MEDICAL SURVEILLANCE MONTHLY REPORT

Transcription

1 AUGUST 2015 Volume 22 Number 8 msmr MEDICAL SURVEILLANCE MONTHLY REPORT PAGE 2 PAGE 9 Updte: Routine screening for ntibodies to humn immunodeficiency virus, civilin pplicnts for U.S. militry service nd U.S. Armed Forces, ctive nd reserve components, Jnury 2010 June 2015 Durtions of militry service fter dignoses of HIV-1 infections mong ctive component members of the U.S. Armed Forces, John F. Brundge, MD, MPH; Devin J. Hunt, MS; Leslie L. Clrk, PhD, MS PAGE 13 Cse report: Probble murine typhus t Joint Bse Sn Antonio, TX Rlph A. Stidhm, MPH, DHSc; Robert L. von Tersch, PhD; Kenneth L. Btey, DVM, DACVP; Cierre Roch, MD CDC/Amnd Mills PAGE 17 Morbidity burdens ttributble to vrious illnesses nd injuries in deployed (per Theter Medicl Dt Store [TMDS]) ctive nd reserve component service members, U.S. Armed Forces, Denise O. Dniele, MS; Leslie L. Clrk, PhD, MS SUMMARY TABLES AND FIGURES PAGE 23 Deployment-relted conditions of specil surveillnce interest CDC A publiction of the Armed Forces Helth Surveillnce Center

2 Updte: Routine Screening for Antibodies to Humn Immunodeficiency Virus, Civilin Applicnts for U.S. Militry Service nd U.S. Armed Forces, Active nd Reserve Components, Jnury 2010 June 2015 This report contins n updte through June 2015 of the results of routine screening for ntibodies to the humn immunodeficiency virus (HIV) mong civilin pplicnts for militry service nd mong members of the ctive nd reserve components of the U.S. Armed Forces. Seroprevlences mong civilin pplicnts in 2014 nd the first hlf of 2015 (0.21 nd 0.22, respectively) were mrkedly lower thn in 2012 (0.28 ). In nerly every component of every militry service, seroprevlences in 2014 nd 2015 were either lower thn, or reltively similr to, prevlences in prior yers; however, in the Army Ntionl Gurd, seroprevlences incresed ech yer nd pproximtely doubled from 2010 (0.18 ) to ( ). Among ctive nd reserve component service members, seroprevlences continue to be higher mong Army nd Nvy members nd mles thn their respective counterprts. of detection of HIV-2 infection cses by Service-specific screening progrms, this report will herefter refer to the trget of the screening progrms s simply HIV without specifying either of the types. This report summrizes numbers, prevlences, nd trends of newly identified HIV ntibody positivity mong civilin pplicnts for militry service nd members of the ctive nd reserve components of the U.S. Armed Forces from 1 Jnury 2010 through 30 June Summries of results of routine screening for ntibodies to HIV mong civilin pplicnts nd ctive nd reserve component members of the U.S. militry since 1990 re vilble t METHODS since the cquired immune deficiency syndrome (AIDS) ws first recognized s distinct clinicl entity in 1981, 1 its spred hs hd mjor impcts on the helth of popultions nd on helthcre systems worldwide. The humn immunodeficiency virus type 1 (HIV-1) ws identified s the cuse of AIDS in Since October 1985, the U.S. militry hs conducted routine screening for ntibodies to HIV-1 to enble dequte nd timely medicl evlutions, tretment, nd counseling; to prevent unwitting trnsmission; nd to protect the bttlefield blood supply. 2 As prt of the U.S. militry s HIV screening progrm, civilin pplicnts for militry service re screened for ntibodies to HIV during pre-ccession medicl exmintions. Infection with HIV is mediclly disqulifying for entry into U.S. militry service. All members of the ctive nd reserve components of the U.S. Armed Forces hve been periodiclly screened since 1986 to detect newly cquired HIV infections. In 2004, the Deprtment of Defense set stndrd testing intervl of 2 yers for ll service members. Service members who re infected with HIV receive clinicl ssessments, tretments, nd counseling; they my remin in service s long s they re cpble of performing their militry duties. 2 Before 2009, ll of the forementioned screening progrms used techniques tht detected only HIV-1-type infection. In 2009, ll progrms dopted lbortory methods tht detect ntibodies to both HIV types (i.e., HIV-1 nd HIV- 2). HIV-2 infection is rre in the U.S. itself, nd there hs been only one HIV-2 infection cse detected mong civilin pplicnts pplying for militry service since Although HIV-2 virus is prevlent in res of the world where service members my be required to serve, to dte no service member hs been found to be infected with HIV-2. To ccommodte the chnge in lbortory methods nd the prospect The surveillnce period ws 1 Jnury 2010 through 30 June The surveillnce popultion included ll civilin pplicnts for U.S. militry service nd ll individuls who were screened for ntibodies to HIV while serving in the ctive or reserve component of the Army, Nvy, Air Force, Mrine Corps, or Cost Gurd during the surveillnce period. All individuls who were nd ll first-time detections of ntibodies to HIV through U.S. militry medicl testing progrms were scertined by mtching specimen numbers nd serologic test results to the personl identifiers of providers of the specimens. With the exception of U.S. Air Force members, ll results were ccessed from records routinely mintined in the Defense Medicl Surveillnce System (DMSS). The U.S. Air Force provided summrized results of serologic screening for ntibodies to HIV mong its members. An incident cse of HIV ntibody seropositivity ws defined s two positive results from serologic testing of two Pge 2 MSMR Vol. 22 No. 8 August 2015

3 FIGURE 1. Dignoses of HIV infection by gender, civilin pplicnts for U.S. militry service, Jnury 2010 June 2015 No. of HIV+ individuls Mle Femle Through 30 June 2015 different specimens from the sme individul, or one positive result from serologic testing of the most recent specimen provided by n individul. Annul prevlences of HIV seropositivity mong civilin pplicnts for service FIGURE 2. Dignoses of HIV infections by rce/ethnicity, civilin pplicnts for U.S. militry service, Jnury 2010 June 2015 No. of HIV+ individuls Blck, non-hispnic White, non-hispnic Hispnic/other Through 30 June 2015 were clculted by dividing the number of pplicnts identified s HIV ntibody seropositive during ech clendr yer by the number of pplicnts during the corresponding yer. For nnul summries of routine screening mong U.S. service members, denomintors were the numbers of individuls in ech component of ech service brnch who were t lest once during the relevnt clendr yer. Civilin pplicnts RESULTS From Jnury 2014 through June 2015, totl of 452,956 civilin pplicnts for U.S. militry service were for ntibodies to HIV, nd 97 pplicnts were identified s HIV ntibody positive (seroprevlence: 0.21 pplicnts ) (Tble 1). During the period, nnul seroprevlences mong pplicnts for service peked in 2012 (0.28 ), then decresed to 0.21 per 1,000 in Throughout the period, seroprevlences were much higher mong mles thn femles nd mong blck non-hispnics thn other rce/ethnicity groups (Tbles 1, 2; Figures 1, 2). Of note, during 2012 to TABLE 1. Dignoses of HIV infections by gender, civilin pplicnts for U.S. militry service, Jnury 2010 June 2015 Yer Totl HIV tests Totl persons Mle Femle Totl mle femle Overll rte Mle rte Femle rte , , ,879 54, , , ,300 49, , , ,480 51, , , ,224 53, , , ,495 53, , , ,251 36, Totl 1,578,343 1,528,642 1,230, , Through 30 June 2015 TABLE 2. Dignoses of HIV infections by rce/ethnicity, civilin pplicnts for U.S. militry service, Jnury 2010 June 2015 Yer Totl persons White, non- Hispnic Blck, non- Hispnic Hispnic/ others Totl White, non- Hispnic Blck, non- Hispnic Hispnic/ others Overll rte per 1,000 White, non- Hispnic rte Blck, non- Hispnic rte Hispnic/ others rte , ,680 41,688 46, , ,445 41,286 40, , ,176 43,992 45, , ,269 49,996 50, , ,848 48,307 50, , ,886 34,017 28, Totl 1,528,648 1,007, , , Through 30 June 2015 August 2015 Vol. 22 No. 8 MSMR Pge 3

4 FIGURE 3. dignoses of HIV infections by gender, ctive component, U.S. Army, Jnury 2010 June 2015 No. of HIV+ individuls Mle Femle Through 30 June , seroprevlences decresed by pproximtely 24% mong mle pplicnts nd by 34% mong blck, non-hispnic pplicnts. During 2014, on verge, one civilin pplicnt for service ws detected with ntibodies to HIV per 4,840 screening tests (Tble 1). U.S. Army Active component: From Jnury 2014 through June 2015, totl of 558,428 soldiers in the ctive component of the U.S. Army were for ntibodies to HIV, nd 114 soldiers were identified s HIV ntibody positive (seroprevlence: 0.20 per 1,000 soldiers ) (Tble 3). Annul seroprevlences incresed 33% from 2010 (0.21 ) to 2012 (0.28 ) nd then decresed to 0.20 in 2014 (Tble 3, Figure 3). During 2014, on verge, one new HIV infection ws detected mong ctive component Army soldiers per 6,306 screening tests (Tble 3). Of the 531 ctive component soldiers dignosed with HIV infections since 2010, 318 (60%) were still in militry service in Army Ntionl Gurd: From Jnury 2014 through June 2015, totl of 346,321 members of the U.S. Army Ntionl Gurd were for ntibodies to HIV, nd 132 TABLE 3. dignoses of HIV infections by gender, ctive component, U.S. Army, Jnury 2010 June 2015 Yer Totl HIV tests Totl persons Mles Femles Totl new mle femle Overll rte Mle rte Femle rte still in militry service in , , ,215 61, , , ,981 59, , , ,451 57, , , ,862 56, , , ,967 51, , , ,522 28, Totl 2,818,349 2,263,170 1,947, , Through 30 June 2015 TABLE 4. dignoses of HIV infections by gender, U.S. Army Ntionl Gurd, Jnury 2010 June 2015 Yer Totl HIV tests Totl persons Mles Femles Totl new mle femle Overll rte Mle rte Femle rte still in militry service in , , ,188 27, , , ,544 26, , , ,897 25, , , ,212 25, , , ,813 39, , ,993 89,925 17, Totl 1,209,831 1,042, , , Through 30 June 2015 TABLE 5. dignoses of HIV infections by gender, U.S. Army Reserve, Jnury 2010 June 2015 Yer Totl HIV tests Totl persons Mles Femles Totl new mle femle Overll rte Mle rte Femle rte still in militry service in ,101 93,577 73,031 20, ,761 88,715 68,935 19, ,095 73,643 57,098 16, , ,145 87,322 25, , ,297 81,903 25, ,837 42,637 32,763 9, Totl 599, , , , Through 30 June 2015 Pge 4 MSMR Vol. 22 No. 8 August 2015

5 FIGURE 4. dignoses of HIV infections by gender, ctive component, U.S. Nvy, Jnury 2010 June 2015 No. of HIV+ individuls Mle Femle Through 30 June 2015 FIGURE 5. dignoses of HIV infections by gender, ctive component, U.S. Mrine Corps, Jnury 2010 June 2015 No. of HIV+ individuls Mle Femle Through 30 June 2015 FIGURE 6. dignoses of HIV infections by gender, ctive component, U.S. Air Force, Jnury 2010 June 2015 No. of HIV+ individuls Mle Femle Through 30 June 2015 soldiers were identified s HIV ntibody positive (seroprevlence: 0.38 soldiers ) (Tble 4). Among Ntionl Gurd soldiers, nnul seroprevlences incresed ech yer, nd more thn doubled, from 2010 through 2014 (seroprevlences: 0.18 nd 0.39 soldiers, respectively) nd then decresed slightly in During 2014, on verge, one new HIV infection ws detected mong Army Ntionl Gurd soldiers per 2,829 screening tests (Tble 4). Of the 313 Ntionl Gurd soldiers who positive for HIV since 2010, 177 (57%) were still in militry service in Army Reserve: From Jnury 2014 through June 2015, totl of 149,934 members of the U.S. Army Reserve were for ntibodies to HIV, nd 62 soldiers were identified s HIV ntibody positive (seroprevlence: 0.41 soldiers ) (Tble 5). Among Army reservists, the seroprevlence in 2012 (0.58 ) ws higher thn in ny other yer of routine HIV ntibody screening of Army reservists since 1991 (dt not shown). However, the seroprevlence mong Army reservists from Jnury 2014 through June 2015 ws 29% lower thn in 2012 (Tble 5). During 2014, on verge, one new HIV infection ws detected mong Army reservists per 2,559 screening tests (Tble 5). Of the 231 Army reservists dignosed with HIV infections since 2010, 160 (69%) were still in militry service in U.S. Nvy Active component: From Jnury 2014 through June 2015, totl of 342,133 ctive component members of the U.S. Nvy were for ntibodies to HIV, nd 115 silors were identified s HIV ntibody positive (seroprevlence: 0.34 silors ) (Tble 6). Among mle ctive component silors, the nnul HIV ntibody seroprevlence declined between 2010 nd 2011 but incresed ech yer since then (Figure 4). During 2014, on verge, one new HIV-infection ws detected mong ctive component silors per 3,430 screening tests (Tble 6). Of the 387 ctive component silors who positive for HIV since 2010, 257 (66%) were still in militry service in Nvy Reserve: From Jnury 2014 through June 2015, totl of 57,626 members of the U.S. Nvy Reserve were for ntibodies to HIV, nd 29 silors were identified s HIV ntibody positive (seroprevlence: 0.50 silors ) (Tble 7). The HIV ntibody seroprevlence mong Nvy reservists nerly doubled between 2013 nd 2015 (seroprevlences: 0.31 nd 0.60 silors, respectively). The seroprevlence in 2015 (through June) ws higher thn in ny other yer of routine HIV ntibody screening of Nvy reservists (dt not shown). Of note, no femle Nvy reservists hve been detected with ntibodies to HIV during routine screening since 2007 (dt not shown). During 2014, on verge, one new HIV infection ws detected mong Nvy reservists per 2,518 screening tests (Tble 7). Of the 86 reserve component silors dignosed with HIV infections since 2010, 58 (67%) were still in militry service in U.S. Mrine Corps Active component: From Jnury 2014 through June 2015, totl of 222,684 members of the ctive component of the U.S. Mrine Corps were for ntibodies to HIV, nd 35 Mrines were identified s HIV ntibody positive (seroprevlence: 0.16 per 1,000 Mrines ) (Tble 8). From 2012 through June 2015, prevlences of ntibodies to HIV remined reltively low nd stble mong routinely Mrines (Figure 5). During 2014, on verge, one new HIV infection ws detected mong ctive component Mrines per 7,879 screening tests (Tble 8). Of the 127 ctive component Mrines dignosed with HIV infections since 2010, 61 (48%) were still in militry service in August 2015 Vol. 22 No. 8 MSMR Pge 5

6 TABLE 6. dignoses of HIV infections by gender, ctive component, U.S. Nvy, Jnury 2010 June 2015 Yer Totl HIV tests Totl persons Mles Femles Totl new mle femle Overll rte per 1,000 Mle rte Femle rte still in militry service in , , ,582 40, , , ,226 40, , , ,638 41, , , ,241 40, , , ,799 41, , ,018 96,949 23, Totl 1,453,158 1,266,535 1,039, , Through 30 June 2015 TABLE 7. dignoses of HIV infections by gender, U.S. Nvy Reserve, Jnury 2010 June 2015 Totl Overll rte Mle rte Totl HIV Mles Femles Totl new Yer persons tests mle femle Femle rte still in militry service in ,309 45,452 36,900 8, ,448 42,850 34,661 8, ,212 41,335 33,312 8, ,151 38,539 30,692 7, ,806 37,609 29,911 7, ,313 20,017 15,761 4, Totl 262, , ,237 44, Through 30 June 2015 TABLE 8. dignoses of HIV infections by gender, ctive component, U.S. Mrine Corps, Jnury 2010 June 2015 Yer Totl HIV tests Totl persons Mles Femles Totl new mle femle Overll rte Mle rte Femle rte still in militry service in , , ,632 10, , , ,237 12, , , ,089 11, , , ,291 11, , , ,128 11, ,707 75,836 69,773 6, Totl 1,030, , ,150 64, Through 30 June 2015 TABLE 9. dignoses of HIV infections by gender, U.S. Mrine Corps Reserve, Jnury 2010 June 2015 Yer Totl HIV tests Totl persons Mles Femles Totl new mle femle Overll rte Mle rte Femle rte still in militry service in ,935 25,339 24,237 1, ,882 28,027 26,889 1, ,271 25,833 24,801 1, ,651 24,160 23, ,335 24,387 23, ,464 13,872 13, Totl 161, , ,930 5, Through 30 June 2015 Pge 6 MSMR Vol. 22 No. 8 August 2015

7 TABLE 10. dignoses of HIV infections by gender, ctive component, U.S. Air Force, Jnury 2010 June 2015 Yer Totl HIV tests Totl persons b Mles Femles Totl new mle femle Overll rte Mle rte Femle rte , , ,830 51, , , ,902 42, , , ,140 46, , , ,889 45, , , ,964 43, , ,463 91,272 22, Totl 1,390,723 1,292,084 1,039, , Through 30 June 2015 b Totl persons includes unknown or missing genders. TABLE 11. dignoses of HIV infections by gender, U.S. Air Ntionl Gurd, Jnury 2010 June 2015 Yer Totl HIV tests Totl persons b Mles Femles Totl new mle femle Overll rte Mle rte Femle rte ,294 22,612 18,837 3, ,231 37,972 31,540 6, ,687 45,197 37,668 7, ,090 35,577 29,577 6, ,615 37,444 30,987 6, ,811 18,005 14,852 3, Totl 209, , ,461 33, Through 30 June 2015 b Totl persons includes unknown or missing genders. TABLE 12. dignoses of HIV infections by gender, U.S. Air Force Reserve, Jnury 2010 June 2015 Yer Totl HIV tests Totl persons b Mles Femles Totl new mle femle Overll rte Mle rte Femle rte ,101 23,938 18,584 5, ,329 24,998 19,570 5, ,444 28,461 21,957 6, ,584 24,956 19,319 5, ,150 27,427 20,975 6, ,336 12,940 9,810 3, Totl 148, , ,215 32, Through 30 June 2015 b Totl persons includes unknown or missing genders. Mrine Corps Reserve: From Jnury 2014 through June 2015, totl of 38,259 members of the U.S. Mrine Corps Reserve were for ntibodies to HIV, nd 14 Mrines were identified s HIV ntibody positive (seroprevlence: 0.37 Mrines ) (Tble 9). Through June 2015, the prevlence of ntibodies to HIV mong mle Mrine reservists ws 0.52 per 1,000 Mrines, the highest seroprevlence mong mle Mrine Corps reservists since 1990 (dt not shown). Of note, since 1990, no femle Mrine Corps reservist hs been detected with ntibodies to HIV during routine screening (dt not shown). During 2014, on verge, one new HIV infection ws detected mong Mrine Corps reservists per 3,905 screening tests (Tble 9). Of the 32 Mrine Corps reservists dignosed with HIV infection since 2010, 17 (53%) were still in militry service in U.S. Air Force Active component: During Jnury 2014 through June 2015, totl of 338,340 ctive component members of the U.S. Air Force were for ntibodies to HIV, nd 51 irmen were dignosed with HIV infections (seroprevlence: 0.15 per 1,000 irmen ) (Tble 10). From 2010 through 2014, nnul seroprevlences remined reltively low nd stble mong August 2015 Vol. 22 No. 8 MSMR Pge 7

8 ctive component Air Force members (Figure 6). During 2014, on verge, one new HIV infection ws detected mong ctive Air Force members per 6,743 screening tests (Tble 10). Air Ntionl Gurd: From Jnury 2014 through June 2015, totl of 55,449 members of the Air Ntionl Gurd were for ntibodies to HIV, nd three irmen were dignosed with HIV infections (seroprevlence: 0.05 irmen ) (Tble 11). Since 2007, no femle Air Ntionl Gurd member hs been detected with ntibodies to HIV during routine testing. During 2014, on verge, one new HIV infection ws detected mong Air Ntionl Gurd members per 38,615 screening tests (Tble 11). Air Force Reserve: From Jnury 2014 through June 2015, totl of 40,367 members of the Air Force Reserve were for ntibodies to HIV, nd six irmen were dignosed with HIV infections (seroprevlence: 0.15 irmen ) (Tble 12). During 2014, on verge, one new HIV infection ws detected mong Air Force reservists per 4,692 screening tests (Tble 12). Dt summries for the U.S. Air Force were provided by the U.S. Air Force School of Aerospce Medicine (USAFSAM). U.S. Cost Gurd Active component: From Jnury 2014 through June 2015, totl of 30,634 ctive component members of the U.S. Cost Gurd were for ntibodies to HIV, nd four Cost Gurd members were dignosed with HIV infections (seroprevlence: 0.13 gurdsmen ) (dt not shown). During 2014, on verge, one new HIV infection ws detected mong ctive Cost Gurdsmen per 7,973 screening tests (dt not shown). Cost Gurd Reserve: From Jnury 2014 through June 2015, totl of 7,594 reserve component members of the U.S. Cost Gurd were for ntibodies to HIV, nd one HIV infection ws detected (seroprevlence: 0.13 gurdsmn ) (dt not shown). During 2014, on verge, one new HIV infection ws detected mong Cost Gurd reservists per 5,698 screening tests (dt not shown). Of note, no femle Cost Gurd reservist hs been detected with ntibodies to HIV during routine screening in more thn 25 yers. EDITORIAL COMMENT For nerly 30 yers, the U.S. militry hs conducted routine screening for ntibodies to HIV mong ll civilin pplicnts for service nd ll ctive nd reserve component members of the services. 2 For 20 yers, results of U.S. militry HIV ntibody testing progrms hve been summrized in the MSMR. 3 This report documents tht, since 2010, prevlences of HIV seropositivity mong civilin pplicnts for militry service hve generlly declined. In fct, the prevlence of ntibodies to HIV mong civilin pplicnts in 2014 ws the lowest nnul seroprevlence since routine testing begn. Of note, however, becuse pplicnts for militry service re not rndomly selected from the generl popultion of U.S. young dults, seroprevlences mong them re not directly indictive of HIV prevlences, infection rtes, or trends in the generl U.S. popultion. As such, reltively low prevlences of HIV mong civilin pplicnts for militry service do not necessrily indicte low prevlences or incidence rtes of HIV mong young dults in the U.S. in generl. This report lso documents tht, in 2014 nd 2015, compred to prior yers, seroprevlences mong most of the ctive nd reserve components of the Services were reltively low, nd tht recent trends of seroprevlences hve been reltively stble. Agin, however, such results should be interpreted with considertion of the limittions of the surveillnce dt summrized herein. For exmple, becuse ll militry members hve been screened s civilin pplicnts for service (since October 1985), routinely every 2 yers (since 2004), nd before nd fter overses deployments (for more thn decde), routine screening now detects reltively recently cquired HIV infections (i.e., infections cquired since the most recent negtive test of ech ffected individul). As such, nnul HIV ntibody seroprevlences during routine screening of militry popultions re reflective of, but re not direct unbised estimtes of, incidence rtes nd trends of cquisitions of HIV infections mong militry members. So, for exmple, the Army Ntionl Gurd ws the only Service nd component defined subgroup in whom nnul seroprevlences consistently incresed since However, incresing seroprevlences mong Army Ntionl Gurd members could reflect lengthening time intervls between routine tests (llowing more newly cquired infections to ccumulte before they re detected through screening), chnges in selection criteri for testing (e.g., trgeting of individuls t presumed higher risk such s those with multiple/nonymous sexul contcts or dignosed with sexully trnsmitted infections), nd/or incresing rtes of cquisitions of new infections. In summry, the U.S. militry hs conducted comprehensive HIV prevention, eduction, counseling, nd tretment progrms for nerly 30 yers. Since the beginning of the progrms, routine screening of ll civilin pplicnts for service nd routine periodic testing of ll ctive nd reserve component members of the Services hve been fundmentl components of the militry s HIV control nd clinicl mngement efforts. Summries of results of screening progrms such s those in this report provide insights into the current sttus nd trends of HIV s impcts in vrious U.S. militry popultions. REFERENCES 1. Centers for Disese Control nd Prevention. Kposi s srcom nd Pneumocystis pneumoni mong homosexul men York City nd Cliforni. MMWR. 1981;30(25): Trmont EC, Burke DS. AIDS/HIV in the US militry. Vccine.1993;11(5): Army Medicl Surveillnce Activity. Supplement: HIV-1 in the Army. MSMR. 1995;1(3): Pge 8 MSMR Vol. 22 No. 8 August 2015

9 Durtions of Militry Service After Dignoses of HIV-1 Infections Among Active Component Members of the U.S. Armed Forces, John F. Brundge, MD, MPH (COL, USA, Ret.); Devin J. Hunt, MS; Leslie L. Clrk, PhD, MS This report describes the trends in length of militry service for ctive component members of the U.S. Armed Forces who were dignosed with humn immunodeficiency virus type 1 (HIV-1) infections during Durtions of service fter service members initil dignoses of HIV-1 infection were compred for five different cohorts tht corresponded to when dignoses were mde during the 5-yer intervls beginning in 1990, 1995, 2000, nd 2005, nd the 4-yer intervl of By severl mesures, the durtions of service fter initil dignoses of HIV-1 infection incresed from the erliest to the lter cohorts. The findings re discussed in the context of chnges in severl fctors during the surveillnce period: the growing vilbility nd effectiveness of tretments for HIV-1 disese; the stigms ssocited with the dignosis of HIV-1 infection nd its link to homosexulity; nd the chnges in U.S. militry policy bout the inclusion of homosexuls in its rnks. Also discussed re the limittions of the estimtes for the most recent cohorts nd the future prospects for continued lengthening of service for those infected with HIV-1. for nerly 30 yers, the U.S. militry hs conducted routine screening for ntibodies to humn immunodeficiency virus type 1 (HIV-1) mong ll civilin pplicnts for nd individuls serving in the U.S. militry. Becuse ll new entrnts to militry service must be HIV-1 seronegtive nd becuse ll members of the militry services re periodiclly for HIV-1 infections, since the lte 1980s, nerly ll HIV-1 infections documented mong U.S. militry members hve been reltively recently cquired. 1,2 When the militry s HIV-1 testing progrm begn, there were no specific tretments to counter the inexorble progression to deth of HIV-1-ssocited diseses. However, in 1987, the ntiretrovirl drug zidothymidine (AZT) (lso known s zidovudine or ZDV) ws pproved by the FDA for use ginst HIV-1. Since then, there hve been extrordinry dvnces in the tretment of HIV-1-ssocited disese (e.g., combintion ntiretrovirl therpy guided by CD4+ T lymphocyte concentrtions nd HIV-1 virl lods). As result, with stte-of-the-rt clinicl mngement, the clinicl courses of HIV-1 disese hve drmticlly lengthened, especilly for those dignosed nd treted in erly (presymptomtic) clinicl stges. 3 6 For exmple, in 1991, Longini nd collegues estimted the rnge of times from HIV-1 seroconversion until the first dignoses of opportunistic infections mong U.S. militry members s yers (more rpid progression mong the older ged). 7 In 1998, Grdner nd collegues estimted tht, in HIV-1-infected U.S. militry members, the reltive risk of progression for those treted erly versus lte with AZT ws 0.58; notbly, the durtion of the beneficil effects ws limited to pproximtely 2 yers. 8 The introduction of combintion therpies for HIV-1 incresed not only the mgnitudes but lso the persistence of tretment effects. So, for exmple, in 2012, Weistrich nd collegues estimted tht, mong HIV-1-infected prticipnts in severl follow-up cohorts in the U.S., ntiretrovirl tretment nerly hlved the hzrd of cquired immune deficiency syndrome (AIDS) or deth (point estimte, hzrd rtio = 0.55), nd the effects persisted throughout the 6.5 yers of follow-up. 6 Since the U.S. militry s HIV-1 screening progrms begn, ll individuls in ctive service who hve been dignosed with HIV-1 infections hve been permitted to remin in ctive service s long s they re cpble of performing their militry duties nd re not subject to dischrge for dministrtive or disciplinry resons. When infected individuls become too debilitted from their illnesses to continue to serve, they re referred for medicl disbility seprtions or retirements. Of course, militry members who re infected with but not significntly debilitted from HIV-1 my elect to terminte their service when their obligtions hve been fulfilled. 9 With the clinicl mngement tools nd tretment regimens tht re currently vilble, the symptomtic stges of the disese courses of HIV-1-infected militry members cn be very long. For this report, we ssessed chrcteristics of nd chnges over time in the durtions of militry service of ctive component members of the U.S. militry fter initil dignoses of HIV-1 infections from 1990 through METHODS The surveillnce cohort consisted of ll individuls who were dignosed with HIV-1 infections while serving in the ctive component of the U.S. Armed Forces ny time between 1 Jnury 1990 nd 31 December For ech surveillnce August 2015 Vol. 22 No. 8 MSMR Pge 9

10 cohort member, survivl time in ctive militry service fter the dignosis of HIV-1 infection extended from the dte of their first documented HIV-1 infection dignosis (per HIV-1 serologic test records mintined in the Defense Medicl Surveillnce System [DMSS]) until the dte of their deth, dischrge, or retirement from militry service, or 30 June 2015 (the end of the surveillnce period). The Kpln-Meier survivl method ws used to estimte the distributions of durtions of militry service fter HIV-1 dignoses mong vrious cohorts of HIV- 1-infected service members. For survivl nlysis purposes, filure events were deths (while still in service), retirements, or dischrges from ctive service. Survivl times of cohort members who remined in ctive service until the end of the surveillnce period (30 June 2015) were censored s of tht dy. 10 To ssess temporl trends in the durtions of ctive militry service fter new dignoses of HIV-1, survivl nlyses were conducted in five cohorts of militry members bsed on the clendr yers of their initil HIV-1 dignoses: Cohort 1, initil dignoses in ; Cohort 2, initil dignoses in ; Cohort 3, initil dignoses in ; Cohort 4, initil dignoses in ; nd Cohort 5, initil dignoses in %; Cohort 2 [ ], 5.6%; Cohort 3 [ ], 16.4%; Cohort 4 [ ], 32.2%; Cohort 5 [ ], 62.9%) (dt not shown). Estimted medin durtions of service fter initil HIV-1 dignoses rnged from 2.29 yers in Cohort 1 ( ) to 3.65 yers in Cohort 4 ( ). Thus, in the 15 yers between nd , the medin durtions of service fter HIV-1 dignoses incresed by 1.4 yers (Figures 1, 2). (Becuse more thn 60% of Cohort 5 were still in service t the end of the surveillnce period, the estimte of the medin durtion of service fter dignoses of Cohort 5 members ws unstble nd is not included here.) The estimted durtion of service from HIV-1 dignoses until 75% of cohort members hd left service ws much longer mong Cohort 2 (8.48 yers), nd more thn twice s long mong Cohort 3 (9.13 yers), thn Cohort 1 (4.39 yers) members. Thus, in the 10 yers between nd , the durtions of service of the 25% who styed in service the longest fter dignoses incresed by 4.7 yers (Figures 1, 2). (Becuse more thn one-third of Cohorts 4 nd 5 were still in service t the end of the surveillnce period, estimtes of the 75%iles of durtions of service fter dignoses of those cohorts were unstble nd re not included here.) The estimted durtion of service from dignoses until one-fourth of cohort members hd left service chnged only slightly between (0.85 yers) nd (1.30 yers). Thus, in the 15 yers between nd , the durtions of service of the first 25% to leve service fter dignoses incresed by less thn 6 months (Figures 1,2). During the surveillnce period overll, medin durtions of service fter HIV-1 dignoses stedily incresed with ge from <20 yers through yers t times of dignoses. Also, compred to their respective counterprts, medin durtions of service fter dignoses were longer mong femles, officers nd senior enlisted members, nd Nvy members (Tble 1). EDITORIAL COMMENT This report documents mrked nd continuous increse (60% overll) in the medin durtions of militry service fter FIGURE 1. Estimted percentges of HIV-1-infected service members still in ctive militry service, by time (in yers) since dignoses of HIV-1 infections, by cohorts of ctive component members dignosed with HIV-1, U.S. Armed Forces, RESULTS During the 24-yer surveillnce period, totl of 5,227 militry members were newly dignosed with HIV-1 infections. The men number of HIV-1 infection dignoses per yer ws 218 (rnge, new dignoses per yer: 86 [1995] to 817 [1990]) (dt not shown). Becuse the cohorts were defined by the yers when their infections were dignosed, the lengths of time from dignoses until the end of the surveillnce period mrkedly vried cross the cohorts. In turn, the proportions of cohort members still in militry service t the end of the surveillnce period vried cross the cohorts (% of cohort members in service t end of the follow-up period: Cohort 1 [ ], Proportion remining in ctive service 1.00 Cohort 5 ( ) ( ) 0.90 Cohort 4 ( ) ( ) 0.80 Cohort 3 ( ) ( ) 0.70 Cohort 2 ( ) ( ) 0.60 Cohort 1 ( ) ( ) Yers fter dignosis Pge 10 MSMR Vol. 22 No. 8 August 2015

11 FIGURE 2. Estimted distributions of durtions (in yers) of ctive militry service fter dignoses of HIV-1 mong cohorts of ctive component members dignosed with HIV-1, U.S. Armed Forces, Yers of militry service fter dignoses %ile 7.44 Medin %ile Cohort 1 ( ) Cohort 2 ( ) Cohort 3 ( ) Cohort 4 ( ) Cohort 5 ( ) Estimte of 75%ile durtion of service of Cohort 5 not included becuse of reltively short follow-up until end of surveillnce period TABLE 1. Estimted distributions of durtions of ctive militry service fter dignoses of HIV-1 infections, by militry/demogrphic chrcteristics, ctive component, U.S. Armed Forces, Distribution of durtion (in yers) of militry service fter dignosis of HIV-1 No. % 25%ile 50%ile 75%ile Overll 5, Sex Mle 5, Femle Age < , , , Service Army 1, Nvy 2, Air Force Mrine Corps Cost Gurd Rnk Junior enlisted (E1 E4) 2, Senior enlisted (E5 E9) 2, Offi cer (including wrrnt) Reson for end of follow-up Terminted service "T" 4, End of follow-up period "C" 1, One service member not included becuse chrcteristic ws unknown HIV-1 dignoses mong cohorts dignosed from (2.29 yers) through (3.65 yers). During the 15-yer period between nd , medin durtions of service fter dignoses incresed by pproximtely 1 month per yer (16 months overll). Of note, the increses in service fter dignoses did not uniformly ffect ll militry members dignosed with HIV-1. For exmple, mong the first 25% of ech infected cohort to leve service, there were reltively smll increses in post-dignosis durtions of service. Of the first 25% of cohort members to leve service, durtions of service only incresed by 5.4 months overll between nd The findings suggest tht regrdless of the vilbility nd effectiveness of tretments for HIV-1 disese, t lest 25% of infected service members left service within the first 16 months fter dignoses. However, it is relevnt tht during most of the surveillnce period considered here, there were significnt stigms ssocited with both HIV-1 infection sttus nd homosexulity; such stigms likely discourged mny HIV-1-infected service members from remining in service. Through the erly 1990s, mny U.S. militry members considered HIV-1 August 2015 Vol. 22 No. 8 MSMR Pge 11

12 infection deth wrrnt becuse it inevitbly progressed to AIDS, n incurble nd ultimtely ftl disese. Also, militry members who were infected with HIV-1 were precluded from some creer-enhncing ssignments nd ctivities (e.g., militry schools, overses deployments). Thus, throughout much of the period of routine HIV-1 testing in the militry, there were significnt stigms ssocited with HIV-1 infection sttus. Also, for most of the period of interest of this report, individuls who were openly homosexul/bisexul were precluded from serving in the U.S. militry. However, in September 2011, ll proscriptions ginst U.S. militry service bsed on sexul orienttion were removed. Thus, until firly recently, there were significnt institutionlized stigms ssocited with homosexulity in the militry. Becuse men who hve sex with men re t reltively high risk of HIV-1 infection, homosexul men constitute reltively lrge proportion of militry members dignosed with HIV-1. 11,12 Becuse of the stigms ssocited with both HIV-1 infection sttus nd homosexulity, it is likely tht some service members who were dignosed with HIV-1 infections, prticulrly if homosexul, were unwilling even if eligible to remin in service. Perhps, mny such individuls were mong the 25% of HIV-1-infected service members who left service soon fter HIV-1 dignoses. However, s the mngement of HIVssocited disese continues to improve nd s the U.S. militry dpts to the inclusion of homosexuls within its rnks, stigms ssocited with HIV-1 infection nd homosexulity will decrese. Thus, in the future, reltively more service members who re dignosed with HIV-1 infections, regrdless of their sexul orienttions, my elect to continue their militry service creers. In regrd to the one-fourth of ech cohort who remined in service the longest fter dignoses (i.e., 75%ile of durtions of service), estimtes of the durtions of service fter dignoses more thn doubled (4.7 yers difference overll) during the 10 yers between the times of dignoses of the nd cohorts. As follow-up of the most recently infected cohort ( ) considered here becomes more complete over time, the durtions of service fter dignoses of those who remin the longest will likely exceed the durtions of the erlier infected cohorts. The findings of this report should be interpreted with considertion of its limittions. Most notbly, pproximtely one-fifth (21%) of ll HIV-1-infected cohort members were in ctive militry service t the end of the follow-up period. And in ech cohort of HIV-1-infected service members, medin durtions of service were much longer mong those who were still in service thn those who hd deprted. The Kpln-Meier survivl methods used for this nlysis enbled the use of ll ctive service time tht ech HIV-1-infected cohort member provided from the dy of dignosis until deth, retirement, dischrge, or the end of the follow-up period. 10 However, becuse the proportions of cohort members still in service t the end of the surveillnce period so mrkedly vried cross the cohorts (rnge, % of cohorts still in ctive service t end of the surveillnce period: 0.2% [Cohort 1: ] to 62.9% [Cohort 5: ]), estimtes of the distributions of durtions of service fter dignoses prticulrly of medin nd 75%ile durtions re more stble nd relible for the erlier thn the lterdignosed cohorts. In summry, the findings of this report document lrge increses in the durtions of service fter HIV-1 dignoses mong service members who re motivted to continue their militry creers. In the pst 30 yers, HIV-1 infection hs gone from n untretble disese mrked by inexorble clinicl progression through extreme debility to deth to tretble disese tht is comptible with ctive service throughout full creer in the U.S. militry. As stigms ssocited with HIV-1 infection sttus nd homosexulity decrese within the militry, it is likely tht durtions of service fter HIV-1 dignoses will continue to lengthen. REFERENCES 1. Burke DS, Brundge JF, Herbold JR, et l. Humn immunodeficiency virus infections mong civilin pplicnts for United Sttes militry service, October 1985 to Mrch Demogrphic fctors ssocited with seropositivity. N Engl J Med. 1987;317(3): McNeil JG, Brundge JF, Wnn ZF, Burke DS, Miller RN. Direct mesurement of humn immunodeficiency virus seroconversions in serilly popultion of young dults in the United Sttes Army, October 1985 to October Wlter Reed Retrovirus Reserch Group. N Engl J Med. 1989;320(24): Plell FJ, Delney KM, Moormn AC, et l. Declining morbidity nd mortlity mong ptients with dvnced humn immunodeficiency virus infection. N Engl J Med. 1998;338: Sterne JAC, Hernn MA, Ledergerber B, et l. Long-term effectiveness of potent ntiretrovirl therpy in preventing AIDS nd deth: prospective cohort study. Lncet. 2005;366: When To Strt Consortium, Sterne JA, My M, Costgliol D, et l. Timing of initition of retrovirl therpy in AIDS-free HIV-1 infected ptients: collbortive nlysis of 18 HIV cohort studies. Lncet. 2009;373(9672): Westreich D, Cole SR, Young JG, et l. The prmetric g-formul to estimte the effect of highly ctive ntiretrovirl therpy on incident AIDS or deth. Stt Med. 2012;31(18): Longini IM Jr, Clrk WS, Grdner LI, Brundge JF. The dynmics of CD4+ T-lymphocyte decline in HIVinfected individuls: Mrkov modeling pproch. J Acquir Immune Defic Syndr. 1991;4(11): Grdner LI, Hrrison SH, Hendrix CW, et l. Size nd durtion of zidovudine benefit in 1003 HIVinfected ptients: U.S. Army, Nvy, nd Air Force nturl history dt. Militry Medicl Consortium for Applied Retrovirl Reserch. J Acquir Immune Defic Syndr Hum Retrovirol.1998;17(4): Undersecretry of Defense for Personnel nd Rediness. Deprtment of Defense Instruction Number Subject: Humn Immunodeficiency Virus (HIV) in Militry Service Members. 7 June Rich JT1, Neely JG, Pniello RC, et l. A prcticl guide to understnding Kpln-Meier curves. Otolryngol Hed Neck Surg Sep;143(3): Hkre S, Armstrong AW, O Connell RJ, et l. A pilot online survey ssessing risk fctors for HIV cquisition in the Nvy nd Mrine Corps, J Acquir Immune Defic Syndr. 2012;61(2): Hkre S, Scoville SL, Pch LA, et l. Sexul risk behviors of HIV seroconverters in the U.S. Army, J Acquir Immune Defic Syndr Jul 31. [Epub hed of print]. Pge 12 MSMR Vol. 22 No. 8 August 2015

13 Cse Report: Probble Murine Typhus t Joint Bse Sn Antonio, TX Rlph A. Stidhm, MPH, DHSc; Robert L. von Tersch, PhD (COL, USA); Kenneth L. Btey, DVM, DACVP (LTC, USA); Cierre Roch, MD (CPT, USA) murine typhus, lso clled fleborne or endemic typhus, is bcteril disese cused by the orgnism Rickettsi typhi. The bcteri re trnsmitted to humns by infected fles tht hve cquired the orgnism from reservoirs such s rts, opossums, nd other smll nimls, including domestic dogs nd cts. Murine typhus cn cuse mild fever, with rsh on the body, hedches, nd muscle ches. The disese is tretble with tetrcycline ntibiotic, usully doxycycline, nd rrely results in deth. This report contins description of probble cse of murine typhus dignosed in resident of Texs who ws treted t the Sn Antonio Militry Medicl Center (SAMMC). The cse provides n opportunity to exmine significnt clinicl nd epidemiologic chrcteristics of murine typhus, nd to remind the reder bout other rickettsil diseses tht might ffect beneficiries of the Militry Helth System (MHS). CASE REPORT The 14-yer-old dughter of retired Air Force non-commissioned officer ws initilly evluted in Jnury 2015 t the Wilford Hll Ambultory Surgicl Center Urgent Cre Center, Joint Bse Sn Antonio, TX, for fever nd bdominl pin. She ws mnged conservtively (supportive cre) but returned 3 dys lter with ongoing fever up to 104 F, continued bdominl pin, nd new onset emesis nd dirrhe. A rpid influenz screen nd Respirtory Virus Pnel were negtive t tht time. Sline ws dministered intrvenously nd the ptient ws trnsferred by mbulnce to the SAMMC peditric wrd. No fmily members or other contcts were ill. The ptient denied ny recent trvel. She hs two pet hermit crbs nd three dogs nd lived with her prents nd one sibling in rurl re of Texs where there re ferl cts, s well s opossums, rccoons, bors, nd coyotes. The ptient indicted tht she does bring ferl cts into her bedroom. Shortly fter rrivl t SAMMC, the ptient ws dmitted to the Peditric Intensive Cre Unit in hypotensive shock. Physicl exm reveled temperture of F nd respirtory rte of 48 ccompnied by mild right upper qudrnt bdominl tenderness nd n erythemtous blnching mculr rsh on the fce, neck, rms, nd legs. An dmission blood pressure ws 113/69 mmhg, but subsequent mesurements showed systolic blood pressure of less thn 90 mmhg. A complete blood count reveled white cells per microliter with 42% segmented neutrophils nd 46% bnd forms. A hemtocrit ws 33.4% nd pltelet count ws 55,000 per microliter. Asprtte nd lnine minotrnsferses were 47 units per liter (U/L) (reference rnge: 5 32 U/L) nd 29 U/L (reference rnge: 4 33 U/L), respectively. Blood cultures obtined upon dmission showed no growth fter 5 dys. A rickettsil disese ws suspected nd the ptient ws treted with intrvenous (IV) doxycycline, 100 mg every 12 hours; ceftrixone nd vncomycin were lso dministered. The ptient recovered promptly nd her tretment ws converted to n orl regimen of doxycycline (within 48 hours of strting IV doxycycline) to complete 7-dy course with the sme orl dosge. The ptient ws hospitlized for totl of 7 dys. During her hospitliztion, serologic testing reveled negtive immunoglobulin M (IgM) nd immunoglobulin G (IgG) ntibody titers for Rickettsi rickettsii (cuse of Rocky Mountin spotted fever) nd Coxiell burnetii (cuse of Q fever). An initil R. typhi IgG ntibody titer ws positive t 1:128 dilution by indirect fluorescent ntibody (IFA) in serum obtined during her hospitliztion. A convlescentphse R. typhi IgG ntibody titer obtined 3 weeks lter ws positive t 1:256 dilution. No serum specimen ws ever for R. typhi IgM ntibody titer. EDITORIAL COMMENT Murine typhus, cused by n obligte intrcellulr, grm-negtive bcteril orgnism, R. typhi (formerly Rickettsi mooseri nd Rickettsi felis), 1 is n uncommon fle-borne infectious disese tht is reported reltively rrely in the U.S. The illness is dignosed less frequently in the U.S. thn in developing ntions becuse of improvements in hygiene nd rt control efforts. The ctul prevlence of murine typhus is difficult to scertin becuse infection cn be mild, self-limiting, nd problemtic to differentite from other cuses of rsh nd fever. Humn cses of fle-borne typhus re reported worldwide, but they predominte in tropicl nd costl res. In the U.S., murine typhus is found most commonly in Southern Cliforni, 2 Texs, 3 nd Hwii, with n verge of bout 200 cses reported ech yer. 4 Texs verged 54 murine typhus cses nnully during ; this verge incresed to 159 cses nnully during , n increse tht is ttributed to ctive surveillnce by public helth uthorities nd enhnced physicin reporting. During , Texs verged 257 cses per yer (K. Owens, Texs Deprtment of Stte Helth Services; personl communiction, 15 Mrch 2015) (Figure). Murine typhus is primrily trnsmitted by the rt fle, Xenopsyll cheopis. 5 In contrst, epidemic typhus August 2015 Vol. 22 No. 8 MSMR Pge 13

14 FIGURE. Annul numbers of reported cses of murine typhus, Texs, No. of cses Avg.: 54 per yer Dt source: K. Owens, Texs Deprtment of Stte Helth Services; personl communiction, 15 Mrch 2015 is trnsmitted primrily by lice. Additionl murine typhus vectors include the ct fle, Ctenocephlides felis, nd the mouse fle, Leptopsylli segnis. 5 Fles remin permnently infected with R. typhi, but their lifespn is not reduced by the presence of rickettsie. Humns re infected by inocultion of infective fle feces into bite wounds. 6 The mjority of cses of murine typhus re ssocited with environments where rts ccumulte in lrge numbers. In the U.S., domestic cts, ct fles, nd opossums my mintin cycle of both R. typhi nd R. felis ( spotted fever group rickettsi tht is fle-borne nd produces n illness tht is cliniclly similr to murine typhus). 6 Fles my become infected when they feed on these nimls nd then cn trnsmit the bcteri to humns, dogs, nd cts. Murine typhus is likely underdignosed becuse it is esily mistken for virl illness, nd most cses resolve spontneously. Moreover, ptients re seldom wre of hving hd fle bites so the ssocition of febrile illness with the vector is usully not Avg.: 159 per yer Avg.: 257 per yer deduced. A serologic study of 513 children from South Texs found tht pproximtely 13% of children ged 1 17 yers hd IgG ntibodies rective to R. typhi. 7 Outbreks of murine typhus re uncommon. A report of cluster of 53 cses of murine typhus in Austin, TX, in 2008 indicted tht high density of infection in domestic nimls or opossums my hve been responsible for the hyperendemic focus of infection secondrily involving humns. 8 Although R. typhi infections cn be mild nd my go undetected, people dignosed with fle-borne typhus experience the onset of nonspecific symptoms (hedche, chills, prostrtion, fever, nd mylgi) pproximtely 6 14 dys fter being bitten by fles. 5 Some ptients my lso develop rsh tht my begin on the chest nd spred to the sides nd bck. Nonspecific gstrointestinl symptoms such s nuse, vomiting, bdominl pin, nd dirrhe my lso occur t this time. Gstrointestinl symptoms seem to be prticulrly common in children with murine typhus, occurring in 77% of 97 infected children in one study. 9 The mjority of reported cses in Cliforni nd Texs hve required hospitliztion, likely reflecting reporting bis towrd more severe cses. Dignosis of murine typhus is usully bsed on clinicl recognition nd serology; the ltter involves comprison of specific ntibody levels in cute- nd convlescent-phse serum specimens nd is thus beneficil only in retrospect. Etiologic gents cn usully be identified only to the genus level by serologic testing. Thrombocytopeni is common finding, occurring in 48% of ptients in one study. 10 Leukocytosis or mild leukopeni occurred frequently nd hypontremi nd bnorml liver function tests occur in 60% nd 90% of ptients, respectively, lthough these bnormlities re typiclly insignificnt. 10 Murine typhus is treted with ntibiotics, typiclly doxycycline for dults. Most people recover within few dys. Deth from murine typhus is rre (2% 4% without tretment, worldwide). 10 Although murine typhus is customrily deemed to be mild illness, the infection my be ftl or severe if misdignosed or insufficiently treted. At this time, there is no vccine of demonstrted efficcy for murine typhus. Ptients surviving infection with R. typhi do develop subsequent nd long-term protective immunity to reinfection. 11 Within the pst 10 yers, 13 cses of murine typhus hve been reported in U.S. service members (Tble 1). Of these cses, 85% (n=11) occurred in mles nd 77% (n=10) occurred in white non-hispnics. Only two of these cses were dignosed outside of the U.S. (Kore nd Gum). The remining cses occurred in the continentl U.S.: Texs (seven), Cliforni (two), Kentucky (one), nd Mrylnd (one). Although the mjority of murine typhus cses occurred in Army service members (n=7), three cses ech occurred in Nvy nd Air Force service members within the pst 10 yers. When murine typhus is dignosed in beneficiry of the MHS, the cse should be reported promptly to locl civilin nd militry public helth uthorities. In turn, militry public helth uthorities re Pge 14 MSMR Vol. 22 No. 8 August 2015

15 TABLE 1. Incident murine typhus cses, U.S. Armed Forces, Totl Service 13 Army 7 Nvy 3 Air Force 3 Mrine Corps 0 Cost Gurd 0 Sex Mle 11 Femle 2 Rce/ethnicity White, non-hispnic 10 Blck, non-hispnic 2 Other 1 Rnk Junior enlisted (E01 E04) 5 Senior enlisted (E05 E09) 4 Junior offi cer (O01 O03) Wrrnt offi cer (W01 W03) 1 Senior offi cer (O04 O10) Wrrnt offi cer (W04 W05) 3 Age < Country/stte of dignosis Cliforni 2 Kentucky 1 Mrylnd 1 Texs 7 Gum 1 South Kore 1 Dt Source: Defense Medicl Surveillnce System (DMSS), s of 12 Mrch 2015 Prepred by the Armed Forces Helth Surveillnce Center on 12 Mr 2015 required to report ll cses to the Disese Reporting System internet (DRSi). Timely, ccurte reporting of probble, suspected, or confirmed cses ensures proper identifiction, tretment, control, nd follow-up of cses. The cse described bove meets the definition of probble cse ccording to the Texs Deprtment of Stte Helth Services Epi Cse Criteri Guide, 2012, 11 TABLE 2. Vectorborne rickettsil diseses most common in U.S. nd where U.S. Armed Forces my be ssigned 14 Disese Agent Vector Distribution Reportble Murine (endemic) typhus Epidemic typhus Rocky Mountin nd other spotted fevers Scrub typhus s evidenced by cute nd convlescent phse specimens tken 3 weeks prt. For this cse, R. typhi IgG ntibody tests were positive, with IFA serologic titers of 1:128 nd 1:256, respectively. In South Texs nd Trvis County, TX, where murine typhus is endemic, cliniclly comptible cses with either R. typhi or R. felis IgG titers greter thn 1:1024 re considered confirmed cses. 11 According to the Armed Forces Reportble Medicl Events Guidelines nd Cse Definitions, 12 the ptient in this report would not be considered cse becuse the guidelines require 4-fold or greter rise in ntibody titer to R. typhi by IgG test in the cute nd convlescent phse specimens tken 3 weeks prt. 12 To cst wider net nd cpture more cses in U.S. service members nd other beneficiries of the MHS, the inclusion of probble cse clssifiction is recommended. The probble cse clssifiction would be defined s cliniclly comptible illness with supportive lbortory results: single IFA serologic titer greter thn 1:64; or single complement fixtion titer greter thn 16; or other supportive serology (single titer greter thn 64 by tests employing ltex gglutintion, indirect hemgglutintion, or microgglutintion). 12 Locl militry public helth uthorities should continue to identify cses of murine typhus Rickettsi typhi Fle Globl Yes Rickettsi prowzekii Rickettsi rickettsii et l. Orienti (Rickettsi) tsutsugmushi Louse, squirrel fl e (U.S.) Globl Yes Tick U.S., globl Yes Mite Asi Yes Rickettsilpox Rickettsi kri Mite Globl No nd other rickettsil diseses nd to report them s soon s lbortory nd clinicl informtion is vilble. After the ptient described in this report hd recovered, she nd her fmily were given instructions for prevention of murine typhus nd other diseses by excluding ferl cts from their home, eliminting food sources tht my ttrct wild nimls, nd controlling fles in their domestic nimls. It should be noted tht other rickettsil diseses though not ll tht occur in the U.S. re lso reportble, in ddition to scrub typhus, which ffected mny U.S. service members in Asi in the pst. Tble 2 summrizes the rickettsil diseses tht could most plusibly ffect members of the U.S. Armed Forces on the bsis of their geogrphic distribution. 14 Disclimer: The view(s) expressed herein re those of the uthor(s) nd do not reflect the officil policy or position of the U.S. Army Public Helth Commnd Region South, Brooke Army Medicl Center, U.S. Army Medicl Deprtment, U.S. Army Office of the Surgeon Generl, Deprtment of the Army, Deprtment of Defense, or U.S. Government. Author ffilitions: Epidemiology nd Disese Surveillnce, U.S. Army Public Helth August 2015 Vol. 22 No. 8 MSMR Pge 15

16 Commnd Region South, Fort Sm Houston, TX (Dr. Stidhm, COL von Tersch, LTC Btey); Sn Antonio Militry Medicl Center, Deprtment of Peditrics, Sn Antonio, TX (CPT Roch). Acknowledgements: The uthors thnk Theodore Cieslk, MD (COL, USA, Ret.) for helping to drft the clinicl section of the cse report; Steven A. Knpp, AN, MPH (LTC, USA) for providing editing; Yeseni Medin, RN, for providing test dt; nd Kmesh Owens, RS, MPH, for providing sttistics. REFERENCES 1. Pickering LD, ed. Endemic Typhus (Fleborne Typhus or Murine Typhus). In: Red Book: 2009 Report of the Committee on Infectious Diseses. 28th ed. Elk Grove Villge, IL: Americn Acdemy of Peditrics; 2009: Cliforni Deprtment of Public Helth. Fle- Borne Typhus. discond/documents/fle-bornetyphus.pdf. Accessed on 6 Mrch Texs Deprtment of Stte Helth Services. Murine typhus sttistics in Texs. stte.tx.us/idcu/disese/murine_typhus/sttistics/. Accessed on 5 Mrch Centers for Disese Control nd Prevention. Rickettsil (Spotted & Typhus Fevers) & Relted Infections Anplsmosis & Ehrlichiosis). Avilble t: chpter-3-infectious-diseses-relted-to-trvel/ rickettsil-spotted-nd-typhus-fevers-nd-reltedinfections-nplsmosis-nd-ehrlichiosis. Accessed on 1 Mrch Heymnn DL, ed. Endemic Fle-borne Typhus (Murine Typhus, Shop Typhus). In: Control of Communicble Diseses Mnul. 19th ed. Wshington, DC: Americn Public Helth Assocition; 2008: Civen R, Ngo V. Murine typhus: n unrecognized suburbn vectorborne disese. Clin Infect Dis. 2008;46(6): Purcell K, Fergie J, Richmn K, Roch L. Murine typhus in children, South Texs. Emerg Infect Dis. 2007;13(6): Centers for Disese Control nd Prevention. Outbrek of Rickettsi typhi infection Austin, Texs, MMWR. 2009;58(45): Whiteford SF, Tylor JP, Dumler JS. Clinicl, lbortory, nd epidemiologic fetures of murine typhus in 97 Texs children. Arch Peditr Adolesc Med. 2001;155(3): Dumler JS, Tylor JP, Wlker DH. Clinicl nd lbortory fetures of murine typhus in south Texs, 1980 through JAMA. 1991;266(10): Chn YG, Riley SP, Chen E, Mrtinez JJ. Moleculr bsis of immunity to rickettsil infection conferred through outer membrne protein B. Infect Immun. 2011; 79(6): Texs Deprtment of Stte Helth Services. Epi Cse Criteri Guide, dshs.stte.tx.us/workare/downlodasset. spx?id= Accessed on 9 Mrch Armed Forces Helth Surveillnce Center. Armed Forces Tri-Service Reportble Events Guidelines & Cse Definitions, Mrch mil/viewdocument?file=triservice_csedefdocs/ ArmedForcesGuidelinesFinl14Mr12.pdf. Accessed on 1 Mrch Mndell GL, Bennett JE, Dolin R, eds. Mndell, Dougls, nd Bennett s Principles nd Prctice of Infectious Diseses. 7th ed. Phildelphi, PA: Churchill Livingstone; 2010: MSMR s Invittion to Reders The Medicl Surveillnce Monthly Report (MSMR) invites reders to submit topics for considertion s the bsis for future MSMR reports. The MSMR editoril stff will review suggested topics for fesibility nd comptibility with the journl s helth surveillnce gols. As is the cse with most of the nlyses nd reports produced by the Armed Forces Helth Surveillnce Center (AFHSC) stff, studies tht would tke dvntge of the helthcre nd personnel dt contined in the Defense Medicl Surveillnce System would be the most plusible types. For ech promising topic, AFHSC stff members will design nd crry out the dt nlysis, interpret the results, nd write mnuscript to report on the study. This invittion represents willingness to consider good ides from nyone who shres the MSMR s objective to publish evidence-bsed reports on subjects relevnt to the helth, sfety, nd well-being of militry service members nd other beneficiries of the Militry Helth System. In ddition, the MSMR encourges the submission for publiction of reports on evidence-bsed estimtes of the incidence, distribution, impct, or trends of illness nd injuries mong members of the U.S. Armed Forces nd other beneficiries of the Militry Helth System. Instructions for uthors cn be found on the MSMR pge of the Armed Forces Helth Surveillnce Center website t: Plese emil your rticle ides nd suggestions to the MSMR editoril stff t: usrmy.ncr.medcom-fhsc.mbx.msmr@mil.mil. Pge 16 MSMR Vol. 22 No. 8 August 2015

17 Morbidity Burdens Attributble to Vrious Illnesses nd Injuries in Deployed (per Theter Medicl Dt Store [TMDS]) Active nd Reserve Component Service Members, U.S. Armed Forces, Denise O. Dniele, MS; Leslie L. Clrk, PhD, MS This report estimtes illness nd injury-relted morbidity nd the helthcre burden for service members during deployments to the CENTCOM nd AFRICOM theters of opertion during During the 7-yer surveillnce period, totl of 2,863,834 medicl encounters occurred mong 1,596,935 service members who were deployed. Four burden ctegories comprised 50% or more of the totl helthcre burden mong both mle nd femle deployers: injury nd poisoning, mentl disorders, musculoskeletl diseses, nd signs nd symptoms. In both genders, injuries nd poisonings, nd signs nd symptoms, were the top two ctegories tht ffected the most individuls. Both genders hd the sme top four hospitliztion ctegories: injuries nd poisonings, signs nd symptoms, genitourinry diseses, nd digestive diseses. The limittions of the dt used in the nlysis re discussed. every April, the MSMR estimtes illness nd injury-relted morbidity nd helthcre burdens on the U.S. Armed Forces nd the U.S. Militry Helth System (MHS) using electronic records of medicl encounters from the Defense Medicl Surveillnce System (DMSS). These records document helth cre delivered in the fixed medicl fcilities of the MHS nd in civilin medicl fcilities when cre is pid for by the MHS. Helthcre encounters of deployed service members re documented in records tht re mintined in the Theter Medicl Dt Store (TMDS), which is incorported into DMSS. An rticle in the November 2011 MSMR compred the burdens of helth cre documented in both DMSS nd TMDS for This report exmines the distributions of illnesses nd injuries tht ccounted for medicl encounters ( morbidity burdens ) of ctive component members in deployed settings in the Centrl Commnd nd the U.S. Afric Commnd res of opertions during METHODS The surveillnce period ws 1 Jnury 2008 through 31 December The surveillnce popultion included ll individuls who served in the ctive or reserve components of the U.S. Army, Nvy, Air Force, Mrine Corps, or Cost Gurd nd who hd records of helthcre encounters cptured in the TMDS during the surveillnce period. The nlysis ws restricted to encounters where the theter of cre specified ws CENT- COM, AFRICOM, or where the theter of opertion ws missing or null; by defult, this excluded encounters in the NORTHCOM, EUCOM, PACOM, or SOUTHCOM theter of opertions. In ddition, TMDS records of helth cre were excluded from this nlysis through exclusion of medicl encounters where the dt source ws identified s Shipbord Automted Medicl System (e.g., SAMS, SAMS8, SAMS9) or the militry tretment fcility descriptor indicted cre ws provided bord ship (e.g., USS George H.W. Bush, USS Dwight D. Eisenhower or similr). Summrized re inptient nd outptient medicl encounters during the 7-yer surveillnce period ccording to the primry (first-listed) dignosis (if reported with n ICD-9 code between 001 nd 999). Primry dignoses tht did not correspond to n ICD-9 code (e.g., 1XXXX, 4XXXX) were not reported in this burden nlysis. For summry purposes, ll illness nd injury-specific dignoses (s defined by the ICD-9 t the three-digit level) were grouped into 135 burden of disese-relted conditions nd 25 ctegories bsed on modified version of the clssifiction system developed for the Globl Burden of Disese (GBD) Study. 2 In generl, the GBD system groups dignoses with common pthophysiologic or etiologic bses nd/or significnt interntionl helth policymking importnce. For this nlysis, some dignoses tht re grouped into single ctegories in the GBD system (e.g., mentl disorders) were disggregted. Also, injuries were ctegorized by the ffected ntomic sites rther thn by cuses becuse externl cuses of injuries re not completely reported in TMDS records. The morbidity burdens ttributble to vrious conditions were estimted on the bsis of the totl number of medicl encounters ttributble to ech condition (i.e., totl hospitliztions nd mbultory visits for the condition with limit of one encounter per individul per condition per dy) nd the numbers of service members ffected by the conditions. August 2015 Vol. 22 No. 8 MSMR Pge 17

18 RESULTS During the 7-yer surveillnce period, totl of 2,863,834 medicl encounters occurred mong 1,596,935 individuls while deployed to Southwest Asi/Middle Est nd Afric. Of the totl medicl encounters, 4,427 (0.15%) were hospitliztions. A mjority of the medicl encounters (80.3%), individuls ffected (80.9%), nd hospitliztions (89.0%) occurred mong mles (Figure 1). Medicl encounters/individuls ffected During , the percentges of totl medicl encounters by burden of disese ctegories in both deployed men nd women were generlly similr; in both genders, more encounters were ttributble to injuries nd poisonings, mentl disorders, musculoskeletl diseses, nd signs nd symptoms thn ny other ctegories (Figures 1, 1b, 2, 2b). Of note, femles hd greter proportion of medicl encounters for genitourinry diseses (6.3%) compred to mles (1.6%). Among mles nd femles, three burden conditions, other bck problems, other signs nd symptoms, nd upper respirtory infections were mong the top five burden conditions tht ccounted for the most medicl encounters (Figures 3, 3b). Among mles, rm nd shoulder injury, nd other skin diseses, nd mong femles, other musculoskeletl diseses, nd bdomen nd pelvis (i.e., referring to signs nd symptoms of the bdomen nd pelvis) were the remining burden conditions mong the top five conditions. The four-digit ICD-9 code with the most medicl encounters in the other signs nd symptoms ctegory ws sleep disturbnces mong both mles nd femles (dt not shown). Non-specific rshes, dizziness/giddiness, nd syncope/collpse were mong the other top other signs nd symptoms in both genders. Among mles, the four-digit ICD-9 codes tht ccounted for the most medicl encounters in other skin diseses included folliculitis, cellulitis, nd crbuncles/furuncles. The four-digit ICD-9 codes with the most medicl encounters in the other musculoskeletl diseses ctegory mong women were pin in limb nd cerviclgi. In the bdomen nd pelvis ctegory mong women, bdominl pin nd nuse/vomiting were the top two fourdigit ICD-9 codes with the most medicl encounters (dt not shown). Of note, mong mles, fewer thn 0.3% of ll medicl encounters during deployment were ssocited with ny of the following morbidity ctegories: congenitl nomlies, dibetes, mlignnt neoplsms, blood disorders, nd mternl/perintl conditions (Figure 1). Among femles, fewer thn 0.3% of ll medicl encounters during deployment were ssocited with: congenitl nomlies, metbolic/immune disorders, mlignnt neoplsms, dibetes, nd perintl conditions (Figure 1b). Among both genders, injuries nd poisonings, nd signs nd symptoms, were the top two ctegories tht ffected the most individuls (Figures 1, 1b). Musculoskeletl diseses rnked third mong mles, nd respirtory infections rnked third mong femles. FIGURE 1. Medicl encounters, individuls ffected, b nd hospitliztions by burden of disese ctegory, c mong deployed mle service members, U.S. Armed Forces, No. of medicl encounters/ individuls ffected (brs) 675, , , , , , , ,000 75,000 0 Medicl encounters Individuls ffected Hospitliztions 1,800 1,600 1,400 1,200 1, No. of hospitliztions (boxes) Injury/poisoning Mentl disorders Musculoskeletl diseses Signs/symptoms Skin diseses Respirtory infections Infectious/prsitic diseses Digestive diseses Sense orgn diseses Respirtory diseses Hedche Crdiovsculr diseses Genitourinry diseses Neurologic conditions Orl conditions Other neoplsms Burden of disese ctegories Metbolic/immune disorders Endocrine disorders Nutritionl disorders Congenitl nomlies Dibetes Mlignnt neoplsms Blood disorders Perintl conditions Mternl conditions Medicl encounters: totl hospitliztions nd mbultory visits for the condition (with no more thn one encounter per individul per dy per condition) b Individuls ffected: individuls with t lest one hospitliztion or mbultory visit for the condition c Mjor ctegories nd conditions defined in the Globl Burden of Disese Study Pge 18 MSMR Vol. 22 No. 8 August 2015

19 FIGURE 1b. Medicl encounters, individuls ffected, b nd hospitliztions by burden of disese ctegory, c mong deployed femle service members, U.S. Armed Forces, No. of medicl encounters/ individuls ffected (brs) 120, ,000 90,000 75,000 60,000 45,000 30,000 15,000 0 Injury/poisoning Mentl disorders Signs/symptoms Musculoskeletl diseses Respirtory infections Burden of disese ctegories Medicl encounters: totl hospitliztions nd mbultory visits for the condition (with no more thn one encounter per individul per dy per condition) b Individuls ffected: individuls with t lest one hospitliztion or mbultory visit for the condition Genitourinry diseses Skin diseses Infectious/prsitic diseses Digestive diseses Hedche c Mjor ctegories nd conditions defined in the Globl Burden of Disese Study Sense orgn diseses Respirtory diseses Medicl encounters Individuls ffected Hospitliztions Crdiovsculr diseses Orl conditions Neurologic conditions Endocrine disorders Other neoplsms Mternl conditions Blood disorders Nutritionl disorders Congenitl nomlies Metbolic/immune disorders Mlignnt neoplsms Dibetes Perintl conditions No. of hospitliztions (boxes) FIGURE 2. Percentge of medicl encounters, nd hospitliztions by burden of disese ctegory, b mong deployed mle service members, U.S. Armed Forces, Percentge of totl Medicl encounters Hospitliztions Other Genitourinry diseses Crdiovsculr diseses Hedche Respirtory diseses Sense orgn diseses Digestive diseses Infectious/prsitic diseses Respirtory infections Skin diseses Signs/symptoms Musculoskeletl diseses Mentl disorders Injury/poisoning Medicl encounters: totl hospitliztions nd mbultory visits for the condition (with no more thn one encounter per individul per dy per condition) b Mjor ctegories nd conditions defi ned in the Globl Burden of Disese Study Percentge of totl FIGURE 2b. Percentge of medicl encounters, nd hospitliztions by burden of disese ctegory, b mong deployed femle service members, U.S. Armed Forces, Medicl encounters Hospitliztions Other Neurologic conditions Orl conditions Crdiovsculr diseses Respirtory diseses Sense orgn diseses Hedche Digestive diseses Infectious/prsitic diseses Skin diseses Genitourinry diseses Respirtory infections Musculoskeletl diseses Signs/symptoms Mentl disorders Injury/poisoning Medicl encounters: totl hospitliztions nd mbultory visits for the condition (with no more thn one encounter per individul per dy per condition) b Mjor ctegories nd conditions defi ned in the Globl Burden of Disese Study August 2015 Vol. 22 No. 8 MSMR Pge 19

20 FIGURE 3. Percentge nd cumultive percentge distribution of burden conditions tht ccounted for the most medicl encounters mong deployed mle service members, U.S. Armed Forces, % of totl medicl encounters (brs) % 50% 75% Other bck problems Cumultive % of totl medicl encounters (line) Other signs nd symptoms Arm/shoulder injury Other skin diseses Upper respirtory infections Foot/nkle injury Other musculoskeletl diseses Knee injury Adjustment Abdomen nd pelvis Other infectious/prsitic diseses Unspecified injury Anxiety Other mentl disorders Hnd/wrist injury Hed/neck injury Other sense orgn diseses Mood Hedche Bck/bdomen injury Other gstroenteritis/colitis Respirtory nd chest All other digestive diseses Leg injury Tobcco dependence Other genitourinry diseses FIGURE 3b. Percentge nd cumultive percentge distribution of burden conditions tht ccounted for the most medicl encounters mong deployed femle service members, U.S. Armed Forces, % of totl medicl encounters (brs) Other signs/symptoms Upper respirtory infections Other bck problems 25% Other musculoskeletl diseses Abdomen nd pelvis Foot/nkle injury Adjustment Hedche Knee injury Other skin diseses 50% Other genitourinry diseses Mood Anxiety Other infectious/prsitic diseses Arm/shoulder injury Unspecified injury Other mentl disorders Other sense orgn diseses Leg injury 75% Other gstroenteritis/colitis Other digestive diseses Hnd/wrist injury Bck/bdomen injury Respirtory nd chest Hed/neck injury Contct dermtitis Cumultive % of totl medicl encounters (line) Hospitliztions During , both genders hd the sme top four hospitliztion ctegories: injuries nd poisonings, signs nd symptoms, genitourinry diseses, nd digestive diseses (Figures 1, 1b, 2, 2b). However, the proportions of ech ctegory by gender vried. Among mles, 44.5% of ll hospitliztions were for injuries nd poisonings, compred to 16.2% for femles. Signs nd symptoms ccounted for the gretest proportion of hospitliztions mong femles (24.8%) (mles: 14.3%). Also of note mong femles, genitourinry disorder hospitliztions ccounted for 10.3% of hospitliztions (mles: 5.2%). Among mles, unspecified injury, leg injury, nd hed/neck injury were the top three burden conditions tht ccounted for the most hospitliztions (Figure 4). Among Pge 20 MSMR Vol. 22 No. 8 August 2015