Impact of Sleep Profiles on Multimorbidity Among US Active-Duty Service Members in the 2018 Health-Related Behaviors Survey.

Purpose: Sleep is a modifiable factor affecting chronic diseases and conditions in the Active-Duty (AD) United States (US) military population. This study assesses the impact of reported sleep health behaviors and sleep profiles on reported multimorbidity in active-duty service members (ADSMs). Participants and methods: The study used a military representative sample of 17,166 active duty SMs from the 2018 Department of Defense Health Related Behaviors Survey (HRBS) to explore sleep patterns and profiles, and medical conditions. Multimorbidity was defined as the presence of two or more medical conditions which we limited to include obesity, hypertension, and hyperlipidemia. The adjusted odds ratios for six sleep-related health behaviors and their unobservable sleep profiles were calculated using a weighted multinomial logistic model. Results: Sleep-related health behaviors were associated with increased odds of obesity, hypertension, and hyperlipidemia. We found higher odds of reported multimorbidity in SMs who reported lack of energy due to poor sleep (adjusted odds ratio [aOR] = 2.35, 95% CI:1.88-2.93), sleep 6 hours or less per night (aOR = 1.95, 95% CI:1.53-2.50), trouble sleeping (aOR = 2.19, 95% CI:1.76-2.72), and use of sleep medications (aOR = 2.10, 95% CI:1.64-2.68). Latent class analysis (LCA) identified three unobservable sleep profiles in SMs: minimal or low-risk sleep patterns (37.43%), moderate-risk sleep patterns (31.11%), and high-risk sleep patterns (31.46%). SMs with high-risk sleep patterns were significantly associated with reported multimorbidity (adjusted odds ratio [aOR] = 3.54, 95% CI:2.75-4.56). Conclusion: We found a strong association between sleep-related health behaviors and their unobservable sleep profiles with multimorbidity in this AD population. Future studies should investigate whether other chronic diseases may be influenced by sleep impairment in the US military population.

Suicidal Behaviors Among Active-Duty US Service Members: Data from the 2018 Health-Related Behaviors Survey.

Background: This study aimed to 1) determine the prevalence of past-year suicidal ideation (SI) and attempts (SA) among active-duty SMs; 2) determine whether differences exist by age, sex, and race; and 3) assess whether prevalence estimates vary by risk profiles of mental health conditions and substance use. Methods: Data were from the 2018 Health-Related Behavior Survey (HRBS), a cross-sectional survey of active-duty SMs (n = 17,166). We used the logistic model to identify the factors of SI and SA and latent class analysis (LCA) to identify the risk profiles. Results: Among active duty SMs, 8.26% had SI and 1.25% had SA in the past year. Gender and age have been shown to influence how race might contribute to suicidal behaviors. Mental health conditions were associated with higher odds of SI and SA, as were younger ages; LGB identity; being separated, divorced, or widowed; use of e-cigarettes, dual use of e-cigarettes and cigarettes, or drugs; and history of deployment of less than 12 months. Frequencies of cigarette and e-cigarette use were also associated with SI and SA, indicating the odds were increasing by 0.3% for every additional cigarette or e-cigarette used. Five risk profiles were identified: class 1 (illegal drug use), class 2 (mental health needs with tobacco and alcohol use), class 3 (mental health conditions only), class 4 ("low risk" SMs with low levels of illegal drug use, mental health visits, tobacco use, and alcohol use), and class 5 (alcohol use). Compared to class 4 ("low risk"), all other risk profiles were associated with increased odds of suicidal behaviors. Conclusion: Despite the resources and increased access provided for mental health support, the prevalence of SI among active-duty SMs is greater than in the general population of the same age, likely due to additional military exposures and stressors.

The Risk of Pregnancy Related Hypertension Disorder Associated with Sickle Cell Trait in U.S. Service Women.

INTRODUCTION: The health impact of the heterozygous (Hb Ss) Sickle Cell Trait (SCT) among the estimated one million females of reproductive age in the United States on pregnancy related hypertensive disorders (PRHD) including preeclampsia is not as well understood or researched as Sickle Cell Disease (SCD). MATERIALS AND METHODS: This retrospective cohort study included 25,020 U.S. enlisted, active duty service women during 1992 to 2013. Race within the sample is primarily black (84%) given that blacks have the highest prevalence of SCT. All 5,004 SCT positive individuals and a matched sample of 20,016 from those considered SCT negative were followed while on active duty for PRHD outcomes including gestational hypertension (GHTN), preeclampsia and eclampsia. RESULTS: The adjusted incidence rate ratio (IRR) for any PRHD in SCT positive compared to negative individuals was 1.46 (95% CI 1.32 - 1.62). SCT positive versus negative subjects had higher health care utilization rates and utilization rate ratios (URR) for all PRHD diagnoses combined 2.03 (95%CI: 1.97 - 2.10) and for each specific PHRD diagnosis. The prevalence of preeclampsia or eclampsia did not vary by SCT status. The overall PRHD attributable risk due to SCT was 30.4% (95% CI 23.1-37.1%) and the overall number needed to screen to detect a case of PRHD was 156 (95% CI 117-220). CONCLUSIONS: The results of this study indicate that being SCT positive is a risk factor for PRHD and provides evidence that SCT status may have an adverse effect on reproductive health. Future research needs to include other known risk factors for PRHD to include gravity and parity history, BMI, past history of PRHD prior to enlistment as well as to examine the association with maternal/child pregnancy outcomes.

Association Between Sickle Cell Trait With Selected Chronic Medical Conditions in U.S. Service Members.

Introduction: Sickle cell trait (SCT), the heterozygous carrier state for hemoglobin S, is present in an estimated 1.6% of all newborns and 7.3% in black individuals in the USA. SCT has long been considered a benign condition with anticipated normal life expectancy and no increased risk for chronic diseases. The medical literature is inconclusive on the potential association between SCT and chronic medical conditions (CMC) including chronic kidney disease, venous thromboembolism, and stroke. Studies addressing these questions are lacking particularly in non-Black young adults. Materials and Methods: We conducted a retrospective cohort study among U.S. active duty, enlisted, service members who entered from 1992 to 2012 using existing Department of Defense (DoD Military Healthcare System databases). SCT positive subjects (1,323) were matched by demographic characteristics to SCT negative subjects (3,136) and followed through 2013 for CMC that included deep vein thrombosis, diabetes mellitus and hematologic, pulmonary, and renal conditions. Results: The rate of developing any of the included CMC was higher for those with SCT (incidence rate ratio = 1.71 95% CI 1.61-1.81) compared with those who were SCT negative and their healthcare utilization rate for any of CMC studied was higher for SCT positive compared with negative individuals (URR = 2.45 95% CI 2.41-2.50), with the highest rate ratios observed for hematologic and renal conditions. SCT positive compared with negative individuals were more likely to have encounter diagnoses of sickle cell disease and diabetes Type II and were less likely to have encounter diagnoses of other hemoglobinopathies and diabetes type I. Conclusion: SCT in these racially diverse, young adults increased both the incidence of and healthcare utilization for thromboembolism, diabetes mellitus type II, sickle cell disease, pulmonary, and chronic renal conditions. These findings suggest that clinicians treating young adults with SCT should exercise heightened surveillance for these CMC to ensure both early diagnosis and access to treatments.

The Association Between Sickle Cell Trait in U.S. Service Members with Deployment, Length of Service, and Mortality, 1992-2012.

Introduction: Sickle cell trait (SCT) affects an estimated 5.02% of non-Hispanic blacks, 1.08% of Hispanics, and 0.1% of Whites in the U.S. military. Policies for SCT screening and occupational restrictions vary by service. Population-based studies of SCT with quantification of military-relevant outcomes are lacking. Methods: The study design was a retrospective cohort of 15,081 SCT-positive versus 60,320 SCT-negative U.S. active duty personnel enlisted from 1992 to 2012 and followed through 2013. Military-relevant outcome included number and days of deployment, length of service, and cause of death. Results: SCT-positive versus SCT-negative service members experienced more deployments (p < 0.01) and longer number of days deployed for all services, especially the Army (p < 0.001). The median length of service was longer for SCT-positive service members stratified by service and by gender (p < 0.05). The adjusted risk of length of service greater than 5 yr by SCT status was 1.37 (95% confidence interval 1.31-1.43) with greater than a three-fold higher risk in the Navy and Air Force compared with the Army. Crude mortality rate was not significantly different by SCT status, although deaths due to suicide, self-directed violence, and other non-specific causes were more common in SCT-positive service members. Conclusion: We found that SCT-positive service members deployed more frequently, for greater lengths of time, and remained in service longer. No significant difference in crude mortality ratio was discovered. Additional research on military-relevant outcomes and a cost-effectiveness analysis of SCT screening practices are needed to inform evidence-based SCT enlistment policies.

Risk of Exertional Heat Illnesses Associated with Sickle Cell Trait in U.S. Military.

Introduction: A number of studies have found an association between sickle cell trait (SCT) and exertional heat illnesses (EHIs) including heat stroke, a potentially fatal condition. The strength of this association varied across studies, limiting the ability to quantify potential benefits of SCT-screening policies for competitive athletics and military service members. We determined the relative rate and attributable risk of developing EHI associated with being SCT positive and the EHI health care utilization. Methods: We conducted a retrospective cohort study among U.S. enlisted, active duty service members during 1992-2012 from the Department of Defense Military Healthcare System databases. All 15,081 SCT-positive individuals and a sample of 60,320 from those considered SCT negative were followed through 2013 for EHI outcomes ranging from mild heat illness to heat stroke. Results: The adjusted hazard ratio for EHI in SCT-positive compared with SCT-negative individuals was 1.24 (95% confidence interval 1.06, 1.45). Risk factors for EHI included age over 30 yr at enlistment, female gender, Marine Corps, combat occupations, and enlistment between April and June. An estimated 216 Department of Defense enlistees (95% confidence interval: 147, 370) would need to be screened to identify and potentially prevent one case of EHI. The attributable risk of EHI due to SCT was 33% (95% confidence interval 19, 45%). Conclusion: Our findings suggest that SCT screening will identify approximately a third of SCT individuals at risk for EHI, but does not provide definitive evidence for universal compared with selective (e.g., occupational based) in military enlistees. A cost-effectiveness analysis is needed for policy makers to assess the overall value of universal SCT screening to prevent morbidity and mortality in both the military and the collegiate athletic populations.

Building a Successful Military-to-Military Partnership through Confronting HIV: The U.S-Nigeria Experience.

BACKGROUND: The Nigerian Ministry of Defence-Walter Reed Army Institute of Research partnership was established in 2004 in response to the growing HIV/AIDS epidemic in Nigeria. METHODS: Here we discuss the emergence of HIV in Nigeria, highlighting the initial barriers to treatment delivery, and outline the origins of the international military-to-military partnership developed to confront the disease. RESULTS: With financial support from the United States President's Plan for AIDS Relief and Nigerian Government Counterpart Funding, we demonstrate how this program led to a successful and sustainable response in the fight against HIV in Nigeria. We detail the continued value of this collaboration in the form of sustainable treatment platforms, prevention strategies, and research projects, and explore the factors which strengthened, and hindered these efforts. CONCLUSION: The program is a model framework for international military health partnership based on the principles of shared responsibility, country ownership and goal attainment.

Sickle Cell Trait Prevalence Among U.S. Military Service Members: 1992-2012.

BACKGROUND: Population-based estimates of sickle cell trait (SCT) prevalence in the U.S. military across services and over time are lacking. METHODS: SCT prevalence by service, race/ethnicity, and gender in 5-year time intervals was estimated using demographic, ambulatory, and hospital SCT encounter (International Classification of Diseases, 9th Revision, Clinical Modification 282.5) data for active duty, enlisted between 1992 and 2012 and limited SCT laboratory results. RESULTS: Our study identified 15,081 SCT subjects. SCT prevalence varied significantly by race, year, gender, and service branch. SCT prevalence was highest for non-Hispanic blacks (5.02%; prevalence ratio = 56.33, confidence interval [CI] = 52.14-60.85; compared to non-Hispanic white) in 2005-2009 (0.40%; prevalence ratio = 10.04, CI = 9.21-10.94; compared to 1992-1994), for women (2.97%; prevalence ratio = 3.14, CI = 3.04-3.25; compared to men), and in the Navy (2.26%; prevalence ratio = 2.96, CI = 2.84-3.02; compared to Army). Among foreign born, Africans were more likely to be SCT+ (prevalence ratio = 1.68, CI = 1.39-2.04; compared to non-U.S. North American). CONCLUSION: This study estimated the prevalence of SCT within U.S. military enlisted force and describes variability across services for race, time intervals, gender, and foreign-born region and will support investigation into the health effects of SCT in young adult populations.

An Evaluation of Selected Populations for HIV-1 Vaccine Cohort Development in Nigeria.

Development of a globally effective HIV-1 vaccine will need to encompass Nigeria, one of the hardest hit areas, with an estimated 3.2 million people living with HIV. This cross-sectional Institutional Review Board (IRB) approved study was conducted in 2009-12 at four market sites and two highway settlements sites in Nigeria to identify and characterize populations at high risk for HIV; engage support of local stakeholders; and assess the level of interest in future vaccine studies. Demographic, HIV risk data were collected by structured interviewer-administered questionnaires. Blood samples were tested on site by HIV rapid diagnostic tests, followed by rigorous confirmatory testing, subtype evaluation and testing for HBV and HCV markers in a clinical reference laboratory. Of 3229 study participants, 326 were HIV infected as confirmed by Western Blot or RNA, with a HIV prevalence of 15.4%-23.9% at highway settlements and 3.1%-9.1% at market sites. There was no observable correlation of prevalence of HIV-1 (10.1%) with HBV (10.9%) or HCV (2.9%). Major HIV-1 subtypes included CRF02_AG (37.5%); G (27.5%); G/CRF02_AG (25.9%); and non-typeable (8.9%), with 0.3% HIV-2. Univariate analysis found age, gender, marital status, level of education, and sex under substance influence as significant risk factors for HIV (p<0.001). Educating and winning the trust of local community leadership ensured high level of participation (53.3-77.9%) and willingness to participate in future studies (95%). The high HIV prevalence and high risk of HIV infection at highway settlement and mammy markets make them well suited for targeting future vaccine trials in Nigeria.

Evaluation of Performance of Two Rapid Tests for Detection of HIV-1 and -2 in High- and Low-Prevalence Populations in Nigeria.

The availability of reliable human immunodeficiency virus types 1 and 2 (HIV-1/2) rapid tests in resource-limited settings represents an important advancement in the accurate diagnosis of HIV infection and presents opportunities for implementation of effective prevention and treatment interventions among vulnerable populations. A study of the potential target populations for future HIV vaccine studies examined the prevalence of HIV infections at six selected sites in Nigeria and evaluated the use of two rapid diagnostic tests (RDTs) for HIV. The populations included market workers at sites adjacent to military installations and workers at highway settlements (truck stops) who may have a heightened risk of HIV exposure. Samples from 3,187 individuals who provided informed consent were tested in parallel using the Determine (DT) and Stat-Pak (SP) RDTs; discordant results were subjected to the Uni-Gold (UG) RDT as a tiebreaker. The results were compared to those of a third-generation enzyme immunoassay screen with confirmation of repeat reactive samples by HIV-1 Western blotting. One participant was HIV-2 infected, yielding positive results on both RDTs. Using the laboratory algorithm as a gold standard, we calculated sensitivities of 98.5% (confidence interval [CI], 97.1 to 99.8%) for DT and 98.1% (CI, 96.7 to 99.6%) for SP and specificities of 98.7% (CI, 98.3 -99.1%) for DT and 99.8% (CI, 99.6 to 100%) for SP. Similar results were obtained when the sites were stratified into those of higher HIV prevalence (9.4% to 22.8%) versus those of lower prevalence (3.2% to 7.3%). A parallel two-test algorithm requiring both DT and SP to be positive resulted in the highest sensitivity (98.1%; CI, 96.7 to 99.6%) and specificity (99.97%; CI, 99.9 to 100%) relative to those for the reference laboratory algorithm.

Medical encounter characteristics of HIV seroconverters in the US Army and Air Force, 2000­2004.

BACKGROUND AND METHODS: Active duty US Army and Air Force military personnel undergo mandatory biennial HIV antibody screening. We compared pre- and post-HIV seroconversion health status by conducting a case-control study, which evaluated all medical encounters and sociodemographic factors among incident HIV seroconverters and HIV-negative controls from June 2000 through February 2004. RESULTS: A total of 274 HIV seroconverters and 6205 HIV-negative personnel were included. In multivariate analysis restricted to male personnel (cases = 261, controls = 5801), single marital status (adjusted odds ratio [AOR] = 14.37), clinical indicators or symptoms within four years of HIV diagnosis (AOR = 6.22), black race (AOR = 5.88), nonindicator clinical syndromes within 2 years of HIV diagnosis (AOR = 3.31), any mental disorder within 4 years of HIV diagnosis (AOR = 3.04), increasing service-connected time (AOR = 1.69), and older age (AOR = 1.12) were associated with HIV diagnosis among males. A prior history of a sexually transmitted infection (STI) was associated with post-HIV seroconversion STI (OR(M-H) = 4.10). Similarly, a prior history of mental disorder was associated with post-HIV seroconversion mental disorder (OR(M-H) = 4.98). Forty-seven (18%) male cases were hospitalized at least once after HIV diagnosis; infectious diseases, and mental disorders made up 53% of initial admissions. CONCLUSIONS: HIV seroconversion was associated with increased health care-seeking behavior, STIs, and mental disorders, some of which may be amenable to screening. The higher STI rate after HIV diagnosis may partially be a consequence of monitoring, but secondary transmission of STI and possibly HIV require further definition and subsequent tailored preventive interventions.

HIV infection among U.S. Army and Air Force military personnel: sociodemographic and genotyping analysis.

Since 1985, the U.S. Department of Defense has periodically screened all military personnel for HIV allowing for the monitoring of the infection in this dynamic cohort population. A nested case-control study was performed to study sociodemographics, overseas assignment, and molecular analysis of HIV. Cases were newly identified HIV infections among U.S. Army and Air Force military personnel from 2000 to 2004. Controls were frequency matched to cases by gender and date of case first positive HIV screening test. Genotyping analysis was performed using high-throughput screening assays and partial genome sequencing. HIV was significantly associated with black race [odds ratio (OR) = 6.65], single marital status (OR = 4.45), and age (OR per year = 1.07). Ninety-seven percent were subtype B and 3% were non-B subtypes (A3, CRF01_AE, A/C recombinant, G, CRF02_AG). Among cases, overseas assignment in the period at risk prior to their first HIV-positive test was associated with non-B HIV subtype infection (OR = 8.44). Black and single military personnel remain disproportionately affected by HIV infection. Most non-B HIV subtypes were associated with overseas assignment. Given the increased frequency and length of assignments, and the expanding HIV genetic diversity observed in this population, there is a need for active HIV genotyping surveillance and a need to reinforce primary HIV prevention efforts.

Serum IgG antibody response to the protective antigen (PA) of Bacillus anthracis induced by anthrax vaccine adsorbed (AVA) among U.S. military personnel.

The seroconversion rates and geometric mean concentrations (GMC) of IgG anti-PA for stored sera from U.S. military personnel immunized 3, 4, and 6 times with the U.S. licensed anthrax vaccine adsorbed were studied. Anti-PA IgG concentrations were measured by ELISA. All 246 vaccinees had low but detectable pre-immunization anti-PA IgG (GMC 1.83 microg/mL). Three doses elicited a GMC of 59.92 microg/mL and a seroconversion rate of 85.3%, four doses elicited a GMC of 157.44 microg/mL and 67.9% and the sixth of 276.95 microg/mL and 45.5%, respectively. The forth dose elicited 100% seroconversion compared to the pre-immunization level. These results should facilitate comparison between different immunization schedules and new vaccines.

Geographic mapping of HIV infection among civilian applicants for United States military service.

We assessed the geographic distribution of HIV infection among civilian applicants for US military service. High smoothed HIV prevalences were observed among white applicants in California, Texas, Florida, New York, and New Jersey, and among African-American applicants in New York, New Jersey, Connecticut, Massachusetts, Washington DC, North and South Carolina, Florida, and California. Three HIV spatial clusters were found among whites: New York/New Jersey, southern California, and in south and central Texas. Among African-Americans, three HIV spatial clusters were found: New York/New Jersey, Washington DC/Virginia, and south and central California. The South accounted for a significant proportion of HIV-infected African-American applicants.

HIV incidence trends among white and african-american active duty United States Army personnel (1986-2003).

OBJECTIVE: To analyze HIV incidence rate (IR) trends among white and African-American active duty US Army personnel between 1986 and 2003. METHODS: Joinpoint regression was applied to identify time periods when significant changes in HIV IRs occurred, along with the corresponding annual percentage changes (APCs). RESULTS: African-Americans had a higher IR than white personnel (0.34/1,000 vs. 0.07/1,000; P < 0.001). Among white personnel, 2 significant time periods of changing HIV IRs were found: between 1986 and 1989 (APC = -31.1; P = 0.006) and between 1989 and 2003 (APC = -5.7; P = 0.003). Among African-Americans, a significant decline in HIV IRs was observed only between 1986 and 1991 (APC = -19.4; P < 0.001). This study revealed that the HIV IRs seem to have increased in 2 African-American groups: unmarried personnel and health care professionals. CONCLUSION: This cohort study (1,280 incident HIV infections among 1.5 million persons with 8.4 million person-years of follow-up) provides invaluable information on HIV trends in the United States Army. Despite an overall decline in HIV IRs, certain subpopulation among African-American personnel were observed to have increasing HIV IRs. Future research is needed to identify the current behavioral risk factors associated with HIV infection among US Army personnel.

Trends in HIV prevalence among white and African-American civilian applicants for United States Military Service, 1985 to 2003.

Data from 5,699,590 white and African-American civilian applicants who applied for service in the US military between 1985 and 2003 were used to analyze HIV prevalence trends. The overall HIV prevalence was 0.72/1000, which declined from 2.63/1000 in 1985 to 0.29/1000 in 1995, after which it remained stable until 2003 (0.30/1000). Larger and more significant declines in annual HIV prevalences were observed among the 4.5 million white applicants (-15.7% per year) compared with the 1.2 million African-American applicants (-10.0% per year). The HIV prevalence decline was also greater among male applicants (-12.4% per year) than female applicants (-7.1% per year). In the most recent 4 years study period, HIV prevalences increased among white applicants 25 to 29 years of age among African-American applicants 30 years of age or older. These data suggest that despite the overall consistent decreases in HIV prevalence from the 1980s to the late 1990s, an increase in HIV prevalence has taken place older African-American and white subgroups in more recent years.

Use of stored serum from Uganda for development and evaluation of a human immunodeficiency virus type 1 testing algorithm involving multiple rapid immunoassays.

We report the development and evaluation of a human immunodeficiency virus type 1 testing algorithm consisting of three rapid antibody detection tests. Stored serum samples from Uganda were utilized with a final algorithm sensitivity of 100% and a specificity of 98.9% (95% confidence interval, 98.6% to 99.3%).