Back to Top Skip to main content Skip to sub-navigation

Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2019

A physician examines and educates a patient. (U.S. Navy photo by Jacob Sippel, Naval Hospital Jacksonville/Released) A physician examines and educates a patient. (U.S. Navy photo by Jacob Sippel, Naval Hospital Jacksonville/Released)

Recommended Content:

Medical Surveillance Monthly Report

WHAT ARE THE NEW FINDINGS?

Three categories of morbidity burdens (injury/poisoning, musculoskeletal diseases, and signs/symptoms and ill-defined conditions) accounted for more than half of the total burden in theater. In 2019, the percentages of encounters due to mental health disorders decreased to levels much lower than during earlier periods of combat engagements. Compared to garrison disease burden, deployed service members had higher proportions of encounters for respiratory infections, skin diseases, and infectious and parasitic diseases.

WHAT IS THE IMPACT ON READINESS AND FORCE HEALTH PROTECTION?

The similarities between the burden of disease and injury among deployed and non-deployed service members emphasize the continuing need for surveillance, research, and preventive measures for those ever-present health threats. The dissimilarities highlight those special health threats associated with the more austere environments of deployment areas and the needed area-specific preventive measures of importance.

BACKGROUND

Every year, the MSMR estimates illness- and injury-related morbidity and healthcare burdens on the U.S. Armed Forces and the Military Health System (MHS) using electronic records of medical encounters from the Defense Medical Surveillance System (DMSS). These records document health care delivered in the fixed medical facilities of the MHS and in civilian medical facilities when care is paid for by the MHS. Healthcare encounters of deployed service members are documented in records that are maintained in the Theater Medical Data Store (TMDS), which is incorporated into the DMSS. This report updates previous analyses examining the distributions of illnesses and injuries that accounted for medical encounters (“morbidity burdens”) of active component members in deployed settings in the U.S. Central Command (CENTCOM) and the U.S. Africa Command (AFRICOM) areas of operations during the 2019 calendar year.1

METHODS

The surveillance population included all individuals who served in the active or reserve components of the U.S. Army, Navy, Air Force, or Marine Corps and who had records of healthcare encounters captured in the TMDS during the surveillance period. The analysis was restricted to encounters where the theater of care specified was CENTCOM or AFRICOM or where the theater of operation was missing or null; by default, this excluded encounters in the U.S. Northern Command, U.S. European Command, U.S. Indo-Pacific Command, or U.S. Southern Command theater of operations. In addition, TMDS-recorded medical encounters where the data source was identified as Shipboard Automated Medical System (e.g., SAMS, SAMS8, SAMS9) or where the military treatment facility descriptor indicated care was provided aboard a ship (e.g., USS George H.W. Bush or USS Dwight D. Eisenhower) were excluded from this analysis. Encounters from aeromedical staging facilities outside of CENTCOM or AFRICOM (e.g., the 779th Medical Group Aeromedical Staging Facility or the 86th Contingency Aeromedical Staging Facility) were also excluded. Inpatient and outpatient medical encounters were summarized according to the primary (first-listed) diagnoses (if reported with an International Classification of Diseases, 9th Revision [ICD-9] code between 001 and 999 or beginning with V27 or with an International Classification of Diseases, 10th Revision [ICD-10] code between A00 and T88 or beginning with Z37). Primary diagnoses that did not correspond to an ICD-9 or ICD-10 code (e.g., 1XXXX, 4XXXX) were not reported in this burden analysis.

In tandem with the methodology described on page 2 of this issue of the MSMR, all illness- and injury-specific diagnoses were grouped into 151 burden of disease-related conditions and 25 major categories based on a modified version of the classification system developed for the Global Burden of Disease (GBD) Study.2 The morbidity burdens attributable to various conditions were estimated on the basis of the total number of medical encounters attributable to each condition (i.e., total hospitalizations and ambulatory visits for the condition with a limit of 1 encounter per individual per condition per day) and the numbers of service members affected by the conditions. In general, the GBD system groups diagnoses with common pathophysiologic or etiologic bases and/or significant international health policymaking importance. For this analysis, some diagnoses that are grouped into single categories in the GBD system (e.g., mental health disorders) were disaggregated. Also, injuries were categorized by the affected anatomic sites rather than by causes because external causes of injuries are not completely reported in TMDS records. It is important to note that because the TMDS has not fully transitioned to ICD-10 codes, some ICD-9 codes appear in this analysis. In addition to the examination of the distribution of diagnoses by the 151 conditions and the 25 major categories of disease burden, a third analysis depicts the distribution of diagnoses according to the 17 traditional categories of the ICD system.

RESULTS

In 2019, a total of 191,887 medical encounters occurred among 69,405 individuals while deployed to Southwest Asia/Middle East and Africa. A majority of the medical encounters (77.4%) and individuals affected (81.8%) occurred among males (Figures 1a, 1b).

Medical encounters/individuals affected, by burden of disease categories

During 2019, the percentages of total medical encounters by burden of disease categories in both deployed men and women were generally similar; in both sexes, more encounters were attributable to injury/poisoning, musculoskeletal diseases, and signs/symptoms (including ill-defined conditions) than any other categories (Figures 1a, 1b, 2a, 2b). Of note, females had a greater proportion of medical encounters for genitourinary diseases (5.6%) compared to males (1.2%). Females also had a higher proportion of medical encounters for mental health disorders (9.1%) compared to males (5.2%).

Among both males and females, 5 burden conditions (other back problems, arm and shoulder injuries, knee injuries, foot and ankle injuries, and upper respiratory infections) were among the top 6 burden conditions that accounted for the most medical encounters in 2019 (Figures 3a, 3b). The remaining burden conditions among the top 6 were organic sleep disorders (specifically, circadian rhythm disorders) among males and all other signs and symptoms among females.

The 4-digit ICD-10 code with the most medical encounters in the other back problems category during 2019 was for lumbago/low back pain (data not shown). For all other musculoskeletal diseases, the most common 4-digit ICD code for both males and females was for cervicalgia. The most common 4-digit ICD-10 code for arm and shoulder injuries among males and for knee injuries among males and females was for pain in the specified body part (e.g., pain in right or left shoulder or pain in right or left knee) (data not shown).

Of note, among males, less than 0.3% of all medical encounters during deployment were associated with any of the following major morbidity categories: other neoplasms, metabolic/immunity disorders, endocrine disorders, congenital anomalies, blood disorders, malignant neoplasms, nutritional disorders, diabetes, and perinatal conditions (Figure 1a). Among females, less than 0.3% of all medical encounters during deployment were associated with endocrine disorders, other neoplasms, blood disorders, nutritional disorders, maternal conditions, congenital anomalies, malignant neoplasms, metabolic/immunity disorders, perinatal conditions, and diabetes mellitus (Figure 1b).

Among both sexes in 2019, injury/poisoning, musculoskeletal diseases, and signs/symptoms were the top 3 categories that affected the most individuals; musculoskeletal diseases ranked second among males and third among females (Figures 1a, 1b).

Medical encounters, by major ICD-9/ICD-10 diagnostic category

In 2019, among the 17 major ICD-9/ICD-10 diagnostic categories, the largest percentages of medical encounters were attributable to musculoskeletal system and “other” (includes factors influencing health status and contact with health services as well as external causes of morbidity) (Figure 4). The percentage of medical encounters attributable to musculoskeletal system conditions increased from 2015 through 2019, and the percentage attributable to “other” decreased during the same period. Of note, the percentages of medical encounters attributable to mental health disorders decreased slightly from 6.4% in 2015 to 4.7% in 2019. However, the percentage of medical encounters attributable to disorders of the nervous system and sense organs more than doubled from 3.5% in 2015 to 7.8% in 2019. The percentages of medical encounters attributable to other major ICD-9/ICD-10 diagnostic categories were relatively similar during the years 2015, 2017, and 2019.

EDITORIAL COMMENT

This report documents the morbidity and healthcare burden among U.S. military members while deployed to Southwest Asia/Middle East and Africa during 2019. Similar to results from earlier surveillance periods,1,3 3 burden categories—injury/poisoning, musculoskeletal diseases, and signs/symptoms—together accounted for more than 50% of the total healthcare burden in theater among both male and female deployers. However, the 2019 percentages of encounters due to mental health disorders among males and females (5.2% and 9.1%, respectively) were much smaller than the corresponding percentages during 2008–2014 (13.1% and 13.8%, respectively).3

Compared to the distribution of major burden of disease categories documented in garrison, this report demonstrates relatively greater proportions of in-theater medical encounters due to respiratory infections, skin diseases, and infectious and parasitic diseases. The lack of certain amenities and greater exposure to austere environmental conditions may have compromised hygienic practices and contributed to this finding. In contrast, compared to the distribution of burden of disease in garrison, a relatively lower proportion of in-theater medical encounters due to mental health disorders was observed.4 This finding may be due to a number of factors including reduced combat and operational stress in deployed settings and the continued emphasis on promoting psychological health and resilience in deployed service members.

However, 4 of the top 5 major burden of disease categories in-theater—injury/poisoning, musculoskeletal diseases, signs/symptoms, and mental health disorders—were the same as those reported in non-deployed settings.4 Injury and musculoskeletal diseases ranked first and second in both settings. In garrison settings, mental health disorders, signs/symptoms, and neurologic conditions ranked third through fifth.4 In contrast, sign/symptoms, respiratory infections, and mental health disorders ranked third through fifth in deployed settings. The similarity in these top conditions is likely attributable to the fact that both deployed and non-deployed populations generally comprise young and healthy individuals undergoing strenuous physical and mental tasks. Some of the similarity in the top conditions could also be attributed to service members receiving follow-up care once out of theater. For example, a service member medically evacuated out of theater for an injury could have encounters for injury recorded in both deployed and non-deployed (hospital or ambulatory care) settings.

Encounters for certain conditions are not expected to occur often in deployment settings. For example, the presence of some conditions (e.g., diabetes, pregnancy, or congenital anomalies) makes the affected service members ineligible for deployment. As a result of this selection process, deployed service members are generally healthier than their non-deployed counterparts and, specifically, less likely to require medical care for conditions that preclude deployment. The overall result of such predeployment medical screening is diminished healthcare burdens (as documented in the TMDS) related to certain disease categories.

Interpretation of the data in this report should be done with consideration of some limitations. Not all medical encounters in theaters of operation are captured in the TMDS. Some care is rendered by medical personnel at small, remote, or austere forward locations where electronic documentation of diagnoses and treatment is not feasible. As a result, the data described in this report likely underestimate the total burden of health care actually provided in the areas of operation examined. In particular, some emergency medical care provided to stabilize combat-injured service members before evacuation may not be routinely captured in the TMDS. Another limitation derives from the potential for misclassification of diagnoses due to errors in the coding of diagnoses entered into the electronic health record. Although the aggregated distributions of illnesses and injuries found in this study are compatible with expectations derived from other examinations of morbidity in military populations (both deployed and non-deployed), instances of incorrect diagnostic codes (e.g., coding a spinal cord injury using a code that denotes the injury was suffered as a birth trauma rather than using a code indicating injury in an adult) warrant care in the interpretation of some findings. Although such coding errors are not common, their presence serves as a reminder of the extent to which this study depends on the capture of accurate information in the sometimes austere deployment environment in which healthcare encounters occur.

REFERENCES

1. Armed Forces Health Surveillance Branch. Morbidity burdens attributable to various illnesses and injuries, deployed active and reserve component service members, U.S. Armed Forces, 2018. MSMR. 2019;26(5):34–39.

2. Murray CJL and Lopez AD, eds. Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard University Press; 1996:120–122.

3. Armed Forces Health Surveillance Branch. Morbidity burdens attributable to various illnesses and injuries in deployed (per Theater Medical Data Store [TMDS]) active and reserve component service members, U.S. Armed Forces, 2008–2014. MSMR. 2015;22(8):17–22.

4. Armed Forces Health Surveillance Branch. Absolute and relative morbidity burdens attributable to various illnesses and injuries, active component, U.S. Armed Forces, 2019. MSMR. 2020;27(5): 2–9.

FIGURE 1a. Medical encountersa and individuals affected,b by burden of disease major category,c deployed male service members, U.S. Armed Forces, 2019

FIGURE 1b. Medical encountersa and individuals affected,b by burden of disease major category,c deployed female service members, U.S. Armed Forces, 2019

FIGURE 2a. Percentage of medical encounters,a by burden of disease major category,b deployed male service members, U.S. Armed Forces, 2019

FIGURE 2b. Percentage of medical encounters,a by burden of disease major category,b deployed female service members, U.S. Armed Forces, 2019

FIGURE 3a. Percentage and cumulative percentage distribution, burden of disease-related conditionsa that accounted for the most medical encounters, deployed male service members, U.S. Armed Forces, 2019

FIGURE 3b. Percentage and cumulative percentage distribution, burden of disease-related conditionsa that accounted for the most medical encounters, deployed female service members, U.S. Armed Forces, 2019

 FIGURE 4. Major ICD-9/ICD-10 diagnostic categories of in-theater medical encounters, active component, U.S. Armed Forces, 2015, 2017, and 2019

You also may be interested in...

Skin and Soft Tissue Infections, Active Component, U.S. Armed Forces, January 2016–September 2020

Article
4/1/2021
Detailed view of elbow with carbuncle or furuncle. iStock.com/andriano_cz

Recommended Content:

Medical Surveillance Monthly Report

Update: Exertional Hyponatremia, Active Component, U.S. Armed Forces, 2005–2020

Article
4/1/2021
Marine Corps Recruit Depot, San Diego  Recruits with Bravo Company, 1st Recruit Training Battalion, hydrate after a physical training session at Marine Corps Recruit Depot San Diego, April 12, 2020. The recruits performed multiple exercises at different stations after completing a 400-meter dash. (U.S. Marine Corps photo by Cpl. Brooke C. Woods)

Recommended Content:

Medical Surveillance Monthly Report

Update: Heat Illness, Active Component, U.S. Armed Forces, 2020

Article
4/1/2021
Fort Jackson, SC. A trainee with 2nd Battalion, 60th Infantry Regiment puts his arms in an arm immersion cooling tank during training. The tanks allow Soldiers to rapidly cool by putting their forearms into a tank of ice water. (Photo by Saskia Gabriel)

Recommended Content:

Medical Surveillance Monthly Report

Disparities in COVID-19 Vaccine Initiation and Completion Among Active Component Service Members and Health Care Personnel, 11 December 2020–12 March 2021

Article
4/1/2021
Capt. Shamira Conerly, 149th Medical Group, gives Staff Sgt. Timmy Sanders, 149th Maintenance Squadron, his first does of COVID-19 vaccine on Joint Base San Antonio-Lackland, Texas, March 18, 2021. Members of the 149th Fighter Wing who have opted to receive their vaccine have been scheduled over the past two weeks by the 149th Medical Group. (US Air National Guard Photo by Senior Airman Ryan Mancuso)

Recommended Content:

Medical Surveillance Monthly Report

Update: Exertional Rhabdomyolysis, Active Component, U.S. Armed Forces, 2016–2020

Article
4/1/2021
Marine Corps Recruit Depot, San Diego  Recruits with Bravo Company, 1st Recruit Training Battalion, hydrate after a physical training session at Marine Corps Recruit Depot San Diego, April 12, 2020. The recruits performed multiple exercises at different stations after completing a 400-meter dash. (U.S. Marine Corps photo by Cpl. Brooke C. Woods)

Recommended Content:

Medical Surveillance Monthly Report

A Retrospective Cohort Study of Blood Lead Levels Among Special Operations Forces Soldiers Exposed to Lead at a Firing Range in Germany

Article
3/1/2021
A soldier assigned to the U. S. Army John F. Kennedy Special Warfare Center and School who is in the Special Forces Weapons Sergeant Course fires a pistol during small arms training at Fort Bragg, North Carolina November 4, 2019. The soldiers were trained to employ, maintain and engage targets with select U.S. and foreign pistols, rifles, shotguns, submachine and machine guns, grenade launchers and mortars and in the utilization of observed fire procedures. (U.S. Army photo illustration by K. Kassens)

Recommended Content:

Medical Surveillance Monthly Report

Influenza Outbreak During Exercise Talisman Sabre, Queensland, Australia, July 2019

Article
3/1/2021
Flight Lt. Michael Campion, an aviation medical officer from No. 3 Aeromedical Evacuation Squadron prepares a medical patient leaving Exercise Talisman Sabre to be transferred to a C-27J Spartan aircraft July 18, 2019 at Rockhampton Airport. No. 3 Aeromedical Evacuation Squadron is providing medical support to troops participating in Talisman Sabre 2019, a bilateral combined Australian and United States exercise designed to train respective military services in planning and conducting Combined and Joint Task Force operations, and improve the combat readiness and interoperability between Australian and US forces. (U.S. Army photo by Sgt. 1st Class John Etheridge)

Influenza Outbreak During Exercise Talisman Sabre, Queensland, Australia, July 2019

Recommended Content:

Medical Surveillance Monthly Report

Update: Sexually Transmitted Infections, Active Component, U.S. Armed Forces, 2012–2020

Article
3/1/2021
Under a magnification of 1150X, this photomicrograph of a Gram-stained urethral discharge specimen, demonstrated the presence of Gram-negative, intracellular diplococci, which is a finding indicative of the possible presence of Neisseria gonorrhoeae bacteria.  Credit: CDC/ Dr. Caldwell

Update: Sexually Transmitted Infections, Active Component, U.S. Armed Forces, 2012–2020

Recommended Content:

Medical Surveillance Monthly Report

Influenza Surveillance Trends and Influenza Vaccine Effectiveness Among Department of Defense Beneficiaries During the 2019–2020 Influenza Season

Article
3/1/2021
Captured in 2011, this transmission electron microscopic (TEM) image depicts some of the ultrastructural details displayed by H3N2 influenza virions, responsible for causing illness in Indiana and Pennsylvania in 2011. See PHIL 13469, for the diagrammatic representation of how this Swine Flu stain came to be, through the “reassortment” of two different Influenza viruses.  Credit: CDC/ Dr. Michael Shaw; Doug Jordan, M.A.

Influenza Surveillance Trends and Influenza Vaccine Effectiveness Among Department of Defense Beneficiaries During the 2019–2020 Influenza Season

Recommended Content:

Medical Surveillance Monthly Report

Surveillance for Vector-borne Diseases Among Active and Reserve Component Service Members, U.S. Armed Forces, 2016–2020

Article
2/1/2021
This image depicts a dorsal view of a female lone star tick, Amblyomma americanum, and is found in the Southeastern, and Mid-Atlantic United States. Females exhibit the star-like spot on their distal scutum. This tick is a vector of several zoonotic diseases, including human monocytic ehrlichiosis, and Rocky Mountain spotted fever (RMSF).  CDC/Michael L. Levin, PhD

Recommended Content:

Medical Surveillance Monthly Report

Historical Perspective: The Evolution of Post-exposure Prophylaxis for Vivax Malaria Since the Korean War

Article
2/1/2021
An Aedes aegypti mosquito can transmit the viruses that cause dengue fever.  CDC/Prof. Frank Hadley Collins, Cntr. for Global Health and Infectious Diseases, Univ. of Notre Dame

Recommended Content:

Medical Surveillance Monthly Report

Update: Malaria, U.S. Armed Forces, 2020

Article
2/1/2021
Spc. Joshua Jones, left, and Pfc. Richard Bower, both preventive medicine specialists, 227th Preventive Medicine Detachment, 62nd Medical Brigade, check an insect trap during a field training exercise on Joint Base Lewis-McChord, June 20. The 227th PMD notionally deployed to Guiria, Venezuela, where a tropical storm caused floods and presented a real world concern for mosquitos, which are known to spawn in stagnant water and cause widespread vector borne illnesses such as malaria, yellow fever and dengue fever.  Photo by Sgt. Sarah Enos 5th Mobile Public Affairs Detachment

Recommended Content:

Medical Surveillance Monthly Report

Attrition Rates and Incidence of Mental Health Disorders in an Attention-Deficit/Hyperactivity Disorder (ADHD) Cohort, Active Component, U.S. Armed Forces, 2014–2018

Article
1/1/2021
Capt. Michelle Tsai, the behavioral health officer for the 4th Brigade, 2nd Infantry Division, reviews medical information in her office at the Joint Readiness Training Center June 17. Tsai, an Alexandria, Va., native, is here with the Raider Brigade in support of training operations for the unit's upcoming deployment to Iraq. (Photo by Pfc. Luke Rollins)

Recommended Content:

Medical Surveillance Monthly Report

Exertional Rhabdomyolysis and Sickle Cell Trait Status in the U.S. Air Force, January 2009–December 2018

Article
1/1/2021
JOINT BASE SAN ANTONIO, Texas - Master Sgt. Daniel Bedford, Air Force Recruiting Service National Events program manager, prepares to pump up a gold medal lift in the bench press during the USPA (United State Powerlifting Association) 2020 Texas State Bench Press Championship. Senior Master Sgt. Michael Lear, AFRS Strategic Marketing Division superintendent, prepares to spot Bedford. Lear and Bedford are Total Force recruiting partners who train together and motivate one another at work and in the gym. (Courtesy photo) (Photo By: babin.)

Recommended Content:

Medical Surveillance Monthly Report

The Prevalence of Attention-Deficit/Hyperactivity Disorder (ADHD) and ADHD Medication Treatment in Active Component Service Members, U.S. Armed Forces, 2014–2018

Article
1/1/2021
New Recruits with Golf Company, 2nd Recruit Training Battalion, are screened after arriving at Marine Corps Recruit Depot, San Diego, Dec. 28, 2020. As recruits arrive to the depot in the future, they will enter a staging period of 14 days during which they will be medically screened, monitored, and provided classes to prepare and orient them to begin recruit training. All of this will occur before they step onto our iconic yellow footprints and make that memorable move toward earning the title Marine. Current planning and execution remain fluid as the situation continues to evolve. The health and well-being of our recruits, recruiting and training personnel, and their families remain our primary concerns. All recruits will be screened and tested for COVID-19 prior to beginning recruit training. (U.S. Marine Corps photo by Lance Cpl. Grace J. Kindred)

Recommended Content:

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

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.