PM2ch31.pdf

MILITARY PREVENTIVE MEDICINE:

MOBILIZATION AND DEPLOYMENT

Volume 2

Section 5: Epidemiology in the Field

Robert Thom

The Conquest of Yellow Fever

1963

The US Army Yellow Fever Board was established to discover the etiology of yellow fever. In Cuba in 1900, the Board

completed a series of classic experiments that showed the role of the mosquito in yellow fever transmission. Attending

Private John Kissinger, who volunteered to be infected with yellow fever, are (from left) Major William C. Gorgas, the

sanitation officer for Havana who would go on to rid Havana of yellow fever; Contract Surgeon Dr. Aristides

Agramonte; Dr. Carlos J. Finlay, a Cuban physician and an early believer in the mosquito’s role in yellow fever;

Contract Surgeon Dr. James Carroll; and Major Walter Reed, the president of the Yellow Fever Board. Missing from

this painting is Dr. Jesse Lazear, also a member of the Board, who contracted yellow fever while conducting

experiments and died.

Art: Courtesy of Pfizer Inc.; 235 E 42nd St.; New York, NY 10017-5755

705

Disease and Nonbattle Injury Surveillance: Outcome Measure for Force Health Protection

Chapter 31

DISEASE AND NONBATTLE INJURY

SURVEILLANCE: OUTCOME MEASURE

FOR FORCE HEALTH PROTECTION

KEVIN HANSON, MD, MPH

INTRODUCTION

DISEASE AND NONBATTLE INJURY SURVEILLANCE AND COMMAND

EMPHASIS

PRACTICAL ASPECTS OF AN OPERATIONAL DISEASE AND NONBATTLE

INJURY SURVEILLANCE SYSTEM

Background—The Medical Infrastructure in an Operational Environment

Disease and Nonbattle Injury Surveillance at the Outpatient Level

Centralized Analysis of Force-wide Data

Centralized Feedback

INPATIENT SURVEILLANCE SYSTEMS IN MILITARY OPERATIONS

Data Sources

Inpatient Disease and Nonbattle Injury Rates

Individual Epidemiologic Investigations

Specialized Public Health Diagnostic Laboratories

Feedback from Inpatient Surveillance

SURVEILLANCE IN ACTION—USMC FORCES IN THE PERSIAN GULF WAR

FUTURE DIRECTIONS

SUMMARY

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Military Preventive Medicine: Mobilization and Deployment, Volume 2

K. Hanson ; Captain, Medical Corps, US Navy; Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda,

Maryland 20814-4799

708

Disease and Nonbattle Injury Surveillance: Outcome Measure for Force Health Protection

INTRODUCTION

In recent years, a great deal of emphasis has been

placed on the concept of Force Health Protection

(FHP). 1,2 Under current doctrine, commanders at all

levels are expected to maximize readiness by tak-

ing every reasonable measure to protect their per-

sonnel from health threats. This includes protection

not only from hostile fire, but also from disease and

nonbattle injury (DNBI). Whether in combat situa-

tions or in routine training, losses from DNBI have

often had a tremendous impact on unit effective-

ness. Ironically, most DNBIs are preventable

through basic measures such as immunization, field

sanitation, protection of food and water sources,

personal protection measures, and an emphasis on

safety. Although these measures are not new, com-

mand failure to implement them has become in-

creasingly unacceptable under FHP.

Operational medical personnel have traditionally

been responsible for providing line commanders

with recommendations for preventive measures. In

effect, medical personnel establish the blueprint for

much of FHP. In addition to this advice, medical

personnel also provide technical assistance in

implementing specific FHP measures. This might

include such things as designing and engineering

appropriate field latrines, inspecting field dining

facilities, and training personnel to use protective

measures against biting insects.

Beyond these traditional roles of advising and

assisting, operational medical personnel are in a

unique position to provide commanders with a tre-

mendously powerful tool in FHP—an outcome

measure. By collecting and analyzing key data on

DNBI, medical personnel can objectively determine

how well the FHP program is working. If DNBI

rates are high, this may indicate a breakdown in

preventive measures. High rates may also be the

first clue to an unanticipated disease threat for

which no countermeasures were mounted. The abil-

ity to rapidly troubleshoot the FHP program, iden-

tify deficiencies, and take corrective action can make

the difference between mission success and failure.

This type of health outcomes monitoring is known

as surveillance and has long been a cornerstone of

public health. The Centers for Disease Control and

Prevention defines surveillance as the ongoing, sys-

tematic collection, analysis, and interpretation of

health data essential to the planning, implementation,

and evaluation of public health practice, closely

integrated with the timely dissemination of these

data to those who need to know. The final link of

the surveillance chain is the application of these

data to prevention and control. 3

Surveillance has been described as a cycle con-

sisting of 4 steps: data collection, analysis, feedback,

and action (Figure 31-1). 4 The whole point of surveil-

lance is taking corrective action to control disease

or injury. In a military context, controlling disease

and injury is the essence of preserving the fighting

strength—the primary focus of military medicine.

DNBI surveillance is therefore an essential compo-

nent of military medicine and central to an effec-

tive FHP program. A formalized, unit-level DNBI

surveillance system has recently been mandated for

deployed military units. 1,2,5

DNBI rates in a unit are the military medical

equivalent of vital signs for an individual patient.

For the clinician, vital signs provide a quick initial

assessment of the patient’s overall condition. Abnor-

mal vital signs do not, by themselves, lead to specific

diagnoses, but they may be an important clue point-

ing to a serious problem. Recognizing this clue may

stimulate and focus a more detailed clinical evalu-

ation, leading ultimately to specific interventions.

In military medicine, the “patient” is an entire

population, typically an operational unit. DNBI

rates (eg, diarrhea or heat injury rates) are key in-

dicators of unit health, and abnormally high rates

indicate a threat to a unit’s readiness. When DNBI

rates are collected, analyzed, disseminated, and

acted on, threats can be identified and countered

early and the health of the force can be better pro-

tected. Continued monitoring of rates will indicate

whether the corrective action has been effective, just

as a patient’s vital signs indicate changes in his or

her condition.

Data collection

ACTION

Analysis

Feedback

Fig. 31-1. Surveillance is actually a continuous cycle be-

ginning with data collection. Data are continuously ana-

lyzed to identify problems. Feedback from this analysis

must be given to decision makers and to the collectors of

the data so that appropriate action can be taken to cor-

rect the problem—action is the focus of the entire sys-

tem. Data are then collected to measure the effectiveness

of the remedying actions.

709

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