Deployment Health Surveillance: Past, Present, and Future

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Deployment Health SurveillancePast, Present,
and Future

• Col Kenneth L. Cox
• Director, Global Health Surveillance
• TMA/FHPRP
• FHP Conference, 6 August 2007

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Service Member Life Cycle Health Assessment
Opportunities
Retirement/ Separation Beyond
Force Health Protection
Transit
Operation
Deployed
Pre-Deployment
Re-Deployment
In Garrison
Annual Preventive Health Assessment or
Sep/Retirement
Post-Deployment Reassessment
Population Health
Accession
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Past

• DNBI surveillance, as we knew it, emerged from
  experiences in 1st Gulf War and Somalia
• Categories created in a one hour brainstorming
  session have served remarkably well
• Primarily a manual system extracted from log
  books and paper records with weekly reporting
• Electronic data collection systems appeared
• Desert Care/GEMS, SAMS, CHCS2-T
• Analysis limited to comparisons with established
  reference thresholds, statistics rarely employed

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Present

• Existing categories and weekly monitoring
  recognized as inadequate for chem/biowarfare
• Added 5 surveillance categories with daily
  reporting
• Electronic systems mature, but not universally
  available, accepted, and still Service-specific
• Implemented JMeWS to provide a standard interface
  to aggregate, analyze, and display
• Purposes command control, surveillance
• Other data streams to integrate/leverage include
• TRAC2ES, JPTA, JTTR, CTS/DTAS/DCAPES

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Deployment Associated Surveillance
Predeployment
Intradeployment
Postdeployment

• Self-assessment with DD Form 2795
• Archive pre-deploy serum sample
• Individual medical readiness
• Periodic Health Assessment (PHA)

• Monitor health events
• Monitor exposures
• Occupational
• Environmental
• Self-assessment with DD Form 2796 prior to
  leaving operational area
• Separation exam

• Archive post-deploy serum sample (lt30d)
• TB test (risk-based)
• Postdeploy health reassessment (90-180d)
  with DD Form 2900
• Health care utilization
• Periodic Health Assessment (PHA)

Routine Public Health Surveillance (communicable
dz, mortality, etc.)
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Disease and Non-Battle Injuries (DNBI) CENTCOM
(OEF/OIF) Combined

• Overall rate 4 per week
• Injuries, all types 26
• Training/Work 44
• Sports 18
• Heat/Cold 3
• Motor Vehicles 2
• Other 33
• Respiratory 13
• Dermatologic 12
• Gastrointestinal 6
• Mental Health 3
• Combat Stress 2
• All other categories 38

Data Source Air Force Institute of Operational
Health As of 21 April 2007
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Data Interpretation Complementary Chart Use
CPEG Chart
Process Control Chart
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JMEWS Surveillance Reports OEF/OIF PEM data Top
10 ICD-9 Codes among Servicemembers 01JAN2005 -
28JUL2007

• 1. Back disorders
• 2. Acute upper respiratory infections
• 3. Joint disorders
• 4. Ankle/foot sprains and strains
• 5. Symptoms involving digestive system
• 6. Back sprains and strains
• 7. Dermatophytosis
• 8. Gastroenteritis and colitis
• 9. Enthesopathies
• 10. General Symptoms

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Limitations/Complaints

• Little perceived value in the field or at HHQ
• Poor quality data, both manual categorization and
  electronic mapping via ICD-9 codes
• Poor compliance, esp with daily reporting
• Reference thresholds inaccurate
• Too much paperwork, esp when EPINATO reporting
  required in addition to JCS
• Too different from garrison setting

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Future

• Establish clear purpose and objectives
• Revise surveillance guidelines and systems
• Assign roles/responsibilities

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Purpose Objectives

• Purpose to promote and maintain healthy, fit
  deployed forces, primarily by minimizing
  illnesses and injuries
• Objectives
• Communicable disease outbreak detection
• Sentinel event detection (RME)
• Other relevant activities of public health and
  preventive medicine, e.g., injury prevention,
  exposure monitoring, etc.
• NOT designed to capture overall facility
  workload, justify resources, or track other
  business-oriented aspects of deployed health care
  operations
• NOT for chronic disease surveillance

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Assumptions

• The best public health (PH) and preventive
  medicine (PM) occur at the local level
• Deployed PH/PM activities should focus on
  conditions amenable to local intervention
• Surveillance must provide actionable information
• Ideally, should apply to all types of operations
  (combat, humanitarian, peacekeeping, disaster
  relief, etc.)
• Rates ideal, when available, but counts very
  useful
• Local reference values superior to generic
  historic
• Must leverage electronic systems to minimize
  administrative burden
• Training and feedback are keys to better data
  quality

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Proposed Disease Injury (DI) Surveillance
Guidelines

• Revise categories into three focus areas
• Outbreak detection (natural or deliberate)
• Other conditions of public health concern
• Injuries
• Require daily monitoring, using JMeWS interface
• Eliminate manual reporting, upstream offices/HQ
  use JMeWS to perform regional surveillance
• Provide daily updates about confirmed outbreaks
  via MEDSITREP

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Outbreak Detection

• Fever, unexplained
• Influenza-like Illness
• Rash
• Localized Cutaneous Lesion
• Hemorrhagic Illness
• Gastrointestinal, infectious
• Botulism-like
• Neurological
• Shock/Coma/Death, suspected infectious cause

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Other Conditions of Public Health Concern

• Combat/Operational Stress Reactions
• Dermatological
• Ophthalmologic
• Psychiatric/Mental disorders
• Respiratory, upper
• Respiratory, lower
• Reportable Medical Events (RME)

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Injuries

• Heat/Cold
• Recreational/Sports
• Motor Vehicle Accidents
• Work/Training
• Other

Still debating relative merits of including a
category for hostile injuries. Local PH/PM
cannot influence outcome.
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Summary of Changes from Current DNBI Categories

• Adopted ESSENCE categories for outbreak
  detection, some revisions per CDC BioSense
• Maintained injury categories, clarified
  definition of Other Injuries
• Deleted
• Gynecological, not actionable in field
• Dental, dentists dont use any of the PEMs
• STDz, replaced with full-spectrum RME
• All Other, catchall, no actionable info
• Misc and follow-up, administrative categories

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Further into the Future

• Include syndromes that utilize signs, symptoms,
  other pre-diagnostic data, e.g., MEDCIN terms
• Fully integrated data streams
• Personnel location, one or more times a day
• Exposure data (weather, occupational, etc.)
• Medical Situational Awareness in Theater

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Measuring Success

• Recommendations to Congress, Oct 2005
• Use CHCS2-T as sole outpatient PEM
• Deploy and use CHCS-NT for inpatient data
• Improve accuracy, completeness, timeliness of
  in-theater denominator data
• Use JMeWS to monitor DNBI
• Reevaluate existing DNBI categories and
  thresholds
• Reconcile BI/NBI definitions among personnel,
  safety, and medical communities
• Consider employing DNBI categories in garrison

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Col Kenneth L. CoxKenneth.Cox1_at_ha.osd.mil

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