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1.  Incidence of Carpal Tunnel Syndrome in the US Military Population 
Hand (New York, N.Y.)  2009;4(3):289-293.
Carpal tunnel syndrome (CTS) is a common disease. Its epidemiology has been evaluated previously, mostly in regional populations or in working groups, with an incidence between 1.5 and 3.5 per 1,000 person-years. We studied this diagnosis in the US military population, with the hypothesis that this young population would have a lower incidence of CTS than previously reported in general populations. The Defense Medical Epidemiology Database notes all medical encounters for all US military personnel and maintains the number of all personnel on active duty each year. We queried the database using the International Classification of Diseases, ninth revision, code 354.0 (CTS) and analyzed the personnel presenting for initial visits for the years 1998–2006. Multivariate Poisson analysis was performed, controlling for rank, gender, age, and race. The raw incidence of CTS in the US military was 3.98 per 1,000 person-years, in a population of 12,298,088 person-years. Females had a significantly higher incidence of CTS than males, with an adjusted incidence rate ratio of 3.29. CTS incidence increased by age, with the age group ≥40 years having a significantly higher incidence. Additionally, military rank was found to be an independent risk factor for CTS, with rates higher in senior officer and enlisted groups. This suggests that occupational requirements have an effect on CTS within the military. We showed a comparable incidence of CTS between the US military and general population, with a significantly higher female cohort with a diagnosis of CTS. Increased age and advanced rank were risk factors for CTS.
PMCID: PMC2724617  PMID: 19172361
Carpal tunnel syndrome; Epidemiology; Military
2.  Epidemiology of Hemorrhagic Fever with Renal Syndrome in Korea, 2001-2010 
Journal of Korean Medical Science  2013;28(10):1552-1554.
This study describes the epidemiology of hemorrhagic fever with renal syndrome (HFRS) in the past 10 yr (2001-2010) in Korea. During this period, a total of 3,953 HFRS patients and an average prevalence rate of 0.81 per 100,000 population were recorded, with a total of 40 fatal cases, corresponding to a case fatality rate of 1.01%. More HFRS cases were found in men than in women (57% vs 43%), and a higher prevalence rate of HFRS was observed in patients older than 40 yr (82.1%). The highest numbers of HFRS cases were found amongst farmers (35.6%). The majority of HFRS cases (71.3%) occurred in the last quarter of the calendar year (October to December). More HFRS cases occurred in the western part than in the eastern part of Korea (68.9% vs 31.1%). The incidence of HFRS was significantly higher (P < 0.001) in rural areas than in urban areas (80.3% vs 19.7%). HFRS still occurs commonly among men, in autumn, and in western rural area of Korea.
PMCID: PMC3792615  PMID: 24133366
Hemorrhagic Fever with Renal Syndrome; Epidemiology; Autumn; Rural Area
3.  Ongoing Spillover of Hantaan and Gou Hantaviruses from Rodents Is Associated with Hemorrhagic Fever with Renal Syndrome (HFRS) in China 
Longquan City, Zhejiang province, China, has been seriously affected by hemorrhagic fever with renal syndrome (HFRS) since the first cases were registered in 1974. To understand the epidemiology and emergence of HFRS in Longquan, which may be indicative of large parts of rural China, we studied long-term incidence patterns and performed a molecular epidemiological investigation of the causative hantaviruses in human and rodent populations.
Method/Principal Findings
During 1974–2011, 1866 cases of HFRS were recorded in Longquan, including 20 deaths. In 2011, the incidence of HFRS remained high, with 19.61 cases/100,000 population, despite the onset of vaccination in 1997. During 1974–1998, HFRS cases in Longquan occurred mainly in winter, while in the past decade the peak of HFRS has shifted to the spring. Notably, the concurrent prevalence of rodent-borne hantaviruses in the region was also high. Phylogenetic analyses of viral sequences recovered from rodents in Longquan revealed the presence of novel genetic variants of Gou virus (GOUV) in Rattus sp. rats and Hantaan virus (HTNV) in the stripe field mice, respectively. Strikingly, viral sequences sampled from infected humans were very closely related to those from rodents.
HFRS represents an important public health problem in Longquan even after years of preventive measures. Our data suggest that continual spillover of the novel genetic variant of GOUV and the new genetic lineage of HTNV are responsible for the high prevalence of HFRS in humans. In addition, this is the first report of GOUV associated with human HFRS cases, and our data suggest that GOUV is now the major cause of HFRS in this region.
Author Summary
Hemorrhagic fever with renal syndrome (HFRS) is a major public health problem in China despite human vaccination. We investigated the epidemiology and emergence of HFRS in Longquan (Zhejiang Province), a rural area with a high incidence of HFRS. During 1974–2011, a total of 1866 cases of HFRS were recorded in Longquan, including 20 deaths. Strikingly, phylogenetic analyses of viral sequences sampled from local rodents in Longquan revealed the presence of novel variants of Gou virus (GOUV) in Rattus sp. rats and Hantaan virus (HTNV) in the stripe field mice, respectively. Moreover, viral sequences sampled from infected humans in Longquan were very closely related to those from rodents. Overall, these data indicate that there is a continual spillover GOUV and HTNV from rodents to humans in Longquan, and this might be responsible for the high prevalence of HFRS. As well as highlighting the importance of the human-animal interface, these data also suggest that GOUV is now the major cause of HFRS in this region.
PMCID: PMC3798614  PMID: 24147168
4.  Multiple physical symptoms in a military population: a cross-sectional study 
Medically unexplained symptoms have been reported among both civilians and military personnel exposed to combat. A large number of military personnel deployed to the Gulf War in 1991 reported non-specific symptoms. These symptoms did not constitute a clearly defined syndrome. Post-traumatic stress disorder (PTSD) and to a lesser degree exposure to combat are associated with physical symptoms.
This is a cross-sectional study of representative samples of Sri Lanka Navy Special Forces and regular forces deployed in combat areas continuously during a 1-year period. Multiple physical symptoms were elicited using a checklist of 53 symptoms. Cases were defined as individuals with ten or more symptoms. Symptoms of common mental disorder were identified using the General Health Questionnaire 12 (GHQ-12). PTSD was diagnosed using the 17-item National Centre for PTSD checklist civilian version.
Prevalence of multiple physical symptoms was 10.4% (95% CI 8.11–12.75). Prevalence was significantly less in the Special Forces (5.79%) than in the regular forces (13.35%). The mean number of symptoms reported by those who met the criteria for PTSD was 12.19 (SD 10.58), GHQ caseness 7.87 (SD 7.57) and those without these conditions 2.84 (SD 3.63). After adjusting for socio-demographic and service variables, ‘thought I might be killed’ , ‘coming under small arms fire’ , and ‘coming under mortar, missile and artillery fire’ remained significant. Multiple physical symptoms were associated with functional impairment and poor perceived general health.
Prevalence of multiple physical symptoms was significantly lower in the Special Forces despite high exposure to potentially traumatic events. More multiple physical symptoms were reported by personnel with PTSD and common mental disorders. Multiple physical symptoms were associated with functional impairment.
PMCID: PMC3718653  PMID: 23866109
Trauma; Stress; Stress disorders; Post-traumatic; Military personnel; Special forces; War; Sri Lanka
5.  Incidence of insulin-requiring diabetes in the US military 
Diabetologia  2009;52(10):2087-2091.
The aim of the study was to determine age- and race-related, and overall incidence rates of insulin-requiring diabetes in adults in the US military.
Electronic records for admissions to US military and Tricare hospitals during 1990–2005 and visits to military clinics during 2000–2005 were identified using the Career History Archival Medical and Personnel System at the Naval Health Research Center, San Diego, CA, USA. Population data were obtained from the Defense Manpower Data Center and Defense Medical Epidemiology Database.
In men there were 2,918 new cases of insulin-requiring diabetes in 20,427,038 person-years at ages 18–44 years (median age 28 years) for a total age-adjusted incidence rate of 17.5 per 100,000 person-years (95% CI 16.4–18.6). Incidence rates were twice as high in black men as in white men (31.5 vs 14.5 per 100,000, p < 0.001). In women there were 414 new cases in 3,285,000 person-years at ages 18–44 years (median age 27 years), for a total age-adjusted incidence rate of 13.6 per 100,000 (95% CI 12.4–14.9). Incidence rates were twice as high in black women as in white women (21.8 vs 9.7 per 100,000, p < 0.001). In a regression model, incidence of insulin-requiring diabetes peaked annually in the winter–spring season (OR 1.46, p < 0.01). Race and seasonal differences persisted in the multivariate analysis.
Differences in incidence rates by race and season suggest a need for further research into possible reasons, including the possibility of a contribution from vitamin D deficiency. Cohort studies using prediagnostic serum 25-hydroxyvitamin D should be conducted to further evaluate this relationship.
Electronic supplementary material
The online version of this article (doi:10.1007/s00125-009-1449-x) contains supplementary material which is available to authorised users.
PMCID: PMC2744779  PMID: 19629431
Incidence rates; Insulin-requiring diabetes; Race; Seasonality; Sex; Vitamin D; Young adults
6.  A civilian-military partnership to reduce the incidence of gonorrhea. 
Public Health Reports  1985;100(1):61-65.
To reduce the incidence of gonorrhea in the Colorado Springs, Colo., area, casefinding measures (interviewing of patients and tracing of contacts) were conscientiously applied by the local health department, in cooperation with the U.S. Army, to more than 90 percent of reported cases during a 3-year period. Nearly 4,000 cases of gonorrhea--2,127 civilian and 1,811 military--were interviewed; they named 7,399 contacts. A total of 1,141 cases of gonorrhea were newly identified and patients brought to treatment in Colorado Springs as a result. Implementation of these measures was associated with a 12.9 percent overall decline in gonorrhea incidence. This decline was most pronounced in the civilian population (20 percent), while little change in incidence occurred in the military population. The data presented suggest that the orderly application of casefinding epidemiology, allied with other control program initiatives, can interrupt transmission of, and prevent, disease.
PMCID: PMC1424709  PMID: 3918326
7.  Hantaviruses in Rodents and Humans, Inner Mongolia Autonomous Region, China 
Emerging Infectious Diseases  2009;15(6):885-891.
Vigilance is needed to prevent hemorrhagic fever renal syndrome caused by Hantaan and Seoul viruses in this region.
Surveys were carried out in 2003–2006 to better understand the epidemiology of hantaviruses in the Inner Mongolia Autonomous Region of China (Inner Mongolia). Hemorrhagic fever with renal syndrome (HFRS) was first reported in this region in 1955 and has been an important public health problem here since then. During 1955–2006, 8,309 persons with HFRS were reported in Inner Mongolia (average incidence rate 0.89/100,000), and 261 (3.14%) died. Before the 1990s, all HFRS cases occurred in northeastern Inner Mongolia. Subsequently, HFRS cases were registered in central (1995) and western (1999) Inner Mongolia. In this study, hantaviral antigens were identified in striped field mice (Apodemus agrarius) from northeastern Inner Mongolia and in Norway rats (Rattus norvegicus) from middle and western Inner Mongolia. Phylogenetic analysis of hantaviral genome sequences suggests that HFRS has been caused mainly by Hantaan virus in northeastern Inner Mongolia and by Seoul virus in central and western Inner Mongolia.
PMCID: PMC2727351  PMID: 19523286
Viruses; zoonoses; hemorrhagic fever with renal syndrome; hantavirus; Hantaan virus; Seoul virus; China; Mongolia; research
8.  Plasmodium vivax Malaria: Status in the Republic of Korea Following Reemergence 
The Korean Journal of Parasitology  2009;47(Suppl):S39-S50.
The annual incidence of Plasmodium vivax malaria that reemerged in the Republic of Korea (ROK) in 1993 increased annually, reaching 4,142 cases in 2000, decreased to 864 cases in 2004, and once again increased to reach more than 2,000 cases by 2007. Early after reemergence, more than two-thirds of the total annual cases were reported among military personnel. However, subsequently, the proportion of civilian cases increased consistently, reaching over 60% in 2006. P. vivax malaria has mainly occurred in the areas adjacent to the Demilitarized Zone, which strongly suggests that malaria situation in ROK has been directly influenced by infected mosquitoes originating from the Democratic People's Republic of Korea (DPRK). Besides the direct influence from DPRK, local transmission within ROK was also likely. P. vivax malaria in ROK exhibited a typical unstable pattern with a unimodal peak from June through September. Chemoprophylaxis with hydroxychloroquine (HCQ) and primaquine, which was expanded from approximately 16,000 soldiers in 1997 to 200,000 soldiers in 2005, contributed to the reduction in number of cases among military personnel. However, the efficacy of the mass chemoprophylaxis has been hampered by poor compliance. Since 2000, many prophylactic failure cases due to resistance to the HCQ prophylactic regimen have been reported and 2 cases of chloroquine (CQ)-resistant P. vivax were reported, representing the first-known cases of CQ-resistant P. vivax from a temperate region of Asia. Continuous surveillance and monitoring are warranted to prevent further expansion of CQ-resistant P. vivax in ROK.
PMCID: PMC2769212  PMID: 19885334
Plasmodium vivax; malaria; Republic of Korea; reemergence; demilitarized zone; local transmission; unstable malaria; chemoprophylaxis; chloroquine-resistance
9.  Epidemiology of CLOSTRIDIUM DIFFICILE infection among active duty United States military personnel (1998-2010) 
BMC Infectious Diseases  2013;13:609.
Clostridium difficile associated disease (CDAD) has risen in incidence and the experience in the US military has not been described.
We evaluated the U.S. military’s database and identified CDAD cases and demographic characteristics among affected military personnel from 1998 to 2010.
2,423 cases were identified. CDAD incidence was 13.2 cases (95% CI: 12.7-13.7) per 100 K p-yr and increased over study years. CA-CDAD and HA-CDAD incidence was 5.5 (95% CI: 5.2, 5.9) per 100 K p-y and 1.3 (95% CI: 1.2, 1.4) per 1,000 hospitalizations respectively. Females comprised a larger proportion of CA-CDAD than HA-CDAD (25.5% vs. 19.3%; p < 0.001) cases as did Air Force service (29% vs. 23.4%; p < 0.01). On multivariate analysis female gender, Coast Guard or Air Force service, and a married status was associated with CA-CDAD whereas Male gender and Marine Corps service were associated with HA-CDAD cases.
CDAD has increased among military personnel, with female cases more likely to be community associated. Gender, marital status and branch of service had the strongest association with CDAD subtype. Further work is needed to evaluate the epidemiologic factors that have led to these increased rates in otherwise low-risk populations and associated sequelae.
PMCID: PMC3880161  PMID: 24373384
Clostridium difficile; C difficile; Clostridium difficile associated disease; Epidemiology; US military
10.  Seroincidence of Coccidioidomycosis during Military Desert Training Exercises 
Journal of Clinical Microbiology  2004;42(10):4552-4555.
Coccidioidomycosis is a common fungal infection acquired in the southwestern United States. This is the first study in over 2 decades to determine the seroincidence of Coccidioides immitis infections among U.S. military members performing training exercises in an area of endemicity. Only 8% of participants were aware of coccidioidomycosis, despite the majority having visited or lived previously in an area of endemicity. One (0.6%) of the 178 participants developed “definite” serologic evidence of infection over a 5-week training period; four (2.3%) additional patients developed “possible” coccidioidomycosis infections. None had complicated disease. The calculated annual incidence ranged from 6 to 32%. This study suggests that the risk of serious coccidioidomycosis is low among military personnel during desert training exercises; however, disease incidence may vary depending on specific activities and geographic factors. Due to the potential morbidity and mortality of this infection, preventative strategies, including vaccine development, are advocated.
PMCID: PMC522372  PMID: 15472308
11.  Hepatitis E Virus Seroprevalence in Austrian Adults: A Nationwide Cross-Sectional Study among Civilians and Military Professionals 
PLoS ONE  2014;9(2):e87669.
Hepatitis E Virus (HEV) infection is globally increasing. The present study was performed to investigate the HEV seroprevalence, exposure risks as well as occupational risks for military personnel in Austria, a Central European country.
Methods and Findings
A nationwide cross-sectional seroprevalence study was performed in 997 healthy Austrian adults, professional soldiers and civilians. Routine laboratory and HEV specific antibodies were determined. In addition, epidemiological information on possible risk factors for exposure to HEV was obtained. The overall seropositivity for HEV antibodies was 14.3% and significantly increased with age. Seroprevalence was significantly higher among individuals with previous military employments abroad (21.4% vs. 9.9%) and among professional soldiers aged 30–39 years (20.2% vs. 7.3%). No association was found for private travel, occupational or private animal contact or regular outdoor activities. Individuals who tested positive for antibodies against HEV had significantly higher laboratory values regarding liver enzymes, lipid levels and blood fasting glucose.
Exposure to HEV is common in Austria. Military employment abroad could be a potential risk factor for HEV infection. Further studies are required to investigate the significance of pathological laboratory results found among asymptomatic individuals previously exposed to HEV.
PMCID: PMC3912018  PMID: 24498349
12.  A Prospective Study of Acute Diarrhea in a Cohort of United States Military Personnel on Deployment to the Multinational Force and Observers, Sinai, Egypt 
To better understand the epidemiology of diarrhea in deployed personnel to the Middle East, a prospective cohort study of travelers' diarrhea (TD) was conducted between May 2004 and January 2005 at the Multinational Force and Observers (MFO) camp in the southern Sinai. A baseline entry questionnaire and stool specimen was provided on study entry, and volunteers were followed every 6 weeks. Of 211 volunteers, 145 (68.7%) completed one or more follow-up visits. In total, 416 follow-up surveys were completed, which described an overall incidence of 25.2 episodes per 100 person months (95% confidence interval = 21.2–30.0). Additionally, stools were collected in 72 of 77 diarrhea-associated clinic visits, with bacterial pathogens most commonly isolated (enterotoxigenic Escherichia coli in 30 [42%] samples and Campylobacter jejuni in 7 [10%] samples) Despite modern preventive methods, diarrhea is still a common problem for deployed US military personnel in Egypt, frequently resulting in diminished ability to work.
PMCID: PMC3005493  PMID: 21212203
13.  Tickborne Relapsing Fever in Israel 
Emerging Infectious Diseases  2005;11(11):1784-1786.
We evaluated the epidemiology of relapsing fever from 1971 to 2003 in Israel. In civilians, incidence declined from 0.35 to 0.11 cases per 100,000 persons annually; in military personnel it averaged 6.4 cases per 100,000 persons annually. These data imply that the pathogen and vector continue to exist in Israel.
PMCID: PMC3367340  PMID: 16318740
relapsing fever; tickborne infections; caves; Israel; Ornithodoros; epidemiology; dispatch
14.  Economic Sanctions, Military Activity, and Road Traffic Crashes in Vojvodina, Serbia 
Political violence has not been examined as a risk factor for traumatic injuries from road traffic crashes. We identify trends in road traffic crashes related to war-related military activity and international economic sanctions in the Autonomous Province of Vojvodina, Serbia.
Overall road traffic crashes and crashes leading to hospitalization and fatality in Vojvodina, Serbia were examined from 1996 through 2001. Rates were calculated per 100,000 population and per 10,000 registered vehicles. Three time periods were examined: years with international sanctions and military activity; years with international sanctions but no military activity; and, years with neither sanctions nor military activity.
Compared to the period with neither sanctions nor military activity, severe injury crashes were 1.23 times more frequent (95% CI = 1.19 – 1.27) during the period with sanctions and military activity and 1.21 times more frequent (95% CI= 1.16 – 1.27) during the period with sanctions but no military activity.
Our data suggest that vehicle travel became safer following the end of military action and economic sanctions. Road traffic safety needs to be a priority both during periods of political unrest and its recovery phase.
PMCID: PMC2666017  PMID: 19074242
epidemiology; road traffic crashes; trauma; injury prevention
15.  Plasmodium vivax Malaria among Military Personnel, French Guiana, 1998–2008 
Emerging Infectious Diseases  2011;17(7):1280-1282.
We obtained health surveillance epidemiologic data on malaria among French military personnel deployed to French Guiana during 1998–2008. Incidence of Plasmodium vivax malaria increased and that of P. falciparum remained stable. This new epidemiologic situation has led to modification of malaria treatment for deployed military personnel.
PMCID: PMC3381416  PMID: 21762587
malaria; Plasmodium vivax; French Guiana; military personnel; parasites; vector-borne infections; dispatch
16.  Incidence and Risk Factors Associated with Meniscal Injuries Among Active-Duty US Military Service Members 
Journal of Athletic Training  2012;47(1):67-73.
Few population-based studies have examined the incidence of meniscal injuries, and limited information is available on the influence of patient's demographic and occupational factors.
To examine the incidence of meniscal injuries and the influence of demographic and occupational factors among active-duty US service members between 1998 and 2006.
Cohort study.
Using the International Classification of Diseases (9th revision) codes 836.0 (medial meniscus), 836.1 (lateral meniscus), and 836.2 (meniscus unspecified), we extracted injury data from the Defense Medical Surveillance System to identify all acute meniscal injuries among active-duty military personnel.
Patients or Other Participants:
Active-duty military personnel serving in all branches of military service during the study period.
Main Outcome Measure(s):
Incidence rate (IR) per 1000 person-years at risk and crude and adjusted rates by strata for age, sex, race, rank, and service.
During the study period, 100201 acute meniscal injuries and 12115606 person-years at risk for injury were documented. The overall IR was 8.27 (95% confidence interval [CI] = 8.22, 8.32) per 1000 person-years. Main effects were noted for all demographic and occupational variables (P< .001), indicating that age, sex, race, rank, and service were associated with the incidence of meniscal injuries. Men were almost 20% more likely to experience an acute meniscal injury than were women (incidence rate ratio = 1.18, 95% CI = 1.15, 1.20). The rate of meniscal injury increased with age; those older than 40 years of age experienced injuries more than 4 times as often as those under 20 years of age (incidence rate ratio = 4.25,95% CI = 4.08, 4.42).
The incidence of meniscal injury was sub-stantially higher in this study than in previously reported studies. Male sex, increasing age, and service in the Army or Marine Corps were factors associated with meniscal injuries.
PMCID: PMC3418117  PMID: 22488232
knee injuries; lower extremity injuries; military athletes; injury epidemiology
17.  Dengue and US Military Operations from the Spanish–American War through Today 
Emerging Infectious Diseases  2012;18(4):623-630.
Dengue may remain problematic for military personnel until an effective vaccine is licensed.
Dengue is a major cause of illness among travelers and a threat to military troops operating in areas to which it is endemic. Before and during World War II, dengue frequently occurred in US military personnel in Asia and the South Pacific. From the 1960s into the 1990s, dengue often occurred in US troops in Vietnam, the Philippines, Somalia, and Haiti. We found attack rates as high as 80% and periods of convalescence up to 3-1/2 weeks beyond the acute illness. The increase in dengue throughout the world suggests that it will remain a problem for military personnel until an effective vaccine is licensed.
PMCID: PMC3309667  PMID: 22469290
dengue; military personnel; history; fever; viruses; vector-borne infections; United States; Spanish–American War; military operations
18.  Viral Hepatitis: Problems of Incidence and Control in Military Personnel 1 
(A) Hepatitis B virus (HBV) is now the major cause of infectious viral hepatitis in U.S. military personnel and probably also in the civilian population over 15 years of age. (B) The incidence of icteric, viral hepatitis is much higher in U.S. military personnel than in comparable age groups in the civilian population. The 17-to 20-year-old enlisted men show the highest rates. (C) In parts of the world (e.g., U.S.A., Germany) where most of the inapparent infection is caused by the adw subtype of HBV, most of the acute clinical disease is caused by the ayw subtype. In the U.S.A. and Germany, 95% or more of HBs Ag isolates from U.S. military personnel with acute hepatitis is ayw. (D) It may be many years before one can expect to have sufficient data for a decision as to the possible availability of an effective HBV vaccine. Accordingly, a decision is urgently needed regarding either the immediate use of the best practically available hepatitis immune gamma globulin, that can be prepared by modern techniques, for the prevention of hepatitis in U.S. military personnel or postponement of such use until an adequate and properly controlled trial can be carried out in active duty military personnel in an area of high incidence.
PMCID: PMC2595361  PMID: 960730
19.  Malaria in Tunisian Military Personnel after Returning from External Operation 
Malaria Research and Treatment  2013;2013:359192.
Introduction. Malaria had been eliminated in Tunisia since 1979, but there are currently 40 to 50 imported cases annually. Soldiers are no exception as the incidence of imported malaria is increasing in Tunisian military personnel after returning from malaria-endemic area, often in Sub-Saharan Africa. Methods. We retrospectively analyzed the clinical and biological presentations, treatment, and outcomes of 37 Tunisian military personnel hospitalized at the Department of Internal Medicine, the Military Hospital of Tunis, between January 1993 and January 2011, for imported malaria. The clinical and laboratory features were obtained from the medical records and a questionnaire was filled by the patients about the compliance of malaria prophylaxis. Results. Thirty-seven male patients, with a mean age of 41 years, were treated for malaria infection. Twenty-two were due to Plasmodium falciparum. The outcome was favourable for all patients, despite two severe access. The long-term use of chemoprophylaxis has been adopted by only 21 (51%) of expatriate military for daily stresses. Moreover, poor adherence was found in 32 patients. Conclusion. The risk of acquiring malaria infection in Tunisian military personnel can largely be prevented by the regular use of chemoprophylactic drugs combined with protective measures against mosquito bites.
PMCID: PMC3676906  PMID: 23766922
20.  Increasing Incidence and Severity of Coccidioidomycosis at a Naval Air Station 
Military medicine  2008;173(8):769-775.
Increasing rates of coccidioidomycosis among the general population are being described. Given the large number of military personnel stationed and training in endemic areas, data regarding infection trends among military members would be informative.
We performed a retrospective epidemiologic study concerning the incidence and severity of clinical cases of coccidioidomycosis at a Naval base located in an endemic area in California.
Eighty-two military beneficiaries at the base were diagnosed with coccidioidomycosis from January 2002 to December 2006. Among active duty personnel, the rate of coccidioidomycosis rose 10-fold during the five-year study period: 29.88 to 313.71 cases per 100,000 person-years. The incidence of coccidioidal infections occurring in active duty members was higher than other military beneficiaries at the base. The median age of patients with a coccidioidal infection was 28 years, and 73% were male. Sixty-six had primary pulmonary disease, and 14 had disseminated disease; data were unavailable for two cases. The number of disseminated cases increased significantly over time; by 2006, 30% of the diagnosed cases were disseminated disease. Among cases of dissemination, 43% occurred among white/non-Hispanics. Disseminated disease was associated with high complement fixation titers and a more recent year of diagnosis. Although the sample size was small, we found no differences in rates of disseminated disease by race, likely due to the large number of cases among Caucasians.
Coccidioidomycosis incidence rates have significantly increased during the last five years among military beneficiaries. Active duty members were more likely to develop coccidioidomycosis than dependents or retirees, perhaps related to the number and intensity of exposures in this group.
PMCID: PMC2728023  PMID: 18751595
coccidioidomycosis; C. immitis; valley fever; military; epidemiology
21.  Alcohol use in a military population deployed in combat areas: a cross sectional study 
Alcohol misuse is more prevalent among military populations. Association between PTSD and heavy drinking have been reported in many studies. Most of the studies on alcohol use among military personnel are from US and UK. Aim of this study is to describe alcohol consumption patterns among military personnel in Sri Lanka, a country where the alcohol consumption among the general population are very different to that in US and UK.
Cross sectional study consisting of representative samples of Sri Lanka Navy Special Forces and regular forces deployed in combat areas continuously during a one year period was carried out. Data was collected using a self report questionnaire. Alcohol Use Disorder Identification Test (AUDIT) was used to assess alcohol consumption.
Sample consisted of 259 Special Forces and 412 regular navy personnel. The median AUDIT score was 2.0 (interquartile range 6.0). Prevalence of current drinking was 71.2 %. Of the current users 54.81 % were infrequent users (frequency ≤ once a month) while 37.87 % of users consumed 2–4 times a month. Prevalence of hazardous drinking (AUDIT ≥ 8) was 16.69 % and binge drinking 14.01 %. Five (0.75 %) had AUDIT total ≥20. There was no significant difference between Special Forces and regular forces in hazardous drinking or binge drinking. Total AUDIT score ≥16 were associated with difficulty performing work.
High rates of hazardous drinking and binge drinking described among military personnel in US and UK were not seen among SLN personnel deployed in combat areas. This finding contrasts with previously reported association between combat exposure and hazardous alcohol use among military personnel. Alcohol use among military personnel may be significantly influenced by alcohol consumption patterns among the general population, access to alcohol and attitudes about alcohol use. Similar to findings from other countries, heavy alcohol use was associated with poorer psychological health and functional impairment.
PMCID: PMC3412745  PMID: 22694799
Sri Lanka; Alcohol; Military Personnel; War; Functional Impairment
22.  Oral and Maxillofacial Injuries in Civilian Recruits During Mandatory Combat Training at Military Garrisons: A Nationwide Survey 
Trauma Monthly  2012;17(3):337-340.
There is significant prevalence of physical injuries sustained by civilian recruits at military training garrisons. Civilian recruits sustain these injuries mostly during the intensive and rigorous military combat-training period.
We sought to determine the prevalence and causes of oral and maxillofacial injuries as the first step in reducing and preventing them in civilian recruits (males aged over18 years) during their 2-year mandatory military service.
Materials and Methods
In this 2-year study, we referred to 11major military training garrisons in 8 provinces and collected data from available medical records of military clinics at each garrison. Injuries occurring in civilian recruits during the intense 2-month military combat training period were documented. Data regarding the number of civilian trainees, percentage of those injured, site where the injury was sustained, type of injury and its causes, etc. as well as demographic data were collected.
The number of civilians called to military service was 153, 886. The ratio of those injured was 4419/153,886. The percentage of maxillofacial injuries was 20.4% (903/4419). The majorities of maxillofacial injuries occurred during the first month (38%) and were due to nonmilitary (86%) rather than military (14%) causes. From among the military causes, bullets (66%) were the most common cause of injury, while falls (73%) were the major cause of nonmilitary injuries. Mountainous terrain was the main cause of falls (51%). The most common military incidents which led to injury were related to artillery fire and explosions (33%). Nasal bone fracture was the most common maxillofacial fracture (49%), and lacerations were the most common soft tissue injury (54%). Among dental injuries, tooth fracture was most common (66%).
The large number of general and maxillofacial injuries in civilian recruits during the 2-month combat-training period at military garrisons is disconcerting. This issue warrants further research to implement methods for identifying, decreasing, and preventing injuries in civilians at military-training garrisons.
PMCID: PMC3860627  PMID: 24350120
Military; Training; Wounds and Injuries
23.  Spatial analysis of hemorrhagic fever with renal syndrome in China 
Hemorrhagic fever with renal syndrome (HFRS) is endemic in many provinces with high incidence in mainland China, although integrated intervention measures including rodent control, environment management and vaccination have been implemented for over ten years. In this study, we conducted a geographic information system (GIS)-based spatial analysis on distribution of HFRS cases for the whole country with an objective to inform priority areas for public health planning and resource allocation.
Annualized average incidence at a county level was calculated using HFRS cases reported during 1994–1998 in mainland China. GIS-based spatial analyses were conducted to detect spatial autocorrelation and clusters of HFRS incidence at the county level throughout the country.
Spatial distribution of HFRS cases in mainland China from 1994 to 1998 was mapped at county level in the aspects of crude incidence, excess hazard and spatial smoothed incidence. The spatial distribution of HFRS cases was nonrandom and clustered with a Moran's I = 0.5044 (p = 0.001). Spatial cluster analyses suggested that 26 and 39 areas were at increased risks of HFRS (p < 0.01) with maximum spatial cluster sizes of ≤ 20% and ≤ 10% of the total population, respectively.
The application of GIS, together with spatial statistical techniques, provide a means to quantify explicit HFRS risks and to further identify environmental factors responsible for the increasing disease risks. We demonstrate a new perspective of integrating such spatial analysis tools into the epidemiologic study and risk assessment of HFRS.
PMCID: PMC1471792  PMID: 16638156
24.  Military Exceptionalism or Tobacco Exceptionalism: How Civilian Health Leaders’ Beliefs May Impede Military Tobacco Control Efforts 
American journal of public health  2013;103(4):599-604.
Smoking impairs the readiness and performance of military personnel, yet congressional opposition has thwarted military tobacco control initiatives. Involvement of civilian organizations might alter this political dynamic.
We interviewed 13 leaders of national civilian public health and tobacco control organizations to explore their perspectives on military tobacco control, inductively analyzing data for themes. Leaders believed that military tobacco use was problematic but lacked specific knowledge. Most supported smoke-free policies and prohibiting smoking in uniform; however, they opposed banning tobacco use, arguing that it would violate smokers’ rights. Most leaders inappropriately applied civilian models of policy development to the military context.
A tobacco-free military is unlikely to be achieved without military–civilian partnerships that include educating civilian health leaders about military policy development and implementation.
PMCID: PMC3673259  PMID: 23409898
25.  Prevalence of Common Skin Diseases and Their Associated Factors among Military Personnel in Korea: A Cross-sectional Study 
Journal of Korean Medical Science  2012;27(10):1248-1254.
This study was conducted to clarify the prevalence of common skin diseases and their associated factors among military personnel in Korea. Four dermatologists visited adjacent military units and examined soldiers. A structured questionnaire that included questions about known skin diseases, demographic information, and questions for the Perceived Stress Index was completed for each participant. The soldiers that had been diagnosed with a skin disease answered one additional questionnaire (Skindex-29) which assess the influence of an individual's skin disease on daily life. Of 1,321 soldiers examined, 798 (60.4%) had one or more skin diseases. The three most common skin problems were acne (35.6%), tinea pedis (15.2%) and atopic dermatitis (5.1%). The diseases closely related to the period of military service were acne, tinea pedis, viral warts and corns. The diseases related to the amount of stress were atopic dermatitis, seborrheic dermatitis, and acne. The most troublesome skin diseases were atopic dermatitis, tinea cruris, and seborrheic dermatitis. These results demonstrated that the prevalence of skin disease among military personnel in Korea is very high, and that some of the skin disorders may have a significant influence on their daily lives.
PMCID: PMC3468764  PMID: 23091325
Army; Military Personnel; Prevalence; Skin Disease

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