Publications by authors named "Bryant J Webber"

45 Publications

Association of Sickle Cell Trait on Career and Operational Outcomes in the United States Air Force.

Mil Med 2021 Jun 12. Epub 2021 Jun 12.

Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.

Introduction: Sickle cell trait (SCT) is a heterozygotic state defined by having one normal hemoglobin gene and one sickle hemoglobin gene. Individuals with SCT are at increased risk for negative health outcomes during intense physical exertion, especially in hot climates and high-elevation locations, or when dehydrated. The U.S. Air Force mitigates this risk through universal screening after accession followed by education of SCT-positive airmen. Airmen who are SCT positive but remain asymptomatic are not restricted in occupation choice or deployment/duty locations based on their SCT status. Previous studies have analyzed the relationship between SCT and health and fitness outcomes. The objective of this study was to analyze the relationship between SCT and career and operational outcomes in a large cohort of airmen and secondarily to analyze the relationship between hemoglobin S (HgbS) percentage and these outcomes.

Methods: This is a retrospective cohort study of all recruits who entered U.S. Air Force (USAF) Basic Military Training (BMT) between January 2009 and December 2013. The SCT status was assessed through a sickle solubility test. Hemoglobin electrophoresis permitted subgroup analysis of SCT-positive individuals by HgbS percentage. The following career and operational outcomes were assessed: BMT graduation; retention at 4 and 6 years; promotion to the rank of staff sergeant by 4 and 6 years; overseas deployment and number of deployments within 6 years; and high-elevation assignment and cumulative months at a high-elevation assignment within 6 years. Multivariable logistic regression was used to assess all binary outcomes, controlling for age, sex, and race, to produce adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Multivariable Poisson regression was used to assess cumulative count outcomes and to produce adjusted incidence rate ratios (aIRRs) with 95% CIs. Attrition from BMT by SCT status was also assessed as a hazards function using the Kaplan-Meier approach with Cox proportional hazards.

Results: A total of 180,355 civilians entered USAF BMT during the 5-year surveillance period, of whom 169,837 graduated and had data available for analysis. Compared to their SCT-negative peers, SCT-positive airmen (n = 1,697) had 26% lower adjusted odds of promotion to staff sergeant within 4 years of BMT graduation (aOR = 0.74; 95% CI: 0.59-0.92) and served less time at a high-elevation assignment during their first 6 years (aIRR = 0.88; 95% CI: 0.85-0.91). The SCT status was not associated with statistically significant differences in BMT graduation, retention at 4 and 6 years, promotion to staff sergeant by 6 years, likelihood or number of overseas deployments, and likelihood of ever working at a high-elevation assignment. Retention at 4 and 6 years was inversely associated with HgbS percentage.

Conclusions: SCT-positive and SCT-negative airmen had similar career and operational outcomes, with two exceptions: SCT-positive airmen were less likely to be promoted to staff sergeant within 4 years, and they spent less time at a high-elevation location during their first 6 years of service. The underlying explanation of these findings should be explored with an aim to support SCT-positive airmen and to reduce potentially unwarranted discrepancies. Efforts should continue to reduce the stigma associated with SCT.
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http://dx.doi.org/10.1093/milmed/usab231DOI Listing
June 2021

Musculoskeletal Injuries in U.S. Air Force Security Forces, January 2009 - December 2018.

J Occup Environ Med 2021 04 3. Epub 2021 Apr 3.

The University of Texas Health Science Center at Houston, School of Public Health in San Antonio, Southwest Center for Occupational and Environmental Health, San Antonio, Texas, USA.

Objective: To determine the incidence, types, and risk factors of musculoskeletal injuries in a military security forces population.

Methods: Demographic and diagnostic data were retrieved on enlisted U.S. Air Force security forces personnel who served on active duty between January 2009 and December 2018. Incidence rates and ratios were calculated using Poisson regression.

Results: During 251,787 person-years of exposure, 62,489 personnel served on active duty. Of these, 40,771 (65.2%) were diagnosed with at least one musculoskeletal injury. The majority (60.1%) of the 164,078 unique musculoskeletal injuries were inflammation and pain secondary to overuse. After adjusting for other factors, females had a 31% higher injury rate than males, and those who were overweight and obese had 15% and 30% higher rates, respectively, than normal-weight peers.

Conclusions: Modifiable and non-modifiable factors contribute to musculoskeletal injuries in the security forces career field.
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http://dx.doi.org/10.1097/JOM.0000000000002207DOI Listing
April 2021

Exertional Rhabdomyolysis and Sickle Cell Trait Status in the U.S. Air Force, January 2009-December 2018.

MSMR 2021 Jan;28(1):15-19

Sickle cell trait (SCT) is associated with incident exertional rhabdomyolysis, but its effect on disease progression and severity is poorly understood. Of 377 exertional rhabdomyolysis cases diagnosed between 2009 and 2018 in the active component of the U.S. Air Force, 200 had records available for chart review, and 185 of these had known SCT status. Pre- and post-event data were stratified by SCT status, and serum chemistry changes among SCT-positive (n=11) and SCT-negative (n=174) airmen were compared using Wilcoxon-Mann-Whitney tests. Of the 200 cases with records available for chart review, 110 (55.0%) were hospitalized; 98 (56.3%) of the 174 who were SCT-negative were hospitalized. Also hospitalized were 4 (36.4%) of the 11 who were SCT-positive, and 8 (53.3%) of the 15 with unknown SCT status. Of the 7 airmen who were admitted to intensive care, 4 required hemodialysis, and 1 underwent a fasciotomy; all 7 were SCT-negative. Alterations in creatine kinase, potassium, creatinine, troponin I, and hemoglobin were statistically equivalent between those with and without SCT. Providers should maintain a high index of suspicion for exertional rhabdomyolysis, especially in warm climates and in the context of high-intensity activities, but should not presume that the presence of SCT portends a higher risk of complications or worse clinical outcomes.
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January 2021

Outcomes of Embedded Athletic Training Services Within United States Air Force Basic Military Training.

J Athl Train 2020 Dec 28. Epub 2020 Dec 28.

United States Air Force School of Aerospace Medicine, Wright-Patterson Air Force Base, OH.

Context: Musculoskeletal injury is the leading cause of attrition from military training.

Objective: To assess the effect of an embedded athletic training musculoskeletal care model within a basic military training unit.

Design: Cluster randomized trial.

Setting: United States Air Force Basic Military Training, Joint Base San Antonio-Lackland.

Patients Or Other Participants: Military recruits randomly assigned to 1 of 3 training squadrons, 2 control and 1 experimental, between January 2016 and December 2018.

Intervention(s): A sports medicine care model was established in 1 squadron by embedding 2 certified athletic trainers overseen by a sports medicine fellowship-trained physician. The athletic trainers diagnosed and coordinated rehabilitation as the primary point of contact for recruits and developed interventions with medical and military leadership based on injury trends.

Main Outcome Measure(s): Recruit attrition from basic training due to a musculoskeletal injury. Secondary outcomes were all-cause attrition, on-time graduation, rates of lower extremity injury and stress fracture, rates of specialty care appointments, and fiscal costs.

Results: Recruits in the athletic training musculoskeletal care arm experienced 25% lower musculoskeletal-related attrition (risk ratio = 0.75 [95% confidence interval (CI) = 0.64, 0.89]) and 15% lower all-cause attrition (risk ratio = 0.85 [95% CI = 0.80, 0.91]), translating to a net saving of more than $10 million. The intervention reduced the incidence of lower extremity stress fracture by 16% (rate ratio = 0.84 [95% CI = 0.73, 0.97]).

Conclusions: An embedded athletic training musculoskeletal care model outperformed usual care across operational, medical, and fiscal outcomes.
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http://dx.doi.org/10.4085/1062-6050-0498.19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901582PMC
December 2020

Malignancy in U.S. Air Force fighter pilots and other officers, 1986-2017: A retrospective cohort study.

PLoS One 2020 22;15(9):e0239437. Epub 2020 Sep 22.

Public Health and Preventive Medicine Department, U.S. Air Force School of Aerospace Medicine, Wright-Patterson Air Force Base, Ohio, United States of America.

Objective: This study sought to determine the incidence rates of cancer, overall and by site, among active component U.S. Air Force fighter pilots, and to compare the rates with those in other active component Air Force officers.

Methods: Using a matched retrospective cohort design, U.S. Air Force fighter pilots were compared with other commissioned officers who entered active component service between 1 January 1986 and 31 December 2006. The cohort was followed for cancer diagnoses in TRICARE and the Veterans Health Administration from 1 October 1995 through 31 December 2017. Fighter pilots and non-fighter pilot officers were compared after matching on sex, age at first observation (15 age groups), and age at last observation (15 age groups). Sex-stratified overall and site-specific cancer rates were compared with matched Poisson regression to determine incidence rate ratios with 95% confidence intervals.

Results: During 1,412,590 person-years of follow-up, among the study population of 88,432 service members (4,949 fighter pilots and 83,483 matched officers), 977 incident cancer cases were diagnosed (86 in fighter pilots and 891 in matched officers). Male fighter pilots and matched officers had similar rates of all malignant cancers (RR = 1.04; 95% CI: 0.83-1.31) and of each cancer site. Female fighter pilots and matched officers also had similar rates of all malignant cancers (RR = 0.99; 95% CI: 0.25-4.04).

Discussion: In the active component U.S. Air Force, fighter pilots and their officer peers had similar overall and site-specific cancer rates.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239437PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508357PMC
November 2020

Musculoskeletal Injuries and Automation in Aerial Port Operations.

Aerosp Med Hum Perform 2020 Aug;91(8):669-673

: Aerial ports are being modernized with automated technologies, but the impact on musculoskeletal injury (MSKI) is unknown.: In this retrospective cohort study of U.S. Air Force aerial port technicians and traffic management technicians, we compared reported injury rates from January 2006-December 2016 and Veterans Benefits Administration disability compensation claims awarded from January 2001-March 2017. Ton-adjusted injury rates, associated lost/affected duty time, and percent risk attributable to lack of automation were compared at Dover Air Force Base (which features base-specific automation), Travis Air Force Base, Ramstein Air Base, and Yokota Air Base.: Injuries most often occurred during aircraft/flight line activities and were typically sprains/strains, with extremities being most affected. Among aerial port technicians there were 8.0 injury reports per 1000 person-years compared to 5.2 per 1000 among traffic management technicians (incidence rate ratio = 1.5; 95% CI: 0.9, 3.0). Of the aerial port technicians with a compensation award, 70.7% included an MSKI component, whereas 75.7% of traffic management awards included an MSKI component. Aerial port technicians at Dover AFB experienced 1.4 injury reports per 1000 personnel per 1000 cargo-tons per year, lower than the other ports: 3.2 (Travis); 3.7 (Ramstein); and 7.6 (Yokota). Overall, 56% of injuries at Travis, 62% at Ramstein, and 82% at Yokota could be attributed to absence of Dover-like automation. However, mean lost/affected duty days at Dover (12.4) far exceeded those at the other bases (range: 4.5-8.6).: Automating aerial ports may reduce injury rates, but the impact on lost/affected duty time requires further investigation.
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http://dx.doi.org/10.3357/AMHP.5475.2020DOI Listing
August 2020

Notes From the Field: Use of Emergency Medical Service Data to Augment COVID-19 Public Health Surveillance in Montgomery County, Maryland, From March to June 2020.

JMIR Public Health Surveill 2020 07 31;6(3):e22331. Epub 2020 Jul 31.

Montgomery County Public Health Emergency Preparedness and Response Program, Rockville, MD, United States.

Epidemiologic and syndromic surveillance metrics traditionally used by public health departments can be enhanced to better predict hospitalization for coronavirus disease (COVID-19). In Montgomery County, Maryland, measurements of oxygen saturation (SpO) by pulse oximetry obtained by the emergency medical service (EMS) were added to these traditional metrics to enhance the public health picture for decision makers. During a 78-day period, the rolling 7-day average of the percentage of EMS patients with SpO <94% had a stronger correlation with next-day hospital bed occupancy (Spearman ρ=0.58, 95% CI 0.40-0.71) than either the rolling 7-day average of the percentage of positive tests (ρ=0.55, 95% CI: 0.37-0.69) or the rolling 7-day average of the percentage of emergency department visits for COVID-19-like illness (ρ=0.49, 95% CI: 0.30-0.64). Health departments should consider adding EMS data to augment COVID-19 surveillance and thus improve resource allocation.
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http://dx.doi.org/10.2196/22331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7398595PMC
July 2020

Impact of Altitude-based Hemoglobin Modification on Pediatric Iron Deficiency Anemia Screening.

J Pediatr 2020 06;221:196-200

Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD; Public Health and Preventive Medicine Department, US Air Force School of Aerospace Medicine, Dayton, OH.

Objective: To determine if additional children attending primary care clinics in moderate-altitude areas would screen positive for anemia if the hemoglobin cutoff were modified for altitude.

Study Design: This cross-sectional study evaluated children aged 11-19 months of age who had a screening hemoglobin conducted between January 2011 and December 2017 at 4 moderate-altitude (1726-2212 m) and 8 low-altitude (1-20 m) US military clinics. The primary outcome was anemia prevalence (hemoglobin <11 g/dL) in moderate-altitude and low-altitude groups, before and after applying the current World Health Organization model for altitude-based hemoglobin modification. Groups were compared with prevalence ORs adjusted for age, sex, weight-for-length percentile, and parental military rank, and the false-negative proportion was calculated for children with anemia at moderate altitude.

Results: Before altitude modification, anemia prevalence was 4.4% in the moderate-altitude group (n = 1488) and 16.8% in the low-altitude group (n = 7090) (prevalence OR, 0.23; 95% CI, 0.17-0.29). After applying the World Health Organization model, anemia prevalence in the moderate-altitude group increased to 14.7% (prevalence OR, 0.82; 95% CI, 0.70-0.97). Nonapplication of the model at moderate altitude resulted in a false-negative proportion of 0.70 (95% CI, 0.63-0.76).

Conclusions: Nonuse of the World Health Organization altitude-based modification model for hemoglobin may result in a large percentage of US children with anemia at moderate altitude screening falsely negative for anemia. Although ancestry disparities in altitude acclimatization may limit universal application of the current World Health Organization model, the existing standard of care may leave children at moderate altitude at risk for complications from iron deficiency anemia.
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http://dx.doi.org/10.1016/j.jpeds.2020.02.085DOI Listing
June 2020

Weight Gain of Service Members After Basic Military Training.

Am J Prev Med 2020 01;58(1):117-121

Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina.

Introduction: Despite weight and fitness requirements, the prevalence of overweight and obesity in the U.S. military approaches that in the general population. The purpose of this study is to assess trends in anthropometric measurements shortly after military enlistment.

Methods: This longitudinal study evaluated the change in objectively measured body weight and waist circumference in the population of U.S. Air Force members who enlisted in 2012-2013 and graduated from Basic Military Training (n=49,466). Individuals were followed for 4 years or until they left the military, for a mean follow-up of 1,218 (SD=261) days. Data were collected in 2018 and analyzed in 2019.

Results: Among Basic Military Training graduates with available and plausible baseline data (n=46,706), weight increased incrementally by a mean of 1.5-1.8 kg per year and waist circumference by 0.3-1.1 cm per year. Over the 4-year period, total mean weight gain was 6.6 (SD=7.7) kg and waist circumference increase was 3.1 (SD=6.4) cm. Male graduates gained 7.0 (SD=7.7) kg and female graduates gained 4.7 (SD=7.5) kg. Of those who stayed in the military for 4 years, 37.3% transitioned to a higher BMI category (i.e., from normal to overweight/obese or from overweight to obese), whereas 3.9% transitioned to a lower category.

Conclusions: Future research is needed to understand determinants of unhealthy weight gain and the association between weight gain and physical fitness among young adults embarking on a military career.
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http://dx.doi.org/10.1016/j.amepre.2019.08.022DOI Listing
January 2020

Positive predictive value of an algorithm used for cancer surveillance in the U.S. Armed Forces.

MSMR 2019 Dec;26(12):18-22

Recent large-scale epidemiologic studies of cancer incidence in the U.S. Armed Forces have used International Classification of Disease, 9th and 10th Revision (ICD-9 and ICD-10, respectively) diagnostic codes from administrative medical encounter data archived in the Defense Medical Surveillance System. Cancer cases are identified and captured according to an algorithm published by the Armed Forces Health Surveillance Branch. Standardized chart reviews were performed to provide a gold standard by which to validate the case definition algorithm. In a cohort of active component U.S. Air Force, Navy, and Marine Corps officers followed from 1 October 1995 through 31 December 2017, a total of 2,422 individuals contributed 3,104 algorithm-derived cancer cases. Of these cases, 2,108 (67.9%) were classified as , 568 (18.3%) as , and 428 (13.8%) as . The overall positive predictive value (PPV) of the algorithm was 78.8% (95% confidence interval [CI]: 77.2-80.3). For the 12 cancer sites with at least 50 cases identified by the algorithm, the PPV ranged from a high of 99.6% for breast and testicular cancers (95% CI: 97.8-100.0 and 97.7-100.0, respectively) to a low of 78.1% (95% CI: 71.3-83.9) for non-Hodgkin lymphoma. Of the 568 cases confirmed as not cancer, 527 (92.7%) occurred in individuals with at least 1 other confirmed cancer, suggesting algorithmic capture of metastases as additional primary cancers.
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December 2019

Evaluation of serological testing for Lyme disease in Military Health System beneficiaries in Germany, 2013-2017.

MSMR 2019 Aug;26(8):22-26

Lyme disease diagnostic workups conducted on active and retired U.S. service members and their dependents at U.S. Air Force military treatment facilities (MTFs) in Germany between 2013 and 2017 were assessed to determine the appropriateness of laboratory testing and antibiotic prescriptions. Of the 1,176 first-tier immunoassays, 1,114 (94.7%) were negative, and of the 285 immunoglobulin M (IgM) immunoblots, 242 (84.9%) followed a negative first-tier assay or were performed without an antecedent first-tier assay. Eighty-three positive IgM immunoblot tests were adjudicated using modified published criteria, of which 40 (48.2%) were deemed false positives. Thirtytwo patients with false-positive tests were treated with an antibiotic. Additionally, 30 patients with uncomplicated erythema migrans could have been treated without laboratory confirmation. Understanding the use and limitations of 2-tier diagnostic criteria, as well as the common pitfalls in diagnosing Lyme disease, may help prevent overdiagnosis, reduce unnecessary testing, and promote antibiotic stewardship.
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August 2019

Physical and Mental Health of US Air Force Military Training Instructors.

Mil Med 2019 05;184(5-6):e248-e254

Military Training Consult Service, 737th Training Group, 1618 Truemper Street, JBSA-Lackland, TX.

Introduction: Many epidemiologic studies have been performed in military recruit populations, but little is known about the health of those who conduct the training. This study aims to characterize the physical and mental health of a military trainer cohort.

Materials And Methods: All US Air Force military training instructors (MTIs) who served between 1 October 2011 and 30 September 2016 were included in this retrospective descriptive study. All International Classification of Diseases, Ninth or Tenth Revision codes received by MTIs as inpatients or outpatients in the TRICARE system were obtained and mapped to Clinical Classifications Software levels. After excluding routine and administrative codes, the relative burden of disease by diagnostic category and subcategory was calculated, with further classification of musculoskeletal conditions by anatomic site. For all conditions accounting for at least 1.0% of the burden of care, incidence density rates and incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated to compare males and females.

Results: A total of 1,269 MTIs received 32,601 non-administrative, non-routine diagnoses while accumulating 50,376 person-months of exposure during the surveillance period. Musculoskeletal conditions were the greatest contributor to overall disease burden, accounting for 39.1% of all diagnoses, followed by mental health (10.4%), respiratory (10.1%), and neurologic and sensory (9.8%). The burden attributed to mental health conditions decreased by 54% over the 5-year period. Twenty-three conditions accounted for at least 1.0% of the healthcare burden. The highest incidence conditions were connective tissue disease (27.18 per 1,000 person-months), non-traumatic joint disorders (25.74), upper respiratory infections (25.14), and back pain (23.70). As compared to males, females had a higher incidence of several conditions, including adjustment disorders (IRR: 2.57; 95% CI: 1.61, 4.11) and anxiety disorders (IRR: 2.24; 95% CI: 1.33, 3.77).

Conclusions: Musculoskeletal conditions are the leading contributor to burden of care among US Air Force MTIs, followed by mental health, respiratory, and neurologic and sensory conditions. The burden of healthcare among US Air Force MTIs more closely resembles active component service members than recruit trainees.
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http://dx.doi.org/10.1093/milmed/usy418DOI Listing
May 2019

Chemoprophylaxis against group A streptococcus during military training.

Prev Med 2019 01 26;118:142-149. Epub 2018 Oct 26.

Department of Infectious Diseases, San Antonio Military Medical Center, 3351 Roger Brooke Drive, MCHE-ZDM, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA. Electronic address:

Chemoprophylaxis with intramuscular benzathine penicillin G has been used widely by the U.S. military to prevent epidemics of group A streptococcus infections during basic training. The recent global shortage of benzathine penicillin prompted a detailed analysis of this issue in 2017 by military preventive medicine and infectious disease authorities in San Antonio, Texas, and San Diego, California, USA. This paper explores the history of group A streptococcus and chemoprophylaxis in the U.S. military training environment, current policy and practice, and challenges associated with widespread chemoprophylaxis. In light of the history presented, preventive medicine authorities at basic training centers should be extremely cautious about discontinuing benzathine penicillin chemoprophylaxis.
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http://dx.doi.org/10.1016/j.ypmed.2018.10.023DOI Listing
January 2019

Association of Sickle Cell Trait and Hemoglobin S Percentage with Physical Fitness.

Med Sci Sports Exerc 2018 12;50(12):2488-2493

Consortium for Health and Military Performance, Uniformed Services University of the Health Sciences, Bethesda, MD.

Purpose: This study aimed to determine the association between sickle cell trait (SCT) as a binary variable and hemoglobin S percentage as a stratified categorical variable with aerobic and anaerobic fitness.

Methods: This retrospective cohort study included all recruits who entered US Air Force Basic Training between January 2009 and December 2014. Fitness parameters among recruits with and without SCT were compared using a standardized fitness assessment of a 1.5-mile timed run, 1 min of push-ups, and 1 min of sit-ups. Performance was further compared by stratifying those with SCT by their hemoglobin S percentage (20%-29.99%, 30%-39.99%, and ≥40%).

Results: Of all recruits (N = 210,461) who entered training during the surveillance period, 2161 (1.0%) had SCT. After adjusting for age, sex, race, body mass index, and ambient temperature while conducting the fitness assessment, recruits with SCT were slower on their initial run than their peers without SCT by a mean (standard error) of 9.4 s (2.6 s) (P < 0.001) and completed 0.5 (0.3) fewer push-ups (P < 0.05); sit-up completion was statistically equivalent between the two groups. When retested 6 wk later, recruits with SCT improved their run time by a margin of 4.3 s (2.1 s) over their counterparts without SCT (P < 0.05). Baseline physical fitness was largely consistent across strata of hemoglobin S percentages; increased percentages were modestly correlated with faster run times (R = 0.374) and fewer push-ups (R = 0.339).

Conclusions: As compared with their peers, recruits with SCT had slightly inferior aerobic fitness and similar anaerobic fitness at the outset of basic training, and gaps further narrowed over 6 wk of training. Stratifying recruits by their hemoglobin S percentage did not dramatically change the strength or direction of association.
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http://dx.doi.org/10.1249/MSS.0000000000001720DOI Listing
December 2018

Diagnostic evaluation of military blood donors screening positive for infection.

MSMR 2018 Feb;25(2):16-19

Routine blood donor screening for , the causative parasitic agent of Chagas disease, began in the U.S. in 2007. Results of follow-up testing and evaluation after a positive screen have not been studied in the armed forces. Among first-time donors at the Joint Base San Antonio- Lackland Blood Donor Center between January 2014 and December 2016 (N=43,402), a total of 23 (0.05%) screened positive for . This descriptive study highlights demographic and follow-up information for all 22 active duty service members who screened positive; a non-active duty member was excluded due to unavailability of clinical records. Members who screened positive received 13 different combinations of confirmatory testing (mean: 2.7 tests per person). In select cases, clinical evaluation included electrocardiogram (n=15) and 30-second rhythm strip (n=5). Two patients met criteria for Chagas disease; 11 patients were considered negative; and nine patients were indeterminate. Among a small cohort of active duty service members who screened positive for infection on blood donation, diagnostic evaluation varied considerably. Opportunities exist to decrease heterogeneity of clinical workup and improve evaluation of persons who screen positive.
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February 2018

Brief report: Prevalence of hepatitis B and C virus infections in U.S. Air Force basic military trainees who donated blood, 2013-2016.

MSMR 2017 Dec;24(12):20-22

Hepatitis B virus (HBV) and hepatitis C virus (HCV) can cause significant morbidity in military service members. Prevalences of HBV and HCV infections among military recruits accessioning into the U.S. Air Force have not previously been described. The Joint Base San Antonio-Lackland Blood Donor Center was queried for the results of HBV and HCV screening tests among all basic military trainees who donated blood between 25 November 2013 and 16 April 2016. Other active and reserve component members were excluded. The estimated prevalences of HBV and HCV infections among recruit blood donors were 0.0098% and 0.007%, respectively. This study suggests that the overall estimated prevalence of HBV and HCV infection is much lower among U.S. Air Force basic trainees, compared to other active and reserve component members and U.S. civilian populations. HBV and HCV viral infections can have a negative impact on mission readiness and individual deployment status, and have significant costs for the military. Additional studies are needed to determine cost effectiveness of screening for viral hepatitis among military populations.
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December 2017

Third Dose of MMR Vaccine for Mumps Control.

N Engl J Med 2017 12;377(24):2402-3

U.S. Air Force Academy, Colorado Springs, CO

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http://dx.doi.org/10.1056/NEJMc1714219DOI Listing
December 2017

Challenges with diagnosing and investigating suspected active tuberculosis disease in military trainees.

MSMR 2017 Aug;24(8):12-16

Between 1 January 2010 and 31 December 2016, a total of 14 U.S. and international military personnel in training at Joint Base San Antonio-Lackland, TX, were hospitalized due to suspected pulmonary tuberculosis (TB); of these, five personnel were diagnosed with active TB disease. Only one TB case had pulmonary symptoms, but these symptoms were not suggestive of TB. The incidence rate in the training population was 1.89 per 100,000 population (95% CI: 0.81, 4.42), with a higher rate when restricted to international military students attending the Defense Language Institute English Language Center. No instances of TB transmission were identified. The variety of atypical presentations and their resulting diagnostic and public health challenges prompted this retrospective review of all hospitalized cases. This case series highlights both the importance of a high index of clinical suspicion when TB is being considered in close congregate settings as well as the risk of overreliance on acid-fast bacilli staining and nucleic acid amplification testing for ruling out active pulmonary disease in young, otherwise healthy trainees. Practical solutions are suggested.
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August 2017

Prevalence and Seroprevalence of Infection in a Military Population in Texas.

Am J Trop Med Hyg 2017 Nov 18;97(5):1477-1481. Epub 2017 Aug 18.

59th Medical Wing, Joint Base San Antonio, Lackland, San Antonio, Texas.

Recent biosurveillance findings at Joint Base San Antonio (JBSA), a large military installation located in south-central Texas, indicate the potential for vector-borne human Chagas disease. A cross-sectional study was conducted to determine the prevalence and seroprevalence of infection in highest risk subpopulations on the installation, including students and instructors who work and sleep in triatomine-endemic field settings. Real-time polymerase chain reaction, enzyme-linked immunosorbent assay, and indirect immunofluorescent antibody assay were performed on enrolled subjects ( = 1,033), none of whom tested positive for or anti- antibodies. Current countermeasures used during field training on JBSA appear to be sufficient for preventing autochthonous human Chagas disease.
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http://dx.doi.org/10.4269/ajtmh.17-0109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5817750PMC
November 2017

Contraceptive prescriptions for US servicewomen, 2008-2013.

Contraception 2017 Jul 31;96(1):47-53. Epub 2017 May 31.

Armed Forces Health Surveillance Branch, Silver Spring, MD 20904.

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.
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http://dx.doi.org/10.1016/j.contraception.2017.05.006DOI Listing
July 2017

A case of Chagas cardiomyopathy following infection in south central Texas.

US Army Med Dep J 2017 Jan-Jun(1-17):55-59

Preventive Medicine Element, 559th Trainee Health Squadron, Wilford Hall Ambulatory Surgical Center, JBSA-Lackland, Texas.

Between 5 and 8 million people globally are infected with Trypanosoma cruzi, the causative parasitic agent of Chagas disease. The vast majority of incident infections originate in pockets of Latin America where domestic vector-borne transmission cycles are more common. Since 1955, when the first locally-acquired case was reported, fewer than 30 autochthonous cases have been documented in the United States. We describe the case of an 18-year-old US Air Force trainee, a native Texan with no travel history beyond the continental United States, who screened positive for T cruzi infection on blood donation and was subsequently found to have chronic Chagasic cardiomyopathy. This is the first documented case of Chagas disease in a US military trainee and one of the first known autochthonous cases of Chagasic cardiomyopathy in a Texas resident. Diagnostic, therapeutic, and military implications are discussed.
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February 2018

Varicella seroepidemiology in United States air force recruits: A retrospective cohort study comparing immunogenicity of varicella vaccination and natural infection.

Vaccine 2017 04 27;35(18):2351-2357. Epub 2017 Mar 27.

Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Building A, Room 1040A, Bethesda, MD, USA.

Background/objectives: Infection with varicella zoster virus (VZV) produces lifelong immunity, but duration of post-vaccination immunity has not been established. The purpose of this study is to determine if a difference exists in the long-term seropositivity of anti-VZV antibodies in a cohort of young adults who were vaccinated against varicella as compared to a similar cohort with a history of chickenpox disease, and to determine which variables best predict waning seropositivity following varicella vaccination.

Methods: This retrospective cohort study captures immunization and serology data from approximately 10,000 recruits who entered basic military training between January 1, 2008, and December 31, 2015, and who have childhood immunization records in the Air Force Aeromedical Services Information Management System. Varicella vaccine immunogenicity was determined relative to the immunogenicity of chickenpox disease, as measured by multiplex flow immunoassay. Among vaccine recipients, waning seroimmunity was modeled and adjusted for several important covariates.

Results: Basic military trainees who received varicella vaccine in childhood were 24% less likely to be seropositive to VZV than trainees who were exempt from vaccine due to a history of chickenpox disease. There was no significant difference in seropositivity between male and female trainees. The odds of a vaccinated trainee being seropositive to VZV decreased by 8% with each year elapsed since vaccination. Seroprevalence declined below estimated herd immunity thresholds in vaccinated trainees born after 1994, and in the cohort as a whole for trainees born after 1995.

Conclusion: Despite prior vaccination, seroimmunity in a large cohort of young adults unexposed to wild-type VZV failed to meet the estimated threshold for herd immunity. If vaccination in accordance with the current US VZV vaccination schedule is inadequate to maintain herd immunity, young adults not previously exposed to wild-type VZV may be at increased risk for varicella outbreaks.
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http://dx.doi.org/10.1016/j.vaccine.2017.03.054DOI Listing
April 2017

Description and Rate of Musculoskeletal Injuries in Air Force Basic Military Trainees, 2012-2014.

J Athl Train 2016 Nov;51(11):858-865

US Air Force School of Aerospace Medicine, Dayton, OH.

Context:  Musculoskeletal injuries are common in military trainees and have significant medical and operational effects.

Objective:  To provide current musculoskeletal injury epidemiology data for US Air Force basic military trainees.

Design:  Descriptive epidemiologic study with cross-sectional features.

Setting:  US Air Force Basic Military Training, Joint Base San Antonio-Lackland, Texas.

Patients Or Other Participants:  All recruits who entered training between July 1, 2012, and June 30, 2014.

Main Outcome Measure(s):  Incidence density rate of all musculoskeletal injuries (stratified by body region and type) and factors and costs associated with injuries.

Results:  Of the 67 525 trainees, 12.5% sustained 1 or more musculoskeletal injuries. The overall incidence density rate was 18.3 injuries per 1000 person-weeks (15.1 for men and 29.4 for women). The most common diagnosis (n = 2984) was Pain in joint, lower leg, as described in the International Classification of Diseases, Ninth Revision, Clinical Modification, code 719.46. Injuries were more common among those with lower levels of baseline aerobic and muscular fitness. Injured trainees were 3.01 times (95% confidence interval = 2.85, 3.18) as likely to be discharged, and injured trainees who did graduate were 2.88 times (95% confidence interval = 2.72, 3.04) as likely to graduate late. During the surveillance period, injuries resulted in more than $43.7 million in medical ($8.7 million) and nonmedical ($35 million) costs.

Conclusions:  Musculoskeletal injuries, predominantly of the lower extremities, have significant fiscal and operational effects on Air Force Basic Military Training. Further research into prevention and early rehabilitation of these injuries in military trainees is warranted.
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http://dx.doi.org/10.4085/1062-6050-51.10.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5224726PMC
November 2016

Preventing Exertional Death in Military Trainees: Recommendations and Treatment Algorithms From a Multidisciplinary Working Group.

Mil Med 2016 Apr;181(4):311-8

Consortium for Health and Military Performance, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.

Despite aggressive prevention programs and strategies, nontraumatic exertional sudden death events in military training continue to prove a difficult challenge for the Department of Defense. In November 2014, the 559th Medical Group at Joint Base San Antonio-Lackland, Texas, hosted a working group on sudden exertional death in military training. Their objectives were three-fold: (1) determine best practices to prevent sudden exertional death of military trainees, (2) determine best practices to establish safe and ethical training environments for military trainees with sickle cell trait, and (3) develop field-ready algorithms for managing military trainees who collapse during exertion. This article summarizes the major findings and recommendations of the working group.
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http://dx.doi.org/10.7205/MILMED-D-15-00299DOI Listing
April 2016

Sexually transmitted infections in U.S. Air Force recruits in basic military training.

MSMR 2016 Feb;23(2):16-9

This study reports the counts, prevalence, and trends of five common sexually transmitted infections (STIs) among U.S. Air Force recruits during 2012-2014. Chlamydia and genital herpes simplex virus (HSV) were the most commonly identified STIs in females, with a prevalence of 4,841.2 and 432.3 per 100,000, respectively. Genital HSV was the most commonly identified STI in males at 133.4 per 100,000. There were 13 cases of chlamydia and gonorrhea co-infection among females and none among males. STI prevalence was lower than in a similarly aged U.S. civilian population.
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February 2016

Sudden cardiac death associated with physical exertion in the US military, 2005-2010.

Br J Sports Med 2016 Jan 26;50(2):118-23. Epub 2015 Nov 26.

Armed Forces Radiobiology Research Institute, Bethesda, Maryland, USA.

Background: Sudden cardiac death associated with physical exertion (SCD/E) is a complicated pathophysiological event. This study aims to calculate the incidence rate of SCD/E in the US military population from 2005 to 2010, to characterise the demographic and cardiovascular risk profiles of decedents, and to evaluate aetiologies of and circumstances surrounding the deaths.

Methods: Perimortem and other relevant data were collected from the Armed Forces Medical Examiners Tracking System, Armed Forces Health Longitudinal Technology Application, and Defense Medical Epidemiology Database for decedents meeting SCD/E case definition. Incidence rates were calculated and compared using negative binomial regression.

Results: The incidence of SCD/E in the Active Component (ie, full-time active duty) US military from 2005 to 2010 was 1.63 per 100 000 person-years (py): 0.98 and 3.84 per 100 000 py in those aged <35 and ≥35 years, respectively. Atherosclerotic cardiovascular disease was the leading cause of death overall (55%) and in the ≥35-year age group (78%), whereas the leading cause of death in the <35-year age group (31%) could not be precisely determined and was termed idiopathic SCD/E (iSCD/E). SCD/E was more common in males than females (incidence rate ratio (IRR) = 5.28, 95% CI 2.16 to 12.93) and more common in blacks than whites (IRR=2.60, 95% CI 1.81 to 3.72). All female cases were black.

Conclusions: From 2005 to 2010, the incidence of SCD/E in US military members aged <35 years was similar to most reported corresponding civilian SCD rates. However, the leading cause of death was iSCD/E and not cardiomyopathy. Improved surveillance and age-based prevention strategies may reduce these rates.
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http://dx.doi.org/10.1136/bjsports-2015-094900DOI Listing
January 2016

Epidemiology, microbiology, and antibiotic susceptibility patterns of skin and soft tissue infections, Joint Base San Antonio-Lackland, Texas, 2012-2014.

MSMR 2015 Jul;22(7):2-6

Skin and soft tissue infections (SSTIs), including those caused by methicillin-resistant Staphylococcus aureus (MRSA), are common in military training environments. In 2014, the healthcare providers for trainees at Joint Base San Antonio (JBSA)-Lackland, TX, notified the surveillance unit of increased antibiotic resistance reported on wound cultures of purulent SSTIs. To provide updated clinical guidance to local providers, the surveillance unit conducted a review of all SSTIs diagnosed among trainees at JBSA-Lackland between 1 October 2012 and 31 December 2014. SSTI cumulative incidence during the surveillance period was 0.81%, with similar rates between males (0.80%) and females (0.84%) and between basic (0.82%) and technical (0.79%) trainees. Of 772 total cases, 254 were cultured; 196 resulted in growth of one or more pathogens: MRSA (n=110); methicillin-sensitive S. aureus (n=68); other gram-positive cocci (n=5); and gram-negative rods (n=18). In vitro activity of commonly used antibiotics against S. aureus isolates dropped slightly from the previous surveillance period. In addition to novel antibiotic research and development, these trends warrant enhanced local preventive efforts and close adherence to evidence-based treatment algorithms.
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July 2015
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