Skip to main content

Military Health System

Animal Bites and Rabies Post-exposure Prophylaxis, Active and Reserve Components, U.S. Armed Forces, 2011–2018.

Image of Big Brown Bat stock photo (iStock.com). Big Brown Bat stock photo (iStock.com)

Recommended Content:

Medical Surveillance Monthly Report

Abstract

During 2011–2018, there were 22,729 diagnoses of animal bites among active and reserve component members of the U.S. Armed Forces. Of these, 899 (4.0%) were documented during medical encounters associated with deployments to overseas theaters of operations. Army, Navy, Air Force, and Marine Corps members were affected by 55.6%, 23.5%, 14.2%, and 6.7% of all animal bites diagnosed in theater, respectively. More than four-fifths of total animal bite cases (82.4%) and bites diagnosed in theater (88.4%) affected enlisted members. The crude overall incidence rate of animal bite diagnoses was 175.7 per 100,000 person-years (p-yrs) among active component service members between 2011 and 2018. Overall rates were highest among active component service members who worked in law enforcement (462.5 per 100,000 p-yrs) or veterinary occupations (437.8 per 100,000 p-yrs). Among active component service members, the crude annual rate of animal bite diagnoses in 2018 was more than twice that in 2001 (191.4 per 100,000 p-yrs and 85.1 per 100,000 p-yrs, respectively). Dog bites accounted for approximately three-quarters (74.8%) of total animal bites during the surveillance period. Only a small proportion of animal bites were associated with documentation of exposure to or post-exposure prophylaxis for rabies. Animal bite avoidance and rabies education should be reinforced before service members travel or deploy to areas where rabies is highly enzootic.

What Are the New Findings?

On average, there were approximately 8 animal bite diagnoses per day among active and reserve component members during 2011–2018. Annual rates of bite diagnoses among active component service members doubled during this period. More than one-third of service members treated for bites in theater received rabies post-exposure prophylaxis. Of 72 bite diagnoses in theater in 2018, only 4 (5.6%) resulted in a confirmed Medical Event Report for rabies post-exposure prophylaxis.

What Is the Impact on Readiness and Force Health Protection?

Human animal-bite injuries remain an important public health concern for the U.S. military. Bite injuries are common, and the risk of transmission of rabies, a fatal disease, makes it essential that medical care providers, especially those in rabies enzootic areas, be knowledgeable about when and how to provide pre-exposure rabies immunizations and post-exposure prophylaxis whenever indicated.

Background

Human animal-bite injuries are relatively common worldwide and represent a significant public health problem because of the associated risk of rabies virus exposure, skin infection, and tissue damage. Most animal bites produce only minor injuries; however, depending on the size and type of biting animal, wounds can range from minimal to life-threatening.1 Risk of infectious complications increases if animal bites are left untreated or if treatment is delayed.1

Despite the potential public health consequences of human animal-bites, such injuries have not been routinely tracked at the local or regional level in the U.S.2,3 Retrospective reviews of hospital records have estimated that between 2 and 5 million animal bites occur annually in North America; these injuries accounted for about 1% of emergency department visits and an estimated 10,000 inpatient admissions annually.3–5

Rabies is the most important public health concern associated with human animal-bite injuries. This disease is caused by infection with viruses in the family Rhabdoviridae, genus Lyssavirus, the most common of which is Rabies lyssavirus.6 Rabies virus is generally transmitted through exposure to the saliva of an infected animal, most commonly through bite wounds, open cuts in skin, or mucous membranes.7 In mammals, including humans, rabies virus spreads via peripheral nerves to the central nervous system.8 Viral replication and shedding of rabies viruses occurs in highly innervated areas such as the salivary glands.8 Infection of the brain causes acute, progressive inflammation leading to difficulty swallowing, hydrophobia, neurologic deficits, abnormal behavior, paralysis, seizures, coma, and ultimately death.9

In the U.S., wild animals are the most likely source of human exposure to rabies.9 Rabies surveillance in the U.S. has identified bats (with multiple rabies virus variants in multiple species), raccoons, skunks, and foxes as the 4 major animal reservoirs.10,11 During 2017, 49 states reported 4,423 rabid animals and 2 human rabies cases to the Centers for Disease Control and Prevention.12 Wildlife accounted for 91.3% of rabies cases reported in the U.S. in 2017; bats were the most frequently reported rabid wildlife species (32.4% of all animal cases), followed by raccoons (28.8%), skunks (21.2%), and foxes (7.1%).12

Currently, there is no known effective treatment for symptomatic rabies, and progression to death is rapid once symptoms appear.7 Human rabies survival is exceptionally rare and, when it does occur, is often associated with severe neurologic sequelae.13 However, if exposure to rabies is identified early, post-exposure prophylaxis (PEP), which includes immediate wound care and the administration of human rabies immune globulin (HRIG) and rabies vaccine, is highly effective in preventing progression of the infection and clinical manifestations.3,14,15 Individuals who have been previously vaccinated or are receiving pre-exposure prophylaxis (PrEP) for rabies should receive only rabies vaccine and any necessary wound care. Administration of HRIG is unnecessary in such cases because the vaccination booster stimulates an effective anamnestic antibody response.14

Service members are at risk for animal bites and rabies exposures in the U.S. and during deployment to areas of the world where canine rabies is enzootic, including Africa, Asia, and parts of Central and South America.16,17 Risk of exposure to rabies is higher for service members in certain military occupations such as veterinary service personnel, working dog handlers, personnel who have animal control duties, certain laboratory workers who work with rabies-suspect samples, and special operations personnel.7,9,18–20 Department of Defense (DOD) instruction mandates personnel in these occupations receive rabies PrEP18–20; however, exposure to a potentially rabid animal still requires administration of rabies PEP.19 PrEP is also considered for service members with longer-term assignments to regions where rabies is enzootic.18–20

In 2011, the MSMR summarized the numbers and types (but not rates) of animal bite diagnoses and rabies PEP among active and reserve component service members during 2001–2010.21 The current analysis updates and expands on this earlier work by describing the incidence rates of animal bite diagnoses among active component service members between 2001 and 2018 and examining the number of reportable medical event (RME) records of "confirmed" rabies PEP for all animal bite cases in 2018.

Methods

The surveillance period for the update of incidence rates was 1 Jan. 2001 to 31 Dec. 2018. For the more detailed analyses of demographic and military characteristics of bite victims, the surveillance period was limited to 2011–2018. The surveillance population included all individuals who served in the active or reserve component of the Army, Navy, Air Force, or Marine Corps at any time during the surveillance period. Diagnoses indicative of animal bites were ascertained from Defense Medical Surveillance System (DMSS) electronic records of all medical encounters of individuals who received care in fixed (i.e., not deployed or at sea) medical facilities of the Military Health System (MHS) or civilian facilities in the 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 system. Records of health care encounters of deployed service members are maintained in the Theater Medical Data Store (TMDS), which is incorporated into the DMSS.

For the current analysis, a case was defined as an individual with an inpatient or outpatient International Classification of Diseases, 9th Revision [ICD-9] or International Classification of Diseases, 10th Revision [ICD-10] diagnosis code of "animal bite" in any diagnostic position (Table 1). In order to prevent the counting of follow-up encounters for single animal bite episodes as new cases, each service member could be counted as a case only once per calendar year. In each calendar year, animal bite diagnoses associated with deployments to overseas theaters of operations (TMDS, "in theater") were prioritized over those from non-deployed settings (DMSS, "outside of theater"). Incidence rates of animal bite diagnoses were calculated for active component service members between 2001 and 2018. Incidence rates were not calculated for reserve/guard members because the DMSS does not contain activated service time for reserve/guard personnel.

For all service members identified as animal bite cases during 2011–2018, the number of such cases whose records contained diagnostic codes for "exposure to rabies" (ICD-9: V01.5; ICD-10: Z20.3) was determined. In addition, for all bite cases, the number who received rabies PEP as shown in immunization records (i.e., rabies vaccine, HRIG, and unspecified immune globulin) within 90 days of animal bite diagnoses were ascertained. The codes used to identify instances of rabies vaccine (CVX codes) and immunoglobulin administration are presented in Table 2.22

RME records of "confirmed" rabies PEP were also identified for all animal bite cases. It is DOD policy that administration of PEP against rabies must be reported electronically through military health channels for surveillance purposes.23 However, because the reporting policy for RMEs of rabies PEP took effect in 2017, the current analysis was limited to those events reported among members of the active and reserve components during 2018.

The new electronic health record for the MHS, MHS GENESIS, was implemented at several military treatment facilities during 2017. Medical data from sites that are using 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. Therefore, medical encounters for individuals seeking care at any of these facilities during 2017–2018 were not included in this analysis.

Results

During the 8-year surveillance period, there were 22,729 diagnoses of animal bites among U.S. service members in the active and reserve components; on average, there were approximately 8 animal bite diagnoses per day throughout the period. Of all animal bite diagnoses among active and reserve component service members, 899 (4.0%) were documented during medical encounters in theater (Table 3a).

Male service members accounted for over three-quarters (77.9%) of animal bite diagnoses overall and 83.8% of those diagnosed in theater. More than one-half (55.9%) of all animal bites and almost two-thirds (66.3%) of those diagnosed in theater affected 20–29 year old service members. Non-Hispanic white service members were affected by almost three-quarters of all animal bites—both overall (71.1%) and in theater (72.2%)—that were documented on electronic health care records during medical encounters (Table 3a).

Army, Navy, Air Force, and Marine Corps members were affected by 55.6%, 23.5%, 14.2%, and 6.7% of all animal bites that were diagnosed in theater. Compared to their in-theater counterparts, Army and Navy members in non-deployed settings accounted for relatively lower percentages (47.3% and 17.1%, respectively) and Air Force and Marine Corps members had relatively higher percentages (25.9% and 9.7%, respectively) of cases. More than four-fifths of total animal bite cases (82.4%) and bites diagnosed in theater (88.4%) affected enlisted members (Table 3a).

Among active and reserve component service members deployed in theater, those in combat-specific (n=268; 29.8%) or repair/engineering occupations (n=221; 24.6%) accounted for the most animal bite diagnoses; together, service members in these occupational groups accounted for more than one-half (54.4%) of animal bites diagnosed in theater (Table 3a). Among service members outside of theater, those in repair/engineering (n=5,492; 25.2%) and communication/intelligence (n=4,753; 21.8%) occupations accounted for the greatest percentages of animal bite diagnoses. These occupational groups accounted for 46.9% of all animal bite diagnoses outside of theater. Veterinarians and other veterinary medicine workers (e.g., animal care specialists, animal health technicians) accounted for 26 (2.9%) animal bite cases in theater and 511 (2.3%) cases outside of theater during the surveillance period.

The crude overall incidence rate of animal bite diagnoses was 175.7 per 100,000 person-years (p-yrs) among active component service members between 2011 and 2018 (Table 3b). Compared to their respective counterparts, active component service members who were female (241.9 per 100,000 p-yrs), 20–29 years old (190.4 per 100,000 p-yrs), members of the Army (204.2 per 100,000 p-yrs), and senior enlisted (199.9 per 100,000 p-yrs) tended to have higher overall rates of animal bite diagnoses. Across military occupations, overall rates of animal bite diagnoses were highest among active component service members working in law enforcement (462.5 per 100,000 p-yrs) and those in veterinary occupations (437.8 per 100,000 p-yrs) (Table 3b). Among service members in the active component, the crude annual rate of animal bite diagnoses in 2018 was more than twice that in 2001 (191.4 per 100,000 p-yrs and 85.1 per 100,000 p-yrs, respectively) (Figure 1).

Among active and reserve component service members, dog bites accounted for the majority of animal bites diagnosed outside of (75.4%) and in theater (58.2%) (Figure 2). Almost 1 in 4 (23.7%) of the animal bites diagnosed in theater were classified as having been attributed to "other animals" including cats, horses, cows, other hoof stock, pigs, and raccoons. Of note, rat bites accounted for 3.4% of animal bite cases in theater and less than 1% of cases outside of theater.

Of all animal bite diagnoses recorded outside of theater (n=21,830) during 2011–2018, 658 (3.0%) were associated with a diagnosis of exposure to rabies during a medical encounter within 90 days after the animal bite diagnosis (Table 4). Almost three-quarters (n=490; 74.5%) of exposures to rabies diagnoses were documented within 1 week after the animal bite diagnosis. Fifty-nine (9.0%) of the 658 exposures to rabies diagnoses were documented 31–90 days after the animal bite diagnosis. Approximately one-eighth (12.6%; n=2,745) of the animal bite diagnoses recorded outside of theater were associated with rabies vaccination that was administered within 90 days after the diagnosis of the bite; less than 5% (3.8%; n=830) of the animal bites were associated with HRIG administration within 90 days after the animal bite diagnosis (Table 4). Almost seven-eighths (87.1%) of the animal bite cases who were reportedly vaccinated and 89.2% of the cases who received HRIG received the respective PEP within 1 week after the bite diagnoses.

Of all animal bite cases diagnosed in theater, 28 (3.1%) were documented as exposure to rabies; more than three-eighths (39.3%) of the exposure to rabies diagnoses were documented within 1 week after the animal bite diagnosis and one-quarter (25.0%) were documented 31–90 days after the animal bite diagnosis (Table 4). Of the 899 in-theater animal bite cases, 316 (35.2%) reportedly received rabies vaccine and 139 (15.5%) received HRIG within 90 days of the bite diagnoses. The vast majority of PEP associated with animal bite diagnoses recorded in theater were documented during medical encounters within 1 week after the respective bite diagnoses.

In 2018, of the 3,031 animal bite diagnoses recorded outside of theater, less than 5% (n=117; 3.9%) resulted in a confirmed RME for rabies PEP (Table 5). Of the 72 animal bite diagnoses recorded in theater in 2018, 4 (5.6%) resulted in a confirmed RME for rabies PEP (Table 5).

Editorial Comment

Human animal-bite injuries remain an important public health concern for the U.S. military.17,24,25 There were an average of 8 animal bite diagnoses per day among active and reserve component service members between 2011 and 2018. During this period, approximately 1 of every 25 animal bites overall were diagnosed in theater. Crude annual rates of animal bite diagnoses more than doubled from 2001 to 2018.

While this report documents about 55 clinically diagnosed animal bite cases among U.S. active and reserve component service members each week during 2011–2018, it undoubtedly significantly underestimates the actual numbers of animal bites. For example, most injuries from animal bites are minor; in such cases, service members are unlikely to seek medical care. However, even minor animal bite injuries can have serious consequences—particularly bites inflicted by wild animals (including bats, foxes, skunks, and raccoons), feral cats and dogs, and pets with unknown rabies vaccination statuses.3

In the current analysis, dog bites accounted for the largest proportion of animal bites of service members overall. Among service members in the U.S., dog bites are most likely inflicted by pets or military working dogs.26,27 Such dogs are generally known to the bite victim and have almost always been vaccinated against rabies.27 As such, it is not surprising that a small proportion of all service members who were treated for animal bites outside of theater received rabies PEP (i.e., rabies vaccination, HRIG). In contrast, more than one-third of service members who were treated for animal bites in theater reportedly received rabies PEP. It is likely that instances of diagnoses of "exposure to rabies" that were associated with HRIG administration but no rabies vaccine were the result of termination of PEP when the biting animal was deemed to be rabies free.

When considering the percentage of animal bite cases in 2018 that were associated with confirmed RMEs for rabies PEP, it is important to note that guidelines specify that cases must meet 1 or more of 3 exposure criteria. These criteria include a bite, scratch, or other contact situation in which saliva or central nervous system tissue of a rabid or potentially rabid animal could have entered an open wound or come into contact with a mucous membrane (i.e., eye, mouth, or nose); inadvertent contact with a bat or situation in which bat contact cannot be ruled out (e.g., finding a bat in a room with a sleeping person); or receipt of donated organ tissue from suspected or known human cases of rabies.23 Guidelines also specify that an RME for PEP should not be reported in cases where PEP was initiated but subsequently deemed unnecessary because a full rabies exposure risk assessment found that none of the criteria were met.23 Among the animal bite cases diagnosed outside of theater, the discordance between the number of cases who reportedly received PEP based on immunization data and the number of confirmed RMEs for PEP suggests that information on a subset of PEP administrations was not captured, accurately classified, and/or submitted through the Disease Reporting System internet (DRSi). Similar gaps in RME surveillance have been noted for other diseases.28 Findings of the current analysis highlight the importance of training DRSi reporters at military treatment facilities on the critical reporting elements and the exposure criteria that inform final case classification.

Given the potentially lethal consequences of rabies, all service members should be educated regarding the importance of avoiding wild and stray animals (particularly feral dogs and cats) and protecting against and seeking medical care for animal bites. Animal bite avoidance and rabies education should be reinforced before service members travel or deploy to areas where rabies is highly enzootic; service members at high risk should be considered for pre-exposure rabies vaccination.19,29 Medical care providers at all levels—and particularly those serving in areas where rabies is enzootic—should communicate with veterinary providers as needed in assessing risk and determining need for PEP as well as be knowledgeable and capable of providing pre-exposure rabies immunizations and PEP whenever indicated (Table 6).

The range of destinations for U.S. military deployments, including humanitarian assistance, peacekeeping, and partnership-building missions, has broadened in recent years, making the potential for rabies exposure more variable and difficult to predict.17,29 The increased likelihood of rabies exposure when conducting operations in areas where rabies is enzootic requires accurate risk assessment, ongoing risk communication, robust surveillance, and strong leadership engagement to prevent service member exposure to potentially rabid animals.17,30

References

  1. Hargrove JR, Freer L. Wild animal attacks and injuries. In: Bledsoe GH, Manyak MJ, Townes, DA, eds. Expedition and Wilderness Medicine. New York, NY: Cambridge University Press; 2009:27–28.
  2. Gilchrist J, Sacks JJ, White D, Kresnow MJ. Dog bites: still a problem? Inj Prev. 2008;14(5):296–301.
  3. Lyu C, Jewell MP, Piron J, et al. Burden of bites by dogs and other animals in Los Angeles County, California, 2009–2011. Public Health Rep. 2016;131(6):800–808.
  4. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2): e10–52
  5. Centers for Disease Control and Prevention. Nonfatal dog bite-related injuries treated in hospital emergency departments—United States, 2001. MMWR Morb Mortal Wkly Rep. 2003;52(26):605–610.
  6. Begeman L, GeurtsvanKessel C, Finke S, et al. Comparative pathogenesis of rabies in bats and carnivores, and implications for spillover to humans. Lancet Infect Dis. 2018;18(4):e147–e159.
  7. Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies prevention—United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2008;57(RR-3):1–28.
  8. Warrell MJ, Warrell DA. Rabies and other lyssavirus diseases. Lancet. 2004;363(9413):959–969.
  9. Brown CM, Slavinski S, Ettestad P, Sidwa TJ, Sorhage FE. Compendium of animal rabies prevention and control, 2016. J Am Vet Med Assoc. 2016;248(5):505–517.
  10. Birhane MG, Cleaton JM, Monroe BP, et al. Rabies surveillance in the United States during 2015. J Am Vet Med Assoc. 2017;250(10):1117–1130.
  11. Feder HM Jr, Petersen BW, Robertson KL, Rupprecht CE. Rabies: still a uniformly fatal disease? Historical occurrence, epidemiological trends, and paradigm shifts. Curr Infect Dis Rep. 2012;14(4):408–422.
  12. Ma X, Monroe BP, Cleaton JM, et al. Rabies surveillance in the United States during 2017. J Am Vet Med Assoc. 2018;253(12):1555–1568. 13. Jackson AC. Human rabies: a 2016 update. Curr Infect Dis Rep. 2016;18(11):38.
  13. Rupprecht CE, Briggs D, Brown CM, et al. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2010;59(RR-2);1–9.
  14. Defense Health Agency, Immunization Health Care Division. Information paper. Rabies disease and rabies vaccine. https://health.mil/Reference-Center/Fact-Sheets/2019/07/03/Rabies-Diseaseand-Rabies-Vaccine. Published 3 July 2019. Accessed 12 Sept. 2019.
  15. Wallace RM, Petersen BW, Shlim DR. Rabies. In: Brunette GW, Nemhauser JB, eds. CDC Yellow Book 2020: Health Information for International Travel. New York, NY: Oxford University Press; 2019:316.
  16. Johnson LA, Lennon RP. Expeditionary force health protection for global health engagement: lessons learned from Continuing Promise 2017. Mil Med. 2018;183(5–6): e166–e173.
  17. Headquarters. Departments of the Army, Navy, and the Air Force. Army Regulation 40-905, SECNAVINST 6401.1B, AFI 48-131. Medical Services: Veterinary Health Services. 29 Aug. 2006.
  18. Woodson J. Assistant Secretary of Defense for Health Affairs. Memorandum: Human Rabies Prevention During and After Deployment. Washington, DC: Department of Defense; 14 Nov. 2011.
  19. Headquarters, Departments of the Army, the Navy, the Air Force, and the Coast Guard. Army Regulation 40-562, BUMEDINST 6230.15B, AFI 48–110_IP, CG COMDTINST M6230.4G. Medical Services: Immunizations and Chemoprophylaxis for the Prevention of Infectious Diseases. 7 Oct. 2013.
  20. Armed Forces Health Surveillance Center. Animal bites, active and reserve components, U.S. Armed Forces, 2001–2010. MSMR. 2011;18(9)12–15.
  21. Centers for Disease Control and Prevention. Immunization information systems (IIS). IIS: HL7 standard code set mapping CVX to vaccine groups. https://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=vg#vg. Accessed 9 Sept. 2019.
  22. Armed Forces Health Surveillance Branch. Armed Forces Reportable Medical Events. Guidelines and Case Definitions, 2017. https://health.mil/Reference-Center/Publications/2017/07/17/Armed-Forces-Reportable-Medical-Events-Guidelines. Accessed 12 Sept. 2019.
  23. Cooper ED, Debboun M. The relevance of rabies to today’s military. US Army Med Dep J. 2012;Jul-Sep:4–11.
  24. Garges EC, Taylor KM, Pacha LA. Select public health and communicable disease lessons learned during Operations Iraqi Freedom and Enduring Freedom. US Army Med Dep J. 2016;(2-16):161–166.
  25. Royal J, Taylor CL. Planning and operational considerations for units utilizing military working dogs. J Spec Oper Med. 2009;9(1):5–9.
  26. Schermann H, Eiges N, Sabag A, et al. Estimation of dog-bit risk and related morbidity among personnel working with military dogs. J Spec Oper Med. 2017;17(3):51–54.
  27. Ambrose JF, Kebisek J, Gibson KJ, White DW, O’Donnell FL. Commentary: Gaps in reportable medical event surveillance across the Department of the Army and recommended training tools to improve surveillance practices. MSMR. 2019;26(8):17–21.
  28. Moe CD, Keiser PB. Should U.S. troops routinely get rabies pre-exposure prophylaxis? Mil Med. 2014;179(7):702–703.
  29. Mease LE, Whitman S, Lawrence RE. Brief report: Increased number of possible rabies exposures among U.S. health care beneficiaries treated in military clinics in southern Germany in 2016. MSMR. 2018;25(11):18–20.

 

Confirmed and possible cases of measles among MHS beneficiaries, by year and month, 1 Jan. 2016–30 June 2019

Age distribution of confirmed cases of measles among all MHS beneficiaries, 1 Jan. 2016–30 June 2019

Confirmed and possible cases of mumps among MHS beneficiaries, by year and month, 1 Jan. 2016–30 June 2019Age distribution of confirmed cases of mumps among all MHS beneficiaries, 1 Jan. 2016–30 June 2019Confirmed and possible cases of rubella among MHS beneficiaries, by year and month, 1 Jan. 2016–30 June 2019Age distribution of confirmed cases of rubella among all MHS beneficiaries, 1 Jan. 2016–30 June 2019Confirmed and possible cases of varicella among MHS beneficiaries, by year and month, 1 Jan. 2016–30 June 2019Age distribution of confirmed cases of varicella among all MHS beneficiaries,a 1 Jan. 2016–30 June 2019

ICD-10 diagnostic and symptom codes used for classification as a "possible" measles caseICD-10 diagnostic and symptom codes used for classification as a "possible" mumps caseICD-10 diagnostic and symptom codes used for classification as a "possible" rubella caseICD-10 diagnostic and symptom codes used for classification as a "possible" varicella caseConfirmed and possible cases of measles, mumps, rubella, and varicella among MHS beneficiaries, 1 Jan. 2016–30 June 2019

You also may be interested in...

Surveillance Snapshot: Illness and Injury Burdens, Reserve Component, U.S. Armed Forces, 2018

Article
5/1/2019
U.S. Navy sailors graduate from boot camp at Recruit Training Command (RTC) in 2018. (Photo courtesy of U.S. Navy)

Recommended Content:

Medical Surveillance Monthly Report

Modeling Lyme Disease Host Animal Habitat Suitability, West Point, New York

Article
4/1/2019
A deer basks in the morning sun at Joint Base San Antonio-Fort Sam Houston, Texas.  (Photo Courtesy: U.S. Air Force)

As the most frequently reported vector-borne disease among active component U.S. service members, with an incidence rate of 16 cases per 100,000 person-years in 2011, Lyme disease poses both a challenge to health care providers in the Military Health System and a threat to military readiness. Spread through the bite of an infected blacklegged tick, infection with the bacterial cause of Lyme disease can have lasting effects that may lead to medical discharge from the military. The U.S. Military Academy at West Point is situated in a highly endemic area in New York State. To identify probable areas where West Point cadets as well as active duty service members stationed at West Point and their families might contract Lyme disease, this study used Geographic Information System mapping methods and remote sensing data to replicate an established spatial model to identify the likely habitat of a key host animal—the white-tailed deer.

Recommended Content:

Medical Surveillance Monthly Report

Incidence, Timing, and Seasonal Patterns of Heat Illnesses During U.S. Army Basic Combat Training, 2014–2018

Article
4/1/2019
U.S. Marines participate in morning physical training during a field exercise at Marine Corps Base Camp Pendleton, California. (Photo Courtesy: U.S. Marine Corps)

Risk factors for heat illnesses (HIs) among new soldiers include exercise intensity, environmental conditions at the time of exercise, a high body mass index, and conducting initial entry training during hot and humid weather when recruits are not yet acclimated to physical exertion in heat. This study used data from the Defense Health Agency’s–Weather-Related Injury Repository to calculate rates and to describe the incidence, timing, and geographic distribution of HIs among soldiers during U.S. Army basic combat training (BCT). From 2014 through 2018, HI events occurred in 1,210 trainees during BCT, resulting in an overall rate of 3.6 per 10,000 BCT person-weeks (p-wks) (95% CI: 3.4–3.8). HI rates (cases per 10,000 BCT p-wks) varied among the 4 Army BCT sites: Fort Benning, GA (6.8); Fort Jackson, SC (4.4); Fort Sill, OK (1.8); and Fort Leonard Wood, MO (1.7). Although the highest rates ofHIs occurred at Fort Benning, recruits in all geographic areas were at risk. The highest rates of HI occurred during the peak training months of June through Sept., and over half of all HI cases affected soldiers during the first 3 weeks of BCT. Prevention of HI among BCT soldiers requires relevant training of both recruits and cadre as well as the implementation of effective preventive measures.

Recommended Content:

Medical Surveillance Monthly Report

Update: Heat Illness, Active Component, U.S. Armed Forces, 2018

Article
4/1/2019
Drink water the day before and during physical activity or if heat is going to become a factor. (Photo Courtesy: U.S. Air Force)

In 2018, there were 578 incident diagnoses of heat stroke and 2,214 incident diagnoses of heat exhaustion among active component service members. The overall crude incidence rates of heat stroke and heat exhaustion diagnoses were 0.45 cases and 1.71 cases per 1,000 person-years, respectively. In 2018, subgroup-specific rates of incident heat stroke diagnoses were highest among males and service members less than 20 years old, Asian/Pacific Islanders, Marine Corps and Army members, recruit trainees, and those in combat-specific occupations. Subgroup-specific incidence rates of heat exhaustion diagnoses in 2018 were notably higher among service members less than 20 years old, Asian/Pacific Islanders, Army and Marine Corps members, recruit trainees, and service members in combat-specific occupations. During 2014–2018, a total of 325 heat illnesses were documented among service members in Iraq and Afghanistan; 8.6% (n=28) were diagnosed as heat stroke. Commanders, small unit leaders, training cadre, and supporting medical personnel must ensure that the military members whom they supervise and support are informed about the risks, preventive countermeasures, early signs and symptoms, and first-responder actions related to heat illnesses.

Recommended Content:

Medical Surveillance Monthly Report

Update: Exertional Hyponatremia, Active Component, U.S. Armed Forces, 2003–2018

Article
4/1/2019
Drink water the day before and during physical activity or if heat is going to become a factor. (Photo Courtesy: U.S. Air Force)

From 2003 through 2018, there were 1,579 incident diagnoses of exertional hyponatremia among active component service members, for a crude overall incidence rate of 7.2 cases per 100,000 person-years (p-yrs). Compared to their respective counterparts, females, those less than 20 years old, and recruit trainees had higher overall incidence rates of exertional hyponatremia diagnoses. The overall incidence rate during the 16-year period was highest in the Marine Corps, intermediate in the Army and Air Force, and lowest in the Navy. Overall rates during the surveillance period were highest among Asian/Pacific Islander and non-Hispanic white service members and lowest among non-Hispanic black service members. Between 2003 and 2018, crude annual incidence rates of exertional hyponatremia peaked in 2010 (12.7 per 100,000 p-yrs) and then decreased to 5.3 cases per 100,000 p-yrs in 2013 before increasing in 2014 and 2015. The crude annual rate in 2018 (6.3 per 100,000 p-yrs) represented a decrease of 26.5% from 2015. Service members and their supervisors must be knowledgeable of the dangers of excessive water consumption and the prescribed limits for water intake during prolonged physical activity (e.g., field training exercises, personal fitness training, and recreational activities) in hot, humid weather.

Recommended Content:

Medical Surveillance Monthly Report

Update: Exertional Rhabdomyolysis, Active Component, U.S. Armed Forces, 2014–2018

Article
4/1/2019
U.S. Marines sprint uphill during a field training exercise at Marine Corps Air Station Miramar, California. to maintain contact with an aviation combat element, teaching and sustaining their proficiency in setting up and maintaining communication equipment.  (Photo Courtesy: U.S. Marine Corps)

Among active component service members in 2018, there were 545 incident diagnoses of rhabdomyolysis likely due to exertional rhabdomyolysis, for an unadjusted incidence rate of 42.0 cases per 100,000 person-years. Subgroup-specific rates in 2018 were highest among males, those less than 20 years old, Asian/Pacific Islander service members, Marine Corps and Army members, and those in combat-specific or “other/unknown” occupations. During 2014–2018, crude rates of exertional rhabdomyolysis increased steadily from 2014 through 2016 after which rates declined slightly in 2017 before increasing again in 2018. Compared to service members in other race/ethnicity groups, the overall rate of exertional rhabdomyolysis was highest among non-Hispanic blacks in every year except 2018. Overall and annual rates were highest among Marine Corps members, intermediate among those in the Army, and lowest among those in the Air Force and Navy. Most cases of exertional rhabdomyolysis were diagnosed at installations that support basic combat/recruit training or major ground combat units of the Army or the Marine Corps. Medical care providers should consider exertional rhabdomyolysis in the differential diagnosis when service members (particularly recruits) present with muscular pain or swelling, limited range of motion, or the excretion of dark urine (possibly due to myoglobinuria) after strenuous physical activity, particularly in hot, humid weather.

Recommended Content:

Medical Surveillance Monthly Report

Vasectomy and Vasectomy Reversals, Active Component, U.S. Armed Forces, 2000–2017

Article
3/1/2019
Sperm is the male reproductive cell  Photo: iStock

During 2000–2017, a total of 170,878 active component service members underwent a first-occurring vasectomy, for a crude overall incidence rate of 8.6 cases per 1,000 person-years (p-yrs). Among the men who underwent incident vasectomy, 2.2% had another vasectomy performed during the surveillance period. Compared to their respective counterparts, the overall rates of vasectomy were highest among service men aged 30–39 years, non-Hispanic whites, married men, and those in pilot/air crew occupations. Male Air Force members had the highest overall incidence of vasectomy and men in the Marine Corps, the lowest. Crude annual vasectomy rates among service men increased slightly between 2000 and 2017. The largest increases in rates over the 18-year period occurred among service men aged 35–49 years and among men working as pilots/air crew. Among those who underwent vasectomy, 1.8% also had at least 1 vasectomy reversal during the surveillance period. The likelihood of vasectomy reversal decreased with advancing age. Non-Hispanic black and Hispanic service men were more likely than those of other race/ethnicity groups to undergo vasectomy reversals.

Recommended Content:

Medical Surveillance Monthly Report

Testosterone Replacement Therapy Use Among Active Component Service Men, 2017

Article
3/1/2019
Image of Marines carrying a wooden log for physical fitness. Click to open a larger version of the image.

This analysis summarizes the prevalence of testosterone replacement therapy (TRT) during 2017 among active component service men by demographic and military characteristics. This analysis also determines the percentage of those receiving TRT in 2017 who had an indication for receiving TRT using the 2018 American Urological Association (AUA) clinical practice guidelines. In 2017, 5,093 of 1,076,633 active component service men filled a prescription for TRT, for a period prevalence of 4.7 per 1,000 male service members. After adjustment for covariates, the prevalence of TRT use remained highest among Army members, senior enlisted members, warrant officers, non-Hispanic whites, American Indians/Alaska Natives, those in combat arms occupations, healthcare workers, those who were married, and those with other/unknown marital status. Among active component male service members who received TRT in 2017, only 44.5% met the 2018 AUA clinical practice guidelines for receiving TRT.

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Male Infertility, Active Component, U.S. Armed Forces, 2013–2017

Article
3/1/2019
Sperm is the male reproductive cell  Photo: iStock

Infertility, defined as the inability to achieve a successful pregnancy after 1 year or more of unprotected sexual intercourse or therapeutic donor insemination, affects approximately 15% of all couples. Male infertility is diagnosed when, after testing both partners, reproductive problems have been found in the male. A male factor contributes in part or whole to about 50% of cases of infertility. However, determining the true prevalence of male infertility remains elusive, as most estimates are derived from couples seeking assistive reproductive technology in tertiary care or referral centers, population-based surveys, or high-risk occupational cohorts, all of which are likely to underestimate the prevalence of the condition in the general U.S. population.

Recommended Content:

Medical Surveillance Monthly Report

Sexually Transmitted Infections, Active Component, U.S. Armed Forces, 2010–2018

Article
3/1/2019
Anopheles merus

This report summarizes incidence rates of the 5 most common sexually transmitted infections (STIs) among active component service members of the U.S. Armed Forces during 2010–2018. Infections with chlamydia were the most common, followed in decreasing order of frequency by infections with genital human papillomavirus (HPV), gonorrhea, genital herpes simplex virus (HSV), and syphilis. Compared to men, women had higher rates of all STIs except for syphilis. In general, compared to their respective counterparts, younger service members, non-Hispanic blacks, soldiers, and enlisted members had higher incidence rates of STIs. During the latter half of the surveillance period, the incidence of chlamydia and gonorrhea increased among both male and female service members. Rates of syphilis increased for male service members but remained relatively stable among female service members. In contrast, the incidence of genital HPV and HSV decreased among both male and female service members. Similarities to and differences from the findings of the last MSMR update on STIs are discussed.

Recommended Content:

Medical Surveillance Monthly Report

Outbreak of Acute Respiratory Illness Associated with Adenovirus Type 4 at the U.S. Naval Academy, 2016

Article
2/1/2019
Malaria case definition

Human adenoviruses (HAdVs) are known to cause respiratory illness outbreaks at basic military training (BMT) sites. HAdV type-4 and -7 vaccines are routinely administered at enlisted BMT sites, but not at military academies. During Aug.–Sept. 2016, U.S. Naval Academy clinical staff noted an increase in students presenting with acute respiratory illness (ARI). An investigation was conducted to determine the extent and cause of the outbreak. During 22 Aug.–11 Sept. 2016, 652 clinic visits for ARI were identified using electronic health records. HAdV-4 was confirmed by real-time polymerase chain reaction assay in 18 out of 33 patient specimens collected and 1 additional HAdV case was detected from hospital records. Two HAdV-4 positive patients were treated for pneumonia including 1 hospitalized patient. Molecular analysis of 4 HAdV-4 isolates identified genome type 4a1, which is considered vaccine-preventable. Understanding the impact of HAdV in congregate settings other than enlisted BMT sites is necessary to inform discussions regarding future HAdV vaccine strategy.

Recommended Content:

Medical Surveillance Monthly Report

Update: Incidence of Glaucoma Diagnoses, Active Component, U.S. Armed Forces, 2013–2017

Article
2/1/2019
Glaucoma

Glaucoma is an eye disease that involves progressive optic nerve damage and vision loss, leading to blindness if undetected or untreated. This report describes an analysis using the Defense Medical Surveillance System to identify all active component service members with an incident diagnosis of glaucoma during the period between 2013 and 2017. The analysis identified 37,718 incident cases of glaucoma and an overall incidence rate of 5.9 cases per 1,000 person-years (p-yrs). The majority of cases (97.6%) were diagnosed at an early stage as borderline glaucoma; of these borderline cases, 2.2% progressed to open-angle glaucoma during the study period. No incident cases of absolute glaucoma, or total blindness, were identified. Rates of glaucoma were higher among non-Hispanic black (11.0 per 1,000 p-yrs), Asian/Pacific Islander (9.5), and Hispanic (6.9) service members, compared with non-Hispanic white (4.0) service members. Rates among female service members (6.6 per 1,000 p-yrs) were higher than those among male service members (5.8). Between 2013 and 2017, incidence rates of glaucoma diagnoses increased by 75.4% among all service members.

Recommended Content:

Medical Surveillance Monthly Report

Re-evaluation of the MSMR Case Definition for Incident Cases of Malaria

Article
2/1/2019
Anopheles merus

The MSMR has been publishing the results of surveillance studies of malaria since 1995. The standard MSMR case definition uses Medical Event Reports and records of hospitalizations in counting cases of malaria. This report summarizes the performance of the standard MSMR case definition in estimating incident cases of malaria from 2015 through 2017. Also explored was the potential surveillance value of including outpatient encounters with diagnoses of malaria or positive laboratory tests for malaria in the case definition. The study corroborated the relative accuracy of the MSMR case definition in estimating malaria incidence and provided the basis for updating the case definition in 2019 to include positive laboratory tests for malaria antigen within 30 days of an outpatient diagnosis.

Recommended Content:

Medical Surveillance Monthly Report

Update: Malaria, U.S. Armed Forces, 2018

Article
2/1/2019
Anopheles merus

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. In 2018, a total of 58 service members were diagnosed with or reported to have malaria. This represents a 65.7% increase from the 35 cases identi­fied in 2017. The relatively low numbers of cases during 2012–2018 mainly reflect decreases in cases acquired in Afghanistan, a reduction due largely to the progressive withdrawal of U.S. forces from that country. The percentage of cases of malaria caused by unspecified agents (63.8%; n=37) in 2018 was the highest during any given year of the surveillance period. The percent­age of cases identified as having been caused by Plasmodium vivax (10.3%; n=6) in 2018 was the lowest observed during the 10-year surveillance period. The percentage of malaria cases attributed to P. falciparum (25.9 %) in 2018 was similar to that observed in 2017 (25.7%), although the number of cases increased. Malaria was diagnosed at or reported from 31 different medical facilities in the U.S., Afghanistan, Italy, Germany, Djibouti, and Korea. Pro­viders of medical care to military members should be knowledgeable of and vigilant for clinical manifestations of malaria outside of endemic areas.

Recommended Content:

Medical Surveillance Monthly Report

Thyroid Disorders, Active Component, U.S. Armed Forces, 2008–2017

Article
12/1/2018
A U.S. naval officer listens through his stethoscope to hear his patient’s lungs at Camp Schwab in Okinawa, Japan in 2018. (Photo courtesy of U.S. Marine Corps) photo by Lance Cpl. Cameron Parks)

This analysis describes the incidence and prevalence of five thyroid disorders (goiter, thyrotoxicosis, primary/not otherwise specified [NOS] hypothyroidism, thyroiditis, and other disorders of the thyroid) among active component service members between 2008 and 2017. During the 10-year surveillance period, the most common incident thyroid disorder among male and female service members was primary/NOS hypothyroidism and the least common were thyroiditis and other disorders of thyroid. Primary/NOS hypothyroidism was diagnosed among 8,641 females (incidence rate: 43.7 per 10,000 person-years [p-yrs]) and 11,656 males (incidence rate: 10.2 per 10,000 p-yrs). Overall incidence rates of all thyroid disorders were 3 to 5 times higher among females compared to males. Among both males and females, incidence of primary/NOS hypothyroidism was higher among non-Hispanic white service members compared with service members in other race/ethnicity groups. The incidence of most thyroid disorders remained stable or decreased during the surveillance period. Overall, the prevalence of most thyroid disorders increased during the first part of the surveillance period and then either decreased or leveled off.31.6 per 100,000 active component service members in 2017. Validation of ICD-9/ICD-10 diagnostic codes for MetS using the National Cholesterol Education Program Adult Treatment Panel III criteria is needed to establish the level of agreement between the two methods for identifying this condition.

Recommended Content:

Medical Surveillance Monthly Report
<< < ... 11 12 13 14 > >> 
Showing results 181 - 195 Page 13 of 14
Refine your search
Last Updated: October 28, 2022
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery