Skip to main content

Military Health System

Brief report: Using syndromic surveillance to monitor MIS-C associated with COVID-19 in Military Health System beneficiaries

Image of Air Force 1st Lt. Anthony Albina, a critical care nurse assigned to Joint Base Andrews, Md., checks a patient’s breathing and heart rate during an intubation procedure while supporting COVID-19 response operations in Cleveland, Jan. 20, 2022. Air Force 1st Lt. Anthony Albina, a critical care nurse assigned to Joint Base Andrews, Md., checks a patient’s breathing and heart rate during an intubation procedure while supporting COVID-19 response operations in Cleveland, Jan. 20, 2022.

Recommended Content:

Medical Surveillance Monthly Report

Background

SARS CoV-2 and the illness it causes, COVID-19, have exacted a heavy toll on the global community. Most of the identified disease has been in the elderly and adults. In April 2020, a rare hyperinflammatory syndrome called multisystem inflammatory syndrome in children (MIS-C) was reported in Europe in a number of children with SARS-CoV2 infections. The cluster was initially characterized as cases with symptoms compatible with Kawasaki's disease.1 Cases presented with symptoms including systemic hyperinflammation, persistent fever, and multisystem organ dysfunction. In the U.S., cases of MIS-C have been disproportionately reported among Hispanic and non-Hispanic Black children 6 to 12 years old who presented with severe symptoms.2 According to the Centers for Disease Prevention and Control (CDC), as of 3 May 2021, 3,742 cases of MIS-C were reported in the U.S., including 35 deaths.3

In an effort to detect potential cases of MIS-C in the Military Health System (MHS), the Armed Forces Health Surveillance Division (AFHSD) used the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE), a syndromic surveillance system which uses outpatient data to monitor trends and increases in health care encounters that may represent changes in the incidence of disease. Users of ESSENCE employ the system to analyze MHS clinical data sources in near real-time, including diagnosis codes, free text chief complaint or reason-for-visit data fields, reportable medical events (RME), laboratory and radiology data, and prescription drug information to develop a picture of disease syndromes based on health care encounters.4,5 The goal of this analysis was to ascertain if user-built ESSENCE queries applied to records of outpatient MHS health care encounters are capable of detecting MIS-C cases that have not been identified or reported by local public health departments.

Methods

The AFHSD used ESSENCE to create a query based on the case definition of MIS-C developed by the CDC to identify potential MIS-C cases. The query included MIS-C-related International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes and free text chief complaint and reason-for-visit data fields from records of outpatient medical encounters for health care beneficiaries of the MHS 20 years old or younger who sought care between Oct. 19, 2020 and March 12, 2021. The query was adapted from the CDC-developed syndromic surveillance query, but the AFHSD query was modified to exclude those codes which are not present in AFHSD ESSENCE (Z86.16 [personal history of COVID-19] and Z20.822 [exposure to COVID-19 or SARS-CoV-2 infection]). The AFHSD-developed query selected ICD-10 codes in any diagnostic position in the electronic medical record for any outpatient encounter during the study period. Chief complaints were retrieved from patients' "reason for visit" free text field for each health encounter. The search criteria for ESSENCE's free text queries are built around Boolean logical operators and regular expressions which allow for a high level of customization.6

Four ICD-10 codes and 12 chief complaints (Tables 1, 2) were used to create the automated ESSENCE MIS-C query for searching records of all outpatient health encounters at nearly 400 military treatment facilities (MTFs) in real-time. Demographic and military variables, including age (in years), sex, race/ethnicity, ICD-10 codes, patient identifiers, and location were extracted for analysis. All Direct CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”direct care outpatient encounters with 1 or more of the ICD-10 codes or chief complaints of interest were selected to create a list of potential cases. Data details were downloaded on a weekly basis, verified, and coded as confirmed MIS-C cases by registrars trained in infectious disease manual data abstraction associated with the Department of Defense (DoD) COVID-19 registry.

The CDC case definition was used to confirm MIS-C cases. This definition includes an individual under 21 years old presenting with fever (>100.4 °F/38.0 °C) or report of subjective fever lasting 24 hours or longer), laboratory evidence of inflammation and a positive test for SARS-CoV-2 infection by RT-PCR, serology, or antigen test or COVID-19 exposure within the 4 weeks prior to the onset of symptoms in the clinical setting of severe inflammatory illness without other identifiable etiology.3

Results

During the surveillance period, the AFHSD MIS-C ESSENCE query identified 60 encounters that met selection criteria. The month of February 2021 had the most MIS-C-related encounters with 15 (25%) occurring during this time (data not shown). Out of 60 possible cases, 40 (66%) were males and 36 (60%) were 0–8 years olds (mean=8.5 years) (data not shown). Half of the MIS-C-related encounters (n=30) were in the southeast region of the U.S., and 9 (15%) were in overseas military clinics (data not shown). The most common ICD-10 code recorded was "M30.3-Mucocutaneous lymph node syndrome (Kawasaki)." Of the 60 records identified as possible cases by ESSENCE, 10 cases of MIS-C were confirmed by the DoD COVID-19 health records review process (17%). Four (40%) of the 10 confirmed cases were male and 4 were female (40%). Information on sex was not available for 2 of the confirmed cases. Half of the confirmed cases were 7–10 years old (mean=12 years; range=7–18 years).

Editorial Comment

Monitoring disease progression of the COVID-19 pandemic for situational awareness has been the current focus of the syndromic surveillance. The emergence of MIS-C reported in military beneficiaries should widen the focus on how to monitor disease progression in diverse populations. Although MIS-C is a rare condition among children who have developed COVID-19, it is still of great concern to public health officials in the military health care system.4 The ability to detect individual cases of disease was not originally how syndromic surveillance was designed to function. The main objective of syndromic surveillance is to detect a cluster or outbreak of disease before diagnosis.

There are some limitations to using ESSENCE to detect MIS-C encounters. A proportion of ESSENCE records that were received were deidentified; these records were not used in the analysis. In addition, records of Purchased CareThe TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.purchased care encounters were not included in the analysis. Given these limitations, the findings of this analysis should not be construed as a complete representation of MIS-C cases in the surveyed population. Moreover, because the use of ESSENCE was limited to outpatient clinic data, the current analysis did not include the more severe cases seen in emergency departments and urgent care centers which are visible through the civilian form of ESSENCE.

The purpose of the analysis was to create a query that could identify possible outpatient cases of MIS-C. The MIS-C query was able to capture 10 cases of the rare condition of MIS-C during the surveillance period while minimizing the number of encounters (n=60) which met the selection criteria out of millions of encounters. ESSENCE has shown the ability to detect potential cases of MIS-C through health encounters at MTFs across the MHS. This capability will expand the biosurveillance efforts of AFHSD in response to future emerging infectious diseases and other threats of military interest. Furthermore, civilian surveillance systems may use this or similar queries to identify previously unreported cases of MIS-C in the civilian population.

Author affiliations: Armed Forces Health Surveillance Division, Silver Spring, MD (Dr. Russell and Col. Vick).

References

1. Riphagen S, Gomez X, Gonzalez-Martinez C, et al. Hyperinflammatory shock in children during COVID-19 Pandemic. Lancet. 2020;395(10237):1607–1608.

2. Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and outcomes of US children and adolescents with multisystem inflammatory syndrome in children (MIS-C) compared with severe acute COVID-19. JAMA. 2021;325(11):1074–1087. 

3. Centers for Disease Control and Prevention. Health Department-Reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) in the United States. Centers for Disease Control and Prevention. 11 May 2021. Accessed 1 June 2021. https://covid.cdc.gov/covid-data-tracker/#mis-national-surveillance

4. Burkom H, Loschen W, Wojcik R, et al. Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE): Overview, Components, and Public Health Applications. JMIR Public Health Surveill. 2021;7(6):e26303.

5. Scholl L, Liu S, Vivolo-Kantor A, et al. Development and Validation of a Syndrome Definition to Identify Suspected Nonfatal Heroin-Involved Overdoses Treated in Emergency Departments. J Public Health Manag Pract. 2021;27(4):369–378. 

6. Stein Z. National Syndromic Surveillance Program (NSSP). Free-text coding in NSSP-ESSENCE: Part 1. Accessed 1 December 2021. https://www.cdc.gov/nssp/tech-tips/free-text-coding/part1.html

7. Centers for Disease Control and prevention. Emergency Preparedness and Response. Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19). Accessed 1 December 2021. https://emergency.cdc.gov/han/2020/han00432.asp

 TABLE 1. ICD-10 diagnostic codes used to identify possible cases of MIS-C

TABLE 2. "List of reasons for visit" used to query the chief complaint field of ESSENCE to identify posible cases of MIS-C

You also may be interested in...

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.

Recommended Content:

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.

Recommended Content:

Medical Surveillance Monthly Report

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.

Recommended Content:

Medical Surveillance Monthly Report

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 Aug.–Sept. 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 Aug.–11 Sept. 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.

Recommended Content:

Medical Surveillance Monthly Report

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.

Recommended Content:

Medical Surveillance Monthly Report

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.

Recommended Content:

Medical Surveillance Monthly Report

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.

Recommended Content:

Medical Surveillance Monthly Report

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

Article
12/1/2018
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)

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.

Recommended Content:

Medical Surveillance Monthly Report

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.

Recommended Content:

Medical Surveillance Monthly Report

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.

Recommended Content:

Medical Surveillance Monthly Report

2018 #ColdReadiness Twitter chat recap: Preventing cold weather injuries for service members and their families

Fact Sheet
2/5/2018

To help protect U.S. armed forces, the Armed Forces Health Surveillance Branch (AFHSB) hosted a live #ColdReadiness Twitter chat on Wednesday, January 24th, 12-1:30 pm EST to discuss what service members and their families need to know about winter safety and preventing cold weather injuries as the temperatures drop. This fact sheet documents highlights from the Twitter chat.

Recommended Content:

Medical Surveillance Monthly Report | Winter Safety | Medical and Dental Preventive Care Fitness | Health Readiness & Combat Support

Demographic and Military Traits of Service Members Diagnosed as Traumatic Brain Injury Cases

Fact Sheet
3/30/2017

This fact sheet provides details on the demographic and military traits of service members diagnosed as traumatic brain injury (TBI) cases during a 16-year surveillance period from 2001 through 2016, a total of 276,858 active component service members received first-time diagnoses of TBI - a structural alteration of the brain or physiological disruption of brain function caused by an external force.

Recommended Content:

Armed Forces Health Surveillance Division | Medical Surveillance Monthly Report

Heat Illnesses by Location, Active Component, U.S. Armed Forces, 2012-2016 Fact Sheet

Fact Sheet
3/30/2017

This fact sheet provides details on heat illnesses by location during a five-year surveillance period from 2012 through 2016. 11,967 heat-related illnesses were diagnosed at more than 250 military installations and geographic locations worldwide. Three Army Installations accounted for close to one-third of all heat illnesses during the period.

Recommended Content:

Armed Forces Health Surveillance Division | Medical Surveillance Monthly Report

Rhabdomyolysis by Location, Active Component, U.S. Armed Forces, 2012-2016 Fact Sheet

Fact Sheet
3/30/2017

This fact sheet provides details on Rhabdomyolysis by location for active component, U.S. Armed Forces during a five-year surveillance period from 2012 through 2016. The medical treatment facilities at nine installations diagnosed at least 50 cases each and, together approximately half (49.9%) of all diagnosed cases.

Recommended Content:

Armed Forces Health Surveillance Division | Medical Surveillance Monthly Report
<< < ... 11 12 13 > >> 
Showing results 181 - 194 Page 13 of 13
Refine your search
Last Updated: May 23, 2022
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery