for the support of our nation’s security. Detailed instructions for prospective authors are available on the &lt;em&gt;MSMR&lt;/em&gt; website.&lt;/p&gt;&lt;h2&gt;Authors' Affiliation&lt;/h2&gt;&lt;p&gt;Epidemiology and Analysis Branch, Armed Forces Health Surveillance Division, Defense Health Agency, Silver Spring, MD: Ms. Rossi, Mr. Pursley.&lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The opinions and assertions expressed herein are those of the authors and do not reflect the official policy nor position of the Department of Defense or the U.S. Government.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. The return of reportable medical event summaries to &lt;em&gt;MSMR&lt;/em&gt;. &lt;em&gt;MSMR&lt;/em&gt;. 2023;30(5):2-3. Accessed Jan. 4, 2024.&lt;/li&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Absolute and relative morbidity burdens attributable to various illnesses and injuries among active component members, U.S. Armed Forces, 2022. &lt;em&gt;MSMR&lt;/em&gt;. 2022;29(6):2-9.&lt;/li&gt;    &lt;li&gt;U.S. Department of Veterans Affairs Office of Inspector General. Testosterone Replacement Therapy Initiation and Follow-Up Evaluation in VA Male Patients. Accessed Jan. 4, 2024. &lt;a rel="noopener noreferrer" href="https://www.oversight.gov/sites/default/files/oig-reports/VAOIG-15-03215-154.pdf" target="_blank" title="Click on the hyperlink to access the Veterans Affairs' report on testosterone replacement therapy"&gt;https://www.oversight.gov/sites/default/files/oig-reports/VAOIG-15-03215-154.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;National Library of Medicine National Center for Biotechnology Information. LinkOut Information for Full Text Providers. Accessed Jan. 4, 2023. &lt;a rel="noopener noreferrer" href="https://www.ncbi.nlm.nih.gov/projects/linkout/doc/fulltext.html" target="_blank" title="Click on the link to access the National Library of Medicine's LinkOut information webpage"&gt;https://www.ncbi.nlm.nih.gov/projects/linkout/doc/fulltext.html&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Scopus, Elsevier. How Are CiteScore Metrics Used in Scopus? &lt;a rel="noopener noreferrer" href="https://service.elsevier.com/app/answers/detail/a_id/14880/supporthub/scopus" target="_blank" title="Click on the link to access Elsevier's Scopus information webpage"&gt;https://service.elsevier.com/app/answers/detail/a_id/14880/supporthub/scopus&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;U.S. Defense Health Agency. News Release. Public Health Supports the Warfighter, Military Community Worldwide. Accessed Jan. 4, 2024. &lt;a rel="noopener noreferrer" href="https://www.dvidshub.net/news/441875/publichealth-supports-warfighter-military-communityworldwide" target="_blank" title="Click on the link to access the Defense Health Agency's news release on public health activities"&gt;https://www.dvidshub.net/news/441875/publichealth-supports-warfighter-military-communityworldwide&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;U.S. Department of Defense. 2023 Biodefense Posture Review. Accessed Jan. 4, 2024. &lt;a rel="noopener noreferrer" href="https://media.defense.gov/2023/Aug/17/2003282337/-1/-1/1/2023_biodefense_posture_review.pdf" target="_blank" title="Click on the link to access the Department of Defense's biodefense posture review report"&gt;https://media.defense.gov/2023/Aug/17/2003282337/-1/-1/1/2023_biodefense_posture_review.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;U.S. Department of Defense. News Release. DOD Unveils Collaborative Biodefense Reforms in Posture Review. Accessed Jan. 4, 2024. &lt;a rel="noopener noreferrer" href="https://www.defense.gov/News/Releases/Release/Article/3495836/dod-unveils-collaborative-biodefensereforms-in-posture-review/#:~:text=%22The%20biodefense%20posture%20review%20fully,global%20risk%20of%20laboratory%20accidents.%22" target="_blank" title="Click on the link to access the Department of Defense's news release on collaborative biodefense reforms"&gt;https://www.defense.gov/News/Releases/Release/Article/3495836/dod-unveils-collaborative-biodefensereforms-in-posture-review/#:~:text=%22The%20biodefense%20posture%20review%20fully,global%20risk%20of%20laboratory%20accidents.%22&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;TRICARE Pharmacy Operations POD Analytics Support. Pharmacy Data Transaction Service. Accessed Jan. 4, 2023. &lt;a href="/Military-Health-Topics/Access-Cost-Quality-and-Safety/Pharmacy-Operations/POD-Analytics-Support" title="Goes to TRICARE Pharmacy Ops"&gt;https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Pharmacy-Operations/POD-Analytics-Support&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Mon, 01 Jan 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{AF58969C-884F-4798-BD9A-D79207F86533}</guid><link>https://www.health.mil/News/Articles/2024/01/01/MSMR-From-the-Editor</link><title>From the Editor’s Desk</title><description>&lt;p&gt;With humility and pride, this month I begin my tenure as the new Editor-in-Chief of the &lt;em&gt;Medical Surveillance Monthly Report&lt;/em&gt;. Since the launch of the &lt;em&gt;MSMR&lt;/em&gt; in 1995, there have been three prior editors-in-chief. For the past five months, &lt;em&gt;MSMR&lt;/em&gt; has continued to thrive with an outstanding interim leader, Dr. Angelia Eick-Cost, who stepped up to take the lead editor role during the search for a permanent editor-in-chief. Dr. Cost has my sincere appreciation for her superb work in maintaining the high professional standards of &lt;em&gt;MSMR&lt;/em&gt;. I know that I share the sentiments of the &lt;em&gt;MSMR&lt;/em&gt; staff and co-workers when I share our heartfelt thanks to Dr. Cost.&lt;/p&gt;&lt;p&gt;In the most recent Armed Forces Health Surveillance Division Annual Report, &lt;em&gt;MSMR&lt;/em&gt; is referred to as the “premiere medical peer-reviewed journal published by the AFHSD and Defense Health Agency,” which provides “evidence-based estimates of the incidence, distribution, impact and trends of illness and injury among U.S. military service members and associated populations.” &lt;em&gt;MSMR&lt;/em&gt; has a distinguished legacy of excellence and professional rigor. I am honored to pick up and carry that standard further.&lt;/p&gt;&lt;p&gt;I come to this position after a 30-year military career followed by academic, research, and executive roles at the University of Texas Medical Branch School of Medicine, the Civil Aerospace Medical Institute (a FAA Federal Laboratory), and as a physician executive with a national managed care support contractor administering the TRICARE East Region for the DHA. My military experience spans operational medical support in five continents, operational epidemiology, longitudinal research that included the role of principal investigator for two long-term military cohort studies, directing the U.S. Air Force Preventive Medicine Residency Program, and numerous teaching and leadership positions. My medical specialty training and certifications include Preventive Medicine and Aerospace Medicine along with academic training in epidemiology. I am excited to bring together my training and experience in the operational medicine, research, and leadership domains in the role of &lt;em&gt;MSMR&lt;/em&gt; editor-in-chief.&lt;/p&gt;&lt;p&gt;Military Public Health continues its steadfast contribution to the health and readiness of the Force. Public Health develops policies and practices to maintain our national defense, informed by timely, operationally relevant, and practical health and safety information that supports leading Armed Forces health professionals and individual service members.&lt;/p&gt;&lt;p&gt;&lt;em&gt;MSMR&lt;/em&gt; focuses on data-driven, health-related information and analysis, embedded in the Epidemiology and Analysis Branch of AFHSD. We are well-positioned within the health and medical surveillance infrastructure of DHA to engage these significant resources and function as its medical journal publishing arm.&lt;/p&gt;&lt;p&gt;As we build on the well-earned accolades of the legacy of &lt;em&gt;MSMR&lt;/em&gt;, we continue the excellence and operational relevance of the published product. I look forward to maintaining the excellent relationships with the leaders and staff of AFHSD and the Public Health Directorate of DHA. We will focus on expanding the involvement of our editorial advisory board partners and actively engage with them to draw upon their expertise and recommendations. We plan to continue to expand our academic affiliations and professional outreach to DOD clinical and operational leaders within the public health domain to assure we address their identified health challenges where we can.&lt;/p&gt;&lt;p&gt;The role of the &lt;em&gt;MSMR&lt;/em&gt;, within and supporting the overall mission of AFHSD, the Public Health Directorate, and DHA, remains vital. The application of appropriate database utilization, information review, and methodologically-valid analysis remains the “gold standard” of epidemiologic surveillance and medical knowledge development. At &lt;em&gt;MSMR&lt;/em&gt;, we continue to strive for timeliness with careful deliberation, relevance with objectivity, and scientific validity focused on readiness and force health protection.&lt;/p&gt;&lt;p&gt;Very Respectfully,&lt;/p&gt;&lt;p&gt;Robert Johnson&lt;br&gt;MD, MPH, MBA, FACPM, FASMA&lt;br&gt;Col (ret) USAF, MC, CFS&lt;br&gt;Editor-in-Chief&lt;br&gt;&lt;em&gt;Medical Surveillance Monthly Report&lt;/em&gt;&lt;/p&gt;</description><pubDate>Mon, 01 Jan 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{A2563C00-A653-467F-9579-2ACF92168724}</guid><link>https://www.health.mil/News/Articles/2024/01/01/MSMR-Ivermectin</link><title>Ivermectin Prescription Fill Rates Among U.S. Military Members During the Coronavirus Disease 2019 (COVID-19) Pandemic</title><description>&lt;p&gt;This report describes ivermectin prescription fill rates among U.S. active component service members over time during the early phases of the COVID-19 pandemic. Information about the unsubstantiated benefits of ivermectin for coronavirus 2019 prevention and treatment was widely available online early in the COVID-19 pandemic. Ivermectin prescription fill rates increased among ACSM during periods of Alpha and Delta coronavirus variant predominance, but not during the predominance of the Omicron variant. At the peak of the fill rate curve, in August 2021, rates were higher among men compared to women, older compared to younger age groups, senior officers compared to junior officers, senior enlisted compared to junior enlisted service members, and those with a bachelor’s or advanced degree compared to those without a bachelor’s degree. Ivermectin prescriptions were more likely to have been filled at a retail pharmacy than at a military hospital or clinic. During the COVID-19 pandemic fill rates for ivermectin prescriptions among ACSM increased, including those without a qualifying diagnosis. Rates peaked in August 2021 but subsequently declined. The decrease in ivermectin fill rates was coincident with vigorous efforts to correct previous misinformation and implement pre-authorization requirements for prescriptions. Research on the impact of unproven online claims about clinical and public health interventions has potential to curtail future unnecessary and potentially harmful treatments.&lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;Ivermectin prescription fill rates increased among active component service members early in the COVID-19 pandemic when misinformation about the effectiveness of ivermectin for prevention and treatment of COVID-19 was widespread.&lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;This study contributes to the understanding of ivermectin prescription uptake among U.S. military members during the early phases of the COVID-19 pandemic, a period of abundant online information purporting its benefit but insufficient evidence to support its use for COVID-19 prevention and treatment. This study supports the call by the U.S. Surgeon General to expand research that deepens our understanding of health misinformation, who is most susceptible, and which strategies are effective in addressing it.&lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;Ivermectin, an anti-parasitic drug, was identified as a potential treatment for coronavirus disease 2019 early in the pandemic. Numerous non-peer-reviewed publications touted the benefit of ivermectin, and it was heavily promoted online.&lt;sup&gt;1&lt;/sup&gt; Many of these studies were subsequently found to have methodological flaws, and some were withdrawn because of data fraud—but not before their widespread circulation. A large study that purported ivermectin mortality reduction of up to 99% was viewed online more than 150,000 times, cited more than 30 times, and was included in several meta-analyses before it was retracted.&lt;sup&gt;2-4&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;Despite multiple studies that found insufficient evidence to support ivermectin use for COVID-19 prevention or treatment,&lt;sup&gt;5-8&lt;/sup&gt; and alerts discouraging its use,&lt;sup&gt;9,10&lt;/sup&gt; national ivermectin prescription monitoring showed that retail dispensing of ivermectin increased significantly during the COVID-19 pandemic.&lt;sup&gt;11-12&lt;/sup&gt; Increased calls to U.S. poison control centers for adverse ivermectin reactions were also reported. On August 26, 2021, the U.S. Centers for Disease Control and Prevention issued a Health Alert Network notice, “Rapid Increase in Ivermectin Prescriptions and Reports of Severe Illness Associated with Use of Products Containing Ivermectin to Prevent or Treat COVID-19,” that indicated a 24-fold increase in ivermectin dispensing from U.S. outpatient retail pharmacies compared to the prepandemic baseline. The CDC notice reminded prescribers that the U.S. Food and Drug Administration did not approve ivermectin for COVID-19 prevention or treatment.&lt;sup&gt;13&lt;/sup&gt; The following week, the American Medical Association, American Pharmacists Association, and American Society of Health-System Pharmacists published a statement strongly opposing ivermectin ordering, prescribing, and dispensing to prevent or treat COVID-19 outside a clinical trial. Many medical facilities and organizations including the U.S. Military Health System instituted pre-authorization requirements for ivermectin prescriptions soon thereafter. This measure reinforced the Department of Defense’s March 2021 COVID-19 Practice Management Guide recommending against use of ivermectin for treatment of COVID-19, except in a clinical trial.&lt;sup&gt;14&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;Misinformation has various definitions in the medical literature.&lt;sup&gt;15&lt;/sup&gt; This article uses the definition proposed by Johns Hopkins University: Medical misinformation is misleading information that is contrary to the best available evidence.&lt;sup&gt;16&lt;/sup&gt; This definition recognizes that what qualifies as misinformation may change over time as new evidence emerges. &lt;/p&gt;&lt;p&gt;Medical misinformation is not a new phenomenon, but it has gained added significance since the dawn of the internet, which allows the spread of misinformation at unprecedented speed, and on an unparalleled scale.&lt;sup&gt;17&lt;/sup&gt; The U.S. Surgeon General considers health misinformation a serious threat to public health due to its ability to cause confusion, promulgate mistrust, harm people’s health, and undermine public health efforts.&lt;sup&gt;18&lt;/sup&gt; The DOD warns that adversaries are becoming more assertive in use of disinformation, which is defined as false or misleading information shared with malicious intent, in their attempts to sow distrust and disrupt world order.&lt;sup&gt;19&lt;/sup&gt; These efforts target all sectors of government, including public health.&lt;sup&gt;20&lt;/sup&gt; Examples include efforts by the former Soviet Union to attribute the HIV pandemic to U.S. government efforts to develop biological weapons,&lt;sup&gt;21&lt;/sup&gt; and Russian internet troll activity between 2014 and 2017 that “weaponized” content about vaccines to fuel political and social discord.&lt;sup&gt;22&lt;/sup&gt; During the COVID-19 pandemic, both Russia and China sponsored conspiracy narratives that included endorsement of ivermectin as an effective treatment for COVID-19, but which asserted that this was withheld from the public by a “Big Pharma cabal.”&lt;sup&gt;23&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;The MHS serves approximately 9.6 million beneficiaries including 1.4 million active duty service members.&lt;sup&gt;24&lt;/sup&gt; In addition to promoting the health of its beneficiaries, the mission of the MHS is to ensure service members are prepared to defend the nation, and that uniformed medical personnel are trained to provide medical care in support of military operations. &lt;/p&gt;&lt;p&gt;The purpose of this study was to determine whether ivermectin prescriptions increased among active component service members during the COVID-19 pandemic, whether fill rates varied by subpopulation, and how fill rates changed over time as information that discouraged ivermectin use for COVID-19 prevention or treatment increased. This study supports the call by the U.S. Surgeon General to expand research that deepens our understanding of health misinformation, who is most susceptible, and which strategies are effective in addressing it.&lt;sup&gt;18&lt;/sup&gt;&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;This study was determined to qualify as Not Research by the DHA Director of the Office of Research Protections on February 7, 2022. The surveillance period was January 1, 2017 to March 31, 2022. The study population included all ACSM in the Army, Navy, Air Force, and Marine Corps who served at least 1 day on active duty during the surveillance period. All data used in this analysis were derived from records maintained in the Defense Medical Surveillance System. These records document both ambulatory encounters and hospitalizations of ACSM of the U.S. Armed Forces in fixed military and civilian (if reimbursed through MHS) treatment facilities. In addition, DMSS contains data from the Pharmacy Data Transaction Service, which includes dispensed outpatient prescriptions for service members at military hospitals and clinics, as well as civilian &lt;span tabindex="0" class="TooltipLink"&gt;&lt;span class="TooltipContent"&gt;&lt;a href="javascript:void(0);"&gt;&lt;span class="visiblyHidden"&gt;Click to close&lt;/span&gt;&lt;span class="cancelButton"&gt;&lt;/span&gt;&lt;/a&gt;&lt;span class="DefinitionTerm"&gt;Purchased Care&lt;/span&gt;The TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.&lt;/span&gt;purchased care&lt;/span&gt;.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/01/01/MSMR-Article-1-Table-1" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-1-Table-1.ashx?h=401&amp;w=750&amp;hash=AF36E7778D0C9127FBD7C0A5D6B4F6FB1C7203CD" style="width: 750px; height: 401px; float: left; margin: 0px 15px 10px 0px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;To identify dispensed outpatient ivermectin prescriptions, records where the drug name included “IVERMECTIN” or “STROMECTOL” were identified in DMSS. Only prescriptions for oral tablets were included; ointments and creams were excluded. Rates of dispensed oral ivermectin prescriptions were calculated as the number of prescriptions per 100,000 person-years (p-years) and results were stratified by demographic characteristics.&lt;/p&gt;&lt;p&gt;To determine the rate of ivermectin prescriptions among those without an ivermectin-qualifying diagnosis (e.g., helminthiasis, lice, scabies), inpatient and outpatient records that contained a diagnosis for any International Classification of Diseases, 10th Revision (ICD-10) code listed in Table 1, in any diagnostic position, were extracted from DMSS. Service members were considered to have an ivermectin-qualifying diagnosis if the diagnosis occurred within 90 days preceding the ivermectin prescription. A service member was considered to have a prior diagnosis of COVID-19 if a medical record of ICD-10 code U07.1 in any diagnostic position during an inpatient or outpatient encounter, a positive PCR or antigen test, or a reportable medical event for COVID-19 were documented on or before the date of the ivermectin prescription. Data from laboratory test results and RMEs were derived from the Armed Forces Health Surveillance Division “master positive list” of COVID-19 cases, which consolidates COVID-19 cases based on diagnosis, laboratory results, and RMEs, and has been used by AFHSD to track COVID-19 cases among MHS beneficiaries since the beginning of the COVID-19 pandemic.&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;p&gt;The annual rate of dispensed prescriptions was stable from calendar years 2017 through 2020, at 25.6 prescriptions per 100,000 p-years in 2017, 22.7 in 2018, 27.2 in 2019, and 22.7 in 2020 (data not shown). In 2021 the annual prescription rate more than doubled: to 52.8 per 100,000 p-years. Ivermectin prescription rates peaked in August 2021, during the period of Delta variant predominance, at 185.3 per 100,000 p-years, then declined through the end of 2021 (Figure 1).&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-1-Figure-1.ashx?h=601&amp;w=850&amp;hash=1E91ACCD334896ADD5B60207E78C336D0E68B20C" style="width: 850px; height: 601px; margin: 5px 150px 10px; vertical-align: middle;" alt="This graph comprises two lines oriented along the horizontal, or x-, axis, each connecting 27 discrete data points oriented along the vertical, or y-, axis. The two lines along the x-axis represent the monthly rate of dispensed outpatient oral ivermectin prescriptions among the active component of the U.S. Armed Forces, from January 2020 through March 2022. One line represents all ivermectin prescriptions, at all military hospitals and clinics, for the period, while the other line excludes ivermectin prescriptions at the Naval Training Center Great Lakes. For 25 of the 27 months represented, the lines are identical. In January and February 2022, however, the two lines sharply diverge, with over 25 times more prescriptions in February 2022 at Naval Training Center Great Lakes than at all other military hospitals and clinics combined. This divergence and extreme spike in Naval Training Center Great Lakes data were due to a documented scabies outbreak at Naval Training Center Great Lakes at the beginning of 2022. The preceding largest spike in prescription rates, which was approximately one-third the size of the one caused by the scabies outbreak, occurred during the Delta wave in the summer of 2021, when there was no divergence between the two lines."&gt;&lt;/p&gt;&lt;p&gt;A large peak in ivermectin prescriptions between January 2022 (59.9 per 100,000 p-yrs) and February 2022 (496.4 per 100,000 p-yrs) was driven by Navy service members receiving prescriptions at Naval Training Center Great Lakes. Communication with the NTC Great Lakes Public Health Emergency Officer revealed a scabies outbreak among approximately 500 recruits during this period, and the entire recruit population had been prophylactically treated with oral ivermectin. These data are presented in the dotted line in Figure 1. Prescriptions filled at NTC Great Lakes during January and February 2022 were excluded from further analysis due to their identified outbreak-related purpose.&lt;/p&gt;&lt;p&gt;After the NTC Great Lakes prescriptions were removed, a total of 2,018 oral ivermectin prescriptions were dispensed among 1,656 individuals between January  1, 2017 and March 31, 2022 (Table 2). The prescription rate declined sharply after August 2021 and remained low and steady from October 2021 until the end of the study period. A total of 1,400 individuals had only 1 oral ivermectin prescription between January 2017 and March 2022, while 256 individuals had 2 or more (data not shown).&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/01/01/MSMR-Article-1-Table-2" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-1-Table-2.ashx?h=1535&amp;w=800&amp;hash=1CA79A7DCBE0F25F3AB374329CE2371376F10962" style="width: 800px; height: 1535px; vertical-align: middle; margin: 5px 100px 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Between January 2017 and March 2022, most prescriptions for ivermectin were filled at military hospitals or clinics, compared to mail order, retail, in-theater, and Veterans Administration pharmacies. Prescription rates from 2017 until March 2022 were similar between men and women (Table 2). Prescription rates increased steadily with increasing age, from 12.8 per 100,000 p-years among service members less than 20 years old, to 66.8 per 100,000 p-years among service members 45 years and older. Rates were slightly higher in the Air Force, followed by the Navy, Army, and Marine Corps. Rates were highest among non-Hispanic White Service members and lowest among non-Hispanic Black Service members. Rates were also higher among senior officers compared to senior enlisted, junior officers, and junior enlisted service members. Compared to those in other military occupations, rates were highest for health care personnel, followed by pilot/air crew. Rates were highest in the South and Midwest compared to other regions of the U.S.&lt;/p&gt;&lt;p&gt;To compare patterns in ivermectin prescription rates prior to the COVID-19 pandemic with rate patterns at the height of the Delta wave, rates from January 2017 to December 2019 and August 2021 were examined separately. Several differences were noted (Table 2). In August 2021, most prescriptions were filled at a retail pharmacy (165.1 per 100,000 p-yrs compared to 17.6 per 100,000 p-yrs filled at a military hospital or clinic). Between January 2017 and December 2019 the prescription fill rate was 8.4 per 100,000 p-years at retail pharmacies compared to 16.1 per 100,000 p-years at military hospitals or clinics. In August 2021, men had a higher ivermectin prescription fill rate (197.6 per 100,000 p-yrs) compared to women (126.6 per 100,000 p-yrs), whereas rates were similar between men and women, 25.1 and 25.6 per 100,000 p-years, respectively, from January 2017 to December 2019.&lt;/p&gt;&lt;p&gt;In both August 2021 and the period preceding 2020, the ivermectin prescription rate increased with increasing age, but the pattern was more marked in August 2021. The August 2021 rate among those older than 45 years was 640.7 per 100,000 p-years—the rate among those younger than 20 years was 36.2 per 100,000 p-years. During January 2017 through December 2019 period, the rate among those older than 45 years was 49.3 per 100,000 p-years, while the rate among those younger than 20 years was 13.5 per 100,000 p-years.&lt;/p&gt;&lt;p&gt;Warrant officers had much higher prescription fill rates than senior or junior officers in August 2021 (685.7 per 100,000 p-yrs among warrant officers vs. 83.7 per 100-000 p-yrs in junior officers, and 225.6 per 100-000 p-yrs among senior officers). Senior enlisted ACSM had a higher rate from January 2017 through December 2019 (25.4 per 100,000 p-yrs), while warrant officers had the lowest fill rate (16.4 per 100,000 p-yrs). Among those for whom educational attainment is known, ivermectin prescription fill rates increased with higher educational levels in both August 2021 and the January 2017 through December 2019 period: 300.5 per 100-000 p-years among those with a bachelor’s degree or an advanced degree compared to 127.3 per 100-000 p-years among those with a high school diploma or less in August 2021; 37.1 per 100-000 p-years among those with a bachelor’s degree or an advanced degree compared to 19.7 per 100-000 p-years among those with a high school diploma or less in the prior period. &lt;/p&gt;&lt;p&gt;Table 2 includes additional information related to comparative rates based on race, service affiliation, military occupational specialty, and region of assignment. &lt;/p&gt;&lt;p&gt;Nearly two-thirds (n=1,308, 64.8%) of the 2,018 ivermectin prescriptions dispensed during the January 2017 through March 2022 surveillance period occurred among individuals without a qualifying ivermectin diagnosis within the 90 days preceding their ivermectin prescription (data not shown). The annual rate of ivermectin prescriptions without a qualifying diagnosis remained relatively stable between 2017 and 2020 but nearly quadrupled in 2021, from 11.4 per 100,000 p-years in 2020 to 44.7 per 100,000 p-years (data not shown). The monthly prescription rate peaked in January 2021 (i.e., Alpha wave) at 47.6 per 100,000 p-years and then peaked at the highest rate observed during the surveillance period in August 2021 (i.e., Delta wave), at 178.3 per 100,000 p-years (Figure 2).&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-1-Figure-2.ashx?h=679&amp;w=800&amp;hash=A41077C2AE19E4BDAE90C6A9B68EDD4CAA9FD531" style="width: 800px; height: 679px; vertical-align: middle; margin: 6px 150px 10px;" alt="This graph shows only one line, oriented along the horizontal, or x-, axis, connecting 27 discrete data points oriented on the vertical, or y-, axis. The line along the x-axis represents, from January 2020 through March 2022, the rate of dispensed outpatient ivermectin prescriptions among active component service members without an ivermectin-qualifying diagnosis 90 days or sooner before an ivermectin prescription. During the Alpha wave of the COVID-19 pandemic, in the winter months of 2021, in a period of two months the rate of prescriptions without a qualifying diagnosis increased nearly five times, to just under 50 per 100,000 person-years. The preceding rate had been fairly consistently around 10 per 100,000 person-years. The winter 2021 increase peaked in January, and then settled, albeit at double the rates from before the winter increase, until July 2021. In one month, from June to July 2021, the rate more than doubled, to around 70 per 100,000 person-years, and then increased again by two and a half times, to 180 per 100,000 person years, from July to August. Rates then fell in September to approximately the July rate (corresponding to the implementation of the pre-authorization requirement for ivermectin), and then in October to the level preceding the initial rise in December 2020, approximately 10 per 100,000 person-years, where they subsequently remained."&gt;&lt;/p&gt;&lt;p&gt;Among the 2,018 ivermectin prescriptions dispensed during the study period, 978 were dispensed following the declaration of the COVID-19 pandemic in March 2020 by the World Health Organization (data not shown). Among those 978 prescriptions, 324 (33%) were filled for individuals with a prior diagnosis of COVID-19. A higher proportion of prescriptions with a prior COVID-19 diagnosis were dispensed to those who did not have a qualifying ivermectin diagnosis (295 / 739=40%) compared to those with a qualifying ivermectin diagnosis (29 / 239=12%).&lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;This study revealed increased ivermectin prescription fill rates among U.S. ACSM during coronavirus Alpha and Delta variant waves, including increased use among those without a qualifying diagnosis. The highest ivermectin fill rates among U.S. ACSM occurred during the period of Delta variant predominance in the U.S., from July 2021 through September 2021. During this period, there was a 7.3-fold increase in prescription fill rates compared to the baseline period (January 2017–December 2019), which correlates with the highest rate of U.S. online interest in ivermectin recorded by Google Trends.&lt;sup&gt;25&lt;/sup&gt; During the week that ended on August 13, 2021, there was a 24-fold increase in ivermectin prescription fills in the U.S. compared to the U.S. baseline. The second-highest ivermectin fill rates occurred from December 2020 until early March 2021, during the Alpha variant wave, when online interest in ivermectin also increased above baseline. Despite online interest, ivermectin prescription fill rates did not increase during Omicron variant predominance, when daily COVID-19 case rates reached the highest level recorded in the U.S.&lt;sup&gt;25&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;The reason ivermectin prescription fill rates did not increase among ACSM during the Omicron wave is likely multifactorial. Retractions of invalid early studies, along with increased availability of evidence demonstrating lack of ivermectin efficacy against COVID-19, as well as vigorous efforts by private and governmental organizations to call attention to false claims and risks associated with off-label use of ivermectin likely contributed.&lt;sup&gt;4-8&lt;/sup&gt; It is also possible the requirement for prescription pre-authorization, implemented by the military after the Delta wave and prior to Omicron, played a role. A significant proportion of ivermectin prescriptions were filled at retail pharmacies in August 2021—while the reverse was true from January 2017 to December 2019—making the impact of the pre-authorization requirement unclear. In addition, this analysis did not evaluate those providers who wrote prescriptions for ivermectin. It is unclear what proportion of prescriptions were provided by providers within the MHS and what proportion were written by civilian providers outside the MHS.&lt;/p&gt;&lt;p&gt;During the peak of the Delta variant wave, in August 2021, comparatively higher rates of ivermectin prescription fills were seen among men compared to women; by comparison, rates according to sex were similar from January 2017 to December 2019. Rates of ivermectin prescription fills were also much higher among older than younger service members in August 2021, whereas the difference in fill rates by age was less marked prior to August 2021. Given that rank and education typically increase with age, it is not surprising that warrant officers had significantly higher fill rates than junior and senior enlisted service members, and those with a bachelor’s or advanced degree had significantly higher fill rates in August 2021 than those with less formal education, compared to previous years.&lt;/p&gt;&lt;p&gt;The findings related to education and ivermectin fill rates are interesting, given that the groups with higher levels of education are traditionally considered less susceptible to medical misinformation. In particular, Scherer et al. found that less educational attainment was consistently associated with greater misinformation susceptibility.&lt;sup&gt;26&lt;/sup&gt; Pan et al. also found that increasing education, as well as age, were protective against acceptance of misinformation.&lt;sup&gt;27&lt;/sup&gt; Interestingly, data presented here are consistent with more recent data reported by Perlis et al., who also found that men, those with a college degree (compared to less education), and those among the highest age group, compared to younger individuals, were all more likely to use non-evidence-based treatments during the COVID-19 pandemic.&lt;sup&gt;28&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;A possible explanation for these findings is that older, more senior, and higher educated individuals have a greater sense of self-efficacy when interpreting online information, and were more proactive in their requests for ivermectin during interactions with health care providers. While it may be assumed that greater educational attainment is protective against misinformation, this may not be true. Studies show that misinformation can go unrecognized by consumers, regardless of educational status, and that even short exposures to misinformation or disinformation can significantly affect unconscious behavior.&lt;sup&gt;29&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;The relatively higher fill rates in August 2021 among non-Hispanic Whites (compared to other racial categories), among airmen compared to other ACSM, pilots compared to other military occupations, and those living in the South, compared to other regions, is unclear. Further stratification of these groups and additional studies could offer insight into these findings.&lt;/p&gt;&lt;p&gt;Medical misinformation has resulted in significant insurance subsidization of ineffective care,&lt;sup&gt;30&lt;/sup&gt; despite the Federation of State Medical Boards’ efforts to discipline practitioners who spread misinformation and disinformation related to COVID-19 management.&lt;sup&gt;31&lt;/sup&gt; Direct-to-consumer advertising of prescription drugs, for-profit interventions, and patient reliance on online medical information are expected to increase.&lt;sup&gt;32&lt;/sup&gt; These trends have the potential to affirmatively influence patients’ use of media-based medicine, and dissuade their use of evidence-based medicine.&lt;/p&gt;&lt;p&gt;State-sponsored online disinformation, including that targeting public health, has increased in recent years.&lt;sup&gt;33&lt;/sup&gt; The availability of social media, increasingly sophisticated algorithms, and rapidly evolving artificial intelligence all increase capacity for conflict escalation within the digital realm that can undermine evidence-based public health responses.&lt;sup&gt;34&lt;/sup&gt; These efforts can directly discredit credible interventions, such as efficacious vaccines, as well as indirectly sow mistrust and delegitimize public health and other governmental institutions.&lt;/p&gt;&lt;p&gt;Potential population-level and organizational countermeasures against misinformation and disinformation include debunking and pre-bunking,&lt;sup&gt;35&lt;/sup&gt; increased investment in research on misinformation,&lt;sup&gt;18&lt;/sup&gt; and modernization of public health communications, including implementation of infodemic surveillance systems.&lt;sup&gt;36&lt;/sup&gt; The National Strategy for the COVID-19 Response and Pandemic Preparedness outlines the federal government’s commitment to mitigating misinformation and disinformation by ensuring Americans have access to science-based information, and developing capacities for quickly identifying disinformation and misinformation.&lt;sup&gt;37&lt;/sup&gt; While recognizing constitutional concerns related to free speech,&lt;sup&gt;38&lt;/sup&gt; Johns Hopkins University Bloomberg School of Public Health calls for expansion of the federal strategy, including improved resources for public verification of questionable content and increased coordination among constituencies to establish a multiagency national security response effort prioritizing management of public health disinformation from both domestic and international sources.&lt;sup&gt;37&lt;/sup&gt; The urgency of managing misinformation and disinformation is highlighted in DOD’s &lt;em&gt;Strategy for Operations in the Information Environment&lt;/em&gt;.&lt;sup&gt;19&lt;/sup&gt; While this document does not specifically address health-related misinformation and disinformation, the findings here suggest that it should.&lt;/p&gt;&lt;p&gt;This report is subject to several limitations. First, this is a descriptive study of a small population, and conclusions based on these findings require further validation. Second, prescriptions filled outside the MHS and not reimbursed through TRICARE, as well as those obtained without a prescription, were not captured in this analysis. Third, prescription fill rates do not necessarily equate to prescription use; fill rates may both under- and overestimate actual drug use. Fourth, qualifying diagnoses were based on encounter data only. Inclusion of laboratory or other diagnostic data to identify qualifying diagnosis may have increased the number of individuals with a qualifying diagnosis. Fifth, the 90-day period for qualifying ivermectin-qualifying diagnoses was meant to identify as many individuals as possible and is somewhat arbitrary. Shortening or lengthening this period could potentially decrease or increase, respectively, individuals with a qualifying diagnosis. Finally, Google Trends is not a measure of increased exposure to misinformation or disinformation, and any suggestion of a relationship between ivermectin fill rates and misinformation or disinformation herein should be considered exploratory.&lt;/p&gt;&lt;p&gt;As with their civilian counterparts, U.S. military members’ ivermectin prescription fill rates increased during the early phases of the COVID-19 pandemic. This trend was coincident with significant online information espousing ivermectin benefits, but during a period when there was lack of scientific evidence to support its use and no FDA approval of ivermectin for COVID-19 prevention or treatment. Older and more educated individuals had relatively high prescription fill rates, counter to the assumption that age and education protect against online misinformation.&lt;/p&gt;&lt;p&gt;Misinformation and disinformation have assumed increasing significance in the digital information age, with direct relevance to both pandemic preparedness and military operations. Bernard et al. suggest we are entering a new era of biowarfare, one that relies less on a biological weapon and more on the ability to weaponize natural outbreaks, with the goal destabilizing social, political, and economic systems.&lt;sup&gt;33&lt;/sup&gt; Understanding how medical misinformation and disinformation affect the military and how these impacts vary among and within subpopulations is important for ensuring the health of military members as well as national security.&lt;sup&gt;18&lt;/sup&gt;&lt;/p&gt;&lt;h2&gt;Author Affiliations&lt;/h2&gt;&lt;p&gt;Uniformed Services University of the Health Sciences: CAPT Clausen; Epidemiology and Analysis Branch, Armed Forces Health Surveillance Division, Defense Health Agency: Ms. Murray, Dr. Stahlman.&lt;/p&gt;&lt;h2&gt;Disclaimers&lt;/h2&gt;&lt;p&gt;The opinions and assertions expressed herein are those of the authors and do not reflect the official policy nor position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government.&lt;/p&gt;&lt;p&gt;References made to non-Federal entities or products do not constitute nor imply endorsement by either the Department of Defense or Uniformed Services University of the Health Sciences.&lt;/p&gt;&lt;p&gt;This work was prepared by a military or civilian employee of the U.S. Government as part of that individual’s official duties and therefore is in the public domain and does not possess copyright protection. Public domain information may be freely distributed and copied; however, as a courtesy it is requested that the Uniformed Services University and the author be given an appropriate acknowledgment.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;National Institutes of Health. COVID-19 Treatment Guidelines: Ivermectin. Accessed Oct. 9, 2021. &lt;a rel="noopener noreferrer" href="https://www.covid19treatmentguidelines.nih.gov/therapies/miscellaneous-drugs/ivermectin" target="_blank" title="Click on the link to access the NIH website with COVID-19 treatment guidelines"&gt;https://www.covid19treatmentguidelines.nih.gov/therapies/miscellaneous-drugs/ivermectin&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Elgazzar A, Hany B, Youssef SA, et al. Efficacy and safety of ivermectin for treatment and prophylaxis of COVID-19 pandemic. &lt;em&gt;Res Sq&lt;/em&gt;. Dec. 28, 2020 (preprint). doi:10.21203/rs.3.rs-100956/v1&lt;/li&gt;    &lt;li&gt;Research Square. 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Increase in outpatient ivermectin dispensing in the US during the COVID-19 pandemic: a cross-sectional analysis. &lt;em&gt;J Gen Intern Med&lt;/em&gt;. 2021;18:1-3. doi:10.1007/s11606-021-06948-6&lt;/li&gt;    &lt;li&gt;U.S. Centers for Disease Control and Prevention. Rapid Increase in Ivermectin Prescriptions and Reports of Severe Illness Associated with Use of Products Containing Ivermectin to Prevent or Treat COVID-19. Accessed Dec. 27, 2023. &lt;a rel="noopener noreferrer" href="https://emergency.cdc.gov/han/2021/pdf/CDC_HAN_449.pdf" target="_blank" title="Click on the link to access the CDC's emergency notice about ivermectin use and severe illness"&gt;https://emergency.cdc.gov/han/2021/pdf/CDC_HAN_449.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Department of Defense. DoD COVID-19 Practice Management Guide: Clinical Management of COVID-19. Mar. 3, 2021. Accessed Feb. 7, 2024. &lt;a href="/Reference-Center/Technical-Documents/2021/03/04/DoD-COVID-19-Practice-Management-Guide-Version-7" title="Opens COVID-19 Practice Management Guide"&gt;https://health.mil/Reference-Center/Technical-Documents/2021/03/04/DoD-COVID-19-Practice-Management-Guide-Version-7&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Chou WYS, Gaysynsky A, Cappella JN. Where we go from here: health misinformation on social media. &lt;em&gt;Am J Public Health&lt;/em&gt;. 2020;110:S273-S275. doi:10.2105/AJPH.2020.305905&lt;/li&gt;    &lt;li&gt;Kirk Sell TK, Hosangadi D, Smith E, et al. &lt;em&gt;National Priorities to Combat Misinformation and Disinformation for COVID-19 and Future Public Health Threats: A Call for a National Strategy&lt;/em&gt;. Johns Hopkins Center for Health Security; 2021.&lt;/li&gt;    &lt;li&gt;Suarez-Lledo V, Alvarez-Galvez J. Prevalence of health misinformation on social media: systematic review. &lt;em&gt;J Med Internet Res&lt;/em&gt;. 2021;23(1). doi:10.2196/1718&lt;/li&gt;    &lt;li&gt;U.S. Surgeon General. &lt;em&gt;Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment&lt;/em&gt;. U.S. Department of Health and Human Services; 2021. &lt;a rel="noopener noreferrer" href="https://www.hhs.gov/sites/default/files/surgeon-general-misinformation-advisory.pdf" target="_blank" title="Click on the link to access the Surgeon General's advisory on health misinformation"&gt;https://www.hhs.gov/sites/default/files/surgeon-general-misinformation-advisory.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;U.S. Department of Defense. Strategy for Operations in the Information Environment. Department of Defense; 2023. Accessed Dec. 1, 2023. &lt;a rel="noopener noreferrer" href="https://media.defense.gov/2023/nov/17/2003342901/-1/-1/1/2023-department-of-defense-strategy-for-operations-in-the-information-environment.pdf" target="_blank" title="Click on the link to access the Department of Defense's information stategy"&gt;https://media.defense.gov/2023/nov/17/2003342901/-1/-1/1/2023-department-of-defense-strategy-for-operations-in-the-information-environment.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Jacobs Gamberini S. Social media weaponization: the biohazard of Russian disinformation campaigns. &lt;em&gt;Joint Force Q&lt;/em&gt;. 2020;99(4):4-13. &lt;/li&gt;    &lt;li&gt;Selvage D. Operation “Denver”: the East German Ministry of State security and the KGB’s AIDS disinformation campaign, 1985-1986 (part 1). &lt;em&gt;J Cold War Stud&lt;/em&gt;. 2019;21(4):71-123. doi:10.1162/jcws_a_00907&lt;/li&gt;    &lt;li&gt;Broniatowski DA, Jamison AM, Qi S, et al. Weaponized health communication: Twitter bots and Russian trolls amplify the vaccine debate. &lt;em&gt;Am J Public Health&lt;/em&gt;. 2018;108(10):1378-1384. doi:10.2105/AJPH.2018.304567&lt;/li&gt;    &lt;li&gt;Johnson C, Marcellino W. Commentary: Reining in COVID-19 Disinformation from China, Russia, and Elsewhere. RAND Corporation. Nov. 19, 2021. &lt;a rel="noopener noreferrer" href="https://www.rand.org/pubs/commentary/2021/11/reining-in-covid-19-disinformation-from-china-russia.html" target="_blank" title="Click on the link to access the RAND report on COVID-19 disinformation"&gt;https://www.rand.org/pubs/commentary/2021/11/reining-in-covid-19-disinformation-from-china-russia.html&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;U.S. Defense Health Agency. About the Military Health System. Accessed Oct. 9, 2022. &lt;a href="/About-MHS" title="Goes to About MHS"&gt;https://www.health.mil/About-MHS&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Google Trends. Accessed Mar. 2, 2022. &lt;/li&gt;    &lt;li&gt;Scherer LD, McPhetres J, Pennycook G, et al. Who is susceptible to online health misinformation? a test of four psychosocial hypotheses. &lt;em&gt;Health Psychol&lt;/em&gt;. 2021;40(4):274-284. doi:10.1037/hea0000978&lt;/li&gt;    &lt;li&gt;Pan W, Liu D, Fang J. An examination of factors contributing to the acceptance of online health misinformation. &lt;em&gt;Front Psychol&lt;/em&gt;. 2021;12:630268. Accessed Mar. 1, 2022. doi:10.3389/fpsyg.2021.630268&lt;/li&gt;    &lt;li&gt;Perlis RH, Lunz Trujillo K, Green J, et al. Misinformation, trust, and use of ivermectin and hydroxychloroquine for COVID-19. &lt;em&gt;JAMA Health Forum&lt;/em&gt;. 2023;4(9):e233257. doi:10.1001/jamahealthforum.2023.3257&lt;/li&gt;    &lt;li&gt;Bastick Z. Would you notice if fake news changed your behavior? an experiment on the unconscious effects of disinformation. &lt;em&gt;Comput Human Behav&lt;/em&gt;. 2021;116:106633. doi:10.1016/j.chb.2020.106633&lt;/li&gt;    &lt;li&gt;Chua K, Conti RM, Becker NV. US Insurer spending on ivermectin prescriptions for COVID-19. &lt;em&gt;JAMA&lt;/em&gt;. 2022;327(6):584-587. doi:10.1001/jama.2021.24352&lt;/li&gt;    &lt;li&gt;Federation of State Medical Boards. Statement: Spreading COVID-19 Vaccine Misinformation May Put Medical License at Risk. Accessed Sep. 3, 2022.&lt;/li&gt;    &lt;li&gt;Anderson J, Rainie L, Vogels EA. Experts Say the “New Normal” in 2025 Will Be Far More Tech-driven, Presenting More Big Challenges. Pew Research Center. Feb. 18, 2021. Accessed Nov. 28, 2023.&lt;/li&gt;    &lt;li&gt;Bernard R, Bowsher G, Sullivan R, Gibson-Fall F. Disinformation and epidemics: anticipating the next phase of biowarfare. &lt;em&gt;Health Secur&lt;/em&gt;. 2021;19(1):3-12. doi:10.1089/hs.2020.0038&lt;/li&gt;    &lt;li&gt;Menz BD, Modi ND, Sorich MJ, Hopkins AM. Health Disinformation use case highlighting the urgent need for artificial intelligence vigilance: weapons of mass disinformation. &lt;em&gt;JAMA Intern Med&lt;/em&gt;. 2024;184(1):92-96. oi:10.1001/jamainternmed.2023.5947&lt;/li&gt;    &lt;li&gt;Smith R, Chen K, Winner D, Friedhoff S, Wardle C. A systematic review of COVID-19 misinformation interventions: lessons learned. &lt;em&gt;Health Aff (Millwood)&lt;/em&gt;. 2023;42(12):1738-1746. doi:10.1377/hlthaff.2023.00717&lt;/li&gt;    &lt;li&gt;Chiou H, Voegeli C, Wilhelm E, et al. The future of infodemic surveillance as public health surveillance. &lt;em&gt;Emerg Infect Dis&lt;/em&gt;. 2022;28(13):121-128. doi:10.3201/eid2813.220696&lt;/li&gt;    &lt;li&gt;The White House. National Strategy for the COVID-19 Response and Pandemic Preparedness. Accessed Nov. 8, 2023. &lt;a rel="noopener noreferrer" href="https://www.whitehouse.gov/wp-content/uploads/2021/01/National-Strategy-for-the-COVID-19-Response-and-Pandemic-Preparedness.pdf" target="_blank" title="Click on the link to access the White House's COVID-19 repsonse and pandemic strategy"&gt;https://www.whitehouse.gov/wp-content/uploads/2021/01/National-Strategy-for-the-COVID-19-Response-and-Pandemic-Preparedness.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Schillinger D, Baron RJ. Health communication science in the balance. &lt;em&gt;JAMA&lt;/em&gt;. 2023;330(9):803-804. doi:10.1001/jama.2023.14763&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Mon, 01 Jan 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{63451167-E608-4D28-B9D9-3DE106CD6D58}</guid><link>https://www.health.mil/News/Articles/2024/01/01/MSMR-RMEs</link><title>Reportable Medical Events at Military Health System Facilities Through Week 48, Ending November 30, 2023</title><description>&lt;p&gt;Reportable Medical Events are documented in the Disease Reporting System internet by health care providers and public health officials throughout the Military Health System for monitoring, controlling, and preventing the occurrence and spread of diseases of public health interest or readiness importance. These reports are reviewed by each service’s public health surveillance hub. The DRSi collects reports on over 70 different RMEs, including infectious and non-infectious conditions, outbreak reports, STI risk surveys, and tuberculosis contact investigation reports. A complete list of RMEs is available in the 2022 Armed Forces Reportable Medical Events Guidelines and Case Definitions.&lt;sup&gt;1&lt;/sup&gt; Data reported in these tables are considered provisional and do not represent conclusive evidence until case reports are fully validated.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/01/01/MSMR-Article-5-Table" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-5-Table.ashx?h=1628&amp;w=1300&amp;hash=F27D04FF34EFBF230EC7BCA6FDACFCFCF3C20EB3" style="width: 1300px; height: 1628px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Total active component cases reported per week are displayed for the top five RMEs for the previous year. Each month, the graph is updated with the top five RMEs, and is presented with the current month’s (October 2023) top five RMEs, which may differ from previous months. COVID-19 is excluded from these graphs due to changes in reporting and case definition updates in 2023.&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-5-Figure.ashx?h=718&amp;w=1300&amp;hash=8BACF490FD2DEE86541E260477C3E96C2FECD20C" style="width: 1300px; height: 718px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="This graph comprises five lines on the horizontal, or x-, axis that depict case counts for the five most frequent reportable medical event conditions among active component service members during the past 52 weeks. Chlamydia remains the most common reportable medical condition, with counts consistently around 300 cases per week. Gonorrhea is generally the second-most common reported condition, averaging approximately 80 cases per week, but in week 26 of 2023 it was surpassed by heat illness, which outnumbered gonorrhea cases for the next eight of nine weeks, but declined to the same number gonorrhea cases by the end of week 35 and has been declining generally thereafter, with one notable spike in 45. Campylobacteriosis cases rose briefly during week 40 to become the fourth-most common reported condition, but declined immediately thereafter to its lowest level until briefly spiking again in week 46 and sharply declining the following weeks. With the overall decline of heat illnesses starting in week 35, syphilis reclaimed the position of the third-most common condition in week 40, excepting the one week spike in heat illnesses in week 45, and has been declining slightly, with just over 10 reported cases per week."&gt;&lt;/p&gt;&lt;p&gt;For questions about this report, please contact the Disease Epidemiology Branch at the Defense Centers for Public Health–Aberdeen. Email: &lt;a href="mailto:dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mi" title="Click on the email address to correspond with the authors of the RME update"&gt;dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mi&lt;/a&gt;l&lt;/p&gt;&lt;h2&gt;Authors' Affiliation&lt;/h2&gt;&lt;p&gt;Defense Health Agency, Disease Epidemiology Branch, Defense Centers for Public Health–Aberdeen&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Armed Forces Reportable Medical Events. Accessed Sep. 6, 2023. &lt;a href="/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines"&gt;https://health.mil/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Department of Defense Active Duty Military Personnel by Rank/Grade of Service, October 31, 2022. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the webpage for Department of Defense active duty personnel data"&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Armed Forces Strength Figures for January 31, 2023. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforcereports" target="_blank" title="Click on the link to access the Department of Defense's webpage on service member data"&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforcereports&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Navy Medicine. Surveillance and Reporting Tools–DRSI: Disease Reporting System Internet. &lt;a rel="noopener noreferrer" href="https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI" target="_blank" title="Click on link to access the Disease Reporting Internet website"&gt;https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Mon, 01 Jan 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{1431CC73-1A2B-4208-973A-24DC645F0ED1}</guid><link>https://www.health.mil/News/Articles/2024/01/01/MSMR-Vector-Diseases</link><title>Brief Report: The Four Most Frequently Diagnosed Vector-borne Diseases Among Service Member and Non-Service Member Beneficiaries in the Geographic Combatant Commands, 2010–2022</title><description>&lt;p&gt;Vector-borne diseases may pose an increased risk for U.S. service members during recurring military training exercises, operations, and response missions, in addition to residence in endemic regions within and outside the continental U.S.&lt;sup&gt;1,2&lt;/sup&gt; Prior &lt;em&gt;MSMR&lt;/em&gt; reports address VBD surveillance, described by surveillance data for 23 reportable medical events, among active duty and reserve component service members.&lt;sup&gt;3,4&lt;/sup&gt; This report covers a 13-year surveillance period, from January 2010 to December 2022, and provides linear trends of selected VBDs among Armed Forces service and non-service member beneficiaries diagnosed at installations within the Northern Command (NORTHCOM), Africa Command (AFRICOM), Central Command (CENTCOM), European Command (EUCOM), Indo-Pacific Command (INDOPACOM), or Southern Command (SOUTHCOM). Trends of only the four most frequently reported VBDs were evaluated, as Lyme disease, malaria, Rocky Mountain Spotted Fever, and dengue fever comprised 90% (n=5,199) of all 23 VBDs (n=5,750) among Military Health System beneficiaries documented as RMEs during the surveillance period.&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;This study includes all MHS beneficiaries from January 2010 through December 2022. Data were acquired from RME records of 23 VBDs from the Defense Medical Surveillance System, limited to the four most-diagnosed VBDs in DMSS during the surveillance period; a full listing of VBD RMEs are available in a prior &lt;em&gt;MSMR&lt;/em&gt; report.&lt;sup&gt;3&lt;/sup&gt; A VBD case was defined as an individual identified through a RME report, classified as “confirmed,” “probable,” or “suspect” by having met specified laboratory or epidemiologic criteria.&lt;sup&gt;5&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Demographic information including military component (active, reserve, guard), beneficiary status (service members or non-service member), and U.S. Combatant Command at time of diagnoses were included. Non-service member beneficiaries included dependents, former service members, and retirees. MHS beneficiaries diagnosed as a case before the surveillance period were excluded. An individual could qualify as a case once for each RME type. Incidence date was the earliest event date, with classification determined by utilizing all available data, prioritizing confirmed over probable or suspect records.&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/01/01/MSMR-Article-3-Table" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-3-Table.ashx?h=749&amp;w=1250&amp;hash=2D767C31AA9B6575405E31A4E6AE89AD8156140E" style="width: 1250px; height: 749px; vertical-align: middle; margin-top: 10px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;A total of 5,199 confirmed, probable, and suspect cases of Lyme disease (n=3,400), RMSF (n=893), malaria (n=679), and dengue fever (n=227) were identified among MHS beneficiaries from January 2010 through December 31, 2022 (Table). Of those confirmed, probable, and suspect cases, 2,343 were diagnosed in service members and 2,918 were diagnosed in non-service member beneficiaries (data not shown). Lyme disease and RMSF, both caused by tick-borne pathogens, accounted for 83% of cases, while malaria and dengue fever, transmitted by mosquito vectors, comprised the remainder.&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-3-Figure.ashx?h=777&amp;w=1250&amp;hash=1EC73C4BB410969E1D86A33C212653C057BB1EC0" style="width: 1250px; height: 777px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This graph comprises three lines oriented on the horizontal, or x-, axis, each of which represents confirmed and probable numbers combined of Lyme disease cases for Military Health System service and non-service member beneficiaries according to combatant command location. One line represents the U.S. Northern Command,  or USNORTHCOM; one line represents U.S. European Command, or USEUCOM; and the third line represents all Combatant Commands combined. All three lines each connects 13 discrete data points representing every calendar year from 2010 through 2022, labeled on the x-axis. Case counts, in numbers, are labeled along the vertical, or y-, axis. Lyme disease cases peaked early in the surveillance period, in 2012 for all combatant commands as well as USNORTHCOM, and a year earlier, in 2011, for USEUCOM, and have been generally declining ever since. For every year except 2011, when cases spiked in USEUCOM, the vast majority of cases were in USNORTHCOM. In 2022 the lowest numbers were recorded for all combatant commands, which reported a total of 90 cases, as well as USNORTHCOM, which contributed 72 of those 90 total cases. USEUCOM lowest number of cases was in 2017, when there were only 11, which was followed by a gradual increase to 49 in 2020, but then leveled off 16 and 18 in 2021 and 2022, respectively."&gt;&lt;/p&gt;&lt;p&gt;Since Lyme disease was the most common VBD of the four diseases evaluated during the surveillance period, trends of confirmed and probable cases of Lyme disease over time by CCMD are presented in the Figure. Confirmed Lyme disease cases peaked in 2012 (n=455) and then gradually decreased over the study period to a low of 75 cases in 2022; probable cases peaked in 2017 (n=53) and steadily decreased to a low of 15 cases in 2022; suspect cases peaked in 2016 (n=73) and progressively declined to a low of 8 cases in 2022 (data not shown). Cases from NORTHCOM represented the greatest number of confirmed and probable Lyme disease cases during the entire surveillance period (Figure). The annual number of confirmed and probable Lyme disease cases from EUCOM were greatest in 2011 and lowest in 2017; Lyme cases were very low in all other CCMDs, ranging from 0 to 6 cases annually (data not shown).&lt;/p&gt;&lt;p&gt;The Atlantic and central regions of the U.S contributed 85% of NORTHCOM’s reported RMSF cases (data not shown). NORTHCOM averaged 30 RMSF cases annually between 2010 and 2016, dramatically increasing to an average of 149 cases between 2017 and 2019 (data not shown). NORTHCOM was only able to confirm 32% of RMSF cases reported during the surveillance period (Table). &lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;Lyme disease cases constituted the largest proportion of overall RMEs in this report, with highest numbers occurring in 2012. A substantial proportion of Lyme disease cases were reported from locations in the northeastern U.S., where Lyme disease is known to be endemic: 43% of service members and non-service beneficiaries were diagnosed at NORTHCOM Groton (New London Submarine Base, CT) and NORTHCOM New England. The New London Submarine Base is close to Lyme, Connecticut, where an epidemiological evaluation of a cluster of children with arthritis resulted in the first complete description of the infection in 1976, giving the disease its name.&lt;sup&gt;6&lt;/sup&gt; Connecticut still ranks in the top 10 states for reported Lyme disease cases.&lt;sup&gt;7&lt;/sup&gt; No Lyme disease cases were reported in AFRICOM during the surveillance period, because the vectors (&lt;em&gt;Ixodes pacificus&lt;/em&gt; and &lt;em&gt;Ixodes scapularis&lt;/em&gt;) are not present in the region.&lt;/p&gt;&lt;p&gt;In 2017, the armed forces expanded its RME guidelines to include all spotted fever rickettsioses (SFR), to better align with CDC case definitions.&lt;sup&gt;2&lt;/sup&gt; Diagnoses and reports of rickettsial diseases at military hospitals and clinics in NORTHCOM (where RMSF is endemic) significantly increased after the surveillance requirement expansion from only RMSF to the broader SFR group. In this review, all SFR cases were RMSF diagnoses (n=893).&lt;/p&gt;&lt;p&gt;Approximately 68% of RMSF cases reported during the surveillance period could not be confirmed. All laboratory tests performed at military health facilities for RMSF were Indirect Fluorescent Antibody (IFA) assay and other antibody tests, and no records of testing with PCR of blood or eschar specimens were found. Definite identification of &lt;em&gt;Rickettsiae&lt;/em&gt; is not feasible solely by IFA due to considerable serologic cross-reactivity, particularly when high-endpoint titers are seen for more than 1 rickettsial antigen.&lt;sup&gt;8&lt;/sup&gt; Increased use of molecular assays (i.e., real-time PCR) can both confirm and offer species-specific diagnosis in a single sample, facilitating identification and management of rickettsial diseases in both service members and non-service beneficiaries.&lt;/p&gt;&lt;p&gt;The observed decline in the incidence of mosquito-borne cases, such as malaria and dengue, among deployed service members over the last decade is likely due to reduced deployments to endemic regions, with the exception of EUCOM.&lt;sup&gt;4&lt;/sup&gt; Although dengue fever is not represented significantly in EUCOM in this study, there is a rising risk of dengue and other VBDs due to environmental changes and expanding global travel and trade.&lt;sup&gt;9,10,11&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;VBDs often manifest with non-specific symptoms, and when unconfirmed could constitute a number of other infections or health conditions. Lyme disease is frequently misdiagnosed as chronic fatigue syndrome, fibromyalgia, or multiple sclerosis. This non-specificity of symptoms and related issues such as diagnostic availability and cross-reactivity in diagnosis confirmation can pose challenges for accurate case identification and classification, resulting in the major limitations to this study’s findings.&lt;/p&gt;&lt;p&gt;This report summarizes data from electronic reports of RMEs and examines the incidence and geographic distribution of the top four vector-borne infectious diseases among service members and non-service MHS beneficiaries in the CCMDs during a recent 13-year period. Awareness of the risk of these VBDs will help senior leaders develop and employ strategies to decrease avertable medical problems in MHS beneficiaries, maximizing the productivity and readiness of the medical force. &lt;/p&gt;&lt;h2&gt;Author Affiliations&lt;/h2&gt;&lt;p&gt;Epidemiology and Disease Surveillance Department, U.S. Army Public Health Command–West, Joint Base San Antonio–Fort Sam Houston, TX: Dr. Stidham; Human Health Services, U.S. Public Health Command–Pacific, Tripler, HI: COL Cole; Epidemiology and Analysis Branch, Armed Forces Health Surveillance Division, Defense Health Agency: Dr. Mabila&lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The contents, views, or opinions expressed herein are those of the authors and do not reflect the official policy nor position of the U.S. Public Health Commands, Pacific and Central, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of Defense, or the U.S. Government.&lt;/p&gt;&lt;h2&gt;Acknowledgements&lt;/h2&gt;&lt;p&gt;The authors thank Shauna Stahlman, PhD, MPH, Armed Forces Health Surveillance Division, for assistance with obtaining laboratory and DMSS data. &lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Garcia MN, Cropper TL, Gunter SM, et al. Vector-borne diseases of public health importance for personnel on military installations in the United States. &lt;em&gt;US Army Med Dep J&lt;/em&gt;. 2017;Jan-Jun(1-17):90-101. &lt;/li&gt;    &lt;li&gt;Kebisek J, Mancuso JD, Scatliffe-Carrion K, et al. Surveillance of spotted fever rickettsioses at Army installations in the U.S. Central and Atlantic regions, 2012-2018. &lt;em&gt;MSMR&lt;/em&gt;. 2020;27(9):17-23.&lt;/li&gt;    &lt;li&gt;O'Donnell FL, Stahlman S, Fan M. Surveillance for vector-borne diseases among active and reserve component service members, U.S. Armed Forces, 2010-2016. &lt;em&gt;MSMR&lt;/em&gt;. 2018;25(2):8-15.&lt;/li&gt;    &lt;li&gt;O’Donnell FL, Fan M, Stahlman S. Surveillance for vector-borne diseases among active and reserve component service members, U.S. Armed Forces, 2016-2020. &lt;em&gt;MSMR&lt;/em&gt;. 2021;28(2):11-15.&lt;/li&gt;    &lt;li&gt;Defense Health Agency. Armed Forces Reportable Medical Events: Guidelines and Case Definitions. 2022. &lt;a rel="noopener noreferrer" href="https://www.health.mil/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines" target="_blank" title="Click on the link to access the Armed Forces Health Surveillance Division's guidelines for RMEs"&gt;https://www.health.mil/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Burgdorfer W, Barbour AG, Hayes SF, et al. Lyme disease—a tick-borne spirochetosis? &lt;em&gt;Science&lt;/em&gt;. 1982;216(4552):1317-1319. doi: 10.1126/science.7043737&lt;/li&gt;    &lt;li&gt;Connecticut Department of Public Health. Lyme Disease Annual Statistics. Accessed Jul. 2, 2023. &lt;a rel="noopener noreferrer" href="https://portal.ct.gov/DPH/Epidemiology-and-Emerging-Infections/Lyme-Disease-Statistics" target="_blank" title="Click on the link to access the state of Connecticut's webpage on Lyme disease statistics"&gt;https://portal.ct.gov/DPH/Epidemiology-and-Emerging-Infections/Lyme-Disease-Statistics&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Delisle J, Mendell NL, Stull-Lane A, et al. Human infections by multiple spotted fever group rickettsiae in Tennessee. &lt;em&gt;Am J Trop Med Hyg&lt;/em&gt;. 2016;94(6):1212. doi:10.4269/ajtmh.15-0372&lt;/li&gt;    &lt;li&gt;Semenza JC, Sudre B, Miniota J, et al. International dispersal of dengue through air travel: importation risk for Europe. &lt;em&gt;PLoS Neglect Trop Dis&lt;/em&gt;. 2014;8(12):e3278. doi:10.1371/journal.pntd.0003278&lt;/li&gt;    &lt;li&gt;Moutinho S, Rocha J, Gomes A, Gomes B, Ribeiro AI. Spatial analysis of mosquito-borne diseases in Europe: a scoping review. &lt;em&gt;Sustainability&lt;/em&gt;. 2022;14(15):8975. doi:10.3390/su14158975&lt;/li&gt;    &lt;li&gt;Hashim ZP, Aguilera-Cruz J, Luke-Currier A, et al. On urgently tackling the mosquito-borne diseases in the European Union. &lt;em&gt;South East Eur J Public Health&lt;/em&gt;. 2023;1:56-78. doi:10.56801/seejph.vi.370&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Mon, 01 Jan 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{8E4B0C7A-FC82-46A2-B289-A3293A976149}</guid><link>https://www.health.mil/News/Articles/2024/01/01/MSMR-Weight-Loss-Rx</link><title>Weight Loss Medication Prescription Prevalence in the Active Component, 2018–2023</title><description>&lt;p&gt;The U.S. military has witnessed rising obesity among active component service members. The Department of Defense authorized coverage of weight loss medications in 2018, but no study has evaluated prescription prevalence within the active component. This descriptive retrospective cohort study analyzed data from active component U.S. military service members from January 2018 through June 2023. The study used data from the Defense Medical Surveillance System to determine prescription period prevalence of weight loss medication. Data on demographics, body mass index, and history of diabetes were considered. The study revealed a 100-fold increase in the prescription period prevalence of weight loss agents in the active component from their initial authorization date. Demographics associated with higher prescription period prevalence were non-Hispanic Black race and ethnicity, female sex, and older age. Service members in the health care occupations and the Navy had higher prevalence compared to other service branches and occupations. The findings indicate a significant rise in the period prevalence of weight loss prescriptions over time. Further research is recommended to assess the effectiveness, safety, and use in austere military environments.&lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;Following their approval for active component use in 2018, the prevalence of weight loss prescriptions within the active component increased nearly 100-fold, from 1.2 to 104.1 per 100,000 service members. Increased weight loss medication prescription rates were associated with demographic categories including female sex, older age, non-Hispanic Black race or ethnicity, Naval service, and health care-associated occupations.&lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;Use of weight loss medications will likely continue to increase due to the ongoing obesity epidemic in the U.S. Further study evaluating their real world effectiveness in weight management and safety for use among service members in austere and deployed environments should be considered. &lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;In 2000, the World Health Organization designated obesity a global epidemic.&lt;sup&gt;1&lt;/sup&gt; The U.S. faces an increasing prevalence of obesity, which affects both the general population and the armed forces.&lt;sup&gt;2&lt;/sup&gt; The prevalence of obesity among active component service members rose from 16.1% in 2018 to 18.8% in 2021.&lt;sup&gt;3&lt;/sup&gt; Furthermore, the combined prevalence of both obesity and overweight increased from 65.5% in 2018 to 67.3% in 2021.&lt;sup&gt;3&lt;/sup&gt; Obesity within military ranks not only compromises readiness and functional capabilities but also correlates with various musculoskeletal injuries and mental health disorders, leading to increased health care provision.&lt;sup&gt;4-8&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;In 2018, the Defense Health Agency added four weight loss agents (phentermine, benzphetamine, diethylpropion, and phendimetrazine) to the TRICARE Formulary, following authorization from the 2017 National Defense Authorization Act.&lt;sup&gt;9&lt;/sup&gt; Additionally, coverage of brand name and specially ordered medication (non-formulary) with prior authorization was expanded to include approved long-term therapies: liraglutide, lorcaserin, naltrexone/bupropion, orlistat, and phentermine/topiramate.&lt;sup&gt;9&lt;/sup&gt; In 2021, semaglutide, a GLP-1 receptor agonist originally developed for diabetes management, was included in the list of covered medications following U.S. Food and Drug Administration approval.&lt;sup&gt;10-14&lt;/sup&gt; While the DHA approved the agents for weight management, consensus indicates these agents remain adjunctive to a comprehensive lifestyle intervention, and prescribers must consider their compatibility with an individual service member’s professional duties and personal lifestyle.&lt;sup&gt;9,10,13,15,16&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;With limited information available on prescription weight loss medication usage among military members, it is important to explore its prevalence for better understanding of obesity management within the military. Describing period prevalence serves as a precursor to further investigation of real world effectiveness, side effects, and cost to the Military Health System. The objective of this descriptive epidemiologic study is to describe weight loss prescription medication prevalence among ACSM from January 2018 through June 2023.&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;This retrospective cohort study included all active component U.S. military service members in the Army, Navy, Air Force, and Marine Corps from January 1, 2018 to June 30, 2023. This report is based on summaries of medical administrative data routinely provided to the U.S. Armed Forces Health Surveillance Division and integrated within the Defense Medical Surveillance System for health surveillance purposes. Periodic Health Assessment, medical encounter, and demographic data were obtained from DMSS, the central repository of longitudinal medical surveillance data for directly and privately purchased medical care within the U.S. military. Records of prescribed and dispensed weight loss medications from the Pharmacy Data Transaction Service were also obtained from DMSS.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/01/01/MSMR-Article-2-Table-1" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-2-Table-1.ashx?h=1083&amp;w=775&amp;hash=707F8ADC72DD43BD3777566C1ECF49FEB73BC097" style="width: 775px; height: 1083px; vertical-align: middle; margin: 5px 150px 10px 100px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;All dispensed formulary and non-formulary weight loss medications covered by DHA were identified in PDTS through a drug name search for medications listed in Table 1; over-the-counter formulations were not analyzed. Both generic and trade names were searched, apart from Qsymia and Contrave, which were identified only by trade name to avoid capturing prescriptions for neurologic treatments. Quarterly prevalence was calculated as the number of service members with a dispensed weight loss medications during the quarter of interest per 100,000 service members in service at any point during the quarter.&lt;/p&gt;&lt;p&gt;Covariates included sex, age, service, race and ethnicity, rank, occupation, history of type 2 diabetes diagnosis, and body mass index. A case of diabetes was defined by a record of two or more inpatient or outpatient medical encounters within 90 days of each other, with a diagnosis of type 2 diabetes mellitus in the first (primary) diagnostic position (International Classification of Diseases, 9th Revision: beginning with ‘250’ and fifth digit ‘0’ or ‘2’; International Classification of Diseases, 10th Revision: E11). Cases with a prior diagnosis for type 1 diabetes (ICD-9: beginning with ‘250’ and fifth digit ‘1’ or ‘3’; ICD-10: E10*) listed in the primary diagnostic position were excluded as a case of type 2 diabetes, as the type could not be determined.&lt;/p&gt;&lt;p&gt;To calculate BMI, records of height and weight were obtained from annual electronic PHA documentation. The greatest weight measurement within the two years prior to the medication dispensation date was included to describe the maximum recorded BMI for service members dispensed a weight loss medication in the last quarter of the surveillance period. Weight records for women with a pregnancy or birth-related diagnosis (ICD-10 code beginning with ‘O’) in any diagnostic position in an inpatient or outpatient record within nine months before or after the date of their weight measurement, were excluded from the analysis. BMI was calculated in kg/m2 [(weight (lbs.) / (height {in})2) * 703].&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;p&gt;The number of monthly prescriptions of weight loss agents in the active component increased from seven prescriptions in January 2018 to 816 prescriptions in June 2023 (Figure 1). Phentermine constituted the largest number of prescriptions throughout the surveillance period, while semaglutide comprised a significant proportion following its FDA approval in June 2021. The vast majority of prescriptions (n=12,037, 99.9%) during the study period were dispensed with a supply of 90 days or less.&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-2-Figure-1.ashx?h=482&amp;w=1250&amp;hash=844A5A12869783D3C5CED95201E225A24373B183" style="width: 1250px; height: 482px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This graph presents a shaded area beneath a primary or topmost line oriented on the horizontal, or x-, axis that represents the cumulative prescription counts from 2018 to 2023 for weight loss medications in the military health system among the active component of the U.S. Armed Forces. The greater shaded area is further differentiated into 10 distinct colors, each of which represents a discrete weight loss medication. The 10 secondary lines that demarcate the color variations within the greater shaded area each connect 66 different data points oriented along the vertical, or y-, axis; these 66 data points on each line represent every month during the period of analysis, from January 2018 through June 2023. The greater shaded area indicates that weight loss prescription counts gradually increased, from a baseline of nearly zero in March 2018, for the first four years—with one small spike in March 2020—for the first four years, reaching approximately 175 in February 2022. A noticeable spike, to just over 250, subsequently occurred in March 2022, and with small monthly fluctuations that case count generally persisted for approximately eight months. Case counts then began gradually rising starting in October 2022, reaching 400 four months later, in February 2023. Case counts then jumped significantly each successive month: to approximately 580 in March 2023, 625 in April, 780 in May, and to a record high of approximately 830 in June 2023. The distinct color variations show that, by far, the most-prescribed medication was phentermine, but the proportion of semaglutide prescriptions increased in March 2022, and then increased again during every spike after November 2022. In June 2023 just over half of prescriptions were for phentermine, while approximately one-third were for semaglutide."&gt;&lt;/p&gt;&lt;p&gt;Initial analysis by agent revealed similar prevalence trends by demographic category (data not shown) and were collapsed to summarize findings as prevalence of all weight loss medications. The quarterly prevalence of ACSM who received any weight loss prescription (per 100,000 persons) increased from 1.2 in the first quarter (Q1) of 2018 to 104.4 in the second quarter (Q2) of 2023 (Figure 2). &lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-2-Figure-2.ashx?h=563&amp;w=1150&amp;hash=DF01B044C6086A80ECD5B85685EC0390C831B9FC" style="width: 1150px; height: 563px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="This graph shows one line, oriented along the horizontal, or x-, axis that represents weight loss prescription prevalence among the active component from 2018 to 2023. The horizontal line connects 22 discrete data points, each which denotes an annual calendar quarter. Rates of prescription prevalence per 100,000 individuals are labeled on the vertical, or y-, axis. Prescription prevalence was at 1.2 per 100,000 individuals in the first quarter of 2018 and gradually increased over the next three years—with one minor spike in the first quarter of 2020—to 19.6 in the second quarter of 2021. In the third quarter of 2021 the rate increased by nearly two and a half points (per 100,000 person-years), and more or less continued that trend for the following year. In the fourth quarter of 2022 the rate increased by nearly five points, to 42.4 (per 100,000 person-years), then jumped to 65.4 in the following quarter, and ended at a dramatically higher 104.4 (per 100,000 person-years) in the second quarter of 2023."&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2024/01/01/MSMR-Article-2-Table-2" title="Click on the table to access a 508-compliant PDF version"&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2024/January/Article-2-Table-2.ashx?h=1607&amp;w=400&amp;hash=55235C8523A457C216A55717E8F7657B8181AC87" style="width: 400px; height: 1607px; float: right; margin: 10px 0px 10px 20px;" alt="Click on the table to access a 508-compliant PDF version"&gt;&lt;/a&gt;Female service members received prescriptions for weight loss at a higher prevalence than their male counterparts during the surveillance period, with a ratio of 339.2 compared to 54.5 in Q2 of 2023 (Table 2). Prevalence ratios increased with increasing age; those in the 50 years and older category had a prevalence of 470.6 in Q2 of 2023. Stratification by age and sex clearly delineated higher prevalence among women in all age groups than men of the same age, with an increasing prevalence with increased age.&lt;/p&gt;&lt;p&gt;Prescription prevalence was consistently higher among Navy ACSM than among other services, at 157.1 in Q2 of 2023, 72% higher than those in the Army (91.3), 54.5% higher than those in the Air Force (101.7), and 363% higher than the Marine Corps (43.2). &lt;/p&gt;&lt;p&gt;After excluding those whose race or ethnicity was ‘Unknown,’ non-Hispanic Black ACSM had the highest prescription prevalence, at 147.3 in Q2 of 2023. By comparison, non-Hispanic White ACSM had a prevalence of 95.9, Hispanic ACSM 93.0, and the “Other” race and ethnicity ACSM category 86.4 per 100,000 in Q2 of 2023. Stratified analysis by race and ethnicity and age showed highest prevalence among non-Hispanic Black personnel in all age categories, with the exception of Hispanic personnel in the 25-39 age category.&lt;/p&gt;&lt;p&gt;Covariate analysis showed increasing prevalence of prescriptions. By rank, senior officers and senior enlisted ACSM had the highest prescription prevalence, reaching their highest rates in Q2 of 2023, 307 and 145.7 per 100,000, respectively. Comparing occupations, ACSM in a health care field had the greatest prescription prevalence over the study period, while those in pilot and air crew positions maintained lowest prevalence. Service members with a prior history of diabetes had significantly higher prescription prevalence, at 2,124.6 per 100,000 in Q2 of 2023.&lt;/p&gt;&lt;p&gt;Data (not shown) from Q2 of 2023 revealed that 62.1% of weight loss agents were prescribed to those with obesity (BMI≥30 kg/m&lt;sup&gt;2&lt;/sup&gt;), 16.9% of prescribed agents were for those with an overweight BMI (25-30 kg/m&lt;sup&gt;2&lt;/sup&gt;), and 2.1% of agents were prescribed to those with a BMI less than 25 kg/m&lt;sup&gt;2&lt;/sup&gt;; 18.9% of personnel on weight loss prescriptions did not have a calculable BMI from the corresponding PHA.&lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;The U.S. Preventive Service Task Force reports that lifestyle change programs are evidence-based and should remain the primary focus for weight loss in adults while data on long-term weight maintenance after discontinuation of weight loss agents are lacking.&lt;sup&gt;17&lt;/sup&gt; The current joint Department of Veterans Affairs and Department of Defense Clinical Practice Guidelines for weight loss medication administration require that patients start lifestyle modifications (i.e., physical training programs and reduced caloric intake) prior to initiating a weight loss medication. After 12 weeks of phentermine use, or in the presence of a contraindication to its use, a patient may be moved to a non-formulary weight loss agent.&lt;sup&gt;18&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;The results of this study demonstrate a substantial increase in the number of monthly prescriptions of weight loss agents among ACSM since initial approval in September 2017, with a four-fold increase in prescribing rates starting in 2022. Phentermine consistently constituted the largest number of prescriptions throughout the study period, which is similar to previous studies of weight loss medication use in civilian populations.&lt;sup&gt;19&lt;/sup&gt; The introduction of semaglutide following FDA approval in June 2021, however, resulted in increases in that agent’s prevalence, but its increase is not consistent with linear adoption patterns in the general U.S. population, and may be a result of the sequential process of obtaining semaglutide for weight loss in the military and inter-service variability in prescribing practices.&lt;sup&gt;20&lt;/sup&gt; Alternatively, such results may demonstrate secondary effects on prescribing practices and treatment of obesity as a chronic disease as obesity prevalence increases within the Armed Forces and service members and providers become more aware of treatment options involving these medications.&lt;/p&gt;&lt;p&gt;The demographic profile of weight loss prescription ratios corresponds to previous observations of demographic factors associated with obesity prevalence in the U.S. military.&lt;sup&gt;3&lt;/sup&gt; Non-Hispanic Black and older (40+) service members received weight loss prescriptions at higher rates than their counterparts, which is consistent with findings in the general U.S. population.&lt;sup&gt;19,21&lt;/sup&gt; Navy ACSM consistently maintained higher prescription prevalence compared to all other service branches, which correlated with the Navy’s higher rates of obesity compared to all other services.&lt;sup&gt;3&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;There were some differences between the previous surveillance of obesity and prevalence of weight loss prescriptions identified in this study. Women had higher prevalence of weight loss medications despite the higher prevalence of obesity among men in the military.&lt;sup&gt;3&lt;/sup&gt; Service members in health care fields had the highest prescription prevalence throughout the study period although obesity is more prevalent in repair/engineering occupations.&lt;sup&gt;3&lt;/sup&gt; These findings may indicate the influence of professional factors and health care knowledge on medication use, general comfort with the concept of using a medication for weight management, improved access to medications through system or institutional knowledge, or increased awareness of overweight or obese status among health care workers. The increased prevalence of dispensed weight loss medications among service members in health care occupations requires further study.&lt;/p&gt;&lt;p&gt;This analysis relied on electronic health records, which may have inherent biases and limitations, including missing or incomplete data and data entry inaccuracies. Data from PHAs may not truly reflect accurate height and weight data; many health care providers conducted PHAs during the COVID-19 pandemic via telehealth, resulting in self-reported data that more commonly results in weight underestimation. Additionally, BMI is an imperfect measure for distinguishing lean versus fat body mass. While the TRICARE health benefit is intended to be the primary health care coverage for all ACSM, there is the infrequent possibility a service member acquires weight loss medications outside the MHS, which would not appear in this analysis. Over-the-counter formulations of the covered weight loss medications were not considered in this analysis, resulting in estimates that may be lower than true prevalence. Additionally, this study focused on ACSM, limiting the generalizability of the findings to other military populations or civilian contexts.&lt;/p&gt;&lt;p&gt;In 2022 the U.S. Centers for Disease Control and Prevention estimated that increased obesity prevalence in military members costs a potential $1.5 billion annually in obesity-related health care and 658,000 lost work days.&lt;sup&gt;8&lt;/sup&gt; The trend in use of weight loss medication in the military should continue to be monitored, as these therapies represent a novel tool to manage obesity in this population. Future efforts should evaluate weight loss medications’ real world effectiveness, effects on health outcomes and comorbidities, safety for use in austere and deployed environments, impacts on readiness and retention, and cost-benefit and utility analyses.&lt;/p&gt;&lt;h2&gt;Author Affiliations&lt;/h2&gt;&lt;p&gt;Uniformed Services University of the Health Sciences: LT Lorei; Armed Forces Health Surveillance Division: Dr. Stahlman, Mr. Oh, CAPT Wells&lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The opinions and assertions expressed herein are those of the authors and do not reflect the official policy nor position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government.&lt;/p&gt;&lt;p&gt;References to non-Federal entities or products do not constitute nor imply a Department of Defense or Uniformed Services University of the Health Sciences endorsement. This work was prepared by a military or civilian employee of the U.S. Government as part of that individual’s official duties and therefore is in the public domain and does not possess copyright protection.&lt;/p&gt;&lt;p&gt;Public domain information may be freely distributed and copied; as a courtesy it is requested that the Uniformed Services University and the author be given an appropriate acknowledgment.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;World Health Organization. &lt;em&gt;Obesity: Preventing and Managing the Global Epidemic–Report of a WHO Consultation: WHO Technical Report Series 894&lt;/em&gt;. World Health Organization; 2000.&lt;/li&gt;    &lt;li&gt;National Center for Chronic Disease Prevention and Health Promotion. Adult Obesity Facts. U.S. Centers for Disease Control and Prevention. Updated May 17, 2022. Accessed Sep. 12, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/obesity/data/adult.html" target="_blank" title="Click on the link to access the CDC webpage on obesity"&gt;https://www.cdc.gov/obesity/data/adult.html&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Stiegmann RA, Payne CB, Kiel MA, Stahlman SL. Increased prevalence of overweight and obesity and incidence of prediabetes and type 2 diabetes during the COVID-19 pandemic, active component service members, U.S. Armed Forces, 2018 to 2021. &lt;em&gt;MSMR&lt;/em&gt;. 2023;30(01):11-18.&lt;/li&gt;    &lt;li&gt;Krauss MR, Garvin NU, Boivin MR, Cowan DN. Excess stress fractures, musculoskeletal injuries, and health care utilization among unfit and overweight female Army trainees. &lt;em&gt;Am J Sports Med&lt;/em&gt;. 2017;45(2):311-316. doi:10.1177/0363546516675862&lt;/li&gt;    &lt;li&gt;Cowan DN, Bedno SA, Urban N, Yi B, Niebuhr DW. Musculoskeletal injuries among overweight army trainees: incidence and health care utilization. &lt;em&gt;Occup Med (London)&lt;/em&gt;. 2011;61(4):247-252. doi:10.1093/occmed/kqr028&lt;/li&gt;    &lt;li&gt;Petry NM, Barry D, Pietrzak RH, Wagner JA. Overweight and obesity are associated with psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. &lt;em&gt;Psychosom Med&lt;/em&gt;. 2008;70(3):288-297. doi:10.1097/PSY.0b013e3181651651&lt;/li&gt;    &lt;li&gt;Rivenes AC, Harvey SB, Mykletun A. The relationship between abdominal fat, obesity, and common mental disorders: results from the HUNT study. &lt;em&gt;J Psychosom Res&lt;/em&gt;. 2009;66(4):269-275. doi:10.1016/j.jpsychores.2008.07.012&lt;/li&gt;    &lt;li&gt;National Center for Chronic Disease Prevention and Health Promotion. Fact Sheet. Unfit to Serve: Obesity and Physical Inactivity Are Impacting National Security. U.S. Centers for Disease Control and Prevention. Updated Jun. 20, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/physicalactivity/resources/unfit-to-serve/index.html" target="_blank" title="Click on the link to access the CDC center fact sheet on obesity"&gt;https://www.cdc.gov/physicalactivity/resources/unfit-to-serve/index.html&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;U.S. Defense Health Agency. Fact Sheet. MTF Formulary Management for Weight Loss Agents. Defense Health Agency. 2018. Accessed Jul. 3, 2023. &lt;a href="/Reference-Center/Fact-Sheets/2018/02/26/Formulary-Management-for-Weight-Loss-Agents" title="Opens Formulary Management for Weight Loss Agents Fact Sheet"&gt;https://www.health.mil/Reference-Center/Fact-Sheets/2018/02/26/Formulary-Management-for-Weight-Loss-Agents&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Rubino DM, Greenway FL, Khalid U, et al. Effect of weekly subcutaneous semaglutide vs daily liraglutide on body weight in adults with overweight or obesity without diabetes: the STEP 8 randomized clinical trial. &lt;em&gt;JAMA&lt;/em&gt;. 2022;3272):138-150. doi:10.1001/jama.2021.23619&lt;/li&gt;    &lt;li&gt;Singh G, Krauthamer M, Bjalme-Evans M. Wegovy (semaglutide): a new weight loss drug for chronic weight management. &lt;em&gt;J Investig Med&lt;/em&gt;. 2022;70(1):5-13. doi:10.1136/jim-2021-001952&lt;/li&gt;    &lt;li&gt;Cohen JB, Gadde KM. Weight loss medications in the treatment of obesity and hypertension. &lt;em&gt;Curr Hypertens Rep&lt;/em&gt;. 2019;21(2):16. doi:10.1007/s11906-019-0915-1&lt;/li&gt;    &lt;li&gt;Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity. &lt;em&gt;NEJM&lt;/em&gt;. 2021;384(11):989-1002. doi:10.1056/NEJMoa2032183&lt;/li&gt;    &lt;li&gt;U.S. Food and Drug Administration. Press Release. FDA Approves New Drug Treatment for Chronic Weight Management, First Since 2014. Food and Drug Adminstration. Jun. 4, 2021. Accessed Jul. 3, 2023. &lt;a rel="noopener noreferrer" href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014" target="_blank" title="Click on the link to access the FDA's press release for new weight loss drug approvals"&gt;https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Mayer SB, Graybill S, Raffa SD, et al. Synopsis of the 2020 US VA/DoD clinical practice guideline for the management of adult overweight and obesity. &lt;em&gt;Mil Med&lt;/em&gt;. 2021;186(9-10):884-896. doi:10.1093/milmed/usab114&lt;/li&gt;    &lt;li&gt;Nadolsky KZ. Rationale for utilization of obesity pharmacotherapy in the active duty population. &lt;em&gt;Mil Med&lt;/em&gt;. 2018;183(3-4):45-50. doi:10.1093/milmed/usx074&lt;/li&gt;    &lt;li&gt;U.S. Preventive Services Task Force. Recommendation Statement: Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions. Updated Sep. 18, 2018. Accessed Jul. 18, 2023. &lt;a rel="noopener noreferrer" href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/obesity-in-adults-interventions" target="_blank" title="Click on the link to access the task force's recommendations on weight loss"&gt;https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/obesity-in-adults-interventions&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;The Management of Adult Overweight and Obesity Work Group, U.S. Department of Veterans Affairs. &lt;em&gt;VA/DOD Clinical Practice Guideline for the Management of Adult Overweight and Obesity&lt;/em&gt;. Department of Veterans Affairs, Department of Defense; 2020. &lt;a rel="noopener noreferrer" href="https://www.healthquality.va.gov/guidelines/CD/obesity/VADoDObesityCPGFinal5087242020.pdf" target="_blank" title="Click on the link to access the Veterans Administration and Department of Defense joint clinical practice guideline on obesity"&gt;https://www.healthquality.va.gov/guidelines/CD/obesity/VADoDObesityCPGFinal5087242020.pdf&lt;/a&gt; &lt;/li&gt;    &lt;li&gt;Saxon DR, Iwamoto SJ, Mettenbrink CJ, et al. Antiobesity medication use in 2.2 million adults across eight large health care organizations: 2009-2015. &lt;em&gt;Obesity (Silver Spring)&lt;/em&gt;. 2019;27(12):1975-1981. doi:10.1002/oby.22581&lt;/li&gt;    &lt;li&gt;Thomas CE, Mauer EA, Shukla AP, Rathi S, Aronne LJ. Low adoption of weight loss medications: a comparison of prescribing patterns of antiobesity pharmacotherapies and SGLT2s. &lt;em&gt;Obesity (Silver Spring)&lt;/em&gt;. 2016;24(9):1955-1961. doi:10.1002/oby.21533&lt;/li&gt;    &lt;li&gt;Zhang S, Manne S, Lin J, Yang J. Characteristics of patients potentially eligible for pharmacotherapy for weight loss in primary care practice in the United States. &lt;em&gt;Obes Sci Prac&lt;/em&gt;. 2016;2(2):104-114. doi:10.1002/osp4.46&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Mon, 01 Jan 2024 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{2396A792-21A2-4177-A236-4523907BE267}</guid><link>https://www.health.mil/News/Articles/2023/12/14/The-Korean-War-Battle-of-Chosin-How-Military-Medics-Saved-the-Chosin-Frozen</link><title>The Korean War Battle of Chosin, How Military Medics Saved the ‘Chosin Frozen’  </title><description>&lt;p&gt;Survivors of the Korean War’s Chosin Reservoir campaign near the Manchurian border are now mostly in their 90s but will never forget the brutal battle 73 years ago that lasted 17 days and ended on Dec. 13, 1950. It cost many of them fingers and toes and still impacts their health today.&lt;/p&gt;&lt;p&gt;In an &lt;a href="/News/Gallery/Dvids-Videos/2023/12/19/video908550" target="_self" title="watch the video"&gt;interview recounting the battle&lt;/a&gt;, retired U.S. Marine Corps Gen. Raymond Davis said, “The snow came. The temperature dropped to 40 below zero ... faces covered with ice, food frozen, water frozen.”&lt;/p&gt;&lt;p&gt;The U.S. Marines and U.S. Army fought in sub-zero conditions—hovering in the minus 30’s—and often in hand-to-hand combat. Survivors call themselves the “Chosin Frozen,” and Marines who fought there are known as the “Chosin Few.”&lt;/p&gt;&lt;p&gt;Nearly 2,500 in the U.S. forces died—some froze to death—the wounded tallied 5,000, and, tellingly, 8,000 suffered frostbite. Experts say everyone suffered a cold injury to some degree. Many also suffered from shock, hunger, and dehydration.&lt;/p&gt;&lt;figure style="width: 270px; font-size: 12px; margin-left: 10px; float: right;"&gt;&lt;img src="/-/media/Images/MHS/Article-Images/KoreanWarFrozinsecondary.ashx?h=181&amp;w=270&amp;hash=46CBD0D967CDAE6481B4CE27D351BB8066AF343B" style="height: 181px; width: 270px; float: right;" alt="frostbite casualties of the embattled 1st Marine Division and 7th Infantry Division during the Chosin Reservoir campaign near the Manchurian border "&gt;These frostbite casualties of the embattled 1st Marine Division and 7th Infantry Division wait Dec. 15, 1950, with set expressions on their faces for pick up by planes of the U.S. Air Force during the Chosin Reservoir campaign near the Manchurian border for quick transport to Japan for healthcare. (Photo from the National Archives and Records Administration)&lt;/figure&gt;&lt;p&gt;The battle began after 120,000 Chinese communist forces poured into North Korea and, in terrifying nighttime attacks, encircled 30,000 allied soldiers and Marines, whom they outnumbered four-to-one.&lt;/p&gt;&lt;h2&gt;U.S. Marine Gunnery Sergeant at Chosin &lt;/h2&gt;&lt;p&gt;Chosin veteran &lt;a rel="noopener noreferrer" href="https://www.loc.gov/item/afc2001001.66119/" target="_blank" title="opens Library of Congress article"&gt;Billy Gene Devasher&lt;/a&gt; was with the 7th Marines Regiment, 1st Marines Division from Inchon up to near the Yalu River. “The plan was to get to the Yalu River, get on a ship and go home” for Christmas, he said. His unit advanced to five miles south of the Yalu when winter came early, and the temperatures plummeted.&lt;/p&gt;&lt;p&gt;They were cut off for five days and six nights when surprised by the Chinese attack, enduring temperatures that reached “minus 50.”&lt;/p&gt;&lt;p&gt;“We went from 236 down to 30 men who were not frozen or wounded,” Devasher recalled. Their guns froze, they couldn’t dig foxholes because the ground was “solid ice,” and they were surrounded by thousands of Chinese “firing on us all the time.” When the U.S Navy Corsairs dropped napalm and bombs on the enemy, “we stacked them up like cordwood for protection.”&lt;/p&gt;&lt;h2&gt;Nurses Recall Events at Chosin and Beyond &lt;/h2&gt;&lt;p&gt;Transport to Mobile Army Surgical Hospitals, or MASH units, saved many at Chosin. Allied forces used air transport to quickly send the wounded to a MASH unit by helicopter, or by Jeep or truck, and then transported them via plane to nearby Japan to the Osaka Army Hospital.&lt;/p&gt;&lt;p&gt;“The stretchers were brought in, we put them on [saw] horses; we didn't have operating room tables,” said U.S. Army nurse &lt;a rel="noopener noreferrer" href="https://www.loc.gov/item/afc2001001.41229/" target="_blank" title="opens Library of Congress article"&gt;Regina Schiffman&lt;/a&gt;, recounting her experience as part of the Library of Congress Veterans History project. Schiffman served with the 8063rd MASH.&lt;/p&gt;&lt;p&gt;“We’d work [in the operating room for 16 or 18 hours] until you were ready to flop, really, and then somebody else would take over and work until there were ready to flop,” she said.&lt;/p&gt;&lt;p&gt;The winter conditions were harsh. “Our enlisted personnel were really great, and they devised an actual scrub sink,” Schiffman said. “They had a big tank outside where they heated water and we could actually scrub with not ice-cold water for surgery.”&lt;/p&gt;&lt;p&gt;“On the first plane that was loaded, there were so many casualties—young kids,” said U.S. Air Force 1st Lt. &lt;a rel="noopener noreferrer" href="https://www.loc.gov/item/afc2001001.32449/" target="_blank" title="opens Library of Congress article"&gt;Mary (Weiss) Hester&lt;/a&gt;, a flight nurse who flew 760 hours between Japan and Korea with the1st Medical Air Evacuation Squadron.&lt;/p&gt;&lt;p&gt;On that day, “the captain I was with came up behind the pilots and said, ‘You aren’t here to cry, you’re here to work.’ So, I was trained very quickly.”&lt;/p&gt;&lt;p&gt;"You didn't have time really to think about what had happened. It was really about what you could do to help them," said &lt;a rel="noopener noreferrer" href="https://www.loc.gov/item/afc2001001.04693/" target="_blank" title="opens Library of Congress article"&gt;Rose Gibbs&lt;/a&gt;, a U.S. Army enlisted service member and telephone operator at Osaka Army Hospital who finished her service in 1956 as a sergeant first class.&lt;/p&gt;&lt;p&gt;She also helped care for patients, recalling the hospital hallways filled with the wounded and dying.&lt;/p&gt;&lt;h2&gt;Frostbite and New Treatments&lt;/h2&gt;&lt;p&gt;It wasn’t just the frigid temperatures and harsh winds from Siberia that caused frostbite at Chosin. It was the lack of adequate winter boots and absence of winter gloves; banned campfires; frozen C-rations and canteens, and, most often, long exposure to the frozen ground as troops were pinned in open spaces or in shallow foxholes by the withering barrage from Chinese guns and grenades. If evacuated, they could spend hours immobile in transports carrying the wounded out of Chosin or be shot from the roadside.&lt;/p&gt;&lt;p&gt;The Feb. 5, 1951, issue of Life magazine highlighted new treatments that saved the limbs of the Chosin Frozen. &lt;/p&gt;&lt;p&gt;At field stations, medical personnel treated frostbite by injecting the local anesthetic procaine into the affected limbs to deaden the pain. The wounded also got shots of the blood thinner heparin to slow down the clotting of blood if they didn’t have other injuries, the article says.&lt;/p&gt;&lt;p&gt;Once stabilized, frostbitten service members were transported to the Osaka Army Hospital, where they were treated intravenously with procaine in sugar water and with heparin shots. The more seriously frostbitten were treated for three to four weeks, Life said, and were then flown to the U.S. Army’s Percy Jones General Hospital in Battle Creek, Michigan, to complete their recovery.&lt;/p&gt;&lt;p&gt;Records show that by March 1951, Percy Jones had a patient population of around 1,000, with a large portion of them frostbite cases from Korea. “Ninety percent of Korea cases are feet. Nine percent are hands. Others are ears, noses,” Life said.&lt;/p&gt;&lt;p&gt;The article graphically describes the deteriorating stages and symptoms of frostbite.&lt;/p&gt;&lt;p&gt;The first stage is frozen limbs. The second stage happens when the flesh is thawed out and the limbs swell and expand enormously. Blisters mark the third stage as fluid seeps out from blood vessels, and there is danger of infection. Gangrene is the final stage of frostbite where fingers and feet wither and turn black. Sometimes, even bones and tendons froze.&lt;/p&gt;&lt;p&gt;At Percy-Jones, “the main objective of the doctors ... is to save the black and gangrenous limbs of their patients from the amputations that would have been almost automatic during World War II,” Life said. “In the great majority of cases, they have been successful.”&lt;/p&gt;&lt;p&gt;“They concentrate on maintaining circulation in the damaged part with drugs which speed the flow of blood. In most cases, new flesh grows again, and dead flesh peels away. Where whole hands would once have been amputated, fingertips are now removed. Men whose entire feet were black and mummified have walked out of Percy Jones without a limp.”&lt;/p&gt;&lt;p&gt;The article includes the story of Chosin’s U.S. Army Pvt. John Baldwin, who had severe frostbite on his hands and feet and suffered a gunshot wound in his leg. Lying in his hospital bed with blackened fingers and toes, he told Life magazine: “It took them 30 minutes to get my boots off. They were froze[n] stuck to my feet.”&lt;/p&gt;&lt;h2&gt;Cold Injuries&lt;/h2&gt;&lt;p&gt;Chosin survivors continued to cope with their injuries. According to the Department of Veterans Affairs, &lt;a rel="noopener noreferrer" href="https://www.publichealth.va.gov/exposures/cold-injuries/index.asp" target="_blank" title="opens VA.gov"&gt;cold injuries&lt;/a&gt; can lead to long-term health problems, including:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;    Changes in muscle, skin, nails, ligaments, and bones&lt;/li&gt;    &lt;li&gt;    Skin cancer in frostbite scars&lt;/li&gt;    &lt;li&gt;    Neurologic injury with symptoms such as bouts of pain in the extremities, hot or cold tingling sensations, and numbness&lt;/li&gt;    &lt;li&gt;    Vascular injury ... with symptoms such as extremities becoming painful and white or discolored when cold&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;By the bitter end of the battle on Dec. 13, the Marines, soldiers, and United Nations forces had broken free from the growing number of encircling Chinese forces, fighting their way to the port of Hungnam, where they evacuated along with more than 91,000 Korean refugees.&lt;/p&gt;&lt;p&gt;It was the largest sea evacuation by the U.S. in its military history, involving some 105,000 military personnel.&lt;/p&gt;&lt;p&gt;U.S. Marine and U.S. Air Force transports airlifted out another 3,600 troops, according to an &lt;a rel="noopener noreferrer" href="https://www.history.navy.mil/research/library/online-reading-room/title-list-alphabetically/h/the-hungnam-and-chinnampo-evacuations.html" target="_blank" title="opens Navy.mil article"&gt;article&lt;/a&gt; published with permission by the &lt;a rel="noopener noreferrer" href="https://www.history.navy.mil/" target="_blank" title="opens Navy.mil"&gt;Naval History and Heritage Command&lt;/a&gt;.&lt;/p&gt;&lt;p&gt;Once recovered, many men were sent back to the front to fight in what has been called “The Forgotten War.” Chosin survivors will never forget.&lt;/p&gt;</description><pubDate>Thu, 14 Dec 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{DE899A3B-3493-4787-9745-99D7970B520E}</guid><link>https://www.health.mil/News/Articles/2023/12/01/In-Memoriam</link><title>In Memoriam: Valerie Williams</title><description>&lt;p&gt;It is with great sadness that the &lt;em&gt;Medical Surveillance Monthly Report &lt;/em&gt;shares the news of the recent death of our colleague, Valerie Williams. Ms. Williams, a senior scientist employed by General Dynamics Information Technology, had served as a writer and editor for the &lt;em&gt;MSMR&lt;/em&gt; since February 2016. Valerie Williams was an exemplary scientist and committed editor who made important contributions to the journal during her tenure.   &lt;/p&gt;&lt;p&gt;Ms. Williams had an astoundingly broad skill set that made her critical to the &lt;em&gt;MSMR&lt;/em&gt;’s production over the last seven years. She co-authored over 40 original &lt;em&gt;MSMR&lt;/em&gt; manuscripts encompassing a broad range of surveillance topics related to the health of military service members. She was also expert in patiently and diligently shepherding external &lt;em&gt;MSMR&lt;/em&gt; submissions through the publication process. She invariably strengthened these external manuscripts through her exceptional editorial acumen and commitment to scientific excellence. She took as much care with the minutiae of table footnote punctuation during final copy edits as she did in rigorously scrutinizing the methods and analysis of initial manuscript submissions.   &lt;/p&gt;&lt;p&gt;She was always willing to step in where needed. She served “double duty” as production editor when the position was vacant, and this remarkable commitment to ensuring continuous production, no matter what it required of her, meant that she was an indispensable resource for every member of the editorial staff. Despite the incumbent challenges in producing a monthly peer-reviewed journal, she faced these challenges with humor and positivity while demonstrating an unwavering focus and commitment to ensuring the scientific accuracy and editorial excellence of the &lt;em&gt;MSMR&lt;/em&gt;.   &lt;/p&gt;&lt;p&gt;Ms. Williams’s dedication to the &lt;em&gt;MSMR&lt;/em&gt; and her colleagues never flagged. Her final project for the &lt;em&gt;MSMR&lt;/em&gt;, in addition to her normal editorial duties, was to lead the preparation of &lt;em&gt;MSMR&lt;/em&gt;’s technical application to the NIH’s National Library of Medicine for full indexing of this journal on PubMed Central. This process involved the creation of numerous sample files according to extremely precise criteria, requiring meticulousness, diligence, and patience.   &lt;/p&gt;&lt;p&gt;Prior to joining the &lt;em&gt;MSMR&lt;/em&gt; staff, Ms. Williams had a productive research career at the Truth Initiative in Washington, DC; the University of Massachusetts Medical School; and the Battelle Centers for Public Health Research and Evaluation, among others. Her work and publication record at these institutions focused primarily on tobacco control, mental health, and juvenile justice. She held master’s degrees in epidemiology and biological anthropology from the University of Illinois, Urbana-Champaign and a bachelor’s degree in anthropology and environmental science from the University of Virginia.&lt;/p&gt;&lt;p&gt;In addition to being an exemplary scientist, committed editor, and dependable colleague, Valerie Williams was highly esteemed as an individual. Perhaps her most outstanding quality was her compassion and concern for others, which manifested in her unwavering willingness to aid her colleagues in whatever way she could. Her conscientiousness was unequaled. She was also a person of great wit, insight, and humor who will be greatly missed by her AFHSD colleagues. We were enriched by her presence. Our deepest sympathies go to her family.&lt;/p&gt;</description><pubDate>Fri, 01 Dec 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{6DB64758-3094-48A7-9D86-BA34EE9245C3}</guid><link>https://www.health.mil/News/Articles/2023/12/01/MSMR-Chikungunya</link><title>Surveillance Snapshot: Chikungunya in Service Members of the U.S. Armed Forces, 2016–2022</title><description>&lt;p&gt;Chikungunya is a viral disease spread by the bite of an infected mosquito,&lt;sup&gt;1&lt;/sup&gt; characterized by severe joint pain and myalgia that can last for weeks or months.&lt;sup&gt;2&lt;/sup&gt; Prior to 2013, cases and outbreaks of Chikungunya were identified in Africa, Asia, and Europe; in late 2013, however, the first local transmission in the Americas was identified in the Caribbean.&lt;sup&gt;1&lt;/sup&gt; Chikungunya became a nationally-notifiable disease in the United States in 2015 following a substantial increase in locally-acquired infections reported in U.S. territories.&lt;sup&gt;3&lt;/sup&gt;     &lt;/p&gt;&lt;p&gt;The U.S. Food and Drug Administration announced its approval of a live attenuated virus vaccine on November 9, 2023, which may eventually be recommended to U.S. travelers.&lt;sup&gt;4&lt;/sup&gt; This could become relevant for U.S. military service members at potential risk for Chikungunya virus infection during deployments to endemic locations, particularly during outbreaks among local populations.     &lt;/p&gt;&lt;p&gt;Prior &lt;em&gt;MSMR&lt;/em&gt; reports describe cases of Chikungunya occurring among U.S. military service members and other beneficiaries between 2010 and 2020.&lt;sup&gt;5,6&lt;/sup&gt; This Surveillance Snapshot updates these results through the end of 2022, using confirmed and probable medical event reports of Chikungunya cases from the U.S. military’s Disease Reporting System internet, which were confirmed via medical chart review.   &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/12/01/MSMR-Article-3-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img alt="" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-3-Table.ashx?h=328&amp;w=1150&amp;hash=D02B31A9B9636D28E7866531152F5283FC58D683" style="width: 1150px; height: 328px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Eight cases of Chikungunya virus disease among service members were documented between 2016 and 2022 (Table). Five cases were recorded in the Army, and three in the Navy. One case was acquired while on deployment to Djibouti; no other cases were deployment-related. Two cases were acquired via unofficial travel to Mexico. One case each was attributed to unofficial travel to Colombia, Brazil, Bangladesh, and the Philippines. Another case was diagnosed during deployment to South Korea, but the DRSi record indicated that the patient had previously lived in Puerto Rico, with no other pertinent travel history.     &lt;/p&gt;&lt;p&gt;Only one case was hospitalized; this case was acquired in Brazil by a 35-year-old male with a medical history of Bell’s palsy. Five cases reported fever and myalgia, which were the most commonly documented symptoms. Other reported symptoms included nausea, vomiting, fatigue, and rash. One case involving a 30-year-old male who acquired the infection in Colombia evidenced long-term symptoms (i.e., lasting longer than 12 weeks) manifesting as bilateral wrist and ankle pain worsened by movement.      &lt;/p&gt;&lt;p&gt;The small number of cases, hospitalizations, and evidence of long-term symptoms reported in the past seven years suggest that risk of Chikungunya virus disease to U.S. service member readiness is small. Prior reports have, however, indicated that cases among U.S. service members increase during periods of outbreak among local populations.&lt;sup&gt;6&lt;/sup&gt; Therefore, service members deployed to endemic locations are encouraged to use standard preventive measures including use of personal protective equipment. Policy development may also benefit from this information as the FDA-approved vaccine becomes more widely available. &lt;/p&gt;&lt;h2&gt;Authors' Affiliation&lt;/h2&gt;&lt;p&gt;Defense Health Agency, Armed Forces Health Surveillance Division, Epidemiology and Analysis Section&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Centers for Disease Control and Prevention. Chikungunya Virus. Accessed Nov. 1, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/chikungunya/index.html" target="_blank" title="Click on the link to access the CDC chikungunya web page."&gt;https://www.cdc.gov/chikungunya/index.html&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;de Lima Cavalcanti TYV, Pereira MR, de Paula SO, Franca RFO. A review on Chikungunya virus epidemiology, pathogenesis and current vaccine development. &lt;em&gt;Viruses&lt;/em&gt;. 2022;14(5):969. doi:10.3390/v14050969&lt;/li&gt;    &lt;li&gt;Mourad O, Makhani L, Chen LH. Chikungunya: an emerging public health concern. &lt;em&gt;Curr Infect Dis Rep&lt;/em&gt;. 2022;24(12):217-228. doi:10.1007/s11908-022-00789-y&lt;/li&gt;    &lt;li&gt;U.S. Food and Drug Administration. FDA News Release: FDA Approves First Vaccine to Prevent Disease Caused by Chikungunya Virus. Nov. 9, 2023. Accessed Dec. 8, 2023. &lt;a rel="noopener noreferrer" href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-vaccine-prevent-disease-caused-chikungunya-virus" target="_blank" title="Click on the link to access the US FDA press release on the virus approval."&gt;https://www.fda.gov/news-events/press-announcements/fda-approves-first-vaccine-prevent-disease-caused-chikungunya-virus&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;O'Donnell FL, Fan M, Stahlman S. Surveillance for vector-borne diseases among active and reserve component service members, U.S. Armed Forces, 2016-2020. &lt;em&gt;MSMR&lt;/em&gt;. 2021;28(2):11-15.&lt;/li&gt;    &lt;li&gt;O'Donnell FL, Stahlman S, Fan M. Surveillance for vector-borne diseases among active and reserve component service members, U.S. Armed Forces, 2010-2016. &lt;em&gt;MSMR&lt;/em&gt;. 2018;25(2):8-15.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Dec 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{22D1672E-508B-4D45-82D8-C5840E081D37}</guid><link>https://www.health.mil/News/Articles/2023/12/01/MSMR-Lupus</link><title>Trends and Disparities in Systemic Lupus Erythematosus Incidence Among U.S. Active Component Service Members, 2000–2022</title><description>&lt;p&gt;Inpatient and outpatient encounter data retrieved from the Defense Medical Surveillance System were used to establish that there were 1,127 diagnoses of systemic lupus erythematosus among active component U.S. service members from 2000 to 2022, with an overall incidence rate of 3.5 cases per 100,000 person-years. Annual incidence remained relatively constant over the 23-year surveillance period, peaking in 2009. Female ACSM accounted for 69.5% of incident cases, with a rate of incidence 12.3 times greater than males, while non-Hispanic Black ACSM accounted for 50.0% of incident cases, with a rate 6.7 times greater than among non-Hispanic Whites. This study further demonstrates greatest SLE incidence among non-Hispanic Black women, in all age groups.&lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;SLE incidence among ACSM remained relatively stable from 2000 to 2022. Incidence was notably highest among non-Hispanic Black women in all age groups.&lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;SLE imposes a substantial burden upon afflicted individuals. Diagnosed ACSM may experience declines in mental and physical acuity that are required for mission execution. Evaluating SLE incidence helps identify factors that contribute to its trends, for early diagnosis and management.&lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;The most common type of lupus is systemic lupus erythematosus, a chronic autoimmune disease that is often difficult to diagnose due to its complex clinical presentations.&lt;sup&gt;1,2&lt;/sup&gt; This disease imposes a substantial burden for those who develop a myriad of symptoms ranging from fatigue to organ damage.&lt;sup&gt;2&lt;/sup&gt; The literature on representative, population-based, national U.S. studies of SLE incidence is limited, but existing research demonstrates an upward trend in incidence within the U.S. and reveals disparities between sexes as well as racial and ethnic groups.&lt;sup&gt;1,3,4,5&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;The U.S. Lupus Midwest Network (LUMEN) has demonstrated several patterns in SLE, including increased prevalence, from 30.6 cases per 100,000 persons in 1985 to 97.4 in 2015, and a 2% increase in incidence each year, starting at 3.32 cases per 100,000 persons from 1976 to 1988 and ending at 6.44 from 2009 to 2018.&lt;sup&gt;1&lt;/sup&gt; The nation’s increasing racial and ethnic diversity, along with improved early detection of the disease, may contribute to this trend.&lt;sup&gt;1,6&lt;/sup&gt; LUMEN and other population-based studies have shown incidence rates three to seven times higher among women than men.&lt;sup&gt;3,4,7&lt;/sup&gt; Incidence rates were higher among non-Hispanic Black individuals of both sexes than among other groups.&lt;sup&gt;3,5&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;Compared to civilians, active component service members may have an increased risk of SLE due to greater exposure to environmental risk factors, such as silica dust and ultraviolet radiation, and higher rates of post-traumatic stress disorder, which have been linked to SLE.&lt;sup&gt;7,8,9,10&lt;/sup&gt; This study reports on annual incidence and sociodemographic disparities from 2000 to 2022 for ACSM in the U.S. Armed Forces diagnosed with SLE.&lt;/p&gt;&lt;h2&gt;Methods &lt;/h2&gt;&lt;p&gt;This study includes ACSM from January 1, 2000 through December 31, 2022, using data from the Defense Medical Surveillance System. Demographic variables of interest were sex, age, race and ethnicity, service, and rank. Diagnoses were ascertained from inpatient as well as outpatient encounter data of individuals who received medical care in the Military Health System or civilian facilities in the &lt;span tabindex="0" class="TooltipLink"&gt;&lt;span class="TooltipContent"&gt;&lt;a href="javascript:void(0);"&gt;&lt;span class="visiblyHidden"&gt;Click to close&lt;/span&gt;&lt;span class="cancelButton"&gt;&lt;/span&gt;&lt;/a&gt;&lt;span class="DefinitionTerm"&gt;Purchased Care&lt;/span&gt;The TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.&lt;/span&gt;purchased care&lt;/span&gt; system. &lt;/p&gt;&lt;p&gt;SLE diagnosis was identified by International Classification of Diseases, 9th Revision code 710.0, or International Classification of Diseases, 10th Revision codes with all extenders under M32.&lt;sup&gt;11&lt;/sup&gt; An incident case was defined as one inpatient encounter with a qualifying code in the first or second diagnostic position, or the first of two outpatient encounters within 365 days at a rheumatology clinic (defined by Medical Expense and Performance Reporting code equal to “BAO”) with a qualifying code in any diagnostic position.&lt;sup&gt;11&lt;/sup&gt; The first encounter meeting the case definition with a qualifying code was considered the incident encounter. ACSM were counted only once during the surveillance period. &lt;/p&gt;&lt;p&gt;Incidence rates were calculated as SLE diagnoses per 100,000 person-years (p-years) using the mid-year population for each year of the surveillance period. Rates were stratified by age, sex, and race and ethnicity. Incidence rate ratios comparing non-Hispanic Blacks to non-Hispanic Whites, Hispanics, and other/unknown races and ethnicities were determined for each age group, stratified by sex.&lt;/p&gt;&lt;h2&gt;Results &lt;/h2&gt;&lt;p&gt;From 2000 to 2022, 1,127 ACSM were diagnosed with SLE. The number of incident cases was highest among ACSM aged 40 years or older, women, and non-Hispanic Black individuals (Table 1).&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/12/01/MSMR-Article-1-Table-1" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img alt="" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-1-Table-1.ashx?h=1015&amp;w=800&amp;hash=CACEB515DD2A43E4911386FF231343DDD9B17522" style="width: 800px; height: 1015px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;There were 545 (48.4%) ACSM incident SLE hospitalizations, with an average hospitalization of 4.7 days (standard deviation: 6.7, range: 0-60) (data not shown). Annual incidence for ACSM remained stable, ranging from 50 incident cases in 2000 to 44 in 2022 (data not shown). There was a slight increase in 2009, to 66 cases (data not shown). &lt;/p&gt;&lt;p&gt;The overall incidence rate of SLE among ACSM from 2000 to 2022 was 3.5 per 100,000 p-years (Table 1). Service members aged 40 years and older had the highest rate of SLE compared to other age categories, with 6.0 cases per 100,000 p-years (Table 1). Non-Hispanic Black and female ACSM also had the highest incidence rates for their respective demographics, at 10.7 and 16.0 per 100,000 p-years, respectively (Table 1). Crude annual incidence rates among both sexes remained relatively constant throughout the surveillance period (Figure). Women started at 19.0 cases per 100,000 p-years in 2000 and ended at 12.9 in 2022, while men started at 1.0 case per 100,000 p-years in 2000 and ended at 1.3 in 2022 (Figure). Incidence rates for both sexes spiked during 2009, with women experiencing 20.9 cases per 100,000 p-years, while men experienced 1.9 cases per 100,000 p-years (Figure). &lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-1-Figure.ashx?h=499&amp;w=1150&amp;hash=EDE79375F16364EBC95DC1CA3D1F6CFE0CCEDD4F" style="width: 1150px; height: 499px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This graph comprises three lines oriented on the horizontal, or x-, axis, each connecting 23 discrete data points oriented along the vertical, or y-, axis. These three horizontal lines represent incidence rates of systemic lupus erythematosus (SLE) among females, males, and both sexes within the active component of the U.S. military. The x axis is divided into 23 marks representing each year between 2000 to 2022, The y-axis charts the annual incidence rates, per 100,000 person-years, or p-yrs. The incidence rates for female service members are consistently around 3 times higher than those of the overall population of the armed forces; female rates are generally between 15.0 and 20.0 per 100,000 p-yrs. Incidence rates of SLE among women in the military peaked in 2009, at just over 20.0, and declined steadily for three years, reaching their next-lowest level, at just under 15.0, in 2012. After a moderate spike in 2019, rates among women subsequently declined overall and reached their lowest level, just under 15.0 again, in 2022. Rates among males and the overall military population are markedly consistent, with overall incidence rates just under 5.0 per 100,000 p-yrs and rates for men lower, at around 1.0 per 100,000 p-yrs."&gt;&lt;/p&gt;&lt;p&gt;Incidence rates overall were highest among non-Hispanic Black ACSM and those of other/unknown race and ethnicity (Table 1). Non-Hispanic Black service members started at 10.1 cases per 100,000 p-years in 2000 and ended at 6.7 in 2022 (data not shown). Service members of other/unknown race and ethnicity started at 12.2 cases per 100,000 p-years in 2000, dropping to a low of 4.4 cases per 100,000 p-years in 2018, before increasing to 10.5 cases per 100,000 p-years in 2022 (data not shown). Meanwhile, non-Hispanic White service members began at 1.8 cases per 100,000 p-years in 2000 and ended at 2.4 in 2022, and Hispanic service members started at 2.5 cases per 100,000 p-years in 2000 and ended at 2.5 in 2022 (data not shown). &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/12/01/MSMR-Article-1-Table-2" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img alt="" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-1-Table-2.ashx?h=689&amp;w=1200&amp;hash=44D5E7D972B8BF8D8C6E3D91F1A0B452883884E7" style="width: 1200px; height: 689px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;SLE incidence rates increased from 19.9 to 54.1 cases per 100,000 p-years for non-Hispanic Black women, compared to 2.9 to 16.8 for non-Hispanic White women with increasing age group (Table 2). Among all age groups and sexes, non-Hispanic Black ACSM had higher incidence rates of SLE compared to both their non-Hispanic White and Hispanic counterparts (Table 2). Incidence rate ratios comparing non-Hispanic Black to non-Hispanic White ACSM ranged from 2.8 to 7.9, while ratios comparing non-Hispanic Black to Hispanic ACSM ranged from 1.6 to 3.7, and ratios comparing non-Hispanic Black to the other/unknown racial and ethnic group ranged from 1.0 to 6.3 (Table 2).&lt;/p&gt;&lt;h2&gt;Discussion &lt;/h2&gt;&lt;p&gt;Overall, this study shows consistent SLE incidence rates among ACSM between 2000 and 2022, with the highest incidence among non-Hispanic Blacks and women. Existing research agrees with this disparity; other studies have shown significantly higher SLE incidence among non-Hispanic Black women.&lt;sup&gt;1,2,4,12,13&lt;/sup&gt; There is evidence suggesting those of African lineage are more likely than other races and ethnicities to possess a gene variant that increases SLE risk.&lt;sup&gt;14,15&lt;/sup&gt; There were more than twice as many incident cases among women (n=783) than men (n=344), and the overall incidence rate was 12.3 times higher among women. This trend was seen in rates for all ages as well as races and ethnicities, consistent with published statistics demonstrating that women are significantly more likely than men to develop SLE, perhaps due to differences in androgen levels and metabolism.&lt;sup&gt;4,12,13,16 &lt;/sup&gt;&lt;/p&gt;&lt;p&gt;&lt;sup&gt;&lt;/sup&gt;Evidence shows that SLE is most common in women of child-bearing age (15 to 44 years). Women diagnosed with SLE aged 40 year or older may have developed the disease earlier in life but were not diagnosed until later.&lt;sup&gt;2,3,17&lt;/sup&gt; This is consistent with the findings of this study.&lt;/p&gt;&lt;p&gt;Unlike previous research of primarily civilian populations, this study found consistent incidence rates rather than increasing rates.1,3,4 This contrast may be due to better access to care for ACSM within the MHS, compared to other health systems that monitor civilians, allowing greater and earlier detection of SLE. &lt;/p&gt;&lt;p&gt;To our knowledge, this is the first study to show trends of SLE incidence in ACSM, yet there are limitations. This study relies on encounter data and does not use laboratory test data to confirm SLE diagnosis, which may have led to misclassification. For instance, patients may have been assigned SLE diagnostic codes based on physical examination and symptoms without laboratory tests confirming the diagnosis. Previous studies using similar case definitions displayed high sensitivity and specificity,&lt;sup&gt;11&lt;/sup&gt; but adding laboratory criteria to the case definition may be limiting, since the blood tests used to detect SLE are often positive in healthy individuals, leading to misdiagnosis.&lt;sup&gt;2&lt;/sup&gt; Likewise, this study did not use pharmacy data, such as the inclusion of selected medications including hydroxychloroquine, to confirm diagnosis.&lt;sup&gt;18&lt;/sup&gt; Future analyses may use pharmacy data to increase study specificity. Furthermore, race and ethnicity are self-reported; misclassification may occur due to limitations in how race and ethnicity are captured in DMSS. Despite these limitations, this study provides strong evidence that non-Hispanic Black women are disproportionately affected by SLE. &lt;/p&gt;&lt;p&gt;Although this disease is uncommon, its effects can be debilitating. ACSM who develop SLE may suffer from arthritis, pleuritis, and nephritis leading to kidney failure.&lt;sup&gt;19&lt;/sup&gt; These physical symptoms hinder ACSM abilities to execute military duties; 1 study demonstrated increased risk of discharge from the U.S. Army for service members with SLE.&lt;sup&gt;20&lt;/sup&gt; Analyzing trends in SLE incidence is valuable, to assess the burden and potential impact of SLE on mission readiness, for improved understanding and management of the disease among ACSM.&lt;/p&gt;&lt;h2&gt;Authors' Affiliation&lt;/h2&gt;&lt;p&gt;Defense Health Agency, Armed Forces Health Surveillance Division, Epidemiology and Analysis Section, Silver Spring, MD: Ms. Denagamage, Dr. Mabila, Ms. McQuistan.&lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The views expressed in this article are those of the authors and do not necessarily reflect the official policy of the Department of Defense nor the U.S. Government.&lt;/p&gt;&lt;h2&gt;References &lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Duarte-García A, Hocaoglu M, Valenzuela-Almada M, et al. Rising incidence and prevalence of systemic lupus erythematosus: a population-based study over four decades. &lt;em&gt;Ann Rheum Dis&lt;/em&gt;. 2022;81:1260-1266. doi:10.1136/annrheum-dis-2022-222276&lt;/li&gt;    &lt;li&gt;Centers for Disease Control and Prevention. Systemic Lupus Erythematosus. Accessed Jul. 21, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/lupus/facts/detailed.html#" target="_blank" title="Click on the link to access the CDC site for SLE."&gt;https://www.cdc.gov/lupus/facts/detailed.html#&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.cdc.gov/lupus/facts/detailed.html#" target="_blank" title="Click on the link to access the CDC site for SLE."&gt; &lt;/a&gt;Duarte-Garcia A, Hocaoglu M, Osei-Onomah SA, et al. Population-based incidence and time to classification of systemic lupus erythematosus by three different classification criteria: a Lupus Midwest Network (LUMEN) study. &lt;em&gt;Rheumatology (Oxford)&lt;/em&gt;. 2021;61(6):2424-2431. doi:10.1093/rheumatology/keab807&lt;/li&gt;    &lt;li&gt;Izmirly PM, Ferucci ED, Somers EC, et al. Incidence rates of systemic lupus erythematosus in the USA: estimates from a meta-analysis of the Centers for Disease Control and Prevention national lupus registries. &lt;em&gt;Lupus Sci Med&lt;/em&gt;. 2021;8(1):e000614. doi:10.1136/lupus-2021-000614&lt;/li&gt;    &lt;li&gt;Gianfrancesco MA, Dall'Era M, Murphy LB, et al. Mortality among minority populations with systemic lupus erythematosus, including Asian and Hispanic/Latino persons—California, 2007-2017. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2021;70(7):236-239. doi:10.15585/mmwr.mm7007a2&lt;/li&gt;    &lt;li&gt;Uramoto KM, Michet CJ Jr, Thumboo J, et al. Trends in the incidence and mortality of systemic lupus erythematosus, 1950-1992. &lt;em&gt;Arthritis Rheum&lt;/em&gt;. 1999;42(1):46-50. doi:w0.1002/1529-0131(199901)42:1&lt;46::AID-ANR6&gt;3.0.CO;2-2&lt;/li&gt;    &lt;li&gt;Bookwalter, DB, Roenfeldt, KA, Leard-Mann, CA et al. Posttraumatic stress disorder and risk of selected autoimmune diseases among US military personnel. &lt;em&gt;BMC Psychiatry&lt;/em&gt;. 2020;20(1):23. doi:10.1186/s12888-020-2432-9&lt;/li&gt;    &lt;li&gt;Refai RH, Hussein MF, Abdou MH. et al. Environmental risk factors of systemic lupus erythematosus: a case-control study. &lt;em&gt;Sci Rep&lt;/em&gt;. 2023;13(1):10219. doi:10.1038/s41598-023-36901-y&lt;/li&gt;    &lt;li&gt;Wolf ST, Kenney LE, Kenney WL. Ultra-violet radiation exposure, risk, and protection in military and outdoor athletes. &lt;em&gt;Curr Sports Med Rep&lt;/em&gt;. 2020 Apr;19(4):137-141. doi:10.1249/JSR.0000000000000702&lt;/li&gt;    &lt;li&gt;Jones KA, Granado NS, Smith B, et al. A prospective study of lupus and rheumatoid arthritis in relation to deployment in support of Iraq and Afghanistan: the Millennium Cohort Study. &lt;em&gt;Autoimmune Dis&lt;/em&gt;. 2011;2011:241267. doi:10.4061/2011/741267&lt;/li&gt;    &lt;li&gt;Moores KG, Sathe NA. A systematic review of validated methods for identifying systemic lupus erythematosus using administrative or claims data. &lt;em&gt;Vaccine&lt;/em&gt;. 2013;31(Suppl 10):K62-K73. doi:10.1016/j.vaccine.2013.06.104&lt;/li&gt;    &lt;li&gt;Dall’Era M, Cisternas M, Snipes K, et al. The incidence and prevalence of systemic lupus erythematosus in San Francisco County, California: the California Lupus Surveillance Project. &lt;em&gt;Arthritis Rheumatol&lt;/em&gt;. 2017;69(10):1996-2005. doi:10.1002/art.40191&lt;/li&gt;    &lt;li&gt;Izmirly PM, Wan I, Sahl S, et al. The incidence and prevalence of systemic lupus erythematosus in New York County (Manhattan), New York: the Manhattan Lupus Surveillance Project. &lt;em&gt;Arthritis Rheumatol&lt;/em&gt;. 2017;69(10):2006-2017. doi:10.1002/art.40192&lt;/li&gt;    &lt;li&gt;Sibanda EN, Chase-Topping M, Pfavayi LT et al. Evidence of a distinct group of Black African patients with systemic lupus erythematosus. &lt;em&gt;BMJ Glob Health&lt;/em&gt;. 2018;3(5)e000697. doi:10.1136/bmjgh-2017-000697&lt;/li&gt;    &lt;li&gt;Chae DH, Martz CD, Fuller-Rowell TE, et al. Racial discrimination, disease activity, and organ damage: the Black Women’s Experiences Living with Lupus (BeWELL) study. &lt;em&gt;Am J Epidemiol&lt;/em&gt;. 2019;188(8):1434-1443. doi:10.1093/aje/kwz105&lt;/li&gt;    &lt;li&gt;Yacoub Wasef SZ. Gender differences in systemic lupus erythematosus. &lt;em&gt;Gend Med&lt;/em&gt;. 2004;1(1):12-17. doi:10.1016/s1550-8579(04)80006-8&lt;/li&gt;    &lt;li&gt;Kernder A, Ritcher JG, Fischer-Betz R, et al. Delayed diagnosis adversely affects outcome in systemic lupus erythematosus: cross sectional analysis of the LuLa cohort. &lt;em&gt;Lupus&lt;/em&gt;. 2021;30(3):431-438. doi:10.1177/0961203320983445&lt;/li&gt;    &lt;li&gt;Basta F, Fasola F, Triantafyllias K, Schwarting A. Systemic lupus erythematosus therapy: the old and the new. &lt;em&gt;Rheumatol Ther&lt;/em&gt;. 2020;7(3):433-446. doi:10.1007/s40744-020-00212-9&lt;/li&gt;    &lt;li&gt;Shin JI, Lee KH, Park S, et al. Systemic lupus erythematosus and lung involvement: a comprehensive review. &lt;em&gt;J Clin Med&lt;/em&gt;. 2022;11(22):6714. doi:10.3390/jcm11226714&lt;/li&gt;    &lt;li&gt;Nelson DA, Kaplan RM, Weisman MH, et al. Service discharges among US Army personnel with selected musculoskeletal and skin conditions: a retrospective cohort study. &lt;em&gt;BMJ Open&lt;/em&gt;. 2022;12(10):e063371. doi:10.1136/bmjopen-2022-063371&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Dec 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{71A59147-98C3-4D59-BBA1-4CB894D8EFB5}</guid><link>https://www.health.mil/News/Articles/2023/12/01/MSMR-MidYear-Populations</link><title>Surveillance Snapshot: Mid-year Populations by Sex, Age, and Race and Ethnicity of Active Component Service Members of the U.S. Armed Forces, 2018–2022</title><description>&lt;p&gt;This Surveillance Snapshot describes the mid-year population for active component service members of the Army, Navy, Air Force, Marine Corps, and Coast Guard between 2018 and 2022, stratified by age, sex, and race and ethnicity. Population counts were obtained from June of each calendar year using personnel data from the Defense Manpower Data Center maintained within the Defense Medical Surveillance System. Counts and percentages were stratified by sex, age group, and race and ethnicity. Both sex and race/ethnicity are self-reported by the service member. Race and ethnicity were categorized into non-Hispanic White, non-Hispanic Black, Hispanic, and Other/unknown. As some services do not provide separate race and ethnicity categories for Asian/Pacific Islanders and American Indian/Alaskan Natives, these groups are included in the Other/unknown category.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/12/01/MSMR-Article-4-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img alt="" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-4-Table.ashx?h=1473&amp;w=1250&amp;hash=177FD2EEE267009A35BE0EBDE5D2A164878C4CF7" style="width: 1250px; height: 1473px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt; Among ACSM, the minimum and maximum mid-year populations ranged from 1,104,484 to 1,141,780 men and 218,748 to 238,448 women during the surveillance period, with the highest population documented in 2021 for both men and women. The overall proportion of women and Hispanic service members increased between 2018 and 2022, while the proportion of non-Hispanic Whites and service members under 20 years of age decreased. When stratified by sex, age, and race and ethnicity, the racial/ethnic differences between ACSM men and women are apparent (Table). In 2022, non-Hispanic White males represented 56.5% of male ACSM, whereas less than half (41.5%) of female ACSM identified as non-Hispanic White. The proportion of non-Hispanic White male and female ACSM decreased throughout the surveillance period. Among men, the proportion of Hispanics increased throughout the surveillance period; however, they represented a smaller proportion of the older age groups, particularly over 50 years of age. Among women, the proportion of Hispanic service members also increased throughout the surveillance period, and they were typically younger.&lt;/p&gt;&lt;h2&gt;Authors' Affiliation&lt;/h2&gt;&lt;p&gt;Defense Health Agency, Armed Forces Health Surveillance Division, Epidemiology and Analysis Section&lt;/p&gt;</description><pubDate>Fri, 01 Dec 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{044DC30C-F262-4672-B743-E8484CC7B446}</guid><link>https://www.health.mil/News/Articles/2023/12/01/MSMR-Pandemics</link><title>Weighing the Risks to Force and Mission in a Public Health Crisis: The Plight of the U.S. Army in Four Pandemics</title><description>&lt;p&gt;History provides no one solution for how the Army should respond to pandemics. Each pandemic presents different risks. During the 20th and 21st centuries, the U.S. Army has continued operations throughout different pandemics, and its response to each pandemic was calibrated. There has been no definitive approach—nor is one likely. &lt;/p&gt;&lt;p&gt;Army leaders must consider current missions against the specific medical risks at a particular time due to the pandemic agent, offset by available mitigation methods. Command decisions for balancing risks—from a pandemic against operational risks—differ in every instance because these decisions occur within a broader cultural context of acceptable health risks determined largely by available technology and scientific knowledge. Commanders can use preventive medicine techniques to protect the force, but with varying costs in reduced readiness and operational tempo. Various measures such as stopping recruiting, quarantining (or reducing access to) posts, pausing troop movements, suspending training, and dispersing troops all reduce disease spread—but also reduce readiness or combat power.&lt;/p&gt;&lt;h2&gt;1918&lt;/h2&gt;&lt;h3&gt;Accepting Deaths by Disease to Win a World War&lt;/h3&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-2-Figure-1.ashx?h=730&amp;w=850&amp;hash=A509B8304C1BCFEAACD014D388DF736AA140AAE0" style="width: 850px; height: 730px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This graph consists of two curved lines, oriented along the horizontal, or x-, axis, each connecting 11 discrete data points oriented along the vertical, or y-, axis. The marks on the x-axis represent specific age ranges, starting with those under one year of age, then one to four year olds, and then 10 year age ranges until the final mark representing those 85 years of age and older. The two curved lines represent mortality rates for influenza, one for the period of 1911 through 1917, and the other for the year 1918. The 1911-1917 curve is U-shaped, which is typical for influenza data visualization, representing higher death rates among the very youngest and very oldest segments of the population, but with minimal mortality from the 5 to 14 through the 45 to 54 age groups. The 1918 curve is W-shaped, with noticeably higher rates than 1911-1917 among the very youngest, and an extraordinary spike in mortality that peaks among the 25 to 34 year-old age group, with only slightly lower rates among the very oldest."&gt;On October 7, 1918, President Woodrow Wilson On October 7, 1918, President Woodrow Wilson walked over to the War Department from the White House. In 1918 the world faced a fast-spreading influenza pandemic, which was deadliest among the military-age population (Figure 1). Wilson was upset, after a briefing by doctors about the medical situation that troops were facing on transport ships to France. The risk of disease due to the influenza pandemic was extreme, and Wilson wanted to talk with War Department leadership.&lt;/p&gt;&lt;p&gt;&lt;img alt="Photo of U.S. Army General Payton March" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-2-Figure-2.ashx?h=524&amp;w=400&amp;hash=9940519A78D0B4519747C082476510300141D2BD" style="width: 400px; height: 524px; float: right; margin-top: 5px; margin-bottom: 10px; margin-left: 15px;"&gt;With the Secretary of War visiting forces in France, the Acting Secretary called in General Peyton March, the Chief of Staff of the Army (Figure 2). March knew that soldiers were going to die, whatever choice he made.&lt;sup&gt;1&lt;/sup&gt; He squared his shoulders and briefed the president on his decision: He was ordering packed troopships to continue sailing for France. It was not a risk but a certainty that soldiers on those ships would catch influenza, and some would die from it, some even before the voyage was over—but the mission was to beat the Germans, and these reinforcements would speed that outcome.&lt;/p&gt;&lt;p&gt;March laid it out for the Commander-in-Chief, including the medical advice he had decided to countermand. March was thorough in his briefing to Wilson; it was clear he understood the medical countermeasures, and their limitations. Puny mitigations were all he could offer. President Wilson accepted the Chief of Staff’s decision. Winning the war for everyone was more important than reducing the risk to individual doughboys.&lt;/p&gt;&lt;p&gt;In August and September 1918, while in the U.S. the lethal mutation of the virus was spreading, in Europe the Allies had engaged in massive military offensives. The major American efforts at St. Mihiel (September 12-16) and Meuse-Argonne (September 26–November 11) resulted in over 100,000 battle casualties. The American Expeditionary forces needed replacements as well as reinforcements, and reducing the flow of troops—pulling America’s punches—would undermine those offensives, reduce American influence during inter-Allied negotiations, and lower American prestige at the imminent peace negotiations.&lt;/p&gt;&lt;p&gt;The U.S. Army knew about avoiding communicable diseases; in a time before antibiotics, an ounce of prevention was worth a pound of cure. Army doctors had immense credibility with line officers when they recommended any of a range of disease countermeasures, especially spacing between soldiers to prevent airborne spread of disease.&lt;sup&gt;2&lt;/sup&gt; World War I was an existential threat, however, and the line accepted more crowding to train more men within limited facilities. Disease outbreaks during the winter of 1917-1918, especially measles, had sickened approximately 95,000 soldiers, but those outbreaks were nothing like what would happen in late 1918.&lt;/p&gt;&lt;p&gt;At the end of August 1918, upon receiving news of the lethal flu variant at an Army base, Surgeon General William Gorgas had taken immediate action. Gorgas sent warnings to Army hospitals and recommended stop-move orders to Chief of Staff March.&lt;sup&gt;3&lt;/sup&gt; March considered Gorgas’s advice, but ultimately rejected most of it. When the disease had been containable, March had canceled troop moves from camps with outbreaks, but once influenza began spreading rapidly, he apparently thought troop movements would make little difference.&lt;sup&gt;2&lt;/sup&gt; At the time scientists could not yet identify viruses, only bacteria, and were unable to determine just what was spreading or how. March understood that Army actions would further spread the pandemic, killing more soldiers and civilians, and he had accepted that outcome. Victor Vaughan, former president of the American Medical Association who served as a colonel during WWI, recalled being told by his command that “The purpose of mobilization is to convert civilians into trained soldiers as quickly as possible and not to make a demonstration in preventive medicine.”&lt;sup&gt;3&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Influenza quickly swept across the U.S. throughout September 1918. The flu arrived in Kansas City on September 23, and within a week Fort Leavenworth placed restrictions on leave and passes, and delayed draftee arrivals. Fort Leavenworth did not have a large troop population, housing its troops in a range of forms: in pre-war barracks along with wartime constructions, in addition to the prison, while some troops attended civilian schools in Kansas City. By September 29, on post 18 influenza cases had been identified—and then 100 the next day. That surge in case numbers presumably drove the order on September 30 to refrain from entering crowded buildings such as theaters and restaurants, and to abstain from spitting, with instruction to use handkerchiefs when sneezing or coughing.   &lt;/p&gt;&lt;p&gt;In late September and early October 1918, in the midst of the Meuse-Argonne campaign in France, which was generating cables emphasizing the need for more troops, the Army experienced its fastest influenza spread: about 80,000 influenza infections during the week of September 28 through October 4, compounded by another 89,000 the following week. Gorgas recommended halving the loading of troop ships for the 2-week voyage to Europe, after week-long quarantines at embarkation camps before boarding. General March overruled the Surgeon General’s recommendations, which led to his meeting with President Wilson on October 7. Following the meeting between Wilson and March, troop ships would be just as packed as before, but troops’ temperatures would be checked before embarkation, and they would be asked about symptoms. It is hard to credit that March or Wilson believed these measures would have meaningful impacts (Figure 3).&lt;/p&gt;&lt;p&gt;&lt;img alt="Photo of WWI, U.S. Army medical inspection line." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-2-Figure-3.ashx?h=576&amp;w=400&amp;hash=05D3621CDED4147653ED1C6E24548BB58D3A3961" style="width: 400px; height: 576px; float: left; margin-top: 5px; margin-right: 15px; margin-bottom: 10px;"&gt;&lt;/p&gt;&lt;p&gt; Not understanding exactly how the disease spread, in the U.S. there was an effort to certify buildings (e.g., restaurants, cinemas, or ice cream parlors) as sanitary and permissible. Differing city and state responses to the growing pandemic included closures of schools, theaters, and churches, as well as limiting group sizes. The Army adopted various techniques that today would be termed “social distancing,” for both off- and on-duty service members: reducing training, keeping troops on post, closing posts to visitors (although not fully quarantined), suspending church services, and other measures to avoid crowding.&lt;sup&gt;2,4&lt;/sup&gt; On October 8 tenant units of Fort Leavenworth were instructed to read aloud the September 30 orders, with commanders to report compliance. By October 26, more than a month into the local Kansas City epidemic, church services on post were suspended—and there were to be no gatherings of any kind, including troop training.&lt;/p&gt;&lt;p&gt; Meanwhile, in Europe the operational situation was rapidly shifting: Multiple Allied attacks had reinforced the others and forced Germany to request an armistice on October 5. Quickly, the Army’s response to the pandemic changed. Draft call-ups were both delayed and reduced—but not stopped—to reduce both crowding in training camps and patients in Army hospitals.&lt;sup&gt;3&lt;/sup&gt;   &lt;/p&gt;&lt;p&gt;By November 2, Fort Leavenworth was able to lift its restrictions, with mixed results. Contemporary data are scarce, but in 1917 Fort Leavenworth’s disciplinary barracks registered 41 cases of pneumonia or influenza, with four deaths, but in 1918 the disciplinary barracks reported 293 cases and 86 deaths, among only 2,026 prisoners.&lt;sup&gt;5,6&lt;/sup&gt;   &lt;/p&gt;&lt;p&gt;The U.S. Army ultimately suffered an estimated 50,000 fatalities from influenza in WWI, a number almost certainly increased due to General March’s decisions. As the pandemic escalated in late summer 1918, March could not have known how soon the fighting in Europe would be over; if battles had continued through the fall and into 1919, American battle casualties would likely have exceeded the added deaths due to influenza. The cessation of fighting within the first weeks of autumn 1918 was the determining factor of whether disease or battle deaths were to be greater that year. &lt;/p&gt;&lt;p&gt; In hindsight, March’s deliberate, even calculated, inaction in all likelihood caused more deaths among U.S. troops, along with the civilian population, but at the time March judged it the better choice. Once operational pressures at the front eased, he chose to increase disease-mitigation protocols. General March adhered to his commander’s intent by prioritizing measures for winning a world war, and not the battle against an influenza pandemic.&lt;sup&gt;7&lt;/sup&gt;&lt;/p&gt;&lt;h2&gt;1968&lt;/h2&gt;&lt;h3&gt;Calculating Risk Against Progress&lt;/h3&gt;&lt;p&gt;In the 1930s new technologies had allowed viruses to be identified, including various strains of influenza virus. An influenza vaccine developed in the 1940s was compulsorily administered to service members during World War II. At the same time, the Army epidemiology board evaluated masks as a preventive measure, but found they had insignificant protective value.&lt;sup&gt;7&lt;/sup&gt; There was no pandemic during WWII; penicillin would have helped with combatting secondary infections, but the Army was watchful. Later, in the 1950s and early 1960s a number of new vaccines were developed, notably the polio and measles vaccines, in addition to the research and development of mumps and rubella vaccines.&lt;/p&gt;&lt;p&gt; In July 1968 another influenza pandemic started in China, reaching the wider world through Hong Kong, then a British colony. The U.S. Army promptly learned of the “Hong Kong flu” outbreak, and a team from the 406th Medical General Laboratory (the forward-deployed diagnostic laboratory for Pacific Command, based in Tokyo) went to Hong Kong. From the data collected during that visit, the Armed Forces Epidemiology Board considered possible actions.&lt;sup&gt;8&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;The new flu of 1968 was H3N2, somewhat similar to 1957’s mild pandemic of H2N2 influenza, and their N2 similarity could offer limited protection. Moreover, six U.S. vaccine manufacturers could attempt different approaches, increasing odds of achieving an effective vaccine quickly.&lt;sup&gt;9&lt;/sup&gt; The Board decided to recommend no immediate action, but instead to wait and rely upon an efficacious vaccine.&lt;/p&gt;&lt;p&gt;If expectations in 1968 were to prove erroneous—that the newest pandemic would affect not just the old and the young (i.e., a U-shaped curve) but include young adults (i.e., a W-shaped curve)—the military had a large hospital system for further risk mitigation. With epidemiologists recommending no immediate action, the Army, unsurprisingly, took none. Soldiers are generally a young and healthy population. Recruitment and draft call-ups continued unabated, with training, worldwide movements, and operations uninterrupted. Fighting in Vietnam increased.&lt;/p&gt;&lt;p&gt;&lt;img alt="Photo of U.S. soldiers on patrol in Vietnam. " src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-2-Figure-4.ashx?h=534&amp;w=800&amp;hash=83D2FD83258FBC297536BC759AF02914A7138BEA" style="width: 800px; height: 534px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px; margin-right: 750px;"&gt;The following year, 1969, would be America’s bloodiest in Vietnam, but not from the pandemic (Figure 4). The pandemic was essentially ignored in Vietnam; rest-and-relaxation leave to Hong Kong was not stopped, although it was a known factor in the disease’s spatial spread. Troop rotation from Vietnam back to the U.S. likely helped spread the virus domestically.&lt;sup&gt;8,10&lt;/sup&gt; Routine troop moves to U.S. Army Europe (USAREUR) may have expedited H3N2’s arrival to Germany.&lt;sup&gt;11&lt;/sup&gt; Neither the 44th Medical Brigade (the medical headquarters in Vietnam) nor USAREUR even mentioned the pandemic in their annual reports.&lt;sup&gt;12&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Bases in the U.S. took little notice of the pandemic, indeed even less than some civilian institutions. Some colleges closed, sending students home, while some hospitals limited visitors.&lt;sup&gt;11&lt;/sup&gt; The entire military district that covered central Louisiana to Fort Bliss, Texas, and as far north as central Oklahoma, had no confirmed H3N2 cases through December. Fort Sam Houston in San Antonio enacted no restrictions. Trainees visited San Antonio, and local residents came on post. Recreation and meetings were unaffected. There was no mention at all of influenza in the post newspaper, with little mention in the civilian press.&lt;sup&gt;19-25&lt;/sup&gt; Contrasted with the restrictions a half century earlier at Fort Leavenworth, the U.S. response to the 1968 H3N2 pandemic was extremely limited.&lt;/p&gt;&lt;p&gt;Confidence in vaccines was high in 1968, and mitigation measures were available, doubtless making risk-taking easier. The media campaign for the 1968-1969 influenza vaccine seemingly increased, and the vaccine was mandated for active duty troops. (Influenza vaccine strains developed before the H3N2 version also proved to provide some protection.&lt;sup&gt;14&lt;/sup&gt;) By November 1968, a mere four months after the pandemic was identified, 1,000,000 H3N2 vaccine doses were available, and in early 1969 doses arrived in Vietnam. The history of medical support in Vietnam notes “only a few cases appeared in military units in Vietnam,” then simply asserts that the vaccine became available in January 1969.&lt;sup&gt;18&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;These calculated risks created negligible adverse consequences. The Army’s rate of influenza cases in the 1968-1969 season was only slightly higher than in previous years, and affected neither combat operations in Vietnam nor deterrence in Europe.&lt;sup&gt;15-17&lt;/sup&gt; The 1968 pandemic seems to have sickened 1-2% of troops at worst, who were off-duty for only a few days.&lt;sup&gt;13&lt;/sup&gt; In 1968, the acceptable answer was to do almost nothing.&lt;/p&gt;&lt;h2&gt;2009&lt;/h2&gt;&lt;h3&gt;Advocating for Better Practice&lt;/h3&gt;&lt;p&gt;An H1N1 swine influenza was first detected in the U.S. in 2009, and by June the outbreak had been declared a pandemic. The U.S. reported the most swine flu pandemic cases in the world, with cases recorded in every state.&lt;sup&gt;26&lt;/sup&gt; Few individuals in the military-age population had antibodies, while around one-third of persons over 60 years of age were found to have antibodies. &lt;/p&gt;&lt;p&gt;The H1N1 variant was neither more contagious nor more virulent than seasonal influenza. The U.S. Centers for Disease Control and Prevention guidance cautioned institutions, as well as officials and individuals, not to react strongly. The influenza virus and countermeasures were well understood, and officials were confident that a vaccine could be produced in time to reduce widespread public health effects.&lt;/p&gt;&lt;p&gt;The Department of Defense followed the guidance provided by the CDC. DOD’s response focused on hygiene—coughing into the elbow was stressed—and use of antivirals when appropriate, in addition to vaccination. The annual influenza vaccination program was advocated more aggressively, including vaccination for family members.&lt;/p&gt;&lt;p&gt;Amid operations in Iraq and Afghanistan, DOD response to a pandemic that was mild in nature could be limited. This proved reasonable. Even though the military population had little previous exposure, the virus was neither more contagious nor more virulent than seasonal influenza. The Military Health System had approximately 1,000 hospitalizations for influenza, averaging 3.63 days in hospital.&lt;sup&gt;27&lt;/sup&gt; The greatest cost incurred by the DOD for the 2009 H1N1 pandemic was for the more robust annual vaccination campaign.&lt;/p&gt;&lt;h2&gt;2020&lt;/h2&gt;&lt;h3&gt;Protecting Service Members Against Unknown Effects&lt;/h3&gt;&lt;p&gt;In the half century that followed 1968, public safety had become more prevalent within civilian society as well as the Army. 1968 was the first year new cars were required to have seatbelts—while wearing them was still optional—and the Occupational Safety and Health Act was passed three years later, in 1971. In 1968 the Army safety program addressed only aviation accidents; the Army Safety Center was created 10 years later, in 1978. If the phrase “protecting the force” was used in the mid-20th century, it was understood differently. &lt;/p&gt;&lt;p&gt;U.S. life expectancy increased from 70 in 1968 to 79 by 2020, with many older individuals survivors of cancer or on dialysis, neither of which was common in 1968. Medicine had also changed, emphasizing outpatient care, with a far smaller military hospital system as a result.&lt;/p&gt;&lt;p&gt;In 2020 the world situation was comparatively benign. Few troops were deployed, and even fewer were in combat. The Army had been an all-volunteer force for almost 50 years. The military could focus on protecting the force, including military families and the military’s civilian workforce (Figure 5). Accidents often damaged commanders’ careers. Army commanders recognized the individual soldier as the Army’s most important weapon, with families viewed as important keys to soldier retention. The importance of an effective civilian work- force was similarly emphasized.&lt;/p&gt;&lt;p&gt;&lt;img alt="Photo of masked U.S. service members conducting field exercises during the COVID-19 pandemic." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-2-Figure-5.ashx?h=515&amp;w=800&amp;hash=4DC1BDF99BADB13B05A6DAF7DFC8FD3CB5479371" style="width: 800px; height: 515px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/p&gt;&lt;p&gt;Early in 2020 the Army faced, in both viral virulence and unknown effects, an unprecedented situation—for both the short- and long-terms. The COVID-19 virus was most lethal among the elderly, not the military-age population, but large numbers of people were immuno-compromised or had other identified COVID risk factors. Protecting a far more varied population added complexities to anticipated responses by the public. The U.S. Armed Forces lost only 14 personnel, of a total force of around 2.2 million, from COVID-19 in 2020.&lt;sup&gt;28&lt;/sup&gt; By contrast, 1 county in Texas, Bexar County, which includes San Antonio, suffered around 5,000 deaths from a population of 2 million.&lt;sup&gt;29&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;The military restricted recruiting, training, and travel in different ways at different times; in addition, service members were issued personal protective equipment; and DOD modified facilities to reduce spread of the virus. With few operational requirements, risk was comparatively limited and command focus could be placed on protecting the force. U.S. Forces Korea had the opportunity to institute the dramatically-named Operation Kill The Virus because USFK had only routine operational requirements.&lt;sup&gt;30&lt;/sup&gt; Notably, one aircraft carrier group had to dock in response to an outbreak aboard ship.&lt;sup&gt;31&lt;/sup&gt;&lt;/p&gt;&lt;h2&gt;No Uniform Answers&lt;/h2&gt;&lt;p&gt;Throughout the past century, the U.S. Army faced wartime pandemics that presented both known and unknown threats. The pandemics of 1918 and 1968 had similarities, most significantly large forces at war overseas, as well as differences, most notably that, by 1968, the influenza virus had been identified and a reliable vaccine developed. The 2009 pandemic occurred during substantial overseas military operations but involved a well-understood virus for which there were effective anti-virals. The latest pandemic was markedly different, and the next pandemic will be different yet again.&lt;/p&gt;&lt;p&gt;Medical advice has always played a role in the Army’s pandemic responses, but there was a time when the Army, as well as national, leadership felt it appropriate to accept the certainty of more sickness and death to reduce risk of battlefield defeat. At various times doctors have advised no immediate action against disease outbreaks. The COVID pandemic occurred in a new operational, as well as societal, paradigm focused on protecting the force, along with military families and the civilian workforce. &lt;/p&gt;&lt;p&gt;History does not provide a ready solution to successfully combat threats posed by pandemics, instead demonstrating military ad hoc pragmatism. None of these examples may be appropriate in the future. One thing is certain: There will be future pandemics, and public health leaders will again have to communicate threats and risks to Army leaders who will, in turn, have to weigh their missions with medical risks and practicable mitigation methods. At some point in the future, the Army may have to explain to its officers, soldiers, and the American public why it is unable to prioritize force health protection, instead putting “mission first” before “people always.”&lt;/p&gt;&lt;h2&gt;Author Affiliation&lt;/h2&gt;&lt;p&gt;U.S. Army Medical Department Center of History and Heritage, U.S. Army Medical Center of Excellence&lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The views expressed in this article are those of the author and do not necessarily reflect the official policy of the Department of Defense nor the U.S. Government.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;March P. &lt;em&gt;The Nation at War&lt;/em&gt;. Doubleday; 1932:359-360.&lt;/li&gt;    &lt;li&gt;Byerly C. &lt;em&gt;Fever of War&lt;/em&gt;. New York University Press; 2005:104-107.&lt;/li&gt;    &lt;li&gt;Barry J. &lt;em&gt;The Great Influenza: The Epic Story of the Deadliest Plague in History&lt;/em&gt;. Penguin; 2004:83-84,148,191-192,301-308.&lt;/li&gt;    &lt;li&gt;Gillett M. &lt;em&gt;The Army Medical Department 1917-1941&lt;/em&gt;. U.S. Army Center of Military History; 2009:166-168,186,212.&lt;/li&gt;    &lt;li&gt;Crow K. Fort Leavenworth and the 1918/19 Flu Pandemic. Manuscript.&lt;/li&gt;    &lt;li&gt;Kansas City, Missouri. Influenza Encyclopedia–The American Influenza Epidemic of 1918-1919: A Digital Encyclopedia. University of Michigan Center for the History of Medicine and Michigan Publishing, University of Michigan Library. Accessed Jan. 8, 2021. &lt;a rel="noopener noreferrer" href="http://www.influenzaarchive.org/cities/city-kansascity.html#" target="_blank" title="Click on the link to access the University of Michigan digitial encyclopedia of Kansas City during the 1918 pandemic."&gt;http://www.influenzaarchive.org/cities/city-kansascity.html#&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Meiklejohn G. History of the Commission on Influenza. In: Woodward T, &lt;em&gt;The Armed Forces Epidemiological Board: History of the Commissions&lt;/em&gt;. Office of The Surgeon General; 1994:164.&lt;/li&gt;    &lt;li&gt;Kundin WD, Wiebenga NH, Rosenberg EB. Hong Kong influenza: serologic, immunochemical, and epidemiologic studies of various aspects of the 1968 outbreak in Americans in Asia. &lt;em&gt;Chinese J Microbiology&lt;/em&gt;. 1970;3(6):6-14.&lt;/li&gt;    &lt;li&gt;Dehner G. (2021). Interview by Dan Snow [video recording]. Hong Kong Flu [internet series/podcast]. In &lt;em&gt;Dan Snow's History Hit&lt;/em&gt;. Accessed Oct. 20, 2021. &lt;a rel="noopener noreferrer" href="http://" target="_blank" title="Click on the link to watch the interview."&gt;https://play.acast.com/s/dansnowshistoryhit/hongkongflu&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Hannoun C, Craddock S. Hong Kong Flu (1968) revisited 40 years later. In: Giles-Vernick T, Craddock S, eds., &lt;em&gt;Influenza and Public Health: Learning from Past Pandemics&lt;/em&gt;. Earthscan; 2010:180-190.&lt;/li&gt;    &lt;li&gt;Blakely D. &lt;em&gt;Mass Mediated Disease: A Case Study Analysis of Three Flu Pandemics and Public Health Policy&lt;/em&gt;. Lexington Books; 2006:129-130,134.&lt;/li&gt;    &lt;li&gt;U.S. Deptartment of the Army. &lt;em&gt;Debriefing Report (RCS-CSFOR-74), Republic of Vietnam, BG Spurgeon Neel, 1 August 1968–1 February 1969, 1 February 1969&lt;/em&gt;. Accessed Dec. 6, 2023. &lt;a rel="noopener noreferrer" href="http://" target="_blank" title="Click on the link to access a copy of the debriefing report."&gt;https://apps.dtic.mil/sti/tr/pdf/AD0513162.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;em&gt;Fort Sam Houston Talon&lt;/em&gt;. Archive, 1968-1969. Located at: Fort Sam Houston Museum.&lt;/li&gt;    &lt;li&gt;Flu shot program stressed by 2nd armd. div. medics. &lt;em&gt;The Armored Sentinel, Fort Hood, Texas&lt;/em&gt;. Oct. 11, 1968:9. Accessed Oct. 20, 2021. &lt;a rel="noopener noreferrer" href="https://texashistory.unt.edu/ark:/67531/metapth255000/m1/8/zoom/?q=date:1968-1969influenza&amp;resolution=4&amp;lat=4488.000000000001&amp;lon=3789.9999999999995" target="_blank" title="Click on the link to access the Armored Sentinel online archive."&gt;https://texashistory.unt.edu/ark:/67531/metapth254999/m1/9/zoom/?q=date:1968-1969influenza&amp;resolution=6&amp;lat=3515.5&amp;lon=2190.5&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Old Ironsides personnel get Asian flu shots. &lt;em&gt;The Armored Sentinel, Fort Hood, Texas&lt;/em&gt;. Oct. 25, 1968:8. Accessed Oct. 20, 2021. &lt;a rel="noopener noreferrer" href="https://texashistory.unt.edu/ark:/67531/metapth255000/m1/8/zoom/?q=date:1968-1969influenza&amp;resolution=4&amp;lat=4488.000000000001&amp;lon=3789.9999999999995" target="_blank" title="Click on the link to access the Armored Sentinel online archive."&gt;https://texashistory.unt.edu/ark:/67531/metapth255000/m1/8/zoom/?q=date:1968-1969influenza&amp;resolution=4&amp;lat=4488.000000000001&amp;lon=3789.9999999999995&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Hong Kong flu not in evidence at FUSA posts. &lt;em&gt;The Armored Sentinel, Fort Hood, Texas&lt;/em&gt;. Dec. 20, 1968:7. Accessed Oct. 20, 2021. &lt;a rel="noopener noreferrer" href="https://texashistory.unt.edu/ark:/67531/metapth255007/m1/7/zoom/?q=date:1968-1969influenza&amp;resolution=3&amp;lat=6165.18046534377&amp;lon=2858.4838700426426" target="_blank" title="Click on the link to access the Armored Sentinel online archive."&gt;https://texashistory.unt.edu/ark:/67531/metapth255007/m1/7/zoom/?q=date:1968-1969influenza&amp;resolution=3&amp;lat=6165.18046534377&amp;lon=2858.4838700426426&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;News script. WBAP-TV, Fort Worth, TX. Dec. 30, 1969. Accessed Oct. 20, 2021. &lt;a rel="noopener noreferrer" href="https://texashistory.unt.edu/ark:/67531/metadc1215834/?q=%20date%3A1968-1969+influenza" target="_blank" title="Click on the link to access the online Texas History archive site."&gt;https://texashistory.unt.edu/ark:/67531/metadc1215834/?q=%20date%3A1968-1969+influenza&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;News script. WBAP-TV, Fort Worth, TX. Dec. 31, 1969. Accessed Oct. 20, 2021. &lt;a rel="noopener noreferrer" href="https://texashistory.unt.edu/ark:/67531/metadc1215088/?q=%20date%3A1968-1969+influenza" target="_blank" title="Click on the link to access the Texas History archive online. "&gt;https://texashistory.unt.edu/ark:/67531/metadc1215088/?q=%20date%3A1968-1969+influenza&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;News script. WBAP-TV, Fort Worth, TX. Dec. 17, 1968. Accessed Oct. 20, 2021. &lt;a rel="noopener noreferrer" href="https://texashistory.unt.edu/ark:/67531/metadc1038188/m1/3/?q=20date:1968-1969%20influenza" target="_blank" title="Click on the link to access the Texas History archive online. "&gt;https://texashistory.unt.edu/ark:/67531/metadc1038188/m1/3/?q=20date:1968-1969%20influenza&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Meiklejohn G, Eickhoff T. &lt;em&gt;Prevention of Influenza and Other Respiratory Diseases: Annual Progress Report&lt;/em&gt;. Armed Forces Epidemiological Board; 1969.&lt;/li&gt;    &lt;li&gt;Neel S. &lt;em&gt;Medical Support of the U.S. Army in Vietnam 1965-1970&lt;/em&gt;. U.S. Army Center of Military History; 1973:111.&lt;/li&gt;    &lt;li&gt;Office of the Surgeon General. &lt;em&gt;Health of the Army&lt;/em&gt;. 1969;23(1).&lt;/li&gt;    &lt;li&gt;Office of the Surgeon General. &lt;em&gt;Health of the Army&lt;/em&gt;. 1969;24(1).&lt;/li&gt;    &lt;li&gt;Office of the Surgeon General. &lt;em&gt;Health of the Army&lt;/em&gt;. 1970;25(1).&lt;/li&gt;    &lt;li&gt;Smith T, Olson LC, Kandel GE, et al. Hong Kong influenza in U.S. military airmen in Thailand. &lt;em&gt;Am J Trop Med Hygiene&lt;/em&gt;. 1970;19(5):866-871.&lt;/li&gt;    &lt;li&gt;Jeffrey DD, Choen M, Brooks A, et al. Impact of the 2009 influenza (H1N1) pandemic on the United States military health care system. &lt;em&gt;Mil Med&lt;/em&gt;. 2013;178(6):653-658. doi:10.7205/MILMED-D-12-00345&lt;/li&gt;    &lt;li&gt;Hayward RT. An Examination of the Response of U.S. Army Reserves (COMPO 3) Medical Units During the COVID-19 Pandemic [Master's thesis]. U.S. Army Command and General Staff College; 2021:91.&lt;/li&gt;    &lt;li&gt;Dutton L, et al. Combating an invisible enemy: the American military response to global pandemics. &lt;em&gt;Mil Med Res&lt;/em&gt;. 2021;8(8):11-20.&lt;/li&gt;    &lt;li&gt;Reports &amp; Statistics. COVID-19 San Antonio. Accessed Nov. 15, 2021. &lt;a rel="noopener noreferrer" href="https://covid19.sanantonio.gov/Reports-Statistics/Surveillance" target="_blank" title="Click on the link to access the San Antonio COVID data site. "&gt;https://covid19.sanantonio.gov/Reports-Statistics/Surveillance&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Kim S, et al. Responding to COVID-19 among U.S. military units in South Korea: the U.S. Forces Korea’s Operation Kill the Virus. &lt;em&gt;Mil Med&lt;/em&gt;. Feb. 2, 2021. Accessed Oct. 20, 2021. https://doi.org/10.1093/milmed/usab013&lt;/li&gt;    &lt;li&gt;Legendre BW, Boltz J, Riegodedios AJ, et al. Seroepidemiologic investigation of a COVID-19 outbreak aboard a U.S. Navy ship. &lt;em&gt;MSMR&lt;/em&gt;. 2022;29(12):2-10.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Dec 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{A0F74BD0-63B7-4109-95E3-D7F3E3E3FF6E}</guid><link>https://www.health.mil/News/Articles/2023/12/01/MSMR-RMEs</link><title>Reportable Medical Events at Military Health System Facilities Through Week 44, Ending November 4, 2023</title><description>&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/12/01/MSMR-Article-5-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img alt="" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-5-Table.ashx?h=1470&amp;w=1200&amp;hash=ED2AF060485C341FD7E3F697B7A37F4DBA745604" style="width: 1200px; height: 1470px; vertical-align: top; margin-bottom: 15px;"&gt;&lt;/a&gt;Reportable Medical Events are documented in the Disease Reporting System internet by health care providers and public health officials throughout the Military Health System for monitoring, controlling, and preventing the occurrence and spread of diseases of public health interest or readiness importance. These reports are reviewed by each service’s public health surveillance hub. The DRSi collects reports on over 70 different RMEs, including infectious and non-infectious conditions, outbreak reports, STI risk surveys, and tuberculosis contact investigation reports. A complete list of RMEs is available in the 2022 Armed Forces Reportable Medical Events Guidelines and Case Definitions.&lt;sup&gt;1&lt;/sup&gt; Data reported in these tables are considered provisional and do not represent conclusive evidence until case reports are fully validated.&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/December/Article-5-Figure.ashx?h=729&amp;w=1200&amp;hash=AC55F7C4357169BD4B3BE3AB07BBDB1868C17616" style="width: 1200px; height: 729px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="This graph comprises five lines on the horizontal, or x-, axis that depict case counts for the five most frequent reportable medical event conditions among active component service members during the past 52 weeks. Chlamydia remains the most common reportable medical condition, with counts consistently around 300 cases per week. Gonorrhea is generally the second-most common reported condition, averaging approximately 80 cases per week, but in week 26 of 2023 it was surpassed by heat illness, which outnumbered gonorrhea cases for the next eight of nine weeks, but declined to the same number gonorrhea cases by the end of week 35 and has been declining steadily thereafter. Campylobacteriosis cases rose briefly at the end of week 34 to become the fourth-most common reported condition,but declined in number through week 39 to again become the fifth-most common condition, with a temporary spike in week 40, followed by further declines thereafter, through week 44. With the overall decline of heat illnesses starting in week 35, syphilis reclaimed the position of the third-most common condition in week 44, with just over 10 reported cases per week."&gt;&lt;/p&gt;&lt;p&gt;Total active component cases reported per week are displayed for the top five RMEs for the previous year. Each month, the graph is updated with the top five RMEs, and is presented with the current month’s (October 2023) top five RMEs, which may differ from previous months. COVID-19 is excluded from these graphs due to changes in reporting and case definition updates in 2023.&lt;/p&gt;&lt;p&gt;For questions about this report, please contact the Disease Epidemiology Branch at the Defense Centers for Public Health–Aberdeen. Email: &lt;a href="mailto:dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mil?subject=December%202023%20RME" title="Email DEB"&gt;dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mil&lt;/a&gt;&lt;/p&gt;&lt;h2&gt;Authors' Affiliation&lt;/h2&gt;&lt;p&gt;Defense Health Agency, Disease Epidemiology Branch, Defense Centers for Public Health–Aberdeen&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Armed Forces Reportable Medical Events. Accessed Sep. 6, 2023. &lt;a href="/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines" title="Click on the link to access the Armed Forces Health Surveillance Division's published RME guidelines."&gt;https://health.mil/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Department of Defense Active Duty Military Personnel by Rank/Grade of Service, October 31, 2022. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the Department of Defense's data on active duty personnel."&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Armed Forces Strength Figures for January 31, 2023. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the Department of Defense's web site on active personnel data. "&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Navy Medicine. Surveillance and Reporting Tools–DRSI: Disease Reporting System Internet. &lt;a rel="noopener noreferrer" href="https://www.med.navy.mil/Navy-and-Marine-Corps-Force-Health-Protection-Command/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI" target="_blank" title="Click on the link to access Navy Medicine's DRSi web page."&gt;https://www.med.navy.mil/Navy-and-Marine-Corps-Force-Health-Protection-Command/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Dec 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{40CBF058-2382-4C34-AE6A-0DDD35A98523}</guid><link>https://www.health.mil/News/Articles/2023/11/30/Wounded-Warrior-Continues-to-Serve-His-Military-Community</link><title>Retiring Wounded Warrior Continues to Serve His Military Community</title><description>&lt;p&gt;Blake Conley enlisted in the U.S. Navy—even though his dad and granddad were U.S. Army men—at 18 years old, feeling he was not mature enough to enroll in college just yet and eager to travel the world for some life experience. &lt;/p&gt;&lt;p&gt;Despite getting an academic scholarship for college, the Columbus, Ohio native was excited to enlist for a career in a technological field that would allow him to travel and be stationed at beach locations. &lt;/p&gt;&lt;p&gt;Twenty-one years later, his interests became a reality and resulted in a successful career culminating at the rank of U.S. Navy chief petty officer. "It's been great for me," he said. "I wanted to join the Navy and I enjoy serving other people. But I also enjoyed all the benefits I've gotten out of it, including getting to see the world and becoming a more responsible adult."&lt;/p&gt;&lt;p&gt;The combination of a career-ending cancer diagnosis and an innate calling to serve led him on a path where he can stay connected to the military community and continue to help service members as a non-medical case manager with the Navy Wounded Warrior program. &lt;/p&gt;&lt;p&gt;After a career as a surface sonar technician, Conley had planned to medically retire in early 2023. &lt;/p&gt;&lt;h2&gt;Headaches Become More&lt;/h2&gt;&lt;p&gt;As a sonar technician, a typical day at the "office" for him meant being at sea, monitoring on sonar for submerged objects or vehicles from the surface of a ship—destroyers or cruisers—and occasionally, in a submarine. &lt;/p&gt;&lt;p&gt;"Sonar is basically a machine that detects when other ships are in the vicinity that are trying not to be seen," he clarified. "So, it's sound navigation and our main goal with sonar is to find submarines."&lt;/p&gt;&lt;p&gt;He had originally planned to retire at 20 years, but life had other plans for him.&lt;/p&gt;&lt;p&gt;In 2019, the senior sailor was 17 years into his Navy career when he was diagnosed with oligodendroglioma, a type of brain tumor lodged in the frontal lobe of his brain. He had just received his last orders for his twilight tour. &lt;/p&gt;&lt;p&gt;That year, he had noticed the migraine headaches that had plagued him since his 20's "getting a little bit worse," he said&lt;/p&gt;&lt;p&gt;What used to be a monthly or bimonthly occurrence became more frequent, stronger, and came with other symptoms. &lt;/p&gt;&lt;p&gt;"In July of 2019, I had 15,” he said. "And I was starting to see different symptoms with them, like the aura that I would typically see on the right side of my vision started moving to the left side. They were getting stronger, and my medicine wasn't working as well."&lt;/p&gt;&lt;p&gt;His command master chief recommended he seek more specialized care and his primary care manager ordered he get an MRI. One day after getting the scan in August, he got a call saying it revealed a tumor. &lt;/p&gt;&lt;p&gt;"When somebody tells you that you have a large mass in your brain, and that they've already told neurosurgery, my first thought was this must be really serious," he recalled. "Like, I might not have much time left and I need to go home and talk to my wife and call my mom."&lt;/p&gt;&lt;p&gt;Within the next month, in October of that year, he underwent surgery to remove the mass.&lt;/p&gt;&lt;p&gt;"They actually took four square inches out of my left frontal lobe, and then I did radiation and chemo after that," he said. &lt;/p&gt;&lt;p&gt;While Conley's medical team at &lt;a rel="noopener noreferrer" href="https://tripler.tricare.mil/" target="_blank" title="Goes to Tripler's website"&gt;Tripler Army Medical Center&lt;/a&gt; in Pearl Harbor, Hawaii, removed the tumor, the process resulted in some memory loss.&lt;/p&gt;&lt;p&gt;"The way my neuro-oncologist explained it is I had a highway system and "all of a sudden, we took out a whole bunch of it, so your brain is going to send signals," wondering where that area is," he said.&lt;/p&gt;&lt;p&gt;He explained that sometimes he has trouble thinking of words.&lt;/p&gt;&lt;p&gt;"I can be a little bit more forgetful than I used to be," he said. "I also still have the problem with migraines."&lt;/p&gt;&lt;p&gt;To count on family support and help alleviate the weight of his convalescence care on his wife, Lexy, and two small children, John Jackson and Emma Rose, Conley asked to be transferred to the Washington D.C. area, where his wife has family and also where he could continue his care at &lt;a rel="noopener noreferrer" href="https://walterreed.tricare.mil/Health-Services/Womens-Health-Pregnancy/Reproductive-Endocrinology-and-Infertility" target="_blank" title="Goes to Walter Reed's website"&gt;Walter Reed National Military Medical Center&lt;/a&gt;. &lt;/p&gt;&lt;p&gt;Today, he's considered to be under surveillance, which means he gets frequent checkups, including an MRI every four months, for monitoring. &lt;/p&gt;&lt;p&gt;"You're not invincible, right? And you need to enjoy every day you get with your kids, every day you get with your family, your wife," he said. "Even if you're having a crappy day, you got to find some way to find some positivity in it."&lt;/p&gt;</description><pubDate>Thu, 30 Nov 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{15C04449-095C-499E-BDF5-76811592D81F}</guid><link>https://www.health.mil/News/Articles/2023/11/29/DHAs-E-Caregiver-Directory-Puts-Resources-at-Your-Fingertips</link><title>DHA's E-Caregiver Directory Puts Resources at Your Fingertips</title><description>&lt;p&gt;The Defense Health Agency's electronic Caregiver Resource Directory provides more than 2,000 resources for caregivers of wounded warriors within three taps on their mobile phone, their computer, or tablet.&lt;/p&gt;&lt;p&gt;"When we update the NRD with new resources, they can be immediately added to the eCRD with just a check box," said Jonathan Morris, with DHA's &lt;a rel="noopener noreferrer" href="https://warriorcare.dodlive.mil/About/" target="_blank" title="opens DODlive.mil"&gt;Warrior Care Recovery Care Programs&lt;/a&gt; Operations, highlighting just one of its user-friendly features.&lt;/p&gt;&lt;p&gt;Other eCRD features include:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Simple searchability through navigations and links    &lt;/li&gt;    &lt;li&gt;No heavy scrolling    &lt;/li&gt;    &lt;li&gt;Single page content printing&lt;/li&gt;    &lt;li&gt;Hyperlinks to each resource&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;"The old version was a PDF and required people to scroll up and down. If they wanted to pull a specific page, they needed to download the complete directory," Morris pointed out.&lt;/p&gt;&lt;p&gt;A hard copy of the Caregiver Resource Directory was launched in 2015, updated yearly, and has had more than 300,000 free copies distributed, he said.&lt;/p&gt;&lt;h2&gt;Taking the Weight Off Relocation&lt;/h2&gt;&lt;p&gt;There are many services and resources available to caregivers and their families if they have to relocate, so that the hand-off can go as smoothly as possible.&lt;/p&gt;&lt;p&gt;"There are direct links to each of the military service relocation programs that are highlighted by location," Morris said.&lt;/p&gt;&lt;p&gt;He added that the NRD and the eCRD connect relocating caregivers and families to "services and agencies to help them settle in and give them access to virtual support through organizations such as the American Red Cross Military and Veterans Caregiver Network."&lt;/p&gt;&lt;p&gt;"They can also reach out to the NRD by email at &lt;a href="mailto:infoNRD.osd@mail.mil" title="email the NRD"&gt;infoNRD.osd@mail.mil&lt;/a&gt;, and the content team will assist with finding resources" down to local community churches, Morris explained.&lt;/p&gt;&lt;h2&gt;Self-Care and Crisis Care&lt;/h2&gt;&lt;p&gt;Caregiving can be a 24/7/365 responsibility, and caregivers need to take care of themselves to be able to continue their roles without burning out.&lt;/p&gt;&lt;p&gt;For Davis, "I'm always looking at ways for rest and relaxation; this helps protect my caregiver mental health and well-being."&lt;/p&gt;&lt;p&gt;She's also used the Veteran Spouse Network and has participated in caregiver retreats at an equestrian therapy ranch, which has programs for wounded warriors and their families. She said these programs add to her "toolkit" of self-care.&lt;/p&gt;&lt;p&gt;Additionally, crises can arise, and caregivers may have an immediate need for resources. "Some caregivers need that information right now," Davis said.&lt;/p&gt;&lt;p&gt;For other caregivers, challenges could be "everything from mental health, to employment, to education," Davis said, adding: "Caregivers need so much, and they just never know what kind of a situation they'll be in."&lt;/p&gt;&lt;h2&gt;Top Searches&lt;/h2&gt;&lt;p&gt;Some of the most commonly searched resources in the eCRD and NRD include:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Access to health care for caregivers    &lt;/li&gt;    &lt;li&gt;Guides to community resources    &lt;/li&gt;    &lt;li&gt;Caregiver resources for family members with traumatic brain injury    &lt;/li&gt;    &lt;li&gt;VA specialty resources for caregivers    &lt;/li&gt;    &lt;li&gt;Mental health support services for children of caregivers&lt;/li&gt;&lt;/ul&gt;</description><pubDate>Wed, 29 Nov 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{06F2AA1D-E348-42B2-82F2-E4BE345618D5}</guid><link>https://www.health.mil/News/Articles/2023/11/21/DHA-Health-Hazard-Assessment-Team-Doing-Critical-Work-to-Improve-Warfighter-Brain-Health</link><title>DHA Health Hazard Assessment Team Doing Critical Work to Improve Warfighter Brain Health</title><description>&lt;p&gt;A little over a year ago, in June 2022, the Department of Defense launched the Warfighter Brain Health Initiative to bring together the operational and medical communities in a more unified approach toward optimizing service member brain health and countering traumatic brain injuries. The WBHI specifically focuses on assessing cognitive capabilities, monitoring brain threats, to include blast overpressure, and minimizing the effects and risk from exposures and TBIs to improve a warfighter’s overall performance.&lt;/p&gt;&lt;p&gt;One of the goals of the initiative was to track a service member’s brain health from initial entry into the military all the way to retirement.&lt;/p&gt;&lt;p&gt;“We want you in for the long haul, and we want you to have a highly functional and productive life when you leave the military,” said Kathy Lee, lead for the WBHI and director of Casualty Management for the Office of the Assistant Secretary of Defense for Health Affairs.&lt;/p&gt;&lt;p&gt;One of the early areas of focus for the initiative was to conduct a longitudinal medical study to improve the DOD’s understanding of the impact of blast overpressure, also referred to as BOP. Blast overpressure is caused by the shock wave results firing weapons systems or explosive detonations (e.g., breaching charges). Some of the main symptoms caused by excessive BOP exposure to the brain are headaches, slowed cognitive processing or slowed reaction time.&lt;/p&gt;&lt;p&gt;As part of this process, OSD(HA) asked each service to identify their top 3–5 high overpressure weapon systems generating blast pressure exposure effects for service members. Then OSD(HA) used the service input, which Lee said was critical in creating a list of these “Tier 1” Weapon Systems, to place them into distinct categories:&lt;/p&gt;&lt;p&gt;Shoulder Mounted Weapons&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;M3 Multi-Role Anti-Armor Anti-Personnel Weapon System (MAAWS)&lt;/li&gt;    &lt;li&gt;M135 AT4 light anti-tank weapon system&lt;/li&gt;    &lt;li&gt;M72 light anti-armor weapon&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;.50 Caliber Weapons&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;MK15 Sniper Rifle&lt;/li&gt;    &lt;li&gt;M107 Sniper Rifle&lt;/li&gt;    &lt;li&gt;M2A1 Machine Gun&lt;/li&gt;    &lt;li&gt;GAU-21 Machine Gun&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;Indirect Fire Systems (Howitzers)&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;M119 Towed 105mm&lt;/li&gt;    &lt;li&gt;M777 Towed 155mm&lt;/li&gt;    &lt;li&gt;M109 Paladin SP 155mm&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;Indirect Fire Systems (Mortars)&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;M224 60mm&lt;/li&gt;    &lt;li&gt;M252 81mm&lt;/li&gt;    &lt;li&gt;M120/M121 120mm&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;Demolition (Breaching Charges)&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Door: Net Explosive Weight – 0.23 – 0.30 pounds&lt;/li&gt;    &lt;li&gt;Wall: New Explosive Weight – 10 – 14 pounds&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;The purpose of identifying these initial Tier 1 systems for review is to improve service member health assessments and outcomes, said Lee.&lt;/p&gt;&lt;p&gt;“We’re offering a mitigation strategy to try to keep service members safe and then the recognition that if they have these symptoms, go get checked out, go and get a medical person to do some eyes on, to do a quick assessment, and check those things that we talked about,” said Lee.&lt;/p&gt;&lt;p&gt;Included in the longitudinal medical study, the Defense Centers for Public Health–Aberdeen, formerly the U.S. Army Public Health Center, is in the process of developing Blast-related Brain Injury Interim Health Protection Criteria and associated risk assessment process. DCPH-A is the Office of Primary Responsibility, or OPR, for FY18 National Defense Authorization Act, Section 734 Line of Inquiry, LOI, 3: Exposure Environment. The LOI 3 has seven objectives, one of which is to conduct Joint Service Member Occupational Health Assessments for each of the Tier 1 Weapons Systems and Breaching Charges. The Health Hazard Assessment Division, along with Industrial Hygiene and Noise subject matter experts, at DCPH-A is supporting this effort by collecting data and measuring exposures from different weapons systems and breaching charges to make recommendations on how to help mitigate risk.&lt;/p&gt;&lt;p&gt;“The DCPH-A team is &lt;a href="https://www.army.mil/article/257374/army_navy_public_health_officials_collect_weapon_system_related_health_hazard_data_in_support_of_blast_overpressure_exposure_assessment" rel="noopener noreferrer" target="_blank" style="color: #0071bb; margin: 0px; padding: 0px; border-width: 0px 0px 1px; border-top-style: initial; border-top-color: initial; border-right-style: initial; border-right-color: initial; border-bottom-style: solid; border-bottom-color: #cccccc; border-left-style: initial; border-left-color: initial; line-height: inherit;" title="opens Army.mil"&gt;investigating blast waves &lt;/a&gt;in terms of what they call incident peak and incident impulse data,” said Dr. Timothy “AJ” Kluchinsky, chief of the DCPH-A Health Hazard Assessment Division, and OPR Lead for LOI 3. “The incident peak is the highest pressure level, and the incident impulse is the highest pressure level AND the time that it is high.”&lt;/p&gt;&lt;p&gt;One of the main goals of the team, in addition to creating the criteria to assess BOP exposures to the brain, was to review the safety precautions that existed for BOP and determine if they are sufficient or if they needed to be updated, said Olivia Webster, a biomedical engineer with HHA and the lead investigator for LOI 3.&lt;/p&gt;&lt;p&gt;“We’re also reviewing features of the environment to determine what was having the most impact on the exposure to the service member, and then one of the other big things that we did was have data fields developed in the Defense Occupational and Environmental Health Readiness System–Industrial Hygiene, or DOEHRS-IH, to capture BOP and Impulse Noise exposure data.” “DOEHRS-IH provides a mechanism that allows the DOD to manage occupational and environmental health risk data and actively track biological, chemical and physical health hazards to individual service members,” said Webster. &lt;/p&gt;&lt;p&gt;&lt;span style="background-color: #ffffff; color: #221f20;"&gt;One of the challenges for the team is collecting data from multiple weapons systems in extreme environmental conditions to help determine the effects of temperature, altitude and humidity on BOP exposure. To date, the team has completed occupational health assessments of the above Tier 1 Weapon Systems and Breaching Charges. These data are included as part of Joint Service member Occupational Health Assessments, or JSOHA. The JSOHA Program provides commanders and other risk managers with a comprehensive assessment of service member exposures to potential occupational hazards inherent to using various weapon systems during training and combat.&lt;/span&gt;&lt;/p&gt;&lt;p&gt;“We’re striving to get involved in the very early stages of weapon system development to establish these criteria,” said Kluchinsky. “We’re establishing an equation for weapon developers, testers, and assessors to facilitate identification of the effects of a weapon on a warfighter’s brain health. The ultimate goal is coming up with ways to reduce the exposure to a crew or service member, while still allowing the weapon design to meet the other key performance parameters. For example, being able to fire munitions far with so much accuracy and with so many repetitions is the goal while taking into account brain health factors. So, ultimately there’s a minimum threshold and an objective associated with each key performance parameter.”&lt;/p&gt;&lt;p&gt;Webster says one of the HHA team’s goals is to associate their recommendations with the risk levels outlined in the Military Standard 882E, Department of Defense Standard Practice System Safety, which delineates the DOD approach for identifying hazards and assessing and mitigating associated risks encountered in developing, testing, production, using and disposing of defense systems.&lt;/p&gt;&lt;p&gt;Kluchinsky says when it comes to BOP, the HHA team is writing the BOP assessment protocol for the WBHI. As part of the effort, the team uses approximately 60 blast gauges issued to service members who wear 3 at each firing position. Then they collect data and download that data to a laptop for processing.&lt;/p&gt;&lt;p&gt;Lee says one of the goals of the WBHI is to act rapidly.&lt;/p&gt;&lt;p&gt;“We need to get the information collected by this team out to the warfighters,” said Lee. “This increases the credibility that medical folks have with the operational folks to demonstrate that we are taking care of them, and we are sharing what we know as quickly as possible.”&lt;/p&gt;&lt;p&gt;The goal is to provide this information to service members who may be experiencing symptoms.&lt;/p&gt;&lt;p&gt;“We want to get this out to the field with the understanding that if you do have these symptoms afterwards, and you do think your thinking skills have been affected, and you do have ringing in your ears and eye movement changes, difficulty reading, things like that, that you need to go get checked out,” said Lee. “Go get checked out and see, especially if they're not transient, and see what we can do to make that better.”&lt;/p&gt;&lt;p&gt;Here are some government resource and information links on TBI and the WBHI:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;&lt;a href="https://media.defense.gov/2022/Aug/24/2003063181/-1/-1/0/DOD-WARFIGHTER-BRAIN-HEALTH-INITIATIVE-STRATEGY-AND-ACTION-PLAN.PDF" rel="noopener noreferrer" target="_blank" style="color: #0071bb; margin: 0px; padding: 0px; border-width: 0px 0px 1px; border-top-style: initial; border-top-color: initial; border-right-style: initial; border-right-color: initial; border-bottom-style: solid; border-bottom-color: #cccccc; border-left-style: initial; border-left-color: initial; line-height: inherit;" title="opens Defense.gov"&gt;DOD Warfighter Brain Health Initiative&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="/Military-Health-Topics/Centers-of-Excellence/Traumatic-Brain-Injury-Center-of-Excellence/TBI-Resources-for-Military-Leadership" target="_self" title="opens Health.mil"&gt;TBI Resources for Military Leadership&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://blastinjuryresearch.health.mil/index.cfm/blast_injury_101" rel="noopener noreferrer" target="_blank" style="color: #0071bb; margin: 0px; padding: 0px; border-width: 0px 0px 1px; border-top-style: initial; border-top-color: initial; border-right-style: initial; border-right-color: initial; border-bottom-style: solid; border-bottom-color: #cccccc; border-left-style: initial; border-left-color: initial; line-height: inherit;" title="opens Blast Injury Research Office"&gt;Blast Injury 101&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://www.research.va.gov/topics/tbi.cfm" rel="noopener noreferrer" target="_blank" style="color: #0071bb; margin: 0px; padding: 0px; border-width: 0px 0px 1px; border-top-style: initial; border-top-color: initial; border-right-style: initial; border-right-color: initial; border-bottom-style: solid; border-bottom-color: #cccccc; border-left-style: initial; border-left-color: initial; line-height: inherit;" title="opens VA.gov"&gt;VA research on traumatic brain injury&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://www.dvidshub.net/video/873993/brain-injury-awareness-with-19th-sgt-maj-marine-corps" rel="noopener noreferrer" target="_blank" style="color: #0071bb; margin: 0px; padding: 0px; border-width: 0px 0px 1px; border-top-style: initial; border-top-color: initial; border-right-style: initial; border-right-color: initial; border-bottom-style: solid; border-bottom-color: #cccccc; border-left-style: initial; border-left-color: initial; line-height: inherit;" title="watch the video on DVIDS"&gt;Brain Injury Awareness with the 19th Sgt. Maj. of the Marine Corps&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://walterreed.tricare.mil/Portals/126/Documents/NICoE%20Research%20Booklet%202020_508_FINAL.pdf" rel="noopener noreferrer" target="_blank" style="color: #0071bb; margin: 0px; padding: 0px; border-width: 0px 0px 1px; border-top-style: initial; border-top-color: initial; border-right-style: initial; border-right-color: initial; border-bottom-style: solid; border-bottom-color: #cccccc; border-left-style: initial; border-left-color: initial; line-height: inherit;" title="opens TRICARE.mil"&gt;National Intrepid Center of Excellence (NICoE) – Contributing to Force Readiness Through Research&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://www.ai.mil/blog_02_04_21_merit_the_right_info_in_the_right_hands_at_the_right_time.html" title="opens AI.mil"&gt;The Right Information in the Right Hands at the Right Time – Chief Digital &amp; Artificial Intelligence Office&lt;/a&gt;&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;The Defense Health Agency supports our Nation by improving health and building readiness–making extraordinary experiences ordinary and exceptional outcomes routine.&lt;/p&gt;&lt;p&gt;NOTE: The mention of any non-federal entity and/or its products is for informational purposes only, and not to be construed or interpreted, in any manner, as federal endorsement of that non-federal entity or its products.&lt;/p&gt;</description><pubDate>Tue, 21 Nov 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{1371B188-0002-419C-8D23-2003A0D27B28}</guid><link>https://www.health.mil/News/Articles/2023/11/01/Cold-Weather-Injuries</link><title>Update: Cold Weather Injuries Among the Active and Reserve Components of the U.S. Armed Forces, July 2018–June 2023</title><description>&lt;p&gt;From July 2022 through June 2023, a total of 423 members of the active (n=376) and reserve (n=47) components of the U.S. Armed Forces had at least one cold weather injury. The crude overall incidence rate of cold injury among all active component service members during the 2022-2023 cold season was 28.5 per 100,000 person-years (p-yrs), 15.2% lower than the rate observed during the 2021-2022 cold season (33.6 per 100,000 p-yrs). The rates of cold injuries varied among the Armed Forces, with the highest rates per 100,000 p-yrs observed in the Army, at 50.9, followed by the Marine Corps, at 32.2, the Air Force, at 18.9, the Navy, at 8.1, and the Coast Guard at 5.1. Consistent with previous cold seasons, frostbite (54.0%) remained the most common type of cold injury among ACSM during the 2022-2023 cold season, while the proportions of hypothermia and immersion injuries were 16.5% and 30.3%, respectively. Cold injury rates among ACSM during the 2018 to 2023 cold seasons were generally highest for males, non-Hispanic Blacks, those under 20 years of age, and enlisted members. The number of cold injuries identified in service members deployed outside the U.S during the 2022-2023 cold season (n=10) was comparable to the two preceding cold seasons (11 in 2020-2021 and 12 in 2021-2022), with frostbite accounting for half (n=5) of the 2022-2023 cases.&lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;For all ACSM, the rate of cold weather injuries in 2022-2023 decreased by 15.2% compared to the preceding cold season. The decrease was most pronounced in the Marine Corps, with a 22.0% reduction in the incidence rate of cold injuries. This year’s report includes cold injury rates for the Coast Guard.&lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;Cold injuries are a predictable and preventable threat. Continuous surveillance is essential to prevent cold weather injuries and mitigate their adverse impacts on military operations. Military training and combat operations require continued emphasis on effective cold weather injury prevention strategies and adherence to relevant policies and procedures to protect service members against such injuries.&lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt; Cold injuries are of significant military concern because of their adverse impact on operations and the  high financial costs of treatment and disability.&lt;sup&gt;1,2&lt;/sup&gt; In response, the U.S. Armed Forces have developed and are continually improving their training, doctrine, procedures, and protective equipment and clothing to counter the threat of cold environments.&lt;sup&gt;3-8&lt;/sup&gt; Although these measures are highly effective, cold injuries continue to affect hundreds of service members each year due to exposure to both cold and wet environments.&lt;sup&gt;9&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Military training or mission requirements in cold and wet weather conditions can preclude immediate warm or dry shelter, the ability to change wet or damp clothing, or even healthy physical activity.&lt;sup&gt;2-4&lt;/sup&gt; Continuous surveillance of cold  weather injuries is essential to inform measures for reducing their impacts and remind leaders of this predictable threat. The Department of Defense guidelines for reportable medical events require reporting of cases of hypothermia, freezing peripheral injuries (e.g., frostbite), and non-freezing peripheral injuries (e.g., immersion injuries, chilblains).&lt;sup&gt;10&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Cold injuries can be broadly categorized in two major groups: those with a central effect, and those primarily affecting peripheral parts of the body. Hypothermia is a classic example of a central cold injury, which occurs when the body’s core temperature falls below 95°F.&lt;sup&gt;7&lt;/sup&gt; Freezing atmospheric temperatures are not required to produce hypothermia.&lt;sup&gt;11&lt;/sup&gt; Severe hypothermia can lead to pulmonary edema, reduced heart rate, coma, ventricular arrhythmias (including ventricular fibrillation), and asystole.&lt;sup&gt;11-13&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Peripheral cold injuries mainly affect extremities such as hands and feet, and can be further classified as either freezing injuries, such as frostbite, or non-freezing injuries such as immersion foot. Freezing peripheral injury is defined as the damage sustained by tissues exposed to temperatures below freezing.&lt;sup&gt;14&lt;/sup&gt; A substantial proportion of patients with peripheral frostbite experience permanent changes in their microcirculation and disruption of local neurological functions (e.g., reduced sensation in the affected area).&lt;sup&gt;15&lt;/sup&gt; The areas of the body most frequently affected by frostbite include the ears, nose, cheeks, chin, fingers, and toes.&lt;sup&gt;15,16&lt;/sup&gt; Although most frostbite damage is minor, severe injury may lead to impaired functioning and inability to work due to cold hypersensitivity, chronic ulceration, vasospasm, localized osteoarthritis, or chronic pain.&lt;sup&gt;15,17&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Non-freezing peripheral cold injury includes a spectrum of localized injuries to the soft tissues, nerves, and vasculature of distal extremities that result from prolonged exposure (12 to 48  hours) to wet, cold (generally 32 to 59°F) conditions; the injury process is generally slower in warmer water.&lt;sup&gt;14,21&lt;/sup&gt; Although non-freezing peripheral cold injuries most often involve feet (e.g., immersion foot), any dependent body part can be affected by the condition, including the hands.&lt;sup&gt;22&lt;/sup&gt; Immersion foot generally presents as waterlogging, with the most marked effect in the soles&lt;sup&gt;20,21&lt;/sup&gt;: The foot becomes hyperemic (i.e., increased  blood flow), painful, and swollen with continuous exposure; progression to blistering, decreased blood flow, ulceration, and gangrene is gradual.&lt;sup&gt;20,21&lt;/sup&gt; Long-term complications of non-freezing cold injury such as immersion foot are similar to, and equally debilitating as, those produced by frostbite: hypersensitivity to cold, chronic pain, and severe pain induced by walking.&lt;sup&gt;17,19,20,21&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Environmental factors that increase the risk of cold weather injuries include prolonged outdoor exposure to temperatures 40°F and below, wind speeds exceeding five miles per hour, high altitude, hypoxia, geographic location, wet conditions due to rain and snow, or submersion in cold water, in addition to lack of adequate shelter and clothing.&lt;sup&gt;22&lt;/sup&gt; Situational factors that increase risk of immersion foot include immobility, wet socks, and constrictive boots.&lt;sup&gt;20,23,24&lt;/sup&gt; Individual risk factors vary and include previous cold injury, exhaustion, dehydration, fatigue, sleep deprivation, improper acclimatization, inadequate nutrition, alcohol use, smoking, chronic  disease (e.g., peripheral vascular disease, diabetes), older age, and medications that impair compensatory  responses (e.g., oral antihyperglycemics, beta-blockers, general anesthetic agents).&lt;sup&gt;13-17,20&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Since 2004, the &lt;em&gt;MSMR&lt;/em&gt; has published annual updates on the incidence of cold weather injuries affecting U.S. military members for the 5 most recent cold seasons.&lt;sup&gt;25&lt;/sup&gt; The timing of these annual updates is intended to call attention to the recurring risks of such injuries as winter approaches in the Northern Hemisphere, where most members of the U.S. Armed Forces are assigned. This 2023 report addresses the occurrence of frostbite, immersion hand and foot, and hypothermia during the cold seasons from July 2018 through June 2023. Cases of chilblains are not included in this report because the condition is common, infrequently diagnosed, usually mild in severity, and thought to have minimal medical, public health, or military impacts.&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;This surveillance population included all individuals who served in the active or reserve components of the U.S. Armed Forces at any time during the surveillance period of July 1, 2018 through June 30, 2023. Service members in the Space  Force were classified as Air Force for this analysis due to data availability beginning January 2023 for the newly formed service. For analysis purposes, “cold years” or “cold seasons” were defined as July 1 through June 30 intervals so complete cold weather seasons could be represented in annual summaries and comparisons.&lt;/p&gt;&lt;p&gt;Records of cold weather injuries for frostbite, immersion hand and foot, and hypothermia were queried from RMEs submitted to the Disease Reporting System internet and diagnostic codes from inpatient and outpatient medical encounters and records from the Theater Medical Data Store. Data from these sources are routinely incorporated into the Defense Medical Surveillance System. A case was defined by the presence of an RME or one of any qualifying  International Classification of Diseases, 9th or 10th revision (ICD-9 and ICD-10, respectively) code in the first diagnostic position of a record of a health care encounter (Table 1).&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-Article-1-Table-1" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="International Classification of Diseases, 9th or 10th codes for cold weather injuries." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-1-Table-1.ashx?h=271&amp;w=850&amp;hash=4B2E6577D452F4FFFE4FE3A3573C91EAF4E60B0B" style="width: 850px; height: 271px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Due to an update to the DRSi medical event reporting  system in July 2017, the type of RME for a cold injury (e.g., frostbite, immersion injury, hypothermia) could not be distinguished using RME records in DMSS data. Instead, information on the types of RMEs for cold injury between July 2018 and June 2023 were extracted from DRSi and then combined with DMSS data.&lt;/p&gt;&lt;p&gt;To estimate the number of unique individuals who suffered a cold injury each cold season, and to avoid counting follow-up health care encounters, only one cold injury per individual per cold season was included. To count types of cold injury, namely frostbite, immersion hand and foot, and hypothermia cases, one of each type of cold injury per individual per cold season could be included. For example, if an individual was diagnosed or reported with immersion hand and foot at one point during a cold season and then with frostbite later in the same cold season, each of those different types of injury would be included in the injury calculation. If a service member had multiple medical encounters for cold injuries on the same day, only one encounter was used for analysis (hospitalizations were prioritized over ambulatory visits, which were prioritized over RMEs).&lt;/p&gt;&lt;p&gt;Annual incidence rates of cold injuries among active component service members were calculated as incident cold injury diagnoses per 100,000 person-years of service. Annual rates of cold injuries among reservists were calculated as cases per 100,000 persons using the total number of reserve component service members for each year of the surveillance period. Counts of persons in the reserves were used as the denominator in these calculations because information on the start and end dates of active duty service periods of reserve component members is not available.&lt;/p&gt;&lt;p&gt;Cold injuries are summarized by the locations where service members were treated for those injuries, identified by a Defense Medical Information System Identifier of an encounter. Because such injuries can occur during field training, temporary duty, or outside usual duty stations, DMIS ID was used as a proxy for the location where the cold injury occurred.&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;h3&gt;2022–2023 cold season&lt;/h3&gt;&lt;p&gt;From July 2022 through June 2023, a total of 423 members of the active (n=376) and reserve (n=47) components had at least one cold weather injury (Table 2). &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-Article-1-Table-2" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="Annual incidence of service members affected by cold injury July 2018-June 2023." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-1-Table-2.ashx?h=775&amp;w=1100&amp;hash=13190E5C17A4D139C1405F2E803BC035608D9E66" style="width: 1100px; height: 775px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;In the active component, Army members had the highest rate of any cold injury (n=231, 50.9 per 100,000 p-yrs) during the 2022-2023 cold season, followed by members of the Marine Corps (n=55, 32.2 per 100,000 p-yrs), Air Force (n=61, 18.9 per 100,000 p-yrs), and Navy (n=27, 8.1 per 100,000 p-yrs). Only two active component Coast Guard members were affected by cold weather injuries during the 2022-2023 cold season (5.1 per 100,000 p-yrs). One cold injury, frostbite, was recorded for a member of the Space Force (counted with the Air Force) (data not shown). Among the reserve component, Army personnel accounted for more than two-thirds of cases (n=33, 6.1 per 100,000 p-yrs) during 2022-2023 (Table 2), although the Marine Corps had the highest rate of cold injuries among reservists (n=4, 10.2 per 100,000 persons).&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-Article-1-Table-3a" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="Annual incidence of frostbite, immersion foot, and hypothermia among all cold injuries July 2018-June 2023 U.S. Army." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-1-Table-3a.ashx?h=1102&amp;w=1150&amp;hash=F626995DDE1281E5C3CD8C5F5E677E4C856DA6AB" style="width: 1150px; height: 1102px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-Article-1-Table-3b" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="Annual incidence of frostbite, immersion foot, and hypothermia among all cold injuries July 2018-June 2023 U.S. Navy" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-1-Table-3b.ashx?h=1106&amp;w=1150&amp;hash=8BB63657528B2D1B7A88871019164536709F3C9B" style="width: 1150px; height: 1106px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-Article-1-Table-3c" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="Annual incidence of frostbite, immersion foot, and hypothermia among all cold injuries July 2018-June 2023 U.S. Air Force." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-1-Table-3c.ashx?h=1110&amp;w=1150&amp;hash=5FB47DCDF365B4675F4246C90F02B83789A51DBE" style="width: 1150px; height: 1110px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-Article-1-Table-3d" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="Annual incidence of frostbite, immersion foot, and hypothermia among all cold injuries July 2018-June 2023 U.S. Marines." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-1-Table-3d.ashx?h=1106&amp;w=1150&amp;hash=5E7014C70135B909C1959957E99BCA931393E7E7" style="width: 1150px; height: 1106px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-Article-1-Table-3e" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="Annual incidence of frostbite, immersion foot, and hypothermia among all cold injuries July 2018-June 2023 U.S. Coast Guard." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-1-Table-3e.ashx?h=1102&amp;w=1150&amp;hash=41A63D5148DB044EED7C59013B32464C614FD610" style="width: 1150px; height: 1102px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;When major types of cold injury case classifications are considered (not numbers of individuals affected), frostbite was the most common type of cold injury (n=202; 54.0% of all cold injuries) among ACSM in all services in 2022-2023 (Tables 3a–3e). Within the Air Force during the 2022-2023 season, 78.7% of all cold injuries were frostbite, but the proportions of frostbite injury in the Army (53.9%), Marine Corps (35.7%) and Navy (29.6%) were much lower. The Coast Guard had two cold weather injuries in 2022-2023, one each of frostbite and hypothermia.&lt;/p&gt;&lt;p&gt;For all active component service members in 2022-2023, the proportions of hypothermia (n=62) and immersion injuries (n=114) were 16.5% and 30.3%, respectively (Tables 3a–3e). The numbers and rates of hypothermia injuries in the 2022-2023 cold season were the lowest among active component Army and Marine Corps members during the 5-year period, while case counts and rates of frostbite were the lowest among active component Navy members (Table 3a, Table 3b, Table 3d).&lt;/p&gt;&lt;h3&gt;Five cold seasons: July 2018–June 2023&lt;/h3&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-1-Figure-1.ashx?h=665&amp;w=850&amp;hash=464EF76371709174036AF005F2ECA5ABB38ED096" style="width: 850px; height: 665px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="FIGURE 1. This graph comprises six lines oriented on the horizontal, or x-, axis, each connecting five discrete data points oriented along the vertical, or y-, axis. Five of these lines represent a branch of the U.S. Armed Forces including the Coast Guard active component, while the sixth line represents the total active component of the U.S. Armed Forces. The y axis of the graph charts the annual incidence rates, per 100,000 person-years, of any cold injury among active component service members during each of the five cold seasons starting in July 2018 and continuing through June 2023. While the service-specific annual cold injury rate was highest among the Marine Corps during the initial (2018-2019) cold season evaluated, since then rates have been consistently highest in the Army, ranging between 50 and 60 cases per 100,000 person-years, or p-years, every cold season. Rates within the Marine Corps dropped dramatically from the 2018-2019 season to the 2019-2020 season, and then rose substantially in the following (2020-2021) season, but have been steadily declining since. Rates among the Coast Guard, Navy, and Air Force are generally consistent, each under 20.0 cases per 100,000 p-years annually. The average numbers of annual cases for the total active component are relatively stable, around 30.0 per 100,000 p-years.  "&gt;&lt;/p&gt;&lt;p&gt;The crude overall incidence rate of cold injury for all ACSM in 2022-2023 was 28.5 per 100,000 p-yrs, representing a 15.2% decline compared to the rate observed in 2021-2022 (33.6 per 100,000 p-yrs) (Table 2, Figure 1). Throughout the surveillance period, cold injury rates were consistently higher among active component members of the Army and the Marine Corps (Figure 1). The active component service-specific incidence rates decreased the most from 2021-2022 to 2022-2023 among Marine Corps members, by 22.0%, followed by the Army, with a 15.8% decrease, while the Navy reported a 13.6% decrease, and the Air Force rate decreased 2.5%. Incidence rates of cold injuries for the last two cold seasons were similar for the Coast Guard (5.1 per 100,000 p-yrs in 2022-2023, 5.0 in 2021-2022). Crude overall incidence rates of cold injuries were also similar for reserve component service members (5.7 per 100,000 p-yrs in 2022-2023 and 5.8 per 100,000 p-yrs in 2021-2022) for the past two seasons (Figure 2).&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-1-Figure-2.ashx?h=662&amp;w=850&amp;hash=27567E0E389394278BE538EE5DFEF5A689AF3DB0" style="width: 850px; height: 662px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="FIGURE 2. This graph comprises six lines oriented on the horizontal, or x-, axis, each connecting five discrete data points oriented along the vertical, or y-, axis. Five of these lines represent a branch of the U.S. Armed Forces including the Coast Guard reserve component, while the sixth line represents the total reserve component of the U.S. Armed Forces. The y axis of the graph charts the annual incidence rates, per 100,000 person-years, or p-years, of any cold injury among reserve component service members during each of the five cold seasons starting in July 2018 and continuing through June 2023. Substantial variability in annual rates of cold injuries was observed among reserve component members in the Marine Corps and Coast Guard due to low case counts. Rates were higher in the Marine Corps every year represented except the 2021-2022 cold season, when Coast Guard reserve case numbers increased from zero in the initial two cold seasons to 1.0 in 2020-2021, doubling to 2.0 in 2021-2022, before returning to zero reported cases in 2022-2023. Marine Corps reserve cases were also highly variable during the first four cold seasons, from a peak of 35.0 cases per 100,000 person-years, or p-years, in 2018-2019, but have been significantly lower, just above 10.0 per 100,000 p-years, for the past two seasons. Rates in the other three branches of the reserves are significantly lower, and generally consistent with the average rates for the total reserve component, which is just above 5.0 reported cases per 100,000 p-years."&gt;&lt;/p&gt;&lt;p&gt;During the 5-year surveillance period, overall rates of cold injuries were generally higher among males in all services except the Coast Guard (Tables 3a–3e). The overall rates among male service members of the Navy, Air Force, and Marine Corps were 1.6 to 1.8 times higher than those of their female counterparts.&lt;/p&gt;&lt;p&gt;For all services, overall rates of cold injuries were higher among non-Hispanic Black service members than those of the other races and ethnicities (Tables 3a–3e). Rates of frostbite among non-Hispanic Black members of the Army were more than three times higher than those of other races and ethnicities, with the biggest differences observed in the Marine Corps—where it was more than four times higher.&lt;/p&gt;&lt;p&gt;Rates of cold injuries in all services were highest among the youngest service members and tended to decrease with increasing age (Tables 3a–3e).&lt;/p&gt;&lt;p&gt;Enlisted members of all five services experienced higher rates of injury than officers. Rates of all cold injuries in the Army, Air Force, and Marine Corps combined were highest among service members in combat-specific (infantry/artillery/combat or engineering/armor) occupations (Tables 3a, 3c–3d). Among the active component of the Navy, rates of cold injuries during the 5-year surveillance period were highest for service members in motor transport occupations (Table 3b).&lt;/p&gt;&lt;p&gt;Among the cold injury cases reported within the active component during the 5-year period (n=2,137), 89 (4.2% of the total) occurred during basic training. The Army (n=36) and Marine Corps (n=51) accounted for 97.8% of all basic trainees affected by cold injuries (data not shown). Throughout the course of the 5-year surveillance period, a total of 46 service members were hospitalized, a figure which represents 2.2% of total cold weather injuries for the period: Army (n=32) and Marine Corps (n=9) members accounted for most (89.1%) of all hospitalized cases (data not shown).&lt;/p&gt;&lt;h3&gt;Cold injuries during deployments&lt;/h3&gt;&lt;p&gt;During the 5-year surveillance period a total of 66 cold injuries were diagnosed among service members deployed outside the U.S. (data not shown), of which 35 (53.0%) were frostbite, 20 (30.3%) were immersion injuries, and 11 (16.7%) were hypothermia. Approximately one-third (n=23) of all 66 deployment-associated cold injuries were diagnosed during the 2018-2019 cold season. The number of cases in subsequent cold seasons were consistent, with 10 to 12 cold injuries recorded each season (data not shown). Frostbite injuries accounted for half (n=5; 50.0%) of cold weather injuries identified in service members deployed outside of the U.S during the 2022-2023 cold season.&lt;/p&gt;&lt;h3&gt;Cold injuries by location&lt;/h3&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-1-Figure-3.ashx?h=659&amp;w=1200&amp;hash=F1BDCE7E315013FDED6813456EB52D0E6905063B" style="width: 1200px; height: 659px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="FIGURE 3. This chart displays 20 vertical columns that represent the military installations reporting at least 25 cold injuries during the 2022-2023 season. The height of each column represents the number of cold injuries reported during the 2022-2023 cold season. Thirteen of the 25 installations reported 10 or fewer cold injury cases during the 2022-2023 cold season. In addition to the columns, independently-plotted horizontal lines also presented on the horizontal, or x-, axis represent each of the 20 locations’ median number of annual cold injury cases during the preceding four cold seasons. Each corresponding vertical column is color-coded to indicate whether incident cases in 2022-2023 at that location exceeded or lagged the median number of cases for the preceding four seasons. Only four locations—namely, Fort Wainwright, Arkansas; U.S. Army Garrison Bavaria, Germany; Fort Moore (formerly Benning), Georgia; and Fort Liberty (formerly Bragg), North Carolina—exceeded their median case numbers in 2022-2023, with all but Army Garrison Bavaria reporting slightly higher numbers of cases. Army Garrison Bavaria, however, reported nearly eight times its median number of cold injury cases in 2022-2023. With the exceptions of Fort Wainwright, Army Garrison Bavaria, and Fort Carson, Colorado, all other installations listed reported less than 20 cold injury cases during the 2022-2023 cold season."&gt;&lt;/p&gt;&lt;p&gt;During the 5-year period, 20 military locations reported at least 25 incident cold injuries (one per person per year) among ACSM (Figure 3). Locations with the highest 5-year counts of incident injuries were Fort Wainwright (n=236), Joint Base Elmendorf-Richardson (n=167), Fort Carson (n=96), Camp Lejeune (n=93), Fort Moore (formerly Benning) (n=79), Fort Drum (n=71), and Fort Campbell (n=71) (data not shown). During the 2022-2023 cold season, incidence rates of cold injuries were higher than the 2021-2022 incidence rates at 6 of the 20 locations (data not shown). The most notable increase was at the Army’s Fort Carson, where 22 cases (98.2 per 100,000 p-yrs) were identified in 2022-2023, compared to 11 (42.1 per 100,000 p-yrs) the prior year (data not shown). U.S. Army Garrison Bavaria's case count increased the most, from 1 in 2021-2022 to 40 in 2022-2023. Figure 3 charts the 2022-2023 seasonal numbers of cold injuries and median case numbers for the prior four seasons for the 20 locations with at least 25 cases. At 16 installations, case numbers in 2022-2023 were less than the median counts for the previous four years.&lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;The overall rate of cold weather injuries among ACSM in 2022-2023 decreased by 15.2% from the previous cold injury season. This decrease was most pronounced within the Marine Corps, with a 22.0% lower incidence rate from 2021-2022. As in prior years, cold injury rates were much higher among members of the Army and Marine Corps. In 2022-2023, frostbite was the most common type of cold injury among ACSM in all five services.&lt;/p&gt;&lt;p&gt;Compared to their respective counterparts, overall rates of cold injuries were higher among male service members, non-Hispanic Black service members, the youngest (less than 20 years old), and enlisted service members. Rates of frostbite were markedly higher among non-Hispanic Blacks compared to non-Hispanic Whites and those in the other/unknown race and ethnicity group. These differences have been noted in prior &lt;em&gt;MSMR&lt;/em&gt; updates, and results of several studies suggest that other factors (e.g., physiological differences, previous cold weather experience) are possible explanations for increased susceptibility.&lt;sup&gt;9,15,26–28&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;It should be noted that this analysis of cold injuries was unable to distinguish between injuries sustained during official military duties (training or operations) and those associated with unrelated or personal activities. RMEs for non-freezing peripheral injuries were excluded if “chilblains” was listed in case comments; some RMEs for chilblains were potentially misclassified, however, as immersion injury if chilblains were not listed in the case comments.&lt;/p&gt;&lt;p&gt;To prepare for all circumstances posing a threat for cold weather injury, service members should be aware of and able to identify signs of cold injury, as well as environmental, individual and situational risk factors, and protective measures for themselves and fellow service members, whether during training, operations, combat, or recreation in wet or freezing conditions.&lt;/p&gt;&lt;p&gt;&lt;em&gt;This article has been revised due to an error in the original published version. &lt;/em&gt;&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Candler WH, Freedman MS. Military medical operations in cold environments. In: Pandolf KB, Burr RE, eds. &lt;em&gt;Medical Aspects of Harsh Environments, Volume 1&lt;/em&gt;. Office of the Surgeon General; 2001:553-566.&lt;/li&gt;    &lt;li&gt;Paton BC. Cold, casualties, and conquests: the effects of cold on warfare. In: Pandolf KB, Burr RE, eds. &lt;em&gt;Medical Aspects of Harsh Environments, Volume 1&lt;/em&gt;. Office of the Surgeon General; 2001:313-349.&lt;/li&gt;    &lt;li&gt;Pozos RS (ed.). Section II: cold environments. In: Pandolf KB, Burr RE, eds. &lt;em&gt;Medical Aspects of Harsh Environments, Volume 1&lt;/em&gt;. Office of the Surgeon General; 2001:311-566.&lt;/li&gt;    &lt;li&gt;DeGroot DW, Castellani JW, Williams JO, Amoroso PJ. Epidemiology of U.S. Army cold weather injuries, 1980–1999. &lt;em&gt;Aviat Space Environ Med&lt;/em&gt;. 2003;74(5):564-570.&lt;/li&gt;    &lt;li&gt;Headquarters, Department of the Army. Technical Bulletin Medical 508. Prevention and Management of Cold-Weather Injuries. Apr. 1, 2005.&lt;/li&gt;    &lt;li&gt;Headquarters, Department of the Army, Training and Doctrine Command. TRADOC Regulation 350-29: Prevention of Heat and Cold Casualties. Jun. 15, 2023.&lt;/li&gt;    &lt;li&gt;Headquarters, Department of the Army, Training and Doctrine Command. TRADOC Regulation 350-6: Enlisted Initial Entry Training Policies and Administration. Aug. 9, 2019.&lt;/li&gt;    &lt;li&gt;Castellani JW, O’Brien C, Baker-Fulco C, Sawka MN, Young AJ. Sustaining health and performance in cold weather operations. Technical Note TN/02-2. U.S. Army Research Institute of Environmental Medicine. Oct. 2001.&lt;/li&gt;    &lt;li&gt;Armed Forces Health Surveillance Branch. Update: cold weather injuries, active and reserve component, U.S. Armed Forces, July 2013–June 2018. &lt;em&gt;MSMR&lt;/em&gt;. 2018;25(11):10-17.&lt;/li&gt;    &lt;li&gt;Armed Forces Health Surveillance Branch. Armed Forces Reportable Events Guidelines and Case Definitions, 2020. &lt;a href="/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines" title="Click on the link to access AFHSD's Reportable Events Guidelines and Case Definitions"&gt;https://health.mil/Reference-Center/Publications/2020/01/01/Armed-Forces-Reportable-Medical-Events-Guidelines&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Jolly BT, Ghezzi KT. Accidental hypothermia. &lt;em&gt;Emerg Med Clin North Am&lt;/em&gt;. 1992;10(2):311-327.&lt;/li&gt;    &lt;li&gt;Rischall ML, Rowland-Fisher A. Evidence-based management of accidental hypothermia in the emergency department. &lt;em&gt;Emerg Med Pract&lt;/em&gt;. 2016;18(1):1-18.&lt;/li&gt;    &lt;li&gt;Biem J, Koehncke N, Classen D, Dosman J. Out of the cold: management of hypothermia and frostbite. &lt;em&gt;CMAJ&lt;/em&gt;. 2003;168(3):305-311.&lt;/li&gt;    &lt;li&gt;Imray CH, Oakley EH. Cold still kills: cold-related illnesses in military practice freezing and non-freezing cold injury. &lt;em&gt;J R Army Med Corps&lt;/em&gt;. 2005;151(4):218-222. doi:10.1136/jramc-151-04-02&lt;/li&gt;    &lt;li&gt;Ervasti O, Hassi J, Rintamaki H, et al. Sequelae of moderate finger frostbite as assessed by subjective sensations, clinical signs, and thermo-physiological responses. &lt;em&gt;Int J Circumpolar Health&lt;/em&gt;. 2000;59(2):137-145.&lt;/li&gt;    &lt;li&gt;Harirchi I, Arvin A, Vash JH, Zafarmand V. Frostbite: incidence and predisposing factors in mountaineers. &lt;em&gt;Br J Sports Med&lt;/em&gt;. 2005;39(12):898-901. doi:10.1136/bjsm.2004.016097&lt;/li&gt;    &lt;li&gt;Handford C, Thomas O, Imray CHE. Frostbite. &lt;em&gt;Emerg Med Clin North Am&lt;/em&gt;. 2017;35(2):281-299.&lt;/li&gt;    &lt;li&gt;Murphy JV, Banwell PE, Roberts AH, McGrouther DA. Frostbite: pathogenesis and treatment. &lt;em&gt;J Trauma&lt;/em&gt;. 2000;48(1):171-178. doi:10.1097/00005373-200001000-00036&lt;/li&gt;    &lt;li&gt;Petrone P, Kuncir EJ, Asensio JA. Surgical management and strategies in the treatment of hypothermia and cold injury. &lt;em&gt;Emerg Med Clin North Am&lt;/em&gt;. 2003;21(4):1165-1178. doi:10.1016/s0733-8627(03)00074-9&lt;/li&gt;    &lt;li&gt;Imray C, Grieve A, Dhillon S, Caudwell Xtreme Everest Research Group. Cold damage to the extremities: frostbite and non-freezing cold injuries. &lt;em&gt;Postgrad Med J&lt;/em&gt;. 2009;85(1007):481-488. doi:10.1136/pgmj.2008.068635&lt;/li&gt;    &lt;li&gt;Hall A, Sexton J, Lynch B, et al. Frostbite and immersion foot care. &lt;em&gt;Mil Med&lt;/em&gt;. 2018;183(suppl 2):168-171. doi:10.1093/milmed/usy085&lt;/li&gt;    &lt;li&gt;van Dongen TTCF, Berendsen RR, de Jong FJM, et al. Frostbite: a systematic review on freezing cold injuries in a military environment. &lt;em&gt;BMJ Mil Health&lt;/em&gt;. Epub. doi:10.1136/military-2022-002171&lt;/li&gt;    &lt;li&gt;McMahon JA, Howe A. Cold weather issues in sideline and event management. &lt;em&gt;Curr Sports Med Rep&lt;/em&gt;. 2012;11(3):135-141. doi:10.1249/JSR.0b013e3182578783&lt;/li&gt;    &lt;li&gt;Centers for Disease Control and Prevention. Natural Disasters and Severe Weather: Trench Foot or Immersion Foot. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/disasters/trenchfoot.html" title="Click on the link to access the CDC's trench or immersion foot web site" target="_blank"&gt;https://www.cdc.gov/disasters/trenchfoot.html&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Army Medical Surveillance Activity. Cold injuries, active duty, U.S. Armed Forces, July 1999–June 2004. &lt;em&gt;MSMR&lt;/em&gt;. 2004;10(5):2-10.&lt;/li&gt;    &lt;li&gt;Burgess JE, Macfarlane F. Retrospective analysis of the ethnic origins of male British Army soldiers with peripheral cold weather injury. &lt;em&gt;J R Army Med Corps&lt;/em&gt;. 2009;155(1):11-15. doi:10.1136/jramc-155-01-04&lt;/li&gt;    &lt;li&gt;Maley MJ, Eglin CM, House JR, Tipton MJ. The effect of ethnicity on the vascular responses to cold exposure of the extremities. &lt;em&gt;Eur J Appl Physiol&lt;/em&gt;. 2014;114(11):2369-2379. doi:10.1007/s00421-014-2962-2&lt;/li&gt;    &lt;li&gt;Kuht JA, Woods D, Hollis S. Case series of non-freezing cold injury: epidemiology and risk factors. &lt;em&gt;J R Army Med Corps&lt;/em&gt;. 2019;165(6):400-404. doi:10.1136/jramc-2018-000992&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Wed, 01 Nov 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{BA3ECB2C-EC35-4B22-955D-90B1D7184E07}</guid><link>https://www.health.mil/News/Articles/2023/11/01/Flu-Vaccination-of-Military-Heath-Care-Workers</link><title>Surveillance Snapshot: Influenza Immunization Among U.S. Armed Forces Health Care Workers, August 2018–April 2023</title><description>&lt;p&gt;The U.S. Advisory Committee on Immunization Practices recommends vaccination for all health care personnel against influenza to protect both themselves and their patients.&lt;sup&gt;1&lt;/sup&gt; The Joint Commission’s standard for infection control emphasizes that individuals infected with influenza virus are contagious to others before any signs or symptoms appear. The Joint Commission mandates 90% influenza vaccination for health care personnel, and health care organizations provide influenza vaccination programs for their practitioners and staff. Within the Department of Defense, seasonal influenza immunization is mandatory for all uniformed and health care personnel who provide direct patient care, and is recommended for all others (excluding those medically exempt).&lt;sup&gt;2-5&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-3-Figure.ashx?h=697&amp;w=1250&amp;hash=B3EA952D2C13C17E3CAE780FF03839F620A5ADF0" style="width: 1250px; height: 697px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This graph comprises three lines oriented on the horizontal, or x-, axis, each connecting five discrete data points oriented along the vertical, or y-, axis. These three lines represent the health care worker populations within the U.S. Army, Navy, and Air Force active components. The y axis of the graph charts the annual percent of those Armed Forces health care workers who received an influenza vaccination. The horizontal, or x-, axis demarcates the preceding five influenza seasons, which begin in August and conclude in April, from August 2018 through April 2023. Influenza vaccination rates among health care workers have remained above 91.0%, but declined steadily over the five years among Air Force personnel, from 97.0% to 93.7%; dropped within the last year from 95.5% to 92.8% among Navy personnel; Army rates were fairly consistent, and lower, than the other two services until declining to the absolute lowest rate, 92.0%, in 2021-2022 but the Army rebounded to its normal range of 93.8% in the 2022-2023 season."&gt;&lt;/p&gt;&lt;p&gt;This Surveillance Snapshot covers a 5-year surveillance period (August 2018–April 2023) and presents the documented percentage of compliance for the influenza immunization requirement among active component health care personnel of the Army, Navy, and Air Force. In general, these health care personnel include health care specialists (DOD occupation code=13) and health care officers (DOD ocupation code=26), but exclude veterinary medicine, environmental health, biomedical equipment maintenance and repair, and health services administration and logistics personnel. In the 2022-2023 influenza season, compliance rates ranged from 92.8% among Navy health care personnel to 93.8% among Army health care personnel (Figure).&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices. &lt;em&gt;MMWR Recomm Rep&lt;/em&gt;. 2011;60(RR-7):1-45.&lt;/li&gt;    &lt;li&gt;Headquarters, Departments of the Army, Navy, Air Force, and Coast Guard. Army Regulation 40-562, BUMEDINST 6230.15B, AFI 48-110_IP, CG COMD-TINST M6230.4G. Medical Services: Immunizations and Chemoprophylaxis for the Prevention of Infectious Diseases. Oct. 7, 2013.&lt;/li&gt;    &lt;li&gt;Assistant Secretary of Defense (Health Affairs). Policy for Mandatory Seasonal Influenza Immunization for Civilian Health Care Personnel Who Provide Direct Patient Care in Department of Defense Military Treatment Facilities. Health Affairs Policy 08-005. Apr. 4, 2008.&lt;/li&gt;    &lt;li&gt;Assistant Secretary of Defense (Health Affairs). Addition of Pandemic Influenza Vaccine or Novel Influenza Vaccine to the Policy for Mandatory Seasonal Influenza Immunization for Civilian Health Care Personnel Who Provide Direct Patient Care in Department of Defense Military Treatment Facilities. Health Affairs Policy 11-010. Jul. 28, 2011.&lt;/li&gt;    &lt;li&gt;Defense Health Agency. Procedural Instruction 6025.34. Guidance for the DOD Influenza Vaccination Program. Aug. 21, 2020.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Wed, 01 Nov 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{3C3B6CDE-669C-460C-AB51-63AC0C40C0FB}</guid><link>https://www.health.mil/News/Articles/2023/11/01/RMEs</link><title>Reportable Medical Events at Military Health System Facilities Through Week 39, Ending September 30, 2023</title><description>&lt;p&gt;Reportable Medical Events are documented in the Disease Reporting System internet by health care providers and public health officials throughout the Military Health System for monitoring, controlling, and preventing the occurrence and spread of diseases of public health interest or readiness importance. These reports are reviewed by each service’s public health surveillance hub. The DRSi collects reports on over 70 different RMEs, including infectious and non-infectious conditions, outbreak reports, STI risk surveys, and tuberculosis contact investigation reports. A complete list of RMEs is available in the 2022 Armed Forces Reportable Medical Events Guidelines and Case Definitions.&lt;sup&gt;1&lt;/sup&gt; Data reported in these tables are considered provisional and do not represent conclusive evidence until case reports are fully validated.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-RMEs" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-5-Table.ashx?h=1540&amp;w=1250&amp;hash=79250860BCD2C0DFB9BCA448851710AB366D0164" style="width: 1250px; height: 1540px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Total active component cases reported per week are displayed for the top five RMEs for the previous year. Each month, the graph is updated with the five leading RMEs, and is presented with the current month’s (September 2023) five leading RMEs, which may differ from previous months. COVID-19 is excluded from these graphs due to changes in reporting and case definition updates in 2023.&lt;/p&gt;&lt;p&gt;&lt;img alt="This graph comprises five lines on the horizontal, or x-, axis that depict case counts for the five most frequent reportable medical event conditions among active component service members during the past 52 weeks. Chlamydia remains the most common reportable medical condition, with counts consistently around 300 cases per week. Gonorrhea is generally the second-most common reported condition, averaging approximately 80 cases per week, but in week 26 of 2023 it was surpassed by heat illness, which outnumbered gonorrhea cases for the next eight of nine weeks, but declined to the same number gonorrhea cases by the end of week 35. Campylobacteriosis cases rose briefly at the end of week 34 to become the fourth-most common reported condition, but  declined in number thereafter through week 39, with syphilis retaining its status as the fourth-most common condition, at just over 10 reported cases per week." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-5-Figure.ashx?h=725&amp;w=1250&amp;hash=B9E780A2EE6A9D70D532BF5EBFECDE9F89CDC770" style="width: 1250px; height: 725px; vertical-align: middle; margin-top: 5px; margin-bottom: 20px;"&gt;&lt;/p&gt;&lt;p&gt;For questions about this report, please contact the Disease Epidemiology Branch at the Defense Centers for Public Health–Aberdeen. Email: &lt;a href="mailto:dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mil" title="Email DEP"&gt;dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mil&lt;/a&gt;.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Armed Forces Reportable Medical Events. Accessed Sep. 6, 2023. &lt;a rel="noopener noreferrer" href="https://health.mil/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines" target="_blank" title="Click on the link to access AFHSD's Reportable Medical Events Guidelines"&gt;https://health.mil/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Department of Defense Active Duty Military Personnel by Rank/Grade of Service, October 31, 2022. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the Defense Manpower Data Center's web page on personnel ranks and grades of service"&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Armed Forces Strength Figures for January 31, 2023. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the Defense Manpower Data Center's web page on personnel strength figures"&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Navy Medicine. Surveillance and Reporting Tools–DRSI: Disease Reporting System Internet. &lt;a rel="noopener noreferrer" href="https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI" target="_blank" title="Click on the link to access the Navy's web page on DRSi"&gt;https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Wed, 01 Nov 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{CE92AAE4-18B4-4740-A0E6-F6E82FD0CB43}</guid><link>https://www.health.mil/News/Articles/2023/11/01/Sunburn</link><title>Clinically Diagnosed Sunburn Among Active Component Service Members, U.S. Armed Forces, 2014–2022</title><description>&lt;p&gt;Sunburn affects U.S. military mission readiness, from clothing and gear discomfort, to infection and dehydration risk due to skin barrier breakdown and fluid loss.&lt;sup&gt;1&lt;/sup&gt; Depending on a service member’s military occupation, ultraviolet radiation exposure will vary, as seen with higher incidences of sunburn in recruits, aircraft and aircraft-related occupations, and infantry.&lt;sup&gt;1&lt;/sup&gt; Clinically, sunburn is classified and managed within two main categories: mild-moderate and severe.&lt;sup&gt;2&lt;/sup&gt; Electronic health record sunburn documentation is determined by International Classification of Diseases, 10th Revision diagnosis codes that classify sunburn as sunburn of first degree, second degree, third degree, or unspecified. Sunburn of first degree (superficial burn) only affects the outer layer of the skin (epidermis), manifesting in mild to moderate erythema without blistering. Sunburn of second degree (partial thickness burn) affects both the epidermis and part of the dermis, resulting in erythema with blistering, with or without edema. Sunburn of third degree (full thickness burn) affects the epidermis and dermis, and occasionally the underlying bones, muscles, and tendons.&lt;/p&gt;&lt;p&gt;A significant cause of skin cancer is excessive UVR exposure, often in the form of repeated sunburn.&lt;sup&gt;3&lt;/sup&gt; Among U.S. military service members, non-melanoma skin cancers are the most frequently diagnosed cancer.&lt;sup&gt;4,5&lt;/sup&gt; Additionally, a recent Department of Defense report found that U.S. military aircrew had an 87% higher rate of melanoma, and aviation support personnel (ground crew) had a 9% higher rate of melanoma, compared to the general U.S. population.&lt;sup&gt;6&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;A 2014 &lt;em&gt;MSMR&lt;/em&gt; report documented 19,172 incident cases of clinically-diagnosed sunburn among active component service members of the U.S. military from January 2002 to December 2013.&lt;sup&gt;1&lt;/sup&gt; Incidence rates were higher among women, non-Hispanic White service members, and those in younger age groups. Additionally, incidence was also higher for those in the Marine Corps and Army, as well as enlisted members, and recruits.&lt;sup&gt;1&lt;/sup&gt; This report describes recent frequencies and rates of clinically-diagnosed sunburn among active component service members.&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;This retrospective cohort study covered a surveillance period from January 1, 2014 to September 30, 2022 and included all ACSM of the U.S. Army, Air Force, Navy, and Marine Corps. Data were derived from the Defense Medical Surveillance System, which is maintained by the Armed Forces Health Surveillance Division. DMSS documents ambulatory care encounters and hospitalizations in fixed military and civilian (if reimbursed through the Military Health System) treatment facilities worldwide.&lt;/p&gt;&lt;p&gt;Outcome of sunburn was identified through inpatient and outpatient medical encounters containing an ICD-9 code of 692.71 (sunburn of first degree), 692.76 (sunburn of second degree), 692.77 (sunburn of third degree), or an ICD-10 code of L55.0 (sunburn of first degree), L55.1 (sunburn of second degree), L55.2 (sunburn of third degree), or L55.9 (sunburn, unspecified), in the first or second diagnostic position. The transition between ICD-9 and ICD-10 codes, in 2015, occurred during the study’s surveillance period.&lt;/p&gt;&lt;p&gt;An individual was classified as a new case of sunburn if at least 30 days passed since the documentation of a previous sunburn-associated medical encounter. Incidence of sunburn was calculated per 100,000 person-years (p-yrs). Negative binomial regression calculated incidence rate ratios for occupation categories, adjusting for sex, age, and race and ethnicity.&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;p&gt;Table 1 provides the total incident case counts and crude incidence rates of clinically-diagnosed sunburn among ACSM during the 9-year surveillance period. Over half of the cases were first degree sunburn (n=6,244; 54.5%), and almost all cases were diagnosed in the ambulatory setting (n=12,029; 99.95%). During the 9-year surveillance period, most, 97.1% (n=11,687), reported cases had only 1 diagnosed sunburn.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-Article-2-Table-1" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="Table outlines total incident case counts and crude incidence rates of clinically-diagnosed sunburn among ACSM from 2014-2022." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-2-Table-1.ashx?h=1375&amp;w=750&amp;hash=C82235AA9D2D407548E4EAFEB9E06E18D1A598DB" style="width: 750px; height: 1375px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;The incidence rate of sunburn diagnosis was higher among women compared to men. Non-Hispanic White service members had the highest rate compared to other races and ethnicities. The three youngest age groups, under 20 years, 20-24, and 25-29 years of age, had the highest incidence rates of sunburn diagnosis, with rates decreasing with increasing age until 45 years of age. The Marine Corps and Army had the highest rates among the services. Recruits had a significantly higher sunburn incidence compared to non-recruit enlisted service members and officers.&lt;/p&gt;&lt;p&gt;The annual total sunburn incidence rates, which varied annually, increased overall 6.4% from 2014 (100.3 per 100,000) through 2022 (106.8 per 100,000). Of the 12,035 cases of sunburn, 5,542 occurred in June (46.0%), more than in any other month (data not shown). Ten military installations/regions accounted for 36% of all sunburns during the surveillance  period. The highest overall counts were in Okinawa, Japan (n=513) and San Diego, CA (n=510), followed closely by Fort Moore (formerly Benning), GA (n=468), and Fort Leonard Wood, MO (n=454) (data not shown).&lt;/p&gt;&lt;p&gt;Table 2 provides the crude and adjusted rate ratios for the association between occupational category and sunburn. The pilot/air crew category had the lowest crude and adjusted incidence rate of sunburn diagnosis.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-Article-2-Table-2" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="Table 2 provides the crude and adjusted rate ratios for the association between occupational category and sunburn." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-2-Table-2.ashx?h=371&amp;w=1250&amp;hash=C2A4945FFA4DCF16B09CB2A95483D1BA627D5319" style="width: 1250px; height: 371px; vertical-align: middle; margin-top: 5px; margin-bottom: 20px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;Compared to the prior &lt;em&gt;MSMR&lt;/em&gt; report, the incidence of clinically-diagnosed sunburn among ACSM decreased 15.9% from 2002-2013 to 2014-2022 (from 124.8 cases per 100,000 p-yrs to 105.0 cases per 100,000 p-yrs).&lt;sup&gt;1&lt;/sup&gt; In both studies, women demonstrated a higher rate of sunburn diagnosis. Epidemiological data of the general U.S. population suggest that women are less likely to report frequent sunburn and are more likely to implement sunburn prevention measures.&lt;sup&gt;7,8,9&lt;/sup&gt; According to National Cancer Institute statistics, however, reported sunburn for women differs from  men by age, with younger women (aged 18-24) accounting for a higher proportion of sunburns than men in the same age group.&lt;sup&gt;10&lt;/sup&gt; The majority of ACSM are under 25 years of age, which could partially explain the higher incidence of sunburn among women described in this study.&lt;/p&gt;&lt;p&gt;Similar to the 2014 &lt;em&gt;MSMR&lt;/em&gt; report, non-Hispanic White service members and younger age groups had higher diagnosed sunburn rates, which is consistent with the general U.S. population.&lt;sup&gt;7&lt;/sup&gt; The current study found that pilot/air crew had the lowest rate of sunburn diagnosis, both before and after adjustment for potential confounders, which suggests that other factors such as differences in health care utilization or sunburn prevention measures may influence lower incidence of sunburn diagnoses. &lt;/p&gt;&lt;p&gt;One limitation of this study is outcome misclassification bias for sunburn diagnosis based upon health care utilization. This report likely underestimates the true rate of sunburn, as only individuals with more serious burns are likely to present for medical care. Additionally, the introduction of the ICD-10 code of “unspecified” may limit ascertainment of burn severity, potentially affecting accurate surveillance. A second limitation of this study is that the data could not differentiate sunburn during work hours versus non-work hours, challenging associations of occupation with sunburn risk.&lt;/p&gt;&lt;p&gt;Sunburn affects military readiness by removing service members from duty while their burns heal, affecting both garrison and combat missions. As a risk factor for future skin cancer, sunburn is a longitudinal concern for both the public health sector and the military due to the health care costs and time involved in management of melanoma and NMSC.&lt;sup&gt;11,12&lt;/sup&gt; Emphasis on prevention should continue.&lt;/p&gt;&lt;p&gt;Sunburn is likely multifactorial, from limited access to sunscreen, to its lack of use, variable encouragement of use by peers or leadership, operational time constraints, and low prioritization or understanding of the long-term effects of sun damage.&lt;sup&gt;12,13&lt;/sup&gt; Mitigation strategies can include pre-deployment or seasonal health promotion focused on increasing use of available sun-protective measures, including sunscreen, sunglasses, headgear, shade structures, and modified outdoor training times to early morning or later day/early evening.&lt;/p&gt;&lt;p&gt;Survey analysis of military-specific populations could help quantify incidence of sunburn that is more specific than clinical diagnoses, and could quantify occurrence of unreported sunburn. Survey research could evaluate behavioral practices, such as use of preventive measures, location and timing (on- or off-duty) of sunburn, and inquiry about unreported burns, which may better inform sunburn-reduction strategies.&lt;/p&gt;&lt;h2&gt;Author Affiliations&lt;/h2&gt;&lt;p&gt;Uniformed Services University of the Health Sciences, Bethesda, MD: LT Van Airsdale; Defense Health Agency, Armed Forces Health Surveillance Division: Dr. Stahlman, Ms. Hiban, CAPT Wells.&lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The opinions and assertions expressed herein are those of the authors and do not reflect the official policy nor position of the Uniformed Services University of the Health Sciences or the Department of Defense. LT Van Airsdale is a military service member. This work was prepared as part of official duties. Title 17, U.S.C., §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C., §101 defines a U.S. Government work as a work prepared by a military Service member or employee of the U.S. Government as part of that person’s official duties.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Armed Forces Health Surveillance Branch. Sunburn among active component service members, U.S. Armed Forces, 2002–2013. &lt;em&gt;MSMR&lt;/em&gt;. 2014;21(7):2-6.&lt;/li&gt;    &lt;li&gt;Young AR and Tewari A. Sunburn. UpToDate. Updated Aug. 4, 2022. Accessed Oct. 10, 2023. &lt;a rel="noopener noreferrer" href="https://www.uptodate.com/contents/sunburn" title="Click on the link to access the web article on sunburn" target="_blank"&gt;https://www.uptodate.com/contents/sunburn&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://www.uptodate.com/contents/sunburn" title="Click on the link to access the web article on sunburn" target="_blank"&gt;&lt;/a&gt;Guerra KC, Crane JS. Sunburn. In: &lt;em&gt;StatPearls&lt;/em&gt;. StatPearls Publishing; 2023. Accessed Apr. 4, 2023. &lt;a rel="noopener noreferrer" href="https://www.ncbi.nlm.nih.gov/books/NBK534837" target="_blank" title="Click on the link to access the StatPearls article online"&gt;https://www.ncbi.nlm.nih.gov/books/NBK534837&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.ncbi.nlm.nih.gov/books/NBK534837" target="_blank" title="Click on the link to access the StatPearls article online"&gt;&lt;/a&gt;Lee T, Taubman SB, Williams VF. Incident diagnoses of non-melanoma skin cancer, active component, U.S. Armed Forces, 2005-2014. &lt;em&gt;MSMR&lt;/em&gt;. 2016;23(12):2-6.&lt;/li&gt;    &lt;li&gt;Mabila S, Dreyer E. Surveillance snapshot: the top 10 incident cancers among active component service members, 2018-2022. &lt;em&gt;MSMR&lt;/em&gt;. 2023;30(9):17.&lt;/li&gt;    &lt;li&gt;U.S. Department of Defense. &lt;em&gt;Phase 1-a—Study on the Incidence of Cancer Diagnosis and Mortality Among Military Aviators and Aviation Support Personnel&lt;/em&gt;. Jan. 2023.&lt;/li&gt;    &lt;li&gt;Braun HA, Adler CH, Goodman M, Yeung H. Sunburn frequency and risk and protective factors: a cross-sectional survey. &lt;em&gt;Dermatol Online J&lt;/em&gt;. 2021;27(4).&lt;/li&gt;    &lt;li&gt;McKenzie C, Nahm WJ, Kearney CA, Zampella JG. Sun-protective behaviors and sunburn among US adults. &lt;em&gt;Arch Dermatol Res&lt;/em&gt;. 2023:1-10. doi:10.1007/s00403-023-02547-z&lt;/li&gt;    &lt;li&gt;Reuter NP, Bower M, Scoggins CR, Martin RC, McMasters KM, Chagpar AB. The lower incidence of melanoma in women may be related to increased preventative behaviors. &lt;em&gt;Am J Surg&lt;/em&gt;. 2010;200(6):765-769. doi:10.1016/j.amjsurg.2010.06.007&lt;/li&gt;    &lt;li&gt;National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services. &lt;em&gt;Cancer Trends Progress Report/Sunburn&lt;/em&gt;. Updated Aug. 2023. Accessed Oct. 13, 2023. &lt;a rel="noopener noreferrer" href="https://progressreport.cancer.gov/prevention/sunburn" target="_blank" title="Click on the link to access the National Cancer Institute's report on sunburn"&gt;https://progressreport.cancer.gov/prevention/sunburn&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://progressreport.cancer.gov/prevention/sunburn" target="_blank" title="Click on the link to access the National Cancer Institute's report on sunburn"&gt;&lt;/a&gt;Kao SYZ, Ekwueme DU, Holman DM, et al. Economic burden of skin cancer treatment in the USA: an analysis of the Medical Expenditure Panel Survey Data, 2012–2018. &lt;em&gt;Cancer Causes Control&lt;/em&gt;. 2023;34:205-212. doi:10.1007/s10552-022-01644-0&lt;/li&gt;    &lt;li&gt;Rosenberg A, Cho S. We can do better at protecting our service members from skin cancer. &lt;em&gt;Mil Med&lt;/em&gt;. 2022;187:311-313. doi:10.1093/milmed/usac198&lt;/li&gt;    &lt;li&gt;Powers JG, Patel NA, Powers EM, Mayer JE, Stricklin GP, Geller AC. Skin cancer risk factors and preventative behaviors among United States military veterans deployed to Iraq and Afghanistan. &lt;em&gt;J Invest Dermatol&lt;/em&gt;. 2015;135(11):2871-2873. doi:10.1038/jid.2015.238&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Wed, 01 Nov 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{35A79D8A-2EDA-46DA-885B-456B5102B72A}</guid><link>https://www.health.mil/News/Articles/2023/11/01/Tripledemic-Commentary</link><title>Commentary: The Role of Vaccines in Combatting the Potential “Tripledemic” of Influenza, COVID-19 and RSV</title><description>&lt;p&gt;Common respiratory viruses are associated with substantial morbidity within the Military Health System. In 2022 more than 250,000 medical encounters were recorded within the MHS for respiratory illness among active component service members, with an additional 160,000 encounters for COVID-19.&lt;sup&gt;1&lt;/sup&gt; Among non-service member beneficiaries, there were approximately 2 million encounters for respiratory infections in 2022, with just over one quarter of these among the pediatric 0-17 years age group.&lt;sup&gt;2&lt;/sup&gt; During the most recent winter season in the Northern Hemisphere, the co-circulation at relatively high levels of influenza, SARS-CoV-2, and RSV was termed the “tripledemic.”&lt;sup&gt;3&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Persons at high risk, especially those over 65 years of age, can be hospitalized or die from complications of infection with influenza, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), respiratory syncytial virus, or from other frequently encountered pathogens. Mortality from respiratory viral illness also occurs among infants, children, and adolescents.&lt;sup&gt;4,5&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;With children returned to school, another respiratory infection season approaches. This year, however, health care providers have new tools to prevent these infections in their patients, in the form of newly licensed or updated vaccines and immunotherapeutics against RSV and SARS-CoV-2. Revised recommendations for annual influenza vaccines will potentially also allow more people to easily receive these products.&lt;sup&gt;6&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Yearly influenza vaccination is recommended for almost all persons aged 6 months or older (including pregnant persons)&lt;sup&gt;6&lt;/sup&gt; and is a requirement for both military personnel and all health care personnel working in military medical facilities.&lt;sup&gt;7&lt;/sup&gt; Data from the 2019-2020 influenza season show that influenza vaccination of U.S. Department of Defense beneficiaries reduced influenza disease by 40-60%, and by 12-31% among military members; for methodological reasons, military vaccine effectiveness may be underestimated.&lt;sup&gt;8&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;The U.S. Centers for Disease Control and Prevention states that the preferred time for vaccination for most persons who need only one dose of influenza vaccine is September or October. Vaccination should continue throughout the season, however, for as long as influenza viruses are circulating and vaccination is available. For children aged 6 months through 8 years, as well as pregnant persons in their third trimester, specific recommendations for timing of vaccination should be consulted.&lt;sup&gt;6&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;A notable change this year, which expands the population eligible for more ready vaccination, is the recommendation that all persons with egg allergy who are aged 6 months or older can receive influenza vaccine without special precautions. Regardless of the severity of prior egg reaction, egg allergy requires no additional safety measures for influenza vaccination. Observational data from numerous sources have documented the extreme rarity of anaphylactic-type allergic reactions to influenza vaccine in persons with egg allergy.&lt;sup&gt;6&lt;/sup&gt; Consistent with best practice recommendations, all vaccines including influenza should be administered in settings where rapid recognition and treatment of acute hypersensitivity reactions can occur.&lt;sup&gt;9&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Vaccines against SARS-CoV-2, the virus which causes COVID-19 disease and its sequelae, are in a transitional period. Bivalent formulations (which should no longer be used) have been replaced by monovalent formulations based on the recent XBB.1.5 variant of the Omicron virus lineage.&lt;sup&gt;10&lt;/sup&gt; Both protein and mRNA-based vaccines are available this fall.&lt;/p&gt;&lt;p&gt;The Food and Drug Administration has approved monovalent vaccines for use as a single dose in all persons 5 years of age and older, provided that two months have elapsed following any prior COVID-19 vaccination. Infants and children 6 months through 4 years of age may receive 1, 2, or 3 doses of a monovalent vaccine, depending on COVID-19 vaccination history and which vaccine is used.&lt;sup&gt;10&lt;/sup&gt; The CDC is recommending the newly available monovalent COVID-19 vaccines for everyone 6 months and older.&lt;/p&gt;&lt;p&gt;In explaining its recommendations, the CDC noted that while older and immunocompromised individuals are at highest risk for hospitalization and death due to COVID-19, serious outcomes continue among healthy children and adults.&lt;sup&gt;11,12&lt;/sup&gt; Data indicate that, among those eligible for vaccination, individuals over age 75 and between 65-74 years of age have the highest hospitalization rates; continued vaccination of working-age adults (ages 18-49, the group that constitutes most military personnel) could prevent as many as 414 added hospitalizations over 6 months per 1 million doses administered.&lt;sup&gt;11&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;While it is well-documented that breakthrough infections can occur with COVID-19 vaccines, a recent evidence synthesis found that vaccination against Omicron variants was nearly 90% effective at preventing hospitalization due to COVID-19 within six weeks, with 71% effectiveness up to 16 weeks after vaccination.&lt;sup&gt;13&lt;/sup&gt; The CDC has estimated that for every 1 million COVID-19 doses administered to adolescents over a period of six months, up to 95 hospitalizations, 19 ICU admissions, and one death can be prevented.&lt;sup&gt;11&lt;/sup&gt; These estimates, complemented by a comprehensive benefit and risk assessment of COVID-19 vaccination provided by the CDC, constitute reliable evidence supporting the CDC Advisory Committee on Immunization Practices recommendation.&lt;sup&gt;14&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;RSV, long known as a widespread and potentially serious pediatric pathogen, is also a known cause of serious illness in older adults.&lt;sup&gt;15&lt;/sup&gt; The 2 new RSV vaccines, with recent FDA approval and CDC recommendation,&lt;sup&gt;16&lt;/sup&gt; are a new addition to the armamentarium against respiratory viruses and their complications. Both vaccines use inactivated RSV proteins to stimulate active immune response.&lt;/p&gt;&lt;p&gt;In clinical trials, both vaccines showed high efficacy in preventing symptomatic lower respiratory infection with RSV. Two-season interim analyses showed 81.0% efficacy of the Pfizer vaccine against medically-attended lower respiratory tract disease, and 77.5% efficacy of the GSK vaccine against the same outcome.&lt;sup&gt;16&lt;/sup&gt; The CDC ACIP recommends a single dose of either vaccine in persons aged 60 and over, using what it terms “shared clinical decision-making.”&lt;sup&gt;16&lt;/sup&gt; This phrase generally describes health care provider discussion of vaccination options with their patients, taking into account their preferences, as well as medical fragility, advanced age, and other clinical characteristics that may increase risk of severe outcomes from RSV.&lt;sup&gt;17&lt;/sup&gt; One of the newly-licensed RSV vaccines was also approved by the FDA for vaccination of pregnant persons for prevention of RSV infection in their infants, and the CDC has recently provided usage recommendations.&lt;sup&gt;18&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Nirsevimab, a long-acting monoclonal antibody designed to prevent severe RSV lower respiratory tract disease in infants and children under 20 months of age, was recently licensed by the FDA. ACIP recommends nirsevimab for all infants under 8 months of age either born during or entering their first RSV season, in addition to infants and children aged 8 to 19 months at increased risk of severe RSV disease who are entering their second RSV season.&lt;sup&gt;19&lt;/sup&gt; Children at high risk include those with chronic lung disease requiring specific types of medical support, with severe immune compromise, or cystic fibrosis-meeting clinical criteria, in addition to children of American Indian or Alaskan Native heritage. &lt;/p&gt;&lt;p&gt;An inherent limitation of Nirsevimab is that as an antibody product rather than a true vaccine: It provides only passive immunity and does not result in longer-term immunologic memory. It is also not a treatment for RSV disease. Compared to palivizumab, a mAb previously approved by the FDA for RSV prevention in children up to 2 years of age,&lt;sup&gt;20&lt;/sup&gt; Nirsevimab has advantages of single dose administration, rather than requiring a 5-dose series, and is recommended for all infants entering RSV season instead of only certain high-risk pediatric patients. Maternal vaccination with the licensed and recommended RSV vaccine is an additional option for protection of all infants.&lt;sup&gt;18&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;While use of influenza, COVID-19, and RSV vaccine products are primary prevention measures against the “tripledemic,” the strategy has limitations. Only the influenza vaccine is currently required for military personnel. Only persons aged 60 years and older and children under 2 years of age can receive active and passive immunization against RSV, respectively. While preliminary laboratory evidence suggests that updated COVID-19 vaccines will offer cross-protection  against recently-circulating SARS-CoV-2 Omicron virus variants such as BA.2.86,&lt;sup&gt;21&lt;/sup&gt; it is unknown how clinically effective the newly updated formulations will be.&lt;/p&gt;&lt;p&gt;While shared vaccine decision-making for RSV protection is a patient-centered approach, it is also more time-consuming and may result in lower overall vaccine uptake. For example, the shared decision-making model precludes standing orders for RSV vaccination of eligible adults within the MHS.&lt;/p&gt;&lt;p&gt;Because none of this group of vaccines is expected to produce sterilizing immunity (i.e., absolute protection against infection), additional voluntary personal protection methods for preventing respiratory virus transmission are warranted. Recent DOD Force Health Protection Guidance includes recommendations for frequent use of hand hygiene and covering the mouth and nose when coughing or sneezing.&lt;sup&gt;22&lt;/sup&gt; Health care providers should refrain from direct patient care while ill with respiratory symptoms, and may wish to consider wearing a securely-fitting mask for the duration of the winter respiratory virus season. Enhancing ventilation in indoor settings, where feasible, may also limit respiratory virus spread. Treatment facilities can monitor local respiratory virus circulation conditions that could affect testing and mitigation strategies by consulting DOD resources from Armed Forces Health Surveillance Division, Global Emerging Infections Surveillance, and CDC sites including Fluview and the Covid Data Tracker.&lt;/p&gt;&lt;p&gt;Evidence-based methods for enhancing immunization (including standing orders where applicable and offers of vaccination at all visits) should be implemented. Patients should be screened for eligibility for all three vaccines during fall and winter season visits (Table). Consistent with CDC best practices, co-administration of recommended vaccines at the same visit is recommended.&lt;sup&gt;9&lt;/sup&gt; Individuals who received the Southern Hemisphere influenza vaccine earlier this year should receive the Northern Hemisphere formulation this fall, as long as it has been 30 days since their most recent dose of influenza vaccine.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/11/01/MSMR-Article-4-Table" target="_blank" title="Click on the table to open a 508-compliant PDF version"&gt;&lt;img alt="Table listing the immunizations for protection against select respiratory viruses." src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/November/Article-4-Table.ashx?h=582&amp;w=1250&amp;hash=37317734FB31DFDEE22E6B0825FCBA21A6AC5389" style="width: 1250px; height: 582px; vertical-align: middle; margin-top: 5px; margin-bottom: 20px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h2&gt;Author affiliations&lt;/h2&gt;&lt;p&gt;Immunization Healthcare Division, Public Health Directorate, Defense Health Agency, Falls Church, VA: CAPT Iskander, LTC Martinez, Lt Col Hsu.&lt;/p&gt;&lt;h2&gt;Acknowledgements&lt;/h2&gt;&lt;p&gt;Cecilia Mikita, MD, MPH, and Margaret Ryan, MD, MPH, Immunization Healthcare Division, Public Health Directorate, Defense Health Agency, Falls Church, VA.&lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The views expressed in this document are those of the author(s) and do not necessarily reflect the official opinion, policy, nor position of the Defense Health Agency, the Department of Defense, or the U.S. Government. The mention of any non-federal entity or its products is for informational purposes only, and is not to be construed, implied, or interpreted, in any manner, as federal endorsement of that non-federal entity or its products.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Absolute and relative morbidity burdens attributable to various illnesses and injuries among active component members, U.S. Armed Forces, 2022. &lt;em&gt;MSMR&lt;/em&gt;. 2023;30(6):3-11.&lt;/li&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Update: absolute and relative morbidity burdens attributable to various illnesses and injuries among non-service member beneficiaries of the Military Health System, 2022. &lt;em&gt;MSMR&lt;/em&gt;. 2023;30(7):11-20.&lt;/li&gt;    &lt;li&gt;Patel TA, Jain B, Raifman J. Revamping public health systems: lessons learned from the “tripledemic.” &lt;em&gt;Am J Prev Med&lt;/em&gt;. 2023:S0749-3797(23)00339-2.&lt;/li&gt;    &lt;li&gt;Bixler D, Miller AD, Mattison CP, et al. SARS-CoV-2-associated deaths among persons aged &lt;21 years–United States, February 12-July 31, 2020. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2020;69(37):1324-1329.&lt;/li&gt;    &lt;li&gt;Shang M, Blanton L, Brammer L, Olsen SJ, Fry AM. Influenza-associated pediatric deaths in the United States, 2010-2016. &lt;em&gt;Pediatrics&lt;/em&gt;. 2018;141(4):e20172918.&lt;/li&gt;    &lt;li&gt;Grohskopf LA, Blanton LH, Ferdinands JM, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices–United States, 2023-24 influenza season. &lt;em&gt;MMWR Recomm Rep&lt;/em&gt;. 2023;72(RR-2):1-25.&lt;/li&gt;    &lt;li&gt;U.S. Department of Defense Immunization Program. U.S. Department of Defense Instruction 6205.02. Feb. 27, 2023.&lt;/li&gt;    &lt;li&gt;Sayers DR, Iskander JK. Influenza vaccine effectiveness and test-negative study design within the Department of Defense. &lt;em&gt;Mil Med&lt;/em&gt;. 2023;usac436.&lt;/li&gt;    &lt;li&gt;Kroger A, Bahta L, Long S, Sanchez P. &lt;em&gt;General Best Practice Guidelines for Immunization&lt;/em&gt;. Accessed Sep. 13, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf" target="_blank" title="Click on the link to access the CDC report on immunization best practices"&gt;https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf" target="_blank" title="Click on the link to access the CDC report on immunization best practices"&gt;&lt;/a&gt;U.S. Food and Drug Administration. Press Announcements. Sep. 11, 2023. Accessed Sep. 13, 2023. &lt;a rel="noopener noreferrer" href="https://www.fda.gov/news-events/press-announcements/fda-takes-action-updated-mrna-covid-19-vaccines-better-protect-against-currently-circulating" target="_blank" title="Click on the link to access the FDA press release on improved COVID vaccines"&gt;https://www.fda.gov/news-events/press-announcements/fda-takes-action-updated-mrna-covid-19-vaccines-better-protect-against-currently-circulating&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://www.fda.gov/news-events/press-announcements/fda-takes-action-updated-mrna-covid-19-vaccines-better-protect-against-currently-circulating" target="_blank" title="Click on the link to access the FDA press release on improved COVID vaccines"&gt;&lt;/a&gt;Centers for Disease Control and Prevention. Respiratory Viruses. Sep. 12, 2023. Accessed Sep. 13, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/respiratory-viruses/whats-new/covid-vaccine-recommendations-9-12-2023.html" target="_blank" title="Click on the link to access the CDC web site on respiratory viruses and COVID vaccine recommendations"&gt;https://www.cdc.gov/respiratory-viruses/whats-new/covid-vaccine-recommendations-9-12-2023.html&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.cdc.gov/respiratory-viruses/whats-new/covid-vaccine-recommendations-9-12-2023.html" target="_blank" title="Click on the link to access the CDC web site on respiratory viruses and COVID vaccine recommendations"&gt;&lt;/a&gt;Regan JJ, Moulia DL, Link-Gelles R, et al. Use of updated COVID-19 vaccines 2023-2024 formula for persons aged ≥6 months: recommendations of the Advisory Committee on Immunization Practices–United States, September 2023. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2023;ePub.&lt;/li&gt;    &lt;li&gt;Wu N, Joyal-Desmarais K, Ribeiro PAB, et al. Long-term effectiveness of COVID-19 vaccines against infections, hospitalisations, and mortality in adults: findings from a rapid living systematic evidence synthesis and meta-analysis up to December, 2022. &lt;em&gt;Lancet Respir Med&lt;/em&gt;. 2023;11(5):439-452.&lt;/li&gt;    &lt;li&gt;Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices. Sep. 12, 2023. Accessed Oct. 18, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/vaccines/acip/meetings/downloads/2+slides-2023-09-12/11-COVID-Wallace-508.pdf" target="_blank" title="Click on the link to access the CDC Advisory Committee on Immunization Practices's presentation"&gt;https://www.cdc.gov/vaccines/acip/meetings/downloads/2+slides-2023-09-12/11-COVID-Wallace-508.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.cdc.gov/vaccines/acip/meetings/downloads/2+slides-2023-09-12/11-COVID-Wallace-508.pdf" target="_blank" title="Click on the link to access the CDC Advisory Committee on Immunization Practices's presentation"&gt;&lt;/a&gt;El Sherif M, Andrew MK, Ye L, et al. Leveraging influenza virus surveillance from 2012 to 2015 to characterize the burden of respiratory syncytial virus disease in Canadian adults ≥50 years of age hospitalized with acute respiratory illness. &lt;em&gt;Open Forum Infect Dis&lt;/em&gt;. 2023;10(7):ofad315.&lt;/li&gt;    &lt;li&gt;Melgar M, Britton A, Roper LE, et al. Use of respiratory syncytial virus vaccines in older adults: recommendations of the Advisory Committee on Immunization Practices–United States, 2023. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2023;72:793-801.&lt;/li&gt;    &lt;li&gt;Havers FP, Whitaker M, Melgar M, et al. Characteristics and outcomes among adults aged ≥60 years hospitalized with laboratory-confirmed respiratory syncytial virus–RSV-NET, 12 states, July 2022-June 2023. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2023;72:1075-1082.&lt;/li&gt;    &lt;li&gt;Fleming-Dutra KE, Jones JM, Roper LE, et al. Use of the Pfizer respiratory syncytial virus vaccine during pregnancy for the prevention of respiratory syncytial virus–associated lower respiratory tract disease in infants: recommendations of the Advisory Committee on Immunization Practices–United States, 2023. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2023;ePub.&lt;/li&gt;    &lt;li&gt;Jones JM, Fleming-Dutra KE, Prill MM, et al. Use of nirsevimab for the prevention of respiratory syncytial virus disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices–United  States, 2023. &lt;em&gt;MMWR Morb Mortal Wkly Rep&lt;/em&gt;. 2023;72:920-925.&lt;/li&gt;    &lt;li&gt;Caserta MT, O’Leary ST, Munoz FM, Ralston SL, Committee on Infectious Diseases. Palivizumab prophylaxis in infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. &lt;em&gt;Pediatrics&lt;/em&gt;. 2023;152(1):e2023061803.&lt;/li&gt;    &lt;li&gt;Centers for Disease Control and Prevention. Respiratory Viruses. Sep. 15, 2023. Accessed Sep. 18, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/respiratory-viruses/whats-new/covid-19-variant-update-2023-09-15.html" target="_blank" title="Click on the link to access the CDC's web page on respiratory viruses and COVID-19 variant updates"&gt;https://www.cdc.gov/respiratory-viruses/whats-new/covid-19-variant-update-2023-09-15.html&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.cdc.gov/respiratory-viruses/whats-new/covid-19-variant-update-2023-09-15.html" target="_blank" title="Click on the link to access the CDC's web page on respiratory viruses and COVID-19 variant updates"&gt;&lt;/a&gt;Memorandum for Senior Pentagon Leadership, Force Health Protection Guidance. Coronavirus Disease 2019 and Other Infectious Respiratory Diseases. Jul. 26, 2023.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Wed, 01 Nov 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{E7DF3DDA-073E-4112-9C05-F90E4C1C1331}</guid><link>https://www.health.mil/News/Articles/2023/10/26/Department-of-Defense-VA-Partnership-Allows-Veteran-Surgeries-at-Naval-Hospital</link><title>Department of Defense-VA Partnership Allows Veteran Surgeries at Naval Hospital</title><description>&lt;p&gt;The Department of Defense Naval Hospital Pensacola is hosting outpatient surgical care provided by clinicians from the Department of Veterans Affairs for approximately 37,000 Gulf Coast-area veterans’ health care system patients under a new partnership.&lt;/p&gt;&lt;p&gt;Beginning the week of Oct. 16, 2023, the partnership gives VA clinical space within the hospital and expands services for both veterans and DOD beneficiaries.&lt;/p&gt;&lt;h2&gt;‘A Win-Win’&lt;/h2&gt;&lt;p&gt;“We are very pleased to announce this new partnership with the VA,” Dr. Lester Martínez-López, the DOD assistant secretary of defense for health affairs, said on Oct. 19. “Not only does it provide increased opportunities to care for those who have sacrificed so much for this country, but it also supports readiness by helping our medical professionals maintain their clinical skills.”&lt;/p&gt;&lt;p&gt;“It is a win-win for all those involved. Plus, we are able to do this without diminishing the quality and access to care for our beneficiaries,” Martínez said.&lt;br&gt;VA plans to expand surgery access for veterans at Naval Hospital Pensacola in 2024, adding services such as orthopedics; ear, nose, and throat; podiatry; ophthalmology; and, urology.&lt;/p&gt;&lt;p&gt;A second, future, phase will include a joint DOD-VA infrastructure investment to activate a 12-bed medical-surgical inpatient unit that will serve DOD beneficiaries and veterans.&lt;/p&gt;&lt;h2&gt;How the Partnership Helps Veterans&lt;/h2&gt;&lt;p&gt;Previously, local veterans traveled to the Biloxi VA Medical Center in Mississippi for these surgical procedures or received their care from community providers. Local veterans will not have to change their normal processes to access this new care; instead, VA will schedule their surgical procedures at the new clinic as appropriate.&lt;/p&gt;&lt;p&gt;VA providers will request referrals and consults as they would for other services in the health care system.&lt;/p&gt;&lt;p&gt;“This partnership will help VA provide more care, more quickly, to more Gulf Coast veterans—as close to their homes as possible,” said VA Undersecretary for Health Dr. Shereef Elnahal.&lt;/p&gt;&lt;p&gt;“Establishing partnerships like this is an efficient and cost-effective method for VA to increase veteran access to care, while helping modernize the veteran health care experience,” he said. “We are proud to work with DOD to better service our nation’s heroes.”&lt;/p&gt;&lt;p&gt;The partnership is a key part of VA’ s strategy to modernize its health care system nationwide. Through this work, VA is aggressively working to expand the amount of available space to meet veteran demand for VA health care services and address challenges associated with aging facilities.&lt;/p&gt;&lt;p&gt;For more information on VA health care for Gulf Coast veterans, visit &lt;a rel="noopener noreferrer" href="https://www.va.gov/gulf-coast-health-care/" target="_blank" title="VA Gulf Coast Health Care"&gt;VA Gulf Coast Health Care&lt;/a&gt;.&lt;/p&gt;</description><pubDate>Thu, 26 Oct 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{A79BAC8C-5403-4ECA-BCF4-02C37FF281C2}</guid><link>https://www.health.mil/News/Articles/2023/10/25/Defense-Health-Agency-Celebrates-10-Years-of-Mission-Readiness-We-Make-a-Difference</link><title>Defense Health Agency Celebrates 10 Years of Mission Readiness: ‘We Make a Difference’</title><description>&lt;p&gt;The &lt;a href="/About-MHS/OASDHA/Defense-Health-Agency"&gt;Defense Health Agency&lt;/a&gt; marked a decade in its commitment to support the nation by improving military health and building readiness—making extraordinary experiences ordinary and exceptional outcomes routine.&lt;/p&gt;&lt;p&gt;“While we are young, we are mighty. We are important, and we make a difference,” said U.S. Army Lt. Gen. &lt;a href="/Meta-Data/Biographies/Bio_Crosland"&gt;Telita Crosland&lt;/a&gt;, the DHA’s fourth director, during an Oct. 23 ceremony to celebrate the agency’s 10th birthday at DHA headquarters in Falls Church, Virginia.&lt;/p&gt;&lt;p&gt;“It is an organization built on a legacy of greatness,” Crosland continued. “The agency started with a fairly defined mission set as a combat support agency and shared services, and in quick order expanded. We absolutely require the best and brightest you all represent.”&lt;/p&gt;&lt;p&gt;During the ceremony, U.S. Air Force Chief Master Sgt. &lt;a href="/Meta-Data/Biographies/Bio_Johnson"&gt;Tanya Johnson&lt;/a&gt;, DHA’s senior enlisted leader, reflected on her pride in the DHA workforce. “I'm actually at 30 years [of service], but I have volunteered to stay longer. I'm excited by our plans for the future and by seeing what each and every one of you do every day.”&lt;/p&gt;&lt;h2&gt;Supporting 9.6 Million Beneficiaries&lt;/h2&gt;&lt;p&gt;The Department of Defense established the &lt;a href="/About-MHS/OASDHA/Defense-Health-Agency/DHA-Strategic-Plan"&gt;DHA on Oct 1, 2013&lt;/a&gt;, as one of eight combat support agencies supporting joint operating forces and combatant commands engaged in military operations around the world. &lt;/p&gt;&lt;p&gt;DHA’s core mission as a joint, integrated combat support agency enables the U.S. Army, U.S. Navy, and U.S. Air Force medical services to supply a medically ready force and ready medical force to combatant commands in both peacetime and wartime. .&lt;/p&gt;&lt;p&gt;The agency directs the execution of joint shared services, including the TRICARE health program; pharmacy operations; health information technology; medical logistics; facility management; research and development; education and training; public health; budget and resource management; and contracting. &lt;/p&gt;&lt;p&gt;The most notable change to the agency’s mission occurred between &lt;a href="/News/Articles/2022/10/06/DHA-Turns-9-Now-Fully-Responsible-for-Health-Care-Delivery-in-DOD"&gt;Oct.1, 2018, and Oct. 1, 2022&lt;/a&gt;, when more than 700 military hospitals and clinics operated by the military departments formally transitioned to the DHA. &lt;/p&gt;&lt;p&gt;After those organizational transitions, the DHA’s global workforce grew to more than 130,000 civilians and military health care professionals delivering care to 9.6 million service members, retirees, and family beneficiaries. This dedicated and inspired team of professionals are committed to medical excellence, health care improvement, and ensuring military personnel are ready to perform combat operations and humanitarian missions at home and abroad.&lt;/p&gt;&lt;p&gt;Most recently, on Oct. 1, 2023, the agency restructured the previous 20 military medical markets worldwide into nine Defense Health Networks. Every military hospital and clinic reports to one of these one networks, each led by a general or flag officer.&lt;/p&gt;&lt;p&gt;In its dedication to enhance warfighter health, the DHA:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Oversees nine medical centers, 36 hospitals, 525 clinics, and 138 dental facilities with an operating budget of approximately $16.9 billion in fiscal year 2023. &lt;/li&gt;    &lt;li&gt;Manages the execution of the DOD’s $55.8 billion unified medical budget, which makes up approximately 7.2% of the overall DOD $773 billion budget.&lt;/li&gt;    &lt;li&gt;Manages the DOD health plan, TRICARE, totaling $18.5 billion.&lt;/li&gt;    &lt;li&gt;Operates an $11 billion-a-year medical supply chain that supplies close to 560,000 medical devices to the joint force.&lt;/li&gt;    &lt;li&gt;Earned the Joint Meritorious Unit Award for Excellence by the U.S. Secretary of Defense for its work during the first months of the global COVID-19 pandemic, from Jan.- Oct. 2020.&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;History of Improving Health and Building Readiness&lt;/h2&gt;&lt;p&gt;In recognition of its first decade as a combat support agency, the DHA published an &lt;a href="/About-MHS/Military-Medical-History/Historical-Timelines/History-of-the-DHA"&gt;interactive timeline &lt;/a&gt;commemorating its foundations.&lt;/p&gt;&lt;p&gt;While the DHA is still a young organization, its history can be traced back to the Continental Congress, which established the Medical Department of the Continental Army in 1776. This marked the beginning of organized medical support for the American military during the Revolutionary War. &lt;/p&gt;&lt;p&gt;Other historical highlights include the establishment of the Army Medical Museum, now the &lt;a rel="noopener noreferrer" href="https://medicalmuseum.health.mil/" target="_blank" title="National Museum of Health and Medicine"&gt;National Museum of Health and Medicine&lt;/a&gt;, in 1862, a center for research in military medicine and surgery; the implementation of the &lt;a href="/Military-Health-Topics/Health-Readiness/ASBP"&gt;Armed Services Blood Program&lt;/a&gt; in 1952 that went on to support all of the military’s blood product needs; and the advent of &lt;a rel="noopener noreferrer" href="https://www.tricare.mil/" target="_blank" title="TRICARE"&gt;TRICARE&lt;/a&gt; in 1993, a health maintenance organization model of health care for active duty service members, retirees, and their families. &lt;/p&gt;&lt;h2&gt;Virtual Health Future for DHA&lt;/h2&gt;&lt;p&gt;Crosland is furthering the evolution of the DHA with an ambitious vision to transition the DHA to a digital-first model of health care delivery centered on the patient.&lt;/p&gt;&lt;p&gt;To that end, Crosland and DHA senior leadership released a new &lt;a href="/About-MHS/OASDHA/Defense-Health-Agency/DHA-Strategic-Plan"&gt;DHA Strategic Plan&lt;/a&gt; for FY 2023-2028, guiding how the agency will provide a strong, integrated health care delivery system in support of the military departments, combatant commands, and beneficiaries.&lt;/p&gt;&lt;p&gt;The plan includes three priorities to guide DHA’s future advancements:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Enabling combat support to the joint force in competition, crisis, or conflict&lt;/li&gt;    &lt;li&gt;Building a modernized, integrated, and resilient health care delivery system&lt;/li&gt;    &lt;li&gt;Empowering dedicated and inspired teams of professionals driving military health’s next evolution&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;"To accomplish our mission, we must use the right tools, at the right place, at the right time, for the right reason," said Crosland upon the release of the strategic plan. "This includes scaling innovative workforce ideas with proven value across the agency."&lt;/p&gt;&lt;p&gt;“Thank you for what you do,” said Johnson addressing attendees. “I am so humbled to be able to be a part of your team and witness how we have evolved over the last several years. I cannot wait to see what you do next.”&lt;/p&gt;</description><pubDate>Wed, 25 Oct 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{7E37929B-2C6F-4D4D-AFD5-D2F7E2FDCF1A}</guid><link>https://www.health.mil/News/Articles/2023/10/23/DHA-Awards-TRICARE-Dental-Program-Contract</link><title>DHA Awards TRICARE Dental Program Contract</title><description>&lt;p&gt;FALLS CHURCH, Virginia – The Defense Health Agency (DHA) announced today the award of the sixth generation of the &lt;a rel="noopener noreferrer" href="https://www.tricare.mil/tdp" target="_blank" title="goes to TDP website"&gt;TRICARE Dental Program&lt;/a&gt; contract (TDP6).  The new TDP6 contract will go into effect Dec. 1, 2024. TDP6 will provide private sector dental care to active duty family members, eligible National Guard and Reservists, and active duty services members serving in remote locations.&lt;/p&gt;&lt;p&gt;The TRICARE Dental Program (6) contract was awarded to United Concordia Companies, Inc. (UCCI), of Harrisburg, Pennsylvania through competitive source selection with a contract value of $3,028,216,101.18 over a period of six years with a one-year transition-in phase. This contract will replace the current TRICARE Dental Program contract on Dec. 1, 2024. UCCI is the TDP incumbent.&lt;/p&gt;&lt;p&gt;“I am pleased that our new TRICARE Dental Program contract will continue to focus on enhancing the private sector dental care for our service members, their families and eligible Guard and Reservists,” said DHA Director U.S. Army Lt. Gen. Telita Crosland. “Affordable, accessible and effective dental care increases readiness and supports retention by providing quality general and specialty dental services.”&lt;/p&gt;&lt;p&gt;The TDP6 contract will bring notable improvements to private sector dental care for enrolled beneficiaries. Three areas of focus include enhanced provider network access, lower costs, and teledentistry.&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Increase access standards for general dentists and specialists.&lt;/li&gt;    &lt;li&gt;Reduce monthly premiums for Junior Enlisted (E-1 – E-4).&lt;/li&gt;    &lt;li&gt;Expand teledentistry for remote dental screening, making diagnoses, providing consultations, and proposing treatment plans.&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;As an incumbent, DHA is confident that UCCI will continue to build on lessons learned to provide ever increasing value of dental care for our beneficiaries.&lt;/p&gt;&lt;p&gt;UCCI will maintain a provider network in the 50 States, District of Columbia, U.S. Virgin Islands, Guam, and Puerto Rico. In addition, the contractor shall develop and maintain a list of Outside of the Continental United States (OCONUS) providers, referred to as TRICARE OCONUS Preferred Dentists (TOPDs).&lt;/p&gt;&lt;p&gt;The TDP6 contract is scheduled to begin a 12-month Transition-in phase beginning December 2023 with the new contract beginning dental care delivery December 2024.&lt;/p&gt;&lt;p&gt;DHA leadership will meet soon and regularly to implement a detailed transition plan intended to prepare UCCI so that they can seamlessly assume their responsibilities under the TDP6 structure and incorporate beneficiary care on the first day of dental care delivery.&lt;/p&gt;&lt;p&gt;Media with additional questions should contact the DHA at &lt;a href="mailto:dha.ncr.comm.cal.dha-media@health.mil"&gt;dha.ncr.comm.cal.dha-media@health.mil&lt;/a&gt;.&lt;/p&gt;</description><pubDate>Mon, 23 Oct 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{5C9C5235-5639-4D7B-8E1E-A015DB8F4C7B}</guid><link>https://www.health.mil/News/Articles/2023/10/05/Air-Force-physician-chosen-to-lead-militarys-largest-medical-network</link><title>Air Force Physician Chosen to Lead Military’s Largest Medical Network</title><description>&lt;p&gt;JOINT BASE SAN ANTONIO-LACKLAND, Texas, Oct. 5, 2023 – An Air Force physician with over 30 years of service became the first director of the newly designated &lt;a href="/About-MHS/Defense-Health-Networks/DHN-Central" target="_blank" title="opens Health.mil"&gt;Defense Health Network Central&lt;/a&gt;, the military’s largest medical network, on Oct. 1.&lt;/p&gt;&lt;p&gt;“I am incredibly honored to lead DHN Central,” said Brig. Gen. (Dr.) Thomas W. Harrell, a board-certified cardiologist and flight surgeon who also serves as director, San Antonio Market, and commander, 59th Medical Wing. “It’s a privilege to serve on this global team of exceptional healthcare professionals.”&lt;/p&gt;&lt;p&gt;As DHN Central director, the general oversees a joint, integrated health network of 39 hospitals and clinics to include the military’s premier readiness, education, and training platforms. The network, headquartered in San Antonio, encompasses &lt;a href="/Military-Health-Topics/Access-Cost-Quality-and-Safety/Patient-Portal-for-MHS-Quality-Patient-Safety-and-Access-Information/See-How-Were-Doing/DHA/AMC-BAMC-FSH" target="_self" title="opens Health.mil"&gt;Brooke Army Medical Center&lt;/a&gt; and &lt;a href="/Military-Health-Topics/Access-Cost-Quality-and-Safety/Patient-Portal-for-MHS-Quality-Patient-Safety-and-Access-Information/See-How-Were-Doing/DHA/AF-C-59TH-MDW-WHASC-LACKLAND" target="_self" title="opens Health.mil"&gt;Wilford Hall Ambulatory Surgical Center&lt;/a&gt; -- the military’s largest inpatient and outpatient medical facilities -- along with hospitals and clinics spanning the world from New Jersey to Japan.&lt;/p&gt;&lt;p&gt;“Our network may span several time zones and coasts, but I have no doubt we have the right leaders and individuals in place to get after our shared mission of ensuring ready medics and medically ready forces and families,” Harrell said.&lt;/p&gt;&lt;p&gt;The new network structure is an integral part of the &lt;a href="/" target="_self" title="opens Health.mil"&gt;Defense Health Agency&lt;/a&gt;’s plan to modernize and stabilize the military health system. For the first phase, effective Oct. 1, DHA moved from 23 geographically aligned military medical markets to nine defense health networks, each with a general officer at the helm. Future phases are aimed at ensuring support systems and work-flow processes are running smoothly and effectively. The intent is to standardize processes, empower decision-making, and improve communication at echelon across the enterprise.&lt;/p&gt;&lt;p&gt;Additionally, each network director will be dual hatted as a military medical readiness leader, ensuring unified guidance and support for both healthcare delivery and service-related requirements, noted &lt;a href="/About-MHS/Biographies/Crosland" target="_self" title="opens Health.mil"&gt;Army Lt. Gen. Telita Crosland&lt;/a&gt;, DHA director.&lt;/p&gt;&lt;p&gt;"The military health system is changing,” the general said in a recent interview. “By simultaneously modernizing and stabilizing our health system, we will meet this change head on."&lt;/p&gt;&lt;p&gt;In his first message to the force, Harrell reiterated the importance of evolving to ensure the military health system in in lockstep with the Defense Department and ready to meet any emerging challenge or threat.&lt;/p&gt;&lt;p&gt;“We’ve risen up to face many challenges in recent years, to include an unprecedented pandemic, &lt;a href="/Military-Health-Topics/Technology/MHS-GENESIS"&gt;MHS GENESIS&lt;/a&gt; [electronic health record] implementation, an enterprise-wide DHA transition, fiscal constraints, and much more,” he said. “I have no doubt we will continue to meet every challenge, whether local or global, with professionalism and excellence.”&lt;/p&gt;&lt;p&gt;In the meantime, Harrell encouraged his network teammates to share their ideas and feedback.&lt;/p&gt;&lt;p&gt;“Innovate and collaborate, find ways to optimize resources and leverage technology to meet our patients where they are, and share those ideas with leadership so we can continually improve,” he said. “It will take the entire team to ensure mission success.”&lt;/p&gt;&lt;p&gt;Additionally, the general encouraged the team to take time each day to reflect on what’s important to them both personally and professionally and to strive for harmony in all areas of life.&lt;/p&gt;&lt;p&gt;“It’s important to discover your ‘why’ or true north and how it aligns with the mission,” he explained. “By doing so, you will be pursuing a passion, not just a job.”&lt;/p&gt;&lt;p&gt;Above all, Harrell stressed the importance of putting people first. “I believe in people-first leadership,” he said. “I want our most important resource, our people, to feel valued, included, fulfilled, and working at the top of their credentials.”&lt;/p&gt;&lt;p&gt;“By taking care of ourselves, we’re better able to take care of those around us,” he added.&lt;/p&gt;&lt;p&gt;Moving forward, Harrell said he is committed to supporting his teammates at every hospital and clinic aligned with DHN Central.&lt;/p&gt;&lt;p&gt;“I am honored to have joined this exceptional team of military and civilian professionals and look forward to our teamwork and close collaboration as we embark on the next stage of DHA’s evolution,” Harrell noted in his message.&lt;/p&gt;&lt;p&gt;“At the end of the day, we may look organizationally different, but our shared mission remains the same: to deliver ready combat medical capability as individuals and as a unit, and to deliver personal, safe, effective care to our patients,” he added. “We can’t go wrong if we continue to focus our attention on our people and on our patients.”&lt;/p&gt;</description><pubDate>Thu, 05 Oct 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{5D7B72B0-C092-47FE-B282-870A9FA5436E}</guid><link>https://www.health.mil/News/Articles/2023/10/02/Medical-Museum-Welcomed-Children-and-Furry-Friends-for-Teddy-Bear-Clinic</link><title>Medical Museum Welcomed Children and Furry Friends for Teddy Bear Clinic</title><description>&lt;p&gt;Unfortunate weather didn’t stop the Sept. 23, 2023, Teddy Bear Clinic at the &lt;a rel="noopener noreferrer" href="https://medicalmuseum.health.mil/" target="_blank" title="opens National Museum of Health and Medicine"&gt;National Museum of Health and Medicine&lt;/a&gt;. After an absence of the event due to COVID-19, children once again donned lab coats and guided their stuffed animal "patients" to several stations to learn about healthy habits and the body. Stations were led by Walter Reed National Military Medical Center pediatric residents, Uniformed Services University of Health Sciences medical students, and audiologists from the Alexander T. Augusta Military Medical Center and WRNMMC.&lt;/p&gt;&lt;p&gt;After a short welcome into the museum, the young visitors came upon their first station focused on immunizations and vitals. The children were invited to listen to their teddy bears’ hearts, take their blood pressure and temperature, and administer a shot.&lt;/p&gt;&lt;p&gt;“These interactive stations help the children understand the procedures they see and experience when they visit a doctor's office,” said Public Programs Manager Andrea Schierkolk. “Hopefully the children feel more comfortable in a medical environment after this event.”&lt;/p&gt;&lt;p&gt;They continued their teddy bear doctor appointments at the dental station where, with the help of a giant teeth model, USUHS med students showed them how to properly brush and floss their teeth.&lt;/p&gt;&lt;p&gt;Across from the dental station, children drew their favorite meals on paper plates. A team made up of a WRNMMC pediatric resident, a USUHS med student, and a museum volunteer docent taught the children the importance of a balanced diet, emphasizing everything in moderation.&lt;/p&gt;&lt;p&gt;The nutrition station was not the only one where the children were invited to craft. Guided by WRNMMC pediatric residents, they made reflective headbands and doctor’s kits filled with images of items like bandages, syringes, cotton balls, and more.&lt;/p&gt;&lt;p&gt;By dressing and acting like a doctor, and other medical professionals, with their stuffed friends, the museum hopes to develop early inspiration in considering a field in medicine. One museum visitor said, “My favorite part was seeing doctors tell my girls if you can dream it, they can be it.”&lt;/p&gt;&lt;p&gt;Family fitness was the most active station. USUHS med students showed the children and their bears a variety of stretches that encourage blood flow and can help them avoid injuries.&lt;/p&gt;&lt;p&gt;Hearing was the final station before the children’s teddy bears received a clean bill of health. Showing real equipment children often find intimidating at a doctor’s office, audiologists Dr. Tasha Cantelmo, U.S. Army 1st Lt. Carly Halley, and Dr. Hannah Willison invited the young visitors to test their stuffed friend’s ears to become more relaxed with the process.&lt;/p&gt;&lt;p&gt;“The Teddy Bear Clinic provides a unique opportunity to highlight the role of military pediatrics and military audiology in a friendly setting that allows us to emphasize the historical and current value of military medicine to the nation,” said Schierkolk.&lt;/p&gt;&lt;p&gt;The museum's public programs provide forums for informal learning that connect the mission of the Department of Defense museum with the public. For more information about upcoming events, call (301) 319-3300 or visit &lt;a rel="noopener noreferrer" href="https://www.medicalmuseum.health.mil" target="_blank" title="opens National Museum of Health and Medicine"&gt;https://www.medicalmuseum.health.mil&lt;/a&gt;.&lt;/p&gt;</description><pubDate>Mon, 02 Oct 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{4CA43FB5-B553-43FA-B3E7-B750622EB445}</guid><link>https://www.health.mil/News/Articles/2023/10/01/Colorectal-cancer-2023</link><title>Incidence of Colorectal Cancer Among Active Component Service Members, 2010–2022</title><description>&lt;p&gt;Colorectal cancer, which is more predominant among men than women, has been shown to be associated with environmental and occupational risk factors experienced by military members. The Defense Medical Surveillance System was used to determine the crude and age-adjusted incidence rates of colorectal cancer among active component service members from all military services from January 1, 2010 to December 31, 2022. Results from this analysis show higher crude incidence rates of colorectal cancer among those who are older and male. The overall age-adjusted incidence rate throughout the surveillance period ranged from 3.56 (95% CI: 2.54-4.58) to 7.92 (95% CI: 5.98-9.86) cases per 100,000 person-years. Age-adjusted colorectal cancer rates were similar for males and females (4.46 and 4.33 cases per 100,000 person-years, respectively) and rates were relatively similar by service as well as race and ethnicity. This finding could be attributed to the small number of cases in this study due to better screening practices in the Military Health System. &lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;Although non-Hispanic Black service members have historically had the highest incidence of colorectal cancer within the U.S. military, this study observed similar rates of colorectal cancer for all races and ethnicities after adjusting for age.&lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;Incident rates of colorectal cancer within the U.S. military increase monotonically with age, with service members over the age of 45 with the highest incidence, re-enforcing the need to promote wellness screening among military populations. The importance of the DHA guideline changes that decreased colorectal screenings to age 45 years is significant.&lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;Colorectal cancer is the third-most common cancer in incidence and mortality in the U.S.&lt;sup&gt;1&lt;/sup&gt; Even though incidence of other digestive cancers such as liver and pancreatic cancers increased during the past 20 years,&lt;sup&gt;2&lt;/sup&gt; colorectal cancer incidence in the U.S. decreased during the same period among adults aged 50 years and older.&lt;sup&gt;3&lt;/sup&gt; This decrease in colorectal cancer is partly due to increased screening, leading to early detection and treatment of pre-cancerous lesions.&lt;sup&gt;4&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;Colorectal cancer can be caused by exposure to risk factors such as tobacco use, alcohol use, diet, body composition, and physical inactivity.&lt;sup&gt;5-9&lt;/sup&gt; There is also evidence showing an association between colorectal cancer and environmental and occupational risk factors.&lt;sup&gt;10-13&lt;/sup&gt; Active component service members (ACSM) tend to be generally healthier than the U.S. general population, but they also tend to have a higher prevalence of smoking and alcohol use, and are more likely to be exposed to occupational risk factors including radiation, particulate matter, and solvents linked to colorectal cancer.&lt;sup&gt;11-13&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Overall, rates of colorectal cancer in U.S. military service members are lower compared to age-adjusted rates within the general U.S. population.&lt;sup&gt;14,15&lt;/sup&gt; In a study assessing incidence of numerous cancers from 2005 to 2014, the rate of colorectal cancer among ACSM was 4.5 cases per 100,000 person-years (p-yrs), with higher rates among men and African Americans.&lt;sup&gt;16&lt;/sup&gt; Another study of colorectal cancer specifically identified 1,108 incident cases of colorectal cancer among ACSM from 1997 to 2016, with a higher incident rate among men (4.4 per 100,000 p-yrs) as well as non-Hispanic Black service members (5.3 per 100,000 p-yrs).&lt;sup&gt;17&lt;/sup&gt; This study aims to build on prior analyses of incident colorectal cases among ACSM&lt;sup&gt;17&lt;/sup&gt; and describe the incidence rate of colorectal cancer among active component U.S. military service members between 2010 and 2022.&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;The results presented in this study include ACSM from all military services from January 1, 2010 through December 31, 2022. Data were obtained from the Defense Medical Surveillance System. Demographic data on age, military service, race and ethnicity, rank, and occupation at the time of colorectal cancer diagnosis were included. Ambulatory and inpatient administrative health records from both direct and &lt;span tabindex="0" class="TooltipLink"&gt;&lt;span class="TooltipContent"&gt;&lt;a href="javascript:void(0);"&gt;&lt;span class="visiblyHidden"&gt;Click to close&lt;/span&gt;&lt;span class="cancelButton"&gt;&lt;/span&gt;&lt;/a&gt;&lt;span class="DefinitionTerm"&gt;Purchased Care&lt;/span&gt;The TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.&lt;/span&gt;purchased care&lt;/span&gt; were used to determine colorectal cancer diagnoses.&lt;/p&gt;&lt;h3&gt;Case definition&lt;/h3&gt;&lt;p&gt;International Classification of Diseases, 9th/10th revision diagnostic codes, along with V-codes and Z-codes indicating a qualifying treatment (radiotherapy, chemotherapy, or immunotherapy), were used to define incident cases of colon and rectum cancer (Table 1).&lt;sup&gt;18&lt;/sup&gt;  Cases of appendiceal malignancies were excluded, as they are histologically different from colorectal cancer.&lt;sup&gt;18&lt;/sup&gt;  An incident case of colorectal cancer was defined as either one hospitalization with a qualifying ICD-9 or ICD-10 diagnosis code in the first diagnostic position, or in the second diagnostic position if a V/Z-code indicating radiotherapy, chemotherapy, or immunotherapy treatment was in the first diagnostic position; or three or more ambulatory encounters within a 90-day period with a qualifying ICD-9/10 diagnostic code in the first or second diagnostic position.&lt;sup&gt;18&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-1-Table-1" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-1-Table-1.ashx?h=277&amp;w=1075&amp;hash=497521DF6080528DAEC4597F0A8C60557E844DCC" style="height: 277px; width: 1075px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;The date of the first case-defining hospitalization or ambulatory medical encounter was used as the incident date. Service members were counted once per lifetime. Person-time contributions for each service member were determined from January 1, 2010 to December 31, 2022. Service members and their person-time contributions were removed from the study population if a case-defining encounter was recorded prior to the start of the surveillance period on January 1, 2010. Person-time was censored when a service member left the active component or military service, and at the time of the incident diagnosis for a colorectal cancer case, whichever occurred first.&lt;/p&gt;&lt;h3&gt;Statistical analysis&lt;/h3&gt;&lt;p&gt;Crude and age-adjusted incident rates were calculated as incident colorectal cancer diagnoses per 100,000 p-yrs with 95% confidence intervals. The standard population used for the age-adjustment was the Military Health System ACSM population in DMSS from 2010 to 2022, and age groups were utilized for adjusting colorectal incident rates. This age adjustment gave more weight to the younger age groups that constitute a majority of the ACSM population, leading to more stable incident rates. Incident rate ratios and 95% CI were calculated to compare colorectal cancer rates by all demographic variables included in the study. All analyses were conducted using SAS (version 9.4) with a significance level set at p&lt;0.05.&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;p&gt;During the 13-year surveillance period 741 incident cases of colorectal cancer among ACSM were recorded, corresponding to an overall crude incident rate of 4.44 (95% CI: 4.12-4.76) cases per 100,000 p-yrs (Table 2). The average age among colorectal cancer cases during the surveillance period was 39.9 years (STD=7.9, range 20-59). The distributions of incident colorectal cancer cases by select demographic characteristics are detailed in Table 2. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-1-Table-2" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-1-Table-2.ashx?h=959&amp;w=1100&amp;hash=A5BD90DE81E5F12520BBB945A4C4783A236ED3B1" style="height: 959px; width: 1100px; margin-top: 5px; margin-bottom: 10px; vertical-align: middle;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Crude incidence rates were higher among men and increased with age, ranging from 0.41 (95% CI: 0.24-0.57) per 100,000 p-yrs among those ages 20-24 to 54.51 (95% CI: 42.64-66.38) per 100,000 p-yrs among those older than 50-54 years (Table 2). Only a few cases were recorded in the 55 and older age group (n=14), with some years—2013, 2015, 2019, 2021, 2022—reporting zero cases in the oldest age group (data not shown).&lt;/p&gt;&lt;p&gt;The overall age-adjusted incidence rate throughout the surveillance period ranged from 3.56 (95% CI: 2.54-4.58) to 7.92 (95% CI: 5.98-9.86) cases per 100,000 p-yrs (Figure 1). The age-adjusted incidence rate peaked in 2017, at 7.92 (95% CI: 5.98-9.86) cases per 100,000 p-yrs, and then fluctuated for the rest of the surveillance period (Figure 1). &lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-1-Figure-1.ashx?h=644&amp;w=750&amp;hash=C2D5BF783AB0CAB4D54CA91CB02E251385EDA4F6" style="height: 644px; width: 750px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="This graph is comprised of 13 discrete vertical lines, each of which represents both the standard deviation and, at its midpoint, the age-adjusted rate of colorectal cancer incidence for an individual year, from 2010 to 2022, for active component service members 20 to 59 years of age. The rates of incidence are expressed per 100,000 person-years. Generally, the average rate of colorectal cancer incidence ranged between 3.5 and 5 (per 100,000 person-years), with notable deviations in 2014, 2017 and 2022. The average rate was slightly elevated in 2022, at just over 5.5 (per 100,000 person-years). Both 2014 and 2017 had wider standard deviations and higher average rates, of 6 and 8, respectively."&gt;&lt;/p&gt;&lt;p&gt;Age-adjusted colorectal rates were similar for men and women (4.46 [95% CI: 4.11-4.80] and 4.33 [95% CI: 3.49-5.17] cases per 100,000 p-yrs, respectively), and rates were relatively similar by service (Table 2). &lt;/p&gt;&lt;p&gt;Age-adjusted rates were also similar for all races and ethnicities, ranging from 4.34 (95% CI: 3.56-5.12) cases per 100,000 p-yrs among non-Hispanic Blacks to 4.63 (95% CI: 3.65-5.62) cases per 100,000 p-yrs among Hispanics (Table 2). The incident rate ratio was also relatively similar for all races and ethnicities, with no statistical significance when compared to non-Hispanic Whites (Table 2). &lt;/p&gt;&lt;p&gt;Service members in the pilot/air crew occupation category had the highest age-adjusted colorectal incident rate (6.03 [95% CI: 4.31-7.74]), followed by those in motor transportation (5.20 [95% CI: 2.50-7.90]) (Table 2). There was no significant difference, however, in the incident rate ratio for all occupation groups when compared to the reference group (infantry/artillery/armor/combat) (Table 2).&lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;This analysis shows a higher crude incidence rate of colorectal cancer among those 50 to 54 years of age; a previous study of the active component military population, from 1997 to 2016, found similar results.&lt;sup&gt;17&lt;/sup&gt; Age-adjusted colorectal cancer incident rates did not show any temporal trends during the study period, except for an increase in 2017. The prior study of colorectal cancer among ACSM from 1997 to 2016 also observed no temporal trends after adjusting for age.&lt;sup&gt;17&lt;/sup&gt; The lack of temporal trends in the military population diverges from general U.S. population data, which from 2011 to 2019 have shown a 1% annual decrease.&lt;sup&gt;19&lt;/sup&gt; This difference between the two populations could be due to the limited number of cases among ACSM, in turn leading to few cases among the younger (20-29 years) and older (55+ years) age groups. &lt;/p&gt;&lt;p&gt;The high incidence of colorectal cancer among service members in the pilot/aircrew occupation correlates with prior surveillance reports.&lt;sup&gt;17&lt;/sup&gt; While this occupation accounts for the highest rate of colorectal cancer, a recent study of military pilots showed evidence that aircrew colorectal cancers were statistically lower in the military population when compared to the general U.S. population, by 44%.&lt;sup&gt;20,21&lt;/sup&gt; Lower rates among ACSM may be attributed to universal health care and improved access to screenings for early pre-cancerous detection and treatment. &lt;/p&gt;&lt;p&gt;Older, White males have historically demonstrated greater use of colorectal cancer screenings within the MHS.&lt;sup&gt;22&lt;/sup&gt; This study did not observe, after adjusting for age, any significant colorectal cancer rate differences between races and ethnicities (Table 2) that could indicate racial differences in health care access and screening. Recent Defense Health Agency guideline changes that lowered the recommended age for colorectal screenings to age 45, combined with promotion of non-invasive colorectal cancer screenings and universal health care for all ACSM, may be contributing factors to the uniform incident rate among races and ethnicities.&lt;sup&gt;22,23&lt;/sup&gt; Continued surveillance of colorectal cancer among ACSM is necessary for understanding the true burden of colorectal cancer within the MHS.&lt;/p&gt;&lt;p&gt;One of this study's primary limitations is that it did not use the DOD’s cancer registry system, Oncolog, formerly known as the ACTUR. Oncolog includes cancer data reported by military hospitals and clinics for all DOD beneficiaries. Because this study relies solely on medical encounter data and does not incorporate Oncolog case reports, it may not include all colorectal cancer cases. Further studies should include both Oncolog and medical encounter data. Efforts are currently underway to determine true estimates of cancer diagnoses and treatment outside the MHS through the incorporation of data shared from state cancer registries.&lt;sup&gt;24&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;This study did not adjust for modifiable risk factors shown to increase risk of colorectal cancer such as obesity, physical inactivity, smoking, alcohol consumption, or environmental exposures.&lt;sup&gt;5-10&lt;/sup&gt; The active component military population tends to be engaged in more physical activity, is required to pass routine physical fitness examinations, and must maintain a healthy body weight, and thereby is less likely to be overweight or obese compared to the general U.S. population.&lt;sup&gt;21&lt;/sup&gt; These protective factors can be accredited to overall lower colorectal incidence rates within the U.S. military. Exposure to environmental toxins attributed to increased risk of colorectal cancer may be greater in this group, however, especially during deployment. Including deployment location and length of deployment in further analyses is important. &lt;/p&gt;&lt;h2&gt;Author Affiliations&lt;/h2&gt;&lt;p&gt;Defense Health Agency, Armed Forces Health Surveillance Division, Silver Spring, MD: Dr. Mabila, Ms. McQuistan, Ms. Murray. &lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;The views expressed in this article are those of the authors and do not necessarily reflect the official policy of the Department of Defense nor the U.S. Government. &lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2021. &lt;em&gt;CA Cancer J Clin&lt;/em&gt;. 2022;72(1):7-33. doi:10.3322/caac.21654&lt;/li&gt;    &lt;li&gt;Gordon-Dseagu VL, Devesa SS, Goggins M, Stolzenberg-Solomon R. Pancreatic cancer incidence trends: evidence from the Surveillance, Epidemiology and End Results (SEER) population-based data. &lt;em&gt;Int J Epidemiol&lt;/em&gt;. 2018;47(2):427-439. doi:10.1093/ije/dyx232&lt;/li&gt;    &lt;li&gt;Siegel RL, Torre LA, Soerjomataram I, et al. Global patterns and trends in colorectal cancer incidence in young adults. &lt;em&gt;Gut&lt;/em&gt;. 2019;68(12):2179-2185. doi:10.1136/gutjnl-2019-319511&lt;/li&gt;    &lt;li&gt;Arnold M, Sierra MS, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global patterns and trends in colorectal cancer incidence and mortality. &lt;em&gt;Gut&lt;/em&gt;. 2017;66(4):683-691. doi:10.1136/gutjnl-2015-310912&lt;/li&gt;    &lt;li&gt;National Center for Chronic Disease Prevention Health Promotion Office on Smoking Health. &lt;em&gt;The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General&lt;/em&gt;. Centers for Disease Control and Prevention (U.S.); 2014.&lt;/li&gt;    &lt;li&gt;Bagnardi V, Rota M, Botteri E, et al. Alcohol consumption and site-specific cancer risk: a comprehensive dose-response meta-analysis. &lt;em&gt;Br J Cancer&lt;/em&gt;. 2014:1-14. doi:10.1038/bjc.2014.579&lt;/li&gt;    &lt;li&gt;World Cancer Research Fund International, American Institute for Cancer Research. &lt;em&gt;Meat, Fish and Dairy Products and the Risk of Cancer: Continuous Update Project Expert Report&lt;/em&gt;. 2018.&lt;/li&gt;    &lt;li&gt;World Cancer Research Fund International, American Institute for Cancer Research. &lt;em&gt;Wholegrains, Vegetables and Fruit and the Risk of Cancer: Continuous Update Project Expert Report&lt;/em&gt;. 2018.&lt;/li&gt;    &lt;li&gt;World Cancer Research Fund International, American Institute for Cancer Research. &lt;em&gt;Other Dietary Exposures and the Risk of Cancer: Continuous Update Project Expert Report&lt;/em&gt;. 2018.&lt;/li&gt;    &lt;li&gt;Matich EK, Laryea JA, Seely KA, Stahr S, Su LJ, Hsu PC. Association between pesticide exposure and colorectal cancer risk and incidence: a systematic review. &lt;em&gt;Ecotoxicol Environ Saf&lt;/em&gt;. 2021;219:112327. doi:10.1016/j.ecoenv.2021.112327&lt;/li&gt;    &lt;li&gt;Weese CB, Abraham JH. Potential health implications associated with particulate matter exposure in deployed settings in southwest Asia. &lt;em&gt;Inhal Toxicol&lt;/em&gt;. 2009;21(4):291-296. doi:1080/08958370802672891&lt;/li&gt;    &lt;li&gt;Aurell J, Gullett BK, Yamamoto D. Emissions from open burning of simulated military waste from forward operating bases. &lt;em&gt;Environ Sci Technol&lt;/em&gt;. 2012;46(20):11004-11012. doi:10.1021/es303131k&lt;/li&gt;    &lt;li&gt;Lowers HA, Todorov R, Strand MJ, et al. Lung biopsies from symptomatic military deployers have variable mineral particle types and higher abundances of silicon, aluminum, cadmium and vanadium compared to controls. &lt;em&gt;Am J Respir Crit Care Med&lt;/em&gt;. 2015;191:A2575.&lt;/li&gt;    &lt;li&gt;Zhu K, Devesa SS, Wu H, et al. Cancer incidence in the U.S. military population: comparison with rates from the SEER program. &lt;em&gt;Cancer Epidemiol Biomarkers Prev&lt;/em&gt;. 2009;18(6):1740-1745.&lt;/li&gt;    &lt;li&gt;Bytnar JA, Shriver CD, Zhu K. Incidence rates of digestive cancers among U.S. military servicemen: comparison with the rates in the general U.S. population. &lt;em&gt;PLoS One&lt;/em&gt;. 2021;16(9):e0257087. doi:10.1371/journal.pone.0257087&lt;/li&gt;    &lt;li&gt;Lee T, Williams VF, Clark LL. Incident diagnoses of cancers in the active component and cancer-related deaths in the active and reserve components, U.S. Armed Forces, 2005-2014. &lt;em&gt;MSMR&lt;/em&gt;. 2016;23(7):23-31.&lt;/li&gt;    &lt;li&gt;Stahlman S, Oetting A. Age-period-cohort analysis of colorectal cancer, service members aged 20-59 years, active component, U.S. Armed Forces, 1997-2016. &lt;em&gt;MSMR&lt;/em&gt;. 2017;24(7):12-19.&lt;/li&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Surveillance Case Definition. Colorectal Cancer. Nov. 2022. &lt;a href="/Reference-Center/Publications/2022/11/01/Colorectal-Cancer" target="_blank" title="Click on the link to access the referenced case definition."&gt;www.health.mil/Reference-Center/Publications/2022/11/01/Colorectal-Cancer&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="/Reference-Center/Publications/2022/11/01/Colorectal-Cancer" target="_blank" title="Click on the link to access the referenced case definition."&gt;&lt;/a&gt;Siegel RL, Wagle NS, Cercek A, Smith RA, Jemal A. Colorectal cancer statistics, 2023. &lt;em&gt;CA Cancer J Clin&lt;/em&gt;. 2023;73(3):233-254.&lt;/li&gt;    &lt;li&gt;Department of Defense. Study on Incidence of Cancer Diagnoses and Mortality Among Military Aviators and Aviation Support Personnel. 2023. &lt;a href="/Reference-Center/Reports/2023/02/09/Study-on-the-Incidence-of-Cancer-Diagnosis-and-Mortality-among-Military-Aviators-and-Aviation-Support-Personnel" title="Opens the referenced article"&gt;https://www.health.mil/Reference-Center/Reports/2023/02/09/Study-on-the-Incidence-of-Cancer-Diagnosis-and-Mortality-among-Military-Aviators-and-Aviation-Support-Personnel&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.documentcloud.org/documents/23713702-military-pilots-cancer-study" target="_blank" title="Click on the link to access the cited Department of Defense study."&gt;&lt;/a&gt;Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974-2013. &lt;em&gt;J Natl Cancer Inst&lt;/em&gt;. 2017;109(8):djw322. doi:10.1093/jnci/djw322&lt;/li&gt;    &lt;li&gt;Debarros M, Steele SR. Colorectal cancer screening in an equal access healthcare system. &lt;em&gt;J Cancer&lt;/em&gt;. 2013;4(3):270-280. doi:10.7150/jca.5833&lt;/li&gt;    &lt;li&gt;Hammer, R. Colorectal Cancer Screening Age Decreases to 45. Accessed Apr. 27, 2023. &lt;a href="/News/Articles/2022/11/22/Colorectal-Cancer"&gt;https://health.mil/News/Articles/2022/11/22/Colorectal-Cancer&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://health.mil/News/Articles/2022/11/22/Colorectal-Cancer" target="_blank" title="Click on the link to access the cited study."&gt;&lt;/a&gt;Stahlman S, Clerkin C, Kohler B, Howe W Jr, Cronin K, Wells N. Brief report: Phase I results using the virtual pooled registry cancer linkage system for military cancer surveillance. &lt;em&gt;MSMR&lt;/em&gt;. 2022;29(7):26-27.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Sun, 01 Oct 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{13CFD96D-4C70-4CB3-B90B-0F52B17EE7DF}</guid><link>https://www.health.mil/News/Articles/2023/10/01/Malaria-RDT-failures</link><title>Force Protection Risks in AFRICOM, INDOPACOM and SOUTHCOM Due to Rapid Diagnostic Test Failures for Falciparum Malaria, 2016–2022</title><description>&lt;p&gt;Malaria, caused by various species of the &lt;em&gt;Plasmodium&lt;/em&gt; parasite, remains a significant health threat in most U.S. military regions—AFRICOM, CENT­COM, INDOPACOM, and SOUTHCOM—and although less prevalent, also poses periodic risks to military personnel in NORTHCOM through imported cases. Early diagnosis is crucial for effective malaria chemotherapy, and rapid diagnostic tests have proven valuable in resource-poor settings and operational environments. The BinaxNow Malaria RDT is currently the sole U.S. Food and Drug Administration-approved test for use on U.S. military personnel. This simple RDT targets &lt;em&gt;Plasmodium falciparum&lt;/em&gt;, the deadliest malaria species, by detecting the histidine-rich protein 2, as well as pan-&lt;em&gt;Plasmodium&lt;/em&gt; species by detecting aldolase. The emergence of mutant &lt;em&gt;P. falciparum&lt;/em&gt; parasites lacking &lt;em&gt;pfhrp2/pfhrp3&lt;/em&gt; genes and thus not expressing HRP2/HRP3 proteins poses a significant challenge in many malaria-endemic areas. This genetic variation has led to false-negative results in all HRP2-detecting RDTs including BinaxNow, undermining its utility. Current U.S. military force health protection measures for preventing malaria, including chemoprophylaxis, permethrin-treated uniforms, and DEET application to exposed skin, are effective, but breakthrough infections still occur. The use of portable and user-friendly malaria diagnostics is necessary in remote locations that lack microscopy or nucleic acid-based diagnostic capabilities. The alarmingly high prevalence of mutant &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites poses a threat to malaria diagnosis in all Combatant Commands where point-of-care testing is vital. This review emphasizes the importance of ongoing monitoring to determine the frequency and distribution of mutant parasites. Urgent attention is needed to develop alternative RDTs that can effectively detect malaria infections caused by these mutant strains.&lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;These findings confirm that mutant &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites are highly prevalent in SOUTHCOM and parts of AFRICOM, rendering HRP2-based RDTs such as BinaxNow an unsuitable diagnostic tool for malaria in many of the SOUTHCOM and AFRICOM countries surveyed: Peru (14.3-62% between 2011-2018), Eritrea (62% in 2016 and 9.4% in 2020), Nigeria (13.3%), Sudan (11.2%), South Sudan (17.7%), and Uganda (3.3%). In INDOPACOM countries surveyed, no prevalence greater than 5%&lt;em&gt; pfhrp2&lt;/em&gt; deletions were observed. It is critical to continue surveillance on the frequency and distribution of these mutant parasites and develop alternative RDTs.&lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;WHO recommends that countries switch to non-HRP2-based RDTs when prevalence of &lt;em&gt;pfhrp2/3&lt;/em&gt; deletions that cause false-negative RDT results exceed 5%. Current prevalence of mutant &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites causing false-negative RDT results has exceeded this threshold in most parts of SOUTHCOM and several areas of AFRICOM. If alternative diagnostic tests are not utilized in areas affected, life-saving malaria treatment for U.S. military personnel could be delayed. Continuous mapping of the frequency and distribution of mutant parasites directly informs FHP protection policy decisions for alternative diagnostic tool utilization.&lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;Malaria remains a major health problem worldwide. In 2021 the global burden of malaria was estimated at 247 million cases, an increase of 2 million cases from 2020.&lt;sup&gt;1&lt;/sup&gt; In 2021, 20 malaria cases were reported among U.S. military personnel,&lt;sup&gt;2&lt;/sup&gt; and this low number of reported cases, despite the massive global burden of malaria, is either an indication that current U.S. Department of Defense countermeasures (e.g., insecticide-treated uniforms, chemoprophylaxis drugs) are currently effective despite increasing mosquito resistance to permethrin and Plasmodium drug resistance, or because few U.S. military personnel are currently in areas of high malaria transmission. &lt;/p&gt;&lt;p&gt;Malaria is caused by the &lt;em&gt;Plasmodium apicomplexan&lt;/em&gt; protozoa parasite, a diverse genus of multiple hosts transmitted by a number of &lt;em&gt;Anopheles&lt;/em&gt; genus mosquitoes. The &lt;em&gt;Plasmodium&lt;/em&gt; species that commonly cause human malaria disease are &lt;em&gt;Plasmodium falciparum&lt;/em&gt;, &lt;em&gt;P. vivax&lt;/em&gt;, &lt;em&gt;P. ovale&lt;/em&gt;, &lt;em&gt;P. cynomolgi&lt;/em&gt;, and &lt;em&gt;P. knowlesi&lt;/em&gt;. While each of these parasites can cause incapacitation unless appropriately treated, &lt;em&gt;P. falciparum&lt;/em&gt; is rapidly fatal if not diagnosed and treated properly. Additionally, &lt;em&gt;P. vivax&lt;/em&gt;, &lt;em&gt;P. ovale&lt;/em&gt;, and &lt;em&gt;P. cynomolgi&lt;/em&gt; have a dormant phase in the liver called hypnozoites that can relapse weeks to months later, causing debilitation and affecting readiness until properly cleared with the 8-aminoquinoline class of drugs. &lt;/p&gt;&lt;p&gt;While microscopy is the gold standard for detecting &lt;em&gt;Plasmodium&lt;/em&gt; parasites, it requires equipment and a competent microscopist not always available in austere environments. U.S. military operations often require movements far from fixed facilities with competent microscopists that can accurately diagnose malaria, and the weight of the diagnostic kit and its reliance on power and reagents is a significant consideration, which makes lightweight, easy-to-use RDTs more attractive than light microscopes. The World Health Organization recommends rapid diagnostic tests as a diagnostic tool when quality microscopy is not available.&lt;sup&gt;3&lt;/sup&gt; Despite many brands of malaria RDTs (89 meeting WHO procurement criteria and 11 WHO pre-qualified) that are commercially available, BinaxNOW Malaria RDT is the only RDT approved by the U.S. Food and Drug Administration for use in the U.S. and by U.S. military personnel, since 2007. &lt;/p&gt;&lt;p&gt;BinaxNOW detects 2 &lt;em&gt;Plasmodium&lt;/em&gt;-specific proteins: histidine-rich protein 2 (HRP2), specifically diagnosing &lt;em&gt;P. falciparum&lt;/em&gt;, and aldolase, a pan-&lt;em&gt;Plasmodium&lt;/em&gt; protein generically detecting all &lt;em&gt;Plasmodium&lt;/em&gt; species. According to the WHO round 1 (2008) product testing of BinaxNOW, the detection rate for &lt;em&gt;P. falciparum&lt;/em&gt; is 91.14% and &lt;em&gt;P. vivax&lt;/em&gt; is 10% at 200/uL; for &lt;em&gt;P. falciparum&lt;/em&gt; it is 100% and &lt;em&gt;P. vivax&lt;/em&gt; 85% at 2000/uL.&lt;sup&gt;4&lt;/sup&gt; Performance characteristics of diagnostic tests can vary depending on several factors, including the expertise of the operator, the quality of the test kit, and the population tested. &lt;/p&gt;&lt;p&gt;A serious threat to the utility of HRP2-based RDTs including BinaxNow has developed with the emergence of mutant &lt;em&gt;P. falciparum&lt;/em&gt; parasites with deleted genes that encode HRP2 or a cross-reactive HRP3 which reduces or eliminates HRP2/3 protein expression, the targets of &lt;em&gt;P. falciparum&lt;/em&gt; detection in BinaxNOW Malaria RDTs. These mutant parasites cause false-negative results. &lt;em&gt;Pfhrp2/3&lt;/em&gt;-deleted &lt;em&gt;P. falciparum&lt;/em&gt; parasites were first reported from patient samples collected between 2003 and 2007 in Peru,&lt;sup&gt;5&lt;/sup&gt; and have now been confirmed in 40 of 47 countries surveyed.&lt;sup&gt;1&lt;/sup&gt; The overall pooled prevalence of &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites is highest in South America, followed by Africa, then Asia&lt;sup&gt;6&lt;/sup&gt;; countries from South America and the Horn of Africa are among the worst-affected by &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted mutant parasites. &lt;/p&gt;&lt;p&gt;In 2019, WHO issued a “Response Plan to &lt;em&gt;pfhrp2&lt;/em&gt; Gene Deletions” outlining major strategies that include defining the frequency and distribution of mutant parasites, changing to non-HRP2-based RDTs when prevalence of &lt;em&gt;pfhrp2/3&lt;/em&gt; deletions that cause false-negative RDT results exceeds 5%, and developing new RDTs.&lt;sup&gt;7&lt;/sup&gt; Over the past 7 years, our team has collaborated with the WHO, national ministries of Health, and partner institutions to map and characterize &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites in several countries. These surveys provided critical data not only for national MoH diagnosis policy guidance, but also provided evidence of the extent of &lt;em&gt;pfhrp2/3&lt;/em&gt; deletions within U.S. Africa Command (AFRICOM), U.S. Indo-Pacific Command (INDOPACOM), and U.S. Southern Command (SOUTHCOM), to directly support Force Health Protection policy decisions. Herein we summarize major survey findings and their implications.&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;This is a review article collating and summarizing our survey findings published over the past seven years, and their implications for public health and FHP. Field surveys conducted by our collaborating teams are described in the Results; the laboratory methods used for determining &lt;em&gt;pfhrp2/3&lt;/em&gt; deletions are previously reported&lt;sup&gt;11&lt;/sup&gt;; presence of parasite DNA was confirmed by PCR amplification of the 18s rRNA gene, msp1 and msp2 single copy genes. Presence or absence of deletions was confirmed by amplification of exon1 and exon2 of &lt;em&gt;pfhrp2&lt;/em&gt; and &lt;em&gt;pfhrp3&lt;/em&gt; using gene-specific PCR&lt;sup&gt;11&lt;/sup&gt;; the work flow is summarized as a flow chart (Figure).&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-2-Figure.ashx?h=748&amp;w=750&amp;hash=9E72BE7AA8342F832C4839B778BE0757ABC841A9" style="height: 748px; width: 750px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="This graph is a flow chart that explicates the laboratory diagnostic process or work flow for determining deletions of Plasmodium falciparum (or Pf) malaria histidine-rich proteins 2 and 3 (or pfhrp 2/3). The first step is “Patients visiting health facilities,” followed by “Rapid diagnostic test (or RDT) and/or microscopy positive for Plasmodium falciparum,” and then “Dried blood spot samples” are used to both “Extract genomic DNA” and “Elute protein.” Both samples—the genomic DNA and protein—are then tested by separate polymerase chain reactions. The genomic DNA samples are analyzed for absence of gene deletions, a single pfhrp 2 or pfhrp 3 deletion, or both; meanwhile, microsatellite marker genotyping provides data on “Multiplicity of infection,” “Genetic diversity,” and “Genetic relatedness” for the samples."&gt;&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;h3&gt;AFRICOM AOR&lt;/h3&gt;&lt;h4&gt;Eritrea&lt;/h4&gt;&lt;p&gt;Eritrea’s seasonal malaria transmission is low. Eritrea’s MoH introduced a HRP2-based combination RDT in 2006, but received complaints of false-negative RDT results in 2015. Initial investigations into possible causes of RDT failures led to suspicions about the presence of &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites. In 2016, the country’s MoH collected patient samples (n=50) from 2 hospitals in the Northern Red Sea Zone, where false-negative RDT results had been reported, to search for &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites. Laboratory analysis of these samples identified that 62% of patients were infected with &lt;em&gt;pfhrp2/3&lt;/em&gt;-double-deleted parasites, and a further 20% with &lt;em&gt;pfhrp3&lt;/em&gt;-deleted parasites. All double-&lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites produced negative RDT results.&lt;sup&gt;8&lt;/sup&gt; Genetic relatedness analysis suggested that &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites in Eritrea likely emerged &lt;em&gt;de novo&lt;/em&gt;. &lt;/p&gt;&lt;p&gt;A follow-up survey in 2019 assessed the trend of &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites in Eritrea 2.5 years after the country’s MoH switched from HRP2-based RDTs. This was the first survey in the world to assess the epidemiology and evolution of mutant &lt;em&gt;pfhrp2&lt;/em&gt;-deleted parasites following RDT switch. The survey collected &lt;em&gt;P. falciparum&lt;/em&gt; samples from malaria patients at nine health facilities in three zones (n=715). Our analysis revealed an overall prevalence of mutant parasites lacking &lt;em&gt;pfhrp2&lt;/em&gt;, &lt;em&gt;pfhrp3&lt;/em&gt;, and both &lt;em&gt;pfhrp2/3&lt;/em&gt; genes of 9.4%, 41.7%, and 7.6%, respectively. The prevalence of mutant parasites was variable both within and between different zones.&lt;sup&gt;9&lt;/sup&gt; We also showed that the genetic diversity of mutant parasites significantly increased. While the prevalence of &lt;em&gt;pfhrp2/3&lt;/em&gt; deletions at all nine survey sites was lower than in 2016 at a different location, the overall prevalence of gene deletions in 2020 still exceeded the WHO threshold for RDT switch.  &lt;/p&gt;&lt;h4&gt;Nigeria, Sudan and South Sudan&lt;/h4&gt;&lt;p&gt;Because field surveys in many African countries are challenging, we analyzed imported &lt;em&gt;P. falciparum&lt;/em&gt; cases (n=210, collected 2010-2018) to determine if &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites were present. We detected gene deletions in patients from 12 of 25 countries: &lt;em&gt;pfhrp2&lt;/em&gt;-deletions in those from Nigeria (13.3%, n=30), Sudan (11.2%, n=39), and South Sudan (17.7%, n=17), and low levels of parasites with &lt;em&gt;pfhrp3&lt;/em&gt;-deletion from Sudan (3.6%) and South Sudan (5.9%). No parasites with double-&lt;em&gt;pfhrp2/3&lt;/em&gt; deletions were detected.&lt;sup&gt;9&lt;/sup&gt; Microsatellite typing of parasites from Nigeria, Sudan, and South Sudan revealed low relatedness among gene-deleted parasites, indicating independent emergencies.&lt;/p&gt;&lt;h4&gt;Uganda&lt;/h4&gt;&lt;p&gt;Uganda has one of highest malaria burdens in Africa. In collaboration with the country’s MoH, we analyzed 300 &lt;em&gt;P. falciparum&lt;/em&gt; isolates collected from cross-sectional malaria surveys in symptomatic individuals from 48 districts of Uganda’s Eastern and Western regions. The prevalence of parasites with &lt;em&gt;pfhrp2&lt;/em&gt;, &lt;em&gt;pfhrp3&lt;/em&gt;, and dual &lt;em&gt;pfhrp2/3&lt;/em&gt; deletions was 3.3%, 3.0%, and 3.3%, respectively.&lt;sup&gt;11&lt;/sup&gt; The proportion of &lt;em&gt;pfhrp2/3&lt;/em&gt; deletions was higher in the Eastern (14.7%) compared to the Western region (3.1%). This is the first large-scale survey reporting the presence of &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites in Uganda. These mutant parasites contributed to 12.3% of false-negative RDT results, along with low parasite density and non-&lt;em&gt;P. falciparum&lt;/em&gt; infections.&lt;sup&gt;12&lt;/sup&gt; Genetic analyses showed a high rate of multiplicity of infections consistent with high transmission intensity in survey areas, and that gene-deleted parasites likely evolved &lt;em&gt;de novo&lt;/em&gt; from the local parasite population.&lt;sup&gt;13&lt;/sup&gt; &lt;/p&gt;&lt;h3&gt;SOUTHCOM AOR&lt;/h3&gt;&lt;p&gt;Peru has low malaria transmission, and despite the fact RDT is not a diagnostic mainstay for malaria in Peru, it was the first country to report &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites. In collaboration with Naval Medical Research Unit-6, we characterized the presence of &lt;em&gt;pfhrp2&lt;/em&gt; and &lt;em&gt;pfhrp3&lt;/em&gt; genes on &lt;em&gt;P. falciparum&lt;/em&gt; samples (n=325) collected in Iquitos and surrounding communities between 2011 and 2018, as part of an ongoing project, Malaria Disease in Peru, to understand the prevalence trend of &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites and evolution over an 8-year period. Overall, double-&lt;em&gt;pfhrp2&lt;/em&gt; and -&lt;em&gt;pfhrp3&lt;/em&gt; deletions were detected in 67% of patient samples. We observed a concordance (Cohen’s Kappa=0.842) between &lt;em&gt;pfhrp2&lt;/em&gt; gene deletion and negligible HRP2 protein levels. Prevalence of gene deletion varied by study site, but the overall prevalence increased between 2011 (14.3%) and 2016 (88.4%), stabilizing around 65% in 2018.&lt;sup&gt;14&lt;/sup&gt; This prevalence increase was associated with rapid expansion of a single new parasite haplotype with double-&lt;em&gt;pfhrp2/3&lt;/em&gt; deletions. Our study showed the increase of &lt;em&gt;pfhrp2/3&lt;/em&gt; deletions in the absence of RDT pressure resulted from a clonal replacement of circulating lines with gene-deleted parasites in the Peruvian Amazon basin, suggesting that low immunity in the community to the new strain is likely the major factor in the rapid spread of &lt;em&gt;pfhrp2/3&lt;/em&gt; deletion. Interestingly, participants infected with double-&lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites had a significantly lower parasitemia than those without gene deletions, which may cause less disease. &lt;/p&gt;&lt;h3&gt;INDOPACOM AOR&lt;/h3&gt;&lt;p&gt;&lt;em&gt;Pfhrp2&lt;/em&gt;-deleted parasites have been reported in India,&lt;sup&gt;15&lt;/sup&gt; the China-Myanmar border,&lt;sup&gt;16&lt;/sup&gt; and Indonesia,&lt;sup&gt;17&lt;/sup&gt; with variable prevalence of 0-25%, 4% and 4%, respectively. To date, there are no published survey reports of &lt;em&gt;pfhrp2&lt;/em&gt;-deleted mutant parasites from other countries in this region.&lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;The rise of &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites is of significant concern for FHP, with current U.S. military personnel reliance on BinaxNOW malaria RDTs as the point-of-care test in austere environments. Deployed small teams of military personnel are most at risk of developing malaria and are simultaneously most reliant on RDTs. The gold standard for malaria diagnosis is by trained microscopist via blood smear. Lack of trained microscopists, however, has led many countries to become reliant upon malaria RDTs for diagnosis. In semi-fixed facilities with sufficient power and specialized equipment, nucleic acid-based methods are available for &lt;em&gt;Plasmodium&lt;/em&gt; diagnosis that circumvents the HRP deletion issue. For deployed forces, this diagnostic capability such as a Biofire, Genexpert, or Loop Mediated Isothermal Amplification testing can be utilized at a Role 2 field hospital.  &lt;/p&gt;&lt;p&gt;&lt;em&gt;P. falciparum&lt;/em&gt; is biodiverse among strains, so stratifying risk based on location is complex and requires active surveillance. These data presented summarize data collected from collaborating countries since 2016. There are inherent biases when focusing on a subset of all data collected on a topic, but our data concur with other published work on HRP2/3 deletions. Our DOD Global Emerging Infections Surveillance-supported findings contributed to the global effort of mapping the frequency of gene-deleted parasites causing false-negative RDT results and inform diagnostic policies of related stakeholders. Our 2016 survey in Eritrea was the first study demonstrating a high prevalence of gene-deleted parasites causing a high rate of RDT failures in Africa, and based on these survey findings, Eritrea switched to non-HRP2-based RDTs in 2016. The results from a 2019 follow-up survey suggest that HRP2-based RDT use is likely the main factor behind the high prevalence of gene-deleted parasites. Switching to non-HRP2-based RDT was partially effective in reducing gene-deleted parasite prevalence in Eritrea. HRP2-based RDTs remain unsuitable for malaria diagnosis in Eritrea at this time, however. &lt;/p&gt;&lt;p&gt;We detected significant proportions of mutant parasites in travelers returning from Nigeria, Sudan, and South Sudan, where surveys are difficult to conduct. The proportions of parasites with gene deletions in those returning travelers signify a risk of false-negative HRP2 RDT results. In many of these countries our findings provided the first report of mutant parasites, which warrants surveillance to determine whether the prevalence of gene-deleted parasites justifies switching malaria RDTs in Nigeria, Sudan, and South Sudan.  &lt;/p&gt;&lt;p&gt;Our detection of gene-deleted parasites in Eastern and Western Uganda led to a nationwide survey to establish the prevalence and distribution of these mutant parasites. Field collection is complete and genetic analysis of samples is underway. We are also conducting surveillance of &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites in Cambodia and Papua New Guinea (PNG) in collaborations with the Armed Forces Research Institute of Medical Sciences and the PNG Defence Force.&lt;/p&gt;&lt;p&gt;Our microsatellite genotyping and genetic relatedness analyses revealed that &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites likely evolved &lt;em&gt;de novo&lt;/em&gt; from local parasite populations. This finding suggests that a control rather than containment strategy may be a more effective intervention. These mutant parasites are prevalent in most malaria-endemic areas surveyed, with the ability to develop &lt;em&gt;de novo&lt;/em&gt;, making false-negative malaria diagnosis a concern for all COCOMS. &lt;/p&gt;&lt;p&gt;Forshey et al. provide a framework for continued assessment of the &lt;em&gt;pfhrp2/3&lt;/em&gt; deletion problem and a framework for U.S. DOD to acquire alternative RDTs that meet DOD requirements including FDA clearance.&lt;sup&gt;18&lt;/sup&gt; Currently, there are limited alternative RDTs available for the detection of parasites lacking HRP2. The WHO product testing round 8 evaluated 34 brands of RDTs against &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites and revealed that only two RDTs targeting Pan-pLDH met WHO procurement criteria, while RDTs specifically targeting Pf-pLDH performed poorly against gene-deleted parasites.&lt;sup&gt;19&lt;/sup&gt; While the two Pan-pLDH RDTs can be used to detect gene-deleted parasites in areas where &lt;em&gt;P. falciparum&lt;/em&gt; is dominant, they are not WHO pre-qualified, nor FDA approved. For areas where discriminating &lt;em&gt;P. falciparum&lt;/em&gt; from &lt;em&gt;P. vivax&lt;/em&gt; and other &lt;em&gt;Plasmodium&lt;/em&gt; species is necessary, combination RDTs detecting Pf-pLDH/Pv-pLDH and Pf-pLDH/pan-pLDH are required; a new Pf-pLDH RDT has shown promising performance against gene-deleted parasites,&lt;sup&gt;20&lt;/sup&gt; and some are in the WHO pre-qualification pipeline. &lt;/p&gt;&lt;p&gt;With the U.S. military operational framework evolving from counterinsurgency to large scale combat operations, doctrine is shifting to a need for prolonged casualty care that would benefit from a next-generation malaria RDT. For FHP in the short- and medium terms, FHP officers and pre-deployment planners should be made aware of the problem of &lt;em&gt;pfhrp2/3&lt;/em&gt;-deleted parasites and given the most up-to-date aggregate surveillance data for their areas of responsibility. Long-term investment should be made in point-of-care testing with alternative targets that can discriminate different &lt;em&gt;Plasmodium&lt;/em&gt; species and detect mutant parasites lacking HRP2.&lt;/p&gt;&lt;h2&gt;Author Affiliations&lt;/h2&gt;&lt;p&gt;Walter Reed Army Institute of Research Engineering and Scientist Exchange Program, Enoggera, QLD, Australia: MAJ Vesely (MSC, USA); Australian Defence Force Malaria and Infectious Disease Insti­tute, Enoggera, QLD, Australia: Dr. Cheng.&lt;/p&gt;&lt;h2&gt;Acknowledgements&lt;/h2&gt;&lt;p&gt;The authors thank our many collaborators and partner institutions in the publications referenced, and GEIS for continued support of sample analysis under P0160_23_AI. &lt;/p&gt;&lt;h2&gt;Disclaimer&lt;/h2&gt;&lt;p&gt;This material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation or publica­tion. The opinions and assertions contained herein are the private views of the author, and are not to be construed as official, nor as reflecting true views of the Department of the Army or the Department of Defense.&lt;/p&gt;&lt;p&gt;The opinions expressed are those of the authors and do not necessarily reflect those of the Australian Defence Force.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;World Health Organization. &lt;em&gt;World Malaria Report 2022&lt;/em&gt;. World Health Organization; 2015. Accessed Apr. 3, 2023. &lt;a rel="noopener noreferrer" href="https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022" target="_blank" title="Click on the link to access the 2022 WHO malaria world report."&gt;https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022" target="_blank" title="Click on the link to access the 2022 WHO malaria world report."&gt;&lt;/a&gt;Armed Forces Health Surveillance Division. Update: malaria, U.S. Armed Forces, 2021. &lt;em&gt;MSMR&lt;/em&gt;. 2022;29(3):2-7.&lt;/li&gt;    &lt;li&gt;WHO. &lt;em&gt;Guidelines for the Treatment of Malaria, 3rd edition&lt;/em&gt;. World Health Organization; 2015. Accessed Apr. 3, 2023. &lt;a rel="noopener noreferrer" href="https://www.afro.who.int/publications/guidelines-treatment-malaria-third-edition" target="_blank" title="Click on the link to access the WHO guidelines for malaria treatment (now superseded by recently-released malaria guidelines)."&gt;https://www.afro.who.int/publications/guidelines-treatment-malaria-third-edition&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://www.afro.who.int/publications/guidelines-treatment-malaria-third-edition" target="_blank" title="Click on the link to access the WHO guidelines for malaria treatment (now superseded by recently-released malaria guidelines)."&gt;&lt;/a&gt;UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Centers for Disease Control (U.S.), and Foundation for Innovative New Diagnostics. &lt;em&gt;Malaria Rapid Diagnostic Test Performance--Results of WHO Product Testing of Malaria RDTs: Round 1 (2008)&lt;/em&gt;. 2009. Accessed Apr. 3, 2023. &lt;a rel="noopener noreferrer" href="https://apps.who.int/iris/handle/10665/44120" target="_blank" title="Click on the link to access the report on RDT product testing."&gt;https://apps.who.int/iris/handle/10665/44120&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://apps.who.int/iris/handle/10665/44120" target="_blank" title="Click on the link to access the report on RDT product testing."&gt;&lt;/a&gt;Gamboa D, Ho MF, Bendezu J, et al. A large proportion of P. falciparum isolates in the Amazon region of Peru lack &lt;em&gt;pfhrp2&lt;/em&gt; and &lt;em&gt;pfhrp3&lt;/em&gt;: implications for malaria rapid diagnostic tests. &lt;em&gt;PLoS One&lt;/em&gt;. 2010;5(1):e8091.&lt;/li&gt;    &lt;li&gt;Jejaw Zeleke A, Hailu A, Bayih AG, et al. &lt;em&gt;Plasmodium falciparum&lt;/em&gt; histidine-rich protein 2 and 3 genes deletion in global settings (2010-2021): a systematic review and meta-analysis. &lt;em&gt;Malar J&lt;/em&gt;. 2022;21(1):26.&lt;/li&gt;    &lt;li&gt;WHO. &lt;em&gt;Response Plan to &lt;/em&gt;pfhrp2 &lt;em&gt;Gene Deletions&lt;/em&gt;. 2019. Accessed Apr. 3, 2023. &lt;a rel="noopener noreferrer" href="https://www.who.int/publications/i/item/WHO-CDS-GMP-2019.02" target="_blank" title="Click on the link to access the WHO response plan to pfhrp2 gene deletions."&gt;https://www.who.int/publications/i/item/WHO-CDS-GMP-2019.02&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.who.int/publications/i/item/WHO-CDS-GMP-2019.02" target="_blank" title="Click on the link to access the WHO response plan to pfhrp2 gene deletions."&gt;&lt;/a&gt;Berhane A, Anderson K, Mihreteab S, et al. Major threat to malaria control programs by &lt;em&gt;Plasmodium falciparum&lt;/em&gt; lacking histidine-rich protein 2, Eritrea. &lt;em&gt;Emerg Infect Dis&lt;/em&gt;. 2018;24(3):462-470.&lt;/li&gt;    &lt;li&gt;Mihreteab S, Anderson K, Pasay C, et al. Epidemiology of mutant &lt;em&gt;Plasmodium falciparum&lt;/em&gt; parasites lacking histidine-rich protein 2/3 genes in Eritrea 2 years after switching from HRP2-based RDTs. &lt;em&gt;Sci Rep&lt;/em&gt;. 2021;11(1):21082.&lt;/li&gt;    &lt;li&gt;Prosser C, Gresty K, Ellis J, et al. &lt;em&gt;Plasmodium falciparum&lt;/em&gt; histidine-rich protein 2 and 3 gene deletions in strains from Nigeria, Sudan, and South Sudan. &lt;em&gt;Emerg Infect Dis&lt;/em&gt;. 2021;27(2):471-479.&lt;/li&gt;    &lt;li&gt;Bosco AB, Anderson K, Gresty K, et al. Molecular surveillance reveals the presence of &lt;em&gt;pfhrp2&lt;/em&gt; and &lt;em&gt;pfhrp3&lt;/em&gt; gene deletions in &lt;em&gt;Plasmodium falciparum&lt;/em&gt; parasite populations in Uganda, 2017-2019. &lt;em&gt;Malar J&lt;/em&gt;. 2020;19(1):300.&lt;/li&gt;    &lt;li&gt;Bosco AB, Nankabirwa JI, Yeka A, et al. Limitations of rapid diagnostic tests in malaria surveys in areas with varied transmission intensity in Uganda 2017-2019: implications for selection and use of HRP2 RDTs. &lt;em&gt;PLoS One&lt;/em&gt;. 2020;15(12):e0244457.&lt;/li&gt;    &lt;li&gt;Bosco AB, Anderson K, Gresty K, et al. Genetic diversity and genetic relatedness in &lt;em&gt;Plasmodium falciparum&lt;/em&gt; parasite population in individuals with uncomplicated malaria based on microsatellite typing in Eastern and Western regions of Uganda, 2019-2020. &lt;em&gt;Malar J&lt;/em&gt;. 2021;20(1):242.&lt;/li&gt;    &lt;li&gt;Valdivia HO, Anderson K, Smith D, et al. Spatiotemporal dynamics of &lt;em&gt;Plasmodium falciparum&lt;/em&gt; histidine-rich protein 2 and 3 deletions in Peru. &lt;em&gt;Sci Rep&lt;/em&gt;. 2022;12(1):19845.&lt;/li&gt;    &lt;li&gt;Bharti PK, Chandel HS, Ahmad A, Krishna S, Udhayakumar V, Singh N. Prevalence of &lt;em&gt;pfhrp2&lt;/em&gt; and/or &lt;em&gt;pfhrp3&lt;/em&gt; gene deletion in &lt;em&gt;Plasmodium falciparum&lt;/em&gt; population in eight highly endemic states in India. &lt;em&gt;PLoS One&lt;/em&gt;. 2016;11(8):e0157949.&lt;/li&gt;    &lt;li&gt;Li P, Xing H, Zhao Z, et al. Genetic diversity of &lt;em&gt;Plasmodium falciparum&lt;/em&gt; histidine-rich protein 2 in the China-Myanmar border area. &lt;em&gt;Acta Trop&lt;/em&gt;. 2015;152:26-31.&lt;/li&gt;    &lt;li&gt;MalariaGen, Ahouidi A, Ali M, et al. An open dataset of &lt;em&gt;Plasmodium falciparum&lt;/em&gt; genome variation in 7,000 worldwide samples. &lt;em&gt;Wellcome Open Res&lt;/em&gt;. 2021;6:42. Accessed Apr. 3, 2023. &lt;a rel="noopener noreferrer" href="https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022" target="_blank" title="Click on the link to access the open dataset of 7,000 worldwide samples."&gt;https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022" target="_blank" title="Click on the link to access the open dataset of 7,000 worldwide samples."&gt;&lt;/a&gt;Forshey BM, Morton L, Martin N, et al. &lt;em&gt;Plasmodium falciparum&lt;/em&gt; rapid test failures threaten diagnosis and treatment of U.S. military personnel. &lt;em&gt;Mil Med&lt;/em&gt;. 2020;185(1-2):e1-e4. doi:10.1093/milmed/usz256Fo&lt;/li&gt;    &lt;li&gt;WHO. &lt;em&gt;Malaria Rapid Diagnostic Test Performance—Results of WHO Product Testing of Malaria RDTs: Round 8 (2016-2018)&lt;/em&gt;. 2018. Accessed Apr. 3, 2023. &lt;a rel="noopener noreferrer" href="https://www.who.int/publications/i/item/9789241514965" target="_blank" title="Click on the link to access the report on more recent RDT product testing."&gt;https://www.who.int/publications/i/item/9789241514965&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.who.int/publications/i/item/9789241514965" target="_blank" title="Click on the link to access the report on more recent RDT product testing."&gt;&lt;/a&gt;Niyukuri D, Sinzinkayo D, Troth EV, et al. Performance of highly sensitive and conventional rapid diagnostic tests for clinical and subclinical &lt;em&gt;Plasmodium falciparum&lt;/em&gt; infections, and hrp2/3 deletion status in Burundi. &lt;em&gt;PLOS Glob Public Health&lt;/em&gt;. 2022;28(2[7]):e0000828. doi: 10.1371/journal.pgph.0000828&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Sun, 01 Oct 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{91930495-13F5-474B-B688-3444ACDA43CF}</guid><link>https://www.health.mil/News/Articles/2023/10/01/RME-Accuracy</link><title>Completeness and Timeliness of Reporting Notifiable Medical Events, U.S. Military Active Component and Other DOD Beneficiaries, 2018–2022</title><description>&lt;p&gt;Complete and timely reporting of notifiable medical conditions among the Department of Defense beneficiary population is important for the control of communicable and preventable diseases and injuries. The Defense Medical Surveillance System was used to identify all hospital and ambulatory care encounters during 2018-2022 for which a notifiable medical condition was indicated among active component service members as well as all other DOD beneficiaries. Inci­dent cases with diagnoses of DOD-notifiable medical conditions were matched with reportable medical events entered through the Disease Reporting System internet. During the study period, 61.2% of notifiable hospitalized cases and 65.5% of notifiable ambulatory care cases at a military hospital or clinic among active component service members were reported. Among other beneficiaries treated at a military hospital or clinic, only 15.2% of notifiable hospitalized cases and 22.1% of notifiable ambulatory care cases were reported to DRSi. Reporting percentages were much lower for care at outsourced facilities, regardless of the population. The timeliness of reporting for active component service members fluctuated annually, but in both 2018 and 2022, 64.2% of notifiable cases at a military hospital were reported within 1 week. For ambulatory care cases, timeliness of reporting decreased over time, with 50.1% reported within 1 week in 2018 and 43.3% in 2022.&lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;A total of 1,306 hospitalized and 100,163 ambulatory incident cases for notifiable medical conditions among active component service members occurred from January 2018 to December 2022. Reporting of these events though the DRSi increased since the last report in 2015, but timeliness decreased. Data on other beneficiaries and outsourced care facilities were added to the analysis for this report.&lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;Improvements to reporting and timeliness of active component service member notifiable medical conditions is needed to effectively track and mitigate communicable diseases and preventable injuries. Although reporting currently is not required for all non-service member beneficiaries, they present another source of communicable diseases that could affect disease among service members, making them a potential population for report consideration. &lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;U.S. military Services are required, by Department of Defense Directive 6490.02E, to report notifiable medical conditions among all DOD personnel and dependents, residing either in garrison or overseas with their military sponsor, during a possible exposure or public health event.&lt;sup&gt;1&lt;/sup&gt; Centralized reporting of preventable and communicable medical conditions is an important tool for facilitating rapid dissemination of information on the occurrence of medical events that could pose a public health threat. Centralized reporting also serves as a mechanism for recording more extensive information about a medical event in hospitalization and ambulatory care administrative data. The guidelines and specific case definitions for all medical conditions required by DOD for reporting are described in &lt;em&gt;Armed Forces Reportable Medical Events: Guidelines and Case Definitions&lt;/em&gt;.&lt;sup&gt;2&lt;/sup&gt; Currently, all services report notifiable medical conditions through a single electronic system, the Disease Reporting System Internet, accessible at all military hospitals and clinics.&lt;sup&gt;3&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;The usefulness of these reportable medical events is highly dependent on the completeness and timeliness of their submission. For optimally-informed determinations by military leadership and public health officers about the locations and extents of possible outbreaks, all cases of notifiable medical conditions need to be reported, with all required information, as soon as possible. During the COVID-19 pandemic, DRSi became a key data source for tracking confirmed cases of COVID-19.&lt;sup&gt;4&lt;/sup&gt; Reports on preventable notifiable medical conditions such as heat and cold injuries are produced frequently to assist the evaluation and potential modification of prevention strategies. The Armed Forces Health Surveillance Division of the Defense Health Agency publishes communicable disease RMEs in each issue of the &lt;em&gt;MSMR&lt;/em&gt;.&lt;/p&gt;&lt;p&gt;The most recent analysis of the completeness and timeliness of RMEs, published in the &lt;em&gt;MSMR&lt;/em&gt; in November 2015, only reported on active component service members.&lt;sup&gt;5&lt;/sup&gt; The 2008-2014 analysis found that 47.6% of notifiable hospitalized cases and 57.2% of notifiable ambulatory cases were reported as RMEs to DRSi. Since the 2015 report on 2008-2014 data, medical encounters are now coded with ICD-10 diagnostic codes, which provide better specificity than ICD, 9th revision diagnostic codes and improve identification of health conditions.&lt;sup&gt;6&lt;/sup&gt; Three revisions to DOD reporting guidelines since 2015 aligned laboratory and clinical criteria with standardized case definitions published by the Nationally Notifiable Disease Surveillance System, which added or removed RMEs.&lt;sup&gt;7&lt;/sup&gt; This report estimates RME completeness and timeliness from 2018 to 2022 among ACSM and all other DOD beneficiaries.&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;The Defense Medical Surveillance System contains administrative records for all medical encounters of DOD beneficiaries who were hospitalized or received ambulatory care at military hospitals and clinics, or for civilian &lt;span tabindex="0" class="TooltipLink"&gt;&lt;span class="TooltipContent"&gt;&lt;a href="javascript:void(0);"&gt;&lt;span class="visiblyHidden"&gt;Click to close&lt;/span&gt;&lt;span class="cancelButton"&gt;&lt;/span&gt;&lt;/a&gt;&lt;span class="DefinitionTerm"&gt;Purchased Care&lt;/span&gt;The TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.&lt;/span&gt;purchased care&lt;/span&gt; at an outsourced care facility. Records of health care encounters from both sources of care were included in this analysis, but analyzed separately. Hospitalizations and ambulatory encounters for all DOD beneficiaries between January 1, 2018 and December 31, 2022 were searched for diagnoses of notifiable medical conditions in the primary diagnostic position using the 10th revision of International Classification of Diseases diagnostic codes listed in Table 1. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-3-Table-1" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-3-Table-1.ashx?h=1416&amp;w=1150&amp;hash=0C1DF2AC42C1813B09886EA7ED54CBE557E9C116" style="height: 1416px; width: 1150px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Potentially notifiable cases were identified by the required numbers and types of encounters delineated in Table 1 for specified conditions. For example, a potential case of amebiasis would require an ICD-10 code of A06.x in the primary diagnostic position in the record of a hospitalization, or 2 ambulatory encounters within 2 weeks. Incident cases of the various conditions for individuals were then identified by applying the incidence rule listed for each condition. For example, an individual who met the criteria for a potentially notifiable case of amebiasis in February 2019 but was previously diagnosed with amebiasis in December 2018 (within 120 days of the February 2019 diagnosis) would not be counted as a newly incident case in 2019 (Table 1). &lt;/p&gt;&lt;p&gt;The DMSS also contains RME records entered in DRSi for all DOD beneficiaries. RMEs from event dates January 1, 2018 through December 31, 2022 were identified from DMSS for DOD beneficiaries with an incident notifiable medical condition hospitalization or ambulatory encounter. By notifiable medical condition, RMEs were matched to incident hospitalization or ambulatory encounters. If more than 1 RME for the specific condition was found, the RME with an event date closest to the encounter event date was selected. The total number of incident notifiable medical conditions and the percentage with a corresponding RME were calculated by population (ACSM or other beneficiaries), source of care (military hospital/clinic or OCF), RME category, and year. The “other beneficiary” category included service members in the reserve or guard components, retirees, and dependents. Reporting timeliness was estimated by calculating the number of weeks between the incident case’s medical encounter or hospitalization date and the RME entry date in DRSi. Among the incident notifiable medical cases matched to an RME, the percentages that were reported within 1 week, 2 weeks, and 4 weeks were calculated. All data were analyzed using SAS Enterprise Guide v8.3 Update 3 (SAS Institute, Cary, NC).&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;h3&gt;Active Component Service Members&lt;/h3&gt;&lt;p&gt;During the study period, 61.2% of incident notifiable hospitalized medical cases among ACSM seen at a military hospital were reported as RMEs, ranging from a low in 2020 (56.0%) to a high in 2022 (71.1%). Reporting percentages for hospitalized cases at OCFs were much lower than at military hospitals, with an overall reporting of 18.1% and a range of 7.9% (2020) to 24.4% (2019) (Table 2). Table 2 also shows the percentage of incident notifiable ambulatory medical cases reported as RMEs. Over the study period, 65.5% of incident notifiable ambulatory medical cases at military clinics among ACSM were reported as RMEs, substantially higher than the percent of ambulatory medical cases reported from OCFs (11.9%). &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-3-Table-2" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-3-Table-2.ashx?h=572&amp;w=1100&amp;hash=36C2029F1A9A46DAD9ABB66DF4C4D3D33D64BAA4" style="height: 572px; width: 1100px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;The total numbers of incident cases for each type of notifiable medical condition among active ACSM at military hospitals and clinics are shown in Table 3. For hospitalized conditions, the largest numbers of incident cases were for heat illness (368 cases), influenza-associated hospitalizations (128 cases), and malaria (65 cases). Of those, 67.7% of heat illness cases, 40.6% of influenza-associated hospitalization cases, and 87.7% of malaria cases were reported as RMEs. The most frequent incident ambulatory conditions were chlamydia (43,673 cases, 91.3% reported), novel and variant influenza (16,083 cases, 0.03% reported), and heat illness (6,915 cases, 48.2% reported).&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-3-Table-3" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-3-Table-3.ashx?h=1431&amp;w=1150&amp;hash=196E6F338035A8B0D771C516A89B2284C3BEAE9B" style="height: 1431px; width: 1150px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Table 4 presents the notifiable medical conditions at OCFs among ACSM. Although much lower in magnitude, hospitalizations at OCFs had similar trends in condition frequency compared to military hospitals and clinics. The most frequently hospitalized medical conditions at OCFs were influenza-associated (58 cases, 10.3% reported), heat illness (57 cases, 17.5% reported), malaria (23 cases, 34.8% reported), and campylobacter infection (23 cases, 13.0% reported). Among ambulatory conditions reported at OCFs, novel and variant influenza (9,170 cases, 0.01% reported), chlamydia (3,396 cases, 34.9% reported), and heat illness (1,603 cases, 10.2% reported) were the most frequent. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-3-Table-4" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-3-Table-4.ashx?h=1423&amp;w=1150&amp;hash=87C22F4E417D86AD8190385DB4B214160F8A2450" style="height: 1423px; width: 1150px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;The timeliness of reporting of incident notifiable medical conditions among ACSM varied by care type and facility (Table 5). Between 2018 and 2022, timeliness of notifiable conditions for military hospitalizations reported within one week to DRSi ranged from 48.5% to 64.2%; this range increased to 91.8% and 98.9% when evaluating timeliness within one month. Regardless of facility type, ambulatory care reporting timeliness to DRSi within one week decreased over time, declining from 40.5% in 2018 to 35.1% in 2022 at military clinics and 26.4% to 17.6% for OCFs. OCF hospitalizations was the only group to improve in reporting timeliness over the study period, with reporting within one week rising from 25.0% in 2018 to 40.0% in 2022.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-3-Table-5" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-3-Table-5.ashx?h=538&amp;w=1150&amp;hash=EBE549AE00C1973F5DAF10700DA2B5EAD62D25D6" style="height: 538px; width: 1150px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;h3&gt;Other Beneficiaries&lt;/h3&gt;&lt;p&gt;During the surveillance period, only 15.2% of incident notifiable hospitalized medical cases among other beneficiaries seen at military hospitals were submitted as RMEs (Table 6). Reporting increased from 8.8% in 2018 to 25.5% in 2021 but dropped to 18.0% in 2022. Reporting for hospitalizations at OCFs were significantly lower than at military hospitals and clinics, with an overall reporting of 0.9% and range of 0.5% (2022) to 2.0% (2021) (Table 6). Table 6 also provides the percentage of incident notifiable ambulatory care medical conditions submitted as RMEs. During the study period, the military clinic reporting percentage for ambulatory conditions among other beneficiaries was higher than for hospitalized conditions (22.1% vs. 15.2%). Reporting of ambulatory conditions at OCFs was very low (0.5%).&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-3-Table-6" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-3-Table-6.ashx?h=574&amp;w=1106&amp;hash=141B7700840D2A2F010C615B5856300ADF61D529" style="height: 574px; width: 1106px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;The total numbers of incident cases for each type of notifiable medical condition among other beneficiaries at military hospitals or clinics are shown in Table 7. For hospitalized conditions during 2018-2022, the largest numbers of incident cases were influenza-associated (928 cases), novel and variant influenza (400 cases), and COVID hospitalization and death (only reportable in 2022; 169 cases). Of those cases, 11.7% of influenza-associated hospitalizations, 0.0% of novel and variant influenza cases, and 16.6% of COVID hospitalizations and death were submitted as RMEs. The most frequent incident ambulatory conditions were novel and variant influenza (42,184 cases, 0.05% reported), chlamydia (13,397 cases, 79.7% reported), and gonorrhea (2,437 cases, 69.8% reported). &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-3-Table-7" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-3-Table-7.ashx?h=1427&amp;w=1150&amp;hash=49B294CD0B6C53E8771B6C6A743FDDF184AFD3F6" style="width: 1150px; height: 1427px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Table 8 lists the notifiable medical conditions among other beneficiaries treated at an OCF. The most frequent hospitalized medical conditions were 5,061 influenza-associated cases (0.45% reported), 3,785 cases of COVID hospitalizations and death (only reportable in 2022; 0.3% reported), and 698 cases of salmonellosis, of which 3.0% were submitted as RMEs. Among ambulatory care conditions, the most frequent were novel and variant influenza (238,111 cases, &lt;0.01% reported), chlamydia (17,890 cases, 5.0% reported), and gonorrhea (6,788 cases, 2.6% reported). &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-3-Table-8" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-3-Table-8.ashx?h=1421&amp;w=1150&amp;hash=4348B2A0F74F2CBB26D558295C0DE69ADE3D78FC" style="height: 1421px; width: 1150px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;The timeliness of reporting incident hospitalized notifiable medical conditions among other beneficiaries fluctuated annually, but increased overall from 2018 to 2022 for both military hospitals and OCFs (Table 9). Between 2018 and 2022, hospitalization reporting within one week rose from 60.0% to 64.1% for military care and from 48.1% to 65.6% for OCF care. Regardless of facility type, reporting timeliness for ambulatory care within one week decreased, from 42.9% in 2018 to 37.5% in 2022 for military care and from 16.4% to 8.2% for OCFs.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-Article-3-Table-9" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-3-Table-9.ashx?h=551&amp;w=1150&amp;hash=9B3A7C8037171C45BD24B0A8780DCCCD949361FA" style="width: 1150px; height: 551px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;The results of this analysis indicate that in recent years just over 60% of ACSM with incident hospitalized notifiable medical conditions identified at a military hospital were reported as RMEs through the DRSi reporting system. Case reporting of notifiable medical conditions identified from ambulatory encounters at military clinics was slightly higher (65.5%) than cases identified from hospitalization records. To compare these results to the 2015 analysis published in the &lt;em&gt;MSMR&lt;/em&gt;,&lt;sup&gt;5&lt;/sup&gt; active component case reporting from both military hospitals and clinics as well as OCFs were combined, resulting in reporting estimates of 50.3% and 56.3% for hospitalized and ambulatory cases, respectively. These findings show an increase in reporting from the 2015 analysis, which found that 46.7% of hospitalized cases and 55.2% of ambulatory cases were reported in 2014.&lt;sup&gt;5&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;This first analysis of RME reporting among other DOD beneficiaries reveals a significantly lower number of incident notifiable medical cases reported among other beneficiaries compared to ACSM. Approximately one-fifth of cases among other beneficiaries from military clinics and hospitals were reported to DRSi, and only a negligible proportion from OCFs were reported. Because DOD Directive 6490.02E specifies health surveillance activities for dependents residing in garrison or overseas with their military sponsor during a possible exposure or public health event, the low proportion of incident notifiable medical cases reported among other beneficiaries was expected.&lt;sup&gt;1&lt;/sup&gt; In addition, because personnel resources for public health reporting may be limited at certain facilities, active component service member case reporting will take precedence over conditions from other beneficiaries, especially considering the greater number of hospitalizations among the other beneficiary population. Despite the fact there is no requirement for reporting of notifiable medical events for all dependents, this analysis was conducted to demonstrate the utility of RME reports for the larger MHS beneficiary population.&lt;/p&gt;&lt;p&gt;The timeliness of reporting for ACSM fluctuated over the 5-year surveillance period. Notifiable case reporting within one week from military hospitals and clinics ebbed from 2020 to 2021. This report does not speculate on factors influencing slower RME reporting, which are likely multi­factorial and may include the COVID-19 pandemic. Throughout the surveillance period, however, the timeliness of reporting for hospitalized active component cases within one month remained above 90%. For active component cases identified from military clinic ambulatory care, timeliness of reporting within one month increased, approaching 90% (89.3%) by 2022.&lt;/p&gt;&lt;p&gt;Interpretation of these findings should be with caution due to methodological limitations. First, use of administrative data from health records to identify cases warranting RME submission likely over­estimates the number of true cases of the conditions of interest, which is especially true for preliminary outpatient diagnoses, which do not meet RME criteria. Laboratory test results that are inconclusive or pending negative do not meet RME criteria. Conversely, common diagnoses such as heat and cold injuries are based on clinical findings at a single ambulatory encounter and do not require laboratory confirmation, and these diagnoses produced RME submissions for only one-third of cold injury and half of heat injury outpatient cases identified. &lt;/p&gt;&lt;p&gt;The data available for this analysis do not permit any insight into subsequent exclusion of preliminary diagnoses of such conditions when considering RME submission. Because many reportable conditions that may be of critical importance for rapid public health response are so infrequently encountered, clinical suspicion may result in diagnosis documentation prior to confirmation. It would not be surprising that many, if not most, such tentative diagnoses would fail to meet RME criteria. &lt;/p&gt;&lt;p&gt;Outsourced care providers are not required to report to the DOD, nor do they have access to DRSi, so reporting of outsourced care encounters for notifiable medical conditions relies on the referring military hospital or clinic to follow up and report, or for public health reporting personnel to identify these cases in the medical record. These additional steps for reporting likely contributed to the low OCF reporting numbers and present a missed opportunity. &lt;/p&gt;&lt;p&gt;This analysis does not include RMEs without a matching incident hospitalization or clinic encounter, and therefore timeliness of non-matching RMEs could not be assessed, nor are the total RMEs in this analysis the complete number of RMEs for the surveillance period.&lt;/p&gt;&lt;p&gt;One of the most frequently diagnosed conditions during ambulatory care, regardless of population or source of care, was novel and variant influenza. Although ambulatory seasonal influenza is not a reportable condition, novel and variant influenza is reportable. Given that influenza surveillance data for the U.S. during the study period do not indicate expansive circulation of novel or variant influenza strains, it is likely encounters for seasonal influenza were miscoded,&lt;sup&gt;8,9&lt;/sup&gt; which is further supported by the finding that only a few of these encounters were reported. &lt;/p&gt;&lt;p&gt;Complete and timely reporting of notifiable medical conditions is an important factor for public health prevention and control of communicable disease and injuries. These findings indicate that improvements are needed for complete and timely reporting among ACSM. Although reporting is not currently required for non-DOD personnel, the large number of notifiable medical conditions in this population present a potential transmission risk to service members, and consideration should be given to tracking notifiable medical conditions in this population as well. Revisions to RME guideline training and corresponding enhancements among public health personnel to increase accuracy of coding for medical encounters could produce needed improvements in RME reporting and timeliness.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Department of Defense. DOD D6490.02E, Comprehensive Health Surveillance. Accessed on Oct. 2, 2023. &lt;a rel="noopener noreferrer" href="https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodd/649002Ep.pdf?ver=2019-04-08-104448-613" target="_blank" title="Click on the link to access the Department of Defense's directive on health surveillance."&gt;https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodd/649002Ep.pdf?ver=2019-04-08-104448-613&lt;/a&gt;Armed Forces Health Surveillance Center. Armed Forces Reportable Medical Events: Guidelines and Case Definitions. Accessed Oct. 2, 2023. &lt;a href="/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines" target="_blank" title="Click on the link to access the referenced RME guidelines."&gt;https://www.health.mil/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines" target="_blank" title="Click on the link to access the referenced RME guidelines."&gt;&lt;/a&gt;Navy and Marine Corps Public Health Center. DRSi: Disease Reporting System Internet. Accessed Oct. 2, 2023. &lt;a rel="noopener noreferrer" href="https://www.med.navy.mil/Navy-and-Marine-Corps-Force-Health-Protection-Command/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI" target="_blank" title="Click on the link to access the DRSi public web site."&gt;https://www.med.navy.mil/Navy-and-Marine-Corps-Force-Health-Protection-Command/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.med.navy.mil/Navy-and-Marine-Corps-Force-Health-Protection-Command/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI" target="_blank" title="Click on the link to access the DRSi public web site."&gt;&lt;/a&gt;Kebisek J, Maule A, Smith J, et al. Integration of multiple surveillance systems to track COVID-19 in the U.S. Army Population. &lt;em&gt;Mil Med&lt;/em&gt;. 2021;188(7-8):e2583-e2591.&lt;/li&gt;    &lt;li&gt;Hurt L, Ying S. Completeness and timeliness of reporting of notifiable medical conditions, active component, U.S. Armed Forces, 2008-2014. &lt;em&gt;MSMR&lt;/em&gt;. 2015;22(11):8-21.&lt;/li&gt;    &lt;li&gt;United States Department of Health and Human Services, Centers for Disease Control and Prevention. National Center for Health Statistics. International Classification of Diseases (ICD-10-CM/PCS) Transition–Background. Accessed Oct. 6, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm" target="_blank" title="Click on the link to access the CDC's ICD-10 web site providing background information."&gt;https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm" target="_blank" title="Click on the link to access the CDC's ICD-10 web site providing background information."&gt;&lt;/a&gt;United States Department of Health and Human Services, Centers for Disease Control and Prevention. National and Notifiable Disease Surveillance System: Surveillance Case Definitions for Current and Historical Conditions. Accessed Oct. 4, 2023. &lt;a rel="noopener noreferrer" href="https://ndc.services.cdc.gov" target="_blank" title="Click on the link to access the CDC's web site on notifiable medical conditions."&gt;https://ndc.services.cdc.gov&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://ndc.services.cdc.gov" target="_blank" title="Click on the link to access the CDC's web site on notifiable medical conditions."&gt;&lt;/a&gt;United States Department of Health and Human Services, Centers for Disease Control and Prevention. Past Weekly Surveillance Reports. Oct. 2, 2023. &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/flu/weekly/pastreports.htm" target="_blank" title="Click on the link to access the CDC's web site providing weekly influenza reporting."&gt;https://www.cdc.gov/flu/weekly/pastreports.htm&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.cdc.gov/flu/weekly/pastreports.htm" target="_blank" title="Click on the link to access the CDC's web site providing weekly influenza reporting."&gt;&lt;/a&gt;Defense Health Agency, Armed Forces Health Surveillance Division. Influenza Summary and Reports. Accessed Oct. 2, 2023. &lt;a href="/Military-Health-Topics/Health-Readiness/AFHSD/Reports-and-Publications/Influenza-Summary-and-Reports" target="_blank" title="Click on the link to access AFHSD's influenza reporting."&gt;https://www.health.mil/Military-Health-Topics/Health-Readiness/AFHSD/Reports-and-Publications/Influenza-Summary-and-Reports&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Sun, 01 Oct 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{F3942B95-07E4-4EC7-975B-77E674A38434}</guid><link>https://www.health.mil/News/Articles/2023/10/01/RMEs</link><title>Reportable Medical Events, Military Health System Facilities, Week 35, Ending September 2, 2023</title><description>&lt;p&gt;Reportable Medical Events are documented in the Disease Reporting System internet by health care providers and public health officials throughout the Military Health System to monitor, control, and prevent the occurrence and spread of diseases of public health interest or readiness importance. These reports are reviewed by each service’s public health surveillance hub. The DRSi collects reports on over 70 different RMEs, including infectious and non-infectious conditions, outbreak reports, STI risk surveys, and tuberculosis contact investigation reports. A complete list of RMEs is available in the 2022 Armed Forces Reportable Medical Events Guidelines and Case Definitions.&lt;sup&gt;1&lt;/sup&gt; Data reported in these tables are considered provisional and do not represent conclusive evidence until case reports are fully validated. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/10/01/MSMR-v-30-no-10-RME-Table" target="_blank" title="Click on the table to access a 508-compliant PDF version."&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-4-Table.ashx?h=1386&amp;w=1150&amp;hash=5996698E26F96BDDA9EA93EE01DA7D0420832A0A" style="width: 1150px; height: 1386px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="Click on the table to access a 508-compliant PDF version."&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Total active component cases reported per week are displayed for the top five RMEs for the previous year. Each month, the graph is updated with the five most frequently occurring RMEs, to present the most recent month’s (August 2023) five most frequent RMEs, which may differ from previous months. COVID-19 is excluded from these graphs due to changes in reporting and case definition updates in 2023. &lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/October/Article-4-Figure.ashx?h=643&amp;w=1150&amp;hash=74E3929F59477F1D86A0FB573E54FA52E47F7560" style="width: 1150px; height: 643px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="This graph of 5 lines on the x-, or horizontal, axis depicts case counts for the 5 most frequent reportable medical event conditions among active component service members during the past 52 weeks. Chlamydia remains the most common reportable medical condition, with counts of approximately 300 cases per week. Gonorrhea is generally the second-most common reported condition, averaging approximately 80 cases per week, but in week 26 of 2023 it was surpassed by heat illness, which outnumbered gonorrhea cases for the last 8 of 9 weeks, but declined to the same number gonorrhea cases by the end of week 35. Campylobacteriosis cases rose briefly at the end of week 34 to become the fourth-most common reported condition, but then declined markedly in week 35, ultimately registering fewer cases than syphilis, which declined gradually for two weeks after week 33 to a new low at the end of week 35, with just under 10 reported cases.  "&gt;&lt;/p&gt;&lt;p&gt;For questions about this report, please contact the Disease Epidemiology Branch at the Defense Centers for Public Health–Aberdeen, email: &lt;a href="mailto:dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mil" title="Click on the link to contact the Disease Epidemiology Branch via email."&gt;dha.apg.pub-health-a.mbx.disease-epidemiologyprogram13@health.mil&lt;/a&gt;. &lt;/p&gt;&lt;h2&gt;Author Affiliations&lt;/h2&gt;&lt;p&gt;Defense Centers for Public Health–Aberdeen, Disease Epidemiology Branch&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Armed Forces Health Surveillance Division. Armed Forces Reportable Medical Events. Accessed Sept. 6, 2023. &lt;a href="/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines" target="_blank" title="Click on the link to access AFHSD's RME guidelines."&gt;https://health.mil/Reference-Center/Publications/2022/11/01/Armed-Forces-Reportable-Medical-Events-Guidelines&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Department of Defense Active Duty Military Personnel by Rank/Grade of Service, October 31, 2022. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the military demographics by rank and grade of service."&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Manpower Data Center. Armed Forces Strength Figures for January 31, 2023. &lt;a rel="noopener noreferrer" href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the U.S. Armed Forces force figures for 2023."&gt;https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports" target="_blank" title="Click on the link to access the U.S. Armed Forces force figures for 2023."&gt;&lt;/a&gt;Navy Medicine. Surveillance and Reporting Tools—DRSI: Disease Reporting System Internet. &lt;a rel="noopener noreferrer" href="https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI" target="_blank" title="Click on the link to access the DRSi public web site."&gt;https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI&lt;/a&gt;&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Sun, 01 Oct 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{83ED9CBA-A238-44D1-98B4-C0D187037A26}</guid><link>https://www.health.mil/News/Articles/2023/09/25/Suicide-Prevention-Resources-That-Can-Help</link><title>Suicide Prevention Resources That Can Help</title><description>&lt;p&gt;How can we help ourselves, loved ones, and others in the military family who may be at risk of suicide? Through a variety of resources available to all service members, veterans, and families. &lt;/p&gt;&lt;p&gt;Former U.S. Army Command Sgt. Maj. Michael Gragg, previous Defense Health Agency’s top enlisted leader, said in a recent &lt;a href="https://www.dvidshub.net/video/855105/suicide-prevention-message-csm-gragg"&gt;video&lt;/a&gt;: “You are not alone. We are all in this together.” &lt;/p&gt;&lt;p&gt;While the Military Health System provides clinical counseling and therapy, it and other DOD entities offer an array of nonclinical programs that are free and confidential.&lt;/p&gt;&lt;p&gt;Service members may experience frequent relocations, overseas deployments, and stressful experiences related to combat as well as significant time away from families or loved ones.&lt;/p&gt;&lt;p&gt;Sometimes, these stressors lead to behavioral health concerns including suicidal ideation, said Nicholas Polizzi, who holds a doctorate in educational psychology and is the program manager of the &lt;a href="/Military-Health-Topics/Centers-of-Excellence/Psychological-Health-Center-of-Excellence/inTransition"&gt;inTransition&lt;/a&gt; program at DHA. &lt;/p&gt;&lt;p&gt;inTransition is a free, confidential program that helps active-duty service members, National Guard members, reservists, veterans, and retirees overcome common barriers to care and quickly access needed services through:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Specialized coaching and assistance    &lt;/li&gt;    &lt;br&gt;    &lt;li&gt;Facilitating connection to a new behavioral health care provider    &lt;/li&gt;    &lt;br&gt;    &lt;li&gt;Sharing information of Department of Defense, Department of Veterans Affairs, and community health care resources    &lt;/li&gt;&lt;/ul&gt;&lt;p&gt;The inTransition program is just one of many nonclinical resources available to MHS beneficiaries that help you monitor your mental health, understand signs and symptoms, and seek help. Others include:&lt;/p&gt;&lt;h2&gt;Tools for Active Duty and Veterans&lt;/h2&gt;&lt;ul&gt;    &lt;li&gt;988 Suicide and Crisis Lifeline. Call 988, option 1, for immediate support through the around-the-clock consulting for military members and veterans having thoughts of self-harm. You can talk to qualified responders through the confidential toll-free hotline, &lt;a href="https://suicidepreventionlifeline.org/chat/"&gt;chat online&lt;/a&gt;, or text 838255.    &lt;/li&gt;    &lt;br&gt;    &lt;li&gt;The Psychological Health Resource Center is available 24/7 for service members, veterans, and family members. Trained mental health consultants can help you access mental health care and community support resources in your local area. Assistance is available through phone (1-866-966-1020), &lt;a href="https://www.health.mil/Military-Health-Topics/Centers-of-Excellence/Psychological-Health-Center-of-Excellence/Psychological-Health-Resource-Center"&gt;email or live chat&lt;/a&gt;.    &lt;/li&gt;    &lt;br&gt;    &lt;li&gt;&lt;a href="https://www.mirecc.va.gov/coaching/"&gt;Coaching into Care&lt;/a&gt; provides veterans direct access to licensed psychologists and social workers for a no-cost telephone consultation at 1-888-823-7458.The program offers help finding ongoing support and provides families information on suicide prevention.    &lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;Military OneSource&lt;/h2&gt;&lt;p&gt;As the DOD’s 24/7 gateway to trusted information for service members and families, Military OneSource provides resources and confidential help. Learn about suicide risk factors, resources for understanding suicide prevention, and immediate resources available to support you or your loved ones. Read about:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;&lt;a href="https://www.militaryonesource.mil/health-wellness/mental-health/suicide/when-a-service-member-may-be-at-risk-for-suicide/"&gt;When a Service Member May Be at Risk&lt;/a&gt;    &lt;/li&gt;    &lt;br&gt;    &lt;li&gt;&lt;a href="https://www.militaryonesource.mil/search/?s=suicide+awareness"&gt;Suicide Awareness&lt;/a&gt;    &lt;/li&gt;    &lt;br&gt;    &lt;li&gt;&lt;a href="https://www.militaryonesource.mil/health-wellness/mental-health/suicide/suicide-prevention-the-essentials/"&gt;Suicide Prevention: The Essentials&lt;/a&gt;    &lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;Chaplains and Unit Teams&lt;/h2&gt;&lt;ul&gt;    &lt;li&gt;&lt;a href="/Military-Health-Topics/Centers-of-Excellence/Psychological-Health-Center-of-Excellence/Clinicians-Corner-Blog/Confidentiality-Chaplains-and-the-Military"&gt;Chaplains&lt;/a&gt; can provide confidential support outside of traditional channels or your chain of command. &lt;/li&gt;    &lt;br&gt;    &lt;li&gt;You don’t need to share the same faith or practice a religion to talk with a chaplain.    &lt;/li&gt;    &lt;br&gt;    &lt;li&gt;Unit behavioral health officers, and military and family life counselors are also readily available.    &lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;Mobile Apps&lt;/h2&gt;&lt;p&gt;DHA promotes &lt;a href="/News/Articles/2021/09/30/DHAs-Mobile-Apps-Can-Help-You-with-Overall-Wellness"&gt;mobile phone applications&lt;/a&gt; for those seeking help or wellness resources. Check out mobile apps that help with post-traumatic stress disorder, tools for coping, and monitoring your health, including:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;&lt;a href="https://mobile.va.gov/app/ptsd-coach"&gt;PTSD Coach&lt;/a&gt;    &lt;/li&gt;    &lt;br&gt;    &lt;li&gt;&lt;a href="https://mobile.health.mil/?page=2"&gt;Breathe 2 Relax&lt;/a&gt;    &lt;/li&gt;    &lt;br&gt;    &lt;li&gt;&lt;a href="https://www.militaryonesource.mil/health-wellness/healthy-living/managing-stress/chill-drills-by-military-onesource-app/"&gt;Chill Drills by Military OneSource&lt;/a&gt;    &lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;LGBTQ+ Communities&lt;/h2&gt;&lt;p&gt;It’s been shown that the LGBTQ+ community can feel a greater sense of isolation than other colleagues and family members and may have increased risk of suicidal thoughts, according to &lt;a href="https://www.militaryonesource.mil/military-life-cycle/friends-extended-family/lgbtq-in-the-military/"&gt;Military OneSource&lt;/a&gt;. In addition to any of the nonmedical services available, MOS suggest it may also be helpful to join an LGBTQ support group on the installation, if offered, or in the local community. &lt;/p&gt;&lt;h2&gt;Postventions for Those Left Behind&lt;/h2&gt;&lt;p&gt;There can also be challenges for those who experience a death by suicide by fellow veterans, combat buddies, family members, loved ones, caregivers, and even those who did not know the person well.&lt;/p&gt;&lt;p&gt;“Postventions,” or interventions after suicides, can be crucial to the mental health of those left behind.&lt;/p&gt;&lt;p&gt;The Defense Suicide Prevention Office postvention &lt;a href="https://www.dspo.mil/Portals/113/Documents/PostventionToolkit.pdf?ver=2020-07-30-224837-353"&gt;toolkit&lt;/a&gt; for military suicide loss states that grief can leave its mark on up to 135 people for every one suicide. For those struggling with this grief, their risk of suicidal thoughts or actions increase as well.&lt;/p&gt;&lt;p&gt;What’s most important is to learn what you can, lean on each other for support, and use these resources to seek help for you or a loved one.&lt;/p&gt;&lt;p&gt;For a complete list of mental health resources available to MHS beneficiaries, visit the &lt;a href="/Military-Health-Topics/Mental-Health"&gt;MHS resource page&lt;/a&gt;.&lt;/p&gt;</description><pubDate>Mon, 25 Sep 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{5BAB8166-8087-4216-9370-84ECC000BA2B}</guid><link>https://www.health.mil/News/Articles/2023/09/20/Ask-the-Doc-Should-My-Child-Get-the-HPV-Vaccine</link><title>Ask the Doc: Should My Child Get the HPV Vaccine?</title><description>&lt;p&gt;Dear Doc: I’ve heard about HPV—I know it’s a sexually transmitted disease, and can cause some health problems, but not much more. I have a 12-year-old daughter, and her pediatrician wants to give her the HPV vaccine. This makes me really uncomfortable. What is HPV? How important is it to get a vaccination? Is it safe for my child?&lt;/p&gt;&lt;p&gt;-Capt. Concerned&lt;/p&gt;&lt;p&gt;Dear Capt. Concerned,&lt;/p&gt;&lt;p&gt;You’re not alone! While many people have heard of human papillomavirus, or HPV, a recent study from the American Association for Cancer Research found U.S. adults are less aware of the link between HPV and certain cancers.&lt;/p&gt;&lt;p&gt;We reached out to an expert to answer your questions: Dr. Margaret Ryan is the medical director of the Defense Health Agency’s &lt;a href="/Military-Health-Topics/Health-Readiness/Immunization-Healthcare" target="_self" title="opens Health.mil"&gt;Immunization Health Division&lt;/a&gt; in the Pacific Region. She is a vaccine expert with a background in preventive medicine and infectious disease.&lt;/p&gt;&lt;p&gt;Dr. Ryan said,&lt;/p&gt;&lt;p&gt;&lt;em&gt;Thanks for asking these great questions. I understand your concern, but please know that HPV vaccines are safe and effective. I confidently recommend HPV vaccination for my patients, and for my own children. HPV vaccination prevents very serious health problems, including certain cancers. When people become fully vaccinated before exposure to HPV, they may maintain protection against these specific health threats for the rest of their lives.&lt;/em&gt;&lt;/p&gt;&lt;h2&gt;What is HPV?&lt;/h2&gt;&lt;p&gt;&lt;em&gt;HPV is a group of more than 200 related viruses that can cause lesions on the skin or mucus membranes, the lining of the mouth or genital areas. The virus is the most common sexually transmitted infection in the United States and spreads from person-to-person by direct skin contact or intimate contact with mucus membranes.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;Some types of HPV viruses cause wart-like lesions on the skin or mucus membranes. Some of these HPV lesions may go away without treatment, while others may require treatment, such as “freezing” with liquid nitrogen. Some HPV lesions are unnoticeable, and some HPV lesions may appear and resolve multiple times in the infected person’s lifetime.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;There are 14 types of HPV considered “high-risk” because the lesions they cause can lead to cancer. In fact, nearly all cervical cancers are associated with previous HPV infection. HPV-related cancers may occur in the mouth or throat, on the genital area, in the anus, in the vagina, or on the &lt;span tabindex="0" class="TooltipLink"&gt;&lt;span class="TooltipContent"&gt;&lt;a href="javascript:void(0);"&gt;&lt;span class="visiblyHidden"&gt;Click to close&lt;/span&gt;&lt;span class="cancelButton"&gt;&lt;/span&gt;&lt;/a&gt;&lt;span class="DefinitionTerm"&gt;Cervix&lt;/span&gt;The cervix is the lower, narrow end of the &lt;span tabindex="0" class="TooltipLink"&gt;&lt;span class="TooltipContent"&gt;&lt;a href="javascript:void(0);"&gt;&lt;span class="visiblyHidden"&gt;Click to close&lt;/span&gt;&lt;span class="cancelButton"&gt;&lt;/span&gt;&lt;/a&gt;&lt;span class="DefinitionTerm"&gt;uterus&lt;/span&gt;Also known as the womb, the uterus is the female reproductive organ where a baby grows. &lt;/span&gt;uterus&lt;/span&gt; (womb).  The cervix connects the uterus to the vagina (birth canal).&lt;/span&gt;cervix&lt;/span&gt;. HPV-related cancers may also appear years after a person was first infected.&lt;/em&gt;&lt;/p&gt;&lt;h2&gt;HPV is a Common Infection&lt;/h2&gt;&lt;p&gt;&lt;em&gt;It’s estimated that more than 90% of people who are sexually active, and not protected from HPV, will become infected with at least one type of HPV in their lifetime. Most infections will not cause serious health problems. However, even with growing understanding of HPV infections and prevention measures, there are many new cases of HPV-related cancer each year. In the U.S., &lt;/em&gt;&lt;a rel="noopener noreferrer" href="https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer" target="_blank" title="opens Cancer.gov"&gt;&lt;em&gt;more than 35,000 new cases&lt;/em&gt;&lt;/a&gt;&lt;em&gt; of HPV-related cancer are diagnosed each year. In the world, it is estimated that at least 500,000 women and 60,000 men will be newly diagnosed with HPV-related cancer this year.&lt;/em&gt;&lt;/p&gt;&lt;h2&gt;Preventing HPV with Vaccination&lt;/h2&gt;&lt;p&gt;&lt;em&gt;Avoiding skin contact, or intimate contact, with HPV lesions can lower the risk of transmitting HPV infection. Using condoms can also lower transmission. However, many HPV infections cause no noticeable lesions on the skin or mucus membranes, so these methods are often not enough to stop transmission.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;HPV vaccination is the best way to prevent infection. HPV vaccines in the U.S. are highly effective at preventing infection from nine of the most serious types of HPV viruses. After a person gets the full vaccine series, they will generally have lifetime protection.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;HPV vaccines are ideally given before a person has exposure to HPV. The Centers for Disease Control and Prevention recommend that all children get the HPV vaccine at a well-child pre-teen visit between ages 9 and 12.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;&lt;em&gt;Unvaccinated people diagnosed with HPV lesions, or even HPV-related cancer, may still benefit from vaccination. The vaccine will not cure lesions or cancer, but it may prevent infection from other high-risk types of HPV viruses, and therefore additional health problems. The vaccine is approved and available for adults up to age 45 years old.&lt;/em&gt;&lt;/p&gt;&lt;p&gt;Capt. Concerned, I hope this information was helpful. For more about HPV and the vaccine, please view the resources below.&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Defense Health Agency, Immunization Healthcare Division: &lt;a href="/Military-Health-Topics/Health-Readiness/Immunization-Healthcare/Vaccine-Preventable-Diseases/Human-Papillomavirus" target="_self" title="opens Health.mil"&gt;Human Papillomavirus&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Defense Centers for Public Health-Aberdeen: &lt;a rel="noopener noreferrer" href="https://phc.amedd.army.mil/topics/healthyliving/rsbwh/Pages/default.aspx" target="_blank" title="opens PHC.AMEDD.Army.mil"&gt;Sexual health&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;TRICARE &lt;a rel="noopener noreferrer" href="https://www.tricare.mil/CoveredServices/IsItCovered/HPVVaccine" target="_blank" title="opens TRICARE.mil"&gt;covered services&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;CDC: &lt;a rel="noopener noreferrer" href="https://www.cdc.gov/hpv/index.html" target="_blank" title="opens CDC.gov"&gt;Human Papillomavirus&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;National Cancer Institute: &lt;a rel="noopener noreferrer" href="https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-and-cancer" target="_blank" title="opens Cancer.gov"&gt;HPV and Cancer&lt;/a&gt;&lt;/li&gt;&lt;/ul&gt;</description><pubDate>Wed, 20 Sep 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{5F138D30-2D00-4F97-BECA-DE28BD5D6D0F}</guid><link>https://www.health.mil/News/Articles/2023/09/05/MHS-GENESIS-Leader-Talks-Sustainment-Following-Deployment</link><title>MHS GENESIS Leader Talks Sustainment Following Deployment</title><description>&lt;p&gt;Since the initial launch of &lt;a href="/Military-Health-Topics/Technology/MHS-GENESIS" target="_self" title="opens Health.mil"&gt;MHS GENESIS&lt;/a&gt; in 2017, the new electronic health record completed the final deployment within the United States in July 2023—reaching the 86% milestone for worldwide deployment.&lt;/p&gt;&lt;p&gt;U.S. Air Force Col. Christina Sheets, program manager for the Defense Healthcare Management System Modernization system, discussed MHS GENESIS during her session at the &lt;a href="/News/Dvids-Articles/2023/08/09/news451019" target="_self" title="opens healht.mil"&gt;2023 Defense Health Information Technology Symposium&lt;/a&gt;, Aug. 8-10, in New Orleans, Louisiana.&lt;/p&gt;&lt;p&gt;Her presentation, titled “ MHS GENESIS: Lessons Learned from Deployment and Sustainment,” discussed the challenges and successes she and her team experienced rolling out the new Defense Health Agency electronic health record system.&lt;/p&gt;&lt;p&gt;“We were told in the beginning that this was impossible,” said Sheets. “But we did it.”&lt;/p&gt;&lt;p&gt;Sheets and her team had to take five different electronic health record systems and combine them into one.&lt;/p&gt;&lt;p&gt;“One lesson we learned was that if we all work hard together for a common goal, there's nothing that can stop us,” said Sheets. &lt;/p&gt;&lt;p&gt;MHS GENESIS is the new, common electronic health record for the Military Health System. It’s an enterprise solution supporting a system of health care delivery with standardized clinical and business practices. It’s designed to be a patient-centric system focusing on quality, safety, security, and readiness.&lt;/p&gt;&lt;p&gt;It is currently operational in the continental U.S., which is 86% of the nearly 3,500 deployment locations worldwide. This includes clinics, hospitals and medical centers and some National Guard and Reserve sites.&lt;/p&gt;&lt;p&gt;Deployment now moves overseas, starting with the European region deploying on Sept. 23 and the Indo-Pacific region on Oct. 28. &lt;/p&gt;&lt;p&gt;More than 164,000 DHA providers currently use MHS GENESIS to provide health care to more than 7.2 million potential beneficiaries.&lt;/p&gt;&lt;p&gt;MHS GENESIS is also considered a federal health record, as it is operational at 109 U.S. Coast Guard locations, seven National Oceanic and Atmospheric Administration sites, and five Department of Veterans Affairs locations.&lt;/p&gt;&lt;h2&gt;Lessons Learned to Guide Future Deployments&lt;/h2&gt;&lt;p&gt;As shared in Sheets’ DHITS session, the MHS GENESIS team learned many things along the way to help future deployments and sustainment of the EHR.&lt;/p&gt;&lt;p&gt;She talked about many of the lessons learned during the initial rollout, including:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Focus on the patient experience by designing products around the end user and tailoring offerings to their needs&lt;/li&gt;    &lt;li&gt;Implement standardization by using consistent tools, process, vocabulary, and problem-solving methodology to drive cross-product usage of capabilities and improve efficiency&lt;/li&gt;    &lt;li&gt;Foster world-class talent by nurturing excitement and reinforcing a customer-centric mindset to seek out and drive innovation throughout the organization&lt;/li&gt;    &lt;li&gt;Drive scalability by understanding needs and requirements of federal partners to enable deployment of MHS GENESIS&lt;/li&gt;    &lt;li&gt;Engage with command leadership early and often to ensure buy-in and alignment of expectations for future events&lt;/li&gt;&lt;/ul&gt;&lt;h2&gt;Sustaining What Has Been Accomplished&lt;/h2&gt;&lt;p&gt;Now that deployment to DHA hospitals and clinics worldwide is nearing completion, the MHS GENESIS team is beginning to transition to sustainment of the system.&lt;/p&gt;&lt;p&gt;“Our original plan was always for deployment; we didn't focus a lot on sustainment until we had people to sustain,” said Sheets. “The sustainment team has to be in tight coordination with deployment teams and vice versa.”&lt;/p&gt;&lt;p&gt;“Transition from deployment to sustainment is going to be an ongoing process,” she added. “I would like to say it's going to be easy ... it's going be hard. Sustaining is the hardest part.”&lt;/p&gt;&lt;p&gt;She highlighted how to keep patients engaged through the EHR, including:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Shift paradigm for a post-deployment environment&lt;/li&gt;    &lt;li&gt;Restructure for a product-centric organization&lt;/li&gt;    &lt;li&gt;Comprise execution teams of product owners to determine what work will be done&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;The presentation then focused on the next steps for MHS GENESIS.&lt;/p&gt;&lt;p&gt;Now that deployment is completed in the continental U.S., Sheets noted there are still steps to be accomplished, including:&lt;/p&gt;&lt;ul&gt;    &lt;li&gt;Completing overseas deployments by the end of 2023&lt;/li&gt;    &lt;li&gt;Completing deployment at the James A. Lovell Federal Health Care Center in March 2024&lt;/li&gt;    &lt;li&gt;Transitioning from deployment to sustainment&lt;/li&gt;    &lt;li&gt;Implementing transformation journey to an integrated product-focused organization&lt;/li&gt;&lt;/ul&gt;&lt;p&gt;Sharing the challenges her team faced, Sheets said, “Don't let perfection be the enemy of progress.”&lt;/p&gt;&lt;p&gt;“If we had just stopped in the beginning because it wasn't perfect, we never would have gotten out there. It wasn’t perfect. It's still not perfect. But it gets better every day,” Sheets said.&lt;/p&gt;&lt;p&gt;“There's a lot of dedicated people who came before who work hard every day to make sure that we're moving the ball forward. We're listening to our customers and we're listening to the people out there so we can keep improving it.”&lt;/p&gt;</description><pubDate>Tue, 05 Sep 2023 00:00:00 Z</pubDate></item><item><guid isPermaLink="false">{006951FD-28EE-4DB4-8CA3-75BBBB49B911}</guid><link>https://www.health.mil/News/Articles/2023/09/01/HIV-screening-2023</link><title>Update: Routine Screening for Antibodies to Human Immunodeficiency Virus, U.S. Armed Forces, Active and Reserve Components, January 2018–June 2023</title><description>&lt;p&gt;This report provides an update through June 2023 of routine screening results for antibodies to the human immunodeficiency virus among members of the U.S. military. Consistent with prior year reports, the HIV-antibody seropositivity rate for 2022 among Army active component service members (0.25 per 1,000 soldiers tested) remained above active component members of the Air Force (0.17 per 1,000 airmen tested), Navy (0.16 per 1,000 sailors tested), Coast Guard (0 per 1,000 Coast Guardsmen tested), and Marine Corps (0.11 per 1,000 Marines tested). In comparison to 2022, the mid-year HIV seropositivity rates as of June 2023 declined for active component service members of the Army and Air Force but increased for the Navy and Marine Corps. &lt;/p&gt;&lt;h2&gt;What are the new findings?&lt;/h2&gt;&lt;p&gt;From January 2018 through June 2023, approximately 7 million U.S. military service members (active component, reserve component, and national guard) were tested for antibodies to HIV, and 1,502 were identified as HIV-antibody positive (seropositivity: 0.21 per 1,000 tested). The rate among men persisted above women throughout the surveillance period.&lt;/p&gt;&lt;h2&gt;What is the impact on readiness and force health protection?&lt;/h2&gt;&lt;p&gt;For over 30 years, the routine screening for antibodies to HIV has enabled the U.S. military to provide adequate and timely medical care to infected service members. Future studies should fully describe seropositivity rates by age and race, to further elucidate trends for the most at-risk populations. Additionally, health-seeking behaviors and co-morbidities should be evaluated to identify those at highest risk for HIV infection.&lt;/p&gt;&lt;h2&gt;Background&lt;/h2&gt;&lt;p&gt;The Department of Defense has conducted an active surveillance program for HIV since 1986, when reliable screening methods for the virus became widely available. The DOD surveillance program consists of screening all service members at specific points in time: prior to entry (all accessions must be HIV-negative prior to start of service), before deployment or any change in status (change in component, between branches, or commissioning), and once every 2 years while a military member.&lt;sup&gt;1&lt;/sup&gt;&lt;/p&gt;&lt;p&gt;Before 2009, the DOD screening program employed laboratory tech­niques that detected only HIV-1-type infections. Since 2009, all programs have adopted methods that detect antibodies to HIV-1 and HIV-2. Although HIV-2 infection is rare in the U.S., it is more prevalent in other parts of the world where service members may support military operations. This report refers to the target of the screening programs as simply “HIV” without specifying types. &lt;/p&gt;&lt;p&gt;Infection with HIV is medically disqualifying for entry into service with the U.S. military. Following significant advances in the diagnosis, treatment, and prevention of HIV, in June 2022 the DOD updated its policy, preventing the discharge or separation of service members living with HIV who have an undetectable viral load solely on the basis of their HIV-positive status.&lt;sup&gt;1&lt;/sup&gt; In addition, HIV-positive personnel are not non-deployable solely for a positive status; decisions on deployability are made on an individual basis and must be justified by the service member’s inability to perform the duties to which he or she would be assigned.&lt;sup&gt;2&lt;/sup&gt; &lt;/p&gt;&lt;p&gt;Summaries of HIV seropositivity for members of the U.S. military have been archived with the &lt;em&gt;MSMR&lt;/em&gt; since 1990. This report summarizes numbers and trends of newly identified HIV-antibody seropositivity from January 1, 2018 through June 30, 2023 among military members of the active and reserve components of 5 services under the U.S. Armed Forces, as well as the Army  National Guard and Air Force National Guard.&lt;/p&gt;&lt;h2&gt;Methods&lt;/h2&gt;&lt;p&gt;The surveillance population included all individuals eligible for HIV antibody screening from January 1, 2018 through June 30, 2023 while serving in the active or reserve component of the Army, Navy, Air Force, Marine Corps, or Coast Guard. All individuals who were tested and all first-time detections of antibodies to HIV through U.S. military medical testing programs were ascertained from the Department of Defense Serum Repository specimens accessioned to the Defense Medical Surveillance System. Due to data availability issues, the Navy and Marine Corps new HIV seropositive numbers for 2023 were obtained by the Navy Bloodborne Infection Management Center from the Navy’s HIV Management System.&lt;/p&gt;&lt;p&gt;An incident case of HIV-antibody seropositivity was defined as an individual with positive HIV test results from 2 serial specimens. Individuals who had just 1 positive result without a subsequent negative result were also defined as positive, to capture those who had yet to test positive a second time.&lt;/p&gt;&lt;p&gt;Annual rates of HIV seropositivity among service members were calculated by dividing the number of incident cases of HIV-antibody seropositivity during each calendar year by the number of individuals tested at least once during the relevant calendar year. Rates were further stratified by service, component, and sex. Overall rates by age category were calculated for all services for the full annual years of 2018 through 2022.&lt;/p&gt;&lt;h2&gt;Results&lt;/h2&gt;&lt;h3&gt;Overall&lt;/h3&gt;&lt;p&gt;From January 2018 through June 2023, approximately 7 million service members (active component, Guard, and reserve) were tested for antibodies to HIV, and 1,502 were identified as HIV-antibody positive (seropositivity: 0.21 per 1,000 tested) (data not shown). The rate among males (0.25 per 1,000 tested) persisted above females (0.03 per 1,000 tested) throughout the surveillance period, as only 39 females were identified as newly HIV antibody-positive during this time. Age-specific HIV seropositivity rates are presented for complete annual years in Figure 1; service members 25 to 34 years of age represented the highest age-specific rates from 2018 to 2022. &lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Figure-1.ashx?h=620&amp;w=800&amp;hash=394794EF65B53EC44DCDDD69C471CB208410C22D" style="height: 620px; width: 800px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px; border-width: 0px; border-style: solid;" alt="This graph presents 4 lines, each of which represents a different age group of service members of the U.S. Armed Forces, namely those under age 25, 25 to 34 years of age, 35 to 44 years of age, and those 45 to 54 years of age. The x-, or horizontal, axis is demarcated annually, for the previous 5 years, from 2018 to 2022. Every line connects 5 data points, each of which represents 1 year, with vertical, or y axis, orientations providing the annual rates of active component members from that age group whose screening tests for human immunodeficiency virus (or HIV) infection were positive. The rates are expressed as the number of HIV-positive individuals per 1,000 tested (seropositivity). During the surveillance period, generally the 2 younger age groups and the 2 older age groups clustered, with the younger age groups demonstrating higher seropositivity. The 25 to 34 age group consistently had the highest seropositivity rates, and the 45 to 54 age group the lowest. The 25 to 34 and 35 to 44 age groups rose to their highest levels in 2021 but then markedly declined in 2022."&gt;&lt;/p&gt;&lt;h3&gt;U.S. Army&lt;/h3&gt;&lt;h4&gt;Active component&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 444,341 soldiers in the active component of the U.S. Army were tested for antibodies to HIV, and 106 soldiers were identified as HIV-antibody positive (seropositivity: 0.24 per 1,000 soldiers tested) (Table 1). &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-1" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-1.ashx?h=411&amp;w=1175&amp;hash=6EB4C1D1EBCFA25BA9723320E654BD0B3CAFAD34" style="height: 411px; width: 1175px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;During the surveillance period, annual seropositivity rates fluctuated between a low of 0.19 per 1,000 tested in 2018 and a high of 0.28 per 1,000 tested in 2021 (Table 1, Figure 2). Annual seropositivity rates for male active component soldiers were considerably higher than those of female active component soldiers (Figure 2). &lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Figure-2.ashx?h=621&amp;w=800&amp;hash=483208713AD6B301386C4C04448D5C43DCFBE056" style="height: 621px; width: 800px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;" alt="The 3 lines of this graph presents the HIV-antibody seropositivity rates by sex and overall for active component service members of the U.S. Army. The x-, or horizontal, axis is demarcated annually, for the previous 5 years, from 2018 to 2022, as well as the first 6 months of 2023. Every line connects 6 data points, each of which represents 1 year, with vertical, or y axis, orientations providing the annual rates of active component Army members whose screening tests for HIV infection were positive. The rates are expressed as the number of HIV-positive individuals per 1,000 tested (seropositivity). Male active component Army members consistently had far higher seropositivity rates. Female Army service member rates were consistently under 0.05 per 1,000 tested, and declined to near 0 in 2023. Male rates rose from 0.23 in 2018 to 0.27 at mid-June 2023, declining from a peak of 0.32 in 2021."&gt;&lt;/p&gt;&lt;p&gt;During 2022, on average, 1 new HIV infection was detected among active component soldiers per 4,924 screening tests (Table 1). Of the 405 active component soldiers diagnosed with HIV infections since 2018, a total of 259 (63.9%) were still in military service in 2023.&lt;/p&gt;&lt;h4&gt;Army National Guard&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 259,873 members of the U.S. Army National Guard were tested for antibodies to HIV, and 63 soldiers were identified as HIV-antibody positive (seropositivity: 0.24 per 1,000 soldiers tested) (Table 2). On average, during 2022, 1 new HIV infection was detected among Army National Guard soldiers per 5,189 screening tests. Of the 284 National Guard soldiers who tested positive for HIV since 2018, a total of 187 (65.8%) were still in military service in 2023.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-2" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-2.ashx?h=416&amp;w=1200&amp;hash=6596A16922E9537B7FDF8DD57D87885A5B0D6C46" style="height: 416px; width: 1200px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h4&gt;Army Reserve&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 119,195 members of the U.S. Army Reserve were tested for antibodies to HIV, and 46 soldiers were identified as HIV-antibody positive (seropositivity: 0.39 per 1,000 soldiers tested) (Table 3). During 2022, on average, 1 new HIV infection was detected among Army reservists per 3,025 screening tests. Of the 180 Army reservists diagnosed with HIV infections since 2018, a total of 114 (63.3%) were still in military service in 2023.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-3" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-3.ashx?h=418&amp;w=1200&amp;hash=95D6D846480CB1F5E5FD5B06D6F98715134C219C" style="height: 418px; width: 1200px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h3&gt;U.S. Navy&lt;/h3&gt;&lt;h4&gt;Active component&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 294,801 active component members of the U.S. Navy were tested for antibodies to HIV, and 53 sailors were identified as HIV-antibody positive (seropositivity: 0.18 per 1,000 sailors tested) (Table 4). &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-4" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-4.ashx?h=411&amp;w=1200&amp;hash=9E9D28BA726AF72017E3E639F51B156373FCC858" style="height: 411px; width: 1200px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;During 2022, on average, 1 new HIV infection was detected among active component sailors per 7,306.6 screening tests. Of the 240 active component sailors who tested positive for HIV since 2018, a total of 161 (67.1%) were still in military service in 2023. During each year of the surveillance period, only 0 to 3 female sailors tested positive. Among male sailors, the rate per 1,000 tested fluctuated between 0.20 to 0.30 from 2018 through 2022 (Figure 3). &lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Figure-3.ashx?h=581&amp;w=800&amp;hash=E5FDC6ECF0479AFB67A9BE47C71734956E8AF3D3" style="height: 581px; width: 800px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="The 3 lines of this graph presents the HIV-antibody seropositivity rates by sex and overall for active component service members of the U.S. Navy. The x-, or horizontal, axis is demarcated annually, for the previous 5 years, from 2018 to 2022, as well as the first 6 months of 2023. Every line connects 6 data points, each of which represents 1 year, with vertical, or y axis, orientations providing the annual rates of active component Navy members whose screening tests for HIV infection were positive. The rates are expressed as the number of HIV-positive individuals per 1,000 tested (seropositivity). Male active component Navy members consistently had far higher seropositivity rates. Female Navy service member rates remained below 0.07 per 1,000 tested during the surveillance period, declining to a rate of 0 in 2022 and mid-2023. Male rates were highly variable, peaking at 0.30 in 2019 and 2021, with record lows of 0.20 immediately thereafter in 2020 and 2022, rising again to 0.29 per 1,000 tested in mid-2023."&gt;&lt;/p&gt;&lt;h4&gt;Navy Reserve&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 45,135 members of the U.S. Navy Reserve were tested for antibodies to HIV, and 7 sailors were identified as HIV-antibody positive (seropositivity: 0.16 per 1,000 sailors tested) (Table 5). On average, during 2022, 1 new HIV infection was detected among Navy reservists per 5,373.8 screening tests. Of the 43 reserve component sailors diagnosed with HIV infections since 2018, a total of 35 (81.4%) were still in military service in 2023. The HIV-antibody seropositivity rate declined from 0.21 per 1,000 Navy reservists in 2022 to 0.06 as of June 2023. &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-5" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-5.ashx?h=417&amp;w=1175&amp;hash=E719E3A83C6D3637D4C80F898F1A68233FC198A4" style="height: 417px; width: 1175px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h3&gt;U.S. Air Force&lt;/h3&gt;&lt;h4&gt;Active component&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 286,900 active component members of the U.S. Air Force were tested for antibodies to HIV, and 43 Air Force members were diagnosed with HIV infection (seropositivity: 0.15 per 1,000 Air Force members tested) (Table 6). &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-6" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-6.ashx?h=418&amp;w=1175&amp;hash=E899C7BD69617865431959949576CD392F915FD1" style="height: 418px; width: 1175px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;On average, 1 new HIV infection was detected among active component Air Force members per 7,461 screening tests in 2022. Of the 151 active component Air Force members diagnosed with HIV infections since 2018, 101 (66.9%) were still in military service in 2023. During the surveillance period, seropositivity rates among male members ranged from a low of 0.11 per 1,000 tested in 2020 to a high of 0.22 per 1,000 tested in 2022 (Figure 4).&lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Figure-4.ashx?h=582&amp;w=800&amp;hash=261B3B8EA7B1BE8BF3D9037AFCB3D31F26890017" style="height: 582px; width: 800px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="The 3 lines of this graph presents the HIV-antibody seropositivity rates by sex and overall for active component service members of the U.S. Air Force. The x-, or horizontal, axis is demarcated annually, for the previous 5 years, from 2018 to 2022, as well as the first 6 months of 2023. Every line connects 6 data points, each of which represents 1 year, with vertical, or y axis, orientations providing the annual rates of active component Air Force members whose screening tests for HIV infection were positive. The rates are expressed as the number of HIV-positive individuals per 1,000 tested (seropositivity). Male active component Air Force members consistently had far higher seropositivity rates, where female Air Force service member rates were consistently near 0 per 1,000 tested. Male rates rose from 0.16 in 2018 to 0.21 in 2019, and then declined in 2020 to their lowest rates, 0.11 per 1,000 tested. The rates then steadily rose again to 0.22 in 2022, and the mid-2023 numbers show a marked decline to 0.15 per 1,000 tested."&gt;&lt;/p&gt;&lt;h4&gt;Air National Guard&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 81,626 members of the Air National Guard were tested for antibodies to HIV, and 7 Air National Guard members were diagnosed with HIV infection (seropositivity: 0.09 per 1,000 airmen tested) (Table 7). During 2022, on average, 1 new HIV infection was detected among Air National Guard members per 15,343 screening tests. Of the 32 Air National Guard members diagnosed with HIV infections since 2018, 27 (84.4%) were still in military service in 2023.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-7" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-7.ashx?h=420&amp;w=1175&amp;hash=1DE68E4132CB7E42CF588063B29A55349CDAA9A4" style="height: 420px; width: 1175px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h4&gt;Air Force Reserve&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 50,556 members of the Air Force Reserve were tested for antibodies to HIV, and 4 Air Force reservists were diagnosed with HIV infections (seropositivity: 0.08 per 1,000 airmen tested) (Table 8). During 2022, on average, 1 new HIV infection was detected among Air Force reservists per 9,321 screening tests. Of the 36 Air Force reservists diagnosed with HIV infections since 2018, 28 (77.8%) were still in military service in 2023.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-8" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-8.ashx?h=418&amp;w=1175&amp;hash=622EAD7C307A3809D30198A4C44AB2275D0F785A" style="height: 418px; width: 1175px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h3&gt;U.S. Marine Corps&lt;/h3&gt;&lt;h4&gt;Active component&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 166,411 members of the active component of the U.S. Marine Corps were tested for antibodies to HIV, and 24 Marines were identified as HIV-antibody positive (seropositivity: 0.14 per 1,000 Marines tested) (Table 9). &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-9" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-9.ashx?h=405&amp;w=1175&amp;hash=C619227F3479934FB4DD7D66C43A7DAF34E7753B" style="height: 405px; width: 1175px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;During 2022, on average, 1 new HIV infection was detected among active component Marines per 10,790 screening tests. Of the 106 active component marines diagnosed with HIV infections since 2018, a total of 47 (44.3%) were still in military service in 2023. Among males, the rate per 1,000 declined from 0.22 per 1,000 tested in 2018 to 0.11 per 1,000 tested in 2022, thereafter increasing to a rate of 0.25 per 1,000 tested as of June 2023 (Figure 5). &lt;/p&gt;&lt;p&gt;&lt;img src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Figure-5.ashx?h=598&amp;w=800&amp;hash=32FF43C456FD385520460F8006AD68852F6959C1" style="height: 598px; width: 800px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;" alt="The 3 lines of this graph presents the HIV-antibody seropositivity rates by sex and overall for the active component service members of the U.S. Marine Corps. The x-, or horizontal, axis is demarcated annually, for the previous 5 years, from 2018 to 2022, as well as the first 6 months of 2023. Every line connects 6 data points, each of which represents 1 year, with vertical, or y axis, orientations providing the annual rates of active component Marine Corps members whose screening tests for HIV infection were positive. The rates are expressed as the number of HIV-positive individuals per 1,000 tested (seropositivity). Female Marine Corps service member rates remained at or below 0.10 per 1,000 tested throughout the surveillance period. Male rates gradually declined from 0.22 in 2018 to 0.11 in 2022, but increased to 0.25 in the first 6 months of 2023."&gt;&lt;/p&gt;&lt;h4&gt;Marine Corps Reserve&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 28,444 members of the U.S. Marine Corps Reserve were tested for antibodies to HIV, and 3 Marine Corps reservists were identified as HIV-antibody positive (seropositivity: 0.11 per 1,000 Marines tested) (Table 10). During 2022, on average, 1 new HIV infection was detected among Marine Corps reservists per 9,983.5 screening tests. Of the 17 Marine Corps reservists diagnosed with HIV infection since 2018, a total of 6 (35.3%) were still in military service in 2023.&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-10" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-10.ashx?h=422&amp;w=1200&amp;hash=EB2298C8434C16C4654A51421C0529793AAC9EDC" style="height: 422px; width: 1200px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h3&gt;U.S. Coast Guard&lt;/h3&gt;&lt;h4&gt;Active component&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 27,896 members of the active component of the U.S. Coast Guard were tested for antibodies to HIV; 0 were identified as HIV-antibody positive (Table 11). &lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-11" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-11.ashx?h=413&amp;w=1175&amp;hash=C839D0698D9D92A766FF923C901F4F5478DF0099" style="height: 413px; width: 1175px; vertical-align: middle; margin-top: 5px; margin-bottom: 10px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;p&gt;Of the 6 active component Coast Guardsmen diagnosed with HIV infections since 2018, a total of 2 (33.3%) were still in military service in 2023.  &lt;/p&gt;&lt;h4&gt;Coast Guard Reserve&lt;/h4&gt;&lt;p&gt;From January 2022 through June 2023, a total of 4,354 members of the U.S. Coast Guard Reserve were tested for antibodies to HIV; 0 Coast Guard reservists were identified as HIV-antibody positive (Table 12).&lt;/p&gt;&lt;p&gt;&lt;a href="/Reference-Center/Reports/2023/09/01/MSMR-Article-1-Table-12" title="Click on the Table to access a 508-compliant version"&gt;&lt;img alt="Click on the Table to access a 508-compliant version" src="/-/media/Images/MHS/Photos/AFHSB-MSMR/2023/September/Article-1-Table-12.ashx?h=408&amp;w=1175&amp;hash=2AF808404BE61E164AD0CECAF34B81FA2B61451C" style="height: 408px; width: 1175px; vertical-align: middle; margin-top: 5px; margin-bottom: 15px;"&gt;&lt;/a&gt;&lt;/p&gt;&lt;h2&gt;Discussion&lt;/h2&gt;&lt;p&gt;The U.S. military has conducted routine screening for antibodies to HIV among all civilian applicants for service and all service members for more than 30 years.&lt;sup&gt;3-6&lt;/sup&gt; Results of U.S. military HIV-antibody testing programs have been summarized in the &lt;em&gt;MSMR&lt;/em&gt; for more than 2 decades.&lt;sup&gt;7&lt;/sup&gt; This year marks the returned inclusion of HIV screening for active and reserve component service members of the U.S. Coast Guard, to include summary data for 5 services of the U.S. Armed Forces. &lt;/p&gt;&lt;p&gt;This report documents that the full-year HIV-antibody seropositivity rate in 2022 among Army active component service members (0.25 per 1,000 soldiers tested) remained greater than among active component members of the Air Force (0.17 per 1,000 airmen tested), Navy (0.16 per 1,000 sailors tested), Coast Guard (0 per 1,000 Coast Guardsmen tested), and Marine Corps (0.11 per 1,000 Marines tested). In comparison to 2022, the mid-year HIV seropositivity rates as of June 2023 declined for active component service members of the Army and Air Force but increased for the Navy and Marine Corps. &lt;/p&gt;&lt;p&gt;The 2022-2025 National HIV/AIDS strategy identifies youth aged 13-24 years as a priority population, based on increased risk for HIV transmission.&lt;sup&gt;8&lt;/sup&gt; While the seropositivity results presented in this report do partially represent this priority population, as almost 45% of all new HIV infections were identified in service members under 25 years of age, these results should not be generalized to the U.S. population. Data from HIV screening in U.S. military populations are based on a negative test prior to entry, as well as voluntary service. In countries with universal conscription, compulsory testing in samples of military recruits will be more representative of the young adult population.&lt;sup&gt;9&lt;/sup&gt; Following pre-accession screening of military recruits, routine screening represents relatively recently acquired HIV infections (i.e., infections acquired since the most recent negative test of each affected individual). &lt;/p&gt;&lt;p&gt;Routine screening of all civilian applicants for service and routine periodic testing of all active and reserve component members of the services have been fundamental components of the military’s HIV control and clinical management efforts.&lt;sup&gt;10&lt;/sup&gt; Previous &lt;em&gt;MSMR&lt;/em&gt; reports presented HIV screening results for civilian applicants to the military service; however, these data are no longer available in the Defense Medical Surveillance System (DMSS), as the U.S. Military Entrance Processing Command stopped reporting data to the DMSS at the end of calendar year 2020. Thus, the data presented in this report reflect service members who had a negative HIV test upon entry to military service, followed by a positive test during uniformed service. &lt;/p&gt;&lt;p&gt;The mid-year 2023 HIV seropositive results for Navy and Marine Corps service members were obtained by the Navy Bloodborne Infection Management Center from the Navy’s HIV Management System. Due to changes in data processing, positive specimens are no longer accessioned in DoDSR, although non-positive HIV samples remain documented in DoDSR and accessioned through DMSS. Consequently, the total number of positive HIV tests were acquired from DMSS to calculate seropositivity rates. The total number of HIV tests completed as of June 2023 for Navy and Marine Corps active component service members approximated half of the tests completed during 2022. &lt;/p&gt;&lt;p&gt;The substantial declines in detection rates associated with routine screening for Army and Air Force service members should be more fully investigated at the end of 2023. If post-accession detection rates continue to decline through routine screening of the full military force, a cost-effectiveness analysis of universal versus indications-based testing after military enlistment may be warranted. Additionally, future studies should fully describe seropositivity rates by age and race, to further elucidate trends for the most at-risk populations. Health-seeking behaviors and co-morbidities should also be evaluated to identify those at highest risk for HIV infection.&lt;/p&gt;&lt;h2&gt;References&lt;/h2&gt;&lt;ol class="refList"&gt;    &lt;li&gt;Department of Defense Instruction 6485.01, Human Immunodeficiency Virus (HIV) in Service Members (Change 2) 2013. Accessed August 11, 2023. &lt;a rel="noopener noreferrer" href="https://www.esd.whs.mil/portals/54/docu­ments/dd/issuances/dodi/648501p.pdf" target="_blank" title="Click on the link to access the DOD instruction regarding HIV"&gt;https://www.esd.whs.mil/portals/54/docu­ments/dd/issuances/dodi/648501p.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a rel="noopener noreferrer" href="https://www.esd.whs.mil/portals/54/docu­ments/dd/issuances/dodi/648501p.pdf" target="_blank" title="Click on the link to access the DOD instruction regarding HIV"&gt;&lt;/a&gt;Secretary of Defense Memorandum for Senior Pentagon Leadership, Commanders of the Combatant Commands, Defense Agency and DOD Field Activity Directors. Policy Regarding Human Immunodeficiency Virus-Positive Personnel Within the Armed Forces. June 6, 2022. Accessed August 11, 2023. &lt;a href="https://media.defense.gov/2022/Jun/07/2003013398/-1/-1/1/policy-regarding-human-immunodeficiency-virus-positive-personnel-within-the-armed-forces.pdf" target="_blank" title="Opens policy on DMA"&gt;https://media.defense.gov/2022/Jun/07/2003013398/-1/-1/1/policy-regarding-human-immunodeficiency-virus-positive-personnel-within-the-armed-forces.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://media.defense.gov/2022/Jun/07/2003013398/-1/-1/1/policy-regarding-human-immunodeficiency-virus-positive-personnel-within-the-armed-forces.pdf"&gt;&lt;/a&gt;Brown AE, Brundage JF, Tomlinson JP, Burke DS. The U.S. Army HIV testing program: the first decade. &lt;em&gt;Mil Med&lt;/em&gt;. 1996;161(2):117-122.&lt;/li&gt;    &lt;li&gt;Office of the Assistant Secretary of Defense. Health Affairs Policy Memorandum—Human Immunodeficiency Virus Interval Testing. HA Policy 04-007. March 29, 2004.&lt;/li&gt;    &lt;li&gt;Office of the Under Secretary of Defense for Personnel and Readiness. Department of Defense Instruction 6485.01. Human Immunodeficiency Virus (HIV) in Military Service Members. June 7, 2013.&lt;/li&gt;    &lt;li&gt;Office of the Under Secretary of Defense for Personnel and Readiness. Department of Defense Instruction 6130.03, Medical Standards for Appointment, Enlistment, or Induction in the Military Services. May 6, 2018.&lt;/li&gt;    &lt;li&gt;Army Medical Surveillance Activity. Supplement: HIV-1 in the Army. &lt;em&gt;MSMR&lt;/em&gt;. 1995;1(3):12-15.&lt;/li&gt;    &lt;li&gt;White House Office of National AIDS Policy. National HIV/AIDS Strategy (2022-2025). Accessed September 6, 2023. &lt;a rel="noopener noreferrer" href="https://www.hiv.gov/federal-response/national-hiv-aids-strategy/national-hiv-aids-strategy-2022-2025" target="_blank" title="Click on the link to access the National HIV/AIDS Strategy"&gt;https://www.hiv.gov/federal-response/national-hiv-aids-strategy/national-hiv-aids-strategy-2022-2025&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;&lt;a href="https://www.hiv.gov/federal-response/national-hiv-aids-strategy/national-hiv-aids-strategy-2022-2025" target="_blank" title="Click on the link to access the National HIV/AIDS Strategy"&gt;&lt;/a&gt;United States Department of Health and Human Services, Centers for Disease Control and Prevention. Introduction to HIV Sero-surveillance. Accessed September 6, 2023. &lt;a rel="noopener noreferrer" href="https://global­healthsciences.ucsf.edu/sites/globalhealthsciences.ucsf.edu/files/sero-surveillance_22sept09.pdf" target="_blank" title="Click on the link to access the CDC's HIV sero-surveillance introduction"&gt;https://global­healthsciences.ucsf.edu/sites/globalhealthsciences.ucsf.edu/files/sero-surveillance_22sept09.pdf&lt;/a&gt;&lt;/li&gt;    &lt;li&gt;Okulicz JF, Beckett CG, Blaylock JM, et al. Review of the U.S. military’s human immunodeficiency virus program: a legacy of progress and a future of promise. &lt;em&gt;MSMR&lt;/em&gt;. 2017;24(9):2-7.&lt;/li&gt;&lt;/ol&gt;</description><pubDate>Fri, 01 Sep 2023 00:00:00 Z</pubDate></item></channel></rss>