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Medical Surveillance Monthly Report

thumbnail image of several MSMRsThe Medical Surveillance Monthly Report (MSMR), a peer-reviewed journal launched in 1995, is the AFHSB's flagship publication. The MSMR provides monthly evidence-based estimates of the incidence, distribution, impact, and trends of health-related conditions among service members. Additionally, the MSMR focuses one issue per year on the absolute and relative morbidity burden attributable to various illnesses and injuries among service members and beneficiaries. You may request an electronic subscription online or via email

Would you like to be published in the MSMRAuthors are welcome to submit their manuscripts to the MSMR. >>See Instructions for Authors

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Here, you can download the current and past issues of the MSMR. Inquiries regarding content or material to be considered for publication should be directed to the MSMR Editor.

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Citing the MSMR

When citing MSMR articles, please use the following formats:

Author Names Listed with the Article

Collier DA, Bayles MK, Barrett, JP. Acute gastroenteritis outbreak at the Armed Forces Retirement Home, Washington, DC, January 2011. MSMR. 2011;18(6):11-14.

No Author Name Listed (April 2007 to current)

Armed Forces Health Surveillance Branch. Mental disorders and mental health problems, active component, U.S. Armed Forces, January 2000 – December 2009. MSMR. 2010;17(11):6-13.

No Author Name Listed (Before April 2007)

Army Medical Surveillance Activity. Overhydration and hyponatremia among active duty soldiers, 1997-1999. MSMR. 2000;6(3):9-11.


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Medical evacuations out of the U.S. Central Command, active and reserve components, U.S. Armed Forces, 2018

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5/1/2019
Airmen from the 19th Medical Group litter-carry a simulated patient onto a C-130J during an aeromedical evacuation training mission at Little Rock Air Force Base in 2019. (Photo Courtesy of U.S. Air Force)

The number of medical evacuations for battle injuries has decreased considerably since 2014. Most medical evacuations in 2018 were attributed to mental health disorders, followed by non-battle injury/poisoning; signs, symptoms, and ill-defined conditions; musculoskeletal disorders; and digestive system disorders.

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Ambulatory visits, active component, U.S. Armed Forces, 2018

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5/1/2019
A U.S. naval officer listens through his stethoscope to hear his patient’s lungs at Camp Schwab in Okinawa, Japan in 2018. (Photo courtesy of U.S. Marine Corps) photo by Lance Cpl. Cameron Parks)

Musculoskeletal disorders and mental health disorders accounted for more than half (52.6%) of all illness- and injury-related ambulatory encounters among active component service members in 2018. Since 2014, the number of ambulatory visits for mental health disorders has decreased, while the numbers of ambulatory visits for musculoskeletal system/connective tissue disorders, nervous system and sense organ disorders, and respiratory system disorders have increased.

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Absolute and relative morbidity burdens attributable to various illnesses and injuries, active component, U.S. Armed Forces, 2018

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5/1/2019
A U.S. naval officer listens through his stethoscope to hear his patient’s lungs at Camp Schwab in Okinawa, Japan in 2018. (Photo courtesy of U.S. Marine Corps) photo by Lance Cpl. Cameron Parks)

In 2018, mental health disorders accounted for the largest proportions of the morbidity and healthcare burdens that affected the pediatric and younger adult beneficiary age groups. Among adults aged 45–64 years, musculoskeletal diseases accounted for the most morbidity and healthcare burdens, and among adults aged 65 years or older, cardiovascular diseases accounted for the most.

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

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

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Surveillance Snapshot: Illness and Injury Burdens, Recruit Trainees, Active Component, U.S. Armed Forces, 2018

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

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Heat Illness

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4/1/2019
Heat Illness

This report summarizes reportable medical events of heat illness as well as heat illness-related hospitalizations and ambulatory visits among active component service members during 2018 and compares them to the previous 4 years. Episodes of heat stroke and heat exhaustion are summarized separately.

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Exertional Hyponatremia

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4/1/2019
Exertional Hyponatremia

Each year, the MSMR summarizes the numbers, rates, trends, risk factors, and locations of occurrences of exertional heat injuries, including exertional rhabdomyolysis. This report includes the data for 2014–2018.

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Exertional Rhabdomyolysis

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4/1/2019
Exertional Rhabdomyolysis

Each year, the MSMR summarizes the numbers, rates, trends, risk factors, and locations of occurrences of exertional heat injuries, including exertional rhabdomyolysis. This report includes the data for 2014–2018.

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Lyme Disease

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4/1/2019
Lyme Disease

Each year, the MSMR summarizes the numbers, rates, trends, risk factors, and locations of occurrences of exertional heat injuries, including exertional rhabdomyolysis. This report includes the data for 2014–2018.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Sexually Transmitted Infections

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3/20/2019
Sexually Transmitted Infections

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.

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