Update: Plant dermatitis among active component service members, U.S. Armed Forces, 2010-2020.

Dermatitis (skin inflammation) caused by the oil of poisonous plants is an occupational hazard for U.S. military members who are assigned and train in endemic areas. Plant dermatitis can cause significant disability, substantial medical costs, and lost duty time. During the 11-year surveillance period there were 73,725 cases of plant dermatitis diagnosed in active component service members (rate: 5.3 per 1,000 person-years [p-yrs]). The overall incidence rates remained relatively stable between 2010 and 2015, increased in 2016 and 2017, then decreased in 2018 through 2020. Compared to their respective counterparts, incidence rates were highest among male service members (5.7 per 1,000 p-yrs), the youngest (<20 years) service members (8.4 per 1,000 p-yrs), non-Hispanic White service members (7.5 per 1,000 p-yrs), members of the Army (7.7 per 1,000 p-yrs) and Marine Corps (6.5 per 1,000 p-yrs), and among those in combat-related occupations (11.9 per 1,000 p-yrs). More than half of the cases occurred during summer months and about one-third of all cases were diagnosed at 4 installations: Fort Benning, Georgia (n=11,257); Camp Pendleton, CA (n=5,399); Fort Bragg, NC (n=4,259), and Fort Campbell, KY (n=3,221). Service members, particularly young individuals in combat-training in endemic states, should be informed of the risks associated with exposures to toxic plants and advised on personal protective measures.

Characterizing the contribution of chronic pain diagnoses to the neurologic burden of disease, active component, U.S. Armed Forces, 2009-2018.

In the annual Medical Surveillance Monthly Report (MSMR) burden of disease analysis, neurologic disorders represent the fifth most common category of diagnoses among active component service members within the Military Health System. One major subcategory of this disease group is "all other neurologic conditions." Incidence analysis from 2009-2018 revealed that the vast majority of diagnoses in this undefined subcategory were related to chronic pain and that such diagnoses have been increasing in burden by a considerable amount. Chronic pain diagnoses increased from a rate of 85.5 per 10,000 person- years (p-yrs) in 2009 to 261.1 per 10,000 p-yrs in 2018. Subgroup analysis by demographic characteristics demonstrated that female, non-Hispanic black, older, and enlisted personnel were at increased risk for chronic pain diagnoses. Among the branches of service, members of the Army were at the highest risk of a chronic pain diagnosis with a rate ratio of 4.8 compared to the Navy, the branch with the lowest risk. Future annual burden analyses should consider chronic pain as its own subcategory to better characterize its impact.

A Burden and Prevalence Analysis of Chronic Pain by Distinct Case Definitions among Active Duty U.S. Military Service Members, 2018.

BACKGROUND: Chronic pain is a growing problem in the military, and the methods by which we have to perform epidemiologic surveillance are insufficient. It represents both a public health and military readiness concern, as those who suffer from it experience adverse impacts on work productivity, physiological health, and quality of life. OBJECTIVES: This study was designed to assess the prevalence of chronic pain among active component military service members utilizing 2 distinct, published case definitions. It sought to describe the demographics and military characteristics of those receiving chronic pain diagnoses. The study also aimed to provide improved granularity regarding military chronic pain patients' pain severity and its impacts on their job performance. STUDY DESIGN: Cross-sectional analysis for 2018. SETTING: This analysis utilized data available from the Defense Medical Surveillance System, a database containing longitudinal data on service members. METHODS: Patients: The surveillance population consisted of all active component service members from the U.S. Army, Navy, Air Force, and Marines of all grades serving at any point during the surveillance period of January 1, 2018 through December 31, 2018. MEASUREMENT: Diagnoses were ascertained from the administrative records of all medical encounters of individuals who received care through the Military Health System or civilian referrals. Data from patients' Periodic Health Assessment (PHA) encounters were also utilized to derive more granular data regarding their experiences of pain. RESULTS: Case Definition 1, more specific for identifying chronic pain, identified a more severe subset of chronic pain patients when compared against Case Definition 2, a more comprehensive method for identifying potential chronic pain patients. Case Definition 1 found a higher prevalence of impactful pain (CD1: 36.7% vs. CD2: 23.5%), and Case Definition 1 patients are more likely to be on limited duty and require treatment related to their pain. Several demographic groups were also found to be at increased risk of chronic pain diagnosis, including women, black non-Hispanic, Army, older age, and enlisted. LIMITATIONS: First, in utilizing administrative data, this allows for the possibility of misclassification bias. Second, some deployment data still used ICD-9 coding even in 2018, resulting in a minor underestimation by approximately 30 patients and approximately 60 encounters. Third, the prevalence estimates for the demographics were not adjusted for potential confounders. CONCLUSIONS: Chronic pain has been difficult to define via administrative and screening data, and as such its burden and prevalence estimates can vary considerably depending on which case definition is used. This is of particular importance in the U.S. military, as these estimates can significantly impact our calculations for force readiness and the protection of our national security. To our knowledge, this study is the first of its kind to examine chronic pain across the entirety of the U.S. armed forces and to utilize granular, annually collected PHA data in this way. The results of this exploratory analysis could be used as a template to better characterize the burden of chronic pain from a population-based perspective and monitor the effectiveness of pain management strategies.

Animal bites and rabies post-exposure prophylaxis, active and reserve components, U.S. Armed Forces, 2011-2018.

During 2011-2018, there were 22,729 diagnoses of animal bites among active and reserve component members of the U.S. Armed Forces. Of these, 899 (4.0%) were documented during medical encounters associated with deployments to overseas theaters of operations. Army, Navy, Air Force, and Marine Corps members were affected by 55.6%, 23.5%, 14.2%, and 6.7% of all animal bites diagnosed in theater, respectively. More than four-fifths of total animal bite cases (82.4%) and bites diagnosed in theater (88.4%) affected enlisted members. The crude overall incidence rate of animal bite diagnoses was 175.7 per 100,000 person-years (p-yrs) among active component service members between 2011 and 2018. Overall rates were highest among active component service members who worked in law enforcement (462.5 per 100,000 p-yrs) or veterinary occupations (437.8 per 100,000 p-yrs). Among active component service members, the crude annual rate of animal bite diagnoses in 2018 was more than twice that in 2001 (194.1 per 100,000 p-yrs and 85.1 per 100,000 p-yrs, respectively). Dog bites accounted for approximately three-quarters (74.8%) of total animal bites during the surveillance period. Only a small proportion of animal bites were associated with documentation of exposure to or post-exposure prophylaxis for rabies. Animal bite avoidance and rabies education should be reinforced before service members travel or deploy to areas where rabies is highly enzootic.

Absolute and relative morbidity burdens attributable to ocular and vision-related conditions, active component, U.S. Armed Forces, 2018.

The current report used an ocular and vision disease classification system and several healthcare burden measures to quantify the impacts of various ocular and vision-related illnesses and injuries among active component service members of the U.S. Armed Forces during 2018. More service members received care for refractive error and related disorders than any other ocular and vision-related major category; this category accounted for slightly more than one-half (51.1%) of all ocular and vision-related medical encounters. Conjunctival disorders accounted for the next highest percentage of total medical encounters (13.3%) followed by corneal disorders (7.5%). The 3 specific ocular and vision-related conditions that accounted for the most medical encounters (i.e., myopia, astigmatism, and acute conjunctivitis) accounted for almost one-half (47.7%) of all ocular and vision-related medical encounters overall. In general, the conditions that accounted for the most medical encounters were predominantly refractive error and related disorders and conjunctival disorders. More active component service members received medical care for myopia than for any other specific condition. Optic nerve conditions and visual discomfort/disturbances accounted for more than onequarter (30.1%) of all ocular and vision-related hospital bed days.

Incidence and prevalence of selected refractive errors, active component, U.S. Armed Forces, 2001-2018.

During 2001-2018, there were approximately 1.38 million incident diagnoses of myopia, 1.21 million incident diagnoses of astigmatism, and 492,000 incident diagnoses of hyperopia among active component service members (crude overall incidence rates of 7.8, 6.6, and 2.2 diagnoses per 100 personyears, respectively). Incidence rates of all 3 conditions were higher among women compared to men. Service members in the Marine Corps, enlisted personnel, and those working in other/unknown military occupations had higher overall rates of incident myopia diagnoses compared to their respective counterparts. Incidence rates of astigmatism diagnoses were similar across all services and among both enlisted personnel and officers. Overall rates of hyperopia diagnoses were similar across all race/ethnicity groups and service branches and among both enlisted personnel and officers. However, across occupational groups, overall rates of hyperopia and astigmatism diagnoses were highest among service members working in healthcare occupations. Future analyses should focus on the specific effects of military refractive surgery programs on the readiness of service members.

Non-alcoholic fatty liver disease (NAFLD), active component, U.S. Armed Forces, 2000-2017.

During 2000-2017, a total of 19,069 active component service members received incident diagnoses of non-alcoholic fatty liver disease (NAFLD), for a crude overall incidence rate of 77.7 cases per 100,000 person-years. The overall rate of incident NAFLD diagnoses among males was more than 1.5 times the rate among females. Overall incidence rates of NAFLD diagnoses increased with advancing age and were highest among service members aged 50 years or older. Asian/Pacific Islander and Hispanic service members had the highest overall incidence of NAFLD diagnoses compared to those in other race/ethnicity groups. The lowest overall incidence by race/ethnicity was observed among non-Hispanic black service members. Crude annual incidence rates of NAFLD diagnoses increased 12-fold between 2000 and 2017. During this period, annual rates of incident NAFLD diagnoses increased in both sexes and in all age groups. Increases in annual rates were seen over time in all race/ethnicity groups and in all services. More than two-thirds of incident NAFLD cases had one or more diagnosed metabolic comorbidities, with dyslipidemia affecting the greatest percentage of cases, followed by obesity/overweight and hypertension. The percentage of NAFLD cases with 2 or more metabolic comorbidities increased 36.0% during the 18-year surveillance period from 22.2% in 2001 to 30.2% in 2017. Selected recommendations from the American Association for the Study of Liver Diseases 2018 practice guidance document for the diagnosis and management of NAFLD are discussed.

Human papillomavirus vaccine initiation, coverage, and completion rates among U.S. active component service members, 2007-2017.

Human papillomavirus (HPV) vaccines have been available and licensed for use in the U.S. among women since 2006 and among men since 2010. Currently, HPV is not a mandatory vaccine for U.S. military service; however, it is encouraged and offered to service members. Between 2007 and 2017, a total of 111,546 (26.6%) eligible active component service women aged 17-26 years and 121,657 (5.8%) men initiated the HPV vaccine. Of those service members who initiated vaccination and remained in service for at least 6 months, less than half of women (46.6%) and only slightly more than one-third of men (35.1%) completed three doses. Initiation and completion rates also varied by service branch, with service members in the Air Force generally having higher initiation and completion rates. The median times between the first and second doses and between the first and third doses were 3.8 months and 10.8 months, respectively. The median time in service at initiation dose was 1.1 years. Continued development and implementation of interventions to enhance HPV vaccination initiation among military service members are warranted.

Fireworks injuries, active component, U.S. Armed Forces, 2008-2017.

Although fireworks shows are considered patriotic and festive, the use of consumer fireworks also can be dangerous. There were 302 records of fireworks injuries during the 10-year surveillance period (2.4 cases per 100,000 person- years [p-yrs]). During 2008-2017, the lowest crude annual incidence of fireworks injury was reported in 2010 (1.5 per 100,000 p-yrs) and the highest was reported in 2017 (3.4 per 100,000 p-yrs). Compared with their respective counterparts, overall incidence of fireworks injury was higher among males, non-Hispanic whites, Army members, those in an enlisted rank, and those in combat-specific occupations. Of all incident fireworks injuries, the most commonly affected body regions were hand/wrist (45.0%), head/neck (27.8%), and leg (7.9%). The most common types of injuries were burns (57.0%), open wounds (14.6%), and contusion/superficial injuries (13.2%). Although the incidence of fireworks injuries among active component service members was found to be generally low, there is still risk of serious injury if proper safety and handling precautions are not taken.

Incidence of acute injuries, active component, U.S. Armed Forces, 2008-2017.

Injuries have consistently ranked among the top morbidity burdens among U.S. military service members. This report describes the incidence, trends, types, causes, and dispositions of acute injuries among active component service members by anatomic region. From 2008 through 2017, there were more than 3.6 million acute incident injuries among more than 1.6 million individuals. The highest rates were for injuries to the foot/ankle, head/neck, and hand/wrist. Injury incidence decreased during the surveillance period for all anatomic sites except for the leg and knee. In addition, incidence varied by military/demographic characteristics and anatomic site. Overall, service members in the Army and service members in motor transport and/or combat-related occupations tended to have higher incidence rates than their respective counterparts. "Sprains and strains" was the most common type of injury (48.5%), and most injuries were due to undocumented or undetermined causes (69.7%). The most common disposition was "returned to duty with no limitations" (69.8%). Findings suggest that injury prevention strategies should be tailored to different populations with different risk factors. Future analyses will describe the epidemiology of cumulative traumatic injuries.

Diagnoses of eating disorders, active component service members, U.S. Armed Forces, 2013-2017.

During 2013-2017, a total of 1,788 active component service members received incident diagnoses of one of the eating disorders: anorexia nervosa (AN), bulimia nervosa (BN) or "other/unspecified eating disorder" (OUED). The crude overall incidence rate of any eating disorder was 2.7 cases per 10,000 person-years. Of the case-defining diagnoses, OUED and BN accounted for 46.4% and 41.8% of the total incident cases, respectively. The overall incidence rate of any eating disorder among women was more than 11 times that among men. Overall rates were highest among service members in the youngest age groups (29 years or younger). Crude annual incidence rates of total eating disorders increased steadily between 2013 and 2016, after which rates decreased slightly. Results of the current study suggest that service members likely experience eating disorders at rates that are comparable to rates in the general population, and that rates of these disorders are potentially rising among service members. These findings underscore the need for appropriate prevention and treatment efforts in this population.

Pregnancies and live births, active component service women, U.S. Armed Forces, 2012-2016.

This report summarizes data on the demographic and military characteristics of women and women of childbearing potential (WOCBP) in the active component of the U.S. Armed Forces during 2012-2016. Data on pregnancy-related care and birth rates are also presented. In 2016, WOCBP comprised the vast majority of active component service women. The largest proportions of WOCBP were in the categories of women who were 20-24 years old, non-Hispanic white, junior enlisted rank, and in a communications/intelligence occupation. WOCBP were roughly equally distributed in the Army, Navy, and Air Force, whereas only 7.5% served in the Marine Corps. Slightly more than one-quarter of WOCBP had ever deployed to the U.S. Central Command area of responsibility (CENTCOM AOR). In 2016, 13.1% of all WOCBP had at least one pregnancy-related event and 1.1% of deployed WOCBP had a pregnancy event during a deployment to CENTCOM AOR. The prevalence of pregnancy decreased slightly over the surveillance period. There were 63,879 live births during the surveillance period, for an overall live birth rate of 64.9 live births per 1,000 person-years (p-yrs). This rate of live births decreased steadily from 69.8 per 1,000 p-yrs in 2012 to 59.7 per 1,000 p-yrs in 2016. Rates of live births were highest among women who were 30-34 years old, enlisted or junior officer rank, Army, in healthcare occupations, and married. About one-quarter of the total live births were cesarean deliveries.

Contraception among active component service women, U.S. Armed Forces, 2012-2016.

This report summarizes the annual prevalence of permanent sterilization, as well as use of long- and short-acting reversible contraceptives (LARCs and SARCs, respectively), contraceptive counseling services, and use of emergency contraception from 2012 through 2016 among active component U.S. service women. Overall, 262,907 (76.2%) women of childbearing potential used either a LARC or a SARC at some time during the surveillance period. From 2012 through 2016, permanent sterilization decreased from 4.2% to 3.6%; LARC use increased from 17.2% to 21.7%; SARC use decreased from 38.5% to 30.4%; and emergency contraception use increased from 0.4% to 1.9%. Annual prevalence of contraceptive counseling only was relatively stable around 4.0%. This report estimates the length of continuation of LARCs, demonstrating that 86.1% continued their intrauterine device at 12 months, 78.5% at 24 months, and 73.4% at 36 months. These data demonstrate that the vast majority of service women have utilized at least one form of contraception, and that women are selecting LARCs in greater numbers with each passing year. The prevalence of contraceptive utilization among deployed service women is also reported.

Complications and care related to pregnancy, labor, and delivery among active component service women, U.S. Armed Forces, 2012-2016.

Diagnoses of "complications of pregnancy, childbirth, and the puerperium" include both morbid complications and indications for routine care of pregnant women. During 2012-2016, a total of 55,601 U.S. service members with live births (n=63,879) had 657,060 medical encounters with primary diagnoses of "pregnancy complications." The most frequent diagnoses were "other" specified conditions complicating pregnancy, childbirth, or the puerperium. Numbers of medical encounters with a primary (first-listed) diagnosis of any pregnancy-related complication or indication for care decreased marginally each year between 2012 (n=178,703) and 2016 (n=146,282). The percentage of live births affected by pre-eclampsia and gestational diabetes remained relatively stable during the surveillance period. For all age groups, percentages of live births affected by preterm labor decreased, but live births affected by obesity complications increased. The percentage of live births affected by gestational diabetes was more than twice as high for obese women, compared with non-obese women (12.4% vs. 5.5%). Findings suggest some opportunities to prevent sequelae for the mother and child and to mitigate longer-term impacts on force readiness.

Incidence and burden of gynecologic disorders, active component service women, U.S. Armed Forces, 2012-2016.

This report describes the incidence, burden, and co-occurrence of four common gynecologic disorders among active component service women during 2012-2016. Overall incidence rates were highest for menorrhagia (100.9 per 10,000 person-years [p-yrs]), followed by uterine fibroids (63.2 per 10,000 p-yrs), endometriosis (30.8 per 10,000 p-yrs), and polycystic ovary syndrome (PCOS, 25.3 per 10,000 p-yrs). Annual incidence rates and medical encounters for menorrhagia decreased by roughly 50% from 2012 through 2015, and then increased slightly in 2016. Annual incidence rates of PCOS decreased modestly between 2012 and 2016, whereas rates for endometriosis and uterine fibroids remained relatively stable. Service women in the Army, older service women, and non-Hispanic black service women had overall higher rates of menorrhagia, uterine fibroids, and endometriosis. Incidence of PCOS was highest among women aged 25-29 years, non-Hispanic black service women, and service women in the Air Force. Approximately one-quarter (25.6%) of women with incident endometriosis, one-third (33.6%) of women with incident uterine fibroids, and 7% of women with PCOS had a co-occurring incident diagnosis for menorrhagia during the surveillance period. Additional research focused on the severity of these conditions would allow for a fuller examination of the impact of these disorders on the readiness of the force and on healthcare utilization.

Incident diagnoses of leishmaniasis, active and reserve components, U.S. Armed Forces, 2001-2016.

During the surveillance period, there were 2,040 incident diagnoses/reports of leishmaniasis among members of the U.S. Armed Forces. Cutaneous leishmaniasis accounted for more than three-fifths (61.0%) of the total diagnoses/ reports among active component service members and for less than half (48.0%) of the total cases among reserve component members. The visceral form of leishmaniasis represented 1.2% of the total cases. Approximately two-fifths (40.6%) of the total diagnoses/reports were classified as "unspecified" with respect to the type of leishmaniasis. The lowest annual numbers of diagnoses/reports in the past decade were seen in 2011-2016 and reached a nadir of 11 cases in 2015. During the entire surveillance period, 71.7% of the total leishmaniasis cases were diagnosed or reported during the 7 months from early autumn to the beginning of spring (September-March) in the northern hemisphere. The majority of cases acquired in the Middle East (73.6%), South/Central America (87.5%), and other or unknown locations (64.5%) were diagnosed or reported during this 7-month interval.

Acetaminophen overdoses, active component, U.S. Armed Forces, 2006-2015.

Acetaminophen, a drug commonly used to relieve pain and fever, is generally safe and effective when used as directed. However, acetaminophen overdose can cause serious adverse events, including liver damage and death. From 2006 through 2015, a total of 2,588 cases of acetaminophen overdose were identified in active component military members. Rates of acetaminophen overdose declined during this 10-year surveillance period, from 2.2 cases per 10,000 person-years (p-yrs) in 2006 to 1.2 cases per 10,000 p-yrs in 2015. Rates of overdose were higher among females, members of the Army, and service members younger than 25 years of age. Despite the apparent decline in acetaminophen overdose in the active component, continued surveillance is warranted to monitor this trend.

Update: Cold weather injuries, active and reserve components, U.S. Armed Forces, July 2011-June 2016.

From July 2015 through June 2016, a total of 447 members of the active (n=383) and reserve (n=64) components had at least one medical encounter with a primary diagnosis of cold injury. The numbers of affected individuals in both components were the lowest since the 2011-2012 cold season, when the total was 394. In the active component, the service-specific incidence rates for each of the four services were lower than the respective rates for the previous (2014-2015) cold season. Frostbite was the most common type of cold injury. During the five cold seasons in the surveillance period (2011-2016), rates tended to be higher among service members who were in the youngest age groups; female; black, non-Hispanic; or in the Army. The numbers of cold injuries associated with service in Iraq and Afghanistan have fallen precipitously in the past four cold seasons and included just 11 cases in the most recent year.

Incidence of abdominal hernias in service members, active component, U.S. Armed Forces, 2005-2014.

From 1 January 2005 through 31 December 2014, a total of 87,480 incident diagnoses of the five types of abdominal hernia (incidence rate 63.3 cases per 10,000 person-years) were documented in the health records of 72,404 active component service members. The overall incidence rate of inguinal hernias among males was six times the rate among females. However, incidence rates of femoral, ventral/incisional, and umbilical hernias were higher among females than males. During the 10-year interval, annual incidence rates for most of the five types of hernia trended downward, but rates increased for umbilical hernias in both males and females and for ventral/ incisional hernias among females. For most types of hernia, the incidence rates tended to be higher among the older age groups. Health records documented 35,624 surgical procedures whose descriptions corresponded to the types of hernia diagnoses in the service members. Most repair procedures were performed in outpatient settings. The proportion of surgical procedures performed via laparoscopy increased during the period, but the majority of operations were open procedures. The limitations to the generalizability of the findings in this study are discussed.