Skip to main content

Military Health System

Case Report: Tick-borne Encephalitis Virus Infection in Beneficiaries of the U.S. Military Healthcare System in Southern Germany

Image of A paratrooper with 1st Squadron, 91st Cavalry Regiment, 173rd Airborne Brigade lies concealed in a forest and observes his target during a combined sniper exercise with the British Army's 1st Battalion, Royal Irish Regiment as part of Exercise Wessex Storm at the 7th Army Joint Multinational Training Command's Grafenwoehr Training Area, Germany, July 30, 2015. Wessex Storm is an annual maneuver exercise for British forces, integrating NATO allies and partners. (U.S. Army photo by Visual Information Specialist Gertrud Zach/released). A paratrooper with 1st Squadron, 91st Cavalry Regiment, 173rd Airborne Brigade lies concealed in a forest and observes his target during a combined sniper exercise with the British Army's 1st Battalion, Royal Irish Regiment as part of Exercise Wessex Storm at the 7th Army Joint Multinational Training Command's Grafenwoehr Training Area, Germany, July 30, 2015. Wessex Storm is an annual maneuver exercise for British forces, integrating NATO allies and partners. (U.S. Army photo by Visual Information Specialist Gertrud Zach/released)

Recommended Content:

Medical Surveillance Monthly Report

Abstract

Tick-borne encephalitis (TBE) is caused by a flavivirus usually transmitted to humans via the bite of an infected Ixodes ricinus tick. The disease is endemic to central Europe, including Germany where it is a potential threat to U.S. service members and other beneficiaries. This report describes 3 cases of TBE in persons living during 2017 and 2018 in the region of Germany with the highest incidence of TBE: a 36-year-old active duty service member and 2 non-service member beneficiaries aged 17 and 7 years. Each patient presented with debilitating symptoms and, following recovery from their acute illnesses, experienced troubling sequelae for months afterward. The nature of their initial illnesses varied from one another, as did the length and nature of their sequelae. The criteria for diagnosing TBE based upon clinical symptoms and laboratory test results are described. Preventive strategies for protecting residents in Germany from TBE include measures to avoid tick bites. The potential for use of the TBE virus vaccine, not Food and Drug Administration-approved in the U.S. but available in Europe, is discussed.

Background

Tick-borne encephalitis (TBE) is caused by tick-borne encephalitis virus (TBEV), a flavivirus distributed throughout Eurasia. Germany has a relatively high incidence of TBE; in 2016, Germany reported 348 of the 1,534 total cases reported in Europe.1 There are 3 TBEV subtypes; the subtype most prevalent in Germany is the European subtype, most commonly transmitted by the tick Ixodes ricinus. Rarely, TBEV can be transmitted through the ingestion of contaminated dairy products, such as unpasteurized milk.2 TBE (known as Frühsommer-Meningoenzephalitis in German) can cause debilitating meningoencephalitis and long-term sequelae; as such, it poses a health threat to U.S. service members and beneficiaries residing in Germany.3

Typical risk factors for TBE include living in a known risk area and engaging in activities in wooded/forested areas, such as hiking, camping, mushroom gathering, and military field exercises.4,5 About half of patients diagnosed with TBE recall a tick bite.6 The majority of TBE cases are among males, in both pediatric and adult populations.7–9

TBEV infection can cause a spectrum of illness ranging from subclinical (about one-third of cases) to death (0–1.4%).2 Differences in clinical severity are believed to be due to varying virulence of the pathogen and individual factors, most prominently age (older age is associated with increased severity of disease) and comorbidities (especially immunosuppresion).1 Presentation is typically biphasic (72–87% of patients), with a generally subclinical, viremic prodromal phase followed by a more severe second phase. The early phase is characterized by non-specific symptoms such as fever, anorexia, muscle aches, nausea, and vomiting.10 The most common laboratory findings during the first phase of TBE include leukopenia and thrombocytopenia. It is estimated that 30–50% of symptomatic TBE patients experience only the initial phase of illness, while the remainder experience both phases.1 Remission between the first and second phases typically lasts about 8 days. The second phase of TBE involves the central nervous system. Patients may have symptoms of meningitis (fever, headache, neck stiffness), encephalitis (drowsiness, confusion, sensory or motor disturbance), or meningoencephalitis.10 The most common laboratory findings during the second phase include an elevated white blood cell count, white blood cells in the cerebrospinal fluid (CSF), and increased protein in the CSF. It is common to see an initial predominance of granulocytes in CSF that shifts to a predominance of lymphocytic cells later in the illness. An abnormal electroencephalogram (EEG) is seen in 77% of patients.1 Sequelae following acute infection are relatively common; 26–46% of patients reported some form of remaining symptoms, such as headache and difficulties with concentration or memory, 6–12 months following acute infection.2

The current report describes 3 cases of TBE that occurred among U.S. Military Health System beneficiaries living in Germany in 2017 and 2018. A large portion of this U.S. population resides in Bavaria and Baden-Wurttemberg, the German states where 80–90% of German TBE cases occur. There is 1 large U.S. military installation located in a county ("Landkreis" in German) that consistently reports some of the highest incidence rates of TBE in Germany.11 Cases of TBE described here were identified through the U.S. military's reportable medical event reporting system—the Disease Reporting System internet (DRSi)—and case details were extracted from Armed Forces Health Longitudinal Technology Application (AHLTA) electronic medical records. Case ascertainment also used inpatient documents from German hospitals, translated and scanned into AHLTA. Individuals were included as cases if they met the European Centre for Disease Prevention and Control (ECDC) definition of TBE requiring 1) clinically apparent disease of the central nervous system and 2) valid laboratory documentation of current TBEV infection in the patient. ECDC laboratory criteria for confirmation of current TBEV infection include at least 1 of the following 5: TBE-specific immunoglobulin M and G (IgM and IgG, respectively) antibodies in blood, TBE-specific IgM antibodies in CSF, seroconversion or 4-fold increase of TBE-specific antibodies in paired serum samples, detection of TBE viral nucleic acid in a clinical specimen, or isolation of TBEV from a clinical specimen.3,12 Diagnosis with TBE-specific IgM and IgG antibodies in blood is the most common method of laboratory confirmation in Germany given the clinical course of TBE (IgM and IgG last longer in serum than the virus does) and clinical simplicity (a single serum sample is easier to draw than CSF or multiple sera samples).13

Case 1

In November 2017, a 36-year-old male, active duty service member presented to a German hospital with fever and delirium. The patient had no known history of a tick bite and was unimmunized against TBE. The patient lived and worked near Hohenfels, Bavaria, Germany, and was frequently in forested, woody, and grassy areas (always in the local region) as part of his military duties.

A companion reported that the patient had experienced fever for approximately 1 week, altered personality at work (including falling asleep there), and left-sided hemiparesis, which appeared on the day of presentation. This is consistent with the published literature, with focal, unilateral, and upper body areas being the most commonly affected by neurological abnormalities, when present.1 At the hospital, the patient complained of headaches, retrobulbar pain, and recurring numbness of the left arm and exhibited several episodes of confusion. Rash (not further described in the hospital record) was noted on physical exam.

The patient was too agitated for lumbar puncture (LP) to be performed; accordingly, he was sedated, after which LP was successful. CSF showed moderate pleocytosis consistent with viral meningoencephalitis. An EEG showed a moderately severe, generalized alteration with encephalitic involvement due to known meningitis.

Initially admitted to intensive care, the patient was moved to regular care as he improved. The patient had persistent headaches and what the hospital record described as "general psychomotor slowing and reactions." Upon admission, the patient was promptly treated with antibacterial and antiviral medications, initially ampicillin, acyclovir, and ceftriaxone. As results of testing became available, the antimicrobials were stopped in a stepwise manner. The patient was diagnosed with TBE on the basis of the compatible clinical presentation and positive serum TBE IgG and IgM antibodies. The patient gradually improved over 10 days of hospitalization. Upon discharge, 2 weeks of rest at home were recommended.

Following discharge, this soldier reported generalized fatigue, weakness in arms and shoulders, imbalance, headaches, and trouble with memory/focus lasting for several months. Although the fatigue and weakness gradually improved after 4–5 months, headaches persisted for over 6 months. These symptoms mostly resolved; however, he reported intermittent difficulties with memory, focus, and persistent headaches.

Case 2

In June 2018, a 17-year-old male presented to a U.S. military hospital emergency department (ED) with right-sided frontal headache. The patient lived near Stuttgart, Baden-Wurttemberg, Germany. The patient noted no tick bite, was unimmunized for TBE, and reported no pertinent outdoor activities. He had a multiyear history of recurrent headaches and reported that his current headache was greater in intensity but in the same location as previous headaches. The patient denied nausea, vomiting, sensitivity to light or sounds, numbness, focal weakness, stiff neck, and fever. He was treated with intramuscular ketorolac (an antiinflammatory drug used to treat pain), intravenous fluids (IV), and IV antiemetics. Computed tomography (CT) scan showed no acute abnormalities. The patient improved significantly with treatment and was diagnosed with tension headache, prescribed butalbital/acetaminophen/caffeine, and released from the ED.

The following day, the patient presented to his regular outpatient clinic for a recommended follow-up. Since discharge from the ED, he had developed fever (39.3°C), worsened headache, neck stiffness, vomiting, photophobia, muscle aches, and dizziness. He reported having a cold recently, but symptoms of his cold had reportedly resolved before the onset of the headache and were mild enough that he did not seek care for them. These symptoms could be consistent with biphasic presentation, reported in about 80% of cases in Germany.1

The patient was referred to a local German hospital and admitted for possible meningitis. Upon presentation, he was still febrile (39.7°C), with meningismus and mild throat inflammation. Blood tests showed leukocytosis, elevated C-reactive protein, and low overall IgG. CSF showed leukocytosis, pleocytosis, and increased protein. Magnetic resonance imaging (MRI) showed no evidence of meningitis or encephalitis. Chest x-ray findings were consistent with bronchopneumonia with left basal consolidation. Urinalysis was positive for protein, ketones, bilirubin, and urobilirubin. An EEG was normal.

On the third day of hospitalization, the patient had low oxygen saturation values (down to 84%) and was transferred to intensive care. The following day, the patient's oxygen saturation improved and he was transferred back to regular care.

Upon admission, the patient was promptly treated with antibacterial and antiviral medications (initially ampicillin, acyclovir, ceftriaxone) and analgesia (ibuprofen, paracetamol, metamizole, and tramadol). On the same day as his intensive care unit transfer, the patient received a one-time, high dose of systemic corticosteroids. He was diagnosed with TBE based on his clinical presentation and positive serum TBE IgG and IgM antibodies. Of note, there was no evidence of TBE IgG or IgM in the CSF.

Following 9 days of hospitalization with gradual improvement, the patient was discharged from the hospital in stable condition. After discharge, the patient experienced fatigue that was disruptive to his work and led to medical follow-up. The fatigue persisted for approximately 3 months before complete resolution.

Case 3

In Sept. 2018, a 7-year-old female developed worsening headache, photophobia, fever (reported 40°C), nausea, vomiting, and diarrhea over 2 days. She lived near Stuttgart, Baden-Wurttemberg, Germany, and was unimmunized against TBE. Her family reported hiking in Germany twice (in May and Sept. of 2018), with no known tick bite or other pertinent travel. Outpatient evaluation yielded a diagnosis of unspecified viral illness for which she was prescribed oral rehydration therapy and antipyretics. Of note, nausea and vomiting are common presenting symptoms of TBE, especially among pediatric patients.9

Upon outpatient follow-up the next day, the patient had experienced no improvement. The patient's parents were instructed to go to a local German hospital, where the patient was admitted with the complaints described above and neck stiffness. On hospital day 1, her condition continued to deteriorate.

LP was performed on hospital day 1. The patient's CSF showed pleocytosis, leukocytosis, and an increased albumin ratio, indicative of a breakdown in the blood-brain barrier consistent with meningitis. The patient's CSF had a positive TBE IgG index. The TBE IgG index is a diagnostic calculation that compares TBE IgG concentrations in the CSF to TBE IgG concentrations in the serum, controlling for total IgG concentrations in both the CSF and serum. A positive TBE IgG index (higher levels of TBE IgG in the CSF than in the serum) demonstrates intrathecal production of TBE antibodies, an indicator of active TBE infection.13 Serum was positive for TBE IgG and IgM. Of note, serum was also IgM positive for herpes simplex virus and enterovirus; however, upon expert consultation, no other good evidence for another (non-TBE) etiology was found among the diseases for which the patient was tested, and this case is consistent with a typical TBE infection in childhood (G. Dobler, MD, Lt Col, Bundeswehr, email communication, 09 April 2019).

An EEG (hospital day 3) was abnormal with right temporo-parieto-occipital slowing and a one-time spike-wave complex on the right frontal side. MRI (hospital day 3) showed prominent superficial cranial vessels and sphenoidal and maxillary sinusitis but no evidence of encephalitis. An EEG (hospital day 7) was normal.

Despite aggressive antipyretic treatment, the patient had persistent fevers during the first 4 inpatient days (ranging between 38° and 40°C) before defervescing on hospital day 4. She received IV glucose/electrolyte solutions for 7 days. Upon admission, she was promptly treated with antibacterial and antiviral medications, initially ampicillin, acyclovir, and ceftriaxone. There appears to have been no significant delay in treatment or diagnosis in this case.

Following 8 days of hospitalization, the patient was discharged in stable condition. Following hospital discharge she suffered significant difficulties with focus (in general) and school. Before infection, she was doing better in school than a twin sister. After infection, her twin was doing better and the patient had significant school difficulties. As of March 2019, the patient continued to have persistent, periodic headaches and to be much less energetic than before the infection. She was reported to be much more socially withdrawn.

The patient was unimmunized against TBE; however, 1 week before the patient first developed symptoms, her family had contacted the military clinic to seek TBE vaccination. The referral process was started; however, given multiple steps in the process, the actual appointment for vaccination with a German clinic was set for 3–4 weeks later. In the interim, the patient developed TBE.

Editorial Comment

Although cases of TBE among U.S. travelers to Europe and Asia have been described previously, this is the first report to describe such cases among U.S. service members and beneficiaries living in Europe.14 The cases illustrate the significant acute debilitation that TBE can cause. For example, case 1, an active duty soldier, experienced dramatically altered mental status, the most common neurological symptom.1 TBE infection in this patient caused a 10-day hospitalization, 2 weeks of convalescence, and months of headaches, decreased energy, and difficulty with concentration; ultimately, there was a significant negative impact on his readiness and deployability. Moreover, all patients reported some degree of sequelae following resolution of TBEV infection, which is well described in the literature.1,8 For example, case 3 (a 7-year-old female) experienced cognitive issues. Pediatric patients often recover physically more quickly from TBE, but cognitive sequelae represent a prominent concern.9 This report also documents that those residing in a risk area (e.g., in Bavaria and Baden-Wurttemberg, Germany) are potentially more likely to contract TBE. Two of 3 cases reported participation in traditionally high-risk outdoor activities; however, none recalled a tick bite.

These cases also highlight the potential for under diagnosis of TBE in the U.S. population stationed in Germany. Under diagnosis occurs in the European health care system and is thought to be due to lack of knowledge of the disease and the relative rarity of "classical" clinical presentation of TBE.5 If TBE is underdiagnosed by European providers, it is likely also underdiagnosed by U.S. providers in Europe. Lack of education and awareness of this Eurasian zoonosis could preclude its consideration in a differential diagnosis. Furthermore, there are challenges accessing diagnostics in the U.S. health care system. Serum testing for TBE IgG and IgM is available; however, it is not included as a standard test and requires direct coordination with the laboratory and a specific request for the test. Failure to appropriately diagnose TBE could lead to unnecessary testing, the lack of a definitive diagnosis, and an unclear prognosis. Such uncertainty might prevent a patient from accessing or utilizing appropriate specialty services during and after the acute phase of the disease. Delays in diagnosis could also contribute to similar problems. Although cases 2 and 3 did have to visit a U.S. provider twice before referral, review of the clinical details (especially the lack of meningeal signs during the first visit for both) suggest there was no delay in appropriate referral to the German system; similarly, there appears to be no delay in appropriate diagnosis once in the German system.

Efforts should be made to prevent TBE in the U.S. military population in Europe. These efforts could mirror the German, Austrian, or World Health Organization (WHO) public health approaches, which include promoting avoidance of ticks/TBE (i.e., through behavior, appropriate clothing, repellants, and early detection of ticks) and vaccination (either targeted or in the general population).5 The Austrian national government recommends and financially supports generalized vaccination for all residents.15 German military personnel are all required to receive TBE vaccine in order to be prepared to support national emergency response efforts in endemic areas (K. Erkens, MD, Lt Col, Bundeswehr, email communication, 13 Nov. 2019). The WHO recommends vaccination of all age groups in areas of high pre-vaccination prevalence (defined as = 5/100,000 per year).16,17 The German government recommends vaccination for all individuals 1 year or older in risk areas defined by the Robert Koch Institute.3 One study showed overall TBE vaccination in Germany at 27%, with higher rates in the highest-risk areas (i.e., 37–40% in Bavaria and Baden-Wurttemberg).18

None of the cases reported here had been immunized against TBEV. Vaccination is safe and effective in preventing TBE. Unfortunately, no TBE vaccines are U.S. Food and Drug Administration (FDA) approved, so purchase or administration by the U.S. government, including U.S. military medical facilities, is legally restricted. Administration of TBE vaccine is, however, now covered by insurance for U.S. military members in Europe. It is administered only at the level of individual patients, not at the level of military units or as a public health effort. Through the efforts of the European Command (EUCOM) and medical providers in Germany, TBE vaccine was approved for all active duty beneficiaries through TRICARE Eurasia in May 2014. Before that (starting in Feb. 2008), it was identified as a TRICARE eligible benefit for dependents and retirees. Currently, obtaining TBE vaccination among the U.S. military population requires a multistep process. The patient must first visit their military provider, who verifies the patient will be in country long enough to complete the series (at least 1 year longer). A referral to a German provider is then made. The patient then makes an appointment and visits the German provider. The patient receives the initial dose then arranges to receive the additional doses 3 and 9 months later. Given the requirement to obtain a special referral and arrange for and make multiple visits to an off-post provider, it is possible this process is sufficiently onerous to deter some from seeking the vaccine. Department of Defense (DOD) civilian employees with private (non-TRICARE) health insurance receive health care through the German medical system. Accordingly, for DOD civilians, TBE vaccine has been covered for as long as it has been standard of care in the German health care system.

Also, because the vaccine is not offered through the U.S. Military Health System or as part of any force health protection efforts, it is possible that U.S. military personnel may simply not be aware of the vaccine or indications for seeking it. There have been efforts by EUCOM and the Defense Health Agency to obtain FDA approval for TBE vaccine. FDA approval would likely simplify the process of obtaining vaccine and would allow it to be considered as a force health protection and/or public health measure. For example, the U.S. military could explore mirroring the German military model of requiring TBE vaccination for all military personnel stationed in Bavaria and Baden-Wurttemberg. Cost-benefit analysis of TBE vaccination of U.S. military personnel would inform this consideration.

This case study has several limitations. Many clinical details were derived from German medical records; all were translated by certified medical translators in an approved but imperfect process. Sequelae and preceding symptoms were ascertained up to a year after TBE infection and were likely subject to recall bias.

U.S. Military Health System beneficiaries living in Germany are at risk of TBE. It is important for providers caring for military service members in Europe to be proficient in the recognition and treatment of TBE. The U.S. military health care system in Europe should educate providers and patients regarding TBE risk, prevention, diagnosis, and treatment. The U.S. military health care system should also strive to make TBE diagnostics readily available to its providers and beneficiaries either internally or through enhanced cooperation with the German health care system.

Author affiliations: U.S. Army Medical Department Activity-Bavaria, Department of Preventive Medicine (LTC Mease, MAJ Maddox, Ms. Whitman); Madigan Army Medical Center (LTC Mease); Fort Hood Public Health (MAJ Maddox); 18th Military Police Brigade (MAJ Noss)

Acknowledgments: The authors thank Prof. Dr. Gerhard Dobler (Lt Col, Bundeswehr) for his thoughtful consultation, MAJ Daniel Weinstein for his valuable operational perspective, Mr. Joey Scaletta for his consistent support, and COL James Mancuso for his excellent guidance.

Funding: All work described herein was performed as part of paid regular duties as part of employment by the U.S. Government.

Disclaimer: The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense, or the U.S. Government.

References

  1. Erber W, Schmitt H-J, Vukovic Jankovic T. Epidemiology by country—an overview. In: Dobler G, Erber W, Schmitt H-J, eds. Tick-Borne Encephalitis (TBE). Singapore: Global Health Press;2018:114–127.
  2. Lindquist L, Vapalahti O. Tick-borne encephalitis. Lancet. 2008;371(9627):1861–1871.
  3. Borde JP, Zajkowska J. TBE in adults. In: Dobler G, Erber W, Schmitt H-J, eds. Tick-Borne Encepahlitis (TBE). Singapore: Global Health Press;2018:70–85.
  4. European Centre for Disease Prevention and Control. Factsheet about tick-borne encephalitis (TBE). https://ecdc.europa.eu/en/tick-borneencephalitis/facts/factsheet. Accessed 28 Aug. 2019.
  5. Kunze M, Haditsch M. TBE as a matter of public health. In: Dobler G, Erber W, Schmitt H-J, eds. Tick-Borne Encephalitis (TBE). Singapore: Global Health Press;2018:283–289.
  6. Hellenbrand W, Kreusch T, Bohmer MM, et al. Epidemiology of tick-borne encephalitis (TBE) in Germany, 2001–2018. Pathogens. 2019;8(2).
  7. Dobler G, Tkachev S. General epidemiology of tick-borne encephalitis. In: Dobler G, Erber W, Schmitt H-J, eds. Tick-Borne Encephalitis (TBE). Singapore: Global Health Press;2018:103–113.
  8. Logar M, Arnez M, Kolbl J, Avsic-Zupanc T, Strle F. Comparison of the epidemiological and clinical features of tick-borne encephalitis in children and adults. Infection. 2000;28(2):74–77.
  9. Sundin M. TBE in children. In: Dobler G, Erber W, Schmitt H-J, eds. Tick-Borne Encephalitis (TBE). Singapore: Global Health Press;2018:85–91.
  10. Centers for Disease Control and Prevention. Tick-borne encephalitis: signs and symptoms. https://www.cdc.gov/vhf/tbe/symptoms/index.html. Accessed 27 Aug. 2019.
  11. Mackenstedt U, Dobler G. TBE in Germany. In: Dobler G, Erber W, Schmitt H-J, eds. Tick-Borne Encephalitis (TBE). Singapore: Global Health Press;2018:170–174.
  12. European Centre for Disease Prevention and Control. Surveillance and disease data for tickborne encephalitis. https://ecdc.europa.eu/en/tickborne-encephalitis/surveillance-and-disease-data. Accessed 20 May 2019.
  13. Dobler G. Diagnosis. In: Dobler G, Erber W, Schmitt H-J, eds. Tick-Borne Encephalitis (TBE). Singapore: Global Health Press;2018:276–282.
  14. Centers for Disease Control and Prevention. Tick-borne encephalitis among U.S. travelers to Europe and Asia—2000–2009. MMWR Morb Mortal Wkly Rep. 2010;59(11):335–338.
  15. Heinz FX, Stiasny K, Holzmann H, et al. Vaccination and tick-borne encephalitis, central Europe. Emerg Infect Dis. 2013;19(1):69–76.
  16. Poellabauer EM, Kollartisch H. Prevention—vaccines and immunoglobulins. In: Dobler G, Erber W, Schmitt H-J, eds. Tick-Borne Encephalitis (TBE). Singapore: Global Health Press;2018:290–304.
  17. World Health Organization. Vaccines against tick-borne encephalitis: WHO position paper—recommendations. Vaccine. 2011;29(48):8769–8770.
  18. Erber W, Schmitt H-J. Self-reported tick-borne encephalitis (TBE) vaccination coverage in Europe: results from a cross-sectional study. Ticks Tick Borne Dis. 2018;9(4):768–777.

You also may be interested in...

MSMR Vol. 29 No. 10 - October 2022

Report
10/1/2022

A monthly publication of the Armed Forces Health Surveillance Division. This issue of the peer-reviewed journal contains the following articles: Surveillance trends for SARS-CoV-2 and other respiratory pathogens among U.S. Military Health System Beneficiaries, Sept. 27, 2020 – Oct. 2,2021; Establishment of SARS-CoV-2 genomic surveillance within the MHS during March 1 – Dec. 31 2020; Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces; Brief report: Phase I results using the Virtual Pooled Registry Cancer Linkage system (VPR-CLS) for military cancer surveillance.

Recommended Content:

Health Readiness & Combat Support | Public Health | Medical Surveillance Monthly Report

MSMR Vol. 29 No. 09 - September 2022

Report
9/1/2022

A monthly publication of the Armed Forces Health Surveillance Division. This issue of the peer-reviewed journal contains the following articles: Surveillance trends for SARS-CoV-2 and other respiratory pathogens among U.S. Military Health System Beneficiaries, Sept. 27, 2020 – Oct. 2,2021; Establishment of SARS-CoV-2 genomic surveillance within the MHS during March 1 – Dec. 31 2020; Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces; Brief report: Phase I results using the Virtual Pooled Registry Cancer Linkage system (VPR-CLS) for military cancer surveillance.

Recommended Content:

Health Readiness & Combat Support | Public Health | Medical Surveillance Monthly Report

Musculoskeletal Injuries During U.S. Air Force Special Warfare Training Assessment and Selection, Fiscal Years 2019–2021.

Article
8/1/2022
U.S. Air Force Capt. Hopkins, 351st Special Warfare Training Squadron, Instructor Flight commander and Chief Combat Rescue Officer (CRO) instructor, conducts a military free fall equipment jump from a DHC-4 Caribou aircraft in Coolidge, Arizona, July 17, 2021. Hopkins is recognized as the 2020 USAF Special Warfare Instructor Company Grade Officer of the Year for his outstanding achievement from January 1 to December 31, 2020.

Musculoskeletal (MSK) injuries are costly and the leading cause of medical visits and disability in the U.S. military.1,2 Within training envi­ronments, MSK injuries may lead to a loss of training, deferment to a future class, or voluntary disenrollment from a training pipeline, all of which are impediments to maintaining full levels of manpower and resources for the Department of Defense.

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Pain and Post-Traumatic Stress Disorder Screening Outcomes Among Military Personnel Injured During Combat Deployment.

Article
8/1/2022
U.S. Air Force Airman 1st Class Miranda Lugo, right, 18th Operational Medical Readiness Squadron mental health technician and Guardian Wingman trainer, and Maj. Joanna Ho, left, 18th OMRS director of psychological health, discuss the suicide prevention training program, Guardian Wingman, at Kadena Air Base, Japan, Aug. 20, 2021. Guardian Wingman aims to promote wingman culture and early help-seeking behavior. (U.S. Air Force photo by Airman 1st Class Anna Nolte)

The post-9/11 U.S. military conflicts in Iraq and Afghanistan lasted over a decade and yielded the most combat casualties since the Vietnam War. While patient survivability increased to the high­est level in history, a changing epidemiology of combat injuries emerged whereby focus shifted to addressing an array of long-term sequelae, including physical, psychologi­cal, and neurological issues.

Recommended Content:

Medical Surveillance Monthly Report

Prevalence and Distribution of Refractive Errors Among Members of the U.S. Armed Forces and the U.S. Coast Guard, 2019.

Article
8/1/2022
Ophthamologist Air Force Maj. Thuy Tran evaluates a patient during an eye exam. (U.S. Air Force photo by Tech. Sgt. John Hughel)

During calendar year 2019, the estimated prevalence of myopia, hyperopia, and astigmatism were 17.5%, 2.1%, and 11.2% in the active component of the U.S. Armed Forces and 10.1%, 1.2%, and 6.1% of the U.S. Coast Guard, respectively.

Recommended Content:

Medical Surveillance Monthly Report

MSMR Vol. 29 No. 08 - August 2022

Report
8/1/2022

A monthly publication of the Armed Forces Health Surveillance Division. This issue of the peer-reviewed journal contains the following articles: Surveillance trends for SARS-CoV-2 and other respiratory pathogens among U.S. Military Health System Beneficiaries, Sept. 27, 2020 – Oct. 2,2021; Establishment of SARS-CoV-2 genomic surveillance within the MHS during March 1 – Dec. 31 2020; Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces; Brief report: Phase I results using the Virtual Pooled Registry Cancer Linkage system (VPR-CLS) for military cancer surveillance.

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Phase I Results Using the Virtual Pooled Registry Cancer Linkage System (VPR-CLS) for Military Cancer Surveillance.

Article
7/1/2022
A patient at Naval Hospital Pensacola prepares to have a low-dose computed tomography test done to screen for lung cancer. Lung cancer is the leading cause of cancer-related deaths among men and women. Early detection can lower the risk of dying from this disease. (U.S. Navy photo by Jason Bortz)

The Armed Forces Health Surveillance Division, as part of its surveillance mission, periodically conducts studies of cancer incidence among U.S. military service members. However, service members are likely lost to follow-up from the Department of Defense cancer registry and Military Health System data sets after leaving service and during periods of time not on active duty.

Recommended Content:

Medical Surveillance Monthly Report

Establishment of SARS-CoV-2 Genomic Surveillance Within the Military Health System During 1 March–31 December 2020.

Article
7/1/2022
Dr. Peter Larson loads an Oxford Nanopore MinION sequencer in support of COVID-19 sequencing assay development at the U.S. Army Medical Research Institute of Infectious Diseases, Fort Detrick, Maryland. (Photo by John Braun Jr., USAMRIID.)

This report describes SARS-CoV-2 genomic surveillance conducted by the Department of Defense (DOD) Global Emerging Infections Surveillance Branch and the Next-Generation Sequencing and Bioinformatics Consortium (NGSBC) in response to the COVID-19 pandemic. Samples and sequence data were from SARS-CoV-2 infections occurring among Military Health System (MHS) beneficiaries from 1 March to 31 December 2020.

Recommended Content:

Medical Surveillance Monthly Report

Suicide Behavior Among Heterosexual, Lesbian/Gay, and Bisexual Active Component Service Members in the U.S. Armed Forces.

Article
7/1/2022
  The DOD’s theme for National Suicide Prevention Month is “Connect to Protect: Support is Within Reach.” Deployments, COVID-19 restrictions, and the upcoming winter season are all stressors and potential causes for depression that could lead to suicidal ideations. Options are available to individuals who are having thoughts of suicide and those around them (Photo by Kirk Frady, Regional Health Command Europe).

Lesbian, gay, and bisexual (LGB) individuals are at a particularly high risk for suicidal behavior in the general population of the United States. This study aims to determine if there are differences in the frequency of lifetime suicide ideation and suicide attempts between heterosexual, lesbian/gay, and bisexual service members in the active component of the U.S. Armed Forces. Self-reported data from the 2015 Department of Defense Health-Related Behaviors Survey were used in the analysis.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Trends for SARS-CoV-2 and Other Respiratory Pathogens Among U.S. Military Health System Beneficiaries, 27 September 2020–2 October 2021.

Article
7/1/2022
Staff Sgt. Misty Poitra and Senior Airman Chris Cornette, 119th Medical Group, collect throat swabs during voluntary COVID-19 rapid drive-thru testing for members of the community while North Dakota Army National Guard Soldiers gather test-subject data in the parking lot of the FargoDome in Fargo, N.D., May 3, 2020. The guardsmen partnered with the N.D. Department of Health and other civilian agencies in the mass-testing efforts of community volunteers. (U.S. Air National Guard photo by Chief Master Sgt. David H. Lipp)

Respiratory pathogens, such as influenza and adenovirus, have been the main focus of the Department of Defense Global Respiratory Pathogen Surveillance Program (DoDGRPSP) since 1976.1. However, DoDGRPSP also began focusing on SARS-CoV-2 when COVID-19 was declared a pandemic illness in early March 2020.2. Following this declaration, the DOD quickly adapted and organized its respiratory surveillance program, housed at the U.S. Air Force School of Aerospace Medicine (USAFSAM), in response to this emergent virus.

Recommended Content:

Medical Surveillance Monthly Report

MSMR Vol. 29 No. 07 - July 2022

Report
7/1/2022

A monthly publication of the Armed Forces Health Surveillance Division. This issue of the peer-reviewed journal contains the following articles: Surveillance trends for SARS-CoV-2 and other respiratory pathogens among U.S. Military Health System Beneficiaries, Sept. 27, 2020 – Oct. 2,2021; Establishment of SARS-CoV-2 genomic surveillance within the MHS during March 1 – Dec. 31 2020; Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces; Brief report: Phase I results using the Virtual Pooled Registry Cancer Linkage system (VPR-CLS) for military cancer surveillance.

Recommended Content:

Health Readiness & Combat Support | Public Health | Medical Surveillance Monthly Report

Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2021

Article
6/1/2022
Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2021

As in previous years, among service members deployed during 2021, injury/poisoning, musculoskeletal diseases and signs/symptoms accounted for more than half of the total health care burden during deployment. Compared to garrison disease burden, deployed service members had relatively higher proportions of encounters for respiratory infections, skin diseases, and infectious and parasitic diseases. The recent marked increase in the percentage of total medical encounters attributable to the ICD diagnostic category "other" (23.0% in 2017 to 44.4% in 2021) is likely due to increases in diagnostic testing and immunization associated with the response to the COVID-19 pandemic.

Recommended Content:

Medical Surveillance Monthly Report

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Non-service Member Beneficiaries of the Military Health System, 2021

Article
6/1/2022
Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Non-service Member Beneficiaries of the Military Health System, 2021

In 2021, 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. As in previous years, this report documents a substantial majority of non-service member beneficiaries received care for current illness and injury from the Military Health System as outsourced services at non-military medical facilities.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance snapshot: Illness and injury burdens, reserve component, U.S. Armed Forces, 2021

Article
6/1/2022
Surveillance snapshot: Illness and injury burdens, reserve component, U.S. Armed Forces, 2021

Recommended Content:

Medical Surveillance Monthly Report

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Active Component, U.S. Armed Forces, 2021

Article
6/1/2022
Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Active Component, U.S. Armed Forces, 2021

In 2021, as in prior years, the medical conditions associated with the most medical encounters, the largest number of affected service members, and the greatest number of hospital days were in the major categories of injuries, musculoskeletal disorders, and mental health disorders. Despite the pandemic, COVID-19 accounted for less than 2% of total medical encounters and bed days in active component service members.

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 13
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