Citation
Medical surveillance monthly report

Material Information

Title:
Medical surveillance monthly report
Alternate title:
MSMR
Creator:
U.S. Army Center for Health Promotion and Preventive Medicine
Armed Forces Health Surveillance Center (U.S.)
Place of Publication:
Silver Spring, MD
Publisher:
Armed Forces Health Surveillance Branch
Publication Date:
Frequency:
Monthly
regular
Language:
English

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Medicine, Preventive -- Periodicals -- United States ( lcsh )
Military Personnel ( mesh )
Morbidity ( mesh )
Population Surveillance ( mesh )
Wounds and Injuries -- epidemiology ( mesh )
Medicine, Military ( fast )
Medicine, Preventive ( fast )
United States ( mesh )
United States ( fast )
Genre:
Periodicals.
Statistics.
Periodicals. ( fast )
serial ( sobekcm )
statistics ( marcgt )
federal government publication ( marcgt )
periodical ( marcgt )
Periodicals ( mesh )
Statistics ( mesh )
Periodicals ( fast )

Notes

Dates or Sequential Designation:
Began with: Vol. 1, issue 1 (Apr. 1995).
General Note:
"A publication of the Armed Forces Health Surveillance Center."

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
671268376 ( OCLC )
2010201449 ( LCCN )
2158-0111 ( ISSN )
ocn671268376
Classification:
ISSN RECORD ( lcc )
355 ( ddc )
W1 MS245L ( nlm )

UFDC Membership

Aggregations:
Digital Military Collection

Downloads

This item is only available as the following downloads:


Full Text

PAGE 1

SEPTEMBER 2018 Volume 25 Number 9 PAGE 2 Update: Routine screening for antibodies to human immunodeficiency virus, civilian applicants for U.S. military service and U.S. Armed Forces, active and reserve components, January 2013June 2018 PAGE 9 Human papillomavirus vaccine initiation, coverage, and completion rates among U.S. active component service members, 2007 Leslie L. Clark, PhD, MS; Shauna Stahlman, PhD, MPH; Stephen B. Taubman, PhD PAGE 15 Update: Accidental drownings and near drownings, active component, U.S. Armed Forces, 2013 Valerie F. Williams, MA, MS; Gi-Taik Oh, MS; Shauna Stahlman, PhD, MPH PAGE 20 Update: Lightning strike injuries, active component, U.S. Armed Forces, 2008 Valerie F. Williams, MA, MS; Alexis A. Oetting, MPH; Shauna Stahlman, PhD, MPH PAGE 25 Fireworks injuries, active component, U.S. Armed Forces, 2008 Shauna Stahlman, PhD, MPH; Stephen B. Taubman, PhD Dr. Frank Siemers

PAGE 2

Page 2 is report provides an update through June 2018 of the results of rou tine screening for antibodies to the human immunodeciency virus (HIV) among civilian applicants for military service and among members of the active and reserve components of the U.S. Armed Forces. During the surveil lance period, full-year seroprevalences among applicants for service peaked in 2015 (0.34 per 1,000 tested) and then decreased during the subsequent 2 years (0.33 and 0.26 per 1,000 tested, respectively). Seroprevalences among Army active component service members, Navy active component members, Navy reservists, Marine Corps reservists, and Air National Guard members also peaked in 2015. Overall (1 January 2013 through 30 June 2018) serop revalences were highest for Army reservists, Army National Guard members, Navy reservists, and Navy active component members. Across active and reserve components of all services, HIV antibody seroprevalences continued to be higher among males than females. Update: Routine Screening for Antibodies to Human Immunodeficiency Virus, Civilian Applicants for U.S. Military Service and U.S. Armed Forces, Active and Reserve Components, January 2013June 2018 ince acquired immune deciency syn drome (AIDS) was rst recognized as a distinct clinical entity in 1981, 1 its spread has had major impacts on the health of populations and on healthcare systems worldwide. e human immunodeciency virus type 1 (HIV-1) was identied as the cause of AIDS in 1983. For more than 30 years, the U.S. military has conducted rou tine screening for antibodies to HIV-1 to enable adequate and timely medical evalua tions, treatment, and counseling; to prevent unwitting transmission; and to protect the battleeld blood supply. 2,3 As part of the U.S. militarys total-force HIV screening program, civilian appli cants for military service are screened for antibodies to HIV during pre-accession medical examinations. Infection with HIV is medically disqualifying for entry into U.S. military service. Since 1986, all mem bers of the active and reserve components of the U.S. Armed Forces have been peri odically screened to detect newly acquired HIV infections. In 2004, the Department of Defense set a standard testing interval of 2 years for all service members. 4,5 All mili tary personnel are periodically screened for HIV infection (at a minimum every 2 years, or on deployment, return from deploy ment, or aer having received a diagnosis of various other conditions such as sexually transmitted infection). 5 Service members who are infected with HIV receive clini cal assessments, treatments, and counsel ing; they may remain in service as long as they are capable of performing their mili tary duties. 2,3 Before 2009, all of the aforementioned screening programs used laboratory techniques that detected only HIV-1type infections. Starting in 2009, all programs adopted methods that allowed the detec tion of antibodies to both major HIV types (i.e., HIV-1 and HIV-2). Although HIV-2 infection is rare in the U.S. itself, and no instances of HIV-2 infection have thus far been detected in civilian applicants or service members since 2009, HIV-2 virus is much more prevalent in other parts of the world where service members may be required to serve. To provide for the change in laboratory methods in the past and for the prospect of future detections of HIV-2 infection in the services screening pro grams, this report will hereaer refer to the target of the screening programs as simply HIV without specifying either of the types. is report summarizes numbers, prevalences, and trends of newly identied HIV antibody positivity among civilian applicants for military service and mem bers of the active and reserve components of the U.S. Armed Forces from 1 January 2013 through 30 June 2018. Summaries of results of routine screening for antibod ies to HIV among civilian applicants and active and reserve component members of the U.S. military since 1990 are available at www.health.mil/MSMRArchives METHODS e surveillance period was 1 January 2013 through 30 June 2018. e surveillance population included all civilian applicants for U.S. military service and all individuals who were screened for antibodies to HIV while serving in the active or reserve compo nent of the Army, Navy, Air Force, or Marine Corps during the surveillance period. All individuals who were tested and all rst-time detections of antibodies to HIV through U.S. military medical testing pro grams were ascertained by matching speci men numbers and serologic test results to the personal identiers of providers of the speci mens. With the exception of U.S. Air Force members, all results were accessed from records routinely maintained in the Defense Medical Surveillance System (DMSS). e U.S. Air Force provided summarized results of serologic screening for antibodies to HIV among its members.

PAGE 3

Page 3 An incident case of HIV antibody sero positivity was dened as two positive results from serologic testing of two dierent speci mens from the same individual, or one posi tive result from serologic testing of the most recent specimen provided by an individual. Annual prevalences of HIV seroposi tivity among civilian applicants for service were calculated by dividing the number of applicants identied as HIV-antibody seropositive during each calendar year by the number of applicants tested during the corresponding year. For annual summaries of routine screening among U.S. service members, denominators were the numbers of individuals in each component of each service branch who were tested at least once during the relevant calendar year. RESULTS Civilian applicants From January 2017 through June 2018, a total of 484,892 civilian applicants for U.S. military service were tested for antibodies to HIV, and 120 applicants were identied as HIV antibody positive (seroprevalence: 0.25 per 1,000 applicants tested) (Table 1) During the surveillance period, full-year seropreva lences among applicants for service peaked in 2015 (0.34 per 1,000 tested) and then decreased during the subsequent 2 years (0.33 and 0.26 per 1,000 tested, respectively). FIGURE 1. Diagnoses of HIV infections, by sex, civilian applicants for U.S. military service, January 2013June 2018 FIGURE 2. Diagnoses of HIV infections, by race/ethnicity, civilian applicants for U.S. military service, January 2013June 2018 a Through 30 June 2018 a Through 30 June 2018 TABLE 1. Diagnoses of HIV infections, by sex, civilian applicants for U.S. military service, January 2013June 2018 TABLE 2. Diagnoses of HIV infections, by race/ethnicity, civilian applicants for U.S. military service, January 2013June 2018 Year Total HIV tests Total persons tested Males tested Females tested Total HIV(+) HIV(+) male HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested 2013 274,776 266,523 214,370 52,153 62 57 5 0.23 0.27 0.10 2014 239,437 233,782 186,147 47,635 57 55 2 0.24 0.30 0.04 2015 252,910 246,160 195,040 51,120 83 73 10 0.34 0.37 0.20 2016 255,654 249,424 197,450 51,974 82 78 4 0.33 0.40 0.08 2017 306,638 299,655 238,121 61,534 78 71 7 0.26 0.30 0.11 2018 a 196,354 185,237 145,135 40,102 42 38 4 0.23 0.26 0.10 Total 1,525,769 1,480,781 1,176,263 304,518 404 372 32 0.27 0.32 0.11 a Through 30 June 2018 Year Total HIV tests Total persons tested NonHispanic white tested NonHispanic black tested Hispanic/ others tested Total HIV(+) NonHispanic white HIV(+) NonHispanic black HIV(+) Hispanic/ others HIV(+) Overall rate per 1,000 tested NonHispanic white rate per 1,000 tested NonHispanic black rate per 1,000 tested Hispanic/ others rate per 1,000 tested 2013 274,776 266,523 161,057 48,524 56,942 62 12 48 2 0.23 0.07 0.99 0.04 2014 239,437 233,782 140,059 42,851 50,872 57 15 38 4 0.24 0.11 0.89 0.08 2015 252,910 246,160 144,579 44,840 56,741 83 21 58 4 0.34 0.15 1.29 0.07 2016 255,654 249,424 145,063 44,122 60,239 82 27 52 3 0.33 0.19 1.18 0.05 2017 306,638 299,656 184,843 48,851 65,962 78 19 53 6 0.26 0.10 1.08 0.09 2018 a 196,354 185,238 122,388 31,271 31,579 42 9 28 5 0.23 0.07 0.90 0.16 Total 1,525,769 1,480,783 897,989 260,459 322,335 404 103 277 24 0.27 0.11 1.06 0.07 a Through 30 June 2018 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 2013 2014 2015 2016 2017 2018 No. of HIV+ individuals per 1,000 tested Male Female 0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 2013 2014 2015 2016 2017 2018 No. of HIV+ individuals per 1,000 tested Non-Hispanic black Non-Hispanic white Hispanic/other

PAGE 4

Page 4 roughout the surveillance period, HIV antibody seroprevalences among male applicants were consistently higher than among female applicants (Table 1; Fig ure 1) Seroprevalences were much higher among non-Hispanic blacks, compared with other race/ethnicity groups (Table 2; Figure 2) Between 2017 and 2018, serop revalences decreased among non-Hispanic white and non-Hispanic black applicants (30.0% and 16.7%, respectively); of note, however, seroprevalences among Hispanic applicants increased markedly during this same period (77.8%). During 2017, on average, one civilian applicant for service was detected with antibodies to HIV per 3,931 screening tests (Table 1) U.S. Army Active component: From January 2017 through June 2018, a total of 557,319 sol diers in the active component of the U.S. Army were tested for antibodies to HIV, and 95 soldiers were identied as HIV anti body positive (seroprevalence: 0.17 per 1,000 soldiers tested) (Table 3) During the surveillance period, seroprevalences uctu ated between 0.23 per 1,000 tested in 2015 FIGURE 3. New diagnoses of HIV infec tions, by sex, active component, U.S. Army, January 2013June 2018 TABLE 3. New diagnoses of HIV infections, by sex, active component, U.S. Army, January 2013June 2018 TABLE 5. New diagnoses of HIV infections, by sex, U.S. Army Reserve, January 2013June 2018 TABLE 4. New diagnoses of HIV infections, by sex, U.S. Army National Guard, January 2013June 2018 Year Total HIV tests Total persons tested Males tested Females tested Total new HIV(+) New HIV(+) male New HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested HIV(+) still in military service in 2018 2013 508,965 405,824 349,391 56,433 87 86 1 0.21 0.25 0.02 22 2014 447,730 361,941 309,981 51,960 71 71 0 0.20 0.23 0.00 31 2015 426,462 349,811 298,191 51,620 82 81 1 0.23 0.27 0.02 44 2016 423,262 345,951 294,252 51,699 72 69 3 0.21 0.23 0.06 52 2017 435,656 351,099 297,017 54,082 61 60 1 0.17 0.20 0.02 51 2018 a 229,625 206,220 174,111 32,109 34 34 0 0.16 0.20 0.00 33 Total 2,471,700 2,020,846 1,722,943 297,903 407 401 6 0.20 0.23 0.02 233 a Through 30 June 2018 Year Total HIV tests Total persons tested Males tested Females tested Total new HIV(+) New HIV(+) male New HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested HIV(+) still in military service in 2018 2013 173,618 147,729 122,225 25,504 52 51 1 0.35 0.42 0.04 16 2014 265,934 239,346 199,824 39,522 93 92 1 0.39 0.46 0.03 35 2015 205,549 181,785 151,139 30,646 68 66 2 0.37 0.44 0.07 29 2016 230,438 207,561 172,202 35,359 80 78 2 0.39 0.45 0.06 50 2017 235,667 205,398 170,161 35,237 65 63 2 0.32 0.37 0.06 48 2018 a 123,637 114,507 94,208 20,299 26 25 1 0.23 0.27 0.05 25 Total 1,234,843 1,096,326 909,759 186,567 384 375 9 0.35 0.41 0.05 203 a Through 30 June 2018 Year Total HIV tests Total per sons tested Males tested Females tested Total new HIV(+) New HIV(+) male New HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested HIV(+) still in military service in 2018 2013 127,374 113,176 87,345 25,831 54 50 4 0.48 0.57 0.15 19 2014 120,291 107,303 81,912 25,391 47 44 3 0.44 0.54 0.12 19 2015 121,897 110,161 84,775 25,386 42 42 0 0.38 0.50 0.00 27 2016 120,510 109,467 83,474 25,993 44 44 0 0.40 0.53 0.00 33 2017 119,371 108,247 82,680 25,567 41 40 1 0.38 0.48 0.04 36 2018 a 63,032 57,443 43,299 14,144 19 17 2 0.33 0.39 0.14 19 Total 672,475 605,797 463,485 142,312 247 237 10 0.41 0.51 0.07 153 a Through 30 June 2018 a Through 30 June 2018 0. 00 0. 050. 100. 15 0. 20 0. 25 0. 30 0. 35 20 13 20 14 20 15 20 16 20 17 20 18 d e t s e t 0 0 0 1 r e p s l a u d i v i d n i + V I H f o o N Ma l e Fem al e

PAGE 5

Page 5 to 0.16 per 1,000 tested in the rst 6 months of 2018 (30.4% decrease) (Table 3) Annual seroprevalences for male active component Army members greatly exceeded those of females (Figure 3) During 2017, on average, one new HIV infection was detected among active component Army soldiers per 7,142 screening tests (Table 3) Of the 407 active component soldiers diagnosed with HIV infections since 2013, a total of 233 (57.2%) were still in military service in 2018. Army National Guard: From January 2017 through June 2018, a total of 319,905 members of the Army National Guard were tested for antibodies to HIV, and 91 sol diers were identied as HIV antibody posi tive (seroprevalence: 0.28 per 1,000 soldiers tested) (Table 4) Among Army National Guard soldiers, annual seroprevalences increased from 2013 through 2014 (serop revalences: 0.35 and 0.39 per 1,000 soldiers tested, respectively), decreased somewhat in 2015 and then increased slightly in 2016. During 2017, the seropreva lences decreased 28.1%. On average, during 2017, one new HIV infection was detected among Army National Guard soldiers per 3,626 screening tests (Table 4) Of the 384 National Guard soldiers who tested positive for HIV since 2013, a total of 203 (52.9%) were still in military service in 2018. Army Reserve: From January 2017 through June 2018, a total of 165,690 mem bers of the Army Reserve were tested for antibodies to HIV, and 60 soldiers were identied as HIV antibody positive (sero prevalence: 0.36 per 1,000 soldiers tested) (Table 5) Among Army reservists, the seroprevalence in 2013 (0.48 per 1,000 tested) was the highest during the surveil lance period. However, the seroprevalence among Army reservists in 2013 repre sented a 17.2% decrease from that in 2012 (Table 5; data not shown) Between 2013 and 2017, HIV antibody seroprevalences among Army reservists decreased 20.8% (Table 5) During 2017, on average, one new HIV infection was detected among Army reservists per 2,640 screening tests (Table 5) Of the 247 Army reservists diagnosed with HIV infections since 2013, a total of 153 (61.9%) were still in military service in 2018. U.S. Navy Active component: From January 2017 through June 2018, a total of 339,926 active component members of the U.S. Navy were tested for antibodies to HIV, and 90 sail ors were identied as HIV antibody posi tive (seroprevalence: 0.26 per 1,000 sailors tested) (Table 6) Among tested male active component sailors, the annual HIV anti body seroprevalence increased each year between 2013 and 2015, declined 32.4% in 2016 and then increased 20.0% in 2017 (Fig ure 4) During 2017, on average, one new HIV infection was detected among active component sailors per 3,324 screening tests (Table 6) Of the 366 active component sail ors who tested positive for HIV since 2013, a total of 240 (65.6%) were still in military service in 2018. Navy Reserve: From January 2017 through June 2018, a total of 53,410 mem bers of the Navy Reserve were tested for antibodies to HIV, and 12 sailors were identied as HIV antibody positive (sero prevalence: 0.22 per 1,000 sailors tested) (Table 7) e HIV antibody seropreva lence among Navy reservists in 2015 was more than two times that in 2016 (serop revalences: 0.46 and 0.22 per 1,000 sailors tested, respectively). e seroprevalence in 2018 (through June) was lower than in any full year of routine HIV antibody screen ing of Navy reservists since 2004 (data not shown) Of note, no antibodies to HIV were detected among female Navy reservists dur ing 2013 (Table 7) On average, during 2017, one new HIV infection was detected among Navy reservists per 5,067 screening tests (Table 7) Of the 65 reserve component sailors diagnosed with HIV infections since 2013, a total of 43 (66.2%) were still in mili tary service in 2018. U.S. Marine Corps Active component: From January 2017 through June 2018, a total of 215,119 mem bers of the active component of the U.S. Marine Corps were tested for antibodies to HIV, and 33 Marines were identied as HIV antibody positive (seroprevalence: 0.15 per 1,000 Marines tested) (Table 8) From Janu ary 2013 through June 2018, prevalences of antibodies to HIV remained relatively low and stable among routinely tested Marines (Figure 5) During 2017, on average, one new FIGURE 4. New diagnoses of HIV infec tions, by sex, active component, U.S. Navy, January 2013June 2018 FIGURE 5. New diagnoses of HIV infec tions, by sex, active component, U.S. Marine Corps, January 2013June 2018 FIGURE 6. New diagnoses of HIV infections, by sex, active component, U.S. Air Force, January 2013June 2018 a Through 30 June 2018 a Through 30 June 2018 a Through 30 June 2018 0. 00 0. 05 0. 10 0. 15 0. 20 0. 25 0. 30 0. 35 0. 40 0. 45 0. 50 20 13 20 14 20 15 20 16 20 17 20 18 d e t s e t 0 0 0 1 r e p s l a u d i v i d n i + V I H f o o N Ma l e Fem al e 0. 00 0. 05 0. 10 0. 15 0. 20 0. 25 0. 30 20 13 20 14 20 15 20 16 20 17 20 18 d e t s e t 0 0 0 1 r e p s l a u d i v i d n i + V I H f o o N Ma l e Fem al e 0. 000. 050. 10 0. 15 0. 20 0. 250. 30 20 13 20 14 20 15 20 16 20 17 20 18 d e t s e t 0 0 0 1 r e p s l a u d i v i d n i + V I H f o o N Ma l e Fem a l e

PAGE 6

Page 6 TABLE 6. New diagnoses of HIV infections, by sex, active component, U.S. Navy, January 2013June 2018 TABLE 7. New diagnoses of HIV infections, by sex, U.S. Navy Reserve, January 2013June 2018 TABLE 8. New diagnoses of HIV infections, by sex, active component, U.S. Marine Corps, January 2013June 2018 TABLE 9. New diagnoses of HIV infections, by sex, U.S. Marine Corps Reserve, January 2013June 2018 Year Total HIV tests Total persons tested Males tested Females tested Total new HIV(+) New HIV(+) male New HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested HIV(+) still in military service in 2018 2013 248,137 217,548 177,262 40,286 70 69 1 0.32 0.39 0.02 35 2014 250,386 222,117 180,795 41,322 73 72 1 0.33 0.40 0.02 41 2015 241,711 214,218 172,615 41,603 79 77 2 0.37 0.45 0.05 46 2016 239,410 212,818 171,548 41,270 54 52 2 0.25 0.30 0.05 41 2017 249,252 219,395 174,694 44,701 66 65 1 0.30 0.37 0.02 53 2018 a 131,175 120,531 96,072 24,459 24 24 0 0.20 0.25 0.00 24 Total 1,360,071 1,206,627 972,986 233,641 366 359 7 0.30 0.37 0.03 240 a Through 30 June 2018 Year Total HIV tests Total persons tested Males tested Females tested Total new HIV(+) New HIV(+) male New HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested HIV(+) still in military service in 2018 2013 45,173 38,551 30,702 7,849 12 12 0 0.31 0.39 0.00 4 2014 42,807 37,608 29,911 7,697 17 17 0 0.45 0.57 0.00 9 2015 39,028 34,625 27,327 7,298 16 16 0 0.46 0.59 0.00 12 2016 41,292 35,680 27,941 7,739 8 8 0 0.22 0.29 0.00 7 2017 40,532 34,769 27,264 7,505 8 8 0 0.23 0.29 0.00 7 2018 a 20,205 18,641 14,463 4,178 4 4 0 0.21 0.28 0.00 4 Total 229,037 199,874 157,608 42,266 65 65 0 0.33 0.41 0.00 43 a Through 30 June 2018 Year Total HIV tests Total persons tested Males tested Females tested Total new HIV(+) New HIV(+) male New HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested HIV(+) still in military service in 2018 2013 180,549 151,897 140,329 11,568 22 21 1 0.14 0.15 0.09 6 2014 173,351 146,849 135,135 11,714 22 22 0 0.15 0.16 0.00 9 2015 162,065 140,440 129,489 10,951 21 21 0 0.15 0.16 0.00 7 2016 157,659 138,112 126,694 11,418 16 15 1 0.12 0.12 0.09 11 2017 164,596 140,972 129,129 11,843 21 21 0 0.15 0.16 0.00 14 2018 a 80,290 74,147 67,115 7,032 12 12 0 0.16 0.18 0.00 12 Total 918,510 792,417 727,891 64,526 114 112 2 0.14 0.15 0.03 59 a Through 30 June 2018 Year Total HIV tests Total persons tested Males tested Females tested Total new HIV(+) New HIV(+) male New HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested HIV(+) still in military service in 2018 2013 27,669 24,171 23,181 990 4 4 0 0.17 0.17 0.00 0 2014 27,337 24,389 23,454 935 7 7 0 0.29 0.30 0.00 4 2015 26,809 24,018 23,141 877 11 10 1 0.46 0.43 1.14 5 2016 26,283 23,140 22,299 841 6 6 0 0.26 0.27 0.00 3 2017 28,806 25,361 24,467 894 8 8 0 0.32 0.33 0.00 4 2018 a 14,236 12,746 12,290 456 2 2 0 0.16 0.16 0.00 2 Total 151,140 133,825 128,832 4,993 38 37 1 0.28 0.29 0.20 18 a Through 30 June 2018

PAGE 7

Page 7 TABLE 10. New diagnoses of HIV infections, by sex, active component, U.S. Air Force, January 2013June 2018 TABLE 11. New diagnoses of HIV infections, by sex, U.S. Air National Guard, January 2013June 2018 TABLE 12. New diagnoses of HIV infections, by sex, U.S. Air Force Reserve, January 2013June 2018 Year Total HIV tests Total persons tested Males tested Females tested Total new HIV(+) New HIV(+) male New HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested HIV(+) still in military service in 2018 2013 255,720 208,558 168,674 39,884 33 31 2 0.16 0.18 0.05 17 2014 243,141 201,184 162,503 38,681 29 27 2 0.14 0.17 0.05 13 2015 231,752 192,811 155,489 37,322 43 42 1 0.22 0.27 0.03 28 2016 239,254 193,941 155,841 38,100 42 40 2 0.22 0.26 0.05 31 2017 254,720 202,783 161,723 41,060 35 34 1 0.17 0.21 0.02 31 2018 a 131,910 118,813 94,861 23,952 17 17 0 0.14 0.18 0.00 17 Total 1,356,497 1,118,090 899,091 218,999 199 191 8 0.18 0.21 0.04 137 a Through 30 June 2018 Year Total HIV tests Total persons tested Males tested Females tested Total new HIV(+) New HIV(+) male New HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested HIV(+) still in military service in 2018 2013 39,923 53,947 43,778 10,169 4 4 0 0.07 0.09 0.00 1 2014 41,242 57,548 46,489 11,059 2 2 0 0.03 0.04 0.00 0 2015 36,579 53,483 43,098 10,385 6 6 0 0.11 0.14 0.00 5 2016 40,948 60,470 48,561 11,909 6 6 0 0.10 0.12 0.00 3 2017 39,788 58,819 46,911 11,908 6 6 0 0.10 0.13 0.00 6 2018 a 21,110 34,331 27,786 6,545 3 3 0 0.09 0.11 0.00 3 Total 219,590 318,598 256,623 61,975 27 27 0 0.08 0.11 0.00 18 a Through 30 June 2018 Year Total HIV tests Total persons tested Males tested Females tested Total new HIV(+) New HIV(+) male New HIV(+) female Overall rate per 1,000 tested Male rate per 1,000 tested Female rate per 1,000 tested HIV(+) still in military service in 2018 2013 39,923 35,234 26,381 8,853 14 14 0 0.40 0.53 0.00 3 2014 41,242 36,717 27,446 9,271 8 8 0 0.22 0.29 0.00 4 2015 36,579 32,681 24,265 8,416 3 2 1 0.09 0.08 0.12 2 2016 40,948 36,227 26,653 9,574 10 10 0 0.28 0.38 0.00 9 2017 39,788 35,252 25,968 9,284 6 6 0 0.17 0.23 0.00 6 2018 a 21,110 20,086 14,646 5,440 2 2 0 0.10 0.14 0.00 2 Total 219,590 196,197 145,359 50,838 43 42 1 0.22 0.29 0.02 26 a Through 30 June 2018 HIV infection was detected among active component Marines per 7,838 screening tests (Table 8) Of the 114 active component Marines diagnosed with HIV infections since 2013, a total of 59 (51.8%) were still in military service in 2018. Marine Corps Reserve: From January 2017 through June 2018, a total of 38,107 members of the Marine Corps Reserve were tested for antibodies to HIV, and 10 Marine Corps reservists were identied as HIV antibody positive (seroprevalence: 0.26 per 1,000 Marines tested) (Table 9) During the surveillance period, seroprevalences among Marine Corps reservists peaked at 0.46 per 1,000 tested in 2015 and reached a low of 0.16 per 1,000 tested in 2018 (through June). Of note, only one female Marine Corps reservist was detected with antibodies to HIV during routine screening in 2015; none were detected during 1990 2014 or during 2016 (through June) (data not shown) During 2017, on aver age, one new HIV infection was detected among Marine Corps reservists per 3,601 screening tests (Table 9) Of the 38 Marine Corps reservists diagnosed with HIV infec tion since 2013, a total of 18 (47.4%) were still in military service in 2018.

PAGE 8

Page 8 U.S. Air Force Active component: From January 2017 through June 2018, a total of 321,596 active component members of the U.S. Air Force were tested for antibodies to HIV, and 52 airmen were diagnosed with HIV infec tions (seroprevalence: 0.16 per 1,000 airmen tested) (Table 10) From 2013 through June 2018, seroprevalences ranged from 0.14 per 1,000 tested to 0.22 per 1,000 tested. HIV antibody seroprevalence decreased among tested males aer 2015 and remained rela tively low and stable among females (Figure 6) During 2017, on average, one new HIV infection was detected among active Air Force members per 7,278 screening tests (Table 10) Of the 199 active component air men diagnosed with HIV infections since 2013, 137 (68.8%) were still in military ser vice in 2018. Air National Guard: From January 2017 through June 2018, a total of 93,150 mem bers of the Air National Guard were tested for antibodies to HIV, and nine airmen were diagnosed with HIV infections (seropreva lence: 0.10 per 1,000 airmen tested) (Table 11) Since 2010, no female Air National Guard member has been detected with anti bodies to HIV during routine testing (data not shown) During 2017, on average, one new HIV infection was detected among Air National Guard members per 6,631 screen ing tests (Table 11) Of the 27 Air National Guard members diagnosed with HIV infec tions since 2013, 18 (66.7%) were still in mili tary service in 2018. Air Force Reserve: From January 2017 through June 2018, a total of 55,338 members of the Air Force Reserve were tested for anti bodies to HIV, and eight airmen were diag nosed with HIV infections (seroprevalence: 0.14 per 1,000 airmen tested) (Table 12) Dur ing 2017, on average, one new HIV infec tion was detected among Air Force reservists per 6,361 screening tests (Table 12) Of the 43 reserve component airmen diagnosed with HIV infections since 2013, 26 (60.5%) were still in military service in 2018. EDITORIAL COMMENT e U.S. military has conducted routine screening for antibodies to HIV among all civilian applicants for service and all active and reserve component members of the ser vices for more than 30 years. 2-5 Results of U.S. military HIV antibody testing programs have been summarized in the MSMR for more than two decades. 6 is report documents that, since 2013, prevalences of HIV seropositivity among civilian applicants for military service have uctuated between 0.23 and 0.34 per 1,000 applicants tested. During this period, serop revalences among civilian applicants peaked in 2015 and then decreased to 0.23 per 1,000 applicants in 2018 (through June). It is impor tant to note that, because applicants for mili tary service are not randomly selected from the general population of U.S. young adults, seroprevalences among applicants are not directly indicative of HIV prevalences, infec tion rates, or trends in the U.S. civilian pop ulation. As such, relatively low prevalences of HIV among civilian applicants for mili tary service do not necessarily indicate low prevalences or incidence rates of HIV among young adults in the U.S. in general. is report also documents that fullyear HIV antibody seroprevalences among members of the active components of all of the services were relatively stable dur ing 2013. As was observed for total civilian applicants, annual seroprevalences among Army active component service members, Navy active component mem bers, Navy reservists, Marine Corps reserv ists, and Air National Guard members peaked in 2015. Seroprevalences among the Army Reserve showed a consistent decrease between 2013 and 2018 (through June) and the Navy Reserve exhibited a pronounced drop in seroprevalences aer 2015. Overall (2013June 2018) HIV antibody seroprev alences were highest among Army reserv ists, Army National Guard members, Navy reservists, and Navy active component members. Across active and reserve compo nents of all services, seroprevalences contin ued to be higher among males than females. Again, however, such results should be inter preted with consideration of the limitations of the surveillance data summarized herein. For example, because of the frequency of screening in the military (as an applicant, routinely every 2 years, and before and aer overseas deployments), routine screening now detects relatively recently acquired HIV infections (i.e., infections acquired since the most recent negative test of each aected individual). As such, annual HIV-antibody seroprevalences during routine screening of military populations are reective of, but are not direct unbiased estimates of, incidence rates and trends of acquisitions of HIV infections among military members. In summary, the U.S. military has conducted comprehensive HIV preven tion, education, counseling, and treatment programs for more than 30 years. Since the beginning of these programs, routine screening of all civilian applicants for ser vice and routine periodic testing of all active and reserve component members of the ser vices have been fundamental components of the militarys HIV control and clinical management eorts. 7 Summaries of results of screening programs such as those in this report provide insights into the current sta tus and trends of HIVs impacts in various U.S. military populations. REFERENCES 1. Centers for Disease Control and Prevention. Kaposis sarcoma and pneumocystis pneumonia among homosexual menNew York City and Cali fornia. MMWR. 1981;30(25):305. 2. Tramont EC, Burke DS. AIDS/HIV in the U.S. military. Vaccine 1993;11(5):529. 3. Brown AE, Brundage JF, Tomlinson JP, Burke decade. Mil Med 1996;161(2):117. 4. March 2004. 5. U.S. Department of Defense, Instruction No. 6485.01; October 2006. 6. Army Medical Surveillance Activity. Supple ment: HIV-1 in the Army. MSMR 1995;1(3):12. 7. Okulicz JF, Beckett CG, Blaylock JM, et al., ciency virus program: a legacy of progress and a future of promise. MSMR 2017;24(9):2.

PAGE 9

Page 9 Human papillomavirus (HPV) vaccines have been available and licensed for use in the U.S. among women since 2006 and among men since 2010. Cur rently, HPV is not a mandatory vaccine for U.S. military service; however, it is encouraged and oered to service members. Between 2007 and 2017, a total of 111,546 (26.6%) eligible active component service women aged 17 years and 121,657 (5.8%) men initiated the HPV vaccine. Of those service members who initiated vaccination and remained in service for at least 6 months, less than half of women (46.6%) and only slightly more than one-third of men (35.1%) completed three doses. Initiation and completion rates also varied by service branch, with service members in the Air Force generally having higher initiation and completion rates. e median times between the rst and second doses and between the rst and third doses were 3.8 months and 10.8 months, respectively. e median time in service at ini tiation dose was 1.1 years. Continued development and implementation of interventions to enhance HPV vaccination initiation among military service members are warranted. Human Papillomavirus Vaccine Initiation, Coverage, and Completion Rates Among U.S. Active Component Service Members, 2007 Leslie L. Clark, PhD, MS; Shauna Stahlman, PhD, MPH; Stephen B. Taubman, PhD enital human papillomavirus (HPV) is the most common sex ually transmitted infection (STI) in the U.S. 1 ; HPV is the second most fre quently diagnosed STI in U.S. military service members. 2 Although most HPV infections are asymptomatic and resolve spontaneously, persistent infection with specic HPV types is causally associated with certain cancers (e.g., cervical, anal, penile, oropharyngeal) and anogenital warts. 3,4 HPV vaccination has been demon strated to be a safe and eective means of preventing HPV infection. 5-9 Since 2006, three HPV vaccines have become avail able and are currently licensed in the U.S. e rst vaccine introduced, in 2006, for girls and women aged 11 years, was a quadrivalent (4-valent) vaccine (Gardasil), which protects against HPV types 6, 11, 16, and 18. HPV 16 and 18, the two most common "high-risk" oncogenic genotypes, cause an estimated 64% of all HPV-related cancers, including 65% of all cervical can cers. HPV 6 and 11, two "low-risk" gen otypes, cause 90% of anogenital warts (condylomata). 10 Gardasil approval was extended to boys aged 11 years in 2010. A bivalent (2-valent) vaccine, Cervarix, which protects against HPV types 16 and 18, was approved in 2010 for use in girls and women aged 9 years, but not in boys. 11,12 A 9-valent HPV vaccine, Garda sil, was approved in 2014 in the U.S. and protects against the same four HPV types as the quadrivalent vaccine and ve addi tional cancer-causing HPV types (31, 33, 45, 52, and 58). 12 Currently, the Centers for Disease Control and Prevention (CDC)'s Advi sory Committee on Immunization Prac tices (ACIP) recommends routine HPV vaccination of both girls and boys at age 11 or 12 years. However, although HPV vaccine coverage has steadily improved in U.S. adolescents and young adults, vac cine uptake remains suboptimal. 13 Conse quently, many U.S. adults, including new accessions to the military, are candidates for catch-up vaccination. ACIP recom mends catch-up vaccination with any of the three currently available HPV vaccines for females aged 11 years and males aged 12 years, if they have not pre viously been vaccinated. 11,12 In addition, males between 22 and 26 years of age who are members of certain groups (e.g., men who have sex with men [MSM], immuno compromised men) are also candidates for catch-up vaccination. 11 Although HPV vac cination is not mandatory for active com ponent service members, it is available and encouraged for unvaccinated individuals. 14 HPV vaccine initiation and comple tion rates in female military members between 2006 and 2011 were previously published in the MSMR is previous report documented that 22.5% of eligible service women initiated HPV vaccination and 15.1% completed the vaccination series according to ACIP guidelines. 15 e cur rent analysis provides updated counts and rates of vaccine initiation and completion in both male and female active component service members. METHODS e surveillance period was 1 Janu ary 2007 through 31 December 2017. e surveillance population included all indi viduals who served in the active com ponent of the Army, Navy, Air Force, or Marine Corps at any time during the sur veillance period and were aged 26 years or younger. All data used to determine HPV vaccination initiation and coverage rates were derived from records routinely main tained in the Defense Medical Surveillance

PAGE 10

Page 10 System (DMSS). In particular, immuni zation records maintained in DMSS are received from the immunization data base of the Defense Enrollment Eligibility Reporting System (DEERS). HPV vaccination initiation was dened by having a rst-ever vaccination recorded in DMSS during the surveillance period. e initiation rate was calculated by dividing the number of service mem bers who initiated in a given year, or dur ing the overall 2007 2017 surveillance period, by the number of service members aged 26 years or younger who had no prior record of HPV vaccination administered while in military service. HPV vaccina tion records prior to military service were unavailable. Coverage rates for one, two, or three or more doses were also calculated. e denominator for the coverage rates was the number of service members who initi ated the vaccine before the last 6 months of the surveillance period and remained in the active component for at least 6 months following their initiation dose. e numer ators for the coverage rates were the num bers of service members who completed up to one, two, or three or more doses during the surveillance period. Next, completion rates were calculated. e denominator for the 6-month completion rate was the num ber of service members who were followed up for a period of at least 6 months aer the initiation dose. e numerator for the 6-month completion rate was the num ber of service members who completed three doses within 6 months following the initiation dose. Completion rates by 7 and 12 months were calculated in a simi lar manner, among the population of ser vice members who were followed up for 7 and 12 months aer the initiation dose, respectively. Similarly, the numerator was the number of service members who com pleted three doses within 7 and 12 months, respectively. Service members were counted as hav ing an HPV dose if they had immuniza tion records for HPV4, HPV2, HPV9, or an unspecied HPV vaccine. However, HPV2 was counted only for female service mem bers. For all service members, the second dose was not counted unless it was at least 28 days aer the initiation dose, and the third dose was not counted unless it was TABLE 1. Human papillomavirus (HPV) vaccine initiation, coverage, and completion rates among eligible active component service members, U.S. Armed Forces, 2007 Service men Service women DoD overall No. vaccinated Population % No. vaccinated Population % Initiation rates 121,657 2,095,494 5.8 111,546 418,748 26.6 Coverage rates a 1 dose 42,193 105,247 40.1 30,189 102,144 29.6 2 doses 26,098 105,247 24.8 24,347 102,144 23.8 3 doses 36,956 105,247 35.1 47,608 102,144 46.6 Completion rates b 6 months 840 105,247 0.8 1,171 102,144 1.1 7 months 7,610 102,792 7.4 12,009 100,589 11.9 1 year 16,993 89,158 19.1 25,191 92,339 27.3 Army Initiation rates 29,195 816,980 3.6 29,465 152,647 19.3 Coverage rates a 1 dose 11,779 24,147 48.8 9,785 26,685 36.7 2 doses 6,605 24,147 27.4 7,520 26,685 28.2 3 doses 5,763 24,147 23.9 9,380 26,685 35.2 Completion rates b 6 months 207 24,147 0.9 417 26,685 1.6 7 months 1,330 23,503 5.7 2,585 26,156 9.9 1 year 2,887 19,785 14.6 4,923 23,602 20.9 Marine Corps Initiation rates 9,176 441,810 2.1 8,311 39,626 21.0 Coverage rates a 1 dose 3,573 7,698 46.4 2,049 7,528 27.2 2 doses 1,811 7,698 23.5 1,871 7,528 24.9 3 doses 2,314 7,698 30.1 3,608 7,528 47.9 Completion rates b 6 months 145 7,698 1.9 120 7,528 1.6 7 months 746 7,439 10.0 746 7,418 10.1 1 year 1,368 6,526 21.0 1,993 6,880 29.0 Navy Initiation rates 19,116 452,418 4.2 31,295 119,749 26.1 Coverage rates a 1 dose 6,816 16,694 40.8 11,401 28,746 39.7 2 doses 4,339 16,694 26.0 8,220 28,746 28.6 3 doses 5,539 16,694 33.2 9,125 28,746 31.7 Completion rates b 6 months 319 16,694 1.9 342 28,746 1.2 7 months 1,792 16,285 11.0 1,979 28,431 7.0 1 year 3,002 13,746 21.8 3,933 26,386 14.9 Air Force Initiation rates 64,170 389,320 16.5 42,475 107,073 39.7 Coverage rates a 1 dose 20,025 56,708 35.3 6,954 39,185 17.7 2 doses 13,343 56,708 23.5 6,736 39,185 17.2 3 doses 23,340 56,708 41.2 25,495 39,185 65.1 Completion rates b 6 months 169 56,708 0.3 292 39,185 0.7 7 months 3,742 55,565 6.7 6,699 38,584 17.4 1 year 9,736 49,101 19.8 14,342 35,471 40.4 a Coverage rates are measured as the percentage of service members who received 1, 2, or 3 doses by the end of the surveillance period, among those who initiated the vaccine. b Completion rates are measured as the percentage of service members who received 3 doses within 6 months (182

PAGE 11

Page 11 at least 84 days aer the second dose. Age, sex, service branch, and year were refer enced at the time of the initiation dose. e median number of months between doses, as well as the median num ber of years in service at the time of HPV vaccine initiation were calculated overall and by sex and service branch. RESULTS From January 2007 through Decem ber 2017, a total of 111,546 (26.6%) ser vice women and 121,657 (5.8%) service men initiated the HPV vaccine (Table 1) Among both men and women, the ini tiation rate varied by service branch, with 39.7% of Air Force, 26.1% of Navy, 21.0% of Marine Corps, and 19.3% of Army service women initiating during the surveillance period. Similarly, 16.5% of Air Force, 4.2% of Navy, 3.6% of Army, and 2.1% of Marine Corps service men initiated during the sur veillance period. Initiation rates decreased from 2007 to 2017 among service women in all service branches (Figure 1) In con trast, initiation rates among service men increased from 2010 through 2012 among all service branches (Figure 2) Notably, rates of initiation among service men in the Air Force increased dramatically from 1.2% in 2011 to 6.0% in 2012 to 10.3% in 2013 and remained at around 9.0% for the remainder of the surveillance period (Figure 2) Among the 418,748 service women aged 17 26 years without prior HPV vac cination history in their military service records, 47,608 (11.4%) completed three doses during the surveillance period (Table 1) Of the 102,144 women who initiated the HPV vaccine during the surveillance period and remained in the active compo nent for 6 months or more following their rst dose, 30,189 (29.6%) received only one dose, 24,347 (23.8%) received only two doses, and 47,608 (46.6%) completed the recommended three doses. Among the 2,095,494 service men aged 17 years without prior HPV vaccination history in their military service records, 36,956 (1.8%) completed three HPV doses dur ing the 2007 2017 surveillance period. Of the 105,247 men who initiated the HPV FIGURE 1. Annual percentage of eligible active component service women who initiated hu man papillomavirus (HPV) vaccine, U.S. Armed Forces, 2007 FIGURE 2. Percentage of eligible active component service men who initiated human papil lomavirus (HPV) vaccine, U.S. Armed Forces, 2010 Figure 1 A nnual per c ent age o f e li g ible a ctiv e c o m ponent se r v ic e w o m en w ho init iat ed hum an papil lom a v iru s ( H PV) v a ccine 2007 0. 0 5. 0 10 .0 15 .0 20 .0 25 .0 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 o h w n e m o w e c i v r e s e l b i g i l e f o % l a u n n A e n i c c a v V P H d e t a i t i n i Do D ov eral l A i r For c e Na v y A r m y Ma r i ne Corps Figure 2 P e r c ent age o f e li g ible a ctiv e c o m ponent se r v ic e m en w ho init iat ed hum an papil lom a v iru s ( H PV) v a ccin e 2010 0 0 2 0 4 0 6 0 8 0 10. 0 12. 0 2010 2011 2012 2013 2014 2015 2016 2017 V P H d e t a i t i n i o h w n e m e c i v r e s e l b i g i l e f o % l a u n n A v a ccine D o D o v e r a l l A ir F o r c e N a v y A r m y Mar ine C o r p s DoD overall 13.3 15.4 12.7 10.3 11.8 10.8 6.9 5.7 5.3 6.0 5.7 Air Force 23.3 22.3 17.3 13.2 12.8 14.1 12.2 10.5 10.2 10.9 10.7 Navy 12.1 18.7 15.7 12.6 12.7 10.5 5.7 4.6 4.2 5.0 3.9 Army 7.6 10.0 8.2 7.1 9.8 8.3 5.2 4.6 4.1 4.8 4.7 Marine Corps 4.2 9.4 11.1 10.4 15.0 13.7 4.4 2.9 2.6 2.9 3.6 DoD overall 0.4 1.3 2.6 3.1 2.6 2.4 2.8 3.1 Air Force 0.7 1.2 6.0 10.3 8.9 8.7 9.2 9.1 Navy 0.6 1.3 1.7 1.8 1.5 1.5 2.3 2.0 Army 0.2 1.7 2.5 1.2 1.1 1.1 1.5 2.3 Marine Corps 0.2 0.6 0.7 1.3 0.9 0.7 0.7 1.1

PAGE 12

Page 12 vaccine during the surveillance period and remained in the active component for 6 months or more following their rst dose, 42,193 (40.1%) received only one dose, 26,098 (24.8%) received only two doses, and 36,956 (35.1%) completed three doses. Among service women who initiated the HPV vaccine, 1.5% completed three doses within 6 months of initiation, 11.9% within 7 months of initiation, and 27.3% within 1 year of initiation (Table 1) Similarly, among men who initiated the HPV vac cine, 0.8% completed three doses within 6 months following initiation, 7.4% within 7 months aer initiation, and 19.1% within 1 year following initiation. Completion rates also varied by sex and service branch. In particular, service women in the Air Force who initiated HPV vaccine had higher three-dose comple tion rates by 7 months, 1 year, and by the end of the surveillance period, compared with women in other service branches (Fig ure 3) However, the completion rate by 6 months was similarly low across all the ser vice branches. Service men in the Air Force who initiated HPV vaccine also had higher completion rates by the end of the surveil lance period, compared with men in other service branches (Figure 4) However, men in either the Navy or Marine Corps had higher completion rates within 6 months, 7 months, and 1 year following initiation. Overall, the median time between the rst and second doses was 3.8 months and the median time was 10.8 months between the rst and third doses (Table 2) Women had somewhat less time between doses, compared with men (3.5 vs. 4.2 months between rst and second doses, and 10.4 vs. 11.4 months between rst and third doses). Overall, Marine Corps members had the shortest time between doses, com pared with other service branches (2.9 months between rst and second doses and 9.5 months between rst and third doses). However, among service women, those in the Air Force had shorter times between doses, compared with other ser vice branches (3.1 months between rst and second doses and 9.9 months between rst and third doses). e median time in service at initia tion dose was 1.1 years overall, with ser vice members in the Navy and Marine Corps tending to initiate a little sooner, at 0.8 and 0.9 years, respectively (data not shown) Women also initiated sooner than men, with the median time in service at ini tiation dose being 0.8 years among service women and 1.5 years among service men. EDITORIAL COMMENT During the 11-year surveillance period covered in this report, more than a quar ter (26.6%) of eligible service women and 5.8% of eligible service men initiated HPV vaccination. Initiation rates among ser vice women declined during the period, and overall initiation rates among women during this 11-year period are only slightly higher than the 22.5% rate reported during the 2006 2011 period in a previous MSMR report. 15 FIGURE 3. Three-dose completion rates, by service and completion time, active compo nent service women who initiated human papillomavirus (HPV) vaccine, U.S. Armed Forces, 2007 FIGURE 4. Three-dose completion rates, by service and completion time, active compo nent service men who initiated human papillomavirus (HPV) vaccine, U.S. Armed Forces, 2010 0 .01 0 0 2 0 03 0 0 4 0 0 5 0 0 6 0 07 0 0 8 0 09 0 0 1 0 0.0En d of th e s u rv e ill anc e p e ri o d 1 y e a r 7 m on ths 6 m on ths d three doses e t e l p m o c o h w n e m o w e c i v r e s f o %T i m e to t h re e -dos e c o m p l e ti o n DoD o v e ra l l Air F orc e M ari ne Corps Arm y Nav y 0.0 10 .02 0 .0 3 0 .040 .0 50 .06 0 .070 .0 80 .09 0 .0 1 0 0 .0En d o f th e s u rv e ill an c e p e ri od 1 y e a r 7 m o n th s 6 m on ths d three doses e t e l p m o c o h w n e m e c i v r e s f o %T i m e to t hre e dos e c o m pleti o n D oD ov era l l Ai r F o rc e Nav y M ari ne C orp s Arm y

PAGE 13

Page 13 To the authors knowledge, this is the rst published summary of popula tion-level HPV vaccination initiation and completion rates in U.S. male service mem bers. Between 2010 and 2017, the percent age of service men initiating vaccination increased almost 8-fold (0.4% in 2010; 3.1% in 2017). is observation mirrors ndings in studies of vaccination rates in U.S. civil ians which demonstrate that HPV vacci nation coverage in males has been steadily increasing in both adolescents and young adults. 13,16 Active component service men are an important target for catch-up HPV vacci nation. 17 High-risk (i.e., oncogenic) HPV prevalence was recently estimated to be 25.1% in U.S. men aged 18 59 years. 18 Pos sible consequences of HPV infection for men include penile, anal, and oral cancers, including oropharyngeal (i.e., head and neck) squamous cell carcinoma (OPSCC). An estimated 41% of all HPV-related can cers diagnosed between 2008 and 2012 were among men. 19,20 e incidence of OPSCC among men has been increasing steadily over the past several decades and is pro jected to exceed that of cervical cancer in women. 19,20 Notably, men do not undergo regular screening for these cancers (com parable to Pap screening for cervical cancer in women); thus, prevention via HPV vac cination should be a focus of intervention eorts in service men. Of service members who initiated HPV vaccination and remained in service for at least 6 months, the three-dose com pletion rate was suboptimal. Less than half of service women (46.6%) and slightly more than one-third of service men (35.1%) received three doses of vaccine as currently recommended for catch-up HPV vaccina tion. Similarly, adherence to the recom mended dosing schedule (which requires receipt of three doses within 6 months) was poor. is lack of adherence to ACIP schedule and dosing recommendations has been a recurring issue in both civilian and military settings and across adolescent and adult vaccination programs. 21-26 e comparison of the HPV vaccina tion initiation rates in this report with com parable civilian rates is dicult because limited data exist for similarly aged, HPV vaccine-nave civilians and available data are largely based on self-report. In 2016, among a sample of 19to 26-year-old U.S. women and men with no prior HPV vacci nation participating in the National Health Interview Survey, vaccine initiation esti mates were 8.6% and 2.7%, respectively. 27 In comparison, the present analysis reported female and male initiation rates in 2016 of 6.0% and 2.8%, respectively, indicating that HPV vaccination initiation rates in active component military members of similar age and without any prior HPV vaccination history are slightly lower than their civilian counterparts in women and slightly higher in men. A signicant limitation to this compar ison, however, is that in the current analysis the HPV vaccination history for military service members prior to entering service is unknown. e 2016 National Immuni zation Survey indicated that 65% of female and 56% of male teenagers aged 13 17 years received one or more HPV vaccine doses, which was an overall increase of 4 percent age points from the previous year. 28 If the proportion of civilian teenagers initiating HPV vaccine is truly increasing, this trend could have decreased the estimated military HPV vaccine initiation rates in this analy sis because there would actually be fewer service members eligible to initiate over time. A 2017 MSMR analysis documented decreasing incidence of HPV-related geni tal warts among female active component service members. 2 is nding would sup port the notion that increasing numbers of service women are protected against HPV, likely as a result of both increased civilian and military vaccination rates. Rates of initiation and completion of HPV vaccination among both males and females were much higher in Air Force members, compared with members of other services. e reasons for this are unclear. is analysis relies on identication of vac cination status through documentation of vaccine receipt in administrative medi cal data. Missing or inaccurate documen tation of vaccination status would have an adverse impact on the accuracy of reported HPV vaccination and completion. Dier ences in the completeness and accuracy of data by service could explain these dif ferences if the Air Force has more com pletely and accurately documented HPV vaccination, compared to other services. In addition, although the Defense Health Agency and each individual service have policies encouraging HPV vaccination, the Air Forces 2007 policy memo included the implementation of electronic prompts to alert providers to unvaccinated females in the Air Force specic immunization tracking systems (i.e., Air Force Com plete Immunization Tracking Application, now Aeromedical Services Information Management System). 29 is system of prompts may have positively aected vaccination rates. Conversely, annual HPV vaccine ini tiation rates dropped substantially between 2012 and 2013 among service members in the Navy (10.5% to 5.7%) and Marine Corps (13.7% to 4.4%). is corresponds to a Navy Bureau of Medicine and Surgery (BUMED) policy letter that was issued in December 2012, which stated that HPV vaccination "should be oered to both male and female Service members at their rst permanent duty station aer their acces sion or training command." 30 is letter likely resulted in the cessation of HPV vac cination at Navy and Marine Corps boot camps, which had previously been oered on a voluntary basis. Studies in military populations have demonstrated that interventions designed to increase knowledge about HPV infec tion and its consequences and to provide vaccine recommendations can increase vaccination rates signicantly. 24,26 Contin ued development and implementation of such interventions to enhance HPV vacci nation initiation and completion in accor dance with ACIP guidelines are warranted. REFERENCES 1. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among U.S. women and men: prevalence and incidence estimates, 2008. Sex Transm Dis 2013;40(3):187. 2. Stahlman S, Oetting AA. Sexually transmitted infections, active component, U.S. Armed Forces, 2007. MSMR 2017;24(9):15. 3. Brianti P, De Flammineis E, Mercuri SR. Re view of HPV-related diseases and cancers. New Microbiol 2017;40(2):80. 4. Forman D, de Martel C, Lacey CJ, et al. Global burden of human papillomavirus and related dis eases. Vaccine 2012;30(Suppl 5):F12F23. 5. Lu B, Kumar A, Castellsagu X, Giuliano AR.

PAGE 14

Page 14 cervical HPV infection and diseases among wom en: a systematic review & meta-analysis. BMC In fect Dis 2011;11:13. 6. Stillo M, Carrillo Santisteve P, Lopalco PL. Safety of human papillomavirus vaccines: a review. Expert Opin Drug Saf 2015;14(5):697. 7. Van Damme P, Meijer CJLM, Kieninger D, et al. A phase III clinical study to compare the immunogenicity and safety of the 9-valent and quadrivalent HPV vaccines in men. Vaccine 2016;34(35):4205. 8. Huh WK, Joura EA, Giuliano AR, et al. Final nine-valent human papillomavirus vaccine in wom en aged 16 years: a randomised, double-blind trial. Lancet 2017;390(10108):2143. 9. Yih WK, Maro JC, Nguyen M, et al. Assess ment of quadrivalent human papillomavirus vaccine safety using the self-controlled tree-temporal scan statistic signal-detection method in the sentinel system. Am J Epidemiol 2018;187(6):1269. 10. Markowitz LE, Dunne EF, Saraiya M, et al. Hu man papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Prac tices (ACIP). MMWR Recomm Rep 2014;63(RR05):1. Erratum in: MMWR Recomm Rep 2014;63(49):1182. 11. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vacci nationupdated recommendations of the Advisory Committee on Immunization Practices. MMWR 2016;65(49):1405. 12. Petrosky E, Bocchini JA, Hariri S, et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the advisory committee on immunization practices. MMWR 2015;64(11):300. 13. Patel EU, Grabowski MK, Eisenberg AL, Pack man ZR, Gravitt PE, Tobian AAR. Increases in hu man papillomavirus vaccination among adolescent and young adult males in the United States, 2011. J Infect Dis 2018;218(1):10913. 14. Defense Health Agency-Immunization Health care Branch. Information Paper: Human Papilloma virus (HPV) and HPV Vaccines. https://health.mil/ Military-Health-Topics/Health-Readiness/Immuni zation-Healthcare/Vaccine-Preventable-Diseases/ Human-Papillomavirus Accessed on 18 May 2018. 15. Maktabi H, Ludwig SL, Eick-Cost A, Yerubandi UD, Gaydos JC. Quadrivalent human papillomavirus vaccine initiation, coverage, and compliance among U.S. active component ser vice women, 20061. MSMR. 2012;19(5):16. 16. Williams WW, Lu PJ, O'Halloran A, et al. Sur veillance of vaccination coverage among adult populationsUnited States, 2015. MMWR Surveill Summ 2017;66(11):1. 17. Sharp WMJ, Nadarzynski T, Dufty NE. Time to consider a targeted HPV vaccination programme for male military recruits. J R Army Med Corps 2018;164(4):284. 18. Han JJ, Beltran TH, Song JW, Klaric J, Choi YS. Prevalence of genital human papillomavirus in fection and human papillomavirus vaccination rates among US adult men: National Health and Nutrition Examination Survey (NHANES) 2013. JAMA Oncol 2017;3(6)810 816. 19. Centers for Disease Control and Prevention. Cancers associated with human papillomavirus, United States. USCS data brief, no. 1. Atlanta, GA: Centers for Disease Control and Prevention. 2017. 20. Pytynia KB, Dahlstrom KR, Sturgis EM. Epide miology of HPV-associated oropharyngeal cancer. Oral Oncol 2014;50(5):380. 21. Liu G, Kong L, Du P. HPV vaccine completion and dose adherence among commercially insured females aged 9 through 26 years in the U.S. Papil lomavirus Res 2016;2:1 8. 22. Spencer JC, Brewer NT, Trogdon JG, Wheeler SB, Dusetzina SB. Predictors of human papillomavirus vaccine follow-through among pri vately insured U.S. patients. Am J Public Health 2018;108(7):946. 23. Shen-Gunther J, Shank JJ, Ta V. Gardasil HPV vaccination: surveillance of vaccine usage and adherence in a military population. Gynecol Oncol 2011;123(2):272. 24. Dawson R, Lemmon K, Trivedi NJ, Hansen S. Improving human papilloma virus vaccination rates throughout military treatment facilities. Vaccine 2018;36(11):1361. 25. Buechel JJ. Vaccination for human papilloma virus: immunization practices in the U.S. military. Clin J Oncol Nurs 2018;22(1):104. 26. Wedel S, Navarrete R, Burkard JF, Clark MJ. Improving human papillomavirus vaccinations in military women. Mil Med 2016;181(10):1224. 27. Hung M, Williams WW, Lu P, et al. Vaccination Coverage Among Adults in the United States, Na tional Health Interview Survey, 2016. www.cdc.gov/ vaccines/imz-managers/coverage/adultvaxview/ pubs-resources/NHIS-2016.html Accessed on 18 May 2018. 28. Walker TY, Elam-Evans LD, Singleton JA, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13 yearsUnited States, 2016. MMWR 2017;66(33):874. 29. U.S. Department of the Air Force. Human Papillomavirus Vaccination Policy. 2007. www.vac cines.mil/documents/1062AFHumanPapillomaviru sPolicyApr2007.pdf Accessed on 16 May 2018 30. Department of the Navy, Bureau of Medicine and Surgery. BUMED Notice 6230. Recommen dations for the Use of Quadrivalent and Bivalent Human Papilloma Virus Vaccines in the Navy and Marine Corps. www.med.navy.mil/sites/nmcphc/ Documents/nepmu-6/Epidemiology/BUMEDNOTE-6230-Recommendations-for-HPV-Vac cine-Use-Dec2012.pdf Accessed on 19 Septem ber 2018.

PAGE 15

Page 15 Service members are at risk for unintentional drownings or near drown ings during training, occupational activities, and o-duty recreation. During 2013, there were 359 incident accidental drowning episodes (includes drownings and near drownings) for a crude rate of 5.7 cases per 100,000 person-years. Compared with their respective counterparts, the overall inci dence rates of drowning episodes were highest among males, those aged 29 years or younger, those who were unmarried, and enlisted service members. Across the services, crude overall rates were highest among Marine Corps and Navy members and lowest among Air Force members. Overall rates of drowning episodes were highest among those working in motor transport and lowest among those in repair/engineering or communications/intel ligence occupations. e overall rate of drowning episodes among service members with any history of alcohol-related disorder was nearly twice that of those without any history of alcohol-related disorder. Between 2015 and 2017, annual rates of drowning episodes decreased in each service, with the greatest decline observed among Navy and Marine Corps members. e results of this report may be useful to increase awareness regarding the ongo ing risks and eects of drowning episodes among U.S. service members. Update: Accidental Drownings and Near Drownings, Active Component, U.S. Armed Forces, 2013 Valerie F. Williams, MA, MS; Gi-Taik Oh, MS; Shauna Stahlman, PhD, MPH n the U.S., unintentional drowning ranks as the sixth leading cause of unin tentional injury death and accounted for an average of 3,558 deaths (non-boating related) annually between 2007 and 2016. 1 Males and members of racial/ethnic minor ities were overrepresented among fatal unintentional drowning victims during this period. 1 Among adolescents and adults, alcohol use was involved in up to 70% of fatalities during recreational aquatic activ ities and close to one-quarter of all emer gency department visits for drowning. 2-4 Inability to swim and failure to wear life jackets are also key risk factors for drown ing among adults. 5,6 Many military occupational activi ties, particularly of the Navy and Marine Corps, occur on or near water. e acci dental drowning deaths of two Navy SEALs at the Combat Swimmer Training Facility at Joint Expeditionary Base Little Creek, VA, in 2015 show that even the most highly trained and t personnel can be at risk of accidental fatal drowning during train ing and diving operations. 7 Recreational aquatic activities also can be dangerous and are commonly associated with drown ing, particularly for non-swimmers and weak swimmers, in hazardous conditions and settings (e.g., storms, currents, rip tides), and when safety measures are not observed. 8 In the U.S., the risk factors for drown ing are well established. Bell and colleagues reviewed 352 fatal drownings of male U.S. Army soldiers during 1980. 9 eir analysis revealed elevated risk among male soldiers who were aged 25 years or younger, black, and unmarried. 9 Most deaths occurred during o-duty activi ties; alcohol use was involved in approxi mately one-third of the cases. A June 2015 MSMR report documented an average of 119 accidental drowning episodes (includes drownings and near drownings) and 16 deaths per year among active component service members during 2005. 10 Results of the 2015 analysis showed that overall incidence rates of accidental drown ings were highest among service members aged 30 years or younger, males, those who were unmarried, Navy or Marine Corps members, and those in combat-specic occupations. 10 Compared with their respec tive counterparts, overall rates of drowning episodes were lowest among non-Hispanic black service members; however, the case fatality percentage among non-Hispanic blacks was the highest among all race/eth nicity groups. 10 e current analysis extends and updates the ndings of the June 2015 MSMR article. 10 Specically, the current report summarizes counts, rates, and cor relates of risk of medical encounters related to drowning episodes (drownings and near drownings) among U.S. military members during 2013. METHODS e surveillance period was 1 Janu ary 2013 through 31 December 2017. e surveillance population consisted of active component service members of the U.S. Army, Navy, Air Force, or Marine Corps who served at any time during the surveil lance period. Diagnoses were ascertained from administrative records of all medical encounters of individuals who received care in xed (i.e., not deployed or at sea) medi cal facilities of the Military Health System or civilian facilities in the purchased care system. ese data are maintained in the electronic database of the Defense Medical Surveillance System (DMSS). Electronic records of all active com ponent service members were searched to identify hospitalizations and ambulatory

PAGE 16

Page 16 en-USencounters that included diagnosis codes en-US indicative of injuries associated with drowning-related episodes. For sur en-US-en-US veillance purposes, the term drowning-en-US related episode included fatal drownings en-US and nonfatal submersions, and was dened en-US by a qualifying ICD-9 or ICD-10 diagen-US -en-US nosis code (in any diagnostic position), en-US ICD-9 or ICD-10 external cause of injury en-US code, or a NATO standardization agreeen-US -en-US ment (STANAG) cause of injury code en-US that indicated a drowning or submersion en-US injury that was not intentionally inicted en-US(Table 1)en-US. Fatal drowning episodes were en-US not distinguished from nonfatal episodes en-US because data on underlying cause of death en-US were not available for the current analyen-US -en-US sis. Healthcare encounters that occurred en-US during deployment were excluded from en-US the analysis. Medical encounters with the en-US following codes in any diagnostic posien-US -en-US tion were excluded from consideration as en-US cases: ICD-9 E964 assault by submersion en-US (drowning); ICD-9 E954 suicide and self-en-US inicted injury by submersion (drownen-US -en-US ing); ICD-10 X92* assault by drowning en-US and submersion; ICD-10 X71* intenen-US -en-US tional self-harm by drowning and submeren-US -en-US sion; and NATO STANAG general class of en-US trauma codes 3 (assault, or intentionally en-US inicted by another person) and 4 (intenen-US-en-US tionally self-inicted) en-US(Table 1)en-US. en-US If a service member had case-dening en-US inpatient and outpatient records in the same en-US calendar year, en-US information from the hospien-US -en-US talization record was used for the analysis.en-US en-US Individuals could be counted as cases once en-US per calendar year. Incidence rates were calen-US -en-US culated using non-deployed person-time en-US in the denominator and as the number of en-US cases per 100,000 person-years (p-yrs). en-US History of an alcohol-related disorder en-US was dened by one hospitalization with a en-US qualifying ICD-9 or ICD-10 diagnosis code en-US in the 1st or 2nd diagnostic position;en-US12en-US en-US oren-US en-US two outpatient encounters within 180 days en-US of each other with a qualifying diagnosis en-US code in the 1st or 2nd diagnostic position; en-US or one outpatient encounter with Medical en-US Expense and Performance Reporting Sysen-US -en-US tem (MEPRS) code BF, indicating psyen-US-en-US chiatric and/or mental health care and a en-US qualifying diagnosis code in the 1st or 2nd en-US diagnostic position. Qualifying ICD diagen-US-en-US noses could occur prior to or during the en-US surveillance period. enRESULTSen-USDuring the 5-year surveillance en-US period, there were 359 incident accidenen-US-en-US tal drowning episodes (includes drownen-US -en-US ings and near drownings) among active en-US component service members, for a crude en-US overall incidence rate of 5.7 cases per en-US 100,000 p-yrs en-US(Table 2)en-US. Compared with en-US their respective counterparts, the overall en-USTABLE 1. en-USICD-9 and ICD-10 diagnosis/external cause of injury codes and STANAGen-USaen-USen-USb en-USICD-9en-US Descriptionen-US ICD-10en-US Descriptionen-US 994.1en-US Drowning and nonfatal submersionen-US T75.1*en-US en-US E830*en-US Accident to watercraft causing submersionen-US V9089X*en-US en-US watercraften-US E832*en-US Other accidental submersion/drowning in water transport en-US accidenten-US V9209X*en-US en-US E910*en-US Accidental drowning and submersionen-US W69XXX*en-US Accidental drowning and submersion while in natural wateren-US W65XXX*en-US Accidental drowning and submersion while in bathtuben-US W67XXX*en-US Accidental drowning and submersion while in swimming poolen-US E984en-US Submersion (drowning), undetermined whetheren-US en-US en-US W74XXX*en-US en-US STANAGen-USaen-USDescriptionen-US 150en-US Water transport accident, involving submersion in boarding en-US and alightingen-US 151en-US Water transport accident, involving submersion of occupant en-US of small boaten-US 159en-US Water transport accident, involving submersion, otheren-US 860 en-US en-USE964en-US Assault by submersion (drowning) en-US Exclusions X92* Assault by drowning and submersion X71* Intentional self harm by drowning and submersionen-USE954 en-US en-US en-US en-USaen-USNATO standardization agreement cause of injury codeen-USben-USThe term "drowning episode" refers to any accidental submersion event that resulted in death or injury.en-US *Any digit/character

PAGE 17

Page 17 incidence rates of accidental drowning were highest among males, those aged 29 years or younger, those who were unmar ried, and enlisted service members. Across the services, crude overall incidence rates were highest among Marine Corps mem bers and Navy members (8.4 and 6.3 per 100,000 p-yrs, respectively) and low est among Air Force members (4.2 per 100,000 p-yrs). Stratication by military occupation revealed that crude overall rates of drowning episodes were highest among those working in motor transport (19.5 per 100,000 p-yrs) and lowest among those in repair/engineering or communi cations/intelligence occupations (4.5 and 4.6 per 100,000 p-yrs, respectively) (Table 2) Of active component service mem bers with known locations of military assignment, overall incidence of drown ing episodes was highest among those sta tioned in the Western region of the U.S. (7.1 per 100,000 p-yrs) and lowest among those stationed in the Northeast (2.1 per 100,000 p-yrs). However, the overall inci dence rate among service members with unknown/missing locations of military assignment was more than 3 and 2 times the rates of service members with mili tary assignments in the Southern and Western regions of the U.S., respectively. Of note, the overall rate of drowning epi sodes among service members with any history of alcohol-related disorder (10.0 per 100,000 p-yrs) was nearly twice that of those without any history of alcoholrelated disorder (5.6 per 100,000 p-yrs) (Table 2) Among all service members with a history of an alcohol-related disorder and a subsequent incident drowning epi sode, for more half of them (52.0%; n=13), more than a year had passed between the last alcohol-related diagnosis and the inci dent date of the drowning event; for nearly three-eighths (36.0%; n=9) of service members with both diagnoses, 30 or fewer days had passed between the last alcoholrelated disorder diagnosis and the date of the incident drowning episode (data not shown) During 2013, the fewest inci dent drowning episodes occurred in 2017 (n=51) and 2016 (n=62) (Figure 1) Crude annual incidence rates of drowning epi sodes increased from 5.8 cases per 100,000 TABLE 2. Incident cases and incidence rates of drowning episodes a active component, U.S. Armed Forces, 2013 Total No. Rate b Total 359 5.7 Sex Male 328 6.2 Female 31 3.2 Age group <20 30 6.9 20 24 145 7.4 25 96 6.5 30 44 4.3 35 23 3.2 40+ 21 3.2 Race/ethnicity Non-Hispanic white 221 6.0 Non-Hispanic black 46 4.5 Hispanic 52 5.9 14 5.8 Other/unknown 26 5.7 Marital status Married 160 4.7 Unmarried 188 7.3 Other/unknown 11 4.0 Service Army 125 5.3 Navy 95 6.3 Air Force 63 4.2 Marine Corps 76 8.4 Rank Recruit 1 0.7 Enlisted (excluding recruits) 308 6.1 50 4.5 Military occupation c 63 7.2 Motor transport 35 19.5 Pilot/air crew 16 6.9 Repair/engineering 83 4.5 Communications/intelligence 62 4.6 Health care 33 5.8 Other/unknown 67 5.6 Geographic region of military assignment d Northeast 4 2.1 Midwest 15 3.7 South 148 5.0 West 119 7.1 Overseas 32 4.3 Unknown/missing 41 16.1 History of alcohol-related disorder Yes 25 10.0 No 334 5.6 a The term "drowning episode" refers to any accidental submersion event that resulted in death or injury. b Rate per 100,000 person-years c Infantry/artillery/combat engineering/armor d Within the U.S., categorization was based on U.S. Census Bureau regions ( www.census.gov/geo/reference/ webatlas/regions.html ).

PAGE 18

Page 18 p-yrs in 2013 to 7.1 cases per 100,000 p-yrs in 2015, aer which rates decreased by 40.6% to a low of 4.2 cases per 100,000 p-yrs in 2017 (Figure 1) Between 2015 and 2017, annual rates of drowning epi sodes decreased in each service with the greatest decline observed among Navy and Marine Corps members (48.3% and 29.0%, respectively) (data not shown) During the 5-year surveillance period, more incident drowning epi sodes occurred in June (n=57) than in any other month; slightly more than one-half (52.4%) of all drowning episodes occurred from May through August (Figure 2) EDITORIAL COMMENT is report documents an average of 72 accidental drowning episodes per year among active component members of the U.S. Armed Forces. Consistent with the ndings of earlier MSMR analyses of acci dental drowning episodes among active component military members as well as Bell and colleagues study of fatal drown ings among U.S. soldiers, the current analysis found relatively high crude over all incidence rates of drowning episodes among service members who were male, young, unmarried, and in combat occupa tions. 9,10,12 As in the previous MSMR stud ies, the overall incidence rate of drowning episodes among non-Hispanic white ser vice members was higher than that among non-Hispanic black service members. However, the dierence between the rates among service members in these two race/ ethnicity groups in the current analysis is much smaller than that reported from ear lier MSMR analyses (2015 analysis: nonHispanic white, 10.8 cases per 100,000 p-yrs; non-Hispanic black, 5.8 cases per 100,000 p-yrs; 2018 analysis: non-Hispanic white, 6.0 cases per 100,000 p-yrs; nonHispanic black, 4.5 cases per 100,000 p-yrs) (data not shown) 10,12 In the current analysis, the highest overall rates of drowning episodes aected members of the Marine Corps and Navy perhaps due to geographic proximity to, more frequent and/or more prolonged exposures to, potentially dangerous water environments (on and o duty). Of inter est, in the Navy and Marine Corps, swim ming and water survival prociencies are required for graduation from recruit train ing. In Army and Air Force recruit train ing, swimming prociency is not required and water survival training is not routinely conducted. During 2015, annual counts and rates of incident accidental drowning epi sodes decreased in all services but were most pronounced among Marine Corps FIGURE 1. Numbers of cases and incidence rates of drowning episodes, a by year, active component, U.S. Armed Forces, 2013 FIGURE 2. Cumulative numbers of drowning episodes, by month of occurrence, active com ponent, U.S. Armed Forces, 2013 5 5 1 2 4 5 6 9 7 8 7 75 8 4 65. 8 6 57 15 0 4 2 0 01 02 0 3 0 4 05 06 0 7 0 8 0 01 02 0 3 0 4 0 5 06 0 7 08 0 9 0 100 2013 2014 2015 2016 2017I n c ide n c e rat e per 100, 000 p y r sN o o f c a s e s (bars) M al e Fem ale Tot a l r a t e 23 15 24 233957 51 41 32 26 17110 102030 40 50 60 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecNo. of casesMonth a The term "drowning episode" refers to any accidental submersion event that resulted in death or injury.

PAGE 19

Page 19 en-USand Navy members. is decrease may be en-US due, at least in part, to improvements in en-US safety and training that were made during en-US this period. For example, new safety guideen-US -en-US lines were put into place aer the shalen-US-en-US low-water blackoutrelated deaths of two en-US Navy Seals in 2015. Shallow-water blackout en-US occurs when a swimmer tries to stay underen-US -en-US water for a long period of time, typically en-US to build endurance. Some swimmers puren-US -en-US posely hyperventilate before going underen-US -en-US water as a way to prolong their submersion en-US time; by so doing, they reduce their blood en-US carbon dioxide levels. Once underwater, en-US carbon dioxide levels fail to rise quickly en-US enough to trigger the urge to breathe. Howen-US -en-US ever, the rapid fall in blood oxygen levels en-US can lead to cerebral hypoxia, seizures, loss en-US of consciousness, and ultimately drowning. en-US e U.S. Navy Diving Manual Revision 7 en-US was updated in December 2016 to include en-US additional guidance on breath-hold diving en-US and the risk of loss of unconsciousness.en-US13en-USCurrent ndings must be considered en-US in light of some important limitations. For en-US example, drowning and near drowningen-US related medical encounters were identied en-US from drowning and nonfatal submersion-en-US specic diagnosis and cause-of-injury en-US codes that were reported on standardized en-US electronic medical records. e completeen-US -en-US ness and accuracy of case ascertainment by en-US these methods are not known; it is possien-US-en-US ble that many medical encounters for conen-US -en-US ditions related to water submersion (near en-US drowning) were not documented with the en-US case indicator codes used for this report. en-US Moreover, drowning episodes that were en-US not associated with inpatient or outpaen-US -en-US tient encounters were not included in this en-US analysis. Another limitation of the current analysis is related to the implementa t ion of MHS GENESIS, the new elec t ronic health en-USrecord for the Military Health System. Duren-US -en-US ing 2017, medical data from sites that were en-US using MHS GENESIS are not available in en-US DMSS. ese sites include Naval Hospital en-US Oak Harbor, Naval Hospital Bremerton, en-US Air Force Medical Services Fairchild, and en-US Madigan Army Medical Center. erefore, en-US medical encounter and person-time data en-US for individuals seeking care at one of these en-US facilities during 2017 were excluded from en-US the analysis.en-US is analysis summarized drowning en-US episodes in relation to demographic and en-US military characteristics. As such, the nden-US-en-US ings do not account for factors such as en-US swimming ability, nature and setting of the en-US drowning episode, frequency and duration en-US of exposure to drowning risk, or adherence en-US to routine safety measures. Absent inforen-US -en-US mation related to these factors, novel speen-US-en-US cic recommendations aimed at prevention en-US are not appropriate. However, the results en-US of this report may be useful to increase en-USawareness regarding the ongoing risks and en-US eects of drowning-related episodes among en-US U.S. service members. enREFERENCES 1. en-USCenters for Disease Control and Prevention,en-US National Center for Injury Prevention and Control.en-US Web-based Injury Statistics Query and Reportingen-US System (WISQARS), Leading Causes of Death Reports, 2007. en-UShttps://webappa.cdc.gov/ en-USsasweb/ncipc/leadcause.html Accessed on 29 May 2018. 2. en-USCenters for Disease Control and Prevention.en-US DrowningUnited States, 2005. en-US MMWRen-US.en-US 2012;61(19):344. 3. en-USU.S. Coast Guard, U.S. Department ofen-US Homeland Security. Recreational Boating Staen-US tistics 2010. en-UShttp://www.uscgboating.org/library/ en-USaccident-statistics/USCGBoatingStatistics2010.en-US pdfen-US. Accessed on 29 May 2018. 4. en-USDriscoll TR, Harrison JA, Steenkamp M. Reen-US -en-US view of the role of alcohol in drowning associen-US -en-US ated with recreational aquatic activity. en-US Inj Prev. en-US2004;10(2):10713. 5. en-USPharr J, Irwin C, Layne T, Irwin R. Predictors ofen-US swimming ability among children and adolescentsen-US in the United States. en-USSports (Basel)en-US 2018;6(1). pii:en-US E17. 6. en-USCummings P, Mueller BA, Quan L. Associationen-US en-US death by drowning among recreational boaters: aen-US matched cohort analysis of United States Coasten-US Guard data. en-USInj Prev.en-US 2011;17(3):156. 7. en-USNaval Safety Center. Mishap Stats File for FYen-US 2015. en-US www.public.navy.mil/NAVSAFECEN/Pages/en-US statistics/index.aspxen-US Accessed on 31 May 2018. 8. en-USBrowne M, Lewis-Michl E, Stark A. Unintenen-US -en-US tional drownings among New York State residents,en-US 1988. en-US Public Health Rep. en-US 2003;118(5):448en-US 458. 9. en-USBell NS, Amoroso PJ, Yore MM, et al. Alcoholen-US and other risk factors for drowning among male acen-US -en-US tive duty U.S. Army soldiers. en-USAviat Space Environen-US Med.en-US 2001;72(12):1086. 10. en-USArmed Forces Health Surveillance Center. Acen-US -en-US cidental drownings, active component, U.S. Armed en-US Forces, 2005. en-US MSMR.en-US 2015;22(6):2. 11. en-USArmed Forces Health Surveillance Branch.en-US March 2018. en-USwww.health.mil/Reference-Center/ en-USPublications/2014/10/01/Alcohol-Relateden-USDisordersen-US 12. en-USArmed Forces Health Surveillance Center. Acen-US -en-US cidental drownings, active component, U.S. Armeden-US Forces, 2005. en-US MSMR.en-US 2009;16(6):11. 13. en-USCommander, Naval Sea Systems Command.en-US U.S. Navy Diving Manual, SS521-AG-PRO-010,en-US Revision 7. Published on 1 December 2016. U.S.en-US en-USMore information about water safety is en-US available from these online resources:en-USAmerican Red Crossen en-US www.redcross.org/services/hss/en-US tips/healthtips/safetywater.htmlen-US Armyen en-US https://safety.army.mil/safetycity/en-US en-US pages/water/watersafety.aspxen-US Navyen-US en-US en-US www.public.navy.mil/NAVSAFEen-US-en-US CEN/Pages/shore/o-duty_en-US rec/o_duty_rec.aspxen-US Air Forceen en-US www.safety.af.mil/Divisions/en-US en-US Occupational-Safety-Division/en-US Summer-Safety/Water-Safety/en-US National Safety Councilen en-US www.nsc.org/home-safety/en-US en-US tools-resources/seasonal-safety/en-US drowning

PAGE 20

Page 20 During 2008, a total of 241 service members had incident lightningrelated medical encounters with ICD-9 or ICD-10 codes that documented specic lightning-associated injuries or illnesses. e crude overall incidence rate of lightning strike injury during the surveillance period was 1.9 cases per 100,000 person-years. Compared to their respective counterparts, overall rates of lightning strike injury were higher among males, those aged 20 years, non-Hispanic whites, Army members, enlisted service members, those in combat-specic occupations, and those stationed in the Southern region of the U.S. During the surveillance period, there was a peak in incidence of lightning strike injury during 2015, as well as two smaller peaks in 2011 and 2013. Disturbance of skin sensation, headache, limb pain, and burns were the four most frequent diagnoses during medical encounters for inci dent lightning strike injuries. e largest numbers of incident lightning strike injuries occurred in June, July, August, and September. Service members who routinely train and work outdoors should be vigilant about the dangers of lightning, especially in eld settings during summer months. Update: Lightning Strike Injuries, Active Component, U.S. Armed Forces, 2008 Valerie F. Williams, MA, MS; Alexis A. Oetting, MPH; Shauna Stahlman, PhD, MPH ccording to the National Weather Service, nearly 2,000 people were reported as injured by lightning in the U.S. between 2006 and 2017. 1 A total of 376 people were killed by lightning dur ing this period. 2 However, research suggests that up to 50% of lightning strike injuries go unreported. 3,4 For more than a century, lightning injuries had ranked among the top ve most common causes of weather-related death in the U.S. 5,6 However, in 2017, light ning killed fewer Americans (n=16) than in any year on record, 1,2 with lightning injuries ranking as the eighth most common cause of weather-related fatalities behind oods, heat, rip currents, wind, hurricanes, tor nadoes, and cold. 7 is record low marks a steady downward trend that has been attributed to urbanization, better light ning-proof construction, heightened light ning safety awareness (through educational outreach and public awareness campaigns), and improved medical treatments (e.g., cardiopulmonary resuscitation, automated external debrillators). 6,8 In the U.S. civilian population, light ning injuries most oen occur during summer months among people who are outdoors between noon and early eve ning (1200 local time). 9 is tempo ral association is related not only to when thunderstorms generally occur, but also to when people are most likely to be engaging in outdoor activities. 2 Activities most fre quently associated with lightning injuries include camping, hiking, jogging, waterrelated activities (e.g., swimming, shing, boating), golng, working on construction or electrical equipment, and using landline telephones. 2,8 Less than one-third of light ning injuries in the U.S. civilian population are work-related and, in approximately one-h of lightning injury events, there are two or more victims. 2,8,10 Lightning-related injuries result from the eect of electrical current, heat, and/ or concussive force (e.g., muscle contrac tion, complication of a fall, impact of fall ing heavy objects) 11,12 and are usually neurological in nature with manifesta tions ranging from temporary confusion to cardiopulmonary arrest. 13 Sleep dis turbances, neurocognitive decits, and chronic pain syndromes are commonly reported sequelae of lightning injuries. 14,15 Military personnel are at risk for light ning injury due to the nature of their train ing and operational activities. Many of those activities take place outdoors in all types of weather conditions and oen in geographic regions of the U.S. associated with higher cloud-to-ground lightning strike densities (e.g., southern and eastern coastal areas). 16 e current analysis updates the ndings of previous MSMR articles on lightning strike injuries among active com ponent service members. 17,18 Specically, the current report summarizes the counts, rates, and correlates of risk of lightning injuries among U.S. military members dur ing 2008. METHODS e surveillance period was 1 Janu ary 2008 through 31 December 2017. e surveillance population included all active component service members who served in the Army, Navy, Air Force, or Marine Corps of the U.S. Armed Forces at any time during the surveillance period. Diagno ses were ascertained from administrative records of all medical encounters of indi viduals who received care in xed (i.e., not deployed or at sea) medical facilities of the Military Health System or civilian facilities in the purchased care system. ese data are maintained in the electronic database of the Defense Medical Surveillance System (DMSS). Electronic records of all active com ponent service members were searched to identify hospitalizations and ambula tory encounters that included diagnosis codes (in any diagnostic position) indica tive of lightning injuries: "eects of light ning" (ICD-9: 994.0; ICD-10: T75.0*) or

PAGE 21

Page 21 TABLE 1. Incident cases and incidence rates of lightning strike injuries, active com ponent, U.S. Armed Forces, 2008 "accident due to lightning" (ICD-9: E907). For analysis purposes, cases of lightningassociated injuries/illnesses were dened by medical encounters that included a diag nosis code indicative of a lightning injury plus one or more injuryor illness-specic diagnosis codes, excluding mental disor ders. More specically, medical encounters were not case dening as lightning-associ ated injuries/illnesses if the primary (rstlisted) diagnosis was an ICD-9 V-/E-code or an ICD-10 Vthrough Z-code (i.e., the primary reason for the encounter was not a current illness or injury); or there were no diagnostic codes for specic illnesses or injuries, ICD-9 Vor E-codes, ICD-10 Vthrough Z-codes, mental disorders (ICD9: 290; ICD-10: F01F99) or other eects of external causes (ICD-9: 994.9; ICD-10: T75.89*). If an individual had both case-den ing inpatient and outpatient records during the surveillance period, information from the hospitalization record was used for the analysis. Each individual was included as a case only once during the surveillance period. Service members with case-den ing diagnoses before the start of the sur veillance period were excluded from the analysis. Incidence rates were calculated using non-deployed person-time in the denominator and as the number of cases per 100,000 person-years (p-yrs). Finally, cases were ascertained from medical records of deployed service mem bers whose healthcare encounters were documented in the eater Medical Data Store (TMDS). ese cases were analyzed separately because of the dierences in coding practices in theater (e.g., second ary diagnoses are not common). A service member was considered a case of lightning strike in theater if he or she had a diagno sis for eects of lightning (ICD-9: 994.0; ICD-10: T75.0*) or accident due to light ning (ICD-9: E907). RESULTS Between 2008 and 2017, a total of 375 non-deployed service members had inci dent lightning-related medical encounters. Of these service members, 241 (64.3%) had encounters that included ICD-9 or ICD-10 codes documenting specic injuries or ill nesses (Table 1) Subsequent analysis using these 241 cases yielded a crude overall inci dence rate of lightning strike injury of 1.9 cases per 100,000 p-yrs. e crude overall rate of lightning strike injury among males (2.1 per 100,000 p-yrs) was more than twice that among females (1.0 per 100,000 p-yrs) (Table 1) Compared to their respective counterparts, rates of lightning strike injury also were higher among service members aged 20 years (20 years: 2.7 per 100,000 p-yrs; 25 years: 2.3 per 100,000 p-yrs), non-Hispanic whites (2.2 per 100,000 p-yrs), enlisted service members (2.1 per 100,000 p-yrs), those in combatspecic occupations (4.4 per 100,000 p-yrs), and those stationed in the Southern region of the U.S. (2.8 per 100,000 p-yrs). Of note, the overall rate among service members in combat-specic occupations was more than twice that of those in the other occupational groups (Table 1) Across the services, Army members had the highest crude overall rate of lightning strike injuries (3.8 per 100,000 p-yrs) and Navy members had the lowest (0.7 per 100,000 p-yrs). Between 2008 and 2017, there were no lightning strike injuries identied among recruit trainees. A total of 18 active component service members were aected by lightning-asso ciated injuries/illnesses in theater during 2008. Deployed cases were most fre quently male (88.9%), aged 20 years (61.1%), non-Hispanic white (66.7%), enlisted (excluding recruits, 100%), and in the Army (61.1%) (data not shown) During the 10-year surveillance period, there was a peak in incidence of lightning strike injury during 2015 (5.2 per 100,000 p-yrs), as well as two smaller peaks in 2011 (2.8 per 100,000 p-yrs) and 2013 (2.2 per 100,000 p-yrs) (Figure 1) In gen eral, however, overall numbers and rates varied from year to year with no appar ent trend. e largest numbers of inci dent injuries occurred during the summer months of June (n=51; 21.2%), July (n=48; 19.9%), August (n=77; 32.0%), and Sep tember (n=32; 13.3%), together accounting for 86.3% of the total number of incident lightning strike injuries (Figure 2) Between 2008 and 2017, the largest number of inci dent cases were diagnosed during two con secutive weeks in August 2015 (n=54) (data not shown) Approximately 13.3% (n=32) of all incident lightning injuries resulted in hos pitalizations (data not shown) Disturbance of skin sensation was the most frequent diagnosis during medical encounters for incident lightning strike injuries (n=62). Headache (n=25), limb pain (n=31), burns (n=17), cardiac dysrhythmias and conduction disorders (n=15), neck/back pain (n=11), and chest symptoms (n=11) To tal No. Rate a Total 241 1.93 Sex Male 222 2.10 Female 19 1.00 Age group <20 8 0.95 20 105 2.67 25 68 2.30 30 29 1.49 35 17 1.18 40+ 14 1.04 Race/ethnicity Non-Hispanic white 168 2.24 Non-Hispanic black 34 1.69 Hispanic 26 1.61 Other/unknown 13 0.97 Rank Recruit 0 0.00 Enlisted (excluding recruits) 207 2.06 34 1.58 Service Army 173 3.75 Navy 21 0.70 Air Force 27 0.88 Marine Corps 20 1.11 Military occupation b 76 4.35 Motor transport 2 0.56 Health care 9 0.81 Other/unknown 154 1.67 Geographic region of military assignment c Northeast 4 1.03 Midwest 6 0.74 South 171 2.82 West 47 1.39 Overseas 10 0.65 Unknown/missing 3 1.08 a Rate per 100,000 person-years b Infantry/artillery/combat engineering/armor c Within the U.S., categorization based on U.S. Census Bureau regions ( www.census.gov/geo/ref erence/webatlas/regions.html )

PAGE 22

Page 22 were the next six most frequent diagnoses among cases of lightning-associated inju ries/illnesses (data not shown) Incident lightning strike injuries were diagnosed at more than 60 U.S. mili tary installations worldwide. However, six installations together accounted for more than half (57.7%) of all incident diagno ses (Table 2) ese installations were Eglin Air Force Base, FL (n=39; 16.2%), Fort Bragg, NC (n=27; 11.2%), Fort Stewart, GA (n=26; 10.8%), Fort Carson, CO (n=19; 7.9%), Fort Benning, GA (n=17; 7.1%), and Marine Corps Base Camp Lejeune, NC (n=11; 4.6%) (Table 2, Figure 3) Lightning strike injuries occurred more oen in the Southern U.S. in Georgia (n=50), Florida (n=46), North Carolina (n=40), and Texas (n=14). Several spatial-temporal clusters of injuries (two or more service members being treated for lightning strike injuries on the same day at the same location) were identied during the surveillance period (data not shown) Clusters aected two to 36 service members each and 125 ser vice members overall. All of the clusters occurred between May and September. e largest cluster occurred at Eglin Air Force Base, FL, in August 2015, when 36 service members were diagnosed with lightning strike injuries on the same day. e next largest cluster occurred at Fort Stewart, GA, in September 2011 when 21 service members were diagnosed with lightning strike injuries on the same day. Large clus ters also occurred at Fort Carson, CO, in July 2013 and at Fort Bragg, NC, in August 2015; 10 service members were diagnosed on the same day at each installation (data not shown) EDITORIAL COMMENT e current ndings by demographic and military characteristics mirror the results of the 2009 MSMR analysis. 17 Most notably, service members in combat-spe cic occupations (generally associated with increased outdoor exposure) had substan tially higher lightning strike injury rates than those in other military occupations. Taken together, these results suggest that lightning injury risk is determined pri marily by the timing, frequency, duration, location, and type of outdoor exposure to thunderstorms. us, specic demographic and military characteristics likely are asso ciated with risk of lightning injury only to the degree they are related to the primary risk determinant. 19 As the results of the current study show, lightning-related injuries in the mili tary oen involve a single lightning strike that injures multiple personnel. At Eglin Air Force Base, FL, on 12 August 2015, a lightning bolt hit a tree and the electrical current side-splashed (i.e., current jumped from a tree to other objects) throughout a wooded area; 44 Ranger School par ticipants (students and instructors) were injured. 20 Of those who were injured, 20 were hospitalized. One patient had cardiac arrest and was admitted to an intensive care unit; 17 other patients were admitted for observation for rhabdomyolysis and/ or cardiac arrhythmias. 20 e day aer the lightning strike, all patients were released without restrictions and returned to duty with increased medical monitoring. 17 At Fort Bragg, NC, on 19 August 2015, two simultaneous lightning strikes FIGURE 1. Numbers of cases and incidence rates of lightning strike injuries, active component, U.S. Armed Forces, 2008 FIGURE 2. Incident cases of lightning strike injuries, by month, active component, U.S. Armed Forces, 2008 1 12 3 6 3 5 1 9 2 81 76 51 42 30 .91 .9 0.5 2 .8 1 .52 .2 1.35 .2 1.11 .90 0 1 0 2 0 3 0 4 0 5 0 6 001 0 2 03 0 4 0 5 06 0 7 0 8 0 2 0 0 8 2 0 0 9 2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6 2 0 1 7In c i de nc e rat e pe r 10 0, 00 0 p y rsNo o f c a s e s (bars) To t a l case s In c i d enc e r a t e 01 1 6 14 51 48 773263 2 0 1020 3040 50 6070 80 90 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecNo. of casesMonth

PAGE 23

Page 23 the lightning strikes; one patient remained hospitalized for a longer period for cardiac monitoring. Several symptoms were con sistent among the patients, including lower extremity paresthesia, headache, tinnitus, brief loss of consciousness, and slightly ele vated creatine kinase levels. 21 In both civilian and military popula tions, most lightning injuries occur dur ing the summer. Among active component U.S. military members during 2008, more than two-thirds (70.1%) of the total lightning strike injuries occurred at instal lations in Georgia, Florida, North Carolina, or Texas; however, the risk is ubiquitous. In the past 10 years, lightning injuries have occurred among active component ser vice members at more than 40 installations worldwide. e geographic distribution of lightning strike injuries presented here, and that presented in the previous MSMR report, reect the geographic distribution of military service members across the U.S.; a disproportionate number of service members are stationed in rural areas and in southern and eastern coastal states. e results of the current study should be interpreted in the context of sev eral important limitations. First, because medical encounters with only nonspe cic diagnoses (e.g., eects of lightning) were excluded from the analysis, the total number of cases of lightning strike injury presented here is an incomplete ascertainment of the total number of ser vice members with any eects of light ning (regardless of how mild or transient). Also, the analysis did not capture service members with lightning-associated inju ries who did not seek medical care or who sought medical care outside the Military Health System (MHS) or purchased care system, but both groups are anticipated to be small. Another limitation of the cur rent analysis is related to the implementation of MHS GENESIS, the new elec tronic health record for the MHS. During 2017, medical data from sites that were using MHS GENESIS were not available in DMSS. ese sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center. erefore, medical encounter and person-time data for individuals seeking care at one of these facilities during 2017 were excluded from the analysis. No single action eliminates the risk of lightning injury to an individual, but risk can be reduced by following simple mea sures such as avoiding working and train ing outside during thunderstorms and seeking appropriate shelter when storms are imminent. e dangers of lightning are not always apparent to ground observ ers. Lightning may strike as far as 10 miles ahead of approaching thunderstorms, before rain starts, and while the sky is still clear. 23 Even with recommendations such as weather monitors and lightning action/ safety plans in place, military training and operations must sometimes continue during thunderstorms. Service members who routinely train and work outdoors (e.g., tactical communications special ists, tactical vehicle and aircra main tenance crews, ground combat forces, recruit trainees) should be particularly knowledgeable of and vigilant regarding the dangers of lightning, especially in eld settings during summer months. In addi tion, during military training and opera tional activities, leaders are responsible and accountable for protecting their sub ordinates from injury. e lightning safety recommendations in Table 3 may be use ful to commanders, training stas, and supervisors at all levels to reduce lightning injury risk. 24-26 FIGURE 3. Locations of active component, U.S. Armed Forces, 2008 TABLE 2. Incident cases of lightning strike injuries, by installation, active component, U.S. Armed Forces, 2008 Installation No. of cases % Eglin Air Force Base, FL 39 16.2 Fort Bragg, NC 27 11.2 Fort Stewart, GA 26 10.8 Fort Carson, CO 19 7.9 Fort Benning, GA 17 7.1 Marine Corps Base Camp Lejeune, NC 11 4.6 Fort Hood, TX 7 2.9 Naval Hospital Jacksonville, FL 5 2.1 Joint Base Lewis-McChord, WA 5 2.1 Other known locations 84 34.9 Unknown locations 1 0.4 Total 241 100.0 occurred; 18 soldiers from a cavalry scout platoon were injured. 21,22 e strikes occurred at opposite ends of camp during a training exercise and resulted in injuries via ground current. 21 All injured soldiers were admitted for evaluation and obser vation. All but one of the injured soldiers were released within the 48 hours following Eglin AFB (n=39)Fort Bragg (n=27)Fort Stewart (n=26) Fort Carson (n=19) Fort Benning (n=17) Camp Lejeune(n=11) Fort Hood (n=7) NH Jacksonville (n=5) Joint Base Lewis McChord(n=5)

PAGE 24

Page 24 TABLE 3. Lightning safety precautions a Prepare for lightning by checking weather forecasts and watching for signs of approaching storms. Most lightning strikes occur during JuneAugust between 1200 and 1800 hours local time. outdoor training. Resume activities only when there has been no lightning or thunder for 30 minutes. Move personnel into an enclosed structure, if possible. Tents and open shelters are not safe. If no building is available, move personnel into a closed, metal-topped vehicle or boat cabin; vehicle, close windows and keep hands on lap. If unable to take shelter and caught in the open or in a forested area, personnel should disperse to minimize the possibility of multiple injuries from a single lightning strike. tents, small, unprotected buildings in the open and canvas topped vehicles. Keep personnel away from fences, electrical wiring, vehicles, heavy equipment or other pos sible conductors of electricity. Move a safe distance away (approximately 100 feet) from metal machinery. When marching in formation, increase the minimum distance and interval to twice that normally maintained. Do not use radios or associated equipment; move away from TV antennas, relay antennas, or vehicles with whip antennas. Weapons should be stacked at least 50 meters away from personnel. Multiple integrated laser engagement system (MILES) gear and other metal conductors should be removed. When indoors, stay away from possible conductors of electricity such as electrical wiring, plumbing, and landline phones. Cell phones are safe to use. Inner rooms within a building provide the best protection. Do not use personal plug-in appliances such as hair dryers, toothbrushes, or razors. a Source: U.S. Army Training and Doctrine Command Guide for Lightning Protective Measures for Personnel, 24 National Weather Service lightning safety tips, 25 and the National Athletic Trainers' Association position state ment on lightning safety for athletics and recreation. 26 Although such measures may be criti cal for the prevention of lightning-related injuries, 27 when injuries do occur, prompt and proper medical management is essen tial to survival and the reduction of mor bidity. Long-term follow-up is also critical to ensure that any sequelae of the lightning strike are managed appropriately. 28 REFERENCES 1. National Oceanic and Atmospheric Administra tion. National Centers for Environmental Informa tion. Storm Events Database. www.ncdc.noaa.gov/ stormevents/ Accessed on 18 June 2018. 2. Jensenius JS. A Detailed Analysis of Lightning Deaths in the United States from 2006 through 2017. National Oceanic and Atmospheric Adminis tration, National Weather Service. May 2018. www. weather.gov/media/safety/06-17lightning_fatality_ analysis.pdf Accessed on 12 June 2018. 3. Holle RL, Lpez RE, Howard KW, Vavrek J, All sopp J. Safety in the presence of lightning. Semin Neurol. 1995;15(4):375. 4. Lpez, RE, Holle, RL, Heitkamp TA, Lang ford K. The underreporting of lightning injuries and deaths in Colorado. Bull Am Meteor Soc. 1993;74(11):2171. 5. Duclos PJ, Sanderson LM. An epidemiological description of lightning-related deaths in the United States Int J Epidemiol. 1990;19(3):673. 6. Lpez RE, Holle RL. Changes in the number of lightning deaths in the United States during the twentieth century. J Clim 1998;11(8):2070. 7. National Oceanic and Atmospheric Administra Water, and Weather Services. Weather fatalities 2017. www.nws.noaa.gov/om/hazstats.shtml Ac cessed on 12 June 2018. 8. Holle RL. A summary of recent nationalscale lightning fatality studies. Weather Clim Soc 2016;8(1);35. 9. Holle RL. Diurnal variations of NLDN-reported cloud-to-ground lightning in the United States. Mon Weather Rev. 2014;142(3);1037. 10. Curran EB, Holle RL, Lpez RE. 2000: Light ning casualties and damages in the United States from 1959 to 1994. J Clim 13(19);3448. 11. Cooper MA. Electrical and lightning injuries. Emerg Med Clin North Am 1984;2(3):489. 12. Cooper MA, Andrews CJ, Holle RL, et al. Light ning-related injuries and safety. In: Auerbach PS, ed. Wilderness Medicine. 7th ed. Philadelphia, PA: Elsevier; 2017:7117. 13. Whitcomb D, Martinez JA, Daberkow D. Light ning injuries. South Med J. 2002; 95(11):1331. 14. Cherington M. Neurologic manifestations of lightning strikes. Neurology. 2003;60(2):182. 15. Ramati A, Rubin LH, Wicklund A, et al. Psychi atric morbidity following electrical injury and its ef fects on cognitive functioning. Gen Hosp Psychia try. 2009;31(4):360. 16. Holle RL, Cummins KL, Brooks WA. Seasonal, monthly, and weekly distributions of NLDN and GLD360 cloud-to-ground lightning. Mon Weather Rev 2016;144(8):2855. 17. Armed Forces Health Surveillance Cen ter. Lightning strike injuries, active compo nent, U.S. Armed Forces, 1999. MSMR 2009;16(6):6. 18. Armed Forces Health Surveillance Center. Lightning-related medical encounters, active and reserve components, U.S. Armed Forces, January 2009August 2012. MSMR 2012;19(9):18. 19. Centers for Disease Control and Prevention. Lightning-associated injuries and deaths among military personnelUnited States, 1998. MMWR 2002;51(38):859. 20. Thompson SN, Wilson ZW, Cole CB, Ken nedy AR, Aycock RD. Case Report: Mass casualty lightning strike at Ranger training camp. Mil Med 2017;182(5):e1803e1806. 21. Houser AP, Larson SL, Fast JS. U.S. Army pla toon gets struck by lightning, A case series. Curr Sports Med Rep 2018;17(4):126 128. 22. Tan M. 18 Paratroopers injured in lightning strike at Fort Bragg. Army Times 20 August 2015. www. armytimes.com/news/your-army/2015/08/20/18paratroopers-injured-in-lightning-strike-at-fortbragg/ Accessed on 6 June 2018. 23. Ulman, MA. All About Lightning. Mineola, NY: Dover Press; 1986. 24. U.S. Army Training and Doctrine Command. Guide for Lightning Protective Measures for Per sonnel January 2002; Updated May 2013. www. tradoc.army.mil/SAFE/docs/TRADOC%20Light ning%20Protection%20Safety%20Guide.docx Ac cessed on 12 June 2018. 25. National Oceanic and Atmospheric Administra tion. National Weather Service. Lightning safety tips and resources. www.weather.gov/media/safety/0617lightning_fatality_analysis.pdf Accessed on 12 Jun 2018. 26. Walsh KM, Cooper MA, Holle R, et al. National Athletic Trainers Association position statement: lightning safety for athletics and recreation. J Athl Train 2013; 48(2):258. 27. Zimmermann C, Cooper MA, Holle RL: Light ning safety guidelines. Ann Emerg Med 2002; 39(6):660. 28. Ritenour AE, Morton MJ, McManus JG, Bari llo DJ, Cancio LC. Lightning injury: a review. Burns 2008;34(5):585.

PAGE 25

Page 25 he use of reworks to celebrate hol idays such as the Fourth of July is a U.S. tradition dating back to the Dec laration of Independence. 1 Although re works shows are considered patriotic and festive, the use of consumer reworks also can be dangerous. According to a 2017 U.S. Consumer Product Safety Commission report, there were more non-occupational, emergency departmenttreated, reworksrelated injuries reported in the U.S. in 2015 than in any surveillance year since 2001. 2 is increase has been correlated with a reduction in state prohibitions against consumer re works as well as an increase in the number of reworks purchased. 3,4 Consumer reworks include shells and mortars, Roman candles, rockets, sparklers, recrackers with a limited amount of pow der, and other novelty items such as snakes, ground spinners, and party poppers. 2 Cur rently, 45 U.S. states allow the sale and/or use of all or some consumer reworks; in some of these states, laws or regulations at the munici pal, city, or county level restrict the sale and/ or use of consumer reworks. 5 Illinois, Ohio, and Vermont allow only wire or wood stick sparklers and certain novelty items. 5 Dela ware and Massachusetts are the only states to have banned the sale and use of all consumer reworks. 5 Consumer reworks also are pro hibited on U.S. government property. 6 In the U.S., young adults aged 20 years have the highest estimated rate of emer gency departmenttreated reworks injuries compared with other age groups, at 4.9 inju ries per 100,000 persons. 2 In addition, males tend to have higher rates than females and experience more severe injuries. 7 However, there are no published data on the incidence of reworks injuries among U.S. service members. e lack of such data is impor tant because males aged 25 years or younger constitute more than two-hs of the U.S. active component population. 8 To ll this gap, this report provides information on the frequency, incidence, and trend of reworks injuries among active component service members during 2008. e frequencies of injury by body region and type of injury are also described. METHODS e surveillance period was 1 January 2008 through 31 December 2017. e surveil lance population included all individuals who served in the active component of the Army, Navy, Air Force, or Marine Corps at any time during the surveillance period. Diagnoses were ascertained from administrative records of all medical encounters of individuals who received care in xed (i.e., not deployed or at sea) medical facilities of the Military Health System or civilian facilities in the purchased care system. ese data are maintained in the electronic database of the Defense Medical Surveillance System (DMSS). For surveillance purposes, a case of reworks-associated injury was dened by a record of a hospitalization or outpatient encounter that included a diagnosis for injury in the 1st or 2nd diagnostic position (ICD-9 codes 800; ICD-10 codes beginning with S or T), and an external cause code for accident caused by reworks (ICD-9: E92.30) or discharge of rework (ICD-10: W39.*) in any other secondary diagnostic position during the same encounter. Health care encounters that occurred during deploy ment were excluded. Each individual was included as a case only once per calendar year. If an individual had case-dening inpatient and outpatient records in the same calendar year, informa tion from the hospitalization record was used in the analysis. Incidence rates were calcu lated using non-deployed person-time in the denominator and as the number of cases per 100,000 person-years (p-yrs). e MSMR burden dictionary was used to assign body region of reworks-related injury, 9 which was based on the injury diag nosis in the 1st or 2nd diagnostic position of the reworks-related injury incident encoun ter. Injuries were categorized by aected ana tomic site: head/neck, arm/shoulder, hand/ wrist, back/abdomen, knee, leg, and foot/ ankle. In addition, the types of injury (e.g., fracture, burn, open wound) were catego rized using methods described in a previous report. 10 RESULTS ere were 302 records of reworks inju ries during the 10-year surveillance period (2.4 cases per 100,000 p-yrs) (Table 1) Of these Fireworks Injuries, Active Component, U.S. Armed Forces, 2008 Shauna Stahlman, PhD, MPH; Stephen B. Taubman, PhD Although reworks shows are considered patriotic and festive, the use of con sumer reworks also can be dangerous. ere were 302 records of reworks injuries during the 10-year surveillance period (2.4 cases per 100,000 per son-years [p-yrs]). During 2008, the lowest crude annual incidence of reworks injury was reported in 2010 (1.5 per 100,000 p-yrs) and the highest was reported in 2017 (3.4 per 100,000 p-yrs). Compared with their respective counterparts, overall incidence of reworks injury was higher among males, non-Hispanic whites, Army members, those in an enlisted rank, and those in combat-specic occupations. Of all incident reworks injuries, the most com monly aected body regions were hand/wrist (45.0%), head/neck (27.8%), and leg (7.9%). e most common types of injuries were burns (57.0%), open wounds (14.6%), and contusion/supercial injuries (13.2%). Although the incidence of reworks injuries among active component service members was found to be generally low, there is still risk of serious injury if proper safety and handling precautions are not taken.

PAGE 26

Page 26 injuries, 20 (6.6%) were documented in the records of hospitalizations and 282 (93.4%) were associated with outpatient encounters (data not shown) During 2008, the low est crude annual incidence of reworks injury was reported in 2010 (1.5 per 100,000 p-yrs) and the highest was reported in 2017 (3.4 per 100,000 p-yrs). e second-highest peak in incidence was reported in 2015 at 3.1 per 100,000 p-yrs (Figure 1) Compared with their respective coun terparts, overall incidence of reworks injury was higher among male service members (2.7 per 100,000 p-yrs), non-Hispanic whites (3.0 per 100,000 p-yrs), Army members (3.6 per 100,000 p-yrs), those in an enlisted rank (2.6 per 100,000 p-yrs), and those in combatspecic occupations (4.5 per 100,000 p-yrs) (Table 1) Of note, infantry was the occupation with the single largest number of reworks injuries (n=50, 16.6%) (data not shown) In addition, incidence of reworks injury was higher among those aged 20 years (3.3 per 100,000 p-yrs), compared with other age groups (Table 1) Of service members with known locations of military assignment, the overall incidence of reworks injury was highest among those stationed in the Mid west (4.0 per 100,000 p-yrs). However, the highest incidence was reported among those with missing or unknown locations of mili tary assignment, compared with all other geographic regions (4.4 per 100,000 p-yrs). Of all incident reworks injuries, the most commonly aected body regions were hand/wrist (45.0%), head/neck (27.8%), and leg (7.9%) (Table 2) e most common types of injuries were burns (57.0%), open wounds (14.6%), and contusion/supercial injuries (13.2%) (Table 3) Incident cases of reworks injury occurred most oen during July (n=169, 56.0%) and January (n=52; 17.2%) (Figure 2) During the surveillance period, the high est number of incident reworks injury diagnoses were recorded at Joint Base LewisMcChord, WA (n=19; 6.3%), Fort Camp bell, KY (n=18; 6.0%), Fort Bragg, NC (n=15, 5.0%), and Joint Base San Antonio-Lackland, TX (n=12; 4.0%) (data not shown) All other installations were associated with less than 3% of the total number of cases. EDITORIAL COMMENT During 2008, the overall incidence of reworks injuries among active compo nent service members was 2.4 per 100,000 p-yrs and uctuated between 1.5 cases and 3.4 cases per 100,000 p-yrs. Similar to the general U.S. population, reworks injuries are more common among male service members and those aged 20 years. 2 Incidence is also higher among Army service members and those in combat-related occupations. Within the regions of the U.S., incidence of reworks injuries was lowest in the North east, which includes the two states with the most stringent regulations against consumer reworks. 5 However, this analysis did not examine and cannot make conclusions about the impact of state laws on reworks injuries. e peaks in the numbers of injuries during January and July suggest that public health TABLE 1. Incident cases and incidence ponent, U.S. Armed Forces, 2008 To tal No. Rate a Total 302 2.4 Sex Male 285 2.7 Female 17 0.9 Age group <20 23 2.7 20 128 3.3 25 72 2.4 30 46 2.4 35 20 1.4 40+ 13 1.0 Race/ethnicity Non-Hispanic white 225 3.0 Non-Hispanic black 22 1.1 Hispanic 36 2.2 8 1.7 Other/unknown 11 1.3 Marital status Married 156 2.3 Unmarried 138 2.8 Other/unknown 8 1.4 Service Army 166 3.6 Navy 41 1.4 Air Force 69 2.3 Marine Corps 26 1.4 Rank Enlisted 272 2.6 30 1.4 Military occupation b 78 4.5 Motor transport 7 1.9 Pilot/air crew 11 2.4 Repair/engineer 94 2.6 Communications/ intelligence 49 1.8 Health care 21 1.9 Other/unknown 42 1.7 Geographic region of military assignment c Northeast 6 1.6 Midwest 32 4.0 South 143 2.4 West 86 2.6 Overseas 22 1.4 Unknown/missing 13 4.4 a Rate per 100,000 person-years b Infantry/artillery/combat engineering/armor c Within the U.S., categorization based on U.S. Census Bureau regions ( www.census.gov/geo/ reference/webatlas/regions.html ) FIGURE 1. U.S. Armed Forces, 2008 3 4 2 3 1 92 93 4 2 8 3 4 3 9 2 1 4 1 2 .91. 91 .5 2 .3 2 .7 2 .22. 7 3. 11.7 3.4 0 .0 0 .5 1 .01. 52 .0 2 .5 3 .03. 54 .0 0 5 1 01 52 0 2 53 03 54 04 5 5 0 2 0 0 8 2 0 0 9 2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6 2 0 1 7In c i de nc e ra te pe r 10 0, 00 0 p y rs ( line )No of c a s e s ( bars ) To t a l c a s e s I n c ide n c e r a t e campaigns about reworks safety and injury prevention should target the New Years and Fourth of July holidays. Among active component service mem bers, the most commonly aected body

PAGE 27

Page 27 regions were hand/wrist (45.0%) and head/ neck (27.8%). Burns were the most common type of injury. ese ndings mirror patterns observed in the U.S. population, where most injuries tend to be burns to the hands and n gers, or to the head, face, and ears. 2 Current ndings should be interpreted in the context of several limitations. Not all adverse health conditions due to reworks were captured in this report. During the sur veillance period, there were three cases of acoustic trauma or hearing loss, two cases of ocular pain, two cases of both headache and tinnitus, one case of cicatricial entropion of the upper eyelid, one conjunctival hemor rhage, one case of perforation of tympanic membrane, one case of iridocyclitis, and one case of photokeratitis. ese 12 cases were not included because they did not meet the case denition requirement of an acute injury diagnosis (ICD-9 codes in the 800 range; ICD-10 codes beginning with S or T) in the 1st or 2nd diagnostic position but did have an external cause code for accident caused by reworks (ICD-9: E92.30) or dis charge of rework (ICD-10: W39.*). In addi tion, data were not available on the types of reworks used, which can aect the severity and type of injury. For example, shell/mortar injuries have been found to be particularly devastating, sometimes resulting in perma nent impairment from eye and hand injury. 11 Another limitation of the current analysis is related to the implementa tion of MHS GEN ESIS, the new elec tronic health record for the Military Health System. During 2017, med ical data from sites that were using MHS GENESIS are not available in DMSS. ese sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medi cal Center. erefore, medical encounter and person-time data for individuals seeking care at one of these facilities during 2017 were excluded from the analysis. Although the incidence of reworks injuries among active component service members was found to be generally low, there is still risk of serious injury if proper safety and handling precautions are not taken. Fire works are classied as hazardous substances under the Federal Hazardous Substances Act. 12 More information about the safe han dling of reworks is available at www.mili tary.com/independence-day/rework-safety. html REFERENCES 1. Heintze JR. Fourth of July Celebrations Da tabase. American University, Washington, DC. http://gurukul.american.edu/heintze/fourth. htm#Beginning Accessed on 29 May 2018. 2. United States Consumer Product Safety Commission. 2016 Fireworks Annual Report. Fireworks-related deaths and emergency depart ment-treated injuries during 2016. www.cpsc.gov/ Research--Statistics/Injury-Statistics Accessed on 24 May 2018. 3. American Pyrotechnics Association. Fireworks https://pyro. memberclicks.net/industry-facts-figures Ac cessed on 29 May 2018. 4. are growing. The Conversation on June 30, 2017. growing/ Accessed on 29 May 2018. 5. American Pyrotechnics Association. 2018 State Fireworks Control Laws. https://www. americanpyro.com/assets/docs/FactsandFig ures/2018%206.12Rev%20State%20Laws%20 Firework%20Map.pdf Accessed on 12 June 2018. 6. U.S. Department of Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives, Enforcement Programs and Services. Federal Explosives Law and Regulations. 2012. Washington, DC. 7. States: 2000. Injury. 2014;45(11):1704. 8. Assistant Secretary of Defense for Military Commu nity and Family Policy (ODASD (MC&FP)). 2016 Washington, DC: Department of Defense; 2018. 9. Armed Forces Health Surveillance Branch. Ab solute and relative morbidity burdens attributable to various illnesses and injuries, active component, U.S. Armed Forces, 2017. MSMR 2018;25(5):2. 10. Stahlman S, Taubman SB. Incidence of acute injuries, active component, U.S. Armed Forces, 2008. MSMR 2018;25(7):2. 11. Sandvall BK, Jacobson L, Miller EA, et al. Fire works type, injury pattern, and permanent impair Am J Emerg Med 2017. 35(10):1469. 12. United States Consumer Product Safety Commission. Federal Hazardous Substances Act (FHSA) Requirements. www.cpsc.gov/Business-Manufacturing/Business-Education/BusinessGuidance/FHSA-Requirements Accessed on 1 June 2018. TABLE 2. works injuries, active component, U.S. Armed Forces, 2008 TABLE 3. type, active component, U.S. Armed Forces, 2008 No. % of total Hand/wrist 136 45.0 Head/neck 84 27.8 Leg 24 7.9 Arm/shoulder 15 5.0 15 5.0 Foot/ankle 14 4.6 Back/abdomen 13 4.3 Knee 1 0.3 No. % of total Burns 172 57.0 Open wounds 44 14.6 injuries 40 13.2 injuries 19 6.3 Fractures 16 5.3 Dislocations 4 1.3 Sprains and strains 3 1.0 Amputations 2 0.7 Internal injuries 1 0.3 Blood vessel injuries 1 0.3 FIGURE 2. Forces, 2008 52 56711 16 169 858 312 020406080100120140160180 200Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecNo. of injuries

PAGE 28

MEDICAL SURVEILLANCE MONTHLY REPORT MSMR in continuous publication since 1995, is produced by the Armed Forces Health Surveillance Branch (AFHSB). e MSMR provides evidence-based estimates of the incidence, distribution, impact, and trends of illness and injuries among U.S. military members and associated populations. 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 Surveillance System for health surveillance purposes. Archive: Past issues of the MSMR are available as downloadable PDF les at www. health.mil/MSMRArchives Online Subscriptions: Submit subscription requests at www.health.mil/MSMRSubscribe Editorial Inquiries : Call (301) 319-3240 or send email to: dha.ncr.health-surv.mbx. msmr@mail.mil Instructions for Authors: Information about article submissions is provided at www. health.mil/MSMRInstructions All material in the MSMR is in the public domain and may be used and reprinted without permission. Citation formats are available at www.health.mil/MSMR Opinions and assertions expressed in the MSMR should not be construed as reecting ocial views, policies, or positions of the Department of Defense or the United States Government. Follow us: www.facebook.com/AFHSBPAGE http://twitter.com/AFHSBPAGE ISSN 2158-0111 (print) ISSN 2152-8217 (online) Chief, Armed Forces Health Surveillance Branch COL Douglas A. Badzik, MD, MPH (USA) Editor Francis L. ODonnell, MD, MPH Contributing Editors Leslie L. Clark, PhD, MS Shauna Stahlman, PhD, MPH Writer/Editor Valerie F. Williams, MA, MS Managing/Production Editor Elizabeth J. Lohr, MA Data Analysis Gi-Taik Oh, MS Layout/Design Darrell Olson Editorial Oversight COL James D. Mancuso, MD, MPH, DrPH (USA) CDR Shawn S. Clausen, MD, MPH (USN) Mark V. Rubertone, MD, MPH


xml version 1.0 encoding UTF-8 standalone no
fcla fda yes
!-- Medical surveillance monthly report ( Serial ) --
METS:mets OBJID AA00047749_00235
xmlns:METS http:www.loc.govMETS
xmlns:xlink http:www.w3.org1999xlink
xmlns:xsi http:www.w3.org2001XMLSchema-instance
xmlns:daitss http:www.fcla.edudlsmddaitss
xmlns:mods http:www.loc.govmodsv3
xmlns:sobekcm http:digital.uflib.ufl.edumetadatasobekcm
xmlns:lom http:digital.uflib.ufl.edumetadatasobekcm_lom
xsi:schemaLocation
http:www.loc.govstandardsmetsmets.xsd
http:www.fcla.edudlsmddaitssdaitss.xsd
http:www.loc.govmodsv3mods-3-4.xsd
http:digital.uflib.ufl.edumetadatasobekcmsobekcm.xsd
METS:metsHdr CREATEDATE 2018-11-01T08:20:13Z ID LASTMODDATE 2018-10-29T12:59:34Z RECORDSTATUS COMPLETE
METS:agent ROLE CREATOR TYPE ORGANIZATION
METS:name UF,University of Florida
OTHERTYPE SOFTWARE OTHER
Go UFDC FDA Preparation Tool
INDIVIDUAL
UFAD\renner
METS:dmdSec DMD1
METS:mdWrap MDTYPE MODS MIMETYPE textxml LABEL Metadata
METS:xmlData
mods:mods
mods:classification authority lcc ISSN RECORD
ddc edition 14 355
nlm W1 MS245L
mods:accessCondition This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
mods:genre Periodicals.
Statistics.
fast Periodicals.
sobekcm serial
marcgt statistics
federal government publication
periodical
mods:identifier type OCLC 671268376
LCCN 2010201449
ISSN 2158-0111
ocn671268376
mods:language
mods:languageTerm text English
code iso639-2b eng
mods:location
mods:physicalLocation University of Florida
UF
mods:name corporate
mods:namePart U.S. Army Center for Health Promotion and Preventive Medicine
Armed Forces Health Surveillance Center (U.S.)
mods:note dates or sequential designation Began with: Vol. 1, issue 1 (Apr. 1995).
"A publication of the Armed Forces Health Surveillance Center."
mods:originInfo
mods:publisher Armed Forces Health Surveillance Branch
mods:place
mods:placeTerm marccountry mdu
mods:dateIssued 09-2018
marc point start 1995
end 9999
mods:frequency Monthly
marcfrequency monthly
monthly
regular
mods:recordInfo
mods:recordIdentifier source AA00047749_00235
mods:recordCreationDate 101020
mods:recordOrigin Imported from (OCLC)671268376
mods:recordContentSource University of Florida
marcorg DLC
eng
NLM
GPO
OCLCF
OCLCO
OCLCQ
mods:languageOfCataloging
English
eng
mods:subject SUBJ650_1 lcsh
mods:topic Medicine, Military
mods:geographic United States
Periodicals
SUBJ650_2
Medicine, Preventive
United States
Periodicals
SUBJ650_3 mesh
Military Personnel
SUBJ650_4
Morbidity
SUBJ650_5
Population Surveillance
SUBJ650_6
Wounds and Injuries
epidemiology
SUBJ650_7
Medicine, Military
SUBJ650_8
Medicine, Preventive
SUBJ651_9
United States
SUBJ651_10
United States
SUBJ655_11
Periodicals
SUBJ655_12
Statistics
SUBJ655_13
Periodicals
mods:titleInfo
mods:title Medical surveillance monthly report
alternative displayLabel Alternate title
MSMR
mods:typeOfResource text
DMD2
OTHERMDTYPE SOBEKCM SobekCM Custom
sobekcm:procParam
sobekcm:Aggregation ALL
IUF
DMNL
sobekcm:MainThumbnail 09-2018thm.jpg
sobekcm:bibDesc
sobekcm:BibID AA00047749
sobekcm:VID 00235
sobekcm:EncodingLevel #
sobekcm:Publisher
sobekcm:Name Armed Forces Health Surveillance Branch
sobekcm:PlaceTerm Silver Spring, MD
sobekcm:Source
sobekcm:statement UF University of Florida
sobekcm:SortDate 728293
sobekcm:serial
sobekcm:SerialHierarchy level 1 order 2018 2018
2 9 September
METS:amdSec
METS:digiprovMD DIGIPROV1
DAITSS Archiving Information
daitss:daitss
daitss:AGREEMENT_INFO ACCOUNT PROJECT UFDC
METS:techMD TECH1
File Technical Details
sobekcm:FileInfo
METS:fileSec
METS:fileGrp USE reference
METS:file GROUPID G1 PDF1 applicationpdf CHECKSUM 6744398dfdbd13f6586948648d1a317c CHECKSUMTYPE MD5 SIZE 1100039
METS:FLocat LOCTYPE OTHERLOCTYPE SYSTEM xlink:href 09-2018.pdf
G2 METS2 unknownx-mets ff9a781f33a8c558722fd54943a22ab1 8885
AA00047749_00235.mets
METS:structMap STRUCT2 other
METS:div DMDID ADMID ORDER 0 main
ODIV1 Main
FILES1 Page
METS:fptr FILEID
FILES2