Defining the magnitude of the problem: U.S. military injury surveillance
Medical Surveillance of Injuries in the U.S. Military: Descriptive Epidemiology and Recommendations for Improvement

https://doi.org/10.1016/j.amepre.2009.10.014Get rights and content

Introduction

Injury surveillance is the first and most critical step of the injury prevention process. Without it, successful injury prevention could not be sustained. The purpose of this paper is to describe advances in military medical surveillance, compare the incidence of injuries with other illnesses, define the size and causes of the injury problem for the military, and make recommendations for improved surveillance and injury prevention.

Methods

Medical and personnel data for nondeployed active duty personnel were obtained from the Armed Forces Health Surveillance Center for 2000–2006. Rates of nonfatal injuries and injury-related musculoskeletal conditions, frequencies of injury types, and causes of injury hospitalizations are described.

Results

Injuries were the leading cause of medical encounters among military personnel. The rate of hospitalization for injuries was approximately 1000 per 100,000 person-years and, for injuries treated in outpatient clinics, 999 per 1000 person-years. The leading injury type resulting in hospitalization was fractures (40%) and the leading injury type resulting in outpatient visits was sprains and strains (49%). Leading causes of hospitalization were falls/near falls (17.5%), motor vehicle mishaps (15.4%), and sports (13.1%).

Conclusions

Injuries are the biggest health problem of the military services. Military medical surveillance data are useful for determining the magnitude and causes of the injury problem, identifying possible prevention targets, and monitoring of trends among military personnel.

Introduction

Surveillance is the first and most important step of the public health process.1, 2, 3, 4 As stated by William Foege in his foreword for the second edition of Principles of Public Health Surveillance,

… epidemiology and analysis cannot be superior to the surveillance system used for collecting the facts analyzed. The analysis of those facts, the interpretation of their health implications, the interventions designed, and the programs launched are all based on the quality of the surveillance system used. Surveillance systems are therefore basic to everything that follows in public health.5

Injury surveillance is critical to sustained injury prevention for a number of reasons1, 6, 7 including:

  • Identification of the biggest, most severe injury problems

  • Detection of emerging injury problems

  • Setting objective, evidence-based priorities

  • Evaluation of newly implemented policies and programs

  • Monitoring continuing success of policies and programs

Where injury prevention is concerned, it is important to keep in mind that if you cannot measure the health outcome, you cannot prevent it with any certainty.7, 8

In the past, public health surveillance of injuries has focused primarily on fatalities,9 but that is not adequate as the vast majority of injuries are nonfatal. In Western European countries and the U.S., for every one death there are approximately 30 hospitalizations and 300 emergency department visits.9 The military is no exception to this observation. Data from the U.S. military show that for each unintentional injury death, there are 33 injury hospitalizations and almost 4000 outpatient visits (includes emergency department visits plus other outpatient clinic visits).10 For this reason, it is strongly recommended that injury surveillance systems capture both morbidity and mortality. At a minimum, injury deaths and hospitalizations should be monitored.11, 12, 13, 14

The Department of Defense (DoD) Injury Surveillance and Prevention Working Group15 and the Armed Forces Epidemiological Board (AFEB) Working Group2 strongly recommended medical surveillance of nonfatal injuries. Only hospitalization data were readily available for use in surveillance at the time of those recommendations in the late 1990s. Now the military services maintain rapidly accessible hospitalization and outpatient data.

The purpose of this paper is to illustrate the potential value of military medical surveillance data for injury epidemiology and prevention. The paper will: (1) compare the occurrence of injuries to other health problems among U.S. military personnel; (2) show the magnitude and causes of the problem of injuries for U.S. military services using routinely available medical data; (3) discuss capabilities and limitations of military medical surveillance for injuries; and (4) make recommendations to improve military medical surveillance systems and the injury prevention process.

Section snippets

Methods

The population for the analyses in this paper encompassed all nondeployed active duty military personnel for the Army, Air Force, Navy, and Marines from January 1, 2000, to December 31, 2006. Most of this paper will focus on data for the most recent year of complete data, 2006. On average, the active duty population was 85% men and 15% women. In addition, 83% of the men and 77% of the women were aged ≤35 years. Table 1 shows the populations for each of the four military services in

Relative Magnitude of the Injury Problem

Figure 1 shows the relative importance of injuries versus other health conditions. In this figure, both acute and traumatic injuries and injury-related musculoskeletal conditions are combined to form the “injury” category. The graph clearly indicates that injuries were the leading cause of medical encounters, with over 1.95 million in 2006. This is more than 2.5 times the next leading category, mental disorders, at just over 755,000 encounters. Almost a million individual service members were

Summary of Current Military Medical Surveillance Data on Injuries

In 2006, a total of 764 military service members died from nonbattle injuries.26 However, this number was small compared to the roughly 1,000,000 service members who suffered nonfatal, nonbattle injuries as reported in this article. When looking at hospitalizations, injuries accounted for 17% (n=11,591) of all hospitalizations. The next most common reason for hospitalization was mental disorders at 15%, followed by gastrointestinal diseases at 9%. Looking at conditions treated in outpatient

Conclusion and Recommendations

There is a growing recognition of the value of medical surveillance to public health, safety, and injury prevention by both civilian6, 13 and military subject matter experts.1, 2 However, priorities for the military are still focused on fatal injuries—primarily motor vehicle and aviation crashes. In comparison to hundreds of thousands of injuries treated in hospitals and outpatient settings each year, there have historically been only a few hundred motor vehicle fatalities per Service each year

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