MSMR Medical Surveillance Monthly Report Vol. 9 No. 1 January 2003 U Contents S Malaria among active duty soldiers, US Army, 2002................................2 A Mortality trends among active duty personnel, 1992-2001........................6 C ARD surveillance update.........................................................................11 H Reportable events, calendar year 2002......................................................12 Sentinel reportable events, calendar year 2002...........................................14 P P M Current and past issues of the MSMR may be viewed online at: http://amsa.army.mil Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. 1. REPORT DATE 3. DATES COVERED JAN 2003 2. REPORT TYPE 00-00-2003 to 00-00-2003 4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER Medical Surveillance Monthly Report (MSMR). Volume 9, Number 1, 5b. GRANT NUMBER January 2003 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) 5d. PROJECT NUMBER 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. 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THIS PAGE Same as 16 unclassified unclassified unclassified Report (SAR) Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18 2 MSMR January 2003 Malaria Among Active Duty Soldiers, US Army, 2002 Malaria is a mosquito-transmitted febrile fewer cases of falciparum malaria, and 5 more cases infectious disease that is endemic throughout the overall (figure 1). tropics.1 It is estimated that malaria accounts for Of 36 soldiers diagnosed with vivax malaria, nearly 500 million clinically significant cases and nearly 80% were White and more than half were more than one million deaths each year worldwide.2,3 younger than 25 (table 1). In contrast, of 10 soldiers In recent years, the intensity and extent of malaria diagnosed with falciparum malaria, 80% were Black endemicity have increased.2,3 and all but one were older than 30 (table 1). Overall, In the U.S. Army, many soldiers are there was only one report of malaria in a female permanently assigned in malaria endemic areas; in soldier (table 1). addition, many soldiers are exposed to malaria risk Approximately two-thirds (n = 39) of all during operations and training overseas.4-9 Since the cases were considered acquired in Korea; however, mid-1990s, a majority of malaria cases among U.S. fewer than one-third (n = 17) of all cases were soldiers have been caused by Plasmodium vivax diagnosed in Korea (figure 2). Of 17 cases diagnosed infections acquired along the Demilitarized Zone in Korea, 13 presented in July, August, or September— (DMZ) in Korea.7-13 Because many P. vivax infections during or immediately following the warmest and acquired in Korea have long incubation times, many wettest months of the year (figure 3). Malaria cases cases acquired by U.S. soldiers in Korea are clinically were also diagnosed at approximately 20 different expressed and diagnosed during subsequent military medical facilities in Hawaii, Europe, and assignments outside of Korea.11-13 This report throughout the United States (figure 2). summarizes the malaria experience of U.S. Army soldiers during calendar year 2002. Editorial comment. During the past 3 years, the numbers of malaria cases overall among U.S. soldiers Methods. The Defense Medical Surveillance System have been relatively stable; however, in 2002 compared was searched to identify all hospitalizations and reports to 2001, there were more cases of vivax malaria and to the Reportable Medical Events System (RMES) fewer cases of falciparum malaria.11 during calendar year 2002 that included diagnoses of Since the mid-1990s, P. vivax infections malaria (ICD-9-CM: 084.0-084.9). Only one episode acquired during summer transmission seasons near of malaria per soldier was included. Locations of the demilitarized zone in Korea have accounted for a malaria acquisition were estimated using the following majority of malaria cases among U.S. soldiers. Of algorithm: (1) cases diagnosed in Korea were general concern, P. vivax infections acquired in Korea considered Korea-acquired; (2) cases that were often have long latency periods; and as a result, more documented with reports (through the Army’s than half of all cases acquired by soldiers in Korea are Reportable Medical Events System) that listed clinically manifested at locations outside of Korea.11- exposures to malaria endemic locations were 13 In 2002, malaria was diagnosed among US soldiers considered acquired in those locations; (3) cases among at more than 20 different locations worldwide; and soldiers who had been assigned to Korea within 2- more than two-thirds of all cases were diagnosed at years of diagnoses were considered acquired in Korea; medical facilities remote from locations where malaria (4) all remaining cases were considered acquired in is endemic. Providers of primary medical care to U.S. “other/unknown” areas. soldiers in nonmalarious areas (e.g., U.S., Europe) must be alert for presentations of malaria acquired Results. During 2002, fifty-seven soldiers were during assignments, deployments, or travel in diagnosed with malaria. Fewer than half (n=24, 42%) malarious areas (e.g., Korea, Africa, Central/South of all cases were hospitalized. In 2002 compared to America, southeast Asia). 200111, there were 14 more cases of vivax malaria, 7 Vol. 09/ No. 01 MSMR 3 Figure 1. Malaria cases, overall and by plasmodium species, by year, active duty, US Army, 1995-2002. 75 60 s e s a a c 45 ari al m of er 30 Total b m u N P. vivax 15 Other/unknown P. falciparum 0 1995 1996 1997 1998 1999 2000 2001 2002 Figure 2. Malaria cases by geographical locations of acquisition and diagnosis, active duty, US Army, 2002. 40 30 s e s a c a ari mal 20 of er b m u N 10 0 K ore*aOthAferri/cuan k n o w n K oreEa uro p eBra g g H o o d L e wiCs arCs oa nm p b ellDru m RileSyh after LSBeilleo nn nairnd gW o o d P olSRkaumc kHero uWstaoSsnthienwOgttarhotenr,/ uDnCk n o w n Acquired Diagnosed *Other/unknown includes Papua New Guinea, Honduras, and Cambodia. 4 MSMR January 2003 Analysis and report by Garret R. Lum, MPH, Analysis 7. Feighner BH, Pak SI, Novakoski, WL, Kelsey LL, Strickman Group, Army Medical Surveillance Activity. D. Reemergence of Plasmodium vivax malaria in the Republic of Korea. Emerg Infect Dis 1998; 4(2):295-7. 8. Strickman D, Miller ME, Kelsey LL, Lee WJ, Lee HW, Lee References KW, Kim HC, Feighner BH. Evaluation of the malaria threat at 1. Malaria. Control of communicable diseases manual, 16th the multipurpose range complex, Yongp’yong, Republic of edition. eds. Benenson AS and Chin J. American Public Health Korea. Mil Med 1999; 164(9):626-9. Association. Washington, DC. 1995:283-92. 9. Lee JS, Lee WJ, Cho SH, Ree H. Outbreak of vivax malaria in 2. Weiss U. Nature insight: malaria. Nature 2002;415:669. areas adjacent to the demilitarized zone, South Korea, 1998. Am 3. Greenwood B, Mutabingwa T. Malaria in 2002. Nature J Trop Med Hyg 2002; 66(1):13-7. 2002;415:671-2. 10. Army Medical Surveillance Activity. Plasmodium vivax 4. Weina PJ. From atabrine in World War II to mefloquine in malaria of Korean origin, 1997. MSMR 1997;3(5), 2-3. Somalia: the role of education in preventive medicine. Mil Med 11. Lum GR. Malaria among active duty soldiers, US Army, 1998 Sep;163(9):635-9. 2001. MSMR 2002; 8(3):2-4. 5. Smoak BL, DeFraites RF, Magill AJ, Kain KC, Wellde BT. 12. Army Medical Surveillance Activity. P. vivax malaria Plasmodium vivax infections in U.S. Army troops: Failure of acquired by US soldiers in Korea: acquisition trends and primaquine to prevent relapse in studies from Somalia. Am J incubation period characteristics, 1994-2000. MSMR Trop Med Hyg 1997;56(2):231-4. 2001;7(1):7-8. 6. Shanks GD, Karwacki JJ. Malaria as a military factor in 13. Petruccelli BP, Feighner BH, Craig SC, Kortepeter MG, Southeast Asia. Mil Med 1991;156(12):684-6. Livingston R. Late presentations of vivax malaria of Korean origin, multiple geographic sites. MSMR 1998;4(5)2-3,8-10. Figure 3. Number of malaria cases acquired and diagnosed in Korea, in relation to average monthly temperature ranges and rainfall, active duty, US Army, 2002. 40 500 Malaria cases 30 7 400 us) A Celci 20 verag ures ( 300 e rain at 10 fa age temper 0 A tvegm hpigh 3 3 200 ll (milimete ver rs) A Rainfall 100 -10 Avg low 1 1 1 1 -20 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of diagnosis *Data was adapted from www.worldclimate.com (Seoul, Korea). Vol. 09/ No. 01 MSMR 5 Table 1. Malaria cases, by selected demographic characteristics, active duty, US Army, 2002. P. vivax P. falciparum Other/unknown Total No. No. No. No. % Total 36 10 11 57 100.0 Gender Male 36 10 10 56 98.2 Female 0 0 1 1 1.8 Age group < 24 20 0 3 23 41.0 25-29 8 1 6 15 26.3 > 30 8 9 2 19 33.3 Race/ethnicity White 28 1 6 35 62.0 Black 5 8 2 15 26.3 Other 3 1 3 7 12.3 6 MSMR January 2003 Mortality Trends among Active Duty Military Personnel, 1992-2001 In the U.S. military, medical surveillance is pending circumstances accounted for the remainder conducted to identify and characterize threats to the (table 1). health, fitness, and operational effectiveness of military Accidents. Accident-related death rates were populations. Deaths of active duty servicemembers two to three times higher among men than women; are events of significant medical surveillance concern. however, among both men and women, accident- This report summarizes the mortality experience of related death rates declined with age (table 1). active duty military personnel from 1992 through Relative to their counterparts, accidental deaths 2001 and highlights mortality trends over the 10-year occurred more frequently among single, enlisted surveillance period. personnel in combat occupations (table 1). The Marines had the highest and least stable declining rate Methods. The occurrence, nature, and circumstances of accidental deaths of any of the services (figure 4). of every death of an active duty servicemember are Illnesses. Illness-related mortality rates were reported using Department of Defense (DoD) Form higher among men than women; however, among both 1300, Report of Casualty. Casualty reports are men and women, illness-related mortality rates forwarded through military service reporting channels increased sharply with age (table 1). For example, to a central DoD archive that is maintained by the illness-related mortality rates were approximately five Directorate for Information Operations and Reports times higher among servicemembers older than 34 (DIOR), Washington Headquarters Services, compared to those younger than 25. Illness-related Washington, DC. These reports are also forwarded to death rates (unadjusted) were highest in the Army and the Armed Forces Institute of Pathology (AFIP) for Navy and lowest in the Marines (table 1). further investigation. To the extent possible, each Suicides. Suicide rates were two to three times death is classified as “accident,” “suicide,” “homicide,” higher among men than women (table 1). Relative to “illness,” “hostile action/terrorism,” or “undetermined/ their counterparts, suicides were less frequent among pending.” Periodically, casualty files are transmitted servicemembers who were Black, married, officers, from both DIOR and AFIP to the Army Medical and in the Navy and Air Force (table 1). Suicide rates Surveillance Activity (AMSA) for inclusion in the did not significantly vary across occupational groups data inventory of the Defense Medical Surveillance (table 1). System (DMSS). Homicides. Female, Black, enlisted, and single servicemembers were more frequent victims Results. From 1992 through 2001, 8,570 of homicide than their respective counterparts (table servicemembers died while on active duty (overall 1). Homicide was the only specific manner of death mortality rate: 57.38 per 100,000 servicemembers per in which women had a higher rate than men.2 year [p-yrs]). Of the military services, the Air Force Homicide-related death rates generally decreased with had the lowest overall mortality rate (42.89 per increasing age. Homicide-related death rates 100,000 p-yrs) and the Marines had the highest (71.89 (unadjusted) were relatively high in the Marines and per 100,000 p-yrs) (table 1). During the surveillance Army and in combat occupational groups (table 1). period, mortality rates generally declined. The decline of mortality rates overall was largely attributable to Editorial comment. From 1992 to 2001, mortality declines in each of the services in accident-related rates among active duty military personnel generally deaths (figures 1-4). declined. The decline in death rates overall was More than half (53%) of all active duty deaths largely attributable to consistent and across-the-board were attributable to accidents, and more than one- declines in accidental death rates. It is likely that fourth of all deaths resulted from intentional acts declines in accidental death rates were due at least in (suicide: 20%, homicide: 6%, hostile action and part to aggressive accident prevention and safety terrorism: 1%). Illnesses (18%) and undetermined/ programs of the services. However, accidents remain Vol. 09/ No. 01 MSMR 7 Table 1. Mortality rate*, overall and by manner, by demographic characteristics, active duty, US Armed Forces, 1992-2001 Hostile action/ Undetermined/ Overall Accident Illness Suicide Homicide terrorism pending Total 57.38 30.21 10.09 11.73 3.54 0.84 0.97 Gender Male 61.42 32.81 10.50 12.90 3.40 0.86 0.96 Female 30.45 12.95 7.37 3.94 4.45 0.72 1.02 Age (years) 15-19 61.56 41.94 5.01 9.59 3.74 0.59 0.68 20-24 67.95 43.20 4.55 12.73 5.55 0.70 1.27 25-29 49.63 28.17 5.64 11.47 2.96 0.66 0.72 30-34 45.56 22.05 7.72 11.70 2.44 0.95 0.71 35-39 50.20 17.34 17.39 11.38 2.07 0.94 1.08 40-65 68.39 13.31 39.07 11.29 1.86 1.70 1.16 Race White 55.69 30.55 8.83 12.30 2.20 0.82 1.01 Black 58.95 26.16 14.35 8.81 7.93 0.82 0.88 Other 71.65 39.46 10.80 14.65 4.71 1.18 0.86 Marital status Single 69.80 43.56 7.21 12.28 4.64 0.98 1.44 Married 47.54 21.09 11.49 10.97 2.85 0.76 0.71 Other 71.81 31.49 19.20 18.05 2.50 0.77 0.00 Service Army 63.67 33.28 11.72 12.56 4.55 1.04 0.52 Air Force 42.98 20.25 9.08 10.84 1.63 0.56 0.61 Marines 71.89 46.49 6.29 13.33 4.80 0.29 0.69 Navy 57.31 29.09 10.66 10.92 3.58 1.11 1.95 Grade Enlisted 59.31 30.81 9.88 12.83 4.00 0.75 1.06 Officer 46.86 26.94 11.22 5.78 1.03 1.37 0.51 Occupation Combat 72.73 44.50 9.98 11.96 4.19 1.07 1.04 Healthcare 41.26 16.83 9.71 11.20 2.74 0.08 0.70 Other 54.69 27.51 10.17 11.73 3.43 0.87 0.98 * Rate per 100,000 person-years 8 MSMR January 2003 Figures 1-4. Mortality rate, by manner, year and service, active duty military, 1992-2001. Figure 1. Army Accident Illness Suicide Homicide 60 Hostile action/terrorism Undetermined/pending s r a e y - n o s r 40 e p 0 0 0 0, 0 1 er 20 p e at R 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Figure 2. Air Force 60 s r a e y - n o s r 40 e p 0 0 0 0, 0 1 er 20 p e at R 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Vol. 09/ No. 01 MSMR 9 Figures 1-4 (continued). Mortality rate, by manner, year and service, active duty military, 1992-2001. Figure 3. Navy Accident Illness Suicide Homicide 60 Hostile action/terrorism s r Undetermined/pending a e y - n o s r 40 e p 0 0 0 0, 0 1 er 20 p e at R 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Figure 4. Marines 60 s r a e y - n o s r 40 e p 0 0 0 0, 0 1 er 20 p e at R 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001