This survey assesses the health related behaviors and lifestyles of military personnel that have the potential to impact readiness. The survey results will be used to monitor service members’ needs, develop policies, and improve health programs and services for military members and their families.

This survey takes about 40 minutes.

The Department of Defense (DoD) asked the RAND Corporation and its data collection contractor, ICF International, to conduct an independent, objective assessment of Service members’ health status and health related behaviors.

RAND is a private, nonprofit organization that conducts research and analysis to help improve public policy and decision-making.

ICF is a leading consulting services and technology solutions firm. ICF manages the technical aspects of the web survey operations and can help you with any computer or technical problems. 

You were randomly selected from all Active Duty and Coast Guard personnel to represent your Service branch in this important research.

We obtained your name from the Defense Manpower Data Center [DMDC], which maintains DoD personnel records. Because we are doing an official, approved DoD survey, DMDC was authorized to give us military members’ names and contact information for research purposes only. We are just using your name to send you information about the survey via email and mail. Study staff will NOT link your survey responses to your name or a survey ID code. The survey is anonymous.

RAND will report survey findings in a way that does not identify individuals to the Services, DoD, or the public. The information you provide will be combined with that from other military personnel to prepare statistical reports. At no time will your individual data be reported.

This is your chance to be heard on issues that directly affect the health, well-being, and readiness of military members and their families. The survey results will help inform DoD of potential health problems in the military and help suggest ways to solve or prevent them. 

Yes

As noted earlier, this survey is anonymous. This means that RAND and ICF will not give DoD information about who participated in the study, or match your individual responses on this survey with your name, identity, military records, or a survey identification code. DoD has agreed to this condition to protect your privacy.

Yes. The Service Chief endorsement letters posted on the survey website indicate that you can use a computer at work to do the survey.

Some questions on the survey are sensitive in nature and it is possible that you may feel discomfort in answering one or more of these items. If you are having any suicidal thoughts, please seek help immediately. We encourage you to contact your unit’s chaplain or a mental health professional. Other resources can be found below:

Military OneSource is a free 24 hour service that is available 7 days a week to provide a full range of services, across the deployment cycle, to military personnel and their families, at no cost. They can be reached at: 

• Stateside: CONUS: 1-800-342-9647 
• Overseas: OCONUS Universal Free Phone: 800-3429-6477 or 703-253-7500 
• Collect from Overseas: OCONUS Collect: 703-253-7599 
• En Español llame al: 877-888-0727 / TTY/TDD: 866-607-6794

DoD Safe Helpline provides worldwide live, confidential support, 24/7. You can initiate a report and search for your nearest Sexual Assault Response Coordinator (SARC). You can find links to Service-specific reporting resources and access information about the prevention of and response to sexual assault on their website or by calling the hotline at 1-877-995-5247.

Military Crisis Line can also provide confidential support and consultation if you feel distressed. They can be reached at 1-800-273-8255 (then press 1).

The survey is entirely voluntary, though we hope you will recognize its importance and make time to complete it. If you choose to take the survey, you may stop at any time. 

Some Service members may have completed surveys like this one in the past. This survey is conducted approximately every three years to get a comprehensive update about the health behaviors of military members. Since DoD wants to understand trends in members’ experiences in the Services, it is important that you take the 2015 Survey to tell us about your current health.

For Computer, Technical or Survey Questions:

• Call the ICF Survey Helpdesk
• Toll-free Phone: 1-844-430-9640
• Send an email

For Questions about the Overall Study:

Contact RAND via email

For Questions about your rights as a participant in this study: 

Contact the RAND Human Subjects Protection Committee at 1-310-393-0411, ext. 6369 in Santa Monica, California.

You should go to the 2015 HRBS website listed in the mail or email invitation you received. If you have problems accessing the website, contact th ICF Survey Help desk listed in the FAQ titled "Who do I contact if I have questions or concerns about the survey" above.

Yes. Please try to complete the survey in one session. To protect your privacy, if you stop before you are finished with the survey, you will need to start the survey over from the beginning when you come back to the website.

Yes. When the survey results are available, an executive summary will be available.

Adenoviruses are medium-sized, nonenveloped icosohedral viruses containing double-stranded DNA. There are at least 52 immunologically distinct types that can cause human infections. Adenoviruses are unusually stable to chemical and physical agents and to adverse pH conditions, thus allowing for prolonged survival outside of the body.

Yes. In the United States, acute respiratory disease is often associated with adenovirus Types 4, 7, and 14. The epidemiology of adenoviruses vary by type; all are transmitted by direct contact, fecal-oral transmission, and occasionally waterborne transmission. Some types can establish persistent asymptomatic infections in tonsils, adenoids, and intestines of infected individuals, and viral shedding can occur for months or years.

Adenoviruses cause a wide range of illnesses, depending on the virus type. Adenovirus types 4 and 7 can cause respiratory (breathing) problems, fever, sore throat, cough, eye infections, runny nose, headache, and pneumonia. The incubation period of the disease is 4 to 5 days. These symptoms can last up to 10 days. Young infants and especially patients with compromised immune systems are more susceptible to severe complications of adenovirus infection.

Yes. Strict attention to good infection-control practices, including contact and droplet precautions is effective for stopping nosocomial outbreaks of adenovirus associated disease. Frequent handwashing is effective for preventing the spread of adenoviruses. Additionally, there is a U.S. Food and Drug Administration (FDA) approved/licensed vaccine for adenovirus types 4 and 7. Adenovirus types 4 and 7 can be prevented with a single vaccine dose administered as two live, oral enteric-coated tablets (type 4 - white tablet, type 7- light peach tablet).

Acute infectious respiratory diseases are a significant preventive medicine problem for military populations living in close quarters. Crowded conditions are often found at training centers, dormitories, tent cities, and deployment-staging areas. Other potential transmission environments include recruit training centers, classrooms, dining facilities, and areas where items, such as resuscitation mannequins and water fountains are shared.

Over the past 10 years adenoviruses have affected about 15,000 military basic trainees annually, with 3-4 days of illness per event and 1-2 deaths occurring per year due to the virus. The United States military processes thousands of recruits each year who arrive from all regions of the country as well as some foreign countries, and from a variety of different environments. The recruits are then formed into close-quartered military units. They may arrive as hosts or with mild cases of respiratory infections endemic to their own particular region of the country; they are housed in close contact with individuals from other parts of the country who may be susceptible. New recruits may also be exposed to respiratory infections that are endemic to the recruit training center. Close contact, coupled with the unique stressors of military operations, often put military recruits at a greater risk for respiratory disease than other cohorts.

To prevent spread of disease, it is important to practice good hand hygiene and infection control. Some respiratory diseases are vaccine-preventable including adenovirus types 4 and 7.

Yes. The FDA licensed the adenovirus vaccine on 16 March 2011 for types 4 and 7 for military populations, 17 to 50 years of age.

The current DoD policy requires the Services to administer adenovirus vaccine to all enlisted military recruits in accordance with the Joint Regulation on Immunizations and Chemoprophylaxis for the Prevention of Infectious Diseases (AR 40-562, BUMEDINST 6230.15B, AFI 48-110_IP, CG COMDTINST M6230.4G).

A vaccine, like any medicine, could cause a serious reaction. But the risk of a vaccine causing serious harm, or death, is extremely small. Several mild problems were reported within 2 weeks of getting the vaccine: headache, upper respiratory tract infection (about 1 person in 3), stuffy nose, sore throat, joint pain (about 1 person in 6), abdominal pain, cough, nausea (about 1 person in 7), diarrhea (about 1 person in 10), and fever (about 1 person in 100). More serious problems have been reported by about 1 person in 100, within 6 months of vaccination. These problems included: blood in the urine or stool, pneumonia, and inflammation of the stomach or intestines. It is not clear whether these common or serious adverse events were caused by the vaccine or occurred after vaccination by chance.

Large-scale studies of the new vaccine in U.S. military recruits showed high efficacy rates in preventing wild type 4 adenovirus-associated febrile acute respiratory disease and inducing neutralizing antibody to type 7 adenovirus.

The adenovirus vaccine contains viable, selected strains of human adenovirus Type 4 and human adenovirus Type 7 prepared in human-diploid fibroblast cell cultures (strain WI-38). The virus strains have not been attenuated. The cells are grown and the virus growth maintained in Dulbecco's Modified Eagle's Medium, fetal bovine serum, and sodium bicarbonate.

Adenovirus vaccine types 4 and 7 are tablets and are given orally. Each tablet must be swallowed whole and cannot be chewed or crushed. Postpone administration to individuals with vomiting and/or diarrhea and those with moderate to severe acute illness.

A single dose is needed, which consists of two live, oral enteric-coated tablets (type 4 - white tablet, type 7- light peach tablet). Adenovirus vaccine types 4 and 7 is administered only once and no booster dose is required.

Adenoviruses vaccine types 4 and 7 can be administered simultaneously or at any interval before or after other vaccines, including live vaccines.

The vaccine must be refrigerated between 2° and 8°C (35° and 46° F) and never frozen. All bottles must be protected from moisture and remain tightly closed. The desiccant canister should not be removed from the bottle.

The duration of immunity and persistence of circulating antibody following immunization has not yet been determined. The vaccine is very effective in reducing disease.

Individuals with known severe allergic reactions to any components of the vaccine; females considering pregnancy within 6 weeks of receiving the vaccine; individuals incapable of swallowing an entire tablet, whole, without chewing should not receive the vaccine.

Yes. Vaccinees should use precaution when around children 7 years of age and younger, immunocomprised individuals and pregnant women during the 28 days following vaccination. Because the vaccine contains live adenovirus that is shed in the stool for up to 28 days following vaccination, strict hand washing and personal hygiene is required to minimize risk of transmitting or infecting others with the virus.

Yes. The adenovirus vaccine should not be administered to pregnant females or nursing mothers.

Pregnancy testing is part of a routine serology panel for newly enlisted female recruits upon accession because pregnancy is a disqualifying condition for basic training. Do not delay vaccination pending routine recruit pregnancy testing unless pregnancy is suspected. If a female recruit has a positive HCG do not administer live vaccines including adenovirus vaccine and refer the female for follow-up per Service policy. Verbal screening for pregnancy in non-recruit populations is standard practice before administering of live vaccines.

No. However, the safety and effectiveness of the Adenovirus Types 4 and 7 Vaccine, Live, Oral in immunocompromised individuals has not been evaluated. A documented negative HIV test is not required before administering live vaccines when the vaccinee is screened for immunocompromising conditions. Verbally screen individuals for HIV/AIDS, medical conditions, and/or medications that may affect the immune system before administering the adenovirus vaccine.

The AFMES performs medical-legal examinations on service members and American citizens who die in a combat zone and certain individuals who are killed or die within the United States or abroad. The AFMES positively identifies decedents and issues death certificates that state the cause and manner of death.

The Armed Forces Medical Examiner, under federal law, has the authority to perform a medical-legal examination when a death occurs under federal jurisdiction. Cases typically involve a violent or unnatural death and/or may be suspicious in nature or possibly involve a threat to the health of the military community.

The examination helps determine the cause and manner of death as well as confirm the identity of your loved one by scientific means. These investigations can assist in identifying potential public health issues. Please be assured that this examination will be carried out with the utmost dignity and respect.

The AFMES legal authority comes from Title 10 United States Code, Section 1471 (Forensic Pathology Investigations).

A medical-legal examination entails reviewing the circumstances of the death, scientifically identifying the decedent, performing an autopsy and writing a report. The circumstances of the death are provided to the AFMES by the local commanders or investigative agencies such as the U.S. Army Criminal Investigation Command, U.S. Naval Criminal Investigative Service, U.S. Air Force Office of Special Investigations, and the Federal Bureau of Investigation. Scientific identification is made by performing fingerprint, dental and/or DNA analyses. During the autopsy, photographs of the decedent are taken, physical characteristics are noted and any natural disease or trauma is documented. Selected fluids and small sections of organs are retained for microscopic, toxicological and/or DNA analyses. These body fluids and tissue samples are similar to those taken at a hospital laboratory for evaluation and are treated in the same manner. In rare instances, it is necessary to retain selected whole organs, such as the heart and/or brain, for expert consultation. If this is required, the person authorized to determine disposition (PADD) or next-of-kin (depending on the circumstance) is notified that these organs are being retained by the AFMES and disposition instructions are obtained.

Your casualty assistance officer (CAO), or casualty assistance calls officer (CACO), will obtain the date and location of the medical-legal examination and provide you this information.

All medical examiners working for the Office of the Armed Forces Medical Examiner are physicians who are either board-certified in the field of forensic pathology by the American Board of Pathology or work directly under the supervision of a board-certified forensic pathologist.

For cases arriving from overseas, the medical-legal examination usually takes 24 hours from the time the remains arrive at Dover AFB, DE. For cases within the United States, the medical examiner team usually deploys within 24 hours of notification and the examination is usually complete within 24 hours of the arrival of the team at the local facility. If identification is in question, it may take up to five days to complete DNA analysis, assuming a suitable reference is available.

The AFMES will retain custody of the decedent until they are positively identified and all required paperwork has been received from the PADD or next-of-kin. Once the AFMES has released the decedent, mortuary services are initiated by the Dover AFB Port Mortuary, the respective casualty/mortuary offices, or contract funeral home, depending on the situation.

In most cases a final report will be issued in approximately 6 to 8 weeks. A copy of the final report is available upon request.

The photographs taken at the time of the autopsy are not normally included with the report. These photographs will be provided with the report if specifically requested.

All information generated by the Armed Forces Medical Examiner in connection with the medical-legal examination is available upon request, unless release of said information would compromise a continuing legal investigation into the fatal incident. The autopsy report summarizes all pertinent findings and answers most questions. Additional documents such as toxicology and DNA reports are summarized in the final autopsy report. If you would like copies of these additional documents they will be provided, but we ask for the opportunity to review them with you, either in person or over the telephone.

Submit an Autopsy Request Form to the AFMES via Email, fax it to (302) 346-8767, or mail it to:

Armed Forces Medical Examiner System
Attn: Office of the Armed Forces Medical Examiner
115 Purple Heart Drive
Dover AFB DE 19902

We value the privacy of you and your loved ones, so we ask that your request for the report be in writing and accompanied by a copy of a government-issued photo ID (e.g.,driver’s license, family member identification card) so that we may comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

The staff of the Armed Forces Medical Examiner System is available to discuss its findings with you. If you would like to speak with a medical examiner, we may be reached at (302) 346-8648. You may be asked for some personal information so that we may verify your identity, and that of your loved one, in order to protect your privacy and comply with HIPAA regulations.

DMSS is a longitudinal, relational database of medical events (hospitalizations, outpatient visits, reportable medical events, immunizations and deaths), personal characteristics (rank, military occupation, demographic factors), and military deployments of all Army, Navy, Air Force, Marine and Coast Guard service members over their entire military careers. These data are captured for active components, and for reserve and guard members when utilizing the Military Health System (MHS)—or civilian health care if purchased through the MHS. DMSS also captures care provided to dependent and military retirees when utilizing the MHS or civilian healthcare if purchased through the MHS. >>Learn More about DMSS

DMED is a subset of DMSS and provides authorized users with queryable access to de-identified data limited to the active component of the U.S. Armed Forces. DMED can be accessed online or by downloading the DMED application. Most users will prefer to access DMED online. >>Learn More about DMED

DMED is available only for authorized users such as U.S. military medical providers, epidemiologists, medical researchers, safety officers and medical operations/clinical support staff responsible for surveying health conditions in the U.S. military. Civilian collaborators in military medical research and operations may also access DMED with documentation supporting their arrangements.

Demographic data (gender, age, race, grade and marital status) are provided by the Defense Manpower Data Center (DMDC), which receives updated data on a monthly basis from each service. The center also provides unit zip codes and Department of Defense (DoD) primary occupation codes, which allows for provision of data at the installation level and by occupational groupings.

Inpatient hospitalization data are provided by the Executive Information and Decision Support (EIDS) Program Office and are a subset of information from the Standard Inpatient Data Record, which receives inpatient treatment data. Standard Inpatient Data Record data are collected by the Composite Health Care System at each DoD medical treatment facility (MTF) and the outsourced (non-DoD hospital) inpatient health care provided to active duty service members. At the time of discharge, for each hospitalization of an active duty service member in a U.S. military hospital, up to eight diagnoses are recorded using standard diagnostic codes from the International Classification of Diseases, 9th Revision (ICD-9). The first diagnosis is generally indicative of the primary reason for admission and is the diagnosis code that is reflected in DMED.

Ambulatory data are provided by the EIDS Program Office. These data are a subset of the Standard Ambulatory Data Record, which records patient-level outpatient treatment data generated by the MTFs and the outsourced (non-DoD clinic) outpatient healthcare provided to active duty service members. Up to four diagnoses are recorded using standard ICD-9 diagnostic codes.

Reportable events data contains information on 70 reportable medical events. These data are reported to DMSS by the Medical Surveillance Centers run by the military services. Army reportable event data are available for calendar years 1995 to present. Navy and Air Force data are available from calendar years 2000 to 16 July 2012.

Please refer to the DMED Users Guide.

Yes, other data resources include theater evacuations (TRANSCOM Regulating and Command and Control Evacuation System [TRAC²ES]).

Primarily operational health surveillance.

Basic Requirements and Restrictions:

• Anyone who requests data, analysis, or serum must be a military service member or government civilian employee working for a U.S. military organization.
• The study/analysis must address a militarily relevant topic.
• Unless an operational requirement is specified, the requester should be from the same organization or service as the population about whom the information is requested. Data summaries regarding members of the other services may be released only with the consent of the other services' public health leadership.
• When operational requests involve information from a single authoritative data source and/or lack a health surveillance function, clients will be referred to the primary source of data archived in DMSS.
• Physicians and other medical personnel involved in patient care may make specific individual requests using an Individual Clinical Data Request Form that can be obtained by calling the Epidemiology and Analysis division at (301) 319-3240.
• Individuals with command authority over an outbreak investigation may make a request by using a tasking letter or memorandum with their signature and a clear description of the requested data and analysis plan.

• The AFHSB does not release personal identifying information or protected health information except in the following circumstances:
  • An Institutional Review Board/Human Use Committee–approved protocol (e.g., for chart reviews, patient interviews). In such cases, informed consent of each study subject is required.
  • Requests made by command authorities involved in conducting outbreak investigations, audits, or other operational investigations.
• Operational health surveillance studies can be supported if all data and serum are irreversibly de-identified.

Minimum Information You Need to Provide Includes the Following:

• Operational
  • Underlying question
  • Title/subject
  • Potential public health intervention
  • Date needed
  • Requestor name, organization, and authority
  • Population of interest (Army, Navy, Air Force, Marines, Coast Guard, All Department of Defense personnel and family members)
  • Component (Active, Guard or Reserves)
  • Population restrictions (deployed, trainee, etc.)
  • Time period (start and end)
  • Outcome of interest (counts and/or rates)
  • Case definition
  • ICD-9/CPT codes of interest (if applicable), diagnostic position (dx1, dx1-4, dx1-8, cpt1, cpt1-4, other)
  • Data fields of interest
  • Inclusion/exclusion criteria
• Other studies
  • The study protocol must be submitted to AFHSB before submission to the military Institutional Review Board/Human Use Committee.
  • Protocols must contain a version number and date, which must be updated with each protocol change.
  • Identify the study population of interest.
  • Define the specific inclusion and exclusion criteria for case and/or control selection (if applicable).
  • Define the matching criteria for cases and controls (if applicable).
  • Specify the requirements for serum sample selection (if applicable).
  • Provide sufficient details on all required DMSS variables, their categorization, and handling of time-varying covariates.
• Serum requests
  • Specific objectives pertaining to the use of the specimens
  • Serologic assays to be performed
  • Volume of serum required per assay to be performed
  • Specific requirements of the Department of Defense Serum Repository (DoDSR) (e.g., number, volume and delivery of aliquots)

• Operational requests for data are submitted via the requester's service liaison, the director of the Epidemiology and Analysis division or the assistant director.
• All surveillance, public health practice, and other study protocol efforts will undergo formal review to determine if the activities are necessary and scientifically sound, and whether they constitute research involving human subjects or human anatomical substances.
• Results of requests are usually sent via e-mail (preferably from ".mil" or ".gov," with encryption where appropriate) in the form of read-only spreadsheets or PDF documents. Identifiable, sensitive, or voluminous data may be sent via the U.S. Army Aviation and Missile Research Development and Engineering Center (AMRDEC) Web Application.
• Any abstract, manuscript, or presentation resulting from the use of the DMSS data and/or DoDSR specimens shall be sent to AFHSB prior to publication for review of methodological accuracy. Non-compliance with this requirement may result in rejection of future requests.
• Please refer to the following Internal Policy Memorandum for further information
• Contact your service liaison for further assistance at (301) 319-3240.

For data, a study identifier is generated in place of the Social Security number (SSN) and the date of birth is replaced with year of birth only; all dates are replaced with the number of days from a pre-defined reference date or as year and quarter; zip codes are provided only to the three-digit level; and locations are provided only at the region level.

For serum, a randomly generated serum identification number (10 characters beginning with "S" and followed by nine digits) is assigned. Temporary files that link original specimen numbers to serum IDs are used for this purpose. Serum IDs are printed on labels that are affixed to aliquot tubes.

To reach a service liaison, please call (301) 319-3240.

The current ABA reimbursement rates were established more than eight years ago when no analytical data was available to determine such rates.  Today, there is data available through Medicaid and commercial insurance rates to equably determine fair and balanced reimbursement rates for the multiple levels of ABA providers, services, evaluations, and supervision that are consistent with the procedures used by TRICARE to determine the CHAMPUS Maximum Allowable Charge for other medical treatments and procedures. These new rates were announced December 1, 2015 and will go into effect in March or April 2016 to coincide with annual CMAC rate changes.

The implementation and evaluation of the Autism Care Demonstration is very important to TRICARE with a priority on providing the highest quality, effective treatment for TRICARE beneficiaries.  Over the past year, we have conducted four Roundtable discussions chaired by the Assistant Undersecretary of Defense for Personnel and Readiness that were widely attended by ABA providers, military pediatric physicians, ABA certification organizations, DHA personnel, and autism advocacy groups.  Together we gained a greater understanding of the field of ABA services. We then commissioned two independent research groups to thoroughly evaluate amounts paid by commercial and government payers for ABA services.  They delivered reports based on both Medicaid and commercial insurers’ ABA reimbursement rates.  TRICARE rates are primarily based on Medicare reimbursement rates.  Since Medicare does not cover ABA services, a further analysis was conducted to determine the average difference between Medicaid and Medicare reimbursements for a number of high-volume TRICARE mental health service codes.  The Medicaid rates were then adjusted so that the resulting rates approximate what Medicare would have paid for ABA services.  TRICARE leadership is confident that our careful analysis of rates resulted in fair and equitable reimbursement rates that remain among the highest across the industry.

We have established a national rate for all categories of ABA care which is consistent with every other medical need TRICARE covers.  In addition, TRICARE implements a universally established procedure to adjusting the national rate to reflect the capacity of the provider network and the cost of living in 88 localities across the country using the Medicare Geographic Practice Cost Index (GPCI).  The reimbursement rates of virtually all TRICARE covered benefits apply this method.  Having the GPCI applied to ABA is a step towards transitioning ABA from an educational resource to a medical service which is stated as an objective of this demonstration project.  Locality rates have also now been calculated and released on December 1, 2015.

This process ensures the ABA rates will be adjusted annually based on the established or newly created statewide Medicaid rates and published at the same time as the CHAMPUS Maximum Allowable Charge rates, which is normally in March or April of each year.

The establishment of a national rate based on the CHAMPUS Maximum Allowable Charge and locality rates through Medicare Geographic Practice Cost Index is standard procedure for the administration of medical benefits under the TRICARE Basic Program. There are 88 local geographic areas under TRICARE.  Each area is evaluated for both cost of living, and network capacity to provide services.  This approach is consistent with our goal to develop efficient and appropriate means for delivering ABA services, create a viable economic model, and maintain administrative simplicity while ensuring access to the best possible care. Access to appropriate and effective health care is our first priority.  Integrating ABA services under the standard administration of medical benefits is a necessary step in the evolution of ABA services from an educational discipline to a medical discipline.  Our rates continue to be very competitive and well above Medicare and most commercial rates.

Recent changes to the ACD now align cost shares and catastrophic cap protections with each beneficiary’s TRICARE option (Prime or Standard), reducing the cost share burden for many of the families.  Further, for those beneficiaries who pay a percentage cost-share whose providers are reimbursed at a lower rate than the legacy rate, the beneficiaries’ cost-share will also decrease.  This combination of changes will reduce the “out-of-pocket” cost for many beneficiaries and their families.

The rates will be released and effective the same date as the CMAC annual rate adjustment for all medical care, typically in the spring of each year. We expect the 2016 CMAC to be released in March or April 2016.

Chikungunya (pronounced chik-en-gun-ye) is an illness caused by chikungunya virus. Its spread primarily through the bite of an infected mosquito. These are the same mosquitoes that spread other viruses like dengue and zika.

Chikungunya virus is transmitted to people through mosquito bites. Mosquitoes become infected when they feed on a person already infected with the virus. Infected mosquitoes can then spread the virus to other people through bites.

Chikungunya virus is most often spread to people by Aedes aegypti and Aedes albopictus mosquitoes. These are the same mosquitoes that transmit dengue virus. They bite mostly during the daytime.

• The most common symptoms are fever and joint pain. 
• Other symptoms may include headache, muscle pain, joint swelling or rash. 
• Symptoms usually begin 3-7 days after being bitten by an infected mosquito. 
• Chikungunya disease does not often result in death, but the symptoms can be severe and disabling.

Chikungunya has been identified in 45 countries or territories throughout the Americas with more than 1.7 million suspected cases reported to the Pan American Health Organization. Currently, chikungunya is monitored by the Armed Forces Health Surveillance Branch.

Anyone who is living in or traveling to an area where the virus is found is at risk for infection.

There is no vaccine to prevent or medicine to treat chikungunya. If infected, you can treat the symptoms:

• Get plenty of rest
• Drink fluids
• Take over-the-counter drugs to reduce fever and pain
• Don’t take aspirin or other non-steroidal anti-inflammatory drugs (NSAIDS)

• No vaccine exists to prevent chikungunya virus infection or disease.
• You can prevent chikungunya virus infection by avoiding mosquito bites.
• The mosquitoes that spread the chikungunya virus bite mostly during the daytime.

Beginning in 2014, chikungunya virus disease cases were reported among U.S. travelers returning from affected areas in the Americas and local transmission was identified in Florida, Puerto Rico, and the U.S. Virgin Islands.

The U.S. mainland does have Aedes species mosquitoes that can become infected with and spread chikungunya virus. U.S. travelers who visit a country where chikungunya is found could become infected if bitten by a mosquito.

On April 14th, 2010, the Assistant Secretary of Defense (Health Affairs) directed the implementation of a broad based DoD pilot program intended to conform to the proceedings, and resulting guidance document, of the Consensus Conference on Cognitive Rehabilitation for Mild Traumatic Brain Injury held in April 2009. This guidance document outlined a standardized and measureable process for the provision of CRT services. This policy mandated the implementation of the guidance at 13 military treatment facilities (MTF’s).

In 2010, DoD provided over 45,000 hours of care involving CRT to service members and over 32,000 hours to family members of active duty members and retirees. These treatments were delivered by a wide array of health professionals, including psychologists; occupational, speech and physical therapists; and physicians.

Patients who have experienced moderate to severe TBI and who suffer from recurring symptoms such as attention and memory deficits, problems with executive functioning and social pragmatics deficits are most likely to benefit from CRT. In cases of mild TBI, nearly 90 percent recover with no residual problems and only those with persistent symptoms need to be evaluated and treated.

Cognitive behavioral therapy is a common type of mental health counseling consisting of a range of therapies designed to treat conditions like anxiety or depression. CBT is meant to help patients become aware of inaccurate or negative thinking and to view challenging situations more clearly and respond to them in a more effective way. CBT can be an effective tool to help anyone learn how to better manage stressful situation.

For more information about CBT visit Brainline.org.

Cognitive Rehabilitation Therapy is a collection of treatment strategies designed to address problems with memory, attention, perception, learning, planning and judgment brought about by brain injury, neurological disorders and other illnesses, Cognitive Behavioral Therapy is a common type of mental health counseling to help a patient become aware of inaccurate or negative thinking.

Limited data on the effectiveness of cognitive rehabilitation programs are available, and this is in part due to the heterogeneity of the subjects, interventions and outcomes studied. Lack of rigorous methodology (ie randomized controlled trials) in efficacy studies has also contributed to the disparity in opinion on the effectiveness of CRT.

The benefit of CRT is not limited to patients with head injuries. Patients with psychological disorders that have impairments in attention, memory, socialization, and reasoning and processing skills can also benefit from CRT.

Neuropsychologists specialize in neuropsychological cognitive testing that is used to determine if a patient will benefit from cognitive rehabilitation. They are also the primary providers who develop the individualized cognitive rehabilitation plan for patients. However, cognitive rehabilitation may be performed by an occupational therapist, physical therapist, speech/language pathologist, neuropsychologist, or a physician.

TRICARE now screens all ingredients in compound drugs to ensure they are safe, effective and medically necessary. TRICARE has always screened drugs for these standards, but now we will be able to screen the specific ingredients in compounds. TRICARE has established prior authorization review for compounds that don’t meet the initial screening criteria.

Beneficiaries can contact Express Scripts at 1-877-363-1303 to see if they are taking a compound prescription. Express Scripts may be able to review your previous claims for compound drugs to see if it meets the criteria will pass the screen.

All ingredients in you compound must be lawfully marketed in the United States, widely recognized as safe and effective, and you must demonstrate that the compound is medically necessary.

Your doctor can request prior authorization from Express Scripts. Requesting prior authorization allows Express Scripts and TRICARE to review each prescription on an individual basis, based on the criteria established by TRICARE. Your doctor must submit to Express Scripts:

• The diagnosis or condition that will be treated by the compound
• List of commercially available products tried in the past
• State if there is a national drug shortage for the commercially available product
• The estimated length of time you will need the compounded medication

Once Express Scripts receives the documentation, the request will be screened on these criteria:

• Has any ingredient been withdrawn from the market by the FDA for safety reasons?
• Are all ingredients lawfully marketed within the United States?
• Is there widely recognized evidence in the U.S. supporting that ingredient being safe and effective?
• Are the commercially available, FDA products inappropriate (e.g., inability to take a solid dosage form, dose based on age or weight) and/or a FDA-approved product cannot be taken due to allergies or contraindication.

In accordance with Sec. 704 of the FY 2015 National Defense Authorization Act, TRICARE will consider as evidence that a compound ingredient is safe and effective:

• Clinical trial published in refereed medical literature
• Formal technology assessments
• The positions of national medical policy organizations, national professional organizations or national expert opinion organizations
• Other validated evidence as the Secretary of Defense considers appropriate

TRICARE has a responsibility to ensure that all drugs we cover are safe, effective and medically necessary. Previously, TRICARE was not able to screen compound claims for specific ingredients to determine if they are safe and effective. The new policy also allows TRICARE to apply similar payment policies to compound drugs as to other prescription drugs. TRICARE has a responsibility to be good stewards of the taxpayer dollars entrusted to us.

TRICARE screens all prescriptions drugs to ensure they are covered. The new process applies this review to the ingredients in compound drugs. Most compound claims should meet the coverage criteria and be approved with no delay to beneficiaries.

TRICARE regulations specify the evidence that can be used and includes published clinical trials in refereed medical literature, formal technology assessments, the positions of national medical policy organizations, national professional associations, or national expert opinion organizations.

Approximately 40,000 line items in a prescription will trigger a prior authorization review. This includes multiple line items for individual ingredients, such as more different dosage levels.

The most common type of compound drugs that require prior authorization are topical pair or scar creams. 

In general, TRICARE’s new compound coverage is still more generous than most government and commercial health plans. The VA only covers very select compounds, but only through VA pharmacies or mail order. Medicare does not cover compound drugs containing non-FDA approved ingredients.

The FDA released recommendations in July 2014 regarding non-sterile compounds and those recommendations have been incorporated into DHA’s compound policy. As additional recommendations or final determinations are released by the FDA, DHA will incorporate them into our policy.

The normal TRICARE rules for non-network pharmacies will apply for compound drugs as for other drugs. Beneficiaries must pay up front and submit a claim to ESI for reimbursement. The claim will be subject to the same screening requirements as claims at a network pharmacy. Reimbursements are subject to deductibles or out-of-network cost shares, and copayments, which vary based on plan type and the sponsor’s status. >>Learn More

The screen will apply to all claims for compound drugs, including pediatric compounds, to ensure they are safe, effective and medically necessary. Most traditional pediatric compounds contain ingredients known to be safe and effective, so they will pass the electronic screen with no delay to the beneficiary.                                

If a prescription does not pass the initial screen, the pharmacist can contact the prescribing provider to discuss substituting an approved ingredient, getting a different prescription, or submitting a prior authorization request.

Prior to May 1, 2015, Express Scripts screened all prescription claims, including compound drugs, for safety, efficacy and to the drug is covered by TRICARE. Compound drug claims were screened on the basis of their “primary ingredient”, which is identified by the pharmacist submitting the claim. Our process now screens all ingredients in a compound claim using the same criteria.

The DHA is actively investigating all cases of suspected fraud against the DoD related to compound drugs. We are collaborating with the appropriate federal and state law enforcement and licensing boards to pursue corrective action. DHA also initiated an audit of all compounding claims in the last 12 months to determine if recoupment is justified in cases where possible violations of state or federal law resulted in inappropriate reimbursement. 

We have received a many reports from TRICARE beneficiaries regarding unsolicited attempts to obtain their personal identifying information and health information by offering them topical compound medications. The DHA, TRICARE and its contractors will never call and ask for personal identifying information or health information.

If beneficiaries are contacted in this fashion, the DHA strongly advises them to share NO information, and please immediately submit a Fraud-Line report to our Pharmacy Benefits contractor, Express Scripts.  You can report the issue to Express Scripts (1-866-759-6139 or via email). Express Scripts can also flag your profile and reject attempts to bill for these medications. If you do receive unsolicited medication in the mail, you can refuse delivery. 

Information Collections are written verbal reports, applications (forms), schedules, surveys (focus groups), questionnaires, reporting or recordkeeping requirements in any format and collected through any media. They may be internal to DoD, External (from members of the public), or Interagency (between Federal Agencies). For examples of licensed information collections, view the DoD Directive 8910.1.

You must license the information collection to comply with the requirements outlined in the following:

• Paperwork Reduction Act (PRA) of 1980
• DoD Instruction 1100.13: Surveys of DoD Beneficiaries
• DoD Instruction 8910.1-M: Procedures for Management of Information Requirements
• DoD Instruction 7750.7 DoD Forms Management Program

Standard Processes:

• OMB Clearance – 120 Days
• DMDC Review – 30 Days
• RCS – 30 Days
• Privacy Statement Review – 7 Days
• HA/TMA IRB Review and Approval - 1-2 weeks
• Forms Review & Development – 2-3 weeks

If you think you have an information collection that may need to be licensed, the first thing you must do is contact the Information Control Officer (IMCO). He/she will assist you in making the determination and identifying the correct processes and procedures. The IMCO will assist you throughout the process.

Officials from the Defense Health Agency (DHA), Washington Headquarters Services (WHS), Defense Manpower Data Center (DMDC), OMB and or the General Services Administration (GSA).

Depending on the licensing authority, your information collection can be terminated. Also, the sponsoring activity can be reported through DoD to OMB for failure to comply with the PRA.

Vendor Day is an opportunity for vendors to showcase their products to the Defense Health Agency (DHA) and six medical materiel agencies under the Department of Defense (DoD), including:

• Defense Health Agency Medical Logistics (DHA MEDLOG)
• US Army Medical Materiel Agency (USAMMA)
• US Army Medical Research and Materiel Command (USAMRMC)
• Naval Medical Logistics Command (NMLC)
• Air Force Medical Logistics Office (AFMLO)
• US Marine Corps System Command (MARCORSYSCOM)

The focus of these events is to assist the services’ medical logistics agencies with strategic market analysis of products and technologies that may be applicable to our austere medical environment. Vendors are required to complete the online registration form for the day they would like to attend. Vendors must identify, at the time of registration, what products they wish to show. Vendors will be limited to a specific area for showcasing their products and will not bring extra shelters to accommodate additional items. Vendors are required to be present at Fort Detrick for the entire event. There will be no formal demonstration times set aside. Interested participants will view products at their leisure within the time allotted for each day, much like at an exhibit hall.

There is NO REGISTRATION FEE for MHS's Vendor Day event.

MHS's Vendor Day event is scheduled for 8 times each year, beginning in March and ending in November.

Military medical logisticians and subject matter experts from the medical materiel agencies attend Vendor Day.

You may arrive as early as 7:00 a.m. to set up for the day’s event.

Due to hightened security, the procedures to get on Ft. Detrick have been modified. >>Get Directions and Access Information

If you are a foreign national, you are required to identify yourself ahead of time as, due to security requirements, you will need an escort to gain entry onto Fort Detrick. Once you receive your confirmation to attend and your Vendor Day Welcome Packet, please send an email message to the MHS Vendor Day mailbox identifying the foreign national(s), if any, who will be attending Vendor Day. Additional instructions will be provided at that time.

Tables and chairs will be provided by the Government in the Vendor Day area.

There are multiple electrical outlets available for use in the walls and in the floor, but caution needs to be used to not overload the circuits. Extension cords will not be available. No "backdrop" signs will be allowed due to space restrictions. Only tabletop signs with the vendor company name will be allowed. Products cannot be mailed to the site. If something needs to be mailed, it will need to be sent to your hotel. During the registration process, you will be asked to identify the products you will be displaying, and we ask that you only bring those products.

In addition, any items that are restricted by Maryland Law or DoD, thay may disallow access to facilities, are forbidden, such as firearms, explosives, knives, etc. Visitors entering Ft. Detrick will have their vehicle searched by law enforcement officials and possession of any of these materials may result in arrest.

Your registration will be reviewed and vetted by the MHS Vendor Day Review Committee. The vetting process will include considerations such as whether your company's identified product(s) are relevant to the agencies' missions, whether your company has already participated in a Vendor Day event in the preceding 12 months, and whether your company was scheduled to participate in a Vendor Day event in the preceding 12 months but was a "no-show" or did not cancel at least one week prior to the scheduled event. Once the review and vetting process is complete, you will be notified via email, if your registration included an email address. Otherwise, notification will be sent through the US Postal Service. For those who have registered in advance, the review, vetting, and notification will be completed approximately 30 days prior to the scheduled MHS Vendor Day event. For any registrations after that date, notifications will be sent as soon as possible.

No. The Eventbrite registration is for the company. If you plan to have two company representatives attend, you only need to register once (one ticket). Keep in mind that companies approved for participation will still be allotted only one display table, regardless of whether there are multiple company representatives who will be attending.

Generally speaking, vendors may display at Vendor Day once per year. However, if you have new products or significant updates, you may request to display a second time per year, subject to the Government’s approval and subject to available space.

Generally speaking, items that are appropriate for presentation at Vendor Day include medical materiel and equipment for use in an austere environment.

On the morning of a scheduled Vendor Day, if you are concerned about adverse weather and possible delays or closures you may call the Fort Detrick Weather Alert Line at 301-619-7611 or 800-256-7621 for information about whether the Post is open on-time, on a two-hour delay, or is closed for the day. If the recording indicates that the Post is on a two-hour delay, then the Vendor Day set-up will begin at 9:00 a.m. and the event will still end at noon. If, however, the recording indicates that the Post is closed, the scheduled Vendor Day event will be cancelled.

Any additional questions you may have may be sent via e-mail to MHS Vendor Day mailbox, and will be answered as quickly as possible.

Vendors who need to cancel must do so at least one week prior to the scheduled event so that we may contact alternates and fill the slot. As the demand for Vendor Day slots is high, vendors who are “no-shows” or who cancel less than one week prior to the scheduled event will not be permitted to register and attend another Vendor Day event for one year.

DMRTI (Defense Medical Readiness Training Institute) is a Tri-Service military command tasked with conducting and coordinating training in areas that enable military medical department personnel, both active duty and reserve, to better perform the wide variety of challenging medical and health service support missions they are faced with around the world.

DMRTI courses are in high demand, and seats are limited. Each course, depending on the how it is funded, takes student applications a little differently. Please review the course descriptions, decide which courses you are interested in, and email the Course Contacts for more information.

If you are interested in ABLS or one of our exportable courses that are not part of the C4 training program, email the Course Contacts with specific questions.

We appreciate your interest in becoming an adjunct faculty member. Please call or email the course contacts and request further information.

DMRTI courses offer various continuing education credits. For more information, please contact the DMRTI Academic Support Branch.

Dengue (pronounced den' gee) is a disease caused by any one of four closely related dengue viruses (DENV 1, DENV 2, DENV 3, or DENV 4). 

The dengue viruses are transmitted to humans by the bite of an infected mosquito. In the Western Hemisphere, the Aedes aegypti mosquito is the most important transmitter of dengue viruses, although a 2001 outbreak in Hawaii was transmitted by Aedes albopictus. 

The principal symptoms of dengue are a high fever that lasts 2-7 days and at least two of the following:

• Severe headache
• Severe eye pain (behind eyes)
• Joint pain
• Muscle and/or bone pain
• Rash
• Mild bleeding manifestation (e.g., nose or gum bleed, petechiae, or easy bruising)
• Low white cell count

Go IMMEDIATELY to an emergency room or the closest health care provider if any of the following warning signs appear:

• Severe abdominal pain or persistent vomiting
• Red spots or patches on the skin
• Bleeding from nose or gums
• Vomiting blood
• Black, tarry stools (feces, excrement)
• Drowsiness or irritability
• Pale, cold, or clammy skin
• Difficulty breathing

Outbreaks of dengue occur primarily in areas where Aedes aegypti (sometimes also Aedes albopictus) mosquitoes live. This includes most tropical urban areas of the world. Dengue viruses may be introduced into areas by travelers who become infected while visiting other areas of the tropics where dengue commonly exists.

Anyone who is living in or traveling to an area where the virus is found is at risk for infection.

There is no specific medication for treatment of a dengue infection. Persons who think they have dengue should use analgesics (pain relievers) with acetaminophen and avoid those containing aspirin. They should also rest, drink plenty of fluids, and consult a physician. If they feel worse (e.g., develop vomiting and severe abdominal pain) in the first 24 hours after the fever declines, they should go immediately to the hospital for evaluation.

As with dengue fever, there is no specific medication for DHF. It can however be effectively treated by fluid replacement therapy if an early clinical diagnosis is made. DHF management frequently requires hospitalization. 

There is no vaccine available against dengue, and there are no specific medications to treat a dengue infection. This makes prevention the most important step, and prevention means avoiding mosquito bites if you live in or travel to an endemic area. 

Dengue rarely occurs in the continental United States, but it is endemic in Puerto Rico and in many popular tourist destinations in Latin America, Southeast Asia and the Pacific islands.

Depleted uranium is what is left over when most of the highly radioactive types (isotopes) of uranium are removed for use as nuclear fuel or nuclear weapons. The depleted uranium used in armor-piercing munitions and in enhanced armor protection for some Abrams tanks is also used in civilian industry, primarily for radiation shielding and aircraft balance control.

Depleted uranium (DU) is a heavy metal that is also slightly radioactive. Heavy metals (uranium, lead, tungsten, etc.) have chemical toxicity properties that, in high doses, can cause adverse health effects. DU that remains outside the body can not harm you.

A common misconception is that radiation is DU's primary hazard. This is not the case under most battlefield exposure scenarios. DU is approximately 40% less radioactive than natural uranium. DU emits alpha and beta particles, and gamma rays. Alpha particles, the primary radiation type produced by DU, are blocked by skin, while beta particles are blocked by the boots and battle dress utility uniform (BDUs) typically worn by Service members. While gamma rays are a form of highly-penetrating energy , the amount of gamma radiation emitted by DU is very low. Thus, DU does not significantly add to the background radiation that we encounter every day. 

When fired, or after "cooking off" in fires or explosions, the exposed DU rod poses an extremely low radiological threat as long as it remains outside the body. Taken into the body via metal fragments or dust-like particles, DU may pose a long-term health hazard to personnel if the amount is large. However, the amount which remains in the body depends on a number of factors, including the amount inhaled or ingested, the particle size and the ability of the particles to dissolve in body fluids.

DoD uses DU tank armor and some DU munitions (bullets) to penetrate enemy armored vehicles. The use of DU has saved the lives of many Service members in combat. The Agency for Toxic Substances and Disease Registry has stated there is no evidence that natural or depleted uranium exposure has caused cancer in people.

The health effects of uranium have been studied extensively for more than 50 years. This is relevant because chemically, depleted uranium (DU) has the same properties as natural uranium, while being 40% less radioactive. While natural and depleted uranium are considered chemically toxic, they are not considered a radiation hazard. In May 1989 the Department of Health and Human Services' Agency for Toxic Substances and Disease Registry published a Toxicological Profile for Uranium reviewing and summarizing the key uranium health effects literature. This document was updated in September 1999. 

The Department of Defense has comprehensively studied the environmental fate of depleted uranium both before and after the Gulf War. Burn tests and other evaluations performed under simulated battlefield conditions indicated that the health risks associated with the battlefield use of depleted uranium were minimal and could be reduced even more by simple, field-expedient measures, especially, avoidance of depleted uranium-contaminated vehicles and sites. 

Depleted uranium (DU) penetrators are only one of many possible hazards on the battlefield. Civilians and soldiers are strongly discouraged from recovering souvenirs, particularly spent ammunition, from the battlefield. 

Fortunately, DU is only mildly radioactive emitting alpha and beta particles, and gamma rays. Alpha particles, the primary radiation type produced by DU, are blocked by skin, while beta particles are blocked by clothing and shoes. While gamma rays are a form of highly-penetrating energy, the amount of gamma radiation emitted by DU is very low. The risk of chemical toxicity is also minimal because there is little likelihood that sufficient quantities of DU could be inhaled or ingested to cause a heavy metal concern. 

The main areas that were not adequately addressed before the Gulf War were the medical implications of embedded depleted uranium (DU) fragments in people and inhalation exposure estimates for friendly fire incidents, recovery activities, and incidental contact scenarios. 

These are recognized weaknesses that are being addressed. The December 19, 2000 Environmental Exposure Report, DU in the Gulf (II) includes the Army's latest health risk exposure estimates for various Gulf War exposure scenarios. Health risk estimates for DU-contaminated vehicle recovery and incidental contact scenarios indicate that these exposures were well within safety standards. Because of gaps in data pertaining to uranium oxide dust levels inside DU-struck vehicles, exposure estimates for personnel inside DU-struck vehicles at the time of impact, or immediately afterwards, were based on conservative assumptions. These estimates for this highest exposed group indicated that medical follow-up was warranted. DoD is currently in the process of conducting additional live-fire testing in order to further refine the exposure estimates for those troops in or around vehicles when they were hit by DU munitions. It is important to note that over 60 friendly-fire victims have been evaluated by the voluntary VA DU Medical Follow-up Program. Aside from the problems associated with their traumatic injuries, to date, this follow-up program has attributed no illness or other harmful effects in the evaluated veterans to DU. 

The voluntary Veterans Affairs DU Medical Follow-up Program began in 1993-1994 with the medical evaluations of 33 friendly-fire DU-exposed veterans, many with embedded DU fragments. An additional 29 of the friendly-fire victims were added to the surveillance program in 1999. In 1998, the program was expanded to include Gulf War veterans who may have been exposed to DU through close contact with DU munitions, inhalation of smoke containing DU particulate during a fire at the Doha depot or while entering or salvaging vehicles that were hit with DU projectiles. The published results of these medical evaluations indicate that the presence of embedded DU fragments is the only scenario predictive of a high urine uranium value, and those with embedded DU fragments continue to have elevated urine uranium levels ten years after the incident. It is unlikely that an individual without embedded DU fragments would have an elevated urine uranium level, and consequently any uranium-related health effects. Those individuals with normal urine uranium levels now are unlikely to develop any uranium-related toxicity in the future, regardless of what their DU exposure may have been in the Gulf War. Those individuals with elevated levels of urine uranium ten years after the Gulf War have not developed kidney abnormalities, leukemia, bone or lung cancer, or any other uranium-related adverse outcome. The DU Medical Follow-up Program will continue to monitor those individuals with elevated urine uranium levels to enable early detection of any adverse health effects due to their continued exposure to DU.

It is highly unlikely that exposure to depleted uranium (DU) ammunition would cause leukemia. The Agency for Toxic Substances and Disease Registry of the U.S. Department of Health and Human Services stated in its Toxicological Profile for Uranium," no human cancer of any type has ever been seen as a result of exposure to natural or depleted uranium." A 1999 RAND study concluded, "there are no peer-reviewed published reports of detectable increases of cancer or other negative health effects from radiation exposure to inhaled or ingested natural uranium at levels far exceeding those likely in the Gulf." Exposures in the Balkans should be no more than those in the Gulf.

After the media reports in early 2001, nations who had deployed peacekeepers to the Balkans have begun medical monitoring and epidemiological studies. The objective of the studies is to determine whether there is an increase in medical problems in troops who served in the region when compared to troops who did not. To date, none of these studies have found a connection between DU exposure and leukemia or any other pathology. The United Nations and other international organizations also have conducted environmental surveys in Bosnia-Herzegovina and Kosovo. These surveys consistently have reported no widespread DU contamination and no current impact on the health of the general population or deployed personnel. 

Leukemias following high doses of radiation peak in frequency five to seven years after exposure. Media accounts of leukemia cases and deaths within months of return from the Balkans are not consistent with current scientific understanding of the time course of radiation-induced leukemia. 

The DoD is fully aware of its responsibility for the safe use of DU. Since the Gulf War, the DoD has dramatically stepped up its emphasis on increasing soldier and leader awareness of the hazards associated with the battlefield use of depleted uranium. The Deputy Secretary of Defense has ordered the Service Chiefs to ensure that DU awareness training is incorporated into their general military training programs. The U.S. Army's Training and Doctrine Command published Training Support Packages for general DU awareness training and certain specialty training in July 1999. The Marine Corps also uses a three-level DU training program. Both the Marines and Navy use a service-specific variant of the Army's DU Awareness Training video. The Air Force program calls for all personnel on mobility status to receive DU awareness training and has incorporated DU awareness guidance in the Nuclear, Biological, and Chemical handbook carried by all deploying personnel. Complete implementation of the various training programs is underway. The Office of the Special Assistant will continue to monitor the status of the Services' DU training efforts.

Yes, trace levels of transuranics have been found in depleted uranium (DU). The Department of Energy (DOE) operated three gaseous diffusion plants (Paducah, Kentucky; Portsmouth, Ohio; and Oak Ridge, Tennessee) where they enriched uranium for nuclear weapons and power plants; creating depleted uranium as a by-product. Some or all of these plants received recycled uranium extracted from spent nuclear fuels in the '50s, '60s, '70s, and '80s. Uranium extracted from spent nuclear fuels included low levels of transuranics, including americium, neptunium, and plutonium, technetium-99, and uranium-236. The gaseous diffusion process concentrates these contaminants in the enriched uranium and decreases the levels in the depleted uranium so that only trace quantities remain. The radioactive contaminants increase the radiation dose from theDU itself by less than 1%, which is considered insignificant.

In March 2001, DOE reported the results of a two-year recycled uranium study that concluded the transuranic content in depleted uranium was very low. The DOE data are consistent with U.S. Army testing of the DU used in armor plate for the Abrams Heavy Tank, which concludes the radioactive contaminants contribute less than a one percent increase in the radioactivity from DU itself. Various NATO countries and the United Nations Environment Programme (UNEP) recently recovered penetrators in the Balkans and tested them for the level of contaminants. Their findings are consistent with DOE/DoD findings. The UNEP concluded that the transuranics have no significant impact on the overall radioactivity or the health risk. These contaminant levels are in the parts per billion range. A part per billion is approximately equivalent to one second in 31.7 years. 

No adverse health effects are expected from such contact. Unfired depleted uranium munitions are encased in thin metal jackets that seal in alpha and beta particles. The amount of gamma emissions from depleted uranium (DU) is very low and falls well below regulatory health and safety limits. Similarly, depleted uranium panels used in tank armor pose no health risk because the depleted uranium is sealed inside several inches of regular steel armor. Alpha radiation, which is the major concern for internalized depleted uranium, is not an external concern because alpha radiation does not penetrate the outer layers of skin. The second source of radiation is from the depleted uranium rounds stored on board the tank. While soldiers are exposed to an increased level of radiation from the stored munitions, the cumulative exposure levels for tank crewmembers are within applicable guidelines. Since depleted uranium munitions are only used in combat, only forward-deployed vehicles are routinely uploaded with depleted uranium munitions. 

While it is impossible to evaluate all potential exposure scenarios, each of the major weapon systems have been fully evaluated and all of the routine exposures are well within exposure guidelines. In fact, radiation levels measured inside the turret of an Abrams Heavy Armor Tank are below background levels measured outside the turret because armor shields the tank occupants from cosmic and terrestrial radiation sources. Crewmembers have their overall radiation exposure reduced by working inside the tank. 

The most frequently cited example of radiation exposure is holding a bare penetrator rod. The penetrator rods in the 120mm, 105mm and 30mm rounds are shielded which prevents direct contact with the actual penetrator rod of intact rounds. But even when holding a bare penetrator rod, an individual could hold the rod for 250 hours before reaching the extremity or skin limit of 50 rem. 

As DU munitions penetrate armor or when DU burns, DU oxide dust is created. DU exposure may occur from inhalation or ingestion of DU dust, contamination of wounds with DU dust, or from embedded DU munitions or armor fragments in the body. To address these risks, DoD has formal policies in place to monitor its Service members for potential DU exposure, and refers exposed Service members to a medical follow-up program. DoD also has training programs for personnel who could be exposed to the metal. The 2003 Health Affairs' Policy, Operation Iraqi Freedom DU Medical Management, offers every Service member the opportunity to confirm possible exposure to DU. This was supplemented in 2004 by the DoD Deployment Biomonitoring Policy. Exposure evaluation of personnel who served in the Gulf War or Operation Iraqi Freedom is initiated based upon participation in an event (such as a friendly fire incident) or with a unit that would place the individual at risk of DU exposure, or positive patient responses to the Post-Deployment Health Assessment, DD Form 2796.

Potentially exposed Service members complete a DU Exposure Questionnaire, which is reviewed to assess the risk level. Those at greatest risk undergo urine testing for uranium. Personnel at lower risk may also undergo testing based on concerns of either the patient or the medical provider. Service members with confirmed positive results are offered a referral to the VA's DU Follow-Up Program.

We have categorized the depleted uranium (DU) exposure scenarios into three levels based on their relative exposures, and have conducted testing to estimate the maximum exposure that could be associated with those scenarios. The levels of possible exposure are described more fully on the Medical Follow-Up page of this website, which also contains links to DoD policy on management of exposures. Level I is the highest exposure group, soldiers who were in, on, or near combat vehicles at the time they were struck by depleted uranium rounds, and soldiers who entered these vehicles immediately afterwards to perform combat rescue. This exposure level also includes personnel who have been struck by DU fragments. Depleted uranium metal fragments have struck a number of US soldiers, and some of these still have embedded DU fragments. Others are believed to have inhaled or ingested DU particles, or had DU dust contaminate their wounds.

The voluntary Veterans Affairs (VA) DU Medical Follow-up program in Baltimore remains the most important source for identifying potential adverse health effects in those friendly-fire victims who have embedded DU fragments, or who may have inhaled significant quantities of DU particles. About one fourth of the Level I exposed individuals who have been evaluated by the VA still carry DU fragments in their bodies, and some of those with embedded fragments have elevated levels of urine uranium more than ten years after the Gulf War. None of the individuals with DU fragments have developed kidney problems, leukemia, bone or lung cancers, or any other uranium-related adverse outcomes. No birth defects have been reported in their children. As a result, there is no reason to believe that other exposed Service members have any elevated risk to their health due to their DU exposures. However, to be cautious, the DoD and the VA continue to medically follow veterans with high-level DU exposures to ensure there are no long-term health effects associated with these ongoing DU exposures. References to some of the research articles reporting follow-up results on these Service members and veterans can be found through Research Projects and Publications in this website, and going to "DeployMed ResearchLink" for Medical Research Publications: Environmental & Occupational Health\DU. 

Level II exposures comprise soldiers who worked in and around combat vehicles (mainly US vehicles that were struck by friendly fire munitions) and as many as 600 personnel who took part in the clean up after the fire at Camp Doha, where DU munitions were burned in a fire. These exposures resulted in significantly lower estimated intakes of DU than the Level I exposures. The radiation estimates were less than the 0.1 rem per year guideline for members of the general public and much less than the 5 rem per year limit for radiation workers. The chemical exposure estimates were also well below the chemical toxicity guidelines. 

Level III is an "all others" category for personnel whose incidental exposure to DU particles were very brief and are highly unlikely to have resulted in any medically significant exposure taking place. This group includes curious personnel who entered Iraqi equipment or personnel down wind from vehicles that burned after being struck by depleted uranium rounds. This group's estimated exposures were minimal. 

A multidisciplinary team from the US Army Aberdeen Test Center, US Army Armament Research, Development, and Engineering Center, USACHPPM, Batelle Memoral Institute, Pacific Northwest National Laboratory, Los Alamos National Laboratory, and the Lovelace Respiratory Research Institute conducted a study of the anticipated exposures under various scenarios, as well as the possible health effects or risks resulting from these exposures. The results were reported in the Capstone DU Project, comprised of two phases, the Capstone DU Aerosols Study, and the Capstone DU Human Health Risk Assessment. The Capstone DU Project realistically assessed possible exposures and risks for personnel in Levels I, II, and III. Both a summary fact sheet and the original study document are available. The Capstone DU Aerosols Study confirmed the value of ventilation in reducing possible exposures to DU aerosols inside vehicles struck by DU munitions, and clearly showed that simply getting out of DU-struck vehicles provided a way to significantly reduce exposures. The Capstone Depleted Uranium Human Health Risk Assessment determined there would be little or no impact on the health of service members who breathe in depleted uranium (DU) dust particles while inside tanks or other vehicles hit by DU munitions. 

More information on combat exposures is also available at Tab O of "Environmental Exposure Report", Depleted Uranium in the Gulf (II), or "Depleted Uranium-Human Exposure Assessment and Health Risk Characterization in Support of the Environmental Exposure Report 'Depleted Uranium in the Gulf' of the Office of the Special Assistant to the Secretary of Defense for Gulf War Illnesses, Medical Readiness and Military Deployments (OSAGWI)". 

Each weapon system that uses DU has undergone extensive developmental testing and evaluation. As part of that process, DoD evaluates possible alternative metal alloys considering operational requirements and medical/environmental impacts. As improvements have been made in the "hardness" of armored vehicles, tests have demonstrated that depleted uranium (DU) offers superior performance to all other alloys. 

DoD must also evaluate the environmental and medical consequences of exposure to any new alloy. Uranium has an advantage in this arena over several candidate materials because of the extensive database on radiological and chemical properties of uranium. While some candidate replacement alloys may not be radioactive, they are not necessarily less toxic to humans.

Uranium can enter the body through many routes, including by inhalation, through the mouth, or through the skin. However, regardless of the route, only a very small amount of uranium, whether natural or depleted, enters the body. On the battlefield, a Service member could be exposed to uranium in the air from the use of munitions containing DU. As these munitions penetrate armor or when DU burns, DU oxide dust is created. The Capstone Depleted Uranium Aerosols Study looked at this issue. The Capstone Depleted Uranium Aerosols study looked at the concentration of DU to which a Service member might actually be exposed in such a situation, including when the Service member is inside an armored tank that is struck. The Human Health Risk Assessment of the Capstone Depleted Uranium Aerosols study determined that there would be little or no impact on the health of those breathing DU dust particles inside a tank hit by a DU projectiles. In addition to inhalation, DU exposure may also occur through ingestion of DU dust, contamination of wounds with DU dust, or from embedded DU munitions or armor fragments in the body. Although DU exposure is possible through direct contact of fired DU munitions or contaminated equipment or with the skin, this is easily avoided by wearing gloves or proper clothing.

Absorption of uranium through the skin has not been well studied. In animals, it appears that only those forms of uranium that are soluble in body fluids can be absorbed through the skin. Some absorption can also occur through the conjuctira of the eye. Thus, some forms of uranium could be absorbed if placed in direct contact with unprotected skin, such as with picking up objects containing uranium. This type of exposure could be easily avoided with simple precautions, such as not picking up fired DU munitions without wearing protective gloves

Most DU dust that is inhaled is rapidly eliminated from the body. Larger particles do not stay in the lungs, and are either coughed out or swallowed in mucus. Swallowed particles are generally passed through the gastrointestinal tract as with the oral route of exposure. One study showed that almost all inhaled uranium dust left the body by this route, without ever being absorbed.

Only smaller particles may stay in the lungs, and then will enter the circulation only if soluble. Some of these small particles may stay in the lungs for longer periods of time, and may gradually dissolve enough to be absorbed and enter the circulation. Those that are not soluble and remain in the lungs and surrounding tissues will not cause chemical toxicity, but may be associated with other concerns, such as local effects in the lungs, or radiation exposure. Depending on those factors, only about 1% to 5% of inhaled uranium dust will be absorbed into the body and enter the circulation. Most of this small amount of uranium eventually will be filtered through the kidneys for elimination from the body. Where large amounts of inhaled uranium dust have been associated with local inflammatory changes in the lungs, those effects have been difficult to separate from the effects of ordinary inhaled dust.

Experiments have shown that less than 5% of uranium that is taken in by mouth is absorbed into the body to reach the circulation. In fact, for soluble uranium compounds, the percent absorption may be as low as 2%, and for those that are not soluble, the percentage absorption may only be 2/10 of a percent. The remainder continues on through the intestinal tract and is eliminated from the body. Because 95-99% of inhaled uranium particles are coughed up and are also swallowed, in addition to most of the uranium taken in directly by mouth, practically all uranium that an individual takes in passes out through the gastro intestinal tract.

Forms of the metal that are more soluble are more likely to be associated with toxic chemical effects, because if taken into the body, they can more readily enter the circulation. After absorption, soluble uranium goes mostly to the bones and kidneys. The kidneys filter chemicals from the body, and are susceptible to damage from uranium, as well as many other more common metals. Because the kidney is recognized as the organ most sensitive to uranium exposure and toxicity, exposure standards are generally designed to protect the kidneys from chemical effects, although standards have been set at even higher exposures based on radiation effects. However, at the same time, the kidneys effectively dispose of this soluble uranium in the urine. This helps to rid the body of the chemical. Within a day, about two-thirds of the uranium in the circulation passes through the kidneys and into the urine. This is why if DU or natural uranium exposure is suspected, a urine uranium test is obtained. This is where uranium exposure is easiest to detect. The amount of uranium in the urine can be compared to the amount that is commonly seen in unexposed people to determine if further investigation is indicated.

The uranium that is not in the circulation or being filtered by the kidneys is mainly found in the bones. However, as the kidneys remove uranium from the circulation for elimination from the body, the uranium in the bones slowly re-enters the circulation, where it, in turn, is filtered by the kidney and excreted in the urine. Although the process of uranium leaving the bone occurs more slowly, about half of the uranium in the bone will enter the circulation every week and a half, and from there will reach the kidneys and urine. This means that the body tends to naturally rid itself of uranium over time.

Everyone has some uranium in their urine, although the amount varies greatly depending on where they live, and the type of work they perform. The National Center for Environmental Health of the U.S. Centers for Disease Control and Prevention (CDC) published data in 2005 on the amount of uranium found in the urine of men, women, and children from throughout the United States in the Third National Report on Human Exposure to Environmental Chemicals. However, people who work in uranium mines or mills may have higher levels in their urine, reflecting greater amounts of uranium in their bodies. The Occupational Safety and Health Administration has established a maximum safe level for those workers that is about 100 times higher than the average level found in the study by the CDC.

As they decay, uranium atoms, whether natural or depleted, give off small amounts of radiation, like sources of natural background radiation in the environment. DU and its decay products give off radiation that could potentially cause exposure inside the body as well as externally. While DU gives off alpha particles, the decay products give off beta and gamma particles as they decay even more. However, the alpha radiation does not penetrate the outer, dead layer of skin, and so uranium must be first taken into the body for alpha particles to be a concern. Beta radiation is screened out by normal military clothing, but could be a concern if uranium were first taken into the body, or protective clothing (such as gloves) was not worn. Gamma radiation, which is penetrating, must be considered even without internal exposure to uranium, but the doses of it from DU are small. Research indicates that exposures to alpha and beta particles would be below occupational guidelines.

There is no solid evidence from human studies that internal uranium exposure is associated with an increased cancer risk. Although cancer is a well known effect of ionizing radiation exposure, it has never been associated with exposure to uranium. A small fraction of the uranium taken into the body becomes deposited in the skeleton, but scientific observations have not shown any increase in bone cancer in persons exposed to uranium, including enriched uranium, which is about 100 times as radioactive as DU.

People are constantly bombarded by radiation from many sources. Radiation comes from space, from radioactive materials in the soil, including natural uranium, and also radioactive isotopes of other more common metals, such as potassium. There is radiation in the air, and the food that we eat. In addition, people receive radiation from routine x-rays to diagnose disease, or with radiation therapy to treat disease. In some areas of the world, people are exposed to levels of background radiation that is three times higher than in the U.S. These people, exposed only to high levels of background radiation, have some alterations in chromosomes due to the higher radiation exposures, but do not show any increase in rates of cancer or other diseases that may be linked to radiation exposure.

There is no solid evidence from human studies that internal uranium exposure is associated with an increased cancer risk. Although cancer is a well known effect of ionizing radiation exposure, it has never been associated with exposure to uranium. A small fraction of the uranium taken into the body becomes deposited in the skeleton, but scientific observations have not shown any increase in bone cancer in persons exposed to uranium, including enriched uranium, which is about 100 times as radioactive as DU.

People are constantly bombarded by radiation from many sources. Radiation comes from space, from radioactive materials in the soil, including natural uranium, and also radioactive isotopes of other more common metals, such as potassium. There is radiation in the air, and the food that we eat. In addition, people receive radiation from routine x-rays to diagnose disease, or with radiation therapy to treat disease. In some areas of the world, people are exposed to levels of background radiation that is three times higher than in the U.S. These people, exposed only to high levels of background radiation, have some alterations in chromosomes due to the higher radiation exposures, but do not show any increase in rates of cancer or other diseases that may be linked to radiation exposure.

Similar mathematical models to those used in the Capstone Study were used by other governments and organizations, including the World Health Organization and the United Nations Environmental Program, to conclude that DU remaining in former areas of conflict did not create a current environmental hazard to the occupants of those areas. Those researchers examined the risk created by DU particles in the soil that could be resuspended in the air through the action of the wind or human activities. Many of these reports may be accessed directly through the section on Environmental Effects and Exposures.