MEDICAL SURVEILLANCE MONTHLY REPORT

MARCH 213 Volume 2 Number 3 msmr MEDICAL SURVEILLANCE MONTHLY REPORT PAGE 2 Chllenges in monitoring nd mintining the helth of pilots engged in telewrfre Hernndo J. Orteg, Jr. PAGE 3 Mentl helth dignoses nd counseling mong pilots of remotely piloted ircrft in the United Sttes Air Force Jen L. Otto, Brynt J. Webber PAGE 9 Externl cuses of trumtic brin injury, 2-211 PAGE 15 Mid-seson influenz vccine effectiveness for the 212-213 influenz seson Angeli A. Eick-Cost, Zheng Hu, Michel J. Cooper, Jose L. Snchez, Jennifer M. Rdin, Anthony W. Hwksworth, Gry T. Brice, Lurel V. Lloyd, Ktie J. Tstd, Shun C. Zorich, Victor H. McIntosh PAGE 17 Updte: het injuries, ctive component, U.S. Armed Forces, 212 PAGE 21 Updte: exertionl rhbdomyolysis, ctive component, U.S. Armed Forces 28-212 PAGE 25 Updte: exertionl hypontremi, ctive component, U.S. Armed Forces, 1999-212 SUMMARY TABLES AND FIGURES PAGE 29 Deployment-relted conditions of specil surveillnce interest Jmes Heilmn, MD A publiction of the Armed Forces Helth Surveillnce Center

Editoril Chllenges in Monitoring nd Mintining the Helth of Pilots Engged in Telewrfre Hernndo J. Orteg, Jr., MD, MPH the growth in the use of remotely piloted ircrft (RPA), lso referred to s unmnned eril vehicles or drones, hs hd significnt impct on overses contingency opertions. As noted by Drs. Otto nd Webber in this issue of the Medicl Surveillnce Monthly Report, RPA opertions begn in ernest fter the 9/11 terrorist ttcks on the World Trde Center. At tht time, very little ws known bout the stressors of, or the requirements for, these opertions. Demnd for RPA pilots hs been incresing nd currently, the Air Force is trining more RPA pilots thn fighter nd bomber pilots combined. Although RPA re often referred to s being unmnned, these systems require the support of tems of highly trined nd experienced service members on the ground, including the RPA pilot. As dvnces in technology hve enbled pilots to control ircrft without physiclly ccompnying them, distinct chllenges hve emerged s result of removing pilots from the physicl bttlespce. Trditionlly, militry opertions hve been expeditionry in nture, with lrge numbers of service members deployed overses. This deployment prdigm often fosters the development of orgniztionl identity nd unit cohesion, both of which hve been demonstrted to help service members cope with the stresses of combt. However, these elements re lcking in RPA pilots. In ddition, RPA pilots fce unique stressors relted to the impct of fighting wr t the office nd going home to fmily t night. Lst, the continully incresing demnd for RPA support hs led to mnning issues; RPA pilots re fced with rotting shifts nd long hours which contribute to stress, sleep issues, nd other negtive consequences. In 28, stories begn to emerge in the ly press bout wr stress mong RPA pilots in the Air Ntionl Gurd nd medi reports hve continued to pper regrding mentl helth issues in this community. 1,2 These reports cited reserch by the U.S. Air Force School of Aerospce Medicine (USAFSAM) nd the Performnce Enhncement Directorte. In 26, Dr. Anthony Tvryns nd collegues conducted the first comprehensive nlysis of the humn stressors involved in RPA opertions. 3,4 Continued surveillnce nd reserch into the helth nd well-being of RPA pilots hve offered flight surgeons nd line leders improved insight into their mentl helth needs. This informtion hs lso informed policy chnges such s the dediction of dditionl mentl helth resources to this community. Aginst this bckdrop, Drs. Otto nd Webber hve objectively quntified the stte of RPA pilots with regrd to mentl helth (MH) endpoints (s represented by ICD-9-CM dignoses ssigned by medicl providers). Their results demonstrte tht Air Force RPA pilots re receiving mentl helth dignoses t rtes equivlent to other Air Force pilots who hve deployed nd t lower rtes thn other Air Force personnel. The findings of this study vlidte severl key principles of humn performnce developed nd pplied by erospce medicine since its inception in the erly 2th century. For exmple, the rigorous selection process vitors undergo nd the ongoing opertionl medicl support they receive re two fctors (of severl) which likely impct their helth nd opertionl performnce; sustined vigilnce nd ppliction of these principles will continue to be the cornerstone of mintining helth nd optiml performnce of the humn wepon system involved in eril combt, no mtter how combt is prosecuted. Volnti subvenimus. Author ffilition: Aerospce Medicine Division, Air Eduction nd Trining Commnd, Rndolph AFB, TX. REFERENCES 1. Associted Press. Remote-control wrriors suffer wr stress. NBC news, 7 Aug 28. http:// www.nbcnews.com/id/267887/#.usap5-jiko. Accessed on 16 Feb 213. 2. Retic A. Drone-pilot burnout. New York Times, 12 Dec 28. http://www.nytimes.com/28/12/14/ mgzine/14ides-section2-b-t-1.html?_r=. Accessed on 15 Feb 213. 3. Tvryns AP, Lopez N, Hickey P, DLuz C, Thompson W, Cldwell, JL. Effects of shift work nd sustined opertions: Opertor performnce in remotely piloted ircrft (OP-REPAIR) (HSW-PE- BR-TR-26-1). Brooks City-Bse, TX: 311th Performnce Enhncement Directorte, United Sttes Air Force, 26. 4. Tvryns AP. Humn systems integrtion in remotely piloted ircrft opertions. Avit Spce Environ Med. 26;77(12):1278-1282. Pge 2 MSMR Vol. 2 No. 3 Mrch 213

Mentl Helth Dignoses nd Counseling Among Pilots of Remotely Piloted Aircrft in the United Sttes Air Force Jen L. Otto, DrPH, MPH; Brynt J. Webber, MD (Cpt, USAF) Remotely piloted ircrft (RPA), lso known s drones, hve been used extensively in the recent conflicts in Irq nd Afghnistn. Although RPA pilots in the U.S. Air Force (USAF) hve reported high levels of stress nd ftigue, rtes of mentl helth (MH) dignoses nd counseling in this popultion re unknown. We clculted incidence rtes of 12 specific MH outcomes mong ll ctive component USAF RPA pilots between 1 October 23 nd 31 December 211, nd by vrious demogrphic nd militry vribles. We compred these rtes to those mong ll ctive component USAF mnned ircrft (MA) pilots deployed to Irq/Afghnistn during the sme period. The undjusted incidence rtes of ll MH outcomes mong RPA pilots (n=79) nd MA pilots (n=5,256) were 25. per 1, person-yers nd 15.9 per 1, person-yers, respectively (djusted incidence rte rtio=1.1, 95% confidence intervl=.9-1.5; djusted for ge, number of deployments, time in service, nd history of ny MH outcome). There ws no significnt difference in the rtes of MH dignoses, including post-trumtic stress disorder, depressive disorders, nd nxiety disorders between RPA nd MA pilots. Militry policymkers nd clinicins should recognize tht RPA nd MA pilots hve similr MH risk profiles. remotely piloted ircrft (RPA), denoted previously in the U.S. Air Force (USAF) s unmnned eril vehicles, nd known colloquilly s drones, joined the ircrft inventory of the U.S. militry in the 196s. RPA pilots in the USAF were designted with unique specilty code in October 23, corresponding to the expnding role of these ircrft in Opertions Enduring Freedom (OEF) nd Irqi Freedom/New Dwn (OIF/ OND). Flight hours for the MQ-1 Predtor the premier intelligence, surveillnce, nd reconnissnce RPA pltform in the USAF incresed tenfold from 23 to 29. 1 The psychologicl impct of this new telewrfre on RPA crew members hs been the subject of reports in the populr press, 2,3 with some reports climing higher rtes of post-trumtic stress disorder (PTSD) mong RPA crew members s compred to their counterprts deployed to the combt theter. 4 Although USAF white pper dismissed this clim s senstionl, 5 the psychologicl helth of RPA crew members remins topic of militry public helth nd opertionl concern. Reserch by Chppelle nd collegues t the USAF School of Aerospce Medicine, Deprtment of Neuropsychitry, hs demonstrted high levels of stress nd ftigue mong the pilots, sensor opertors, nd imge nlysts who comprise the RPA crews. Among 6 crew members of the wepon-deploying Predtor nd Reper RPAs who completed voluntry survey, 15.3 percent reported feeling very or extremely stressed nd 19.5 percent reported high emotionl exhustion. Among 264 crew members of the RQ-4 Globl Hwk, non-wepon-deploying RPA, these proportions rose to 19.4 percent nd 33. percent, respectively. 6 At the Brookings Institution in 212, Chppelle noted tht 4 percent of ctive duty RPA pilots were t high risk for PTSD bsed on this survey. Although this represents substntil number of service members, it is lower thn the 12-17 percent of soldiers returning from OEF or OIF/OND who re plced in this high-risk ctegory bsed on post-deployment questionnires. 7 Along with witnessing trumtic experiences, such s those ssocited with PTSD in trditionl combt, RPA crew members my fce severl dditionl chllenges, some of which my be unique to telewrfre: lck of deployment rhythm nd of combt comprtmentliztion (i.e., cler demrction between combt nd personl/fmily life); 5 ftigue nd sleep disturbnces secondry to shift work; 8 ustere geogrphic loctions of militry instlltions supporting RPA missions; 6 socil isoltion during work, which could diminish unit cohesion nd thereby increse susceptibility to PTSD; 9 nd sedentry behvior with prolonged screen time, implicted s psychologicl chllenges in the dult video gming community. 1 This retrospective cohort study is the first to document the frequencies, incidence rtes, nd trends of mentl helth (MH) outcomes mong RPA pilots within the ctive component of the USAF, nd how these rtes compre to those mong mnned ircrft (MA) pilots (fixed wing nd rotry wing) nd mong irmen in other USAF occuptions during the sme time period. For the purposes of this study, combt is defined brodly s ctul or remote deployment to combt zone, nd not necessrily s enggement with enemy combtnts. METHODS The surveillnce period ws 1 October 23 the dte t which n irmn could first be identified s n RPA pilot by Air Force Specilty Code (AFSC) through 31 December 211. The surveillnce Mrch 213 Vol. 2 No. 3 MSMR Pge 3

popultion included service members who hd served t ny time in the ctive component of the USAF. RPA pilots were defined by the following AFSCs: 11U (RPA pilot); 18A (ttck RPA pilot); 18G (generlist RPA pilot); 18R (reconnissnce RPA pilot); nd 18S (specil opertions RPA pilot). MA pilots were defined s irmen deployed to OEF or OIF/ OND for greter thn 3 dys nd who hd one of the following AFSCs: 11B (bomber pilot); 11F (fighter pilot); 11G (generlist pilot); 11H (rescue pilot); 11M (mobility pilot); 11R (reconnissnce/surveillnce/ electronic wrfre pilot); nd 11S (specil opertions pilot). A pilot could pper in only one cohort during the surveillnce period; pilots who met criteri for both RPA nd MA were clssified s RPA pilots. RPA pilots were eligible to receive MH outcome during window beginning 3 dys fter designtion s n RPA pilot (to llow for development nd dignosis of the outcome) nd ending t seprtion from ctive service or the conclusion of the surveillnce period. MA pilots were eligible to receive MH outcome during window beginning 3 dys fter the strt of their first OEF or OIF/OND deployment nd lso ending t seprtion from ctive service or the conclusion of the surveillnce period. Pilots with MH outcome recorded prior to the strt of this window were considered prevlent cses nd therefore were ineligible to become incident cses for tht specific MH outcome. Those dignosed with more thn one MH outcome during the surveillnce period were considered incident cses in ech ctegory for which they met cse-defining criteri, but they were considered n incident cse only once for ny specific MH outcome. Time-sensitive covrites, such s ge, were determined t the strt of the surveillnce period or, for those who entered fter this time, t entry to ctive militry service. MH outcomes were ctegoried into two groups: ctul mentl helth dignoses defined by ICD-9-CM codes (e.g., djustment disorders, lcohol buse/dependence, nxiety disorders) nd mentl helth counseling defined by V-codes nd E-codes (e.g., suicide idetion/ttempt, prtner reltionship problems, fmily circumstnce problems). For ll MH outcomes other thn suicide ttempt or idetion, cses were defined by t lest one hospitliztion record with the relevnt dignosis in the first or second dignostic position, or two records of mbultory encounters within 18 dys with the relevnt dignosis in the first or second dignostic position, or one mbultory encounter in psychitric or MH cre specilty setting with the relevnt dignosis in ny dignostic position (Tble 1). Cses of suicide ttempt nd suicide idetion were defined by just one mbultory encounter or hospitliztion with tht dignosis. As implied by the nme, the ctegory ll outcomes refers to the totl number of times tht pilots stisfied cse definition for the outcome of interest, wheres ny refers to the number of unique individuls who stisfied the cse definition for t lest TABLE 1. Mentl helth outcomes nd cse-defining dignostic codes, V- codes nd E- codes (ICD-9-CM) Outcome ICD-9-CM codes Adjustment disorder 39.x-39.9x (exclude 39.81) Alcohol buse nd dependence 33.xx, 35.x Anxiety disorder 3.-3.9, 3.2-3.29, 3.3 Depressive disorder 296.2-296.35, 296.5-296.55, 296.9x, 3.4, 311 Post-trumtic stress disorder 39.81 Substnce buse/dependence 34.xx, 35.2x-35.9x Suicide idetion/ttempt V62.84, E95.xx-E958.x Prtner reltionship problems V61.x, V61.1, V61.1 (exclude V61.11, V61.12) Fmily circumstnce problems V61.2, V61.23, V61.24, V61.25, V61.29, V61.8, V61.9 Mltretment relted V61.11, V61.12, V61.21, V61.22, V62.83, 995.8-995.85 Life circumstnce problems V62.xx (exclude V62.6, V62.83) Mentl, behviorl problems V4xx (exclude V4., V4.1), V65.42 nd substnce buse counseling one of the outcomes. All outcomes were obtined from the electronic helth cre records mintined in the Defense Medicl Surveillnce System (DMSS) nd the Theter Medicl Dt Store (TMDS). We clculted incidence rtes (IR) per 1, person-yers nd incidence rte rtios (IRR) with 95% confidence intervls (CI). In multivrite nlysis, IRRs were djusted for ge, number of deployments, time in service, nd history of ny MH outcome. Time in service ws determined bsed on the time from entry into militry service to first record s n RPA pilot or fixed wing or rotry wing pilot. All nlyses were performed with STATA/IC version 11.2 (STATACorp). P-vlues less thn.5 were considered sttisticlly significnt; ll P-vlues were bsed on 2-sided tests. RESULTS A totl of 79 USAF service members were identified s RPA pilots nd 5,256 s MA pilots (including 4,786 fixed-wing nd 47 rotry-wing) during the surveillnce period (Tble 2). The two cohorts were reltively similr in terms of demogrphics nd militry chrcteristics. RPA pilots were predominntly mle (94.6%) with n verge (stndrd devition) ge of 32.3 (5.5) yers. Nerly 86 percent were white, non-hispnic, 74 percent were mrried, nd 7 percent were compny grde officers (i.e., lieutennts nd cptins). Compred to MA pilots, greter percentge of RPA pilots hd been deployed three or more times in ny occuptionl cpcity (48% versus 31%; p<.1), hd prior MH dignoses (27% versus 16%; p<.1) nd hd six or more yers in service (75% versus 6%; p<.1). Of the 79 USAF service members who met criteri for n RPA pilot, only 82 were RPA pilots exclusively nd hd never been deployed. The mjority of RPA pilots hd been previously deployed s MA pilots. (While use of mutully exclusive cohorts is idel, restricting the RPA cohort to those 82 pilots would hve resulted in insufficient sttisticl power to conduct our nlysis.) Approximtely 8.2 percent (n=58) of RPA pilots nd 6. percent (n=313) of MA pilots hd t lest one MH outcome Pge 4 MSMR Vol. 2 No. 3 Mrch 213

TABLE 2. Demogrphic nd militry chrcteristics of USAF RPA nd MA pilots, 1 October 23-31 December 211 RPA pilots MA pilots No. % No. % Totl 79 1 5,256 1 Sex Femle 38 5.4 142 2.7 Mle 671 94.6 5,114 97.3 Age 2-24 1.1 41 7.6 25-29 271 38.2 2,194 41.7 3-34 243 34.3 936 17.8 35-39 18 15.2 87 16.6 4+ 86 12.1 855 16.3 Rce/ethnicity White, non-hispnic 66 85.5 4,792 91.2 Blck, non-hispnic 21 3. 1 1.9 Hispnic 34 4.8 1 1.9 Asin/Pcifi c Islnder 19 2.7 65 1.2 Other 29 4.1 199 3.8 Mritl sttus Single 152 21.4 1,374 26.1 Mrried 526 74.2 3,752 71.4 Other 31 4.4 13 2.5 Eduction level College 5 7.5 3,38 62.9 Advnced degree 175 24.7 1,793 34.1 Other 34 4.8 155 2.9 No. of deployments 82 11.6. 1 148 2.9 2,1 38.1 2 138 19.5 1,627 31. 3+ 341 48.1 1,628 31. Totl time deployed <6 months 283 39.9 1,978 37.6 6-12 months 239 33.7 1,959 37.3 13-18 months 14 19.7 935 17.8 18+ months 47 6.6 384 7.3 Militry rnk 2LT-CPT 494 69.7 3,297 62.7 MAJ-COL 215 3.3 1,959 37.3 Time in USAF prior to AFSC <6 yers 178 25.1 2,126 4.4 6-1 yers 253 35.7 1,129 21.5 11-15 yers 187 26.4 1,487 28.3 16+ yers 91 12.8 514 9.8 Prior MH outcome 191 26.9 852 16.2 Abbrevitions: AFSC, Air Force Specilty Code; MA, mnned ircrft; MH, mentl helth; RPA, remotely piloted ircrft; USAF, United Sttes Air Force (Tble 3). The incidence rtes of ll MH outcomes mong RPA pilots ws 25. per 1, person-yers nd mong MA pilots ws 15.9 per 1, person-yers (djusted IRR=1.1, 95% CI=.9-1.5). After djustment, RPA pilots nd MA pilots hd sttisticlly equivlent incidence rtes of totl nd individul MH outcomes evluted (Tble 3, Figure 1). Adjustment disorder nd depressive disorder were the two most common dignoses in both RPA nd MA pilots, while prtner reltionship nd life circumstnce problems were the two most common counseling codes. The trend of nnul rtes (undjusted) of MH outcomes mong RPA pilots mrkedly differed from the trend mong MA pilots. For exmple, nnul rtes of MH outcomes mong MA pilots slowly incresed throughout OEF nd OIF/OND nd were highest (29 per 1, personyers) in 211. In contrst, mong RPA pilots, nnul rtes remined reltively stble from 25 through 28, incresed mrkedly in 29 nd 21, nd then nerly returned to bseline in 211. Of note, ech yer from 25 through 211 (nd prticulrly in 29 nd 21), rtes (undjusted) of MH outcomes were higher mong RPA thn MA pilots (Figure 2). Finlly, incidence rtes (undjusted) of ny mentl helth outcomes were lower mong RPA nd MA pilots thn USAF members in helth cre, dministrtive/ supply, combt-specific, nd other occuptions, s well s mong USAF members overll (Figure 3). EDITORIAL COMMENT This report documents the frequencies, incidence rtes, nd trends of MH outcomes mong RPA pilots within the ctive component of the USAF compred to those mong USAF MA pilots during the sme time period. Between October 23 nd December 211, pproximtely one of every 12 RPA pilots nd one of every 17 MA pilots received t lest one incident MH outcome (i.e., first dignosis of the outcome during their militry creers). After djusting for the effects of severl fctors tht differed between the RPA nd MA pilots, incidence rtes mong the cohorts did not significntly differ. Despite selfreports of high levels of stress nd ftigue mong RPA pilots, this study did not find higher djusted rtes of MH outcomes mong this cohort compred to MA pilots. RPA nd MA pilots hd lower undjusted incidence rtes of ny MH outcome s compred to USAF members overll nd to specific occuptionl groups within the USAF. Severl fctors my explin this finding. First, s highly screened nd selected group, USAF pilots re likely less prone to MH outcomes s compred to irmen in other occuptions. All USAF pilots re college grdutes who hve pssed stringent physicl requirements, psychologicl Mrch 213 Vol. 2 No. 3 MSMR Pge 5

TABLE 3. Incidence rtes nd rte rtios of mentl helth outcomes by pilot type, 1 October 23-31 December 211 RPA pilots MA pilots Undjusted IRR Adjusted IRR b Mentl helth outcomes No. IR (95% CI) No. IR (95% CI) (95% CI) (95% CI) Adjustment disorders 22 6.6 (4.4-1.1) 14 3.6 (2.9-4.3) 1.9 (1.2-2.9) 1.4 (.9-2.3) Alcohol buse/dependence 3.9 (.3-2.7) 25.9 (.6-1.3) 1. (.3-3.4) 1. (.4-2.7) Anxiety disorder 9 2.7 (1.4-5.1) 36 1.2 (.9-1.7) 2.2 (1.-4.5) 1.3 (.6-2.9) Depressive disorder 11 3.3 (1.8-5.9) 46 1.6 (1.2-2.1) 2.1 (1.1-4.) 1.4 (.7-2.9) Post-trumtic stress disorder 3.9 (.3-2.7) 2.7 (.4-1.) 1.3 (.4-4.3).6 (.2-2.2) Substnce buse/dependence 1.3 (.-2.1) 1. (.-.2) 8.6 (.5-138) --- Any mentl helth dignosis 37 1.9 (7.9-15.) 176 6. (5.2-7.) 1.8 (1.3-2.6) 1.3 (.9-1.9) Suicide idetion/ttempt. 1. (.-.2) --- --- Prtner reltionship problems 14 4.2 (2.5-7.1) 11 3.5 (2.9-4.2) 1.2 (.7-2.1) 1. (.5-1.7) Fmily circumstnce problems 2.6 (.1-2.4) 7.2 (.1-.5) 2.5 (.5-11.8) 1.9 (.4-9.6) Mltretment relted. 4.1 (.1-.4) --- --- Life circumstnce problems 16 4.8 (2.9-7.8) 85 2.9 (2.4-3.6) 1.6 (1.-2.8) 1.3 (.7-2.2) Mentl, behviorl problems, substnce buse 4 1.2 (.4-3.1) 34 1.2 (.8-1.6) 1. (.4-2.9).7 (.2-1.9) Any mentl helth counseling 3 8.8 (6.2-12.6) 25 7. (6.1-8.) 1.3 (.9-1.8) 1. (.6-1.4) Any mentl helth outcome 58 17.1 (13.2-22.1) 313 1.7 (9.6-12.) 1.6 (1.2-2.1) 1.2 (.9-1.6) All mentl helth outcomes 85 25. (2.2-3.9) 464 15.9 (14.5-17.4) 1.6 (1.3-2.) 1.1 (.9-1.5) Dignoses Counseling Incidence rtes per 1, person-yers Abbrevitions: CI, confi dence intervl; IR, incidence rte; IRR, incidence rte rtio; MA, mnned ircrft; RPA, remotely piloted ircrft Undjusted incidence rtes b Adjusted for ge, number of deployments, time in service, nd history of ny mentl helth outcome stndrds, legl nd behviorl bckground checks, nd rigorous opertionl trining progrms. 11 Flight surgeons evlute ll pilot cndidtes for occuptionl suitbility, which includes emotionl nd behviorl screening. Discovery of psychoses, neuroses, or personlity disorders, for exmple, my result in disqulifiction. 12 Second, these findings my reflect the effects of specil preventive mesures for pilots. As compred to irmen in other occuptions, pilots undergo more robust periodic helth ssessments nd my hve better ccess to cre given the reltively low rtio of pilots to flight surgeons. Conversely, the reltively low rtes of mentl disorder dignoses mong Air Force pilots compred to their counterprts my reflect rtificil underreporting of the concerns of pilots due to detrimentl creer rmifictions from incurring MH dignoses (but not counseling); the creer-thretening effects of MH dignoses include removl from flying sttus, loss of flight py, nd diminished competitiveness for promotion. Current USAF eromedicl policy requires tht pilots with MH dignosis be immeditely grounded, or removed from flying FIGURE 1. Adjusted incidence rtes of MH outcomes, by pilot type, U.S. Air Force, 1 October 23-31 December 211 Any MH dignosis Any MH counseling Any MH outcome All MH outcomes.6 (.2-2.).5 (.2-1.5) Incidence rtes per 1, person-yers with 95% confidence intervls Abbrevitions: MH, mentl helth; RPA, remotely piloted ircrft sttus. An eromedicl wiver to resume flight duty cnnot be submitted until the individul hs been ppropritely treted nd hs been symptomtic nd without medictions for specified time period. Although this time period vries by dignosis nd flight surgeon discretion, it typiclly rnges from six months to one yer. A pilot with n lcohol buse or dependence 2.9 (1.2-7.1) 2.4 (1.-5.9) 3.8 (1.8-8.) 3.3 (1.6-6.8) 4.5 (1.4-15.5) 4.8 (1.5-15.6). 1. 2. 3. 4. 5. 6. Adjusted incidence rtes per 1, person-yers RPA pilots MA pilots dignosis, for exmple, cnnot return to flying sttus until completion of lcohol rehbilittion, which includes bstinence trining nd 9 dys in post-tretment ftercre progrm. 13 Some MH dignoses my require medicl evlution bord for the individul to remin in the USAF. 14 Severl importnt fctors distinguish these findings from those reported Pge 6 MSMR Vol. 2 No. 3 Mrch 213

FIGURE 2. Undjusted incidence rtes of MH outcomes, b by pilot type, U.S. Air Force, 1 October 23-31 December 211 FIGURE 3. Undjusted incidence rtes of MH outcomes by USAF occuption, 1 October 23-31 December 211 225 2 175 15 RPA MA All Air Force (n=64,534) MA pilots (n=5,256) RPA pilots (n=79) Any MH dignosis Any MH counseling 125 Combt (n=44,13) Any MH outcome 1 75 5 Helthcre (n=38,577) Admin/supply (n=92,153) 25 Other (n=459,79) 2 4 6 8 1 23 24 25 26 27 28 29 21 211 Incidence rte per 1, person-yers Incidence rtes per 1, person-yers Abbrevitions: MA, mnned ircrft; MH, mentl helth; RPA, remotely piloted ircrft Incidence rtes per 1, person-yers (non-rpa nd non-ma pilots re included in "Other") Abbrevitions: MA, mnned ircrft; MH, mentl helth; n, number of unique individuls; RPA, remotely piloted ircrft; USAF, United Sttes Air Force in cse series nd the ly press. The results presented here reflect helthcre providerssigned clinicl dignostic codes entered into the electronic medicl records of service members. In contrst, other published studies hve relied upon selfreported dt from nonymous questionnires, which reflect symptoms rther thn forml dignoses. The findings of this report should be interpreted within the context of t lest four limittions. First, cpture of incident MH outcomes my be incomplete. Incident cses were scertined from ICD-9-CM dignostic codes recorded on stndrdized dministrtive records of medicl encounters. As such, the findings only reflect outcomes tht were cliniclly detected. To the extent tht pilots received cre from sources not cptured by DMSS (e.g., privte prctitioner), or did not seek cre (e.g., due to creer concerns outlined bove, socil stigms, or the unvilbility of MH providers), the numbers reported here re underestimtes. Moreover, dignoses used to identify cses for this report were not confirmed by medicl record review. In ddition, while TMDS cptures most MH outcomes dignosed in deployed medicl fcilities, this dt source my be incomplete. However, since the percentge of totl person-time deployed ws smll nd comprble 6 percent mong MA pilots nd 5 percent mong RPA pilots this is unlikely to introduce bis. Second, nlyses for this report were limited to the medicl encounters of ctive component members of the USAF only. This report does not contin dt for the Air Force Reserves or Air Ntionl Gurd, nor does it include dt on other services within the ctive component (i.e., Army, Nvy, nd Mrine Corps). Its findings, therefore, my not be generlizble to other militry components nd services. Third, this study utilized AFSCs s surrogtes for exposure (i.e., remote combt or trditionl combt). In relity, both RPA nd MA pilots likely experienced differentil levels of exposure. An idel nlysis would incorporte hours exposed to remote combt in the RPA cohort nd the hours exposed to trditionl combt in the MA cohort, but such grnulr dt were unvilble. Insted, deployment nd demogrphic records were employed to determine exposure time, nd multivrite nlysis ws used to control for deployment durtion. Even if hours engged in combt were identicl in the two cohorts, combt experiences my diverge. Both RPA nd MA pilots conduct different types of missions with different objectives (e.g., conducting surveillnce or deploying munitions). Given the lck of evidence linking type of eril mission with likelihood of mentl helth outcomes, we did not strtify within ech cohort. In ddition, irmen were clssified s RPA pilots even if they lso met criteri s MA pilots during the surveillnce period; without mutul exclusivity of the cohorts, there my be bis towrd the null. Fourth, the findings re bsed on incident, dichotomous MH outcomes. Recurrent outcomes were not ssessed, nd the dignostic codes used to determine cses do not reflect the clinicl severity of the outcome. In summry, the findings of this report suggest tht remote combt does not increse the risk of MH outcomes beyond tht seen in trditionl combt. Militry policymkers nd clinicins should recognize tht RPA pilots hve similr MH risk profile s MA pilots. Although undjusted rtes of MH outcomes mong both cohorts of pilots were much lower thn rtes mong those in other USAF occuptions, further reserch is needed to evlute the impct of eromedicl policy on these rtes, s well s the effect of remote combt on other RPA crew members. Mrch 213 Vol. 2 No. 3 MSMR Pge 7

Author ffilitions: Armed Forces Helth Surveillnce Center nd the Henry M. Jckson Foundtion for the Advncement of Militry Medicine (Dr. Otto); nd the Uniformed Services University of the Helth Sciences, Deprtment of Preventive Medicine nd Biometrics (Cpt Webber). REFERENCES 1. Chppelle W, McDonld K, McMilln K. Importnt nd Criticl Psychologicl Attributes of USAF MQ-1 Predtor nd MQ-9 Reper Pilots According to Subject Mtter Experts. Wright-Ptterson AFB, OH: Air Force Reserch Lbortory; My 211. 2. Zucchino D. Stress of Combt Reches Drone Crews. Los Angeles Times. Mrch 23, 212. 3. Mulrine A. Wr from fr, but still jrring. The Christin Science Monitor. Mrch 5, 212. 4. Singer P, Gross T (host). The Ethicl, Psychologicl Effects of Robotic Wrfre. Ntionl Public Rdio. Jnury 22, 29. 5. Fisher CR, Stnczyk D, Orteg H. Telewrfre nd Militry Medicine White Pper/Stte of the Art Report on AFMS Support to the Emerging Prdigm of Employed-in-Plce Opertions 211. 6. Chppelle W, Slins A, McDonld K. Psychologicl Helth Screening of Remotely Piloted Aircrft (RPA) Opertors nd Supporting Units. Deprtment of Neuropsychitry, USAF School of Aerospce Medicine, Wright-Ptterson Air Force Bse, OH. 7. Chppelle W, McDonld K. Occuptionl Helth Stress Screening for Remotely Piloted Aircrft & Intelligence (Distributed Common Ground System) Opertors. Pper presented t: Foreign Policy nd 21st Century Defense Inititive Event 212; The Brookings Institution, Wshington, DC. 8. Tvryns AP, McPherson GD. Ftigue in pilots of remotely piloted ircrft before nd fter shift work djustment. Avit Spce Environ Med. My 29;8(5):454-461. 9. Dickstein BD, McLen CP, Mintz J, et l. Unit cohesion nd PTSD symptom severity in Air Force medicl personnel. Mil Med. Jul 21;175(7): 482-486. 1. Wever JB, 3rd, Mys D, Srgent Wever S, et l. Helth-risk correltes of video-gme plying mong dults. Am J Prev Med. Oct 29;37(4): 299-35. 11. Dvis J, Johnson R, Stepnek J, Fogrty J, eds. Fundmentls of Aerospce Medicine. 4th ed. Phildelphi: Lippincott Willims & Wilkins; 28. 12. Jones D, Mrsh R. Psychitric considertions in militry erospce medicine. Avit Spce Environ Med. Feb 21;72(2):129-135. 13. Deprtment of the Air Force, USAF School of Aerospce Medicine. Air Force Wiver Guide. 212; Found t: http://www.wpfb.f.mil/ shred/medi/document/ AFD-121219-2.pdf. Accessed 14 Jnury 213. 14. United Sttes Air Force. Air Force Instruction 48-123. 29; Found t: http://www.e-publishing.f.mil/ shred/medi/epubs/afi48-123.pdf. Accessed 14 Jnury 213. Pge 8 MSMR Vol. 2 No. 3 Mrch 213

Externl Cuses of Trumtic Brin Injury, 2-211 This report summrizes frequencies, distributions, nd trends of externl cuses of trumtic brin injuries (TBIs) tht re recorded on stndrdized records of medicl encounters of U.S. militry members. Cuses of TBI were reported for 1 percent of cses hospitlized in militry fcilities, but were reltively infrequently reported in other tretment settings (i.e., militry outptient fcilities, combt theter nd civilin medicl fcilities). During 28 to 211 in ll clinicl settings combined, 24,115 service members hd TBI cse-defining medicl encounters with recorded injury cuses. Accidents represented 74 percent of recorded cuses; the most frequently reported specific cuses were motor vehicle trffic ccidents (2%), flls (2%), nd being struck by or struck ginst n object (15%). Similr proportions of TBIs were reportedly due to intentionl ssults unrelted to wr (11%) nd bttle injuries (11%). Assults were second only to motor vehicle ccidents s reported cuses of TBIs treted in civilin hospitls. Some TBIs reportedly due to ccidents with guns/explosives were likely combt injuries tht were miscoded in militry hospitls. The doubling of the number of combt-relted TBIs reported from Irq/Afghnistn between 21 nd 211 undoubtedly reflects the U.S. militry s incresed focus on identifying nd treting TBIs mong deployed militry members. trumtic brin injury (TBI) is dmge to nd functionl impirment of the brin cused by sudden externl force. Surveillnce of TBIs mong U.S. militry members is conducted by monitoring numbers nd rtes of TBIrelted dignoses in routinely reported records of medicl encounters. Concussion nd hed injury, unspecified ccount for pproximtely two-thirds of ll incident TBI-relted dignoses recorded during hospitliztions nd mbultory visits of U.S. service members. 1 TBI hs long been n importnt source of morbidity mong U.S. service members. Although TBI hs been referred to s the signture injury of the wrs in Irq nd Afghnistn, rtes of TBI-relted hospitliztions hve not significntly incresed from before to during those conflicts. 1,2 A previous MSMR report indicted tht, since the beginning of the wrs in Irq/ Afghnistn, fewer thn five percent of ll TBI-relted hospitliztions of ctive component service members were relted to bttle csulties (per cuses of injuries documented in stndrdized medicl records). 3 In generl, the most frequent cuses of TBIs mong both militry members nd sme-ged civilins hve been ccidents (e.g., motor vehicle crshes, flls, strikes by/ginst objects) nd intentionl ssults (e.g., fights, brwls). 4,5 This report summrizes the frequencies, distributions, nd trends of externl cuses of TBIs tht re recorded on stndrdized records of medicl encounters of U.S. militry members, including records of tretment provided in combt theters. It ssesses the completeness of recording of externl cuses of TBIs in vrious clinicl settings nd describes the distribution of cuses of TBIs by gender nd in reltion to clinicl severity. METHODS The surveillnce period ws 1 Jnury 2 to 31 December 211. The surveillnce popultion included ll individuls who served in the ctive component of the U.S. militry ny time during the surveillnce period. For surveillnce purposes, TBI cses were defined by records of hospitliztions or mbultory visits of ctive component members tht included n ICD-9-CM dignosis code indictive of trumtic brin injury (per the Deprtment of Defense stndrd cse definition) 6 in the primry (first-listed) dignostic position; or TBI indictor dignosis in ny nonprimry dignostic position, if the primry (first-listed) dignosis during the sme encounter ws indictive of n injury (to the brin or ny other ntomicl entity). Of note, individuls whose only TBIrelted dignoses during the surveillnce period were for injuries tht occurred in the pst, i.e., post-concussion syndrome (ICD-9-CM: 31.2), personl history of TBI (ICD-9:V15.5), were not considered cses for this nlysis. Only one TBI-relted medicl encounter per individul ws included for nlysis. If individuls hd more thn one TBI cse-defining medicl encounter during the period, the record used for nlysis ws the erliest tht included both TBI csedefining dignosis nd n externl-cuseof-injury code. If cuse-of-injury codes were bsent from ll records of TBI-relted medicl encounters of cses, the record from the erliest TBI-relted encounter of ech cse ws used for nlysis. Externl cuses of TBIs were scertined from externl cuse of injury codes (ICD-9-CM E-codes) reported on records of TBI-relted inptient nd outptient encounters in militry nd civilin tretment fcilities; nd from cuse of injury codes (STANAG codes) reported on records of TBI-relted hospitliztions in militry hospitls in signtory ntions of the North Atlntic Trety Orgniztion s Stndrd Agreement on cuse-of-injury coding (STANAG 25). The ICD-9-CM E-code nd STANAG cuse-of-injury clssifiction systems hve been described, compred, nd contrsted elsewhere. 7 If TBI-relted Mrch 213 Vol. 2 No. 3 MSMR Pge 9

hospitliztion records included both E- codes nd STANAG codes, the STANAG code ws considered indictive of the cuse of the respective TBI. Externl cuses of TBIs were clssified into nine ctegories bsed on whether the injuries were intentionlly inflicted or ccidentl nd bsed on the circumstnces or ctivities ssocited with the injuries (Tble 1). An ll other cuses ctegory combined non-specific or infrequent cuses of TBI, including intentionlly self-inflicted, which ccounted for less thn one percent of TBI-relted encounters with recorded cuses. TBIs for which the only cusl informtion ws E849 ( plce of occurrence ) were considered to hve missing cuses. Externl cuses of TBI were evluted in three tretment settings: militry tretment fcilities in the U.S., Europe, Kore nd Jpn; civilin fcilities (contrcted/ reimbursed cre) in U.S. nd overses loctions; nd deployed medicl fcilities in the combt theters of Irq nd Afghnistn. RESULTS During the 12 yers between 2 nd 211, 175,29 ctive component service members hd t lest one TBI dignosis (in ny dignostic position) tht ws ssocited with contemporneous injury. These individuls hd 155,486 TBI cse-defining medicl encounters with primry (first-listed) dignoses of TBI or other injuries; of these TBI cse-defining medicl encounters, 85 percent were mbultory visits, nd 42 percent were in non-militry fcilities (Figure 1). Completeness of externl cuse recording During the 12-yer period, more thn two-thirds of ll records of TBI cse-defining medicl encounters did not include cuse-of-injury codes. The completeness of reporting of externl cuses of TBIs shrply vried cross clinicl settings (Figure 2). For exmple, of TBIs treted in non-deployed militry tretment fcilities (MTFs), cuses TABLE 1. Cuse of injury ctegories s defi ned by externl cuse of injury codes (E- codes) nd STANAG codes Externl cuse ctegory STANAG codes E-code (ICD-9-CM) Bttle injury Assult (non-bttle), legl intervention Gun/explosive ccident Fll Struck by/mchinery STANAG 3-479 (except with Trum 4). Trum or 1 plus STANAG 5-999 Trum 2 or 3 plus STANAG 5-999 STANAG 48-599 (except with Trum 4) Trum 5-9 plus STANAG 9-929 Trum 5-9 plus STANAG 66-699 E99-E999, E979 E96-E978 E922, E923, E928.7 E833-E835, E888, E88-E885, E886.9, E929.3 E916, E917.1-E917.4, E917.6- E917.9, E918-E921, E836, E837 Motor vehicle trffic STANAG 1-149 E81-819, E929. Other trnsporttion ccident STANAG -59, 15-199 Sports/thletics STANAG 2-249 E8-E87, E82-E832, E838- E848 E6-E1, E917., E917.5, E886. All other cuses Trum 4 plus STANAG 3-999, ll other STANAG All other E codes except E849 codes not listed bove No cuse recorded No STANAG code No E code or E849 only Per United Ntions Stndrd Agreement (STANAG) 25. Trum indictes the generl clss of trum per the fi rst digit of ech 4 digit-stanag code. STANAG codes were vilble from records of militry hospitliztions only. STANAG codes were prioritized over E codes when both were present in the sme medicl record. Self-infl icted injuries re included in ll other cuses. of TBI-relted injuries were reported for 1 percent (7,982/7,983) of hospitlized but only 4 percent (29,282/72,45) of outptient treted cses. Becuse codes indictive of cuses of TBIs were infrequently reported in records of medicl encounters in combt theter deployed nd civilin medicl fcilities, especilly prior to 28 (Figure 2), nlyses of cuses of TBIs dignosed in deployed nd civilin medicl fcilities were restricted to the period 28 through 211. During this period, the proportions of records of TBI cse-defining encounters tht included cuse-of-injury codes, by clinicl setting, were 39 percent of 2,118 hospitliztions in civilin fcilities; 23 percent of 24,733 encounters in civilin mbultory clinics; nd 15 percent of 6,95 encounters in medicl fcilities in combt theters. Cuses of injuries During 28 to 211 in ll clinicl settings combined, 24,115 service members hd TBI cse-defining medicl encounters with recorded injury cuses. Accidents represented 74 percent of recorded cuses; the most frequently reported specific cuses were motor vehicle trffic ccidents (2%), flls (2%), nd being struck by or struck ginst n object (15%). Among TBI cse-defining medicl encounters FIGURE 1. Number of TBI cse-defining medicl encounters (n=155,486), by clinicl setting of tretment, ctive component, U.S. Armed Forces, 2-211 No. 9, 8, 7, 6, 5, 4, 3, 2, 1, 72,45 59,963 7,983 6,9 9,126 Militry tretment fcility Ambultory visit Hospitliztion Non-militry fcility Combt theter Medicl encounters (one per individul) with TBI indictor code in ny dignostic position. Only encounters with primry (first-listed) dignosis of n injury (ICD-9-CM: 8-999) were retined for nlysis. Pge 1 MSMR Vol. 2 No. 3 Mrch 213

with recorded cuses, similr numbers of injuries were reportedly due to intentionl ssults unrelted to wr (n=2,526, 11%) nd bttle injuries (n=2,711, 11%) (dt not shown). Militry tretment fcilities (nondeployed): During 2 to 211, of the nerly 8, TBIs tht were treted in fixed (e.g., not deployed or t se) militry hospitls, 81 percent were reportedly due to ccidentl injuries (Figure 3). The most frequently reported cuse-of-injury codes were motor vehicle trffic ccidents (32%), gun/explosive ccidents (24%) nd flls (13%). Six percent of TBI-relted injuries treted in fixed militry hospitls were ttributed to bttle injuries. Notbly, of the eight percent of TBI-relted hospitliztions with other cuses of injury, pproximtely one-qurter (n=192, 26%) were reported s unintentionl injuries due to fighting, not elsewhere clssified, including horseply (dt not shown). A mjority (6%) of the records of TBI cse-defining mbultory visits in fixed militry medicl fcilities hd no cuse-of-injury codes (Figure 3). Accidents were the most frequently reported cuses of injuries (76%) on records of TBI csedefining mbultory visits with cuse-ofinjury codes (n=29,282) (dt not shown). In comprison to the percentge distribution of cuses of TBIs tht were treted in militry hospitls, TBIs treted during mbultory visits with reported cuses were reltively less frequently due to motor vehicle ccidents (15%) nd gun/explosive ccidents (1%) nd more frequently due to flls (22%), ccidentl strikes by or ginst objects (19%) nd ssults (11%) (dt not shown). Among service members treted in militry medicl fcilities during 2 to 211, the numbers of first-time TBIs due to motor vehicle trffic ccidents declined stedily in hospitls but remined reltively stble in mbultory settings (Figures 4, 4b). Notble increses in numbers of TBIs due to combt injuries nd gun/explosive ccidents begn in 23 nd 26 in hospitlized nd mbultory settings, respectively. In contrst, nnul numbers of TBIs due to flls nd ccidentl strikes by or ginst objects were reltively stble during the period (dt not shown). FIGURE 2. Percentge of TBI cse-defi ning medicl encounters with ny cuse of injury code, by clinicl setting, ctive component, U.S. Armed Forces, 2-211 Percentge 1 9 8 7 6 5 4 3 2 1 2 21 22 FIGURE 3. Percentge of TBI cse-defi ning medicl encounters with specifi c cuse or with no cuse recorded, by clinicl setting of tretment, militry tretment fcilities, ctive component, U.S. Armed Forces, 2-211 Missing Motor vehicle trffic Gun/explosive ccident Flls Other Bttle injury Assult (non-bttle) Sports/thletics Other trnsport ccident Struck by/mchinery 23 24 25 Combt theter medicl encounters were incompletely reported prior to 28 26 27 28 Hospitliztion (n=7,983) Ambultory visit (n=72,45) 1 2 3 4 5 6 % of encounters "Assult (non-combt)" nd "combt" re intentionl injuries. All others re unintentionl (ccidentl) injuries. Over the entire period, nerly ll (96%) TBI cse-defining hospitliztions due to gun/explosive ccidents were treted t Lndstuhl Regionl Medicl Center (LRMC) in Germny; LRMC is the principl hospitl to which wr-wounded service members re evcuted. By comprison, only 12 percent of TBI cse-defining hospitliztions due to flls were treted t Lndstuhl (dt not shown). Civilin tretment fcilities: During 28 to 211, cuse of injury codes were not recorded on pproximtely three-qurters 29 21 211 Militry hospitls Militry mbultory settings Civilin hospitls Civilin mbultory settings Combt theter of ll records of TBI cse-defining encounters treted in non-militry fcilities (Figure 5). Accidents were the most frequently reported cuses of injuries (78%) on records with cuses of injuries tht documented TBI cse-defining inptient (n=823) nd outptient (n=5,692) encounters in civilin fcilities (dt not shown). Motor vehicle trffic ccidents were by fr the leding specific cuse of TBI cse-defining encounters in civilin inptient (45%) nd outptient (35%) settings. Assults were the second nd third leding cuses of TBI Mrch 213 Vol. 2 No. 3 MSMR Pge 11

cse-defining hospitliztions (19%) nd mbultory visits (16%), respectively. In comprison to the experience in militry fcilities, the proportions of cse-defining TBIs treted in civilin fcilities tht were reportedly due to bttle injuries nd gun/ explosive ccidents were smll. Of csedefining TBIs due to other trnsporttion ccidents, those treted in civilin fcilities were primrily due to off-rod vehicles nd bicycles, while the mjority of those treted in militry fcilities were cused by militry prchuting ccidents. Combt theter: During 28-211, medicl encounters in the combt theters of Irq/Afghnistn ccounted for FIGURE 4. Number of TBI cse-defi ning medicl encounters ttributble to selected cuses of injury, ctive component, U.S. Armed Forces No.. Hospitliztions in militry tretment fcilities, 2-211 8 7 6 5 4 3 2 1 Bttle injury Gun/explosive ccident Assult (non-bttle) Motor vehicle trffic 2 21 22 23 24 25 26 27 28 29 21 211 No. b. Ambultory visits in militry tretment fcilities, 2-211 16 14 12 1 8 6 4 2 Bttle injury Gun/explosive ccident Assult (non-bttle) Motor vehicle trffic 2 21 22 23 24 25 26 27 28 29 21 211 1 percent of ll TBI cse-defining medicl encounters overll but 34 percent of ll cse-defining TBIs reportedly due to bttle injuries. Of the records tht documented 6,95 TBI cse-defining medicl encounters in combt theters, only 15 percent (n=1,51) included cuse-of-injury codes; of cuses of injuries tht were reported, nerly ll were ttributed to combt injuries (88%) or gun/explosive ccidents (7%) (Figure 6). Between 21 nd 211, numbers of TBI-relted encounters due to combt injures more thn doubled while numbers due to gun/explosive ccidents incresed only slightly. Severity Of cse-defining TBIs treted in fixed militry hospitls during 2 to 211, those reported s severe or penetrting brin injuries (per ICD-9-CM dignosis codes) were reltively frequently cused by gun/explosive ccidents (43%), while those reported s moderte (15%) or mild (26%) brin injuries were reltively frequently due to motor vehicle ccidents nd flls (Figure 7). In other clinicl settings, such reltionships were difficult to ssess becuse the cuses of injuries were so frequently unreported. FIGURE 5. Percentge of TBI cse-defi ning medicl encounters in civilin tretment fcilities specifi c cuse or with no cuse recorded, by clinicl setting of tretment, ctive component, U.S. Armed Forces, 28-211 No cuse recorded Motor vehicle trffic Assult (non-bttle) Flls Other trnsporttion ccident Other Struck by/mchinery Sports/thletics Gun/explosive ccident Bttle injury 2 4 6 8 % of encounters Hospitliztions (n=2,118) Ambultory visits (n=24,733) "Assult (non-combt)" nd "combt" re intentionl injuries. All others re unintentionl (ccidentl) injuries. FIGURE 6. Of TBI cse-defining medicl encounters in the combt theter with recorded cuses of injury (n=1,51), number nd percent due to bttle injury nd gun/explosives ccident, ctive component, U.S. Armed Forces, 28-211 No. (brs) 6 5 4 3 2 1 Bttle injury, no. Gun/explosive ccident, no. Bttle injury, % Gun/explosive ccident, % 28 29 21 211 1. 9. 8. 7. 6. 5. 4. 3. 2. 1.. % (lines) Pge 12 MSMR Vol. 2 No. 3 Mrch 213

Cuses of injuries, by gender Of ll cse-defining TBIs treted in ll clinicl settings nd with documented cuses, those mong men compred to women were reltively more often intentionlly inflicted (i.e., ssults, bttle injuries) (dt not shown). Of note, of ll cse-defining TBIs with reported cuses, reltively more were due to gun/explosive ccidents mong mles (12%) thn femles (2%) nd to motor vehicle trffic ccidents mong femles (3%) thn mles (21%) (dt not shown). EDITORIAL COMMENT This report documents tht, since 2, ccidents nd in prticulr, motor vehicle ccidents, flls, nd strikes by or ginst objects re the most frequent cuses of the first trumtic brin injuries tht require medicl cre of militry service members while in ctive service. Assults re nother leding cuse of TBIs mong militry members. Previous MSMR reports hve documented tht trumtic brin injuries re the most frequent primry dignoses during ssult-relted hospitliztions of militry members. 8 In this report, ssults ccounted for 19 percent of ll TBI-relted hospitliztions (with documented TBI cuses) of militry members in civilin hospitls. Assults were second only to motor vehicle ccidents s reported cuses of TBIs tht required civilin hospitl cre. The findings of this report should be ssessed with considertion of its limittions. For exmple, in this report, gun/ explosive ccidents ccounted for reltively more of the TBIs tht received inptient tretment in militry hospitls (24%) thn those treted in other clinicl settings. It is likely, however, tht t lest some TBIs reportedly due to ccidentl injuries were in fct combt injuries tht were miscoded. Of note in this regrd, nerly ll hospitlized TBI cses reportedly due to gun/explosive ccidents received cre t Lndstuhl Regionl Medicl Center in Germny. For mjority of such cses, the cuses of the injuries re reported s guns, explosives nd relted gents, except when used s instrumentlities of wr in wrtime (per STANAG 25). Amoroso nd collegues hve observed tht the STANAG cuse-of FIGURE 7. Externl cuses of trumtic brin injury (TBI), by severity of TBI dignosis, mong TBI-relted hospitliztions in fi xed militry tretment fcilities, ctive component, U.S. Armed Forces, 2-211 1 9 8 7 6 5 4 3 2 1 Severe/ penetrting (n=853) Moderte (n=2,153) Severity determined by ICD-9-CM codes Mild (n=4,625) Struck by/mchinery Assult (non-bttle), legl intervention Bttle injury Flls Other Motor vehicle trffic Gun/explosive ccident injury coding system chieves greter specificity thn ICD-9-CM E-codes becuse the STANAG system requires seprte coding of the intent (e.g., ccident) nd the cuse (e.g., explosive). However, the STANAG system increses the possibility of error. 7 Of specific interest in this regrd, there re hundreds of permuttions of STANAG codes tht cn indicte tht guns, explosives nd other instrumentlities of wr were cuses of relted injuries. Also, compred to the reported cuses of TBIs mong militry hospitlized cses, gun/explosive ccidents were reltively much less frequently reported on records of TBIs tht were treted in militry combt theters (using E- rther thn STANAG cuse of injury codes). Finlly, the distinction between bttle csulties nd ccidents could in some cses be obscured by the unconventionl nture of combt during the recent wrs in Irq/Afghnistn. In summry, if some TBIs from bttle injuries were miscoded s due to ccidents, the overll numbers nd proportions of TBIs due to bttle injuries tht re reported here re underestimtes. In nlyses of dministrtive dt, morbidity trends often reflect chnges in policies nd prctices, e.g., introductions of new screening progrms, mndtory medicl tests. The doubling of the number of combt-relted TBIs reported from Irq/Afghnistn between 21 nd 211 undoubtedly reflects, t lest in prt, the shrp increse in the focus of the U.S. militry on identifying nd treting trumtic brin injuries mong deployed militry members. In July 21, the Deprtment of Defense issued Policy Guidnce for the Mngement of Concussion/Mild Trumtic Brin Injury in the Deployed Setting. 9,1 [DTM 9-33 nd DoDI 649.1] The policy mndtes TBI screening for deployed service members exposed to potentilly concussive events nd medicl evlution for those who sustined physicl injury, endorsed TBI symptoms (e.g., hedche, er ringing), or were less thn 5 meters from blst. A July 212 report to Congress on the implementtion of the policy sttes tht of service members reported with potentilly concussive events during August 21 through August 211, 15 percent received subsequent medicl dignosis of concussion. 11 The report lso Mrch 213 Vol. 2 No. 3 MSMR Pge 13