Estimating Chlamydia and Gonorrhea Burden Among US Army Soldiers From Military Health System Data: Mind the Gap.

BACKGROUND: Reporting systems are commonly used for chlamydia and gonorrhea surveillance and community burden assessments. Estimates are conservative given high proportions of asymptomatic cases and underreporting. The military's unified health system, which includes laboratory and medical encounter data, could offer insight into surveillance gaps and improve burden analyses. METHODS: Confirmed chlamydia and gonorrhea cases reported among active component soldiers were merged with laboratory and medical encounter records indicative of infection to identify incident cases during 2015-2019. Case capture across data systems was assessed, and reported case rates were compared with those derived from the enhanced 3-source database. Attributable medical encounters for total cases were extrapolated using average visits for the subset of cases with supporting encounter data. Multivariable generalized linear models were generated to characterize infections. RESULTS: Approximately 83% and 76% of respective chlamydia and gonorrhea cases were identified through reporting, compared with 87% and 67% through laboratory records, and 58% for both through medical encounters. Rates from enhanced 3-source surveillance peaked at 2844 chlamydia and 517 gonorrhea cases per 100,000 person-years in 2019, reflecting 17% and 28% increases in respective rates compared with reported rates. Overall, 3163 cases of chlamydia and/or gonorrhea per 100,000 person-years were detected in 2019, affecting 13,004 soldiers and requiring an estimated 21,690 medical encounters. Soldiers who were younger, female, racial/ethnic minorities, nonmarried, enlisted, less educated, and Southern residents had significantly higher risk. CONCLUSION: Integration of laboratory and medical encounter data substantially improved burden estimation over reporting alone. Rates generated remain conservative because they only reflect documented cases. Increasing rates support prevention prioritization, particularly among young soldiers.

A Comparative Analysis of Reported Chlamydia and Gonorrhea Cases Among US Army Soldiers, 2015 to 2019.

BACKGROUND: Chlamydia and gonorrhea have increased nationally and in the US Army. Rates reported in the Army are elevated relative to the general population, partly because of differing population demographics. METHODS: Age- and sex-specific chlamydia and gonorrhea case rates among Army active component soldiers and the wider 18- to 64-year-old US adult population were computed from reports submitted through national and military surveillance systems in 2015 to 2019. Rates were standardized using the 2015 Army age and sex population distribution. Multivariable generalized linear models were generated to evaluate associated risk factors. RESULTS: Army age- and sex-adjusted chlamydia rates (per 100,000 person-years) were nearly twice those of US adults (2019 rates, 2317 vs. 1241), whereas US age- and sex-adjusted gonorrhea rates surpassed Army rates (2019 rates, 536 vs. 396). Chlamydia and gonorrhea rates were significantly elevated in Army women younger than 25 years relative to US women aged 18 to 24 years (2015-2019 crude rates, 10,404 Army/4243 US for chlamydia and 1014 Army/694 US for gonorrhea). Gonorrhea rates were significantly elevated in US men aged 25 to 44 years (2015-2019 crude rates, 506 US/251 Army and 223 US/86 Army for men aged 25-34 and 35-44 years, respectively). Age, sex, and race-ethnicity were significantly associated with infection among soldiers. CONCLUSIONS: Observed increases in chlamydia and gonorrhea and identified risk factors are consistent with those reported nationally. Higher adjusted chlamydia rates among soldiers may reflect greater individual or sexual network risks, screening biases, or increased health care access. The Army's lower adjusted gonorrhea rates may reflect differences in high-risk subgroups (e.g., men who have sex with men), differing sexual networks, or other confounders.

Detection of Three Sexually Transmitted Infections by Anatomic Site: Evidence From an Internet-Based Screening Program.

Urogenital and rectal specimens collected from the "IWantTheKit" Internet-based sexually transmitted infection screening program were evaluated for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Of 881 paired specimens submitted from August 2013 to December 2016, 15.0% (n = 132) tested positive for 1 or more sexually transmitted infections, of which 50.8% (n = 67) were identified exclusively through rectal testing.

Acute Respiratory Disease in US Army Trainees 3 Years after Reintroduction of Adenovirus Vaccine 1.

The 1999 cessation of vaccination against adenovirus types 4 and 7 among US Army trainees resulted in reemergence of acute respiratory disease (ARD) outbreaks. The 2011 implementation of a replacement vaccine led to dramatic and sustained decreases in ARD cases, supporting continuation of vaccination in this population at high risk for ARD.

Seroprevalence and seroincidence of herpes simplex virus (2006-2010), syphilis (2006-2010), and vaccine-preventable human papillomavirus subtypes (2000-2010) among US military personnel.

BACKGROUND: Sexually transmitted infections have historically been burdensome in military populations. We describe the seroprevalence and seroincidence of vaccine-preventable human papillomavirus (VP-HPV) subtypes in a sample of 200 servicemen, along with the seroprevalence and seroincidence of herpes simplex virus (HSV-1/2) and syphilis in a sample of 200 men and 200 women. METHODS: Sera from 200 men, along with associated demographic data, were obtained and tested for HPV serotypes at service entry and 10 years later. Similarly, 200 active-duty men and 200 active-duty women were tested for HSV-1/2 at entry to service and 4 years later. RESULTS: The baseline prevalence of VP-HPV subtypes was 14.5%, and cumulative seroincidence of new infection was 34% over a 10-year period (n = 68). Of these, 63% (n = 43) represented HPV-6, HPV-11, or both; 18% of new infections were either HPV-16 or HPV-18, and 19% (n = 13) were a mixture of all 4 strains. At entry to military service, 33.5% of men were seropositive for HSV-1 and 1.5% were positive for HSV-2; seroincidence was 3.4 and 1.1 per 100 person-years, respectively. Among women, 39% were seropositive for HSV-1 and 4.0% for HSV-2; seroincidence was 5.5 and 3.3 per 100 person-years, respectively. There were 2 prevalent and 3 incident cases of syphilis. CONCLUSIONS: Sexually transmitted infections in military populations are highly prevalent, incident, and epidemiologically distinct. Our data show the rates of HPV and HSV-1/2 acquisition that are higher than those seen in the general public, again highlighting the need for continued preventive efforts. Consideration of universal HPV vaccination among men is warranted.

Preparedness of Military Public Health for Epidemic and Pandemic Recognition and Response.

Disease epidemics have threatened American military preparedness and operational capabilities since 1775. The ongoing Severe Acute Respiratory Syndrome Coronavirus 2 (COVID-19) pandemic, which began in 2019, again demonstrates the significant potential for infectious diseases to impact military units and threaten military readiness. We reviewed the historical and continuing threats to the U.S. Military from infectious disease outbreaks, as well as changes in U.S. Military capabilities for conducting meaningful surveillance and response. We concluded that a structured review of military public health and preventive medicine capabilities should be conducted to assess the response to the COVID-19 pandemic and determine the capabilities necessary for infectious disease surveillance and response to future threats.

Adenovirus-associated deaths in US military during postvaccination period, 1999-2010.

Adenoviruses are frequent causes of respiratory disease in the US military population. A successful immunization program against adenovirus types 4 and 7 was terminated in 1999. Review of records in the Mortality Surveillance Division, Armed Forces Medical Examiner System, identified 8 deaths attributed to adenovirus infections in service members during 1999-2010.

Influenza and wound infections: laboratory support for deployed U.S. forces.

Since 1997, the absence of a global, DoD public health laboratory system has been identified as a vulnerability in the U.S. military's effort to identify and quickly respond to emerging infections. The AFHSC Division of GEIS Operations has attempted to mitigate this vulnerability by supporting initiatives such as the DoD Global Influenza Surveillance Program and the DoD Directory of Public Health Laboratory Services. AFHSC continues to be engaged in identifying and addressing diagnostics needed to protect deployed forces. The GASI and the enhanced capability for identification of MDROs and threatening influenza strains in deployed areas are recent examples of GEIS utilizing its financial resources and position as a DoD organization to coordinate the efforts of the military services and other U.S. government organizations to improve preparedness for EID agents. However, the absence of a defined, comprehensive public health system that contains surveillance systems, reference laboratories, and public health communication systems functioning in unison to provide reach back and reference laboratory support to the global MHS remains a significant gap.

Hazardous Non-Combat Exposures in the U.S. Department of Defense.

Hazardous non-combat exposures are inherent to military service and occur in three settings: installation workplaces, installation environments, and deployment environments. Few military clinicians receive training in how to recognize, assess, and manage patients with these exposures, and systems improvements are needed to support clinicians with respect to exposure recognition and management. This commentary highlights key concepts surrounding military non-combat exposures by discussing three case examples of exposures occurring in each of these settings. In the workplace, well-coordinated, interdisciplinary occupational health teams improve identification of exposure-related illnesses, and these teams may be further supported by the development of automated clinical decision-support systems. Installation environmental exposures are characterized by high perceived risk, uncertainty in estimating actual risk, and a wide range of stakeholders including military family members and individuals in the surrounding community. Recognizing environmental exposure concerns, gathering a thorough environmental exposure history, and practicing exposure risk communication are vital skills to address these situations. During deployments, exposures may initially be perceived as low risk but then become a concern years later. A functional understanding of the capabilities and limitations of exposure monitoring and potential health effects of exposures helps the military clinician effectively communicate potential health risks to line leaders. For any of these exposure settings, service public health centers and OEM specialty leaders and consultants are available for consultation.

The Future of Military Occupational and Environmental Medicine in the Department of Defense.

OBJECTIVE: Transfer of military medical facilities to the Defense Health Agency is transforming the Military Health System. Our objective is to inform this transformation with respect to optimum application of occupational and environmental medicine (OEM) expertise. METHODS: We defined and analyzed the external influences on military OEM practice using a structured framework to identify key drivers. RESULTS: Key drivers are political and economic factors. These may change the size or military/civilian ratio of the specialty. Limited career development pathways should prompt consideration of making OEM a second or combined residency, and military-funded training of civilian physicians may be required. OEM specialist utilization should be reassessed. CONCLUSIONS: OEM is a highly adaptable specialty defined by the needs of its stakeholders. Comprehensive analysis of external influences can ensure that OEM practice remains in step with changing needs.

Military Epidemics, Then and Now: Smallpox and COVID-19.

We compared the COVID-19 experience in the first year of the current pandemic in the US with the smallpox experience of the 18th century, focusing on the US military but recognizing civilian and military populations are not separate and distinct. Despite the epidemics being separated by 21/2 centuries and with great advancements in technology having occurred over that time, we observed similarities which led us to several conclusions: • Infectious disease outbreaks will continue to occur and novel agents, naturally occurring or manipulated by humans, will threaten military and civilian populations nationally and globally. • Infectious disease outbreaks can affect both military and civilian populations, persist for long periods, and be catastrophic to military peacetime and wartime operations. • Effective surveillance is a prerequisite for early identification and subsequent meaningful responses to novel and reemerging threat agents and diseases. • Socio-cultural, religious, or political factors may limit the implementation of effective interventions in military or civilian populations. Public health officials must assess impediments to implementation of interventions and develop plans to overcome them.

The AFHSC-Division of GEIS Operations Predictive Surveillance Program: a multidisciplinary approach for the early detection and response to disease outbreaks.

The Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System Operations (AFHSC-GEIS) initiated a coordinated, multidisciplinary program to link data sets and information derived from eco-climatic remote sensing activities, ecologic niche modeling, arthropod vector, animal disease-host/reservoir, and human disease surveillance for febrile illnesses, into a predictive surveillance program that generates advisories and alerts on emerging infectious disease outbreaks. The program's ultimate goal is pro-active public health practice through pre-event preparedness, prevention and control, and response decision-making and prioritization. This multidisciplinary program is rooted in over 10 years experience in predictive surveillance for Rift Valley fever outbreaks in Eastern Africa. The AFHSC-GEIS Rift Valley fever project is based on the identification and use of disease-emergence critical detection points as reliable signals for increased outbreak risk. The AFHSC-GEIS predictive surveillance program has formalized the Rift Valley fever project into a structured template for extending predictive surveillance capability to other Department of Defense (DoD)-priority vector- and water-borne, and zoonotic diseases and geographic areas. These include leishmaniasis, malaria, and Crimea-Congo and other viral hemorrhagic fevers in Central Asia and Africa, dengue fever in Asia and the Americas, Japanese encephalitis (JE) and chikungunya fever in Asia, and rickettsial and other tick-borne infections in the U.S., Africa and Asia.

Capacity-building efforts by the AFHSC-GEIS program.

Capacity-building initiatives related to public health are defined as developing laboratory infrastructure, strengthening host-country disease surveillance initiatives, transferring technical expertise and training personnel. These initiatives represented a major piece of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) contributions to worldwide emerging infectious disease (EID) surveillance and response. Capacity-building initiatives were undertaken with over 80 local and regional Ministries of Health, Agriculture and Defense, as well as other government entities and institutions worldwide. The efforts supported at least 52 national influenza centers and other country-specific influenza, regional and U.S.-based EID reference laboratories (44 civilian, eight military) in 46 countries worldwide. Equally important, reference testing, laboratory infrastructure and equipment support was provided to over 500 field sites in 74 countries worldwide from October 2008 to September 2009. These activities allowed countries to better meet the milestones of implementation of the 2005 International Health Regulations and complemented many initiatives undertaken by other U.S. government agencies, such as the U.S. Department of Health and Human Services, the U.S. Agency for International Development and the U.S. Department of State.

Malaria and other vector-borne infection surveillance in the U.S. Department of Defense Armed Forces Health Surveillance Center-Global Emerging Infections Surveillance program: review of 2009 accomplishments.

Vector-borne infections (VBI) are defined as infectious diseases transmitted by the bite or mechanical transfer of arthropod vectors. They constitute a significant proportion of the global infectious disease burden. United States (U.S.) Department of Defense (DoD) personnel are especially vulnerable to VBIs due to occupational contact with arthropod vectors, immunological naiveté to previously unencountered pathogens, and limited diagnostic and treatment options available in the austere and unstable environments sometimes associated with military operations. In addition to the risk uniquely encountered by military populations, other factors have driven the worldwide emergence of VBIs. Unprecedented levels of global travel, tourism and trade, and blurred lines of demarcation between zoonotic VBI reservoirs and human populations increase vector exposure. Urban growth in previously undeveloped regions and perturbations in global weather patterns also contribute to the rise of VBIs. The Armed Forces Health Surveillance Center-Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) and its partners at DoD overseas laboratories form a network to better characterize the nature, emergence and growth of VBIs globally. In 2009 the network tested 19,730 specimens from 25 sites for Plasmodium species and malaria drug resistance phenotypes and nearly another 10,000 samples to determine the etiologies of non-Plasmodium species VBIs from regions spanning from Oceania to Africa, South America, and northeast, south and Southeast Asia. This review describes recent VBI-related epidemiological studies conducted by AFHSC-GEIS partner laboratories within the OCONUS DoD laboratory network emphasizing their impact on human populations.

Military occupational and environmental health: challenges for the 21st century.

In May 2010, a Symposium and Workshop entitled "Assessing Potentially Hazardous Environmental Exposures among Military Populations" was held in Bethesda, MD. Participants were particularly interested in environmental exposures that are challenging to identify and characterize and that may be associated with a delayed health impact. Speakers and discussion groups reviewed past exposures and the ability of the U.S. military to: predict, identify, quantify, and prevent or mitigate potentially harmful exposures; identify, assess, and follow up military members potentially exposed; accurately determine risks of disease or injury and actual health outcomes; and expeditiously and effectively communicate to military and other leaders needed interventions, individual risks and data to support or refute associations between exposures and health outcomes. Improvements in military capabilities and shortcomings were evaluated using reports on strategies to protect the health of deployed U.S. Forces that were published by the Institute of Medicine and National Research Council in 1999-2000. Significant improvements have occurred, but many shortcomings need attention.

Chlamydia trachomatis reported among U.S. active duty service members, 2000-2008.

OBJECTIVES: To review reported chlamydia infection trends in the U.S. military and identify reasons for differences. METHODS: Defense Medical Surveillance System 2000-2008 reports for nondeployed, active duty members were studied. Incidence, rate ratios, and confidence intervals were generated. Age- and gender-specific rates were compared with US national rates. Screening and reporting policies and procedures were reviewed. RESULTS: Overall incidence was 922 cases per 100,000 person-years, with considerable service variability (392-1,431 cases per 100,000 person-years in the Navy and Army, respectively). Navy-Marine Corps rates increased more than 2 fold in 2008. Rates were higher among women, minorities, and members under 25 years. Military rates exceeded national rates. CONCLUSIONS: The 2008 increase in Navy-Marine Corps rates may be due to the implementation of web-based reporting. Demographic differences were consistent with published reports. The civilian-military disparity may reflect higher percentages of military at-risk women screened.

Hepatitis E seroprevalence and seroconversion among US military service members deployed to Afghanistan.

BACKGROUND: Hepatitis E virus (HEV) has been recognized as a threat to military forces since its discovery. Although HEV seroprevalence in Afghanistan is not known, HEV infection is thought to be highly endemic in that country. This study determined the incidence of HEV seroconversion among United States (US) service members who were deployed to Afghanistan, as well as the prevalence of antibodies to HEV prior to the deployment. METHODS: A random sample of 1500 subjects was selected from the cohort of service members who were deployed to Afghanistan between 2002 and 2006. Predeployment and postdeployment serum samples from these subjects were tested by enzyme immunoassay for total antibodies to HEV. Results. The seroprevalence of antibodies to HEV in US service members prior to deployment was 1.1%. The seroconversion rate among service members deployed to Afghanistan was 0.13%. CONCLUSIONS: Although subpopulations may be at higher risk for HEV exposure during deployment, the risk among US service members deployed to Afghanistan in this study was low. Previously implemented and current preventive measures in theater appear to have been adequate. With future deployments to new areas or changes in military operations in areas of risk, continued surveillance for HEV infection in the military will be warranted.

Training Occupational and Environmental Medicine (OEM) Residents at the Uniformed Services University.

OBJECTIVE: To develop an actionable plan to sustain and improve the quality of the Uniformed Services University of the Health Sciences (USU) Occupational and Environmental Medicine (OEM) Residency Program. METHODS: Program metrics were collected and analyzed to assess strengths, weaknesses, opportunities, and threats (SWOT analysis). RESULTS: Program strengths are stable funding, full-time faculty and large class size. Weaknesses are limited toxicology curriculum, and the lack of complex clinical cases. Opportunities include establishing an OEM referral clinic, collaborating with U.S. Department of Defense (DoD) toxicology programs, aligning OEM research priorities in DoD, and including DoD Civilian physicians in OEM residency training. Threats are Military Health System reorganization, budget, and personnel cuts. CONCLUSIONS: The USU OEM Residency is strong but must be flexible to adjust to personnel, fiscal, and organizational changes. Aggregating the SWOT analyses for all the OEM residency programs may help identify strategies to sustain OEM training in the United States.

Spread of adenovirus to geographically dispersed military installations, May-October 2007.

In mid-May 2007, a respiratory disease outbreak associated with adenovirus, serotype B14 (Ad14), was recognized at a large military basic training facility in Texas. The affected population was highly mobile; after the 6-week basic training course, trainees immediately dispersed to advanced training sites worldwide. Accordingly, enhanced surveillance and control efforts were instituted at sites receiving the most trainees. Specimens from patients with pneumonia or febrile respiratory illness were tested for respiratory pathogens by using cultures and reverse transcription-PCR. During May through October 2007, a total of 959 specimens were collected from 21 sites; 43.1% were adenovirus positive; the Ad14 serotype accounted for 95.3% of adenovirus isolates. Ad14 was identified at 8 sites in California, Florida, Mississippi, Texas, and South Korea. Ad14 spread readily to secondary sites after the initial outbreak. Military and civilian planners must consider how best to control the spread of infectious respiratory diseases in highly mobile populations traveling between diverse geographic locations.