Deployment Health Research. DoD Center for Deployment Health Research Naval Health Research Center

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1 NHRC_Logo_NoStars Deployment Health Research DoD Center for Deployment Health Research Naval Health Research Center Prepared for Committee on a National Surveillance System for Cardiovascular and Select Chronic Diseases MOMRP Science to Soldier

2 Deployment Health Research Lessons learned from 1991 Gulf War..

3 Gaps Highlighted with 91 GW Research Baseline health unknown Behavioral characteristics unknown Appropriate comparison populations Information on Reserve and National Guard Health information post service limited Prospective and individual level exposure assessment

4 NHRC_Logo_NoStars Medical Research Solution Post-immunization studies Deployment and healthcare studies Birth and Infant Health Registry Recruit Assessment Program Millennium Cohort Study Team 9 PhD/DO/MD, 15 Masters (n>35)

5 Electronic Data Sources Deployment Data Environmental Exposure Data Dept of Veterans Affairs Data Mortality Data Immunization Data Recruit Assessment Program Pharmacologic Data Military Inpatient and Outpatient Care Family Data e.g., DoD Birth and Infant Health Registry Civilian Inpatient and Outpatient Care Medical History Survey Data (Millennium Cohort, PDHA/RA) Induction Demographic Data DoD Serum Repository

6 Deployment and Healthcare Research Deployed service members between 1/1/2003 and 12/31/2004 Deployed service members who were active duty without a second deployment 18 months following deployment Active duty service members (deployed and non-deployed), monthly hospitalization rates from 1/1/ /31/2005 Monthly Hospitalization Rates Smith TC, LeardMann CA, Smith B, Jacobson IG, Ryan MA. Postdeployment Hospitalizations Among Service Members Deployed in Support of the Deployments in Iraq and Afghanistan. Ann Epidemiol, Sep 2009;19(9):

7 Recruit Health Research The Recruit Assessment Program (RAP) was established at MCRD San Diego since 2001, to assess collection of baseline health data Understanding health risks at entrance Understanding how service-related exposures/deployments affect health Developing early intervention and prevention programs RAP will potentially transition to DoD-wide use (HART-A) Continued analyses of RAP data at NHRC, especially linked to OIF/OEF deployment, remain extremely valuable

8 The DoD Birth and Infant Health Registry Military Outpatient Encounters Civilian Hospitalization Data Military Hospitalization Data DoD Birth and Infant Health Registry Civilian Outpatient Encounters 100,000 military births annually; health data through first year of life Parental Demographic and Military Exposure Data Linking to parental occupations and exposures is unique capability

the impact of deployment prospectively Section 743 of the FY1999 Strom Thurmond Act authorized the Secretary of Defense to

9 Millennium Cohort Study IOM recommended coordinated prospective cohort study of service members Capitalize on new DoD surveillance and health care data Data sources that were not available at the time of the Gulf War For the first time, measure the impact of deployment prospectively Section 743 of the FY1999 Strom Thurmond Act authorized the Secretary of Defense to establish a longitudinal study to evaluate data on the health conditions of members of the Armed Forces upon their return from deployment.

10 Basic Methodology Survey refined based on focus group testing, pilot study, and expert review Questionnaire leverages standard instruments (PHQ, PCL, SF-36V, others) Includes measures of physical health, behavioral health, mental health Includes exposure questions, and other metrics (deployment, sleep, etc.) Participants respond via traditional paper or over secure website DMDC Reference # * RCS # DD-HA(AR)2106 * OMB Approval # ASD/HA/TMA Protocol # CDO * Primary IRB Protocol # NHRC

11 Current Status 2001: Study launched 77,047 enrolled in Panel : Panel 1 follow-up and Panel 2 enrollment initiated 86,131 enrolled / followed-up 2007: Panel 1 and 2 follow-up; Panel 3 enrollment N > 150, : Follow-up of 150,000 Cohort members and last enrollment of 50,000 additional members; enrollment of family cohort > 70% follow-up ~ 50% deployed in support of operations in Iraq and Afghanistan ~ 25% have left military service

12 Oversight and Management Funded by the Department of Defense through the Military Operational Medicine Research Program (MOMRP) Co-investigators from all services and the VA Protocols designed with external consultation Multiple IRB reviews AIBS external scientific reviews OMB reviews of survey efforts Defense Health Board (previously AFEB) reviews Scientific Steering and Advisory Committee review

13 Summary of Published Efforts Baseline mental health comparison (JCE, 2007) Mental health prior and post 9/11 (JOEM, 2004) Weighted/non-weighted functional health comparison (BMC Pub Health, 2007) New onset and persistent PTSD and deployment (BMJ, 2008) Prior assault and PTSD in combat deployers (Epidemiology, 2008) Alcohol use and problems and deployment (JAMA, 2008) Cigarette smoking and deployment (AJPM, 2008) PTSD prevalence, exposures, and functional health (Pub Hlth Rep, 2009) Disordered eating, weight change, and deployment (AJE, 2009) Functional health and PTSD in combat deployers (BMJ, 2009) Health symptoms and conditions in CAM users (Ann Epi, 2009) Career span and beyond follow-up (JOEM, 2009) Hypertension and deployment (Hypertension, 2009) Respiratory conditions and deployment (AJE, 2009) Depression and deployment (AJPH, 2010) Diabetes and combat deployment (In press Diabetes Care, 2010) In Review Sleep problems and deployment, psych impact of injury, PTSD and CAM, PTSD and physical activity

14 Ongoing Analyses General approach to comparisons include differentiating between combat deployers, non-combat deployers, and nondeployers; multiple and prolonged deployments; and active duty, Reserve/National Guard Burn pit exposure Chronic multi-symptom illness, immune disorders, respiratory conditions, cancer Special populations Special forces, women, individual augmentees, caregivers Parental stress and infant health outcomes Chronic back pain Migraine and severe headache Prospective analyses head trauma

15 Ongoing Analyses General approach to comparisons include differentiating between combat deployers, non-combat deployers and nondeployers; multiple and prolonged deployments; and active duty, Reserve/National Guard BMI and PTSD CVD / CHD and PTSD Supplement use Smokeless tobacco use Reasons for leaving military service Physical disabilities, separation from service, and weight change Employment post military service Suicidal thoughts, attempt, completion

16 Future Directions Findings are assisting in design of intervention studies Biologic sampling to investigate markers of health outcomes Serial neurocognitive assessments in select subgroups Neuro-imaging in select subgroups Investigation of mental and functional health of service members families

17 Summary 10 years; 2010 follow-up of P1-P3, enrollment of P4 and family Deployment related vaccinations not associated with increased symptoms or health outcomes Combat related stressors associated with increased risk for alcohol misuse, smoking, depression, PTSD, eating disorders in women, hypertension, and diabetes Certain subpopulations at increased risk for postdeployment health issues: low SF36V scores and Reserve/National Guard Studies have highlighted ways to decrease mental health symptoms : physical activity weight Current studies ongoing to document transient symptoms or progression of symptoms to chronic illness

18 Acknowledgements Millennium Cohort Study Team, San Diego Melissa Bagnell, MPH; Gina Creaven, MBA; James Davies; Nisara Granado, G MPH, PhD; Gia Gumbs, MPH; Lesley Henry; Dennis Hernando; Jaime Horton; Isabel Jacobson, MPH; Kelly Jones,, MPH; Lauren Kipp; Cynthia LeardMann, MPH; Travis Leleu; Gordon Lynch; Jamie McGrew; Hope McMaster, PhD; Stacie Nguyen; Amanda A Pietrucha, MPH; Teresa Powell, MS; Donald Sandweiss, MD; Kari Sausedo, MA; Amber Seelig, MPH; Beverly Sheppard; Besa Smith, MPH, PhD; Katherine Snell; Steven Speigle; Marleen Welsh, PhD; Martin White, MPH; James Whitmer; and Charlene Wong, MPH Millennium Cohort Co-Investigators Dr. Tyler Smith, Dr. Paul Amoroso, Dr. Edward Boyko, Dr. Gary Gackstetter, Dr. Gregory Gray, Dr. Tomoko Hooper, Dr. James Riddle, Dr. Margaret Ryan, and Dr. Timothy Wells Scientific Steering and Advisory Committee Members Dr. Elizabeth Barrett-Connor; Dr. Dan Blazer; Dr. Harold Koenig; Mr. Michael O Rourke; O Dr. Larry Palinkas; Dr. Michael Peddecord; Mr. Joseph Sharpe; Dr. Marie Swanson Additional Collaborators and Supporters Scott Seggerman, Management Information Division, DMDC; COL Carl Castro, Dr. Dennis Goodes, Mr. Mark Bither, MAJ Bonilla, Dr. Joan Hall, and Dr. Kate Nassauer, MOMRP; COL Karl Friedl and Dr. Richard Satava, MRMC; Dr. Charles Hoge, WRAIR; Dr. Susan Proctor and Dr. Kristin Heaton, USARIEM; COL Charles Engel, WRAMC; Dr. William Schlenger, Abt Associates; Dr. John Fairbank, Duke University; Dr. Charles Marmar, UCSF; Dr. Seth Eisen, VA; Dr. Roger Gibson, USUHS; Dr. Deborah Wingard, Dr. Donna Kritz-Silverstein, and Dr. Thomas Patterson, UCSD; Dr. Caroline Macera,, Dr. James Sallis, and Dr. Donald Sylmen, SDSU; Dr. Pam Keel, Univ of Iowa; COL Gaston Bathalon, USARIEM; Dr. Alyson Littman, Seattle ERIC; Anna Bukowinski, Sydney Lee and Carter Sevick, DoD BIHR; LtCol Chris C Philips, RAP; Dr. Robin Harris, Dr. Eyal Shahar, Dr. Grant Skrepnek and Dr. Stephen Coons, Univ of Arizona; Dr. Sarah S Fortuna, AFRL; CAPT Robert Koffman, BUMED; Dr. Judith Lytle and CDR James Patrey, ONR; and professionals from the Institute for Systems Biology The views expressed in this research are those of the authors and d do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. Human subjects participated in this study after giving their free and informed consent. This research has been conducted in compliance with all applicable Federal Regulations governing the Protection of Human Subjects in Research. We are indebted to the Millennium Cohort Study members for their continued participation! MOMRP Science to Soldier

19 Type 2 Diabetes and Combat Deployment and Mental Health Incidence of diabetes over ~3 yr follow-up => 3/1,000 person years Persons reporting Type 2 diabetes at follow-up were significantly: Older More likely to have greater baseline body mass index Less likely to be white non-hispanic Those with baseline posttraumatic stress disorder were more than twice as likely to report Type 2 diabetes after adjustment for demographic, military and behavioral characteristics Deployments with or without reported combat exposures in support of the current conflicts were not significantly associated with higher odds for reporting Type 2 diabetes at follow-up MOMRP Science to Soldier

Millennium Cohort Study Overview

Millennium Cohort Study Overview Principal Investigator Naval Health Research Center, San Diego, CA Defense Health Board Briefing 10 February 2016 Origin of the Millennium Cohort Study By 1998 the DoD,