DTIC ADA496234: Medical Surveillance Monthly Report (MSMR). Volume 13, Number 1, January 2007

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by  Defense Technical Information Center

MSMR
Medical Surveillance Monthly Report
Vol. 13 No. 1 January 2007
U
Contents
S
Relationships between abnormal findings during medical
examinations and subsequent diagnoses of significant conditions,
A active components, U.S. Armed Forces, January 1998-October
2006.................................................................................................................. 2
ARD surveillance update.................................................................................6
C
Epidemiologic consultation (EPICON): Outbreak of invasive group A
streptococcal infections among trainees, Fort Leonard Wood,
H Missouri, 2006..................................................................................................7
Update: Malaria, U.S. Armed Forces, 2006................................................11
P
Pre- and post-deployment health assessments, U.S. Armed Forces,
January 2003-December 2006....................................................................15
P
Deployment-related conditions of special interest....................................20
Sentinel reportable events............................................................................22
M
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1. REPORT DATE 3. DATES COVERED
JAN 2007 2. REPORT TYPE 00-00-2007 to 00-00-2007
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
Medical Surveillance Monthly Report (MSMR). Volume 13, Number 1,
5b. GRANT NUMBER
January 2007
5c. PROGRAM ELEMENT NUMBER
6. AUTHOR(S) 5d. PROJECT NUMBER
5e. TASK NUMBER
5f. WORK UNIT NUMBER
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U.S. Army Center for Health Promotion and Preventive Medicine,Armed REPORT NUMBER
Forces Health Surveillance Center (AFHSC),2900 Linden Lane, Suite
200,Silver Spring,MD,20910
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11. SPONSOR/MONITOR’S REPORT
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13. SUPPLEMENTARY NOTES
14. ABSTRACT

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2 MSMR January 2007
Relationships between Abnormal Findings during Medical Examinations and
Subsequent Diagnoses of Significant Conditions, Active Components,
U.S. Armed Forces, January 1998-October 2006
Military service is physically and psychologically abnormality”; “neoplasm, testis.” (Details of the
demanding. Examinations of applicants for military method, including relevant ICD-9-CM codes, were
service are routinely conducted to identify conditions reported in the December 2006 issue of the MSMR).
that may preclude the full and safe performance of For each abnormal finding associated with a
required military duties. Because military members medical examination, we identified the first subsequent
are generally healthy when they enter service, military medical encounter of the same individual during which
medical departments emphasize the prevention of a related significant medical condition (selected) was
illnesses and injuries, the promotion of health and diagnosed. For example, among individuals with a
fitness, and the enhancement of military operational finding of “breast lump,” subsequent diagnoses of
capabilities during service (“force health protection “malignant neoplasm” or “carcinoma in situ” of the
and readiness”).1 A major part of these illness and breast were identified. The indicator findings and
injury prevention/health promotion efforts includes associated medical conditions of interest for this
medical examinations (e.g., routine periodic, pre/post analysis are shown in Table 1, pages 3-5.
deployment, occupational). During 2005, To increase the likelihood that reports of medical
approximately 2.8 million medical examinations of conditions were true diagnoses (rather than “rule outs”
active component military members (more than one- or miscodes, for example), we defined “confirmed
fifth of all outpatient encounters) were conducted and diagnoses” as conditions that were diagnosed during
reported on standardized medical records.2,3 three or more medical encounters with at least seven
The December 2006 issue of the MSMR included days between encounters. Frequencies and cumulative
a summary of numbers and rates of abnormal findings incidence rates of confirmed diagnoses of conditions
that were temporally associated with the conduct of of interest were calculated among all and in subgroups
routine medical examinations.2 However, in generally of military members with related abnormal findings.
healthy young adult populations such as the U.S.
military, abnormal findings on routine examinations are Results: Of the eleven abnormal findings of interest
often not indicative of significant, treatable underlying during this analysis, those with the highest rates of
medical conditions (and may, in fact, be harmful).4,5 confirmed diagnoses of related conditions were
This report includes a summary of the numbers, rates, “neoplasm of the testis” (18.6% with “malignant
and distributions of confirmed diagnoses of selected neoplasm of the testis”), “elevated PSA” (13.7% with
significant medical conditions following “indicator” “malignant neoplasm of the prostate”), “wheezing”
abnormal findings associated with routine medical (13.0% with “asthma”), and “elevated blood pressure”
examinations. (10.3% with “hypertensive disease”) (Table 1).
In contrast, 0.3% of those with “abnormal
Methods: The surveillance period was 1 January 1998 Papanicolaou smear of the cervix” had subsequent
to 31 October 2006. The surveillance population confirmed diagnoses of “malignant neoplasm” or
included all individuals who served in an active “carcinoma in situ” of the cervix; 0.4% of those with
component of the U.S. Armed Forces any time during “blood in stool” had subsequent confirmed diagnoses
the surveillance period. For this report, we identified of “malignant neoplasm” or “carcinoma in situ” of
all military members who had one or more of the the colon, rectum, rectosigmoid, or anus; 1.5% of those
following abnormal findings reported as a diagnosis with “breast lump” had subsequent confirmed
during a medical encounter within 30 days of a routine diagnoses of “malignant neoplasm” or “carcinoma in
medical examination (as indicated by a “V code” in situ” of the breast; and 1.9% of those with “enlarged
the ICD-9-CM): “elevated blood pressure”; lymph nodes” had subsequent confirmed diagnoses
“nonspecific abnormal Papanicolaou smear of the of “malignant neoplasm” of lymphatic or hematopoietic
cervix”; “breast lump”; “cardiac murmur”; “blood in tissue (Table 1).
stool”; “enlarged lymph nodes”; “abnormal glucose Among those with abnormal findings, rates of
tolerance”; “wheezing”; “elevated prostate specific confirmed diagnoses of related significant medical
antigen (PSA)”; “retinopathy/retinal vascular conditions generally increased or were stable with age.
Vol. 13/No. 1 MSMR 3
her enital maly, art Percent with disease 0.18 0.12 0.19 0.20 0.12 0.24 0.11 0.22 0.19 0.10 0.24 0.00 0.11 0.16 0.19 0.05 0.18 0.12 0.23 0.16 0.16
ons, Otconganohe Number with disease 8 6 6 4 12 12 4 9 4 3 4 0 5 4 15 1 23 2 4 18 24
al conditi ac murmur Cardiac anomaly, incl septal closure Percent Number with with diseasedisease 80.18 60.12 60.19 40.20 120.12 120.24 40.11 90.22 40.19 30.10 40.24 00.00 50.11 40.16 150.19 10.05 230.18 20.12 40.23 180.16 240.16
ed medic Cardi Other endocardium (e.g., valve disorder) Percent Number with with diseasedisease 501.10 310.63 421.32 30.15 991.02 270.55 50.14 190.45 170.80 501.74 281.71 72.89 260.60 130.52 871.12 361.88 900.71 311.79 110.64 840.75 1260.86 ngs.
d relat Number with finding 4,543 4,885 3,185 2,001 9,703 4,911 3,551 4,177 2,135 2,872 1,637 242 4,364 2,505 7,745 1,919 12,695 1,734 1,709 11,171 14,614 ated findi
n ci
nations aber 2006 mp Carcinoma in situ, breast Percent Number with with diseasedisease 70.13 120.33 90.17 10.14 nana 290.22 00.00 00.00 20.07 80.19 160.76 31.53 100.20 20.08 170.23 130.46 160.13 10.10 100.31 180.17 290.20 hose with asso
medical examiary 1998-Octo Breast lu Malignant neoplasm, female breast Percent Number Number with with with diseasediseasefinding 5,255801.52 3,678421.14 5,170611.18 69460.86 nanana 13,3991861.39 1,18100.00 4,23840.09 2,88470.24 4,201761.81 2,097914.34 196115.61 5,019811.61 2,534200.79 7,244881.21 2,828752.65 11,9691140.95 994121.21 3,217531.65 10,5861241.17 14,7971891.28 es of disease among t
n u nc
normal findings oArmed Forces, Jan onspecific abnormal nicolaou smear of cervix Malignant neoplasm, Carcinoma in cervixsitu, cervix Percent Number Percent Number with with with with diseasediseasediseasedisease 50.05200.20 50.04240.20 60.06260.26 00.0050.25 nananana 160.05750.22 00.0090.12 10.01340.21 30.05150.26 80.21140.37 40.3730.27 00.0000.00 70.08160.17 30.04140.18 60.03450.25 50.1680.26 110.03670.21 20.0890.35 40.0770.13 100.04590.22 160.05750.22 ups with the highest prevale
Table 1. Relationships between ab active components, U.S. NElevated blood Papapressure Hypertensive disease Number Percent Number Number with with with with findingdiseasediseasefindingService Army14,6941,3939.4810,237 Navy8,61691810.6512,208 Air Force16,1681,83811.3710,111 Marine Corps1,570845.352,021 Gender Male35,2043,55210.09na Female5,84468111.6534,474 Age group <201,395433.087,378 20-248,5433784.4216,508 25-297,7825467.025,751 30-3914,2441,97613.873,765 40-498,1911,18214.431,094 50+89310812.0981 Race ethnicity Black nonhisp10,5711,60315.169,315 Hispanic/other6,3375719.017,613 White nonhisp24,1402,0598.5317,649 Status Officer6,98573210.483,094 Enlisted34,0633,50110.2831,483 Occupation Combat6,2665138.192,595 Medical4,46746010.305,508 Other30,3153,26010.7526,474 Total41,0484,23310.3134,577 Shaded cells indicate demographic/military subgro
4 MSMR January 2007
ated PSA Malignant neoplasm, prostate Percent Number with with diseasedisease 12614.65 6014.60 6511.69 1113.41 26213.77 nana 00.00 00.00 00.00 115.24 16314.16 8817.32 7616.93 279.89 15913.40 16216.56 10010.74 6414.58 3914.72 15913.20 26213.72
v
dical Ele Number with finding 860 411 556 82 1,903 na 4 17 19 210 1,151 508 449 273 1,187 978 931 439 265 1,205 1,909
e
ed m06 g ma Percent with disease 13.35 11.66 15.64 5.48 11.76 16.06 7.97 12.33 15.77 16.08 12.78 3.70 18.53 10.76 11.71 13.12 13.02 12.84 13.03 13.07 13.03
relater 20 heezin Asth Number with disease 211 68 150 16 283 162 40 142 97 119 45 2 139 69 237 45 400 62 55 328 445
s and Octob W Number with finding 1,581 583 959 292 2,406 1,009 502 1,152 615 740 352 54 750 641 2,024 343 3,072 483 422 2,510 3,415
al examinationJanuary 1998- Abnormal glucose tolerance Diabetes mellitus Percent Number Number with with with diseasediseasefinding 1,465976.62 1,4941348.97 833738.76 159116.92 3,2692628.01 682537.77 5400.00 336175.06 471285.94 1,34113510.07 1,4311117.76 318247.55 9839910.07 915758.20 2,0531416.87 806384.71 3,1452778.81 514285.45 558407.17 2,8792478.58 3,9513157.97 h associated findings.
c, wit
normal findings on medients, U.S. Armed Forces Enlarged lymph nodes Malignant neoplasm, lymphatic / hematopoieticHIV infection Percent Number Percent Number Number with with with with with diseasediseasediseasediseasefinding 3,831621.62110.29 1,435342.3780.56 2,139421.9650.23 603121.9910.17 5,2001202.31220.42 2,808301.0730.11 73750.6810.14 2,885401.3970.24 1,664291.7440.24 1,840462.5080.43 808232.8550.62 7479.4600.00 2,101321.52120.57 1,195231.9220.17 4,712952.02110.23 1,107332.9840.36 6,9011171.70210.30 1,322342.5740.30 1,065222.0730.28 5,621941.67180.32 8,0081501.87250.31 prevalences of disease among those
abon est
ed. Relationships between conditions, active comp Blood in stool Malignant Malignant neoplasm, neoplasm Ulcerative colonrectum, anuscolitis Percent Number Percent Number Percent Number with with with with with with diseasediseasediseasediseasediseasedisease 100.2360.14751.69 90.3270.25361.27 70.2860.24381.52 00.0010.1681.25 230.28170.211231.49 30.1430.14341.59 00.0000.0040.85 10.0510.05391.86 20.1310.07442.87 90.3250.18461.62 130.45130.45220.76 10.1700.0020.35 30.1440.19291.39 40.2140.21180.96 190.29120.191101.71 80.3240.16341.38 180.23160.201231.55 30.1630.16351.88 40.3230.24211.70 190.26140.191011.38 260.25200.191571.51 mographic/military subgroups with the high
ntinu Number with finding 4,430 2,834 2,502 640 8,274 2,132 471 2,098 1,535 2,831 2,898 573 2,089 1,875 6,442 2,466 7,940 1,860 1,238 7,308 10,406 cate de
o di
Table 1 C Service Army Navy Air Force Marine CorpsGender Male FemaleAge group <20 20-24 25-29 30-39 40-49 50+Race ethnicity Black nonhisp Hispanic/other White nonhispStatus Officer EnlistedOccupation Combat Medical OtherTotal Shaded cells in
Vol. 13/No. 1 MSMR 5
Table 1 Continued. Relationships between
Editorial comment: This summary suggests that
abnormal findings on medical
most abnormal findings during medical examinations
exams and related conditions,
of generally healthy, physically active U.S. military
January 1998-October 2006
members are not indicative of severe underlying
Retinopathy/retinal medical illnesses. For example, in this analysis, blood
vascular Neoplasm, testis in stool and abnormal Papanicolaou smears of the
Malignant cervix were associated with malignant neoplasms in
Diabetes neoplasm, fewer than one of 200 cases overall (and much less
mellitus testis
often in service members younger than 30). On the
Number Number Percent Number Number Percent other hand, more than one of ten service members
with with with with with with
finding disease disease finding disease disease who had testicular masses or elevated PSAs
Service
documented during/shortly after routine medical
Army 358 14 3.91 74 18 24.32
examinations had malignant neoplasms of the testis
Navy 193 16 8.29 40 5 12.50
(particularly those in their twenties) or prostate
Air Force 426 15 3.52 83 13 15.66
Marine Corps 79 0 0.00 24 5 20.83 (particularly those older than 40), respectively.
Gender The results reported here must be interpreted with
Male 894 38 4.25 221 41 18.55 caution. For example, for the final analysis, we used
Female 162 7 4.32 na na na
only confirmed diagnoses of selected medical
Age group
conditions. Because most of the medical conditions
<20 54 0 0.00 12 1 8.33
20-24 153 1 0.65 54 13 24.07 that we used as endpoints are severe (e.g., malignant
25-29 113 1 0.88 49 12 24.49 neoplasms) and/or chronic (e.g., hypertensive
30-39 309 9 2.91 77 12 15.58 disease), we felt that our definition of “confirmed
40-49 356 25 7.02 29 3 10.34
diagnoses” would correctly classify most “true cases”
50+ 71 9 12.68 0 0 0.00
Race ethnicity and eliminate most cases that were evaluated and
Black nonhisp 271 14 5.17 31 1 3.23 eventually “ruled out” or miscoded. Still, our strict
Hispanic/other 174 9 5.17 37 7 18.92 definition may have eliminated some true cases
White nonhisp 611 22 3.60 153 33 21.57 (causing underestimation of the positive predictive
Status
values of some abnormal findings). In addition, some
Officer 248 10 4.03 51 11 21.57
Enlisted 808 35 4.33 170 30 17.65 significant medical conditions that we did not include
Occupation as endpoints may have been diagnosed subsequent to
Combat 180 3 1.67 48 14 29.17 the abnormal findings that we considered for this
Medical 118 8 6.78 27 6 22.22
report. The result would be underestimation of the
Other 758 34 4.49 146 21 14.38
prevalence of significant medical conditions among
Total 1,056 45 4.26 221 41 18.55
those with abnormal findings on medical examinations.
Shaded cells indicate demographic/military subgroups with the highest
prevalences of disease among those with associated findings. Also, results of some medical examinations
(including abnormal findings) may not have been
Notable exceptions were the relationships between
reported through standardized electronic data systems
“blood in stool” and “ulcerative colitis” (declining rates
and, in turn, not included in the Defense Medical
over age 30 years) and “wheezing” and “asthma”
Surveillance System (which was the source of data
(sharply declining rates over age 40 years) (Table 1).
for the analysis). As a result, some severe medical
Compared to their counterparts, Black non-
conditions that were diagnosed subsequent to abnormal
Hispanic members were much more likely to have
findings during medical examinations would not have
confirmed diagnoses of “hypertensive disease” and
been considered as such in this analysis.
“asthma” following findings of “elevated blood
Given the shortcomings, the results are still
pressure” and “wheezing,” respectively (Table 1).
informative and potentially useful. For example, care
Finally, there was not a consistent relationship
providers may reference them when interpreting the
between Service and rates of confirmed diagnoses
results of routine examinations of active military
after related abnormal findings (Table 1).
patients — particularly regarding the likely meanings
Data summaries by Stephen B. Taubman, PhD, of abnormal findings that may indicate severe
Army Medical Surveillance Activity underlying diseases.
6 MSMR January 2007
References
3. Defense Medical Surveillance System (DMSS). Defense Medical
1. U.S. Department of Defense. 2003 force health protection Epidemiology Database (DMED). Queried on-line: 10 January
capstone document. Washington, D.C. Accessed on-line 10 2007.
January 2007 at < http://www.deploymentlink.osd.mil/pdfs/ 4. Oboler SK, LaForce FM. The periodic physical examination in
fhp2004.pdf >. asymptomatic adults. Ann Intern Med. 1989 Feb 1;110(3):214-
2. Incident abnormal findings within 30 days of medical 26.
examinations, active components, U.S. Armed Forces, January 5. Marshall KG. Prevention. How much harm? How much benefit?
1998-October 2006. Medical Surveillance Monthly Report 2. Ten potential pitfalls in determining the clinical significance
(MSMR). 2006 Dec;22(9):10-6. of benefits. CMAJ. 1996 Jun 15;154(12):1837-43.
Acute respiratory disease (ARD) and streptococcal pharyngitis (SASI),
Army basic training centers, by week through December 30, 2006
ARD SASI2
3 Fort Benning 50
40
2
Epidemic threshold2 30
20
1
10
0 0
Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06 Jul-06 Oct-06 Jan-07
3 Fort Jackson 50
40
2
30
20
1
10
0 0
Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06 Jul-06 Oct-06 Jan-07
3 Fort Knox 50
40
2
30
20
1
10
0 0
Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06 Jul-06 Oct-06 Jan-07
3 Fort Leonard Wood 50
40
2
30
20
1
10
0 0
Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06 Jul-06 Oct-06 Jan-07
3 50
Fort Sill
40
2
30
20
1
10
0 0
Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06 Jul-06 Oct-06 Jan-07
1 ARD rate = cases per 100 trainees per week
2 SASI (Strep ARD surveillance index) = (ARD rate)x(rate of Group A beta-hemolytic strep)
3 ARD rate >=1.5 or SASI>=25.0 for 2 consectutive weeks indicates an “epidemic”
Vol. 13/No. 1 MSMR 7
Epidemiologic Consultation (EPICON): Outbreak of Invasive Group A Streptococcal
Infections among Trainees, Fort Leonard Wood, Missouri, 2006
Military trainee populations have historically been trainees; identify and characterize potential risk
at high risk for outbreaks of acute respiratory disease factors; assist in assessing indoor environments; and
(ARD).1,2 Since the 1980s, there have been numerous recommend outbreak control, infection prevention,
outbreaks of diseases (including pharyngitis, tonsillitis, active surveillance, infectious disease clinical
peritonsillar abscess, pneumonia, necrotizing fasciitis, management, and environmental practices to improve
streptococcal toxic shock, acute rheumatic fever) and protect the health of trainees at FLW. This report
secondary to group A beta-hemolytic streptococcal summarizes significant clinical and laboratory findings
(GABHS) infections.1 The trainee population at Fort and recommendations of the investigation team.
Leonard Wood (FLW), Missouri, has been particularly
susceptible to such outbreaks.1 Since 1994, basic Activities: The EPICON team deployed to FLW on
combat trainees at Fort Leonard Wood who are not 22 October 2006. While at FLW, they searched
allergic to penicillin have been given an injection of inpatient, outpatient, and laboratory records to identify
long-acting benzathine penicillin (BPG) routinely during all cases of invasive GABHS (using relevant ICD-9-
their medical in-processing to prevent outbreaks of CM codes) that occurred during 2005 and 2006 (to
GABHS-related diseases. date). In addition, they conducted comprehensive
In 2005, King Pharmaceuticals, Inc., became the environmental assessments (including sanitation
sole U.S. manufacturer of BPG (trade name: inspections of barracks, common areas, and field
Bicillin®). Difficulties with the production facility training sites), performed indoor air quality testing,
resulted in supply interruptions that became especially reviewed HVAC maintenance procedures, evaluated
severe in late summer 2006. Between July and barracks isolation practices for ARD cases, and
September 2006, FLW was allocated only 20% of the conducted environmental surface sampling for
BPG required for routine prophylaxis of incoming GABHS. Also, they conducted site visits and
trainees. interviews with key personnel at FLW, the Missouri
Two trainees at FLW were hospitalized with State Health Department, and the University of
necrotizing fasciitis due to GABHS in September and Missouri-Columbia Medical Center.
October 2006. The first case required amputation of Of note, the EPICON team sent 12 GABHS
the affected trainee’s hand. The second case required isolates to the CDC (two from the necrotizing fasciitis
multiple fasciotomies and debridement of all cases, five from others in the same battalion, and
extremities. Both trainees were assigned to the same five from other training units) and 27 isolates to the
battalion. Routine surveillance did not reveal significant Navy Health Research Center (NHRC) laboratory in
increases in the ARD rate or the Strep-ARD San Diego, California (two from the necrotizing
Surveillance Index (SASI) prior to the cases (see figure fasciitis cases, 12 from others in the same battalion,
on page 6). two with mucoid colony morphology, two from Marine
In response to the cases of necrotizing fasciitis, Corps units, and nine from other training units) for M-
General Leonard Wood Army Community Hospital typing.
(GLWACH) personnel gave BPG to all non-allergic
members of the affected battalion (“mass Methods: Confirmed cases of invasive streptococcal
prophylaxis”), initiated environmental assessments of disease were defined as those infections that were
barracks, and briefed line commanders and medical clinically consistent with GABHS and confirmed with
providers regarding the nature of the threat, the current a positive GABHS culture obtained from the site of
situation, and intervention measures. In addition, infection. Probable cases were defined as those
epidemiologic support was requested through the Great infections that were clinically consistent with GABHS
Plains Regional Medical Command (GPRMC). and lacked culture confirmation from the site of
The objectives of the epidemiologic consultation infection, but where GABHS was isolated from
(EPICON) were to characterize the nature, timing, another site (e.g., throat culture) and/or where
and distribution of severe GABHS infections among GABHS is known to be the infectious agent in the
8 MSMR January 2007
majority of cases (e.g., peritonsillar abscesses). (47.8%) from ARD cases during 2005-2006 was in
Results: At Fort Leonard Wood, there were more than October 2006 (Figure 2). During most weeks in 2006,
twice as many hospitalized invasive GABHS cases in GABHS recovery rates – but not ARD rates (data
2006 (n=38, through November) than in 2005 (n=17). not shown) –were higher than in corresponding weeks

The rate of invasive GABHS at Fort Leonard Wood in 2005 (Figure 2).
increased 2.2-fold from 2005 (0.7 cases per 1,000) to In general, the GABHS recovery rate was
2006 (1.6 cases per 1,000). A slightly higher proportion significantly higher among male than female ARD
of 2006 (71%) than 2005 (59%) cases was confirmed. cases; no other demographic factors (race, education
In both 2005 and 2006, the most frequent clinical level, home of record) were associated with GABHS
expressions of invasive GABHS were peritonsillar infection. Not surprisingly, the battalion with the most
abscess (2005: n=10, 59%; 2006: n=15, 39%) and invasive GABHS cases during the period also had the
pneumonia (2005: n=6, 35%; 2006: 12, 32%). In 2006 highest GABHS recovery rate among ARD cases
in contrast to 2005, there were also cases of (35.9 per 100 cultures). Barracks type was not
necrotizing fasciitis (n=4, 11%) and streptococcal toxic significantly associated with GABHS-positive throat
shock syndrome (n=2, 5%) (Table 1). cultures among ARD cases.
In 2005, cases of invasive GABHS per month Among the 12 GABHS isolates sent to the CDC
ranged from 0 to four, and there were no clear trends for M-typing, a single virulent strain, M5.14, was
(Figure 1). In 2006 (through November), cases per identified. Of the 27 GABHS isolates sent to the
month ranged from one to nine, and cases increased NHRC laboratory, 20 (74%) were M5.14 (M18, M77,
by 3 per month from July (n=3) through September and M101 were also identified). Most of the isolates
(n=9) (Figure 1). Routine prophylaxis with BPG was from invasive GABHS cases did not have mucoid
discontinued (due to supply shortages) in late July colony morphology.
2006. No trainees with invasive GABHS disease in In summary, the rate of invasive GABHS disease
2006 received BPG prophylaxis within 4 weeks of at FLW in 2006 was approximately 50% higher than
the onsets of their illnesses. in 2005. In addition, prevalences of GABHS infection
More than one-third (n=14, 37%) of all confirmed among ARD cases were higher in 2006 than 2005.
and probable invasive cases in 2006 (including both There were increasing numbers of invasive GABHS
necrotizing fasciitis cases) were from one battalion. cases beginning in August 2006 (following the
No other battalion-sized unit at FLW had more than 5 discontinuation of routine BPG prophylaxis in July 2006
invasive GABHS cases during the period. due to a supply shortage). A high proportion (and the
Throat cultures of trainees with ARD revealed that most severe) of the invasive cases in 2006 occurred
recovery rates were higher when BPG was not in one battalion; of note, the same battalion had the
available. The highest weekly GABHS recovery rate highest prevalence of GABHS infections among ARD
Table 1. Hospitalized cases of invasive group A beta hemolytic streptococcal
(GABHS) disease, by clinical expression, Fort Leonard Wood, MO, by year,
January 2005-November 2006
2005 2006 (through November)
Total Total
% of % of
Clinical expression Confirmed Probable Number total Confirmed Probable Number total
Necrotizing fasciitis 0 0 0 0.0 4 0 4 10.5
Streptococcal toxic shock 0 0 0 0.0 1 1 2 5.3
Peritonsillar abscess 6 4 10 58.8 9 6 15 39.5
Pneumonia 3 3 6 35.3 8 4 12 31.6
Other* 1 0 1 5.9 5 0 5 13.2
Total 10 7 17 100.0 27 11 38 100.0
*includes deep neck and parapharyngeal abscess (n=4), septic arthritis/bursitis (n=1), and sinusitis (n=1)
Vol. 13/No. 1 MSMR 9
cases during the year. Despite general increases in accessions with oral penicillin (Pen VK) twice daily
GABHS positive throat cultures in 2006, the weekly for 28 days was begun in late October. Shortly
ARD rate and the Strep-ARD Surveillance Index thereafter, additional doses of BPG were obtained from
(SASI) remained stable and relatively low through King Pharmaceuticals to extend the mass treatment
September of the year. Finally, one predominant regimen. Thus, to eradicate virulent strains of GABHS
GABHS strain (M5.14) circulated at FLW during the and prevent new infections among trainees in general,
outbreak. beginning in late October, all non-allergic trainees
received either BPG or a 28-day course of Pen VK.
Interventions: Following the identification of the
second case of necrotizing fasciitis, all non-allergic Recommendations: The consultation team
members of the most affected battalion were given recommended that routine prophylaxis of all non-
BPG from emergency stocks. Prophylaxis of all new allergic new accessions to basic combat training should
Figure 1. Hospitalized cases of invasive GABHS disease, Fort Leonard Wood, MO,
by month, Jan 2005-Nov 2006
9
8
7
s
e 6
s
a
c
d 5
e
z
ali 4
pit
s
o 3
H
2
1
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2005 2006
Figure 2. GABHS-positive throat cultures among trainees with ARD, Fort Leonard
Wood, MO, by week, 2005-2006
2005 2006
%) 60
(
e 50
at
r 40
y
r
e
v 30
o
ec 20
r

S 10
H
B
A 0
G
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Calendar week