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Cross-Sectional Analysis of the Association between Perceived Barriers to Behavioral Health Care and Intentions to Leave the U.S. Army

Image of U.S. Army Central Reserve component Soldiers swear the oath of enlistment during a mass reenlistment ceremony in celebration of the U.S. Army Reserve 113th birthday at Camp Arifjan, Kuwait, April 23, 2021. U.S. Army Central Reserve component Soldiers swear the oath of enlistment during a mass reenlistment ceremony in celebration of the U.S. Army Reserve 113th birthday at Camp Arifjan, Kuwait, April 23, 2021. This ceremony reaffirms their commitment to the U.S. Army Reserve and the people of the United States. (U.S. Army photo by Sgt. Robert Torres, 203rd Public Affairs Detachment)

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Abstract

The attrition of service members is a costly concern for the U.S. military and can lead to reduced readiness. While there have been studies identifying reasons for attrition, little is known about the relationship between perceived barriers to behavioral health care and attrition. A cross-sectional survey was conducted as part of a behavioral health epidemiological consultation at a U.S. Army division (n=5,842) during the COVID-19 pandemic in 2020. Odds of intending to leave the Army increased by 6% for each additional perceived barrier to behavioral health care. Soldiers’ concerns about the potential negative impacts on their careers or work environments were the most frequently cited barriers to behavioral health care.

What are the new findings?   

This study found that 55% of surveyed soldiers intended to leave the Army at the end of their contract, and each additional perceived barrier to behavioral health care was associated with 6% higher odds of intentions to attrite. Soldiers who screened positive for depression or anxiety were also more likely to report intentions to leave the Army.

What is the impact on Readiness and Force health protection?

High levels of attrition result in high costs and lowered readiness. Soldiers with behavioral health conditions may intend to leave service for numerous reasons. To sustain readiness, the Army should dedicate resources to ensure soldiers have adequate access to behavioral health care and are not subject to stigma for accessing care for behavioral health concerns.

BACKGROUND

Service member attrition within the first term of service ranges from 18.5% in the U.S. Marine Corps to 29.7% in the U.S. Army.1 First term attrition is a costly occurrence in the U.S. military with each instance costing from $15,000 to $25,000 to include training and equipment costs in the case of enlisted soldiers.1 Attrition is of particular concern to the military because of its negative impact on readiness and its potential to increase training costs. Although the costs of first term attrition have been quantified1, little is known about the factors that impact career attrition beyond the first term and before 20 years of service.

There is extensive knowledge about the impact of injuries and chronic diseases on military careers, but the knowledge about the behavioral health aspects of attrition is limited in comparison.2–6 One possible reason for early career attrition related to behavioral health concerns is insufficient access to, or perceived barriers to use of, behavioral health care resources. The Army has the highest reported burden of behavioral health conditions of all military branches.7–8 In 2016, 26% of active duty Army soldiers had a behavioral health diagnosis, such as a mood disorder or adjustment disorder, which is 6% higher than the average for service members across the 4 branches.7–8

Similar to civilians, soldiers may encounter barriers to accessing behavioral health care. Soldiers may perceive that seeking care for behavioral health needs will lead to career stagnation or will result in occupational stressors, such as being seen as weak, being treated differently, and difficulty getting time off for appointments. There is extensive literature demonstrating that seeking behavioral health care does not affect career trajectory, unless the behavioral health issue has already led to duty-limiting recommendations, the service member intends to commit a crime, or engages in conduct unbecoming.9–13 

While there are previous studies of the relationship between stigma, help-seeking, and treatment outcomes, there is limited evidence on what impact service members’ perceived barriers to behavioral health care may have on early career attrition.4 Several studies have shown that the service members who report the highest perceived barriers to behavioral health care are also the ones who have the highest utilization of such services, presumably indicating a more severe condition or inability to get the treatment that they desire.7,14–16 A study published using data from a U.S Marine Corps sample found that Marines who sought treatment for behavioral health conditions were more likely to be separated from the military and have shorter lengths of service than Marines who did not seek such treatment.10,17 However, Marines who sought treatment for behavioral health conditions were not significantly more likely to be separated involuntarily, which indicates that most of the Marines in the study sample could have left of their own volition.10 Further investigation is warranted; therefore, the objective of this analysis was to examine the association between perceived barriers to behavioral health care and intentions to leave the Army after contract completion.

METHODS

Study Population 

This secondary analysis used survey data from a behavioral health epidemiological consultation conducted in 2020 by the U.S. Army Public Health Center’s Division of Behavioral and Social Health Outcomes Practice. The purpose of this behavioral health epidemiological consultation was to assess adverse behavioral and social health outcomes among soldiers following a perceived increase in suicide in an Army division, in addition to the potential exacerbating factors introduced by the COVID-19 pandemic. The survey included questions pertaining to demographics, Army career characteristics, COVID-19 health behaviors, food security, physical fitness, sleep, behavioral health, substance use, operational tempo, leadership, social support, behavioral health access and perceived barriers to care, and suicide ideation. Soldiers completed the survey in the summer of 2020. For the purpose of this secondary analysis, survey data (n=5,842 soldiers) on sociodemographic characteristics, Army career characteristics, and behavioral health characteristics were examined. 

Main predictor and outcome

The main predictor was based on soldiers’ responses to the question, “Rate each of the possible concerns that might affect your decision to seek behavioral health services.” Twelve possible concerns were listed (adapted from Hoge et al. 2004; Table 1).18 The response options for each concern ranged from “strongly disagree” to “strongly agree” with a decline to answer option for each concern. Responses to each concern were dichotomized (strongly agree or agree=1; neutral, disagree, or strongly disagree=0; decline to answer was coded as missing) and then summed to create a total behavioral health care barrier concerns score (range: 0–12). 

The main outcome was soldiers’ intent to leave the Army after the current service period. Soldiers were asked their intentions to leave the Army after contract completion based on a 5-point Likert scale (very unlikely, somewhat unlikely, neither likely nor unlikely, somewhat likely, very likely, and decline to answer). Responses to this question were collapsed into 2 categories: yes (somewhat likely, very likely) and no (very unlikely, somewhat unlikely, neither likely nor unlikely). Decline to answer responses were coded as missing.

Sociodemographic and Army career characteristics 

To assess the association between perceived barriers to behavioral health care and intentions to leave the Army, the analysis controlled for sociodemographic characteristics including sex; Hispanic origin (Hispanic and non-Hispanic); racial group (White/Caucasian, Black/African American, Asian/Pacific Islander, other/multiracial and unspecified race with Hispanic origin); marital status (married/in a relationship, separated/divorced/widowed, and single, never married); and parental status (children or no children). Racial group was based on responses to the question, “What is your race/ethnicity? Select all that apply.” The response options included 1) White, 2) Black or African American, 3) Asian/Pacific Islander, 4) Hispanic, Latino, or Spanish Origin, or 5) other race, ethnicity, or origin. Soldiers who only selected "other race, ethnicity or origin" were classified as "other". Soldiers who selected more than one racial group were classified as "multiracial." "Multiracial" and "other" categories were combined because of small cell sizes. Soldiers who selected "Hispanic, Latino, or Spanish origin" without indicating whether they were White, Black, Asian/Pacific Islander, or other were classified as "Unspecified race with Hispanic origin." This was done to distinguish this group from soldiers who did not provide a response to this question. Soldiers who selected "Hispanic, Latino, or Spanish Origin," regardless whether they were White, Black, Asian/Pacific Islander, or other, were classified as "Hispanic." Soldiers who did not select "Hispanic, Latino, or Spanish Origin," but indicated that they were White, Black, Asian/Pacific Islander, or other, were classified as "non-Hispanic." 

Army career characteristics included rank (junior enlisted [E1–E4], junior noncommissioned officer [E5–E6], senior noncommissioned officer [E7–E9], junior commissioned officer [O1–O3], senior commissioned officer [O4 or above], and warrant officer [WO1–CW5]) and job satisfaction. Although E4s are classified as junior enlisted, certain E4s (corporals) are also considered junior non-commissioned officers. For the purposes of this study, no distinction was made between specialists and corporals. Job satisfaction was assessed using the survey question, “How satisfied are you with your job overall?” with a 5-point Likert scale ranging from very satisfied to very dissatisfied. For this analysis, job satisfaction was collapsed into 3 categories including satisfied, neutral, or dissatisfied. 

Behavioral health characteristics 

Depression and anxiety were assessed using the 4-item Patient Health Questionnaire (PHQ-4).

19

The first 2 questions of this tool measure anxiety and the last 2 questions measure depression. Composite scores of negative (0–2) and positive (3–6) were used for each condition. Post-traumatic stress disorder (PTSD) was assessed using the PTSD Checklist Civilian Version 2 (PCL-C2) with composite scores of 0–3 coded as negative and 4–8 as positive.

20

Resilience (low [1.00–2.99], normal [3.00–4.30], and high [4.31–5.00]) was measured using the average score of 6 questions from the Brief Resilience Scale.

21

The analysis also controlled for current access to behavioral health services (e.g., unit or garrison chaplain, behavioral health officer, Substance Use Disorder Clinical Care program, psychologist, psychiatrist, and licensed counselor) (yes/no). On the survey, this question was asked immediately before asking about perceived behavioral health care barriers.

Statistical analysis

Soldiers with missing responses on any covariate were excluded from the analysis. To descriptively compare the overall study population and the analytic sample, both sets of demographics and military characteristics were analyzed. Due to the analytic sample nesting within the overall study population (i.e., not mutually exclusive), no statistical tests were performed. Multivariable logistic regression was used to determine the association between the perceived behavioral health care barriers score and intentions to leave the Army after contract completion, adjusting for sociodemographic, Army career, and behavioral health characteristics. Adjusted odd ratios (AORs) and their 95% confidence intervals (CIs) were calculated for each variable. The regression model was built in 1 step, and all predictors were selected a priori based on existing literature. All analyses were completed using SAS, version 9.4 (SAS Institute, Cary, NC). The alpha to determine statistical significance was set at p<.05.

RESULTS

A total of 5,842 soldiers were surveyed (5,120 men, 629 women, 93 sex unspecified) (Table 2). Of the 5,484 respondents with data on the main outcome, approximately 55% had intentions to leave the Army after contract completion. Of those with intent to leave, the majority were White (62%), non-Hispanic (81%), junior enlisted (61%), and without children (70%); had normal resilience (65%), and were not accessing behavioral health services at the time of the survey (68%). Nearly half of respondents with intentions to leave the Army were single, never married (48%) or dissatisfied with their jobs (48%). The most commonly perceived barriers to behavioral health care were related to stigma (data not shown). On average, soldiers reported 2 out of 12 behavioral health care concerns (median=1.0; standard deviation=2.8) (data not shown). The majority of soldiers with an intent to leave the Army screened negative for anxiety (69%), depression (70%), or PTSD (80%) (Table 2)

A total of 3,854 respondents (66% of the full sample) with complete information on the covariates were included in the logistic regression analysis (Table 3). The analytic sample was descriptively similar to the overall study population in terms of demographic and military characteristics. The odds of a soldier intending to leave the Army increased by 6% for each additional perceived barrier to behavioral health care, after adjusting for covariates. Soldiers with a rank of major (O4) and above (AOR=0.28; 95% CI: 0.14–0.56) were less likely to intend to leave the Army compared to soldiers in other rank groups. Soldiers who reported they were dissatisfied with their jobs (AOR=4.40; 95% CI: 3.67–5.27) had odds of intention to leave the Army that were 4.4 times that of those who reported being satisfied with their jobs (Table 3). For soldiers who screened positive for anxiety or depression, odds of leaving the Army were 36% and 39% higher, respectively, than those who screened negative for these conditions (AOR=1.36; 95% CI: 1.08–1.72 and AOR=1.39; 95% CI: 1.08–1.79, respectively). There was no association between behavioral health care access at the time of the survey and soldiers’ intentions to leave the Army (p=.07).

EDITORIAL COMMENT

Attrition in the military is a multifaceted issue that can have wide-ranging, long-lasting effects. High levels of attrition result in high costs and lowered readiness. The factors that influence decisions to leave the military prior to 20 years of service are not well understood. Survey results demonstrated that 55% of the surveyed soldiers intended to leave the Army at the end of their current contract. Additionally, each additional reported perceived barrier to behavioral health care was associated with 6% higher odds of intentions to leave. Soldiers who screened positive for depression or anxiety were also more likely to report intentions to leave compared to those who screened negative for these conditions. The findings also indicate that job satisfaction and being a senior officer are both potential protective factors for attrition.

This study had notable limitations. The sample used in this study was from 1 Army division and may not have been representative of the entire Army. Second, this sample did not distinguish between the 2 E4 pay grades (specialist and corporal). As a result, the findings did not capture potential differences between these 2 groups. Third, although no identifying information was collected, social desirability bias (i.e., the tendency to underreport socially undesirable attitudes/behaviors) could have been present leading to an attenuation of reporting barriers to behavioral health care. Fourth, it is also possible that the healthy warrior effect resulted in selection bias for the sample. The healthy warrior effect states that there is a disproportionate loss of psychologically unfit personnel early in training, which is amplified by numerous efforts to screen out as many individuals as possible prior to enlistment or commissioning.22 Fifth, it is also possible that the results are skewed due to an already existing issue in this specific population since behavioral health epidemiological consultations are only requested by units who have a perceived increase in social or behavioral health conditions. The pre-existing social, behavioral health, or organizational environment concerns within this division that were not measured by this study, including from the COVID-19 pandemic, could have contributed to intentions to leave the Army. Sixth, the analytic sample included individuals who may intend to leave the Army after the current service contract primarily because they are eligible for retirement (e.g., 20 years of service). However, results of the bivariate analyses indicated that respondents who were senior in ranks (i.e., O4 and above, E7 and above) were less likely to intend to attrite than other rank groups. Lastly, given that this was a cross-sectional study, no conclusions about causality can be drawn. The strengths of this study included a large sample within the Army and the minimization of social desirability bias since the survey was self-directed and anonymous. 

The findings of the current study point to numerous potential areas for future investigation. The COVID-19 pandemic has had a significant impact on behavioral health and continues to affect the psychological well-being of individuals worldwide.23–26 Previous studies have shown the pandemic exacerbated already existing racial disparities, loneliness, and strained social support systems, especially as a result of the restrictions put in place to reduce the spread of COVID-19.23–29 While the effects of the pandemic on the results of this study are unknown, it is likely that the results were biased away from the null due to COVID-19. 

One of the most commonly reported barriers to seeking or receiving behavioral health care in military populations is stigma. In this study, 6 stigma specific questions were incorporated into the 12-item questionnaire on barriers to behavioral health care. Although race and ethnicity did not significantly impact the intention to leave the Army (except for unspecified race with Hispanic origin), elucidating racial disparities in perceived stigma could be a future direction.

30

Another important area to address is the number of behavioral health care providers in the military.

31,32

A 2010 report by the Department of Defense found that a dearth of providers made it difficult for service members to seek care and led to negative outcomes, such as suicidal behavior.

33

Subsequent studies found that the number of providers has not increased in the years since.

34–37

The most persistent barriers continue to be the stigma associated with seeking behavioral health care.

9,14,38,39

To ensure that readiness is maintained and soldiers maintain holistic health, additional resources need to be dedicated to making sure soldiers have adequate access to, and perceive little stigma when seeking, behavioral health care resources. 

Affiliations: Division of Behavioral and Social Health Outcomes Practice, U.S. Army Public Health Center, Aberdeen Proving Ground, MD (Ms. Kaplansky, Ms. Ackah-Toffey, Dr. Beymer, and Dr. Schaughency); Oak Ridge Institute for Science and Education, Oak Ridge, TN (Ms. Kaplansky); General Dynamics Information Technology Inc., Falls Church, VA (Ms. Ackah-Toffey).

Disclaimer: The views expressed in this publication are those of the authors and do not necessarily reflect the official policy or position of the U.S. Department of the Army, the U.S. Department of Defense, or the U.S. Government.

Human research protection: The Public Health Review Board of the U.S. Army Public Health Center determined this activity to be public health practice under 21-960.

Project support: This project was supported in part by an appointment to the Research Participation Program for the U.S. Army Public Health Center administered by the Oak Ridge Institute for Science and Education through an agreement between the U.S. Department of Energy and the U.S. Army Public Health Center.



REFERENCES

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15. Boulos D, Zamorski MA. Do shorter delays to care and mental health system renewal translate into better occupational outcome after mental disorder diagnosis in a cohort of Canadian military personnel who returned from an Afghanistan deployment? BMJ Open. 2015;5(12):e008591. 

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17. Zuromski KL, Dempsey CL, Ng THH, et al. Utilization of and barriers to treatment among suicide decedents: Results from the Army Study to Assess Risk and Resilience Among servicemembers (Army STARRS). J Consult Clin Psychol. 2019;87(8):671–683.

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25. Usher K, Durkin J, Bhullar N. The COVID-19 pandemic and mental health impacts. Int J Ment Health Nurs. 2020;29(3):315–318. 

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27. Selden TM, Berdahl TA. COVID-19 and racial/ethnic disparities in health risk, employment, and household composition. Health Aff (Millwood). 2020;39(9):1624–1632. 

28. Gravlee CC. Systemic racism, chronic health inequities, and COVID-19: A syndemic in the making? Am J Hum Biol. 2020;32(5):e23482. 

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30. Chu KM, Garcia SMS, Koka H, Wynn GH, Kao TC. Mental health care utilization and stigma in the military: comparison of Asian Americans to other racial groups. Ethn Health. 2021;26(2):235–250. 

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32. Russell MC, Schaubel SR, Figley CR. The darker side of military mental healthcare part Two: Five harmful strategies to manage its mental health dilemma. Psychol Inj Law. 2018;11(1):37–68. 

33. Defense Health Board. The Challenge and the Promise: Strengthening the Force, Preventing Suicide and Saving Lives. Final Report of the Department of Defense Task Force on the Prevention of Suicide by Members of the Armed Forces. Washington, DC: United States of America, Dept. of Defense; 2010. Accessed 30 August 2021. https://apps.dtic.mil/sti/citations/ADA529502 

34. Health Resources and Services Administration. Bureau of Health Workforce. National Center for Health Workforce Analysis. National projections of supply and demand for selected behavioral health practitioners: 2013–2025. Rockville, MD; 2016. Accessed 30 August 2021. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/behavioral-health-2013-2025.pdf

35. U.S. Department of Defense. Office of the Inspector General. Access to care at selected military treatment facilities. Alexandria, VA; 2018. Accessed 30 August 2021. https://media.defense.gov/2018/May/16/2001917965/-1/-1/1/DODIG-2018-111.PDF

36. U.S. Department of Defense. Office of the Inspector General. Evaluation of access to mental health care in the Department of Defense. Alexandria, VA; 2020. Accessed 30 August 2021. https://media.defense.gov/2020/Aug/12/2002475605/-1/-1/1/DODIG-2020-112_REDACTED.PDF

37. Office of the Under Secretary of Defense for Personnel and Readiness. Report to Congressional Armed Services Committees. House Report 115-676. Mental Health Care in the Military Health System; 2019. Accessed 30 August 2021. https://health.mil/Reference-Center/Congressional-Testimonies/2019/05/24/Mental-Health-Care-in-the-MHS. 

38. Gardiner F, Gardiner EC. Similarities between military and medical service: stigma of seeking mental health assistance. BMJ Mil Health. 2020;166(3):181–182. 

39. Tanielian T, Woldetsadik MA, Jaycox LH, et al. Barriers to engaging service members in mental health care within the U.S. military health system. Psychiatr Serv. 2016;67(7):718–727.

TABLE 1. Perceived barriers to behavioral health care from the 12-item questionnairea (adapted from Hoge et al.14)

TABLE 2. Sociodemographic, Army career, and behavioral health characteristics among survey respondents

TABLE 3. Multivariable logistic regression of sociodemographic, Army career, and behavioral health characteristics and the intention to leave the Army (n=3,854)

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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.

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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.

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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.

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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.

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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 August–September 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 August–11 September 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.

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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.

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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.

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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.

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

Article
12/1/2018

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.

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Incidence and Prevalence of the Metabolic Syndrome Using ICD-9 and ICD-10 Diagnostic Codes, Active Component, U.S. Armed Forces, 2002–2017

Article
12/1/2018

This report uses ICD-9 and ICD-10 codes (277.7 and E88.81, respectively) for the metabolic syndrome (MetS) to summarize trends in the incidence and prevalence of this condition among active component members of the U.S. Armed Forces between 2002 and 2017. During this period, the crude overall incidence rate of MetS was 7.5 cases per 100,000 person-years (p-yrs). Compared to their respective counterparts, overall incidence rates were highest among Asian/Pacific Islanders, Air Force members, and warrant officers and were lowest among those of other/unknown race/ethnicity, Marine Corps members, and junior enlisted personnel and officers. During 2002–2017, the annual incidence rates of MetS peaked in 2009 at 11.6 cases per 100,000 p-yrs and decreased to 5.9 cases per 100,000 p-yrs in 2017. Annual prevalence rates of MetS increased steadily during the first 11 years of the surveillance period reaching a high of 38.9 per 100,000 active component service members in 2012, after which rates declined slightly to 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.

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Adrenal Gland Disorders, Active Component, U.S. Armed Forces, 2002–2017

Article
12/1/2018

During 2002–2017, the most common incident adrenal gland disorder among male and female service members was adrenal insufficiency and the least common was adrenomedullary hyperfunction. Adrenal insufficiency was diagnosed among 267 females (crude overall incidence rate: 8.2 cases per 100,000 person-years [p-yrs]) and 729 males (3.9 per 100,000 p-yrs). In both sexes, overall rates of other disorders of adrenal gland and Cushing’s syndrome were lower than for adrenal insufficiency but higher than for hyperaldosteronism, adrenogenital disorders, and adrenomedullary hyperfunction. Crude overall rates of adrenal gland disorders among females tended to be higher than those of males, with female:male rate ratios ranging from 2.1 for adrenal insufficiency to 5.5 for androgenital disorders and Cushing’s syndrome. The highest overall rates of adrenal insufficiency for males and females were among non-Hispanic white service members. Among females, rates of Cushing’s syndrome and other disorders of adrenal gland were 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.

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