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AFHSB's health surveillance program supports Defense Department global health engagement efforts

U.S. Air Force Senior Airman Joshua Douglass, left, an aerospace medical technician, watches as Liberian health care workers properly put on their personal protective equipment as part response by the Defense Department operation to provide logistics, training and engineering support during the Ebola virus outbreak. (U.S. Army photo by Staff Sgt. Terrance D. Rhodes) U.S. Air Force Senior Airman Joshua Douglass, left, an aerospace medical technician, watches as Liberian health care workers properly put on their personal protective equipment as part response by the Defense Department operation to provide logistics, training and engineering support during the Ebola virus outbreak. (U.S. Army photo by Staff Sgt. Terrance D. Rhodes)

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Armed Forces Health Surveillance Division | Global Emerging Infections Surveillance | Antimicrobial Resistance (AMR) Surveillance | Febrile and Vector-Borne Infections (FVBI) Surveillance | Enteric Infections (EI) Surveillance | GEIS Partners | Global Health Engagement

Both the U.S. Armed Forces’ operational posture and the emergence and spread of infectious diseases relevant to military operations have evolved in recent decades. Worldwide, people are more mobile and interconnected than ever before. At the same time, land use in the developing world is changing in such a way that long-dormant pathogens have the opportunity to re-emerge and become health problems for a significant proportion of the population again. These conditions threaten not only the health of populations, but also the security and stability of nations around the world.

The Defense Department has long recognized the link between global health and security, and its global health engagement efforts address the intersection of these concerns. Defense Department health agencies are primarily focused on protecting the health of the force and medical readiness, but their global health engagement efforts also address other security priorities for the U.S. government such as helping partner nations build health capacity, combatting global health threats (e.g., emerging infectious diseases and antibiotic-resistant bacteria), and supporting U.S. government humanitarian assistance and disaster relief initiatives.

The Global Emerging Infections Surveillance (GEIS) section of the Armed Forces Health Surveillance Branch (AFHSB) supports global health engagement by leveraging a network of Defense Department laboratory partners that are positioned in critical locations globally and work with partner nations to combat infectious disease threats. Defense Department laboratories around the world execute coordinated, integrated surveillance efforts to detect and respond to febrile and vector-borne infections, respiratory infections, antimicrobial-resistant and sexually transmitted infections, and enteric infections regardless of the source. These efforts are conducted in more than 70 countries and serve to protect the health of a highly mobile force by informing risk assessments and countermeasure development, providing support to outbreak response efforts when they arise, and supporting operational access and freedom of movement in high-threat areas.

In support of the Defense Health Agency’s combat support efforts, the GEIS network’s ultimate goal is early, accurate detection of emerging infectious disease and rapid communication regarding those that potentially threaten the health of U.S. forces so that preventive measures can be taken to enable operational readiness and mitigate the risk of mission failure. Surveillance efforts are conducted in partnership with partner nation ministries of health and defense, thereby improving their health capacity by enabling rapid identification and response to infectious disease threats to their population and strengthening relationships with key U.S. partners. In this way, the GEIS program supports the U.S. geographic combatant commands (GCCs) in their areas of responsibility, advancing their campaign plans, lines of efforts, and end states. Additionally, by providing direct technical support to GCC-led international scientific coalitions and strategic engagement efforts, GEIS enhances Defense Department global health engagements and advances information sharing with partner nations. These activities ultimately better inform force health protection decision making at the GCCs and enable global health security for partner nations and U.S. government assets abroad.

Throughout December, in celebration of the Global Health Engagement Month, AFHSB will showcase some of the surveillance efforts conducted by GEIS’s laboratory partners around the world. These stories are available on DHA’s Global Health Engagement Spotlight page.

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Staphylococcus

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8/27/2018
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Staphylococcus: Staphylococcus aureus is a major cause of skin and soft tissue infection (SSTI). Military personnel in congregate settings (e.g., training, deployment) are at increased risk for S. aureus colonization and SSTI. For a 7-month period in 2016, an observational cohort study of S. aureus colonization and SSTI among U.S. Navy submariners was conducted.

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Norovirus

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8/27/2018
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Beginning in 2011, the Operational Infectious Diseases (OID) laboratory at the Naval Health Research Center has undertaken routine surveillance of four U.S. military training facilities to systematically track the prevalence of acute gastroenteritis and to establish its etiologies among U.S. military recruits.

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Diagnoses of Eating Disorders, Active Component Service Members, U.S. Armed Forces, 2013–2017 Eating Disorders

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7/3/2018
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Absolute and Relative Morbidity Burdens, Attributable to Various Illnesses and Injuries, 2017

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5/23/2018
Absolute and Relative Morbidity Burdens, Attributable to Various Illnesses and Injuries, 2017

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Mental Health Problems

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4/4/2018
This report summarizes the numbers, natures, and rates of incident mental health disorder diagnoses as well as mental health problems among active component U.S. service members during 2007–2016.

This report summarizes the numbers, natures, and rates of incident mental health disorder diagnoses as well as mental health problems among active component U.S. service members during 2007–2016.

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Malaria U.S. Armed Forces, 2017

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2/14/2018
Since 1999, the Medical Surveillance Monthly Report (MSMR) has published periodic updates on the incidence of malaria among U.S. service members. Malaria infection remains an important health threat to U.S. service members, who are located in endemic areas because of long-term duty assignments, participation in shorter-term contingency operations, or personal travel. This update for 2017 describes the epidemiologic patterns of malaria incidence in active and reserve component service members of the U.S. Armed Forces. Findings •	A total of 32 service members were diagnosed with or reported to have malaria, which is the lowest number of cases in any given year during the 10-year surveillance period. •	Health records documented the performance of laboratory tests for malaria for 22 of the cases. The tests for 17 of the 22 were positive for malaria ( stick figure graphic visually depicts this information). •	In 2017, 75.0% (24 of 32) of malaria cases among U.S. service members were diagnosed during May – October (calendar graphic showing the months visually). •	Of the 32 malaria cases in 2017, more than 1/3 of the infections were considered to have been acquired in Africa. Two bar charts display the following information: •	Bar chart 1: Numbers of malaria cases by Plasmodium species and calendar year of diagnosis/report, active and reserve components, U.S. Armed Forces, 2008 – 2017  •	Bar chart 2: Annual numbers of cases of malaria associated with specific locations of acquisition, active and reserve components, U.S. Armed Forces, 2008 – 2017  The majority of U.S. military members diagnosed with malaria in 2017 were: •	Male (96.9%) •	Active component (81.3%) •	In the Army (75.0%) •	In their 20’s (56.3%) Access the full report in the February 2018 MSMR (Vol. 25 No. 2). Go to www.Health.mil/MSMR  Picture of a mosquito displays on the graphic.

This update for 2017 describes the epidemiologic patterns of malaria incidence in active and reserve component service members of the U.S. Armed Forces.

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Insomnia and motor vehicle accident-related injuries, Active Component, U.S. Armed Forces, 2007 – 2016

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1/25/2018
Insomnia is the most common sleep disorder in adults and its incidence in the U.S. Armed Forces is increasing. A potential consequence of inadequate sleep is increased risk of motor vehicle accidents (MVAs). MVAs are the leading cause of peacetime deaths and a major cause of non-fatal injuries in the U.S. military members. To examine the relationship between insomnia and motor vehicle accident-related injuries (MVAs) in the U.S. military, this retrospective cohort study compared 2007 – 2016 incidence rates of MVA-related injuries between service members with diagnosed insomnia and service members without a diagnosis of insomnia. After adjustment for multiple covariates, during 2007 – 2016, active component service members with insomnia had more than double the rate of MVA-related injuries, compared to service members without insomnia. Findings:  •	Line graph shows the annual rates of motor vehicle accident-related injuries, active component service members with and without diagnoses of insomnia, U.S. Armed Forces, 2007 – 2016  •	Annual rates of MVA-related injuries were highest in the insomnia cohort in 2007 and 2008, and lowest in 2016 •	There were 5,587 cases of MVA-related injuries in the two cohorts during the surveillance period. •	Pie chart displays the following data: 1,738 (31.1%) in the unexposed cohort and 3,849 (68.9%) in the insomnia cohort The highest overall crude rates of MVA-related injuries were seen in service members who were: •	Less than 25 years old •	Junior enlisted rank/grade •	Armor/transport occupation •	 •	With a history of mental health diagnosis •	With a history of alcohol-related disorders Access the full report in the December 2017 (Vol. 24, No. 12). Go to www.Health.mil/MSMR Image displays a motor vehicle accident.

To examine the relationship between insomnia and motor vehicle accident-related injuries (MVAs) in the U.S. military, this retrospective cohort study compared 2007 – 2016 incidence rates of MVA-related injuries between service members with diagnosed insomnia and service members without a diagnosis of insomnia.

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Seizures among Active Component service members, U.S. Armed Forces, 2007 – 2016

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1/25/2018
This retrospective study estimated the rates of seizures diagnosed among deployed and non-deployed service members to identify factors associated with seizures and determine if seizure rates differed in deployment settings. It also attempted to evaluate the associations between seizures, traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD) by assessing correlations between the incidence rates of seizures and prior diagnoses of TBI and PTSD. Seizures have been defined as paroxysmal neurologic episodes caused by abnormal neuronal activity in the brain. Approximately one in 10 individuals will experience a seizure in their lifetime. Line graph 1: Annual crude incidence rates of seizures among non-deployed service members, active component, U.S. Armed Forces data •	A total of 16,257 seizure events of all types were identified among non-deployed service members during the 10-year surveillance period. •	The overall incidence rate was 12.9 seizures per 10,000 person-years (p-yrs.) •	There was a decrease in the rate of seizures diagnosed in the active component of the military during the 10-year period. Rates reached their lowest point in 2015 – 9.0 seizures per 10,000 p-yrs. •	Annual rates were markedly higher among service members with recent PTSD and TBI diagnoses, and among those with prior seizure diagnoses. Line graph 2: Annual crude incidence rates of seizures by traumatic brain injury (TBI) and recent post-traumatic stress disorder (PTSD) diagnosis among non-deployed active component service members, U.S. Armed Forces •	For service members who had received both TBI and PTSD diagnoses, seizure rates among the deployed and the non-deployed were two and three times the rates among those with only one of those diagnoses, respectively. •	Rates of seizures tended to be higher among service members who were: in the Army or Marine Corps, Female, African American, Younger than age 30, Veterans of no more than one previous deployment, and in the occupations of combat arms, armor, or healthcare Line graph 3: Annual crude incidence rates of seizures diagnosed among service members deployed to Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn, U.S. Armed Forces, 2008 – 2016  •	A total of 814 cases of seizures were identified during deployment to operations in Iraq and Afghanistan during the 9-year surveillance period (2008 – 2016). •	For deployed service members, the overall incidence rate was 9.1 seizures per 10,000 p-yrs. •	Having either a TBI or recent PTSD diagnosis alone was associated with a 3-to 4-fold increase in the rate of seizures. •	Only 19 cases of seizures were diagnosed among deployed individuals with a recent PTSD diagnosis during the 9-year surveillance period. •	Overall incidence rates among deployed service members were highest for those in the Army, females, those younger than age 25, junior enlisted, and in healthcare occupations. Access the full report in the December 2017 MSMR (Vol. 24, No. 12). Go to www.Health.mil/MSMR

This infographic documents a retrospective study which estimated the rates of seizures diagnosed among deployed and non-deployed service members to identify factors associated with seizures and determine if seizure rates differed in deployment settings. The study also evaluated the associations between seizures, traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD) by assessing correlations between the incidence rates of seizures and prior diagnoses of TBI and PTSD.

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Five cold seasons: July 2012-June 2017, Active reserve component service members who were diagnosed with a cold weather injury

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1/18/2018
Did you know during the 5-year surveillance period, the 2,717 service members who were affected by any cold weather injury included 2,307 from the active component and 410 from the reserve component. Overall, Army members comprised the majority (61.6%) of all cold injuries affecting active and reserve component service members. Of all affected reserve component members, 71.7% (n=294) were members of the Army. Cold weather injuries During Basic Training Of all active component service members who were diagnosed with a cold weather injury (n= 2,307), 230 (10.0% of the total) were affected during basic training. Additionally, during the surveillance period, 60 service members who were diagnosed with cold weather injuries during basic training (2.6% of the total) were hospitalized, and most (93.3%) of the hospitalized cases were members of either the Army (n=32) or Marine Corps (n=24). Cold weather injuries during basic training pie chart: The Army (n=122) and Marine Corps (n=99) comprised 96.1% of all basic trainees who were diagnosed with a cold weather injury. Access the full report in the October 2017 MSMR (Vol. 24, No. 10). Go to: www.Health.mil/MSMR  #ColdReadiness Image of service member tracking in the snow is the infographic background graphic.

This infographic provides information on active and reserve component service members who were affected by any cold weather injury during the July 2012 – June 2017 cold seasons.

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Update: Cold Weather Injuries, Active and reserve components, U.S. Armed Forces, July 2012 – June 2017

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1/18/2018
The total number of cold weather injuries among active component service members in 2016 – 2017 cold season was the lowest since 1999. 2016 – 2017 versus the previous four cold seasons  •	A total of 387 members of the active (n=328) and reserve (n=59) components had at least one medical encounter with a primary diagnosis of cold weather injury. •	Rates tended to be higher among service members who were in the youngest age groups, female, non-Hispanic black, or in the Army. •	Cold weather injuries associated with overseas deployments have fallen precipitously in the past three cold seasons due to changes in military operations in Iraq and Afghanistan. There were just 10 cases in the 2016 – 2017 season.  •	Frostbite was the most common type of cold weather injury. Bar chart displays numbers of service members who had a cold injury (one per person per year), by service and cold season, active and reserve components, U.S. Armed Forces, July 2012 – June 2017. Access the full report in the October 2017 MSMR (Vol. 24, No. 10). Go to: www.Health.mil/MSMR  #ColdReadiness

This infographic provides an update for cold weather injuries among active and reserve components, U.S. Armed Forces, July 2012 – June 2017.

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Cold weather injuries during deployments, July 2012 – June 2017

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1/18/2018
During the 5-year surveillance period, 105 cold weather injuries were diagnosed and treated in service members deployed outside the U.S. of these, 39 (37%) were immersion injuries; 33 (31%) were frostbite; 16 (15%) were hypothermia; and 17 (16%) were “unspecified” cold weather injuries. Pie chart for cold weather injuries during deployments displays depicting the information above. Number of cold weather injuries bar chart: Of all 105 cold weather injuries during the surveillance period, 68% occurred during the first two cold seasons. Bar chart shows the number of cold weather injuries by year: •	2012-2013 cold season had 35 cold weather injuries •	2013-2014 cold season had 100 cold weather injuries •	2014 -2015 cold season had 13 cold weather injuries •	2015-2016 cold season had 11 cold weather injuries •	2016 – 2017 had 10 cold weather injuries Access the full report in the October 2017 MSMR (Vol. 24, No. 10). Go to: www.Health.mil/MSMR  #ColdReadiness

This infographic documents cold weather injuries during deployments for the July 2012 – June 2017 cold seasons.

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Complications and Care Related to Pregnancy, Labor and Delivery among Active Component Service Women U.S. Armed Forces, 2012 – 2016

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1/5/2018
Maternal complications and delivery outcomes are important components of the overall health and well-being of reproductive-age service women. This analysis provides an update on pregnancy complications and characterizes the counts, rates, and trends of several specific pregnancy complications. FINDINGS •	55,601 U.S. service women whose pregnancies resulted in 63,879 live births had 657,060 medical encounters •	For all age groups, percentages of live births affected by preterm labor decreased, but during 2012 – 2016, the percentages of pregnant service members diagnosed with obesity increased. •	The percentage of pregnant service members affected by gestational diabetes was more than twice as high for obese women, compared with non-obese women (12.4% vs. 5.5%). Bar graph shows the number of medical encounters with a primary (first-listed) diagnosis of any pregnancy-related complication or indication for care decreased each year between 2012 and 2016. Access the full report in the November 2017 MSMR (Vol. 24, No. 11). Go to: www.Health.mil/MSMR  Background image: New born being provided medical attention by nurse. Secondary image: babies of diverse background on a blanket.

This analysis provides an update on pregnancy complications and characterizes the counts, rates, and trends of several specific pregnancy complications.

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

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1/5/2018
Because the majority of women serving in the Armed Forces are of childbearing age, and women’s military career opportunities have expanded into combat roles, contraceptive health care is an increasingly important public health issue. The lack of available, population-based descriptive information on contraceptive use among U.S. service women has generated questions and concerns about ready access to these medical products. This infographic summarizes the annual prevalence of permanent sterilization, as well as use of long – and short-acting reversible contraceptives (LARCs and SARCs, respectively), contraceptive counseling services, and use of emergency contraception from 2012 through 2016, among active component service women. FINDINGS •	2012 through 2016, Sterilization decreased from 4.2% to 3.6% LARC use increased from 17.2% to 21.7%; SARC use decreased from 38.5% to 30.4%. •	Emergency contraception use increased from 0.4% to 1.9%. •	Among deployed women, the average annual prevalence of permanent sterilization was 4.2%. •	For deployed women, LARC use was 17.9% SARC use was 28.0%. •	Emergency contraception use among deployed women was 0.4%. •	262,907 (76.2%) women of childbearing potential (WOCBP) used either a LARC or a SARC at some time during the surveillance period. •	The vast majority of service women have utilized at least one form of contraception, and women are selecting LARCs in greater numbers with each passing year. The bar graph displays information on the annual prevalence of contraceptive utilization, by type, service women of child-bearing potential, active component, U.S. Armed Forces, 2012– 2016. Graphic displayed: contraception option. Access the full report in the November 2017 MSMR (Vol. 24, No. 11). Go to: www.Health.mil/MSMR

This infographic summarizes the annual prevalence of permanent sterilization, as well as use of long – and short-acting reversible contraceptives (LARCs and SARCs, respectively), contraceptive counseling services, and use of emergency contraception from 2012 through 2016, among active component service women.

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Five cold seasons: July 2012 – June 2017, Cold injuries during deployments

Infographic
11/3/2017
During the 5-year surveillance period, 105 cold injuries were diagnosed and treated in service members deployed outside of the U.S. Of these 105 cold injuries, 68% occurred in the first two cold seasons. Total no. of cold injuries, by season: •	35 cold injuries during cold season 2012 – 2013 •	36 during 2013 – 2014 •	13 during 2014 – 2015 •	11 during 2015 – 2016 •	10 during 2016 – 2017 The decrease in the number of cases is most likely a byproduct of: •	The dramatic decline in the number of service members deployed to Iraq and Afghanistan •	Changes in the nature of military operations there Access the full report in MSMR Vol. 24 No. 10 October 2017 at Health.mil/MSMR Pie Chart showing cold injuries during deployments: •	39 Immersion •	33 Frostbite •	17 unspecified  •	16 Hypothermia Background image shows service member walking in the snow.

This infographic documents cold injuries during deployments outside of the United States for the July 2012 – June 2017 cold seasons (five-year surveillance period).

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Measles, Mumps, Rubella, and Varicella: Among service members and other beneficiaries of the Military Health System, 2010 – 2016

Infographic
11/3/2017
Measles, mumps, rubella, and varicella (MMR/V) are highly communicable infectious diseases whose causative agents are spread through contact with contaminated surfaces or airborne droplets. MMR/V were common in the U.S. before the introduction of licensed vaccines: measles (1963), mumps (1967), rubella (1969), and varicella (1995). Since then, these vaccines have been important components of routine pediatric preventive care. This report highlights the recent trends in MMR/V in both military and civilian populations as well as the importance of primary and booster vaccinations.  During 2010 – 2016, there were: •	11 confirmed measles cases – one was in a service member. •	76 confirmed mumps cases – 28 were in service members. •	7 confirmed rubella cases – two were in service members. •	62 confirmed varicella cases among service members. The reporting of cases of varicella in non-military personnel was not mandated until 2017. Individuals at highest risk for MMR/V •	Infants •	Unvaccinated persons •	Inadequately vaccinated persons •	Individuals living in communities with low vaccination rates •	Persons living in crowded and unsanitary conditions •	Those with compromised immune systems Access the full report in MSMR Vol. 24 No. 10 October 2017 for more information at Health.mil/MSMR A picture of service members in communal area displays as well as an image of team work activities.

This infographic highlights the recent trends in Measles, Mumps, Rubella, and Varicella (MMR/V) in both military and civilian populations as well as the importance of primary and booster vaccinations.

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Armed Forces Health Surveillance Division | Measles-Mumps-Rubella
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