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(https://health.mil/News/Articles/2023/08/16/Walter-Reeds-NICoE-Scientists-to-Present-at-2023-MHSRS) Walter Reed’s NICoE Scientists to Present New TBI Battlefield Biomarkers Research During 2023 MHSRS
Aug 15th 2023, 20:00

(https://walterreed.tricare.mil/) Walter Reed National Military Medical Center is pleased to announce that researchers from the (https://health.mil/Military-Health-Topics/Centers-of-Excellence/NICOE) National Intrepid Center of Excellence will present a groundbreaking study on diagnosing traumatic brain injuries during the 2023 (https://health.mil/News/In-the-Spotlight/MHS-Research-Symposium) Military Health System Research Symposium taking place Aug. 14-17, 2023 at the Gaylord Palms Resort and Convention Center in Kissimmee, Florida.
Elevating Diagnostic Research, Improving Outcomes for Patients with Mild TBIs

Presentation Title: Brain white matter alterations in military service members after a remote mild traumatic brain injury

Abstract ID: MHSRS-23-10510

Session Title: Battlefield Biomarkers for TBI: Diagnostic and Prognostic Indicators

Presenter: Ping-Hong Yeh, Ph.D., National Intrepid Center of Excellence, Walter Reed National Military Medical Center

Poster Session Date and Time: Wednesday, August 15th, 15:30-17:30 p.m. EDT

Medical Research: A High Calling, Serving Those Who Serve Our Country

Dr. Ping-Hong Yeh, who completed his post-doctoral studies at the University of California, San Francisco, has spent more than a decade studying biomarkers that inform health care workers with vital information in diagnosing and treating TBIs. "I feel blessed to have the opportunity to work in an environment that allows me to help injured warriors," Yeh emphasized. He’s determined to improve outcomes for those overcoming brain trauma caused by the concussive strength of the weapons of war, especially improvised explosive devices.
According to the National Institutes of Health, the current lag in TBI incidence and hospitalization can be reduced if digital biomarkers such as hard fall detection are standardized and used as a mechanism to alert paramedics to an unresponsive trauma patient. Yeh and his colleagues are on a mission to turn the tide on mild TBIs, which may cause a wide range of debilitating outcomes - including headaches, dizziness, tinnitus, loss of memory and major mood swings.
About Walter Reed National Military Medical Center
The Walter Reed National Military Medical Center is one of the nation's largest and most renowned military medical centers. Recently dubbed "The Nation's Medical Center", we represent the joining of the "Best of the Best" in military medicine when National Naval Medical Center and Walter Reed Army Medical Center came together in September of 2011, to form Walter Reed National Military Medical Center as decreed by the Base Realignment and Closure law of 2005.
We are comprised of nearly 7,100 dedicated staff members who make it their daily mission to achieve the vision and mission of our medical center. Our vision is to serve military families and our nation's active duty, returning war heroes, veterans, and our Nation's leaders. We’re committed to operational readiness, outstanding customer service, and world-class health care delivery for our beneficiaries.

(https://health.mil/News/Articles/2023/08/14/Military-Health-System-Recognizes-Innovators-Committed-to-Warfighter-Care) Military Health System Recognizes Innovators Committed to Warfighter Care
Aug 13th 2023, 20:00

The 2023 Military Health System Research Symposium recognized innovative researchers focused on enhancing warfighter health.
Dr. Lester Martinez-López, the Department of Defense’s assistant secretary of defense for health affairs, presented the awards to the winning individuals and teams. Their research spans diverse topics, such as combat casualty care, wearable monitoring devices, traumatic eye injury treatment, and lifesaving medications.
Individual Distinguished Service Award Winners
Two researchers in the military medical community were recognized for distinguished service over a lifetime of innovative work.
Dr. Thomas Davis of the (https://health.mil/About-MHS/OASDHA/Uniformed-Services-University-of-the-Health-Sciences) Uniformed Services University of the Health Sciences in Bethesda, Maryland, was honored for researching how the human body responds to severe combat-related injuries, and how to help the body’s immune system favorably respond to organ transplants. His work led to major breakthroughs in combat-related wound healing, and a greater understanding of a condition known as heterotopic ossification, the formation of painful bony regrowth following a traumatic event. He has culminated his career with more than five years as the vice chair for research and the scientific director of the cell biology and regenerative medicine lab at USU, totaling more than 30 years of government service. His academic career and mentorship paved the way for the next generation of military medical investigators. (https://health.mil/News/Gallery/Dvids-Videos/2023/08/14/video893583) Watch the Video
Richard D. Branson, a professor emeritus at the University of Cincinnati College of Medicine, Department of Surgery, Division of Trauma and Critical Care, was recognized for his role in establishing the Center for Sustainment and Trauma Readiness Skills platform, known as CSTARS, and installing the advanced Critical Care Air Transport Team training platform at the university. Utilizing his skills in medical and respiratory care and capitalizing on his medical research, he helped develop clinical protocols and training for the course. The training and maturation of this platform and course are credited with a 99% survival rate by CSTARS teams while deployed. The program trains approximately 300 students annually. His research efforts have been directed at improving mechanical ventilation, care of the patient with acute respiratory distress syndrome, trauma resuscitation, and critical care throughout the continuum of care. His most recent initiatives focus on finding solutions for caregivers in resource-constrained environments, such as during aeromedical evacuation events. This includes trials on closed-loop control of ventilation and oxygenation and improving trauma resuscitation utilizing proper composition and volume of blood products. The novel knowledge he generated has translated directly into how patients are stabilized during en route care and at military and civilian hospitals and clinics. The son of a U.S. Marine, he dedicated his career to improving care for military service members. (https://health.mil/News/Gallery/Dvids-Videos/2023/08/14/video893586) Watch the Video
Team Awards in Outstanding Research
Four teams were awarded for their work focused on the challenges warfighters face both on and off the battlefield. Their research continues to promote progress in the military medical community.
Dr. Rachel Markwald and the team at the Naval Health Research Center in San Diego, California, to include collaborations with Massachusetts Institute of Technology, Commander, Naval Surface Forces, and Naval Information Warfare Center, were recognized for their work establishing the Command Readiness, Endurance, and Watchstanding program. The CREW program uses wearable monitoring devices to provide key health and readiness indicators to commanders to help evaluate sailor fatigue, reducing operational risk, and enhancing combat readiness. The team established that wearables and the associated data capture processes are operationally feasible, can provide valuable feedback to the individual, and inform group-level decision-making thus enabling novel insights for Force readiness. Further, CREW has provided empirical insights to U.S. Navy leadership on the status of sleep as a key component of combat readiness. (https://health.mil/News/Gallery/Dvids-Videos/2023/08/14/video893165) Watch the Video
The Strategy to Avoid Excessive Oxygen research team from the University of Colorado Anschutz Medical Campus and the Center for Combat Medicine and Battlefield Research, led by Dr. Adit Ginde and his team, are awarded for their examination of supplemental oxygen and the benefits of targeted normoxemia, or managing blood oxygen levels in a specific range, in critically injured and ill patients. The team’s efforts led to the determination that targeted normoxemia is safe, maintains and may improve clinical outcomes, and reduces the need for high concentrated oxygen. The team works closely with the military services and the Defense Health Agency to update training programs and clinical practice guidelines and is providing data to inform future requirements for next generation oxygen-generator acquisitions. The body of evidence developed by the SAVE-O2 research team at CU and with the CU Center for COMBAT Research presents a phenomenal example of research leading to change in clinical practice guidelines and training curricula, and how research drives requirements for material-solution acquisitions. DOD’s continued funding of the SAVE-O2 research team provides clear evidence of their outstanding contributions to military medical research. (https://health.mil/News/Gallery/Dvids-Videos/2023/08/14/video893749) Watch the Video
Dr. Rudy P. Rull and the (https://www.militaryonesource.mil/data-research-and-statistics/research-partners/millennium-cohort-program/) Millennium Cohort Program team were recognized as the premier longitudinal research program of warfighter, veteran, and military family health and wellbeing. Sponsored by both the DOD and the Department of Veterans Affairs, the program is an active collaborative effort between researchers from the Naval Health Research Center, the Veterans Health Administration, and multiple military, academic, and nongovernmental research organizations. Now in its third decade, the Millennium Cohort Program has enrolled and collected longitudinal survey data from 260,000 service members, 28,000 military spouses, and 4,000 military-connected adolescents to date and generated over 180 peer-reviewed publications. This highly informative portfolio of research is called on to support high-level engagements, including data analyses supporting the PACT Act and the White House’s Joining Forces initiative, and produced recent high-profile publications on a variety of important topics including cancer mortality, health effects of blast exposure, health disparities among LGB service members, and family factors influencing military separation. (https://health.mil/News/Gallery/Dvids-Videos/2023/08/10/video893394) Watch the Video
Dr. Kendra Lawrence, Dr. Lindsey Garver, and Ms. Andrea Renner of the U.S. Army Medical Materiel Development Activity, with commercial partner Ophirex, Inc., were honored for the Broad-Spectrum Snakebite Antidote program. They accelerated the technical and programmatic maturity of the critical life-saving drug, varespladib, including two pivotal clinical trials in four years. Their efforts will provide an important capability for warfighters deployed in far-forward, austere conditions where snakebites are a significant threat to life and limb. This team’s drug development effort, funded by the DHA, is the direct result of a collaboration between the integrated product team and their small-business partner to identify and mitigate risks early in development and to identify and implement regulatory, financial, contracting, and acquisition planning mechanisms to realize benefits for the program. (https://health.mil/Error?item=web%3A%7B496EBB2C-A990-4DCB-B9D5-416867824EAE%7D%40en) Watch the Video
Individual Award for Outstanding Research
Dr. Steven E. Wilson of the Cole Eye Institute, Cleveland Clinic, in Cleveland, Ohio was honored for his work envisioning and providing evidence on (https://pubmed.ncbi.nlm.nih.gov/35074340/) topical losartan, a medication used to prevent and treat vision-compromising corneal and conjunctival fibrosis (scarring of the clear front part of the eye) after trauma, chemical burns, infections, and numerous other disorders of the cornea and conjunctiva in the eye. This research is revolutionizing treatment of these injuries throughout the world and will be used to treat those types of injuries in American service members, as well as in their families, in addition to all patients afflicted with these numerous corneal and conjunctival scarring conditions. (https://health.mil/News/Gallery/Dvids-Videos/2023/08/14/video893397) Watch the Video
Several other awards will be presented during the week-long symposium. A Young Investigator Competition will be held during the conference to honor three top investigators during an awards program. More than 1,300 scientific posters will be presented during MHSRS, and top poster presenters will be recognized by their peers.
For more about MHSRS, the research being presented, and additional areas of interest, visit the (https://health.mil/News/In-the-Spotlight/MHS-Research-Symposium) MHSRS webpage.

(https://health.mil/News/Articles/2023/07/31/Defense-Health-Agency-Veterinary-Services-Protect-Military-Working-Animals) Defense Health Agency Veterinary Services Protect Military Working Animals
Jul 30th 2023, 20:00

Military working animals, along with their human counterparts, play an important role in protecting our nation and U.S. interests worldwide.
>From bomb and drug sniffing working dogs to working mules and horses—these animals are crucial to the safety and security on and off the battlefield.
The (https://www.dvidshub.net/news/446018/veterinary-corps-vital-army-107-years) U.S. Army Veterinary Corps promotes the health, safety, and welfare of all military working animals to maintain mission readiness. The corps also provides care for service members’ pets at veterinary treatment facilities around the globe. The Defense Health Agency Veterinary Services Division supports the Veterinary Corps’ animal health mission by providing policy guidance, support, and coordination with other departments and agencies when needed.
“We accomplish this by providing veterinary public health capabilities through veterinary medical and surgical care, food safety and defense, and biomedical research and development,” said U.S. Army Lt. Col. Patti Glen, chief of DHA’s veterinary services division. “In addition to the vet corps, officers provide military veterinary expertise in response to natural disasters and other emergencies. We're an integral part of supporting a nation at war. Everything we do ultimately focuses on the warfighter, the soldier, sailor, airmen, and Marines.
Taking Care of Military Working Animals is a Team Effort
U.S. Army Lt. Col. Melissa Hehr, deputy chief of DHA’s veterinary services division, said that military working dogs receive semi-annual physical exams at a minimum, as well as other routine and preventive veterinary care that includes vaccinations, and flea, tick, and heartworm prevention.
She said wellness exams are recommended for personal pets on an annual basis. Consulting a veterinarian is recommended to “determine what vaccinations are most appropriate, given their pet’s location, breed, age, health status, and activities.
“For our working animals, the handlers have a really close relationship with the veterinarian so that they can call them anytime they need to,” said Glen. “There is an Army veterinarian on call 24/7 for our working animals.
Glen noted the summertime can be especially hard on working animals, particularly dogs.
“The working dogs are out there in the heat, and their work is so intense that they must be on work-rest cycles. They need to have plenty of shade. Their coat gives them more insulation, so it's harder to keep them cool. It is important for them to have access to shade, and water to cool down and to drink.”
Even something as common as walking your dog can be dangerous for their health during the warmer months.
“If the concrete is too hot for you to touch,” said Glen, “then it’s too hot for them to walk on. Find some grass to get them off the hot concrete.”
“Another thing for military families to keep in mind is maintaining their pet's rabies vaccinations and rabies titers.” She added  this is especially important if a service member is about to move outside of the U.S. Having pet records up to date is vital to prevent delays.

(https://health.mil/News/Articles/2023/07/03/Walter-Reed-Performs-Historic-First-Single-Port-Robotic-Surgery) Walter Reed National Military Medical Center Performs Historic First Single-Port Robotic Surgery
Jul 2nd 2023, 20:00

Walter Reed unveiled its new single-port robotic surgical system, becoming the first Department of Defense facility, and the first military hospital in the National Capital Region, to use the newly FDA-approved medical device.
“This is one of the most transformative technological advances across disciplines right now, reshaping how we approach surgical disease,” said U.S. Navy Lt. Cmdr. (Dr.) Brandon R. Garren, who with his team today, performed a minimally invasive surgery on a patient with an enlarged prostate. Garren, the service chief of the Department of Urology at Walter Reed, worked with a multidisciplinary team that trained for months to perform today’s milestone surgery.
During the groundbreaking procedure, Garren utilized a console with hand and foot controls to command the robots, while a second surgeon stood by to supervise the way the surgical instruments worked. Garren controlled the robot's motions, adjusting its precision with his hand and foot gestures, while a series of robotic arms picked up and manipulated the surgical instruments.
Robotic surgery has exponentially improved outcomes for patients: minimizing scarring, improving recovery times and post-operative pain – as well as reducing hospital stays. The technology has wide-ranging applications for a variety of surgical procedures including coronary artery bypass, joint replacement, organ transplantation, gynecological operations, and cancer treatments.

(https://health.mil/News/Articles/2023/07/01/RMEs) Reportable Medical Events, Military Health System Facilities, Week 22, Ending June 3, 2023
Jun 30th 2023, 20:00

Reportable Medical Events are documented in the Disease Reporting System internet by health care providers and public health officials across the Military Health System for the purpose of monitoring, controlling, and preventing the occurrence and spread of diseases of public health interest or readiness importance. These reports are reviewed by each service’s public health surveillance hub. The DRSi collects reports on over 70 different RMEs, including infectious and non-infectious conditions, outbreak reports, STI risk surveys, and tuberculosis contact investigation reports. A complete list of RMEs is available in the 2022 Armed Forces Reportable Medical Events Guidelines and Case Definitions.1 Data reported in these tables are considered provisional and do not represent conclusive evidence until case reports are fully validated.
(https://health.mil/Reference-Center/Reports/2023/07/01/Article-6-Table) 

Total active component cases reported per week are displayed for the top five RMEs for the previous year. Each month, the graph is updated with the top five RMEs, and is presented with the current month’s (May 2023) top five RMEs, which may differ from previous months. COVID-19 is excluded from these graphs due to changes in reporting/case definition updates in 2023.

References

Armed Forces Health Surveillance Division. Armed Forces Reportable Medical Events. Accessed April 6, 2023. (https://health.mil/Military-Health-Topics/Health-Readiness/AFHSD/Reports-and-Publications/Armed-Forces-Reportable-Medical-Events) https://www.health.mil/Military-Health-Topics/Health-Readiness/AFHSD/Reports-and-Publications/Armed-Forces-Reportable-Medical-Events


(https://health.mil/Military-Health-Topics/Health-Readiness/AFHSD/Reports-and-Publications/Armed-Forces-Reportable-Medical-Events) Defense Manpower Data Center. Department of Defense Active Duty Military Personnel by Rank/Grade of Service, October 31, 2022. (https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports) https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports


(https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports) Defense Manpower Data Center. Armed Forces Strength Figures for January 31, 2023. (https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports) https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports


(https://dwp.dmdc.osd.mil/dwp/app/dod-data-reports/workforce-reports) Navy Medicine. Surveillance and Reporting Tools–DRSI: Disease Reporting System Internet. (https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI) https://www.med.navy.mil/Navy-Marine-Corps-Public-Health-Center/Preventive-Medicine/Program-and-Policy-Support/Disease-Surveillance/DRSI


(https://health.mil/News/Articles/2023/07/01/Reserves) Surveillance Snapshot: Illness and Injury Burdens Among Reserve Component Members, U.S. Armed Forces, 2022
Jun 30th 2023, 20:00

(https://health.mil/News/Articles/2023/07/01/Medical-Evacuations) Medical Evacuations out of U.S. Central and U.S. Africa Command Among Active and Reserve Components, U.S. Armed Forces, 2022
Jun 30th 2023, 20:00

During deployed military operations, initial medical care is provided by military medical personnel stationed within the operational theater, but some injuries and illnesses require medical care outside the theater of operation. In such cases, affected individuals are usually transported to a permanent military medical facility, usually in Europe or the U.S., for definitive diagnosis or care. Because medical evacuations are resource-intensive, they are employed for serious medical conditions, some of which are directly related to participation in, or support of, military operations. Other medical conditions that are unrelated to operational activities but necessitate medical evacuation may be preventable. This report summarizes the nature, numbers, and trends of conditions for which military members were medically evacuated from the U.S. Central Command (CENTCOM) or Africa Central Command (AFRICOM) operations during 2022, with historical comparisons to the previous 4 years.
With completion of the withdrawal of all U.S. military forces from Afghanistan on August 31, 2021, followed by the conclusion of the U.S. combat mission in Iraq on December 9, 2021,1,2 U.S. military operations have been substantially reduced in the CENTCOM area of responsibility (AOR). To sustain counterterrorism operation successes, deployment of forces continues in all AORs, in addition to assistance, advice, and accompaniment of security forces for selected partners, particularly in the CENTCOM and AFRICOM AORs.3 This report only includes medical evacuations from CENTCOM and AFRICOM, without describing any medical evacuations from recent troop deployment to the U.S. European Command (EUCOM), U.S. Indo-Pacific Command (INDOPACOM), or U.S. Southern Command (SOUTHCOM). MSMR has historically reported medical evacuations from CENTCOM due to large numbers of service members deployed for named operations such as Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn. The AFRICOM AOR was added to this annual report in 2021, due counterterrorism force deployment.3 Future reports may review medical evacuations from other AORs, as required by leadership interest or changing operational tempos.
What are the new findings?

Mental health disorders and injuries constituted the most frequent diagnostic categories for service members medically evacuated in 2022 from U.S. Central Command (CENTCOM) and U.S. Africa Command (AFRICOM). Of the 691 CENTCOM service members and 229 from AFRICOM who were evacuated, hospitalization was required for 245 (35.5%) and 59 (25.8%), respectively. Most service members evacuated from CENTCOM or AFRICOM were returned to full duty status after their post-evacuation hospitalizations or outpatient evaluation.

What is the impact on readiness and force health protection?

While the number of medical evacuations from CENTCOM declined to the lowest point observed over the last 5 years, during the same period AFRICOM medical evacuations increased to their highest level. These trends correspond with the changes in deployed troop strength within these 2 geographic combatant commands.

Methods

The surveillance population for this analysis includes all members of the active and reserve components of the U.S. Army, Navy, Air Force, and Marine Corps deployed to the CENTCOM or AFRICOM AORs for any length of time from January 1, 2018 through December 31, 2022. Medical evacuations by the U.S. Transportation Command (TRANSCOM) from the CENTCOM or AFRICOM AORs to a medical treatment facility outside the operational theater were assessed from records maintained in the TRANSCOM Regulating and Command & Control Evacuation System (TRAC2ES). Inclusion criteria for this analysis required that any medical evacuee have at least one inpatient or outpatient medical encounter at a permanent military medical facility in the U.S. or Europe within an interval of 5 days before to 10 days after the reported evacuation date. CENTCOM and AFRICOM evacuation data are presented separately.
Medical evacuations were classified by the cause and nature of the precipitating medical condition, based on information in relevant evacuation and medical encounter records. All medical evacuations were classified as “battle injuries” or “non-battle injuries and illnesses,” based on entries in the TRAC2ES evacuation record.
Evacuations due to non-battle injuries and illnesses were further classified into 18 illness/injury categories based on International Classification of Diseases, 9th and 10th Revisions (ICD-9 and ICD-10, respectively) diagnostic codes reported in medical encounter records following evacuation. All records of hospitalizations and ambulatory visits from 5 days before until 10 days after the reported date of each medical evacuation were identified from Defense Medical Surveillance System data. The primary (first-listed) diagnosis for either hospitalization or earliest ambulatory visit after evacuation was used to classify the condition that necessitated the evacuation. If the first-listed diagnostic code specified an external cause of injury (ICD-9 E-code/ICD-10 V-, W-, X-, or Y-code) or an encounter for a condition other than a current illness or injury, the secondary diagnosis specifying illness or injury (ICD-9: 001–999/ICD-10: A00–T88, U07.1, or U09.9) was used. If no secondary diagnosis was provided, or if the secondary diagnosis also was an external cause code, the first-listed diagnostic code of a subsequent encounter was used.
The disposition codes associated with the DMSS medical encounter were used to create a disposition category for each medical evacuation. Inpatient disposition categories include: Returned to duty (code 01), Transferred/discharged to other facility (codes 02–04, 09, 21–28, 43, or 61–66), Died (codes 20, 30, 40–42, 50, or 51), Separated from service (codes 10–15), and Other/unknown. Outpatient disposition categories include: Released without limitation (code 1), Released with work/duty limitation (code 2), Immediate referral (code 4), Sick at home/quarters (codes 3 or S), Admitted/transferred to civilian hospital (codes 7, 9, A–D, or U), Died (codes 8 or G), Discharged home (code F), and Other/unknown.

Results

In 2022, 691 service members were medically evacuated from the CENTCOM AOR, while 229 were evacuated from the AFRICOM AOR, with each experiencing at least one subsequent medical encounter at a fixed medical facility outside the operational theater, within the requisite inclusion time frame (Table 1). Mental health disorders accounted for the most medical encounters after a CENTCOM evacuation (n=268; 38.8%), while injury represented the most common diagnostic category after evacuation from AFRICOM (n=69; 30.1%) (Table 1).
(https://health.mil/Reference-Center/Reports/2023/07/01/Article-2-Table-1) 
  
Annual CENTCOM medical evacuations attributable to battle injuries remained relatively stable in 2018 (n=57), 2019 (n=59), and 2020 (n=59), subsequently decreasing to near 0 (n=8 in 2021; n=3 in 2022) with the conclusion of major combat operations (data not shown). Annual CENTCOM medical evacuations attributable to non-battle injuries also declined, from 1,266 to 691, during the 2018-2022 surveillance period (Figure). Annual medical evacuations from AFRICOM attributed to battle injuries peaked at six in 2019, then declining to four in 2020 and zero in 2021, with two in 2022 (data not shown). Notably, in 2022 AFRICOM medical evacuations attributable to non-battle injuries and diseases (n=229) exceeded the numbers attributed in the prior four years but remained much lower than CENTCOM (Figure).

Demographic and military characteristics

The leading major diagnostic categories following medical evacuations from CENTCOM and AFRICOM were the same for men and women: mental disorders (from CENTCOM) and non-battle injury (from AFRICOM) (Table 1). Compared to men, female CENTCOM and AFRICOM service members had a higher proportion of medical evacuations for mental health disorders and genitourinary system disorders (Table 1). In contrast, male service members from both AORs had higher proportions of evacuation for injuries, musculoskeletal system disorders, and digestive system conditions.
The largest numbers and proportions of CENTCOM and AFRICOM evacuees were non-Hispanic White service members, those aged 20-24 years, members of the Army, and junior and senior enlisted personnel (Table 2). Most CENTCOM (84.5%) and AFRICOM (80.8%) medical evacuations were assigned routine precedence.
(https://health.mil/Reference-Center/Reports/2023/07/01/Article-2-Table-2) 

Most frequent specific diagnoses

Among men and women in both AORs, the leading 3-digit ICD-10 code for mental health disorders indicated reaction to severe stress and adjustment disorders (F43) (Table 3). This ICD-10 code represented over 75% of mental disorder diagnoses among men and women in both AORs (data not shown). 
(https://health.mil/Reference-Center/Reports/2023/07/01/Article-2-Table-3) 
The proportion of medical encounters for signs, symptoms and ill-defined conditions (R00-R99) accounted for over 10% of all medical evacuations in both AORs (Table 1). The primary diagnoses for the R00-R99 major diagnostic category were not clustered to 1 diagnosis but were diffused throughout this ICD-10 code chapter (data not shown).

Disposition

Hospitalization was required for 245 (35.5%) of CENTCOM (n=691) and 59 (25.8%) of AFRICOM (n=229) medical evacuees in 2022. About four-fifths (82.9% in CENTCOM and 83.1% in AFRICOM) of all service members hospitalized after medical evacuation were returned to duty. A smaller proportion of CENTCOM medical evacuees with subsequent outpatient encounters were released without limitation (69.5%) compared to AFRICOM evacuees (84.1%) (data not shown).

Discussion

Only 5 (0.3%) medical evacuations from CENTCOM (n=3) and AFRICOM (n=2) in 2022 were associated with battle injuries in the TRAC2ES records. While CENTCOM medical evacuations attributable to non-battle injuries declined to the lowest number observed in the last 5 years, during the same period AFRICOM non-battle injury medical evacuations increased to their highest level. These trends coincide with the drawdown in forces from CENTCOM and reestablishment of persistent military forces throughout East Africa.3
The leading diagnoses of AFRICOM non-battle injuries were not clustered around any specific ICD-10 code but distributed among diagnoses such as dislocation and sprain of joints and knee ligaments, intracranial injuries, and wrist or hand fractures. This heterogeneity of injury type may be due to the large proportion resulting from occupational hazards in the deployed environment. Classification by cause of injury rather than affected body system may be more appropriate for this population.
The proportion of CENTCOM medical evacuations in 2022 attributed to mental health disorders (38.8%; n=268) represents a continued increase from the proportions reported in 2021 (33.5%; n=323), 2020 (27.2%; n=327), and 2019 (27.1%; n=308). These rates of medical evacuation due mental health disorders are also considerably higher than the proportion (11.6%; n=5,892) described by a MSMR report examining evacuations from Iraq during a 9-year period between 2003 and 2011.4-7
Several important limitations should be considered when interpreting these results. Demographic data for the deployed population, i.e. person-time for individuals eligible for medical evacuation, are not readily available. A Government Accountability Office finding that the DOD does not maintain complete data to allow monitoring of personnel tempo limits assessment of the amount of time service members are deployed or assigned for service away from home for other events.8 The lack of deployed individual person-time precludes calculation of stratified and overall rates for medical evacuations.
Most causes of medical evacuations were estimated for this report from primary (first-listed) diagnoses in DMSS recorded during hospitalizations or initial outpatient encounters following evacuation. Diagnoses recorded in theater through the Theater Medical Data Store are not reflected in this analysis. In some cases, clinical evaluations at fixed medical treatment facilities following medical evacuation may have ruled out serious conditions clinically suspected while in theater, resulting in possible misclassification errors. Battle injuries rely on proper classification in the TRAC2ES system. Misclassification errors may occur, and given the small number of battle injuries, any misclassification will have an outsized effect.
As troop drawdown continues in CENTCOM, increasing non-battle injuries among AFRICOM medical evacuees may pose challenges due to AFRICOM’s particular logistical conditions, including extreme force dispersion, long distances for medical evacuation, and relatively few medical assets. While the substantial number of mental disorders following evacuation may indicate ongoing need for mental health services or reexamination of the pre-deployment screening process, the large proportion of service members evacuated with injury and musculoskeletal disorders from the AFRICOM AOR constitutes a major potentially preventable risk that degrades the readiness of the deployed force.

References

White House Briefing Room. Remarks by President Biden on the End of the War in Afghanistan. August 31, 2021. Accessed March 24, 2022. (https://www.whitehouse.gov/briefing-room/speeches-remarks/2021/08/31/remarks-by-president-biden-on-the-end-of-the-war-in-afghanistan) https://www.whitehouse.gov/briefing-room/speeches-remarks/2021/08/31/remarks-by-president-biden-on-the-end-of-the-war-in-afghanistan


(https://www.whitehouse.gov/briefing-room/speeches-remarks/2021/08/31/remarks-by-president-biden-on-the-end-of-the-war-in-afghanistan) Kullab, Samya. US formally ends combat mission in Iraq. Military Times. December 9, 2021. Accessed March 24, 2022. (https://www.military%C2%ADtimes.com/news/your-military/2021/12/09/us-formally-ends-combat-mission-in-iraq) https://www.military­times.com/news/your-military/2021/12/09/us-formally-ends-combat-mission-in-iraq


(https://www.military%C2%ADtimes.com/news/your-military/2021/12/09/us-formally-ends-combat-mission-in-iraq) White House Briefing Room. Letter to the Speaker of the House and President Pro Tempore of the Senate Regarding the War Powers Report. December 8, 2022. Accessed July 5, 2023. (https://www.whitehouse.gov/briefing-room/statements-releases/2022/12/08/letter-to-the-speaker-of-the-house-and-president-pro-tempore-of-the-senate-regarding-the-war-powers-report-4) https://www.whitehouse.gov/briefing-room/statements-releases/2022/12/08/letter-to-the-speaker-of-the-house-and-president-pro-tempore-of-the-senate-regarding-the-war-powers-report-4


(https://www.whitehouse.gov/briefing-room/statements-releases/2022/12/08/letter-to-the-speaker-of-the-house-and-president-pro-tempore-of-the-senate-regarding-the-war-powers-report-4) Armed Forces Health Surveillance Division. (https://health.mil/News/Articles/2020/05/01/Medical-Evacuations-out-of-the-US-Central-Command-MSMR-2020) Medical evacuations out of the U.S. Central Command, active and reserve components, U.S. Armed Forces, 2019. MSMR. 2020;27(5):27-32.
    Armed Forces Health Surveillance Division. (https://health.mil/News/Articles/2021/05/01/Medical-Evacuation-2021) Medical evacuations out of the U.S. Central Command, active and reserve components, U.S. Armed Forces, 2020. MSMR. 2021;28(5):28-33.
    Armed Forces Health Surveillance Division. (https://health.mil/News/Articles/2022/06/01/Med-Evac-MSMR) Medical evacuations out of the U.S. Central and U.S. Africa Commands, active and reserve components, U.S. Armed Forces, 2021. MSMR. 2022; 29(6):27-33.
    Armed Forces Health Surveillance Center. Medical evacuations from Operation Iraqi Freedom/Operation New Dawn, active and reserve components, U.S. Armed Forces, 2003–2011. MSMR. 2012;19(2):18-21.
    United States Government Accountability Office. Report to Congressional Committees. GAO-18-253, Military Readiness: Clear Policy and Reliable Data Would Help DOD Better Manage Service Members’ Time Away from Home. April 2018. Accessed July 5, 2023. (https://www.gao.gov/assets/gao-18-253.pdf) https://www.gao.gov/assets/gao-18-253.pdf


(https://health.mil/News/Articles/2023/07/01/Deployed) Morbidity Burdens Attributable to Various Illnesses and Injuries Among Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2022
Jun 30th 2023, 20:00

Each year, the MSMR estimates illness- and injury-related morbidity and health care burdens on the U.S. Armed Forces and the Military Health System, and this report updates previous analyses of these burden distributions among active and reserve component service members in deployed settings. While deployed service members are primarily selected from a subset of the active component, the reserve component also contributes a substantial portion of U.S. deployed forces. This report focuses on the health encounters of service members during deployment to two specific theaters of operation: U.S. Central Command (CENTCOM) and U.S. Africa Command (AFRICOM). While U.S. service members are deployed to all geographic combatant commands, the largest concentrations without access to fixed medical facilities are in the CENTCOM and AFRICOM areas of operation.1 
This report utilizes data from the Theater Medical Data Store, which documents service members’ inpatient and outpatient encounters while treated in an operational environment; MHS GENESIS captures health care data at permanent military facilities. TMDS receives medical data from Theater Medical Information Program-Joint applications, including AHLTA-Theater, TMIP-Composite Health Care System Cache, Mobile Computing Capability, Maritime Medical Modules, and the U.S. Transportation Command Regulating and Command and control Evacuation System (TRAC2ES).2

While this report focuses on medical encounters of service members treated in CENTCOM and AFRICOM operational environments during the 2022 calendar year, future reports may incorporate other combatant commands as circumstances dictate and data become available.
What are the new findings?
Administrative and other health services (ICD-10 “Z” codes) together with musculoskeletal disorders accounted for more than half of total medical encounters in 2022 among service members deployed to the U.S. Central Com­mand (CENTCOM) or the U.S. Africa Command (AFRICOM). Three common injury conditions—other back problems, arm/shoulder injuries, and knee injuries—were shared by male and female service members deployed to CENTCOM and AFRICOM.
What is the impact on readiness and force health protection?
Understanding the most common causes of injury and illness during deployment will help senior leaders develop and implement strategies to reduce preventable medical issues, preserving the fighting strength and enhancing readiness.

Methods
The surveillance population includes all individuals who served in the active or reserve components of the U.S. Army, Navy, Air Force, or Marine Corps with health care encounters captured in the TMDS during the surveillance period. This analysis was restricted to encounters where the theater of care specified was CENTCOM or AFRICOM, or where the name of the theater of operation was missing or null; by default, this excluded encounters in the U.S. Northern Command, U.S. European Command, U.S. Indo-Pacific Command, or U.S. Southern Command theaters of operations. In addition, TMDS-recorded medical encounters where the data source was identified as Shipboard Automated Medical System, or where the military treatment facility descriptor indicated that care was provided aboard a ship, were excluded from this analysis. Encounters from aero­medical staging facilities outside of CENTCOM or AFRICOM were also excluded.
Inpatient and outpatient medical encounters were summarized according to the primary (first-listed) diagnoses (if reported with an International Classification of Diseases, 10th Revision [ICD-10] code between A00 and U09 and Z codes, excluding Z37). TMDS has not fully transitioned to ICD-10 codes, so some ICD-9 codes were included. Primary diagnoses that did not correspond to an ICD-9 or ICD-10 code are not reported in this burden analysis. Medical encounters were summarized by ICD code chapters, plus an additional category for separate classification of COVID-19 diagnoses.
Morbidity burdens attributable to various conditions were estimated by the distribution of diagnoses corresponding to the 17 traditional categories of the ICD system, with an 18th category for COVID-19. Extended ICD-10 code groupings were also reviewed for the most common diagnoses.
Results
In 2022, 48,446 individuals initiated a total of 136,009 medical encounters while deployed to Africa and Southwest Asia/Middle East. Of the 136,009 total medical encounters, 231 (0.17%) were recorded as hospitalizations. Most medical encounters (75.8%), individuals affected (80.0%), and hospitalizations (74.5%) occurred among male service members (data not shown). 
In 2022, the largest percentages of medical encounters attributable to a major ICD-10 diagnostic category were coded as administrative and other health services (Z codes; includes factors influencing health status and health service contact), followed by musculoskeletal system/connective tissue disorders (Figure). 

The percentage of total medical encounters attributed to other health services increased from 26.2% in 2018 to 30.6% in 2022, when the most common ICD-10 diagnoses in this category included Z1152 (COVID-19 screening, 4.6%), Z0289 (other administrative examinations, 4.3%), and Z5682 (military deployment status, 2.6%). COVID-19 accounted for 1.2% of all medical encounters in 2022 (Table).
(https://health.mil/Reference-Center/Reports/2023/07/01/Article-1-Table) 
>From 2018 to 2022, the percentage of in-theater medical encounters due to musculoskeletal disorders (28.2% to 25.1%) and injury (8.2% to 5.9%) decreased (Figure). Lower back pain (M545) was the most frequent diagnostic code for musculoskeletal encounters in both men and women, followed by pain in the right shoulder (M25511), pain in the left shoulder (M25512), pain in the right knee (M25561), and pain in the left knee (M25562) (Table).
The percentage of in-theater medical encounters attributed to mental health disorders increased from 4.4% to 6.2% during the surveillance period (Figure). Adjustment disorder with mixed anxiety and depressed mood (F4323) was the most frequent mental health disorder diagnosis, with a higher percentage of in-theater encounters for this disorder among women (1.5%) than men (0.9%) (Table).
Discussion
As in prior annual reports of illness- and injury-related morbidity and health care burdens in deployed settings, administrative and other health services together with musculoskeletal disorders accounted for more than half of total medical encounters in theater. COVID-19 screening may have partially contributed to the increase in encounters for administrative and other health services during the surveillance period, as this specific Z-code (Z1152) accounted for almost 5% of all in-theater medical encounters in 2022. 
This report documents an increased percentage of mental health disorder medical encounters in theater, which is consistent with the 2018-2022 increased rate of ambulatory encounters for mental health disorders in garrison. The distribution of ambulatory encounters for mental health disorders in garrison (13.0%), however, was substantially higher than the percentage observed in theater (1.0%).3 No absolute rate comparisons can be made due to the lack of denominator (person-time) data in theater.
Encounters for certain conditions are generally rare in deployment settings. Some conditions, including diabetes, pregnancy, or congenital anomalies, often preclude deployment for service members. As a result of pre-screening, deployed service members demonstrate a lower rate of medical conditions that may interfere with deployment operations than their non-deployed counterparts. Deployed service members are also less likely to require medical care for pre-screened conditions. 
Several limitations of the data presented in this report should be considered when interpreting these results and analyses. Not all medical encounters in theaters of operation are recorded in the TMDS. Some care by in-theater medical personnel occurs at small, remote, or austere forward locations where electronic documentation of diagnoses and treatment is infeasible, and some emergency medical care to stabilize combat-injured service members before evacuation may not be routinely captured in the TMDS. Due to the exigencies of deployment settings that complicate accurate data reporting or transmission, this report may underestimate the true burden of health care in the areas of operation examined.
In any review relying on ICD coding, some misclassification of diagnoses should be expected due to coding errors in the electronic health record. Although the aggregated distributions of illnesses and injuries presented in this report are compatible with expectations derived from other examinations of morbidity in military populations (both deployed and non-deployed), instances of highly unlikely diagnostic codes based on the deployed population have been observed. This misclassification bias is likely minor and non-differential.
The DOD does not maintain complete data to monitor personnel tempo data, which limits assessment of the amount of time service members are deployed or assigned to serve away from home for other events.4 This lack of denominator data for person-time makes direct comparison of numbers and percentages of medical evacuations by cause difficult.
This report only includes CENTCOM and AFRICOM medical encounters, and thus does not describe any medical encounters from the recent deployment of troops to the U.S. European Command (EUCOM), the U.S. Indo-Pacific Com­mand (INDOPACOM), and the U.S. South­ern Command (SOUTHCOM). Each area of operation is unique, with vastly different medical assets and numbers of deployed service members. The results from CENTCOM or AFRICOM may not be generalizable to other combatant commands.
References

White House Briefing Room. Letter to the Speaker of the House and President Pro Tempore of the Senate Regarding the War Powers Report. December 8, 2022. Accessed July 18, 2023. (https://www.whitehouse.gov/briefing-room/statements-releases/2022/12/08/letter-to-the-speaker-of-the-house-and-president-pro-tempore-of-the-senate-regarding-the-war-powers-report-4) https://www.whitehouse.gov/briefing-room/statements-releases/2022/12/08/letter-to-the-speaker-of-the-house-and-president-pro-tempore-of-the-senate-regarding-the-war-powers-report-4


(https://www.whitehouse.gov/briefing-room/statements-releases/2022/12/08/letter-to-the-speaker-of-the-house-and-president-pro-tempore-of-the-senate-regarding-the-war-powers-report-4) Joint Operational Medicine Information Systems Program Management Office. TMDS Fact Sheet. Accessed July 18, 2023. (https://www.health.mil/Reference-Center/Fact-Sheets/2019/07/30/TMDS-Fact-Sheet) https://www.health.mil/Reference-Center/Fact-Sheets/2019/07/30/TMDS-Fact-Sheet


(https://www.health.mil/Reference-Center/Fact-Sheets/2019/07/30/TMDS-Fact-Sheet) Armed Forces Health Surveillance Division. (https://health.mil/News/Articles/2023/06/01/Ambulatory-Burden) Ambulatory visits among active component members, U.S. Armed Forces, 2022. MSMR. 2023;30(6):19-25.
    United States Government Accountability Office. Report to Congressional Committees. GAO-18-253, Military Readiness: Clear Policy and Reliable Data Would Help DOD Better Manage Service Members’ Time Away from Home. April 2018. Accessed July 5, 2023. (https://www.gao.gov/assets/gao-18-253.pdf) https://www.gao.gov/assets/gao-18-253.pdf


(https://health.mil/News/Articles/2023/07/01/Coast-Guard-Reserves) Surveillance Snapshot: Illness and Injury Burdens Among Reserve Component Members, U.S. Coast Guard, 2022
Jun 30th 2023, 20:00

(https://health.mil/News/Articles/2023/07/01/Beneficiaries) Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries Among Non-Service Member Beneficiaries of the Military Health System, 2022
Jun 30th 2023, 20:00

Military Health System beneficiaries are a diverse and heterogeneous population: Individuals who are eligible for care through the MHS include active component service members, activated National Guard and Reserve service members, family members of active component members, retirees, and family members of retirees. Each of these beneficiary categories has different demographics, enrollment, and utilization patterns.
An important distinction of beneficiary care is the transition from TRICARE to Medicare. Once an individual reaches age 65, TRICARE eligibility ends, as beneficiaries become eligible for Medicare. If they enroll in Medicare, those individ­uals receive a Medicare gap insurance, known as TRICARE for Life. TFL is funded through mechanisms outside of the Defense Health Program. While TFL patients are eligible for (javascript:void(0);) Direct CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”direct care at military hospitals and clinics, most care is provided at civilian institutions, paid through the Medicare benefit. While Medicare-eligible individuals remain eligible for direct care at a military medical facilities, such care is on a space-available basis.
Beneficiaries enrolled in TRICARE Prime and TRICARE Select, which includes many family members of active duty service members and a portion of non-Medicare eligible retirees and their family members (primarily those aged 64 and younger), may receive care at fixed military hospitals and clinics or from civilian health care resources ((javascript:void(0);) Purchased CareThe TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.purchased care) that supplement direct military medical care.1 In 2022, approximately 6.66 million non-service member beneficiaries utilized health care services through the MHS.1
This report provides an updated summary of care provided to non-service members in the MHS during calendar year 2022. Health care burden estimates are stratified for 4 age groups of health care recipients. Medicare-eligible beneficiaries (over age 65) are considered separately, as most of their care is provided and paid for by non-MHS resources.
What are the new findings?
In 2022, mental health disorders accounted for the largest proportions of the morbidity and health care burdens that affected the pediatric and younger adult beneficiary age groups. Among adults aged 45-64 and those aged 65 or older, musculoskeletal diseases accounted for the most morbidity and health care burdens. Nearly all care for Medicare-eligible beneficiaries (those over age 65 along with select other groups) was at non-military medical facilities, which resulted in over 90% of total non-service member beneficiaries encounters (Medicare-eligible and TRICARE-eligible) at non-military medical facilities.

What is the impact on readiness and force health protection?
Service member focus and morale are improved by the assurance of medical care to family members, especially during deployment or other periods of separation. The promise of lifetime medical benefits upon retirement for a service member and immediate family has been a powerful recruiting and retention tool over the past several decades. Non-member beneficiaries provide important opportunities for active duty health care providers to maintain medical skills, knowledge, and abilities, improving the readiness of the medical force. Trends in utilization and diagnostic patterns can help senior leaders allocate health care resources within the Military Health System to maximize efficiency, medical readiness, and the readiness of the medical force. 

Methods

The surveillance population included all non-service member beneficiaries of the MHS who had at least one hospitalization or outpatient medical encounter from January 1 through December 31, 2022, either through a military medical facility or provider or a civilian facility or provider (if reimbursed through TRICARE or through Medicare with a copay by TFL). For this analysis, all inpatient and outpatient medical encounters were summarized according to the primary (first-listed) International Classification of Diseases, 10th Revision (ICD-10) codes that indicate the natures of illnesses or injuries (i.e., ICD-10 codes A00–T88). Nearly all records of encounters with first-listed diagnoses that were Z-codes (care other than for a current illness or injury—e.g., general medical examinations, after care, vaccinations) or V/W/X/Y-codes (indicators of the external causes but not the natures of injuries)—were excluded from the analysis; encounters with a code of Z37 (“outcome of delivery, single liveborn”) in the primary position were retained.
For summary purposes, all illness- and injury-specific diagnoses (as defined by the ICD-10) were grouped into 153 burden of disease-related conditions and 25 major morbidity categories based on a modified version of the classification system developed for the Global Burden of Disease Study.2 The methodology for summarizing absolute and relative morbidity has been used annually since 2014 and described elsewhere.3 Results were stratified by source of health care (direct care [military treatment facilities] vs. non-direct care [non-military medical facilities]) and by age group (0-17 years, 18-44 years, 45-64 years, and 65 years old or older). For analysis of morbidity burdens within the youngest age group, developmental disorders were included in the general category of mental health disorders.

Results
In 2022, the population of non-service member MHS care recipients included more female beneficiaries (56.8%) than male beneficiaries (43.2%). Adults aged 65 years and older accounted for the highest number of individuals receiving health care (n=2.07 million; 31.6%), followed by adults 18-44 years old (n=1.58 million; 24.1%), pediatric beneficiaries under 17 years of age (n=1.47 million; 22.5%), and older adults 45-64 years of age (n=1.43 million; 21.8%) (Table 1).
(https://health.mil/Reference-Center/Reports/2023/07/01/Article-3-Table-1) 
In 2022, a total of 6,544,033 non-service member beneficiaries of the MHS experienced 88,440,430 medical encounters. The 2,068,635 beneficiaries over age 65 accounted for over half (50.2%) of these encounters (Table 1). Among TRICARE-eligible beneficiaries (under age 65), the three most frequent morbidity-related categories accounting for the most medical encounters were mental health disorders, signs/symptoms and ill-defined conditions, and injury/poisoning. While mental health disorders and injury also accounted for 1 of the 3 highest morbidity-related groupings for hospital bed days, maternal conditions accounted for the second-most bed days among beneficiaries under 65 years of age (Figures 1a, 1b).

Direct care versus care at non-military medical facilities

Most medical encounters (90.7%) among non-service member beneficiaries in 2022 were at non-military medical facilities (purchased care or care received under the Medicare benefit) (Table 1). Of all non-service member beneficiaries (individuals affected) with any illness or injury-related encounters during the year, many more exclusively received their care in non-military medical facilities (n=4,841,140; 74.0%) than either exclusively by military medical (direct) care (n=750,969; 11.5%) or a combination of both (n=951,924; 14.5%).
The highest proportion of care among beneficiaries of all age groups was exclusively from non-military hospitals or clinics. While individuals under 64 years of age utilized both direct and non-direct care within a range of 16.7% to 19.6%, combined care among beneficiaries ages 65 and older was lower (6.6%). Medicare-eligible beneficiaries (over age 65) accounted for the largest age-specific proportion of care exclusively outside military hospitals and clinics (91.0%); accordingly, just 2.5% received care exclusively in military hospitals or clinics (Table 2).
(https://health.mil/Reference-Center/Reports/2023/07/01/Article-3-Table-2) 

Pediatric beneficiaries (aged 0 to 17)

In 2022, pediatric beneficiaries accounted for 14.7% of all medical encounters, 22.5% of all individuals affected, and 6.7% of all hospital bed days (Table 1). On average, each pediatric beneficiary experienced 9 medical encounters during the year. Among TRICARE-eligible beneficiaries (excluding Medicare-eligible beneficiaries 65 and older), this group accounted for 29.5% of medical encounters, 32.8% of individuals affected, and 24.8% of all bed days.
Mental health disorders represented the largest burden of disease among pediatric beneficiaries when examining all medical encounters (37.1%; n=4,811,215) and hospital bed stays (59.2%; n=282,905) (Figures 2a, 2b). 

On average, pediatric beneficiaries affected by a mental health disorder had 15 medical encounters related to this morbidity category during the year (data not shown). More than two-thirds (67.0%) of all medical encounters for mental health disorders among pediatric beneficiaries were attributed to three groups of disorders: autism-related disorders (31.1%), followed by developmental disorders of speech and language (25.7%), and attention-deficit hyperactivity disorders (10.2%) (Figure 2c). 

On average, there were 41 autism-related encounters per individual affected by an autistic disorder (data not shown). Despite the high numbers of encounters associated with these three categories of mental health disorders, approximately three-quarters (73.7%) of mental health disorder-related hospital bed days were attributable to mood disorders, and 29.8% of mood disorder-related bed days were attributable to “major depressive disorder, recurrent, severe without psychotic features (ICD10: F332)” (data not shown).
Among pediatric beneficiaries overall, perinatal conditions (i.e., medical issues occurring within 1 year of birth) accounted for the second highest number of hospital bed days (n=41,114; 8.6%) after mental health disorders (Figures 2a, 2b). Among pediatric beneficiaries with at least 1 illness or injury-related diagnosis, those with malignant neoplasms had the second-highest number (14) of related encounters per affected individual. The highest numbers of malignant neoplasm-related encounters and hospital bed days were attributable to leukemias (data not shown).
Respiratory infections (including upper and lower respiratory infections and otitis media) accounted for relatively more medical encounters among pediatric beneficiaries (9.8%) when compared to any older age group of beneficiaries (Figures 2b, 3b, 4b, and 5b). Respiratory infections were attributed to a larger proportion of hospital bed days for adults 65 and older (6.5%) than pediatric beneficiaries (3.2%). 

Beneficiaries aged 18 to 44
In 2022, non-service member beneficiaries aged 18-44 accounted for 15.6% of all medical encounters, 24.1% of all individuals affected, and 8.9% of hospital bed days (Table 1). On average, each individual affected with an illness or injury (any cause) had 9 medical encounters during the year. Excluding those eligible for Medicare according to age, non-service member beneficiaries aged 18-44 accounted for 31.3% of all medical encounters, 35.3% of individuals affected, and 32.9% of all bed days in 2022.The morbidity-related category that accounted for the most medical encounters among beneficiaries aged 18-44 was mental health disorders (n=3,309,402; 24.0% of all encounters) (Figures 3a, 3b). Among these adult beneficiaries, mental health disorders accounted for over one-fifth (21.3%) of all bed days, and on average, each adult affected by a mental health disorder had 8 mental health disorder-related encounters during the year. Anxiety disorders (33.9%), mood disorders (29.9%), and adjustment disorders (16.5%) accounted for approximately four-fifths (80.3%) of all mental health disorder-related medical encounters among beneficiaries aged 18-44 (data not shown). Among adult beneficiaries in this age group, mood and substance abuse disorders accounted for over three-quarters (50.3% and 24.1%, respectively) of total mental health disorder-related hospital bed days.

Maternal conditions accounted for more than two-fifths (45.0%) of all bed days among adults aged 18-44, and on average, 6 medical encounters per affected individual (Figures 3a, 3b). Deliveries accounted for 9.8% of maternal condition-related medical encounters (data not shown).
Examination of an average number of medical encounters per person within a respective morbidity category identified malignant neoplasms as a diagnostic group accounting for individual health care use (6.4 encounters per individual) relatively comparable to mental health disorders (7.8 encounters per individual) and maternal conditions (6.1 encounters per individual). Of the 101,006 medical encounters for malignant neoplasms among adults aged 18-44, 29.5% were attributed to malignant neoplasm of the breast (data not shown).

Beneficiaries aged 45 to 64

In 2022, non-service member beneficiaries aged 45-64 accounted for approximately one-fifth (19.5%) of all medical encounters, 21.8% of all individuals affected, and 11.4% of hospital bed days (Table 1). On average, each affected individual had 12 medical encounters during the year. Excluding Medicare-eligible beneficiaries, this group accounted for 39.2% of medical encounters, 31.9% of individuals affected, and 42.2% of all bed days.
Of all morbidity-related categories, musculoskeletal diseases accounted for the most medical encounters (n=2,509,110; 14.5%) among older adult beneficiaries aged 45-64 (Figures 4a, 4b); back problems accounted for 42.5% of these musculoskeletal disease-related encounters (data not shown). Cardiovascular diseases represented the highest proportion of hospital bed days (17.0%), second to injury/poisoning (15.1%) (data not shown). Digestive diseases (9.3%) and malignant neoplasms (7.6%) accounted for a larger percentage of total hospital bed days among beneficiaries compared to other age groups. Malignant neoplasm of the breast represented the leading cause of neoplasm-related encounters (25.7%) in adult beneficiaries ages 45-64 (data not shown).

Beneficiaries aged 65 or older (Medicare-eligible or TFL)

In 2022, non-service member beneficiaries aged 65 or older accounted for more medical encounters and more than 2.5 times the number of hospital bed days than all other age groups combined. On average, each affected individual had 21 medical encounters during the year. In addition, the number of individuals affected was greater than any other age group (Table 1).
Musculoskeletal diseases (n=6, 443,154; 14.5%) and cardiovascular diseases (n=6,082,418; 13.7%) together represented the leading causes for medical encounters among beneficiaries aged 65 or older, while cardiovascular diseases as a discrete cause accounted for the most bed days (1,201,613 days; 23.2%) (Figures 5a, 5b). Back problems accounted for a little more than one-third (35.8%) of all musculoskeletal disease-related medical encounters (data not shown).

Discussion
This report documents health care among non-service member beneficiaries through direct care at military hospitals and clinics, non-military medical facility purchased care reimbursements, and Medicare services external to the MHS. A substantial majority of individuals received care exclusively from non-military medical clinics and hospitals, reflecting the fact that just under 10% of all ambulatory encounters documented in DMSS were provided from a direct care military medical facility in 2022. This low figure is somewhat misleading, however, as most encounters and bed days among non-service member beneficiaries are attributable to Medicare-eligible (65 or older) beneficiaries who are often distant from military hospitals and clinics and can generally only receive direct care if space is available.
The National Ambulatory Medical Care Survey of 2019 documents a substantially lower rate of ambulatory visits (3.2 visits per p-yr) among the general U.S. population than among non-service member MHS beneficiaries (13.5 visits per p-yr) reported here.4 This increased rate of ambulatory visits among non-service member beneficiaries compared to national civilian data was observed for all age groups. Future analyses comparing the major diagnostic category rates to civilian counterparts, by age and sex, may be useful to identify longitudinal morbidity outcomes unique to military service. Since the National Ambulatory Medical Care survey includes uninsured individuals, the financial barrier to care may explain a portion of the lower overall utilization rate.
Pronounced differences between beneficiary age groups are evident for types of morbidity-related diagnoses and disease-specific conditions. Individuals aged 65 or older—31.6% of all non-service member beneficiaries receiving an illness- or injury-specific diagnosis in 2022—accounted for approximately half (50.2%) of all medical encounters and nearly two-thirds (72.9%) of all hospital bed days among all beneficiaries. As those individuals receive care primarily through a Medicare benefit at non-MHS facilities, the impact on the MHS is minimal.
While ambulatory encounters among non-service member beneficiaries in 2022 remained relatively stable (2.1% increase) compared to the previous year, the crude annual difference in hospital bed days increased by over 20%. This trend was influenced by hospital bed days for beneficiaries ages 65 and older, among whom hospital bed days for cardiovascular disease increased from 787,739 bed days in 2021 to 1,201,613 bed days in 2022. The number of individuals 65 years and older affected by cardiovascular disease remained stable (from 1,211,692 individuals in 2021 to 1,213,404 individuals in 2022). Since this report does not include person-time nor approximate rates, annual comparisons are not proportionate to changes in the number of beneficiaries utilizing care. Further investigation of this finding may be of interest to MHS researchers.
In 2022, as in previous years, mental health disorders were the leading cause for medical encounters among pediatric (aged 0-17) and young adult (aged 18-44) beneficiary age groups, although the proportion of medical encounters attributed to mental health disorders was markedly lower among young adult (24.0%) than pediatric (37.1%) beneficiaries. Developmental disorders were a significant factor for pediatric beneficiary health care, with 67% of medical encounters for mental health disorders attributable to autism-related disorders, specific developmental disorders of speech and language, or attention-deficit hyperactivity disorders. Children affected by autistic disorder had an average of 41 autism-related encounters in 2022. Among young adult beneficiaries, the mental health disorders accounting for the largest health care burdens included anxiety, mood, and adjustment disorders.
As the MHS completes its transition to the new MHS GENESIS electronic health record, AFHSD is also in the process of completely transferring or mapping EHR data to the Defense Medical Surveillance System. During the transition to the new MHS Information Platform, the number of records transmitted from MHS GENESIS and the Tricare Encounter Detail to DMSS are being continually reviewed for completeness of data capture. The annual burden summary for active component service members indicated a substantial drop in the number of ambulatory encounters as well as incomplete data elements.5 This limitation was not seen among non-service member beneficiaries, however, as the number of ambulatory encounters remained relatively stable and hospital bed days increased substantially. This limitation appears to be primarily related to administrative (“Z”) codes, which were excluded from this analysis.
While this report aims to describe morbidity-related diagnoses for all MHS beneficiaries, the data are limited to beneficiaries who received care at military hospitals and clinics or at a non-military medical facilities that was reimbursed through TRICARE (as primary or secondary insurance) or through Medicare, if TFL was also billed. Certain care, e.g., paid with other health insurance and not billed to TRICARE, or paid directly by the patient (or family member), is not captured in this report.

References

Department of Defense. Evaluation of the TRICARE Program: Fiscal Year 2022 Report to Congress: Access, Cost, and Quality Data Through Fiscal Year 2022. Accessed 18 May 2023. (https://www.health.mil/Reference-Center/Reports/2022/10/07/Evaluation-of-the-TRICARE-Program-FY-2022-Report-to-Congress) https://www.health.mil/Reference-Center/Reports/2022/10/07/Evaluation-of-the-TRICARE-Program-FY-2022-Report-to-Congress


(https://www.health.mil/Reference-Center/Reports/2022/10/07/Evaluation-of-the-TRICARE-Program-FY-2022-Report-to-Congress) Armed Forces Health Surveillance Center. Ab­solute and relative morbidity burdens attributable to various illnesses and injuries, non-service member beneficiaries of the Military Health System, 2013. MSMR. 2014;21(4):23-30.
    Murray CJ and Lopez AD, eds. In: Global Bur­den of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cam­bridge, MA: Harvard University Press; 1996:120-122.
    National Ambulatory Health Care Survey: 2019 National Summary. Accessed July 19, 2023. Na­tional Ambulatory Medical Care Survey: 2019 Na­tional Summary (cdc.gov).
    Armed Forces Health Surveillance Center. (https://health.mil/News/Articles/2023/06/01/Ambulatory-Burden) Am­bulatory visits among active component members, U.S. Armed Forces, 2022. MSMR. 2023;30(6): 19-25.


(https://health.mil/News/Articles/2023/06/22/Lifestyle-Changes-Lead-to-Longer-Healthier-Life) Lifestyle Changes Lead to Longer, Healthier Life
Jun 21st 2023, 20:00

Lifestyle changes can help you live longer with fewer chronic diseases, feel great, and reduce your cancer risk, according to U.S. Air Force Col. (Dr.) Mary Anne Kiel, chair of the Defense Health Agency Primary Care Clinical Community. The practice of lifestyle and performance medicine offers ways to be healthier by enhancing a multitude of areas of your life through six key pillars.
Kiel is a leading DHA proponent of lifestyle and performance medicine, and chairs the (https://www.hprc-online.org/total-force-fitness/service-specific-resources/air-force-space-force/air-force-lifestyle) U.S. Air Force’s Lifestyle and Performance Medicine Working Group as well.
Clinicians trained in the practice “focus on using the six pillars of lifestyle medicine as the foundation of care for patients,” Kiel said. The six pillars “emphasize complete strategies for improving health, even as we age. Optimizing each of those pillars is critical to maintaining health, reducing our risk of chronic disease, and improving our daily performance.”
This also can be seen through the “lens of readiness and deployability of our service members,” she added.
The six pillars are:

Whole-food, plant-predominant eating patterns
    Physical activity
    Restorative sleep
    Stress management
    Avoidance of risky substances
    Positive social connections

These are “evidence-based prescriptive therapeutic lifestyle interventions” used as a primary means of treating chronic conditions including, but not limited to, cardiovascular diseases, type 2 diabetes, and obesity, Kiel explained. “They have been shown to improve longevity, decrease morbidity and mortality, and also improve the quality of life in our older years.”
The focus of lifestyle and performance medicine is “optimizing health care system performance and patient outcomes,” Kiel said. “Critical factors include patient experience, reducing costs, improving population health through preventive measures, and the well-being of the health care team,” she explained.
“Our core working group remains Air Force members, but we have gained much support and involvement from members of the other services through our broader coalition of interested membership, which is approaching 350 individuals across all services, as well as the DHA and Department of Veterans Affairs, which are engaged in integrating lifestyle medicine within the Military Health System and VA,” Kiel said.
The U.S. Army has its own functional medicine precepts. The broad-ranging holistic approach, the (https://www.army.mil/e2/downloads/rv7/acft/h2f_operating_concept.pdf) Health and Holistic Fitness program, encourages service members and their families to engage in healthy behaviors and a lifestyle to promote healthy aging.
The breadth of lifestyle medicine practices is growing within the military as a whole. Already, there are multiple clinics using lifestyle-and-performance-based medicine-immersed approaches in the U.S. Air Force and U.S. Navy, as well as the National Guard and Reserve, that encompass the entire range of providers across many specialties. There are also eight military graduate medical education programs that have adopted the lifestyle medicine residency curriculum.
“Patients are presented with options and educated expertise, but ultimately, they decide what health plan meets their needs,” Kiel said. Not only does this allow for more autonomy for the patient but it can also “result in more buy-in from patients since this becomes their plan and they are vested in it being successful,” she said. “Medical care for the lifestyle medicine patient is therefore characterized by a person-centered approach resulting in an improved state of well-being, and our patients often require fewer medications or procedures long term to combat chronic disease,” Kiel said.
Sleep is One Lifestyle Pillar
“Research on sleep health has shown how critical it is at all ages, but especially when it comes to chronic disease mitigation and reducing risk of dementia and overall morbidity and mortality,” Kiel said.
Improved sleep “can produce almost instantaneous results for improved mental health, pain levels, and risk for infectious disease,” she noted.
A (https://health.mil/Reference-Center/Reports/2021/02/26/Study-on-Effects-of-Sleep-Deprivation-on-Readiness-of-Members-of-the-Armed-Forces-Final-Report) 2021 Pentagon report on the effects of sleep deprivation on readiness in service members found that 64% of service members lack enough sleep compared to 28-37% of civilians. This “significantly increases the risk of accidents in training, operational, and combat environments,” Kiel said.
Good sleep is vital to health and readiness, and sleep and heart health “go hand in hand,” said Dr. Travis Batts, chief of cardiology at (https://wilfordhall.tricare.mil/) Wilford Hall, Lackland Air Force Base, Joint Base-San Antonio, Texas.
“Sleep is a time for our body to repair itself. When our body isn't given adequate time to repair, we keep pressing the same buttons and pushing the same triggers. And before we know it, our body starts to respond in ways that it would during other high stress levels,” Batts explained.
Batts actively incorporates the six pillars of lifestyle medicine into his patient interactions and addresses the sleep issue up front.
“I'm a big advocate of ensuring that my patients …  get a long enough time where they're asleep, so that they can reap those benefits and really value the sleep that they get,” Batts said.
He tells his patients that he has some of the same lifestyle issues as they do. “I tell my patients that as much as I'm your physician, I’m my own patient. I have the same lifestyle challenges that you have to get enough sleep,” he said.
A lifestyle medicine appointment often includes a detailed review of a patient’s health history, as well as their daily habits, including things like sleep, environment, what foods they eat and what barriers they have faced in the past.
“A lifestyle medicine approach to health differs from conventional medicine in that it relies heavily on patient engagement and interaction, involves lifestyle prescriptions more often than pharmaceutical prescriptions and focuses on guiding patients towards their short-term and long-term health goals,” Kiel said.
“Even though we have some of the best medicines and best therapies in the world, we can't overcome a poor lifestyle,” Batts said. That’s where patient education comes in. “You don't have to be a cardiologist to promote lifestyle medicine. You can be any type of physician, any provider, any individual.”
Resources
If you would like to learn more about integrating a lifestyle medicine approach for treating your health concerns, talk to your provider.

The Uniformed Services University Consortium for Health and Military Performance has a broad range of resources available to anyone interested in addressing lifestyle challenges. These include:

(https://www.hprc-online.org/) Human Performance Resources by CHAMP
    (https://www.hprc-online.org/nutrition/performance-nutrition) Performance Nutrition
    (https://www.hprc-online.org/nutrition/warfighter-nutrition-guide) Warfighter Nutrition Guide
    (https://www.hprc-online.org/sites/default/files/document/HPRC_Sleep_and_TFF_Leader_Guide_032223_508.pdf) Guide on Sleep


(https://health.mil/News/Articles/2023/06/15/Learn-about-TRICARE-Pharmacy-Benefit-Formulary-Changes) Learn about TRICARE Pharmacy Benefit Formulary Changes
Jun 14th 2023, 20:00

Summary:  This article provides an overview of the TRICARE pharmacy benefit and the beneficiary formulary change communication process over the last five years, describes emerging challenges and outlines the impact associated with these changes.
(http://tricare.mil/) TRICARE is the health care program that provides coverage to 9.6 million uniformed service members, retirees, and their family members. The National Defense Authorization Act for Fiscal Year 2000 required the establishment of a (https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Pharmacy-Operations/DOD-PT-Committee) Pharmacy and Therapeutics committee to develop and maintain a Uniform Formulary of medications—a list of brand name and generic drugs and supplies that TRICARE covers—which provides pharmacy benefits in the outpatient setting. Implementation occurred in 2005. The TRICARE Uniform Formulary provides three points of service for prescription dispensing and includes (https://tricare.mil/CoveredServices/Pharmacy/FillPrescriptions/MilitaryPharm) military hospitals and clinics worldwide, one (https://tricare.mil/CoveredServices/Pharmacy/FillPrescriptions/HomeDelivery) TRICARE Mail Order Pharmacy (home delivery) and (https://tricare.mil/CoveredServices/Pharmacy/FillPrescriptions/Network) retail network pharmacies located in the United States and several U.S. territories. 
The Department of Defense P&T committee meetings are held quarterly, with recommendations determining which medications are included on the (https://www.express-scripts.com/frontend/open-enrollment/tricare/fst/#/) Uniform Formulary based on clinical and cost-effectiveness of the agents. The outpatient TRICARE pharmacy benefit evaluates several components including prior authorization criteria, step therapy, quantity limits, formulary status, and a tiered copay structure. The (https://tricare.mil/CoveredServices/Pharmacy/Drugs) pharmacy tiered copays are based on the point of service and formulary status (generic, formulary brand and nonformulary agents), with the Tier 3 (nonformulary) copay being the most expensive.
The DOD P&T committee recommendations are then discussed publicly with the (https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Pharmacy-Operations/BAP) Beneficiary Advisory Panel, which is comprised of nongovernmental organizations representing DOD beneficiaries, pharmacy contractors and TRICARE network providers. Federal law requires that the BAP review and comment on the DOD P&T committee recommendations for implementing formulary changes to Tier 3 status, prior authorization criteria, and implementation periods. The BAP is unique in that it gives beneficiaries a voice in what medications are included on the formulary, while providing transparency to what is often an unpublicized process in other health systems. Following the BAP comments, the final formulary decisions are reviewed and signed by the director of the Defense Health Agency.
Since its creation, the TRICARE Uniform Formulary has evolved considerably. In 2018, the NDAA directed TRICARE to add a fourth “not covered” tier to its formulary, which excludes coverage of pharmaceutical agents that have little clinical effectiveness. Similar to commercial pharmacy benefit plans, beneficiaries must pay the full out-of-pocket cost for Tier 4 drugs at retail network pharmacies and these agents are not available at military hospitals or clinics or TRICARE Mail Order pharmacy. The P&T committee not only evaluates drugs for exclusion from coverage, but also identifies branded drugs that may be moved to Tier 1 status with a lower copayment for beneficiaries. Providers and beneficiaries can refer to the TRICARE formulary search tool2 for information on tiered copay status and other requirements, including prior authorization or quantity limits.
Given the variety of formulary changes that have occurred over the years, communication to impacted beneficiaries is essential. Although the 2000 NDAA directed patient notification to inform beneficiaries of pharmaceutical agents changing formulary status to Tier 3 or (nonformulary status), it became apparent that communication on several other formulary actions (e.g., prior authorization criteria, Tier 4 designation) were also needed.  
Beginning in October 2007, the DOD has taken key steps to improve communication with beneficiaries concerning formulary changes. Patient-specific notification letters are mailed to beneficiaries impacted by a variety of formulary changes. Examples include removal of a drug from the formulary (Tier 4 status), an increase in the cost-share (Tier 3 status), and a change from a preferred to a non-preferred status, which can include but is not limited to new step therapy or prior authorization requirements. The DOD beneficiary formulary change communication process is driven by the recommendations found in the published DOD P&T committee meeting minutes3.
TRICARE is unique in that a limited number of over-the-counter drugs are included on the formulary and available all three points of service. Additionally, a variety of OTC products are available only at the military hospitals and clinics. The P&T committee reviews the OTC drug classes to determine which drugs should and should not be covered, and occasionally an OTC drug will be removed from the benefit, in which case affected beneficiaries are notified. 
The individual letters describe the (https://militaryrx.express-scripts.com/notices/formulary) upcoming formulary change, lists options for formulary alternatives that the beneficiary and their doctor can consider, includes the associated copay information, and documents the implementation date for the associated change. The letters are mailed to impacted beneficiaries by the pharmacy contractor at least 30 days prior to the formulary change. 
In previous years, the formulary change letters resulted in increased beneficiary confusion and call volume. Beneficiaries contacted DHA because they had questions regarding the letter’s content and were confused on what, if any, action should be taken. In addition, beneficiaries were confused on the cost of the medication, relayed they did not understand the medical terminology included in the letters, were unclear about the prior authorization requirements and were confused about which drug was impacted by the formulary change. Working with several avenues for beneficiaries to submit questions and through different sources, including the PBM contractor, DHA realized the letters had to be streamlined.  
The TRICARE formulary change beneficiary letters have significantly evolved since the first communications in 2005. In 2018, due to the beneficiary confusion and comments regarding the letters, DHA created five letter templates for prior authorization, step therapy, non-formulary, non-covered and OTC removal changes. 
Formulary changes that usually warrant a beneficiary letter include the following:

(https://tricare.mil/CoveredServices/Pharmacy/FillPrescriptions/PreAuthMedical) Prior Authorization: a formulary or non-formulary drug has a new prior authorization requirement and the beneficiaries currently using the drug are required to go through the prior authorization process to obtain the drug
    Step therapy: a formulary or non-formulary drug has a new step therapy requirement, where a trial of another clinically and cost effective agent is required first before the requested agent
    Non-formulary: a formulary drug moves to non-formulary drug status, with a resulting higher copay
    Not covered: a formulary or non-formulary drug moves to non-covered drug status (Tier 4) 
    OTC removal: an OTC drug previously available at the MTFs moves to a not covered status

All letters immediately begin with the date of change and impacted drug in bolded font so beneficiaries can easily know the important details up front. In addition, the letter outlines the reason for the formulary change. A separate letter is attached so that beneficiaries can share the information to review with their health care provider. These options are listed in an easy-to-read table with the preferred alternatives along with the cost options for the alternatives. Lastly, the beneficiaries are provided with the link to the TRICARE formulary search tool that provides more information on TRICARE covered drugs, including any restrictions and which provides any applicable prior authorization forms. Starting in 2019, in addition to mailing letters to beneficiaries 30 days prior to the formulary change implementation date, the letter templates are also published on the beneficiary website4 for beneficiaries to access directly. Posting the letters on the website has helped alert beneficiaries of upcoming formulary changes and has also aided in reducing the level of confusion. Since 2018, a total of approximately 189,000 letters were mailed to impacted beneficiaries of the formulary changes. 
Over the years, the TRICARE pharmacy benefit has evolved significantly but its focus has always been on its beneficiaries. DHA continues to reflect on lessons learned and feedback from its beneficiaries to streamline the beneficiary communication process.
References

Trice S, Devine J, Mistry H, Moore E, Linton A. Formulary management in the Department of Defense. J Manag Care Pharm. 2009;15(2):133-46.  Available at: (https://www.jmcp.org/doi/10.18553/jmcp.2009.15.2.133) https://www.jmcp.org/doi/10.18553/jmcp.2009.15.2.133.
    Formulary Search Tool link: (https://www.express-scripts.com/frontend/open-enrollment/tricare/fst/#/) https://www.express-scripts.com/frontend/open-enrollment/tricare/fst/#/.
    DoD Pharmacy & Therapeutics (P&T) Committee meeting minutes link: (https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Pharmacy-Operations/DOD-PT-Committee) https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Pharmacy-Operations/DOD-PT-Committee.
    Formulary Changes link: (https://militaryrx.express-scripts.com/notices/formulary) https://militaryrx.express-scripts.com/notices/formulary


(https://health.mil/News/Articles/2023/06/07/Media-Advisory-Typhoon-Mawar) TRICARE Waives Primary Care Manager Referrals for Guam and Northern Mariana Islands due to Typhoon Mawar
Jun 6th 2023, 20:00

FALLS CHURCH, Virginia – The Defense Health Agency (DHA) today announced that a Primary Care Manager (PCM) Referral Waiver is in place for all TRICARE Prime Overseas and TRICARE Prime Remote Overseas enrolled beneficiaries seeking/receiving care in Guam and the Northern Mariana Islands due to the impacts of Typhoon Mawar.
To ensure that Active Duty Service Members (ADSMs) and command-sponsored Active Duty Family Members (ADFMs) continue to have access to health care services in these locations, a PCM referral will NOT be required from the beneficiary’s enrolled Military Treatment Facility (MTF) or TRICARE Overseas Program (TOP) Network Providers for medically necessary care. 
This PCM Referral Waiver will remain in place until it has been determined that it is no longer necessary. 
Impacted beneficiaries should (http://www.tricare-overseas.com/contact-us) contact the TOP Regional Call Center directly to coordinate health care needs.  International SOS is available to assist 24/7/365. 
When (http://www.tricare-overseas.com/contact-us) contacting the TOP Regional Call Center, listen carefully to the prompts for the option that best serves you.
Please use the phone numbers below if dialing from Guam or the Northern Mariana Islands directly:
 

For additional toll-free country-specific contact information, visit (http://www.tricare-overseas.com/contact-us) www.tricare-overseas.com/contact-us.
To access International SOS’ Provider Search Tool, visit (http://www.tricare-overseas.com/beneficiaries/resources/provider-search) www.tricare-overseas.com/beneficiaries/resources/provider-search. Beneficiaries are also reminded to download and register on the MyCare Overseas™ App for assistance. Visit (http://www.tricare-overseas.com/beneficiaries/resources/provider-search) www.tricare-overseas.com/beneficiaries/resources/beneficiary-app for more information. Beneficiaries are advised to visit (https://newsroom.tricare.mil/Disaster) https://newsroom.tricare.mil/Disaster for updates.
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(https://health.mil/News/Articles/2023/06/06/Media-Advisory-Bugapalooza) National Museum of Health and Medicine Hosts “Bugapalooza” as Part of Military Health System’s 2023 “Bug Week” Campaign
Jun 5th 2023, 20:00

FALLS CHURCH, Virginia – The National Museum of Health and Medicine (NMHM) is excited to host “Bugapalooza,” a family-friendly event to educate the community on the role of bugs in military medicine. “Bugapalooza” is the kick-off to the Military Health System's (MHS) 2023 “Bug Week,” a campaign aimed at raising awareness of bug-borne illnesses and treatment options among members of the military community and the public.
Event:  During “Bugapalooza” museum staff and members of the military community will present on which bugs are bizarre, beneficial, or downright deadly. Learn how to battle the bugs or use them to your advantage.

Date/Time:  June 10, 2023, 10 a.m-12 p.m.

Location:  National Museum of Health and Medicine, 2500 Linden Lane, Silver Spring, Maryland 20910

Additional Information:  The program is free, open to the public, and suitable for all ages. Bug costumes are encouraged.

The MHS initially launched “Bug Week” in 2018 as an innovative approach to educating service members and their families as well as the general public about bug-borne illnesses and infectious diseases. Following a hiatus during the COVID-19 pandemic, the MHS is thrilled to reintroduce “Bug Week” and “Bugapalooza” this year.
For more information, visit (https://medicalmuseum.health.mil/index.cfm?p=visit.events.2023.bugapalooza) https://medicalmuseum.health.mil/index.cfm?p=visit.events.2023.bugapalooza or search #bugweek on Facebook, Instagram and Twitter.
Media interested in attending should contact Andrea Schierkolk, Public Programs Manager at the National Museum of Health and Medicine, at 301-319-3303, or email (mailto:USArmy.Detrick.MEDCOM-USAMRMC.List.Medical-Museum at health.mil) USArmy.Detrick.MEDCOM-USAMRMC.List.Medical-Museum at health.mil.
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(https://health.mil/News/Articles/2023/06/01/Active-Component-Burden) Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries Among Active Component Members, U.S. Armed Forces, 2022
May 31st 2023, 20:00

Reducing preventable injury and illness enhances the readiness of the Armed Forces, as illnesses and injuries degrade service member readiness and can hinder mission accomplishment. Since 2012, the MSMR has used a classification system derived from the Global Burden of Disease Study,1,2 in combination with an International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) chapter-based system to broadly describe the morbidity burden among active component service members and categorize hospitalizations and ambulatory visits among this population. The MSMR editorial staff continues to refine these classification schemes to improve the usefulness of the information presented.
In these annual burden of disease reports, the MSMR groups diagnoses to inform our readership of the major drivers of health care utilization within the Military Health System and where changes in policy or preventive emphasis may improve the medical readiness of the force. The major classification system for diagnoses, ICD-10-CM, features over 68,000 separate codes, a more than 5-fold increase from the 13,000 codes available in the previous version (ICD-9-CM).2 While the ICD-10-CM is organized in logical chapters, the groupings are not optimized to describe burdens of disease in a military population. A delicate balance between “lumping” and “splitting” of diagnoses is required to achieve a meaningful portrayal of the burden in the military population. 
The burden of disease in a young, healthy, predominantly male service member population will differ substantially from the general U.S. or global populations. The numerous readiness-related ambulatory visits required of each active duty service member, as well as military living circumstances, training requirements, and access to medical care without cost, may contribute to differing morbidity burden profiles in comparisons to other populations. Unique distributions in population demographics require, at a minimum, age and gender adjustment when comparing military rates to other populations. Typical adjustments are often insufficient to compensate for these unique factors, making comparisons challenging.
Demographic differences are particularly striking when comparing the active component to the general U.S. population. Service applicants are medically screened prior to military service to ensure fitness requirements for physically demanding jobs, and throughout their service mandatory periodic (typically annual) health assessments and screenings among active component members may detect conditions potentially undetected in other populations. People enlist or are commissioned into the active component, typically between 17 and 25 years of age, with the end of service for nearly all members by age 50. In 2022, the mean age of active component service members was approximately 29, with less than 1% of the population over 50.3 By contrast, the median age of the U.S. population was 38.7, with 36.1% over age 50 in 2021.4 Women constituted 17.5% of the active component in 2022, compared to 51.0% in the general U.S. population.4 
Within the military population and its specific settings, categories of illnesses and injuries requiring hospitalization have historically differed from those resulting in the most ambulatory visits. The added requirements for readiness are likely a major factor in ambulatory health care utilization, but rarely for hospitalization. The categories of medical conditions and readiness requirements that account for the most medical encounters overall may differ from those that affect the most individuals or have the most debilitating or long-lasting effects.1 
This annual summary uses several health care burden measures to quantify the impacts of various illnesses and injuries in 2022 among members of the active component of the U.S. Armed Forces. Health care burden metrics include the total number of medical encounters, individuals affected, and hospital bed days.
What are the new findings?  
Provisional data from 2022 indicate injuries, musculoskeletal diseases, and mental health disorders constitute the categories of medical conditions associated with the most medical encounters, largest number of affected service members, and greatest number of hospital days, consistent with previous burden reports. COVID-19 accounted for 1.4% of total active component service member medical encounters in 2022, a slight increase from the 1.2% rate in 2021. Only 0.3% of total hospital bed days in active component service members were for COVID-19 in 2022, an 83% drop from the 1.8% rate in 2021.
What is the impact on readiness and force health protection?
As in previous years, this report documents relatively few illnesses and injury categories that account for a substantial proportion of morbidity and health care burdens affecting U.S. active component service members. Preventable illnesses and injuries proven as disproportionate contributors to morbidity and health care burdens should be high priorities for intervention, research, and resources. Certain conditions that may affect readiness (e.g., pregnancy and maternal conditions) require scheduled, sustained care for optimal health, while other conditions such as injuries resulting from rigorous training for readiness, necessitate proven policies and safeguards to reduce injury rates while maintaining requisite training standards approved by senior leaders and commanders.
Methods
The population for this analysis includes all individuals who served in the active component of the Army, Navy, Air Force, or Marine Corps at any time during the surveillance period of January 1, 2022 through December 31, 2022. Each service member contributed encounters and person-time only for the actual months served during the surveillance period. All data in this analysis were derived from records maintained in the Defense Medical Surveillance System, which documents both ambulatory care encounters and hospitalizations of active component members of the U.S. Armed Forces. DMSS contains all encounters in military medical and civilian treatment facilities when reimbursed through the MHS. Encounters not routinely and completely documented within fixed military and non-military medical treatment facilities (e.g., during deployments, field training exercises, or at sea) are excluded from this analysis. This is the first year that DMSS data were housed and analyzed from the Military Health System Information Platform. Data quality assessments for completeness and timeliness are ongoing during the transition to MIP, and data presented in this report are considered provisional but current as of March 20, 2023.
DMSS data for all inpatient and outpatient medical encounters of active component service members during the surveillance period were summarized according to the primary (first-listed) diagnosis if reported with an ICD-10 code between A00 and T88, an ICD-10 code beginning with Z37 (outcome of delivery), or Department of Defense unique personal history codes DOD0101–DOD0105 (personal history of traumatic brain injury). All illness- and injury-specific diagnoses, as defined by ICD-10 codes, were grouped into 153 burden of disease-related “conditions” and 25 “categories” based on a modified version of the classification system developed for the GBD Study.1 This classification system was developed by the MSMR editorial staff in 2012 and is updated annually.
The GBD system groups diagnoses with common pathophysiologic or etiologic bases or significant DOD health policy importance. In this article, some diagnoses grouped into single categories in the GBD system (e.g., mental health disorders) were disaggregated to increase military relevance. In addition, injuries are classified by affected anatomic site rather than cause, as external causes of injuries using NATO Standardization Agreement (STANAG) 2050 codes are incompletely reported in military outpatient records.5 
The morbidity burdens attributable to various conditions were estimated based on the total number of medical encounters associated with each condition, i.e., total hospitalizations and ambulatory visits for the condition with a limit of 1 encounter for an individual per condition each day; and numbers of service members affected by each condition, i.e., individuals with at least 1 medical encounter for the condition during the year; as well as total bed days during hospitalizations for each condition.
Results
Morbidity burden, by category
Provisional data indicate that in 2022 active component service members (individuals affected; n=508,355) experienced medical encounters due to injury more than any other morbidity-related category (Figure 1a).

Ranking third in terms of hospital bed days, this major burden of disease category accounted for over one-fifth (21.8%) of all medical encounters (Figure 1b).

The injury category combines ICD-10 S (injury) and T codes (burns and poisonings); however, injuries account for nearly 90% of ambulatory encounters within the category (data not shown).6
Mental health disorders accounted for more hospital bed days (n=213,002) than any other morbidity-related category, contributing over half (57.7%) of all hospital bed days and ranking fifth for individuals affected (Figures 1a, 1b). Together, injury and mental health disorders accounted for over two-thirds (67.3%) of all hospital bed days and 41.0% of all medical encounters. 
Maternal conditions (e.g., pregnancy complications and delivery) accounted for a relatively large proportion of all hospital bed days (n=48,041; 13.0%) but a much smaller proportion of medical encounters overall (n=176,401; 1.5 %) (Figures 1a, 1b). As women comprised only 17.5 % of the active duty force in 2022, these summary statistics understate the impact of these conditions among that group. Maternal conditions were the most frequent medical condition among active component women.
Medical encounters, by condition
In 2022, 5 burden of disease-related conditions accounted for almost one-third (32.0%) of all illness- and injury-related medical encounters: other back problems (e.g., low back pain, other dorsalgia); organic sleep disorders (e.g., insomnia, obstructive sleep apnea); all other signs and symptoms (e.g., fever, headache, general signs and symptoms not otherwise specified); knee injuries; and arm/shoulder injuries (Figure 2). Moreover, the 10 conditions associated with the most medical encounters constituted more than half (55.4%) of all illness- and injury-related medical encounters. 

The health conditions that accounted for the most medical encounters among active component service members in 2022 were predominantly injuries, mental health disorders, and musculoskeletal diseases. Of the injuries reported in 2022, knee (5.6%), arm/shoulder (5.6%), foot/ankle (3.8%), and leg (3.0%) resulted in the most medical encounters (Figure 2, Table [at the bottom of the page]). The most frequent mental health disorder diagnoses resulted from anxiety (5.2%), adjustment (4.6%), mood (4.5%), and substance abuse disorders (3.0%). Other back problems (9.3%), all other musculoskeletal diseases (5.4%; e.g., pain in foot, pain in leg), and cervicalgia (1.7%) constituted the most medical encounters among musculoskeletal diseases. COVID-19 accounted for 1.4% of total medical encounters during 2022, a proportion nearly unchanged since 2021 (1.2%).
Individuals affected, by condition
In 2022, the 10 conditions that affected the most service members were all other signs and symptoms and respiratory/chest; other back problems and all other musculoskeletal diseases; knee and arm/shoulder injuries; upper respiratory infections; organic sleep disorders; refraction/accommodation disorders; and all other skin diseases. COVID-19 affected 129,923 service members, ranking 12th for number of service members affected in 2022, an increase in rank from 16th in 2021.
Hospital bed days, by condition
Mood and substance abuse disorders accounted for over one-third (34.1%) of all hospital bed days (Figure 3) experienced by active component members in 2022.

Four mental health disorders (mood, substance abuse, adjustment, and anxiety) and two maternal conditions (pregnancy complications and delivery) combined accounted for almost two-thirds (65.5%) of all hospital bed days (Table, Figure 3). About 10% of all hospital bed days in 2022 were attributable to injuries and poisonings. COVID-19 accounted for 0.3% of total hospital bed days in 2022 within the active component, down from 1.8% in 2021 (Table).
Relationships between health care burden indicators
There was a strong positive correlation between the number of medical encounters attributable to various conditions and the number of individuals affected by those conditions (r=0.87) (data not shown). The three leading causes of medical encounters were among the five conditions that affected the most individuals (Table). Meanwhile, weak to moderate positive relationships were determined for hospital bed days attributable to conditions and either numbers of individuals affected (r=0.20) by, or medical encounters associated (r=0.43) with, the same conditions. For example, substance abuse disorders and labor and delivery were among the top-ranking conditions by proportion of total hospital bed days, but these conditions affected relatively few active component service members in 2022.
Discussion
This report is consistent with the major findings of prior annual reports on morbidity and health care burdens among U.S. military members. Mental health disorders (including substance abuse disorders), injuries, and musculoskeletal disorders of the back have been leading causes of morbidity and disability among service members throughout military history.7-13 It is well-recognized that the prevention, treatment, and rehabilitation of back problems and joint injuries, and the detection, characterization, and management of mental health disorders—including substance abuse and deployment stress-related disorders (e.g., post-traumatic stress disorder)—should be the highest priorities for military medical research, public health, and force health protection programs.
In a given population and setting, the classification system or measure utilized to quantify condition-specific morbidity burdens determines conclusions about the relative importance of various conditions and, in turn, resources allocated for their treatment. The additional visits due to readiness requirements may be administrative or a consequence of a training or occupational injury. There is an interest among senior leaders and policymakers in the “cost of readiness,” and an ideal burden of disease classification scheme for the military population would enable identification of readiness-related visits.   
In 2022, consistent with previous reports, the burden of disease major categories of injury, musculoskeletal diseases, mental health disorders, and maternal conditions accounted for relatively large proportions of the morbidity and health care burdens that affected active component service members. Only 9 (5.9%) of the 153 burden of disease-related conditions accounted for slightly more than half of all illness- and injury-related medical encounters: These conditions included two musculoskeletal conditions (other back problems and all other musculoskeletal diseases), two anatomic site-defined injuries (knee and arm/shoulder), organic sleep disorders, all other signs and symptoms, and three mental health disorders (anxiety, adjustment, and mood disorders). This pattern of illness and injury among U.S. active component members is distinct from other population groups with different demographic distributions and occupational hazards, such as the general U.S. population and non-service member MHS beneficiaries; differing burdens of disease and injury for non-service member MHS beneficiaries will be described in the July 2023 MSMR. As noted, the data presented in this report are considered provisional, and ongoing inquiries regarding data completeness in the MHS MIP may result in later updates to the patterns of morbidity and health care burden reported here.
Although 2022 was affected by the COVID-19 pandemic, COVID-19 accounted for relatively modest numbers of medical encounters and bed days compared to other conditions in this analysis, likely due to several factors, among them the fact that active component service members represent a relatively young and healthy population. The unique coding scheme for COVID-19 may also mask its true impact. COVID-19 encounters have a special purpose ICD-10 code (U07.1) not included with other infectious diseases. The number of ambulatory encounters for COVID-19 alone was nearly equal to the total ambulatory encounters for all infectious diseases (ICD codes A and B). It is possible some COVID-19 encounters were coded under either infectious diseases, acute respiratory infections (ICD-10 codes J00-J06), or other general symptoms and signs (ICD-10 code R68.89). ICD-10 code U07.1 may have been used as a secondary code, or not at all, for some COVID-19 encounters.
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-2-Table-sheet-1) 
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-2-Table-sheet-2) 
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-2-Table-sheet-3) 
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-2-Table-sheet-4) 
References

Murray CJL, Lopez AD, eds. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard University Press, 1996:120-122.
    World Health Organization. The Global Burden of Disease: 2004 Update. Geneva, Switzerland: World Health Organization, 2008.
    Defense Manpower Data Center. Self-Service Reports, Active Duty by Demographics, Service Branch. Accessed June 15, 2023. (https://dmdcrs.dmdc.osd.mil/dmdcrs/public) https://dmdcrs.dmdc.osd.mil/dmdcrs/public

    United States Census Bureau. Age and Sex Composition in the United States: 2021. Table 1: Population by Age and Sex. Accessed June 15, 2023. (https://www.census.gov/data/tables/2021/demo/age-and-sex/2021-age-sex-composition.html) https://www.census.gov/data/tables/2021/demo/age-and-sex/2021-age-sex-composition.html

    Armed forces Health Surveillance Branch. Hospitalizations, active component, U.S. Armed Forces, 2019. MSMR. 2020;27(5):10-17.
    Armed Forces Health Surveillance Division. Ambulatory visits, active component, U.S. Armed Forces, 2022. MSMR. 2023;29(6):19-25. 
    Packnett ER, Elmasry H, Toolin CF, Cowan DB, Boivin MR. Epidemiology of major depressive disorder disability in the US military: FY 2007–2012. J Nerv Ment Dis. 2017;205(9):672-678.
    Moradi Y, Dowran B, Sepandi M. The global prevalence of depression, suicide ideation, and attempts in the military forces: a systematic review and meta-analysis of cross sectional studies. BMC Psychiatry. 2021;21(1):510. doi:10.1186/s12888-021-03526-2
    Stahlman S, Oetting AA. Mental health disorders and mental health problems, active component, U.S. Armed Forces, 2007–2016. MSMR. 2018;25(3):2-11.
    Update: Mental health disorders and mental health problems, active component, U.S. Armed Forces, 2016–2020. MSMR. 2021;28(8)2-9.
    Jones BH, Perrotta DM, Canham-Chervak ML, Nee MA, Brundage JF. Injuries in the military: a review and commentary focused on prevention. Am J Prev Med. 2000;18(3 suppl):71-84.
    Lovalekar M, Hauret K, Roy T, et al. Musculoskeletal injuries in military personnel—Descriptive epidemiology, risk factor identification, and prevention. J Sci Med Sport. 2021;24(10):963-969. doi: 10.1016/j.jsams.2021.03.016
    To D, Razai M, Murnaghan K, Cancelliere, C. Risk factors for low back pain in active military personnel: a systematic review. Chiropr Man Therap. 2021 Dec 30;29(1):52. doi:10.1186/s12998-021-00409-x


(https://health.mil/News/Articles/2023/06/01/Instructions-to-Authors) Updated Instructions for MSMR Authors
May 31st 2023, 20:00

Criteria for Publication Appropriateness 
MSMR is dedicated to reporting evidence-based estimates of the incidence, distribution, impact, or trends of illness and injuries among members of the United States Armed Forces and other beneficiaries of the Military Health System (e.g., family members, retirees, civilian employees).
MSMR reports generally focus on data or public health information directly relevant to the health, safety, and well-being of MHS beneficiaries or military members’ operational readiness. Submissions with a focus beyond the U.S. Armed Forces may be considered if relevant and generalizable to a current military health issue. 
Quality

Reports must be based on analyses that use standardized, validated, or accepted scientific methods and should include sufficient data samples to adequately address the aim of the report. Results should yield actionable public health information or recommendations. Recommendations presented in the Discussion should reflect the quality and nature of the study design. Any major limitations resulting from data quality should be included for transparency. Reports primarily descriptive in nature, i.e., not testing a proposed hypothesis, should have a limited Discussion section. Use of active voice, in addition to succinct language, are strongly encouraged for clarity and reports should be logically organized for ready comprehension by MSMR readers
Originality

Reports must be submitted exclusively to MSMR, should be original, and otherwise unpublished in the peer-reviewed literature, either previously or in the future. As part of the submission package, all prior related publications and presentations must be disclosed, including presentations (oral or poster) at scientific conferences and technical publications internal to a governmental agency. Updates of surveillance summaries previously published in MSMR will be considered if they add significant new information.
Timeliness

Reports should employ the most current data available from surveillance systems or analyses of electronic health records, surveys, case reports, or other studies. Data from emergency response or outbreak investigations should be no older than 12 months at time of submission. Generally, data presented as a Full or Brief Report should include a surveillance period within the last five years.
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-7-Table) (https://health.mil/Reference-Center/Reports/2018/11/01/MSMR-Index-November-2018) 
Full Reports
Full Reports present the verified results of a completed epidemiologic investigation or study that answers a question of military health importance. All Full Reports are submitted to two voluntary, independent reviewers for peer review.
The Introduction, Methods, Results, and Discussion sections of a Full Report should not exceed 2,000 words. Full Reports exceeding 2,000 words may be considered if a supported justification is presented to the editor. Cited references in a Full Report are limited to 25, and data tables and figures should complement the text succinctly and logically. Recommendations presented in the Discussion of a Full Report should reflect the quality and nature of the study design.
Full Report submissions comprise 10 elements or sections, in the following order:
1.  Title: Brief and descriptive, indicating major result(s) in as few words as possible.
2.  Authorship and Affiliations: List all authors and affiliations immediately after title, according to MSMR authorship guidelines (see Submission Formats below). MSMR policy requires all authors satisfy all (https://www.icmje.org) International Committee of Medical Journal Editors (https://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html) authorship criteria:

Substantial contributions to the conception or design, or acquisition, analysis or interpretation of data.
    Drafting and critical revision of important intellectual content.
    Final approval published version.
    Agreement to accountability for all aspects to ensure accuracy or integrity questions are appropriately investigated and resolved.

3.  Military Relevance: In 100 words maximum, convey succinctly what is novel about the findings and describe how they can inform decisions and actions supporting readiness and force health protection: MSMR aims to disseminate actionable medical surveillance information to military medical and public health professionals to enhance health, fitness, and readiness. This information is presented in a text box with two key questions: What are the new findings? and What is the impact on readiness and force health protection? 

For the new findings statement, in 50 words or less describe, in plain English, the findings of the analysis or report that either are new or provide confirmation of earlier reports.
    For the impact on readiness and force health protection statement, in 50 words or less describe, in plain English, how the findings can be applied to decisions or actions for military operational readiness or force health protection. (See (https://health.mil/Reference-Center/Reports/2018/11/01/MSMR-Index-November-2018) MSMR November 2018, volume 25 issue 11.)

4.  Structured Abstract: In 175 words maximum, summarize the report, with a focus on the main findings, in sections labeled Introduction, Methods, Results, and Discussion. 
5.  Background: Include contextual information (e.g., brief, relevant literature review) and relevance to U.S. military populations or operations. Conclude with objective or specific question(s).
6.  Methods: Specify, as appropriate, target population, time period, definitions, exposures, outcomes or endpoints, other characteristics of interest, sources and methods of data collection, and data summary and statistical analysis methods. The Methods must have sufficient detail to allow study reproduction or verification. If analysis involved databases or methods already published, limited text should be devoted to information available elsewhere, referenced. For descriptive studies, the Methods must describe how data were obtained, including source(s), case and covariate definitions, and most recent date(s) data sources were refreshed.
7.  Results: Communicate, logically and concisely, findings and analysis results. Excepting emphasis on important or significant observations, do not repeat numerical data in tables and graphs; limit tables and figures to those required to explain and support the argument and report key outcomes identified. Descriptive studies should limit analyses to those appropriate for hypothesis-generating submissions.
8.  Discussion: Provide interpretive com­ments that address the importance of the study findings. Contextualize the main findings within broader military or general public health conditions or concerns, including previously published comparative studies, as applicable. Articulate both study strengths and limitations, including likely impacts of the limitations (e.g., shortcomings of data sources, sources of bias). Propose specific strategies for future studies or changes in practice. Descriptive (hypothesis-generating) studies should limit their discussions to new or noteworthy trends, strengths and limitations, and suggestions for future work. Analytic (hypothesis-testing) studies should include comparisons to published literature (if any) and whether the new findings confirm or refute those studies.
Acknowledgements (optional): Recognize contributors who do not qualify as authors.
Disclaimers (optional): Disclose any necessary legal, service-specific, or DOD disclaimers. Submissions from within any DOD service or agency must have legal and public affairs review.
9.  References: Cite a maximum of 25, directly related to the topic. All references must be cited in the text, in superscript. List references in AMA style. (See Submission Formats.)
10. Tables and figures: Submit in a separate Excel file. The number of tables and figures should complement the text succinctly and logically. (See Submission Formats.)
Brief Reports 
Brief Reports condense 8 of the 10 elements of a Full Report—Military Relevance and Structured Abstract are not required—to 1,000 words maximum. Brief Reports are generally more descriptive and suitable for most descriptive (hypothesis-generating) studies, due to their simplified and limited Methods and Discussion sections. All Brief Reports are peer-reviewed. Brief reports are generally limited to one or two tables and figures, to focus the scope of the report, with a maximum of 10 references. 
TIP: Simplicity expedites the review of a Brief Report, which only summarizes an analysis of data or prior reporting.  
Outbreak Reports 
Outbreak Reports detail the chronology of an epidemiologic investigation with a surveillance period of 12 months preceding report submission. Outbreak Reports include all 10 elements of Full Reports and should not exceed 2,000 words. The Methods should summarize the full investigation with case definitions, case-defining activities, and epidemiologic study design. The Results should describe case characteristics (e.g., clinical characteristics) as well as person, place, and time measurements. The Discussion may include a brief summary of public health interventions, interpretation of results, implications for public health practice, and recommendations for future prevention and control. All Outbreak Reports are peer-reviewed. 
TIP: This type of report may include clusters of disease where no specific etiology was discovered after a thorough investigation.
Case Reports 
Case Reports, limited to 1,000 words, describe a disease occurrence to share timely, pertinent, and potentially actionable information for medical, scientific, or educational purposes. Case Reports should clearly establish a relevance to matters of public health importance. Case Reports should include a Summary of each case(s) followed by a Discussion, and may contain images, as appropriate. Specific section headers may be proposed by authors. Acknowledgements, Disclaimers, and References should be included, when applicable. All Case Reports are peer-reviewed.

Surveillance Snapshots 
Surveillance Snapshots depict the incidence or distribution of disease within a single chart and can include one or two paragraphs of text (with no section heading), limited to 500 words. Surveillance Snapshots are not peer-reviewed but are subject to editorial review that may include consultation with other AFHSD staff. Acknowledgements, Disclaimers, and References should be included, as applicable.

Letters to the Editor 
Letters to the Editor offer timely and concise opinions or interpretations of articles published in the MSMR. Letters should not include unpublished data and should be submitted within one year of publication of the referenced article. They are not peer-reviewed, but it is customary for the editorial team to send each letter to the author(s) of the original work for an opportunity to reply; the authors’ response is generally published as a companion to the letter. Text for a letter to the editor is limited to 1,000 words, with references limited to five. Tables and figures are discouraged but may be considered on an individual basis. Acknowledgements, Disclaimers, and References should be included, as applicable. Letters are subject to abridgement and editing for style and content. 

Historical Perspectives 
Historical Perspectives discuss the historical impact(s) of a disease or condition on a specific military operation or the military overall, limited to 2,000 words and one or two images. Section headers can be proposed by the authors; Acknowledgements, Disclaimers, and References should be included, as applicable. Historical Perspectives may be peer-reviewed by historians or relevant subject matter experts.  

Notices to Readers 
Notices to Readers announce changes in recommended public health practices (e.g., vaccine recommendations) or the availability of clinical or surveillance resources (e.g., laboratory testing), in 500 words or less. Notices to Readers are not peer-reviewed. MSMR does not publish meeting announcements or summaries of past meetings. 

Images in Health Surveillance 
Images in Health Surveillance illustrate militarily relevant public health information with photographs, drawings, or other images, with accompanying text limited to 500 words, with no section headers. Acknowledgements, Disclaimers, and References should be included, as applicable. 

Guest Editorials 
Editorials are usually invited but may be proposed. An editorial may serve as an opinion piece, or a comprehensive narrative relevant to public health professionals serving MHS beneficiaries. This may include a narrative review of literature or knowledge base, an update on the current understanding and state-of-the art of the topic, theory, and practice of epidemiology and/or military public health sciences. Editorials are generally limited to 2,000 words and may contain up to 2 tables or figures. The section headers of this report may be proposed by the authors. Acknowledgements, Disclaimers, and References should be included, as applicable. 

Other article types
May be proposed to the editor.

Submission Formats
MSMR follows the (https://academic.oup.com/amamanualofstyle/book/27941) American Medical Association Manual of Style, 11th edition as well as the MHS Editorial Style Guide. Please refer to the AMA manual if you have questions about formatting or structure not addressed in these instructions. Submissions should be sent to the (mailto:dha.ncr.health-surv.mbx.msmr at health.mil) MSMR editor.
Required for submission:

a Microsoft Word document of the manuscript text of the proposed article
    a completed (https://health.mil/Military-Health-Topics/Health-Readiness/AFHSD/Reports-and-Publications/Medical-Surveillance-Monthly-Report/Instructions-for-Authors) Authorship Submission Form

    a Microsoft Excel file containing any associated tables and figures, or associated images, as applicable. 

Manuscript Text 
All manuscript text should be submitted in one Microsoft Word file, using the structure and section headers (applicable) noted for each type of report. Please submit all Word documents in 12-point Times New Roman font, with text double-spaced, and leave right margins unjustified (ragged). Do not embed tables or charts in the Word document (see Tables and Figures). A title page is not required. 
Word limits only apply to the body of the text, which include 2,000 words for Full Reports, Outbreak Reports, Topical Reviews, and Historical Perspectives; 1,000 words for Brief Reports and Case Reports; and 500 words of text may accompany Surveillance Snapshots, Images in Health Surveillance, and Notices to Readers.
Submissions longer than these suggested word counts will be considered individually and must be justified by the authors in their submission e-mails.

References
References should be listed in accordance with AMA style.

List authors by last name and initials with no punctuation other than commas separating authors. When listing more than 6 authors, list only the first 3 followed by “et al.”
    Only proper nouns are capitalized for article or chapter titles.
    Use journal title abbreviations as listed in PubMed and italicize journal title abbreviations and book titles.
    Journal issue citations should include no spaces after year of publication, followed by a semicolon; then volume number with issue number in parentheses, followed by a colon with page number(s) immediately after.
    Online updates and dates of access should precede the URL.
    Do not include URLs for references indexed in PubMed. 

Example references:

Stahlman S, Oetting AA. Mental health disorders and mental health problems, active component, U.S. Armed Forces, 2007–2016. MSMR. 2018;25(3):2-11. 
    Armed Forces Health Surveillance Division. Armed Forces Reportable Medical Events Guidelines and Case Definitions. October 2022. Accessed April 6, 2023. https://www.health.mil/Reference-Center/Publica­tions/2022/11/01/Armed-Forces-Report­able-Medical-Events-Guidelines 
    O’Connor FG, Sawka MN, Deuster P. Disorders due to heat and cold. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:692-693.

Authorship and Affiliations 
The Microsoft Word file submission must include a list of all authors and affiliations, immediately below the title. For each author list first name, middle initial, last name, highest academic degree(s). Examples: John Snow, MD, MPH; Mary L. Archer, MD. If an author holds two doctoral degrees (e.g., MD and PhD), either or both may be used, in the author’s preferred order. List academic degrees below the highest degree only when representative of a specialized field or other than highest degree (e.g., MPH, BSN). List each author’s current assignment and/or affiliation. Examples: U.S. Naval Medical Research Unit 3, Cairo, Egypt (Dr. Archer); Department of Surgery, University of Chicago, Chicago, Illinois (Dr. Snow, Dr. Smith, Dr. Jones).
Only authors with substantive contributions qualifying for authorship credit according to ICMJE guidelines may be listed; listing authors who do not meet ICMJE authorship criteria is considered a serious breach of scientific ethics. The primary author is solely responsible for verifying the academic contributions of each co-author. Each co-author must approve the final version of the article prior to publication. An author must satisfy all of the following criteria:

Substantial contributions to the conception or design of the work; or the acquisition, analysis or interpretation of data. For contributions to be substantial, the work could not have proceeded without that author’s contributions. Granting authorship to a senior individual solely by virtue of position, e.g., department 	head, commander, is prohibited. MSMR may request additional information to verify contributions.
    Drafting and critical revision for important intellectual content: Each author should provide substantive comments during reviews—authors should record comments during reviews so each author’s contributions to the final product can be verified.
    Final approval of the version published.
    Agreement to accountability for all aspects of the work, ensuring that questions of accuracy or integrity for any part are appropriately investigated and resolved: Scientific misconduct, e.g., falsifying or intentionally presenting misleading data is a serious offense. All authors are expected to fully cooperate in any investigation where scientific misconduct is alleged.
    The primary author must be able to identify which co-authors are responsible for specific parts of the work. This information should be included in the initial submission packet.

Tables and Figures 
Tables and figures should adhere to AMA style and must be submitted as a Microsoft Excel file, i.e., not embedded in the text. Microsoft Excel is the preferred software for generating tables and figures. Figures generated with other software (e.g., SAS, SPSS) will be considered individually.   
Each table or figure should constitute one worksheet tab. The data used to create a figure in Excel must be included in tabular form and link to the figure. Number each table and figure, with a descriptive title.
Every table and figure should be cited in the text. Verify that data are consistently reported within all text, tables, and figures. 
Place legends within the figure—line labels for graphs are preferred—and titles above the figure. Do not use pie charts or 3-D graphs. Format all tables and figures with Arial font 8-point. Use lowercase superscripted letters (e.g., a,b,c) for footnotes in tables and figures.
TIP: Authors should study tables in the example and previously published reports for specific style guidance.

Photographs that illustrate a prevention intervention, risk factor, or outbreak setting are encouraged. Only submit photographs within the public domain; if a photo credit is required, submit the name.

Submission and Acceptance
Submit via email at (mailto:dha.ncr.health-surv.mbx.msmr at health.mil) dha.ncr.health-surv.mbx.msmr at health.mil. Consult the Submission Formats section for all formatting requirements and instructions. Submit the Microsoft Word report document, Excel tables/figure file (or photographs, if applicable), and authorship submission form as separate attachments.

Publication Timeline

Accepted reports are typically published within 60 days of acceptance.
Information on Clearance and Consent, as well as Ethics and Publication Malpractice should be reviewed at the (https://health.mil/Military-Health-Topics/Health-Readiness/AFHSD/Reports-and-Publications/Medical-Surveillance-Monthly-Report/Instructions-for-Authors) Instructions for Authors page.

(https://health.mil/News/Articles/2023/06/01/RMEs) Reportable Medical Events, Military Health System Facilities, Week 18, Ending May 6, 2023
May 31st 2023, 20:00

Reportable Medical Events are documented in the Disease Reporting System internet by health care providers and public health officials throughout the Military Health System. The DRSi collects reports on over 70 different RMEs, including infectious and non-infectious conditions, outbreak reports, STI risk surveys, and tuberculosis contact investigations. These reports are reviewed by each service’s public health surveillance hub, which serves as an active primary prevention component to identify other service members at risk, assess need for post-exposure screening and prophylaxis, or inform other actions to protect and assure public health. Primary prevention (reducing disease occurrence) is the most effective method for preserving the medical readiness of the force.
Routine monitoring, evaluation, and publication of RMEs provide an important data resource for both policymakers and commanders, to guide their efforts for controlling and preventing diseases with potential measurable impacts on public health and force readiness—strategic, operational, and tactical. RMEs were chosen by consensus and recommendations from each service, which evaluated lists of nationally-notifiable diseases from the Centers for Disease Control and Prevention, position statements from the Council of State and Territorial Epidemiologists, and other events identified as significant military health threats meriting added surveillance. A complete list of RMEs is available in the 2022 Armed Forces Reportable Medical Events Guidelines and Case Definitions. 
The data presented in the table not only list the most recent case counts but reveal trends of incidence for the past two months, year-to-date, and over the preceding year.
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-6-Table) 
Data reported in the table are considered provisional and do not represent conclusive evidence until case reports are fully validated. 
The most recent data on the five most frequent RMEs among total active component cases, as reported per week during the preceding year, are depicted in the Top 5 RME Trends by Calendar Week graph. COVID-19 is excluded from the graph due to 2023 changes in reporting and case definitions.

(https://health.mil/News/Articles/2023/06/01/Hospitalization-Burden) Hospitalizations Among Active Component Members, U.S. Armed Forces, 2022
May 31st 2023, 20:00

This report documents the frequencies, rates, trends, and distributions of hospitalization among active component members of the U.S. Army, Navy, Air Force, and Marine Corps during calendar year 2022. Summaries are based on standardized hospitalization records at U.S. military and non-military (reimbursed through the Military Health System) medical facilities worldwide that are routinely maintained in the Defense Medical Surveillance System. This is the first year that DMSS data were housed and analyzed from the Military Health System Information Platform. Data quality assessments for completeness and timeliness are ongoing during the transition to MIP. Thus, data presented in this report are considered provisional but current as of March 28, 2023.
In this report, primary (first-listed) discharge diagnoses are considered indicative of the main reason for hospitalization. As in previous MSMR reports, summaries are based on the first 3 digits of the International Classification of Diseases, 10th Revision of the primary discharge diagnoses. Hospitalizations not routinely documented by standardized, automated records, e.g., during field training exercises or while shipboard, are not available in a centralized location for health surveillance purposes and are excluded from this report. Incidence rates were calculated per 1,000 p-yrs. Percent change in incidence was calculated using unrounded rates.
What are the new findings?  
The provisional estimate of the hospitalization rate in U.S. military and non-military medical facilities in 2022 is 43.9 per 1,000 person-years (p-yrs), the lowest rate in 10 years. As in prior years, the majority (57.5%) of hospitalizations were associated with primary diagnoses in the categories of mental health disorders and pregnancy-related conditions. Less than 0.5% of total hospitalizations in active component service members in 2022 were attributed to COVID-19, a substantial decrease from 1.5% in 2021.

What is the impact on readiness and force health protection?
As in previous years, mental health disorders, including substance abuse disorders, were associated with the longest median hospital stay (6 days). Moreover, 5% of mental health disorder hospitalizations lasted longer than 30 days. Prolonged hospitalizations, aftercare, and early attrition due to these common disorders can diminish not only individual but unit operational readiness.
Frequencies, rates, and trends
In 2022, 57,009 hospitalizations were recorded for the active component members of the U.S. Army, Navy, Air Force, and Marine Corps (Table 1); 46.4% of these hospitalizations were in non-military facilities (data not shown), compared to 37.7% in 2021.
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-3-Table-1) 
The crude annual hospitalization rate (all causes) in 2022 was 43.9 per 1,000 service member p-yrs (Table 1), the lowest rate from 2013 through 2022, during which rates fell 23.8% (Figure 1).

Provisional data indicate that hospitalization rates have declined monotonically over the past 10 years, with the largest rate drop, 12%, within the current reporting period.
Hospitalizations by ICD-10 major diagnostic categories
In 2022, four ICD-10 major diagnostic categories accounted for almost three-quarters (73.7%) of all active component hospitalizations: mental health disorders (33.5%), pregnancy- and delivery-related conditions (24.0%), injury (8.7%), and digestive system disorders (7.5%) (Table 1). Consistent with findings from 2018 and 2020, hospitalizations for mental health disorders in 2022 accounted for more than for any other major diagnostic category; 2009 was the last year in which another diagnostic category (pregnancy- and delivery-related conditions) surpassed hospitalizations for mental health disorders (data not shown). COVID-19 accounted for 0.44% of total hospitalizations in active component service members in 2022, a 70% decline from 1.5% in 2021.
Provisional data indicate that numbers and rates of hospitalizations from 2018 to 2022 decreased for all major diagnostic categories except mental health disorders, which increased slightly (5.7% to 5.9%) (Table 1). The largest decline in hospitalizations from 2018 to 2022 was in the musculoskeletal system and connective tissue diagnostic category (1,659 fewer hospitalizations; 34.1% decrease). The next largest drop in hospitalizations from 2018 to 2022 was in the injury category (1,570 fewer hospitalizations; 24.1% decrease). The largest hospitalization rate declines occurred in the categories of skin and subcutaneous tissue (44.0%), respiratory system (40.0%), other (39.4%), and genitourinary system (37.0%). 
The relative proportion of hospitalizations by major diagnostic category was generally stable over the surveillance period (Table 1). COVID-19 was included as a separate diagnostic category in 2020 and ranked 13th in total hospitalizations, but declined to 16th in total visits in 2022.

Hospitalizations, by sex
The hospitalization rate (all causes) among service women in 2022 was more than three times that of service men (101.9 per 1,000 p-yrs and 31.4 per 1,000 p-yrs, respectively). These data are consistent with general U.S. population hospitalization rate trends published in 2022 for women and men aged 18-44 (95 per 1,000 p-yrs and 37 per 1,000 p-yrs respectively).1 Excluding pregnancy and delivery, the rate of hospitalizations among women (41.7 per 1,000 p-yrs) was 32.2% higher than among men (31.6 per 1,000 p-yrs) in 2022 (data not shown). This rate difference was primarily due mental health disorder hospitalizations (female : male rate difference [RD]: 6.6 per 1,000 p-yrs) and genitourinary disorders (RD: 2.0 per 1,000 p-yrs) (data not shown). Excluding pregnancy- and delivery-related conditions, hospitalization rates were relatively similar among men and women for the remaining 15 major diagnostic categories (data not shown).
Relationships between age and hospitalization rates varied by major diagnostic category (Figure 2).

Rates among women in all age groups were consistently higher for several categories: other factors influencing health status and contact with health services; signs/symptoms and other ill-defined conditions; genitourinary system; neoplasms; nervous system; and hematologic and immune disorders. Except in the youngest age group, male rates were higher for the injury and circulatory system categories. Among both sexes, hospitalization rates generally increased with age for neoplasms, musculoskeletal system/connective tissue disorders, digestive system diseases, genitourinary system diseases, circulatory system diseases, other factors influencing health status and contact with health services, and signs/symptoms and other ill-defined conditions. Rates decreased with increasing age for mental health disorders and were relatively stable across all age groups for injury, infectious/parasitic diseases, respiratory system disorders, skin and subcutaneous tissue, hematologic and immune disorders, as well as COVID-19. 

Most frequent diagnoses
Adjustment disorders was the most frequent primary discharge diagnosis among both men (n=4,861) and women (n=1,321) (Table 2), accounting for 10.8% of total hospitalizations in 2022.
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-3-Table-2) 
Alcohol dependence (n=2,525), recurrent major depressive disorder (severe without psychotic features) (n=1,490), other and unspecified acute appendicitis (n=802), post-traumatic stress disorder (n=697), and single episode major depressive disorder (unspecified) (n=530) were the next most frequent diagnoses in men (Table 2). Mental health disorder diagnoses accounted for more than two-fifths (42.9 %) of all hospitaliza­tions among men. 
For women, pregnancy- and delivery-related conditions constituted the leading major diagnostic category, accounting for almost three-fifths (59.1%) of all female hospitalizations, although adjustment disorders were the most frequent cause when examining ICD-10 diagnoses through the fourth character (Table 3).
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-3-Table-3) 
 Other leading causes of hospitalization included recurrent major depressive disorder (severe without psychotic features) (n=660), PTSD (n=492), and alcohol dependence (n=313). Mental health disorder diagnoses accounted for about one-fifth (19.7 %) of all hospitalizations among women (Table 3).

Durations of hospitalizations
Hospitalization durations show a highly right-skewed (positive) distribution when charted, with the lower limit equal to one day and a mode of two days. Because length of hospital stay is not normally distributed, the median duration with interquartile range was chosen as the best measure of central tendency. From 2013 to 2022, the median (IQR) duration of hospital stays (all causes) remained stable at three (2-5) days with an increase to four (2-6) days in 2022 (Figure 3).

Medians and IQRs of hospitalization durations varied substantially by major diagnostic category. Median lengths of hospitalization varied from two (2-4) days (musculoskeletal system [2-3]; genitourinary system disorders [2-3]; digestive system; respiratory system [2-4]; signs, symptoms, and ill-defined conditions [1-4]) to six days for mental health disorders (4-12). For one half of ICD diagnostic categories, 5% of hospitalizations exceeded 10 days: circulatory system disorders (11 days), hematologic and immune disorders (12 days), signs, symptoms, and ill-defined conditions (14 days), COVID-19 (18 days), neoplasms (23 days), nervous system/sense organ disorders (25 days), injury/poisoning (25 days), mental health disorders (34 days), and other non-pregnancy-related factors influencing health status and contact with health services (primarily orthopedic aftercare and rehabilitation following prior illness or injury) (41 days) (Figure 4).

Hospitalizations, by service
Among Air Force active component members, pregnancy- and delivery-related conditions accounted for more hospitalizations than any other illnesses or injury category, while among active component members of the Army, Navy, and Marine Corps, mental health disorders were the leading cause (Table 4), a pattern observed in recent years.
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-3-Table-4) 
Prior to 2020, pregnancy- and delivery-related conditions were ranked first for both the Navy and Air Force. Among all services the crude hospitalization rate for mental health disorders was highest among active component Army members (16.5 per 1,000 p-yrs).
Injury was the third leading hospital­ization category in the Army and Marine Corps, and fourth in the Navy and Air Force. The hospitalization rate for injury was highest for Army (4.8 per 1,000 p-yrs) and Marine Corps members (4.3 per 1,000 p-yrs) and lowest in the Air Force (2.4 per 1,000 p-yrs), a service-ranked distribution observed since 2010.

Discussion
The total hospitalization rate for all causes in both military and non-military medical facilities among active component members in 2022 was the lowest in the past decade. As in past years, in 2022 mental health disorders, pregnancy- and delivery-related conditions, and injury accounted for more than half of all active component hospitalizations. Adjustment disorders, alcohol dependence, depressive disorders, and PTSD were among the leading primary discharge diagnoses for both men and women. The continued decline of hospitalization frequencies and rates in 2022 is attributed to a generalized decline for most major diagnostic categories since 2019, with substantial declines in the musculoskeletal system and injury categories.
Certain limitations should be considered when interpreting these results. The data presented in this report are considered provisional, as ongoing assessments of data completeness in the MHS MIP and any subsequent resolutions may result in changes in trends reported here. This summary is based on primary (first-listed) discharge diagnoses only, but in many hospitalized cases multiple conditions can be present; for example, joint pain (category: musculoskeletal) may be co-listed with an injury (category: injury). In such cases, only the first-listed discharge diagnosis would be accounted in this report, which could underestimate hospitalization rates for common conditions by dividing them among two or more subcategories. 
Medical data from July 2017 to October 2019 at sites that had already transitioned to the new MHS electronic health record system, MHS GENESIS, are not available in the DMSS and thus not included in this report—these sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center. These missing data reduce the true hospitalization rates for that period.

Reference

National Center for Health Statistics. National Health Interview Survey. Health, United States, 2020-2021. Table HospStay. Accessed June 15, 2023. (https://www.cdc.gov/nchs/data/hus/2020-2021/HospStay.pdf) https://www.cdc.gov/nchs/data/hus/2020-2021/HospStay.pdf


(https://health.mil/News/Articles/2023/06/01/Editorial-Comment) Editorial Comment: Increased Missing Data Affects Burden Estimates
May 31st 2023, 20:00

During the preparation of the MSMR’s annual burden of disease issue, Armed Forces Health Surveillance Division epidemiologists and the MSMR staff noted data patterns that indicate incomplete transfer or capture of certain routinely reported elements. As the Military Health System completes its transition to the new MHS GENESIS electronic health record, AFHSD is also in the process of completely transferring or mapping EHR data to the Defense Medical Surveillance System. As a result, some data elements typically reported in the annual MSMR burden issues may not be completely mapped at this time, including duty disposition status and ambulatory appointment type (in-person vs. virtual).
In addition to these data mapping aspects, 2022 was the first year DMSS data were housed and analyzed from the new MHS Information Platform. During this transition to the MIP, the number of records transmitted from MHS GENESIS to DMSS are being continually reviewed for completeness of data capture. While both hospitalization and ambulatory records are routinely updated after the end of each calendar year, data transfer completeness has not yet been fully assessed during the MIP transition. 
To bring our readership as much information as possible, and in a timely fashion, the MSMR staff has elected to mark much of the data in this issue as “provisional.” The MSMR may publish revised figures later this year, after data completeness issues have been fully investigated. While the effect of these missing data is most pronounced on the absolute value comparisons year-to-year, e.g., total number of encounters in 2022 versus 2021, the relative values and rank order of the major diagnostic categories are likely unaffected. Notably, the largest decline in ambulatory encounters was observed for ‘Z’ codes (other factors influencing health status and contact with health services).
While the primary purpose of any EHR is to document care during inpatient and outpatient encounters, extracts of these data are critical to public health surveillance efforts. These extracts are utilized to continuously expand the DMSS as a central repository of medical surveillance data for the U.S. Armed Forces. The AFHSD will continue to monitor data capture from MHS GENESIS to DMSS for quality and completeness and collaborate with health informatics experts within MHS to resolve any remaining data issues.

(https://health.mil/News/Articles/2023/06/01/Coast-Guard-Burden) Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries Among Active Component Members, U.S. Coast Guard, 2022
May 31st 2023, 20:00

With approximately 40,000 active duty service members, the U.S. Coast Guard is by far the smallest of the military branches and is the only branch outside the Department of Defense. Since 2016, missing data have precluded analysis of USCG health care data from the MSMR’s annual burden reports.1,2 A recent analysis demonstrated a USCG hospitalization rate 40% lower than DOD active component counterparts, indicating that concerns raised in 2016 about incomplete capture of USCG medical record data have not been completely addressed. Until these data issues can be resolved, a separate analysis of USCG burden is warranted. 
The USCG operates primary care clinics in areas with sufficiently large Coast Guard populations. Although USCG personnel are eligible to use DOD health care facilities, many are not stationed near any DOD installation. A higher proportion of civilian hospitalizations among USCG members has been noted,1 and this difference may extend to ambulatory care as well. 
This summary uses the same disease classification system and health care burden measures as employed in the initial burden analysis to quantify the impacts of various illnesses and injuries among members of the active component of the USCG in 2022.
What are the new findings?  

Among active component Coast Guard members in 2022, injuries, musculoskeletal diseases, and mental health disorders were the categories of medical conditions associated with the most medical encounters, the largest number of affected service members, and the greatest number of hospital days. COVID-19 accounted for 1.4% of total medical encounters and 0.7% of total hospital bed days.

What is the impact on readiness and force health protection?

Loss of duty availability because of illness and injury degrades personnel readiness. Coast Guard members have unique occupational exposures that may benefit from specific risk-reduction programs to mitigate these threats. Complete hospitalization data is critical to accurately estimate the medical burden among Coast Guard members. Efforts to ensure data completeness should be prioritized.

Methods

The population for this analysis includes all individuals who served in the active component of the USCG at any time during the surveillance period of January 1, 2022 through December 31, 2022. The methodology for summarizing absolute and relative USCG morbidity burdens in 2022 is identical to that used in the absolute and relative burdens attributed to various illnesses and injuries among the active component of the U.S. Armed Forces. This is the first year that DMSS data were housed and analyzed from the Military Health System Information Platform. Data quality assessments for completeness and timeliness are ongoing during the MIP transition, and data presented in this report are considered provisional but current as of March 21, 2023.

Results

In 2022, a total of 34,506 USCG service members experienced 390,665 total medical encounters. There were 8,717 bed days reported, for a rate of 0.22 bed days per USCG member who had at least one medical encounter (in- or out-patient).3
Morbidity burden, by category
In 2022, more active component USCG members (individuals affected; n=14,737) had medical encounters for injury than any other morbidity-related category (Figure 1a).

Ranking third in terms of hospital bed days, this morbidity category accounted for over one-fifth (22.0%) of all medical encounters (Figure 1b).

Mental health disorders accounted for more hospital bed days (n=4,680) than any other morbidity-related category, contributing over half (57.7%) of all hospital bed days and ranking sixth for number of individuals affected (Figures 1a, 1b). Together, injury and mental health disorders accounted for over three-fifths (63.2%) of all hospital bed days and almost two-fifths (39.2%) of all medical encounters. 
Maternal conditions, e.g., pregnancy complications and delivery, accounted for a relatively large proportion of all hospital bed days (n=1,047; 12.0%) but a much smaller proportion of total medical encounters (n=3,626; 0.9%) (Figures 1a, 1b). Maternal conditions were the most prevalent medical condition among active component female USCG members. Women comprised approximately one-sixth (16.0%) of the active duty USCG in 2022.3
Medical encounters, by condition 
In 2022, five burden of disease-related conditions accounted for more than one-third (35.0%) of all illness- and injury-related medical encounters: other back problems e.g., low back pain, other dorsalgia; arm/shoulder injuries; organic sleep disorders (e.g., obstructive sleep apnea, insomnia); anxiety disorders; and knee injuries (Figure 2). Moreover, the 10 conditions associated with the most medical encounters constituted more than half (56.0%) of all illness- and injury-related medical encounters.

The conditions that accounted for the most medical encounters among active component USCG members in 2022 were predominantly injuries, mental health disorders, and musculoskeletal diseases. Among injuries, arm/shoulder (7.3%), knee (5.1%), foot/ankle (3.3%), and leg (2.5%) contributed the most medical encounters (Figure 2, Table [bottom of the page]). Anxiety (6.2%), mood (4.5%), adjustment (3.8%), and alcohol/substance abuse disorders (1.7%) were the four most frequent mental health disorder diagnoses. Of the musculoskeletal diseases, other back problems (9.5%), all other musculoskeletal diseases (4.5%), e.g., muscle weakness, radiculopathy of the cervical region, pain in foot, and neck pain (2.3%) contributed the most medical encounters. COVID-19 accounted for 1.4% of total medical encounters during 2022.
Individuals affected, by condition
The 10 conditions that affected the most USCG members in 2022 were all other signs and symptoms and respiratory/chest; other back problems and all other musculoskeletal diseases; refraction/accommodation disorders; organic sleep disorders; COVID-19 and upper respiratory infections; arm/shoulder injuries; and all other skin diseases. COVID-19 affected 4,546 USCG members and ranked seventh for the number of individuals affected.  
Hospital bed days, by condition
In 2022, substance abuse and mood disorders accounted for about two-fifths (40.7%) of all hospital bed days (Fig­ure 3).

Together, four mental health disorders (substance abuse, mood, anxiety, and adjustment) and two maternal conditions (pregnancy complications and delivery) accounted for three-fifths (60.3%) of all hospital bed days (Table, Figure 3). About 10% of all hospital bed days were attributable to injuries and poisonings. COVID-19 accounted for 0.7% of total hospital bed days among active component USCG members (Table).
Discussion
The USCG’s health care use in 2022 is similar to the DOD when measured by total encounters/persons affected. The USGC rate was 11.3 encounters per person (390,665 / 34,506), compared to the DOD rate of 10.7 encounters per person (11,874,264 / 1,108,975). The USCG had a lower rate of hospital utilization, however, with only 0.25 bed days per individual reporting a medical encounter; the DOD reported 0.33 bed days per individual (369,097 / 1,108,975). This finding is consistent with prior reporting and raises concerns that the missing data issues discovered in 2016 have not yet been fully resolved.4 
This report is consistent with the major findings of prior annual reports on morbidity and health care burdens among active component members. Injuries, musculoskeletal diseases, and mental health disorders are the categories of medical conditions associated with the most medical encounters, the largest number of affected service members, and the greatest number of hospital bed days. USCG and DOD service members shared many disease-related conditions when examining ICD codes to the fourth digit character: other back problems within the musculoskeletal disease major diagnostic category; arm/shoulder and knee injuries within the injury major diagnostic category; anxiety disorders within the mental health disorder major diagnostic category; and organic sleep disorders within the neurologic condition major diagnostic category. The data presented in this report are considered provisional, as ongoing investigations for data completeness in the MHS MIP may result in later updates to the patterns of morbidity and health care burden reported here.  
Although 2022 was affected by the COVID-19 pandemic, COVID-19 accounted for relatively modest numbers of medical encounters and bed days compared to other conditions included in this analysis, likely due to several factors. Besides the waning of the pandemic, active component service members represent a relatively young and healthy population less likely to experience severe consequences of COVID-19 infection. Notably, COVID-19 accounted for the most medical encounters but not bed days within the infectious and parasitic disease major diagnostic category. This finding was consistent with DOD service members. 
Consistent with past analyses, this report documents that relatively few illnesses and injuries account for a substantial proportion of morbidity and health care burdens that affect USCG active component service members. Preventable illnesses and injuries that disproportionately contribute to morbidity and health care burdens should be high-priority targets for intervention, research, and resources. Opportunities to address and resolve the missing data issues from USCG hospitalizations should be prioritized to ensure an accurate depiction of the true burden of disease among this population.
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-5-Table-sheet-1) 
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-5-Table-sheet-2) 
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-5-Table-sheet-3) 
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-5-Table-sheet-4) 
References

Pillai S, Chau M, Kamara I, Thomas D, Iskander J. Hospitalizations among active duty members of the U.S. Coast Guard, Fiscal Year 2021. MSMR. 2023;30(2):3-5.
    Armed Forces Health Surveillance Branch. Hospitalizations among members of the active component, U.S. Armed Forces, 2015. MSMR. 2016;23(4):8-16.
    Defense Manpower Data Center. Self-service reports, Active duty by demographics, service branch. Accessed June 15, 2023. (https://dmdcrs.dmdc.osd.mil/dmdcrs/public) https://dmdcrs.dmdc.osd.mil/dmdcrs/public


(https://health.mil/News/Articles/2023/06/01/Ambulatory-Burden) Ambulatory Visits Among Active Component Members, U.S. Armed Forces, 2022
May 31st 2023, 20:00

This report documents the frequencies, rates, trends, and characteristics of ambulatory health care visits in 2022 of active component members of the U.S. Army, Navy, Air Force, and Marine Corps. Ambulatory visits by U.S. service members in fixed military and non-military (reimbursed through the Military Health System) medical treatment facilities are documented by standardized records routinely archived for health surveillance purposes in the Defense Medical Surveillance System. Ambulatory visits not routinely and completely documented within fixed military and non-military medical treatment facilities (e.g., during deployments, field training exercises, or at sea) are not included in this analysis. 
This year marks the first for which data from the DMSS were housed and analyzed from the Military Health System Information Platform. As part of the continuing transition to MIP, data quality assessments for completeness and timeliness are ongoing. Thus, data presented in this report are considered provisional but current as of March 27, 2023.
As in prior MSMR reports, all records of ambulatory visits of active component service members were categorized according to the International Classification of Diseases, 10th Revision codes entered in the primary (first-listed) diagnostic position of the visit records. Incidence rates were calculated per 1,000 p-yrs. Percent change in incidence was calculated using unrounded rates.
What are the new findings?  

Provisional data indicate that the 2022 rate of ambulatory visits in U.S. military and non-military medical facilities was 14.6% lower than the rate observed in 2021. This decline was due to reduced administrative (ICD-10 Z code) visits. The ranked distribution of primary causes for ambulatory visits has remained stable, with disorders of the musculoskeletal system, mental disorders, and nervous system/sense organs accounting for the three most prevalent rates of illness- and injury- related major diagnostic groups.

What is the impact on readiness and force health protection?

The crude annual rate of 9.6 visits per person-year (p-yr) for ambulatory visits for illnesses and injuries in 2022 was slightly higher than the rates in 2020 (8.6 visits per p-yr) and 2018 (9.3 visits per p-yr). The ambulatory visit rate among active component service members far exceeds civilian health care encounters; future analyses comparing the major diagnostic category rates among these two groups may help better define cost of readiness.

Frequencies, rates, and trends
In 2022, active component service members made 17,861,941 ambulatory visits for health care, resulting in a crude annual rate (all causes) of 13,750.9 visits per 1,000 p-yrs or 13.8 visits per p-yr (Table 1).
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-4-Table-1) 
Provisional data indicate that this rate was the lowest observed in the past 10 years, declining from its peak in 2021 (Figure 1). This decline was driven by a reduction in administrative (ICD-10 Z code) visits.

The 12,472,615 documented ambulatory visits in 2022 for illnesses and injuries (ICD-10: A00–T88, including relevant pregnancy Z-codes) not including diagnoses classified as “Other” resulted in a crude annual rate of illness- and injury-related visits of approximately 9.6 per p-yr (Table 1). The crude annual rate of ambulatory visits for illness and injury in 2022 was slightly higher than the rates in 2020 (8.6 visits per p-yr) and 2018 (9.3 visits per p-yr). 
As in prior years, the “Other” major diagnostic category, i.e., other factors influencing health status and contact with health services, excluding pregnancy, accounted for the highest rank number of ambulatory visits (Table 1). This care is identified by a “Z code” in the first diagnostic position, which is not generally billable to insurance and normally utilized for administrative and other agency-specific requirements. The military uses Z codes to document some of the health care system burden imposed by readiness requirements; examples include routine and special medical examinations, e.g., periodic, occupational, or retirement, along with immunizations, counseling, deployment-related assessments, suspected exposure to infectious diseases, and screening. From 2018 to 2022, over half of visits attributed to this major diagnostic category included 3 ICD-10 Z codes: encounters for administrative examinations (Z02; n=11,544,607), immunization (Z23; n=4,739,324), and other special examinations without complaint, suspected or reported diagnosis (Z01; n=3,814,985), which includes examinations for eyes and vision, ears and hearing, blood pressure, dental examination and cleanings, and gynecological exams (data not shown).
Ambulatory visits, by ICD-10 major diagnostic categories
In 2022, four major diagnostic categories accounted for almost three-quarters (73.6%) of all illness- and injury-related ambulatory visits by active component service members (not including “Other” diagnoses): musculoskeletal system/connective tissue disorders (32.7%); mental health disorders (18.6%); disorders of the nervous system and sense organs (11.9%); and signs, symptoms, and ill-defined conditions (10.4%) (Table 1). Among visits for illness and injury, COVID-19 caused 1.3% of visits in 2022, a minor increase from 1.1% in 2021 (data not shown).  
In general, the relative distributions of ambulatory visits by ICD-10 diagnostic categories remained stable throughout the surveillance period (Table 1). Provisional data indicate that the rate of ambulatory visits increased in nine major diagnostic cat­egories of illness and injury from 2018 to 2022 (Table 1). The rate of mental health conditions increased by 20.4% from 2018 to 2022, with adjustment disorders accounting for the leading diagnosis in this major diagnostic category (Table 1; Table 2; Table 3).
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-4-Table-2) 
(https://health.mil/Reference-Center/Reports/2023/06/01/Article-4-Table-3) 
The encounter rate increase for congenital anomalies and hematologic and immune disorders from 2018 through 2022 also exceeded 20%, although the absolute change in the frequency of encounters for these conditions remained the lowest of all major diagnostic categories (Table 1). While congenital anomalies were not a most frequent diagnosis among women, almost 25% of the congenital anomaly conditions in men were diagnosed as congenital pes planus (flat foot) and congenital pes cavus (high arch) in 2022 (Table 2). Unspecified anemia represented the top diagnosis under hematologic and immune disorders for both men and women (Table 2; Table 3).
>From 2018 through 2022, the largest declines of illness and injury-specific major diagnostic categories were observed for infectious and parasitic diseases (-20.9%), respiratory system disorders (-20.4%), and injury (-11.1%) (Table 1). While these data are considered provisional, ongoing investigations on data timeliness may indicate these declines are not as substantial. Unspecified viral infection and unspecified acute upper respiratory infection were the leading diagnoses in 2022 for infectious and parasitic diseases and disorders of the respiratory system, respectively (Table 2; Table 3). Consistent with prior years, diagnostic S codes (injury), as opposed to T codes (burns and poisonings), accounted for nearly 90% of all ambulatory encounters within this major diagnostic category (data not shown).
Ambulatory visits, by sex
In 2022, service men accounted for nearly three-fourths (72.7%) of all illness- and injury-related visits; however, the annual crude rate among service women (15.0 visits per p-yr) was 77.5% higher than the rate among men (8.5 visits per p-yr) (data not shown). Excluding pregnancy- and delivery-related visits (which accounted for 9.9% of all non-Z-coded ambulatory visits by women), the illness and injury ambulatory visit rate among women, 13.5 per p-yr, was 60% higher than the rate among men. 
The female rates of illness- and injury-specific diagnoses exceeded male rates by 50% in all major diagnostic categories, except for diagnoses relating to nervous system and sense organs, circulatory system, digestive system, musculoskeletal system/connective tissue, and injury (data not shown). Relationships between age group and ambulatory visit rates were broadly similar among men and women across diagnostic categories (Figure 2).

Ambulatory rates for neoplasms, nervous system and sense organ disorders, circulatory system disorders, and endocrine, nutrition and immunity issues rose more steeply with advancing age than other categories of illness or injury (Figure 2). Ambulatory visit rates for COVID-19 infection diagnoses were relatively stable with advancing age.
The four leading diagnoses among ambulatory visits were the same for both male and female service members, although the rates for women exceeded those among men: pain in joint (women: 1,565.8; men: 1,130.4; female: male rate ratio [RR]: 1.4); low back pain (women: 514.8; men: 394.1; RR: 1.1); adjustment disorders (women: 699.3; men: 306.2; RR: 2.3); and pain in the limb, hand, foot, fingers, or toes (female: 315.0; male: 223.6; RR: 1.4) (data not shown). Five other diagnoses were among the 10 most common diagnoses for both men and women: post-traumatic stress disorder; cervicalgia (neck pain); dorsalgia (back pain); unspecified anxiety disorder; and sleep apnea. Sleep apnea was the second-most frequent illness- or injury-specific primary diagnosis for men during ambulatory visits but ranked 10th for women. The difference in the rate rank order of mental disorders is also worth noting: While alcohol dependence was the sixth most frequent diagnosis among men, it was not identified among 10 leading causes of ambulatory visits for women (Table 2, Table 3).
Discussion
Ambulatory visits among active component service members in 2022 declined to the lowest rate observed in the last 10 years; however, this overall decline was affected by a substantial change in the rate of ambulatory visits for “Other” factors influencing health status and health service contact. When excluding visits documented by ICD-10 Z-codes, the rate of illness- and injury-specific ambulatory visits was elevated compared to 2018 and 2020. The ranked distribution of primary causes of ambulatory visits remained stable, with musculoskeletal system, mental, and nervous system and sense organ disorders accounting for the 3 most prevalent rates among illness and injury-related major diagnostic groups. 
Notably, since 2018 the rate of ambulatory visits for mental health disorders increased by 20%. The rate of COVID-19 encounters also increased from 2020 to 2022, which partly reflects administrative coding procedures, as the ICD-10 code for COVID-19 was not available until April 2020. Conversely, encounter rate for the infectious disease and respiratory system major diagnostic categories declined by over 20% from 2018 to 2022. The data presented in this report are considered provisional, and ongoing investigations for data completeness in the MHS MIP may indicate a change in trends reported here.
While the National Ambulatory Medical Care Survey of 2019 indicates that civilian women use health care services more than men (3.7 vs. 2.7 visits per p-yr, respectively), the sex-specific rate ratio for illness and injury-specific ambulatory encounters indicates a larger disparity among active component service members (15.0 vs. 8.5 visits per p-yr, respectively).1 Furthermore, the rate of ambulatory office visits among civilians 15-24 years of age (1.6 visits per p-yr) and 25-44 years of age (2.0 visits per p-yr) far exceed the crude annual rate of illness- and injury-related visits (9.6 visits per p-yr) among active duty service members.1 Future analyses comparing the major diagnostic category rates to civilian counter­parts may be useful to further define cost of readiness.
Several limitations should be considered when interpreting these findings. Ambulatory care at the unit level by non-credentialed providers and at deployed medical treatment facilities (including ships at sea) are not included. This summary does not reflect the fact that the nature and rates of illnesses and injuries may vary between deployed and non-deployed active component service members.
The transition to a new MHS electronic health record system, MHS GENESIS, has introduced new limitations. In prior MSMR reports, dispositions following ambulatory visits described a proportion of encounters classified as limited duty, convalescence in quarters, or no limitation. These findings were not included in this report, due to a substantial increase in missing disposition data. Disposition information may be included in future reports if data completeness issues are resolved. Prior reports have described the number of virtual versus in-person ambulatory encounters; however, data quality issues have also been identified regarding the variable delineating this encounter type and is an area of active inquiry. Finally, medical data from sites using MHS GENESIS between July 2017 and October 2019 were not available in the DMSS—these sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center. Medical encounter data for individuals seeking care at any of these facilities from July 2017 through October 2019 were not included in the 2018 comparison data.
This summary is based on primary (first-listed) diagnosis codes reported on ambulatory visit records, and the current summary discounts morbidity related to comorbid and complicating conditions that may have been documented in secondary diagnostic positions in health care records. The accuracy of reported diagnoses likely varies by medical condition, clinical setting, care provider, and treatment facility, as this information is not collected for health surveillance. Although specific diagnoses during individual encounters were potentially not definitive, final, or even correct, summaries of the frequencies, nature, and trends of ambulatory encounters among active component members provide descriptive evidence for further research and evaluation. 
Rates and frequencies reported herein do not reflect unique individuals, but a rate of total ambulatory visits per p-year. This report documents all ambulatory health care visits but does not estimate incidence rates for the diagnoses described. These data provide descriptors for health care use, which elevate rates for disorders requiring increased numbers of ambulatory visits. In contrast to common, self-limited, and minor illnesses and injuries that require very little, if any, follow-up or continuing care, illnesses and injuries necessitating multiple ambulatory visits for evaluation, treatment, and rehabilitation are over-represented in this summary. 
Finally, the dataset is incomplete. Encounter data continues to be reported well after data are extracted from DMSS via the MHS MIP. The timing of data reporting varies annually, affecting direct comparisons to prior reports. While the relative rank order of utilization categories is most likely representative of the full data set, the absolute values are likely underestimated by 10-15%.
Reference

National Ambulatory Health Care Survey: 2019 National Summary. Accessed June 12, 2023. (https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2019-namcs-web-tables-508.pdf) https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2019-namcs-web-tables-508.pdf


(https://health.mil/News/Articles/2023/05/25/Ask-the-Doc-How-to-Get-Caught-Up-on-Childhood-Immunizations) Ask the Doc: How to Get Caught Up on Childhood Immunizations
May 24th 2023, 20:00

Hi Doc,
I am getting back into a regular schedule for doctor appointments for my children following the pandemic and am worried I may have missed some scheduled vaccinations. How can I get them caught up on recommended vaccines, even if it’s off the normal schedule? Also, my children and I are going on a trip to Europe this summer. What immunizations are recommended for my kids before going on our trip?

— U.S. Coast Guard Petty Officer 1st Class Vic Vack
____

Dear Petty Officer 1st Class Vack,

It’s great to hear you want to get your kids caught up on their scheduled vaccinations. Many service members face the same issues. I found just the person to talk to about this. I contacted Dr. David Hrncir, medical director of central region vaccine safety hub for the Defense Health Agency Immunization Healthcare Division. Here's what he said:

Studies show that certain groups of children got very behind on their immunizations during the COVID-19 pandemic. Newborns and infants generally got their vaccines on time. Older children missed some of their doctor visits and the associated vaccinations. Now is the time to schedule those visits and get necessary immunizations.

The Centers for Disease Control and Prevention specifically addresses catch-up immunizations for children and adolescents who start their immunizations late or who are more than one month behind, and I strongly recommend using CDC as your guide.

Military beneficiaries can contact the Immunization Healthcare Division support center for help with sorting out missed immunizations and getting a recommended plan for catching back up to an age-appropriate schedule.

A 24/7 support center manned by nurses and physicians is available to address all vaccine concerns. You can contact the support center by telephone or email at: 1-877-GETVACC (1-877-438-8222, option 1) or (mailto:DODvaccines at mail.mil) DODvaccines at mail.mil.

Your civilian and TRICARE-authorized providers can provide recommended vaccinations during your routine office visit. You can always discuss your concerns with your primary care provider or immunization technician.

You can get the catch-up shots at your local TRICARE network pharmacy, your local provider, or a military hospital or clinic. Military beneficiaries can get covered vaccines for free at participating retail network pharmacies when administered by a pharmacist. Call in advance to make sure the site you select has all the vaccines in stock.

As for vaccinations needed for your European trip, CDC has a wonderful website under its Traveler’s Health Destinations section for travel to a large variety of countries. Recommendations cover routine vaccines and other immunizations such as COVID-19, hepatitis A, hepatitis B, rabies, and tick-borne encephalitis.

There is also a handy list covering the benefits and risks associated with immunizations, as well as adverse event management and informational resources. These are based on the recommendations of the CDC’s Advisory Committee on Immunization Practices and are updated as needed.

___
Petty Officer 1st Class, I hope this advice is helpful as you do the right thing to get your kids up to date on their shots and ready for Europe.

Good luck my friend, and as always … take care out there!

(https://health.mil/News/Articles/2023/05/19/Find-Answers-to-Your-Health-Care-Questions-through-MHS-GENESIS) Find Answers to Your Health Care Questions through MHS GENESIS
May 18th 2023, 20:00

The health library is a unique feature on the (https://health.mil/Military-Health-Topics/Technology/MHS-GENESIS) MHS GENESIS patient portal, giving patients the ability to search for almost anything they would like to know about their health.
“If you have a health-related question about yourself or if you and one of your dependents are just looking for more information, this is the place to do that,” said U.S. Navy Lt. Kenny Bush, chief information officer of the Naval Medical Center at (https://www.lejeune.marines.mil/) Marine Corps Base Camp Lejeune, North Carolina. “It gives you the right information and is something that can be viewed by you and your health care provider to go over any clarification that may be needed.”
The heath library is accessible to patients through the MHS GENESIS patient portal online. Wherever patients have access to the patient portal, they will have access to the health library.
The library, accessible through the health records feature, acts as a database with an interface like an internet search engine.
“Patients will see a search bar at the top of the health library page, where they can input a term or issue and immediately receive results to select from and read,” said Bush. “The page also has ‘search content’ drop downs to further break down the search selection between health issues, medication, and lab results. You can also separate the searches by gender and age. Patients can literally search for almost anything related to their health and find information.”
According to U.S. Air Force Tech. Sgt. Candace Stanfield, the noncommissioned officer in charge of the Technology Management Integration Health Informatics Branch at the Defense Health Agency, the health issue tab provides a simple description of symptoms and treatments of illnesses, and the lab results tab provides the reasons for the lab work and how to prepare for the lab visit. “The medication tab gives you the different prescription doses and actually has the images of the pills in the catalogue of identification,” she added.
The health library goes a long way toward supporting operational readiness and provides beneficiaries with another source of health care information.
Health information on the individual level is protected under privacy laws, so those details are not accessible to anyone except the patient.
Bush added: “The information is quite extensive, and if there is a question, you can almost surely find it in the health library.”
Stanfield provided an example of how the MHS GENESIS health library educates service members about their health care to remain ready and resilient.
“A person could be told to get a liver function panel test. And I always think that most non-medical personnel don't really know what the test is looking for,” said Stanfield. “The health library will break down the tests by blood levels and enzymes along with definition for better understanding. This, in turn, can help keep members more compliant with health care needs, which will result in increased readiness.”
Visit the (https://health.mil/Military-Health-Topics/Technology/MHS-GENESIS) MHS GENESIS patient portal to access the health library.

(https://health.mil/News/Articles/2023/05/01/Mpox-Case-Detection) Enhanced Mpox Outbreak Case Detection Among MHS Beneficiaries Through Use of ESSENCE (Electronic Surveillance System for the Early Notification of Community-based Epidemics)
Apr 30th 2023, 20:00

Early awareness of cases of infectious disease facilitates timely implementation of control measures and policies to prevent disease or reduce spread. To support force health protection, the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE)1 collects near real-time biosurveillance data globally on U.S. military personnel. ESSENCE systematically queries millions of health encounters to detect records of potential public health importance. Statistical algorithms detect unusual increases, alerting public health staff to findings that may warrant investigation.1 ESSENCE receives several types of data including outpatient health encounter records from U.S. Military Health System (MHS) facilities, pharmacy prescriptions, laboratory results, and radiology reports. This report describes how ESSENCE contributed to case detection from the onset of the mpox outbreak.

The U.S. government declared mpox a national public health emergency on August 4, 2022.2 Nearly 3 months earlier, on May 13, 2022, the World Health Organization (WHO) was notified of a cluster of 3 mpox cases from a single household in the United Kingdom. These cases were suspected to be locally acquired; 2 days later 4 additional cases were reported by sexual health clinics, all among male patients who have sex with men.3 By May 21, 2022, locally acquired cases of this zoonotic disease had been confirmed in 11 other non-endemic countries including the U.S.4

To detect specific health events, queries in ESSENCE are typically constructed with chief complaint keywords or codes from the International Classification of Diseases 10th Revision, Clinical Modification (ICD-10-CM) linked by logical oper­ators (e.g., “and”, “or”). An initial mpox query was developed on May 20, based on known symptoms and specific criteria for discharge diagnosis ICD-10-CM codes and chief complaint keywords (Table 1).
(https://health.mil/Reference-Center/Reports/2023/05/01/Article-2-Table-1) 

While ESSENCE is designed to support surveillance and outbreak detection, the system’s performance should be evaluated when utilized during a public health response. This report describes how ESSENCE was used to monitor the mpox outbreak, assesses the system’s performance to detect confirmed/probable cases among MHS beneficiaries during May–August 2022, and describes approaches for improving system performance and utilization.

Methods

The initial mpox ESSENCE query was modified 5 days after its creation, to align with the WHO case definition for suspected cases (lowest threshold to meet the case criteria), followed by a minor change to additionally capture the keyword “monkey” without “pox” due to frequent misspellings (Table 1).5 Potential mpox cases included all health encounters that met the query criteria. Encounters with a discharge diagnosis ICD-10-CM code for diaper rash or hand, foot, and mouth disease, a chief complaint mentioning monkey bars, or a missing Electronic Data Interchange Personal Identifier (EDI-PI) were excluded as potential cases.

To assess the performance of the final version of the ESSENCE mpox query results, potential cases identified from May 1 through August 31, 2022 were compared to a validated master case list maintained by the Armed Forces Health Surveillance Division (AFHSD) Integrated Biosurveillance (IB) Branch. Epidemiologists at AFHSD IB created the master case list by compiling information about potential cases from various sources including the ESSENCE mpox query, reportable medical events (RMEs) from the Disease Reporting System internet (DRSi),6 service-specific reporting to AFHSD, notifications from stakeholders who received weekly case count reports, as well as direct informal communications. AFHSD IB epidemiologists contacted the appropriate Defense Center for Public Health (DCPH) to inform them of potential cases and request additional information. To validate the master case list, AFHSD IB epidemiologists reviewed electronic medical records of potential cases using Armed Forces Health Longitudinal Technology Application (AHLTA) to gather epidemiological, laboratory, and clinical information. CDC case definitions were used to classify potential cases as confirmed, probable, suspect, or not a case.7 Starting in July, the master case list was cross-checked daily with Defense Health Agency (DHA) Composite Health Care System and MHS GENESIS medical records in which mpox was recorded as a diagnosis, using reports provided by DHA administrative personnel. Results from 2 simpler, alternative queries, B04 ICD-10-CM code (alternative query 1 [AQ1]) and B04 ICD-10-CM code (AQ2) or mention of “monkey” in the chief complaint, were also compared with the mpox master case list to evaluate potential approaches to improve case detection. These queries were not implemented during the mpox outbreak but were retrospectively reviewed.

Results

A total of 3,067 unique encounters, from 2,750 unique individuals, as determined by EDI-PIs, were detected between May 1 and August 31, 2022. ESSENCE mpox surveillance of MHS beneficiaries was initiated earlier, on May 1, than U.S. mpox case reporting, on May 17 (Figure 1). 

The peak in the total number of health encounters returned by the mpox query preceded the peak in reported U.S. cases by 2 weeks. The first confirmed case of mpox among MHS beneficiaries was detected as a potential case by the ESSENCE mpox query 5 days prior to laboratory confirmation (Figure 2). 

The patient, an active duty service member in Germany, developed symptoms in late May, and reported no travel within the previous 90 days.

Table 2 summarizes the ESSENCE mpox query results by validated, master list case status and compares its results to those from the alternative queries (AQs). 
(https://health.mil/Reference-Center/Reports/2023/05/01/Article-2-Table-2) 
The ESSENCE mpox query detected 70.1% of confirmed/probable mpox cases based on a review of medical records for 2,750 individuals. AQ1 and AQ2 reduced the number of potential cases requiring medical record review (64 and 259, respectively), while still detecting 63.2% and 70.1% of confirmed/probable cases, respectively. The positive predictive value (PPV) of the ESSENCE mpox query was 2.2% (61/2,750). AQ2 had a higher PPV, at 23.5% (61/259), with equal sensitivity. AQ1 had the highest PPV, 85.9% (55/64), but was less sensitive, detecting 6 fewer confirmed/probable cases.

Discussion

The time series plot of ESSENCE mpox query encounter counts closely tracked the U.S. outbreak peak late in the summer of 2022. The CDC’s U.S. data included MHS beneficiary case data, as mpox is a nationally notifiable condition as well as a DOD RME. ESSENCE detected the first confirmed mpox case among MHS beneficiaries 5 days prior to laboratory confirmation and 6 days prior to reporting in DRSi. Detection was facilitated by the inclusion of the ICD-10-CM code for mpox (B04) in the discharge diagnosis prior to laboratory confirmation. Practitioners may use this code broadly to indicate a clinically suspected or confirmed case, exposure, or testing. 

The development and usefulness of queries to detect health events of interest is challenging when associated signs or symptoms are nonspecific or shared with other health events (i.e., many potential ICD-10-CM codes), or the code(s) do not yet exist (e.g., novel diseases, unknown etiology), or are not unique. Many potential cases detected by the mpox query were ultimately ruled out based on medical record review, or subsequent test results or alternate diagnoses (i.e., not a case) despite initial clinical suspicion. Depending upon the health event, the latter group may still be useful for public health detection.

Reviewing the medical records for 2,750 potential cases detected by the mpox query was time-intensive (5-10 minutes per record) and completing a review the same day as detection became unfeasible for a single, dedicated reviewer. The cost, in both time and effort, could make the approach impractical in many outbreak scenarios or not worth the benefit, given that opting for AQ2 would have reduced the number of records for review by more than 10-fold, without sacrificing identification of true positive cases.

ESSENCE queries can easily be modified as knowledge of the disease epidemiology evolves, transmission patterns change, and case definitions are updated. Adjustments to the query, to reduce potential cases requiring review, must be carefully evaluated, as it could lead to confirmed cases being missed, as the AQ1 results demonstrate. Over the course of the outbreak the number of encounters with chief complaints mentioning “monkeypox” increased as patients requested educational information or were offered or received the vaccine, especially when it became more widely available. The ESSENCE mpox query was subsequently modified by removing symptom keywords and including negation terms to exclude vaccination-related encounters and persons without exposure or symptoms seeking medical education. When the modified query was executed for the analysis period, it returned 430 unique encounters (246 unique EDI-PIs; PPV=20.2%) with a sensitivity of 100%.

The desired tolerance for the completeness of case capture should consider human resources, surveillance goals, and characteristics of the health event (e.g., incidence, disease epidemiology), among other factors. In contrast to the results of this study, a recent study of case definitions to identify COVID-19-related encounters among MHS beneficiaries found that inclusion of a greater number of ICD-10-CM codes increased sensitivity at the cost of specificity.8

The analyses in this report had several limitations. The mpox query likely under­estimated the detection of potential cases and therefore missed detection of some confirmed/probable cases (i.e., decreased sensitivity) for several reasons. Data from MTFs using MHS GENESIS were initially received in ESSENCE following a lag of a month; beginning on July 28, 2022, data were received daily beginning with July 23 encounters, but were incomplete (approximately 10% of the expected number were received). The sensitivity of the mpox detection query is dependent upon the completeness and accuracy of the chief complaint and ICD-10-CM codes entered in the medical records. ESSENCE does not capture health encounters or testing for MHS beneficiaries at non-MHS facilities, which could mean that some confirmed/probable cases among MHS beneficiaries are missed (i.e., decreased sensitivity). The master case list likely under­estimated the true number of confirmed/probable cases, as health encounter notes and test results for MHS beneficiaries visiting non-MHS facilities were often not available in AHLTA. The population most at risk of mpox infection, men who have sex with men, may be more likely to seek care outside MHS, which would lead to a true case rate higher than stated in the AFHSD master list. MHS GENESIS medical records were not reviewed, so some cases may have gone undetected and led to an underestimation of the true incidence. Once test results became available, some cases classified as suspected in this analysis may have subsequently been classified as confirmed/probable, or not a case, which may have led to underestimation of the sensitivities of confirmed/probable case detection queries.

During the mpox outbreak ESSENCE biosurveillance was centralized, with AFHSD IB conducting all aspects of query development, data review and extraction, and electronic medical record review for all MHS beneficiaries. More efficient biosurveillance utilizing ESSENCE would be decentralized, incorporating the 2 designated ESSENCE users required at each MTF9 to conduct ongoing data review and initiate public health investigations. These MTF ESSENCE users’ awareness of local events and collaboration with local public health and clinical staff for record reviews would expand resources for timely follow-up of potential cases. In a decentralized approach AFHSD IB would refine queries, receive and compile critical findings reported by local users or DCPH, and maintain and report the master case list results to key stakeholders. Valuable insights and refinements on the specific process could be informed by pilot programs between AFHSD and a DCPH or several MTFs. Advancing towards a decentralized MHS-wide approach would improve the effectiveness of the ESSENCE biosurveillance process, by employing the situational awareness of those closest to the location of a public health event, in collaboration with strategic oversight and technical support provided by AFHSD staff.

Author Affiliations
Armed Forces Health Surveillance Division, Integrated Biosurveillance, Silver Spring, MD (Dr. McGee, Dr. Russell, Ms. Metcalf-Kelly); Cherokee Nation Strategic Programs, Tulsa, OK (Dr. McGee).

References

Burkom H, Loschen W, Wojcik R, et al. Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE): overview, components, and public health applications. JMIR Public Health Surveill. 2021;7(6):e26303. doi:10.2196/26303
        Biden-Harris Administration Bolsters Monkeypox Response; HHS Secretary Becerra Declares Public Health Emergency. August 4, 2022. Accessed August 17, 2022. (https://www.hhs.gov/about/news/2022/08/04/biden-harris-administration-bolsters-monkeypox-response-hhs-secretary-becerra-declares-public-health-emergency.html) https://www.hhs.gov/about/news/2022/08/04/biden-harris-administration-bolsters-monkeypox-response-hhs-secretary-becerra-declares-public-health-emergency.html

        World Health Organization. Monkeypox—United Kingdom of Great Britain and Northern Ireland. May 18, 2022. Accessed July 15, 2022. (https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON383) https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON383

        World Health Organization. Multi-country monkeypox outbreak in non-endemic countries. May 21, 2022. Accessed October 6, 2022. (https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385) https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385

        World Health Organization. Surveillance, case investigation and contact tracing for monkeypox: interim guidance, 22 May 2022. Accessed May 25, 2022. (https://apps.who.int/iris/handle/10665/354486) https://apps.who.int/iris/handle/10665/354486

        Armed Forces Health Surveillance Division. Armed Forces Reportable Events Guidelines and Case Definitions, 1 January 2020. Accessed October 4, 2022. (https://www.health.mil/Military-Health-Topics/Health-Readiness/AFHSD/Reports-and-Publications) https://www.health.mil/Military-Health-Topics/Health-Readiness/AFHSD/Reports-and-Publications 
        Centers for Disease Control and Prevention. Case Definitions for Use in the 2022 Mpox Response. July 22, 2022. Accessed March 14, 2023. (https://www.cdc.gov/poxvirus/mpox/clinicians/case-definition.html) https://www.cdc.gov/poxvirus/mpox/clinicians/case-definition.html

        Evaluation of ICD-10-CM-based case definitions of ambulatory encounters for COVID-19 among Department of Defense health care beneficiaries. MSMR. 2022;29(5):12-16.
         Department of Defense (DOD). Instruction 6200.03 Public Health Emergency Management (PHEM) Within the DOD. March 28, 2019. Accessed March 14, 2023. (https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/620003p.pdf) https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/620003p.pdf


(https://health.mil/News/Articles/2023/05/01/Eosinophilic-Esophagitis) Increasing Incidence Rates of Eosinophilic Esophagitis in Active Component Service Members, U.S. Armed Forces, 2009–2021
Apr 30th 2023, 20:00

Eosinophilic esophagitis (EoE) is characterized by symptoms associated with dysfunction of the esophagus due to chronic mucosal eosinophilia and inflammation.1,2 Environmental and food allergens, enhanced type 2 helper T cell (Th2) activity, genetic predisposition, impaired esophageal epithelial barrier, and potential for fibrosis have all been implicated in EoE.1,3 Predominant symptoms in adults include dysphagia and food impaction, with 1 systematic review indicating symptom prevalence ranging from 29-100% and 25-100% respectively.1,4 Treatment is focused on the triad of dietary modifications, medications, and dilation to control symptoms and restore normal esophageal function.1

The reported prevalence of EoE has been increasing worldwide, with a recent meta-analysis estimating 34.2 cases per 100,000 persons.5 Subgroup analysis of North American adults reveals similar rates, at 31.9 cases per 100,000 adults, with individual studies on U.S. adults ranging from 9.45 to 58.9 cases per 100,000.5 The incidence of EoE has been increasing over the past several decades, and while this phenomenon is at least partially due to increased awareness and interest in the condition, some studies report that the rate of EoE has disproportionately risen with the increased rate of biopsies during the same study periods, suggesting a true increase in EoE.6,7 

EoE is more common in men, those of White race/ethnicity, and those with atopic disease.8 It can present at any age, but the majority of cases occur among children, adolescents, and adults under 50 years.8 Because the majority of the active component military is comprised of White men under 50 years, EoE may be an important contributor to the burden of disease in this population. This study examines the incidence of EoE among active component service members (ACSM) to characterize the disease impact on this population, and evaluate change in the incidence over the study period. EoE is disqualifying for accession into military service due to potential for uncontrolled symptoms or food impactions in austere or medically limited environments; consequently, new service members should not have a diagnosis of EoE.9
Methods
The surveillance period covered January 1, 2009 through December 31, 2021. The surveillance population included all ACSM of the Army, Navy, Air Force, and Marine Corps. The data used to determine incident cases of EoE were derived from the Defense Medical Surveillance System (DMSS), which documents both ambulatory encounters and hospitalizations of active component members of the U.S. Armed Forces in fixed military and civilian (if reimbursed through the Military Health System) clinics and hospitals.

An incident case of EoE was defined by 2 outpatient medical or Theater Medical Data Store (TMDS) encounters within 365 days of each other or 1 hospitalization with a diagnosis of EoE in any diagnostic position (ICD-9: 530.13, ICD-10: K20.0). The incident date was defined as the date of the first hospitalization or outpatient medical encounter that included a defining diagnosis of EoE. ICD codes were used to define cases because histologic data were not available and previous studies indicated high specificity of the ICD codes.10,11
 
Results(https://health.mil/Reference-Center/Reports/2023/05/01/Article-4-Table) 

The 7,592 incident cases of EoE among ACSM during the 2009 to 2021 surveillance period resulted in an overall incidence rate of 43.5 cases per 100,000 person years (p-yrs). Crude (i.e., unadjusted) incidence rates for selected covariates in 2021 are shown in Table 1. In 2021, the incidence rate of EoE among men was more than twice than the rate among women. The rate of EoE increased with each older age category, with the highest rates in those over the age of 40. Among racial/ethnic groups, the highest rate of EoE was among non-Hispanic Whites. Service members of the Air Force had the highest rate, and those in the Marine Corps had the lowest, while the rate among officers was almost twice the rate for enlisted members. Pilots and aircrew had the highest rates among occupation groups, followed by health care workers. 

Incidence rates steadily climbed throughout the surveillance period, from 21.2 cases per 100,000 in 2009 to 62.4 cases per 100,000 p-yrs in 2021 (Figure 1).

Rates among the 2 oldest age categories increased at a faster rate than service members in their 20s (Figure 1). Incidence rates among men increased at a higher rate compared to rates among women (Figure 2).

 
In addition, the incidence rate increased most notably among non-Hispanic Whites during the surveillance period (Figure 3).

Discussion
The results of this study show a steady increase in the incidence of EoE among ACSM between 2009 and 2021. Previously published literature has indicated that the incidence and prevalence of other Th2 type allergic and atopic diseases are increasing among ACSMs.12 Although there is variability in methodology, multiple studies demonstrate the increasing incidence and prevalence of EoE in a variety of populations studied worldwide.13-15 The increasing trend is largely unexplained and likely not due to increase disease recognition alone.6,7,14 
Although the incidence rates presented in this study are in accordance with findings from some studies in the U.S. adult population with similar methodology, these rates are higher compared to other studies in the U.S. and Europe that used more stringent case definitions, such as pathologist-validated reports.13,15-17 The demographic risk factor results of this study are consistent with published literature, with higher incidence rates of EoE in men, non-Hispanic Whites, and adults in their 30s and 40s.18 ACSMs are predominantly younger (55% are in their 20s), White (69%), and male (83%), which may account for the higher rates in this study compared to others. With universal health care in the military, more members may have access to care than in other U.S. studies, which could also account for the increased rates identified in this study. Military members may seek medical care towards the end of the career to prevent career-ending medical evaluations, which could contribute to the highest rates within the oldest age range. This study did not attempt to identify specific occupational, environmental, or demographic risk factors among ACSM, which would require additional analyses.  
As with all studies that utilize administrative data, this study is reliant upon the coding of medical encounters. Incident cases in this study may have been ruled out later by biopsy, which would have overestimated incidence rates. A full review of pathology reports or chart reviews would need to be conducted to validate all cases. A prior study, however, found that the use of the ICD-9 code (530.13) is very specific for EoE (99% specificity), which would suggest that most cases identified by ICD codes are true cases.10
The incidence of EoE among ACSM should continue to be monitored, as the rate did not appear to plateau during the surveillance period despite a reduction during the first 21 months of the COVID-19 pandemic, when medical care was less available for non-urgent conditions. As more ACSM are diagnosed with EoE, complications from treatment and need for periodic endoscopic interventions will increase. Management options are currently limited, with only 1 FDA-approved biologic, dupilumab, for the treatment of EoE—and ongoing biologic therapy is disqualifying for military service. Other treatments include proton pump inhibitors and topical “swallowed” cortico­steroids (asthma inhalers) that are used off-label for EoE.19 Strictures require endoscopic dilation, which has associated risks of anesthesia and procedural complications. More studies are needed to evaluate specific and modifiable exposures such as pollutants, diet, infectious diseases, and environmental allergens that may be associated with EoE.20-22 
Author Affiliations
Office of the Air Force Surgeon General, Falls Church, VA (Dr. Baldovich); Armed Forces Health Surveillance Division, Defense Health Agency, Silver Spring, MD (Dr. Stahlman); Department of Medicine, Allergy & Immunology, Walter Reed National Military Medical Center, Bethesda, MD (Dr. Lee).
References

Furuta GT, Katzka DA. Eosinophilic esophagi-tis. NEJM. 2015;373(17):1640-1648. doi:10.1056/NEJMra1502863
    Muir A, Falk GW. Eosinophilic esophagi-tis: a review. JAMA. 2021;326(13):1310-1318. doi:10.1001/jama.2021.14920
    Merves J, Muir A, Modayur Chandramou-leeswaran P, Cianferoni A, Wang ML, Spergel JM. Eosinophilic esophagitis. Ann Allergy Asthma Immunol. 2014;112(5):397-403. doi:10.1016/j. anai.2014.01.023
    Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. J Gastroenterol. 2007;133(4):1342-1363. doi:10.1053/j.gas-tro.2007.08.017
    Navarro P, Arias Á, Arias-González L, Laserna-Mendieta EJ, Ruiz-Ponce M, Lucendo AJ. System-atic review with meta-analysis: the growing incidence and prevalence of eosinophilic oesophagitis in children and adults in population-based studies. Aliment Pharmacol Ther. 2019;49(9):1116-1125. doi:10.1111/apt.15231
    Dellon ES, Erichsen R, Baron JA, et al. The in-creasing incidence and prevalence of eosinophilic oesophagitis outpaces changes in endoscopic and biopsy practice: national population-based estimates from Denmark. Aliment Pharmacol Ther. 2015;41(7):662-670. doi:10.1111/apt.13129
    Warners MJ, de Rooij W, van Rhijn BD, et al. Incidence of eosinophilic esophagitis in the Nether-lands continues to rise: 20-year results from a nationwide pathology database. Neurogastroenterol Motil. 2018;30(1). doi:10.1111/nmo.13165
    Dellon ES. Epidemiology of eosinophilic esophagitis. Gastroenterol Clin North Am. 2014;43(2):201-218. doi:10.1016/j.gtc.2014.02.0029.	Department of Defense. Medical Standards for Appointment, Enlistment, or Induction in the Military Services (DOD Instruction 6130.03). 2011.
    Department of Defense. Medical Standards for Appointment, Enlistment, or Induction in the Military Services (DOD Instruction 6130.03). 2011.
    Rybnicek DA, Hathorn KE, Pfaff ER, Bulsiewicz WJ, Shaheen NJ, Dellon ES. Administrative coding is specific, but not sensitive, for identifying eosinophilic esophagitis. Dis Esophagus. 2014;27(8):703-708. doi:10.1111/dote.12141
    Robson J, Korgenski K, Parsons K, et al. Sensitivity and specificity of administrative medical coding for pediatric eosinophilic esophagitis. J Pediatr Gastroenterol Nutr. 2019;69(2):e49-e53. doi:10.1097/mpg.0000000000002340
    Lee RU, Stahlman S. Increasing incidence and prevalence of food allergies in the US military, 2000-2017. J Allergy Clin Immunol Pract. 2020;8(1):361-363. doi:10.1016/j.jaip.2019.08.031
    de Rooij WE, Barendsen ME, Warners MJ, et al. Emerging incidence trends of eosinophilic esophagitis over 25 years: results of a nationwide register-based pathology cohort. J Neurogastroenterol Motil. 2021;33(7):e14072. doi:https://doi. org/10.1111/nmo.14072
    Kumar S, Choi SS, Gupta SK. Eosinophilic esophagitis: current status and future directions. Pediatr Res. 2020;88(3):345-347. doi:10.1038/s41390-020-0770-4
    Dellon ES, Hirano I. Epidemiology and natural history of eosinophilic esophagitis. J Gastroenterol. 2018;154(2):319-332.e3. doi:10.1053/j.gas-tro.2017.06.067
    Parton J, Yang X, Eke R. S503 examining the diagnostic pattern of eosinophilic esophagitis among Medicaid enrollees in the deep south U.S. Am J Gastroenterol. 2022;117(10S):e356-e357. doi:10.14309/01.ajg.0000858652.02201.c4
    Dellon ES, Jensen ET, Martin CF, Shaheen NJ, Kappelman MD. Prevalence of eosinophilic esophagitis in the United States. Clin Gastroenterol Hepatol. 2014;12(4):589-596.e1. doi:10.1016/j. cgh.2013.09.008
    Lipowska AM, Kavitt RT. Demographic features of eosinophilic esophagitis. Gastrointest Endosc Clin N Am. 2018;28(1):27-33. doi:10.1016/j. giec.2017.07.002
    Dellon ES, Rothenberg ME, Collins MH, et al. Dupilumab in adults and adolescents with eosinophilic esophagitis. NEJM. 2022;387(25):2317-2330. doi:10.1056/NEJMoa2205982
    Jensen ET, Dellon ES. Environmental factors and eosinophilic esophagitis. J Allergy Clin Immunol. 2018;142(1):32-40. doi:10.1016/j. jaci.2018.04.015
    Shah MZ, Polk BI. Eosinophilic esophagitis: the role of environmental exposures. Immunol Allergy Clin North Am. 2022;42(4):761-770. doi:10.1016/j. iac.2022.05.006
    Angerami Almeida K, de Queiroz Andrade E, Burns G, et al. The microbiota in eosinophilic esophagitis: a systematic review. J Gastroenterol Hepatol. 2022;37(9):1673-1684. doi:https://doi. org/10.1111/jgh.15921

 
 


(https://health.mil/News/Articles/2023/05/01/Wastewater-Biosurveillance) Portable RT-PCR and MinION Nanopore Sequencing as a Proof-of-Concept SARS-CoV-2 Biosurveillance in Wastewater
Apr 30th 2023, 20:00

In this study, wastewater samples collected from a participating sentinel site were initially screened for the presence or absence of SARS-CoV-2 RNA using portable RT-PCR, with positive samples sequenced using a handheld MinION nanopore sequencing device. Genomic biosurveillance of SARS-CoV-2 and its variants within wastewater has been established as an early warning system of infectious disease spread in a given catchment area, due to good correlation between spikes in viral levels detected in wastewater coincident with increases in COVID-19 incidence rates.1-3
 Moreover, viral titers detected in a single wastewater sample are reflective of pre-symptomatic, asymptomatic, and post-symptomatic cases, making wastewater-based epidemiology (WBE) a cost-effective, non-invasive public health surveillance method complementary to clinical diagnostic testing. The results of this study demonstrate the utility of population-scale SARS-CoV-2 epidemiology for insights into the viral evolution and transmission dynamics associated with specific SARS-CoV-2 variants that are necessary for effective strategies of containment and timely deployment of appropriate countermeasures.  

What are the new findings?

In this study, 2 different portable nucleic acid detection technologies, RT-PCR and MinION Mk1C nanopore sequencing, identified SARS-CoV-2 variants in wastewater collected at Tyndall AFB during a 2-month surveillance period. This highly multiplexed approach circumvented signal dropout associated with the detection of newly emerging SARS-CoV-2 variants, significantly reducing time for sample-to-pathogen identification, for improved infectious disease surveillance.

What is the impact on readiness and force health protection?

Based on the biosurveillance data obtained through portable detection technologies, viral levels in wastewater monitored at military installations can signify SARS-CoV-2 spatio-temporal dynamics in relation to population density as well as other crucial variables. Wastewater biosurveillance can contribute to data-informed policy decisions such as force health protection condition (HPCON) level adjustments.Wastewater-based epidemiology serves as an early warning system of surges in viral levels in a geographically-defined catchment area that has been utilized to monitor infectious disease emergence and spread, including COVID-19.4-8 Although primary transmission of SARS-CoV-2 is through the respiratory aerosol,9-10 other routes of transmission are possible11,12 as a result of viral shedding due to broad tissue tropism of SARS-CoV-2, including the gastrointestinal (GI) tract.13-15 SARS-CoV-2 lineages were detected in wastewater throughout the COVID-19 pandemic, making wastewater-based epidemiology a valuable tool in understanding and tracking SARS-CoV-2 transmission dynamics at a population level.16-21
Methods
Sample collection from wastewater lift station and initial processing

Site selection for this study was based on reported positive COVID-19 clinical cases. Wastewater influent, prior to any treatment, was collected weekly by an autosampler at a lift station servicing Tyndall AFB in May-June of 2021. During the 8-week study, 50mL composite wastewater samples collected over 24 hours, at 2 hour intervals, were processed for SARS-CoV-2 detection. Each sample was pasteurized at 58oC for 30 minutes to inactivate any virus before further sample handling (Figure 1).

Concentration of virions and genomic RNA extraction

Viral particles were concentrated using 700µL of magnetic nanobeads (Ceres Nano) by incubation at room temperature for 20 minutes, magnetic nanobead collection, followed by supernatant discarding. Viral particles were lyzed and RNA extracted using M1 Sample Prep kit (Biomeme). SARS-CoV-2 virions were lyzed through incubation in lysis buffer for 10 minutes at room temperature, followed by genomic RNA binding to syringe resin, and sequential resin washing to remove protein and salt contaminants. Purified RNA was eluted in 0.2mL buffer and concentration deter­mined with Qubit (ThermoFisher). 

Viral titer determination by RT-PCR and MinION sequencing
RT-PCR assay (Biomeme) was performed using SARS-CoV-2 panel targeting Orf1ab gene and S gene. Briefly, 25-100ng of extracted RNA template was added to the lyophilized qPCR mix containing master mix, reverse transcriptase and DNA polymerase enzymes, primers and probes (20µL total reaction volume) under the specific cycling conditions: cDNA synthesis (55oC for 2 min), polymerase activation (95oC for 60 sec), PCR (45 cycles of denaturation at 95oC for 1 sec, and annealing/extension at 60oC for 20 sec). For the SARS-CoV-2 variant assignment, a proprietary variant panel targeted variant-specific mutations and the modified cycling condition of annealing/extension at 62oC for 20 seconds. 
To prepare the sequencing library, cDNA synthesis was performed using random hexamers (NEB S1330S) and SuperScript IV reverse transcriptase (ThermoFisher Scientific 18090010), followed by PCR amplification using primers generating 1,200 base pairs (bp) amplicons spanning 29 kilobases (kb) SARS-CoV-2 genome in a tiled fashion with a 20 bp overlap. Odd-numbered primer pairs (FWD+REV primer pairs 1,3,5…29) were pooled in equimolar concentration (Primer Pool 1), while even-numbered primer pairs (FWD+REV pairs 2,4,6...28) were grouped in a separate primer pool (Primer Pool 2). Each sample was amplified twice using primer pools 1 and 2 and Q5 Hot Start High-Fidelity Master Mix (NEB M0494), followed by combining amplicons generated with each primer pool for every sample. Following Agencourt AMPure XP beads clean-up (Beckman Coulter) and Qubit quantification, end-repair and dA-tailing of the amplified cDNA samples used NEBNext Ultra II End Repair/dA-Tailing Module (NEB E7546). Barcode ligation used Native Barcoding Expansion (Oxford Nanopore EXP-NBD104), followed by adapter ligation using Ligation Sequencing Kit (Oxford Nanopore SQK-LSK109) to the pooled barcoded samples (equimolar concentration of 100 fM). After the final AMPure XP beads clean-up and Qubit quantification, the sequencing library was loaded on a primed R9.4.1 flow cell (Oxford Nanopore FLO-MIN106D) and sequenced for 8 hours. 
Bioinformatics pipeline for sequence analysis and variant calling
Primary data acquisition used MinKNOW operating software (Oxford Nanopore Technologies), while base-calling employed Guppy (Oxford Nanopore Technologies). Processed reads were mapped against SARS-CoV-2 reference (NC_045512.2, Wuhan-Hu-1) with Mini­map 2. SAMtools sorted aligned BAM files for coverage data and a consensus sequence.
Results
Portable multiplex RT-PCR pre-screening resulted in identification of SARS-CoV-2 positive samples
A primary sample screening used multiplex RT-PCR assay with 2 different primers-probe sets targeting SARS-CoV-2 Orf1ab and S-gene. Additional primers-probe set targeting MS2 bacteriophage provided an internal process control. RT-PCR analysis for each sample was systematically performed in triplicate using water as a no-template control. Overall, 6 of the 8 samples tested positive for SARS-CoV-2, evidenced by a positive signal in the red (S-gene) and green (Orf1ab) channels, as well as the corresponding amplification plots and Cq values (Figure 2a), which allowed initial sample assessment for the presence or absence of SARS-CoV-2 RNA. 

RNA process control (RPC) signal corresponding to MS2 bacteriophage RNA (amber channel) allowed a semi-quantitative estimation of SARS-CoV-2 titer relative to the MS2 phage particles based on corresponding Cq values. Overall, 4 samples contained higher levels of genome copies/mL relative to the internal control (Figures 2b-c), which was consistent with high levels of COVID-19 cases reported at the installation and throughout Florida during the sampling period.

MinION nanopore sequencing using whole genome PCR tiling approach resulted in a comprehensive mutational profiling of SARS-CoV-2 variants
Wastewater samples that tested positive for SARS-CoV-2 RNA were sequenced by tiled amplicon sequencing, while lineage assignment and genome coverage assessment with ARTIC+NextClade bioinformatics pipeline identified distinct SARS-CoV-2 variants in all 6 wastewater samples (Figure 3). 

In comparison to the previous ARTIC SARS-CoV-2 sequencing workflow that generated 400 bp amplicons, fewer primer pairs generating longer amplicons resulted in good genome coverage and unambiguous lineage assignment while maintaining good overall sequencing yield and read quality (Table). 
(https://health.mil/Reference-Center/Reports/2023/05/01/Article-3-Table) 
A comprehensive mutational profile of SARS-CoV-2 isolates was obtained by whole genome sequencing with varying degrees of nucleotide substitutions, but no deletions or insertions. Lineage-defining amino acid substitutions in the Spike protein were generated using NextClade bioinformatics analysis and included previously uncharacterized mutations (Figure 3). Interestingly, in addition to lineage-defining mutations, additional mutations both in the Spike protein as well as other genomic regions were identified within variants with a defined lineage, e.g. B.1.1.7 (Alpha), thus reflecting the complexity of wastewater samples and genetically divergent SARS-CoV-2 isolates. 
SARS-CoV-2 Delta specific RT-PCR assay confirmed lineage assignment by targeting variant defining mutations in the S-gene
Lineage assignment of SARS-CoV-2 variants determined by MinION sequencing was confirmed using a Delta RT-PCR panel of assays targeting mutations specific to the Delta variant (Figure 4).

 When the wastewater sample NB24_MIN149-1-10-PHT containing SARS-CoV-2 Delta variant, determined by MinION sequencing, was assayed with Delta-specific RT-PCR triplex, the observed signals in the green and amber channels targeting 681R and 452R mutations, respectively, combined with a lack of signal in the red channel targeting deletion at position 156, confirmed unique mutations previously identified with MinION sequencing.
Discussion
In this study, 8 composite wastewater samples were collected, using an autosampler for a 24-hour preiod each week, from a wastewater lift station servicing a military installation. Each sample was screened for SARS-CoV-2 RNA using multiplex RT-PCR targeting a conserved Orf1ab region and variable Spike gene. This method resulted in unambiguous identification of 6 SARS-CoV-2-positive samples, using very low input RNA. 

Relatively high SARS-CoV-2 viral titers detected in the wastewater provided good sequencing output, as evidenced by the number of sequencing reads obtained from each sample that tested positive. The RNA material was of sufficient quantity and purity for whole genome tiled amplicon sequencing using long-read nanopore sequencing, allowing several assays for comprehensive SARS-CoV-2 characterization from a single sample source. 

Based on this proof-of-concept study, the combination of portable RT-PCR and MinION sequencing for nucleic acid detection can reduce the time for sampling-to-pathogen identification from days to hours (under 10 hours from wastewater sample concentration to SARS-CoV-2 variant identification in the current study) if sampling at the source and circumventing sample transport to a research facility. This method potentially avoids informational loss due to viral instability in the absence of the host, or RNA instability in the absence of the virus. 

Lineage ID assignment with ARTIC+Nextclade bioinformatics pipeline allowed identification of variants of concern including Delta and Alpha of the Wuhan-Hu-1 strain originally isolated at the onset of the pandemic. Similarly, 5 of 6 isolates contained P681 mutation in the furin cleavage site (P681 RRAR) at the S1/S2 junction of the Spike protein. P681 mutation renders furin cleavage site less acidic and increases recognition and cleavage efficiency by the furin enzyme, resulting in greater SARS-CoV-2 infectivity. The other notable Spike protein mutations identified with MinION nanopore sequencing included N501Y and L452R, located in the receptor-binding domain and thought to be responsible for more efficient RBD-ACE2 binding and increased viral infectivity.22-27

The presence of S-gene mutations identified with MinION nanopore sequencing was confirmed by a variant-specific RT-PCR assay targeting lineage-defining mutations in the gene-encoding Spike protein. A Delta variant panel targeting 452R, 681R, and 156/157del mutations in the Spike protein that confirmed variant ID assignment was found consistent with the sequencing data, as evidenced by the amplification of the regions encoding the 452R and 681R mutations and absence of signal corresponding to the 156/157 deletion. Interestingly, whole-genome sequencing revealed additional non-lineage-defining mutations in the Spike protein, specifically 112L, indicating the utility of whole-genome sequencing in the SARS-CoV-2 variant tracking and newly emerging variant evolution. It is unclear whether 112L mutation is the consequence of genetic viral diversification from animal reservoirs or human intrahost-dependent viral recombination, as the corresponding clinical SARS-CoV-2 specimens were not available for compari­son. Notably, 112L Spike protein mutation is not found in any other variants of concern and has not been linked to any of the evolutionary advantageous viral phenotype traits such as higher infectivity and transmission, more effective replication and potentially increased disease severity due to higher viral burden, or more efficient evasion of host defenses.

At the height of the pandemic, and during specific variants of concern surges such as Delta or Omicron, on average 5-10% of the symptomatic population was tested daily through PCR-based methods or antigen tests, depending on the size of the installation and corresponding population size. This strategy is both cost-prohibitive and labor-intensive for extended periods of time. In contrast, wastewater SARS-CoV-2 levels can be monitored continuously, as demonstrated by this study, on a weekly basis and cost-effectively. A single wastewater sample can be assayed with 1 test per sample to capture a majority of the population, including symptomatic and asymptomatic cases. It is cost prohibitive to continue randomly testing up to 10% of the population when numbers of new cases approach baseline, but continuous monitoring of SARS-CoV-2 levels in wastewater can provide early indicators of SARS-CoV-2 resurgence due emergences of new variants of concern.  

Some of the potential limitations of this wastewater biosurveillance include the inability to capture 100% of the population, particularly for more targeted (e.g., building-level) biosurveillance, as an entire population cannot effectively contribute to a sewer shed, particularly from any given building on a sampling day. Wastewater surveillance sustainability at DOD installations will depend upon the ability to expand beyond COVID-19 to include additional pathogens of public health concern. Initial training of bioenvironmental engineering staff is required to make portable WBE feasible. 

Overall, portable wastewater SARS-CoV-2 biosurveillance is a sustainable, highly informative, and effective methodology for continuous population monitoring because it can be implemented at the outbreak source, facilitating outbreak containment by providing public health responders with actionable, data-driven information for health force protection more expeditiously.  
This study demonstrates the utility of portable RT-PCR and nanopore sequencing platforms for rapid SARS-CoV-2 detection and variant identification at the lineage level, effectively applying this highly multiplexed technology for genomic biosurveillance and public health response to current and future pandemics. Nanopore sequencing in conjunction with variant-specific RT-PCR was validated as an effective method for rapid identification and tracking of the distribution and prevalence of SARS-CoV-2 variants at military installations, which can lack clinical laboratory capabilities while experiencing potential outbreak clusters for newly emerging variants of concern.
Author Affiliations
Air Force Medical Readiness Agency, Falls Church, VA (Lt Col Dietrich); Materials and Manufacturing Directorate, U.S. Air Force Research Laboratory, WPAFB, OH (Dr. Stamps); ERP360 Solutions Group LLC (Craig Strapple); The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD (Dr. Pavlyuk, Ms. Jacque Engler).
Acknowledgements
The authors would like to thank the Global Emerging Infectious Surveillance and the Department of Public Health and Preventive Medicine of USAF School of Aerospace Medicine at Wright-Patterson AFB, in particular Dr. Anthony Fries and Col. Brett Nishikawa for proofreading the manuscript. HJF award FA8650-18-2-6951 is gratefully acknowledged.
Disclaimer
The views expressed are those of the authors and do not reflect the official guidance or position of the United States Government, the Department of Defense, nor the United States Air Force.
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(https://health.mil/News/Articles/2023/05/01/RMEs) The Return of Reportable Medical Events Summaries to MSMR
Apr 30th 2023, 20:00

MSMR is pleased to announce the return of a recurring feature, a summary of reportable medical events (RMEs) affecting DOD service members and other MHS beneficiaries. Sentinel RME summaries were a regular feature of MSMR until 2010. The MSMR editors welcome reader comments on the format and content of these summaries as we seek to expand the usefulness of the journal.

RMEs are documented in the Disease Reporting System internet (DRSi) by health care providers and public health officials throughout the Military Health System (MHS). The DRSi collects reports on over 70 different RMEs, including infectious and non-infectious conditions, outbreak reports, STI risk surveys, and tuberculosis contact investigations. These reports are reviewed by each service’s public health surveillance hub, which serves as an active primary prevention component to identify other service members at risk, assess need for post-exposure screening and prophylaxis, or inform other actions to protect and assure public health. Primary prevention (reducing disease occurrence) is the most effective method for preserving the medical readiness of the force. 

Routine monitoring, evaluation, and publication of RMEs provide an important data resource for both policymakers and commanders, to guide their efforts for controlling and preventing diseases with potential measurable impacts on public health and force readiness—strategic, operational, and tactical. RMEs were chosen by consensus and recommendations from each service, which evaluated lists of nationally-notifiable diseases from the Centers for Disease Control and Prevention, position statements from the Council of State and Territorial Epidemiologists, and other events identified as significant military health threats meriting added surveillance. A complete list of RMEs is available in the 2022 Armed Forces Reportable Medical Events Guidelines and Case Definitions.1 

The data presented in the Table not only list the most recent case counts but reveal trends of incidence for the past 2 months, year-to-date, and throughout the preceding year. Data reported in the Table are considered provisional and do not represent conclusive evidence until case reports are fully validated.
(https://health.mil/Reference-Center/Reports/2023/05/01/Article-1-Table) 

The most recent data on the 5 most frequent RMEs among total active component cases, as reported per week during the preceding year, are depicted in the Top 5 RME Trends by Calendar Week graph. COVID-19 is excluded from the graph due to 2023 changes in reporting and case definitions.

Top 5 RME trends for preceding Year by Calendar Week. This line graph depicts the top 5 reportable medical conditions by case count among active component service members over the past 52 weeks. Chlamydia was the most common with counts of approximately 300 cases per week. Gonorrhea was the second-most common reported disease, averaging approximately 80 cases per week. Gonorrhea was surpassed by heat illnesses in weeks 24, 27, 29, and 30 of 2022, and by norovirus in week 7 of 2023. Syphilis and heat illnesses alternated as the third and fourth most-common reported diseases, with case counts averaging approximately 20 per week. Norovirus rounded out the top 5, averaging between 1 and 8 cases per week.

(https://health.mil/News/Articles/2023/04/20/Defense-Health-Agency-Reaffirms-Award-of-TRICARE-West-Region-Contract-to-TriWest-Healthcare-Alliance) Defense Health Agency Reaffirms Award of TRICARE West Region Contract to TriWest Healthcare Alliance
Apr 19th 2023, 20:00

FALLS CHURCH, Virginia– The Defense Health Agency today reaffirmed the award of the TRICARE West region managed care support contract to TriWest Health Alliance.
On Dec. 22, 2022, the Defense Health Agency awarded two contracts to serve as the Managed Care Support Contractors for the fifth generation of TRICARE Managed Care Support contracts, also known as “T-5”: one to TriWest Healthcare Alliance Corporation, Phoenix, Ariz. in the West region and the other to Humana Government Business, Louisville, Ky. in the East region. T-5 seeks to improve military readiness, health care delivery, clinical quality, patient safety, and beneficiary access to healthcare and experience while containing costs for more than 9.6 million TRICARE beneficiaries.
On Jan. 17, 2023, Health Net Federal Services filed a protest against the T-5 award in the West region with the Government Accountability Office. After receiving the protest, DHA discovered information potentially impacting one area of the evaluation.  To assure the integrity of the acquisition process, DHA undertook to conduct an examination of the source selection record, and the protest was dismissed. Please note that DHA is constrained in discussing specifics about the protest allegations because the protest remains under a protective order at GAO.
If there is an additional protest at GAO, DHA will be required to suspend any performance. Generally, protests must be filed 10 days after public posting of the award or 5 days after a debrief, when one is required if requested, as here.  GAO resolves protests within 100 days of the filing of the protest.  There also remains the possibility of a separate legal challenge at the United States Court of Federal Claims instead of protest at GAO or after a GAO decision.  Assuming GAO denies or dismisses all protest allegations and there is no subsequent litigation, DHA may proceed with contract performance, including a one-year transition period from the current T-2017 contract to the T-5 contract. Start of health care delivery would then begin in August 2024.
### 

The (https://health.mil/About-MHS/OASDHA/Defense-Health-Agency) Defense Health Agency provides health services to approximately 9.6 million beneficiaries, including uniformed service members, military retirees, and their families. The DHA operates one of the nation’s largest health plans, the TRICARE Health Plan, and manages a global network of more than 700 military hospitals, clinics and dental facilities.

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(https://health.mil/News/Articles/2023/04/06/DHA-Director-Shares-Military-Health-System-Story-with-Spouses) DHA Director Shares Military Health System Story with Spouses
Apr 5th 2023, 20:00

Defense Health Agency Director U.S. Army (https://health.mil/About-MHS/Biographies/Crosland) Lt. Gen. Telita Crosland spoke at the Department of the Air Force Spouses conference, held at Joint Base Andrews, Maryland, March 23. With an audience of spouses from the U.S. Air Force and U.S. Space Force, she shared how the Military Health System serves as a global integrated health care system for military families.
Crosland informed spouses on recent updates to DHA programs and answered questions on how best to help families of airmen and guardians. She discussed DHA’s focus on mission readiness and overseeing the health care delivery system worldwide.
“The biggest thing we do for the Department of Defense is run the health care system, both inside our MTFs and with managed care support contractors. That is the most important thing we do … we support communities in the world,” she said. “Every health care system is about improving health. We want our patients to be healthy and live a good quality of life. And if they're not healthy, we want to restore their health … if we improve health, we will [have] readiness.”
Crosland discussed the importance of telehealth and the evolution and digitalization of the MHS.
“Our patients will put on wearables, will stay in their homes, and will communicate virtually,” said Crosland. “We've got to move in a more deliberate direction, leveraging technology and innovation in a way to bring greater value to not just our patients, but to the people in the system providing that care. And that's what digitalization is getting after.”
She also shared that the future of DHA will focus on a person-centered health care system within an ecosystem of overall patient wellness.
“In three years, we're going to demonstrate the way ahead, [putting] patients at the center of the system,” said Crosland. “People that we have given tools to that allow them to be well. And health is just one dimension of wellness. In that ecosystem, you have nutrition, you have finance, you have spiritual, you have community, you have connectedness, you have other things in this world that contribute to your wellness as a person. And there are tools and technology in the health space that we can put in the hands of people so that they can develop and be part of it.”

(https://health.mil/News/Articles/2023/04/04/Public-Health-Supports-the-Warfighter-Military-Community-Worldwide) Public Health Supports the Warfighter, Military Community Worldwide
Apr 3rd 2023, 20:00

It's National Public Health Awareness Week from April 5-11, and Defense Health Agency Public Health is committed to recognizing the health professionals and support staff caring for the total health of the joint force, military services, and the Department of Defense global community.
U.S. Public Health Service Rear Adm. Brandon Taylor, director of DHA Public Health, looks forward to participating in this year's activities as he reflects on his first year leading this organization. The one-year anniversary coincided with a visit to Aberdeen Proving Ground in Maryland, where Taylor led a town hall discussion about the transformation and reorganization of public health capabilities within the DOD.
"The time has gone by so quickly. In spite of the challenges we continue to face, we've proven we are better together," said Taylor.
During his first year, Taylor visited facilities and organizations transferred to DHA as a result of the National Defense Authorization Act for Fiscal Year 2019. He welcomed three new Defense Centers for Public Health to DHA: DCPH-Aberdeen, DCPH-Dayton, and DCPH-Portsmouth, expanding the DHA Public Health team to over 1,000 people. These centers continue to protect the health of their service members and now share a joint mission.
Other highlights of Taylor’s first year include touring the large, minus-30-degree Celsius walk-in freezers at DOD's serum repository; presenting DHA's biosurveillance efforts at a NATO meeting in Munich, Germany; and holding conversations with public health leaders and staff from the military services and the U.S. Public Health Service.
DHA Public Health Deputy Director Sean Friendly spoke positively of the transition at a recent meeting of DHA Public Health leaders and a military public health delegation from Japan.
"DHA Public Health’s health surveillance mission is useful to the combatant commands and to our international military partners that are in contact with an ever-present enemy,” said Friendly. “This enemy is disease. The joint force operational areas and missions drive the science behind the types of surveillance conducted by this organization."
The group discussed the value of accurate health data to protect military forces from various health diseases and threats worldwide. Health surveillance branch leaders shared how they provide timely, relevant, actionable, and comprehensive health surveillance support to the joint staff, combatant commands, and military services.
Taylor looks to the future as transformation continues. Biosurveillance remains a high-priority mission. To further this mission, Taylor and U.S. Navy Cmdr. Matthew Kasper, the DHA Global Emerging Infections Surveillance branch chief, will visit the U.S. Naval Medical Research Unit No. 6 in Lima, Peru. GEIS routinely visits its partners at the overseas service laboratories. These visits strengthen relationships between the service laboratories, DHA PH, combatant commands, and the host nation partner. 
As 2023 continues to unfold, DHA Public Health will focus on:

Developing DHA’s biosurveillance capabilities to support a better biodefense posture for the DOD
    Ensuring interoperable and agile delivery of public health products and services across the DOD
    Acquiring and retaining an exceptional public health workforce 
    Fostering current and new relationships with interagency, industry, and international military public health partners

“We’re still in the middle of an extended transition and transformation, and the dust has not yet settled,” said Taylor. “The process will take months and years to complete, and we will navigate situations as they surface. We will work together as a singular Public Health enterprise, as a sum greater than our individual parts.”

(https://health.mil/News/Articles/2023/04/01/Rhabdomyolysis-Update) Update: Exertional Rhabdomyolysis Among Active Component Members of the U.S. Armed Forces, 2018–2022
Mar 31st 2023, 20:00

Exertional rhabdomyolysis is a pathologic muscle breakdown associated with strenuous physical activity. A largely preventable condition, it persists as an occupational hazard of military training and operations, especially in high heat environments among individuals exerting themselves to endurance limits. During the 5-year surveillance period, unadjusted incidence rates of exertional rhabdomyolysis among U.S. service members declined by approximately 15%, from 43.1 cases per 100,000 person-years (p-yrs) in 2018 to 36.5 cases per 100,000 p-yrs in 2022. Consistent with prior reports, subgroup-specific rates in 2022 were highest among men, those younger than 20 years, non-Hispanic Black service members, Marine Corps or Army members, and those in combat-specific and “other” occupations. Recruit trainees had the highest rates of exertional rhabdomyolysis in 2021 and 2022, with incidence rates 10 times higher than all other service members. Prompt recognition of the symptoms of exertional rhabdomyolysis (muscular pain or swelling, limited range of motion, or the excretion of darkened urine after strenuous physical activity, especially in hot, humid weather) by health care providers is crucial to avoid the most severe consequences of this potentially life-threatening condition.

What are the new findings?

The 473 incident cases in 2022 of exertional rhabdomyolysis represent an unadjusted annual incidence rate of 36.5 cases per 100,000 p-yrs among the active component, the lowest rate observed between 2018 and 2022. Exertional rhabdomyolysis occurred most frequently from mid-spring until early autumn at installations that support basic combat/recruit training or major Army or Marine Corps combat units.

What is the impact on readiness and force health protection?

Exertional rhabdomyolysis is a potentially serious condition requiring vigilance for early diagnosis and aggressive treatment to prevent severe consequences. Service members who experience exertional rhabdomyolysis may be at risk for recurrence, which could limit their military efficacy and potentially predispose them to serious injury. The risk of exertional rhabdomyolysis can be reduced by command awareness of environmental conditions and troop fitness levels, with emphasis on graded, individual preconditioning for more strenuous training, and adhering to recommended work and rest ratios with appropriate hydration schedules, especially in hot, humid weather.
Background

Rhabdomyolysis is characterized by the breakdown of skeletal muscle cells and subsequent release of intracellular contents into the circulatory system. This damage to skeletal muscle is generally caused by high-intensity, protracted, or repetitive physical activity, usually after strenuous exercise at unaccustomed intensity or duration.1 Initiation of a new strenuous activity during high levels of environmental heat stress heightens risk of exertional rhabdomyolysis.1 Among members of the U.S. military, this condition is most commonly identified at recruit training and combat installations, where physiological adaptation and environmental acclimatization required for the first 90 days of basic training may predispose new recruits.2,3 Even carefully monitored athletes who are accustomed to intense training are at risk of exertional rhabdomyolysis,4 especially when exerting themselves to endurance limits.5 A history of heat illness and prior heat stroke have also been described as significant risk factors for recruits who sustained rhabdomyolysis,3,6 revealing the potential for comorbid conditions.

Rhabdomyolysis severity ranges from asymptomatic elevation in serum muscle enzyme levels to life-threatening disease associated with extreme enzyme elevations, electrolyte imbalances, acute kidney failure, disseminated intravascular coagulation, compartment syndrome, cardiac arrhythmia, and liver dysfunction.1,7-9 The characteristic triad of rhabdomyolysis symptoms are weakness, muscle pain, and red-to-brown urine due to high levels of myoglobin, which are accompanied by an elevated serum concentration of creatine kinase.7,8 Diagnostic criteria for exertional rhabdomyolysis include severe muscle symptoms (e.g., pain, stiffness, and/or weakness) with laboratory results indicating myonecrosis (usually defined as a serum creatine kinase level 5 or more times the upper limit of normal) following recent exercise.10

Each year, the MSMR summarizes the numbers, rates, trends, risk factors, and locations of exertional heat injury occurrences including exertional rhabdomyolysis. This report includes data from 2018 to 2022. Additional information about the definition, causes, and prevention of exertional rhabdomyolysis can be found in previous issues of the MSMR.2

Methods

The surveillance period ranged from January 2018 through December 2022 and includes all individuals who served in the active component of the Army, Navy, Air Force, or Marine Corps during that time. All data used to determine incident exertional rhabdomyolysis diagnoses were derived from routine Defense Medical Surveillance System (DMSS) records. These records document both ambulatory encounters and hospitalizations of active component members of the U.S. Armed Forces in fixed military and civilian (if reimbursed through the Military Health System [MHS]) treatment facilities worldwide. In-theater diagnoses of exertional rhabdomyolysis were identified from medical records of service members deployed to Southwest Asia or the Middle East whose health care encounters were documented in the Theater Medical Data Store.

For this analysis, a case of exertional rhabdomyolysis was defined as an individual with 1) a hospitalization or outpatient medical encounter with a diagnosis in any position of either “rhabdomyolysis” (International Classification of Diseases, 9th Revision [ICD-9]: 728.88; International Classification of Diseases, 10th Revision [ICD-10]: M62.82) or “myoglobinuria” (ICD-9: 791.3; ICD-10: R82.1) with a diagnosis in any position of 1 of the following: “volume depletion (dehydration)” (ICD-9: 276.5*; ICD-10: E86.0, E86.1, E86.9), “effects of heat and light” (ICD-9: 992.0–992.9; ICD-10: T67.0*–T67.9*), “effects of thirst (deprivation of water)” (ICD-9: 994.3; ICD-10: T73.1*), “exhaustion due to exposure” (ICD-9: 994.4; ICD-10: T73.2*), or “exhaustion due to excessive exertion (overexertion)” (ICD-9: 994.5; ICD-10: T73.3*).2 Each individual could be considered an incident case of exertional rhabdomyolysis only once per calendar year. 

To exclude secondary cases of rhabdomyolysis due to either traumatic injury, intoxication, or adverse drug reaction, medical encounters with diagnoses in any position of “injury, poisoning, toxic effects” (ICD-9: 800.*–999.*; ICD-10: S00.*–T88.*, except the codes specific for “sprains and strains of joints and adjacent muscles” and “effects of heat, thirst, and exhaustion”) were not considered indicative of exertional rhabdomyolysis.11 

For health surveillance purposes, recruit trainees were identified as active component members assigned to service-specific training locations during coincident service-specific basic training periods. Because of the lack of Army personnel data in November and December 2022, soldiers who started basic training during this period were not counted as recruits. Recruit trainees were considered a separate category of enlisted service members in summaries of exertional rhabdomyolysis by overall military grade.

In-theater diagnoses of exertional rhabdomyolysis were analyzed separately using the same case-defining criteria and incidence rules that identified incident cases at fixed treatment facilities. Records of medical evacuations from the U.S. Central Command (CENTCOM) area of responsibility (AOR) (i.e., Southwest Asia/Middle East) to a medical treatment facility outside the CENTCOM AOR were analyzed separately. Evacuations were considered case-defining if affected service members met the aforementioned criteria in a permanent military medical facility in the U.S. or Europe, from 5 days preceding until 10 days following their evacuation dates.

Medical data from sites using the new electronic health record for the Military Health System, MHS GENESIS, between July 2017 and October 2019 are not available in the DMSS—these sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center. Medical encounter data for individuals seeking care at any of these facilities from July 2017 through October 2019 were not included in the current analysis.

Results

In 2022, there were 473 cases of rhabdomyolysis likely associated with physical exertion and/or heat stress (i.e., exertional rhabdomyolysis), with 35.3% (n=167) resulting in hospitalization (Table 1). 
(https://health.mil/Reference-Center/Reports/2023/04/01/Article-3-Table-1-MSMR-April-2023) 
Consistent with prior annual reports, crude incidence rates remained highest among men, those younger than 20 years of age, non-Hispanic Black service members, Marine Corps or Army members, and those in combat-specific and “other” occupations. Recruit trainees continued to present the highest rates of exertional rhabdomyolysis in 2022, at a rate 10 times higher than officers and enlisted members. 

During the surveillance period, from 2018 through 2022, crude rates of exertional rhabdomyolysis declined by approximately 15% (Figure 1). 

This reduction was observed among all services except the Army (Figure 2). 

Since 2020, less than 40% of cases resulted in hospitalization, a notable decline from the proportions identified from inpatient data records in 2018 (47.3%) and 2019 (42.3%) (Figure 1). During 2018-2022, approximately three-quarters (75.9%) of cases occurred in the warmer months (May through October) (Figure 3).

Rhabdomyolysis by location

During the 5-year surveillance period, 12 installations diagnosed at least 50 cases each; combined, those 12 installations diagnosed more than half (56.7%) of all cases (Table 2). 
(https://health.mil/Reference-Center/Reports/2023/04/01/Article-3-Table-2-MSMR-April-2023) 
Four of these 12 installations support recruit/basic combat training centers: Marine Corps Recruit Depot (MCRD) Parris Island/Beaufort, SC; Fort Benning, GA; Joint Base San Antonio-Lackland, TX; and Fort Leonard Wood, MO; while 7 installations support large combat troop populations: Fort Bragg, NC; MCB Camp Lejeune/Cherry Point, NC; Marine Corps Base (MCB) Camp Pendleton, CA; Fort Hood, TX; Fort Shafter, HI; Fort Campbell, KY; Fort Carson, CO. From 2018 to 2022, MCRD Parris Island/Beaufort and Fort Bragg together accounted for about one-fifth (20.7%) of all cases (Table 2).

Rhabdomyolysis in Iraq and Afghanistan

Six cases of exertional rhabdomyolysis were diagnosed and treated in Iraq/Afghanistan during the 5-year surveillance period; half were diagnosed in 2018, with with 1 case each year from 2019 to 2021 and none in 2022 (data not shown). The majority of those deployed service members affected by exertional rhabdomyolysis were non-Hispanic Black (n=3) or non-Hispanic White (n=3), male (n=4), in the Army (n=5), enlisted (n=5), and in health care occupations (n=3). One active component service member was medically evacuated for exertional rhabdomyolysis during the surveillance period, in November 2020 (data not shown).

Discussion

The results of this report document a crude reduction of approximately 15% in exertional rhabdomyolysis rates from 2018 to 2022. Exertional rhabdomyolysis continues to occur most frequently from mid-spring through early autumn at installations that support basic combat/recruit training or major Army or Marine Corps combat units. Recruits can be exposed to environmental situations that require acclimatization to high heat and humidity during the warmer months, while Soldiers and Marines in combat units often perform rigorous unit physical training, field training exercises, and personal fitness training regardless of weather conditions.

The annual incidence rates of exertional rhabdomyolysis observed among non-Hispanic Black service members were higher than rates observed among members of other racial/ethnic groups. This observation has been attributed, at least in part, to increased risk of exertional rhabdomyolysis among individuals with sickle cell trait (SCT),12-15 for which the U.S. carrier frequency is approximately 1 in 13 Black/African Americans.16 A significant association between SCT and a risk of exertional rhabdomyolysis is supported by studies among U.S. service members.17,18 The rhabdomyolysis-related deaths of 2 SCT-positive service members (a Navy recruit and an Air Force member) in 2019 after physical training stress this potential risk.19,20 Although previous studies have established that SCT is associated with a 54% increase in risk of exertional rhabdomyolysis,17,18 its association with disease progression and severity is unclear and warrants further study. 

The findings of this report should be interpreted with consideration of its limitations. A diagnosis of “rhabdomyolysis” alone does not indicate cause. Ascertaining the probable causes of exertional rhabdomyolysis cases was attempted through a combination of ICD-9/ICD-10 diagnostic codes related to rhabdomyolysis with additional codes indicating effects of exertion, heat, or dehydration. Other ICD-9/ICD-10 codes were used to exclude cases of rhabdomyolysis that may have been secondary from trauma, intoxication, or adverse drug reactions. 

Recruit trainees were identified using an algorithm based on age, rank, location, and time in service, which was only an approximation and likely resulted in some misclassification of recruit training status. The imputation used to address the gap in Army personnel data from November and December 2022 is another potential source of misclassification, which may have resulted in an underestimation of Army recruits and periods of recruit training during the last quarter of 2022. Due to this data discrepancy, recruit rates should be interpreted with caution.

Management after treatment for exertional rhabdomyolysis, including the decision to return to physical activity and duty, is a persistent challenge for both athletes and military members.21 Service members who experience a clinically-confirmed exertional rhabdomyolysis event should be further evaluated and risk-stratified for recurrence before return to activity or duty.10,21,22 The Defense Health Agency publishes practice recommendations that provide a synopsis of care for initial management of exertional rhabdomyolysis, high-risk or recurrent exertional rhabdomyolysis, and inpatient care.23,24 The most severe consequences of exertional rhabdomyolysis are preventable with effective mitigation measures and hightened awareness of probability when environmental conditions favor muscular injury. Commanders and supervisors at all levels should ensure that guidelines for heat illness prevention are consistently implemented, maintain vigilance for early signs of exertional heat injury, and intervene aggressively when exertional rhabdomyolsis is suspected.10

References

Rawson ES, Clarkson PM, Tarnopolsky MA. Perspectives on exertional rhabdomyolysis. Sports Med. 2017;47(suppl 1):33-49. doi:10.1007/s40279-017-0689-z
    Armed Forces Health Surveillance Branch. Update: exertional rhabdomyolysis among active component members, U.S. Armed Forces, 2014-2018. MSMR. 2019;26(4):21-26.
    Hill OT, Scofield DE, Usedom J, et al. Risk factors for rhabdomyolysis in the U.S. Army. Mil Med. 2017;182(7):e1836-e1841. doi:10.7205/MILMED-D-16-00076
    McKewon S. Two Nebraska football players hospitalized, treated after offseason workout. Omaha World-Herald. January 20, 2019. Accessed March 1, 2022. (https://www.omaha.com/huskers/football/two-nebraska-football-players-hospitalized-treated-after-offseason-workout/article_d5929674-53a7-5d90-803e-6b4e9205ee60.html) https://www.omaha.com/huskers/football/two-nebraska-football-players-hospitalized-treated-after-offseason-workout/article_d5929674-53a7-5d90-803e-6b4e9205ee60.html


(https://www.omaha.com/huskers/football/two-nebraska-football-players-hospitalized-treated-after-offseason-workout/article_d5929674-53a7-5d90-803e-6b4e9205ee60.html) Raleigh MF, Barrett JP, Jones BD, Beutler AI, Deuster PA, O'Connor FG. A cluster of exertional rhabdomyolysis cases in a ROTC program engaged in an extreme exercise program. Mil Med. 2018;183(suppl 1):516-521. doi:10.1093/milmed/usx159
    Hill OT, Wahi MM, Carter R, Kay AB, McKinnon CJ, Wallace RF. Rhabdomyolysis in the U.S. active duty Army, 2004-2006. Med Sci Sports Exerc. 2012;44(3):442-449. doi:10.1249/MSS.0b013e3182312745
    Zutt R, van der Kooi AJ, Linthorst GE, Wanders RJ, de Visser M. Rhabdomyolysis: review of the literature. Neuromuscul Disord. 2014;24(8):651-659. doi:10.1016/j.nmd.2014.05.005
    Chavez L, Leon M, Einav S, Varon J. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care. 2016;20:135. doi:10.1186/s13054-016-1314-5
    Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009;361(1):62-72. doi:10.1056./NEJMra0801327
    O’Connor FG, Deuster P, Leggit J, et al. Clinical Practice Guideline for the Management of Exertional Rhabdomyolysis in Warfighters 2020. Bethesda, Maryland: Uniformed Services University. 2020.
    Armed Forces Health Surveillance Branch. Surveillance Case Definition: Exertional Rhabdomyolysis. Accessed March 1, 2023. (https://www.health.mil/Reference-Center/Publications/2017/03/01/Rhabdomyolysis-Exertional) https://www.health.mil/Reference-Center/Publications/2017/03/01/Rhabdomyolysis-Exertional

    Gardner JW, Kark JA. Fatal rhabdomyolysis presenting as mild heat illness in military training. Mil Med. 1994;159(2):160-163.
    Makaryus JN, Catanzaro JN, Katona KC. Exertional rhabdomyolysis and renal failure in patients with sickle cell trait: is it time to change our approach? Hematology. 2007;12(4):349-352. doi:10.1080/10245330701255254
    Ferster K, Eichner ER. Exertional sickling deaths in Army recruits with sickle cell trait. Mil Med. 2012;177(1):56-59. doi:10.7205/milmed-d-11-00106
    Naik RP, Smith-Whitley K, Hassell KL, et al. Clinical outcomes associated with sickle cell trait: a systematic review. Ann Intern Med. 2018;169(9):619-627. doi:10.7326/M18-1161
    Centers for Disease Control and Prevention. Data and Statistics on Sickle Cell Diseae. Accessed April 18, 2023. (https://www.cdc.gov/ncbddd/sicklecell/data.html) https://www.cdc.gov/ncbddd/sicklecell/data.html

    Nelson DA, Deuster PA, Carter R, Hill OT, Wolcott VL, Kurina LM. Sickle cell trait, rhabdomyolysis, and mortality among U.S. Army soldiers. N Engl J Med. 2016;375(5):435-442. doi:10.1056/NEJMoa1516257
    Webber BJ, Nye NS, Covey CJ, et al. Exertional rhabdomyolysis and sickle cell trait status in the U.S. Air Force, January 2009–December 2018. MSMR. 2021;28(1):15-19.
    Air Combat Command. U.S. Air Force Ground Accident Investigation Board Report. 20th Component Maintenance Squadron 20th Fighter Wing, Shaw Air Force Base, South Carolina. Fitness Assessment Fatality; 24 May 2019.
    Mabeus C. Autopsy reports reveal why two recruits died at boot camp. Navy Times. November 8, 2019. Accessed March 1, 2022. (https://www.navytimes.com/news/your-navy/2019/11/08/autopsy-reports-reveal-why-two-recruits-died-at-boot-camp) https://www.navytimes.com/news/your-navy/2019/11/08/autopsy-reports-reveal-why-two-recruits-died-at-boot-camp

    O’Connor FG, Brennan FH, Campbell W, Heled Y, Deuster P. Return to physical activity after exertional rhabdomyolysis. Curr Sports Med Rep. 2008;7(6):328-331. doi:10.1249/JSR.0b013e31818f0317
    Atias D, Druyan A, Heled Y. Recurrent exertional rhabdomyolysis: coincidence, syndrome, or acquired myopathy? Curr Sports Med Rep. 2013;12(6):365-369. doi:10.1249/JSR.0000000000000007
    DeHan PJ, Buchanan BK, DeGroot DW, O’Connor, FG. Initial Management of Exertional Rhabdomyolysis. Defense Health Agency. September 2022. Accessed April 25, 2023. (https://www.hprc-online.org/sites/default/files/document/DHA_PR_Initial_Management_of_Exertional_Rhabdomyolysis_508.pdf) https://www.hprc-online.org/sites/default/files/document/DHA_PR_Initial_Management_of_Exertional_Rhabdomyolysis_508.pdf

    DeHan PJ, Bartlett SI, Buchanan BK, DeGroot DW, O’Connor, FG. Inpatient Management of Exertional Rhabdomyolysis. Defense Health Agency. August 2022. Accessed April 25, 2023. (https://www.hprc-online.org/sites/default/files/document/DHA_PR_Inpatient_Management_of_Exertional_Rhabdomyolysis_508.pdf) https://www.hprc-online.org/sites/default/files/document/DHA_PR_Inpatient_Management_of_Exertional_Rhabdomyolysis_508.pdf


(https://health.mil/News/Articles/2023/04/01/Hyponatremia-Update) Update: Exertional Hyponatremia Among Active Component Members of the U.S. Armed Forces, 2007–2022
Mar 31st 2023, 20:00

Exertional hyponatremia occurs either during or following periods of heavy exertion, when losses of water and electrolytes due to the body’s normal cooling mechanisms are replaced only with water. Hyponatremia can lead to death or serious morbidity if left untreated. Between 2007 and 2022, there were 1,690 diagnoses of exertional hyponatremia among active component service members, for an overall incidence rate of 7.9 cases per 100,000 person-years (p-yrs). Those younger than 20 years or older than 40, non-Hispanic White service members, Marine Corps members, and recruit trainees had higher overall rates of exertional hyponatremia diagnoses. Between 2007 and 2022, annual rates of incident exertional hyponatremia diagnoses peaked (12.7 per 100,000 p-yrs) in 2010 and then decreased to a low of 5.3 cases per 100,000 p-yrs in 2013. During the last 9 years of the surveillance period, rates fell between a range of 6.1 and 8.6 cases per 100,000 p-yrs. Service members and their supervisors must know the dangers of excessive water consumption and prescribed limits for water intake during prolonged physical activity, such as field training exercises, personal fitness training, as well as recreational activities, particularly in hot, humid weather.
What are the new findings?  
The vast majority of exertional hyponatremia cases were treated in outpatient settings, suggesting that most cases were identified during the early and less severe stages.
What is the impact on readiness and force health protection?
Exertional hyponatremia continues to pose a health risk to U.S. military members and can be fatal if not promptly recognized and appropriately treated. Military members, leaders, and trainers must be vigilant for early signs of hyponatremia, intervene immediately and appropriately, and observe the published guidelines for proper hydration during physical exertion, especially during hot weather.
Background
Exertional hyponatremia, or exercise-associated hyponatremia, refers to a low plasma sodium concentration (below 135 milliequivalents per liter) that develops within 24 hours of prolonged physical activity.1 Exertional hyponatremia usually results from consumption of large volumes of water in a short time. Acute hyponatremia creates an osmotic gradient that causes water to flow into the cells of various organs, including the lungs and brain, producing serious and sometimes fatal clinical effects.1,2 Exertional hyponatremia can result from loss of sodium or potassium, relative body water excess, or a combination of both,3 but overconsumption of fluids and a resultant excess of total body water are the primary factors in the development of exertional hyponatremia.1,3,4 
Exertional hyponatremia has been described in relation to a variety of activities including endurance competitions, hiking, police training, American football, fraternity hazing, and military exercises.1 Hyponatremia incidence from these events varies widely, and is dependent upon activity duration, stress from heat or cold, water availability, and other risk factors. Water consumption in volumes greater than its loss through sweat, respiration, and renal excretion remains the single most important risk factor.1 The amount of excess water consumption required to induce exertional hyponatremia is substantial. In an outbreak among Marine recruits in 1995, between 10 and 22 quarts of water were consumed by each person over a few hours.5 In endurance sports competitions, lack of acclimatization to local environmental conditions is another risk factor for exertional hyponatremia.6 Other important risk factors include an exercise duration greater than 4 hours, inadequate event training, and either a high or low body mass index.1  
Exertional hyponatremia continues to pose a health risk to U.S. military members that can significantly impair performance and reduce combat effectiveness. This report summarizes the frequencies, rates, trends, geographic locations, and both demographic and military characteristics of incident cases of exertional hyponatremia among active component service members, from 2007 to 2022.
Methods
The surveillance population for this report consists of all active component service members of the U.S. Army, Navy, Air Force, or Marine Corps who served at any time during the surveillance period, from January 1, 2007 to December 31, 2022. All data used to determine incident exertional hyponatremia diagnoses were derived from records routinely collected and maintained in the Defense Medical Surveillance System (DMSS). These records document both ambulatory encounters and hospitalizations of active component service members of the U.S. Armed Forces in fixed military and civilian (if reimbursed through the Military Health System [MHS]) treatment facilities worldwide. In-theater diagnoses of hyponatremia were identified from medical records of service members deployed to Southwest Asia or the Middle East and whose health care encounters were documented in the Theater Medical Data Store (TMDS).  
For this report, a case of exertional hyponatremia was defined as 1) a hospitalization or ambulatory visit with a primary (first-listed) diagnosis of “hypoosmolality and/or hyponatremia” (International Classification of Diseases, 9th and 10th Revisions, ICD-9: 276.1; ICD-10: E87.1) and no other illness or injury-specific diagnoses (ICD-9: 001–999; ICD-10: A–U) in any diagnostic position or 2) both a diagnosis of “hypoosmolality and/or hyponatremia” (ICD-9: 276.1; ICD-10: E87.1) and at least 1 of the following within the first 3 diagnostic positions (dx1–dx3): “fluid overload” (ICD-9: 276.9; ICD-10: E87.70, E87.79), “alteration of consciousness” (ICD-9: 780.0*; ICD-10: R40.*), “convulsions” (ICD-9: 780.39; ICD-10: R56.9), “altered mental status” (ICD-9: 780.97; ICD-10: R41.82), “effects of heat/light” (ICD-9: 992.0–992.9; ICD-10: T67.0*–T67.9*), or “rhabdomyolysis” (ICD-9: 728.88; ICD-10: M62.82).7
Medical encounters were not considered case-defining events if the associated records included the following diagnoses in any diagnostic position: alcohol/illicit drug abuse; psychosis, depression, or other major mental disorders; endocrine disorders; kidney diseases; intestinal infectious diseases; cancers; major traumatic injuries; or complications of medical care. An individual could be considered a case of exertional hyponatremia only once per calendar year. Incidence rates were calculated as cases of hyponatremia per 100,000 person-years (p-yrs) of active component service. Percent change in incidence was calculated using unrounded rates. At the time of this analysis, Army personnel data were not available for November and December 2022. To calculate person-time for Army members during this period, the October personnel data were used.
For health surveillance purposes, recruit trainees were identified as active component members assigned to service-specific training locations during coincident service-specific basic training periods. Because of the lack of personnel data in November and December 2022, Army members who started basic training during this period were not counted as recruits. Recruit trainees were considered a separate category of enlisted service members in summaries of heat illnesses by overall military grade. 
In-theater diagnoses of exertional hyponatremia were analyzed separately using the same case-defining criteria and incidence rules used to identify incident cases at fixed treatment facilities. Records of medical evacuations from the U.S. Central Command (CENTCOM) area of responsibility (AOR) (i.e., Southwest Asia/Middle East) to a medical treatment facility outside the CENTCOM AOR were analyzed separately. Evacuations were considered case-defining if the affected service members met the aforementioned criteria in a permanent military medical facility in the U.S. or Europe, from 5 days preceding until 10 days following their evacuation dates.
Medical data from sites using the new electronic health record for the Military Health System, MHS GENESIS, between July 2017 and October 2019 are not available in the DMSS and thus not included in this report—these sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center.
Results
In 2022, there were 104 diagnoses of exertional hyponatremia among active component service members, with a crude incidence rate of 8.0 per 100,000 p-yrs (Table 1). 
(https://health.mil/Reference-Center/Reports/2023/04/01/Article-4-Table-1-MSMR-April-2023) 
The 2022 incidence rate patterns were broadly similar by demographic and military characteristics to those in prior years. Demographic categories are presented as cumulative rates to promote rate stability, since stratification of the annual rates yielded frequencies of less than 20 in more than 40% of the table sub-categories. 
Between 2007 and 2022, men represented the vast majority (84.0%) of exertional hyponatremia cases but had an incidence rate comparable to women (Table 1). Subgroup-specific incidence rates were highest among those in the youngest (under 20 years) and oldest (40 years or older) age groups, non-Hispanic White service members, Marine Corps members, and recruit trainees. The rate of hyponatremia among Marine Corps members was markedly higher than the rates of those in other services. Although recruit trainees accounted for approximately one-sixth (16.5%) of all exertional hyponatremia cases, their crude incidence rate was 10.4 and 6.5 times the rates among other enlisted members and officers, respectively.
During the 16-year period, 86.8% (n=1,467) of all cases were diagnosed and treated without hospitalization (Figure 1).

Between 2007 and 2022, the crude annual rates of incident exertional hyponatremia diagnoses peaked in 2010 (12.7 per 100,000 p-yrs) and then decreased to a low of 5.3 cases per 100,000 p-yrs in 2013 (Figure 1). During the last 9 years of the surveillance period, rates fluctuated between 6.1 and 8.6 cases per 100,000 p-yrs. With the exception of 2021, annual incidence rates of exertional hyponatremia diagnoses were markedly higher in the Marine Corps than in other services (Figure 2). 

Exertional hyponatremia by location
During the 16-year surveillance period, exertional hyponatremia cases were diagnosed at more than 150 U.S. military installations and geographic locations worldwide, but 16 U.S. installations contributed 20 or more cases each and accounted for 50.9% of total cases (Table 2). 
(https://health.mil/Reference-Center/Reports/2023/04/01/Article-4-Table-2-MSMR-April-2023) 
Marine Corps Recruit Depot (MCRD) Parris Island/Beaufort, SC reported 209 cases of exertional hyponatremia, the highest in the DOD.
Exertional hyponatremia in the CENTCOM AOR 
Between 2007 and 2022, a total of 23 cases of exertional hyponatremia were diagnosed and treated in the CENTCOM AOR (data not shown). Two new cases were diagnosed in 2022. Deployed service members affected by exertional hyponatremia were most frequently male (n=19; 82.6%), non-Hispanic White (n=19; 82.6%), 20-24 years old (n=10; 43.5%), in the Army (n=14; 60.9%), enlisted (n=19; 82.6%), and in combat-specific (n=7; 30.4%) or communications/intelligence (n=6; 26.1%) occupations (data not shown). Seven service members were medically evacuated from the CENTCOM AOR for exertional hyponatremia, in 2007 or 2018 (data not shown).
Discussion
For the last decade, incidence rates of exertional hyponatremia have remained relatively stable among active component service members. Subgroup-specific patterns (e.g., age, racial/ethnic group, service, and military status) of overall incidence rates were generally similar to those reported in previous MSMR updates.8  In MSMR analyses before April 2018, in-theater cases included diagnoses of hypoosmolality and/or hyponatremia in any diagnostic position, but in 2018 case-defining criteria for inpatient and outpatient encounters were applied to in-theater encounters. As a result, the results of the in-theater analysis are not comparable to those presented in earlier MSMR updates. 
Recruits remain at high risk for exertional hyponatremia. In this report, rates were relatively high among the youngest, hence most junior service members, with highest case numbers diagnosed at medical facilities that support large recruit training centers (e.g., MCRD Parris Island/Beaufort, SC; Fort Benning, GA; Joint Base San Antonio–Lackland Air Force Base, TX) and large Army and Marine Corps combat units (e.g., Fort Bragg, NC; Marine Corps Base Camp Lejeune/Cherry Point, NC). 
Several important limitations should be considered when interpreting these results. First, there is no diagnostic code specific for exertional hyponatremia. This lack of specificity may result in the inclusion of some non-exertional cases of hyponatremia, thus overestimating the true rate. Consequently, these results should be considered estimates of the actual incidence of symptomatic exertional hyponatremia from excessive water consumption among U.S. military members. In addition, the accuracy of estimated numbers, rates, trends, and correlates of risk depends on the completeness and accuracy of diagnoses documented in standardized records of relevant medical encounters. As a result, an increase in recorded diagnoses indicative of exertional hyponatremia may reflect, at least in part, increasing awareness, concern, and aggressive management for incipient cases by military supervisors and primary health care providers. 
Finally, recruit trainees were identified using an algorithm based on age, rank, location, and time in service, which was only an approximation and likely resulted in some misclassification of recruit training status. The imputation used to address the gap in Army personnel data from November and December 2022 is another potential source of misclassification that may have resulted in underestimation of Army recruits and periods of recruit training during the last 2 months of 2022. Due to this data discrepancy, recruit rates should be interpreted with caution.
Military training may have to be conducted in difficult conditions, and during hot and humid weather commanders, supervisors, instructors, and medical support staff must be aware of, monitor, and enforce guidelines for work-rest cycles and water consumption.2 The continued necessity of training and operations under challenging environmental conditions creates a high-risk environment for exertional hyponatremia and other heat illnesses. While the rates of exertional hyponatremia have remained relatively low over the past 15 years, the Defense Health Agency continues to publish practice recommendations intended to guide the prevention, assessment, and management of exercise associated hyponatremia.10 Thoughtful risk assessment and planning are necessary for keeping this preventable illness at its current low levels.
References

Hew-Butler T, Rosner MH, Fowkes-Godek S, et al. Statement of the Third International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Clin J Sport Med. 2015;25(4):303-320. doi:10.1097/JSM.0000000000000221

    Buchanan BK, Sylvester JE, DeGroot DW. Exercise associated hyponatremia practice recommendation. March 17, 2021. Accessed March 12, 2023. (https://www.hprc-online.org/sites/default/files/document/HPRC_WHEC_Exercise%20Associated%20Hyponatremia%20Practice%20Recommendation_508_0.pdf) https://www.hprc-online.org/sites/default/files/document/HPRC_WHEC_Exercise Associated Hyponatremia Practice Recommendation_508_0.pdf


    Nguyen MK, Kurtz I. Determinants of plasma water sodium concentration as reflected in the Edelman equation: role of osmotic and Gibbs-Donnan equilibrium. Am J Physiol Renal Physiol. 2004;286(5):F828-F837. doi:10.1152/ajprenal.00393.2003

    Noakes TD, Sharwood K, Speedy D, et al. Three independent biological mechanisms cause exercise-associated hyponatremia: evidence from 2,135 weighed competitive athletic performances. Proc Natl Acad Sci USA. 2005;102(51):18550-18555. doi:10.1073/pnas.0509096102

    Bennett BL, Hew-Butler T, Rosner MH, Myers T, Lipman GS. Wilderness Medical Society clinical practice guidelines for the management of exercise-associated hyponatremia: 2019 update. Wilderness Environ Med. 2020;31(1):50-62. doi:10.1016/j.wem.2019.11.003

    Gardner JW. Death by water intoxication. Mil Med. 2002;167(5):432-434. doi:10.1093/milmed/167.5.432

    Martinez-Sanz JM, Nunez AF, Sospedra I, et al. Nutrition-related adverse outcomes in endurance sports competitions: a review of incidence and practical recommendations. Int J Environ Res Pub Health. 2020;17(11):4082. doi:10.3390/ijerph17114082

    Armed Forces Health Surveillance Branch. Surveillance Case Definition. Hyponatremia. March 2017. Accessed March 20, 2023. (https://health.mil/Reference-Center/Publications/2017/03/01/Hyponatremia-Exertional) //Reference-Center/Publications/2017/03/01/Hyponatremia-Exertional


    Armed Forces Health Surveillance Branch. Update: exertional hyponatremia, active component, U.S. Armed Forces, 2006–2022. MSMR. 2022;29(4):21-26.

    Buchanan BK, Sylvester, JE, DeGroot DW. Exercise Associated Hyponatremia. Defense Health Agency. January 2022. Accessed April 25, 2023. (https://www.hprc-online.org/sites/default/files/document/DHA_PR_Exercise_Associated_Hyponatremia_25Aug22_508.pdf) https://www.hprc-online.org/sites/default/files/document/DHA_PR_Exercise_Associated_Hyponatremia_25Aug22_508.pdf 


(https://health.mil/News/Articles/2023/04/01/Heat-Illnesses-Introduction) The Military Relevance of Heat Illnesses and Their Sequelae
Mar 31st 2023, 20:00

This issue of the MSMR provides an annual update on adverse health consequences most often associated with training or operations in high heat environments. Military training and operation environments create a constellation of circumstances that make service members highly susceptible to heat illnesses and their associated morbidities of exertional hyponatremia and exertional rhabdomyolysis. Leaders and medical staff must be attuned to the inherent health risks for operations in a high heat environment, especially for service members who are deconditioned or pushed to the limits of their physical endurance.
The mantra “train as you fight” requires service members to be frequently exposed to harsh environmental conditions. During initial recruit training, large amounts of time are spent outdoors, often in high heat; training installations are generally located in the southern U.S. for perennial use. The environmental stresses of heat and humidity at these installations that are experienced by individuals encumbered with heavy gear, unconditioned for the duration and intensity of the physical activity required during training, combine to create the perfect conditions for heat illness.
The first topic of this MSMR issue, heat illnesses, focuses on heat exhaustion and heat stroke. These conditions present 2 different occasions when the body can no longer rid itself of heat, either generated through activity or absorbed from the environment. Internal body temperature begins to rise during the earlier stage, heat exhaustion, when affected individuals are generally still aware of their surroundings and can assist in their own care. Heat stroke represents a much more dangerous condition in which organs begin to fail from heat overload. Heat stroke is distinguished by alteration of consciousness, typically stupor, delirium, lethargy, or unconsciousness. Mortality is a serious risk with heat stroke, and immediate action to cool the body is required.
This issue’s second and third topics, exertional rhabdomyolysis and exertional hyponatremia, are both commonly associated with heat illness, but represent organ damage (rhabdomyolysis) or unintended side effects from over-aggressive rehydration (hyponatremia). Both of these conditions can result in rapid deterioration or death if not promptly recognized and treated. While both rhabdomyolysis and hyponatremia have many non-heat-related causes, this issue deals exclusively with cases associated with high levels of exertion.
These consequences can generally be mitigated, if not fully prevented, by careful environmental risk assessment and implementation of appropriate heat countermeasures. Leaders, as part of their risk assessments, must balance mitigation efforts against the requirements of their operations or trainings. The most effective countermeasures against heat illness include restricting activity to early morning or evening when environmental heat is lower; adherence to work and rest cycles based upon current heat conditions; removal or modification of gear to facilitate heat loss; maintenance of proper hydration levels; maximized physical fitness; and gradual acclimatization to a local heat environment.

(https://health.mil/News/Articles/2023/04/01/Heat-Illness-Update) Update: Heat Exhaustion and Heat Stroke Among Active Component Members of the U.S. Armed Forces, 2018–2022
Mar 31st 2023, 20:00

The most serious types of heat illness, heat exhaustion and heat stroke, are occupational hazards of the military’s training and operational environments. These conditions can be mitigated with appropriate situational awareness and effective countermeasures. In 2022, the crude incidence rates of heat stroke and heat exhaustion among active component service members were 32.1 and 147.7 per 100,000 person-years, respectively. The rates of incident heat stroke and heat exhaustion generally declined during the 2018 to 2022 surveillance period. In 2022, those at highest risk were men, those younger than age 20, Marine Corps and Army members, recruit trainees, and those in combat-specific occupations. Leaders, training cadres, and supporting medical personnel must inform their supervised and supported service members of heat illness risks, preventive measures, early signs and symptoms, and first-responder actions.
What are the new findings?
The crude annual incidence rates of heat stroke and heat exhaustion decreased 30.0% and 15.1%, respectively, from 2018 to 2022. The annual number of heat illnesses diagnosed in the CENTCOM AOR dropped from a high of 73 in 2019 to 48 in 2022, likely due to the reduction in forces deployed there. Only about half of heat stroke and heat exhaustion cases were identified in mandatory reports submitted to the Disease Reporting System internet.
What is the impact on readiness and force health protection?
Heat illness can be fatal, even with prompt recognition and treatment. Situational awareness and implementation and enforcement of appropriate countermeasures by commanders at all levels are the most effective means of reducing incidence of these preventable illnesses. Complete, timely submission of mandatory reports of heat illness events ensures that local public health and command leaders have ready access to surveillance data, to identify trends and guide preventive measures.
Background
Heat-related illness remains a persistent threat to the health and operational effectiveness of military members and their units, and accounts for considerable annual morbidity. Strenuous physical activity for extended durations during operational and training exercises exposes service members to considerable heat stress due to the absorption of high environmental heat along with elevated rates of metabolic heat production.1,2 Although numerous effective countermeasures are available, operational necessity may preclude their full employment. Deconditioned and unacclimated service members are at particularly high risk, as exemplified by the rates of heat injuries during U.S. military recruit training.1,3-5 
Heat illness refers to a group of disorders that result from core body temperature surpassing the compensatory limits of thermoregulation6 due to environmental heat stress, usually accompanied by heavy exertion. Heat illness constitutes a set of conditions along a continuum, from less severe (heat cramps, rash, edema, and syncope) to potentially life-threatening (heat stroke). The DOD definition of reportable heat illness includes only heat exhaustion and heat stroke, the 2 conditions covered in this report. Heat exhaustion and heat stroke are reportable medical events (RMEs) in the U.S. Military Health System (MHS), and all cases of heat illness that require medical intervention or result in change of duty status are reportable.7
To be confirmed, a case of heat exhaustion must fulfill 3 conditions, during or immediately following exertion or heat exposure: 1) a core body temperature greater than 100.5º F / 38º C and less than 104º F / 40º C, 2) short-term physical collapse or debilitation during or shortly after physical exertion, and 3) no significant central nervous system dysfunction.5 Acute dehydration often accompanies heat exhaustion but is not required for diagnosis.8 If any central nervous system dysfunction develops (e.g., dizziness or headache), it should be mild and rapidly resolve with rest and cooling measures.5,8 

Heat stroke is a debilitating and potentially life-threatening condition characterized by severe hyperthermia. A probable case of heat stroke requires, concomitant to the setting of exertion or heat exposure, 1) evidence of elevated core body temperature and 2) central nervous system dysfunction (change in mental status, delirium, stupor, loss of consciousness, or coma). A confirmed case of heat stroke requires verification and documentation of a core body temperature of 104º F / 40º C or greater with central nervous system dysfunction.8,9 The onset of heat stroke should prompt aggressive clinical treatment featuring rapid cooling and supportive therapy such as fluid resuscitation to stabilize organ function.8-10 Multiorgan system failure is the ultimate cause of mortality from heat stroke.9
Heat illnesses represent a threat to the health of individual service members during military training and operations, but are frequently preventable. Mitigation methods include heat acclimatization, sufficient hydration, mandated work-rest cycles, uniform modifications to improve evaporative heat loss, limiting weight loads during training, and scheduling high intensity exercise during cooler times of day.3,11-14 
Since 2001, the MSMR has published regular updates on the incidence of heat illness among U.S. active duty service members. This report presents the case counts and incidence rates of heat illnesses between 2018 and 2022 as well as the locations of heat illness case occurrences during this period. Heat stroke and heat exhaustion are summarized separately.
Methods
The surveillance population for this analysis includes all individuals who served in the active component of the Army, Navy, Air Force, or Marine Corps at any time during the surveillance period of January 1, 2018 through December 31, 2022. All data used to determine incident heat illness diagnoses were derived from records routinely maintained in the Defense Medical Surveillance System (DMSS), which documents both ambulatory care encounters and hospitalizations of active component service members of the U.S. Armed Forces in fixed military and civilian (if reimbursed through MHS) treatment facilities worldwide. In-theater diagnoses of heat illness were identified from medical records of deployed service members whose health care encounters were documented in the Theater Medical Data Store. Because they are an occupational hazard of rigorous outdoor training intrinsic to the military, and often preventable, heat illnesses are RMEs recorded within service-specific electronic reporting systems that are routinely transmitted and incorporated into the DMSS. 
In this update, the same definition for heat illness was used as in MSMR reports since 2018. A case of heat illness was defined as an individual with 1) a hospitalization or outpatient medical encounter record with a primary (first-listed) or secondary (second-listed) diagnosis of heat stroke (International Classification of Diseases, 9th Revision [ICD-9]: 992.0; International Classification of Diseases, 10th Revision [ICD-10]: T67.0*) or heat exhaustion (ICD-9: 92.3–992.5; ICD-10: T67.3*–T67.5*) or 2) an RME record of heat exhaustion or heat stroke.15 Because of a July 2017 update to the Disease Reporting System internet (DRSi) medical event reporting system, the type of heat illness (i.e., heat stroke or heat exhaustion) could not be distinguished using RME records in DMSS data. Instead, information on the type of RME for heat illness during the entire 2018-2022 surveillance period was extracted directly from DRSi records. MSMR analyses before 2018 included diagnosis codes for other and unspecified effects of heat and light (ICD-9: 992.8 and 992.9; ICD-10: T67.8* and T67.9*) within an “other heat illnesses” category; these codes were excluded from this report. 
An individual could be considered a case of heat illness only once per calendar year. If a service member had a diagnosis for both heat stroke and heat exhaustion during a given year, the more severe (heat stroke) diagnosis was selected. Order of precedence for encounter selection followed: 1) hospitalization (inpatient record), 2) RME (report in DRSi), then 3) ambulatory visit (outpatient record). Incidence rates were calculated as incident cases of heat illness per 100,000 person-years (p-yrs) of active component service. Percent change in incidence was calculated using unrounded rates. 
For health surveillance purposes, recruit trainees were identified as active component members assigned to service-specific training locations during coincident service-specific basic training periods. Recruit trainees were considered a separate category of enlisted service members in summaries of heat illnesses by overall military grade. 
In-theater diagnoses of heat illnesses were analyzed separately using the same case-defining criteria and incidence rules that were applied to identify cases at fixed treatment facilities. Records of medical evacuations from the U.S. Central Command (CENTCOM) area of responsibility (AOR) to a medical treatment facility outside their AOR were analyzed separately. Evacuations were considered case defining if the affected service members met the aforementioned criteria in a permanent military medical facility in the U.S. or Europe, from 5 days preceding until 10 days following their evacuation dates.
Results
In 2022, the MHS reported 415 cases of heat stroke, resulting in a crude overall incidence rate of 32.1 per 100,000 p-yrs (Table 1). 
(https://health.mil/Reference-Center/Reports/2023/04/01/Article-2-Table-1-MSMR-April-2023-issue) 
Subgroup-specific incidence rates of heat stroke were highest among men, those younger than 20 years, Marine Corps and Army members, recruit trainees, and those in combat-specific occupations. The 25 cases of heat stroke reported among recruit trainees resulted in incidence rates 3 and 6 times higher than other enlisted service members and officers, respectively. 
The crude annual incidence rate of heat stroke decreased 30.0% (Figure 1) from 2018 through 2022, and was associated with an overall reduction in the proportion of heat stroke cases with hospitalization, which dropped most markedly from 2021 to 2022. Of the heat stroke cases identified from inpatient data, 55.7% were also reported as RMEs. Half (50.7%) of cases identified from outpatient data were also recorded as RMEs.

The 1,912 cases of heat exhaustion in 2022 correspond to a crude overall incidence rate of 147.7 per 100,000 p-yrs (Table 1). The rate of heat exhaustion among women was 16.6% lower than the rate among men. Notably higher overall rates of heat exhaustion were recorded for service members younger than age 20, Marine Corps and Army members, recruit trainees, and service members in combat-specific occupations when compared to their respective counterparts. 
Between 2018 and 2020, the crude annual rate of heat exhaustion decreased 27.4%, followed by a 16.8% increase from 2020 to 2022 (Figure 2). 

The increase in heat exhaustion cases during the last two years of the surveillance period was accompanied by an increase in the proportion of cases recorded as RMEs. Of the heat exhaustion cases identified from inpatient data, 54.5% were also RMEs, while only 39.2% of heat exhaustion cases identified from outpatient data were recorded as RMEs.
Heat illnesses by location
During the 5-year surveillance period, 12,404 heat-related illnesses were diagnosed at more than 250 military installations and geographic locations worldwide (Table 2). 
(https://health.mil/Reference-Center/Reports/2023/04/01/Article-2-Table-2-MSMR-April-2023) 
Of these total heat illness cases, 5.7% occurred outside the U.S., including 321 in Okinawa. Between 2018 and 2022, 20 locations reported at least 100 cases of heat illness, and those locations accounted for over three-quarters (75.7%) of all active component cases. Four Army installations in the U.S. accounted for more than one-third (34.9%) of all heat illnesses during the period: Fort Benning, GA; Fort Bragg, NC; Fort Campbell, KY; and Fort Polk, LA. Of the 20 locations with at least 100 cases of heat illness, 9 are in the southeastern U.S.
Heat illnesses in the CENTCOM AOR
During the 5-year surveillance period, 293 heat illnesses were diagnosed and treated in the CENTCOM AOR (Figure 3). 

Of the total cases of heat illness, 6.1% (n=18) were diagnosed as heat stroke. Deployed service members affected by heat illnesses were most frequently male (n=225; 76.8%), non-Hispanic White (n=153; 52.2%), 20-24 years old (n=153; 52.2%), in the Army (n=113; 38.6%), enlisted (n=280; 95.6%), and in repair/engineering (n=96; 32.8%) occupations (data not shown). During the surveillance period, 2 service members were medically evacuated for heat illnesses from the CENTCOM AOR; 1 evacuation occurred in November 2020 and 1 in August 2022 (data not shown).
Discussion
Among service members in the active component, the crude incidence rate of heat stroke decreased 30.0% between 2018 and 2022, accompanied by an overall reduction in the proportion of heat stroke cases resulting in hospitalization. While between 2018 and 2020 the rate of heat exhaustion also declined by approximately 30%, rates then increased through 2022. This increase in heat exhaustion cases observed in the last 2 years of the surveillance period coincides with an increase in the proportion of cases identified from RMEs.
As has been noted in previous MSMR heat illness updates, results indicate that a sizable proportion of cases identified through DMSS records (hospitalizations and ambulatory visits) did not prompt mandatory reports through the reporting system.12 In 2022, only about half of heat illness cases were accompanied by RMEs. It is possible that cases of heat illness, whether diagnosed during an inpatient or outpatient encounter, were not documented as RMEs either because treatment providers were unaware of the reporting criteria, or due to ambiguities in their criteria interpretation. Underreporting is especially concerning for cases of heat stroke due to its severity and potential necessity of timely local intervention for preventing additional cases. 
In 2022, rates of heat stroke and heat exhaustion were slightly higher among men than women, which is not consistent with published observational studies of military personnel that reported elevated risk of exertional heat illness among women.13 Because this finding may be due to variation in true exposure time rather than physiologic or morphologic differences in body temperature responses between men and women, further investigation is warranted.  
Of all members of the military, Marine Corps and Army recruit trainees, particularly those training at installations in the southeastern U.S., along with those in combat-specific occupations, suffered the highest rates of heat stroke and heat exhaustion. Army and Marine Corps members in combat units often engage in intense physical training, field training exercises, as well as personal fitness training in varied environmental conditions, which may account, at least in part, for this finding. The annual numbers of heat illnesses diagnosed in the CENTCOM AOR have declined since 2019, likely due to the reduction in forces deployed to that area.
There are limitations to this update that should be considered when interpreting these results. Because management and coding of similar heat-related clinical illnesses are often location-specific, direct rate comparisons of nominal heat stroke and heat exhaustion events could be imprecise when comparing cases from different locations and settings. Heat illnesses during training exercises and deployments treated in field medical facilities were potentially not fully ascertained as cases for this report. Recruit trainees were identified using an algorithm based on age, rank, location, and time in service. This method was only an approximation and likely resulted in some misclassification of recruit training status. At the time of the analysis, Army personnel data were not available for November and December 2022. Therefore, personnel data were imputed from previous months, which likely resulted in the underestimation of Army recruits and periods of recruit training during the last 2 months of 2022. Due to this data discrepancy, recruit rates should be interpreted with caution.
The guidelines for mandatory heat illness reporting were modified in the 2017 revision of the Armed Forces guidelines and RME case definitions and remained in the 2020 revision.7 This updated version of the guidelines and case definitions removed the heat injury category, leaving only case classifications for heat stroke and heat exhaustion. To compensate for possible reporting variation, the analysis for this update, as in previous years, included cases identified in DMSS records of ambulatory care and hospitalizations using a consistent set of ICD-10 codes for the entire surveillance period. The exclusion of diagnosis codes for other and unspecified effects of heat and light (formerly included within the “other heat illnesses” category) in the current analysis precludes direct comparison of numbers and rates of cases of heat exhaustion to numbers and rates of “other heat illnesses” reported in MSMR updates before 2018. It should be noted that medical data from July 2017 to October 2019 at sites using the new MHS electronic health record, MHS GENESIS, are not available in the DMSS and thus not included in this report——these sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center. 
Heat illnesses, which are largely preventable, remain a persistent threat to both the health of U.S. military members and the effectiveness of military operations. Appropriate command emphasis, recognition, and employment of preventive countermeasures for heat illness are crucial steps in effective risk reduction.
References

Carter R, Cheuvront SN, Williams JO, et al. Epidemiology of hospitalizations and deaths from heat illness in soldiers. Med Sci Sports Ex­erc. 2005;37(8):1338-1344. doi:10.1249/01.mss.0000174895.19639.ed
    Hancock PA, Ross JM, Szalma JL. A meta-analysis of performance response under thermal stressors. Hum Factors. 2007;49(5):851-877. doi:10.1518/001872007X230226

    DeGroot, D., Henderson, K., O’Connor, F. Exertional heat illness at Fort Benning, GA: Unique insights from the Army Heat Center. MSMR.2022;29(4):2-7.

    Armed Forces Health Surveillance Division. Update: heat illness, active component, U.S. Armed Forces, 2021. MSMR. 2022;29(4):8-14.

    Alele FO, Bunmi SM, Aduli EOM, Crow MJ. Epidemiology of exertional heat illness in the military: a systematic review of observational studies. Int J Environ Res Public Health. 2020;17(19):7037. doi:10.3390/ijerph17197037

    Atha WF. Heat-related illness. Emerg Med Clin North Am. 2013;31(4):1097-1108. doi:10.1016/j.emc.2013.07.012

    Armed Forces Health Surveillance Branch, Defense Health Agency. In collaboration with U.S. Air Force School of Aerospace Medicine, Army Public Health Center, and Navy and Marine Corps Public Health Center. Armed Forces Reportable Medical Events. Guidelines and Case Definitions, January 2020. Accessed March 3, 2022. (https://www.med.navy.mil/Portals/62/Documents/NMFA/NMCPHC/root/Documents/program-and-policy-support/Armed-Forces-Reportable-Medical-Events-DOD-VERSION.pdf) https://www.med.navy.mil/Portals/62/Documents/NMFA/NMCPHC/root/Documents/program-and-policy-support/Armed-Forces-Reportable-Medical-Events-DOD-VERSION.pdf


    O’Connor FG, Sawka MN, Deuster P. Disorders due to heat and cold. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016:692-693.

    Epstein Y, Yanovich R. Heatstroke. N Engl J Med. 2019;380(25):2449-2459. doi:10.1056/NEJMra1810762

    DeGroot DW, O’Connor FG, Roberts WO. Exertional heat stroke: an evidence-based approach to clinical assessment and management. Exp Physiol. 2022;107(10):1172-1183. doi:10.1113/EP090488

    Périard JD, DeGroot D, Jay O. Exertional heatstroke in sport and the military: epidemiology and mitigation. Exp Physiol. 2022;107(10):1111-1121. doi:10.1113/EP090686

    Headquarters, Department of the Army. Heat Stress Control and Heat Casualty Management Technical Bulletin, Medical, 507. April 12, 2022.

    Périard JD, Eijsvogels TMH, Daanen HAM. Exercise under heat stress: thermoregulation, hydration, performance implications and mitigation strategies. Physiol Rev. 2021;101(4):1873-1979. doi:10.1152/physrev.00038

    Roberts WO, Armstrong LE, Sawka MN, Yeargin SW, Heled Y, O’Connor FG. ACSM expert consensus statement on exertional heat illness: recognition, management, and return to activity. Curr Sports Med Rep. 2021;20(9):470-484. doi:10.1249/JSR.0000000000000878

    Armed Forces Health Surveillance Branch. Surveillance Case Definition: Heat illness. Accessed on March 13, 2022. (https://health.mil/Reference-Center/Publications/2019/10/01/Heat-Injuries) https://health.mil/Reference-Center/Publications/2019/10/01/Heat-Injuries


(https://health.mil/News/Articles/2023/03/30/news441455) DHA Honors Military Medical "Young Investigators"
Mar 29th 2023, 20:00

U.S. Army Capt. Stephanie Bulder of Womack Army Medical Center, Fort Bragg, North Carolina, was recognized in February 2023 by the Defense Health Agency’s (https://health.mil/Military-Health-Topics/Research-and-Innovation/DHA-Research-and-Engineering/Research-Support-Division/Clinical-Investigations-Program-Branch) Clinical Investigations Program, a branch of DHA’s Research and Engineering directorate, for her research into human papillomavirus vaccination rates in service members. 
Bulder’s was one of several scientific presentations delivered as part of the Clinical Investigations Program second annual Young Investigator Competition. The presentations were delivered at the 2023 annual meeting of AMSUS, the Society of Federal Health Professionals.
“I am honored to be awarded first prize for this year’s Young Investigator Competition … and could not have achieved this accomplishment without the assistance and the support of [my] mentors and leaders in the Womack Departments of research and gynecologic surgery and obstetrics,” Bulder said.
Bulder, a native of Santa Clarita, California, won the competition for her poster titled, "Human Papillomavirus Vaccination and Disease Burden within the U.S. Military [Health] System.” Bulder received her medical degree from Midwestern University College of Osteopathic Medicine and is in her final year of a gynecologic surgery and obstetrics residency at Womack, which serves the Fort Bragg, North Carolina, community.
“The annual Young Investigators Competition shows how cutting-edge graduate health education research conducted by our residents in collaboration with the Clinical Investigations Program creates an environment of excellence,” said U.S. Army Brig. Gen. Katherine Simonson, DHA’s Acting Assistant Director for Support, who presented the award to Bulder. “We are proud of the research conducted by our residents and trainees that will help us build the modernized, integrated, and resilient health delivery system that elevates provider care, patient safety, and improves outcomes for our valued beneficiaries.”
“It was inspiring to be surrounded by leaders from around the country who have dedicated their work to improving the lives and health of our military service members," said Bulder about AMSUS. “As a gynecologic surgeon and obstetrician, I have a vested interest in human papillomavirus as it disproportionally affects women, and I have directly seen the effects of this infection. Our team is enthusiastic about continuing to spread awareness and education regarding the impacts of human papillomavirus, the safety and effectiveness of the available vaccine, and its role in cancer prevention. We will continue to advocate for evidence-based prevention measures.”
“The DHA Clinical Investigations Program promotes exceptionally high standards of care, elevating patient safety, and improving health outcomes,” stated Dr. Saafan Malik, chief of the Research and Engineering Directorate’s research support division. “The Young Investigator Competition is just one example of how we promote cutting-edge research that enables us to provide high-quality health care to our warfighters—a responsibility as a combat support agency—and beneficiaries. We are proud to support and acknowledge the accomplishments of our residents.”
In addition to (https://health.mil/Reference-Center/Presentations/2023/03/22/2023-Young-Investigator-Competition-Poster) Bulder’s winning entry, this year’s competition featured participants from Clinical Investigations Programs at six other military hospitals.

U.S. Air Force Maj. Brett Jessen, Lackland Air Force Base, San Antonio, Texas - Developing an In Vitro Model of Post-Extraction Bleeding and Evaluating the Feasibility of Xstat for Dental Hemorrhage Control
    U.S. Air Force Cadet Amy LeClair, U.S. Air Force Academy, Colorado Spring, Colorado - Designing a Wastewater-Based Epidemiology Study at the United States Air Force Academy
    U.S. Army Capt. Lisa Marinelli, Brooke Army Medical Center, San Antonio, Texas - Histologic Evaluation of Wound-Bed Preparedness Following Microsurfaced Skin Grafts for the Treatment of Deep Burn Wounds: Results from a Randomized Controlled Trial
    U.S. Army Capt. Holly Spitzer, William Beaumont Army Medical Center, El Paso, Texas - Impact of Adherence to Operative Standards and Stage-Specific Guideline-Recommended Therapy in Non-Metastatic Pancreatic Adenocarcinoma
    U.S. Army Maj. Kristina Thompson, Tripler Army Medical Center, Honolulu, Hawaii - Investigating Acute Respiratory Infections and their Early Biomarkers in Austere Environment
    U.S. Navy Lt. Aaron Van Dyne, Naval Medical Center Portsmouth, Portsmouth, Virginia - Social Factors Increasing Risk for Mental Health Conditions Resulting in Separation from the United States Navy


(https://health.mil/News/Articles/2023/03/29/news441370) COVID-19 Registry Provides Pandemic Response Insights, Optimizes Patient Care
Mar 28th 2023, 20:00

Three years ago, the world braced for the impacts of an unforeseen global pandemic. While this time proved challenging, it also highlighted the Department of Defense’s flexibility, resilience, and innovation in the face of a health care crisis.
Prior to the pandemic, the DOD began deploying (https://health.mil/Military-Health-Topics/Technology/MHS-GENESIS) MHS GENESIS, the new federal electronic health record, to improve health care outcomes for our service members, veterans, and their families. Critical enterprise needs quickly came to light to combat the impacts of the COVID-19 disease.
The Enterprise Intelligence and Data Solutions program management office quickly built population health management capabilities. EIDS and the DOD Center of Excellence for Trauma (https://jts.health.mil/) Joint Trauma System office established the COVID-19 registry.
This new registry collected COVID-19 patient data—including vaccination data—from MHS GENESIS and all relevant legacy systems into one patient view. JTS brought more than two decades of trauma registry experience to this effort. The new registry began collecting COVID-19 data in May 2020.
According to U.S. Air Force Col. Stacy Shackelford, JTS chief during the pandemic and clinical lead for the COVID-19 registry, "Data from the registry, although not perfect, filled a knowledge gap that improved leadership awareness of the effects of the pandemic within the DOD and guided clinical practice."
JTS and EIDS tracked clinical performance improvement metrics and trends throughout the pandemic. The COVID-19 registry did not replace the public health functions of tracking total numbers and patient contacts. The registry allowed DOD to monitor evolving treatment priorities and critical at-risk patients more closely, while tracking surveillance data on all identified COVID-19-positive patients.
Prior to the pandemic, COVID-19 data standards did not exist. Thousands of providers across the world coded COVID-19 tests and diagnosis codes differently until the clinical community established coding standards and common reporting protocols. The lack of COVID-19 data standards, use of different electronic health records, and reporting of laboratory results in the notes section of a patient’s record made it difficult to search for one name or one code to obtain a comprehensive list. This disparate reporting caused another problem in standardization which the COVID-19 registry aimed to resolve.
The COVID-19 registry, built on the best available data definitions and codes at the time, was stood up within approximately 60 days of defining initial requirements. As the data matured, the COVID-19 team remained flexible, continuously evolving their analytics to include nomenclature in the manner captured.
“The COVID-19 registry is a success story for our team. It demonstrates our ability to standardize and be flexible and nimble to any impending health care crisis,” explained Shackleford. “Most importantly, our systems pivoted quickly, leveraging existing capabilities and creating new capabilities to support the needs of this once-in-a-lifetime pandemic.”
The COVID-19 registry is a useful tool, allowing population health officials to look at treatments and outcomes. Used in conjunction with other larger data sources, it enables improved clinical decision-making and better patient outcomes.
According to Chris Nichols, program manager of EIDS, “We are proud to have partnered with JTS experts to create a solution that refined reporting variance and standardized accounting across data sources around COVID-19 providing actionable pandemic response insights.”

(https://health.mil/News/Articles/2023/03/24/news441065) DOD Welcomes New Assistant Secretary of Defense for Health Affairs
Mar 23rd 2023, 20:00

Dr. Lester Martinez-López took the Oath of Office on Tuesday, March 21, 2023, as the Department of Defense’s new assistant secretary of defense for health affairs. The oath was administered by Undersecretary of Defense for Personnel and Readiness Gilbert R. Cisneros.
“I could not be more pleased to be here today to officially welcome our newly confirmed assistant secretary,” Cisneros said. “His arrival has been a long time coming, and we are so grateful that he stuck with us through the nomination, hearing, and confirmation process. We are fortunate, indeed, to welcome this distinguished public servant to our team.”
Martinez was joined by his wife, Lydia; their three sons, Lester, Luis and Lucas; daughters-in-law Ragan, Barbara, and Shama; five of their nine grandchildren, and more than 100 friends and supporters. In his speech following the oath, Martinez noted that he believes in the adage that “it takes a village,” which in his case, starts with his family. He also recognized the presence of his long-time mentor, former Assistant Secretary of Defense for Health Affairs Dr. Enrique Mendez, and friends and supporters who filled the Hall of Heroes at the Pentagon for the ceremony.
Martinez answered a question that he said he’s been asked many times: Why, at this point in his life and his career, would he want to take on a job of this magnitude? 
“My answer is simple,” he said. “It is an opportunity, a calling, to continue my life’s work, which has always been about taking care of people. There is no greater duty than to ensure the health of the people who serve our country selflessly and with great sacrifice, and I am truly grateful for this chance to make a difference for them.”
Nominated by President Joe Biden in 2022, Martinez was confirmed on Feb. 16, 2023. He is a retired U.S. Army major general and a family medicine physician, who served in leadership positions in the private health care sector after concluding his U.S. Army career. He holds a doctorate of medicine degree from the University of Puerto Rico and a master’s degree of public health from Johns Hopkins University.

(https://health.mil/News/Articles/2023/03/10/Tidewater-Market-Saves-by-Integrating-and-Optimizing-Pathology-Services) Tidewater Market Saves by Integrating and Optimizing Pathology Services
Mar 9th 2023, 19:00

In a Defense Health Agency Market that serves more than 390,000 beneficiaries, U.S. Navy Capt. Stacie Milavec is the subject matter expert on all matters concerning clinical laboratory and anatomic pathology services. Her work to establish a laboratory/pathology collaboration in the (https://health.mil/News/Articles/2021/04/19/Tidewater-set-to-become-fifth-Military-Health-System-market) Tidewater Market, in southeast Virginia, streamlined efficiencies, cut costs, and created an unprecedented partnership across military hospitals and clinics in the region.
(https://portsmouth.tricare.mil/) Naval Medical Center Portsmouth Commanding Officer U.S. Navy Capt. Shelley Perkins asked Milavec to look for ways to optimize services within the newly established Tidewater Market. With more than 23 years of experience in military medicine, she took on the challenge and immediately began to identify opportunities.
"One of DHA's goals with setting up a market structure is to find efficiencies and optimize and standardize processes and services wherever possible," said Milavec. "We’ve been able to do exactly that by collaborating within our working group."
In 2022, Milavec established a Tidewater Market Laboratory/Pathology Integration Working Group with representatives from NMCP, the 633d Medical Group at (https://www.jble.af.mil/) Joint Base Langley-Eustis, (https://mcdonald.tricare.mil/) McDonald Army Health Center, and members from DHA's Tidewater Market office.
The working group began meeting monthly to discuss collaborative efforts and identify ways to cut costs by sharing resources. As a full-service medical center laboratory, NMCP had the capacity to take on pathology caseloads from the Market. The laboratory at NMCP began taking on head and neck pathology cases, human papillomavirus testing for all Market military hospitals and clinics, and breast biopsy and PAP cases. These services were previously supported by other means and, in some instances, through commercially contracted laboratories for analysis at a price.
The working group’s efforts saved the Tidewater Market an estimated $80,000 during fiscal year 2022. The military hospitals and clinics working geographically close to one another also equated to quicker turnaround times for test results.
Beginning this month, NMCP will take on additional clinical chemistry tests from the 633d Medical Group at Joint Base Langley-Eustis, which up until recently were sent to commercially contracted laboratories off base.
“[Through collaboration between the MTFs] We’ve been able to successfully transition civilian marketplace send-out testing back into the military market by utilizing market resources,” said U.S. Air Force Capt. Dianna Chormanski, a staff pathologist and laboratory medical director with the 633d Medical Group at Joint Base Langley-Eustis. “I’m a big fan of cooperation and working together, and that’s what a Market should be.”
Derived from the National Defense Authorization Act for Fiscal Year 2017, DHA established the market-based structure to consolidate the management of military hospitals and clinics into regions and to support the sharing of patients, staff, budget, and other functions across facilities to improve readiness and the delivery and coordination of health services.
The Tidewater Market, established in 2021, is the nation's fifth Military Health System market established to manage military medical treatment facilities that support the delivery of integrated, affordable, and high-quality health services for active duty service members, retirees, reservists, guardsmen, and their families enrolled at Naval Medical Center Portsmouth, McDonald Army Health Center, the 633d Medical Group at Joint Base Langley-Eustis, U. S. Naval Hospital Guantanamo Bay, Cuba, as well as 14 health clinics in the Tidewater region.

(https://health.mil/News/Articles/2023/03/07/Federal-EHR-Patient-Safety-Outperforms-Legacy-Per-Industry-Standards) Federal EHR Patient Safety Outperforms Legacy, Per Industry Standards
Mar 6th 2023, 19:00

An annual Leapfrog evaluation showed the Department of Defense’s new electronic heath record, known as MHS GENESIS, outperformed legacy systems on safe medication ordering.
As part of the Leapfrog Group Hospital Survey, the DOD added participation in the Computerized Provider Order Entry evaluation process in 2022. This industry standard tool uses randomized scenarios to assess the performance of the federal EHR patient medication ordering decision support tools. The evaluation helps providers at military hospitals and clinics identify strategies to improve safe medication ordering and enhance patient safety.
Through results of this survey, the federal EHR demonstrated that its clinical decision support tools improve medication and patient safety. The federal EHR rates a 3.36 out of 4.0 for safe medication ordering. Clinical decision support tools are computer-based programs that provide evidence-based prompts/reminders to help caregivers improve the quality/safety of care.
“The survey results show that the federal EHR supports enhanced patient safety,” said Bill Tinston, director of the Federal Electronic Health Record Modernization office. “The separate, legacy EHR systems are outdated and unable to create a seamless care experience as provided by the federal EHR. There is recognition that the federal EHR saves providers time and enables more standard workflows to support enhanced clinical decision-making and patient safety.”
Within a year of participating in the industry standard Leapfrog Group Hospital Survey, the Defense Health Agency Leapfrog Program Team, DHA Health Informatics, and Defense Healthcare Management Systems Modernization Program Management Office Baseline Clinical Informatics team developed a process for DOD Leapfrog CPOE testing and support. Together, they streamlined the workflow testing process, saving frontline clinicians and administrative teams countless hours—allowing them to stay focused on their mission of patient care.
The inclusion of DHMSM PMO and DHA-HI with the DHA Leapfrog Team allows for rapid identification and remediation of CPOE testing challenges.
In addition, this collaboration will allow efficient identification of other changes that may be needed to enhance patient care. Through the FEHRM’s Joint Sustainment and Adoption Board, changes are jointly approved. This allows all federal EHR participants to take advantage of these new capabilities.
“These capabilities demonstrate how the federal EHR allows for agile improvements that support patients and providers,” said Tinston. “The FEHRM and its partners continue to deliver common capabilities that evolve the federal EHR and respond to the needs of the departments and our patients and providers.”
The FEHRM, along with DOD, Department of Veterans Affairs, Department of Homeland Security’s U.S. Coast Guard, and Department of Commerce’s National Oceanic and Atmospheric Administration, are implementing a single, common federal EHR together. As of February 2023, there are more than 150,000 DOD, VA and USCG doctors, nurses, and other health care providers using the EHR. They account for 75% of all hospitals and clinics across DOD, five VA Medical Centers, and 109 USCG sites. More than 6.1 million unique patients are now able to engage with their new federal EHR system.
“With a vision for federal organizations to share a single, common federal EHR and meaningfully exchange and use data with participating provider organizations, patients benefi­t from a continuity of care that spans across health care systems,” said Tinston.
To learn more about the federal EHR, visit (http://www.fehrm.gov/) www.FEHRM.gov. 
To learn more about MHS GENESIS, visit: (https://health.mil/) www.Health.mil. 

(https://health.mil/News/Articles/2023/03/06/Virtual-Education-Center-Provides-Health-Information-to-Patients) Virtual Education Center Provides Health Information to Patients
Mar 5th 2023, 19:00

The Defense Health Agency’s Education and Training Directorate launched the (https://health.mil/Military-Health-Topics/Education-and-Training) Virtual Education Center, a new online tool giving physicians and patients easier access to relevant and validated medical and health information. The VEC, which launched at (https://bamc.tricare.mil/)  Brooke Army Medical Center at Joint Base San Antonio, Texas, on Jan. 30, seeks to improve the quality of medical appointments and patient health by enhancing beneficiary education opportunities and resources.
According to the National Academy of Medicine, 90 million American adults have limited health literacy, which is associated with higher rates of hospitalization and higher use of emergency services and can result in billions of dollars in avoidable health care costs.
In 2020, the Naval Air Warfare Center Training Systems Division performed an in-depth analysis of patient education across the Military Health System for DHA, which examined the current state of patient education and effective best practices throughout the organization.
Results revealed that patient education across the MHS was fragmented, left up to individual military hospitals or clinics and providers to provide patient education. One of the primary recommendations from the analysis was to invest in a single patient-centric education platform to allow persistent access to patient education, which can include information about preventive health and hospital or clinic-specific resources. This was the catalyst for the development of the VEC. 

(https://health.mil/News/Articles/2023/03/02/Leaders-Emphasize-Inspiring-Change-Creating-Community-at-DHAs-Black-History-Month-Observance) Leaders Emphasize Inspiring Change, Creating Community at DHA’s Black History Month Observance
Mar 1st 2023, 19:00

The Defense Health Agency held a Black History Month event, themed “Inspiring Change,” on Feb. 15.
“We have to get to the point as people, as human beings, where we recognize that our privilege is not predicated on another group’s oppression,” said guest speaker Dr. Zoe Spencer.
Spencer is a professor of Sociology and Criminal Justice at the Virginia State University, Emmy award winner for her spoken word piece “Say Her Name,” and the creator of the university’s Center for Policing Leadership and Social Justice, which builds collaborative relationships between local and national law enforcement and legal officials, and community leaders.
“When we get to that point,” Spencer said, “then we start to erase the lines, the social constructs, that divide us and begin to look at the human condition as a whole. And so, words like multiculturalism or diversity or justice don’t seem foreign to us, or it doesn’t seem like a threat to our existence.”
Only then, Spencer said, “we will be able to collectively work towards eradicating oppression in all its forms.”
Now is the time to speak up and act, Spencer said.
Referencing a quote from the Holocaust, she said, “Silence is not the right answer, complacency is not the right answer. It is about speaking up and using the voice that we are given and to recognize the fellow humanity around us lest it comes to us and there is no one left to speak up.”
How DHA Can Move Forward
Moderator Christianne Witten, DHA chief of internal communications, asked Spencer about cultural actualization and empathic modeling in clinical practice, and how the DHA can apply it “to increase levels of trust with those we serve in the African American community.”
That means working “to undo all of the things that we learn, and how we’re actualized and the ways in which our learning impacts our connection with other people who are not like us to be able to do the work of feeling safe in an environment with others, and not viewing others that don’t look like us as a threat,” Spencer answered.
This fosters “the ability to create a community of belonging, the ability to develop a sense of esteem and regard for other cultures,” Spencer said. She hopes this will allow medical professionals “to really develop a holistic, empathic model to use in navigating through those relationships.”
More Conversations Needed
DHA Senior Enlisted Leader U.S. Army Command Sgt. Maj. Michael Gragg said, “Hopefully, this discussion will transition into conversations that are had throughout the agency about all the challenges that our agency has about fairness and equality and showing empathy and compassion to all.”
“It goes back to making us better as a whole, as a people, and as an agency,” Gragg said.
Spencer’s comments, he said: “should help guide these conversations in a positive manner and allow each other to see each other, not to just look at each other, but to see each other, and not to just hear each other, but to listen to each other, because oftentimes that is the greatest challenge: ‘I hear you, but I don’t hear you.’”
DHA Resources
DHA’s (https://health.mil/About-MHS/OASDHA/Defense-Health-Agency/EODM-Office) Equal Opportunity and Diversity Management Office is committed to providing equal opportunity for all employees, former employees, and applicants for employment on the basis of merit and without regard to race, color, national origin, sex (including sexual orientation or pregnancy discrimination), religion, age, retaliation, genetic information, or physical or mental disability.
DHA’s Force Resilience Office sponsors the agency’s special observance series and is the agency’s program office for military equal opportunity, sexual assault prevention and response, diversity and inclusion, anti-extremism, and anti-harassment.
Employees can watch the playback of the entire conversation on (https://militaryhealth.sharepoint-mil.us/sites/infohub) Microsoft Teams InfoHub.

(https://health.mil/News/Articles/2023/03/01/Surveillance-Snapshot) Surveillance Snapshot: Zika Virus Among Department of Defense Service Members and Beneficiaries, 2013–2022
Feb 28th 2023, 19:00

Zika virus is an arboviral infection transmitted primarily through Aedes mosquitoes in tropical and subtropical regions. Although most infections are asymptomatic or mild, Zika virus infection during pregnancy can lead to infant complications and congenital abnormalities.1 In the U.S., the Centers for Disease Control and Prevention reported 5,559 travel-associated and 231 locally-acquired Zika virus cases from 2015 to 2021.2 The majority of these cases (n=5,168) were identified in 2016, which translates to a peak of 1.6 confirmed or probable noncongenital Zika virus cases per 100,000 persons in the U.S.3,4
>From January 1, 2013 through December 31, 2022, 212 Zika virus cases were detected among Department of Defense service members and beneficiaries. Zika virus’s presentation in the Western Hemisphere in early 20155 led to peak rates (n=143) for all services in 2016, which declined substantially thereafter, until no cases were identified among DOD beneficiaries from 2021 to 2022.
Zika virus cases described in this Snapshot reflect documentation from the Disease Reporting System-internet and laboratory records generated from the Composite Healthcare System. The DRSi Zika virus reporting option was not available until July 2017,6 and until then a medical event report from DRSi included those entered as “Any other unusual condition not listed” that contained case report notes indicating a positive Zika case. Cases indicated by laboratory records include culture identification, antigen detection, nucleic acid detection, and plaque reduction neutralization test detection. Immunoglobulin M-positive cases were included in the absence of PRNT testing.
The rates depicted in this figure were estimated from the number of service members and dependents most likely enrolled in TRICARE Prime, as DRSi reports and CHCS laboratory records primarily reflect individuals with (javascript:void(0);) Direct CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”direct care at a military clinic or hospital. These population estimates do not clearly delineate risk for services more likely to deploy, travel, or live in assigned unit areas with endemic risk.
Author Affiliations
Defense Centers for Public Health—Portsmouth (Mr. Seliga, Ms. Touchstone, Mr. Matsumoto); Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (Mr. Matsumoto)
Disclaimers
The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, the U.S. Government, nor the Henry M. Jackson Foundation for the Advancement of Military Medicine. Kati Touchstone, Kenji Matsumoto, and Nicholas Seliga are employees of the U.S. Government. This work was prepared as part of their official duties. Title 17, U.S.C., §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C., §101 defines a U.S. Government work as a work prepared by a military Service member or employee of the U.S. Government as part of that person’s official duties. This material is based upon work supported by the DOD Information Analysis Center Program Management Office, sponsored by the Defense Technical Information Center under Contract FA807518D0011.
References

World Health Organization. Zika virus. Accessed January 25, 2023. (https://www.who.int/news-room/fact-sheets/detail/zika-virus) https://www.who.int/news-room/fact-sheets/detail/zika-virus

    Centers for Disease Control and Prevention. Zika cases in the United States. Published January 13, 2023. Accessed February 14, 2023. (https://www.cdc.gov/zika/reporting/index.html) https://www.cdc.gov/zika/reporting/index.html

    Hall V, Walker WL, Lindsey NP, et al. Update: noncongenital zika virus disease cases–50 U.S. states and the District of Columbia, 2016. MMWR. 2018;67(9):265-269.
    United States Census Bureau. American Community Survey 5-Year Estimate Data Tables, 2016. Accessed March 21, 2022. (https://data.census.gov/table?tid=ACSDP5Y2016.DP05) https://data.census.gov/table?tid=ACSDP5Y2016.DP05

    Poss DE, Writer JV, Harris S. Zika virus infections in Military Health System beneficiaries since the introduction of the virus in the Western Hemisphere, 1 January 2016 through 30 November 2016. MSMR. 2016;23(12):7-11.
    Armed Forces Health Surveillance Division. Zika virus. Updated December 2017. Accessed March 13, 2023. (https://www.health.mil/Reference-Center/Publications/2017/12/01/Zika-Virus) https://www.health.mil/Reference-Center/Publications/2017/12/01/Zika-Virus


(https://health.mil/News/Articles/2023/03/01/STIs-2022) Update: Sexually Transmitted Infections Among Active Component Service Members, U.S. Armed Forces, 2014–2022
Feb 28th 2023, 19:00

This report summarizes incidence rates and trends of sexually transmitted infections (STIs) from 2014 to 2022 among active component service members of the U.S. Armed Forces. The data compiled for this report are derived from medical surveillance of chlamydia, gonorrhea, and syphilis as nationally notifiable diseases. Case data for 2 additional STIs, human papilloma virus (HPV) and genital herpes simplex virus (HSV), are also presented. Since 2019 case rates for all STIs have declined, excluding syphilis, which declined briefly but rose among male and female service members by approximately 40% between 2020 and 2022. Overall age- and gender-adjusted case rates for chlamydia, gonorrhea, and syphilis remain somewhat higher within the U.S. Armed Forces than among the general U.S. population, which may be due to factors including mandatory screening, more complete reporting, incomplete adjustment for age distribution, and inequitable comparisons between the active duty military and entire U.S. population. While case rates among female service members for chlamydia, gonorrhea, HPV, and HSV are significantly higher, syphilis rates display a male preponderance for all except the youngest age group. Social restrictions during the COVID-19 pandemic may have contributed to declines in true case rates and screening coverage.
What are the new findings?
STI rates have declined since 2019, except for syphilis, which has increased for 2 consecutive years. These trends may be partially influenced by changes in screening coverage or behavior associated with the COVID-19 pandemic. Future analyses of screening rates are warranted to assess a true decline in incidence and examine the recent increase in syphilis reports.
What is the impact on readiness and force health protection?
To assist service leader and medical corps planning and assessment of STI prevention and control measures for operational readiness, this report provides an updated epidemiologic profile of the most commonly reported STIs. STIs can adversely affect service member ability and availability for duty performance and result in serious medical sequelae if untreated. Continued behavioral and educational interventions are needed to mitigate STI risk among military service members.
Background
In 2021, sexually transmitted infections (STIs) represented 1 of the highest health care burdens attributable to infectious diseases (other than COVID-19) among active component service members of the U.S. Armed Forces.1 The National Academies of Sciences, Engineering and Medicine recently convened a committee to provide recommendations for STI prevention and control in the U.S., concluding that military recruits and active duty service members required focused consideration.2  While multiple and interrelated factors influence STI risk within military populations,3 the strongest risk factors are age and sex. The military population is young (mean age 26) and predominantly male (85%), so its rates are not directly comparable to the general U.S. population unless adjusted for these demographics. Previous reports have found higher incidence rates of all STIs in specific ethnic/racial groups, which may represent a true difference, or may be an artifact of the categories used for those analyses.
The Centers for Disease Control and Prevention (CDC) publishes annual summaries of national surveillance data for notifiable diseases covered by federally-funded control programs, including Chlamydia trachomatis (chlamydia), Neisseria gonorrhoeae (gonorrhea), and Treponema pallidum (syphilis). Preliminary data from the National Notifiable Diseases Surveillance System indicate that these 3 STIs continued to increase into the second year of the COVID-19 pandemic, underscoring the importance of continued prevention and control programs.4 Although these 3 relatively common bacterial STIs are curable with antibiotics, there is continued concern about the threat of multidrug resistance.5–7
Common viral STIs in the U.S. also include infections caused by human papillomavirus (HPV) and genital herpes simplex virus (HSV). Studies assessing the National Health and Nutrition Examination Survey (NHANES) provide prevalence estimates for adolescents and young adults ages 15-24, estimating 1.3 million prevalent HSV-2 infections and 9.0 million infected with at least 1 disease-associated HPV type in 2018.8 Neither HPV nor HSV viral infections are curable with antibiotics; however, suppression of recurrent herpes is attainable using antiviral medication, and a vaccine prevents infection from 4 of the most common HPV serotypes as well as 5 cancerous types.9
This report presents an epidemiologic profile for STIs among active component service members from 2014 to 2022, updating previous MSMR articles.10,11 Data are presented for 5 common STIs: chlamydia, gonorrhea, syphilis, HPV, and HSV. This year marks the first where rates are expressed per 100,000 to match CDC reports; thus, any comparisons to prior MSMR reports using rates per 10,000 should account for this methodologic change.
Methods
The surveillance population for this report comprises all active component service members of the U.S. Army, Navy, Air Force, or Marine Corps who served at any time during the surveillance period of January 1, 2014 to December 31, 2022. STI diagnoses were ascertained from medical administrative data and reports of notifiable medical events routinely provided to the Armed Forces Health Surveillance Division (AFHSD) and maintained in the Defense Medical Surveillance System (DMSS) for health surveillance. STI cases were also derived from positive laboratory test results recorded in the Health Level 7 (HL7) chemistry and microbiology databases maintained by the Epi­Data Center at Defense Centers for Public Health-Portsmouth (DCPH-P).
(https://health.mil/Reference-Center/Reports/2023/03/01/MSMR-March-2023-Article-1-Table-1) Each service member's number of days in active service was determined and then aggregated to a total for all service members in each calendar year. The resultant annual totals were expressed as person-years (p-yrs) of service and used as the denominators for calculating annual incidence rates. Person-time not considered time at risk for each STI (i.e., the 30 days following each incident chlamydia or gonorrhea infection and all person-time following the first diagnosis, medical event report, or positive laboratory test of HSV, HPV, or syphilis) was excluded. An incident case of chlamydia was defined by either 1) a case-defining diagnosis (Table 1) in the first or second diagnostic position in a record of an outpatient or in-theater medical encounter, 2) a confirmed notifiable disease report, or 3) a positive laboratory test (of any specimen source or test type). An incident case of gonorrhea was similarly defined by 1) a case-defining diagnosis in the first or second diagnostic position of an inpatient, outpatient, or in-theater encounter record, 2) a confirmed notifiable disease report, or 3) a positive laboratory test (any specimen source or test type). For both chlamydia and gonorrhea, an individual could be counted as having a subsequent case only if more than 30 days occurred between the dates recorded for each case-defining diagnosis.
An incident case of syphilis was defined by either 1) a qualifying ICD-9 or ICD-10 code in the first, second, or third diagnostic position of a hospitalization record, 2) at least 2 outpatient or in-theater encounters within 30 days with a qualifying ICD-9 or ICD-10 code in the first or second position, 3) a confirmed notifiable disease report for any type of syphilis, or 4) a record of a positive polymerase chain reaction or treponemal laboratory test. Stages of syphilis (primary, secondary, late, latent) could not be distinguished because HL7 laboratory data do not allow for stage differentiation, and because a high degree of misclassification is associated with ICD diagnosis code usage for stage determination.12,13 An individual could be considered an incident case of syphilis only once during the surveillance period; those with evidence of prior syphilis infection were excluded.
Incident cases of HSV were identified by either 1) a requisite International Classification of Diseases, 9th or 10th Revision (ICD-9 or ICD-10, respectively) code in either the first or second diagnostic positions of an outpatient or in-theater encounter record or 2) a positive laboratory test from a genital specimen source. Antibody tests were excluded because they do not allow distinction between genital and oral infections. Incident cases of HPV were similarly identified by either 1) the presence of the requisite ICD-9 or ICD-10 codes in either the first or second diagnostic positions of an outpatient or in-theater encounter record or 2) a positive laboratory test from any specimen source or test type. Outpatient encounters for HPV with evidence of HPV immunization within 7 days before or after the encounter date were excluded, as were outpatient encounters with a procedural or Current Procedural Terminology (CPT) code indicating HPV vaccination, as such encounters were potentially related to vaccination administration. An individual could be counted as an incident case of HSV or HPV only once during the surveillance period. Individuals with HSV or HPV infection diagnoses before the surveillance period were excluded. Incidence rates were calculated as incident cases of a given STI per 100,000 p-yrs of active component service, with percent changes in incidence calculated by unrounded rates.
Results
Between 2014 and 2022, the number of incident chlamydia infections among active component service members exceeded the other 4 STIs combined, and was 4.4 times the total number of genital HPV infections—the next most frequently identified STI during this period (Table 2). 
(https://health.mil/Reference-Center/Reports/2023/03/01/MSMR-March-2023-Article-1-Table-2) 
In 2022, 34% of syphilis cases, 71% of gonorrhea cases, and 87% of chlamydia cases that were qualified by laboratory or medical encounter data had a corresponding reportable medical event (RME). Table 2 provides the crude, unadjusted STI rates by other sociodemographic variables including service, age, education, marital status, rank/grade, and occupation. Patterns of incidence rates over time for each specific STI are described in subsequent subsections.
Chlamydia
Annual chlamydia rates among all active component members increased 53.2% between 2014 and 2019, with rates among both women and men peaking in 2019 (5,461.1 per 100,000 p-yrs and 1,883.4 per 100,000 p-yrs, respectively) (Figure 1a; Figure 1b). 

>From 2019 to 2022, chlamydia rates for both male and female service members declined by 35.0%. The younger age categories constituted a majority of this decline. Among women, non-Hispanic Black service members younger than age 25 demonstrated the largest absolute rate change, declining from a peak of 15,402.9 per 100,000 p-yrs in 2019 to 9,951.5 per 100,000 p-yrs in 2022 (Figure 2a). The relative change in chlamydia rates among female service members younger than age 25 was comparable among racial/ethnic categories, declining approximately 33-37% between 2019 and 2022. This trend was also comparable among male service members under 25 years of age, whose rates declined by approximately 35-40% in each racial/ethnic category during the same period (Figure 2b). 

Gonorrhea
Between 2014 and 2022, the crude annual incidence rate of gonorrhea increased 28.7%; however, after peaking in 2019 (370.2 per 100,000 p-yrs), the rate declined to 324.7 per 100,000 p-yrs in 2022. During the last 5 years of the surveillance period (2018 to 2022), more substantial declines were observed among women (490.5 to 376.5 per 100,000 p-yrs) than men (346.2 to 313.7 per 100,000 p-yrs) (Figure 3a; Figure 3b). 

These recent trends in declining female gonorrhea incidence were primarily driven by rates among service members under age 25. While male gonorrhea rates declined for those 20-24 years of age during the last 5 years, the rates among men under age 20 and ages 25-29 remained relatively stable. Gonorrhea rates remained highest among non-Hispanic Black service members throughout the surveillance period, peaking at 1,229.3 per 100,000 p-yrs in 2020 and declining to 984.9 per 100,000 p-yrs in 2022 (data not shown).
Syphilis
The crude incidence rate for total cases of syphilis in 2022 (73.5 per 100,000 p-yrs) almost doubled the rate observed in 2014 (40.7 per 100,000 p-yrs). After a period of brief decline starting in 2019, rates increased by nearly 40% from 2020 to 2022. During this 3-year period, the 61.1% increase in female syphilis rates (37.8 to 60.9 per 100,000 p-yrs) exceeded the 35.8% increase among men (56.1 to 76.2 per 100,000 p-yrs) (Figure 4a; Figure 4b). 

Overall incidence rates of syphilis generally decreased with advancing age among both sexes; this pattern was consistent among all racial/ethnic groups. Non-Hispanic Black service members consistently accounted for the highest rates of syphilis throughout the surveillance period, with women under 25 years of age (122.6 per 100,000 p-yrs), men under age 25 (254.4 per 100,000 p-yrs), and men ages 25-34 (201.7 per 100,000 p-yrs) substantiating the largest rates stratified by age and biological sex within this racial/ethnic group in 2022 (data not shown).
Genital HPV
The crude annual incidence rates of genital HPV infections decreased 47.3% among all active component service members from the start of the surveillance period until the end, with the most marked absolute decrease among women. Incidence rates of genital HPV infections among female service members decreased from a high of 2,559.0 cases per 100,000 p-yrs in 2014 to a low of 1,406.6 cases per 100,000 p-yrs in 2022 (45.0%) (Figure 5a). While this crude decline was observed for all age groups, the rate of genital HPV among females 30-34 years old increased at 3 points annually during the surveillance period. The rate of genital HPV among males remained substantially lower than among women throughout the surveillance period, also demonstrating a major decline from 307.3 HPV cases per 100,000 p-yrs 2014 to 122.1 cases per 100,000 p-yrs in 2022 (60.3%). Beginning in 2020, genital HPV rates in men older than age 34 increased (Figure 5b). 

Genital HSV
Crude annual incidence rates of genital HSV infections decreased from 237.9 to 158.2 per 100,000 p-yrs over the course of the surveillance period (33.5%). Rates among female service members ranged from a high of 782.8 per 100,000 p-yrs in 2016 to a low of 434.0 per 100,000 p-yrs in 2022. During the last 5 years of the surveillance period, genital HSV rates among female service members declined by approximately 40% for all age groups except women ages 35-49, who had a more stable rate reduction of 22.3% (Figure 6a). Rates for male service members were also highest in 2016 (181.8 per 100,000 p-yrs) and lowest in 2022 (101.5 per 100,000 p-yrs). Men ages 20-24 demonstrated the largest HSV rate decline, of 38.6%, from 2018 to 2022 (Figure 6b). 

Over the surveillance period, the incidence rates of genital HSV infections decreased among service members in all age and racial/ethnic groups (data not shown). 

Discussion
This surveillance report documents a continued period of decline since 2019 for all STI case rates, with the exception of syphilis. After a brief decline in 2019, the incidence rate of syphilis among male and female active component service members increased by approximately 40% between 2020 and 2022. As noted by CDC national surveillance reports, the COVID-19 pandemic likely contributed to changes in STI screening coverage; thus, incidence rates during this time should be interpreted with caution.14 Future analyses of STI screening practices for active component service members may help elucidate true incidence rate declines, particularly for STIs more commonly associated with asymptomatic infection.
While age- and gender-adjusted STI rates among active duty service members remain elevated when compared to U.S. rates, this comparison is subject to unmeasured sociodemographic differences and case surveillance methodologies unique to each population. The U.S. military represents a ‘healthy worker’ population with no-cost access to complete preventive and primary care, for maintenance of a medically ready force.15 The electronic health records generated by the Military Health System (MHS) also enable more complete disease burden capture for notifiable disease reporting. The data source descriptions for chlamydia, gonorrhea, and syphilis in this report are provided to clarify the percentage of cases identified by sources supplemental to medical event reports.
Chlamydia rates were marked by a pronounced decline from 2019 to 2022, substantiated by distributed rates of decline by biological sex and all racial/ethnic groups among service members 25 years of age or younger. An assessment of screening rates may clarify whether this constituted a true decline in incidence, as chlamydia rates in the general population continued to increase during this period.4 Compared to most recently published 2021 national statistics, the chlamydia case rate for service members 20-24 years of age remains elevated in relation to the general population for both male (2,556.2 service members vs. 1,680.0 civilians per 100,000) and female (7,466.4 service members vs. 3,797.8 civilians per 100,000) rates among the same age group.16 These rate comparisons should, however, be interpreted with an understanding of the unique surveillance methods for each population, as well as their differences in screening access and use. Laboratory and medical encounter data from service members in 2022 supplemented chlamydia case rates by 13%; these cases had no medical event reports and would not have been identified without supplemental electronic health record data. 
While the national gonorrhea rate for civilians has continued to increase since its historic low in 2009, gonorrhea case rates among both male and female service members of the youngest age groups have reduced, with male service members ages 25-29 demonstrating a relatively stable rate of decline. Recently published national statistics for 2021 demonstrate relatively equivalent gonorrhea case rates for female service members and female civilian populations ages 20-24 (768.9 service members vs. 873.2 civilians per 100,000), while gonorrhea case rates among male service members 20-24 years of age were lower (540.5 service members vs. 844.2 civilians per 100,000) during the same year.17 These rate comparisons should be interpreted in concert with aforementioned case detection and surveillance methods, as 29% of the gonorrhea cases among service members in this report were identified from supplemental laboratory or medical encounter data.
Routine surveillance reports do not assess anatomic sites from gonorrhea case reports or laboratory records, which could provide more comprehensive understanding of extragenital infections in high-risk populations. National guidelines recommend screening for gonorrhea, including pharyngeal or rectal testing, at least annually for MSM and HIV-positive patients. Extragenital gonorrhea screening may be considered for females on the basis of reported sexual behaviors and exposure.18 Despite these recommendations, extragenital screening for high-risk civilian and military populations is underused.19,20 A recent assessment of extragenital STI screening by primary care physicians for HIV-positive airmen found that approximately one-third of patients had undetected STIs, the majority due to extragenital infections of the rectum and pharynx.20
A male-to-female syphilis rate ratio greater than 1 persisted throughout the surveillance period; meanwhile a recent relative increase in syphilis rates among female service members, particularly within the youngest age group, could indicate either improved accession screening or a true increase in rates among women. This finding is reflected in national surveillance reports: Although civilian rates of primary and secondary syphilis are lower among women, female incidence rates more than doubled from 2016 to 2020.21 This evidence reinforces U.S. Preventive Services Task Force recommendations on early screening for syphilis infection in all pregnant women, particularly for female military service members, who are largely within child-bearing years.22
No data on sexual risk behaviors were available, but prior surveys of military personnel have indicated increased behaviors of possible concern. The 2018 Department of Defense Health-Related Behaviors Survey (HRBS) documented that 19.3% of active component respondents reported 2 or more sexual partners within the past year, and 34.9% reported sex with a new partner without condom use in the past year; these percentages are almost double those from the 2011 survey.23
This report has several limitations that should be considered when interpreting its results. First, STI diagnoses could be incorrectly coded. For example, STI-specific “rule out” diagnoses or vaccinations (e.g., HPV vaccination) may be reported with STI-specific diagnostic codes, which would result in overestimation of STI incidence. Cases of syphilis, genital HSV, and genital HPV infections based solely upon laboratory test results are considered “suspect” because laboratory test results cannot distinguish between active and chronic infections. Because incident cases of those STIs were identified based upon a first qualifying encounter or laboratory result, it is likely most cases were acute and not chronic.
STI cases coded in the medical record using symptom codes (e.g., urethritis) rather than STI-specific codes may not be captured. In addition, the counts of STI diagnoses reported here may underestimate actual diagnoses because some affected service members may have been diagnosed and treated by non-reimbursed, non-military care providers (e.g., county health departments or family planning centers) or in deployed settings (e.g., overseas training exercises, combat operations, or aboard ships). Laboratory tests provided through (javascript:void(0);) Purchased CareThe TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.purchased care or from a shipboard facility, battalion aid station, or in-theater facility were not captured by the current analysis. Finally, medical data from July 2017 to October 2019 at sites using the new MHS electronic health record, MHS GENESIS, are not available in the DMSS—these sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center. Medical encounter data for individuals seeking care at any of those facilities between July 2017 and October 2019 could not be included in the current analysis.
For some STIs, detection of prevalent infection may occur long after an initial infection. Changes in incidence rates may reflect, at least in part, temporal changes in case detection, including shifts to more aggressive screening. The lack of standard service and installation practices for STI screening, testing, treatment, and reporting complicate interpretations of the differences between services, military and demographic subgroups, as well as locations. Establishing STI screening, testing, treatment, and reporting standards throughout the services, and ensuring adherence, would likely improve detection and characterization of STI-related health threats. Continued behavioral risk-reduction interventions are still required to counter STIs among military service members.
References

Armed Forces Health Surveillance Center. Absolute and relative morbidity burdens attributable to various illnesses and injuries, active component, U.S. Armed Forces, 2021. MSMR. 2022;29(6):2-9.
    National Academies of Sciences, Engineering and Medicine. 2021. Sexually Transmitted Infections: Adopting a Sexual Health Paradigm. Washington, DC: The National Academies Press. Accessed March 28, 2023. (https://pubmed.ncbi.nlm.nih.gov/34432397) https://pubmed.ncbi.nlm.nih.gov/34432397


(https://pubmed.ncbi.nlm.nih.gov/34432397) Boyer CB, Gaydos CA, Geller AB, et al. Sexually transmitted infections in the U.S. military: a sexual health paradigm to address risk behaviors, unintended pregnancy, alcohol use, and sexual trauma. Mil Med. 2022;187(5-6):140-143.
    Centers for Disease Control and Prevention. Preliminary 2021 STD Surveillance Data. Accessed March 28, 2023. (https://www.cdc.gov/std/statistics/2021/default.htm) https://www.cdc.gov/std/statistics/2021/default.htm


(https://www.cdc.gov/std/statistics/2021/default.htm) Krupp K, Madhivanan P. Antibiotic resistance in prevalent bacterial and protozoan sexually transmitted infections. Indian J Sex Transm Dis AIDS. 2015;36(1):3-8.
    Growing antibiotic resistance forces updates to recommended treatment for sexually transmitted infections [news release]. Geneva, Switzerland: World Health Organization. August 30, 2016. Accessed February 23, 2021. (https://www.who.int/news-room/detail/30-08-2016-growing-antibiotic-resistance-forces-updates-to-recommended-treatment-for-sexually-transmitted-infections) https://www.who.int/news-room/detail/30-08-2016-growing-antibiotic-resistance-forces-updates-to-recommended-treatment-for-sexually-transmitted-infections


(https://www.who.int/news-room/detail/30-08-2016-growing-antibiotic-resistance-forces-updates-to-recommended-treatment-for-sexually-transmitted-infections) Tien V, Punjabi C, Holubar MK. Antimicrobial resistance in sexually transmitted infections. J Travel Med. 2020;27(1):1-11.
    Kreisel KM, Spicknall IH, Gargano JW, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2018. Sex Transm Dis. 2021;48(4):208-214.
    Garland SM, Steben M, Sings HL, et al. Natural history of genital warts: analysis of the placebo arm of 2 randomized phase III trials of a quadrivalent human papillomavirus (types 6, 11, 16, and 18) vaccine. J Infect Dis. 2009;199(6):805-814.
    Armed Forces Health Surveillance Center. Sexually transmitted infections, active component, U.S. Armed Forces, 2000–2012. MSMR. 2013;20(2):5-10.
    Armed Forces Health Surveillance Division. Sexually transmitted infections, active compo­nent, U.S. Armed Forces, 2013–2021. MSMR. 2022;28(3):13-22.
    Garges E, Stahlman S, Jordan N, Clark LL. P3.69 Administrative medical encounter data and medical event reports for syphilis surveillance: a cautionary tale. Sex Transm Infect. 2017;93(suppl 2):A118.
    Armed Forces Health Surveillance Branch. Use of ICD-10 code A51.31 (condyloma latum) for identifying cases of secondary syphilis. MSMR. 2017;24(9):23.
    Centers for Disease Control and Prevention. National Overview of STDs, 2020. Accessed March 28, 2020. (https://stacks.cdc.gov/view/cdc/125947) https://stacks.cdc.gov/view/cdc/125947


(https://stacks.cdc.gov/view/cdc/125947) Tanielian T, Farmer C. The US Military Health System: promoting readiness and providing health care. Health Affairs. 38(8):1259-1267.
    Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021, Table 4: Chlamydia–Reported Cases and Rates of Reported Cases by Age Group and Sex, United States, 2017-2021. Accessed April 27, 2023. (https://www.cdc.gov/std/statistics/2021/tables/4.htm) https://www.cdc.gov/std/statistics/2021/tables/4.htm

    Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021, Table 9: Gonorrhea–Reported Cases and Rates of Reported Cases by Age Group and Sex, United States, 2017-2021. Accessed April 27, 2023. (https://www.cdc.gov/std/statistics/2021/tables/9.htm) https://www.cdc.gov/std/statistics/2021/tables/9.htm


(https://www.cdc.gov/std/statistics/2021/tables/9.htm) Workowski KA, Bachmann LH, Chan PA. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.
    Li J, Armon C, Palella FJ, et al. Chlamydia and gonorrhea incidence and testing among patients in the Human Immunodeficiency Virus Outpatient Study (HOPS), 2007-2017. Clin Infect Dis. 2020;71(8):1824-1835.
    Yabes JY, Lamb CC, Hakre S, et al. Provider uptake of extragenital screening for gonorrhea and chlamydia in a cohort of Air Force members with incident HIV diagnosis. Medicine. 2022;101(42):e31209.
    Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021. Table 15. Primary and Secondary Syphilis–Reported Cases and Rates of Reported Cases by Age Group and Sex, United States, 2017-2021. (https://www.cdc.gov/std/statistics/2021/tables/15.htm) https://www.cdc.gov/std/statistics/2021/tables/15.htm


(https://www.cdc.gov/std/statistics/2021/tables/15.htm) U.S. Preventive Services Task Force, Curry SJ, Krist AH, Owens DK, et al. Screening for syphilis infection in pregnant women: US Preventive Services task force reaffirmation recommendation statement. JAMA. 2018;320(9):911-917.
    Meadows SO, Engel CO, Collins RL, et al. 2018 Department of Defense Health Related Behaviors Survey (HRBS): Results for the Active Component. Sexual Behavior and Health. RAND Corporation Report. Accessed March 16, 2022. (https://www.rand.org/pubs/research_reports/RR4222.html) https://www.rand.org/pubs/research_reports/RR4222.html


(https://health.mil/News/Articles/2023/03/01/Notice-to-Readers) Notice to Readers: Vector-borne Disease Branch Detects Borrelia miyamotoi in Human Tick Submission
Feb 28th 2023, 19:00

The Defense Centers Public Health–Aberdeen Vector-Borne Disease Branch has confirmed the presence of Borrelia miyamotoi, an emerging tick-borne pathogen that causes hard tick relapsing fever. This pathogen was detected for the first time at DCPH-A, following implementation of a new molecular test to detect and differentiate between the related agents of Lyme disease and HTRF. The pathogen was found in a human-biting tick submitted in January 2023 to the Military Tick Identification/Infection Confirmation Kit (MilTICK) Program.

MilTICK offers free testing and identification services for ticks removed from Department of Defense beneficiaries, including service members from all branches, civilians, contractors, retirees, and dependents. Any tick found biting an eligible person can be submitted to MilTICK by health care providers through tick kits available at DOD health care facilities, or by individuals through a simple mail-in process. Approximately 3,000 human-biting ticks are tested each year, with each tick species identified, assessed for duration of attachment, and tested for the relevant suite of human pathogens. Results are returned via email to the point of contact provided on the MilTICK form and are used to assess the risk of tick-borne disease to military personnel. Recent tick surveillance data can be accessed through the MilTICK CAC-enabled data dashboard at (https://carepoint.health.mil/) https://carepoint.health.mil/.
For additional information, or to request tick kits or services, contact the VBD Branch:
Phone: 410-436-5421 or 410-436-5425
Email: (mailto:usarmy.apg.medcom-a.phc.mbx.tickcom at health.mil) usarmy.apg.medcom-a.phc.mbx.tickcom at health.mil

Website: (https://phc.amedd.army.mil/topics/envirohealth/epm/Pages/HumanTickTestKitProgram.aspx) https://phc.amedd.army.mil/topics/envirohealth/epm/Pages/HumanTickTestKitProgram.aspx

(https://health.mil/News/Articles/2023/03/01/Malaria-Update) Update: Malaria Among Members of the U.S. Armed Forces, 2013–2022
Feb 28th 2023, 19:00

Malaria infection remains a potential health threat to U.S. service members located in or near endemic areas due to duty assignment, participation in contingency operations, or personal travel. In 2022, a total of 30 active and reserve component service members were diagnosed with or reported to have malaria, a 42.9% increase from the 21 cases identified in 2021. Over half of the malaria cases in 2022 were caused by Plasmodium falciparum (53.3%; n=16) and one-sixth (16.7%; n=5) were attributed to P vivax. The remaining 9 cases were associated with other or unspecified types of malaria. Malaria cases were diagnosed or reported from 19 different medical facilities—15 in the U.S. and 1 each from Germany, Africa, South Korea, and Japan. Of the 28 cases with a known location of diagnosis, 9 (32.1%) were reported from or diagnosed outside the U.S.
What are the new findings? 

Total malaria cases have decreased since 2016, likely due to the reduction in forces deployed to Afghanistan, a known malaria risk area. The reduction in case counts over the last three years of the period may be due in part, to COVID-19-related travel restrictions, curtailing travel to malaria risk areas.

What is the impact on readiness and force health protection?
Malaria infection causes acute incapacitation. P falciparum malaria poses a high risk of serious sequelae including death. Unprotected forces can experience extraordinarily high attack rates in highly endemic areas, potentially causing mission failure. Malaria poses a risk for service members deployed to endemic regions as well as those traveling to such areas for personal reasons. The finding that P falciparum malaria was diagnosed in more than half of cases in 2022 underscores the need for continued emphasis on effective preventive measures against this most dangerous malaria strain.
Background
Since 1999, the MSMR has published regular updates on malaria incidence among U.S. service members.1-3 This year's update employs methods similar to previous analyses describing the epidemiologic patterns of malaria incidence among service members in the active and reserve components of the U.S. Armed Forces. The MSMR's focus on malaria reflects both historical lessons about this mosquito-borne disease and its continuing threat to military operations and service members’ health. 
Malaria is a febrile parasitic disease transmitted through the bite of an infected female Anopheles mosquito. The parasite P falciparum is responsible for the deadliest form of malaria and is most prevalent in Africa.4P vivax is the most widely distributed parasite species, with relatively high infection prevalence in the Western Pacific, Southeast Asia, and Eastern Mediterranean regions and less densely populated areas of the Americas.4
P vivax and P falciparum have distinct epidemiologies. A major difference is P vivax's ability to cause relapses weeks or months following primary infection due to its activation of hypnozoites, dormant liver-stage parasites.5 This infection reservoir allows P vivax's survival during mosquito-free cold seasons, expanding its geographic range far into temperate zones such as the Korean peninsula.6 Relapse can be prevented with presumptive anti-relapse therapy (PART), but the risk must be recognized, with appropriate therapy (primaquine or tafenoquine) prescribed and regimen successfully completed after departing the malaria-endemic area.7,8
In 2021, approximately 95% of global malaria cases and related deaths were in sub-Saharan Africa, where four countries accounted for more than half (52%) of this mortality: Nigeria (31%), Democratic Republic of the Congo (13%), the Niger (4%), and the United Republic of Tanza­nia (4%).4 Most of these cases and deaths were due to mosquito-transmitted P falciparum among children under age 5.4 In 2021, 2% of global estimated malaria cases were caused by P vivax.4 While heightened malaria-control efforts have reduced the incidence of P falciparum malaria in many areas, the proportion of P vivax malaria cases has increased in some regions where both parasites are present.9,10 
(https://health.mil/Reference-Center/Reports/2023/03/01/MSMR-March-2023-Article-2-Table-1) 
Methods
The surveillance period for this report was January 1, 2013 through December 31, 2022. The surveillance population included Army, Navy, Air Force, and Marine Corps active and reserve component members of the U.S. Armed Forces. The records of the Defense Medical Surveillance System were searched for qualifying evidence of malaria diagnoses from reportable medical events, hospitalizations or outpatient encounters (in military and non-military facilities), and laboratory results generated at military facilities. The case definition criteria included 1) an RME record of confirmed malaria, 2) a hospitalization record with a primary diagnosis of malaria, 3) a hospitalization record with a nonprimary diagnosis of malaria due to a specific Plasmodium species, 4) a hospitalization record with a nonprimary diagnosis of malaria and diagnosis of anemia, thrombocytopenia and related conditions, or malaria complicating pregnancy in any diagnostic position, 5) a hospitalization record with a nonprimary diagnosis of malaria plus diagnoses of signs or symptoms consistent with malaria in each diagnostic position antecedent to malaria,11 or 6) a positive malaria antigen test plus an outpatient record with a diagnosis of malaria in any diagnostic position within 30 days of the specimen collection date. The relevant International Classification of Diseases, 9th and 10th Revision (ICD-9 and ICD-10, respectively) codes used to identify cases are shown in Table 1.
The analysis restricted each service member to one episode of malaria per 365-day period. When multiple records documented a single episode, the date of the earliest record was considered the date of clinical onset. Records within 30 days of the clinical onset date were reviewed for evidence of a Plasmodium species.

Presumed location of malaria acquisition was estimated using a hierarchical algorithm: 1) cases diagnosed in a malaria-endemic country were considered acquired there, 2) RMEs listing exposures to malaria-endemic locations were considered acquired in those locations, 3) RMEs not listing exposures to malaria-endemic locations but reported from installations in such locations were considered acquired there, 4) cases diagnosed among service members during or within 30 days of deployment or assignment to a malaria-endemic country were considered acquired in that country, and 5) cases diagnosed among service members deployed or assigned to a malaria-endemic country within two years before diagnosis were considered acquired in those respective countries. All remaining cases were considered acquired in unknown locations.
Results
In 2022, a total of 30 U.S. service members were diagnosed with or reported to have malaria (Table 2), resulting in a rate of 1.4 per 100,000 persons (data not shown).
(https://health.mil/Reference-Center/Reports/2023/03/01/MSMR-March-2023-Article-2-Table-2) 
The 2022 total is a 42.9% increase from the 21 cases ascertained in 2021 (Figure 1). Twenty-two of the 30 cases (73.3%) in 2022 were identified from inpatient data and reported as RMEs; the remaining eight cases were identified from inpatient data and did not have associated RMEs. In 2022, no cases were identified from laboratory data in combination with an outpatient record of malaria.

As in previous years, in 2022 the majority of U.S. military members diagnosed with malaria were men (96.7%), members of the active component (90.0%), and in the Army (66.7%). In 2022, non-Hispanic Black service members and those under age 30 accounted for the most cases of malaria (56.7% and 53.3%, respectively) (Table 2). 
Over half of the malaria cases in 2022 were caused by P falciparum (53.3%; n=16). Of the 14 cases not attributed to P falciparum, 5 (16.7%) were identified as due to P vivax and 9 were labeled as associated with other/unspecified types of malaria (30.0%) (Figure 1). This result reflects historical data over a 10-year surveillance period, where malaria cases caused by P falciparum have accounted for the largest number of cases (n=170; 43.1%), followed by other/unspecified species (n=116; 29.4%), P vivax (n=93; 23.6%), and other Plasmodium species (n=15; 3.8%). The annual percentages of cases attributed to P vivax showed the greatest variability during the period, ranging from 9.5% in 2021 to 53.6% in 2020.
During the 2013 to 2022 surveillance period, malaria cases attributed to Africa accounted for the greatest number of cases (n=149; 37.8%), followed by other/unspecified locations (n=96; 24.4%), Korea (n=67; 17.0%), Afghanistan (n=80; 9.6%), and South/Central America (n=2; 0.5%) (Figure 2).

The annual percentages of cases associated with Africa had the greatest variability during the 10-year surveillance period, ranging from 17.9% in 2020 to 57.1% in 2021. From 2021 to 2022, the number of cases associated with Korea demonstrated the greatest increase, from 3 to 9; these 9 cases are the most from Korea since 2018. Since 2013, only 2 years (2014, with 13 cases; and 2016, with 11 cases) recorded higher totals (Figure 2). Malaria cases were diagnosed or reported in 2022 at 19 different medical facilities in the U.S., Germany, Africa, South Korea, and Japan (Table 3).
(https://health.mil/Reference-Center/Reports/2023/03/01/MSMR-March-2023-Article-2-Table-3) 
Most cases acquired in Africa were caused by P falciparum (80.0%;12/15), and more than two-fifths (44.4%; 4/9) of the cases considered as acquired in Korea were caused by P vivax (Figure 3). Of the 15 malaria infections in 2022 considered to be acquired in Africa, 4 were linked to Nigeria; 4 were associated with unknown African locations; 3 were linked to Niger; and 1 each were linked to Chad, Cameroon, Djibuti, and Uganda (data not shown). Examination of 22 malaria case records reported as RMEs revealed that 12 of the exposures were classified as deployment-related while 10 were categorized as nonduty-related, of which nine were considered acquired in Africa. Non-Hispanic Black service members accounted for eight of those nonduty cases; leisure travel to African countries was documented in the RME records of four of these service members.

>From 2013 to 2022, most non-P vivax malaria cases (70.2%) were diagnosed or reported during the six months from the middle of spring through the middle of autumn (May-October) in the Northern Hemisphere (Figure 4). This result is comparable to 2022, when 72.0% (n=23) of non-P vivax malaria cases among U.S. service members were diagnosed from May through October (data not shown). During the 10-year surveillance period, the proportions of non-P vivax malaria cases diagnosed or reported from May to October varied by region of acquisition: Korea (87.1%; 27/31); Afghanistan (86.8%; 33/38); Africa (68.3%; 97/142); and South/Central America (100.0%; 1/1) (data not shown).

Discussion
In 2022 P falciparum was responsible for more than half of U.S. service member malaria cases, underscoring the need for continued emphasis on prevention of this disease, given its potential severity and risk of death. Adherence to malaria prevention protocols is critical for military personnel when entering malaria-endemic areas. Personal protective measures against malaria include bed nets, topical insect repellent, permethrin-treated uniforms, along with chemoprophylaxis regimen compliance. Current Department of Defense guidance on medications for malaria prophylaxis summarizes the roles of chloroquine, atovaquone-proguanil, doxycycline, mefloquine, primaquine, and tafenoquine.12 
Malaria remains a potential health threat to U.S. military personnel in endemic areas as a consequence of long-term duty assignments, shorter-term contingency operations, as well as personal travel. The low case counts and rate of malaria reported during the surveillance period are primarily due to the limited number of service members at risk, as most duty locations in malaria-endemic countries are far removed from areas of malaria transmission. Complacency and inattention to the serious threat of malaria, however, can have disastrous consequences during deployment to malaria-endemic regions. Just 2 decades ago, in 2003, 225 U.S. Marines were sent to augment U.S. embassy security in Liberia,13 and that mission’s failure of appropriate countermeasures led to 80 suspected cases of P falciparum malaria, with an estimated attack rate of 36%. Those malaria cases necessitated 44 medical evacuations and resulted in 5 complicated cases requiring ICU admission, ventilator, and vasopressor support.13  

In addition to deployment exposures, malaria poses a significant medical concern for service members on leave traveling to malaria-endemic regions14,15; of particular concern is foreign-born personnel who travel on personal leave to their countries of origin. A prior study demonstrated that malaria rates among military members born in 7 western Africa countries were 44 times greater than those born in the U.S.14 Leisure travel to specific African countries as reported on RME records may account, at least in part, for the disproportionately high malaria rates observed among non-Hispanic Black service members in this report. Among those service members visiting their birth countries in malaria-endemic regions, susceptibility due to loss of partial immunity from previous continuous exposure poses a substantial risk for infection and morbidity.16
The observations about diagnosis seasonality for non-P vivax malaria are compatible with the presumption that risk of acquiring malaria in a temperate climatic zone of the Northern Hemisphere is greatest from May through October. Given the typical incubation periods of malaria infection (approximately 9-14 days for P falciparum, 12-18 days for P vivax and P ovale, and 18-40 days for P malariae)17 and the seasonal disappearance of biting mosquitoes during the winter, most malaria acquired in Korea and Afghanistan would be expected to cause initial symptoms during the warmer months. If primary prophylaxis is taken during the exposure period, however, initial symptoms may be suppressed. Studies of P vivax malaria in Korea have found that duration between primary infection and relapse among different P vivax strains ranges between 8 days and 8-13 months.18 Up to 40–50% of infected individuals do not manifest symptoms until 6-11 months after infection.19 Transmission of malaria in tropical regions such as sub-Saharan Africa occurs year-round but is location-specific.20
Much of the decline in cases early in the surveillance period is attributable to the decreases in military personnel in Afghanistan. The lower case counts in the last 3 years of the period may be due, at least in part, to COVID-19-related travel restrictions to, from, or through many malaria-endemic areas.
There are limitations to this report that should be considered when interpreting its findings. Ascertainment of malaria cases, especially among reserve components as well as non-deployment-related exposures, is likely incomplete, leading to rate underestimation. Some cases treated at deployed or non-U.S. military medical facilities may not have been reported or otherwise ascertained at the time of analysis. It should be noted that medical data from July 2017 through October 2019 at sites using the Military Health System's new electronic health record, MHS GENESIS, are not available in the DMSS—these sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center. Medical encounter data for individuals seeking care at any of those facilities from July 2017 through 2019 were not included in the current analysis.
Diagnoses of malaria documented only in outpatient settings without confirmatory testing and not reported as notifiable events were not included in this report. The geographic location where malaria was acquired was estimated from reported information. Some cases had reported exposures in multiple malaria-endemic regions or areas, and others had no relevant exposure or information. Personal travel to or deployment in malaria-endemic countries was not accounted for unless specified in notifiable event reports. Limited information on species type in RME records highlights the need for more attention to complete documentation of reportable conditions.
Acknowledgements
The authors thank the Navy Marine Corps Public Health Center, Portsmouth, VA, for providing laboratory data for this analysis.
References

U.S. Army Center for Health Promotion and Preventive Medicine. Malaria, U.S. Army, 1998. MSMR. 1999;5(1):2-3.
    U.S. Army Center for Health Promotion and Preventive Medicine. Malaria experience among U.S. active duty soldiers, 1997-1999. MSMR. 1999;5(8)2-3.
    Armed Forces Health Surveillance Branch. Update: malaria, U.S. Armed Forces, 2021. MSMR. 2022;27(2):2-7.
    World Health Organization. World Malaria Report 2022. Geneva, Switzerland: World Health Organization; 2022. Accessed January 23, 2023. (https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022) https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2022

    Howes RE, Battle KE, Mendis KN, Smith DL, Cibulskis RE, Baird JK, Hay SI. Global epidemiology of Plasmodium vivax. Am J Trop Med Hyg. 2016;95(suppl 6):15-34.
    Gething PW, Elyazar IR, Moyes, et al. A long neglected world malaria map: Plasmodium vivax endemicity in 2010. PLoS Negl Trop Dis. 2012;6(9):e1814. 
    Nascimento TL, Vasconcelos SP, Peres Y, Oliveira MJS, Taminato M, Souza KMJ. Prevalence of malaria relapse: systematic review with meta-analysis. Rev Latino-Am Enfermagem. 2019;27:e3111. 
    Haston JC, Hwang J, Tan KR. Guidance for using tafenoquine for prevention and antirelapse therapy for malaria–United States, 2019. MMWR Morb Mortal Wkly Rep. 2019;68(46):1062-1068. 
    Price RN, Commons RJ, Battle KE, Thriemer K, Mendis K. Plasmodium vivax in the era of the shrinking P. falciparum map. Trends Parasitol. 2020;36(6):560-570. 
    Battle KE, Lucas TC, Nguyen M, et al. Mapping the global endemicity and clinical burden of Plasmodium vivax, 2000–17: a spatial and temporal modelling study. Lancet. 2019;394(10195):332-343. Armed Forces Health Surveillance Branch. Surveillance Case Definition: Malaria. February 2019. Accessed February 24, 2023. (https://reference-center/Publications/2014/12/01/Malaria) //Reference-Center/Publications/2014/12/01/Malaria. 
    Defense Health Agency. Procedural Instruction 6490.03. Deployment Health Procedures. December 17, 2019. 
    Whitman TJ, Coyne PE, Magill AJ, et al. An outbreak of Plasmodium falciparum malaria in U.S. Marines deployed to Liberia. Am J Trop Med Hyg. 2010;83(2):258-265.
    Wertheimer ER, Brundage JF, Fukuda MM. High rates of malaria among US military members born in malaria-endemic countries, 2002–2010. Emerg Infect Dis. 2011;17(9):1701-1703. 
    Ashley DP, et al. for the IDCRP TravMil study group. A comparison of pretravel health care, travel-related exposures, and illnesses among pediatric and adult U.S. Military beneficiaries. Am J Trop Med Hyg. 2019;100(5):1285-1289. 
    Pousibert-Puerto J, Lozano-Serrano AB, Soriano-Perez MJ, et al. Migration-associated malaria from Africa in southern Spain. Parasites Vectors. 2021;14(240). 
    White NJ. Malaria. In: Cook GC, Zumla AI, eds. Manson’s Tropical Diseases. 22nd ed. London: Saunders Elsevier; 2009:1201-1300.
    White, NJ. Determinants of relapse periodicity in Plasmodium vivax malaria. Malar J. 2011;(10):297. 
    Distelhorst JT, Marcum RE, Klein TA, Kim HC, Lee WJ. Report of two cases of vivax malaria in U.S. soldiers and a review of malaria in the Republic of Korea. MSMR. 2014;21(1):8-14.
    Fairhurst RM, Wellems TE. Plasmodium species (malaria). In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Churchill Livingstone Elsevier; 2010.


(https://health.mil/News/Articles/2023/03/01/Letter-to-the-Editor) Letter to the Editor: Military Health System Exceeded Healthy People 2020 Goal for Rotavirus Vaccination
Feb 28th 2023, 19:00

We read with great interest the (https://health.mil/News/Articles/2022/11/01/Brief-Report-MSMR) Brief Report in the November 2022 issue of the MSMR about pediatric vaccination rates by Romano et al.1 The immunization schedule recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention provides guidance on protecting infants and children from preventable infectious diseases, and well-established national metrics allow assessment of Military Health System performance.
While the authors make some comparisons to national vaccination data, CDC’s Healthy People 2020 goals also provide a benchmark to compare MHS vaccination rates. The Healthy People initiative is the federal government’s prevention agenda, developed and published by the CDC, for building a healthier nation that includes goals to attain longer lives free of preventable disease.2 It is updated every 10 years.
For rotavirus vaccine, the Healthy People 2020 goal was 80% of children receiving two or more doses of vaccine by ages 19-35 months (can receive vaccine up to eight months of age). The data presented by Romano et al. not only show that completion of rotavirus vaccine series well exceeded this metric by 2016 (92.4%), but that compliance with the rotavirus vaccine series was also above 80%. In comparison, at the Healthy People 2020 final review, only 73.5% of children in the U.S. had completed two or more doses of rotavirus vaccine. The data presented by Romano et al. also demonstrate better vaccination rates for polio and DTaP compared to the Healthy People 2020 final review.3
This is an important perspective, as medical care for pediatric dependents of military service members involves extra variables that add complexity to vaccine series completion (e.g. frequent moves, parent deployments). Nevertheless, high vaccination rates for pediatric dependents of military service members occurred, with 82.5% of children receiving care in military clinics, despite 61.1% of children experiencing a change in well-child care location and 16.8% of mothers deploying within 24 months postpartum.1
We concur with Romano et al. to suggest continued efforts for improving pediatric vaccination rates and the removal of barriers delaying vaccination within the MHS. We encourage the authors and other researchers to consider quantifying their data in relation to well-established national metrics to demonstrate MHS successes, as in this case, as well as identifying areas in need of improvement.
Author Affiliations
Air Force Medical Readiness Agency, Falls Church, VA (Lt. Col. Sayers); Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, Maryland (Lt. Col. Reynolds).
Disclaimer
The contents described in this publication are those of the authors and do not necessarily reflect official policy of the Department of the Air Force or Walter Reed National Military Medical Center.
References

Romano CJ, Bukowinski AT, Hall C, Burrell M, Gumbs GR, Conlin AVS, Ramchandar N. Brief report: pediatric vaccine completion and compliance among infants born to female active duty service members, 2006-2016. MSMR. 2022;29(11):18-22. 
    Centers for Disease Control and Prevention. Healthy People 2020. Updated March 14, 2014. Accessed February 25, 2023. (https://www.cdc.gov/dhdsp/hp2020.htm#:~:text=The%20over%C2%ADarching%20goals%20of%20Healthy,good%20health%20for%20all%3B%20and) https://www.cdc.gov/dhdsp/hp2020.htm#:~:text=The%20over­arching%20goals%20of%20Healthy,good%20health%20for%20all%3B%20and


(https://www.cdc.gov/dhdsp/hp2020.htm#:~:text=The%20over%C2%ADarching%20goals%20of%20Healthy,good%20health%20for%20all%3B%20and) National Center for Health Statistics. Healthy People 2020 Final Review. Accessed March 9, 2023. (https://dx.doi.org/10.15620/cdc:111173) https://dx.doi.org/10.15620/cdc:111173

In Reply
We thank Drs. Sayers and Reynolds for their interest in our brief report, "(https://health.mil/News/Articles/2022/11/01/Brief-Report-MSMR) Pediatric Vaccine Completion and Compliance Among Infants Born to Female Active Duty Service Members, 2006-2016." 
We agree with Drs. Sayers and Reynolds that the MHS performed well in relation to the U.S. population. We included comparisons to national estimates throughout the study period to facilitate this assessment, but elected not to include Healthy People 2020-realized estimates for comparative benchmarking because the study period did not fully correlate with the dates for this national framework. We agree, however, that there is added value in contextualizing our measures with Healthy People 2020 targets. Although MHS vaccination coverage did not achieve the Healthy People 90% target for diphtheria, tetanus, and acellular pertussis, MHS coverage surpassed the 90% and 80% targets for inactivated polio virus and rotavirus vaccines, respectively. In our ongoing work on pediatric immunizations, where we extend the study period to include the COVID-19 era and assess the complete pediatric immunization series, we will integrate discussion of Healthy People 2020 and 2030 targets.
Celeste J. Romano, M.S.; Anna T. Bukowinski, M.P.H; Clinton Hall, Ph.D.; Monica Burrell, M.P.H; Gia R. Gumbs, M.P.H; Ava Marie S. Conlin, D.O., M.P.H; Nanda Ramchandar, M.D., M.P.H

(https://health.mil/News/Articles/2023/03/01/Defense-Intrepid-Network-Supports-Service-Members-Across-the-Continuum) Defense Intrepid Network Supports Service Members Across the Continuum
Feb 28th 2023, 19:00

The (https://health.mil/Military-Health-Topics/Centers-of-Excellence/NICOE/About/Defense-Intrepid-Network-for-TBI-and-Brain-Health) Defense Intrepid Network for TBI and Brain Health’s Continuum of Caring, Healing, and Thriving initiative, headquartered at the (https://www.health.mil/Military-Health-Topics/Centers-of-Excellence/NICOE) National Intrepid Center of Excellence in Bethesda, Maryland, is a comprehensive interdisciplinary approach to address the full continuum of traumatic brain injury, behavior health, and brain health.
Over the past 22 years, (https://health.mil/Military-Health-Topics/Centers-of-Excellence/Traumatic-Brain-Injury-Center-of-Excellence/DOD-TBI-Worldwide-Numbers) more than 468,000 service members have sustained a TBI. The majority of TBI events occur in training: Breaching, anti-tank weapon use, combatives, parachute jumping, and blast exposure, according to the (https://health.mil/Military-Health-Topics/Centers-of-Excellence/Traumatic-Brain-Injury-Center-of-Excellence/DOD-TBI-Worldwide-Numbers) Traumatic Brain Injury Center of Excellence.

This high rate of TBI affects the readiness of the U.S. armed forces. To ensure a medical ready force, we must engage service members prior to an initial TBI event. This is the beginning of the continuum of care.
“We know the service members at highest risk for TBI and associated conditions and recognize the importance of preparing them for the careers they go into,” said U.S. Navy Capt. Carlos Williams, director of the NICoE. “In fact, to gain a better understanding of how widespread brain injuries are and the impact these injuries can have on our service members, we should also begin to more closely engage our aviation and undersea communities.”
“During this pre-TBI phase, we must use foundational tools such as education, integrative health services, and other best practices to build resilience and, when possible, prevent the event or complications altogether,” he said.
A goal of the continuum of care is to partner with the operational community and others in the TBI clinical, research, and academic spaces to educate service members and their families about TBI, its effect on brain function, and activities to help restore the brain immediately after an injury or after having persistent symptoms for many years.
In addition, service members can be taught elements of the integrative health services that are a part of the Defense Intrepid Network’s patient-centric interdisciplinary care model. These may include yoga, meditation, breath work, and art therapy to help process fragmented trauma memories and be used life-long to address future trauma and build resiliency, said Dr. Thomas DeGraba, chief innovations officer for the NICoE.
The continuum aligns with the (https://health.mil/News/Articles/2022/11/17/DOD-Brain-Health-Initiative-is-at-Work-Across-the-Military) Warfighter Brain Health Initiative that supports prevention and establishes resilience in the pre-TBI state.
The five lines of effort of the Warfighter Brain Health Initiative are:

Optimize cognitive and physical performance 
    Identify, monitor, and mitigate brain exposures 
    Prevent, recognize, and minimize the effect of TBI 
    Reduce or eliminate long-term/late effects 
    Advance warfighter brain health science

The next step in the continuum of care is treating those with TBI. For service members who visit the NICoE, one of the 11 Intrepid Spirit Centers or two clinics in the Defense Intrepid Network, the interdisciplinary care model enhances their trajectory of recovery with skills-based training and education. Patients can go at their own pace and process things in a safe environment at one of the ISCs or clinics.
After treatment, the continuum facilitates continued healing, recovery, and the transition to full duty or civilian life through a network of partnerships across the Department of Defense, Department of Veterans Affairs, non-governmental military and veterans support organizations, academia, industry, and the TBI community. 
These partners provide top quality follow-up care, case management, peer support groups, and other services to assist in healing and thriving.
“Any organization that offers resources to our beneficiaries, we hope to identify them and help our members take advantage of those resources. Simply put, the continuum ensures that we prepare for, treat when needed, and continue to support lifelong recovery so that no one is left behind,” said Williams. 
It also means continually evaluating how service members respond to care in the Defense Intrepid Network, which leads to constant updating of best practices throughout the continuum. 
“I am excited for the future of the Defense Intrepid Network,” said Williams. “It is built on inclusiveness and allows participation from providers and experts across the Military Heath System and beyond to contribute to improving care and quality of life of our service members.”

(https://health.mil/News/Articles/2023/02/27/DHA-Supports-National-Guard-and-Reserve-Deployment-Health-Needs) DHA Supports National Guard and Reserve Deployment Health Needs
Feb 26th 2023, 19:00

The (https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program) Reserve Health Readiness Program provides services to members of the National Guard or Reserve and to active duty service members enrolled in (https://www.tricare.mil/tpr) TRICARE Prime Remote, including medical readiness, dental readiness, and deployment services.
 “The RHRP helps to ensure that all service members are ready for mobilization or deployment,” said U.S. Army Col. Eric Bullock, director of the RHRP Program Management Office. “We are making sure they are ready to go out with their units in order to project power.”
The RHRP serves about 400,000 service members annually, providing an estimated 3 million individual services.
Who does the RHRP support?
RHRP supports active duty service members enrolled in TRICARE Prime Remote who live and work more than 50 miles (or one hour’s drive time) from a military hospital or clinic. In addition, RHRP supports the following reserve components:

(https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program/Army-National-Guard) U.S. Army National Guard
    (https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program/Army-Reserve) U.S. Army Reserve
    (https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program/Marine-Forces-Reserve) U.S. Marine Forces Reserve
    (https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program/Navy-Reserve) U.S. Navy Reserve
    (https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program/Air-Force-Reserve-Command) U.S. Air Force Reserve
    (https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program/Air-National-Guard) U.S. Air National Guard
    (https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program/Coast-Guard-Reserve) U.S. Coast Guard Reserve

The program also covers post-deployment health reassessments for (https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program/DoD-Civilian) federal civilians of the (http://) U.S. Army Corps of Engineers and the (https://www.army.mil/inscom) U.S. Army Intelligence and Security Command.
There are no out-of-pocket costs for authorized services when service members and federal civilians have an approved voucher for care.
RHRP Services
“The RHRP fills the gap when MTFs [military hospitals or clinics] are either not available, at capacity, or unable to provide the level of support that reserve components require for medical readiness and deployment related services,” said Mark Chin, DHA RHRP program manager.
The RHRP’s contract partner provides a network of civilian providers and facilities to support services including individual medical readiness, dental, deployment readiness, and physical exams (some occupational exams).
The service member, their unit leadership, or their service component can request these services.
“The RHRP gives these members the assessments they need in order to maintain their individual medical readiness,” said Bullock.
How to Access Services
There are three ways to get (https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program/Our-Services) RHRP services:

In-clinic appointments: Service members can get individual services by using the RHRP's network of civilian medical and dental providers. These providers are located within one hour of the service member's preferred location. 
    Group events: These group events are held at unit armories or other medical facilities. Unit commanders can request this service.

(https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program) Call center: Mental health assessments, consultations, and periodic health assessments are available using the call center if a clinic isn’t available within a reasonable distance.

What is Individual Medical Readiness?
Maintaining one’s individual medical readiness is a continuous responsibility. It rests with the individual being supported and monitored through unit leadership. This ensures military personnel are mission ready and worldwide deployable. Members of the National Guard, Reserve, and active duty service members in remote locations face unique challenges, as military medical readiness and deployment-related requirements are sometimes not available in all civilian communities.
In addition to the periodic health assessments mentioned previously, the RHRP also offers:

(https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/DES/Separation-Health-Assessment) Separation History and Physical Examinations(https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Disability-Evaluation/Separation-Health-Assessment)  

    Immunizations
    Dental services
    Vision assessments
    Hearing assessments
    Post-deployment health assessments
    Physical exams
    Mental health assessments
    Laboratory services
    Deployment health readiness assessments

(https://health.mil/Reference-Center/Frequently-Asked-Questions/Reserve-Health-Readiness-Program-General) RHRP’s website has answers to questions concerning services provided and how to access RHRP services or contact information for help.
What Happens if a Service Member Fails an Assessment?
Service members may have an underlying health problem. This may cause them to fail an assessment.
“If something is found, a profile is started and the service member and service component are made aware,” said Chin. “If a service member requires a referral for something found during an assessment, it’s up to that member to follow up.”
Unless the condition is service connected, the reserve component service member will need to make their own arrangements for civilian follow-up. “If they’re eligible, this is a great opportunity to enroll in (javascript:void(0);) TRICARE Reserve SelectA premium-based plan for qualified Selected Reserve members and their families.TRICARE Reserve Select,” said Bullock.
“We have no authority to make a referral appointment for them,” said Chin. “It’s up to the service member and the unit commander to ensure things get accomplished.”
RHRP Changes Coming in March
In March 2023, the RHRP contract services will be assumed by a company called QTC.
During this time, RHRP’s focus remains on the readiness of reservists, guardsmen, and active duty service members.
“From a service member perspective, they will not see any changes in service,” said Chin. A new website and telephone number will be available on March 1.
Check back often for new information on the (https://health.mil/Military-Health-Topics/Health-Readiness/Reserve-Health-Readiness-Program) RHRP website.

(https://health.mil/News/Articles/2023/02/24/Innovations-in-Military-Medicine-Recognized-by-Military-Health-System) Innovations in Military Medicine Recognized by Military Health System
Feb 23rd 2023, 19:00

Military Health System leaders were recognized in two ceremonies at the annual meeting of AMSUS, the Society of Federal Health Professionals, held in National Harbor, Maryland, from Feb. 13-16. 
AMSUS recognized federal health care professionals from the U.S. Army, U.S. Navy, U.S. Air Force, U.S. Public Health Service, U.S. Department of Veterans Affairs, U.S. Department of Homeland Security, U.S. Department of Health and Human Services, and the Uniformed Services University of the Health Sciences.

(https://health.mil/News/Articles/2023/02/23/How-to-Exercise-and-Train-during-this-Winters-Extremes) How to Exercise and Train During this Winter's Extremes
Feb 22nd 2023, 19:00

California has been lashed with storms piling up record amounts of snow in the Sierras and flooding many other parts of the state, while the southwest and northern states have seen bitter cold and dangerous amounts of snow and wind. These weather extremes can affect your ability to stay healthy and safe while exercising, training, or working outdoors during the winter. Here’s what our military experts have to say.
Dress Correctly
Many people struggle to maintain their exercise routines while indoors. Outdoor exercise routines can still be enjoyed in cold weather with the appropriate pre-planning and exercise precautions, said U.S. Army Lt. Col. Chad Hulsopple, assistant professor of family medicine at the (https://www.usuhs.edu/) Uniformed Services University of the Health Sciences and director of the National Capital Consortium’s Sports Medicine Fellowship.
“Icy, snowy, and wet conditions can result in rapid cooling of the body and injuries from slips and falls,” he said. “Avoid overdressing and materials with cotton, which can result in excessive sweating and sweat retention, respectively. The body can lose heat 25 times faster with wet skin,” Hulsopple pointed out.
“Consider at least three loose clothing layers—moisture-wicking base layer, insulating mid-layer, and a breathable wind and waterproof outer layer,” he said. “Multiple layers allow temperature control by removing and adding layers throughout your workout to maintain comfort.”
And don’t forget to protect your entire body. You can lose heat rapidly in your head, neck, and extremities, so wear stocking caps, gloves, and moisture-wicking socks. “Some cold-weather environments might require thicker socks with insulating and moisture-wicking properties,” he said.
Also consider waterproof breathable shoes and gaiters to decrease the likelihood of getting your feet wet. There are commercially available traction cleats for additional grip on snow and ice, Hulsopple noted.
Pay Attention to Hydration and Hunger
Hydration and energy intake are key components of being able to withstand the rigors of outdoor exercise and training in starkly cold, windy conditions, or high altitudes.
“Both of those are really important to ensure your safety and your well-being, and also in making sure you have enough energy to perform in whatever capacity is needed,” said U.S. Navy Lt. Victoria Selkirk, a sports dietician and the combined food service department head at U.S. Navy Medicine and Training Command and U.S. Marine Corps Air Ground Center (https://www.29palms.marines.mil/) Twentynine Palms in California.
“Factors like thirst mechanisms are not being triggered in colder temperatures, so it is extremely important to remember to make sure you are drinking preferably warm, non-caffeinated fluid when performing prolonged, arduous activities outdoors in cold weather,” she said.
Energy intake, including the consumption of high-calorie snacks, becomes highly important while operating in cold weather and higher altitude environments.
“The colder climate dramatically increases the rate at which your body burns calories and you need to replace those,” Selkirk said. “The heat your body generates comes from the foods that you eat, so carbohydrates and fat can help with that.”
One way to do that is “continuous chow,” meaning eating small, healthy snacks constantly to maintain a consistent level of energy while working or training. Selkirk suggested roasted almonds, dried cranberries, raisins, dried vegetables, crackers, and energy bars.

Forwarded by:
Michael Reeder LCPC
Baltimore, MD

 

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