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Increased Number of Possible Rabies Exposures Among U.S. Healthcare Beneficiaries Treated in Military Clinics in Southern Germany in 2016

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Increased Number of Possible Rabies Exposures Among U.S. Healthcare Beneficiaries Treated in Military Clinics in Southern Germany in 2016

Luke E. Mease MD (MAJ, MC, USA); Sahinaz Whitman; Rachel E. Lawrence DVM (CPT, VC, USA)

What are the new findings?

In 2016, the U.S. Army Medical Department Activity-Bavaria recorded 108 possible rabies exposures, a 112% increase from the previous year. Of these, 49 (45%) occurred during prior deployments to Egypt and Eastern Europe in which they had not received timely rabies post-exposure prophylaxis.

What is the impact on readiness and force health protection?

Military members are at risk for rabies exposure because of personal and military travel and deployments to rabies endemic areas. In order to avoid a repeat of the rabies fatalities of the past, commanders must enforce General Order #1 which calls for avoidance of contact with local animals, including mascots and pets.

Following the death of a soldier from rabies in 2011, linked to exposure to rabies in Afghanistan,1 the U.S. military implemented enhanced active surveillance of animal exposures to prevent rabies in service members and other Military Health System beneficiaries.2 Because many exposures were related to deployment to Iraq or Afghanistan, the Department of Defense (DoD) added questions about animal exposure to post-deployment health assessments to improve the detection of possible rabies exposures. Exposures identified through post-deployment health assessments as well as exposures documented through local military healthcare or law enforcement reports are collected by military public health personnel.

Although Germany is rabies-free for terrestrial land mammals,3 rabies exposure remains a concern for U.S. military personnel assigned there because of personal and military travel and deployments to rabies endemic countries. Since 2011, however, the number of service members deploying to Southwest Asia has greatly declined; as a result, deployments have become much more variable both in location and duration. Deployments have increasingly focused on enhancing partnerships and peacekeeping. For example, U.S. soldiers stationed in Germany have been involved in partnering missions with European allies and UN peacekeeping operations in the Sinai region of Egypt.4 In 2016, U.S. Army Medical Department Activity-Bavaria (MEDDAC-B) Preventive Medicine (PM) personnel suspected an increase in the risk of rabies exposure for soldiers deployed in support of the Sinai peacekeeping mission. This report describes efforts that were undertaken to investigate this possible increased risk of rabies exposure faced by service members.

METHODS

For purposes of this report, the term “exposure” refers to all instances of human contact with animals, including bites, contact with animal saliva, scratches, or casual contact, which came to medical attention and were evaluated for the potential that the patient might have been exposed to rabies virus. The U.S. Army Medical Department Activity Bavaria (MEDDAC-B) provides public health support to all U.S. military and affiliated personnel stationed in southern Germany. For such personnel, all reported exposures, independent of location, are reviewed by PM and Veterinary personnel to ensure appropriate care and follow-up. Decisions about whether to initiate rabies post-exposure prophylaxis (RPEP) are made on the basis of the risk of the exposure. Such assessments consider the type of animal, the geographic location of the exposure event, and the immunization status of the animal. In general, exposures are reported per DoD Policy using DoD Form 2341, Report of Animal Bite– Potential Rabies Exposure (DD Form 2341);5 however, some exposures were reported through other channels, such as email, phone call, or Military Police Report forwarded to MEDDAC-B PM. In those cases, a DD Form 2341 is completed by the treating or evaluating medical facility to which the patient is assigned and referred (if needed). The DD Form 2341 captures information on patient demographics and consists of four parts: animal bite history, management of animal bite case, management of biting animal, and case review. The biting animal is handled in accordance with the Compendium of Animal Rabies Prevention and Control; for dogs and cats (the vast majority of exposures considered here), the animal is observed for 10 days from the time of exposure for the development of signs consistent with rabies, if possible. For unwanted/stray animals, euthanasia for testing of the brain was an option, though to the best of our knowledge this was not carried out.6

In cases where prophylaxis is clearly indicated (such as exposure to bats or bite from a stray dog in a non-rabies-free area), prophylaxis is initiated by the evaluating provider and then reported to MEDDAC-B PM as part of information collected on DD Form 2341. If there is any question about whether prophylaxis is indicated, the evaluating provider can contact MEDDAC B PM for discussion and consultation. Upon receipt of DD 2341, MEDDAC-B PM reviews the prophylaxis given, if any. If further prophylaxis (including RPEP) is indicated, MEDDAC-B PM immediately contacts the treating provider to discuss this. The exposure and prophylaxis, as recorded on DD Form 2341, are concurrently reviewed by a local veterinarian. After any additional prophylaxis and veterinary review, the MEDDAC-B PM physician again reviews the case and is the final signatory. Under normal circumstances, potential exposures (and attendant DD Form 2341) are reviewed concurrently with periodic in-person meetings between all involved (Rabies Advisory Board) to review cases. In response to the concerns described above, in 2016 the Rabies Advisory Board increased the frequency of its meetings, and included leadership from the units of the deployed soldiers, staff from the treating clinic, and others as appropriate.

Since mid-2011, MEDDAC-B personnel have recorded details of exposures to assure appropriate and timely follow up and have documented rabies post-exposure prophylaxis when indicated. The number of individuals affected by possible rabies exposures and the number of individuals who received RPEP in 2016 were compared to data from 2011–2015 and 2017. In addition, details from the 2016 exposures were extracted, including age, sex, military status, animal type, location and exposure type. All exposures reported to MEDDACB PM or Veterinary Section through the means described above were included in the study. Exposures were included independent of the final determination of risk for transmission of rabies or the status of the victim (U.S. Military or Civilian, German National, or citizen from other country); however, because most exposure reports were initiated at U.S. military health clinics, these data represent primarily individuals who had access to healthcare in such clinics in southern Germany.

Investigation

In response to the suspected increase in rabies exposures in 2016, several actions were immediately undertaken. PM and Veterinary assets in Bavaria began closely coordinating follow-up and risk stratification of reported exposures, especially those from Egypt. Veterinary personnel coordinated directly with personnel stationed in Egypt to identify the names, appearance (through photos) and locations of all approved NATO mascot dogs in Egypt. These data were discussed with individual soldiers reporting possible exposure upon return from deployment. Prophylaxis and follow-up efforts, where indicated, were closely coordinated with the local clinic and the unit medical assets (Regimental Surgeon) of the unit to which the soldiers were assigned. All soldiers started on RPEP were followed up for prophylaxis completion, even those who moved back to the U.S. or deployed again.

RESULTS

Among service members and other persons (e.g., family members, civilian employees) located in southern Germany in 2016, 108 individuals were associated with reports of possible rabies exposure. Numbers of individuals with possible rabies exposures and the numbers and percentages who received RPEP by year (2011–2017) are presented in Table 1. In 2016, compared to prior years, there was a notable increase in the numbers of individuals evaluated in southern Germany for possible exposure to rabies (Table 1). Moreover, in 2016, compared to the previous 5 years, a larger proportion of exposed individuals were prescribed rabies post-exposure prophylaxis (RPEP). In 2017, the number of exposures reported was much closer to historical numbers in the years 2011–2015.

Characteristics of the individuals with possible rabies exposures in 2016 are presented in Table 2. Most exposures occurred in individuals who were active duty service members, male, those aged 18–29 years, and junior (E1–E4) or senior (E5–E7) enlisted service members. Many exposures (47.2%) occurred outside of Germany (Egypt or Eastern Europe). The animals most commonly implicated in the exposures were stray/feral cats or dogs or other wild animals and the most common exposure type was animal bite.

EDITORIAL COMMENT

Several factors appeared to be related to the 2016 increase in possible rabies exposures. First, a large number of soldiers was assigned to United Nations (UN) peacekeeping operations in Egypt during 2016. Of the years considered, only in 2016 were a large number of troops supported by MEDDAC-B deployed to Egypt. In Egypt, UN camp policies permitted mascot dogs. Many soldiers brought onto their base camps non-approved/informal mascots (cats and dogs). Approved mascots received complete and ongoing preventive veterinary care (including rabies vaccine). Some non-approved/informal mascots were captured in a trap-neuter-release program (spayed/neutered and provided a single dose of rabies vaccine) while other non-approved mascots received no such care. This situation led to the common misperception that interaction with any animal on the base was permissible and safe (i.e., many soldiers believed that all animals had been fully immunized against rabies). Only through retrospective discussion with veterinary staff in Egypt was it discovered that most animals on base were unprotected from rabies. This misperception among soldiers about the status of an animal (unclear if mascot or stray) was a very significant, and likely preventable, cause of the increased number of exposures seen in 2016. 

Second, exposures from foxes or other (unidentified) wild animals occurred in a forested training area in Germany. Although Germany is rabies-free for terrestrial mammals, these exposures were determined to be of sufficient risk to merit prophylaxis, given the close proximity of the training areas to the border of the Czech Republic where rabies is present in bats.7 These exposures from foxes/wild animals in the training area occurred at an increased level in 2016, compared to other years. Finally, some U.S. soldiers who were in Eastern Europe (i.e., outside Germany) for partnership building and training events were exposed to stray animals with unknown immunization status. Of note, there were no local policy changes, new leadership or meaningful demographic changes in the MEDDAC-B supported population in 2016 that might have resulted in increased rabies reports.

U.S. combat operations in Iraq and Afghanistan have diminished, but peacekeeping and partnership building missions continue. The characteristics of U.S. military deployments have changed, becoming generally shorter, more frequent, and to a much broader range of destinations; accordingly, the potential for rabies exposure is more variable and difficult to predict. As years pass since the last rabies case and as the nature of deployments changes, the U.S. military faces the risk of again underappreciating the threat from this highly lethal virus.8 The findings presented here suggest a need for accurate risk assessment with clear risk communication9 and ongoing robust surveillance with strong command engagement in preventing service member contact with possibly rabid animals.10


Author affiliations: U.S. Army Medical Department Activity–Bavaria (Dr. Mease, Ms. Whitman); Bavaria Veterinary Services, Public Health Activity Rheinland-Pfalz (Dr. Lawrence); Guantanamo Bay Veterinary Services, Public Health Activity–Fort Gordon, GA (Dr. Lawrence).

Acknowledgments: The authors thank Catrina Caswell, LPN; Daniel Weinstein, DO (MAJ, MC, USA); and Justin Garner (SSG, USA) for providing outstanding support and teamwork.

Funding: All work described herein was performed as part of paid regular duties as part of employment by the U.S. Government.

Conflicts of interest: None.

REFERENCES

1. Centers for Disease Control and Prevention. Imported human rabies in a U.S. Army soldier New York, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(17):302–305.
2. The Assistant Secretary of Defense Health Affairs, Jonathan Woodson. Human Rabies Prevention During and After Deployment. Memorandum to Army, Navy, and Air Force. 23 September 2011.
3. Müller T, Bätza H-J, Freuling C, et al. Elimination of terrestrial rabies in Germany using oral vaccination of foxes. Berl Munch Tierarztl Wochenschr. 2012;125(5-6):178–190.
4. MFO - The Multinational Forces and Observers. http://mfo.org/en. Accessed on 9 May 2018.
5. Department of Defense Form 2341, Report of Animal Bite – Potential Rabies Exposure. www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2341.pdf. Updated June 2015. Accessed on 18 April 2018.
6. Brown CM, Slavinski S, Ettestad P, Sidwa TJ, Sorhage FE. Compendium of Animal Rabies Prevention and Control, 2016. J Am Vet Med Assn. 2016;248(5):505–517.
7. Helesic J, Bartonícka T, Krbková L. Bat rabies in Europe and the Czech Republic. Klin Mikrobiol Infekc Lek. 2007; 13(3):93–98.
8. Garges EC, Taylor KM, Pacha LA. Select public health and communicable disease lessons learned during Operations Iraqi Freedom and Enduring Freedom. US Army Med Dep J. 2016;(216):161–166.
9. Duron S, Ertzscheid C, de Laval F, et al. Public health investigation in a military cAMP after diagnosis of rabies in a dog-Afghanistan, 2012. J Travel Med. 2014;21(1):58–61.
10. Mease LE, Baker KA. Monkey bites among US military members, Afghanistan, 2011. Emerg Infect Dis. 2012;18(10):1647–1649.

Numbers of individuals with possible rabies exposures and numbers and percentages who received rabies post-exposure prophylaxis (RPEP) among U.S. healthcare beneficiaries in southern Germany, 2011–2017Characteristics of individuals with possible rabies exposures, U.S. healthcare beneficiaries in southern Germany, 2016


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Update: Cold Weather Injuries, Active and Reserve Components, U.S. Armed Forces, July 2013–June 2018

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Update: Cold Weather Injuries, Active and Reserve Components, U.S. Armed Forces, July 2013–June 2018

 

ABSTRACT

From July 2017 through June 2018, a total of 478 members of the active (n=402) and reserve (n=76) components had at least one medical encounter with a primary diagnosis of cold injury. The crude overall incidence rate of cold injury for all active component service members in 2017–2018 was 19.6% higher than the rate for the 2016–2017 cold season and was the highest rate since the 2013–2014 season. Frostbite was the most common type of cold injury among active component service members in 2017–2018. Among active component members during the 2013–2018 cold seasons, overall rates of cold injuries were generally highest among males, non-Hispanic black service members, the youngest (less than 20 years old), and those who were enlisted. As noted in prior MSMR updates, the rate of all cold injuries among active component Army members was considerably higher in females than in males due to a much higher rate of frostbite among female soldiers. The numbers of cold injuries associated with overseas deployments have fallen precipitously in the past three cold seasons and included 17 cases in the most recent year.

What are the new findings?

Cold weather injuries increased by 20% in 2017-2018 from the previous year. Rates were highest among exposed Army and Marine Corps personnel. Frostbite remained the most common cold weather injury.

What is the impact on readiness and force health protection?

Prevention of cold injuries is the responsibility of commanders at all levels and cold weather injuries such as hypothermia, frostbite, and trench foot can be avoided during cold weather exercises. Preparation for cold weather operations involves advance planning by leaders, individual compliance, and supervisory follow-through.

Since 2004, the MSMR has published annual updates on the incidence of cold weather injuries that affected U.S. military members during the five most recent cold seasons.1 The content of this 2018 report addresses the occurrence of such injuries during the cold seasons from July 2013 through June 2018. The timing of the annual updates is intended to call attention to the recurring risks of such injuries as winter approaches in the Northern Hemisphere, where most members of  the U.S. Armed Forces are assigned. For many years, the U.S. Armed Forces have developed and improved robust training, doctrine, procedures, and protective equipment and clothing to counter the threat from cold environments.2-4 Although these measures are highly effective, cold injuries have continued to affect hundreds of service members each year because of exposure to cold and wet environments.5 Such environmental conditions pose the threat of hypothermia, frostbite, and nonfreezing cold injury such as immersion injury. The human physiologic response to cold exposure is to retard heat loss and preserve core body temperature, but this response may not be sufficient to prevent hypothermia if heat loss is prolonged.6 Moreover, the response includes constriction of the peripheral (superficial) vascular system, which may result in non-freezing injuries or hasten the onset of actual freezing of tissues (frostbite).6 Traditional measures to counter the dangers associated with cold environments include minimizing loss of body heat and protecting superficial tissues through such means as protective clothing, shelter, physical activity, and nutrition. However, military training or mission requirements in cold and wet weather may place service members in situations where they may be unable to be physically active, find warm shelter, or change wet or damp clothing.2,3

Military history has well documented the toll of cold weather injuries. Continuous surveillance of these injuries is essential to inform steps to reduce their impact as well as to remind leaders of the predictable threat of cold injuries. This update summarizes the frequencies, incidence rates, and correlates of risk of cold injuries among members of both active and reserve components of the U.S. Armed Forces during the past 5 years.

METHODS

The surveillance period was 1 July 2013 through 30 June 2018. The surveillance population included all individuals who served in the active or reserve component of the U.S. Armed Forces at any time during the surveillance period. For analysis purposes, “cold years” or “cold seasons” were defined as 1 July through 30 June intervals so that complete cold weather seasons could be represented in year-to-year summaries and comparisons.

Because cold weather injuries represent a threat to the health of individual service members and to military training and operations, the Armed Forces require expeditious reporting of these reportable medical events (RMEs) via one of the service-specific electronic reporting systems; these reports are routinely incorporated into the Defense Medical Surveillance System (DMSS). For this analysis, the DMSS and the Theater Medical Data Store (which maintains electronic records of medical encounters of deployed service members) were searched for records of RMEs and inpatient and outpatient care for the diagnoses of interest (frostbite, immersion injury, and hypothermia). A case was defined by the presence of an RME or of any qualifying ICD-9 or ICD-10 code in the first diagnostic position of a record of a healthcare encounter (Table 1). The DoD guidelines for RMEs require the reporting of cases of hypothermia, frostbite, and immersion injuries but not “other specified/unspecified effects of reduced temperature.”7Cases of chilblains are not included in this report because the condition is common, infrequently diagnosed, usually mild in severity, and thought to have minimal medical, public health, or military impacts.

To estimate the number of unique individuals who suffered a cold injury each cold season, and to avoid counting follow-up healthcare encounters after single episodes of cold injury, only one cold injury per individual per cold season was included. A slightly different approach was taken for summaries of the incidence of the different types of cold injury diagnoses. In counting types of diagnoses, one of each type of cold injury per individual per cold season was included. For example, if an individual was diagnosed with immersion foot at one point during a cold season and then with frostbite later during the same cold season, each of those different types of injury would be counted in the tally of injuries. If a service member had multiple medical encounters for cold injuries on the same day, only one encounter was used for analysis (hospitalizations were prioritized over ambulatory visits which were prioritized over RMEs). Annual incidence rates of cold injuries among active component service members were calculated as incident cold injury diagnoses per 100,000 person-years (p-yrs) of service. Annual rates of cold injuries among reservists were calculated as cases per 100,000 persons using the total number of reserve component service members for each year of the surveillance period. Counts of persons were used as the denominator in these calculations because information on the start and end dates of active duty service periods of reserve component members was not available.

The numbers of cold injuries were summarized by the locations at which service members were treated for these injuries as identified by the Defense Medical Information System Identifier (DMIS ID) recorded in the medical records of the cold injuries. Because such injuries may be sustained during field training exercises, temporary duty, or other instances for which a service member may not be located at his/her usual duty station, DMIS ID was used as a proxy for the location where the cold injury occurred.

The new electronic health record for the Military Health System, MHS GENESIS, was implemented at several military treatment facilities during 2017. Medical data from sites using MHS GENESIS are not available in the DMSS. These sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center. Therefore, medical encounter and person-time data for individuals seeking care at one of these facilities during 2017 were not included in this analysis.

RESULTS

2017-2018 cold season

From July 2017 through June 2018, a total of 478 members of the active (n=402) and reserve (n=76) components had at least one medical encounter with a primary diagnosis of cold injury (Table 2). The crude overall incidence rate of cold injury for all active component service members in 2017–2018 (32.9 per 100,000 p-yrs) was 19.6% higher than the rate for the 2016– 2017 cold season (27.5 per 100,000 p-yrs) and was the highest rate since the 2013–2014 season (Table 2, Figure 1). Throughout the surveillance period, the cold injury rates were consistently higher among active component members of the Army or the Marine Corps than among those in the Air Force or Navy. In 2017–2018, the service-specific incidence rate for active component Army members (54.6 per 100,000 p-yrs) was 26.5% higher than the 2016– 2017 Army rate (43.2 per 100,000 p-yrs). The Army contributed slightly more than three-fifths (60.9%; n=245) of all cold injury diagnoses in the active component during the 2017–2018 cold season. For the Marine Corps, the active component rate for 2017–2018 was 15.9% higher than the rate for the previous season. The 85 members of the Marine Corps diagnosed with a cold injury in 2017–2018 represented 21.1% of all affected active component service members. Navy service members (n=27) had the lowest service-specific rate of cold injuries during the 2017–2018 cold season (9.8 per 100,000 p-yrs) (Table 2, Figure 1).

This update for 2017–2018 represents the second year that annual rates of cold injuries for members of the reserve component were estimated. Army personnel (n=51) accounted for 67.1% of all reserve component service members (n=76) affected by cold injuries during 2017–2018 (Table 2). As was true for the active component, service-specific rates among reserve component members were higher among those in the Army or Marine Corps than among those in the Air Force or Navy (Figure 2). For the 2017–2018 cold season, the overall rate of cold injuries for the reserve than in the 2016–2017 season. Among reserve component members, the most pronounced increase in service-specific rates between the 2016–2017 and 2017– 2018 seasons was seen in the Marine Corps.

When all injuries were considered, not just the numbers of individuals affected, frostbite was the most common type of cold injury (n=247; 60.8% of all cold injuries) among active component service members in 2017–2018 (Tables 3a–3d). In the Air Force and Army respectively, 84.4% and 65.0% of all cold injuries were frostbite, whereas the proportions in the Navy (55.6%) and Marine Corps (38.6%) were much lower. For the Army and Marine Corps, the 2017–2018 numbers and rates of frostbite injuries among active component service members were the highest of the past 4 years. For all active component service members during 2017–2018, the proportions of all cold weather injuries that were hypothermia and immersion injuries were 18.7% and 20.4%, respectively (data not shown). Among active component Navy members, the numbers and rates of hypothermia cases and immersion injuries in 2017–2018 were the lowest of the 5-year surveillance period and of the past 4 years, respectively (Table 3b). The number and rate of immersion injury cases in 2017–2018 in the Air Force were the lowest of the surveillance period (Table 3c).

Five cold seasons: July 2013-June 2018

During the 5-year surveillance period, the rates of cold injuries among members of the active components of the Navy, Air Force, and Marine Corps were higher among males than females. Among active component Army members, there was a striking difference between the rates for females (61.3 per 100,000 p-yrs) and males (48.5 per 100,000 p-yrs). In all of the services during 2013–2018, females had lower rates of immersion injury and hypothermia than did males but higher rates of frostbite (except in the Air Force) (Tables 3a–3d). For active component service members in all four services combined, the overall rate of cold injury was slightly higher among males (32.6 per 100,000 p-yrs) than among females (29.4 per 100,000 p-yrs) (data not shown).

In all of the services, overall rates of cold injuries were higher among non-Hispanic black service members than among those of the other race/ethnicity groups. In particular, within the Marine Corps and Army, and for all services combined, rates of cold injuries were more than twice as high among non-Hispanic black service members than among either non-Hispanic white service members or those in the “other/unknown” race/ethnicity group (Tables 3a–3d). The major underlying factor in these differences is that rates of frostbite among non-Hispanic black members of all services were 1.5 or more times higher than those of the other race/ethnicity groups across the active components of all services during 2013–2018, non-Hispanic black service members had incidence rates of cold injuries greater than the rates of other race/ethnicity groups in nearly every military occupational category (data not shown).

Rates of cold injuries were generally highest among the youngest service members (less than 20 years old) and tended to be lower with each succeeding older age group. Enlisted members of the Army, Air Force, and Navy had higher rates than officers, but the opposite was true of Marine Corps members (Tables 3a–3d). In the Army and Air Force, rates of all cold injuries combined were highest among service members in combat-specific occupations (infantry/artillery/combat engineering/armor) (Tables 3a, 3c).

During the 5-year surveillance period, the 2,405 service members who were affected by any cold injury included 2,056 from the active component and 349 from the reserve component. Of all affected reserve component members, 70.5% (n=246) were members of the Army (Table 2). Overall, soldiers accounted for the majority (60.0%) of all cold injuries affecting active and reserve component service members (Table 2, Figure 3).

Of all active component service members who were diagnosed with a cold injury (n=2,056), 195 (9.5% of the total) were affected during basic training. The Army (n=79) and Marine Corps (n=107) accounted for 95.4% of all basic trainees who suffered a cold injury (data not shown). Additionally, during the surveillance period, 73 service members who were diagnosed with cold injuries (3.6% of the total) were hospitalized, and most (91.8%) of the hospitalized cases were members of either the Army (n=40) or Marine Corps (n=27) (data not shown).

Cold injuries during deployments

During the 5-year surveillance period, a total of 77 cold injuries were diagnosed and treated in service members deployed outside of the U.S. Of these, 38 (49.4%) were immersion injuries; 26 (33.8%) were frostbite; and 13 (16.9%) were hypothermia. Of all 77 cold injuries during the surveillance period, nearly one-third (32.5%) occurred in the first cold season. There were 25 cold injuries during cold season 2013–2014 but only 13 during 2014–2015, 11 during 2015–2016, 11 during 2016–2017, and 17 during 2017–2018 (data not shown).

Cold injuries by location

During the 5-year surveillance period, 21 military locations had at least 30 incident cold injuries (one per person per year) among active and reserve component service members (data not shown). Among these locations, those with the highest counts of five-year injuries were Fort Wainwright, AK (n=155); Bavaria (Vilseck/Grafenwoehr), Germany (117); Marine Corps Recruit Depot Parris Island/Beaufort, SC (100); Fort Benning, GA (86); San Diego, CA (78); Fort Carson, CO (67); and Fort Campbell, KY (65). During the 2017–2018 cold season, the numbers of incident cases of cold injuries were 2016–2017 cold season at 13 of the 21 locations (data not shown). The most noteworthy increases were found at the Army’s Fort Benning and Fort Campbell, where there were 16 total cases diagnosed at each location in 2017–2018, compared to just five and six, respectively, the year before (data not shown). Figure 4 shows the numbers of cold injuries during 2017–2018 and the median numbers of cases for the previous 4 years for those locations that had at least 30 cases during the surveillance period. For nine of the 21 installations, the numbers of cases in 2017–2018 were below the median counts for the previous 4 years.

EDITORIAL COMMENT

Overall incidence rates of cold injuries among U.S. service members increased in 2017–2018 compared with the previous winter. Across all services, the number of cold injury cases in 2017–2018 was the highest count of the past 3 years.

In 2017–2018, frostbite was the most common type of cold injury among active component service members in all the services except for the Marine Corps, in which immersion injury was the most common. Compared to their respective counterparts, overall rates of cold injuries were generally higher among males, non-Hispanic black service members, the youngest (less than 20 years old), and those who were enlisted. Increased rates of cold injuries affected nearly all enlisted and officer occupations among non-Hispanic black service members. Of note, rates of frostbite were markedly higher among non-Hispanic blacks compared to non-Hispanic whites and those in the other/unknown race/ethnicity group. These differences have been noted in prior MSMR updates and the results of several studies suggest that other factors (e.g., physiologic differences and/or previous cold weather experience) are possible explanations for increased susceptibility.8-11

The numbers of cold injuries associated with deployment have fallen precipitously in the past four cold seasons. This reduction in the number of cases is almost certainly a result of the dramatic decline in the numbers of service members deployed to Iraq and Afghanistan and of changes in the nature of military operations there.

Policies and procedures are in place to protect service members against cold weather injuries. Modern cold weather uniforms and equipment provide excellent protection against the cold when used correctly. However, in spite of these safeguards, a significant number of individuals within all military services continue to be affected by cold weather injuries each year. It is important that awareness, policies, and procedures continue to be emphasized to reduce the toll of such injuries. In addition, enhancements in protective technologies deserve continued research. It should be noted that this analysis of cold injuries was unable to distinguish between injuries sustained during official military duties (training or operations) and injuries associated with personal activities not related to official duties. To provide for all circumstances that pose the threat of cold weather injury, service members should know well the signs of cold injury and how to protect themselves against such injuries they are training, operating, fighting, or recreating under wet and freezing conditions.

The most current cold injury prevention materials are available at: 
https://phc.amedd.army.mil/topics/discond/cip/Pages/Cold-Weather-Casual-ties-and-Injuries.aspx

REFERENCES

1. Army Medical Surveillance Activity. Cold injuries, active duty, U.S. Armed Forces, July 1999– June 2004. MSMR 2004;10(5):2–10.

2. Pozos RS (ed.) Section II. Cold environments. In Medical Aspects of Harsh Environments, Vol 1. DE Lounsbury and RF Bellamy (eds.). Washington, DC: Office of the Surgeon General, Department of the Army, United States of America, 2001:311–609.

3. Castellani JW, O’Brien C, Baker-Fulco C, Sawka MN, Young AJ. Sustaining health and performance in cold weather operations. Technical Note No. TN/02-2. U.S. Army Research Institute of Environmental Medicine, Natick, MA. October 2001.

4. DeGroot DW, Castellani JW, Williams JO, Amoroso PJ. Epidemiology of U.S. Army cold weather injuries, 1980–1999. Aviat Space Environ Med. 2003;74(5):564–570.

5. Armed Forces Health Surveillance Branch. Update: Cold weather injuries, active and reserve component, U.S. Armed Forces, July 2011–June 2016. MSMR. 2016;23(10):12–20.

6. Castellani JW, Young AJ. Human physiological responses to cold exposure: acute responses and acclimatization to prolonged exposure. Auton Neurosci. 2016;196:63–74.

7. Armed   Forces   Health   Surveillance Branch. Armed Forces Reportable Events Guidelines and Case Definitions, 17 July 2017. https://health. mil/Reference-Center/Publications/2017/07/17/ Armed-Forces-Reportable-Medical-Events-Guide- lines. Accessed on 5 October 2018.

8. Armed Forces Health Surveillance Center. Update: Cold weather injuries, active and reserve components, U.S. Armed Forces, July 2008–June 2013. MSMR. 2013;20(10):12–17.

9. DeGroot  DW, Castellani  JW, Williams  JO, et  al. Epidemiology  of  U.S. Army cold weather injuries, 1980–1999. Aviat Space Environ Med. 2003;74(5):564–570.

10. Burgess J, Macfarlane F. Retrospective analysis of the ethnic origins of male British Army soldiers with peripheral cold weather injury. J R Army Med Corps. 2009;155(1):11–15.

11. Maley MJ, Eglin CM, House JR, Tipton M. The effect of ethnicity on the vascular responses to cold exposure of the extremities. J Eur J Appl Physiol. 2014;114(11):2369–2379.

Annual incidence rates of cold injuries (one per person per year), by service, active component, U.S. Armed Forces, July 2013–June 2018 Annual incidence rates of cold injuries (one per person per year), by service, reserve component, U.S. Armed Forces, July 2013–June 2018 Numbers of service members who had a cold injury (one per person per year), by service and cold season, active and reserve components, U.S. Armed Forces, July 2013–June 2018 Annual number of cold injuries (cold season 2017–2018) and median number of cold injuries (cold seasons 2013–2017) at locations with at least 30 cold injuries during the surveillance period, active component members, U.S. Armed Forces, July 2013–June 2018 ICD-9/ICD-10 diagnostic codes for cold weather injuries Any cold injury (one per person per year), by service and component, U.S. Armed Forces, July 2013–June 2018

Any cold injury (one per person per year), by service and component, U.S. Armed Forces, July 2013–June 2018 Counts and incidence rates of cold injuries (one per type per person per year), active component, U.S. Army, July 2013–June 2018Counts and incidence rates of cold injuries (one per type per person per year), active component, U.S. Navy, July 2013–June 2018 Counts and incidence rates of cold injuries (one per type per person per year), active component, U.S. Air Force, July 2013–June 2018 Counts and incidence rates of cold injuries (one per type per person per year), active component, U.S. Marine Corps, July 2013–June 2018

 

Annual incidence rates of cold injuries (one per person per year), by service, active component, U.S. Armed Forces, July 2013–June 2018Annual incidence rates of cold injuries (one per person per year), by service, reserve component, U.S. Armed Forces, July 2013–June 2018Numbers of service members who had a cold injury (one per person per year), by service and cold season, active and reserve components, U.S. Armed Forces, July 2013–June 2018Annual number of cold injuries (cold season 2017–2018) and median number of cold injuries (cold seasons 2013–2017) at locations with at least 30 cold injuries during the surveillance period, active component members, U.S. Armed Forces, July 2013–June 2018ICD-9/ICD-10 diagnostic codes for cold weather injuriesAny cold injury (one per person per year), by service and component, U.S. Armed Forces, July 2013–June 2018Counts and incidence rates of cold injuries (one per type per person per year), active component, U.S. Army, July 2013–June 2018Counts and incidence rates of cold injuries (one per type per person per year), active component, U.S. Navy, July 2013–June 2018Counts and incidence rates of cold injuries (one per type per person per year), active component, U.S. Air Force, July 2013–June 2018Counts and incidence rates of cold injuries (one per type per person per year), active component, U.S. Marine Corps, July 2013–June 2018


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Department of France conducts PSO training

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The American Legion Department of France continued its training of post service officers (PSOs) with two days of training in Ansbach-Katterbach, Germany, on 1-2 December 2018. This training was a follow-up to the one-day initial training conducted in March 2018. The training was conducted to get PSOs from the various posts throughout Germany up to date on the latest disability claims information and requirements from the Department of Veterans Affairs (VA).

The training took place next door to the newly established offices of the department service officer (DSO). The new office is located in the Welcome Center, Building 5818, room 317, 318 and 319, in the USAG Ansbach Katterbach Kaserne. This was a great way to introduce the PSOs to the new DSO facilities.

The primary purpose of the training was to offer deeper training to those post service officers and advance their knowledge, so they can better assist our veterans. All PSOs within the department who had completed the first course in March were offered the training.

DSO Frank Phillips and guest speaker/VA representative Joshua Gregory conducted the training. Joshua is a rating specialist with VA but is currently working as a VA outreach officer in Germany for a six-month period.

A total of five PSOs from various areas of Germany attended this training.

The VA Outreach Program is a relatively new program offering veterans in Europe direct access to VA personnel who can more effectively assist them with questions about disability claims. Veterans in the United States have much more access to VA programs, as well as direct access to personnel who can answer their questions.

Gregory started the training on Saturday with discussion about the Death and Indemnity Claim (DIC). He also discussed the differences between the DIC and the VA Survivor Benefit or Death Pension. He then went into an extended discussion of some best practices, or as he called it, “Do’s and Don’ts from a Rater’s Point of View.”

The next subject was the various ways to submit a claim, including the pros and cons of submitting via U.S. Mail or fax as opposed to the online submission. It was explained that any of these methods can be used, but the online submission is usually timelier. Additionally, with the online submission there is no worry about mail possibly not getting to its destination, or fax machines on either end jamming during transmission.

Phillips’ discussions started with several forms. Each of these forms was discussed in detail, including which areas the PSOs should watch for problems of omissions or conflicting information. Either of these issues might cause delays in completing the adjudication of a claim by VA.

He also explained several systems available to the PSO/DSO to review veterans’ files and to help track the progress of a submitted claim. The individual veteran can use eBenefits, but the DSO can also access the VA Stakeholders Enterprise Portal (SEP), the Regional Office Cloud database system in Pittsburgh (VetraSpec) and the Veterans Benefits Management System (VBMS) in order to upload files and track progress of submitted claims.

The training entailed how to take care of the veteran from the very first meeting with the PSO up to their current status. Topics that were also covered were presumptive disabilities (Agent Orange!), education, and almost all the entitlements a veteran is entitled to.

The Foreign Medical Program portion of the training was taught in depth. This program is not widely known to veterans and is a tremendous advantage to veterans living overseas.

The final examination was a combination of live exercises (assisting a veteran from Day 1 to present, including their enrollment in the Foreign Medical Program) and verbal communication skills in answering the examination questions.

Phillips discussed the importance of being a post service officer. He emphasized the importance of the service officer’s role in the community and post. The PSO is a valuable asset to the post and is a great instrument for membership enrollments.

The training was very well received by the PSOs. Harvey Briggs, PSO from Gelsenkirchen, GE, expressed his feelings with the comment. “This is good training! There is so much positive energy in this group. You can feel it!”

Phillips is already feeling the effects of the better training of PSOs – his workload is increasing. Since the word has gotten out that knowledgeable PSOs are locally available to assist veterans with claims, there has been a substantial increase in claim submissions.

As DSO, he reviews each claim submission sent by PSOs before they go to VA. The “second set of eyes” on the forms minimizes minor errors that could delay adjudication.

“Previously it was primarily retired soldiers and older veterans who submitted claims. Now, we are getting an increase in active-duty reserve soldiers. Especially those nearing retirement are talking with us and starting to get their information together for a claim,” Phillips expressed.

“The biggest selling point for us is that claims are being adjudicated and that veterans and soldiers are getting disability payments in a timely manner,” he stated. He explained that such success stories move through the retired soldier and active-duty community very fast. This, of course, brings in additional “customers” with their questions and claims.

He was also quick to mention that the services are available to all veterans who request assistance. He reminded all PSOs of this fact.

“You can tell them that you are an American Legion PSO, but they are not required to be a Legion member to get your help,” stated Phillips. “Of course, if they express a desire to join, you can certainly assist them with that procedure.”

Department Vice Commander Dennis Owens attended the training and was impressed. “With this advanced training, I can apply for my VA disabilities the smart way, and we can actually do what The American Legion is best at - veterans helping veterans. I am looking forward to using this new information.”

Harvey Briggs also felt good about the training. “This is amazing and it inspired the he-- out of me! I left feeling like I wanted to pull in every vet I see and get them compensation. I truly enjoyed the classes.”

The training was completed Sunday afternoon. It appeared that everyone had learned much about the claims process, and how they could better assist veterans with this process. All who attended returned to their home posts with an expanded knowledge base, and with an increased desire to assist fellow veterans.

This advanced level of training will be offered again, hopefully in the spring of 2019.


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A salute to minorities' service in the Great War

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Blacks and Latinos proudly served their country in uniform overseas during the Great War, even as they faced discrimination at home, and a long-overdue records review may reveal that some were unfairly denied the nation's highest military decoration.

At a Nov. 8 event honoring minorities' contributions to the U.S. war effort, retired Army Col. Gerald York – special adviser to the U.S. World War One Centennial Commission and grandson of Sgt. Alvin York, recipient of the Medal of Honor – praised the Valor Medals Review Task Force, which is conducting the research necessary to identify and correct injustices.

"People say, 'Why are you looking back, that's 100 years ago,'" York told an audience gathered at Pershing Park in Washington, D.C., site of the future National World War I Memorial. "If we made mistakes, we need to rectify those mistakes. We're not a perfect nation, but we try."

York noted that his grandfather was initially awarded a Distinguished Service Cross for his bravery in the Argonne on Oct. 8, 1918. Further investigation resulted in an upgrade to the Medal of Honor. "Unfortunately, a lot of African-Americans and a lot of Latinos who did heroic things on the battlefield got lesser awards because of their race, because of their color," York said.

The 1918 armistice ended the fighting between the Allies and Germany, but the work of the American Expeditionary Forces is still not complete, said retired Maj. Gen. Christopher Leins, chairman of the Valor Medals Review Task Force.

One significant post-war task was to make sure that the brave acts of U.S. soldiers were appropriately honored, leading to the initial awarding of 118 Medals of Honor. Yet seven decades passed before a black servicemember, Cpl. Freddie Stowers of the 371st Infantry Regiment, was recognized for his heroism. Reasons included an inconsistent understanding and application of standards, unclear writing, misplaced paperwork and, unfortunately, prejudice, Leins said. In 1991, Stowers became the first African-American soldier from World War I to receive the Medal of Honor, opening the door to retroactive award recommendations for minorities who served in World War II, the Korean War and other conflicts. Yet there was little interest in expanding reviews to include World War I.

Since then, isolated efforts have resulted in the posthumous awarding of Medals of Honor to only two more minority servicemembers from that period, in 2015: Sgt. William Shemin, a Jewish-American soldier from the 47th Regiment, 4th Infantry Division, and Sgt. Henry Johnson, an African-American soldier from the 369th Regiment. Last summer, the World War One Centennial Commission established a partnership with faculty at New York University and Missouri's Park University to see if there are others like Stowers, Shemin and Johnson; a systematic effort is underway to determine if minorities who received the Distinguished Service Cross or foreign valor awards were downgraded due to racial or ethnic bias.

The work will take years and be difficult due to the passage of time and loss of Army personnel records in a 1973 fire, Leins said. Nevertheless, the task force is pressing Congress to officially authorize the records review for 2019, coinciding with the 100th anniversary of the return of American forces from Europe.

"The gravity of this award means its rarity must be jealously safeguarded," Leins said. "(The Medal of Honor) can never be allowed to be diluted in the name of making a political point." Yet the nation has an obligation to ensure that every American who demonstrates gallantry and intrepidity in action "receives due recognition regardless of the circumstances incurred or the color of his skin. Only then can we truly say that no veteran, no hero, has been left behind."

Construction of a national memorial is another way to honor all who served, particularly those who fought for a country that did not yet treat them equally under the law, said Eleanor Holmes Norton, U.S. representative for the District of Columbia.

"Once Woodrow Wilson declared that we had entered the war to make the world safe for democracy, the black press took hold of this slogan, and it inspired African-Americans to join the effort," Norton said. "Most saw going to war as an opportunity to show their patriotism and equal citizenship." In fact, black veterans of World War I laid the groundwork for the civil rights movement, she added.

Also delivering remarks was Lawrence Romo, national commander of American GI Forum, a congressionally chartered Hispanic veterans and civil rights organization, and former director of Selective Service System.

Romo told the stories of two highly decorated Latinos who fought in World War I: Army Pvt. Marcelino Serna, a Mexican immigrant and the first Hispanic to receive the Distinguished Service Cross, and Army Pvt. David Barkeley Cantu, the first Spanish-American to receive the Medal of Honor.

On Sept. 28, 1918, during a battle in the Meuse-Argonne, Serna wounded a German sniper and followed him to a trench, throwing in three grenades. Altogether, he killed 26 German soldiers and took 24 prisoners, and became Texas' most decorated World War I soldier. In 1924, Serna became a U.S. citizen, and upon his death in 1992, was buried with full military honors at Fort Bliss National Cemetery in El Paso.

David Barkeley Cantu is one of three Texans awarded the Medal of Honor during World War I. He swam the icy Meuse river in France to gather information behind German lines, but drowned during his return. Cantu was honored posthumously, his Hispanic heritage unknown until 1989.

Romo praised the diversity of today's armed forces, pointing out that roughly 1 percent of Americans are serving in uniform. "Our military today is a true representation of our population and the melting pot we are," he said. "No matter one's ethnic group, religion or gender, their service provides the freedom that everyone in this great country enjoys daily without notice."

The Pershing Park event concluded with a concert by the 369th Experience, a re-creation of the legendary 369th Infantry "Hellfighters" Band that introduced France to ragtime, jazz and blues.

Bobby Sanabria, a drummer, percussionist and leader of his Multiverse Big Band, said every jazz musician today, himself included, owes a debt of gratitude to the 369th Infantry Band, led by Lt. James Reese Europe. "They spread what we call jazz today, which really represents the best of who we are as Americans," Sanabria said. "Jazz represents only one thing, freedom, and that's something to be proud of."

Sanabria, who is of Puerto Rican descent, spoke of Puerto Ricans' contributions to the 369th's role as a musical and cultural ambassador to Europe. One of the most famous was Sgt. Rafael Hernandez Marin, a trombonist who played with the band overseas and later became part of the Harlem jazz scene.

Emceeing the show were James Reese Europe III, grandson of the original 369th Infantry's bandleader, and Noble Sissle Jr., son of the 369th's lead vocalist. Together, they spoke briefly of the band's history and the songs it helped make famous, including "Memphis Blues," "Tiger Rag," "Darktown Strutters' Ball" and "Ja-Da."

The original 369th Infantry Band had 65 African-American and Puerto Rican members. The younger Europe and Sissle assembled a similar group for the 369th Experience over a couple of years, recruiting and auditioning dozens of student musicians from historically black colleges and universities (HBCU). Their first time playing together was a rehearsal for their first performance, on the Intrepid Air, Sea & Space Museum last Memorial Day weekend.

"I’ve been able to listen to some of those original 1919 recordings that Jim Europe and my dad went into the studio and recorded," Sissle said. "Now I’m hearing them in stereo, updated just a little but played pretty much to the note. When they re-create that sound I’m up there tapping my feet like everyone else."

Europe said that as the Great War's centennial began, he saw an opportunity to educate himself on his family's musical roots. "My grandfather and (Sissle's) father brought jazz to Europe and introduced the world to a whole new style of music," he said. "I'm proud of my legacy now, and I'm proud of all these young men who are reviving it. Together we're bringing it back."

The 369th Experience is led by Isrea Butler, a sergeant in the North Carolina National Guard and chairman at the music department at North Carolina Central University who enjoys educating young people on "lost music" like that played by the 369th Infantry Hellfighters.

"This is really part of the fabric of my mission because I’m the secretary on the board for the HBCU band directors consortium," Butler said. "As a band director, I had started incorporating this music almost by accident, because I was teaching about it in my jazz history course ... students before this, none of them heard about James Reese Europe."

There's also the challenge of helping students reproduce the band's improvisational sound. "If you try to play what’s on the page, it just sounds nothing like what you hear in the recordings," Butler said. "We go back and forth, and it’s a lightbulb moment for them."

Stephen Gregory of Beaumont, Texas, heard about the 369th Experience opportunity from his school's band director. He attends Southern University in Baton Rouge, La., where he plays French horn in the Human Jukebox Marching Band at SU.

"I auditioned and I was accepted, and the first trip we took was to New York," Gregory said. "This program today at Pershing Park has opened my eyes even more. I've been able to learn more about the Harlem Hellfighters and the 369th Regiment. It's a grand occasion. They could have gotten any other musicians from around the country, but they chose HBCU students, so I’m really blessed and honored."


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The kindness of American Legion donors

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Dear American Legion Family and Friends,

I don’t often get surprised, especially when it comes to the generosity of American Legion Family members.

But when I read the report detailing the Giving Tuesday results of donations to The American Legion’s Veterans and Children Foundation, I experienced a mix of surprise, gratitude and pride. While I know how generous our members are, we have never before had such a successful Giving Tuesday campaign.

On Giving Tuesday, 396 donations worth a total of $22,620 were made to the Veterans and Children Foundation. Without donations like this, our ability to support our veterans in need and our military families in distress would be severely compromised.

These contributions go toward two specific areas of need. Some of the funding goes to assist military and veteran parents who are experiencing financial crises. For example, the funding would support a military family struggling to pay bills while a parent is on deployment.

Additionally, the funds go toward supporting the tireless work of American Legion service officers. These men and women provide free assistance to all veterans who need help in their attempts to receive the care, benefits and opportunities they earned through their service to the nation.

While the success of Giving Tuesday is wonderful news, the needs of veterans, servicemembers and their families continue 365 days a year. Our ability to fund these programs must all remain viable throughout the year.

As this season of giving continues, please consider a donation to The American Legion Veterans and Children Foundation. Donations may be made securely on the Legion's website. You may also download a printable form, fill it out and mail in your donation.

Thank you for your support of our nation’s veterans, servicemembers and their families yesterday, today and every day.


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