Seroprevalence as an Indicator of Undercounting of COVID-19 Cases in a Large Well-Described Cohort.

Introduction: Reported confirmed cases represent a small portion of overall true cases for many infectious diseases. The undercounting of true cases can be considerable when a significant portion of infected individuals are asymptomatic or minimally symptomatic, as is the case with COVID-19. Seroprevalence studies are an efficient way to assess the extent to which true cases are undercounted during a large-scale outbreak and can inform efforts to improve case identification and reporting. Methods: A longitudinal seroprevalence study of active duty U.S. military members was conducted from May 2020 through June 2021. A random selection of service member serum samples submitted to the Department of Defense Serum Repository was analyzed for the presence of antibodies reactive to SARS-CoV-2. The monthly seroprevalence rates were compared with those of cumulative confirmed cases reported during the study period. Results: Seroprevalence was 2.3% in May 2020 and increased to 74.0% by June 2021. The estimated true case count based on seroprevalence was 9.3 times greater than monthly reported cases at the beginning of the study period and fell to 1.7 by the end of the study. Conclusions: In our sample, confirmed case counts significantly underestimated true cases of COVID-19. The increased availability of testing over the study period and enhanced efforts to detect asymptomatic and minimally symptomatic cases likely contributed to the fall in the seroprevalence to reported case ratio.

Factors Associated With U.S. Army Physician Service After Obligation Completion.

INTRODUCTION: Approximately, 320 physicians enter active duty in the U.S. Army each year, replacing a similar number separating from service. Despite the significant costs involved in educating and training physicians, factors associated with continued active service after completing obligations have not been well studied. MATERIALS AND METHODS: A retrospective cohort study was conducted of all U.S. Army physicians who graduated medical school in 1987 or later and entered active physician service on or before December 31, 2015. A Cox proportional hazards model was used to evaluate the likelihood of continued service after initial obligations to the Army were satisfied. A logistic regression model examined the likelihood of reaching retirement eligibility for the subgroup entering service before October 1998. RESULTS: Of the 10,490 physicians who met inclusion criteria, 8,009 physicians completed their service obligation by the end of the study. There were 4,524 physicians who entered service before October 1998 and were eligible for the retirement analysis. Several factors were found to be independently associated with a higher likelihood of continued post-obligation service and reaching retirement eligibility. These factors were: years of active service accumulated when obligations were complete; preventive medicine and infectious disease specialization; and male gender. CONCLUSIONS: The physicians most likely to continue serving after completion of their obligation and ultimately retire are those who had the most years of service accumulated when they could leave the Army. Graduates from the Uniformed Services University of the Health Sciences (USU) incur an obligation of 7 years vs. 4 years for most other programs. USU also attracts a higher proportion of applicants with prior military service and pre-medical school service obligations. The lack of significant difference in service after obligation completion or achievement of retirement eligibility between USU and non-USU graduates was explained by the greater total service of USU graduates when their obligations were complete. Changing the obligation and incentives, such as salary, for other accessioning programs to mirror the USU model would likely minimize service differences between USU and non-USU graduates.

Executive summary: Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society.

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

U.S. military recruits waived for pathological curvature of the spine: increased risk of discharge from service.

Selective accession waivers for medically disqualifying conditions like spinal curvature are one way the military meets its manpower needs. We evaluated retention patterns during the first 2 years of service of a cohort of military recruits with waivers for pathological curvature of the spine (spinal curvature). Recruits waived for spinal curvature (n = 417), who accessed from 1998 to 2005 were identified and matched with 3 qualified recruits. Kaplan-Meier survival analysis and Cox proportional hazards model were used to compare survival patterns and adjusted attrition hazard estimates. Waived recruits experienced significantly increased risk of "all cause" discharge (relative risk = 1.3; 95% confidence interval: 1.1, 1.5) and "existing prior to service" discharge (relative risk = 2.4; confidence interval: 1.6, 3.5). Despite the increased risk of discharge, current waiver criteria allowed a majority with spinal curvature to complete at least 2 years of service. Policy makers must consider risks and benefits before modifying the current accession standard for spinal curvature.

Association of weight at enlistment with enrollment in the Army Weight Control Program and subsequent attrition in the Assessment of Recruit Motivation and Strength Study.

The ongoing obesity epidemic has made recruiting qualified Army applicants increasingly difficult. A cohort of 10,213 Army enlisted subjects was enrolled in the Assessment of Recruit Motivation and Strength (ARMS) study from February 2005 through September 2006. Overweight recruits obtained a waiver for enlistment (n = 990) if they passed a screening physical fitness test. Recruits were evaluated for enrollment into the Army Weight Control Program (AWCP) and discharged during the 15 months following enlistment. Enrollment was higher among overweight recruits than recruits who met entrance standards (men: adjusted OR = 13.3 [95% CI: 10.3, 17.2]; women: adjusted OR = 3.6 [3.3, 3.9]). Although the discharge frequency was higher in the waiver group than in those who met standards (25.4% versus 19.9%, p < 0.001), there were only 10 (0.5% of total) discharges directly attributed to weight. Granting overweight waivers through the ARMS program increases enrollment to the AWCP but has little effect on weight-related attrition.

The anthrax vaccine adsorbed vaccine generates protective antigen (PA)-Specific CD4+ T cells with a phenotype distinct from that of naive PA T cells.

Cellular immune responses against protective antigen (PA) of Bacillus anthracis in subjects that received the anthrax vaccine adsorbed (AVA) vaccine were examined. Multiple CD4(+) T-cell epitopes within PA were identified by using tetramer-guided epitope mapping. PA-reactive CD4(+) T cells with a CD45RA(-) phenotype were also detected by direct ex vivo staining of peripheral blood mononuclear cells (PBMC) with PA-specific tetramers. Surprisingly, PA-specific T cells were also detected in PBMC of nonvaccinees after a single cycle of in vitro PA stimulation. However, PA-reactive CD4(+) T cells in nonvaccinees occurred at lower frequencies than those in vaccinees. The majority of PA-reactive T cells from nonvaccinees were CD45RA(+) and exhibited a Th0/Th1 cytokine profile. In contrast, phenotyping and cytokine profile analyses of PA-reactive CD4(+) T cells from vaccinees indicated that vaccination leads to commitment of PA-reactive T cells to a Th2 lineage, including generation of PA-specific, pre-Th2 central memory T cells. These results demonstrate that the current AVA vaccine is effective in skewing the development of PA CD4(+) T cells to the Th2 lineage. The data also demonstrated the feasibility of using class II tetramers to analyze CD4(+) cell responses and lineage development after vaccination.

Guidelines for the prevention of infection after combat-related injuries.

Management of combat-related trauma is derived from skills and data collected in past conflicts and civilian trauma, and from information and experience obtained during ongoing conflicts. The best methods to prevent infections associated with injuries observed in military combat are not fully established. Current methods to prevent infections in these types of injuries are derived primarily from controlled trials of elective surgery and civilian trauma as well as retrospective studies of civilian and military trauma interventions. The following guidelines integrate available evidence and expert opinion, from within and outside of the US military medical community, to provide guidance to US military health care providers (deployed and in permanent medical treatment facilities) in the diagnosis, treatment, and prevention of infections in those individuals wounded in combat. These guidelines may be applicable to noncombat traumatic injuries under certain circumstances. Early wound cleansing and surgical debridement, antibiotics, bony stabilization, and maintenance of infection control measures are the essential components to diminish or prevent these infections. Future research should be directed at ideal treatment strategies for prevention of combat-related injury infections, including investigation of unique infection control techniques, more rapid diagnostic strategies for infection, and better defining the role of antimicrobial agents, including the appropriate spectrum of activity and duration.

Laboratory-measured pregnancy rates and their determinants in a large, well-described adult cohort.

OBJECTIVE: To measure the pregnancy rate directly, to describe the characteristics of women who become pregnant, and to identify the predictors of pregnancy. No recent studies have estimated population pregnancy rates using objective, laboratory-based criteria. Furthermore, none have characterized predictive factors of pregnancy. METHODS: Population-based prospective cohort study of 5578 women, ages 18 to 44, on active duty at Fort Lewis, Washington, from 1995 to 1997. Main outcome measures were standardized pregnancy incidence rate and predictive factors for pregnancy. RESULTS: In the cohort, 887 pregnancies and 597 births occurred during the study period. The age- and race-standardized pregnancy rate was 108.1 per 1000 person-years. When compared with the 1995 U.S. population, the pregnancy rate ratio was 1.05 (95% confidence interval, 0.96-1.14). Factors that significantly affected the likelihood of pregnancy included age (=0.87/year), marital status (3.0, married versus single), race (1.2, African American versus Caucasian), Pap smear during study period (0.6), educational level (1.8, graduate training versus high school), and at least one prescription for oral contraceptives during the study period (0.8). CONCLUSIONS: Standardized pregnancy rates in the study population were statistically indistinguishable from United States estimates. Use of health care services was an important independent determinant of pregnancy occurrence.

Relationship between prepregnancy anthrax vaccination and pregnancy and birth outcomes among US Army women.

CONTEXT: Substantial concern surrounds the potential health effects of the anthrax vaccine, particularly the potential adverse effects on reproductive processes. OBJECTIVE: To determine whether receipt of anthrax vaccination by reproductive-aged women has an effect on pregnancy rates. DESIGN, SETTING, AND PATIENTS: Cohort study, based on information from a computer database, of women aged 17 to 44 years who were stationed at Fort Stewart, Ga, or Hunter Army Airfield, Ga, from January 1999 through March 2000. MAIN OUTCOME MEASURES: Pregnancy and birth rates and adverse birth outcomes. RESULTS: Of a total of 4092 women, 3136 received at least 1 dose of the anthrax vaccine. There was a total of 513 pregnancies, with 385 following at least 1 dose of anthrax vaccine. The pregnancy rate ratio (before and after adjustment for marital status, race, and age) comparing vaccinated with unvaccinated women was 0.94 (95% confidence interval [CI], 0.8-1.2; P =.60). There were 353 live births and 25 pregnancies lost to follow-up. The birth odds ratio after anthrax vaccination (before and after adjustment for marital status and age) was 0.9 (95% CI, 0.5-1.4; P =.55). After adjusting for age, the odds ratio for adverse birth outcome after receiving at least 1 dose of anthrax vaccination was 0.9 (95% CI, 0.4-2.4; P =.88). However, this study did not have sufficient power to detect adverse birth outcomes. CONCLUSION: Anthrax vaccination had no effect on pregnancy and birth rates or adverse birth outcomes.