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Military Health System

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On this page you can find various studies developed by Military Health System. Please scroll down or use the search box to find specific studies.

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Completeness and timeliness of reporting of notifiable medical conditions, active component, U.S. Armed Forces, 2008-2014.

Study

Abstract

The complete and timely reporting of notifiable medical conditions occurring among U.S. military service members is important for the control of communicable and preventable diseases and injuries. The Defense Medical Surveillance System (DMSS) was used to identify all hospital and ambulatory care encounters among service members occurring during 2008-2014. Incident encounters with diagnoses of Department of Defense notifiable medical conditions were matched to reportable medical events entered through the Disease Reporting System Internet. Over this time period, the Services reported 47.6% of notifiable hospitalized cases and 57.2% of notifiable ambulatory care cases. Timeliness of reporting improved over the time period with 40.0% of notifiable hospitalized cases reported within 1 week in 2008 and 73.6% in 2014. For ambulatory care cases, 62.3% were reported within 1 week in 2008 and 81.3% in 2014.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Armed Forces Health Surveillance Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: October 01, 2015
  • Citation: Hurt L, Ying S. Completeness and timeliness of reporting of notifiable medical conditions, active component, U.S. Armed Forces, 2008-2014. MSMR. 2015 Nov;22(11):8-21.

An Overview of Biorepositories-Past, Present, and Future

Study

Abstract

The collection, storage, and distribution of biological materials for research and improving health have been employed for more than a century. Biorepositories have been used to maintain and reallocate these specimens. Historically, the Department of Defense (DoD) has been maintaining biorepositories and using the materials stored to expand our understanding of diseases and for developing medical countermeasures since the Civil War. Other U.S. Government and nongovernmental organizations are also engaged in curating human and other samples for future studies, as are organizations in other countries. The reasons for collection and the possible uses of specimens maintained within repositories have changed with the advent of novel technologies and the genomics discipline. However, over the years, many of the issues faced by repositories have remained largely the same, although of increased importance more recently because of limited funding and enhanced ethical concerns. These issues include what samples to collect; how to collect, transport, and store the samples; legal and ethical matters relating to sample collection and use; durability of analytes of interest in stored specimens; assessing the quality of stored specimens and providing researchers with statements of specimen quality; costs; maintenance and sustainability of the repository; and, implementing and maintaining laboratory quality programs and possibly accreditation. National and international scientific groups are working to identify and define best practices, but universal standards and practices remain challenges for the future. To begin addressing the above issues, the DoD implemented several initiatives, which are described elsewhere in this Military Medicine Supplement. Additionally, staff members working on the issues saw potential value in identifying other biorepository groups and similar work being done by these groups with the expectation of developing lines of communication and, eventually, even collaboration in establishing universal standards and practices. The repositories identified are briefly discussed in this report.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Armed Forces Health Surveillance Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: October 01, 2015
  • Citation: Siwek M. An Overview of Biorepositories-Past, Present, and Future. Mil Med. 2015 Oct;180(10 Suppl):57-66.

Group Prenatal Care Outcomes in a Military Population: A Retrospective Cohort Study.

Study

Abstract

OBJECTIVE: To evaluate pregnancy outcomes in Centering Pregnancy patients. METHODS: This was an IRB-approved retrospective cohort study from November 2009 to January 2013 involving 202 Centering Pregnancy patients and 202 Certified Nurse Midwife patients. The primary outcome was mean gestational age at time of delivery. Secondary outcomes included cesarean and operative vaginal delivery rate, triage visit frequency, Neonatal Intensive Care Unit admission rate, 1 and 5 minute APGAR scores, birth weight, breastfeeding rate at discharge and 6 weeks postpartum, third and fourth degree laceration rate, weight gain in pregnancy, and excessive weight gain rate. RESULTS: There was no statistically significant difference in any obstetric outcome including preterm delivery rate. Centering Pregnancy patients were more likely to be active duty (52.0 vs. 35.6%, p = 0.001), younger (24.8 vs. 26.3 years old, p < 0.001), and nulliparous (75.2 vs. 56.9%, p < 0.001). There was a statistically significant increase in triage visit frequency ≥ 6 for Centering Pregnancy patients (11.9% vs. 8.9%, p = 0.011). CONCLUSION: There were no clinically significant differences in the primary or secondary outcomes. Significant cost savings could be realized by expanding Centering Pregnancy in the military health system.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Walter Reed National Military Medical Center
  • Congressionally Mandated: No
  • Funding Source:
  • Release Date/Publication: July 01, 2015
  • Citation: Walton RB, Shaffer S, Heaton J. Group Prenatal Care Outcomes in a Military Population: A Retrospective Cohort Study. Mil Med. 2015 Jul;180(7):825-9.

Trends in Androgen Prescriptions From Military Treatment Facilities: 2007 to 2011.

Study

Abstract

INTRODUCTION: The role of testosterone in health and quality of life has become increasingly visible and overtly marketed to the public. Some evidence suggests that testosterone levels in men may be low because of a variety of reasons, including stress and environmental exposures. OBJECTIVE: This study examines trends in testosterone prescriptions dispensed by military treatment facilities (MTFs). METHODS: We examined data from the Department of Defense Pharmacy Data Transaction Service to determine the nature of androgen prescriptions dispensed through MTFs from 2007 through 2011. RESULTS: The number of androgen prescriptions increased more than two-fold across the military from 19,494 in 2007 to 45,270 in 2011. Most prescriptions (99%) were for men. Androgen prescription rates rose 23% per year from 2007 through 2011 (p < 0.001, CI 23-24%). The prescription rate for 35- to 44-year-olds increased more than any other age group, with annual increases averaging 33% (p < 0.001, CI 32-34%). CONCLUSION: The number of androgen prescriptions within MTFs rose significantly from 2007 through 2011. This is similar to rises in androgen prescriptions seen in civilian medical systems. Clinical indications for the sharp increase in testosterone prescriptions are unknown, and the indications for clinically appropriate testosterone replacement need further clarification.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: July 01, 2015
  • Citation: Canup R, Bogenberger K, Attipoe S, Jones DR, Olsen CH, Stephens MB, Deuster PA. Trends in Androgen Prescriptions From Military Treatment Facilities: 2007 to 2011. Mil Med. 2015 Jul;180(7):728-31.

Trends in B-Vitamin Prescriptions From Military Treatment Facilities: 2007 to 2011.

Study

Abstract

INTRODUCTION:

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: July 01, 2015
  • Citation: Krieger JA, Arnold RM, Attipoe S, Jones DR, Stephens MB, Deuster PA. Trends in B-Vitamin Prescriptions From Military Treatment Facilities: 2007 to 2011. Mil Med. 2015 Jul;180(7):732-6.

Insomnia in the Military: Application and Effectiveness of Cognitive and Pharmacologic Therapies.

Study

Abstract

Insomnia is one of the most common complaints of US armed service members. Diagnosis and treatment of insomnia in active duty and veteran populations are often complicated by comorbid disorders experienced by military personnel, such as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). Cognitive behavioral therapy for insomnia (CBTi), pharmacologic interventions, and alternative therapies are discussed as relevant to their applications within military populations. Future directions in research are suggested.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Walter Reed National Military Medical Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: October 01, 2015
  • Citation: Capaldi VF 2nd, Kim JR, Grillakis AA, Taylor MR, York CM. Insomnia in the Military: Application and Effectiveness of Cognitive and Pharmacologic Therapies. Curr Psychiatry Rep. 2015 Oct;17(10):85

Causes of combat ocular trauma-related blindness from Operation Iraqi Freedom and Enduring Freedom.

Study

Abstract

BACKGROUND: The incidence of eye injuries in military service members is high in the combat setting. This is the first study that identifies the primary reason for poor visual acuity (worse than 20/200). METHODS: This is a retrospective, noncomparative, interventional case series analyzing US Operation Iraqi and Enduring Freedom members who were evacuated from the theater of operations to Walter Reed Army Medical Center from 2001 through 2011. Primary outcome measures were the length of follow-up, globe survival, and anatomic causes of blindness. Secondary outcome measures included surgical procedures performed, use of eye protection, nonocular injuries, incidence of traumatic brain injury, source of injury, visual outcomes, and predictability of Ocular Trauma Score (OTS) on visual outcome. Univariate analysis was performed using χ and Fisher's exact test. A p < 0.01 was considered significant because of the multiple hypotheses tested. RESULTS: There were 265 eyes of 239 patients who had final best-corrected visual acuity of worse than 20/200. The average age was 27.4 years (range, 19-53 years). Of the patients, 97.5% were male, and 28.9% had documented use of eye protection. The average follow-up was 350.19 days (range, 3-2,421 days). There were 128 right-eye and 133 left-eye injuries, with a total of 26 bilateral injuries. There were 206 open-globe and 56 closed-globe injuries, which were further subdivided into zones. Open-globe Zone III injuries (81.6%) were the number one cause of blindness, and most injuries were caused by improvised explosive devices (64.2%). Enucleation was the most common surgery performed (40.6%) and therefore the leading cause of blindness, followed by a multifactorial cause and direct traumatic optic neuropathy. CONCLUSION: Ocular trauma is common among combat injuries. Close to a third of service members that experience an ocular trauma become legally blind. Further research is needed to focus on strategies to prevent injury and improve visual outcomes.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Walter Reed National Military Medical Center
  • Congressionally Mandated: No
  • Funding Source:
  • Release Date/Publication: October 01, 2015
  • Citation: Vlasov A, Ryan DS, Ludlow S, Weichel ED, Colyer MH. Causes of combat ocular trauma-related blindness from Operation Iraqi Freedom and Enduring Freedom. J Trauma Acute Care Surg. 2015 Oct;79(4 Suppl 2):S210-5.

Development and validation of trauma surgical skills metrics: Preliminary assessment of performance after training.

Study

Abstract

BACKGROUND: Maintaining trauma-specific surgical skills is an ongoing challenge for surgical training programs. An objective assessment of surgical skills is needed. We hypothesized that a validated surgical performance assessment tool could detect differences following a training intervention. METHODS: We developed surgical performance assessment metrics based on discussion with expert trauma surgeons, video review of 10 experts and 10 novice surgeons performing three vascular exposure procedures and lower extremity fasciotomy on cadavers, and validated the metrics with interrater reliability testing by five reviewers blinded to level of expertise and a consensus conference. We tested these performance metrics in 12 surgical residents (Year 3-7) before and 2 weeks after vascular exposure skills training in the Advanced Surgical Skills for Exposure in Trauma (ASSET) course. Performance was assessed in three areas as follows: knowledge (anatomic, management), procedure steps, and technical skills. Time to completion of procedures was recorded, and these metrics were combined into a single performance score, the Trauma Readiness Index (TRI). Wilcoxon matched-pairs signed-ranks test compared pretraining/posttraining effects. RESULTS: Mean time to complete procedures decreased by 4.3 minutes (from 13.4 minutes to 9.1 minutes). The performance component most improved by the 1-day skills training was procedure steps, completion of which increased by 21%. Technical skill scores improved by 12%. Overall knowledge improved by 3%, with 18% improvement in anatomic knowledge. TRI increased significantly from 50% to 64% with ASSET training. Interrater reliability of the surgical performance assessment metrics was validated with single intraclass correlation coefficient of 0.7 to 0.98. CONCLUSION: A trauma-relevant surgical performance assessment detected improvements in specific procedure steps and anatomic knowledge taught during a 1-day course, quantified by the TRI. ASSET training reduced time to complete vascular control by one third. Future applications include assessing specific skills in a larger surgeon cohort, assessing military surgical readiness, and quantifying skill degradation with time since training.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source:
  • Release Date/Publication: July 01, 2015
  • Citation: Shackelford S, et. al., . Development and validation of trauma surgical skills metrics: Preliminary assessment of performance after training. J Trauma Acute Care Surg. 2015 Jul;79(1):105-10.

A Brief Description of the Operation of the DoD Serum Repository.

Study

Abstract

Beginning in 1985, the United States military has consistently maintained repositories of frozen human serum for force health protection reasons. The separate repositories created by the Army, Navy, and Air Force during the startup of their human immunodeficiency virus (HIV) screening programs were fully combined by 1996, along with the Defense Medical Surveillance System, to form the DoD Serum Repository (DoDSR). Currently comprised of 450,000 square feet of storage space at a constant -30 degrees Celsius, the DoDSR, operated by the Armed Forces Health Surveillance Center (AFHSC), receives approximately 2 million new serum specimens per year as a result of current HIV screening programs and pre- and post-deployment serum collection. Following initial testing for HIV when required, each specimen remains frozen until needed for clinical testing or a public health study, and its physical location is carefully tracked. Certain militarily-relevant research studies occur, though the serum from a specific individual is never allowed to be fully exhausted. AFHSC maintains careful control over the repository, utilizing a scientific review board to determine which requests for serum will be granted. As of 2012, only 0.42% of all of the frozen specimens in the DoDSR had been thawed for any type of use. The addition of new specimen processing capacity and significant changes to policy would be required if more of the specimens were to be used to answer relevant epidemiological, operational, or medical research questions.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Armed Forces Health Surveillance Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: October 01, 2015
  • Citation: Perdue CL, Eick-Cost AA, Rubertone MV. A Brief Description of the Operation of the DoD Serum Repository. Mil Med. 2015 Oct;180(10 Suppl):10-2.

The DoD Joint Pathology Center as a Resource for Researchers.

Study

Abstract

The Department of Defense's Joint Pathology Center (JPC) is the world's largest collection of human pathology specimens, comprising some 7.4 million accessions. The biorepository, which began during the Civil War as a collection of materials obtained from medical and surgical procedures performed by Army physicians, houses specimens and associated data obtained for diagnostic purposes. It also holds several collections of specimens from military personnel who shared a common, service-related exposure or medical condition. This article, which is excerpted and adapted from the 2012 Institute of Medicine report "Future Uses of the Department of Defense JPC Biorepository,"1 summarizes information on the repository, its past uses, and the future operational issues and challenges that the JPC faces as it develops a concept of operations that will allow it to move forward as a resource for researchers.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Joint Pathology Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: October 01, 2015
  • Citation: Butler DA, Baker TP. The DoD Joint Pathology Center as a Resource for Researchers. Mil Med. 2015 Oct;180(10 Suppl):85-9.

Trends in Mineral Supplement Prescriptions From Military Treatment Facilities: 2007 to 2011.

Study

Abstract

INTRODUCTION: Mineral supplements such as calcium and iron are readily available over the counter and are some of the most frequently consumed dietary supplements. Health care providers also prescribe mineral supplements for treatment of certain conditions and to maintain health. OBJECTIVE: This study examines trends in mineral-supplement prescriptions dispensed by military treatment facilities. METHODS: We examined data from the DoD Pharmacy Data Transaction Service to determine the nature of mineral-supplement prescriptions dispensed by MTFs from 2007 through 2011. RESULTS: Overall, 1,785,158 calcium, 844,655 iron, 166,207 magnesium, and 23,297 zinc prescriptions were dispensed over this 5-year period. Although the number of zinc prescriptions decreased considerably by an average of 30% across the 5-year period, calcium and magnesium prescriptions increased by 3% and 8%, respectively. The number of iron prescriptions dispensed was relatively stable across the 5 years. CONCLUSIONS: Patterns of mineral-supplement prescriptions in the military changed over the 5-year period examined. However, the patterns within the DoD medical system may or may not represent those of the civilian medical system. Because we could not determine the reasons why the mineral supplements were prescribed, we cannot report whether the supplements were effective for the intended uses.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: July 01, 2015
  • Citation: Attipoe S, Jones DR, Olsen CH, Stephens MB, Deuster PA. Trends in Mineral Supplement Prescriptions From Military Treatment Facilities: 2007 to 2011. Mil Med. 2015 Jul;180(7):742-7.

Molecular Epidemiology of Adenovirus Type 21 Respiratory Strains Isolated From US Military Trainees (1996-2014).

Study

Abstract

BACKGROUND: The circulation of human adenovirus type 21 (HAdV21) in the United States has been documented since the 1960s in association with outbreaks of febrile respiratory illness (FRI) in military boot camps and civilian cases of respiratory disease. METHODS: To describe the molecular epidemiology of HAdV21 respiratory infections across the country, 150 clinical respiratory isolates obtained from continuous surveillance of military recruit FRI, and 23 respiratory isolates recovered from pediatric and adult civilian cases of acute respiratory infection were characterized to compile molecular typing data spanning 37 years (1978-2014). RESULTS: Restriction enzyme analysis and genomic sequencing identified 2 clusters of closely related genomic variants readily distinguishable from the prototype and designated 21a-like and 21b-like. A-like variants predominated until 1999. A shift to b-like variants was noticeable by 2007 after a 7-year period (2000-2006) of cocirculation of the 2 genome types. US strains are phylogenetically more closely related to European and Asian strains isolated over the last 4 decades than to the Saudi Arabian prototype strain AV-1645 isolated in 1956. CONCLUSIONS: Knowledge of circulating HAdV21 variants and their epidemic behavior will be of significant value to local and global FRI surveillance efforts.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Walter Reed National Military Medical Center
  • Congressionally Mandated: No
  • Funding Source:
  • Release Date/Publication: October 01, 2015
  • Citation: Kajon AE, et. al., Molecular Epidemiology of Adenovirus Type 21 Respiratory Strains Isolated From US Military Trainees (1996-2014). J Infect Dis. 2015 Sep 15;212(6):871-80.

Longitudinal determinants of mental health treatment-seeking by US soldiers.

Study

Abstract

Background Studies with members of the armed forces have found a gap between reports of mental health symptoms and treatment-seeking. Aims To assess the impact of attitudes on treatment-seeking behaviours in soldiers returning from a combat deployment. Method A sample of 529 US soldiers were surveyed 4 months (time 1) and 12 months (time 2) post-deployment. Mental health symptoms and treatment-seeking attitudes were assessed at time 1; reported mental healthcare visits were assessed at time 2.Results Factor analysis of the total time 1 sample revealed four attitude factors: professional concerns, practical barriers, preference for self-management and positive attitudes about treatment. For the subset of 160 soldiers reporting a mental health problem at time 1, and controlling for mental health symptom severity, self-management inversely predicted treatment-seeking; positive attitudes were positively related. Conclusions Results demonstrate the importance of broadening the conceptualization of barriers and facilitators of mental healthcare beyond stigma. Techniques and delivery models emphasising self-care may help increase soldiers' interest in using mental health services.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Walter Reed National Military Medical Center
  • Congressionally Mandated: No
  • Funding Source: Army
  • Release Date/Publication: October 01, 2015
  • Citation: Adler AB, Britt TW, Riviere LA, Kim PY, Thomas JL. Longitudinal determinants of mental health treatment-seeking by US soldiers. Br J Psychiatry. 2015 Oct;207(4):346-50.

All Military Adolescents Are Not the Same: Sexuality and Substance Use among Adolescents in the U.S. Military Healthcare System.

Study

Abstract

Data examining sexuality and substance use among active duty and military-dependent youth is limited; however, these psychosocial factors have military implications. Adolescents and young adults aged 12-23 were recruited from an active-duty trainee clinic (n = 225) and a military pediatric clinic (n = 223). Active duty participants were more likely to be older, male, White, previous tobacco users, and report a history of sexual activity and less contraception use at their most recent intercourse, compared to the dependent group. Over 10% of all participants indicated attraction to members of the same gender or both genders. In logistic regression analysis, non-White participants were less likely to use contraception compared to White participants. Adolescents and young adults seen in military clinics frequently engage in high-risk behavior. Clinicians who care for military youth should assess their patient's psychosocial history. Further study of this population is warranted to identify factors that may influence risk and resilience.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Uniformed Services University of Health Sciences
  • Congressionally Mandated: No
  • Funding Source: Air Force
  • Release Date/Publication: October 01, 2015
  • Citation: Klein DA, Adelman WP, Thompson AM, Shoemaker RG, Shen-Gunther J. All Military Adolescents Are Not the Same: Sexuality and Substance Use among Adolescents in the U.S. Military Healthcare System. PLoS One. 2015 Oct 29;10(10):e0141430

Chikungunya infection in DoD healthcare beneficiaries following the 2013 introduction of the virus into the Western Hemisphere, 1 January 2014 to 28 February 2015.

Study

Abstract

The introduction and rapid spread of chikungunya virus (CHIKV) into the Western Hemisphere after December 2013 pose a potentially significant risk to Department of Defense (DoD) personnel, operations, and the military healthcare system. This report describes the DoD experience with CHIKV between January 2014 and February 2015 using case reports in the Defense Medical Surveillance System's (DMSS) Reportable Medical Events database and the Navy and Marine Corps Public Health Center's laboratory test results database. Case finding identified 157 confirmed cases; of these, 118 (75.2%) were either active or reserve component service members and 39 (24.8%) were other beneficiaries. Exposure locations were known for 117 (74.5%) of all cases, and of these, 113 (96.6%) reported likely exposures in the Western Hemisphere; 85 (75.2%) of those cases occurred in Puerto Rico. Although historical data on CHIKV in DoD populations are scant, introduction of CHIKV into the Western Hemisphere with ongoing transmission appears to have resulted in a significant increase in the number of cases among DoD healthcare beneficiary populations.

  • Publication Status: Published
  • Sponsoring Organization: Defense Health Agency (formerly TRICARE Management Activity)
  • Sponsoring Office: Armed Forces Health Surveillance Center
  • Congressionally Mandated: No
  • Funding Source: Defense Health Agency (formerly TRICARE Management Activity)
  • Release Date/Publication: October 01, 2015
  • Citation: Chikungunya infection in DoD healthcare beneficiaries following the 2013 introduction of the virus into the Western Hemisphere, 1 January 2014 to 28 February 2015. MSMR. 2015 Oct;22(10):2-6.
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Last Updated: April 30, 2020
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