MEDICAL SURVEILLANCE MONTHLY REPORT

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1 NOVEMBER 213 Volume 2 Number 11 msmr MEDICAL SURVEILLANCE MONTHLY REPORT PAGE 2 Syncope mong U.S. Air Force Bsic Militry Trinees, August 212-July 213 Brynt Webber, MD, MPH; Thoms Cropper, DVM, MPVM, DACVPM; Susn Federinko, MD, MPH PAGE 5 Syncope, ctive nd reserve components, U.S. Armed Forces, PAGE 1 PAGE 15 Updte: motor vehicle-relted deths, ctive nd reserve components, U.S. Armed Forces, Surveillnce snpshot: bcteril meningitis mong beneficiries of the Militry Helth System, PAGE 16 Surveillnce snpshot: ge nd gender distribution of service members, ctive component, U.S. Armed Forces, compred to the U.S. popultion, 211 SUMMARY TABLES AND FIGURES PAGE 17 Deployment-relted conditions of specil surveillnce interest A publiction of the Armed Forces Helth Surveillnce Center

2 Syncope Among U.S. Air Force Bsic Militry Trinees, August 212-July 213 Brynt J. Webber, MD, MPH (Cpt, USAF); Thoms L. Cropper, DVM, MPVM, DACVPM (Col, USAF, Ret); Susn P. Federinko, MD, MPH (Lt Col, USAF) Syncope is common event with mny possible etiologies, rnging from benign to severe. Syncopl episodes of ny origin, however, my result in trumtic injury due to posturl collpse. Bsed on the prevlence of internl nd externl stressors during trining, bsic militry trinees my be t incresed risk for syncope. Between 1 August 212 nd 31 July 213, there were 112 unique individuls who experienced syncopl or pre-syncopl events mong bsic militry trinees t Joint Bse Sn Antonio-Lcklnd, Texs, the only bsic trining site in the U.S. Air Force. The overll rte ws 19.6 cses per 1, person-yers (18.4 nd 36.1 per 1, person-yers in mles nd femles, respectively). Bsed upon the findings of electronic chrt review of the 112 cses, mjority of events occurred either during or immeditely fter exercise (n=38) or during blood drw, immuniztion, or lcertion repir (n=22). The most common etiologies were judged to be neurocrdiogenic (n=54) nd orthosttic hypotension (n=4), nd two cses were ttributed to crdiovsculr disese. These findings support current preventive mesures, including nemi screening during medicl in-processing, n emphsis on hydrtion throughout trining, nd pdded floor in the trinee vccintion by. syncope is trnsient loss of consciousness due to impired globl cerebrl perfusion. This hypoperfusion cn be trced to number of fctors, brodly ctegorized into three etiologic clsses: reflexmedited; orthosttic; nd crdiovsculr. 1 The first ctegory which represents the lrgest frction of cses mong individuls of ll ges cn be further subdivided into neurocrdiogenic syncope, situtionl syncope (e.g., during urintion), nd crotid sinus hypersensitivity. 2 Nonetheless, in order to rule out crdiovsculr disese s the underlying cuse, the evlutions of ptients who hve experienced syncope often include electrocrdiogrms, echocrdiogrms, nd 24-hour Holter monitoring 1,3 costly dignostics in terms of dollrs spent nd, for militry trinees, trining time interrupted. A pre-syncopl stte, chrcterized by lighthededness, diphoresis, nuse, nd blurred vision without loss of consciousness, precedes some, but not ll episodes of syncope. During pre-syncope, the individul or nerby witnesses my be ble to prevent injury by prepring for posturl collpse. Even in the presence of witnesses, distinguishing between syncope nd presyncope my be difficult; moreover, given their similr etiologies, the two conditions often prompt the sme kind of dignostic evlution. 3 Over third of individuls will experience syncopl event t some point in their lives, with pek incidence of first cses occurring between the ges of 1 nd 35 yers. 4 Between 1998 nd 212, the crude incidence rte of syncope mong ctive component members of the U.S. Armed Forces ws 7.2 per 1, person-yers (p-yrs). Rtes were higher mong femles nd highest in those ged <2 yers. Among mles nd femles in this ge cohort, respective rtes were pproximtely 13 nd 4 per 1, p-yrs. Immuniztions were found to be mjor trigger of events mong young, newly enlisted personnel, nd incidence of postvccintion syncope ws correlted to the number of immuniztions delivered. 5 Documented civilin rtes re lower. The Frminghm Offspring study found rtes of 2.6 nd 4.7 per 1, p-yrs for mles nd femles, respectively, between the ges of 2 nd 29 yers. 6 In younger individuls, prominent syncopl triggers re wrm environments (31% of events), prolonged stnding (27%), pin (25%), illness (18%), lcohol (13%), emotion (11%), nd venipuncture/ seeing blood (1%). 7 This report summrizes counts, rtes, etiologies, nd surrounding circumstnces for syncopl nd pre-syncopl events mong U.S. Air Force bsic militry trinees over one-yer surveillnce period. METHODS Cses of syncope nd pre-syncope were scertined from the Joint Bse Sn Antonio (JBSA)-Lcklnd disese nd non-bttle injury dtbse, which synthesizes dignoses mde in the electronic helth record during ll trinee medicl encounters with demogrphic informtion from the bsic militry trining (BMT) personnel file. The dtbse ws queried for Interntionl Clssifiction of Diseses, Ninth Revision, Clinicl Modifiction (ICD-9-CM) dignostic code 78.2 ( syncope nd collpse ) to identify cses. A trinee could be cse only once during the surveillnce period of 1 August 212 through 31 July 213. For ll cses identified by this query, retrospective electronic chrt reviews were performed to determine the circumstnces surrounding the event, the week of trining (WOT) in which it occurred, comorbid conditions dignosed nd lbortory vlues found during the workup (specificlly hemoglobin, glucose, nd electrolyte levels), whether or not n injury ws sustined, nd whether or not the event prompted militry seprtion (i.e., entry level seprtion or medicl evlution bord). In ccordnce with stndrd reference vlues, nemi ws defined s hemoglobin concentrtion of <13.5 g/dl in Pge 2 MSMR Vol. 2 No. 11 November 213

3 mles or <12. g/dl in femles, hypoglycemi s rndom glucose concentrtion of <7 mg/dl t the time of initil evlution, hypontremi s <135 meq/l, nd hypoklemi s <3.5 meq/l. 8 For the ske of more detiled nlysis, nemi ws further strtified ccording to hemoglobin concentrtions, with different criteri mong mles nd femles, s severe (<11.5 g/dl nd <1. g/dl, respectively), moderte ( g/dl nd g/dl, respectively), nd borderline ( g/dl nd g/dl, respectively). Using denomintor dt provided by the 737th Trining Support Squdron, period prevlence rtes were clculted, where period ws defined by the 8.5-week BMT session. It ws ssumed tht ll trinees completed exctly 8.5 weeks of trining (i.e., no ttrition nd no prolonged trining). FIGURE 1. Syncopl nd pre-syncopl events by circumstnces nd gender, U.S. Air Force Bsic Militry Trinees, August 212-July 213 No.r of trinees Exercise/post-exercise Blood drw, immuniztion, etc. Stnding in formtion or mel line Mle Femle Sitting in clss or dorm One of the syncopl events occurred during lcertion repir In full chemicl protective clothing During urintion During vomiting Unknown RESULTS Among the 34,791 bsic militry trinees t JBSA-Lcklnd between 1 August 212 nd 31 July 213, there were 112 cses of syncope or pre-syncope, for period prevlence of 3.2 per 1, trinees (3. per 1, mle trinees nd 5.9 per 1, femle trinees). Under the ssumptions outlined bove, the overll incidence rte ws 19.6 per 1, p-yrs, nd the rtes for mles nd femles were 18.4 nd 36.1 per 1, p-yrs, respectively. Thirty-one cses (28%) were specificlly clssified by the helth cre provider s pre-syncope; the remining 81 cses were either clssified s syncope or were not further distinguished in the ptients medicl records. The mjority of events occurred either during or immeditely fter exercise (n=38) or during blood drw, immuniztion, or lcertion repir (n=22). Seventeen events (15%) occurred while the trinee ws stnding in formtion or in mel line (Figure 1). Bsed upon either the etiology ssigned by the provider or the investigtors best clinicl judgment during chrt review, the most frequent etiologies were determined to be neurocrdiogenic (n=54) nd orthosttic hypotension (n=4); two cses were ttributed to crdiovsculr disese (Figure 2). Syncopl events occurred throughout the 8.5 weeks of trining (Figure 3). Erly in trining ( WOT nd 1 WOT), the mjority of events were due to either blood drw/ immuniztions or exercise. The secondry pek during the sixth week of trining ( BEAST week ) ws likely ssocited with the use of Mission Oriented Protective Posture (MOPP) ger. Two cses during WOT 7 were ttributed to blood dontion. In terms of contributing fctors, 26 trinees were dignosed with comorbid conditions during their syncope evlutions. These conditions included clinicl psychitric dignoses (n=9), unexplined leukocytosis (n=5), upper respirtory infections (n=5), cute gstroenteritis (n=2), crdiovsculr disese (n=2), pneumoni (n=1), urinry trct infection (n=1), nd hypothyroidism (n=1). Of those with crdiovsculr disese, one hd significnt coronry hert disese nd the other hd long QT syndrome with nomlous venous return. Twenty-three trinees were nemic, representing 38 percent of those tested (52 trinees with syncope did not hve hemoglobin mesurement). Of those with moderte (n=11) or severe (n=2) nemi, six hd syncopl events during or immeditely fter exercise nd three while in formtion. Among trinees who hd metbolic pnel, three (7%) were hypoglycemic, four (9%) were hypoklemic, two (4%) were hypontremic, nd one (2%) ws both hypoklemic nd hypontremic. Four trinees (3.6%) sustined lcertions during syncopl collpse, requiring repir with sutures. Fourteen trinees begn the militry seprtion process shortly fter their syncopl events. Of these, seven (5%) were FIGURE 2. Syncopl nd pre-syncopl events by etiology nd gender, U.S. Air Force Bsic Militry Trinees, August 212-July 213 No. of trinees Neurocrdiogenic Orthosttic Situtionl Crdiovsculr Unknown The fi ve situtionl cuses of syncope were urintion (n=4) nd vomiting (n=1). Mle Femle November 213 Vol. 2 No. 11 MSMR Pge 3

4 FIGURE 3. Syncopl nd pre-syncopl events by circumstnce nd week of trining, U.S. Air Force Bsic Militry Trinees, August 212-July 213 No. of trinees given clinicl psychitric dignosis during their evlutions. EDITORIAL COMMENT Week of trining By virtue of their diverse etiologies nd potentil for cusing secondry injuries, syncope nd pre-syncope comprise complex nd serious chllenge to preventive medicine in the militry trinee environment. In one-yer time spn t JBSA- Lcklnd, 112 U.S. Air Force bsic militry trinees experienced syncopl or pre-syncopl events. The sex-specific rtes of 18.4 (mles) nd 36.1 (femles) per 1, person-yers pproximte the corresponding rtes of 13 nd 4 mong ctive component U.S. militry members from 1998 through 212, 5 but vstly exceed the rtes of 2.6 nd 4.7 in similrly ged civilin popultion. 6 The difference likely reflects the greter density of syncopl risk fctors encountered during U.S. Air Force bsic militry trining, mong which re wrm environments, dehydrtion, prolonged stnding, stress, illness, immuniztions, nd venipuncture. 5,7 In ddition to these known risk Unknown Other In full chemicl protective clothing During urintion During vomiting Sitting in clss or dorm Stnding in formtion or mel line Exercise/post-exercise Blood drw, immuniztion, etc. fctors, this nlysis identified nemi both upon entrnce to bsic militry trining nd s result of blood dontion s potentil contributing fctor. As result of this nlysis, the following three recommendtions were mde to the trining commnd. First, continue the hemoglobin nd hemtocrit screening during bsic militry trining medicl inprocessing, which hs been in plce t JBSA- Lcklnd since lte June 213, in order to identify nd correct nemi to minimize ny ssocited morbidity, such s syncope secondry to orthosttic hypotension. Second, continue to stress the importnce of hydrtion to trining squdron commnders nd militry trining instructors. Additionlly, trining cdre should encourge ll trinees to self-identify if they feel ill nd to fll out of physicl trining or formtion t the first signs of pre-syncope. Such pre-emptive ctions my prevent injuries sustined during syncopl collpse. Third, despite the best preventive strtegies, some syncopl events, such s neurocrdiogenic syncope secondry to blood drws, will continue to occur. Given this likelihood, the gol should be minimiztion of injuries. In light of the lrge number of cses during blood drws nd immuniztions, the floor of the immuniztion by should be pdded. In 27, fom surfce ws dded to the concrete floor of the Trinee Vccintion Center. As new trinee helth center is being built t JBSA-Lcklnd, similr floor should be instlled in the new immuniztion by. The results of this report should be interpreted in light of its limittions. First, only syncopl nd pre-syncopl cses recorded in the electronic helth record were included in the nlysis. If trinee experienced syncopl event in the dorm room nd did not seek medicl ttention, for exmple, tht cse would not be included. Second, some providers did not specify etiologies for syncopl events; in these cses, etiologies were determined by best clinicl judgment during medicl chrt review. Third, lb vlues were not obtined in mny cses, so the prevlence of concomitnt nemi, hypoglycemi, nd electrolyte bnormlities ws bsed on only subset of cses. Finlly, the rtes scertined re for U.S. Air Force bsic militry trinees, ll of whom re trined t JBSA- Lcklnd, nd therefore my not be generlizble to militry recruits in the sister services, who experience different trining regimens in different geogrphic loctions. Author ffilitions: Trinee Helth Surveillnce, Joint Bse Sn Antonio-Lcklnd, Texs (Drs. Webber, Cropper, nd Federinko). REFERENCES 1. Sklni P, Krhn A, Klein G. Syncope. Circultion. 213;127: Grubb BP. Neurocrdiogenic syncope. N Eng J Med. 25;352: Moy A, Sutton R, Ammirti F, et l. Guidelines for the dignosis nd mngement of syncope (version 29). Europen Hert J. 29;3: Gnzeboom KS, Miruhu G, Reitsm JB, Linzer M, Wieling W, vn Dijk N. Lifetime cumultive incidence of syncope in the generl popultion: study of 549 Dutch subjects ged 35-6 yers. J Crdiovsc Electrophysiol. 26; 17: Armed Forces Helth Surveillnce Center. Syncope, ctive nd reserve components, U.S. Armed Forces, MSMR. 213;2(11): Soterides ES, Evns JC, Lrson MG, et l. Incidence nd prognosis of syncope. N Eng J Med. 22;347: Gnzeboom KS, Colmn N, Reitsm JB, Shen WK, Wieling W. Prevlence nd triggers of syncope in medicl students. Am J Crd. 23; 91: Ksper SL, Brunwld E, Fuci AS, Huser SL, Longo DL, Jmeson JL, eds. Hrrison s Principles of Internl Medicine. 16th ed. New York, NY: McGrw-Hill;25:A2-A6. Pge 4 MSMR Vol. 2 No. 11 November 213

5 Syncope, Active nd Reserve Components, U.S. Armed Forces, During the period of 1 Jnury 1998 to 31 December 212, the helth cre records of 153,172 ctive component service members documented t lest one helth cre encounter with dignosis of syncope nd collpse (overll incidence rte of 7.2 cses per 1, person-yers). The nnul incidence rtes rose by 89 percent during the period. During the 15-yer surveillnce period, there were 4,954 instnces of documented helth cre encounter with dignosis of syncope on the sme dy tht the service member hd received n immuniztion by injection. Annul rtes of syncope ssocited with immuniztion rnged from low of 4.4 events per 1, immuniztion episodes in 1998 to mximum of 14.1 events per 1, episodes in 26. For both syncope dignoses in generl nd syncope ssocited with immuniztion, rtes were higher mong women thn men nd were highest mong those under ge 2. Nerly ten percent of syncopl events ssocited with immuniztion occurred during the first two weeks of militry service. Rtes of syncope incresed with the number of injections received per immuniztion episode. Dignoses of physicl injury were documented in the records of helth cre encounters for syncope for 4. percent of ll syncopl events nd 6.9 percent of episodes of syncope linked to immuniztions. syncope (finting) is temporry loss of consciousness due to sudden reduction of blood flow to the brin. Syncope is reltively common, even mong young, helthy dults such s militry members. Situtions tht re ssocited with syncope in members of the U.S. Armed Forces include invsive medicl procedures (such s blood dontions, other venipunctures, nd immuniztions), stnding for long periods (such s in militry formtions or witing lines), nd physiclly demnding trining or exercise, especilly in hot environments. 1-3 Frequencies nd rtes of syncope nd postvccintion syncope mong U.S. militry members hve been described previously in the MSMR, 1,2 nd n in depth study mong Air Force bsic militry trinees is reported in this month s MSMR (pge 2). 3 The objective of this nlysis ws to updte the estimted frequencies, rtes, trends, correltes of risk, nd co-occurring conditions for syncope mong ctive component U.S. service members during recent 15-yer period. Additionlly, the experiences of ctive nd reserve component members of the U.S. militry regrding syncope relted to injectble immuniztions (postvccintion syncope) re described. METHODS The surveillnce period ws 1 Jnury 1998 to 31 December 212. For surveillnce purposes, cses of syncope were identified from medicl records of inptient nd outptient encounters tht included dignoses of syncope nd collpse (ICD-9-CM code: 78.2) in ny dignostic position. For summry purposes, cse of syncope ws defined s service member with t lest one medicl encounter for syncope nd collpse ny time during the surveillnce period; s such, ech individul could be cse only once during the period. A syncopl event ws defined s service member with t lest one syncope-relted encounter in dy; s such, service members could be ffected by multiple syncope events during the surveillnce period. Frequencies, rtes, nd trends of syncope cses nd syncopl events were clculted seprtely. For incidence rte estimtes, popultion-time t risk ws ll ctive duty time of individuls serving in the ctive component of the U.S. Armed Forces during the surveillnce period. For estimtion purposes, n immuniztion episode ws defined s one or more immuniztions dministered to n individul in given dy. A cse of postvccintion syncope ws defined s syncope-relted medicl encounter tht occurred on the sme dy s n immuniztion episode. Affected service members could be considered cses of postvccintion syncope only once per dy regrdless of the number of immuniztions received during the immuniztion episode. Rtes of postvccintion syncope were clculted by dividing the number of postvccintion syncope cses by the number of immuniztion episodes in popultion nd during time period of interest. Becuse immuniztions given by injection re those most consistently ssocited with syncope risk, vccines dministered orlly (e.g., denovirus vccine) or nslly (e.g., FluMist influenz vccine) nd tuberculin skin tests were not considered exposures of interest in the nlysis. Illnesses nd injuries were considered co-occurring with syncope if they were dignosed (nd reported in the first or second dignostic positions) during medicl encounter in which syncope ws lso dignosed. RESULTS During the 15-yer surveillnce period, 322,823 syncopl events were documented mong 153,172 ffected service members (men: 2.1 syncopl events per November 213 Vol. 2 No. 11 MSMR Pge 5

6 TABLE 1. Incident counts nd incidence rtes (per 1, person-yers) of syncope cses nd syncopl events, b ctive component, U.S. Armed Forces, Syncope cses Syncopl events b No. Rte No. Rte Totl 153, , Gender Mle 16, , Femle 46, , Age <2 28, , , , , , , , , , , , Rce/ethnicity White, non-hispnic 96, , Blck, non-hispnic 29, , Hispnic 13, , Asin/Pcific Islnder 4, , Other/unknown 9, , Service Army 62, , Nvy 31, , Air Force 38, , Mrine Corps 17, , Cost Gurd 3, , Grde Enlisted 138, , Officer 14, , Sttus Recruit 13, , Active (non-recruit) 14, , Militry occuption Combt-specific c 15, , Armor/motor trnsport 7, , Pilot/ircrew 2, , Repir/engineer 36, , Communiction/intelligence 34, , Helth cre 14, , Other 41, , A syncope cse=one syncope medicl encounter per person per surveillnce period. b A syncopl event=one syncope medicl encounter per person per dy. c Infntry, rtillery, combt engineering ffected individul) (Tble 1). The incidence rte of syncope in ctive component service members ws 7.2 per 1, person-yers (p-yrs); the rte of syncopl events ws 15.1 per 1, p-yrs. Of ll ffected individuls, pproximtely two-thirds (n=99,46; 64.6%) hd one, 15.9 percent (n=24,322) hd two, 6.8 percent (n=1,436) hd three, 3.8 percent (n=5,79) hd four, nd 2.5 percent (n=3,773) hd five syncopl events during the surveillnce period (dt not shown). The remining 6.5 percent (n=1,25) of ffected service members hd from 6 to 88 reported syncopl events during the period. The crude nnul incidence rte of syncope cses incresed by 88.6 percent from 1998 (rte: 4.6 per 1, p-yrs) to 212 (8.6 per 1, p-yrs) (Figure 1). Overll nd in every yer during the period, incidence rtes of syncope cses were highest mong service members under 2 yers of ge. The incidence rte in service members under 2 yers of ge incresed 115 percent from 1998 to 27 (23.2 per 1, p-yrs), ws stble from 27 to 29, nd then decresed 21 percent through 212 (18.3 per 1, p-yrs). Incidence rtes in the other ge groups incresed linerly, but by much less overll, from 1998 through 212 (Figure 1). In generl, incidence rtes of both syncope cses nd syncopl events were much higher mong women thn men, prticulrly mong those younger thn ge 2. Among both mles nd femles, incidence rtes of syncope were highest by fr in the youngest group (<2 yers) nd declined with incresing ge through the mid-thirties (Tble 1, Figure 2). Among rcil/ethnic groups, rtes of syncope nd syncopl events were highest mong service members who were blck, non-hispnic or other/unknown rcil/ethnic identities nd lowest mong Asin/Pcific Islnders (Tble 1). Compred to their respective counterprts, service members who were in the Army, enlisted, recruits, nd with other militry occuptions (e.g., no militry occuptionl specilty skills, initil entry trinees) hd higher rtes nd those in pilot/ircrew occuptions hd lower rtes, of syncope nd syncopl events. Co-occurring conditions Injuries were dignosed during 12,998 (4.%) medicl encounters t which syncope nd collpse ws lso dignosed (dt not shown). The injuries tht were most frequently dignosed during the sme medicl encounters s syncope were open wounds of the hed (n=2,547); other/unspecified injuries (n=2,59); contusions of the Pge 6 MSMR Vol. 2 No. 11 November 213

7 FIGURE 1. Annul incidence rtes of syncope cses overll nd by ge groups, ctive component, U.S. Armed Forces, Incidence rte per 1, person-yers One per person during the surveillnce period. FIGURE 2. Incidence rtes of syncope cses nd syncopl events b by gender nd ge, ctive component, U.S. Armed Forces, Incidence rte per 1, person-yers hed (n=1,395); concussions (n=1,145); sprins nd strins of the bck (n=667); nd frctures of the skull, fce, clvicle, or vertebre (n=584). Of note, more serious injuries within these ctegories include skull frctures (n=119), frctures of vertebrl column (n=91), cerebrl lcertions, contusions, or other intrcrnil injuries (n=335), nd open wound of the eyebll or oculr dnex (n=62). Other reltively common dignoses during syncope-relted medicl encounters were diseses nd symptoms involving the crdiovsculr system (e.g., dysrhythmis, plpittions, hypertension) (n=23,995); diseses nd symptoms involving the respirtory system (e.g., respirtory infections, unspecified chest pin) (n=22,965); Events mong femles Femle cses Events mong mles Mle cses. < Age group One per person during the surveillnce period. b One event per person per dy. symptoms involving the hed nd neck (e.g., hedche nd migrines) (n=12,151); disorders of fluid, electrolyte, nd cid-bse blnce (e.g., dehydrtion, volume depletion) (n=8,558); nd diseses nd symptoms of the digestive system (e.g., nuse/vomiting, virl enteritis) (n=7,42) (dt not shown). Postvccintion syncope < Totl During the 15-yer surveillnce period, there were 51,11,639 immuniztion episodes nd 4,954 medicl encounters for syncope nd collpse on the sme dys s immuniztion episodes. The crude overll rte of medicl encounters for postvccintion syncope ws 9.7 per 1, immuniztion episodes (Tble 2). Annul rtes of postvccintion syncope more thn tripled from 1998 (4.4 per 1, immuniztion episodes) to 26 (14.1 per 1, immuniztion episodes) nd then were reltively stble from 26 to 212 (rnge: per 1, immuniztion episodes) (Figure 3). Overll, nd in every yer of the period, rtes of postvccintion syncope were much higher mong TABLE 2. Counts nd rtes (per 1, immuniztions) of postvccintion syncope, ctive nd reserve components, U.S. Armed Forces, No. Rte Totl 4, Component Active 3, Reserve\Gurd 1, Gender Mle 3, Femle 1, Age <2 1, , Rce/ethnicity White, non-hispnic 3, Blck, non-hispnic Hispnic Asin/Pcifi c Islnder Other/unknown Service Army 1, Nvy Air Force 1, Mrine Corps Cost Gurd Grde Enlisted 4, Offi cer Militry occuption Combt-specifi c b Armor/motor trnsport Pilot/ircrew Repir/engineer Communiction/ intelligence Helth cre Other 2, No more thn one immuniztion episode per individul per dy. b Infntry, rtillery, combt engineering November 213 Vol. 2 No. 11 MSMR Pge 7

8 FIGURE 3. Annul rtes (per 1, immuniztions) of postvccintion syncope by ge, ctive nd reserve components, U.S. Armed Forces, FIGURE 4. Rtes (per 1, immuniztions) of postvccintion syncope by gender nd ge, ctive nd reserve components, U.S. Armed Forces, Rte per 1, immuniztion episodes < Totl Rte per 1, immuniztion episodes Femles Mles < Age group service members younger versus older thn 2 yers. The rte of postvccintion syncope ws more thn twice s high mong femles s mles nd shrply declined with incresing ge (Tble 2, Figure 4). Crude rtes were higher mong members of the Cost Gurd nd Air Force, those in other occuptions (which include those without n identified occuption, e.g., recruits), nd mong white, non-hispnic nd enlisted service members compred to their respective counterprts (Tble 2). Approximtely 9.7 percent of ll postvccintion syncope cses (n=479) occurred during the first two weeks of service (dt not shown). The Mrine Corps (16.8%), Cost Gurd (13.6%), nd Air Force (12.%) hd higher percentges of postvccintion syncope cses during the first two weeks of service thn the Nvy (6.6%) nd Army (6.5%). In generl, the rte of syncope shrply incresed s the number of injections per immuniztion episode incresed. Compred to episodes with only one injection, rtes of syncope were 1 percent, 286 percent, nd 49 percent higher during episodes with two, three, nd four or more injections, respectively (Figure 5). Co-occurring conditions Injuries were dignosed during 343 (6.9%) of the 4,954 medicl encounters for postvccintion syncope nd collpse (dt not shown). The most frequently cooccurring injuries with postvccintion syncope were open wounds of the hed (n=111); contusions of the hed (n=65); other/unspecified injuries (n=46); concussions (n=22); other/unspecified injuries of the hed (n=15); nd frctures of the skull, fce, or clvicle (n=1). Of note, more serious injuries within these ctegories include other intrcrnil injuries (n=5), skull frctures (n=2), nd open wound of the eyebll or oculr dnex (n=2). Other conditions tht were reltively frequently dignosed during the sme medicl encounters s postvccintion syncope were diseses nd symptoms involving the crdiovsculr system (e.g., dysrhythmis, hypertension) (n=22); disorders of fluid, electrolyte, nd cid-bse blnce (e.g., dehydrtion, volume depletion) (n=177); diseses nd symptoms involving the respirtory system (e.g., respirtory infections, unspecified chest pin) (n=264); nd symptoms involving the hed nd neck (e.g., hedche nd migrines) (n=118) (dt not shown). FIGURE 5. Rtes (per 1, immuniztion episodes) of postvccintion syncope by the number of immuniztions given during n immuniztion episode, ctive nd reserve component, U.S. Armed Forces, Rte per 1, immuniztion episodes EDITORIAL COMMENT This report documents tht, ech yer on verge over the pst 15 yers, pproximtely 21,5 syncopl events (ll types) hve ffected 1,2 ctive component service members or more No. of immuniztions during the immuniztion episode Pge 8 MSMR Vol. 2 No. 11 November 213

9 Mny syncopl events were ssocited with medicl conditions tht likely precipitted the syncopl episodes (e.g., crdic rrhythmis, cute gstrointestinl/ respirtory illnesses) or with injuries tht likely were cused by syncope-relted collpses. Of prticulr note, some injuries tht were dignosed t the sme medicl encounters s syncope were extremely serious nd potentilly life thretening (e.g., cerebrl lcertions/contusions, spinl column frctures). The findings strongly suggest the need for better syncope-relted injury prevention policies nd prctices. In this regrd, the identifiction nd protection from injury of individuls t prticulrly high risk of postvccintion syncope nd collpse should be high priority. Such individuls include militry recruits (prticulrly femles) nd dults of ll ges nd genders with histories of immuniztionrelted syncope. In this report, fter first documented syncopl episode while in militry service, pproximtely one-third of those ffected hd hd t lest one dditionl syncopl event during service. After second or third syncopl episode while in militry service, more thn one hlf (55%) nd two-thirds (65%), respectively, of those so ffected hd t lest one dditionl syncopl event during service. Clerly, service members with ny history of syncope re t shrply incresed risk of dditionl episodes nd those with multiple prior episodes of syncope re t extremely incresed risk of dditionl episodes nd should be specificlly protected from syncope-relted injuries. Syncope is well-known consequence of vccintion. During the 15-yer surveillnce period, 4,954 syncope events occurred on the sme dys s immuniztions. The rte of postvccintion syncope mong ctive nd reserve component service members ws 9.7 per 1, immuniztions. Similr to rtes of syncope (ll types) in the ctive component, postvccintion syncope ws highest mong femles nd younger ged service members. The Cost Gurd nd Air Force hd the highest rtes of postvccintion syncope (>13 per 1, immuniztions) s well s the reltively highest proportions of postvccintion syncope during the first two weeks of service. The rte of cliniclly significnt syncope fter receiving immuniztions by injection is generlly low; however, this report documents tht the rte shrply incresed when multiple injections were dministered. Becuse so mny service members receive immuniztions by injection, nd since multiple injections re often given concurrently, hundreds of service members re treted for postvccintion syncope ech yer. This report documented hundreds of trumtic injuries tht were t lest temporlly relted to syncope nd collpse of service members fter immuniztion; mny such injuries were severe, nd most, if not ll, likely were preventble. The Advisory Committee on Immuniztion Prctices (ACIP) of the Centers for Disese Control nd Prevention (CDC) recommends tht vccine providers strongly consider observing ptients for 15 minutes fter they re vccinted. If syncope develops, ptients should be observed until symptoms resolve. 4 At the strt of recruit trining, newly inducted service members receive multiple immuniztions by injection; nd in preprtion for overses deployments, members of militry units often receive immuniztions in lrge groups. The risk of serious complictions of postvccintion syncope my be incresed when immuniztions re given to militry groups outside of medicl fcilities - rther thn to individuls in clinic settings. For exmple, in clinics, vccinees cn be seted during nd fter injections nd monitored for syncope for resonble time periods; in ddition, flooring cn be pdded, nd furniture nd equipment cn be shielded or removed from immuniztion rooms nd ptient witing res. Such precutions my be difficult to implement in non-medicl fcilities where mss immuniztions re given (e.g., theters, gymnsiums). Nonetheless, every mesure to ensure the sfety of immuniztion recipients should be tken, regrdless of the loction, setting, or circumstnces of dministrtion. The results presented in this report should be interpreted in light of severl limittions. The numbers reported here likely underestimte the ctul numbers of syncope cses (individuls) nd events (both overll nd for postvccintion syncope). Uncomplicted syncopl episodes my be mnged t sites where they occur (for exmple, t medicl id sttion or troop clinic) but my not be documented in medicl records. Furthermore, some individuls my never seek cre for syncopl episodes occurring t home nd/or while off-duty. Conversely, in the nlysis tht exmined the totl numbers of syncopl events nd the numbers of such events per person, it is possible tht the numbers of such events were overestimted. The dignostic evlutions of some persons who experienced syncope my hve required series of subsequent outptient encounters for consulttions, specil testing (e.g., Holter monitoring, other crdiovsculr ssessments), nd follow-up visits. The medicl record documenttion of such encounters my hve included repet recordings of the dignostic code for the originl syncopl events tht precipitted the follow-on evlutions. This nlysis did not ttempt to clrify the impct of follow-up cre for syncope on the numbers of encounters for service members whose records suggested multiple events. Additionlly, the definition of postvccintion syncope used in this report is bsed on temporl ssocition (sme dy occurrence). True cuse nd effect (i.e., the vccintion cused the syncope event) could not be confirmed; therefore, some postvccintion syncope events my be clssified s such incorrectly. Similrly, cuse nd effect reltionship between syncope nd co-occurring conditions prticulrly injuries documented during the sme encounter cnnot be estblished with certinty. REFERENCES 1. Army Medicl Surveillnce Activity. Syncope, ctive duty, U.S. Armed Forces, MSMR. 9(4): Armed Forces Helth Surveillnce Center. Syncope fter immuniztion by injection, U.S. Armed Forces, MSMR. 15(7): Webber BJ, Cropper TL, Federinko SP. Syncope mong U.S. Air Force Bsic Militry Trinees, August 212-July 213. MSMR. 2(11): Advisory Committee on Immuniztion Prctices (ACIP), Centers for Disese Control nd Prevention. Generl recommendtions on immuniztion. MMWR. 26;55(No. RR-15):19. November 213 Vol. 2 No. 11 MSMR Pge 9

10 Updte: Motor Vehicle-relted Deths, Active nd Reserve Components, U.S. Armed Forces, From 1999 to 212, there were 4,479 motor vehicle ccident (MVA)-relted deths mong members of the U.S. Armed Forces. Of these, the single most common underlying cuse of deth ws motorcycle ccidents (n=1,134; 25.6%). Among ctive component service members during the 14-yer surveillnce period, the nnul number (n=355) nd rte (25.1 per 1, person-yers[p-yrs]) of MVA-relted deths peked in 24. Since then, stedy downwrd trend followed nd the 212 number (n=184) nd rte (13.2 per 1, p-yrs) were the lowest of the entire period. For members of the reserve component, the nnul number of deths peked in 25 (n=86), but the number in 212 (n=22) ws the lowest of the period. In 212, the number (n=9) nd rte of deths (6.5 per 1, p-yrs) relted to motorcycle ccidents mong ctive component service members lmost equled the number (n=94) nd rte of deths (6.7 per 1, p-yrs) from ll other types of motor vehicle ccidents combined. During the entire period, numbers of ftl motor vehicle ccidents tended to be higher in the wrmer months of the yer. After 29, motor vehicle ccidents were no longer the leding, nonwr-relted cuse of deth mong U.S. service members. motor vehicle ccidents (MVAs) hve ccounted for nerly one third of U.S. militry deths nnully, nd through 29 were the leding non-wr-relted cuse of deth mong U.S. militry personnel. 1,2 Deths due to MVAs mong service members hve been declining in recent yers, to such n extent tht in 21 nd 211 there were more deths from suicide nd from wr thn from trnsporttion ccidents. Studies focused on service members hve identified severl fctors ssocited with incresed risk of deth due to motor vehicle crshes: reltive youth, single mritl sttus, mle gender, nd highest eductionl level of high-school completion. 3,4 Compred to their older counterprts, younger service members more commonly tke risks while driving (e.g., speeding, inconsistent use of set belts, driving while intoxicted) or ride motorcycles. All services within the U.S. Armed Forces conduct sfe driving cmpigns nd mke such informtion vilble to their respective service members using vriety of medi. The Army for exmple, requires ll soldiers to undergo the Army Trffic Sfety Trining Progrm, which includes mndtory motorcycle trining under the Progressive Motorcycle Progrm for soldiers who own motorcycles. Aprt from the usul messging on the voidnce of, or moderte consumption of lcohol before driving, wering set belts or helmets s pproprite, nd defensive driving, these sfety trining progrms extend to cover such topics s the proper instlltion nd use of child sfety sets, nd mintining sfe personl motor vehicles in order to sfegurd the lives of fmily members nd other pssengers. This report updtes previous summries of numbers, rtes, trends, nd correltes of risk of motor vehicle ccident relted ftlities mong service members since This report lso describes militry nd demogrphic chrcteristics of service members who died in motorcycle nd other motor vehicle ccidents. METHODS The surveillnce period ws 1 Jnury 1999 to 31 December 212. The surveillnce popultion included ll individuls who served on ctive duty s members of the ctive or reserve components of the U.S. Armed Forces t ny time during the surveillnce period. Motor vehicle-relted deths of service members were scertined from records mintined in the DoD Medicl Registry of the Armed Forces Medicl Exminer System nd routinely provided to the Armed Forces Helth Surveillnce Center for integrtion into 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 corresponding to collision or non-collision motor vehicle ccident. Motor vehicle deths tht were considered intentionl (i.e., suicide or homicide) or wr-relted were excluded. In this nlysis, the summries comprise numbers of deths in the surveillnce popultion overll (i.e., ctive nd reserve component members on ctive duty) nd mortlity rtes for members of the ctive component using person-yers t risk rther thn individuls t risk. Mortlity rtes were clculted s deths per 1, person-yers of ctive militry service during the surveillnce period. 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. 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 There were 4,479 motor vehicle-relted deths mong service members during the Pge 1 MSMR Vol. 2 No. 11 November 213

11 14-yer surveillnce period from 1999 through 212 (Tble 1). These included 3,784 deths in the ctive component (rte: 19.5 per 1, person-yers [p-yrs]) nd 695 deths in the reserve component (Tble 2). Among the 1 ctegories of underlying motor vehicle ccident-ssocited cuse of deth used in this nlysis, the lrgest number of service member deths (n=1,158; 25.9% of the totl) ws ssocited with motorcycle ccidents (motorcyclist involved in ny ccident except collision with rilwy trin). The second highest number of deths in single ctegory of vehicle deths ws for other nd unspecified motor vehicle ccidents which ccounted for 783 or 17.5 percent of ll MVA deths. Throughout the surveillnce period, there were 262 (5.8%) pedestrin-involved ftlities in collisions with motor vehicles. The five ctegories tht specified tht the decedent ws the occupnt of vehicle ccounted for 2,243 deths (5.1% of ll MVA deths) (Tble 1). Overll, there were 3,321 non-motorcycle relted deths during the period. Annul numbers of deths from MVA mong ctive component service members during the surveillnce period peked in 24 (n=355; rte: 25.1 per 1, p-yrs) (Figure 1). In generl, nnul counts nd rtes of motor-vehicle relted deths mong ctive component service members hve been declining since 27. The yer 212 hd the lowest nnul number (n=184) nd rte (13.2 per 1, p-yrs) of MVA deths mong ctive component service members during the entire surveillnce period (Figure 1). Annul MVA deths mong reserve component service members were highest from 23 to 25 (81, 81, nd 86 deths, respectively), but hve been consistently lower since 28. Most notbly, reserve component MVA deths in 212 (n=22) were by fr the fewest of ny yer in the surveillnce period (Figure 2). Among ctive component service members in ll of the services, the Army hd the highest number of motor vehicle-relted deths overll (n=1,568; rte: 22. per 1, p-yrs; 41.4% of ll MVA deths) (Tble 2) nd in ech yer during the 14-yer period (Figure 3). However, the Mrines hd the highest overll rte, 29.8 per 1, p-yrs (Tble 2). TABLE 1. Motor vehicle-relted deths by underlying cuse of deth ctegory, ctive nd reserve components, U.S. Armed Forces, Jnury 1999-December 212 Underlying cuse of deth (UCOD) Service member deths No. % of totl Motorcyclist involved in ny ccident except collision with rilwy trin 1, Other nd unspecifi ed motor vehicle ccidents Occupnt of cr, pickup, truck, or vn involved in collision with other motor vehicle Occupnt of motor vehicle involved in collision with non-motorized rod vehicle streetcr, niml, pedestrin, or fi xed object Occupnt of motor vehicle involved in noncollision ccident Occupnt of specil-use motor vehicle involved in ny ccident (including militry vehicle) Pedestrin involved in collision with motor vehicle Pedl cyclist involved in collision with motor vehicle 22.5 Other motor vehicle ccident involving collision with rilwy trin 11.2 Occupnt of hevy trnsport vehicle or bus involved in collision with other motor vehicle 5.1 Totl 4, FIGURE 1. Annul numbers nd rtes of motor vehicle-relted deths, ctive component, U.S. Armed Forces, Jnury 1999-December 212 No. of deths (brs) Mle service members died s result of MVAs t higher rte overll when compred to their femle counterprts (mle rte: 21.4 per 1, p-yrs vs. femle rte: 8.4 per 1, p-yrs). Although there were more deths (counts) mong white, non-hispnic service members nd those ged 2-24 compred to their respective counterprts, the rtes of MVA deths were highest mong blck, non-hispnic service members (rte: 22.2 per 1, p-yrs) nd those under the ge of 2 (rte: 29.5 per 1, p-yrs) (Tble 2). In 212, ech of the services (except Nvy) hd its lowest nnul number of Rte per 1, person-yers (line) FIGURE 2. Annul numbers of motor vehiclerelted deths, reserve component, U.S. Armed Forces, Jnury 1999-December 212 No. of deths November 213 Vol. 2 No. 11 MSMR Pge 11

12 TABLE 2. Demogrphic nd militry chrcteristics of motor vehicle-relted deths (ll types), ctive nd reserve components, U.S. Armed Forces, Jnury December 212 Active nd reserve components Active component No. No. of deths Rte Totl 4,479 3, Service Army 2,67 1, Nvy Air Force Mrine Corps Sex Mle 4,173 3, Femle Rce/ethnicity White, non-hispnic 2,772 2, Blck, non-hispnic Other Age < ,58 1, Militry occuption Combt-specific 1,17 1, Helth cre Admin/supply Other 2,114 1, Rte per 1, person-yers MVA-relted deths (ctive nd reserve components combined) of the entire surveillnce period. Among ctive component service members, 212 hd the lowest nnul rtes of MVA-relted deths mong the Army nd Mrine Corps (Figure 3). Drmtic declines in the numbers nd rtes of non-motorcycle-relted MVA deths were responsible for the fll in rtes for ll MVA-relted deths (Figure 4). For the entire 14-yer surveillnce period, slightly over 25 percent of ll motor vehicle-relted deths were due to motorcycle ccidents mong ctive nd reserve component service members combined. However, s result of the decline in non-motorcycle-relted MVA deths since 25, motorcycle-relted deths hve become n incresingly higher proportion of ll MVArelted deths in the ltter prt of the surveillnce period (Figure 4). In 212, mong ctive component service members, the rte of motorcycle deths (6.5 per 1, p-yrs) ws lmost tht of non-motorcycle MVAs (6.7 per 1, p-yrs) (Figure 4). The lrgest numbers of motorcycle-relted deths ffected ctive component service members (n=1,23), soldiers (n=457 overll; n=373 nd rte: 5.2 per 1, p-yrs mong ctive component FIGURE 3. Annul numbers of motor vehicle-relted deths, by service, ctive nd reserve components, U.S. Armed Forces, Jnury 1999-December 212 FIGURE 4. Motor vehicle-relted deths by yer nd underlying cuse (motorcycle vs. ll other), ctive component, U.S. Armed Forces, Jnury 1999-December Army Nvy Air Force Mrine Corps No. of non-motorcycle deths Rtes of non-motorcycle deths 275 No. of motorcycle deths Rtes of motorcycle deths 2. No. of nnul deths No. of deths (brs) Rte per 1, person-yers (lines) Pge 12 MSMR Vol. 2 No. 11 November 213

13 only), those ged 2-24 yers, mles, nd white, non-hispnics. The highest rtes (ctive component only) were mong Mrines (rte: 6.9 per 1, p-yrs), those ged 2-24 yers (rte: 6.4 per 1, p-yrs), nd blck, non-hispnics (rte: 6.8 per 1, p-yrs) (Tble 3). For the entire surveillnce period, motorcycle-relted deth counts were lowest in Jnury nd higher during the months of April to September (wrmer months) (Figure 5). The verge number of motorcycle-relted deths per month over the surveillnce period ws highest in July (n=15 overll). July lso hd the highest verge number of deths per dy overll during the 14-yer surveillnce period. For non-motorcycle MVA-relted deths, there ws similr, though less-striking, sesonl pttern of numbers of ftlities. When compred to ll cuses of deth mong service members for the lst five yers (28 through 212), MVA-relted deths hve ccounted for decresing proportion of ll deths in the ctive nd reserve components of the U.S. Armed Forces (Figure 6). In 212, the percentge of ll deths mong ctive nd reserve component service members ttributble to MVAs ws the lowest (15.8%) in the 5-yer period. TABLE 3. Demogrphic nd militry chrcteristics of motorcycle-relted deths, ctive nd reserve components, U.S. Armed Forces, Jnury 1999-December 212 Active nd reserve components Active component No. No. of deths Rte Totl 1,158 1, Service Army Nvy Air Force Mrine Corps Sex Mle 1, Femle Rce/ethnicity White, non-hispnic Blck, non-hispnic Other Age < Militry occuption Combt-specifi c Helth cre Admin/supply Other Rte per 1, person-yers FIGURE 5. Motor vehicle-relted deths by month (motorcycle vs. ll other), ctive nd reserve components, U.S. Armed Forces, No. of deths (brs) Non-motorcycle-relted deths AVG non-motorcycle deths per dy Motorcycle-relted deths AVG motorcycle deths per dy Averge no. of deths per dy (lines) FIGURE 6. Comprison of number of deths from ll non-motor vehicle-relted cuses to motor vehicle-relted deths, ctive nd reserve components, U.S. Armed Forces, No. of deths 1,6 1,4 1,2 1, Motor vehicle-relted deths No. of non-motor vehicle-relted deths % motor vehicle-relted deths 2.9% 17.6% 16.4% 17.1% 15.8% Jnury Februry Mrch April My June July August September October November December November 213 Vol. 2 No. 11 MSMR Pge 13

14 EDITORIAL COMMENT Bell, et l. 4 reported in 2 nlysis of self-reported risk tking behviors mong soldiers hospitlized for injuries s result of motor vehicle ccidents tht hevy drinking, drinking nd driving, speeding, low set belt use, younger ge, minority rce/ethnicity, nd enlisted rnk were significntly ssocited with motor vehicle injury. They concluded tht mny of the self-identified risk fctors ssocited with motor vehicle injuries were indeed modifible (e.g., drinking, speeding, nd infrequent set belt use). Moreover, the uthors recommendtion ws tht progrms tht meet the needs of young nd minority soldiers, nd tht trget high risk behviors re needed. Twelve yers lter, the dt in this report show some encourging improvements within the U.S. militry popultion. During the 14-yer surveillnce period, nnul counts nd rtes of MVA deths mong ctive component service members peked in 24, nd begn sustined decline through 212. By 212, nnul deths due to MVAs hd declined by 34.8 percent since 1999 nd by 48.2 percent since the pek in 24. In 212 counts nd rtes of MVA deths in the ctive component of ll services reched their lowest levels of the entire surveillnce period. Similrly, MVA deths mong reservists in 212 were drmticlly lower thn ny other yer of the surveillnce period. Although the findings of this updte re encourging with respect to motor vehicle ccidents overll, it is concerning tht rtes of motorcycle-relted ftlities mong service members hve risen in the two yers since 21. Moreover, the counts nd rtes of motorcycle-relted deths mong U.S. militry service members hve remined higher in recent yers thn they were t the beginning of the surveillnce period. In 212, the counts nd rtes of deths from motorcycle ccidents mong ctive component service members were nerly equl to those from non-motorcycle ccidents. Since 29, the Deprtment of Defense hs required service members who intend to own motorcycle to enroll nd prticipte in motorcycle sfety courses. Such trining is expected to be conducted within 3 duty dys of request for trining for initil riders, nd t lest every five yers s refresher. 5 The underlying or min chllenges in reducing motorcycle-relted ftlities mong service members remin uncler. By ll ppernces, the requisite policies nd progrms re in plce, nd hve been mde pplicble to ll service members meeting the criteri (i.e., those who own or intend to own motorcycle). Furthermore, the sfety trining progrms incorporte motorcycle mintennce tips nd dvice on protective clothing, nd some even go so fr s to provide first hnd testimonils from service members who hve been involved in ccidents, but somehow survived. Perhps greter efforts need to be mde to encourge those most t risk young service members to pprecite their own vulnerbility with respect to motorcycle crshes nd to modify their riding behviors ccordingly. Severl differences in temporl nd epidemiologic chrcteristics of ftl MVAs re described in this report. Ftlities due to motorcycle ccidents occurred more frequently during wrmer months, in contrst to the less drmtic sesonl pttern of incident non-motorcycle-relted ftlities. Mle service members in the ctive component died from motor vehicle ccidents t rte more thn twice tht of their femle counterprts. Compred to their older counterprts, younger members of the Armed Forces re t higher risk of ftlities due to motor vehicle ccidents. The sme is true for blck, non-hispnic service members in comprison to their counterprts. There re severl limittions to this nlysis tht should be considered when interpreting the results. First, the outcomes mesured were deths from MVAs. The nlysis did not compile the numbers or rtes of ll MVAs (ftl nd non-ftl), so it ws not possible to ssess whether or not decrese in rtes of MVAs ws responsible for the decline in MVA deth rtes. Accordingly, it is uncler if the previously described sfety trining inititives hve hd the desired effect on the incidence of MVA ccidents overll, mjor determinnt of MVA ftlities. It is possible tht modern utomotive engineering dvnces designed to mke MVAs more survivble hve yielded lower ftlity rtes even if the numbers of ccidents hve not declined pprecibly. Second, lthough the documented recent trends in ftl MVAs ttributble to motorcycle ccidents do not show mjor improvements in the ssocited rtes in contrst to the shrp declines in deths from non-motorcycle MVAs this nlysis does not clrify the risks ttendnt to motorcycle-relted deths. Rtes in this report were clculted using popultionbsed denomintor, i.e., person-yers of ll ctive component service members. A better denomintor for ssessment of trends in motorcycle ftlities would be personyers of service of motorcycle opertors. It is possible tht the numbers of motorcycle owners or opertors hve incresed significntly during the surveillnce period, so more ccurte, rte-bsed estimte of the risk of ftl motorcycle ccidents over time would be possible with such exposure dt (currently not vilble). Third, the nlysis does not ccount for the deths of service members who were on ctive duty t the time of ultimtely ftl MVAs but who died of the resulting injuries fter they left ctive duty (e.g., following medicl disbility retirement). Also the nlysis did not ccount for ftl MVAs mong reserve component members who were not on ctive duty t the times of their ccidents. Becuse such deths were not included, the mortlity impct of motor vehicle ccidents on the totl U.S. Armed Forces is likely underestimted in this report. REFERENCES 1. Krhl PL, Jnkosky CJ, Thoms RJ, Hooper TI. Systemtic review of militry motor vehicle crsh-relted injuries. Am J Pre Med. 21: 38(1S); S189-S Armed Forces Helth Surveillnce Center. Deths while on ctive duty in the U.S. Armed Forces, MSMR. 212 My. 19(5): Hooper TI, Debkey SF, Bellis KS, et l. 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 Army personnel. Am J Prev Med. 2 Apr; 18(3 Suppl): DoDI DOD Trffi c Sfety Progrm. Jnury 213. Pge 14 MSMR Vol. 2 No. 11 November 213

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