Navy and Marine Corps Force Health Protection Command

Abstract Reports of environmental and human health impacts of per- and polyfluoroalkyl substances (PFAS) have greatly increased in the peer-reviewed literature. The goals of the present review are to assess the state of the science regarding toxicological effects of PFAS and to develop strategies for advancing knowledge on the health effects of this large family of chemicals. Currently, much of the toxicity data available for PFAS are for a handful of chemicals, primarily legacy PFAS such as perfluorooctanoic acid and perfluorooctane sulfonate. Epidemiological studies have revealed associations between exposure to specific PFAS and a variety of health effects, including altered immune and thyroid function, liver disease, lipid and insulin dysregulation, kidney disease, adverse reproductive and developmental outcomes, and cancer. Concordance with experimental animal data exists for many of these effects. However, information on modes of action and adverse outcome pathways must be expanded, and profound differences in PFAS toxicokinetic properties must be considered in understanding differences in responses between the sexes and among species and life stages. With many health effects noted for a relatively few example compounds and hundreds of other PFAS in commerce lacking toxicity data, more contemporary and high-throughput approaches such as read-across, molecular dynamics, and protein modeling are proposed to accelerate the development of toxicity information on emerging and legacy PFAS, individually and as mixtures. In addition, an appropriate degree of precaution, given what is already known from the PFAS examples noted, may be needed to protect human health. Environ Toxicol Chem 2021;40:606–630. © 2020 SETAC Abstract Many health effects have been reported in association with or due to per- and polyfluoroalkyl substance (PFAS) exposures in humans and toxicologic models. Species concordance of effects is evident for a handful of legacy PFAS. With hundreds of PFAS in commerce that lack exposure and health effects data, contemporary and novel methods must be implemented to inform exposed communities, risk assessors, and concerned citizens and prioritize those most likely to affect human health.

We report an outbreak of 235 community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections among military recruits. In this unique environment, the close contact between recruits and the physical demands of training may have contributed to the spread of MRSA. Control measures included improved hygiene and aggressive clinical treatment.

BACKGROUND: Since the Persian Gulf War ended in 1991, many veterans of that conflict have reported diverse, unexplained symptoms. To evaluate the health of Gulf War veterans, we studied their postwar hospitalization experience and compared it with that of other military personnel serving at the same time who did not go to the Persian Gulf. METHODS: Using a retrospective cohort approach and data from Department of Defense hospitals, we studied hospitalizations of 547,076 veterans of the Gulf War who were serving in the Army, Navy, Marine Corps, and Air Force and 618,335 other veterans from the same era who did not serve in the Persian Gulf. Using multivariate logistic-regression models, we analyzed risk factors for hospitalization both overall and in 14 broad diagnostic categories during three periods from August 1991 through September 1993 (a total of 45 specific comparisons). RESULTS: After the war, the overall odds ratio for hospitalization of the Gulf War veterans was not higher than that of the other veterans, even after adjustment for selection effects related to deployment. In 16 of the 42 comparisons involving specific diagnoses, the risk of hospitalization among Gulf War veterans differed significantly from that among other veterans. Among these 16 comparisons, Gulf War veterans were at higher risk in 5: neoplasms (largely benign) during 1991, diseases of the genitourinary system during 1991, diseases of the blood and blood-forming organs (mostly forms of anemia) during 1992, and mental disorders during both 1992 and 1993. The differences were not consistent over time and could be accounted for by deferred care, postwar pregnancies, and postwar stress. CONCLUSIONS: During the two years after the Persian Gulf War, there was no excess of unexplained hospitalization among Americans who remained on active duty after serving in that conflict.

BACKGROUND: Staphylococcus aureus is a major cause of infection in both adult and pediatric populations. After several decades of increasing prevalence, the proportion of S aureus infections due to methicillin-resistant S aureus has been reported to be in decline in adults. Data for similar changes in pediatric populations are limited. METHODS: Evaluation of S aureus susceptibility data for pediatric patients receiving care in the US Military Health System was performed. Microbiology and demographic data were collected for years 2005 through 2014. Trends in antibiotic susceptibility results were evaluated. Clinical and demographic characteristics were explored to assess for association with antibiotic susceptibilities. RESULTS: In this study, 41 745 S aureus isolates from 39 207 pediatric patients were included. An overall increase in susceptibility of isolates to oxacillin was noted over this 10-year period; with over 60% of isolates oxacillin-susceptible in 2014. S aureus susceptibility to clindamycin declined over the study period; notably methicillin-susceptible S aureus susceptibility to clindamycin declined from 90% to 83% (P < .0001). Differences in oxacillin susceptibility between US regions decreased over time. CONCLUSIONS: Similar to recent trends seen in adults, the proportion of pediatric S aureus infections secondary to methicillin-resistant S aureus appear to be decreasing, as is variability in US geographical resistance rates. Increasing clindamycin resistance among methicillin-susceptible S aureus should raise caution in the use of empirical clindamycin in presumed S aureus infection. Clinicians should be aware of regional susceptibility patterns when choosing empirical regimens.

A cluster of testicular germ cell tumors occurred among 3 of 153 white men who worked in a shop engaged in repair of exterior surfaces and electrical components of the airframes of F4 Phantom Jet aircraft. Evaluation of an occupationally identical shop at a second F4 rework facility at which there had been no previous reports of excess neoplasms revealed 4 additional men with a history of testicular germ cell tumors (p less than 0.01, Poisson, compared to the expected number of cases based on national incidence rates). Our investigation raises but does not prove a hypothesis of association between subsequent development of testicular germ cell cancer and history of extensive exposure to a mixture containing dimethylformamide, which had been used in F4 repair work at these facilities in the 1960s and 1970s. This represents the first report of 2 corresponding mini-epidemics of testicular tumors among workers in occupationally identical industrial settings.

This article reviews diseases that are aggravated by shiftwork (gastrointestinal and cardiovascular disorders), the potential of shiftwork to adversely affect pregnancy, shift maladaptation syndrome, and the ability of shiftwork to exacerbate existing disorders and interfere with pharmacological treatments. It offers guidelines for pre-employment screening and medical surveillance of shiftworkers.

BACKGROUND: The military presents a unique opportunity to study the incidence of disease in a population with complete knowledge of person-time and occupation. Women in the Army are employed more frequently in non-traditional, industrial jobs such as auto mechanic and motor transport operators than in the general US population, increasing the probability of exposure to industrial chemicals. A cohort to investigate the risk of breast cancer among active duty Army women occupationally exposed to volatile organic chemicals (VOCs) was constructed. METHODS: Age-adjusted incidence rates for breast cancer were calculated for more than 270,000 enlisted women who served between 1980-1996. Twenty-one VOCs, described in previously published literature as having a potential risk of breast cancer, were identified in an Army industrial hygiene survey database. Job title histories were linked to workplace chemical evaluations conducted by Army industrial hygienists, which included a subjective exposure potential rating (high, medium, low, and none) for each VOC. Poisson regression analysis was used to evaluate the association between the exposure rating by job title and breast cancer. RESULTS: The incidence of breast cancer in the cohort was significantly elevated in women younger than 35 years of age, especially among black women, when compared to the age-specific rates in the general population. Women who worked in occupations with a moderate to high exposure potential to at least one VOC had a 48% increased risk (P < 0.05) of breast cancer while on active duty between 1980-1996 when compared to those women with low to no exposure potential. CONCLUSIONS: This study provides preliminary evidence that exposure to one or more of the study VOCs is associated with an increased risk of breast cancer. Further substance-specific, quantitative analyses are warranted.

The overall hypersensitivity reaction rate among 14,249 U.S. Marine Corps personnel who received 36,850 doses of an investigational Japanese encephalitis vaccine was 10.3 per 10,000 doses; reaction rates were 16.1 and 10.3 per 10,000 doses for the first two doses, and 2.0 per 10,000 doses for the third. The reaction rate was 26.7 per 10,000 vaccinees. Of 38 reactors, 26 had urticaria and/or angioedema, and 11 had pruritus. Vaccine reaction intervals clustered within 48 hours for dose 1, but the median reaction interval for dose 2 was 96 hours. A history of urticaria or allergic rhinitis was associated with an increased probability of a vaccine reaction.

A sailor on a U.S. Navy ship had smear-positive, cavitary, pulmonary tuberculosis. Contact investigation of the entire ship's crew found 216 new reactors to tuberculin skin test (24.5%) among 881 previously tuberculin-negative sailors. The risk for new infection was highest among sailors in the patient's department (relative risk, 4.4; 95% confidence interval 3.7, 5.3); 95% (15/16) of sailors in his division were new reactors. While crewmembers in all departments were at risk for a new tuberculosis infection, working and berthing in compartments that were distant from those of the index case were protective. The ship's closed ventilation system contributed to the outbreak.

This study evaluated the risk to hearing health associated with duty on the flight deck of a Nimitz class aircraft carrier. Descriptive data includes time-weighted average noise exposure and an evaluation of temporary threshold shift for a group of nonaviator flight deck personnel (FD), and a comparison of accrued permanent threshold shift among three shipboard occupational groups that had been matched for years of military service. The study participants included 76 FD personnel in a high-exposure group, 77 engineers in a moderate-exposure group, and 52 administrative personnel who were considered to have low occupational noise exposure. The study found a mean FD time weighted average of 109 dBA over workdays averaging 11.5 hours. Only 2 (4%) of 52 administrative personnel had any appreciable hearing loss (defined as worse than 20 dB at any frequency 1,000 through 4,000 Hz), whereas FD and engineers demonstrated 17% and 27% hearing impairment, respectively.

Most extra-articular metacarpal fractures can be managed nonoperatively. While the conventional wisdom is that the metacarpophalangeal joint should be immobilized in a position of flexion, alternative methods for cast immobilization have been described. The purpose of this study was to retrospectively evaluate three methods of closed treatment; specifically, we investigated whether the position of immobilization of the metacarpophalangeal joint or the absence of a range of motion of the interphalangeal joints affected the short-term outcome or fracture alignment.Between November 2000 and April 2004, extra-articular metacarpal fractures were immobilized for five weeks in one of three ways: with the metacarpophalangeal joints in flexion and full interphalangeal joint motion permitted (Group 1); with the metacarpophalangeal joints in extension and full interphalangeal joint motion permitted (Group 2); and with the metacarpophalangeal joints in flexion, the interphalangeal joints in extension, and no interphalangeal joint motion permitted (Group 3). Radiographs and the range of motion were evaluated at five weeks after application of the cast, and the range of motion and grip strength were assessed at nine weeks.Two hundred and sixty-three patients met the inclusion criteria. At five weeks, there was no difference among the treatment methods with regard to the range of motion or the maintenance of fracture reduction. At nine weeks, there was no significant difference with regard to the range of motion or grip strength.When immobilization was discontinued by five weeks, the position of the metacarpophalangeal joints and the absence or presence of interphalangeal joint motion during the immobilization had little effect on motion, grip strength, or fracture alignment. This finding contradicts the conventional teaching that the metacarpophalangeal joint must be immobilized in flexion to prevent long-term loss of joint extension. Patient comfort, ease of application, and the surgeon's familiarity with the technique should influence the choice of immobilization.Therapeutic Level III.

International infectious disease surveillance has been conducted by the United States (U.S.) Department of Defense (DoD) for many years and has been consolidated within the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) since 1998. This includes activities that monitor the presence of antimicrobial resistance among pathogens. AFHSC-GEIS partners work within DoD military treatment facilities and collaborate with host-nation civilian and military clinics, hospitals and university systems. The goals of these activities are to foster military force health protection and medical diplomacy. Surveillance activities include both community-acquired and health care-associated infections and have promoted the development of surveillance networks, centers of excellence and referral laboratories. Information technology applications have been utilized increasingly to aid in DoD-wide global surveillance for diseases significant to force health protection and global public health. This section documents the accomplishments and activities of the network through AFHSC-GEIS partners in 2009.

Benzathine penicillin G has been used in United States Navy and Marine Corps recruit camps since 1953 to reduce the incidence of streptococcal disease and its nonsuppurative complications-acute rheumatic fever and acute glomerulonephritis. This paper reviews the history of prophylactic penicillin use among U.S. Navy and Marine Corps recruits and discusses the rationale for continuing this practice today.

Ixodes affinis, which is similar morphologically to Ixodes scapularis, is widely distributed in North Carolina. Collections have documented this species in 32 of 41 coastal plain counties, but no piedmont or mountain counties. This coastal plain distribution is similar to its distribution in Georgia and South Carolina, where it is considered an enzootic vector of Borrelia burgdorferi sensu stricto. An updated list of hosts for I. affinis in the U.S.A. is included, increasing the number to 15 mammal and one bird species. The presence of questing adults of I. affinis from April to November reinforces the need for confirmed identifications of suspected tick vectors of Borrelia spirochetes collected during warm months. Ixodes affinis Neumann is a Central and South American species belonging to the Ixodes ricinus complex, which contains most of the primary vectors of the agents of Lyme borreliosis and a number of other human pathogens (Keirans et al. 1999). This species extends northward into the southeastern U.S.A. (Kohls and Rogers 1953), and previously has been recorded only from Florida, Georgia, and South Carolina (Clark et al. 1998). Oliver et al. (1987) described the immature stages of I. affinis and provided distribution, phenology, and host records. Ixodes affinis is morphologically very similar to Ixodes scapularis Say, the primary vector of Lyme disease borreliae in the eastern U.S.A. (Keirans et al. 1996), which can cause identification problems (Lavender and Oliver 1996). Also, Oliver et al. (2003) reported that in coastal regions of the southeastern U.S.A., I. affinis and Ixodes minor Neumann are more important than I. scapularis in the maintenance of enzootic cycles of Lyme borreliosis spirochetes, including Borrelia burgdorferi Johnson, Schmid, Hyde, Steigerwalt and Brenner, and Borrelia bissettii Postic, Ras, Lane, Hendson, and Baranton. As part of an effort to develop a better understanding of the primary tick vectors and tick-borne pathogens in North Carolina (NC), thousands of ticks were collected between October 23, 2008 and July 31, 2009 by personnel of the Public Health Pest Management (PHPM) Section, NC Department of Environment and Natural Resources, collaborating county personnel, and U.S. Navy personnel. Additionally, preserved ticks collected before October 2008 were re-examined. During this latter process, BAH observed a female collected by WHR in the spring of 2008 that exhibited characters of Ixodes affinis, a species not known to be present in NC. In April 2009, this tick was shipped to LAD and confirmed as Ixodes affinis. Upon confirmation, the issue of possible misidentifications between October 2008 and April 2009 required the re-examination of the entire collection of Ixodes specimens. This paper presents preliminary results from ongoing investigations of the presence, distribution, and hosts of I. affinis in NC. Implications of these findings for future tick-borne disease studies in NC are discussed. To date, tick collections in NC have been based on specimens collected on drag cloths or found attached to humans and animals and mailed to PHPM. For this paper the records of I. affinis were based on specimens collected through July 31, 2009. Only the first collection of I. affinis in each county has been tabulated, regardless of subsequent collections. Location and habitat descriptions were recorded along with GPS coordinates. Special emphasis was placed on descriptions of basic habitats, shade, vegetation height, proximity to water, animal associations, and man-hours of field effort. Specimens were preserved in 95% ethanol for later pathogen assays and identified using the morphological keys in Keirans and Clifford (1978), Keirans and Litwak (1989), and Durden and Keirans (1996). Also, local keys were prepared for the females, males, and nymphs of Ixodes ticks confirmed in the state, as well as several other species likely to occur in NC. The mammal names used here are the scientific names recognized by mammalogists at the North Carolina Museum of Natural Sciences, Raleigh (Benjamin Hess, personal communication). Following the discovery in NC of the 2008 specimen of I. affinis, an intense literature review was conducted, and the first collection record of I. affinis in NC was found in Lockhart et al. (1996), who collected this species on deer in 1987 in Hyde County. The specimen(s?) from that collection is no longer available for confirmation (D. E. Stallknecht, personal communication). However, since that publication, neither the NC record nor one for I. affinis reported on deer in Arkansas in 1991 by Lockhart et al. (1996) have been acknowledged or cited by tick researchers. Thus, our records of I. affinis in NC confirm the previous 1987 record, as do several other confirmed pre-study specimens we found back to 1999. The earliest confirmed NC specimens of I. affinis are a pair of mating ticks collected in 1999 in Jones County on a house cat. All I. affinis specimens collected to date, except two nymphs, are adults. In 2009 we collected I. affinis in January and March through July. Only single specimens were collected during January and March; beginning in April large numbers were collected. Based on collections through July 31, and including all preserved pre-study specimens, 307 I. affinis have been confirmed from 32 of 41 coastal plain counties in NC (Table 1). To date, collections of this species have occurred only in coastal plain counties (Figure 1). Distribution of Ixodes affinis in North Carolina counties as of July 31, 2009, including date of first collection. Ixodes affinis has been collected on only three hosts in NC: white-tailed deer, dog, and cat. Specimens of this species have also been found crawling on the clothing and skin of collectors, but none have been found attached to humans. Also, two specimens were found on or next to suspended mosquito light traps with CO2 emitted as an attractant. Currently there are no published records of I. affinis parasitizing the white-footed mouse, Peromyscus leucopus (Rafinesque), humans, or reptiles, although it may eventually be found attached to these hosts. One bird and 15 mammals are currently recorded as hosts for I. affinis in the U.S.A. (Table 2). Following the confirmation of I. affinis in NC in April 2009, questions arose concerning how long I. affinis has been present in the state. This initiated a re-examination of preserved specimens of Ixodes from NC. Specimens collected during the period 1983–1988 were found in the NC State University Insect Museum, Raleigh. That collection period includes the first NC collection of I. affinis in 1987 in Hyde County (Lockhart et al. 1996). No specimens of I. affinis were found in those collections, but 222 I. scapularis were confirmed from Brunswick, Columbus, Currituck, Gates, Hyde, Jones, Martin, New Hanover, Onslow, and Sampson counties, where I. affinis does or should occur. Those specimens were collected during the period October-February, all months that coincide with the primary period when I. scapularis adults are questing (Goddard 2002). In South Carolina, adults of I. affinis normally begin questing in March-April and continue through the summer months (Clark et al. 1998). During the 1980s and 1990s, a number of tick studies involving I. scapularis were conducted in the coastal plain of NC, including, in part, Magnarelli et al. (1986), Levine et al. (1989, 1991), Apperson et al. (1993), Solberg et al. (1995), and Rich et al. (1995). Several of those studies included collection times that overlapped the questing time for adult I. affinis, and either used a key (Sonenshine 1979) that did not include I. affinis, or did not reference a key or the confirmation of their identifications. Specimens of I. scapularis from two other studies were confirmed by Dr. J.E. Keirans. Another study utilized the key of Keirans and Clifford (1978) and confirmed I. scapularis specimens from four sites in eastern NC by mitochondrial 16S rDNA sequences. Thus, specimens in some of these studies were collected at times when I. affinis would not be questing or on hosts, while the other studies were conducted at times when I. affinis could have been collected, if they were present. The absence of I. affinis in these published studies and among the 1983–1988 preserved specimens of I. scapularis provides preliminary evidence that I. affinis may have been uncommon in NC between 1987 and 1999, and probably was transported to NC as larvae or nymphs on migrating birds; alternatively, if established in NC, it may have existed in small separated foci. Ixodes affinis is now widely distributed in the coastal plain counties of NC (Figure 1), as it is in Georgia and South Carolina (Wells et al. 2004). Also, in certain foci in coastal counties of NC, this species is common. Its distribution extends continuously from South Carolina to the Virginia border, and westward to the edge of the piedmont region. However, despite aggressive collection efforts, no I. affinis have been collected in piedmont counties, even those that adjoin positive coastal plain counties. The distribution in NC abuts the southeastern corner of Virginia, which suggests, along with rodent host distributions (Webster et al. 1985), that I. affinis may also occur in Virginia. In Georgia and South Carolina, abundance of I. affinis has been associated with the distributions of three rodent species - cotton mouse, hispid cotton rat, and eastern wood rat (Durden and Oliver 1999, Clark et al. 2001, Oliver et al. 2003) - with the first being the most important host for this species. These rodents serve as the primary hosts for the immature stages of I. affinis (Clarke et al. 1998), and they are also major amplifying hosts for Borrelia burgdorferi s. s. and Borrelia bissettii. Furthermore, I. affinis serves as a primary enzootic vector for Borrelia burgdorferi s. s. in the coastal plains of those two states (Oliver et al. 2003). In NC, the distribution of I. affinis overlaps the distributions of these three rodent species, except for the eastern wood rat, which is confined to the southeastern part of the coastal plain and the mountains. The distribution of I. affinis also overlaps those of the marsh rice rat along the coast, and the white-footed mouse in northern portions of the coastal plain (Webster et al. 1985). Spielman et al. (1985) implicated the white-footed mouse as the primary amplifying mammal host of Borrelia burgdorferi s. s. in the northeastern Lyme disease cycle, yet Webster et al. (1985) indicated that the white-footed mouse does not occur in coastal counties of South Carolina or NC south of Pamlico Sound. If this distribution has not changed it raises the question: Is I. affinis a primary enzootic vector of B. burgdorferi s. s. in the rodent cycle in southeastern NC? As an indication of both the importance of accurate tick identification and the potential significance of I. affinis in the transmission cycle of B. burgdorferi s. s. in eastern NC, 17 Ixodes adults collected on drags in Onslow County in July 2008 were initially identified as I. scapularis, but when re-examined due to unusual seasonal occurrence, all 17 were actually found to be I. affinis. Six (35%) of those ticks tested positive for B. burgdorferi s. s. (BFP, unpublished), yet this species has never been documented to bite humans. This positive rate is slightly higher than the positive rate found in I. affinis in South Carolina, where this tick is a primary enzootic vector of B. burgdorferi s. s. in rodent hosts (Clark et al. 2002). North Carolina has a greater diversity of rodents and reptiles with differing distributions, a more diverse tick fauna utilizing these hosts, and more diverse Borrelia populations (Ryan et al. 1998, 2000) than those found in the northeastern U.S.A. This suggests that there may be several different basic cycles of Borrelia burgdorferi s. s. in the state, each operating in different regions, as in the diverse Borrelia life cycles known from Georgia and South Carolina (Oliver et al. 2003). Thus, investigations of these spirochetes and their tick vectors in NC should initially confirm the identifications of ticks, rodents, and/or reptiles in targeted study sites and not rely on information from the Borrelia life cycle prevalent in the northeastern U.S.A. This will provide valuable information about: seasonality of different life stages of each tick species, selection of appropriate collection methods, rodent and/or reptile species to examine for tick immature stages, medium to large mammal hosts on which adult ticks will occur, and likely amplifying rodent hosts for Borrelia spirochetes. We especially appreciate the collection efforts of the following county personnel: Jeff Brown and Rick Hickman, Brunswick; Eugene McRoy, Beaufort; Robert Collins, Nash; and Jim Gardner and Courtney Silverthorne, Pitt County. Also, we gratefully acknowledge the guidance of Nolan Newton, PHPM, also Amadou Jallow, PHPM, for his collection efforts early in the study, Melissa Miller, U.S.A. MEDCOM, CHPPM - North, Fort Meade, MD, for testing and re-examining the Onslow County tick specimens, and Bob Blinn, NC State University Insect Museum, Raleigh, NC, for the loan of preserved specimens. The views expressed in this article are those of the authors and do not necessarily reflect the official policy of the Department of the Navy, Department of the Army, Department of Defense, or the U. S. Government.

The authors identified hospitalizations for pneumonia (n = 6,522) in active-duty Navy and Marine Corps personnel during 1981-1991 from computerized inpatient records. The crude mean annual rate of pneumonia hospitalization was 77.6 per 100,000 active-duty personnel; 65% of pneumonia hospitalizations had no etiologic agent identified. The most commonly reported agents to cause pneumonia hospitalization were Streptococcus pneumoniae (12.3%), Mycoplasma pneumoniae (10.8%), other streptococcal species (2.1%), and Haemophilus influenzae (1.9%). The median age at hospitalization was 22 years. The median duration of hospital stay was 4 days and the case fatality rate was 0.4%. The authors used a 2% sample of the entire population and by means of stepwise unconditional multivariate logistic regression modeling for pneumonia found that, independent of age, the most junior Navy and Marine Corps personnel were at highest risk. Whites were at higher risk than blacks, Hispanics, or Filipinos. These results indicate that among this generally healthy US young adult military population, pneumonia hospitalization is common, often brief, and frequently without specifically identified pathogens.

Responding to escalating antimicrobial resistance (AMR), the US Department of Defense implemented an enterprise-wide collaboration, the Antimicrobial Resistance Monitoring and Research Program, to aid in infection prevention and control. It consists of a network of epidemiologists, bioinformaticists, microbiology researchers, policy makers, hospital-based infection preventionists, and healthcare providers who collaborate to collect relevant AMR data, conduct centralized molecular characterization, and use AMR characterization feedback to implement appropriate infection prevention and control measures and influence policy. A particularly concerning type of AMR, carbapenem-resistant Enterobacteriaceae, significantly declined after the program was launched. Similarly, there have been no further reports or outbreaks of another concerning type of AMR, colistin resistance in Acinetobacter, in the Department of Defense since the program was initiated. However, bacteria containing AMR-encoding genes are increasing. To update program stakeholders and other healthcare systems facing such challenges, we describe the processes and impact of the program.

A Marine deployed aboard a U.S. Navy amphibious ship had smear-positive, cavitary pulmonary tuberculosis (TB). Contact investigation ultimately found 21 active cases of TB among sailors and Marines who were aboard the affected ship. Approximately 3 months lapsed between onset of the source patient's illness and appropriate diagnosis and treatment. During the contact investigation, 3,338 persons received tuberculin skin tests and 712 were identified as new latent tuberculosis infection cases. Four persons diagnosed with latent tuberculosis infection developed active TB because of poor compliance with treatment. After personnel disembarked from the ship, persistent efforts to identify persons with active disease and latent infections were successful in controlling further spread of tuberculosis in military units and local communities. The Mycobacterium tuberculosis bacteria isolated from the source patient and 16 of the other active cases were susceptible to all drugs commonly used to treat TB.

Age-adjusted and age-specific incidence rates of testicular cancer in US Navy personnel did not differ significantly from those of the US population, and age-adjusted incidence rates did not increase with length of service in the Navy. There was a group of three occupations, however, which involved duties similar to those of the civilian occupation of automobile mechanic, and which had a significantly elevated age-adjusted rate of testicular cancer compared with the US population and the total Navy population. These occupations were aviation support equipment technician, engineman, and construction mechanic. All involve maintenance of internal combustion engines and exposure to the attendant lubricants, solvents, paints, and exhausts.

A 26-year-old male was presented to a military treatment facility in Afghanistan shortly after taking a weight-lifting supplement called Jack3d with a severe headache and was subsequently found to have suffered a Dejerine-Roussy variant right thalamic hemorrhagic stroke. Jack3d active ingredients include geranamine, schizandrol A, caffeine, beta-alanine, creatine monohydrate, and L-arginine alpha-ketoglutarate. A literature search revealed case reports suggesting some of the constituent ingredients may predispose to stroke and hemorrhage and also revealed a substantial paucity of data existed regarding schizandrol A, a herb used in traditional eastern medicine. The product has no readily apparent disclaimer or warning regarding the risks or lack of data regarding the components. Jack3d is sold as a nutritional supplement and is therefore not subject to same FDA regulation and scrutiny that a pharmaceutical receives. The potential adverse effect was reported to the FDA via MedWatch in accordance with the recently passed Dietary Supplement and Nonprescription Drug Consumer Protection Act.

OBJECTIVES: To review reported chlamydia infection trends in the U.S. military and identify reasons for differences. METHODS: Defense Medical Surveillance System 2000-2008 reports for nondeployed, active duty members were studied. Incidence, rate ratios, and confidence intervals were generated. Age- and gender-specific rates were compared with US national rates. Screening and reporting policies and procedures were reviewed. RESULTS: Overall incidence was 922 cases per 100,000 person-years, with considerable service variability (392-1,431 cases per 100,000 person-years in the Navy and Army, respectively). Navy-Marine Corps rates increased more than 2 fold in 2008. Rates were higher among women, minorities, and members under 25 years. Military rates exceeded national rates. CONCLUSIONS: The 2008 increase in Navy-Marine Corps rates may be due to the implementation of web-based reporting. Demographic differences were consistent with published reports. The civilian-military disparity may reflect higher percentages of military at-risk women screened.