In-theater Health Surveillance
Systems and Findings
Col Kenneth L. Cox
Director, Force Health Readiness (TMA/DHSD)
25 January 2005
Outline
• Comprehensive Health Surveillance
– Concept
– Service Member Life Cycle
– Success Factors
• Deployment Health Surveillance
– Goals/Purposes
– In-theater Systems
– Examples of Reports
– Future Directions
• Summary
2
Comprehensive Health Surveillance
Throughout Military Life
PRD-5 Mandates ―Cradle to Grave Surveillance…‖
B
M M G D G D G D G
E T a e a e a e a
P r p r p r p r
S O l l l r
r r r
T o o o i
i i i
S y y y s
s s s
A o m o m o m o
c n e n e n e n
a n n n
d t t t
Accession & Active Duty, National Guard, Reserve Separation Death
Initial Training Episodic Health Assessments in Garrison (PHA, ―HEAR‖)
and/or Mortality Registry
Baseline Assessment Retirement
Pre- and Post-deployment Health Assessments DD 2795/2796
Chronologic Summary of Health Status DD 2766
3
Service Member Life Cycle
Surveillance at Home & Away (DoDD 6490.2, DoDI 6490.3)
Retirement/
Deployment Separation &
Beyond
Operation Pre-Deployment
Integrated
Delivery
Force Health Protection System
Re-Deployment Primary
Health & Prevention
Wellness
Population Health
Post-Deployment
Secondary
Tertiary Prevention
Prevention
Accession
4
Surveillance Success Factors
• Timely data flow
Field Responsibility
• ‗Accurate‘ data
• Appropriate analyses and interpretation
with a goal of actionable information
• Timely reporting to decision makers
Analyze
– Forward field unit Data and
Collection Interpret
– Intermediate command levels
– ‘Rear’ top-level (AF, DoD, etc.)
• Appropriate action/intervention
Disseminate
• Continuous monitoring for effectiveness
5
Total Information Capture
LEVEL 5
LEVEL 4
Integrate Medical
LEVEL 3
Information Systems
to Capture the
Medical Record and
link care in the
―Theater of Conflict‖
LEVEL 1/2
with the sustaining
base for Enhanced
Medical Care to the
Warfighter
6
Deployment Health Surveillance
• Outbreak detection
– Health event surveillance,
• Diagnostic
• Reportable events
• Syndromic
• Medical evacuation
– Ancillary data, e.g., laboratory
• Occupational health exposure surveillance
• Environmental threat-based surveillance
– Ambient
– Operational, e.g., weapons of mass destruction
7
Existing Systems/Programs
• Casualty Reports (hostile injuries/deaths)
– Personnel Component
– Medical Component (AFIP Mortality Surveillance)
• Disease and Non-battle Injury Reports
• Joint Patient Tracking Application
• Patient Movement (aka Medical Evacuation) Reports
• Post-deployment Survey Results
• Other (Safety Reports, Trauma Registries, etc.)
8
Theater Health Surveillance
Data Sources and Flow Patterns
GEMS SAMS CHCS2-T
TRAC2ES
JMeWS
• JCS DNBI data Customers
• Weekly • SecDef
• CENTCOM SSC • CENTCOM
• Daily • SGs
• Field units
9
Disease Non-battle Injury (DNBI)
Dermatologic Injuries, heat/cold
GI, infections
Injuries, sports/recreation
Gynecologic
Ophthalmologic Injuries, motor vehicle
Psychiatric Injuries, work/training
Combat stress Injuries, other
Respiratory
Intimate diseases Problems:
Fever, >24 hours Data 10-14 days old when analyze
Neurologic (new) This won’t detect WMD attacks
All other, med/surg Solution?—Special Surveillance
10
Special Surveillance Categories
Category Definition
Systemic Fever Unexplained temp > 38C (100.5F) for 24
(generic flu-like hours or a history of chills and fever without
prodromes, e.g., a clear diagnosis. Includes flu-like illnesses
tularemia) with fever and multiple systemic complaints
(such as cough).
Lower Respiratory Bronchitis, pneumonia, new onset reactive
Illness (anthrax) airway disease, pleurisy, or respiratory
difficulty of unclear etiology
Infectious GI (ricin) Any infection primarily manifested by
vomiting and/or diarrhea.
Dermatologic Skin infections, blisters, ulcers, etc.
Unclear Dx (s-pox)
Unexplained Neuro Cases of altered levels of consciousness,
(botulinum toxin) cranial nerve dysfunction, muscle weakness
11
Analysis & Interpretation
CPEG Chart Process Control Chart
Weekly FRI Rate 25-Week Average
FRI Report Alarm Threshold Alert Threshold
Week of: 14-March-2003; As of: 26 Mar 2003
4.0
320 19
Weekly FRI Report for squadron 320
321 19
3.0
Rate per 100
322 24
323 4
2.0
324 21
331 32
1.0
-1 3
20-Sep 15-Oct 9-Nov 4-Dec 29-Dec 23-Jan 17-Feb 14-Mar
Week Ending 14-March-2003
12
Recent vs. Historic DNBI Rates
DNBI Rate per 1,000 Personnel per Week
DNBI Category War Phase3 Stabilization Phase4
ODS/S1 OJE1 OJG2
OEF OIF OEF OIF
Respiratory 10.4 10.0 20.9 9.9 6.1 6.3 4.9
GI, Infectious 8.7 4.5 4.5 7.2 3.4 4.3 3.1
Dermatologic 9.3 7.2 9.2 6.6 6.1 4.5 4.5
Total Injury 11.9 19.5 21.9 14.2 9.6 14.4 10.5
Total DNBI 64.8 70.9 81.2 57.3 51.9 50.8 39.2
1Sanchez, Craig, Kohlhase, et al. Mil Med 2001;166:470-4. ODS=Operation DESERT STORM
2McKee, Kortepeter, Ljaamo. Mil Med 1998;163:733-42. OJE=Operation JOINT ENDEAVOR
315 March 2003 to 3 May 2003. OJG=Operation JOINT GUARD
44 May 4 2003 to 1 January 2005. OEF=Operation ENDURING FREEDOM
OIF=Operation IRAQI FREEDOM
13
Total Injuries Over Time
OIF TRAC2ES Data
Total Injury Injury Rate Average
Alarm Level Alert Level
2.00
1.51
Rate per 1000
1.00
0.37
0.00
Mar2003 May2003 Jul2003 Sep2003 Nov2003 Jan2004 Mar2004
Month
OIF avg monthly total NBI rate = 0.63/1000
Note: “retuned” average after combat phase 14
Rank Order Barell Matrix Results
―Top 7‖ for Various Environments
OIF (TRAC2ES) OEF (TRAC2ES) GarInpatient GarOutpatient
Fracture, Lower Sprains, Lower
1 Dislocation, Knee Dislocation, Knee
Leg/Ankle Leg/Ankle
Fracture, Lower Fracture, Low Sprains, Lower Limb,
2 Fracture, Face
Leg/Ankle Leg/Ankle unspec.
Fracture,
3 Fracture, unspec *TBI, Type 1 Sprains, unspec.
Hand/Wrist
System Wide/ Late Sprains, System Wide/ Late Sprains, Shoulder/
4
Effects Shoulder/Arm Effects Arm
System Wide/ Late Fracture,
5 Fracture, Hand/Wrist *TBI, Type 2
Effects Hand/Wrist
Dislocation, Fracture, Fracture, Open Wound,
6
Shoulder/Arm unspecified Hand/Wrist Hand/Wrist
Fracture,
7 Fracture, Foot/Toes Fracture, Face Sprains, Wrist/Hand
Forearm/Elbow
*TBI=Traumatic Brain Injury, Type 1 most severe
15
Comparison of Selected Injury Complexes
Annualized Rates per 1000 Servicemembers
2.5
Data Sources
OIF & OEF: TRAC2ES
2 Garrison: SIDR
1.5
1
0.5
0
Knee, Fx, Lower Leg System Wide Fx,
dislocation Hand/Wrist
OIF OEF Garrison, inpt
16
Deployment Health Surveillance
Future Directions
• Fill critical data gaps (e.g., location data, environmental
exposure data, in-theater hospitalization/surgery data,
• Automate data collection & analysis as much as possible
• Validate and refine syndromic categories, threshold
determination, risk assessment methodologies, etc.
• Integrate diverse data streams (e.g., lab results, personnel data,
geospatial data, etc.)
• Monitor cohorts (unusual exposures, risk groups, etc.)
• Evaluate new technologies (e.g., biomarkers, microarrays) and
analytical approaches
17
Summary
• Health surveillance is a valuable tool to:
– Detect, confirm, and/or characterize outbreaks
– Monitor success of public health and preventive medicine programs
• Building on past lessons, the DoD established
screening and surveillance programs that cover a
service member‘s entire military career
• Critical garrison roles:
– Respond appropriately to post-deployment health concerns
– Train staff on in-theater electronic data collection systems
– Ensure compliance with data collection and reporting
– Provide feedback to developers for future improvements
– Integrate in-theater data into medical records
18
Questions and Discussion
Backup Material
Casualty Reports
Personnel Component
Official source of summary data for Data Characteristics: Available in 24-48
injuries (WIA) and deaths (KIA and hrs. Public web site updated monthly.
non-hostile). Collected through service Includes basic demographics, cause or type
personnel casualty reporting offices. of casualty, and location.
Findings/Actions/Results. Primary use Future Directions
is to supply information to general
public and media.
20
Casualty Reports
Medical Component
AFIP investigates and performs Data Characteristics: gold standard for
autopsies on all active duty deaths, mortality data. Lag time between x and y
including KIA. for all tox results and final report.
Findings/Actions/Results: Cause of Future Directions
death info vital to refining protective
measures, driving research, etc.
21
Disease, Non-battle Injury
Weekly DNBI
JCS broad-based disease categories, e.g., Data Characteristics: compliance highly
Respiratory, GI, Derm, Injuries (4 variable. Last week’s data analyzed by
types), etc. Wed/Thu of following week. Accuracy
also varies due to multiple data collection
systems, some manually assigned, others
based on ICD-9 codes as entered by field
medical staff, most who don’t have training
in coding. Outpatient data only.
Findings/Actions/Results Future Directions
•Documented natural disease outbreaks •Facilitate better compliance and improved
that were already recognized by field accuracy via TMIP, e.g., CHCS2-T
–Thanksgiving “food poisoning” •Add inpatient electronic data collection
–Norovirus on aircraft carrier •Evaluate value of other category
•Outbreaks found by other means definitions and more frequent DNBI data
–Severe penumonias (AEP) collection, e.g., daily syndromic
–Leishmaniasis surveillance
–Malaria 22
Aeromedical Evacuations
TRAC2ES
Aeromedical evacuation tracking data Data Characteristics: severity biased.
serves as a surrogate for in-theater Preliminary, often unconfirmed diagnoses
inpatient disease and injury rates. subject to change during and after
evacuation. Web-enabled data entry with
immediate transmission to central database
facilitates real-time analysis.
Findings/Actions/Results Future Directions
•Used primarily to answer questions
about injury patterns. Provides some
insight about requisite in-theater
resource levels (equipment, specialty
mix, etc.)
23
Post-deployment Survey
DD Form 2796
Self-assessment of individual health Data Characteristics: electronic versions
after deployment available in real-time for analysis, hand-
written forms lag 1-2 months. Inaccurate
or missing data, e.g., location, limits
usefulness.
Findings/Actions/Results Future Directions
•Ensure those who develop illnesses (or •Improve reporting compliance
concerns) while deployed receive •OSD/HA signed memo to encourage total
appropriate follow-up electronic capture
•Monitor trends in concerns, sites with
reported exposures, identify cohorts for
additional study, identify risk commun-
ication topics
24
Deployment Health
Surveillance
Baseline Risk Separation/
Assessment
Routine and
Incident-specific
Retirement
Environmental
Monitoring Pre-deployment
Health Assessments
During
Deployments
Medical
Surveillance: Routine Medical
DNBI* Care
Post-Deployment
In Garrison Clinical Practice
Post-deployment
Pre-deployment Guidelines
Health
Health Screens
Assessments
Preventive Medicne/
Health & Wellness
Accession *Disease and Nonbattle Injury Programs
Deployment Health Surveillance
Part of a Layered Force Health Protection System
• Intelligence/Hazard Assessment
• Medical Prevention
• Deployment Health Policies
• Training and Safety Policies
• Detection
• Physical Protection
• Medical Surveillance
• Command/Control Decisions
• Medical Treatment
• Decontamination
• Medical Monitoring
26
Deployment Health Surveillance Shortfalls in
Operation Desert Shield/Desert Storm
• No common operational picture to support medical decision-making on the
battlefield
• No centralized data available to coordinate medical intervention and control
measures
• Limited disease, illness, injury data reporting
• Spotty immunization and medical encounter record keeping in theater
• Limited exposure or environmental hazard data
• No systematic effort to establish baseline health status of deploying personnel, or
post deployment assessment
• Limited documentation of patient data in permanent health records
27
Surveillance Implementation
Capabilities
• Medical Command and Control
- Facility readiness
- Patient visibility
• Real –Time Medical Surveillance
- Patient encounters
- Disease Non-battle Injuries (DNBI)
• Web Based Reporting/Analysis Tools
- WatchBoard
- Medical Data Surveillance System (MDSS)
- Electronic Surveillance System for the Early Notification of Community-based
Epidemics (ESSENCE)
- Medical Common Operational Picture (MEDCOP)
28
Joint Theater Medical Surveillance System
• Includes disease, injury and illness reporting capability as medical
encounters are updated – for participating forces in theater
• Enables visibility and readiness status of all medical assets in theater
• Data collected and updated by units and centrally maintained by
Deployment Health Data Center for 24/7 analysis
• Any authorized Commander, Medical or Senior decision-maker can access
through Web on SIPRNET – in theater or in CONUS.
29
Patient Visibility in OIF
Theater JMeWS
TRAC2ES RTD
Duty
1 2 3 4
Evac
Medical Site
Landstuhl
DWMMC
Txt TRAC2ES
Optional Step
Movement RHS
3
KEY
1 Medical care required
2 Return to Duty (RTD) or
Home
possible move within theater Station
3 Movement out of theater to CONUS
Landstuhl or CONUS CHCS I
4 RTD, Return to Home Station CHCS II
RHS), or further evacuation to TRAC2ES
CONUS from Landstuhl
Operational Injury & Disease Report
Potential Data Sources
Diseases-Illnesses JMeWS (CHCS2-T, GEMS, etc.)
Wounds/Injuries
Hostile (WIA) DIOR
RTD in 72 hr DIOR
Leave theater DIOR (100-RTD rate)
Return to theater DWMMC
Return home, continue service Service MEB/PEB results
Non-hostile (NBI) JMeWS (CHCS2-T, GEMS, etc.)
RTD in 72 hr JMeWS, DWMMC
Leave theater TRAC2ES, DWMMC
Return to theater DWMMC
Return home, continue service Service MEB/PEB results
Deaths
Hostile (KIA) DIOR
Non-hostile DIOR
31
Operational Injury & Disease
Potential Report Sources (Cont.)
• Joint Medical Workstation (JMeWS)
– Web-based medical C2 and surveillance system. Provides interfaces for input of
individual medical treatment facility readiness and patient treatment information.
Generates individual and aggregate facility status reports and disease/outbreak
surveillance reports for CoCOM decision-making
• TRANSCOM Regulating and Command and Control Evacuation System
(TRAC2ES)
– Web-based system combining transportation, logistics and clinical decision
elements. Provides capability to prioritize requirements and assign proper
resources to efficiently deliver patients, and in-transit visibility to locate and track
medically evacuated patients, in peacetime and contingencies
• Directorate for Information Operations and Reports (DIOR)
– Division of Washington Headquarters Services that collects, analyzes and reports
statistics on casualties from US conflicts going back to the Revolutionary War
32
Operational Injury & Disease
Potential Report Sources (Cont.)
• Joint Patient Tracking Application
– Formerly known as the Deployed Warrior Medical Management Center
(DWMMC) Patient Information Application (PIA)
– Web-based application currently used at Landsthul Regional Medical
Center in Germany to track and manage patients moved from
OIF/OEF. The application tracks a wide range of information about
patients, including arrival, status, case manager notes and departure
– Being deployed to all major MTFs that receive casualties
33
DIOR
• OIF/OEF Wounded in Action Summary
• Hostile/Non-hostile Wounded in Action Report
• OIF/OEF Casualty Summary Report by State
• OIF/OEF Casualty Summary Report
• OIF/OEF Hostile Death Reports
• OIF/OEF Non-Hostile Death Reports
34
JPTA Reports
•Outpatient Report •Inpatient Report
•OIF/OEF Daily Report •Patient Treatment History
•Liaison Report •Landstuhl Air Transport
•Average Number of Days •Patient Arrivals
•Pending Departures •GWOT Patient Evacuation Report
•Mission Summary •Aeromedical Evacuation
Form 3899
•Physical Profile Form 3349
•Patient Downrange Report
•Daily Update
•Patient Notes
•Graphical History
•Treatment Totals Report
35
Comparison Pitfalls:
Deployed vs. Garrison
• Valid comparisons require groups that match, except
for an exposure of concern, e.g., operational exposures
like combat
• Garrison environments differ from deployed operations
in ways beyond the obvious lack of combat
– Available data differs in timeliness, completeness, level of detail, &
accuracy
– Culture varies for care-seeking behavior, access, diagnosis,
treatment, & disposition
36
Overcoming Comparison Pitfalls
• Identify best available data sources
• Analyze using appropriate statistical techniques
(counts vs. rates)
• Interpret results based on insight
• Annotate/state limitations clearly
• Improve processes methodically
37
Current Focus Areas
Force
Health Protection
Healthy & Prevention & Medical &
Fit Force Protection Rehabilitative Care
•Immunizations & • Scalable, Modular, Joint
• Periodic Health
Assessment Countermeasures Medical Capabilities
• Individual Medical •Safe & Healthy Working • First Responder
Readiness Conditions • Forward Surgery
• Health Promotion •Protective Equipment
• Theater Hospitalization
• Stress Management •Assess/Mitigate Hazards
• Enroute Care
• Pre/Post Deployment •Health & Environmental
• Definitive Care
Health Assessment Surveillance
•Risk Communication
Joint Centered
Balanced Approach: Preventive and Curative
38
Force Health Protection
Goals and Needs
• If we want to: • We will need:
– Monitor injury patterns, lost – Real-time global health &
duty time, etc. exposure surveillance
Near-term to Long-term
– Detect outbreaks – Accurate, systematic & thorough
• Natural disease data collection
• Chem-bio attacks • Locations
– Maximize readiness & mission • Exposures
effectiveness • Health events
– Evaluate exposures vs. health – Local and reachback analyses
outcomes – Electronic medical records
– Long-term epidemiological
analyses
39