Attrition Rates and Incidence of Mental Health Disorders in an Attention-Deficit/Hyperactivity Disorder (ADHD) Cohort, Active Component, U.S. Armed Forces, 2014-2018.

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood diagnosis and affects the pool of potential military applicants. Early detection and treatment of ADHD may decrease the risk of developing comorbidities; however, accession policy in place during this study period (2014-2018) disqualified applicants who used ADHD medication for more than 24 months cumulative after age 14. The objective of this study was to assess attrition from military service in newly accessed active component service members diagnosed with ADHD as compared to controls. In addition, attrition rates and incidence rates of mental health diagnoses were assessed in service members with ADHD by treatment status (i.e., treated vs untreated ADHD) where treatment was defined as being dispensed an FDA-approved ADHD medication at least twice within 181 days. Almost two-thirds (64.8%) of newly accessed ADHD cases in 2014 were identified after enlistment medical screening at Military Entrance Processing Stations (MEPS) (i.e., post-MEPS). These post-MEPS ADHD cases accounted for 99.1% of the treated ADHD cases. The vast majority of treated cases (91.0%) were dispensed ADHD medication within 6 months of accession. The treated ADHD group had higher rates of attrition and incidence of mental health disorders during the followup period. These study findings highlight the problem of nondisclosure of ADHD among military applicants. Future changes to enlistment standards should consider the optimal way to promote applicant disclosure of ADHD during MEPS screening or for medical waiver review and should discourage withholding an ADHD diagnosis during enlistment.

Characterizing the contribution of chronic pain diagnoses to the neurologic burden of disease, active component, U.S. Armed Forces, 2009-2018.

In the annual Medical Surveillance Monthly Report (MSMR) burden of disease analysis, neurologic disorders represent the fifth most common category of diagnoses among active component service members within the Military Health System. One major subcategory of this disease group is "all other neurologic conditions." Incidence analysis from 2009-2018 revealed that the vast majority of diagnoses in this undefined subcategory were related to chronic pain and that such diagnoses have been increasing in burden by a considerable amount. Chronic pain diagnoses increased from a rate of 85.5 per 10,000 person- years (p-yrs) in 2009 to 261.1 per 10,000 p-yrs in 2018. Subgroup analysis by demographic characteristics demonstrated that female, non-Hispanic black, older, and enlisted personnel were at increased risk for chronic pain diagnoses. Among the branches of service, members of the Army were at the highest risk of a chronic pain diagnosis with a rate ratio of 4.8 compared to the Navy, the branch with the lowest risk. Future annual burden analyses should consider chronic pain as its own subcategory to better characterize its impact.

Update: Incidence of acute gastrointestinal infections and diarrhea, active component, U.S. Armed Forces, 2010-2019.

Laboratory, reportable medical event, and medical encounter data were analyzed to identify cases of acute gastrointestinal (GI) infections caused by Campylobacter, nontyphoidal Salmonella, Shigella, Escherichia coli (E. coli), or norovirus, as well as cases of unspecified gastroenteritis/diarrhea among U.S. active component service members during 2010-2019. Unspecified gastroenteritis/ diarrhea diagnoses accounted for 98.8% of identified incident cases (4,135.1 cases per 100,000 person-years [p-yrs]). Campylobacter was the most frequently identified specific etiology (17.6 cases per 100,000 p-yrs), followed by nontyphoidal Salmonella (12.7 cases per 100,000 p-yrs), norovirus (10.8 cases per 100,000 p-yrs), E. coli (7.5 cases per 100,000 p-yrs), and Shigella (3.2 cases per 100,000 p-yrs). Crude annual rates of norovirus, E. coli, Campylobacter, and Salmonella infections and unspecified gastroenteritits/diarrhea increased between 2010 and 2019 while rates of Shigella infections were relatively stable. Among deployed service members during the 10-year period, only 150 cases of the 5 specific causes of gastroenteritis were identified but a total of 20,377 cases of unspecified gastroenteritis/diarrhea were diagnosed (3,062.9 per 100,000 deployed p-yrs).

A Burden and Prevalence Analysis of Chronic Pain by Distinct Case Definitions among Active Duty U.S. Military Service Members, 2018.

BACKGROUND: Chronic pain is a growing problem in the military, and the methods by which we have to perform epidemiologic surveillance are insufficient. It represents both a public health and military readiness concern, as those who suffer from it experience adverse impacts on work productivity, physiological health, and quality of life. OBJECTIVES: This study was designed to assess the prevalence of chronic pain among active component military service members utilizing 2 distinct, published case definitions. It sought to describe the demographics and military characteristics of those receiving chronic pain diagnoses. The study also aimed to provide improved granularity regarding military chronic pain patients' pain severity and its impacts on their job performance. STUDY DESIGN: Cross-sectional analysis for 2018. SETTING: This analysis utilized data available from the Defense Medical Surveillance System, a database containing longitudinal data on service members. METHODS: Patients: The surveillance population consisted of all active component service members from the U.S. Army, Navy, Air Force, and Marines of all grades serving at any point during the surveillance period of January 1, 2018 through December 31, 2018. MEASUREMENT: Diagnoses were ascertained from the administrative records of all medical encounters of individuals who received care through the Military Health System or civilian referrals. Data from patients' Periodic Health Assessment (PHA) encounters were also utilized to derive more granular data regarding their experiences of pain. RESULTS: Case Definition 1, more specific for identifying chronic pain, identified a more severe subset of chronic pain patients when compared against Case Definition 2, a more comprehensive method for identifying potential chronic pain patients. Case Definition 1 found a higher prevalence of impactful pain (CD1: 36.7% vs. CD2: 23.5%), and Case Definition 1 patients are more likely to be on limited duty and require treatment related to their pain. Several demographic groups were also found to be at increased risk of chronic pain diagnosis, including women, black non-Hispanic, Army, older age, and enlisted. LIMITATIONS: First, in utilizing administrative data, this allows for the possibility of misclassification bias. Second, some deployment data still used ICD-9 coding even in 2018, resulting in a minor underestimation by approximately 30 patients and approximately 60 encounters. Third, the prevalence estimates for the demographics were not adjusted for potential confounders. CONCLUSIONS: Chronic pain has been difficult to define via administrative and screening data, and as such its burden and prevalence estimates can vary considerably depending on which case definition is used. This is of particular importance in the U.S. military, as these estimates can significantly impact our calculations for force readiness and the protection of our national security. To our knowledge, this study is the first of its kind to examine chronic pain across the entirety of the U.S. armed forces and to utilize granular, annually collected PHA data in this way. The results of this exploratory analysis could be used as a template to better characterize the burden of chronic pain from a population-based perspective and monitor the effectiveness of pain management strategies.

Cardiovascular disease-related medical evacuations, active and reserve components, U.S. Armed Forces, 1 October 2001-31 December 2017.

From 1 October 2001 through 31 December 2017, a total of 697 medical evacuations of service members from the U.S. Central Command (CENTCOM) area of responsibility were followed by at least one medical encounter in a fixed medical facility outside the operational theater with a diagnosis of a cardiovascular disease (CVD). The vast majority of those (n=660; 94.7%) evacuated were males. More than a third of CVD-related evacuations (n=278, 39.9%) occurred in service members 45 years of age or older; slightly more than half (n=369; 52.9%) occurred in reserve or guard members. The most common CVD risk factors which had been diagnosed among evacuated service members prior to their deployment were hypertension (n=236; 33.9%) and hyperlipidemia (n=241; 34.9%). Much lower percentages had been previously diagnosed with obesity (n=74, 10.6%) or diabetes (n=21, 3.0%). More than 1 in 4 service members with a CVD-related medical evacuation had been diagnosed with more than one risk factor (n=182, 26.1%). Both limitations to the data available and strategies to reduce CVD morbidity in theater are discussed.

Human papillomavirus vaccine initiation, coverage, and completion rates among U.S. active component service members, 2007-2017.

Human papillomavirus (HPV) vaccines have been available and licensed for use in the U.S. among women since 2006 and among men since 2010. Currently, HPV is not a mandatory vaccine for U.S. military service; however, it is encouraged and offered to service members. Between 2007 and 2017, a total of 111,546 (26.6%) eligible active component service women aged 17-26 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. The median times between the first and second doses and between the first and third doses were 3.8 months and 10.8 months, respectively. The median time in service at initiation dose was 1.1 years. Continued development and implementation of interventions to enhance HPV vaccination initiation among military service members are warranted.

Pregnancies and live births, active component service women, U.S. Armed Forces, 2012-2016.

This report summarizes data on the demographic and military characteristics of women and women of childbearing potential (WOCBP) in the active component of the U.S. Armed Forces during 2012-2016. Data on pregnancy-related care and birth rates are also presented. In 2016, WOCBP comprised the vast majority of active component service women. The largest proportions of WOCBP were in the categories of women who were 20-24 years old, non-Hispanic white, junior enlisted rank, and in a communications/intelligence occupation. WOCBP were roughly equally distributed in the Army, Navy, and Air Force, whereas only 7.5% served in the Marine Corps. Slightly more than one-quarter of WOCBP had ever deployed to the U.S. Central Command area of responsibility (CENTCOM AOR). In 2016, 13.1% of all WOCBP had at least one pregnancy-related event and 1.1% of deployed WOCBP had a pregnancy event during a deployment to CENTCOM AOR. The prevalence of pregnancy decreased slightly over the surveillance period. There were 63,879 live births during the surveillance period, for an overall live birth rate of 64.9 live births per 1,000 person-years (p-yrs). This rate of live births decreased steadily from 69.8 per 1,000 p-yrs in 2012 to 59.7 per 1,000 p-yrs in 2016. Rates of live births were highest among women who were 30-34 years old, enlisted or junior officer rank, Army, in healthcare occupations, and married. About one-quarter of the total live births were cesarean deliveries.

Contraception among active component service women, U.S. Armed Forces, 2012-2016.

This report summarizes the annual prevalence of permanent sterilization, as well as use of long- and short-acting reversible contraceptives (LARCs and SARCs, respectively), contraceptive counseling services, and use of emergency contraception from 2012 through 2016 among active component U.S. service women. Overall, 262,907 (76.2%) women of childbearing potential used either a LARC or a SARC at some time during the surveillance period. From 2012 through 2016, permanent sterilization decreased from 4.2% to 3.6%; LARC use increased from 17.2% to 21.7%; SARC use decreased from 38.5% to 30.4%; and emergency contraception use increased from 0.4% to 1.9%. Annual prevalence of contraceptive counseling only was relatively stable around 4.0%. This report estimates the length of continuation of LARCs, demonstrating that 86.1% continued their intrauterine device at 12 months, 78.5% at 24 months, and 73.4% at 36 months. These data demonstrate that the vast majority of service women have utilized at least one form of contraception, and that women are selecting LARCs in greater numbers with each passing year. The prevalence of contraceptive utilization among deployed service women is also reported.

Complications and care related to pregnancy, labor, and delivery among active component service women, U.S. Armed Forces, 2012-2016.

Diagnoses of "complications of pregnancy, childbirth, and the puerperium" include both morbid complications and indications for routine care of pregnant women. During 2012-2016, a total of 55,601 U.S. service members with live births (n=63,879) had 657,060 medical encounters with primary diagnoses of "pregnancy complications." The most frequent diagnoses were "other" specified conditions complicating pregnancy, childbirth, or the puerperium. Numbers of medical encounters with a primary (first-listed) diagnosis of any pregnancy-related complication or indication for care decreased marginally each year between 2012 (n=178,703) and 2016 (n=146,282). The percentage of live births affected by pre-eclampsia and gestational diabetes remained relatively stable during the surveillance period. For all age groups, percentages of live births affected by preterm labor decreased, but live births affected by obesity complications increased. The percentage of live births affected by gestational diabetes was more than twice as high for obese women, compared with non-obese women (12.4% vs. 5.5%). Findings suggest some opportunities to prevent sequelae for the mother and child and to mitigate longer-term impacts on force readiness.

Using records of diagnoses from healthcare encounters and laboratory test results to estimate the incidence of norovirus infections, active component, U.S. Armed Forces, 2007-2016: limitations to this approach.

During the 10-year surveillance period, there were 709 incident cases of norovirus (NoV) infection identified among active component service members, with an overall crude incidence rate of 5.7 cases per 100,000 person-years (p-yrs). The overall incidence rate of NoV infection was slightly higher among female service members than males. Compared to their respective counterparts, service members aged 24 years or younger, members of the Army, junior enlisted, and recruits had the highest rates of NoV infection. Overall rates were similar across all race/ethnicity groups. Service members in "other" occupations had the highest overall incidence rate, compared to service members in other occupational groups. Annual incidence rates of NoV infection ranged from a low of 2.5 cases per 100,000 p-years in 2008 to 11.2 cases per 100,000 p-yrs in 2010. The monthly distribution of the cumulative number of incident cases of NoV infection during the surveillance period showed a pattern of seasonality with higher numbers of diagnosed cases from November through March. Comparing the results of this analysis to modeled estimates of the underreported incidence of NoV infections demonstrated the limited utility of using only medical encounter diagnoses, reportable events, and laboratory data to report on NoV incidence. The disparity between such estimates highlights the importance of developing and using other methodologies to derive estimates of norovirus incidence and burden in future analyses.

Contraceptive prescriptions for US servicewomen, 2008-2013.

OBJECTIVE: To determine the proportion and characteristics of US servicewomen who were prescribed contraception between 2008 and 2013 and to estimate the prevalence of contraceptive utilization among women who deployed during the surveillance period. STUDY DESIGN: This is a descriptive study of all servicewomen of child-bearing potential serving in the active component of the US armed forces at any time between 2008 and 2013. We estimated contraceptive utilization status using pharmacy, procedural and diagnostic codes as recorded in the Defense Medical Surveillance System and Pharmacy Data Transaction Service. Estimates of contraceptive utilization were compared by demographic and military variables, including deployment status. Poisson regression with robust error variance was used to estimate adjusted prevalence ratios and 95% confidence intervals. RESULTS: Among eligible servicewomen (N=375,847), 68.7% received at least one form of contraception during the surveillance period. Contraceptive methods included short acting only (55.6%), long-acting (11.9%), permanent (1.0%) and barrier methods (0.2%). An additional 8.2% received counseling services only without an associated procedure or prescription. After adjusting by several demographic variables, receipt of contraception was highest among women aged 25-29 years and lowest among those aged 17-19 and 45-49 years. Receipt of any contraception was similar across racial/ethnic groups, although Hispanic and black, non-Hispanic women were more likely to receive long-acting reversible contraception. Of those who deployed (N=131,597), 53.6% received contraception before or during their deployment, with 7.9% using long-acting contraception. CONCLUSION: US servicewomen utilize contraception at high levels, with few demographic disparities. Gaps still exist, especially among the youngest women and around the time of deployment. IMPLICATIONS: US servicewomen are prescribed contraception at high levels, but utilization is lower in the youngest servicewomen and around the time of deployment. Such data provide opportunities for development and evaluation of interventions designed to improve access to contraceptive services for all servicewomen and to reduce the rate of unintended pregnancy.

Rates of Chlamydia trachomatis infections across the deployment cycle, active component, U.S. Armed Forces, 2008-2015.

High rates of sexually transmitted infections (STIs), including Chlamydia trachomatis (CT), have been documented among U.S. military service members. However, it is unknown whether phases of the deployment cycle affect risk for CT. This article characterizes the rates of CT infections during the predeployment, deployment, and post-deployment phases for active component members of the U.S. Army, Navy, Air Force, and Marine Corps during 2008-2015. Cases of CT were defined using laboratory, reportable medical event, and prescription data in a sensitivity analysis approach. Adjusted incidence rate ratios for CT were calculated using a multivariable Poisson model. In these analyses, the crude and adjusted incidence rates of CT were found to be highest during the pre-deployment phase for both sexes. However, men's rates of CT differed only slightly across pre-, post-, and non-deployed phases, while women had substantial rate differences between phases. These analyses call for better screening and documentation of STIs during deployment, as well as continued surveillance of STIs in the Military Health System, to assess the true burden of disease.

Neuropsychiatric Outcomes After Mefloquine Exposure Among U.S. Military Service Members.

Mefloquine was widely prescribed to U.S. military service members until 2009 when use was limited to personnel with contraindications to doxycycline and no contraindications to mefloquine. The need to estimate the occurrence of neuropsychiatric outcomes (NPOs) in service members prescribed mefloquine warranted a comprehensive evaluation of this issue. Active component service members filling a prescription for mefloquine, doxycycline, or atovaquone/proguanil (A/P) between January 1, 2008 and June 30, 2013, were included in the analysis. The risk of developing incident NPOs and the risk of subsequent NPOs among subjects with a history of the condition were assessed. A total of 367,840 individuals were evaluated (36,538 received mefloquine, 318,421 received doxycycline, and 12,881 received A/P). Among deployed individuals prescribed mefloquine, an increased risk of incident anxiety was seen when compared with doxycycline recipients (incidence rate ratio [IRR] = 1.12 [1.01-1.24]). Among nondeployed mefloquine recipients, an increased risk of posttraumatic stress disorder (PTSD) was seen when compared with A/P recipients (IRR = 1.83 [1.07-3.14]). An increased risk of tinnitus was seen for both deployed and nondeployed mefloquine recipients compared with A/P recipients (IRR = 1.81 [1.18-2.79]), 1.51 (1.13-2.03), respectively). Six percent of the mefloquine cohort had an NPO in the year before receiving mefloquine. When comparing individuals with a prior neuropsychiatric history to those without, the ratio of relative risks for adjustment disorder, anxiety, insomnia, and PTSD were higher (not statistically significant) for mefloquine compared with doxycycline. These findings emphasize the continued need for physicians prescribing mefloquine to conduct contraindication screening.