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ABSTRACT |
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Combat-related injuries are typically the most severe and dramatic health risks encountered during wartime operations, as has been true for the current military operations in Afghanistan and Iraq.4,5 However, non-combat injuries and illnesses have also been shown to have a significant adverse impact on military operations, resulting in more hospitalizations and lost person-days than combat casualties in every war from the American Revolution through the Gulf War.6–8 Since the United States currently has more than 140,000 troops deployed to Afghanistan and Iraq, military health care planners and providers should have a clear understanding of all health risks encountered in the region and the impact of common infections and non-combat injuries on the military mission. The four most commonly reported diagnoses during U.S. military deployments over the last 15 years have been non-combat orthopedic injuries, respiratory infections, skin diseases, and gastrointestinal infections.9 A recent study reported detailed rates of diarrhea on U.S. military personnel deployed to Iraq and Afghanistan.10 In addition, infections such as leishmaniasis,11,12 malaria,13 pneumonia,14 and brucellosis15 have been reported. However, to date, no studies have evaluated the impact of illness and non-combat injury among troops deployed to the regions during current campaigns. To assess this, we conducted a systematic survey among soldiers currently on deployment or returning to the United States after their initial tour in Iraq and Afghanistan.
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METHODS |
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Study sites. Study personnel were placed in the terminals of two airports, Rhein-Main Air Base, Germany and Incirlik Air Base, Turkey, which are commonly used to transport personnel to and from Iraq and Afghanistan. Additionally, study personnel were stationed at Camp As Sayliyah, Doha, Qatar, the primary site for the rest and recuperation program. Study personnel conducted a convenience sampling of troops whose flights were transiting these airbases. Troops were met as they exited the plane and were asked if they would participate in the project. Researchers systematically distributed the study forms to the participants and subsequently collected the completed forms. Each volunteer completed only one form.
Study questionnaire. A previously tested questionnaire10 assessing diarrhea prevalence, associated symptoms, treatment, and mission impact was significantly expanded to include questions concerning general health, respiratory illness, and non-combat injuries, as well as health risk behaviors and attitudes. A total of 199 questions were asked on the expanded questionnaire. However, because of time constraints of the transiting personnel and the anticipated large number of participants, the expanded questionnaire was divided into 20 separate single-page forms to ensure a representative distribution of responses across all health categories. The single-page forms were composed of eight demographic and two clinical questions that were found on every form and 9–12 additional questions. The constant demographic and clinical questions were placed on multiple forms to later test for internal survey validity.
Mission impact was assessed through certain indicator questions. For personnel reporting that they participated in patrols, missing a patrol was the index used to assess impact. For personnel on flight status or from air units, being grounded was used as the index. These indexes would be familiar to the respective specialties, but would also provide a valid estimate of disease/injury impact.
Data entry and analysis. Data was entered into MS Access® (Microsoft, Inc., Redmond, WA). Data accuracy and data integrity checks were performed on all 20 single-page forms. The demographic data that was present on all 20 forms was statistically tested to ensure internal validity of results using the chi-square test (sex, rank, branch of service, and military component) and the Kruskal-Wallis test (time-in-country and age).
For statistical testing of continuous variables, normality testing was conducted, followed by either parametric (Student’s t-test or analysis of variance) or non-parametric (Kruskal-Wallis test) analysis. Categorical variable (proportions) were statistically tested using chi-square or Fisher’s exact tests. Point estimates and 95% confidence intervals (CIs) for all variables of interest were calculated by using OpenEpi version 8 statistical software (Stata Corporation, College Station, TX). Poisson regression was used to evaluate factors associated with differential incidence estimates. SAS version 8.software 2 (SAS, Cary, NC) was used for all other statistical analyses. All statistical tests were two-tailed and significance was defined as P < 0.05.
Operation Iraqi Freedom (OIF) was divided into three periods as defined by the Department of Defense that denoted both time and activity: pre-combat operations (prior to March 19, 2003), combat operations (March 19, 2003 through April 30, 2003), and post-combat operations (after April 30, 2003).16 The survey questions assessing self-reported symptoms and impact referred to these phases by name only. Dates were used to calculate cumulative person-time for these phases to estimate incidence.
This study was conducted as an anonymous survey and was reviewed and approved by the Institutional Review Board of the Naval Medical Research Unit, No. 3 (Cairo, Egypt) under work unit number 6000.RAD1.D.E0301.
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RESULTS |
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) of age, sex, rank, and military component and the two clinical questions were similar across all 20 forms (P > 0.05). Time in country ranged from a median of 333 days to a median of 345 days across the forms.
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). In Iraq, the self-reported incidence of diarrhea and respiratory infections nearly doubled from the pre-combat phase to the combat phase and then decreased considerably in the post-combat phase (Table 2). The perceived impact of these common illnesses on the combat unit effectiveness also increased significantly during the combat operations phase, and although it decreased in the post-combat operations phase, it never returned to the pre-combat phase perception level.
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). Diarrhea was reported more commonly among personnel deployed to Iraq compared with Afghanistan (76.8% versus 54.4%, P < 0.0001) even when controlling for the demographic differences in the two groups. Additionally, troops in Iraq tended to have more severe symptoms and a longer duration of illness along with a higher likelihood of having more than one episode of diarrhea during their time in the country compared with troops stationed in Afghanistan (Table 3). Nearly half of the troops who developed diarrhea stated it was severe enough for them to seek medical care at least once, translating to a monthly estimated incidence of six clinic visits per 100 person-months for treatment of diarrhea. Combining results from Iraq and Afghanistan, 46.1% of the episodes of diarrhea were reported to result in decreased job performance for an average of two days. Extrapolated to the entire population, we estimate 13 days of job performance (95% CI = 12–14 days) were decreased because of diarrhea per 100 person-months. In 14.2% of the cases, diarrhea resulted in the troops being confined to bed for a median of two days, and 1.8% were hospitalized, resulting in an estimated 3.7 days (Poisson 95% CI = 3.4–4.0 days) of complete work loss per 100 person-months.
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). Inquiries about tobacco use showed that 38.9% of the troops smoked at least half a pack of cigarettes per day and of the smokers, 47.6% either began smoking or restarted smoking during the deployment.
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). No significant differences were noted in non-combat injuries among troops stationed in Iraq compared with those in Afghanistan. A variety of different etiologies of the injuries were reported, with the largest single identified cause being sports or physical training. Additionally, numerous sites of injuries were reported, with the back being the most common single site of injury.
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DISCUSSION |
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In previous wars, rates of illness and non-combat injuries have been recorded through the Disease Non-Battle Injury (DNBI) system, but this data has been difficult to obtain in the current conflict. Even when reported from past conflicts, the DNBI system has been shown to dramatically underestimate rates of illness and injury and their impact on the mission.19 Assessing the actual impact of illnesses and non-combat injuries on the ability of the troops to perform their mission is difficult, requiring specific knowledge of the mission (combat versus support), human resources, environmental conditions, and personnel safety issues.20 Although some objective measures of impact can be obtained from official measurements,16 such as casualty, hospitalization, and medical evacuation rates, other assessment tools are necessary to account for the multitude of other mission impact outcomes. The most direct way to account for these variables and measure impact is to conduct post-mission surveys among persons directly involved in the operation. The Department of Defense routinely performs pre- and post-deployment health assessment surveys on every deployable member of the U.S. military,21,22 which are updated and reported regularly.23 Unlike these surveys, which are designed to ensure medical fitness prior to deployment and to identify medical conditions and/or exposures of concern following deployment, our survey was designed to assess the incidence, perceived impact on the mission, and associated attitudes and risk behaviors of commonly occurring illnesses and non-combat injuries among combat personnel. The success of this study may lead to the development of additional survey tools and other studies designed to assess the actual impact of these complaints, including cost-benefit analysis of treatment and prevention strategies.
Approximately 75% of all troops reported having at least one episode of diarrhea, and multiple episodes were common. Also, diarrheal illness was often moderately severe, with nearly 16.5% requiring intravenous fluids, 14.2% being restricted to bed for a median of two days, and almost 2% being hospitalized to treat their diarrhea. Other inconveniences caused by illness are less obvious, but potentially important in terms of mission impact. For example, only 13.4% of the volunteers with diarrhea had access to flush toilets and nearly one-third reported that they were unable to find any toilet facility during a diarrhea episode.
As with prior studies demonstrating an increase in both battle- and non-battle–related injuries and illnesses during the period of combat,24,25 diarrhea and respiratory infections were observed to be more common during the combat phase of operations in Iraq. Although unproven, the combination of an increased pace of operations along with a breakdown in the ability to provide clean water and food, appropriate hygiene, and medical resources likely led to the increase in illness.26 The perceived impact of these illnesses also increased dramatically during combat operations, an expected finding when loss of any individual can be seen to have a negative effect on unit efficiency. As logistical infrastructure was reestablished in the post-combat operations phase, the incidence of non-combat injuries and illnesses decreased significantly, but the perceived impact of these ailments only decreased slightly. This likely reflects the continued high pace of operations and the continued need for both individual and unit effectiveness and efficiency.
Past studies have shown that even relatively minor upper respiratory tract infections can have significant impact on military operations.27 In this survey, respiratory illnesses were not as common as diarrhea, but more than two-thirds of troops had at least one respiratory illness and 17% of these individuals sought medical care for their condition. Concern has been raised about a perceived increase in the expected frequency of pneumonia among personnel deployed to Iraq.14 In the current study, 2% of the troops reported having been diagnosed with pneumonia but it appears the condition was typically mild, not requiring hospitalization. An association between smoking, especially cigarettes from Iraq, and eosinophilic pneumonia has been proposed.28 However, we were unable to show any association between smoking Iraqi cigarettes and development of any respiratory illness, which is consistent with past surveys of deployed personnel.7 As in the Persian Gulf War,29,30 of the 39% reporting that they were smokers, almost half reported starting or restarting smoking during this deployment.
Non-combat injuries were less likely to be reported as seen in past surveys,31 but of the 34% of the troops reporting non-combat injuries, 77% sought care multiple times. The impact of these injuries on the mission can be underestimated if the main measures are medical evacuation or hospitalization because extensive outpatient care is often provided at lower echelon–level clinics.31 For instance, 21% of the respondents required immobilization or splinting and 17% received narcotics for pain. This extensive outpatient care likely maintained troop numbers in the field, but it is difficult to measure the decreased capabilities of patients treated in this manner. Systems have been developed to project and measure both casualty rates and non-combat injuries and illnesses,31,32 but further enhancements are needed to account not only for time completely lost but also diminished abilities.
The self-reported use of DEET in Iraq and Afghanistan is extremely low and puts troops at increased risk of various arthropod-borne infections. This is a critical issue because 2.1% of the respondents report having been diagnosed with leishmaniasis, and the treatment of cutaneous leishmaniasis has accounted for an average of 4.4% of the monthly medical evacuations from the Iraqi theater.18 The limited use of DEET appears to be primarily due to a misunderstanding of its safety profile and documented efficacy. DEET has been associated with a few case reports of seizures in young children,33 and there have been concerns expressed about potential neurologic complications resulting from DEET in veterans of the Persian Gulf War of 1991.34 However, after nearly 50 years of widespread use, there is a strong consensus among toxicologists and epidemiologists that DEET is extremely safe and efficacious.33,35–37 A survey of military personnel found similarly poor results in the use of DEET,38 and another report has emphasized the need for troop commanders and field leaders to enforce the use of DEET.39 However, our survey found that officers and senior enlisted personnel were just as likely to be misinformed about the safety and efficacy of DEET as junior enlisted personnel. It is therefore clear that preventive medicine educational efforts are needed to overcome the misperceptions regarding the use of DEET.
This study had several potential limitations that should be mentioned. As with any survey, there is a possibility of recall bias, especially differential recall (i.e., those with an illness or injury may be more likely to recall exposures or impact). There is also the issue of selection bias. Personnel who were medically evacuated and not returned to duty because of a severe illness or injury would likely not have been available for this survey, potentially resulting in an underestimate of the impact of illness and injury. Special operations units or task forces, which may have been exposed to especially austere or dangerous conditions, may have had separate transportation capabilities and could be under-represented. Furthermore, a recent study found that those involved in combat operations in Iraq and Afghanistan may be at significant risk of mental health problems.40 This study was not designed to assess the impact of combat stress or mental health problems, but the issue certainly needs further study as well as significant preparations for providing appropriate care to those affected.41,42
A novel aspect of the current study was the use of multiple small data collection forms that were sub-parts of a larger, detailed questionnaire. Collection of demographic data (age, sex, rank, and service) on every study subject allowed the statistical comparisons across each form. Since there was no significant difference across the demographics, it is likely the derived point estimates for each question are generalizable to the entire population.
The military is undergoing a major systematic transformation to deal with the challenges of the 21st century, using advances in technology and communication to improve operational efficiency.43 It is clear from the data presented that despite modern preventive medicine measures, illnesses and non-combat injuries are common and may have significant impact on military readiness and operational efficiency. Therefore, the transformation of the military should include continued improvements in surveillance, prevention, and management of common disabling illnesses and non-combat injuries.
Received April 28, 2005. Accepted for publication May 25, 2005.
Acknowledgments: We thank HMCS Pedrito Villanueva, HM1 Bridgett Ruiz, Roberta Strangfeld-Russel, Erin Leonard, and Jamie Bland for their assistance in collecting these surveys. We also thank Manal Moustafa, Yasmine Farid, Noha Effat, Hanan Raafat, and Mohamed Fakhry for their work on data entry and analysis.
Disclaimer: The opinions and assertions herein should not be construed as official or representing the views of the Department of the Navy, the Department of Defense, or the U.S. Government. This is a U.S. Government work. There are no restrictions on its use.
* Address correspondence to John W. Sanders, Enteric Disease Research Program, U.S. Naval Medical Research Unit No. 3, Cairo, Egypt, PSC 452, Box 117, FPO AE 09835. E-mail: sandersj{at}namru3.med.navy.mil 
Authors’ addresses: John W. Sanders, Carla Frankart, Robert W. Frenck, Marshall R. Monteville, Mark S. Riddle, David M. Rock-abrand, and Trueman W. Sharp, U. S. Naval Medical Research Unit No. 3., Cairo, Egypt, PSC 452, Box 117, FPO AE 09835, E-mails: sandersj{at}namru3.med.navy.mil, carlafrankart{at}hotmaol.com, rfrenck{at}uclacvr.labiomed.org, montevillem{at}namru3.med.navy.mil, riddlem{at}namru3.med.navy.mil, rockabrandd{at}namru3,ned.navy.mil, and sharpt{at}namru3.ned.navy.mil. Shannon D. Putnam, Naval Medical Research Unit No. 2, Jakarta, Indonesia, E-mail: shan8{at}hotmail.com. David R. Tribble, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910, E-mail: tribbled{at}nmrc.navy.mil.
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