MEDICAL SURVEILLANCE MONTHLY REPORT

Transcription

1 VOL. 17 NO. 3 MARCH 21 msmr A publiction of the Armed Forces Helth Surveillnce Center Motorcycle deths MEDICAL SURVEILLANCE MONTHLY REPORT HEAT INJURY ISSUE: Motor vehicle-relted deths, U.S. Armed Forces, 29 2 Updte: Het injuries, ctive component, U.S. Armed Forces, 29 6 Updte: Exertionl rhbdomyolysis mong U.S. militry members, 29 9 Updte: Exertionl hypontremi, ctive component, U.S. Armed Forces, Summry tbles nd figures Acute respirtory disese, bsic trining centers, U.S. Army, Mrch 28-Mrch Updte: Deployment helth ssessments, U.S. Armed Forces, Februry Sentinel reportble medicl events, service members nd beneficiries, U.S. Armed Forces, cumultive numbers through Februry of 29 nd 21 2 Deployment-relted conditions of specil surveillnce interest 25 Red the MSMR online t:

2 2 VOL. 17 / NO. 3 Motor Vehicle-relted Deths, U.S. Armed Forces, Jnury 1998-September 29 Motor vehicle ccidents re the leding cuse of deth mong U.S. militry members during pecetime. During the four yers prior to opertions in Irq nd Afghnistn, one-third of service member deths were cused by motor vehicle ccidents. Since the beginning of those opertions, there hve been nerly s mny deths of service members due to trnsporttion ccidents s wrrelted injuries. 1 Mny militry members re young, single, mle, nd high-school educted; these chrcteristics re ssocited with high risk of dying in motor vehicle crshes. 2,3 Compred to their older counterprts, young militry members hve less driving experience nd re more likely to tke risks while driving (such s to drive without setbelts or while under the influence of lcohol). 3 However, becuse militry service is inherently dngerous, nd becuse ll U.S. militry members re volunteers, they my be more willing to tke risks, independently of ge. Motorcycles re used by mny U.S. militry members for trnsporttion nd recretion; of note, motorcyclists re 37 times more likely thn pssenger cr occupnts to die in rod ccidents. 4 Also, driving nd riding in militry motor vehicles during trining nd opertionl missions cn be hzrdous prticulrly, in unfmilir nd intrinsiclly unsfe settings (e.g., blckout conditions; inclement wether; nrrow rodwys, bridges, nd overpsses). 5,6 This report summrizes numbers, rtes, trends nd correltes of risk of ftl motor vehicle ccidents mong U.S. militry members. Tble 1. Motor vehicle deths by underlying cuse of deth ctegory, Jnury 1998-September 29 Underlying cuse of deth Totl service members No. % Motorcyclist involved in ny ccident except collision with rilwy trin Other nd unspecifi ed motor vehicle ccidents Occupnt of cr pickup truck or vn in collision with other motor vehicle Occupnt of motor vehicle in collision with non-motorized vehicle, pedestrin, fi xed object Occupnt of motor vehicle in noncollision ccident Occupnt of specil-use motor vehicle in ny ccident (include militry vehicle) Pedestrin in collision with motor vehicle Pedl cyclist in collision with motor vehicle 17.4 Other motor vehicle ccident involving collision with rilwy trin 1.2 Other nd unspecifi ed lnd trnsport ccidents 1.2 Occupnt of hevy trnsport vehicle or bus in collision with other motor vehicle 5.1 Totl 4,31 1 Methods: The surveillnce period ws 1 Jnury 1998 to 3 September 29. The surveillnce popultion included ll individuls who served on ctive duty s member of the ctive or Reserve component of the Army, Nvy, Air Force, or Mrine Corps ny time during the surveillnce period. Motor vehicle-relted deths of service members while on ctive duty were scertined from records mintined in the DoD Medicl Mortlity Registry of the Armed Forces Medicl Exminer System nd routinely provided to the Armed Forces Helth Surveillnce Center for integrtion in the Defense Medicl Surveillnce System (DMSS). For this nlysis, motor vehicle-relted deth ws defined by csulty record with n underlying cuse of deth code (Tble 1) corresponding to collision or noncollision motor vehicle ccident. Motor vehicle deths tht were considered intentionl (i.e., suicide, homicide, wrrelted) were excluded. Summry mesures were numbers of motor vehicle deths in the surveillnce popultion overll (i.e., ctive nd Reserve component members who died while on ctive duty) nd mortlity rtes. For members of the ctive component, mortlity rtes were clculted s deths per 1, person- Figure 1. Number nd percent (of ll motor vehicle deths) of motorcycle-relted deths, ctive nd Reserve component, U.S. Armed Forces, Jnury 1998-September 29 Number of deths (brs) Through September No. of motorcycle deths % of ll motor vehicle deths Yer Percent of ll motor vehicle deths (line)

3 MARCH 21 3 Tble 2. Demogrphic nd militry chrcteristics of individuls who died in motor vehicle ccidents, ctive nd Reserve components, with rtes (per 1, person-yers of service) for ctive component only, U.S. Armed Forces, Jnury 1998-September 29 Active nd Reserve components Active component No. No. Rte Totl 4,31 3, Service Army 1,82 1, Nvy Air Force Mrine Corps Sex Mle 3,732 3, Femle Rce ethnicity White, non-hispnic 484 2, Blck, non-hispnic 1, Other Age < ,878 1, Militry occuption Combt 1, Helth Admin/supply Other 1,895 1, Deth rte per 1, person-yers of service yers of ctive militry service during the surveillnce period. Mortlity rtes were summrized using person-yers t risk (rther thn individuls t risk) becuse the U.S. militry is dynmic cohort ech dy, mny individuls enter nd mny others leve service. Thus, in given yer, there re mny more individuls with ny service thn there re totl person-yers of ctive service; the ltter ws considered more consistent mesure of exposure to mortlity risk for service members. Reserve component members were not included in rte clcultions becuse the strt nd end dtes of their ctive duty service periods were not vilble. Results: From 1998 through September 29, 4,31 service members died from motor vehicle ccidents (MVAs) while on ctive duty (Tble 1). Nerly one-fourth (921; 23%) of ll service members who died in motor vehicle ccidents were riding motorcycles. Remrkbly, the proportion of ll MVA-relted deths tht were due to motorcycle ccidents incresed from 14% (4) in 21 to 38% (113) in 28 (Figure 1). Of ll non-motorcycle-relted deths from MVAs, pproximtely 15% (466) were relted to non-collision ccidents (e.g., rollovers, fires, loss of control); 13% (392) ffected occupnts of specil-use (including militry) vehicles; nd 8% ffected pedestrins (223) or bicyclists (17) who were hit by motor vehicles (Tble 1). Of ll militry members who died in motor vehicle ccidents during the period, 85% (3,414) were in the ctive component (Tble 2). Among ctive component members, the crude MVA-relted ftlity rte ws 21.1 per 1, person-yers (p-yrs). The highest MVA-relted deth rtes ffected service members who were in the Mrine Corps (33. per 1, p-yrs), younger thn 2 yers (32.8 per 1, p-yrs), nd in combt occuptions (27.1 per 1, p-yrs). The MVA-relted deth rte declined with incresing ge nd ws 2.4-times higher mong mles thn femles (Tble 2). Among ctive component members, numbers nd rtes of MVA-relted deths were generlly stble from 1998 to 21, incresed from 21 to 24, slightly declined from 24 to 26, nd shrply declined from 26 through 29 (Figure 2). The men of MVA-relted deths per yer during the period ws 285; however, the rnge ws wide. The most MVA-relted deths in yer were in 24 (356; rte: 25.2 per 1, p-yrs) nd the fewest in 29 (through September) (169; rte: 16.1 per 1, p-yrs) (Figure 2). Among ctive component members, trends of motorcyclend other motor vehicle-relted deths differed substntilly over the period (Figure 3). Motorcycle-relted deth rtes Figure 2. Motor vehicle deths per yer mong members of the ctive component, U.S. Armed Forces, Jnury 1998-September 29 Number of deths (brs) Through September Motor vehicle deths Rte per 1, p-yrs Yer Motor vehicle deth rte per 1, person-yers (line)

4 4 VOL. 17 / NO. 3 Figure 3. Motor vehicle deths, by yer nd underlying cuse (motorcycle vs. non-motorcycle ccidents), ctive component, U.S. Armed Forces, Jnury 1998-September 29 Number of deths (brs) Through September 2 Non-motorcycle deths Motorcycle deths Rte, non-motorcycle Rte, motorcycle doubled from 21 (2.6 per 1, p-yrs) to 22 (5.2 per 1, p-yrs) nd incresed by nerly 5% from 22 to 28 (7.6 per 1, p-yrs). In shrp contrst, MVArelted deths not involving motorcycles declined by 42% from 24 (273) to 28 (158) (Figure 3). In 1998, motorcycle ccidents ccounted for 16% of ll ftl MVAs mong U.S. militry members of ll components; in 28, they ccounted for 38% of ll ftl MVAs mong U.S. militry members (Figure 1). Of the services, the Mrine Corps hd the highest rtes of MVA-relted deths overll (33. per 1, p-yrs) nd motorcycle-relted deths specificlly (6.8 per 1, p-yrs) during the entire period. The MVA-relted deth rte overll ws higher in the Army (23.9 per 1, p-yrs) thn the Nvy (17.9 per 1, p-yrs); however, the motorcyclerelted deth rte ws higher in the Nvy (5.3 per 1, p-yrs) thn the Army (4.8 per 1, p-yrs). Of note, in 28 (the yer with the most motorcycle-relted deths), motorcycle-relted deth rtes were 11.3, 9.2, 7.3 nd 4.3 per 1, person-yers in the Mrine Corps, Nvy, Army nd Air Force, respectively (dt not shown). Alcohol ws reported s fctor in 9.5% of ll MVArelted deths overll nd 7.8% of ll ftl motorcycle ccidents (dt not shown). Forty-three percent (1,728) of service members who died from motor vehicle ccidents hd documented medicl encounters (hospitliztions: 2%; mbultory visits: 23%) within 7 dys before the dtes of their 24 Yer Deth rte per 1, person-yers (lines) deths; of these individuls, 53 (31%) hd primry (firstlisted) dignoses of serious injuries to the hed. Hed injuries (including skull frcture, intrcrnil injury nd cerebrl hemorrhge) ccounted for five of the six most frequent injuries (t the 3-digit level of the ICD-9-CM) documented during medicl encounters preceding MVA-relted deths (dt not shown). Dt summries by Stephen B. Tubmn, PhD, Dt Anlysis Group, AFHSC. Editoril comment: This report reitertes the importnce of motor vehicle ccidents s significnt cuse of deths of U.S. service members. The most striking finding, however, is the shrp increse in the proportion of ll MVA-relted deths tht re due to motorcycles ccidents. In 28, 38% of ll U.S. service members in ctive service (nd 4% of ll ctive component members) who were killed in motor vehicle ccidents were riding motorcycles; in 21, only 14% of ll MVA-relted deths of service members were due to motorcycle ccidents. The recent shrp increse in motorcycle-relted deths hs been noted nd ggressively countered by the Services. For exmple, Service nd locl sfety centers highlight vehicle sfety in publictions, messges, eductionl, nd trining mterils; instlltions require trining nd proficiency testing before issuing permits for on-post motorcycle use; nd some instlltions provide controlled, supervised venues for high performnce uses of motorcycles nd other vehicles. The effects of such efforts should be closely trcked; effective interventions should be identified nd documented to enble broder implementtion. There re limittions to the nlysis tht should be considered when interpreting the results. For exmple, t the time of the nlysis, records of deths of U.S. service members were vilble only through September 29; lso, finl determintions of underlying cuses were pending for pproximtely 8% of deths in 29. Hence, numbers of MVA-relted deths, overll nd by cuses, during the most recent clendr yer of interest for the nlysis re incomplete. Also, this nlysis did not include MVA-relted deths of Reserve component members who were not on ctive duty t the times of their ccidents or deths secondry to but long fter motor vehicle ccidents tht occurred during ctive service (e.g., mediclly retired service members). Becuse such deths were not included, the mortlity impct of motor vehicle ccidents on the totl force is significntly higher thn documented here. Finlly, this overview summrizes numbers, rtes, trends, nd demogrphic nd militry chrcteristics of U.S. militry members who died from motor vehicle ccidents. A future MSMR report will document temporl

5 MARCH 21 5 chrcteristics of ftl motor vehicles ccidents of militry members (e.g., sesons of the yer, dys of the week, reltionships to federl holidys). References: 1. Armed Forces Helth Surveillnce Center. Deths while on ctive duty. MSMR. 29 My. 16(5):3. 2. Hooper TI, Debkey SF, Bellis KS, Kng HK, Cown DN, Lincoln AE, Gckstetter GD. Understnding the effect of deployment on the risk of ftl motor vehicle crshes: nested cse-control study of ftlities in Gulf Wr er veterns, Accid Anl Prev. 26 My;38(3): Bell NS, Amoroso PJ, Yore MM, Smith GS, Jones BH. Self-reported risk-tking behviors nd hospitliztion for motor vehicle injury mong ctive duty rmy personnel. Am J Prev Med. 2 Apr;18(3 Suppl): Ntionl Center for Sttistics nd Anlysis, Ntionl Highwy Sfety Administrtion. Trffi c sfety fcts. 28 Dt: Motorcycles (DOT HS ). U.S.Deprtment of Trnsporttion, Wshington, DC 28. Accessed on 24 June 29 t: PDF. 5. Krhl PL, Jnkosky CJ, Thoms RJ, Hooper TI. Systemtic review of militry motor vehicle crsh-relted injuries. Am J Prev Med. 21 Jn;38(1 Suppl):S Hmmett M, Wtts D, Hooper T, Perse L, Nito N. Drowning deths of U.S. Service personnel ssocited with motor vehicle ccidents occurring in Opertion Irqi Freedom nd Opertion Enduring Freedom, Mil Med. 27 Aug;172(8):875-8.

6 6 VOL. 17 / NO. 3 Updte: Het Injuries, Active Component, U.S. Armed Forces, 29 Het-relted injuries re significnt threts to the helth nd opertionl effectiveness of militry members nd their units. 1,2 Lessons lerned during trining nd opertions in hot environments nd findings of numerous reserch studies hve resulted in doctrine, equipment, nd methods tht cn significntly reduce the dverse effects of militry ctivities in het. 1-3 Although numerous nd effective countermesures re vilble, physicl exertion in hot environments still cuses hundreds of injuries some life thretening mong U.S. militry members ech yer. 4,5 In June 29, the Armed Forces Helth Surveillnce Center issued revised Tri-Service Reportble Event Guidelines 6 in which definitions of notifible het injuries were modified. Effective 31 July 29, notifible cse of het stroke (ICD-9-CM: 992.) is cliniclly defined s severe het stress injury, specificlly including injury to the centrl nervous system, chrcterized by centrl nervous system dysfunction nd often ccompnied by het injury to other orgns nd tissue. Notifible cses of het injuries Tble 1. Incident cses nd rtes of het injury, ctive component, U.S. Armed Forces, 29 Het stroke ICD-9-CM: 992. Other het injury ,992.9 No. Rte No. Rte Totl , Sex Mle , Femle Age group < Rce/ethnicity White, non-hispnic , Blck, non-hispnic Other Service Army , Nvy Air Force Mrine Corps Cost Gurd Militry sttus Enlisted , Offi cer Militry occuption Combt Helth cre Other , Rte per 1, person-yers other thn het stroke ( unspecified effects of het [ICD-9- CM: 992.9]) re moderte to severe het injuries ssocited with strenuous exercise nd environmentl het stress tht require medicl intervention or result in lost duty time. All het injuries tht require medicl intervention or result in lost duty re reportble. Cses of het exhustion (ICD-9-CM: 992.3) tht do not require medicl intervention or result in lost duty re not reportble. This report summrizes het injury-relted hospitliztions, mbultory visits nd reportble medicl events mong members of ctive components during 29 nd compres them to recent yers. Het stroke (reportble during ll of 29) is summrized seprtely from other het injuries which includes het exhustion reportble prior to 31 July 29) nd unspecified effects of het (reportble since 31 July 29). Methods: The surveillnce popultion included ll individuls who served in n ctive component of the Army, Nvy, Air Force, Mrine Corps or Cost Gurd ny time from 1 Jnury 25 through 31 December 29. The Defense Medicl Surveillnce System (DMSS) ws serched to identify ll Figure 1. Incident cses nd rtes of het stroke, by source of report nd yer of dignosis, ctive component, U.S. Armed Forces, Number of cses Reportble events Hospitliztions Yer Ambultory visits Incidence rte Rte per 1, person-yers

7 MARCH 21 7 Figure 2. Incident cses nd rtes of other het injury, by source of report nd yer of dignosis, ctive component, U.S. Armed Forces, Number of cses 2,5 2, 1,5 1, 5 25 Reportble events Hospitliztions Yer Ambultory visits Incidence rte medicl encounters nd notifible medicl event reports tht included either primry (first listed) or secondry (second listed) dignoses of het stroke (ICD-9-CM: 992.) or other het injury ( het exhustion [ICD-9-CM: nd unspecified effects of het [ICD-9-CM:992.]). The nlytic methods used to summrize het injuries in this report re different from those used in previous het injury updtes. First, this report estimtes nnul numbers of both individuls ffected by het injury nd het injury events. Individuls were counted s n incident cse only once per clendr yer. When counting het injury events, individuls were llowed one event every 6 dys. Second, for individuls with more thn one documented het injury in clendr yer, informtion for summry purposes ws derived from hospitliztion records (if vilble) or reportble event records. Ambultory records were used only if they were the sole source of informtion documenting cse. For individuls with more thn one het injury dignosis in clendr yer, dignoses of het stroke were prioritized over other het injury dignoses. In previous het injury summries published in the MSMR, multiple medicl events of het injury for n individul were prioritized by clinicl setting nd type of het injury dignosis only if such events occurred on the sme dy. Also, once het injury event ws documented, the ffected individul ws removed from follow-up until six months fter the lst encounter for the previous injury. These methods limited the bility to detect recurrent het injuries Rte per 1, person-yers nd to ccurtely ssess the severity of het injury encounters mong service members. As expected, the revised methods resulted in modest increses in numbers of het-relted hospitliztions/notifible events (reltive to mbultory visits) nd het stroke cses (reltive to other het injury cses) in this updte s compred to those previously published. Results: In 29, there were 323 incident cses of het stroke nd 2,38 incident cses of other het injury mong ctive component members. Overll crude incidence rtes of het stroke nd other het injury were.22 nd 1.41 per 1, person-yers (p-yrs), respectively (Tble 1). The incidence rte (undjusted) of het stroke in 29 ws the sme s the rte in 26 nd lower thn in other prior yers of the surveillnce period (Figure 1). In 29 compred to recent prior yers, there were similr numbers of hospitliztions nd mbultory visits for, but fewer notifible medicl event reports of, het stroke (perhps reflecting the mid-yer revision of the clinicl definition of notifible het stroke cse) (Figure 1). The overll incidence rte (undjusted) of other het injury in 29 ws slightly higher thn in 28; in generl, however, the rte in 29 ws not remrkbly different from the rtes in recent prior yers (Figure 2). In 29, bsolute nd reltive (compred to their respective counterprts) rtes of het stroke were shrply higher mong those younger thn 2 yers old (.44 per 1 p-yrs), in combt-specific occuptions (.42 per 1 p-yrs), nd in the Mrine Corps (.4 per 1 p-yrs) nd Army (.38 per 1 p-yrs). Het stroke rtes were higher mong enlisted members (.23 per 1 p-yrs) nd mles (.24 per 1 p-yrs) thn officers nd femles, respectively. Tble 2. Het injuries by loction of dignosis/report, ctive component, U.S. Armed Forces, Medicl fcility loction No. % of totl Fort Brgg, NC 1, Fort Benning, GA 1, MCRD Prris Islnd/Beufort, SC 1, MCB Cmp Lejeune/Cherry Point, NC Fort Polk, LA Fort Jckson, SC Fort Cmpbell, KY Fort Hood, TX Fort Stewrt, GA Fort Sill, OK MCB Cmp Pendleton, CA MCRD Sn Diego, CA NH Okinw, Jpn MCB Quntico, VA MCB Twentynine Plms, CA NH Penscol, FL Fort Shfter, HI NH Portsmouth, VA All other loctions 4, Totl 12,416 1.

8 8 VOL. 17 / NO. 3 Of note, crude rtes of het stroke were very similr cross rce-ethnicity-defined subgroups (Tble 1). There were generlly similr reltionships of crude rtes of other het injuries cross militry nd demogrphic subgroups. In contrst to het stroke, however, the rte of other het injuries ws higher mong femles thn mles nd more thn 2.5-times higher mong enlisted members thn officers (Tble 1). The 323 individuls ffected by het stroke in 29 experienced totl of 369 seprte het stroke events. The 2,38 individuls with other het injury dignoses or reports hd totl of 2,1 events. The number of individuls with more thn one het stroke event in 29 (34) ws lower thn the verge during the previous 4 yers (25-28 verge number of individuls with more thn one het stroke event: 58), while the verge number of individuls with multiple events of other het injuries (52) ws higher thn the verge during the previous 4 yers (25-28 verge number of individuls with multiple other het injury events: 33) (dt not shown). During the five-yer surveillnce period, het-relted injuries were dignosed t more thn 2 militry medicl fcilities worldwide. However, six Army nd two Mrine Corps instlltions ccounted for pproximtely one-hlf of ll het injury events: Fort Brgg, NC (1,598), Fort Benning, GA (1,227), MCRD Prris Islnd/Beufort, SC (1,152), MCB Cmp Lejeune/Cherry Point, NC (531), Fort Polk, LA (453) Fort Jckson, SC (442), Fort Cmpbell, KY (397) nd Fort Hood, TX (359) (Tble 2). Nvy/Mrine Corps instlltions represented onehlf of the loctions with more thn 15 incident het injury reports/dignoses during the period (Tble 2). Editoril comment: This updte indictes tht, over the lst four yers, incidence rtes of het injuries (both het stroke nd other cliniclly significnt het-relted injuries) hve been firly stble mong ctive component members of the U.S. militry. However, there re limittions to the report tht should be considered when interpreting the results. For exmple, the report is bsed on records of medicl encounters t fixed (e.g., not deployed, t se) medicl fcilities. In turn, het injuries during trining exercises nd deployments tht re treted in field/deployed medicl fcilities re not scertined s cses for this report. In spite of surveillnce limittions, it is cler tht het injuries remin significnt thret to the helth of U.S. militry members nd the effectiveness of militry opertions. Of ll militry members, the youngest nd most inexperienced Mrines nd soldiers re t highest risk of het injuries including het stroke, exertionl hypontremi, nd exertionl rhbdomyolysis (see pges 9-16). Commnders, smll unit leders, trining cdre, nd supporting medicl personnel, prticulrly t recruit trining centers nd instlltions with lrge combt troop popultions, must ensure tht militry members whom they supervise nd support re informed regrding risks, preventive countermesures (e.g., wter consumption), erly signs nd symptoms, nd first responder ctions relted to het injuries. 1-3 Leders should be wre of the dngers of insufficient hydrtion on the one hnd nd excessive wter intke on the other; they must hve detiled knowledge of nd rigidly enforce countermesures ginst ll types of het injuries. Policies, guidnce, nd other informtion relted to het injury prevention nd tretment mong U.S. militry members re vilble on-line t: < pge.rmy.mil/het/#pm> nd < news/publictions/documents/mco%262.1e%2 W%2CH%21.pdf>. References: 1. Goldmn RF. ch 1: Introduction to het-relted problems in militry opertions, in Textbook of Militry Medicine: Medicl Aspects of Hrsh Environments (vol 1). Borden Institute, Offi ce of the Surgeon Generl, U.S. Army. Wshington, DC. 21:3-49. Accessed on 3 Mrch 21 t: Ch1-IntroductiontoHet-ReltedProblemsinMilitryOper.pdf. 2. Sonn LA. ch 9: Prcticl medicl spects of militry opertions in the het, in Textbook of Militry Medicine: Medicl Aspects of Hrsh Environments (vol 1). Borden Institute, Offi ce of the Surgeon Generl, U.S. Army. Wshington, DC. 21: Accessed on 3 Mrch 21 t: hrshenv1/ch9-prcticlmediclaspectsofmilitryopertionsinthe.pdf. 3. Technicl Bulletin Medicl 57/AFPAM (l) Het stress control nd het csulty mngement, prevention, trining nd control of het injury. Hedqurters, Deprtment of the Army nd Air Force. Wshington, DC. 7 Mrch Crter R 3rd, Cheuvront SN, Willims JO, et l. Epidemiology of hospitliztions nd deths from het illness in soldiers. Med Sci Sports Exerc. 25 Aug;37(8): Armed Forces Helth Surveillnce Center. Updte: Het injuries, ctive component, U.S. Armed Forces, 28. Medicl Surveillnce Monthly Report (MSMR). 29 Mr. 16(3): Armed Forces Helth Surveillnce Center. Tri-Service Reportble Events Guidelines nd Cse Defi ntions, June 29. Accessed 26 Mr 29 t: le=triservice_ CseDefDocs/June9TriServGuide.pdf.

9 MARCH 21 9 Updte: Exertionl Rhbdomyolysis mong U.S. Militry Members, 29 Rhbdomyolysis is the brekdown of strited muscle cells with relese into the bloodstrem of their potentilly toxic contents. In U.S. militry members, rhbdomyolysis is significnt thret during physicl exertion, prticulrly under het stress. Ech yer, the MSMR summrizes numbers, rtes, trends, risk fctors nd loctions of occurrences of exertionl het injuries, including exertionl rhbdomyolysis. Informtion regrding the definition, cuses nd prevention of exertionl rhbdomyolysis cn be found in previous issues of the MSMR. 1 Tble 1. Incident dignoses nd incidence rtes of exertionl rhbdomyolsis, ctive component, U.S. Armed Forces, 29 Hospitlized Ambultory Totl No. Rte No. Rte No. Rte Totl Service Army Nvy Air Force Mrine Corps Cost Gurd Sex Mle Femle Rce/ethnicity White, non-hispnic Blck, non-hispnic Other Age < Rnk Enlisted Offi cer Militry occuption Combt Helth cre Other Rte per 1, person-yers Methods: The surveillnce period ws 1 Jnury 25 to 31 December 29. The surveillnce popultion included ll individuls who served in n ctive component of the U.S. Armed Forces ny time during the surveillnce period. For surveillnce purposes, cse of exertionl rhbdomyolysis ws defined s hospitliztion or mbultory visit with dischrge dignosis in ny position of: rhbdomyolysis (ICD-9-CM: ) nd/or myoglobinuri (ICD-9- CM: 791.3); plus dignosis in ny position of volume depletion (dehydrtion) (ICD-9-CM: 276.5), effects of het (ICD- 9-CM: ), effects of thirst (deprivtion of wter), exhustion due to exposure, or exhustion due to excessive exertion (overexertion) (ICD-9-CM: ). Ech individul could be included s cse only once per clendr yer. To exclude cses of rhbdomyolysis tht were secondry to trumtic injuries, intoxictions, or dverse drug rections, medicl encounters with dignoses in ny position of ICD- 9- CM: injury, poisoning, toxic effects (except ICD- 9-CM: , , nd sprins nd strins of joints nd djcent muscles ) were excluded from considertion s exertionl rhbdomyolysis cse defining encounters. Figure 1. Corrected version (posted 2 My 211) Incident dignoses of presumed exertionl rhbdomyolysis, by type of medicl encounter nd clendr yer, ctive component, U.S. Armed Forces, Number of medicl encounters (brs) Ambultory visits Hospitliztions 94 Results: In 29, there were 315 incident episodes of rhbdomyolysis likely due to physicl exertion nd/or het Rtes (hospitliztions + mbultory) Yer Incidence rte per 1, person-yers (line)

10 1 VOL. 17 / NO. 3 Tble 2. Exertionl rhbdomyolysis, by instlltion (mong instlltions with t lest 2 cses during the period), ctive component, U.S. Armed Forces, Figure 2. Hospitliztion rtes of presumed exertionl rhbdomyolysis, by service nd clendr yer, ctive component, U.S. Armed Forces, Totl Loction of dignosis No. % Fort Brgg, NC MCRD Prris Islnd/Beufort, SC Cmp Pendleton, CA Lcklnd AFB, TX Fort Benning, GA Cmp Lejeune/Cherry Pt, NC MCRD Sn Diego, CA Fort Jckson, SC Fort Shfter,HI NMC Portsmouth, VA Fort Knox, KY Fort Cmpbell, KY Fort Belvoir, VA Other loctions Totl 1,25 1. Incident hospitliztions per 1, p-yrs Mrine Corps Nvy Army Air Force stress ( exertionl rhbdomyolysis ) (Tble 1). The crude incidence rte ws 21.8 per 1, person-yers (p-yrs). In 29, reltive to their respective counterprts, the highest incidence rtes of exertionl rhbdomyolysis were mong service members who were in the Mrine Corps (42.9 per 1, p-yrs) or Army (27.4 per 1, p-yrs), younger thn 2 yers old (49.5 per 1, p-yrs), Blck non-hispnic (31. per 1, p-yrs), enlisted (23.8 per 1, p-yrs), nd in combt-specific occuption (25. per 1, p-yrs) (Tble 1). There were more incident dignoses of exertionl rhbdomyolysis in 29 thn in ny previous yer of the period (Figure 1). From 28 to 29, the number of hospitlized cses declined slightly while the number of cses dignosed in outptient settings incresed; 29 ws the first yer since 25 in which there were more outptient thn inptient cses (Figure 1). During the five-yer period, the rte of incident dignoses of exertionl rhbdomyolysis nerly doubled (25: 11.8 per 1, p-yrs; 29: 21.8 per 1, p-yrs) (Figure 1). Approximtely three-fourths (73%) of ll service members hospitlized with exertionl rhbdomyolysis in 29 were in the Army (65) or Mrine Corps (41) (Tble 1). In 29, the rte of hospitlized cses continued to generlly increse mong soldiers but decresed to like rtes mong Mrines (Figure 2). During the period, the medicl tretment fcilities t ten instlltions ccounted for t lest 3 cses ech nd more thn one-hlf of ll cses; of these instlltions, five support recruit/bsic combt trining centers (Fort Benning, GA, nd Fort Jckson, SC; Lcklnd AFB, TX; MCRD Prris Yer Islnd, SC nd MCRD Sn Diego, CA) nd three support lrge combt troop popultions (Fort Brgg, NC; Cmp Lejeune, NC; Cmp Pendleton, CA) (Tble 2). The most cses overll (ccounting for nerly one-fourth of the totl) were reported from Fort Brgg, NC (157) nd Beufort, SC (which supports the Mrine Corps Recruit Depot Prris Islnd) (131) (Tble 2). Editoril comment: This report documents continuing increse in incident dignoses of presumbly exertionl rhbdomyolysis mong ctive component members of the U.S. militry. Most cses re dignosed t instlltions tht support bsic combt/ recruit trining centers or mjor Army nd Mrine Corps combt units. Individuls who suddenly increse overll levels of physicl ctivity nd/or increse stress on weight bering muscles prticulrly in high het nd humidity re t incresed risk of exertionl rhbdomyolysis. Recruits who re not physiclly fit when they begin trining hve reltively high risks of trining-relted (including exertionl het) injuries, in generl. Also, recruits from reltively cool nd dry climtes my not be cclimted to the high het nd humidity t trining cmps in mid-summer. Soldiers nd Mrines in combt units often conduct rigorous unit physicl trining, personl fitness trining, nd field trining exercises regrdless of wether conditions. It is not surprising, therefore, tht recruit cmps nd instlltions

11 MARCH with lrge combt units ccount for most exertionl rhbdomyolysis cses. The findings of this report should be interpreted with considertion of severl limittions. For exmple, becuse the dignostic code specific for rhbdomyolysis ws not dded to the Interntionl Clssifiction of Diseses, 9th revision, clinicl modifictions [ICD-9-CM] until 24, complete nd consistent record of recent experience is not vilble. The recency of implementtion of specific dignostic code mkes it difficult to determine if the stedy increse in dignoses of rhbdomyolysis from 25 through 29 reflects incresing wreness nd use of the indictor code in stndrdized reporting, n ctul increse in cse incidence, or both. Also, the dignosis of rhbdomyolysis does not indicte the cuse; hence, it is difficult to discern cses tht re exertionl nd/or het-relted from those with other precipitting cuses. The mesures tht re effective t preventing exertionl het injuries in generl re indicted for preventing exertionl rhbdomyolysis. Work-rest cycles should be dpted not only to mbient wether conditions but lso to the fitness levels of prticipnts in strenuous ctivities. Of prticulr note, the strenuous physicl ctivities of overweight nd/or previously sedentry new recruits especilly in hot, humid wether should increse grdully nd be closely monitored. Wter intke should comply with current guidelines (see pge 15) nd be closely supervised. Strenuous ctivities during reltively cool mornings following dys of high het stress should be closely monitored; in the pst, such situtions hve been ssocited with incresed risk of exertionl het injuries (including rhbdomyolysis). 2 Commnders nd supervisors t ll levels should be wre of nd lert for erly signs of exertionl het injuries including rhbdomyolysis nd should ggressively intervene when dngerous conditions, ctivities, or suspicious illnesses re detected. Finlly, medicl cre providers should consider exertionl rhbdomyolysis in the differentil dignosis when service members prticulrly recruits present with musculr pin, swelling, nd limited rnge of motion fter strenuous physicl ctivity, prticulrly in hot, humid wether. Brown colored urine from incresed concentrtions of myoglobin in urine is distinctive clinicl sign of rhbdomyolysis. References: 1. Armed Forces Helth Surveillnce Center. Updte: Exertionl rhbdomyolysis mong ctive component members. MSMR. 29 Mr;16(3): Krk JA, Burr PQ, Wenger CB, Gstldo E, Grdner JW. Exertionl het illness in Mrine Corps recruit trining. Avit Spce Environ Med Apr;67(4):354-6.

12 12 VOL. 17 / NO. 3 Updte: Exertionl Hypontremi, Active Component, U.S. Armed Forces, Hypontremi is defined s bnormlly low concentrtions of sodium in the blood (serum sodium concentrtion <135 meq/l); hypontremi cn hve serious nd sometimes ftl clinicl effects. 1,2 In otherwise helthy, physiclly ctive young dults (e.g., long distnce runners, militry recruits), hypontremi is often ssocited with excessive wter consumption during prolonged physicl exertion ( exertionl hypontremi ), prticulrly during het stress. 1-3 Acute hypontremi cretes n osmotic imblnce between fluids outside nd inside of cells. The osmotic grdient cuses wter to flow from outside to inside the cells of vitl orgns, including the lungs ( pulmonry edem ) nd brin ( cerebrl edem ). Swelling of the brin increses intrcrnil pressure which cn decrese cerebrl blood flow nd disrupt brin function (i.e., hypotonic encephlopthy, seizures, com). Without rpid nd definitive tretment to relieve incresing intrcrnil pressure, the brin stem cn hernite through the bse of the skull, compromisng life sustining functions controlled by the crdio-respirtory centers of the brin stem. 1-3 In the summer of 1997, multiple hospitliztions of soldiers for hypontremi secondry to excessive wter consumption during militry trining in hot wether were reported from Army trining centers one cse ws ftl nd severl others required intensive medicl cre. 4 In April 1998, the U.S. Army Reserch Institute of Environmentl Medicine (USARIEM), Ntick, Msschusetts, published new guidelines for fluid replcement during militry trining in het. The new guidelines were designed to protect service members not only from het injury but lso from hypontremi due to excessive wter consumption. The guidelines limited fluid intke regrdless of het ctegory or work level to no more thn 1½ qurts hourly nd 12 qurts dily. 5 There were fewer hospitliztions of soldiers for hypontremi due to excessive wter consumption during the yer fter compred to before implementtion of the new guidelines. 5 This report uses surveillnce cse definition for exertionl hypontremi (slightly modified from tht used previously) to estimte frequencies, rtes, trends, geogrphic loctions, nd demogrphic nd militry chrcteristics of exertionl Tble 1. Incident cses nd rtes of hypontremi/overhydrtion, ctive component, U.S. Armed Forces, Jnury 1999-December 29 Totl No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte No. Rte Totl Service Army Nvy Air Force Mrine Corps Cost Gurd Sex Mle Femle Rce/ethnicity White, non-hispnic Blck, non-hispnic Other Age < Militry occuption Combt Helth cre Other Rte per 1, person-yers

13 MARCH Figure 1. Incident dignoses of hypontremi (presumbly cused by excessive wter consumption during physicl exertion/het stress), ctive component, U.S. service members, Ambultory visits Hospitliztions 9. Number of medicl ecounters (brs) Rtes (hospitliztions + mbultory visits) Rte per 1, person-yers (line) Yer hypontremi cses mong U.S. militry members from 1999 through 29. Tble 2. Hypontremi/overhydrtion by loction of dignosis, ctive component, U.S. Armed Forces, Medicl fcility loction No. % of totl MCRD Prris Islnd/Beufort, SC Fort Benning, GA MCB Cmp Lejeune/Cherry Point, NC Sn Diego, CA Fort Brgg, NC NMC Portsmouth, VA MCB Cmp Pendleton, CA MCB Quntico, VA Lcklnd AFB, TX NNMC Bethesd, MD Fort Shfter, HI Fort Sm Houston, TX Fort Leonrd Wood, MO Wlter Reed AMC et l/wshington, DC Fort Knox, KY Fort Lewis, WA Fort Jckson, SC All other loctions Totl Methods: The surveillnce period ws 1 Jnury 1999 to 31 December 29. The surveillnce popultion included ll individuls who served in n ctive component of the U.S. Armed Forces ny time during the surveillnce period. For surveillnce purposes, possible cse of exertionl hypontremi ws defined s hospitliztion or mbultory visit with primry (first-listed) dignosis of hyposmollity nd/or hypontremi (ICD-9-CM: ) without other illness or injury-specific dignoses (ICD-9-CM: 1-999) in ny position; or both hyposmollity nd/or hypontremi (ICD-9-CM: 276.1) nd t lest one of the following within the first three dignostic positions (dx1-dx3): fluid overlod (ICD-9-CM: 276.6), ltertion of consciousness (ICD-9-CM: 78.), convulsions (ICD-9-CM: 78.39), ltered mentl sttus (ICD-9-CM: ), effects of het/light (ICD-9-CM: ) or rhbdomyolysis (ICD-9-CM: ). Medicl encounters were not considered cse-defining events if they included complicting dignoses such s lcohol/illicit drug buse; psychosis, depression, other mjor mentl disorders; endocrine (e.g., pituitry, drenl) disorders; kidney diseses; intestinl infectious diseses, cncers; mjor trumtic injuries; nd complictions of medicl cre. Ech individul could be included s cse only once per clendr yer.

14 14 VOL. 17 / NO. 3 Figure 2. Incident rtes of hypontremi (presumbly cused by excessive wter consumption during physicl exertion/het stress), by Service, ctive component, U.S. service members, Incident cses per 1, person-yers Mrine Corps Army Air Force Nvy Cost Gurd Yer Results: From 1999 through 29, there were 859 incident dignoses of exertionl hypontremi mong ctive component members. During the 11-yer period, the verge number of incident cses per yer ws 78 nd the rnge ws 43 (1999) to 133 (29) (Tble 1). In 29, there were 133 incident dignoses (incidence rte: 9.2 per 1, person-yers [p-yrs]) of exertionl hypontremi mong ctive component members. The number nd rte in 29 were higher thn in ny other yer of the period (Tble 1, Figure 1). In 29, the incidence rte ws highest in the Mrine Corps (24.7 per 1, p-yrs), lowest in the Nvy nd Cost Gurd (5.2 nd 4.7 per 1, p-yrs, respectively), nd intermedite in the Army nd Air Force (8. nd 6.1 per 1, p-yrs, respectively) (Tble 1, Figure 2). In the Mrine Corps nd Army, the numbers nd rtes of hypontremi cses were higher in 29 thn ny other yer of the period. During the pst 5 yers, rtes of exertionl hypontremi incresed more thn 2.5-fold in the Mrine Corps but were reltively stble in the Army (Figure 2). In 29, 85% of exertionl hypontremi cses ffected mles, but the rte ws slightly higher mong femles (femleto-mle incidence rte rtio, 29: 1.7) (Tble 1). In every yer from 22 through 29, the incidence rte hs been higher mong white non-hispnic thn blck non-hispnic or other rcil/ethnic subgroup members (Tble 1). In every yer of the period (including 29), the highest rtes ffected the youngest (29, incidence rte, <2 yers old: 21.2 per 1, p-yrs) nd the oldest (29, incidence rte, >39 yers old: 1.9 per 1, p-yrs) service members. Figure 3. Hypontremi cses reported by Mrine Corps Recruit Depot Prris Islnd/Beufort, South Crolin, ctive component, U.S. Armed Forces, Number of cses Yer

15 MARCH Also, in 29, service members in combt occuptions hd slightly higher rtes of exertionl hypontremi thn those in non-combt-specific occuptions (Tble 1). During the 11-yer period, exertionl hypontremi cses were dignosed t more thn 15 medicl fcilities; however, five loctions reported more thn 25 cses ech nd ccounted for nerly one-third (31%) of ll cses. The loctions with the most cses overll were MCRD Prris Islnd/Beufort, SC (113), Fort Benning, GA (63), MCB Cmp Lejeune/ Cherry Point, NC (33), Sn Diego, CA (27) nd Fort Brgg, NC (26) (Tble 2). Of note, MCRD Prris Islnd/ Beufort, SC reported 33 cses in 29 25% of ll cses in 29 nd more thn twice s mny thn t Prris Islnd or ny other loction in ny other yer (Figure 3). Editoril comment: This report documents shrp increse in the incidence of exertionl hypontremi mong ctive component U.S. militry members in 29. The incresed incidence in the U.S. militry overll reflects shrply incresing rtes in the Mrine Corps since 25. Of note, two-thirds of ll cses in the Mrine Corps in 29 were reported from the Mrine Corps Recruit Depot t Prris Islnd or its supporting Nvy hospitl t Beufort, SC. The results suggest tht serious nd potentilly life thretening trining-relted condition tht is preventble is incresing in incidence mong Mrine recruits t Prris Islnd. If so, policies nd prctices relted to wter consumption prticulrly limits per hour nd dy during physiclly rigorous trining in hot, humid wether should be reviewed nd enforced t Prris Islnd nd ll other recruit trining sites. The results of this report should be interpreted with considertion of severl limittions. For exmple, there is not dignostic code specific for exertionl hypontremi. Thus, for surveillnce purposes, cses re scertined by identifying medicl encounter records tht include dignoses of hyposmollity nd/or hypontremi without concurrent dignoses indictive of medicl conditions tht increse risk of hypontremi (e.g., metbolic, renl, psychitric, itrogenic). The results should be considered estimtes of the ctul incidence of symptomtic exertionl hypontremi from excessive wter consumption mong U.S. militry members. The ccurcy of estimted numbers nd trends of cses depends on the completeness nd ccurcy of dignoses tht re reported on stndrdized records of relevnt medicl encounters. In turn, n increse in reporting of dignoses indictive of exertionl hypontremi my not indicte n ctul increse in the incidence of such cses. In the pst, concerns regrding hypontremi from excessive wter consumption were focused t trining prticulrly bsic combt trining instlltions. Not surprisingly, in this nlysis, the highest rtes were mong the youngest hence, the most junior service members; nd the most cses were dignosed t medicl fcilities tht support lrge trining centers nd combt units: Prris Islnd, SC; Fort Benning, GA; Fort Brgg, NC; Sn Diego, CA; Cmp Lejeune/Cherry Point, NC. In mny circumstnces (e.g., recruit trining, Rnger School), militry trinees rigorously dhere to their trining schedules regrdless of the wether conditions. In hot, humid wether, commnders, supervisors, instructors, nd medicl support stffs must be wre of nd enforce guidelines for work-rest cycles nd wter consumption. With regrd to hypontremi, service members nd their supervisors must be knowledgeble of the dngers of excessive wter consumption nd the prescribed limits for wter intke (Figure 4) during prolonged physicl ctivity in hot, humid wether during militry ctivities, personl Figure 4. Fluid replcement guidelines for wrm wether trining (pplies to verge cclimted soldier wering BDU, hot wether) Het WBGT Ctegory Index, F The work:rest times nd fluid replcement volumes will sustin performnce nd hydrtion for t lest 4 hours of work in the specifi ed het ctegory. Individul wter needs will vry ± ¼ qt/hour. NL= no limit to work time per hour. Rest mens miniml physicl ctivity (sitting or stnding), ccomplished in shde if possible. CAUTION: Hourly fluid intke should not exceed 1½ qurts. Dily fluid intke should not exceed 12 qurts. Wering body rmor dd 5 F to WBGT Index Wering MOPP overgrment dd 1 F to WBGT Index. Esy Work Moderte Work Hrd Work Wlking Hrd Surfce t 2.5 mph, < 3 Ib Lod Wepon Mintennce Mnul of Arms Mrksmnship Trining Drill nd Ceremony Esy Work Moderte Work Hrd Work Work / Rest Wter Intke, Qt/hr Wlking Hrd Surfce t 3.5 mph < 4 Ib Lod Wlking Loose Snd t 2.5 mph no Lod Clisthenics Ptrolling Individul Movement Techniques. i.e. low crwl, high crwl Defensive Position Construction Field Assults Work / Rest Wter Intke, Qt/hr Work / Rest NL ½ NL ¾ 4/2 min 2 (Green) NL ½ 5/1 min ¾ 3/3 min 3 (Yellow) NL ¾ 4/2 min ¾ 3/3 min 4 (Red) NL ¾ 3/3 min ¾ 2/4 min 5 (Blck) > 9 5/1 min 1 2/4 min 1 1/5 min USARIEM 4 December 98 Wter Intke, Qt/hr ¾ Wlking Hrd Surfce t 3.5 mph, 4 Ib Lod Wlking Loose Snd t 2.5 mph with Lod

16 16 VOL. 17 / NO. 3 fitness trining, nd recretionl ctivities. Service members prticulrly trinees nd their supervisors must be vigilnt for erly signs of het-relted illnesses nd immeditely nd ppropritely intervene in such cses. References: 1. Montin, S.J. Strtegies to prevent hypontremi during prolonged exercise. Curr. Sports Med. Rep. 7:S28-35, Chorley J, Cinc J, Divine J. Risk fctors for exercise-ssocited hypontremi in non-elite mrthon runners. Clin J Sport Med. 27 Nov;17(6): O'Connor, R.E. Exercise-induced hypontremi: cuses, risks, prevention, nd mngement. Cleve. Clin. J. Med. 73:S13-S18, Army Medicl Surveillnce Activity. Cse reports: Hypontremi ssocited with het stress nd excessive wter consumption: Fort Benning, GA; Fort Leonrd Wood, MO; Fort Jckson, SC, June August Medicl Surveillnce Monthly Report (MSMR). Sep 1997; 3(6):2,3,8. 5. Army Medicl Surveillnce Activity. Surveillnce trends: Hypontremi ssocited with het stress nd excessive wter consumption: the impct of eduction nd new Army fl uid replcement policy. Medicl Surveillnce Monthly Report (MSMR). Mr 1999; 3(6):2,3,8,9.

17 MARCH Acute respirtory disese (ARD) nd streptococcl phryngitis rtes (SASI ), bsic combt trining centers, U.S. Army, by week, Mrch 28-Mrch 21 ARD per 1/week 2 1 Fort Benning, GA ARD SASI Epidemic threshold SASI Mr-8 Jun-8 Sep-8 Dec-8 Mr-9 Jun-9 Sep-9 Dec-9 Mr-1 ARD per 1/week 2 1 Fort Jckson, SC Epidemic threshold SASI ARD per 1/week ARD per 1/week ARD per 1/week Mr-8 Jun-8 Sep-8 Dec-8 Mr-9 Jun-9 Sep-9 Dec-9 Mr-1 4 Fort Knox, KY 2 Epidemic threshold 3 1 Mr-8 Jun-8 Sep-8 Dec-8 Mr-9 Jun-9 Sep-9 Dec-9 Mr-1 4 Fort Leonrd Wood, MO 2 Epidemic threshold 3 1 Mr-8 Jun-8 Sep-8 Dec-8 Mr-9 Jun-9 Sep-9 Dec-9 Mr Fort Sill, OK Mr-8 Jun-8 Sep-8 Dec-8 Mr-9 Jun-9 Sep-9 Dec-9 Mr-1 Streptococcl-ARD surveillnce index (SASI) = ARD rte x % positive culture for group A streptococcus ARD rte = cses per 1 trinees per week ARD rte > 1.5 or SASI > 25. for 2 consecutive weeks re surveillnce indictors of epidemics Epidemic threshold SASI SASI SASI

18 18 VOL. 17 / NO. 3 Updte: Deployment Helth Assessments, U.S. Armed Forces, Februry 21 Since Jnury 23, peks nd troughs in the numbers of pre- nd post-deployment helth ssessment forms trnsmitted to the Armed Forces Helth Surveillnce Center generlly corresponded to times of deprture nd return of lrge numbers of deployers. Since April 26, numbers of post-deployment helth ressessments (PDHRA) trnsmitted per month hve rnged from 17, to 43, (Tble 1, Figure 1). During the pst 12 months, the proportions of returned deployers who rted their helth s fir or poor were 8-11% on postdeployment helth ssessment questionnires nd 11-14% on PDHRA questionnires (Figure 2). In generl, on post-deployment ssessments nd ressessments, deployers in the Army nd in reserve components were more likely thn their respective counterprts to report helth nd exposure-relted concerns (Tble 2, Figure 2). Both ctive nd reserve component members were more likely to report exposure concerns three to six months fter compred to the time of return from deployment (Figure 3). At the time of return from deployment, soldiers serving in the ctive component were the most likely of ll deployers to receive mentl helth referrls; however, three to six months fter returning, ctive component soldiers were less likely thn Army nd Mrine Corps Reservists to receive mentl helth referrls (Tble 2). Finlly, during the pst three yers, reserve component members hve been more likely thn ctive to report exposure concerns on postdeployment ssessments nd ressessments (Figure 3). Tble 1. Deployment-relted helth ssessment forms, by month, U.S. Armed Forces, Mrch 29-Februry 21 Pre-deployment ssessment DD2795 Post-deployment ssessment DD2796 Post-deployment ressessment DD29 No. % No. % No. % Totl 457, , , Mrch 4, , , April 43, , , My 36, , , June 44, , , July 39, , , August 39, , , September 3, , , October 36, , , November 32, , , December 3, , , Jnury 54, , , Februry 29, , , Figure 2. Proportion of deployment helth ssessment forms with self-ssessed helth sttus s fir or poor, U.S. Armed Forces, Mrch 29-Februry 21 2 Percent Mrch April My Post-deployment ressessment (DD 29) Post-deployment ssessment (DD 2796) Pre-deployment ssessment (DD 2795) June July August September October November December Jnury Februry Figure 1. Totl deployment helth ssessment nd ressessment forms, by month, U.S. Armed Forces, Jnury 23-Februry 21 Number of completed forms 12, 11, 1, 9, 8, 7, 6, 5, 4, 3, 2, 1, Post-deployment ressessment (DD 29) Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury Post-deployment ssessment (DD 2796) Pre-deployment ssessment (DD 2795)

19 MARCH Tble 2. Percentge of service members who endorsed selected questions/received referrls on helth ssessment forms, U.S. Armed Forces, Mrch 29 - Februry 21 Active component 153,961 Includes behviorl helth, combt stress nd substnce buse referrls. b Record of inptient or outptient visit within 6 months fter referrl. Army Nvy Air Force Mrine Corps All service members 127, ,372 19,829 1,21 13,792 59,391 52,312 51,453 32,468 21,519 35,74 265, ,226 % % % % % % % % % % % % % % % Generl helth "fir" or "poor" Helth concerns, not wound or injury Helth worse now thn before deployed n n n n n Exposure concerns n n n n n PTSD symptoms (2 or more) n n n n n Depression symptoms (ny) n n n n n Referrl indicted by provider (ny) Mentl helth referrl indicted* Medicl visit following referrl Army Nvy Air Force Mrine Corps All service members 82,993 69,538 Predeplodeploy Post- DD2795 DD2796 Predeplodeplodeplodeplodeplodeplodeplodeploy Post- Pre- Post- Pre- Post- Pre- Post- Ressess Ressess Ressess Ressess DD29 DD29 DD29 DD29 DD2795 DD2796 DD2795 DD2796 DD2795 DD2796 DD2795 DD2796 Predeplodeploy Post- DD2795 DD2796 Predeplodeplodeplodeplodeplodeplodeplodeploy Post- Pre- Post- Pre- Post- Pre- Post- Ressess Ressess Ressess Ressess DD29 DD29 DD29 DD29 DD2795 DD2796 DD2795 DD2796 DD2795 DD2796 DD2795 DD ,64 5,731 2,793 Reserve component % % % % % % % % % % % % % % % Generl helth "fir" or "poor" Helth concerns, not wound or injury Helth worse now thn before deployed n n n n n Exposure concerns n n n n n PTSD symptoms (2 or more) n n n n n Depression symptoms (ny) n n n n n Referrl indicted by provider (ny) Mentl helth referrl indicted* Medicl visit following referrl ,897 16,245 15,34 16,393 3,881 4,57 6,318 18,85 91,422 Ressess DD29 218,691 Ressess DD29 81,672 Figure 3. Proportion of service members who endorsed exposure concerns on post-deployment helth ssessments, U.S. Armed Forces, Jnury 24-Februry Reserve, post-deployment ressessment (DD29) Reserve, post-deployment ssessment (DD2796) Active, post-deployment ressessment (DD29) Active, post-deployment ssessment (DD2796) Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury April July October Jnury Percent

20 2 VOL. 17 / NO. 3 Sentinel reportble events mong service members nd beneficiries t U.S. Army medicl fcilities, cumultive numbers for clendr yers through 28 Februry 29 nd 28 Februry 21 NORTHERN Reporting loctions Number of Food-borne Vccine preventble reports ll Cmpylobcter c events b Slmonell Shigell Heptitis A Heptitis B Vricell Aberdeen Proving Ground, MD Fort Belvoir, VA Fort Brgg, NC Fort Dix, NJ Fort Drum, NY Fort Eustis, VA Fort George G Mede, MD Fort Knox, TN Fort Lee, VA Fort Monmouth, NJ Wlter Reed AMC, DC West Point Militry Reservtion, NY SOUTHERN Fort Benning, GA Fort Cmpbell, KY Fort Gordon, GA Fort Hood, TX Fort Jckson, SC Fort Polk, LA Fort Rucker, AL Fort Sm Houston, TX Fort Sill, OK Fort Stewrt, GA WESTERN Fort Bliss, TX Fort Crson, CO Fort Huchuc, AZ Fort Levenworth, KS Fort Leonrd Wood, MO Fort Lewis, WA Fort Riley, KS Fort Winwright, AK NTC nd Fort Irwin, CA PACIFIC Hwii Jpn Kore EUROPEAN Heidelberg Lndstuhl Bvri OTHER LOCATIONS Other Totl 2,365 2, Army Events reported by Mr 8, 29 nd 21 b Sixty-seven medicl events/conditions specifi ed by Tri-Service Reportble Events Guidelines nd Cse Defi nitions, June 29. c Service member cses only. Note: Completeness nd timeliness of reporting vry by fcility.

21 MARCH Sentinel reportble events mong service members nd beneficiries t U.S. Army medicl fcilities, cumultive numbers for clendr yers through 28 Februry 29 nd 28 Februry 21 NORTHERN Reporting loction Arthropod-borne Sexully trnsmitted Environmentl Trvel ssocited Lyme Mlri Chlmydi Gonorrhe Syphilis Cold disese c Het c Q Fever Tuberculosis Aberdeen Proving Ground, MD Fort Belvoir, VA Fort Brgg, NC Fort Dix, NJ Fort Drum, NY Fort Eustis, VA Fort George G Mede, MD Fort Knox, TN Fort Lee, VA Fort Monmouth, NJ Wlter Reed AMC, DC West Point Militry Reservtion, NY SOUTHERN Fort Benning, GA Fort Cmpbell, KY Fort Gordon, GA Fort Hood, TX Fort Jckson, SC Fort Polk, LA Fort Rucker, AL Fort Sm Houston, TX Fort Sill, OK Fort Stewrt, GA WESTERN Fort Bliss, TX Fort Crson, CO Fort Huchuc, AZ Fort Levenworth, KS Fort Leonrd Wood, MO Fort Lewis, WA Fort Riley, KS Fort Winwright, AK NTC nd Fort Irwin, CA PACIFIC Hwii Jpn Kore EUROPEAN Heidelberg Lndstuhl Bvri OTHER LOCATIONS Other Totl ,995 1, Army

22 22 VOL. 17 / NO. 3 Sentinel reportble events mong service members nd beneficiries t U.S. Nvy medicl fcilities, cumultive numbers for clendr yers through 28 Februry 29 nd 28 Februry 21 Reporting loctions NATIONAL CAPITOL AREA Number of Food-borne Vccine preventble reports ll Cmpylobcter events b Slmonell Shigell Heptitis A Heptitis B Vricell c NNMC Bethesd, MD NHC Annpolis, MD NHC Ptuxent River, MD NHC Quntico, VA NAVY MEDICINE EAST NH Beufort, SC NH Cmp Lejeune, NC NH Chrleston, SC NH Cherry Point, NC NH Corpus Christi, TX NHC Gret Lkes, IL NH Guntnmo By, Cub NH Jcksonville, FL NH Nples, Itly NHC New Englnd, RI NH Penscol, FL NMC Portsmouth, VA NH Rot, Spin NH Sigonell, Itly NAVY MEDICINE WEST NH Bremerton, WA NH Cmp Pendleton, CA NH Gum-Agn, Gum NHC Hwii, HI NH Lemoore, CA NH Ok Hrbor, WA NH Okinw, Jpn NMC Sn Diego, CA NH Twentynine Plms, CA NH Yokosuk, Jpn NAVAL SHIPS COMNAVAIRLANT/CINCLANTFLEET COMNAVSURFPAC/CINCPACFLEET OTHER LOCATIONS Other Totl 1,578 1, Nvy Events reported by Mr 8, 21 b Sixty-seven medicl events/conditions specifi ed by Tri-Service Reportble Events Guidelines nd Cse Defi nitions, June 29. c Service member cses only. Note: Completeness nd timeliness of reporting vry by fcility.

23 MARCH Sentinel reportble events mong service members nd beneficiries t U.S. Nvy medicl fcilities, cumultive numbers for clendr yers through 28 Februry 29 nd 28 Februry 21 Reporting loction Arthropod-borne Sexully trnsmitted Environmentl Trvel ssocited Lyme Mlri Chlmydi Gonorrhe Syphilis Cold disese c Het c Q Fever Tuberculosis NATIONAL CAPITOL AREA NNMC Bethesd, MD NHC Annpolis, MD NHC Ptuxent River, MD NHC Quntico, VA NAVY MEDICINE EAST NH Beufort, SC NH Cmp Lejeune, NC NH Chrleston, SC NH Cherry Point, NC NH Corpus Christi, TX NHC Gret Lkes, IL NH Guntnmo By, Cub NH Jcksonville, FL NH Nples, Itly NHC New Englnd, RI NH Penscol, FL NMC Portsmouth, VA NH Rot, Spin NH Sigonell, Itly NAVY MEDICINE WEST NH Bremerton, WA NH Cmp Pendleton, CA NH Gum-Agn, Gum NHC Hwii, HI NH Lemoore, CA NH Ok Hrbor, WA NH Okinw, Jpn NMC Sn Diego, CA NH Twentynine Plms, CA NH Yokosuk, Jpn NAVAL SHIPS COMNAVAIRLANT/CINCLANTFLEET COMNAVSURFPAC/CINCPACFLEET OTHER LOCATIONS Other Totl ,354 1, Nvy

24 24 VOL. 17 / NO. 3 Sentinel reportble events mong service members nd beneficiries t U.S. Air Force medicl fcilities, cumultive numbers for clendr yers through 28 Februry 29 nd 28 Februry 21 Reporting loctions Air Force Number of Food-borne Vccine preventble reports ll Cmpylobcter c events b Slmonell Shigell Heptitis A Heptitis B Vricell Air Combt Cmd Air Eduction & Trining Cmd Air Force Dist. of Wshington Air Force Mteriel Cmd Air Force Specil Ops Cmd Air Force Spce Cmd Air Mobility Cmd Pcifi c Air Forces U.S. Air Forces in Europe U.S. Air Force Acdemy Other Totl 1, Events reported by Mr 8, 21 b Sixty-seven medicl events/conditions specifi ed by Tri-Service Reportble Events Guidelines nd Cse Defi nitions, June 29. c Service member cses only. Note: Completeness nd timeliness of reporting vry by fcility. Arthropod-borne Sexully trnsmitted Environmentl Trvel ssocited Reporting loction Lyme disese Mlri Chlmydi Gonorrhe Syphilis Cold c Het c Q Fever Tuberculosis Air Combt Cmd Air Eduction & Trining Cmd Air Force Dist. of Wshington Air Force Mteriel Cmd Air Force Specil Ops Cmd Air Force Spce Cmd Air Mobility Cmd Pcifi c Air Forces U.S. Air Forces in Europe U.S. Air Force Acdemy Other Totl