The Cycle of Surveillance
Medical surveillance—the practice of tracking injuries, chronic conditions
and diseases —is common throughout the medical community and is an
important part of maintaining a soldier’s health and well-being.
Combining art and science to ensure a global understanding.
By Kenya McCullum
Medical surveillance—the practice of tracking injuries, chronic conditions and diseases—is common throughout the medical community and is an important part of maintaining a soldier’s health and well-being. The process begins when a patient first goes to a medical service provider to report a problem and continues after an action has been taken to resolve it.
“Anywhere that we have clinics, hospitals, public health offices, preventive medicine offices, environmental science offices and populations that are at risk then we practice surveillance,” said Colonel Kenneth Cox, director of global health surveillance in the office of the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness (FHP&RP). “Surveillance is a cyclical process that starts with the collection of relevant data, and then that data—which is raw when you get it—usually has to be taken care of and put into the right forms to be analyzed and then interpreted. It’s not something that just artificial intelligence can do at our current state of understanding, so humans are still involved in the interpretation.”
The data that begins the process is whatever medical issues patients report to be bothering them. In the case of soldiers, military epidemiologists are concerned with paying attention to any malady that keeps them from their work.
“When you’re talking about deployed soldiers, anything that takes them away from the ability to do their job is a concern. If it’s going to lay them up with a fever for a week and they’re not going to be able to carry a weapon, that’s a big deal. It may not be a severe illness, but it may be severe enough that they can’t do their job,” said Cox. “That’s really where the balance is—are these people doing what they were trained to do? If they’re not, that’s significant. That’s why injuries get so much attention because most injuries, people hypothesize, are preventable.”
After a health event is noted, epidemiologists go on to analyze the data and interpret it to determine what actions should be taken to rectify the problem. This action is the third and most important step of the process, and it involves reporting findings to the right people who can do something about what was discovered.
“That’s the critical step, otherwise there’s lots of data running around, and people can sit in little closed, dark rooms and analyze it until their heart’s content, but it’s reporting and distribution that matters,” said Cox.
The last step in this process is the review stage, where epidemiologists look at the results of the actions that were taken to determine whether the conditions they treated got better, got worse or stayed the same.
Illnesses Tracked
The illnesses tracked by military epidemiologists range from the common to the exotic. Some of the more common illnesses that are looked at with deployed soldiers—which Cox said are the same as the ones that are common in the general population—include back pain, musculoskeletal conditions, viral infections (like the common cold), head aches, sore throats and flu-like illnesses. Likewise, injuries that troops experience during training activities don’t tend to differ much from those that occur with people who participate in sports.
More unusual illnesses, like malaria, can be limited to a certain geographic location (e.g., in the case of malaria, troops are not likely to encounter it in Iraq because their location is not known for the disease). Although these kinds of diseases don’t show up very often, on the rare occasions that they do affect soldiers, military epidemiologists spring into action to assess why instances of the disease are occurring.
“We don’t see very many cases of malaria when we’re deployed because of the interventions that we make, the protective equipment we provide, the training on how to use it, and the medications people take when they are in the malarious areas. If a malaria case shows up, that triggers an investigation,” said Cox. “We’re not just looking for large outbreaks, we’re also looking for unusual diseases in small numbers because that can be a sign that our processes, our logistics and our supplies may be not what we expected.”
Another agency that looks at soldiers’ medical incidents is the DoD Global Emerging Infections Surveillance and Response System (DoD-GEIS), which conducts lab-based surveillance by receiving samples, analyzing them and reporting on the outcomes from those samples. DoD-GEIS, which has been incorporated into the recently formed Armed Forces Health Surveillance Center (Provisional), has nine primary labs around the world that track diseases of military relevance—including respiratory illnesses, parasitic illnesses and sexually-transmitted infections (with the exception of HIV).
Practical Applications
The medical events of servicemembers are recorded throughout their military careers, from the time they enter basic training. According to Colonel Robert DeFraites, director of the Armed Forces Health Surveillance Center (Provisional), looking at the recruit population is especially important because illnesses found in recruits could be indicative of problems that may erupt in other populations. Additionally, an outbreak of illnesses in this population has the potential to drastically affect military operations if they aren’t kept in check.
“Historically, that population has been very vulnerable to outbreaks of respiratory disease, including adenovirus,” said DeFraites. “This past summer there was an outbreak of adenovirus at Lackland Air Force Base in Texas, which is where Air Force has basic training. An outbreak like that can really have the potential for shutting down basic training, though it didn’t at the time. The Air Force only has one basic training post, so if they shut that down, they can’t really bring anymore airmen in, so it’s a very significant operational service that we provide.”
In addition to adenovirus, DeFraites added that recruits can also be prone to illnesses related to heat and cold, which can also mean that military operations need to be looked at in order to eliminate the problem.
“Heat stroke, or heat illness, in the general population is a problem of the elderly or the very young, but in our case, it’s in recruits that may not be in the best physical shape, so they’re more vulnerable to some of these heat injuries. We pay particular attention to that because it has some military operational significance,” he said. “The military has to operate in all environments and in all climates, so we also pay close attention to cold injuries. If we get a couple of cases of frostbite, that can be a very severe injury—like a burn—and from a preventive medicine standpoint, it’s very important to track those and notify the commander about these problems so that they can take appropriate action. Most of these actions from cold injuries are not really medical interventions, they’re more making sure that soldiers are wearing protective clothing and making sure that they’re not staying out in the cold too long and getting hypothermic.”
Another example of how medical surveillance has an effect on procedure is when the military used data compiled by epidemiologists to handle cases of Leishmaniasis, an illness carried by sand flies. During the first summer of Operation Iraqi Freedom, medical providers were documenting about 125 to 140 cases of this illness per month. After investigating those cases of Leishmaniasis, epidemiologists were able to determine that the reason there were such large numbers of this illness was because soldiers were sleeping on the ground at the time. As a result of changing their living accommodations—sleeping in cots that are off the ground, which prevents contact with the sand flies—the instances of the condition have dropped dramatically.
“If we have a health event or an exposure, we maintain those records,” said Tommy Morris, the director of deployment technologies at the Office of Deputy Assistant Secretary of Defense for Force Health Protection & Readiness Programs. “So 10 years from now, if a servicemember comes back and says ‘I was injured or exposed to something in a certain area’, we have the records to be able to verify it or disprove it.”
Tracking Software
There are several computer programs that allow military epidemiologists to perform their jobs and stay ahead of the curve technologically. “For the electronic health records systems, basically the DoD is on the cutting edge, or bleeding edge, of deploying electronic health records to an enterprise in such a short period of time, in such an austere environment,” Morris said.
Among these programs are the Theater Medical Data Store (TMDS), which allows users to see all theater patients’ records; the Defense Medical Surveillance System (DMSS), a database that stores all historical information on soldiers’ medical events—including hospitalizations, reportable diseases and ambulatory visits; and AHLTA-Theater, which gives users access to a medical library and health records. In addition, military epidemiologists use the Joint Medical Workstation (JMeWS), which gives users multiple capabilities such as medical surveillance, asset visibility (including information on blood supplies, medical supplies and beds status), and the ability to zoom in on a particular geographical area. To enhance the capabilities offered by JMeWS, the military is currently developing the next generation of the health surveillance system—the Medical Situational Awareness in Theater (MSAT)—which Morris said will allow users more advanced decision support and will be available in 2009. ♦