The Roles of Medical Surveillance, Research and the AFEB in Military Injury Prevention: A Historical Perspective

1. The Roles of Medical Surveillance, Research and the AFEB in Military Injury Prevention: A Historical Perspective Bruce H. Jones, MD, MPH Colonel (Retired, U.S. Army) Injury Control Program Manager USACHPPM, APG, MD

2. Outline of Presentation on Injury Prevention in the Military Background Reasons for concern 5 Step Public Health Process Process evolved out of sequence Medical Research Key organizations Key findings in 1980s and 1990s Medical Surveillance Key organizations and events Data and databases in the 1990s Surveillance and Research Today Conclusions and Future Directions

4. Five Steps of Public Health Approach Applied to Injury Control Surveillance Research Intervention Trials Implementation of Programs and Policies Evaluation

5. Medical Research in the 1980s and 1990s Physical training-related injuries Key Organizations Army Research Institute of Environmental Medicine Naval Health Research Center Key events Army SG Task Force 1985 NHRC Expert Panel 1994

7. Past Physical Activity Level and Incidence (%) of Injury in Male Trainees

8. Incidence of Stress Fractures in High Risk vs. Low Risk Marine Recruits, 1995

9. Effects of Running Mileage on Stress Fracture Incidence and Run Times Among Marine Recruits*

10. Marine Corps Recruit Depot: Morbidity and Cost Savings prevented 14,800 lost training days demonstrated a cost savings of $4.5 million/yr

11. Successes and Problems of Military Injury Research in 1980s and 1990s Contributions to understanding of PT and exercise-related injuries Problems Under funded Under staffed Vision for remedy Assess full magnitude of injury problem Establish routine, systematic, integrated medical surveillance

12. Medical Surveillance in the 1990s Key Organizations ASD/HA and DUSD/ES (OH&S) USACHPPM Key Events DOD Injury Surveillance and Prevention Work Group 1991 AFEB Work Group 1994 Work Groups’ objectives: to assess data supporting injury control process AMSA established 1994; EA for DMSS 1997

13. Magnitude of the Problem

14. Deaths in the Army -FY 1994

17. Distribution (%) of Hospitalizations of Marines in Vietnam by Principal Diagnostic Groups, 1965 to 1970

18. Sick Call Visit Rates for Injuries and Illness Among Infantry Soldiers*

19. Army Injury Pyramid*

20. Causes of Injury

21. Leading Causes of Accidents and Injuries in the Army 1994*

22. Prevention of Injuries

23. Army Motor Vehicle Fatalities Fiscal Years 1980-1994

24.  Navy Rates of Aviation Fatalities 1949-1995

26. Results of Surveillance Effortsin the 1990s DOD ISP Work Group identified potential data sources and compiled data ‘92 to ‘95 AFEB Work Group Reviewed and evaluated DOD ISP WG data ’94 to ’95 Report in ’96 resulted in ASD(HA) memo DOD ISP Atlas of Injuries…Milit Med ’99 and AFEB report, Injuries in U.S. Armed Forces… in AJPM 2000 WGs’ Recommendations Comprehensive, integrated medical surveillance Allocate research resources commensurate with problem

27. Surveillance and Research Today

28. Surveillance and Research Today Integrated medical surveillance Ambulatory, hospitalization, deaths Personnel, demographic data On-line access through DMED Installation Injury Report on-line monthly Medical Surveillance Monthly Report Secretary of Defense Goal 50% reduction in injury rates Chartered military injury metrics work group

29. Injuries vs. Illnesses Resulting in Outpatient Visits Among Soldiers, CY 2001

31. Victory Fitness Intervention Trial in Army Trainees Ft. Jackson, SC 2000*

32. Alphabetical list external causes of injury* Accidents with own instruments of war Athletics/sports Complications of medical/surgical procedures Cut/pierced by object Drowning/submersion Excessive cold Excessive heat Falls/jumps Fighting Guns, explosives, and related devices Hanging/suffocation Late effects of injury Lifting/pushing/pulling Machinery/tools Marching/drilling Military air transport accidents Military vehicle accidents Nonmilitary air transport accidents Other environmental Physical training (e.g., running, calisthenics) Poisoning POV accidents Twisting/turning/slipping Unconventional weapons injury (chemical&biological weapons, terrorism) Water transport

33. Conclusions About Military Medical Surveillance and Research on Injuries Interest in injuries data driven Need context of other diseases to show magnitude of injury problems Successes in MV and aviation required surveillance of “accident” deaths Committees and external validation invaluable Today’s surveillance tools more powerful Research still underfunded PT-related injury studies show potential of research to make a difference

34. Progress with the Five Steps of Public Health Approach to Injury Control Surveillance – AMSA/DMSS Research – PT/Running, SBs, ETOH Intervention Trials – VF (reduced running) Implementation of Programs and Policies – New PT + enforcement Evaluation -

35. Future Directions Systematic approach Set prevention and policy priorities based on magnitude and ability to prevent problem using public health criteria Implement off-the-shelf solutions Make evidence-based recommendations for prevention programs and policies Inventory and catalogue methods of prevention Track and evaluate effectiveness of prevention efforts Set research priorities using public health criteria

36. Supplemental Slides

37. Injury vs Illness in the Armed Forces Death Rates /100,000 person years 1989-96

38. CY2001 Army Injury Data Reported by Military Injury Metrics Work Group

39. Amount of Research Needed to Support Prevention – Example Stress Fractures Program Evaluation Intervention & Experimental Trials Risk Factor and Causation Studies Descriptive Epi and Case Series 1 9 52 86