Hepatitis B seroprevalence in the U.S. military and its impact on potential screening strategies.

INTRODUCTION: Knowledge of the contemporary epidemiology of hepatitis B virus (HBV) infection among military personnel can inform potential Department of Defense (DoD) screening policy and infection and disease control strategies. MATERIALS AND METHODS: HBV infection status at accession and following deployment was determined by evaluating reposed serum from 10,000 service members recently deployed to combat operations in Iraq and Afghanistan in the period from 2007 to 2010. A cost model was developed from the perspective of the Department of Defense for a program to integrate HBV infection screening of applicants for military service into the existing screening program of screening new accessions for vaccine-preventable infections. RESULTS: The prevalence of chronic HBV infection at accession was 2.3/1,000 (95% CI: 1.4, 3.2); most cases (16/21, 76%) identified after deployment were present at accession. There were 110 military service-related HBV infections identified. Screening accessions who are identified as HBV susceptible with HBV surface antigen followed by HBV surface antigen neutralization for confirmation offered no cost advantage over not screening and resulted in a net annual increase in cost of $5.78 million. However, screening would exclude as many as 514 HBV cases each year from accession. CONCLUSIONS: Screening for HBV infection at service entry would potentially reduce chronic HBV infection in the force, decrease the threat of transfusion-transmitted HBV infection in the battlefield blood supply, and lead to earlier diagnosis and linkage to care; however, applicant screening is not cost saving. Service-related incident infections indicate a durable threat, the need for improved laboratory-based surveillance tools, and mandate review of immunization policy and practice.

Damage Control Resuscitation.

Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.

The Armed Services Blood Program: blood support to combat casualty care 2001 to 2011.

BACKGROUND: The Armed Services Blood Program (ASBP) provides the farthest-reaching blood supply in the world. This article provides statistics and a review of blood operations in support of combat casualty care during the last 10 years. It also outlines changes in blood doctrine in support of combat casualty care. METHODS: This is a descriptive overview and review of blood product use and transfusions used by ASBP personnel to support combat operations in Iraq and Afghanistan between October 2001 and November 2011. RESULTS: The ASBP initiated major changes in blood availability and age of blood in theater. In support of data published by physicians in theater, showing improved patient survival when a higher ratio of fresh frozen plasma and red blood cells (RBCs) is achieved, plus the use of platelets, the ASBP increased availability of plasma and established platelet collection facilities in theater. New capabilities included emergency collection of apheresis platelets in the battlefield, availability and transfusion of deglycerolized red cells, rapid diagnostic donor screening, and a new modular blood detachment. Forward surgical facilities that were at one time limited to a blood inventory consisting of RBCs now have a complete arsenal of products at their fingertips that may include fresher RBCs, fresh frozen plasma, cryoprecipitate, and platelets. A number of clinical practice guidelines are in place to address these processes. Changes in blood doctrine were made to support new combat casualty care and damage-control resuscitation initiatives. CONCLUSION: Despite the challenges of war in two theaters of operation, a number of improvements and changes to blood policy have been developed during the last 10 years to support combat casualty care. The nature of medical care in combat operations will continue to be dynamic and constantly evolving. The ASBP needs to be prepared to meet future challenges. LEVEL OF EVIDENCE: Epidemiologic study, level IV.