Risk factors for positive depression screening across a shipboard deployment cycle.

BACKGROUND: Depression is a leading cause of healthcare use and risk for suicide among US military personnel. Depression is not well characterised over the shipboard deployment cycle, and personnel undergo less screening than with land-based deployments, making early identification less likely. AIMS: To determine the demographic and behavioural risk factors associated with screening positive for risk of depression (ROD) across the shipboard deployment cycle. METHOD: Active-duty ship assigned personnel completed an anonymous assessment using the Center for Epidemiologic Studies Depression Scale (CES-D) in the year prior to deployment, during deployment and in the months following deployment. Longitudinal models were used to determine risk factors. RESULTS: In total, 598 people were included in the analysis. Over 50% of the study population screened positive for ROD (CES-D score ≥16) and over 25% screened positive for risk of major depressive disorder (CES-D score ≥22) at all time points. Lower age, female gender, alcohol use, stress and prior mental health diagnoses were all associated with greater odds of screening positive for ROD in multivariable models. CONCLUSIONS: Although the risk factors associated with screening positive for ROD are similar to those in other military and civilian populations, the proportion screening positive exceeds previously reported prevalence. This suggests that shipboard deployment or factors associated with shipboard deployment may present particular stressors or increase the likelihood of depressive symptoms. DECLARATION OF INTEREST: The authors are military service members (or employees of the US Government). This work was prepared as part of the authors' official duties. Title 17, U.S.C. §105 provides the 'Copyright protection under this title is not available for any work of the United States Government.' Title 17, USC, §101 defines a US Government work as work prepared by a military service member or employee of the US Government as part of that person's official duties. The views expressed in this research are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of the Air Force, Department of Veterans Affairs, Department of Defense, or the US Government. Approved for public release; distribution unlimited. Material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of Defense.

Longitudinal survey of condom use across a US Navy and Marine Corps shipboard deployment.

OBJECTIVES: Condoms are highly effective in preventing sexually transmitted infections (STIs) but implementation is often inconsistent with use rarely examined across travel transition periods. We examined the prevalence of condom use among ship-assigned US military personnel across an overseas deployment cycle and identified factors associated with condom non-use. METHODS: Longitudinal survey data were collected from ship-assigned US Navy/Marine Corps personnel on 11 ships before (T1), during (T2) and after (T3) an overseas deployment. The anonymous, self-completed survey included demographics, condom use at last sex, STI diagnosis, alcohol misuse and drug use with sex. Descriptive and generalised regression model analyses were conducted. RESULTS: Analysis included 1900 (T1), 549 (T2) and 1168 (T3) personnel who reported age, sex and condom use/non-use at last sex. The proportion reporting condom use was significantly higher during T2 (53%, p<0.0001) than T1 (27%) or T3 (28%), with STI prevalences of 1% (T1), 7% (T2) or 2% (T3), with fewer (29%) sexually active individuals at T2. In adjusted models, condom non-use was associated with hazardous alcohol use (OR 1.44, 95% CI 1.21 to 1.71), or drug use to enhance sex (OR 1.37, 95% CI 1.06 to 1.77), but transactional sex was negatively associated (OR 0.69, 95% CI 0.50 to 0.84). CONCLUSIONS: Condom use was highest during deployment, as was STI prevalence (among non-users), possibly reflecting concentration of high-risk sexual activities/individuals and/or sexual partners more likely to be infected. Higher condom use with transactional sex likely reflects awareness of higher STI risk. These data can be used to facilitate targeted interventions to reduce STI transmission and may extend to similarly aged cohorts travelling outside the US (eg, college students on spring break).

Cross-Sectional Study of Sexual Behavior, Alcohol Use, and Mental Health Conditions Associated With Sexually Transmitted Infections Among Deploying Shipboard US Military Personnel.

INTRODUCTION: Limited comprehensive data exist on risk behavior associated with sexually transmitted infections (STI) among ship-assigned US military personnel during the predeployment time period (PDT). This study examined whether sexual risk behaviors, alcohol use, involuntary drug consumption (IDC), posttraumatic stress disorder (PTSD), and depression during the 12 months prior to deployment were associated with provider-diagnosed STIs in this population. MATERIALS AND METHODS: Using cross-sectional data collected during 2012-2014 among sexually active personnel, multivariable regression assessed factors associated with STIs among all men (n = 1,831). Stratified analyses were conducted among men who have sex with women (MSW, n = 1,530), men who have sex with men or men and women (MSM, n = 83), and excluded those not reporting sexual partner gender (n = 218). RESULTS: Among MSW, transactional sex (AOR 3.8, 95% CI 1.5-9.4) meeting sexual partners at work (AOR 4.3, 95% CI 2.0-9.2), IDC (AOR 6.6, 95% CI 3.0-14.5), and incomplete mental health assessments (AOR 4.4, 95% CI 1.6-12.0) were significantly associated with STIs after adjustment. Among all men, those who identified as MSM (AOR 4.6, 95% CI 1.9-11.2) and drug screen positive (AOR 3.3, 95% CI 1.3-8.6) were significantly more likely to report an STI. CONCLUSIONS: Previously unreported factors significantly associated with STIs at the PDT among MSW in the adjusted analysis were meeting sexual partners at work and IDC. IDC during the PDT warrants further exploration. These results can inform tailored STI reduction interventions among shipboard personnel and similarly aged civilians undergoing similar transition/travel experiences.

Self-reported HIV-positive status but subsequent HIV-negative test result using rapid diagnostic testing algorithms among seven sub-Saharan African military populations.

HIV rapid diagnostic tests (RDTs) combined in an algorithm are the current standard for HIV diagnosis in many sub-Saharan African countries, and extensive laboratory testing has confirmed HIV RDTs have excellent sensitivity and specificity. However, false-positive RDT algorithm results have been reported due to a variety of factors, such as suboptimal quality assurance procedures and inaccurate interpretation of results. We conducted HIV serosurveys in seven sub-Saharan African military populations and recorded the frequency of personnel self-reporting HIV positivity, but subsequently testing HIV-negative during the serosurvey. The frequency of individuals who reported they were HIV-positive but subsequently tested HIV-negative using RDT algorithms ranged from 3.3 to 91.1%, suggesting significant rates of prior false-positive HIV RDT algorithm results, which should be confirmed using biological testing across time in future studies. Simple measures could substantially reduce false-positive results, such as greater adherence to quality assurance guidelines and prevalence-specific HIV testing algorithms as described in the World Health Organization's HIV testing guidelines. Other measures to improve RDT algorithm specificity include classifying individuals with weakly positive test lines as HIV indeterminate and retesting. While expansion of HIV testing in resource-limited countries is critical to identifying HIV-infected individuals for appropriate care and treatment, careful attention to potential causes of false HIV-positive results are needed to prevent the significant medical, psychological, and fiscal costs resulting from individuals receiving a false-positive HIV diagnosis.

Conducting HIV Seroprevalence and Behavioral Epidemiology Risk Surveys (SABERS) Among Partner Military Populations.

BACKGROUND: Characterizing HIV infection and associated risk behaviors within military populations is critical for understanding the epidemic and informing prevention activities. However, the prevalence of HIV and related risk behaviors is often unknown. Further, militaries may not have the systems in place or the staff expertise to conduct HIV surveillance and risk behavior studies. METHODS: The Department of Defense HIV/AIDS Prevention Program (DHAPP), funded by the President's Emergency Plan for AIDS Relief and the US Department of Defense, provides technical assistance, management and administrative support for HIV/AIDS prevention, care and treatment for approximately 65 partner militaries. Collaborating with partner militaries in conducting Seroprevalence and Behavioral Epidemiology Risk Surveys (SABERS) and using the data to monitor the epidemic and inform activities is a key component of DHAPP. CONCLUSION: This paper describes the methodology used to plan, adapt, implement and report SABERS studies.

HIV/AIDS Securitization: Outcomes and Current Challenges.

BACKGROUND: The securitization (i.e., framing of a health issue as a security threat) of HIV/AIDS by the United Nations Security Council in 2000 changed the belief that HIV/AIDS is only a health issue. Although now accepted that HIV/AIDS represents a security threat, the consequences of securitization are still not widely established. METHODS: The purpose of this paper was to present an evidence-based review of the outcomes and current challenges associated with HIV/AIDS securitization in the context of national security. RESULTS/CONCLUSION: We provided an overview of HIV/AIDS securitization, followed by a discussion of the impact of securitization on peacekeeping personnel and uniformed services. We also reviewed the United States Government's response to securitization and potential risks and benefits of securitization.

Missed opportunity to screen and diagnose PTSD and depression among deploying shipboard US military personnel.

BACKGROUND: Depression and post-traumatic stress disorder (PTSD) are significant risks for suicide and other adverse events among US military personnel, but prevalence data among ship-assigned personnel at the onset of deployment are unknown. AIMS: To determine the prevalence of shipboard personnel who screen positive for PTSD and/or major depressive disorder (MDD) at the onset of deployment, and also those who reported these diagnoses made by a physician or healthcare professional in the year prior to deployment. METHOD: Active-duty ship-assigned personnel (N = 2078) completed anonymous assessments at the beginning of deployment. Depression was measured using the Center for Epidemiologic Studies Depression Scale (CES-D; score of ≥22), and PTSD was assessed using the PTSD Checklist-Civilian Version (PCL-C; both score and symptom criteria were used). RESULTS: In total, 7.3% (n = 151 of 2076) screened positive for PTSD and 22% (n = 461 of 2078) for MDD at deployment onset. Only 6% and 15% of those who screened positive for PTSD or MDD, respectively, had been diagnosed by a healthcare professional in the past year. CONCLUSIONS: Missed opportunities for mental healthcare among screen-positive shipboard personnel reduce the benefits associated with early identification and linkage to care. Improved methods of mental health screening that promote early recognition and referral to care may mitigate psychiatric events in theatre. DECLARATION OF INTEREST: This work was performed as part of the official duties of the authors as military service members or employees of the US Government. COPYRIGHT AND USAGE: This work was prepared by military service members or employees of the US Government as part of their official duties. As such, copyright protection is not available for this work (Title 17, USC, §105).

Pre-deployment Alcohol Misuse Among Shipboard Active-Duty U.S. Military Personnel.

INTRODUCTION: The burden of alcohol misuse is unknown among shipboard U.S. Navy and Marine Corps military personnel immediately prior to deployment and may be elevated. METHODS: Anonymous survey data on hazardous, dependent, and binge alcohol misuse and involuntary drug consumption were collected during 2012-2014 among shipboard personnel within approximately 2 weeks of deployment. Using the Alcohol Use Disorders Identification Test Consumption (AUDIT-C), hazardous alcohol misuse was defined using two cut-point scoring criteria: (1) ≥3 for women and ≥4 for men; and (2) ≥4 for women and ≥5 for men; binge drinking as ≥4 drinks for women and ≥5 drinks for men on a typical day in past 30 days; and dependent alcohol misuse as an AUDIT-C score of ≥8. Demographic- and sex-stratified self-reported alcohol misuse prevalence was reported for analysis conducted during 2014-2015. RESULTS: Among 2,351 male and female shipboard personnel, 39%-54% screened positive for hazardous, 27% for binge, and 15% for dependent alcohol use. Seven percent reported involuntary drug consumption history. A larger proportion of those aged 17-20 years screened positive for dependent alcohol use compared with the overall study population prevalence. CONCLUSIONS: A large proportion of shipboard personnel screened positive for hazardous and dependent alcohol use (18% among those aged <21 years) at deployment onset. These data can inform interventions targeting shipboard personnel engaging in hazardous use before progression to dependent use and enable early identification and care for dependent users. Future studies should include more comprehensive assessment of factors associated with involuntary drug consumption.

Sexually transmitted infections and sexual behaviour of deploying shipboard US military personnel: a cross-sectional analysis.

OBJECTIVES: Sexually transmitted infection (STI) prevalence and risk behaviour may differ at different phases of deployment. We examined STI prevalence and sexual behaviour in the predeployment time period (12 months prior) among recently deployed shipboard US Navy and Marine Corps military personnel. METHODS: Data were collected from 1938 male and 515 female service members through an anonymous, self-completed survey assessing sexual behaviours and STI acquisition characteristics in the past 12 months. Cross-sectional sex-stratified descriptive statistics are reported. RESULTS: Overall, 67% (n=1262/1896) reported last sex with a military beneficiary (spouse, n=931, non-spouse service member, n=331). Among those with a sexual partner outside their primary partnership, 24% (n=90/373) reported using a condom the last time they had sex and 30% (n=72/243) reported their outside partner was a service member. In total, 90% (n=210/233) reported acquiring their most recent STI in the USA (88%, n=126/143 among those reporting ≥1 deployments and an STI ≥1 year ago) and a significantly higher proportion (p<0.01) of women than men acquired the STI from their regular partner (54% vs 21%) and/or a service member (50% vs 26%). CONCLUSIONS: Findings suggest a complex sexual network among service members and military beneficiaries. Findings may extend to other mobile civilian and military populations. Data suggest most STI transmission within the shipboard community may occur in local versus foreign ports but analyses from later time points in deployment are needed. These data may inform more effective STI prevention interventions.

Low prevalence of neurocognitive impairment in early diagnosed and managed HIV-infected persons.

OBJECTIVE: To describe the prevalence of neurocognitive impairment (NCI) among early diagnosed and managed HIV-infected persons (HIV+) compared to HIV-negative controls. METHODS: We performed a cross-sectional study among 200 HIV+ and 50 matched HIV-uninfected (HIV-) military beneficiaries. HIV+ patients were categorized as earlier (<6 years of HIV, no AIDS-defining conditions, and CD4 nadir >200 cells/mm(3)) or later stage patients (n = 100 in each group); both groups were diagnosed early and had access to care. NCI was diagnosed using a comprehensive battery of standardized neuropsychological tests. RESULTS: HIV+ patients had a median age of 36 years, 91% were seroconverters (median window of 1.2 years), had a median duration of HIV of 5 years, had a CD4 nadir of 319, had current CD4 of 546 cells/mm(3), and 64% were on highly active antiretroviral therapy (initiated 1.3 years after diagnosis at a median CD4 of 333 cells/mm(3)). NCI was diagnosed among 38 (19%, 95% confidence interval 14%-25%) HIV+ patients, with a similar prevalence of NCI among earlier and later stage patients (18% vs 20%, p = 0.72). The prevalence of NCI among HIV+ patients was similar to HIV- patients. CONCLUSIONS: HIV+ patients diagnosed and managed early during the course of HIV infection had a low prevalence of NCI, comparable to matched HIV-uninfected persons. Early recognition and management of HIV infection may be important in limiting neurocognitive impairment.

Cross-sectional assessment of prevalence and correlates of blood-borne and sexually-transmitted infections among Afghan National Army recruits.

BACKGROUND: Few data are available in Afghanistan to shape national military force health practices, particularly with regard to sexually-transmitted infections (STIs). We measured prevalence and correlates of HIV, syphilis, herpes simplex 2 virus (HSV-2), and hepatitis C virus (HCV) among Afghan National Army (ANA) recruits. METHODS: A cross-sectional sample of male ANA recruits aged 18-35 years were randomly selected at the Kabul Military Training Center between February 2010 and January 2011. Participants completed an interviewer-administered questionnaire and serum-based rapid testing for syphilis and hepatitis C virus antibody on-site; HIV and HSV-2 screening, and confirmatory testing were performed off-site. Prevalence of each infection was calculated and logistic regression analysis performed to identify correlates. RESULTS: Of 5313 recruits approached, 4750 consented to participation. Participants had a mean age of 21.8 years (SD±3.8), 65.5% had lived outside Afghanistan, and 44.3% had no formal education. Few reported prior marijuana (16.3%), alcohol (5.3%), or opiate (3.4%) use. Of sexually active recruits (58.7%, N = 2786), 21.3% reported paying women for sex and 21.3% reported sex with males. Prevalence of HIV (0.063%, 95% CI: 0.013- 0.19), syphilis (0.65%, 95% CI: 0.44 - 0.93), and HCV (0.82%, 95% CI: 0.58 - 1.12) were quite low. Prevalence of HSV-2 was 3.03% (95% CI: 2.56 - 3.57), which was independently associated with age (Adjusted Odds Ratio (AOR) = 1.04, 95% CI: 1.00 - 1.09) and having a television (socioeconomic marker) (AOR = 1.46, 95% CI: 1.03 - 2.05). CONCLUSION: Though prevalence of HIV, HCV, syphilis, and HSV-2 was low, sexual risk behaviors and intoxicant use were present among a substantial minority, indicating need for prevention programming. Formative work is needed to determine a culturally appropriate approach for prevention programming to reduce STI risk among Afghan National Army troops.

Elevated CD8 counts during HAART are associated with HIV virologic treatment failure.

OBJECTIVE: To evaluate whether elevated CD8 counts are associated with increased risk of virologic treatment failure in HIV-infected individuals. DESIGN: Retrospective cohort study. METHODS: US Military HIV Natural History Study participants who initiated highly active antiretroviral therapy (HAART) in 1996-2008 had 6- and 12-month post-HAART HIV RNA <400 copies per milliliter, ≥ 2 subsequent HIV viral loads and a baseline CD8 count were eligible (n = 817). Baseline was 12 months after the start of HAART, virologic failure (VF) was defined as confirmed HIV RNA ≥ 400 copies per milliliter, and CD8 counts ≥ 1200 cells per cubic millimeter were considered elevated. Cox models were used to examine the effect of baseline and time-updated CD8 counts on VF. RESULTS: There were 216 failures for a rate of 5.6 per 100 person-years [95% confidence interval (CI): 4.9 to 6.4]. Among those initiating HAART in 2000-2008, the participants with elevated baseline CD8 counts had significantly greater risk of VF compared with those with baseline CD8 counts ≤ 600 cells per cubic millimeter [hazard ratio (HR) = 2.68, 95% CI: 1.13 to 6.35]. The participants with elevated CD8 counts at >20% of previous 6-month follow-up visits had a greater risk of failure at the current visit than those who did not (HR = 1.53, 95% CI: 1.14 to 2.06). Those with CD8 counts that increased after the start of HAART had a greater risk of failure than those with CD8 counts that decreased or remained the same (HR = 1.59, 95% CI: 1.19 to 2.13). CONCLUSIONS: Initial or serial elevated CD8 counts while on HAART or an increase in CD8 counts from HAART initiation may be early warnings for future treatment failure.

A randomized clinical trial comparing revaccination with pneumococcal conjugate vaccine to polysaccharide vaccine among HIV-infected adults.

BACKGROUND: The risk of pneumococcal disease persists, and antibody responses to revaccination with the 23-valent polysaccharide vaccine (PPV) are low among human immunodeficiency virus (HIV)-infected adults. We determined whether revaccination with the 7-valent pneumococcal conjugate vaccine (PCV) would enhance these responses. METHODS: In a randomized clinical trial, we compared the immunogenicity of revaccination with PCV ( n = 131) or PPV (n = 73) among HIV-infected adults (median CD4 cell count, 533 cells/mm(3)) who had been vaccinated with PPV 3-8 years earlier. HIV-uninfected adults (n = 25) without prior pneumococcal vaccination received 1 dose of PCV. A positive response was defined as a >or=2-fold increase (from baseline to day 60) in capsule-specific immunoglobulin G, with a postvaccination level >or=1000 ng/mL for at least 2 of the 4 serotypes. RESULTS: HIV-infected persons demonstrated a higher frequency of positive antibody responses to PCV than to PPV (57% vs 36%) (P = .004) and greater mean changes in the immunoglobulin G concentration from baseline to day 60 for serotypes 4, 9V, and 19F (P < .05, for all), but not for serotype 14. However, by day 180, both outcomes were similar. Responses to PCV were greater in frequency and magnitude for all serotypes in HIV-uninfected adults, compared with those in HIV-infected adults. CONCLUSIONS: Among persons with HIV infection, revaccination with PCV was only transiently more immunogenic than PPV, and responses were inferior to those in HIV-uninfected subjects with primary vaccination. Pneumococcal vaccines with more robust and sustained immunogenicity are needed for HIV-infected adults. Clinical trial registration. ClinicalTrials.gov identifier NCT00622843.

Clinical and epidemiologic characteristics of an outbreak of novel H1N1 (swine origin) influenza A virus among United States military beneficiaries.

BACKGROUND: A novel swine-origin influenza A (H1N1) virus was identified in March 2009 and subsequently caused worldwide outbreaks. The San Diego region was an early focal point of the emerging pandemic. We describe the clinical and epidemiologic characteristics of this novel strain in a military population to assist in future outbreak prevention and control efforts. METHODS: We performed an epidemiologic evaluation of novel H1N1 virus infections diagnosed in San Diego County among 96,258 local US military beneficiaries. The structured military medical system afforded the ability to obtain precise epidemiologic information on the impact on H1N1 virus infection in a population. The novel H1N1 virus was confirmed using real-time reverse transcriptase polymerase chain reaction (rRT-PCR). RESULTS: From 21 April through 8 May 2009, 761 patients presented with influenza-like illness and underwent rRT-PCR testing. Of these patients, 97 had confirmed novel H1N1 virus infection, with an incidence rate of 101 cases per 100,000 persons. The median age of H1N1 patients with H1N1 virus infection was 21 years (interquartile range, 15-25 years). Fever was a universal symptom in patients with H1N1 virus infection; other symptoms included cough (present in 96% of patients), myalgia or arthralgia (57%), and sore throat (51%). Sixty-eight (70%) of our patients had an identifiable epidemiologic link to another confirmed patient. The largest cluster of cases of H1N1 virus infection occurred on a Navy ship and involved 32 (8%) of 402 crew members; the secondary attack rate was 6%-14%. The rapid influenza testing that was used during this outbreak had a sensitivity of 51% and specificity of 98%, compared with rRT-PCR. Only 1 patient was hospitalized, and there were no deaths. CONCLUSIONS: A novel H1N1 influenza A virus caused a significant outbreak among military beneficiaries in San Diego County, including a significant cluster of cases onboard a Navy ship. The outbreak described here primarily affected adolescents and young adults and resulted in a febrile illness without sequelae.

Melioidosis after brief exposure: a serologic survey in US Marines.

Melioidosis is endemic to Southeast Asia. The incidence of infection in visitors is not well known, especially for short visits. Thirteen (38%) of 34 previously unexposed US Marines had positive serology after 2 weeks in Thailand, and one developed acute disseminated disease. Asymptomatic infection with Burkholderia pseudomallei may be common, even from brief exposures.

Increasing rates of community-acquired methicillin-resistant Staphylococcus aureus infections among HIV-infected persons.

Community-acquired (CA) methicillin-resistant Staphylococcus aureus (MRSA) rates have rapidly increased in the general population; however, little data on recent incidence rates and risk factors of CA-MRSA infections among HIV patients appear in the literature. A retrospective study was conducted from 1993 through 2005 among patients at a large HIV clinic. Trends in CA-MRSA infection incidence rates, clinical characteristics and risk factors for CA-MRSA were evaluated. Seven percent of our cohort developed a CA-MRSA infection during the study period. The rate of CA-MRSA infections among HIV-infected population significantly increased since 2003, with an incidence of 40.3 cases/1000 person-years in 2005, which was 18-fold higher than the general population served at our facility. In all, 90% of infections were skin/soft tissue infections with a predilection for buttock or scrotal abscess formation; 21% of patients experienced a recurrent infection. Risk factors included a low CD4 count at the time of infection (odds ratio [OR] per 100 CD4 cells 0.84, P = 0.03), high maximum log(10) HIV viral load (OR 4.54, P<0.001), recent use of beta-lactam antibiotics (OR 6.0 for receipt of two prescriptions, P<0.001) and a history of syphilis (OR 4.55, P = 0.01). No patient receiving trimethoprim-sulfamethoxazole prophylaxis developed a CA-MRSA infection. Over the study period, CA-MRSA accounted for an increasing percentage of positive wound cultures and Staphylococcus aureus isolates, 37% and 65%, respectively, during 2005. In conclusion, CA-MRSA infections have rapidly increased among HIV-infected patients, a group which has a higher rate of these infections than the general population. Risk factors for CA-MRSA among HIV-infected patients include low current CD4 cell count, recent beta-lactam antibiotic use and potentially high-risk sexual activity as demonstrated by a history of syphilis infection.

Use of bilirubin as a marker of adherence to atazanavir-based antiretroviral therapy.

We retrospectively reviewed 134 patients to evaluate atazanavir-related bilirubin elevation as an adherence marker. Using a 2 log reduction or undetectable viral load as a marker for suppression, the median bilirubin increase at first follow-up was 1.3 (0.7-2.2), versus 0.2 (-0.05-0.65) for those not suppressed. An increase in bilirubin of more than 0.4 mg/dl correctly classified 81% of patients as having successful treatment response (sensitivity 87%, specificity 63%), suggesting that bilirubin is a good adherence marker.

History of U.S. military contributions to the study of rickettsial diseases.

Rickettsial diseases have affected the military throughout history. Efforts such as those of the Joint U.S. Typhus Commission near the beginning of World War II and of military researchers since have reduced the impact of these diseases on U.S. and Allied forces. Despite the postwar development of effective antibiotic therapies, the newly emerging antibiotic-resistant scrub typhus rickettsial strains of the Asian Pacific region mandate continued research and surveillance. Similarly, tick-infested training areas in the United States and similar exposure abroad render the spotted fevers and the ehrlichioses problematic to deployed troops. The military continues to work on countermeasures to control the arthropod vectors, as well as actively participating in the development of rapid accurate diagnostic tests, vaccines, and improved surveillance methods. Several rickettsial diseases, including epidemic typhus, scrub typhus, the ehrlichioses, and the spotted fevers, are reviewed, with emphasis on the military historical significance and contributions.

Pneumonia outbreak associated with group a Streptococcus species at a military training facility.

BACKGROUND: Although group A streptococci (GAS) infections are a major cause of morbidity and mortality, outbreaks of associated pneumonia are rare. We report an outbreak of GAS pneumonia that occurred at a US military training camp. METHODS: Standard epidemiologic and laboratory procedures were used to characterize the outbreak and causative organism(s). A case-control study and determination of the prevalence of GAS infection among camp personnel were also performed. RESULTS: A total of 162 of 4500 Marine Corps personnel were hospitalized for respiratory symptoms during the period of 1 November and 20 December 2002, and 127 (78%) had radiographically confirmed pneumonia. The attack rate was 1.6 cases per 100 person-months. Thirty-four (27%) of 127 patients with pneumonitis had definite or probable GAS pneumonia; an additional 22 (17.3%) were coinfected with GAS and another pathogen. Pathogens, in addition to GAS, included Chlamydia pneumoniae (27 patients), Mycoplasma pneumoniae (19), adenovirus (5), and Streptococcus pneumoniae (2). A survey revealed that the pharyngeal carriage rate of GAS among camp personnel was 16%. Molecular characterization of the GAS isolates found emm type 3, multilocus sequence type 15. The epidemic ended after administration of additional prophylaxis with a single dose of intramuscular benzathine penicillin (1.2 million U) or azithromycin (1 g orally). Because the number of days from the last penicillin injection was correlated with a positive throat culture result and the occurrence of pneumonia, the dosing interval of benzathine penicillin was shortened from every 28-35 days to every 21 days. CONCLUSIONS: This is the largest outbreak of GAS pneumonia reported in >30 years. This outbreak emphasizes the potential for GAS to cause epidemics of severe infection and demonstrates the need for surveillance and consideration of appropriate antibiotic prophylaxis among particularly high-risk populations.