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2016 marks first year of zero combat amputations since the start of the Afghan, Iraq wars

An analysis by the Medical Surveillance Monthly Report recently reported 2016 marks the first year without combat amputations since the wars in Afghanistan and Iraq began. U.S. Armed Forces are at risk for traumatic amputations of limbs during combat deployments and other work hazards. (DoD photo) An analysis by the Medical Surveillance Monthly Report recently reported 2016 marks the first year without combat amputations since the wars in Afghanistan and Iraq began. U.S. Armed Forces are at risk for traumatic amputations of limbs during combat deployments and other work hazards. (DoD photo)

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Medical Surveillance Monthly Report | Epidemiology and Analysis

Amputations of upper and lower extremities profoundly alter the lives of both active duty and reserve components of U.S. Armed Forces. Our troops are at risk for traumatic amputations of limbs during combat deployments and other hazards such as motor vehicle accidents and falls. Moreover, the permanent disability results in restricted or lost duty time for military members.

Service members, such as 1st Lt. Melissa Stockwell, who lost her left leg from a roadside bomb, “felt very lucky” to have only lost a limb as one of about a dozen U.S. troops in Iraq who suffered an amputation. But the year 2016 had good news for troops - it is the first year the U.S. military had no combat amputations of deployed troops since the Afghan, Iraq wars began. This was assessed recently in the Medical Surveillance Monthly Report (MSMR), a publication from the Defense Health Agency’s Armed Forces Health Surveillance (AFHSB), tracking amputations involving deployed troops by month since 2003.

To accurately track amputations, AFHSB breaks out by service in order to help military officials identify incidence, distribution, impact and trends. Col. Douglas Badzik, AFHSB chief said such analyses help provide “a force that is healthy and ready to carry out its mission.” Additionally, improvements in protective equipment and innovations in medical procedures and battlefield trauma care continue to strengthen force health protection of U.S. service members. For more details on this assessment, See the December 2016 issue of the MSMR. You also may be interested in reading amputation surveillance reports listed in the MSMR Index


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The current report represents an update and provides a summary of care provided to non-service members in the MHS during calendar year 2018. Healthcare burden estimates are stratified by direct versus outsourced care and across 4 age groups of healthcare recipients.

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

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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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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

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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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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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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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Heat Illness

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