A summary of the U.S. Marine Recruit Assessment Program (RAP) procedures and survey from 2003 to 2021

The Recruit Assessment Program (RAP) is a cross-sectional, baseline survey of U.S. Marine recruits administered at Marine Corps Recruit Depot, San Diego. This report presents RAP study procedures and survey content that was administered to 229,015 participants between 2003 and 2021. Self-reported data were collected on recruit demographics, physical and mental health, adverse life experiences, lifestyle and risky behaviors, and substance use. In 2013, the survey was updated to remove questions with other linkable and reliable sources and those with low completion rates and low relevance to Marine health research; the removal of these items allowed for the addition of instrument measures for major depression, post-traumatic stress disorder, anger, and resilience with no significant change to overall survey length. Average completion rates are approximately 95%. Multiple studies have shown the utility of RAP data collected thus far as a robust data repository of pre-service health and behavioral measures.

Postdeployment Respiratory Health Care Encounters Following Deployment to Kabul, Afghanistan: A Retrospective Cohort Study

Inhalational hazards are numerous in operational environments. A retrospective cohort study was conducted to investigate associations between deployment to Kabul, Afghanistan and subsequent respiratory health among U.S. military personnel. The study population consisted of personnel who deployed to Kabul, select Operation Enduring Freedom locations, personnel stationed in the Republic of Korea, and U.S.-stationed personnel. Incidence rate ratios (IRRs) were estimated for respiratory symptoms, signs, and ill-defined conditions, asthma, and chronic obstructive pulmonary disease. A significantly elevated rate of symptoms, signs, and ill-defined conditions was observed among Kabul-deployed personnel compared to personnel deployed or stationed in Bagram (IRR 1.12; 95% confidence interval [CI], 1.05-1.19), Republic of Korea (IRR 1.20; 95% CI, 1.10-1.31), and the United States (IRR 1.52; 95% CI, 1.43-1.62). A statistically elevated rate of asthma was observed among personnel deployed to Kabul, relative to U.S.-stationed personnel (IRR 1.61; 95% CI, 1.22-2.12). Statistically significant rates were not observed for chronic obstructive pulmonary disease among Kabul-deployed personnel compared to other study groups. These findings suggest that deployment to Kabul is associated with an elevated risk of postdeployment respiratory symptoms and new-onset asthma.

Neuropsychiatric Outcomes After Mefloquine Exposure Among U.S. Military Service Members

Mefloquine was widely prescribed to U.S. military service members until 2009 when use was limited to personnel with contraindications to doxycycline and no contraindications to mefloquine. The need to estimate the occurrence of neuropsychiatric outcomes (NPOs) in service members prescribed mefloquine warranted a comprehensive evaluation of this issue. Active component service members filling a prescription for mefloquine, doxycycline, or atovaquone/proguanil (A/P) between January 1, 2008 and June 30, 2013, were included in the analysis. The risk of developing incident NPOs and the risk of subsequent NPOs among subjects with a history of the condition were assessed. A total of 367,840 individuals were evaluated (36,538 received mefloquine, 318,421 received doxycycline, and 12,881 received A/P). Among deployed individuals prescribed mefloquine, an increased risk of incident anxiety was seen when compared with doxycycline recipients (incidence rate ratio [IRR] = 1.12 [1.01-1.24]). Among nondeployed mefloquine recipients, an increased risk of posttraumatic stress disorder (PTSD) was seen when compared with A/P recipients (IRR = 1.83 [1.07-3.14]). An increased risk of tinnitus was seen for both deployed and nondeployed mefloquine recipients compared with A/P recipients (IRR = 1.81 [1.18-2.79]), 1.51 (1.13-2.03), respectively). Six percent of the mefloquine cohort had an NPO in the year before receiving mefloquine. When comparing individuals with a prior neuropsychiatric history to those without, the ratio of relative risks for adjustment disorder, anxiety, insomnia, and PTSD were higher (not statistically significant) for mefloquine compared with doxycycline. These findings emphasize the continued need for physicians prescribing mefloquine to conduct contraindication screening.

Deployment-Associated Exposure Surveillance With High-Resolution Metabolomics

OBJECTIVE

The aim of this study was to assess the suitability of high-resolution metabolomics (HRM) for measure of internal exposure and effect biomarkers from deployment-related environmental hazards.

METHODS

HRM provides extensive coverage of metabolism and data relevant to a broad spectrum of environmental exposures. This review briefly describes the analytic platform, workflow, and recent applications of HRM as a prototype environmental exposure surveillance system.

RESULTS

Building upon techniques available for contemporary occupational medicine and exposure sciences, HRM methods are able to integrate external exposures, internal body burden of environmental agents, and relevant biological responses with health outcomes.

CONCLUSIONS

Systematic analysis of existing Department of Defense Serum Repository samples will provide a high-quality, cross-sectional reference dataset for deployment-associated exposures while at the same time establishing a foundation for precision medicine.

The Challenges of Implementing Next Generation Sequencing Across a Large Healthcare System, and the Molecular Epidemiology and Antibiotic Susceptibilities of Carbapenemase-Producing Bacteria in the Healthcare System of the U.S. Department of Defense

OBJECTIVE

We sought to: 1) provide an overview of the genomic epidemiology of an extensive collection of carbapenemase-producing bacteria (CPB) collected in the U.S. Department of Defense health system; 2) increase awareness of the public availability of the sequences, isolates, and customized antimicrobial resistance database of that system; and 3) illustrate challenges and offer mitigations for implementing next generation sequencing (NGS) across large health systems.

DESIGN

Prospective surveillance and system-wide implementation of NGS.

SETTING

288-hospital healthcare network.

METHODS

All phenotypically carbapenem resistant bacteria underwent CarbaNP® testing and PCR, followed by NGS. Commercial (Newbler and Geneious), on-line (ResFinder), and open-source software (Btrim, FLASh, Bowtie2, an Samtools) were used for assembly, SNP detection and clustering. Laboratory capacity, throughput, and response time were assessed.

RESULTS

From 2009 through 2015, 27,000 multidrug-resistant Gram-negative isolates were submitted. 225 contained carbapenemase-encoding genes (most commonly blaKPC, blaNDM, and blaOXA23). These were found in 15 species from 146 inpatients in 19 facilities. Genetically related CPB were found in more than one hospital. Other clusters or outbreaks were not clonal and involved genetically related plasmids, while some involved several unrelated plasmids. Relatedness depended on the clustering algorithm used. Transmission patterns of plasmids and other mobile genetic elements could not be determined without ultra-long read, single-molecule real-time sequencing. 80% of carbapenem-resistant phenotypes retained susceptibility to aminoglycosides, and 70% retained susceptibility to fluoroquinolones. However, among the CPB-confirmed genotypes, fewer than 25% retained susceptibility to aminoglycosides or fluoroquinolones.

CONCLUSION

Although NGS is increasingly acclaimed to revolutionize clinical practice, resource-constrained environments, large or geographically dispersed healthcare networks, and military or government-funded public health laboratories are likely to encounter constraints and challenges as they implement NGS across their health systems. These include lack of standardized definitions and quality control metrics, limitations of short-read sequencing, insufficient bandwidth, and the current limited availability of very expensive and scarcely available sequencing platforms. Possible solutions and mitigations are also proposed.

Use of quadrivalent human papillomavirus vaccine and the prevalence of antibodies to vaccine-targeted strains among female service members before and after vaccination

The quadrivalent human papillomavirus vaccine (HPV4) has been shown to generate a robust immune response among fully vaccinated individuals; however, among U.S. service members, HPV vaccine completion rates are low. This study compared the immunogenicity of HPV4 vaccine among partially and fully vaccinated service members at 4-6 years post-vaccination. A random sample was obtained of 2,091 female service members, aged 17-26 years, who received 1-3 HPV4 doses during 2006-2012, stratified by number of doses (one, two, or three). Pre- and post-immunization sera from these service members were tested for antibodies to the HPV strains covered by the vaccine. Prior to immunization 42% were seropositive for HPV strain 6; 34% for strain 11; 29% for strain 16; and 16% for strain 18. Among those naive to all four strains prior to immunization, there was 100% seroconversion after one, two, or three doses. The results indicate that many service members had already been exposed to strains of HPV prior to receiving the vaccine; however, seropositivity prevalence was lower for the oncogenic HPV strains 16 and 18. The data demonstrate sustained immunogenicity after a single dose of vaccine, with modest improvement with successive doses for all strains except 18.

Incident and recurrent Chlamydia trachomatis and Neisseria gonorrhoeae infections, active component, U.S. Armed Forces, 2010-2014

Chlamydia trachomatis and Neisseria gonorrhoeae infections impose a significant clinical and public health burden on the Military Health System. Repeat infections contribute significantly to that burden. This report summarizes rates and relative risks of true incident (i.e., initial or "first time ever") and recurrent (i.e., repeat) chlamydia and gonorrhea infections among active component members between 1 January 2010 and 31 December 2014. During the surveillance period, a total of 66,396 initial chlamydia and 9,138 initial gonorrhea cases were diagnosed. Annual crude rates of initial chlamydia infections increased by 23%. Crude rates of initial gonorrhea infections remained stable overall, but female rates decreased by 28.3% over the period. Among the incident cohorts, 11,699 cases of repeat chlamydia, and 1,138 cases of repeat gonorrhea were diagnosed over the period, accounting for 15.0% and 11.1% of overall cohort chlamydia and gonorrhea infections, respectively. The Army branch, those aged 17-19 years, females, non-Hispanic black service members, junior enlisted ranks, and single/never-married service members had the highest crude rates of initial chlamydia and gonorrhea infection, and (single/never-married service members excepted) highest adjusted relative risk of repeat chlamydia infection.

Urinary Tract Infections in Active Component U.S. Armed Forces Women Before and After Routine Screening Pap Examination

It has been suggested that Pap tests, when used as surrogate markers for routine pelvic examinations in asymptomatic women, may be associated with an increased short-term risk of urinary tract infections (UTIs). This retrospective cohort study used Defense Medical Surveillance System (DMSS) data from 2007 through 2013 to compare the incidence of UTIs in active component women before and after receiving a routine screening Pap examination. The pre-Pap (baseline) UTI incidence rate in this cohort was 105.9 per 1,000 person-years (p-yrs) compared to 129.8 per 1,000 p-yrs post-Pap; the rate ratio was 1.23 (95% CI: 1.18-1.27). The adjusted relative risk of UTI post-Pap was 1.14 (95% CI: 1.10-1.18) and the adjusted percentage of UTIs attributable to a Pap test in the post-exposure period was 12.2% (95% CI: 9.1-15.2). Routine Pap tests, when used as a surrogate marker for pelvic examination, may be a modifiable risk factor for UTI in active component U.S. military women.

Characterizing the relationship between tick bites and Lyme disease in active component U.S. Armed Forces in the eastern United States

Lyme disease (LD) is the most commonly diagnosed vector-borne illness in the U.S. Analysis of ticks that are removed from patients (rather than collected from the environment) may inform LD surveillance. In this ecological study, LD rates among active component U.S. Armed Forces in the eastern U.S. were compared with tick data from the U.S. Army Public Health Command Human Tick Test Kit Program (HTTKP) covering the same geographic region. In the population of service members in the study sample, mean annual LD incidence was 52.2 per 100,000 person-years (95% CI±; 7.6 per 100,000) between 1 January 2006 and 31 December 2012. A 10% increase in the rate of ticks submitted to the HTTKP corresponded to an increase in LD incidence of 5.7% (p<0.01). Where Borrelia burgdorferi infection of Ixodes scapularis ticks was high (20% or greater tick infection prevalence), tick removal rates explained 53.7% of the annual variation in LD incidence (p=0.01). These data support using location-specific rates of ticks removed while feeding on active component service members to complement LD surveillance.

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.

Risk of type II diabetes and hypertension associated with chronic insomnia among active component, U.S. Armed Forces, 1998-2013

Chronic insomnia is a common clinical complaint and its incidence in both U.S. military and civilian populations has increased. Several studies have evaluated the association between chronic insomnia and the development of other chronic diseases. This study estimates the incidence of chronic insomnia. In addition, this report examines the association between both hypertension and type II diabetes and chronic insomnia in active component military members. The Defense Medical Surveillance System was used to identify a cohort of individuals with chronic insomnia between 1998 and 2013 and to match them by age and gender with a cohort without insomnia. During 1998-2013, there were 205,740 incident cases of chronic insomnia among active component service members with an overall rate of 90.3 per 10,000 person-years. Individuals in the chronic insomnia cohort were at higher risk for type II diabetes (adjusted hazard ratio [HR], 2.17 [95% CI, 1.75-2.69]) and hypertension (adjusted HR, 2.00 [95% CI, 1.85-2.16]). Sleep hygiene education along with evaluation and treatment of persistent symptoms are of public health importance in active duty service members.

Fractures among active component, recruit trainees, and deployed service members, U.S. Armed Forces, 2003-2012

Injuries are the leading cause of healthcare encounters and lost work days among military service members in the U.S. Armed Forces. Fractures often entail a lengthy recovery time and can affect the operational ability of both the individual and the unit. From 1 January 2003 through 31 December 2012, active component service members were diagnosed with 244,248 incident fractures (19.4 per 1,000 person-years[p-yrs]). Hand and foot/ankle fractures were the most common types. During the same surveillance period, recruit trainees were diagnosed with 18,773 incident fractures (66.0 per 1,000 p-yrs). Annual incidence rates among trainees declined 38% from 2003 to 2012. Stress fractures were the most common type in this population. From 1 January 2008 through 31 December 2012, deployed service members were diagnosed with 12,328 incident fractures (16.5 per 1,000 p-yrs). The most common sites of fracture among the deployed population were of the hand, foot/ankle, and arm. Comments address preventive interventions, stress fractures in trainees, gender differences in incidence, and limitations of the study.

U.S. Armed Forces air crew: incident illness and injury diagnosis during the 12 months prior to retirement, 2003-2012

U.S. Armed Services retirees are eligible for disability compensation for medical illness/injury incurred during their service. This analysis of recently retired U.S. active component air crew/aviation service members from all Services evaluated incident diagnoses among aviation retirees during the 12 months prior to retirement and assessed trends in first-time diagnoses by major diagnostic category and aviation component stratification. Most aviation retirees were in their 40s, Air Force, male, white, and senior officers and warrant officers. Among the study population, 14,191 (88%) of aviation retirees had at least one first-time diagnosis recorded during the 12 months prior to retirement. During 2003-2012, 63.8% of all diagnoses in aviation retirees during the 12 months prior to retirement were new. The highest proportions of new diagnoses were for "other disorders of the ear," "organic sleep disorders," and "general symptoms." Among the four subtypes of aviators, general air crew/air craft crew had the lowest proportion of new diagnoses (60.2%).

Depression and suicidality during the postpartum period after first time deliveries, active component service women and dependent spouses, U.S. Armed Forces, 2007-2012

Although suicide is a leading cause of death among new mothers during the postpartum period, there has been limited research on self-harm in the postpartum period and associated risk factors. One potential risk factor for suicidality (completed suicides, suicide attempts, and suicide ideation including thoughts of self harm) during the postpartum period is postpartum depression (PPD). In this study of women who gave birth for the first time between 1 January 2007 and 31 December 2011, 5,267 (9.9% of all who delivered) active component service women and 10,301 (8.2%) dependent spouses received incident PPD diagnoses during the one year postpartum period; 213 (0.4%) service women and 221 (0.2%) dependent spouses were diagnosed with incident suicidality. After adjusting for the effects of other covariates, service women with PPD had 42.2 times the odds to be diagnosed with suicidality in the postpartum period compared to service women without PPD; dependent spouses with PPD had 14.5 times the odds compared to those without PPD. The findings of this report suggest that a history of mental disorders was common among service women and dependent spouses with PPD in the postpartum period, and, in turn, PPD was a strong predictor for suicidality in the postpartum period. These results emphasize the importance of PPD screening during the postpartum period. They also suggest that additional focused screening for suicidal behavior among those already diagnosed with PPD may be warranted.

Pelvic inflammatory disease among female recruit trainees, active component, U.S. Armed Forces, 2002-2012

Pelvic inflammatory disease (PID) is a bacterial infection causing an inflammatory reaction in the upper genital tract. It can be treated with antibiotics, but since it is often asymptomatic, women often delay seeking health care, which may result in long-term sequelae such as infertility. Among 161,501 female recruits who began basic training between January 2002 and December 2011, 1,750 (1.1%) met the surveillance case definition for PID during the 12 months following completion of their basic military training. The overall incidence rate (11.2 per 1,000 person-years) showed a stable trend during the surveillance period, with the exception of a decline for females accessed in 2011. The unadjusted rates were higher among women who were not screened for chlamydia during basic training. Compared to their respective counterparts, rates were higher in service women aged 17-20, of black, non-Hispanic race/ethnicity, married, in the Army, and who had a chlamydia diagnosis after basic training. The lowest rates were among women 25 years and older, other race/ethnicity, and in the Coast Guard. The findings in this report may warrant further evaluation of the long-term impact of chlamydia screening programs for recruit trainees on PID and PID-related sequelae among service women.

Mental disorders and mental health problems among recruit trainees, U.S. Armed Forces, 2000-2012

Annual counts and rates of incident diagnoses of mental disorders or mental health problems have increased in the U.S. military active component since 2000, but less is known about recruit trainees. From 2000 to 2012, 49,999 active component recruit trainees were diagnosed with at least one mental disorder, and 7,917 had multiple mental disorder diagnoses. Annual incidence rates of at least one mental disorder decreased by approximately 37.4 percent over the last 13 years. Approximately 80.5 percent of all incident mental disorder diagnoses were attributable to adjustment disorders, depression and "other" mental disorders. Rates of incident mental disorder diagnoses were higher in females than males. Even though the Army had the highest overall incidence rates of mental disorders, the Air Force had slightly higher rates for adjustment disorder, and the Navy had higher rates of alcohol abuse-related disorders, post-traumatic stress disorder (PTSD), anxiety, other psychoses, and personality disorders. These findings document differences in the mental disorders experienced by recruit trainees compared to members of the active component of the U.S. military overall. Continued focus on detection and treatment of mental health issues during basic training is warranted.

Quality of diet related to food insecurity and food stamps use among older people

We explore the association between quality of diet and food security status among older persons. Cross-sectional survey of large national samples, from the National Health & Nutrition Examination Surveys (1988-1994 & 2001-2002), in the United States. A total of 5,039 and 2,040 men and women aged 60 and older, respectively. The dependent variable was the healthy eating index (HEI; 2000 and 2005) as a measure of diet quality. The independent variable of interest was food security status and was categorized as food secure, food insecurity receiving food stamps and food insecurity not receiving food stamps. In multivariate analyses, food insecure individuals not receiving food stamps had lower total HEI-2000 scores compared to food secure individuals (b=-3.91, SE=1.81, P=0.0310). Factors independently associated with high HEI (2000 or 2005) scores were female gender, being married, highly educated or wealthy, with very good/ excellent perceived health, or without functional limitations. Food secure individuals had better quality of diet than food insecure individuals. Among food insecure individuals, receiving food stamps was not associated with diet quality. Food insecure families with older individuals may need new methods of dissemination of food and nutrition programs – methods that yield positive and promising changes in the health status of this special population group.

Hydration status of Air Force military basic trainees after implementation of the back-mounted hydration system

The Air Force makes an extraordinary effort to prevent heat-related illnesses associated with basic military training (BMT) in south Texas. However, inadequate hydration can still contribute to lost training time and qualified trainees leaving military service without completing BMT. The purpose of the present study was to determine whether equipping BMTs with back-mounted hydration systems (BM) is better than the standard-issue (SI) canteens with respect to hydration status. Male BMTs were randomly assigned to either BM (n = 40) or SI (n = 38) groups. Baseline values were assessed at week 0 before any physical readiness training (PRT). Subsequent data collection took place in the a.m. before PRT and in the p.m. before dinner the first 3 weeks, and during the 5 weeks of training. BMT total body water (TBW) and body composition were assessed by bioelectrical impedance. Saliva osmolality and total protein concentration were also determined. Hydration status increased daily in BM and SI and was well maintained over the duration of BMT. A significant hydration effect (p < 0.05) was observed for average daily increases in TBW and body weight with BM gaining more compared to SI. Average a.m. TBW was 0.3-0.8 L greater in SI versus BM (p < 0.05). Our findings demonstrate that adequate hydration status is maintained during Air Force BMT in a hot environment using either hydration mode and therefore do not support widespread issuance of the BM system on the premise of improved hydration during USAF BMT military training.