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.

Outbreak of Chlamydia pneumoniae Infections and X-ray-Confirmed Pneumonia in Army Trainees at Fort Leonard Wood, Missouri, 2014.

INTRODUCTION: Chlamydia pneumoniae (Cp) is a bacterium that causes pneumonia and other respiratory diseases. Fever may be present early but absent by time of presentation to clinic. Increases in X-ray-confirmed pneumonia (XCP) and laboratory-confirmed Cp infections were observed in new soldiers in training at Fort Leonard Wood (FLW), Missouri, early in 2014. These findings prompted a site assistance visit from the U.S. Army Public Health Command, Aberdeen Proving Ground, Maryland, with a review of available data and information to describe the outbreak, and inspections of barracks and training facilities and review of training practices to identify opportunities for interventions to reduce the risk of respiratory disease agent transmission. MATERIALS AND METHODS: The study population was trainee soldiers at FLW in 2013-2014. Data from two acute respiratory disease surveillance systems were studied. A local surveillance system operated by the FLW General Leonard Wood Army Community Hospital Preventive Medicine Department tracked weekly chest X-rays taken and the numbers positive for pneumonia. A Naval Health Research Center, San Diego, California, laboratory-based Febrile Respiratory Illness Surveillance Program collected clinical data and nasal, or nasal and pharyngeal swabs, for nucleic acid amplification testing from up to 15 trainees/week with fever and either cough or sore throat. Up to 4 of the 15 specimens could be from afebrile patients with XCP. Specimens were tested for a variety of agents. RESULTS: Monthly rates of XCP rose quickly in 2014 and peaked at 0.9/100 trainees in May. The percentage of the San Diego surveillance system specimens that were positive for Cp also increased quickly in 2014, peaking at 54% in May. During the first half of 2014, the San Diego program studied specimens from 141 ill trainees; 37% (52/141) were positive for Cp, making it the most common organism identified, followed by rhinoviruses (8%), influenza viruses (4%), Mycoplasma pneumoniae (2%), and adenoviruses (1%). The remaining specimens (48%) were negative for all respiratory pathogens. Only 12% (6/52) of Cp positive patients were febrile. Facilities inspections and review of training practices failed to identify variables that might be contributing to an increased risk of respiratory agent transmission. CONCLUSION: The XCP rate and the percentage of specimens positive for Cp increased in early 2014, peaking in May. Only 12% of trainees with laboratory-confirmed Cp were febrile. Historically, acute respiratory disease surveillance at military training centers focused on febrile diseases, particularly those caused by adenoviruses. With introduction of an adenovirus vaccine in late 2011, respiratory disease rates dropped with only sporadic occurrences of adenovirus-associated disease. In 2012, the San Diego surveillance program began providing data on multiple respiratory disease agents, in addition to adenoviruses and influenza viruses. Since then, Cp, rhinoviruses and Mycoplasma pneumoniae have frequently been detected in trainees with acute respiratory disease. Respiratory surveillance programs supporting Army training centers should be re-evaluated in this post-adenovirus vaccine era, to include assessment of the fever criterion for selecting patients for study, the value of chest X-ray surveillance and the value of rapidly providing laboratory results to inform provider decisions regarding antibiotic use.

Survey of Sexually Transmitted Disease Laboratory Methods in U.S. Army Laboratories, 2012.

INTRODUCTION: Sexually transmitted diseases (STD) affect primarily young people (17-24 years). The U.S. Military, with many young people, strives to maintain effective STD treatment and prevention programs using current methods. Laboratory testing technology and capacity are important for appropriate clinical management and to provide data to direct prevention programs. STD laboratory capabilities are assessed in civilian and military laboratories using surveys. An Army laboratory survey was conducted in 2007. The Army laboratory survey reported here was conducted on 2012 to describe STD tests done, laboratory testing practices, and testing volume to include the use of human immunodeficiency virus point-of-care tests and a novel reverse syphilis testing algorithm. MATERIALS AND METHODS: A web-based survey was offered to all 32 Army laboratories in 2013 to assess testing in 2012. Twenty-two laboratories (69%), including all medical center laboratories, completed the survey. The survey was approved by the U.S. Army Human Protection Review Board. RESULTS: The Army laboratories reported testing more than 230,000 specimens for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), with 82% and 86% using nucleic acid amplification test (NAAT) methods for CT and NG, respectively. Eleven laboratories (50%) performed combined NAAT methods for CT and NG. Four (18%) performed NG antimicrobial susceptibility testing. Two (10%) screened for syphilis using the reverse algorithm. All offered in-house wet-mount microscopy for Trichomonas vaginalis. Thirteen (62%) used rapid human immunodeficiency virus testing. CONCLUSION: Comparing the 2012 results to the 2007 Army survey results, use of NAAT methods remained relatively stable while antimicrobial NG susceptibility testing decreased. Efforts to promote NAAT methods, to include testing vaginal and nongenital specimens for CT and NG, must continue. NG antibiotic resistance testing should be increased. Monitoring the use of the reverse syphilis screening algorithm is recommended to assess the impact of false-positive results.

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.

Incidence of Chlamydia trachomatis infections and screening compliance, U.S. Army active duty females under 25 years of age, 2011-2014.

Reported chlamydia infection rates among active duty U.S. Army females less than 25 years old declined by 20% from 2011 to 2014 (11,028 infections per 100,000 person-years [p-yrs] to 8,793 infections per 100,000 p-yrs, respectively). An overall decline in the proportions of high-risk female soldiers tested for chlamydia occurred during the same period, declining from a high of 85% in 2011 to a low of 71% in 2012, with an increase to 80% in 2014. Chlamydia laboratory testing volume also decreased from 2011 to 2013 but the test positivity rate remained stable at 6.0%-6.4%. By using projected incidence rates based on 100% of at-risk women being screened with a stable laboratory positivity rate, there was an estimated 15% decline in chlamydia incidence from 2011 to 2014 (12,794 to 10,991 infections per 100,000 p-yrs, respectively). Surveillance for chlamydia infections must include consideration of screening program performance in addition to passive reporting.

Update: Community-acquired methicillin-resistant Staphylococcus aureus skin and soft tissue infection surveillance among active duty military personnel at Fort Benning GA, 2008-2010.

BACKGROUND: Increasing numbers of Staphylococcus aureus infections demonstrate antibiotic resistance. Military populations experiencing crowding are at increased risk of community-acquired methicillin-resistant S. aureus (CA-MRSA) infection. High prevalence of CA-MRSA infection among Army personnel was previously documented at Fort Benning, GA from 2002 to 2007. PURPOSE: To ascertain recent CA-MRSA trends at Fort Benning regarding antibiotic susceptibility, infection rates, and treatment regimens among Army personnel. METHODS: Incident CA-MRSA cases among active duty members/trainees from January 2008 to December 2010 were identified using active surveillance and laboratory data. RESULTS: In total, 2,171 infections were identified, representing 5,794 CA-MRSA-related clinic visits. Annual rates decreased from 33 to 27 infections per 1,000 soldiers from 2008 to 2010. Approximately 78% of isolates were from training units. Approximately 4% of infections required hospitalization. Most infections (97%) were treated with antibiotics (36% received antibiotics and wound drainage). Antibiotic susceptibility patterns remained comparable to previous assessments. CONCLUSION: The observed decline in CA-MRSA rates and associated hospitalizations, coupled with stable antibiotic susceptibility patterns, is encouraging. Passive surveillance using laboratory records proved useful in identifying infection and could enhance detection across training sites. Given the continued high CA-MRSA prevalence among trainees, providers/public health personnel should remain vigilant to bolster prevention, detection, and treatment efforts.

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.

Noise-induced hearing injury and comorbidities among postdeployment U.S. Army soldiers: April 2003-June 2009.

PURPOSE: To evaluate noise-induced hearing injury (NIHI) and blast-related comorbidities among U.S. Army soldiers in an effort to understand the morbidity burden and future health service requirements for wounded war fighters returning from the Central Command Area of Responsibility, predominantly from Iraq and Afghanistan deployments. METHOD: Inpatient and outpatient records with diagnosed NIHI or blast-related comorbidities (e.g., significant threshold shift [STS], noise-induced hearing loss, tinnitus, sensorineural hearing loss, eardrum perforations, mild traumatic brain injury, and posttraumatic stress disorder) were extracted for active duty soldiers returning from combat deployments. Records were limited to those within 6 months of the soldier's return date from April 2003 through June 2009. To account for changes in STS coding practice, STS rates observed after October 1, 2006, were used to extrapolate prior probable postdeployment STS. RESULTS: Statistically significant increases were observed for tinnitus, dizziness, eardrum perforations, and speech-language disorders. The combination of observed and extrapolated STS yielded a conservative estimate of 27,427 cases. CONCLUSIONS: Estimates can be used to forecast resource requirements for hearing services among veterans. This article could serve as a guide for resourcing and innovating prevention measures and treatment in this population. Data provided may also serve as a baseline for evaluating prevention measures.

The army health hazard assessment program's medical cost-avoidance model.

BACKGROUND: The Logistics Management Institute initially developed a medical cost-avoidance model (MCAM) to estimate the costs associated with the failure to eliminate or control health hazards of army materiel systems during 1997. METHODS: Presented is an updated version of the MCAM that uses cost factors for individual health hazard categories. The earlier MCAM calculated army materiel acquisition-life cycle medical costs based on a single cost factor for all hazard categories. RESULTS: The Army's Health Hazard Assessment (HHA) Program, which uses the MCAM while assessing 18 types of health hazards commonly found in materiel undergoing the acquisition process, recognized the need to refine the MCAM to be hazard-type specific. These hazard types have unique cost factors and serve as the basis for the revised model. CONCLUSIONS: The revision will assist the HHA program in targeting health hazards that have the potential to affect soldier health and readiness.

Selected nonvaccine interventions to prevent infectious acute respiratory disease.

INTRODUCTION: Infectious acute respiratory disease (ARD) is a significant cause of worldwide morbidity, disproportionately affecting individuals living in crowded conditions, such as found at military training centers, school dormitories, and correctional facilities. Vaccines have been used to protect against ARD; however, these are not always available or effective. METHODS: The medical literature (1963-2004) on preventive nonvaccine ARD interventions (NOVARDIs) for infectious diseases, which addressed personal measures, administrative controls, and engineering controls, was studied during 2000 to 2004. Population-based studies in community settings (non-health care) were reviewed in detail to evaluate the effectiveness of NOVARDIs. Budgetary and logistic factors as well as acceptance were considered in formulating recommendations for implementation of NOVARDIs in military training centers. RESULTS: Thirty-eight population-based studies contained in 35 publications were examined. Three studies contained information on multiple NOVARDIs. Nine studies supported the use of personal measures relating to hand hygiene. Ten studies supported administrative controls such as cohorting military training units to reduce contact between units (4 studies), providing adequate personal space to reduce crowding (5), and cloth barriers between beds (1); and 14 studies supported the use of engineering controls such as increased indoor air dilution and ventilation (2), dust suppression (4), and air sterilization (8). CONCLUSIONS: Promoting hand hygiene and reducing crowding through the provision of adequate living space and cohorting of training units may offer benefits in respiratory disease control. These interventions, along with UV lights and air dilution/ventilation, deserve further evaluation in controlled studies to assess their efficacy. NOVARDIs could benefit military and other populations living in close contact.

An outbreak of malaria in US Army Rangers returning from Afghanistan.

CONTEXT: With numerous US military personnel currently deployed throughout the world, military and civilian health care professionals may encounter imported malaria from this population. OBJECTIVE: To identify malaria in US Army personnel deployed to a combat zone. DESIGN, SETTING, AND PATIENTS: Case series in the US Army health care system. A total of 38 cases of malaria were identified in a 725-man Ranger Task Force that deployed to eastern Afghanistan between June and September 2002. MAIN OUTCOME MEASURES: Identification of malaria cases and soldiers' self-report of compliance with antimalarial measures. RESULTS: A total of 38 patients were infected with Plasmodium vivax, yielding an attack rate of 52.4 cases per 1000 soldiers. Diagnosis was confirmed a median of 233 days (range, 1-339 days) after return from the malaria endemic region, with additional laboratory findings noting anemia and thrombocytopenia. One case was complicated with acute respiratory distress syndrome during the patient's primary attack and a spontaneous pneumothorax during relapse. This case accounted for 1 of 2 relapse cases in the study population. From an anonymous postdeployment survey of 72% (521/725) of the task force, the self-reported compliance rate was 52% for weekly chemoprophylaxis, 41% for terminal (postdeployment) chemoprophylaxis, 31% for both weekly and terminal chemoprophylaxis, 82% for treating uniforms with permethrin, and 29% for application of insect repellent. CONCLUSIONS: Delayed clinical presentation can occur with P vivax. Symptoms are often vague, but malaria should be included in the differential diagnosis for soldiers returning from an endemic region. Suboptimal compliance with preventive measures can result in a malaria outbreak.

Postdeployment hearing loss in U.S. Army soldiers seen at audiology clinics from April 1, 2003, through March 31, 2004.

PURPOSE: U.S. Army soldiers face unique noise exposures in the current deployed setting. The effects of these deployment-related exposures have not previously been documented. METHOD: In an attempt to initiate this process, medical evaluations performed at military audiology clinics from April 2003 through March 2004 were reviewed to compare noise-induced hearing loss injury (NIHLI) outcomes among soldiers whose diagnoses were classified as postdeployment-related versus non-postdeployment-related. Sentinel NIHLI outcomes of interest included acoustic trauma, permanent threshold shift, eardrum perforation, tinnitus, and military-specific H-3 and H-4 hearing loss profiles. RESULTS: Significantly higher rates of NIHLI and associated outcomes were observed among soldiers whose diagnoses were postdeployment-related. CONCLUSIONS: Based on the findings from this evaluation, recommendations are provided for enhancing the force health protection posture for prevention of hearing loss in future deployments.

Mental health impact of 9/11 Pentagon attack: validation of a rapid assessment tool.

BACKGROUND: Following the tragic events of 9/11/2001, the Pentagon Post Disaster Health Assessment (PPDHA) survey was created to identify healthcare needs and concerns among Pentagon personnel and to assure that appropriate care and information was provided. The PPDHA was fielded from October 15, 2001, to January 15, 2002. Fundamental in this assessment was the evaluation of the mental health impact as a result of the attack. METHODS: Although a number of standardized instruments exist for mental health domains, most are lengthy and could not be used as a rapid health assessment. Instead, a short screening instrument consisting of 17 questions was developed that covered important mental health symptom domains, mental health functioning, and possible predictive risk factors. High-risk groups for post-traumatic stress disorder (PTSD), depression, panic attacks, generalized anxiety, and alcohol abuse were assessed, and validation of risk groups was assessed across functional levels. RESULTS: Overall, 1837 (40%) respondents met the screening criteria for any of the symptom domains of interest 1 to 4 months after the attack: PTSD (7.9%), depression (17.7%), panic attacks (23.1%), generalized anxiety (26.9%), or alcohol abuse (2.5%). Mental health risk groups were highly correlated with self-reported reduced daily functioning and use of counseling services. Additionally, risk factors known to be associated with mental health problems after traumatic events were strongly predictive of the high-risk categories identified. CONCLUSIONS: Mental health concerns were common among Pentagon employees in the 4 months after the 9/11 attack. Data from this study suggested that the short mental health screening instrument had validity and can serve as a prototype for rapid public health assessment of the mental health impact of future traumatic events.