Beruflich Dokumente
Kultur Dokumente
Volume 25
Number 7
MSMR
M E D I C A L SU RV E I L L A N C E M O N T H LY R E P O RT
METHODS
S
ervice members in the U.S. Armed sustained at least one injury in 2015, with
2008 through 31 December 2017. The sur-
Forces frequently engage in high lev- 1,361 new injuries per 1,000 person-years
veillance population included all individu-
els of physical activity to perform their (p-yrs).2 The incidence rate of injuries
als who served in the active component of
duties, and such activity can potentially was about 34% higher among female sol-
the Army, Navy, Air Force, or Marine Corps
result in training- or duty-related injuries. diers (1,735 per 1,000 p-yrs) than among
at any time during the surveillance period.
Injuries have consistently ranked among male soldiers (1,299 per 1,000 p-yrs), and
All data used to determine incident acute
the highest burden of disease categories was highest among those in the oldest age injury diagnoses were derived from records
for numbers of associated medical encoun- category (≥45 yrs).2 Other risk factors for routinely maintained in the Defense Medical
ters and of individuals affected in the U.S. increased injuries identified in studies of Surveillance System (DMSS). These records
Armed Forces. In 2017, injuries accounted U.S. Army service members or recruits document both ambulatory encounters and
for more medical encounters (n=2,775,393) include high amounts of running (fre- hospitalizations of active component mem-
among active component service members quency and mileage), tobacco use, lack of bers of the U.S. Armed Forces in fixed mili-
than any other morbidity category and previous experience with sports and exer- tary and civilian (if reimbursed through the
approximately one-quarter of all medical cise, and having a sedentary lifestyle.3,4 Military Health System [MHS]) treatment
encounters.1 Knee injuries ranked third in Some of the most common causes of non- facilities.
total number of medical encounters, with battle-related injuries identified in mili- For surveillance purposes, acute injuries
arm/shoulder and foot/ankle and leg inju- tary populations include military training, were defined using records of inpatient and
ries ranking fourth and sixth, respectively.1 sports, falls, and motor vehicle accidents.5,6 outpatient medical encounters that included
According to the U.S. Army Public Injuries are of major significance to injury-specific diagnoses in the first diagnos-
Health Center’s 2016 Health of the Force the U.S. military because of their potential tic position. ICD-9 and ICD-10 codes used
Report, approximately half of all soldiers impact on lost duty or training time, costs, to define acute injuries were extracted from
TA B L E 4 . Type of acute incident injuries, by anatomic site, active component, U.S. Armed Forces, 2008–2017
Other/
Blood vessels Contusion/superficial Crush Burns Nerves
unspecifieda
Category No. % No. % No. % No. % No. % No. %
Head/neck 415 0.07 130,146 21.89 198 0.03 6,797 1.14 1,389 0.23 87,469 14.71
Arm/shoulder 245 0.04 42,401 7.56 400 0.07 6,292 1.12 7,605 1.36 40,751 7.26
Hand/wrist 518 0.09 87,803 15.61 7,877 1.40 11,810 2.10 773 0.14 22,971 4.08
Back/abdomen 342 0.07 55,695 11.08 311 0.06 2,033 0.40 549 0.11 17,502 3.48
Knee 0 0.00 36,708 14.28 197 0.08 243 0.09 0 0.00 14,477 5.63
Leg 389 0.09 49,333 11.32 481 0.11 4,103 0.94 3,027 0.69 116,375 26.71
Foot/ankle 44 0.01 112,080 14.58 2,979 0.39 2,228 0.29 218 0.03 8,176 1.06
Total 1,953 0.05 514,166 13.96 12,443 0.34 33,506 0.91 13,561 0.37 307,721 8.36
a
Includes effects of foreign bodies, lacerations, traumatic ruptures, "other," and "unspecified" injuries.
foot/ankle injuries were the least common service members from 2008 through 2017. of injuries to the knee, leg, and foot/ankle.
(60.2%). In 2010, there was a spike in inci- The highest overall incidence rates during Service members in the Army had higher
dent injuries that resulted in being returned the surveillance period were for injuries to rates of acute injuries to all anatomic sites,
to duty with no limitations accompanied the foot/ankle, followed by head/neck, and compared to the other service branches. In
by a corresponding drop in injuries that hand/wrist. Rates of injuries to the leg and general, rates of injuries to most anatomic
resulted in being returned to duty with lim- those to the foot/ankle were higher among sites tended to be higher among service
itations (data not shown). younger service members, whereas inci- members in motor transport and/or com-
dence of injuries to the knee and to the bat-related occupations.
arm/shoulder increased with increasing Data presented in this report suggest
EDITORIAL COMMENT
age. Males had higher rates of injuries to that injury prevention strategies should
the arm/shoulder as well as to the hand/ be tailored to different populations with
This report summarizes the incidence, wrist, whereas females had higher rates different risk factors, including training
type, external causes, and disposition of of injuries to the back/abdomen, leg, and and occupational exposures. For exam-
acute injuries among active component U.S. foot/ankle. Recruits also had higher rates ple, female soldiers have traditionally been
shown to be at much higher risk of lower identified six interventions that were rec- injury by anatomic site, injuries to unspeci-
extremity musculoskeletal injuries during ommended for implementation in the mili- fied or “other” sites, environmental inju-
training, and this is further supported by tary: prevention of overtraining, agility-like ries, and poisonings were excluded. Other
the high rate of foot/ankle injuries among training, mouthguards, semirigid ankle studies have included selected diagnoses of
young female service members observed braces, nutrient replacement, and synthetic musculoskeletal disorders (e.g., stress frac-
in this study.10 Physical training is also the socks.13 In contrast, the use of back braces tures, tendonitis, bursitis) in the definition
leading cause of injuries among service and pre-exercise administration of anti- of injury6; however, this analysis focused on
members, which is supported by the find- inflammatory medication were not recom- only “acute” injuries included in the ICD-9
ing of high rates of lower extremity injuries mended due to evidence of ineffectiveness 800–999 and ICD-10 S-T code series. Inju-
among recruit trainees identified in this or harm.13 The working group also identi- ries that occur during deployment were
study.5,7,10,11 However, aside from increas- fied education, leader support, and surveil- also not included in this analysis. How-
ing physical fitness requirements, there is lance as essential factors that are needed for ever, some injuries that occurred during
little opportunity for military intervention successful injury prevention programs.13 deployment may have been unintentionally
to prevent injuries among recruits before There are several limitations to this included if a service member was medi-
the start of basic training. Instead, inter- study. The high level of missing data for cally evacuated out of theater and treated in
ventions for training-related injuries must external cause codes hinders the ability to an inpatient or outpatient setting. Because
focus on the training regimens themselves. make prevention recommendations based data were based on diagnoses made using
In addition, different occupations for active on the causes of injury. Although external ICD-9 and ICD-10 codes, the severity of
component service members have different cause coding is not mandatory, the ICD- various injuries could not be quantified
physical demands. Such differences should 10-CM Official Guidelines for Coding (aside from the type of injuries). In addi-
be considered when deciding whether spe- and Reporting strongly encourage medi- tion, data were not available to quantify
cialized protective equipment or training cal professionals to code external causes to time lost due to injuries.
is needed. For example, paratroopers have “provide valuable data for injury research MHS GENESIS, the new electronic
traditionally been identified as being at and evaluation of injury prevention strat- health record for the MHS, was imple-
high risk of ankle injuries and have bene- egies.”14 There were several substantial mented at several military treatment facil-
fitted by the use of parachute ankle braces changes in the number and structure of ities during 2017. Medical data from sites
during airborne operations.13 injury codes in the transition from ICD-9 that are using MHS GENESIS are not
In 2004, the Military Training Task to ICD-10 coding systems (which occurred available in DMSS. These sites include
Force of the Defense Safety Oversight on 1 October 2015); the impact of this tran- Naval Hospital Oak Harbor, Naval Hospi-
Council chartered a working group to sition on coding practices is not yet fully tal Bremerton, Air Force Medical Services
identify, evaluate, and assess the level understood.9 Therefore, time trends should Fairchild, and Madigan Army Medical
of scientific evidence for various physi- be interpreted with caution. Center. Therefore, medical encounter and
cal training-related injury prevention Not all types of injuries were included person-time data for individuals seeking
strategies through an expedited system- in this report. Because one of the goals of care at one of these facilities during 2017
atic review process.13 This working group this report was to categorize incidence of were excluded from analysis.
M
ajor limb amputations are life- On 8 April 2015, the Defense Health
threatening and life-altering Board published a series of recommenda- METHODS
events for service members tions in a report entitled “Sustainment and
injured in combat. While amputations are Advancement of Amputee Care” focused
viewed as lifesaving procedures in many on maintaining the current level of military The surveillance period for this report
cases, limb loss can often result in imme- competency and clinical readiness in the was 1 January 2001 through 31 October
diate and long-term decline in physi- event of future conflicts.8 One of the core 2017. The surveillance population con-
cal, social, and financial well-being of the recommendations of this report described sisted of all individuals who served in an
injured service members.1 Additionally, the need for better characterization of the active and/or reserve component of the U.S.
caring for service members with limb loss current landscape of military amputee Armed Forces at any time during the sur-
places a tremendous burden on their fami- care, to gain a better understanding for veillance period. Diagnosis codes from the
lies, as well as the Departments of Defense the health, healthcare needs, and health- International Classification of Diseases, 9th
(DoD) and Veteran Affairs (VA) health sys- care utilization of the amputee population.8 and 10th Revisions, Clinical Modifications
tems.2,3 As a result of the extensive advanced A fundamental step toward achieving this (ICD-9/ICD-10) specific for amputations
medical and rehabilitative care provided goal requires a thorough and up-to-date were used to identify major amputations
within the DoD and VA healthcare systems, understanding of the numbers, types, and among service members during the surveil-
young, otherwise healthy combat amputees anatomic locations of the upper and lower lance period (Table 1).
may now live active and productive lives.4-7 limb amputations, along with demographic All data to determine the numbers,
As a result, better understanding of the size and military characteristics of this injured types, and anatomic locations of lower and
and characteristics of the combat-injured cohort. upper limb amputations were derived from
amputee population is critical to formulate In 2012, the MSMR reported a sum- records routinely maintained in the Expe-
sound strategies for current and future pol- mary of the annual numbers and the ditionary Medical Encounter Database
icy, healthcare, and readiness decisions. types of upper and lower limb traumatic (EMED). The EMED is a comprehensive
deployment-related data repository that amputations before 1 October 2015) and R E SULT S
provides a high-quality source of clinical, ICD-10 (for amputations on or after 1 Octo-
tactical, and personnel data for each casu- ber 2015) diagnostic codes for all amputa-
alty, sickness or injury, during deployment.10 tions of partial hand or foot and greater During the surveillance period, a total
These data are used for determining the- from 1 January 2001 through 31 October of 1,705 service members sustained deploy-
ater medical requirements (modeling and 2017. The Extremity Trauma and Amputa- ment-related, major amputations (Table
simulation) and for performing research. tion Center of Excellence Amputation Reg- 2). Lower limb amputations were far more
For each casualty, sick or injured, in over- istry also was utilized for confirmation of common than upper limb amputations,
seas contingency operations, a compre- identified cases. Additional data collected with 1,496 service members sustaining a
hensive clinical record is established from the EMED included anatomic ampu- total of 1,914 lower limb amputations com-
beginning with the first medical treatment tation information, gender, age, branch of pared to 284 service members sustaining
at the point of injury. As the patient moves service, and military paygrade, all at time a total 302 upper limb amputations. Dur-
through the medical chain of evacuation, of injury. Other demographic variables ing the surveillance period, bilateral ampu-
additional clinical data are added to the such as active or reserve status, race/ethnic- tations were more common in the lower
EMED, including injury, disease, and psy- ity, and military occupation were obtained extremities (n=418; 25% of all individu-
chiatric profile, procedures administered, from the Defense Manpower Data Center als who had amputations), compared to
clinical complications of care, and patient Contingency Tracking System. the upper extremities (n=18; 1%; Table 2).
outcomes. In addition, ICD-9 and ICD-10 Amputations of fingers or toes were Additionally, there were 46 service mem-
clinical diagnoses and injury severity codes excluded. Service members who were bers who sustained triple amputations and
are assigned by trained clinicians. Finally, determined to have been killed in action or six service members who sustained qua-
tactical data describing the circumstances to have died of wounds were also excluded druple amputations during the surveillance
that generated the casualty and person- from this report. Service members with period (data not shown).
nel data describing the casualty’s pre- and multiple amputations were counted only Of the lower limb amputations, the
post-injury military and medical histories once in the population as individuals; most common type was transtibial (n=995;
are added. however, each amputation was included 52%), followed by transfemoral (n=469;
For surveillance purposes, the EMED separately in total counts and analyses of 25%), knee disarticulation (n=266; 14%),
was queried for case-defining ICD-9 (for amputations. foot or partial foot (n=115; 6%), ankle
F I G U R E 1 . Numbers of major deployment-related lower limb amputations, by anatomic location, active and reserve components, U.S. Armed
Forces, 2001–2017
400
377 Hip disarticulation
Knee disarticulation
350 Transfemoral
66
Transtibial
300 Ankle
266 Foot/partial foot
93
250 234
No. of amputations
31
24 200
200
172 88
162 60 51
20
150 132 17
33 45 117 38
111 199
17
100 80 44
118 21 21 113
18 98 99
98 43
50 56 65
41 73
8
2 2 22 2 1 3
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
50
47 Hand or partial hand
Wrist disarticulation
45
42 Transradial
10
39 Elbow disarticulation
40
7 Transhumeral
35
3 6 Shoulder disarticulation
35
7
No. of amputations
30 6
26 26 26
14 3
25 3 19 3 23
6
3
20 6 5
2 16 11
3
3
15 10 13
2 12
10 2 3 6
11
10 16 3 6
10 6 6
5 11 2
2 9 8 6 2
1 5 4 1
4 5 3
3 2 2
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
However, after 2009, the frequency of The vast majority of deployment- period. The report also compares trend dif-
Marine Corps members sustaining amputa- related major amputations were sustained ferences regarding major lower and upper
tions increased dramatically, going from 22 by active component service members as limb amputations, overall and in relation
in 2009 to 91 in 2010 and 155 in 2011, repre- compared to those in the Reserve/Guard to various demographic and military char-
senting 23%, 43% and 57% of injured service components (Figure 5). Between 2003 and acteristics. During 2001–2017, there were
members for each year, respectively. In 2011, 2006, the active component service mem- a total of 2,216 reported cases of deploy-
the year with the most amputations for the bers accounted for 74%–84% of each year’s ment-related, major lower and upper limb
whole surveillance period, members of the total amputation injuries. However, from amputations sustained by 1,705 service
Marine Corps made up the majority of ser- 2007 through 2014, the annual propor- members. The greatest number of ampu-
vice members with amputations (Figure 3). tions for the active component increased to tations in a single year occurred in 2011
Throughout the entire surveillance 91%–100% (Figure 5). at the height of the surge in operations in
period, mid-level enlisted (E4–E6) service Afghanistan, with a reported total of 403
members comprised the majority of the major lower and upper limb amputations
deployment-related amputation popula- EDITORIAL COMMENT sustained by 273 service members.
tion, followed by junior enlisted (E1–E3) Overall, and consistent with a previous
service members (Figure 4). However, the report,9 relatively large numbers of major
numbers and proportions of junior enlisted This report reiterates and extends the limb amputations were observed during
service members sustaining amputations findings of previous surveillance reports periods of more widespread and intense
increased markedly from 2010 through in describing the annual numbers, types, ground combat operational activities. More
2011, with junior enlisted service members and anatomic locations of deployment- specifically, an increasing number of major
representing 32% and 40% of all injured related major limb amputations during the lower limb amputations were observed
service members, respectively. 16 years and 10 months of the surveillance between 2003 through 2007 and again
300
Air Force
273
Navy
9 Marine Corps
250 Army
218
213
200 25
No. of service members
169 155
162 165
91 151
150
42 38
46 34
105
95 97
100
190 22
22
119 121 113
50 107 105 110
84 37
80
69
4 3 29 8 1 2 2
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
F I G U R E 4 . Numbers of service members with deployment-related amputations, by grade, active and reserve components, U.S. Armed
Forces, 2001–2017
300
Officer
272
E7–E9
15
E4–E6
250
E1–E3
218 213
15
200 18
No. of service members
12
169 143
162 165
17 151
150 17
9 14
11
114
149 104
95 97
100 110 8
102 105 79
59 54
50 62 109 37
69
40 38 42 46 47 21 8
4 3 32 30 1 2 2
20
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Note: Two service members with missing grade information at the time of analysis were excluded.
300
272 Reserve/Guard Active
18
250
218 213
20 13
200
No. of service members
167 164
159 151
150 26
36 43
254
104
94 95
100 198 200
17
138 144
123 124
50 98 37
77 87
3 2 37 8 2 2
1
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Note: A total of 13 service members with missing or unknown component information at time of analysis were excluded.
4. Pasquina PF, Fitzpatrick KF. The Walter 8. Dickey NW. Sustainment and Advancement of
REFERENCES Reed experience: current issues in the care Amputee Care. Defense Health Agency/Defense
of the traumatic amputee. J Prosthet Orthot. Health Board Falls Church United States; 2015.
2006;18(6):119–122. 9. Armed Forces Health Surveillance Center.
1. Isaacson BM, Weeks SR, Pasquina PF, Web-
5. Gajewski D, Granville R. The United States Amputations of upper and lower extremities, ac-
ster JB, Beck JP, Bloebaum RD. The road to recov-
ery and rehabilitation for injured Service members Armed Forces Amputee Patient Care Program. J tive and reserve components, U.S. Armed Forces,
with limb loss: a focus on Iraq and Afghanistan. US Am Acad Orthop Surg. 2006;14(10):S183–S187.
2000–2011. MSMR. 2012;19(6):2–6.
Army Med Dep J. 2010;Jul–Sep:31–36. 6. Goldberg CK, Green B, Moore J, et al. In-
10. Galarneau MR, Hancock WC, Konoske P, Mel-
2. Geiling J, Rosen JM. Medical costs of war in tegrated musculoskeletal rehabilitation care at
a comprehensive combat and complex casu- cer T. The Navy-Marine Corps Combat Trauma
2035: long-term care challenges for veterans of
alty care program. J Manipulative Physiol Ther. Registry. Mil Med. 2006;171(8):691.
Iraq and Afghanistan. Mil Med. 2012;177(11):1235–
1244. 2009;32(9):781–791. 11. Cross JD, Ficke JR, Hsu JR, Masini BD, Wen-
3. Makin-Byrd K, Gifford E, McCutcheon S, Glynn 7. Granville R, Menetrez J. Rehabilitation of the ke JC. Battlefield orthopaedic injuries cause the
S. Family and couples treatment for newly returning lower-extremity war-injured at the center for the in- majority of long-term disabilities. J Am Acad Orthop
veterans. Prof Psychol Res Pr. 2011;42(1):47–55. trepid. Foot Ankle Clin. 2010;15(1):187–199. Surg. 2011;19:S1–S7.
I
n recent years, there have been sub- or prolonged diagnostic, therapeutic, and conducted by the U.S. Transportation Com-
stantial reductions in combat opera- rehabilitative care required. mand (TRANSCOM), maintained in the
tions taking place in the U.S. Central Medical air transports (“medical evac- TRANSCOM Regulating and Command
Command (CENTCOM) area of responsi- uations”) are costly and generally indica- & Control Evacuation System (TRAC2ES),
bility (AOR) in Southwest Asia.1-3 However, tive of serious medical conditions. Some were also utilized.
the number of service members deployed serious conditions are directly related to Medical evacuations included in the
to CENTCOM AOR since 2012 is still sig- participation in or support of combat oper- analyses were classified by the causes and
nificant. From 1 January 2013 through 31 ations (e.g., battle wounds); however, many natures of the precipitating medical con-
December 2017, there were more than others are unrelated to combat and may be ditions (based on information reported in
650,000 deployments in support of CENT- preventable. This report summarizes the relevant evacuation and medical encounter
COM AOR operations, including Opera- natures, numbers, rates, and trends of con- records). First, all medical conditions that
tion Enduring Freedom (OEF), Operation ditions for which male and female military resulted in evacuations were classified as
Freedom’s Sentinel (OFS), Operation New members were medically evacuated from “battle injuries” or “non-battle injuries and
Dawn (OND), and Operation Inherent CENTCOM AOR operations during 2017 illnesses” (based on entries in an indicator
Resolve (OIR). In theaters of operations and compares them to the previous 4 years. field of the TRAC2ES evacuation record).
such as Afghanistan, most medical care Evacuations due to non-battle injuries and
is provided by deployed military medical illnesses were subclassified into 17 illness/
personnel; however, some injuries and ill- METHODS injury categories based on International
nesses require medical management out- Classification of Diseases (ICD-9/ICD-
side the operational theater. In these cases, 10) diagnostic codes reported on records
the affected individuals are usually trans- The surveillance period was 1 January of medical encounters after evacuation.
ported by air to a fixed military medical 2013 through 31 December 2017. The sur- For this purpose, all records of hospital-
facility in Europe or the U.S. At the fixed veillance population included all members izations and ambulatory visits from 5 days
facility, the service members receive the of the active and reserve components of the before to 10 days after the reported date of
specialized, technically advanced, and/ U.S. Army, Navy, Air Force, and Marine each medical evacuation were identified. In
TA B L E 1 . Numbers and rates of medical encounters following medical evacuation from theater, by ICD-9/ICD-10 diagnostic category, U.S.
Armed Forces, 2017
Rate Rate
Total Males Females
ratio difference
Female: Female–
Diagnostic category (ICD-9/ICD-10) No. % Ratea No. % Ratea No. % Ratea
Male Male
Mental disorders (ICD-9: 290–319, ICD-10: F01–F99) 148 23.64 3.80 119 22.24 3.47 29 31.87 6.26 1.80 2.79
Non-battle injury and poisoning (ICD-9: 800–999,
132 21.09 3.39 116 21.68 3.38 16 17.58 3.45 1.02 0.07
ICD-10: S00–T88, DOD0101–DOD0105)
Musculoskeletal system (ICD-9: 710–739, ICD-10: M00–M99) 74 11.82 1.90 68 12.71 1.98 6 6.59 1.30 0.65 -0.69
Signs, symptoms, and ill-defined conditions
69 11.02 1.77 59 11.03 1.72 10 10.99 2.16 1.25 0.44
(ICD-9: 780–799, ICD-10: R00–R99)
Battle injury (from TRAC2ES records) 53 8.47 1.36 52 9.72 1.52 1 1.10 0.22 0.14 -1.30
Digestive system (ICD-9: 520–579, ICD-10: K00–K95) 37 5.91 0.95 31 5.79 0.90 6 6.59 1.30 1.43 0.39
Nervous system and sense organs (ICD-9: 320–389,
23 3.67 0.59 22 4.11 0.64 1 1.10 0.22 0.34 -0.43
ICD-10: G00–G99, H00–H95)
Genitourinary system (ICD-9: 580–629, ICD-10: N00–N99) 21 3.35 0.54 11 2.06 0.32 10 10.99 2.16 6.73 1.84
Circulatory system (ICD-9: 390–459, ICD-10: I00–I99) 20 3.19 0.51 17 3.18 0.50 3 3.30 0.65 1.31 0.15
Neoplasms (ICD-9: 140–239, ICD-10: C00–D49) 14 2.24 0.36 12 2.24 0.35 2 2.20 0.43 1.23 0.08
Other (ICD-9: V01–V99, except pregnancy-related,
9 1.44 0.23 7 1.31 0.20 2 2.20 0.43 2.12 0.23
ICD-10: Z00–Z99, except pregnancy-related)
Respiratory system (ICD-9: 460–519, ICD-10: J00–J99) 6 0.96 0.15 6 1.12 0.17 0 0.00 0.00 -- --
Skin and subcutaneous tissue (ICD-9: 680–709,
6 0.96 0.15 4 0.75 0.12 2 2.20 0.43 3.70 0.32
ICD-10: L00–L99)
Endocrine, nutrition, immunity (ICD-9: 240–279,
5 0.80 0.13 3 0.56 0.09 2 2.20 0.43 4.94 0.34
ICD-10: E00–E89)
Infectious and parasitic diseases (ICD-9: 001–139,
5 0.80 0.13 5 0.93 0.15 0 0.00 0.00 0.00 -0.15
ICD-10: A00–B99)
Hematologic disorders (ICD-9: 279–289, ICD-10: D50–D89) 3 0.48 0.08 2 0.37 0.06 1 1.10 0.22 3.70 0.16
Congenital anomalies (ICD-9: 740–759, ICD-10: Q00–Q99) 1 0.16 0.03 1 0.19 0.03 0 0.00 0.00 0.00 -0.03
Pregnancy and childbirth (ICD-9: 630–679, relevant
0 0.00 0.00 -- -- -- 0 0.00 0.00 -- --
V-codes, ICD-10: O00–O99, relevant Z-codes)
Total 626 100.00 16.08 535 100.00 15.59 91 100.00 19.64 1.26 4.05
TRAC2ES, U.S. Transportation Command (TRANSCOM) Regulating and Command & Control Evacuation System
a
Rate per 1,000 deployed person-years
F I G U R E . Numbers of battle injury and disease/non-battle injury medical evacuations of U.S. service members, by month, 2013–2017
Figure. Numbers of battle injury and disease/non-battle injury medical evacuations of U.S. service members, by month, 2013–2017
250
Battle injury
Disease, non-battle injuries
No. of medical evacuation-linked medical encounters
OEF ends;
OIR begins OFS begins
200
150 ORS
begins
100
50
0
Feb
Feb
Apr
Aug
Sep
Oct
Feb
Feb
Feb
Aug
Sep
Oct
Apr
Aug
Sep
Oct
Nov
Dec
Apr
Aug
Sep
Oct
Apr
Aug
Sep
Oct
Apr
Nov
Dec
Nov
Dec
Nov
Dec
Nov
Dec
Mar
May
Jun
Jul
Jun
Jul
Jan
Mar
May
Jun
Jul
Jan
Jan
Mar
May
Jun
Jul
Jan
Mar
May
Jun
Jul
Jan
Mar
May
evacuations, the majority (83.0%) were TA B L E 4. Dispositions after inpatient or outpatient encounters following medical evacua-
discharged back to duty without work/ tion, U.S. Armed Forces, 2017
duty limitations; 14.0% were released with
work/duty limitations; and less than 1% Non-battle injury
Disposition Total Battle injury
and poisoning
each were admitted/transferred to a civil-
ian hospital, immediately referred, or dis- No. % No. % No. %
charged to “home sick” for recuperation. Inpatient 219 44 35
Service members treated as outpatients Returned to duty 134 61.2 5 11.4 26 74.3
after battle injury–related evacuations were Transferred/discharged to other facility 82 37.4 39 88.6 9 25.7
more likely to be released without limita- Discharged home 0 0.0 0 0.0 0 0.0
tions (n=9, 100.0%) than medical evacuees Separated 0 0.0 0 0.0 0 0.0
treated as outpatients for non-battle inju- Died 0 0.0 0 0.0 0 0.0
ries (n=71, 73.2%) (Table 4). Other/unknown 3 1.4 0 0.0 0 0.0
Outpatient 407 9 97
Released without limitation 338 83.0 9 100.0 71 73.2
EDITORIAL COMMENT
Released with work/duty limitation 57 14.0 0 0.0 23 23.7
Sick at home/quarters 1 0.2 0 0.0 0 0.0
This report documented that only 8.5% Immediate referral 1 0.2 0 0.0 1 1.0
of all medical evacuations during 2017 Admitted/transferred to civilian hospital 1 0.2 0 0.0 1 1.0
were associated with battle injuries. Rates Died 0 0.0 0 0.0 0 0.0
of evacuations for battle injuries were con- Discharged home 0 0.0 0 0.0 0 0.0
siderably lower in 2017 than in 2013, the Other/unknown 9 2.2 0 0.0 1 1.0
first year of the surveillance period, which
is likely a reflection of both the reduction
in troop levels that took place during this
period and the change in mission away
to females. The majority of service mem- the end of Operation Enduring Freedom.4
from direct combat. Most evacuations in
bers who were evacuated were returned to As Operation Freedom's Sentinel began,
2017 as well as during the overall 2013–
normal duty status following their post- U.S. troop withdrawal slowed and began to
2017 surveillance period were attributed to
evacuation hospitalizations or outpatient level off in 2015.4 The relatively low rate of
mental health disorders, followed by non-
battle injuries, signs and symptoms, and encounters, as in previous years. However, medical evacuation (16.1 evacuations per
musculoskeletal disorders. Rates of evacu- only about one-quarter of those evacuated 1,000 dp-yrs in 2017) suggests that most
ation in 2017 were higher among females for battle injuries were returned to duty deployers were sufficiently healthy and
than males, as in previous years. Of the immediately after their initial healthcare ready for their deployments, and received
major diagnostic categories for which there encounters. the medical care in theater necessary to
was more than one medical evacuation for Overall, the changes in numbers of complete their assignments without having
both men and women, only rates of mus- medical evacuations over the course of the to be evacuated. This level of health is fur-
culoskeletal disorders evacuations were surveillance period reflect the drawdown of ther supported by the generally low rates of
noticeably higher among males compared U.S. troops from Afghanistan leading up to medical evacuations for chronic conditions
This article provides continuing education (CE) and continuing medical education (CME) credit.
CE/CME Please see information at the end of the article.
F
o o d-a l lerg y anaphy l axis is an comes from multiple sources, including describe EAI prescription fill rates.
immunoglobulin E (IgE)-mediated, surveys,6 medical claims data from hospital
systemic reaction that is often unan- admissions,7,8 emergency room visits,9 and
ticipated and can rapidly lead to death. medically coded encounters from popula- METHODS
Prevention of anaphylaxis includes identifi- tion-based databases (Table 1).10-18 Incidence
cation of individuals at risk for anaphylaxis rate estimates vary widely due to variable
and avoidance of both the offending agent case definitions, populations, data sources, Anaphylaxis incidence
as well as cofactors that have the potential and study design. Among retrospective
to induce or exacerbate reactions to an oth- studies utilizing medically coded encoun- This was a retrospective cohort study.
erwise tolerated allergen.1 The Joint Task ters, rates range from 6.7 per 100,000 An incident case of food-allergy anaphy-
Force on Practice Parameters recommends person-years (p-yrs) in the general popu- laxis was defined as any inpatient, out-
that patients with a history of food-allergy lation17 to 109.0 per 100,000 p-yrs among patient, or Theater Medical Data Store
anaphylaxis and those who are at risk for asthmatics.13. Studies in the U.S. and else- (TMDS) medical encounter identified
anaphylaxis due to a previous systemic reac- where suggest that the incidence of ana- using ICD-9 code 995.6* and ICD-10 code
tion to foods or other factors be prescribed phylaxis is increasing (Table 1).11,14,15,17 T78.0* in any diagnostic position. Ser-
an epinephrine autoinjector (EAI).2,3 In Individuals with a history of anaphy- vice members who had been diagnosed
spite of this recommendation, studies indi- laxis or a systemic reaction to food do not with food-allergy anaphylaxis prior to the
cate that EAIs are underutilized.4,5 meet military accession standards.19 Waiv- surveillance period were excluded from
Knowledge related to the epidemiology ers may be granted, however, based on the the study population. The surveillance
of anaphylaxis in the general population severity of a reaction, risk of recurrence, period for an incident case of food-allergy
Decker (2008)11 1990–2000 Rochester, Rochester All 49.8 Increased Most frequent Not evaluated 29.3 yrs ±18.2 yrs
MN Epidemiology from 46.9 to cause
Project 58.9
Lee (2017)14 2001–2010 Olmsted Rochester All 42 Increased Most frequent Males 10–19 Median age 31 yrs
County, Epidemiology from 36.8 cause in 0–9 yrs; Females
MN Project to 46.6 y/o 30–39 yrs;
no difference
in other age
groups
Yang (2017)15 2008–2014 Republic of Korean National All 22.01 Increased Second most Males 40–69 yrs
Korea Health from 16.0 frequent cause
Insurance to 32.2 after
unspecified
Sheikh (2008)17 2001–2005 United QRESEARCH All 6.7–7.9 Increased Not reported Males <14 yrs; 50–65 yrs
Kingdom from 6.7 Females >14
to 7.9 yrs
a
Rate per 100,000 person-years
anaphylaxis was 1 January 2007 through 31 component members of the U.S. Armed outpatient, or TMDS medical encoun-
December 2016. The surveillance popula- Forces in fixed military and civilian (if ter with ICD-9 codes V15.01–V15.05 and
tion included all individuals, deployed and reimbursed through the Military Health ICD-10 codes Z91.010–Z91.013 or Z91.018
non-deployed, who served in the active System) treatment facilities. in any diagnostic position during the sur-
component of the Army, Navy, Air Force, veillance period. Individuals were consid-
or Marine Corps at any time during the EAI prescription fill rates ered candidates for an EAI prescription fill
surveillance period. Individuals with an incident case of for 18 months prior to and 3 months after
All data used to determine incident food-allergy anaphylaxis or an incident a diagnosis of food allergy or food-allergy
food-allergy anaphylaxis were derived from diagnosis of food allergy from 30 June 2008 anaphylaxis.
records routinely maintained in the Defense through 30 September 2016 were consid- Prescription information was obtained
Medical Surveillance System (DMSS). ered candidates for an EAI prescription. from the Pharmacy Data Transaction Ser-
These records document both ambulatory An incident diagnosis of food allergy was vice, a central data repository that con-
encounters and hospitalizations of active defined by having a first-ever inpatient, tains medication records for all TRICARE
Non-Hispanic white
aimed at identifying factors associated with
80.0 severe, life-threatening anaphylaxis in the
military could help stratify risk and further
inform accession standards, fitness for duty
60.0
determinations, and prevention and treat-
ment efforts.
40.0 This study has several limitations.
Notably, not all cases of anaphylaxis come
to medical attention and the true incidence
20.0 of food-allergy anaphylaxis is likely under-
estimated here. In addition, this study
relied on medically coded encounters that
0.0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
were not validated by chart review or a
criteria-based approach to diagnosis; this
may further contribute to underestima-
tion of the true incidence of food-allergy
F I G U R E 4 . Percentages of incident cases of food allergy and food-allergy anaphylaxis with anaphylaxis. Of note, a study utilizing the
epinephrine autoinjector (EAI) prescriptions filled during specified time frames, active com- National Electronic Injury Surveillance
ponent, U.S. Armed Forces, 30 June 2008 through 30 September 2016
System found that 57% of patients present-
70.0 ing to an emergency department with a
% of cases with EAI prescriptions filled within 18 likely case of anaphylaxis did not receive a
months prior to incident diagnosis diagnosis of anaphylaxis.9 Finally, it is not
58.4
60.0 % of cases with EAI prescriptions filled within 3 clear whether the increasing incidence of
months on or after incident diagnosis food-allergy anaphylaxis reported here
% of cases with filled prescriptions
Key points
• The crude annual incidence rates of food-allergy anaphylaxis among active component service members increased over the
course of the surveillance period; the rates among females were almost three times those of males, and this pattern was consistent
over much of the surveillance period.
• Compared to their respective counterparts, the overall incidence of food-allergy anaphylaxis was highest among females, those
aged 30–34 years, and non-Hispanic black service members.
• Of the total incident anaphylaxis cases during the surveillance period, 29% and 58% had filled a prescription for an epinephrine
autoinjector within 18 months before or 3 months after the incident diagnosis, respectively.
Learning objectives
1. The reader will interpret data related to the incidence of anaphylaxis among active component service members.
2. The reader will explain how the incidence of food-allergy anaphylaxis among active component service members compares to
that in the general population, and how the incidence has changed over time.
3. The reader will describe ways to prevent food-allergy anaphylaxis.
Disclosures: MSMR staff authors, DHA J7, AffinityCE/PESG, as well as the planners and reviewers of this activity have no financial or non-
financial interest to disclose.
I
n 2013, the MSMR summarized cardio- was age with the greatest number and per- TA B L E 2. Demographic characteristics of
vascular-related deaths in U.S. military centage of deaths occurring in service cardiac deaths during deployment, U.S.
members overall.1 This snapshot pro- members aged 45 years or older. The most Armed Forces, October 2001–December
vides a summary of cardiovascular-related frequently diagnosed cardiovascular risk 2012
deaths occurring in service members factor was hypertension and approximately Deaths
while deployed. The surveillance popula- one in seven service members had more No. %
tion included all individuals who served on than one cardiovascular risk factor diag- Total 62 100.0
Sex
active duty at any point between 1 October nosed prior to deployment (Table 2).
Male 60 96.8
2001 and 31 December 2012 as a member of The relatively few numbers of cardio- Female 2 3.2
the active, reserve, or guard component of vascular-related deaths occurring during Age group
the U.S. Army, Navy, Air Force, or Marine deployment is likely attributable to multi- ≤19 0 0.0
Corps. Cardiovascular-related deaths in ple factors. Military members who deploy 20–24 6 9.7
active duty service members were ascer- 25–29 7 11.3
are generally younger and healthier than
30–34 5 8.1
tained as previously described.1 Deaths their civilian counterparts and undergo 35–39 9 14.5
were included in this analysis if the date comprehensive health assessment prior to 40–44 14 22.6
of death occurred during the surveillance deployment to identify potential deploy- >45 21 33.9
period and between the start and end dates ment limiting health conditions. However, Race/ethnicity
of a deployment identified from the Con- not all deploying service members undergo Non-Hispanic white 34 54.8
Non-Hispanic black 20 32.3
tingency Tracking System from the Defense specific cardiovascular screening even in Hispanic 2 3.2
Manpower Data System. For each death the presence of cardiovascular risk factors.2 Other 6 9.7
identified, the presence of a cardiovascular Significantly, the deployment of forward- Grade
risk factor was defined by the documenta- deployed cardiologists with access to first- Jr. Enlisted (E1–E4) 10 16
tion of specific ICD-9 codes in any diagnos- line cardiovascular diagnostic tools (e.g., Sr. Enlisted (E5–E9) 37 60
tic position of a hospitalization discharge Jr. Officer (O1–O3) 6 10
echocardiography, stress testing, ambula-
Sr. Officer (O4–O10) 8 13
record or an outpatient medical encounter tory electrocardiography) allows for expert Warrant Officer (W1–W5) 1 2
prior to the start of the deployment during evaluation of cardiac complaints in theater. Component
which the death occurred (Table 1). This capability enables expert risk strati- Active 27 44
Between October 2001 and December fication that provides an effective tool in Reserve/guard 35 56
2012, there were a total of 62 deaths attrib- Service
discriminating life-threatening diagnoses
Army 49 79
uted to cardiovascular causes occurring dur- from more benign conditions, and likely Navy 6 10
ing deployment. Of these deaths, more than enhances the appropriate disposition of Air Force 5 8
half occurred in reserve or guard members cardiac patients.2-4 Marine Corps 2 3
(n=35; 56.5%). The strongest demographic Military occupation
correlates of a cardiovascular-related death Combat-specifica 13 21
REFERENCES Motor transport 3 5
Pilot/air crew 0 0
Repair/engineering 15 24
TA B L E 1 . ICD-9 codes used for identifi- 1. Armed Forces Health Surveillance Center. Communications/
18 29
cation of cardiovascular risk factors Deaths attributed to underlying cardiovascular dis- intelligence
ease, active and reserve components, U.S. Armed Health care 4 6
Risk factors ICD-9 codes Forces, 1998–2012. MSMR. 2013;20(12):20–21. Other 9 15
Essential hypertension 401.* 2. Watts JA, Russo FD, Villines TC, et al. Cardio-
With pre-deployment risk factor
vascular complaints among military members dur-
Hyperlipidemia 272.0–272.4 Hypertension 15 24
ing Operation Enduring Freedom. US Army Med
Dep J. 2016;(2–16):148–152. Hyperlipidemia 11 18
Obesity 278.00, 278.01,
278.03, 3. Nayak G, Seidensticker D, Shmorhun D. Obesity 5 8
V85.3*–V85.4*, Military cardiology under a tent. Cardiology. Abnormal glucose level 1 2
V85.54 2007;107(4):395–398. Diabetes 1 2
4. Sullenberger L, Gentlesk PJ. Cardiovascular >1 risk factor 9 15
Abnormal glucose level 790.2* disease in a forward military hospital during Opera-
Diabetes mellitus 250.* tion Iraqi Freedom: a report from deployed cardi- a
Infantry/artillery/combat engineering/armor
ologists. Mil Med. 2008;173(2):193–197.
Chief, Armed Forces Health Surveillance Branch MEDICAL SURVEILLANCE MONTHLY REPORT (MSMR), in continuous publication
COL Douglas A. Badzik, MD, MPH (USA) since 1995, is produced by the Armed Forces Health Surveillance Branch (AFHSB). The
MSMR provides evidence-based estimates of the incidence, distribution, impact, and
Editor trends of illness and injuries among U.S. military members and associated populations.
Francis L. O’Donnell, MD, MPH Most reports in the MSMR are based on summaries of medical administrative data
that are routinely provided to the AFHSB and integrated into the Defense Medical
Contributing Editors
Surveillance System for health surveillance purposes.
Leslie L. Clark, PhD, MS
Shauna Stahlman, PhD, MPH Archive: Past issues of the MSMR are available as downloadable PDF files at www.
health.mil/MSMRArchives.
Writer/Editor
Valerie F. Williams, MA, MS Online Subscriptions: Submit subscription requests at www.health.mil/MSMRSubscribe.
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