Sexually Transmitted Infections in the U'S' Military, 20002006

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• Sexually Transmitted Infections in the U.S.
  Military, 2000-2006
• Nikki Jordan1 Seung-eun Lee2, Steven Tobler2,
  Joel Gaydos3
• 1US Army Center for Health Promotion Preventive
  Medicine
• 2Armed Forces Health Surveillance Center
• 3DoD Global Emerging Infections System
• 2008 Institute of Federal Health Care Roundtable
• Examining Collaborative Efforts In STD Screening
  and Treatment
• Washington, DC, June 27, 2008

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Background
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STI Risk factors in the U.S. military

• Similar to U.S. general population
• Female gender
• 25 yrs of age
• Black race
• Home from southern U.S.
• gt1 sex partner
• New sex partner
• History of STIs

Data source Gaydos CA, et al. Sustained high
prevalence of chlamydia trachomatis infections
in female Army recruits. Sex Trans Dis.
200330(7)539-44.
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Characteristics of U.S. military population

• Active duty service members in 2006
• Military, 40 are in high risk age group (lt25
  years old)
• U.S., 14 are in high risk age group
• Military, 6-20 females
• U.S., 51 females
• Military, 11-22 Black
• U.S., 12 Black

Data source Defense Medical Surveillance System
(DMSS). U.S. high risk age group includes ages
15-24 for U.S. Population estimate abstracted
from U.S. Census Bureau 2000.
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Objectives

• Summarize reported rates of chlamydia, gonorrhea,
  and primary/secondary syphilis in the Army
• Describe screening variations between services

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Methods
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Data sources

• STI reports
• Armed Forces Health Surveillance Center (AFHSC)
  maintains the Defense Medical Surveillance System
  (DMSS)
• Reportable medical events (RME) are captured by
  service specific electronic reporting programs
  and then forwarded to AFHSC for integration into
  the DMSS
• RMES Army system
• AFRESS Air Force system
• NDRS Navy system
• Screening policies
• Document review
• Interviews with medical personnel at recruit
  training centers

RMES managed by AFHSC
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Study population

• All Army active duty service members, 2000-2006
• Both lab confirmed and unconfirmed cases reported
  during non-deployment
• Multiple STI events allowed (i.e., 30-day
  incident rule)
• Denominator Person-time during deployment
  excluded

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Data limitations
Chlamydia rates by service, 2000-2006

• Passive surveillance systems with considerable
  variation in reported rates across services
• Completeness of reporting RMEs across services
  unknown
• Diagnostic tests used for STI confirmation is
  unknown

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• Chlamydia

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Male Chlamydia rates by age group Army vs U.S.,
2006
Note For US general population, 17-19 age group
includes 15-16 years olds. US general population
rates extracted from the CDCs STD Surveillance
Report 2006.
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Female Chlamydia rates by age group Army vs
U.S., 2006
Note For US general population, 17-19 age group
includes 15-16 years olds. US general population
rates extracted from the CDCs STD Surveillance
Report 2006.
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Chlamydia rates by sex Army vs U.S., 2000-2006
Note For US general population, rates include
ages 15-64. US general population rates
extracted from the CDCs STD Surveillance Reports
2004 and 2006.
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• Gonorrhea

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Male Gonorrhea rates by age group Army vs U.S.,
2006
Note For US general population, 17-19 age group
includes 15-16 years olds. US general population
rates extracted from the CDCs STD Surveillance
Report 2006.
16
Female Gonorrhea rates by age group Army vs
U.S., 2006
Note For US general population, 17-19 age group
includes 15-16 years olds. US general population
rates extracted from the CDCs STD Surveillance
Report 2006.
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Gonorrhea rates by sex Army vs U.S., 2000-2006
Note For US general population, rates include
ages 15-64. US general population rates
extracted from the CDCs STD Surveillance Reports
2004 and 2006.
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• Syphilis

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• Primary/Secondary Syphilis
• 2000-2006 Army reported rates have fluctuated
  between 4 and 8 cases/100,000 p-yrs, peaking in
  2004 then steadily decreasing
• 2006 Army reported rate 6.3 cases/100,000 p-yrs
• 2000-2006 U.S. general population rates have
  steadily increased from 2 to 3.5 cases/100,000
  p-yrs
• 2006 reported national rate 3.5 cases/100,000
  p-yrs

Note US general population rates extracted from
the CDCs STD Surveillance Report 2006.
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Screening Practices
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Service specific screening policies
Data source Communication with recruit training
center medical personnel. Test used for
chlamydia screening also tests for gonorrhea.
Navy males tested with leukocyte esterase.
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Service specific screening policy updates

• Delayed recruit screening in Army may increase
  Chlamydia sequelae
• 62 higher incident rate of pelvic inflammatory
  disease (PID), Army vs Navy, 2001-2005
• New Army policy to screen female accessions
  during AIT approved in 2008
• Timeline for implementation TBD
• May still represent significant screening delay
  as compared to recommended recruit screening

Bloom, et al. Incidence Rates of Pelvic
Inflammatory Disease Diagnoses among Army and
Navy Recruits. Am J Prev Med 200834(6)471-7.
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Conclusions
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• Army age gender specific Gonorrhea and
  Chlamydia rate trends similar to national trends
• Higher crude rates of Chlamydia and Gonorrhea
  reported in the Army as compared to U.S.
  civilians
• Army has higher access to care
• Higher rates of screening in Army women (70) vs
  civilian women (42)
• Recruit screening policies vary by service
• The Defense Health Board (DHB) continues to
  recommend screening of all female recruits
• Further study to determine feasibility and
  benefit of screening male recruits is warranted
• Issues impacting completeness of reporting across
  the services need to be systematically reviewed
  and addressed

U.S. screening rates among 16-25 yr olds (Tao,
et al. Sexually Transmitted Diseases.
200734(3)180-2. Military screening rates among
Army 17-25 yr olds (Kelly, et al. Defense Health
Board Meeting. 12 Dec 2007.)
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Questions?