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This study examined monthly prevalence of obesity and exercise in active component U.S. military members prior to and during the COVID-19 pandemic. Information about obesity (BMI≥30) and self-reported vigorous exercise (≥150 minutes per week) were collected from Periodic Health Assessment (PHA) data. From 1 January 2018 through 31 July 2021, there was a gradual increase in obesity and an overall decrease in vigorous exercise. Comparing the mean monthly percentage of obesity during the 12-month period prior to the pandemic to the 12 months after its start showed an overall increase in obesity (0.43%); however, no obvious spike in the obesity trend was apparent following the onset of the pandemic. The prevalence of vigorous exercise showed an abrupt decrease following the onset of the COVID-19 pandemic, but this change did not coincide with an abrupt change in the obesity trend. These results suggest that the COVID-19 pandemic had a small effect on the trend of obesity in the active component U.S. military and that obesity prevalence continues to increase.

This report provides mid-season vaccine effectiveness (VE) estimates from the Armed Forces Health Surveillance Division (AFHSD), the DoD Global Respiratory Pathogen Surveillance (DoDGRS) program, and the Naval Health Research Center (NHRC) for the 2019-2020 influenza season. Using a test negative case-control study design, the AFHSD performed a VE analysis for active component service members while the DoDGRS program and NHRC collaborated to perform a VE analysis for DoD beneficiaries and U.S.-Mexico border civilians. Among active component service members, there was low to moderate protection against influenza B, moderate protection against A(H3N2), and non-statistically significant low protection against influenza A overall and A(H1N1). Among DoD beneficiaries and U.S.-Mexico border civilians, there was statistically significant moderate protection against influenza B, influenza A overall, A(H1N1), and A(H3N2).

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood diagnosis and affects the pool of potential military applicants. Early detection and treatment of ADHD may decrease the risk of developing comorbidities; however, accession policy in place during this study period (2014-2018) disqualified applicants who used ADHD medication for more than 24 months cumulative after age 14. The objective of this study was to assess attrition from military service in newly accessed active component service members diagnosed with ADHD as compared to controls. In addition, attrition rates and incidence rates of mental health diagnoses were assessed in service members with ADHD by treatment status (i.e., treated vs untreated ADHD) where treatment was defined as being dispensed an FDA-approved ADHD medication at least twice within 181 days. Almost two-thirds (64.8%) of newly accessed ADHD cases in 2014 were identified after enlistment medical screening at Military Entrance Processing Stations (MEPS) (i.e., post-MEPS). These post-MEPS ADHD cases accounted for 99.1% of the treated ADHD cases. The vast majority of treated cases (91.0%) were dispensed ADHD medication within 6 months of accession. The treated ADHD group had higher rates of attrition and incidence of mental health disorders during the followup period. These study findings highlight the problem of nondisclosure of ADHD among military applicants. Future changes to enlistment standards should consider the optimal way to promote applicant disclosure of ADHD during MEPS screening or for medical waiver review and should discourage withholding an ADHD diagnosis during enlistment.

The Armed Forces Health Surveillance Branch conducts weekly surveillance of influenza activity among Department of Defense (DoD) populations each influenza season. This report provides a summary of the data from the 2018-2019 influenza season. Ambulatory data for influenza-like illnesses (ILIs), influenza hospitalization data, and lab data for influenza-confirmed cases were used for the surveillance. The 2018-2019 season differed from past seasons in that it was much longer, had a later peak, and the predominant strain of influenza changed from influenza A(H1N1)pdm09 at the beginning of the season to influenza A(H3N2) in the middle of the season. Non-service member beneficiaries accounted for the majority of ILI-related encounters and hospitalizations. However, there were still 149 influenza-related hospitalizations among service members during the 2018- 2019 season. Continued weekly surveillance of influenza among DoD populations is crucial to track increases in activity each season and the potential emergence of new and/or severe influenza subtypes.

Pelvic inflammatory disease (PID) is a consequence of untreated or inadequately treated sexually transmitted infections that can itself lead to infertility and ectopic pregnancy. Annual screening for asymptomatic chlamydia and gonorrhea infection helps reduce the incidence of acute PID. In the military, routine versus risk-based individual screening for chlamydia and gonorrhea began in some services in 2001, with full implementation across the services by 2005. From 1996 through 2016, rates of acute PID among active component women started to decline in the mid-2000s, consistent with national trends and coinciding with implementation of routine annual chlamydia and gonorrhea screening. Of active component women diagnosed with acute PID from 1996 through 2012, 6.1% were subsequently diagnosed with infertility or ectopic pregnancy, with higher proportions found among women in the Army and those aged 25-34 years. The overall decrease in the rates of acute PID in the military is consistent with national trends, and continued screening for asymptomatic chlamydia and gonorrhea infections should result in a continuing decline in the incidence of acute PID.

The Department of Defense (DoD) generates influenza vaccine effectiveness (VE) estimates each season. The Armed Forces Health Surveillance Branch Air Force (AFHSB-AF) satellite, Naval Health Research Center Operational Infectious Disease Directorate at the Naval Health Research Center (NHRCOID), and the Armed Forces Health Surveillance Branch (AFHSB) all conduct influenza surveillance and perform test-negative case-control analyses to estimate seasonal influenza VE for DoD populations. The mid-season estimates contribute to the aggregate data utilized by the Food and Drug Administration's Vaccine and Related Biological Products Advisory Committee to select the composition of the influenza vaccine for the next influenza season. The full season data provide DoD with direct estimates for force health protection decisions. The 2017-2018 DoD influenza season was predominated by influenza A(H3N2) with varying levels of adjusted overall VE estimates. AFHSB-AF satellite's VE for dependents was moderate at 49% (95% confidence interval [CI]: 42%-55%) for all strains. NHRC-OID's VE among dependents was moderate-high at 63% (95% CI: 50%-73%) for all strains. AFHSB service member VE was low at 18% (95% CI: 4%-30%). These estimates highlight the need for continued influenza surveillance and VE estimate calculations each season among the different DoD populations as circulating strains and VE may change annually.

From 2008 through 2015, a total of 9,092 incident cases of diabetes mellitus (DM) were reported among active component service members (incidence rate 82.8 cases per 100,000 person-years [p-yrs]). The overall incidence rate of type 1 DM was 3.0 cases per 100,000 p-yrs. The rate of type 2 DM was 74.5 cases per 100,000 p-yrs and rates doubled within each successive age group. Male service members had higher rates of both types of DM, compared to female service members. Black, non-Hispanic service members; service members of other or unknown race/ethnicity; and Hispanic service members had much higher rates of type 2 DM, compared to white, non-Hispanic service members. Rates of type 2 DM were highest among service members of the Army and the Navy, and lowest among Marine Corps members. Crude annual rates of type 2 DM peaked in 2010 and thereafter steadily decreased. During 2010-2015, decreases in rates of type 2 DM were observed for both sexes, those aged 25 years or older, all race/ethnicity groups, and all services except the Marine Corps. Potential explanations for these differences are discussed.

Traumatic brain injury (TBI) is a common injury in the U.S. Compared to the general population, military service members can be at increased risk for TBI because of the nature of their work. Sequelae of TBI, such as headache or migraine, can lead to military duty limitations or separation from service. To determine whether the severity of TBI is associated with the risk of these sequelae, this 2006-2015 retrospective cohort study compared the incidence of diagnosed headache or migraine among all service members with a first-time mild or moderate/severe TBI (N=111,018) against a matched sample without any history of TBI. Risk increased according to the severity of TBI. Compared to service members without TBI, those who sustained a mild TBI were 3.99 times more likely to have a headache or migraine, and those with a moderate/severe TBI were 8.89 times more likely. Patients, medical providers, and military leaders can use these results to guide care after a TBI. Early identification of those at higher risk of these sequelae could improve medical management and reduce disability.

Functional gastrointestinal disorders (FGIDs) are common chronic conditions with an unknown pathophysiology and etiology. FGIDs elevate healthcare costs and cause substantial burden to public health and the military, including diminished readiness, productivity, and quality of life. This retrospective cohort study of active component U.S. military personnel covered a 10-year surveillance period, 2005-2014. The Defense Medical Surveillance System (DMSS) was the data source. Incident cases were identified and rates were calculated and stratified by important covariates. Trends were described over the surveillance period. Incidence rates among deployed personnel were compared to rates in non-deployed personnel, stratified by age and sex. An increasing trend in functional constipation was observed during 2005-2012. Being female, black, in the Army or Air Force, and younger than 20 years of age or 40 years of age or older was associated with higher incidence rates. Deployment-exposed personnel had incidence rates that were 53% higher than those of non-deployed personnel. Elevated rates in personnel younger than 20 years of age and deployed personnel evoke interest concerning readiness and cost implications for the Military Health System. These subgroups should be examined in future studies.

This report summarizes frequencies and timing of first and recurrent episodes of back pain treated in the U.S. Military Health System among more than 2 million military members who began active service between July 2000 and June 2012. In the population overall, at least 5% were affected by clinically significant back pain within 6 months and 10% within 13 months of beginning active service; and 34% had at least one episode of back pain while in active service during the surveillance period. After initial episodes of back pain, more than half (54%) of those affected had at least one recurrent episode; and after first recurrences, 65% had second recurrences while still in active service. In general, back pain episode-free periods preceding initial and between successive episodes markedly decreased during the period. Frequencies and timing of back pain episodes varied in relation to service branch, gender, and occupation. Acute back pain is a common disorder that is unpredictable in onset and often debilitating. Its prevention should be a military medical research objective of high priority.

Low back pain (LBP) is a common cause of disability, lost worker productivity, and healthcare costs in both military and civilian populations. During the 5-year surveillance period of this analysis, the LBP diagnoses of interest were associated with more than 6 million outpatient healthcare encounters and more than 25,000 hospitalizations among active component service members. Annual numbers of outpatient encounters for LBP diagnoses increased 34% during 2010-2014. Annual numbers of inpatient encounters decreased during the period. Incidence rates were lowest among the youngest service members and increased with advancing age. Of all service members ever given a LBP diagnosis during the surveillance period, 91% were diagnosed at least once with a condition in the broad category "nonspecific back pain." The most common specific diagnosis during the surveillance period was lumbago. The discussion covers the importance of LBP in the military, initiatives to lower the incidence of, and enhance the care of, LBP, and methodologic limitations to the analysis.

Postpartum depression (PPD) is one of the most common psychiatric conditions of the postpartum period. Several studies have found an association between PPD and other mental health disorders. The Defense Medical Surveillance System (DMSS) was used to identify a cohort of primiparous service women with PPD between 1998 and 2010 and match them by month of delivery to a cohort of women without PPD. During the surveillance period, there were 5,203 incident cases of PPD with a crude rate of 44.9 per 1,000 person-years. Individuals in the PPD cohort, when compared to their matched controls, were at higher risk for subsequent depressive disorders (adjusted hazard ratio [HR]: 7.3 [95% CI: 5.2-10.3]), anxiety disorders (adjusted HR: 3.2 [95% CI: 2.5-4.0]), and bipolar disorders (adjusted HR: 4.7 [95% CI: 1.9-11.9]). There were higher rates of these mental health diagnoses among individuals who eventually left service. Early screening, support, and treatment are essential during this vulnerable postpartum time frame to preserve the female fighting force.

Tetanus, diphtheria, and acellular pertussis (Tdap) vaccines have been licensed for use in the U.S. since 2006 and have been recommended during pregnancy since 2011. Low vaccination coverage during pregnancy among the general U.S. population has been reported. Therefore, this surveillance study was conducted to assess the percentage of service women with a live birth delivery during 2006-2014 who received a Tdap vaccination during their pregnancy. Only 1%-3% of service women during 2006-2011 received a Tdap vaccine during their pregnancy. However, coverage increased to 8% in 2012 and 54% in 2014. Although this moderate Tdap coverage among military service women is an improvement over past years, more education and attention by military physicians and pregnant service women to the benefits of Tdap vaccination are needed to bring coverage closer to 100%.

U.S. Armed Services retirees are eligible for disability compensation for medical illness/injury incurred during their service. This analysis of recently retired U.S. active component air crew/aviation service members from all Services evaluated incident diagnoses among aviation retirees during the 12 months prior to retirement and assessed trends in first-time diagnoses by major diagnostic category and aviation component stratification. Most aviation retirees were in their 40s, Air Force, male, white, and senior officers and warrant officers. Among the study population, 14,191 (88%) of aviation retirees had at least one first-time diagnosis recorded during the 12 months prior to retirement. During 2003-2012, 63.8% of all diagnoses in aviation retirees during the 12 months prior to retirement were new. The highest proportions of new diagnoses were for "other disorders of the ear," "organic sleep disorders," and "general symptoms." Among the four subtypes of aviators, general air crew/air craft crew had the lowest proportion of new diagnoses (60.2%).

Although suicide is a leading cause of death among new mothers during the postpartum period, there has been limited research on self-harm in the postpartum period and associated risk factors. One potential risk factor for suicidality (completed suicides, suicide attempts, and suicide ideation including thoughts of self harm) during the postpartum period is postpartum depression (PPD). In this study of women who gave birth for the first time between 1 January 2007 and 31 December 2011, 5,267 (9.9% of all who delivered) active component service women and 10,301 (8.2%) dependent spouses received incident PPD diagnoses during the one year postpartum period; 213 (0.4%) service women and 221 (0.2%) dependent spouses were diagnosed with incident suicidality. After adjusting for the effects of other covariates, service women with PPD had 42.2 times the odds to be diagnosed with suicidality in the postpartum period compared to service women without PPD; dependent spouses with PPD had 14.5 times the odds compared to those without PPD. The findings of this report suggest that a history of mental disorders was common among service women and dependent spouses with PPD in the postpartum period, and, in turn, PPD was a strong predictor for suicidality in the postpartum period. These results emphasize the importance of PPD screening during the postpartum period. They also suggest that additional focused screening for suicidal behavior among those already diagnosed with PPD may be warranted.

Annual counts and rates of incident diagnoses of mental disorders or mental health problems have increased in the U.S. military active component since 2000, but less is known about recruit trainees. From 2000 to 2012, 49,999 active component recruit trainees were diagnosed with at least one mental disorder, and 7,917 had multiple mental disorder diagnoses. Annual incidence rates of at least one mental disorder decreased by approximately 37.4 percent over the last 13 years. Approximately 80.5 percent of all incident mental disorder diagnoses were attributable to adjustment disorders, depression and "other" mental disorders. Rates of incident mental disorder diagnoses were higher in females than males. Even though the Army had the highest overall incidence rates of mental disorders, the Air Force had slightly higher rates for adjustment disorder, and the Navy had higher rates of alcohol abuse-related disorders, post-traumatic stress disorder (PTSD), anxiety, other psychoses, and personality disorders. These findings document differences in the mental disorders experienced by recruit trainees compared to members of the active component of the U.S. military overall. Continued focus on detection and treatment of mental health issues during basic training is warranted.

Drug misuse is associated with serious health consequences and has detrimental effects on military readiness. During 2000 to 2011, 70,104 service members received an incident diagnosis of a substance use disorder (SUD) (excluding alcohol and tobacco-related disorders). Incidence rates declined with increasing age, time in service, rank, and number of combat deployments. Service members in a combat occupation had 1.2 times the rate of individuals in a health care or administation/supply occupation. The median time to discharge after an SUD diagnosis was longest in the Air Force (327 days) and shortest in the Navy (133 days). The substances with the highest incidence rates were cannabis (160 per 100,000 person-years [p-yrs]), "mixed/unspecified/other" (125 per 100,000 p-yrs), and cocaine (61 per 100,000 p-yrs). Incidence rates of cannabis and cocaine use diagnoses generally declined while rates of mixed/unspecified/other and opioid use increased over the surveillance period. The increasing trend in opioid-related diagnoses since 2002 may reflect an increase in prescription drug misuse. The Department of Defense recently expanded its drug testing program to screen for hydrocodone and benzodiazepines.