Preparedness of Military Public Health for Epidemic and Pandemic Recognition and Response

Disease epidemics have threatened American military preparedness and operational capabilities since 1775. The ongoing Severe Acute Respiratory Syndrome Coronavirus 2 (COVID-19) pandemic, which began in 2019, again demonstrates the significant potential for infectious diseases to impact military units and threaten military readiness. We reviewed the historical and continuing threats to the U.S. Military from infectious disease outbreaks, as well as changes in U.S. Military capabilities for conducting meaningful surveillance and response. We concluded that a structured review of military public health and preventive medicine capabilities should be conducted to assess the response to the COVID-19 pandemic and determine the capabilities necessary for infectious disease surveillance and response to future threats.

Military Epidemics, Then and Now: Smallpox and COVID-19

We compared the COVID-19 experience in the first year of the current pandemic in the US with the smallpox experience of the 18th century, focusing on the US military but recognizing civilian and military populations are not separate and distinct. Despite the epidemics being separated by 21/2 centuries and with great advancements in technology having occurred over that time, we observed similarities which led us to several conclusions: • Infectious disease outbreaks will continue to occur and novel agents, naturally occurring or manipulated by humans, will threaten military and civilian populations nationally and globally. • Infectious disease outbreaks can affect both military and civilian populations, persist for long periods, and be catastrophic to military peacetime and wartime operations. • Effective surveillance is a prerequisite for early identification and subsequent meaningful responses to novel and reemerging threat agents and diseases. • Socio-cultural, religious, or political factors may limit the implementation of effective interventions in military or civilian populations. Public health officials must assess impediments to implementation of interventions and develop plans to overcome them.

The Capability Gap in Occupational Health Information Management

The lack of an integrated approach to data capture, information management, and analysis limits the contribution of occupational and environmental medicine to protecting 2.3 million uniformed and civilian DoD workers. Despite an abundance of military information systems that include the terms "Safety" and "Occupational Health" in their names, none of these systems provide capabilities needed to aggregate and analyze the results of occupational medicine exams, use medical surveillance to mitigate exposure incidents, provide enterprise-level management of occupational medicine services, or comply with privacy and recordkeeping law and regulation. Instead, they provide a patchwork of data that meets most regulatory compliance requirements but fails to achieve the true objectives of occupational health programs. Bridging these capability gaps will improve the occupational health care of the DoD workforce, improve the quality of occupational medicine services, increase public trust in the DoD management of exposure incidents, and potentially generate hundreds of millions of dollars through cost-avoidance on workers' compensation claims and through identification and elimination of non-value-added medical certification exams. The ongoing Military Health System transformation represents a unique opportunity to bridge these long-recognized but persistent capability gaps.

The Future of Military Occupational and Environmental Medicine in the Department of Defense

OBJECTIVE

Transfer of military medical facilities to the Defense Health Agency is transforming the Military Health System. Our objective is to inform this transformation with respect to optimum application of occupational and environmental medicine (OEM) expertise.

METHODS

We defined and analyzed the external influences on military OEM practice using a structured framework to identify key drivers.

RESULTS

Key drivers are political and economic factors. These may change the size or military/civilian ratio of the specialty. Limited career development pathways should prompt consideration of making OEM a second or combined residency, and military-funded training of civilian physicians may be required. OEM specialist utilization should be reassessed.

CONCLUSIONS

OEM is a highly adaptable specialty defined by the needs of its stakeholders. Comprehensive analysis of external influences can ensure that OEM practice remains in step with changing needs.

Hazardous Non-Combat Exposures in the U.S. Department of Defense

Hazardous non-combat exposures are inherent to military service and occur in three settings: installation workplaces, installation environments, and deployment environments. Few military clinicians receive training in how to recognize, assess, and manage patients with these exposures, and systems improvements are needed to support clinicians with respect to exposure recognition and management. This commentary highlights key concepts surrounding military non-combat exposures by discussing three case examples of exposures occurring in each of these settings. In the workplace, well-coordinated, interdisciplinary occupational health teams improve identification of exposure-related illnesses, and these teams may be further supported by the development of automated clinical decision-support systems. Installation environmental exposures are characterized by high perceived risk, uncertainty in estimating actual risk, and a wide range of stakeholders including military family members and individuals in the surrounding community. Recognizing environmental exposure concerns, gathering a thorough environmental exposure history, and practicing exposure risk communication are vital skills to address these situations. During deployments, exposures may initially be perceived as low risk but then become a concern years later. A functional understanding of the capabilities and limitations of exposure monitoring and potential health effects of exposures helps the military clinician effectively communicate potential health risks to line leaders. For any of these exposure settings, service public health centers and OEM specialty leaders and consultants are available for consultation.

Training Occupational and Environmental Medicine (OEM) Residents at the Uniformed Services University

OBJECTIVE

To develop an actionable plan to sustain and improve the quality of the Uniformed Services University of the Health Sciences (USU) Occupational and Environmental Medicine (OEM) Residency Program.

METHODS

Program metrics were collected and analyzed to assess strengths, weaknesses, opportunities, and threats (SWOT analysis).

RESULTS

Program strengths are stable funding, full-time faculty and large class size. Weaknesses are limited toxicology curriculum, and the lack of complex clinical cases. Opportunities include establishing an OEM referral clinic, collaborating with U.S. Department of Defense (DoD) toxicology programs, aligning OEM research priorities in DoD, and including DoD Civilian physicians in OEM residency training. Threats are Military Health System reorganization, budget, and personnel cuts.

CONCLUSIONS

The USU OEM Residency is strong but must be flexible to adjust to personnel, fiscal, and organizational changes. Aggregating the SWOT analyses for all the OEM residency programs may help identify strategies to sustain OEM training in the United States.

Uniformed Services University Occupational and Environmental Medicine Residency Program

In 2019, the Uniformed Services University of the Health Sciences (USU) F. Edward Hébert School of Medicine celebrated the 30th anniversary of its Occupational and Environmental Medicine (OEM) Residency program. This unique program is among the largest preventive medicine residency programs in the United States. Residents from the US Army, Navy, Air Force, other federal institutions, and the Canadian Forces come to Bethesda, Maryland, to become OEM specialists in a unique training program encompassing both military and civilian OEM settings. This publication describes the historical development and practice of OEM in the military leading to the development of the USU OEM Residency Program, along with the program's past accomplishments and current operation. Finally, the publication explores potential future directions for this relatively small but important preventive medicine specialty in the practice of military medicine, considering the impacts of reorganization of the Military Health System along with the opportunities this reorganization presents for the USU OEM Residency program.

Machine Learning Approach for Predicting Past Environmental Exposures From Molecular Profiling of Post-Exposure Human Serum Samples

OBJECTIVE

To develop an approach for a retrospective analysis of post-exposure serum samples using diverse molecular profiles.

METHODS

The 236 molecular profiles from 800 de-identified human serum samples from the Department of Defense Serum Repository were classified as smokers or non-smokers based on direct measurement of serum cotinine levels. A machine-learning pipeline was used to classify smokers and non-smokers from their molecular profiles.

RESULTS

The refined supervised support vector machines with recursive feature elimination predicted smokers and non-smokers with 78% accuracy on the independent held-out set. Several of the identified classifiers of smoking status have previously been reported and four additional miRNAs were validated with experimental tobacco smoke exposure in mice, supporting the computational approach.

CONCLUSIONS

We developed and validated a pipeline that shows retrospective analysis of post-exposure serum samples can identify environmental exposures.

Systematic review of military motor vehicle crash-related injuries

CONTEXT

Motor vehicle crashes account for nearly one third of U.S. military fatalities annually. The objective of this review is to summarize the published evidence on injuries due specifically to military motor vehicle (MMV) crashes.

EVIDENCE ACQUISITION

A search of 18 electronic databases identified English language publications addressing MMV crash-related injuries between 1970 and 2006 that were available to the general public. Documents limited in distribution to military or government personnel were not evaluated. Relevant articles were categorized by study design.

EVIDENCE SYNTHESIS

The search identified only 13 studies related specifically to MMV crashes. Most were case reports or case series (n=8); only one could be classified as an intervention study. Nine of the studies were based solely on data from service-specific military safety centers.

CONCLUSIONS

Few studies exist on injuries resulting from crashes of military motor vehicles. Epidemiologic studies that assess injury rates, type, severity, and risk factors are needed, followed by studies to evaluate targeted interventions and prevention strategies. Interventions currently underway should be evaluated for effectiveness, and those proven effective in the civilian community, such as graduated driver licensing, should be considered for implementation and evaluation in military populations.

Mental health disorders in a cohort of U.S. Navy and Marine Corps personnel receiving waivers of medical accession standards

To assess risk of disability discharge in U.S. Navy and Marine Corps personnel receiving waivers of medical accession standards for mental health, we retrospectively identified a cohort of 22,960 waiver recipients from February 2001 to November 2005. Relative risk of Medical Evaluation Board (MEB) for any diagnosis was the same in the mental health waiver versus other waiver groups, but risk of MEB specifically for a mental health diagnosis was five times higher in the mental health waiver group. Also, risk of MEB for a musculoskeletal condition was significantly decreased in the mental health waiver group. Because of the high per-case compensation cost for mental health disability, this excess risk represents an estimated 32% higher disability compensation cost. We recommend further analysis of the waiver cohort to identify disqualifying conditions without excess disability risk. Targeting these conditions for policy changes could increase manpower without incurring long-term disability costs.

Harmful algal bloom-associated marine toxins: a risk assessment framework

Marine toxins produced by harmful algal blooms (HABs) present a health risk to humans, but the extent of that risk remains unquantified. Increases in bloom frequency and geographic distribution present a potential for increased human exposure to these toxins, raising concerns among HAB researchers regarding an emerging public health problem. A risk assessment framework is presented with 2 objectives: (1) to provide a road map for integration and coordination of health-related research efforts and (2) to provide an overview of this complex problem to possible collaborators.

Public health potential of a disability tracking system: analysis of U.S. Navy and Marine Corps physical evaluation boards 2005-2006

Clinical and demographic data in administrative disability tracking systems have the potential to support disability reduction programs. We analyzed recent Navy Physical Evaluation Board data, compared our findings with previous studies, and evaluated the quality of the case-tracking database as a public health information system. The overall rate of cases was 50% higher than in 2000 and 40% higher than the rate of new long-term group disability insurance claims. The most common diagnostic categories remain musculoskeletal disorders, injuries and poisonings, mental health conditions, and neurological syndromes. Diagnosis rates have increased in every category since 2000. The tracking system provided unprecedented timeliness and data accessibility, but fell short of its full potential as a public health tool due to poor information quality. Improved interface design and data entry processes combined with improved reporting capability will enhance its epidemiological value. Continued system improvement requires functional evaluation in conjunction with periodic data analysis.