The Impact of Deployment and Combat Exposure on Physical Health Among Military Personnel: A Systematic Review of Incidence, Prevalence, and Risks.

OBJECTIVES: The impact of deployment and combat on mental health of military personnel is well described. Less evidence is available to demonstrate and summarize the incidence, prevalence, and risks of these exposures on physical health. This study aims to (1) systematically review the available literature to determine the incidence and prevalence of physical health conditions among military personnel during and after deployment and (2) investigate the risks of deployment and combat exposure on physical health. METHODS: A systematic review using the PubMed and EMBASE databases was performed. The literature search was limited to articles written in English, published from 2000 through 2019. The quality of studies was assessed with the Joanna Briggs Institute Appraisal Checklist. The results were grouped per system or condition of physical health and presented by forest plots without a combined effect size estimate. RESULTS: Thirty-two studies were found eligible for this review. We identified a wide variety of incidence and prevalence rates of numerous physical health conditions and a high heterogeneity across the included studies. Acute respiratory symptoms, diarrhea, musculoskeletal injuries, pain, and tinnitus were found to be the most incident or prevalent conditions. Except for hearing loss, no associations with deployment and physical health problems were observed. An increased risk for asthma, headache, hearing loss, and pain was reported in relation to the combat exposure. CONCLUSION: Given the characteristics of included studies and extracted data, the magnitude of the found differences in incidence and prevalence rates is most likely to be due to methodological heterogeneity. The specific exposures (e.g., infrastructure, environmental conditions, and activities during deployment) are suggested to be the determinants of (post) deployment physical health problems and need to be addressed to decrease the impact of deployment. Findings from this systematic review highlight which conditions should be addressed in response to service members' health and wellness needs in the (post)deployment phase and may be used by clinicians, researchers, and policy-makers. However, knowledge gaps regarding the potential risk factors during deployment and combat still exist. Studies using consistent methods to define and measure the physical health conditions and specific exposures are needed.

A longitudinal study of health related quality of life and functioning in severely injured Dutch service members.

BACKGROUND: Optimal health is demanded for service members in military operations. However, the strains of deployment can result in a deterioration, moreover when combat-related injuries are sustained, affecting level of participation and health related quality of life (HRQOL). Secondary health conditions may occur in time, however existing studies measure coping, level of activity and participation and HRQOL at one point in time. AIM: To assess the change over time concerning coping, mobility, level of participation and HRQOL in Dutch service members with combat-related injuries sustained during operation Task Force Uruzgan (TFU). METHODS: The lower extremity functional scale (LEFS), the cognitive emotion regulation questionnaire (CERQ), the assessment of life habits short version (LIFE-H) and the EuroQol-5D (EQ-5D), measuring HRQOL, were administered in 2010 and 2014. Change of scores between the two time points was tested with the Wilcoxon signed rank test. RESULTS: The response rate was 53% (28/53). The score on the coping strategy self-blame showed a significant increase over time with low scores on both occasions. The coping strategies positive reappraisal and acceptance showed the highest scores. No significant change is shown in mobility, the level of participation or HRQOL. CONCLUSION: service members with combat-related injuries remain stable in level of activity and participation and HRQOL in time and they use adaptive coping strategies.

Coping strategies of Dutch servicemembers after deployment.

BACKGROUND: This study examines the relationship between coping strategies and symptoms of anxiety or depression among Dutch servicemembers deployed to Afghanistan. METHODS: Coping strategies were assessed in 33 battlefield casualties (BCs) and the control group (CTRLs) of 33 uninjured servicemembers from the same combat units using the Cognitive Emotion Regulation Questionnaire. A factor analysis was performed, and two clusters of coping strategies were derived, namely, adaptive and maladaptive coping. Symptoms of anxiety and depression were evaluated using the depression and anxiety subscales of the Symptom Checklist-90-Revised. Correlations between coping and symptoms of anxiety and between coping and symptoms of depression were calculated, and a logistic regression was performed. RESULTS: A moderate correlation was observed between maladaptive coping and symptoms of anxiety in the BC group (r = 0.42) and among the CTRLs (r = 0.56). A moderate correlation was observed between maladaptive coping and symptoms of depression in both groups (r = 0.55). The statistical analysis for the total sample (BCs and CTRLs) demonstrated no association between coping and symptoms of anxiety or depression. CONCLUSIONS: A correlation but no association was observed between maladaptive coping and mental health disorders in deployed Dutch servicemembers. Further research should focus on constructing cluster profiles of coping strategies and associating them with mental health outcomes and reintegration into society.

Evaluating the Military Medical Evacuation Chain: Need for Expeditious Evacuation Out of Theater?

BACKGROUND: An important factor within the military medical logistical chain is the capability of expeditious evacuation from point of injury, through a Medical Treatment Facility, to the country of residence where highest level of care can be provided. Although many factors can relate to patient outcome, the evaluation of the medical evacuation chain related to long-term patient outcome can be important for investigating possibilities for performance improvement in this domain. This article aims to provide a means to evaluate the quality of care of the medical evacuation chain. METHODS: Repatriated service members from the Afghan theater between 2004 and 2014 were invited to participate in a survey concerning functional outcome and quality of life using Lower Extremity Functional Scale, Short Form health survey 36, and EuroQol-6D questionnaires. Possible associations between these outcomes were analyzed in respect to duration of medical evacuation from point of injury to arrival in the Dutch military hospital. The duration was dichotomized into within and after 72 hours. Ordinal regression was used to analyze a possible association with duration as a continuous variable. FINDINGS: Sixty percent (28/47) of battle casualties arrived in The Netherlands within 72 hours. For the nonbattle injury cohort this was 30% (7/23). Of those who became ill, 18% (5/28) was evacuated in 72 hours. No significant independent associations between interval duration and measured outcomes were found. CONCLUSION: Repatriated battle casualties had lower outcome scores compared to the disease nonbattle injured service members. Significant differences in functional outcome and quality of life with respect to evacuation duration were not found. Specialized tactical evacuation and en route care capability during strategic evacuation contributed to relative high standards of care. Combined with our results, this could implicate that delivery of the right care to the right patient at the right time is a justifiable paradigm. The main focus of the medical support organization is to offer the highest level of care per echelon as soon as possible in conjunction with facilitating maximum social support through expeditious evacuation out of theater. Further research using semistructured interviews among the direct circle around battle casualties, including caregivers, is needed to provide insight into these complex matters.

Transfusion: -80°C Frozen Blood Products Are Safe and Effective in Military Casualty Care.

INTRODUCTION: The Netherlands Armed Forces use -80°C frozen red blood cells (RBCs), plasma and platelets combined with regular liquid stored RBCs, for the treatment of (military) casualties in Medical Treatment Facilities abroad. Our objective was to assess and compare the use of -80°C frozen blood products in combination with the different transfusion protocols and their effect on the outcome of trauma casualties. MATERIALS AND METHODS: Hemovigilance and combat casualties data from Afghanistan 2006-2010 for 272 (military) trauma casualties with or without massive transfusions (MT: ≥6 RBC/24hr, N = 82 and non-MT: 1-5 RBC/24hr, N = 190) were analyzed retrospectively. In November 2007, a massive transfusion protocol (MTP; 4:3:1 RBC:Plasma:Platelets) for ATLS® class III/IV hemorrhage was introduced in military theatre. Blood product use, injury severity and mortality were assessed pre- and post-introduction of the MTP. Data were compared to civilian and military trauma studies to assess effectiveness of the frozen blood products and MTP. RESULTS: No ABO incompatible blood products were transfused and only 1 mild transfusion reaction was observed with 3,060 transfused products. In hospital mortality decreased post-MTP for MT patients from 44% to 14% (P = 0.005) and for non-MT patients from 12.7% to 5.9% (P = 0.139). Average 24-hour RBC, plasma and platelet ratios were comparable and accompanying 24-hour mortality rates were low compared to studies that used similar numbers of liquid stored (and on site donated) blood products. CONCLUSION: This report describes for the first time that the combination of -80°C frozen platelets, plasma and red cells is safe and at least as effective as standard blood products in the treatment of (military) trauma casualties. Frozen blood can save the lives of casualties of armed conflict without the need for in-theatre blood collection. These results may also contribute to solutions for logistic problems in civilian blood supply in remote areas.

Feasibility and acceptability of a workers' health surveillance program for hospital physicians.

OBJECTIVES: A Workers' Health Surveillance (WHS) program is an occupational health strategy used to detect and address the health of individual workers to improve their ability to work. This study aims to investigate the feasibility and acceptability of a new job-specific WHS for hospital physicians. MATERIAL AND METHODS: All hospital physicians of the general surgery, radiotherapy and obstetrics and gynecology departments from 1 academic hospital were invited to participate in the WHS by the in-company occupational health service. An occupational physician and a medical assistant were trained to use the protocol. Feasibility was operationalized as the received and delivered dose, observed success factors and potential obstacles. Acceptability was assessed by asking whether the WHS was desirable and feasible for future use and by estimating the effects on health and work ability. Written questions and semi-structured interviews were conducted with the participating physicians, 5 department managers and the 2 occupational health professionals involved in the study. RESULTS: One-third of the hospital physicians (34%) participated in every part of the WHS. The delivered dose was 77/84 (92%). Almost all hospital physicians who received recommendations expected to adhere to this advice. The study participants appreciated the organization of the WHS. This WHS was positively graded (8 out of 10 max) in terms of acceptability. Positive effects of the WHS on health, work functioning and long-term work ability were perceived by 2/3 of the physicians. CONCLUSIONS: The new job-specific WHS for hospital physicians showed good feasibility and acceptability among participating hospital physicians, occupational health professionals and medical managers.

Long-term impact of battle injuries; five-year follow-up of injured Dutch servicemen in Afghanistan 2006-2010.

OBJECTIVES: Units deployed to armed conflicts are at high risk for exposure to combat events. Many battle casualties (BCs) have been reported in the recent deployment to Afghanistan. The long-term impact of these combat injuries, at their five-year end point, is currently unknown. To date, no systematic inventory has been performed of an identified group of BCs in comparison to non-injured service members from the same operational theatre. DESIGN: Observational cross-sectional cohort study. SETTING: Open online survey among Dutch BCs that deployed to Afghanistan (2006-2010). PARTICIPANTS: The Dutch BCs (n = 62) were compared to two control groups of non-injured combat groups (battle exposed [n = 53], and non-battle exposed [n = 73]). MAIN OUTCOME MEASURES: Participants rated their impact of trauma exposure (Impact of Events [IES]), post deployment reintegration (Post Deployment Reintegration Scale [PDRS]), general symptoms of distress (Symptom Checklist 90 [SCL-90]), as well as their current perceived quality of life (EuroQol-6D [EQ-6D]). Also cost effectiveness (Short From health survey [SF-36]) and care consumption were assessed (Trimbos/iMTA questionnaire). RESULTS: Over 90% of BCs were still in active duty. The mean scores of all questionnaires (IES, EQ-6D, SF-36, and SCL-90) of the BC group were significantly higher than in the control groups (p<0.05). The PDRS showed a significantly lower (p<0.05) outcome in the negative subscales. The mean consumption of care was triple that of both control groups. A lower score on quality of life was related to higher levels of distress and impact of trauma exposure. CONCLUSIONS: This study showed a clear long-term impact on a wide range of scales that contributes to a reduced quality of life in a group of BCs. Low perceived cost effectiveness matched with high consumption of care in the BC group in comparison to the control groups. These results warrant continuous monitoring of BCs.

Impact of combat events on first responders: experiences of the armed conflict in Uruzgan, Afghanistan.

INTRODUCTION: Care for battle casualties demands special skills from medics, nurses, and tactical commanders. To date, no inventory has been performed evaluating the first responders (medics, nurses and tactical commanders) around battle casualties. METHOD: This observational cohort study was conducted amongst the first responders (n=195) who were deployed to Southern Afghanistan (2009-2010) in three Marine companies. The survey focused on four main topics: (1) participants general background, (2) exposure to combat (casualty) situations, (3) self-perceived quality of care (1 [low]-10 [high]) in the pre-hospital phase, and (4) the effects of combat stressors on professional skills and social environment using the Post Deployment Reintegration Scale (PDRS) and the Impact of Event Scale-Revised (IES-R). RESULTS: 71% of the eligible Dutch tactical commanders, medics, and nurses participated in this survey. Most (14/16) medics and nurses scored their pre-deployment training as sufficient The overall self-perceived quality of care score was above average (7.8). Most (80%) of the participants were exposed to battle casualties. There were no significant differences regarding rank, gender, age and military task using the impact of event scale and PDRS, except for a worse score on the work negative, family positive and personal positive subscales (p<0.05) in the PDRS for the first responders in comparison to the armed forces norm score. CONCLUSION: The quality of care in the pre-hospital phase was considered adequate, symptoms of post-traumatic stress in this group was low. Active involvement of co-combatants and the social support network are essential in adaption after exposure to combat events. Further research is necessary to identity predisposing preventable high stress factors, and to compose a "waterproof" aftercare programme.

The reproducibility of two task-specific functional capacity evaluation protocols for household waste collectors.

OBJECTIVE: The aim of this study was to assess the reproducibility (i.e., agreement and inter-rater reliability) of two task-specific functional capacity evaluation protocols meant to simulate the daily workload of collectors using either two-wheeled waste containers or bags. METHODS: A within-subjects design was used to assess reproducibility in terms of agreement and reliability. Twenty-one household waste collectors were assessed twice with both task-specific protocols with a time interval of seven days. Agreement was assessed using the Standard Error of Measurement (SEM), and inter-rater reliability was assessed using the Intra-Class Correlation Coefficient (ICC). RESULTS: For the task-specific protocol for waste collection using two-wheeled containers, agreement was excellent (SEM=0.9 points; 0-340 scale; mean score 339), but inter-rater reliability was poor (ICC=0.22). For the task-specific protocol for bag collection, agreement was acceptable (SEM=53 s; continuous scale; mean time 779 s), and inter-rater reliability was good (ICC=0.79). CONCLUSIONS: Reproducibility of the task-specific protocol for bag collection is acceptable to good, while the task-specific protocol for waste collection using two-wheeled containers has an excellent agreement but a poor reliability. Although face and content validity have been covered within the development of both protocols, further studies should evaluate the construct and criterion-related validity of both task-specific protocols.

Return to work: Police personnel and PTSD.

OBJECTIVE: This study i) describes the number of police personnel with PTSD who are working and those who are on sick leave before and after an out-patient-clinic treatment program and ii) examines which factors are related to return to work. PARTICIPANTS: Police personnel treated for PTSD (n=121). METHODS: In this retrospective study all police officers had an intake interview before and an outtake interview following a 16-week treatment for PTSD. Information about several personal characteristics, PTSD complaints, and work related factors were gathered. A t-test and chi-square test were used to evaluate differences between working police personnel and police personnel on sick leave at intake and outtake. Binary logistic regression was used to test whether the intake data were related to returning to work at outtake. RESULTS: At the start of the treatment half of the police personnel were on sick leave (n=59) and at outtake 48 participants who were not working at intake had returned to work. None of the variables at intake contributed significantly to return to work at outtake. CONCLUSION: The majority of police officers returned to work after the treatment program. We recommend that attention be paid to successful return to work as part of the treatment program, therefore the occupational health professional and employer should be involved.

Diminished health status in firefighters.

The objective was to assess the diminished health status of firefighters in the Netherlands. Two hundred and seventy-eight firefighters were tested during a workers' health surveillance. Psychological, physical, sense-related and cardiovascular markers vital to job performance were investigated and the relative frequency of deficiencies in health markers was determined. Deficiencies were found in all health markers investigated. The most prevalent deficiencies were (1) physical status when not passing a job-specific test (25%) and (2) cardiovascular disease risk factors - BMI (57%), systolic hypertension (23%) and smoking (22%). Diminished health status of firefighters typically involved deficiencies in physical markers and cardiovascular disease risk factors. It is recommended that occupational physicians initiate interventions for individual firefighters to address diminished health in these respects. Practitioner Summary In this study, health markers required for firefighter job performance were assessed. Diminished health status typically involved deficiencies in physical markers and cardiovascular disease risk factors. This study makes ergonomists and other health-care professionals aware of the most prevalent health marker deficiencies in firefighters and results highlight the relevance of performing workers' health surveillance in firefighters.

Impact of chronic diseases on work ability in ageing firefighters.

OBJECTIVES: The aim of this study was to study the impact of chronic diseases on work ability in different age groups of Dutch firefighters. METHODS: Firefighters filled out a questionnaire about the presence of nine types of chronic diseases and rated their current work ability (0 unable to 10 best ever). The differences in work ability in firefighters in total and in four age groups with and without chronic diseases were calculated with a Fisher's exact test. RESULTS: Of 276 firefighters 23% reported having a chronic disease, with the rate varying among the age groups between 18 and 41%. Median work ability was 8, varying between 7 and 8 in the age groups. No significant difference was found in work ability for firefighters with and without chronic diseases, independent of the age groups. CONCLUSIONS: Having a chronic disease is not associated with a significantly lower self-reported work ability estimate in firefighters.

Which subgroups of fire fighters are more prone to work-related diminished health requirements?

PURPOSE: To determine whether certain subgroups of fire fighters are prone to work-related diminished health requirements. METHODS: The health requirements for fire-fighting were tested in a workers' health surveillance (WHS) setting. These health requirements included psychological, physical and sense-related components as well as cardiovascular risk factors. The odds ratio (OR) and 95% confidence interval (95% CI) for the presence of the diminished health requirements were calculated for the subgroups of gender, professionalism and age. RESULTS: The prevalence of diminished psychological requirements was equivalent among the subgroups, and no significant high-risk group was identified. As compared to men fire fighters, women fire fighters were more likely to have diminished physical requirements (OR 28.5; 95% CI 12.1-66.9) and less likely to have cardiovascular risk factors (OR 0.3; 0.1-0.5). As compared to volunteer fire fighters, professionals were less likely to have diminished physical requirements (OR 0.5; 0.3-0.9), but professionals had a higher prevalence of cardiovascular risk factors with an odds ratio of 1.9 (1.1-3.2). As compared to the youngest fire fighters, the oldest fire fighters were more likely to have diminished sense-related requirements (OR 7.1; 3.4-15.2); a similar comparison could be made between oldest and middle-aged fire fighters (OR 5.1; 2.5-10.5). In addition, the oldest fire fighters were more likely to have cardiovascular risk factors when compared to the youngest (OR 4.4; 1.7-11.1) and to the middle-aged fire fighters (OR 3.1; 1.2-7.9). CONCLUSIONS: Subgroups (gender, professionalism and age) of fire fighters are prone to at least one specific work-related diminished health requirement. Therefore, parts of the WHS could be applied with more attention to these high-risk groups.

Feasibility and acceptability of workers' health surveillance for fire fighters.

OBJECTIVES: The objective of this study was to test the feasibility and acceptability of a new workers' health surveillance (WHS) for fire fighters in a Dutch pilot-implementation project. METHODS: In three fire departments, between November 2007 and February 2009, feasibility was tested with respect to i) worker intent to change health and behavior; ii) the quality of instructions for testing teams; iii) the planned procedure in the field; and iv) future WHS organisation. Acceptability involved i) satisfaction with WHS and ii) verification of the job-specificity of the content of two physical tests of WHS. Fire fighters were surveyed after completing WHS, three testing teams were interviewed, and the content of the two tests was studied by experts. FEASIBILITY: nearly all of the 275 fire fighters intended to improve their health when recommended by the occupational physician. The testing teams found the instructions to be clear, and they were mostly positive about the organisation of WHS. Acceptability: the fire fighters rated WHS at eight points (out of a maximum of ten). The experts also reached a consensus about the optimal job-specific content of the future functional physical tests. CONCLUSION: Overall, it is feasible and acceptable to implement WHS in a definitive form in the Dutch fire-fighting sector.

Clinimetric quality of the fire fighting simulation test as part of the Dutch fire fighters Workers' Health Surveillance.

BACKGROUND: Clinimetric data for the fire fighting simulation test (FFST), a new test proposed for the Workers' Health Surveillance (WHS) of Dutch fire fighters, were evaluated. METHODS: Twenty-one fire fighters took the FFST three times with one and three weeks between testing. Clinimetric quality was determined by means of reliability, agreement and validity. For reliability and agreement, the intraclass correlation coefficient (ICC), and standard error of measurement (SEM), were analysed. For construct validity, the tests from 45 fire fighters were correlated with their own and their supervisors' rated work ability. RESULTS: The ICCs were 0.56 and 0.79 at the one-week and three-week test-retest periods, respectively. Testing times ranged from 9 to 17 minutes; the SEMs were 70 s at the one-week and 40 s at the three-week test-retest periods. The construct validity was moderate (-0.47 < or = r < or = -0.33; p < 0.05). CONCLUSIONS: The FFST was reliable with acceptable agreement after three weeks. Construct validity was moderate. We recommend using FFST as a part of the WHS for Dutch fire fighters. It is advised that fire fighters should perform the FFST once as a trial before judging their performance in testing time during the second performance.

Reproducibility and validity of the stair-climb test for fire fighters.

PURPOSE: A new job-specific test for fire fighters, the stair-climb test (FFstair-climb) was evaluated for reproducibility and validity for use in future workers' health surveillance. METHODS: The FFstair-climb was performed at three times by 20 male fire fighters (one and three weeks in between test and retest) to examine the reliability and agreement. An intraclass correlation coefficient (ICC) and standard error of measurement (SEM) were calculated. In addition, 45 fire fighters (2 women, 43 men) performed the test once, while heart rate and testing time were monitored, to study the content validity. Construct validity was tested by correlating both self-rated and supervisor-rated work ability scores with testing time. RESULTS: The reliability, reflected by the ICC, was high for the one-week and the three-week test-retest period, 0.82 and 0.91, respectively. The mean testing time for the FFstair-climb was about 65 s; the agreement showed SEMs of 5.4 s at the one-week test-retest period and 3.8 s at the three-week test-retest period. Content validity was good in 78% of the fire fighters, while the construct validity between testing times and work ability ratings was not sufficient (r < 0.30). CONCLUSIONS: The FFstair-climb can be used in the Workers' Health Surveillance of fire fighters as a reproducible instrument, with good content validity. Testing criterion validity in future research would be an appropriate next step.