Outbreak of Acute Respiratory Illness Associated with Adenovirus Type 4 at the U.S. Naval Academy, 2016.

Human adenoviruses (HAdVs) are known to cause respiratory illness outbreaks at basic military training (BMT) sites. HAdV type-4 and -7 vaccines are routinely administered at enlisted BMT sites, but not at military academies. During August-September 2016, U.S. Naval Academy clinical staff noted an increase in students presenting with acute respiratory illness (ARI). An investigation was conducted to determine the extent and cause of the outbreak. During 22 August-11 September 2016, 652 clinic visits for ARI were identified using electronic health records. HAdV-4 was confirmed by realtime polymerase chain reaction assay in 18 out of 33 patient specimens collected and 1 additional HAdV case was detected from hospital records. Two HAdV-4 positive patients were treated for pneumonia including 1 hospitalized patient. Molecular analysis of 4 HAdV-4 isolates identified genome type 4a1, which is considered vaccine-preventable. Understanding the impact of HAdV in congregate settings other than enlisted BMT sites is necessary to inform discussions regarding future HAdV vaccine strategy.

Expeditionary Force Health Protection for Global Health Engagement: Lessons Learned from Continuing Promise 2017.

Background: Global health engagement (GHE) is an important priority for the Military Health Service as such activities strengthen the health capabilities of partner nations and improve interoperability. By their very nature, GHE activities are predominantly conducted in low-resource areas with limited infrastructure and substantial humanitarian need. The Department of Defense is evaluating leaner, flexible force packages to accomplish GHE missions and better prepare uniformed medical providers to provide care in austere environments. Methods: Observations made during the execution of Continuing Promise 2017, a recurring civil-military humanitarian operation conducted in Central and South America, are offered herein. Descriptions of relevant force health protection (FHP) threats experienced by mission personnel and mitigation measures successfully employed to prevent illness are provided. Relevant Department of Defense instructions are reviewed and risk mitigation strategies are compared with published standards and expert recommendations. Findings: In addition to well-described sanitation, hygiene, and infectious disease challenges that traditionally accompany military field activities, providing health care services to host nation populations in low-resource settings generates unique FHP vulnerabilities. Public health expertise leveraged throughout the planning and execution of GHE activities is instrumental for successfully identifying and mitigating the numerous FHP risks present. Discussion: Experiences from Continuing Promise 2017 demonstrate the expeditionary public health practitioner's role as a force multiplier has never been more relevant. A variety of public health countermeasures are available to successfully mitigate FHP threats experienced during GHE events. The public health lessons learned from Continuing Promise 2017 assist mission planners, commanders, and health care providers ensure that GHE participants remain healthy enough to accomplish the mission and meet America's commitments to partner nations.

Service Member Completion of Laboratory Follow-Up After Emergency Transfusion With Freshly Collected Blood Products.

BACKGROUND: Transfusion of freshly collected blood products (FCBP) is sometimes necessary to save service member (SM) lives in austere deployed environments. Recipients of FCBPs are administratively tracked and offered serial serologic testing via the Armed Services Blood Program "Blood Look Back" (BLB) program to assure early detection of post-transfusion infections. OBJECTIVES: This study evaluates demographic and clinical features influencing SM completion of recommended BLB laboratory follow-up after transfusion with FCBPs. METHODS: Using BLB programmatic data, a retrospective cohort study was performed examining U.S. SM transfusion recipients of FCBPs from June 1, 2006, through December 31, 2012. Multivariate logistic regression was used to examine clinical and demographic factors influencing completion of BLB recommended follow-up. RESULTS: Of eligible subjects, 69% (n = 778) completed 12-month recommended BLB follow-up. As compared to other services, U.S. soldiers demonstrated greatest compliance with BLB recommendations with 71.7% completing recommended follow-up. As compared to the Army, SMs from the Air Force (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.15-0.85), Marine Corps (OR = 0.51, 95% CI = 0.37-0.71), and Navy (OR = 0.29, 95% CI = 0.11-0.74) were less likely to complete recommended follow-up; however, differences in follow-up among the services attenuated over time. Neither the type of FCBP (platelets versus whole blood) nor the volume of FCBP transfused significantly altered SM likelihood of competing recommended follow-up. CONCLUSIONS: More than 2 out of 3 SMs completed recommended 12-month BLB follow-up after transfusion with FCBPs with greater compliance in Army SMs compared to other services. Programmatic changes implemented by the BLB program were temporally associated with increased SM compliance with recommended follow-up as well as reduction of disparities in follow-up observed between the services.

Health care worker follow-up compliance after occupational bloodborne pathogens exposure: A brief report.

A retrospective cohort study was conducted examining health care worker (HCW) compliance with Centers for Disease Control and Prevention recommendations following occupational bloodborne pathogen (BBP) exposure. HCWs with a BBP exposure from a known HIV- or hepatitis C virus-seropositive individual were less likely to complete recommended follow-up compared with HCWs with seronegative source patient exposures (adjusted odds ratio, 0.02 and 0.09, respectively). Continued targeted education and extra vigilance in performing postexposure surveillance are warranted in this higher-risk population.

Risk of alcohol use disorder or other drug use disorder among U.S. Service members following traumatic brain injury, 2008-2011.

OBJECTIVES: Evaluate the risk of developing an alcohol use disorder (AUD) or other drug use disorder (ODUD) in U.S. service members (SMs) after incident traumatic brain injury (TBI) in both the deployed and the nondeployed setting. PARTICIPANTS AND METHODS: Retrospective cohort study of U.S. SMs who served on active duty from January 1, 2008 to December 31, 2010. The exposed cohort consisted of SMs who received an incident diagnosis of TBI during the exposure period. The unexposed cohort was populated with a 10% random sample of SMs with any other medical diagnosis over the exposure period. RESULTS: After adjusting for various demographic factors, TBI severity, historic diagnosis of post-traumatic stress disorder (PTSD), comorbid PTSD, and comorbid mental health outcomes, the TBI cohort (n = 53,817) demonstrated elevated incident rate ratio of developing AUD (adjusted incidence rate ratios (IRR) 1.5, 95% confidence interval (CI) 1.4, 1.6, p < 0.0001) as compared to an unexposed cohort (n = 151,776). The TBI cohort did not demonstrate elevated risk of ODUD as compared to the unexposed cohort (adjusted IRR 1.0, 95% CI 1.0, 1.2, p = 0.178). CONCLUSIONS: U.S. SMs diagnosed with incident TBI demonstrated increased risk of developing an AUD within 1 year of incident TBI as compared to SMs without diagnosed TBI.

Tuberculosis contact investigation in a military health care setting: case report and evidence review.

Tuberculosis (TB) remains a global threat to the U.S. armed forces. A single individual with TB disease exerts an immediate and disruptive impact upon patients' lives, military operations, and daily functioning at military treatment facilities. Medical personnel in operational or limited-resource settings are sometimes challenged to perform a TB outbreak investigation with minimal specialized training or limited logistic assistance. This article presents a case of a patient with TB disease presenting to a large military treatment facility and outlines the current, evidence-based recommendations for performing a TB outbreak investigation.

Notes from the field: investigation of contacts of a health care worker who worked while ill with pertussis--Maryland, August-September 2014.

On September 5, 2014, the public health department of a Maryland hospital was notified of a case of Bordetella pertussis infection confirmed by polymerase chain reaction (PCR) in a staff health care worker (HCW). The HCW experienced onset of diarrhea and malaise (nonrespiratory symptoms atypical of the catarrhal phase of pertussis) on August 26. By September 2, paroxysms of coughing led the HCW to consult a colleague, who ordered the PCR test, prescribed a 5-day course of azithromycin, and advised avoidance of patient care until treatment completion. Contrary to the hospital's infection control policy, neither the HCW nor the colleague reported the presumptive diagnosis of pertussis to the hospital's public health department. The HCW continued to work in the outpatient department until the positive PCR result was received on September 5, at which time the hospital's public health department was first notified. The hospital barred the HCW from further work at the hospital while ill, and, in collaboration with local and state public health counterparts, began a contact investigation and stratified patient and HCW contacts by level of exposure.

Transfusion-transmissible infections among U.S. military recipients of emergently transfused blood products, June 2006-December 2012.

In austere deployment environments, transfusion of freshly collected blood products from volunteer donors is sometimes necessary to save wounded service members' lives. Because these blood products may have an increased risk of transmitting bloodborne pathogens, recipients are administratively tracked and offered serial serologic testing by the Blood Look Back (BLB) program. This study evaluates the frequency of transfusion-transmissible infections (TTIs) in U.S. service member (SM) recipients of non-FDA-compliant blood products from 1 June 2006 through 31 December 2012. Routine BLB program efforts identified and evaluated 1,127 SM recipients for evidence of seven TTIs for 12 months following transfusion. The Defense Medical Surveillance System was then queried for evidence of provider-diagnosed TTIs and the results were compared. A single, previously reported incident case of human T-lymphotropic virus (rate of 1.3 per 1,000 persons) was the only TTI identified during the study period. Screening of recipients identified two (rate of 1.9 per 1,000 persons) prevalent (pre-transfusion) cases of chronic hepatitis B virus (HBV) infection, 16 (rate of 15.5 per 1,000 persons) prevalent cases of naturally acquired immunity to HBV and seven (rate of 6.8 per 1,000 persons) prevalent cases of hepatitis C virus infection. No cases of infection with human immunodeficiency virus, syphilis, Trypanosoma cruzi, or West Nile virus were identified.

Energy drinks: review of performance benefits, health concerns, and use by military personnel.

Energy drinks (EDs) are highly caffeinated beverages usually containing herbal ingredients promoted and consumed for purported improvements in attention and athletic performance. The popularity of EDs among adolescents and young adults has steadily increased for more than a decade. Reports suggest U.S. military populations consume EDs with greater frequency as compared to age-matched civilian populations. This article reviews the literature and outlines the current body of evidence evaluating the human performance benefits and potential harms associated with ED use.

Impact of illness per ICD-9 classification on progression to physical evaluation board for U.S. marines placed on limited duty status 2006-2010.

Mission readiness is of paramount importance to Marine Corps commanders. Personnel medically unable to perform at full capacity negatively affect a unit's readiness and ability to accomplish mission objectives. A retrospective cohort study was designed to evaluate the impact of diseases and conditions per International Statistical Classification of Diseases and Related Health Problems, Revision 9 (ICD-9) classification of primary diagnosis on likelihood of progressing to Physical Evaluation Board (PEB) for U.S. Marines placed on Limited Duty. A total of 30,937 records belonging to 19,042 unique individuals were identified in the Medical Board Online Tri-Service Tracking System database over the study surveillance period. Approximately half (9,133) of all Marines placed on Limited Duty were eventually referred to PEB. After multivariate adjustment Marines with a primary ICD-9 diagnosis indicating a blood disorder (OR = 4.1, 95% CI 2.1-8.1) or nervous system disorder (OR = 3.3, 95% CI 2.8- 3.8) were at greater risk of progressing to PEB as compared to the lowest risk group, Marines with an orthopedic diagnosis. Occupational category, rank grouping, race/ethnicity, and ICD-9 category had statistically significant impacts of varying magnitude on the risk of progressing to PEB; no significant difference was found for sex.

Current "legal highs".

BACKGROUND: A growing number of novel substances have been abused as recreational drugs by young people in the United States (US), Europe, and Australia. Called "legal highs," these substances range from plant-based to completely synthetic compounds. Spice, Salvia, mephedrone, methylenedioxypyrovalerone (MDPV), and other cathinone derivatives have psychotropic effects and are marketed for recreational use through exploitation of inadequacies in existing controlled substance laws. OBJECTIVES: This article reviews available literature on the most common "legal highs" as well as discussing the scientific basis for the legal difficulties in controlling trafficking in these novel substances. CONCLUSIONS: "Legal highs" continue to increase in use in the US, Europe, and Australia. These substances are powerful, can mimic effects of more traditional drugs of abuse, and are intentionally manufactured to circumvent existing controlled substance laws. As controlled substance legislation may be inadequate in the face of the quickly evolving legal highs, physicians are likely to see an increase in the prevalence of legal highs.

Spice: a legal marijuana equivalent.

Spice, an herbal mixture containing synthetic cannabinoids, is a legal drug increasingly abused by adolescents and young adults for its narcotic-like effects. A paucity of English language literature exists on the clinical effects of Spice use. A case report of substance-induced psychosis and a summary of available literature follows later.