1. 1 Jeffery Paulson, CAPT, MC USN Fleet Forces Command Norfolk, VA, USA L06 Understand DNBI in the Maritime Environment L06 Understand DNBI in the Maritime Environment NATO UNCLASSIFIED Releasable to the INTERNET

2. Implement FHP  FHP  Elements of DNBI  Challenges of a Ship Environment  Management of Outbreaks  Sources of Information

3. NATO UNCLASSIFIED Releasable to the INTERNET FHP  Force Health Protection  “ Actions taken to counter the effects of the environment, occupational health risks and disease through preventive and reactive measures”  AJMEDP-1, AJP-3.14

4. NATO UNCLASSIFIED Releasable to the INTERNET Implement FHP  Goals of FHP  {Environment, Occupation, Disease}  Maximize Health of the Forces  Protect the Health of the Forces  Minimize threats

5. NATO UNCLASSIFIED Releasable to the INTERNET Implement FHP  Measures of FHP  Disease Rates  Injury Rates  Baseline Measures  Metrics of Changes

6. NATO UNCLASSIFIED Releasable to the INTERNET FHP Process  Hazard Identification  Health Risk Assessment  Health Risk Management  Health Risk Control  Health Risk Communication  Evaluation  AJMedP-4

7. NATO UNCLASSIFIED Releasable to the INTERNET Medical Surveillance  Medical/Morbidity Surveillance  Amount and type of illness – Readiness  Health Needs Assessment – Requirements  Incidence /Prevalence – Alert Systems  CBRN/Toxin releases  Medical Intelligence  Audit

8. NATO UNCLASSIFIED Releasable to the INTERNET Ex: Preventive Medicine  Arthropod borne diseases  Animal associated diseases  Infection Control in MTF’s  Outbreak Control  Non-infections disease  Oral Health and Oral Disease  Mental Illness

9. NATO UNCLASSIFIED Releasable to the INTERNET DNBI  BI, KIA, WIA  DNBI  Disease Non-Battle Injury  High Rates MAY signal a need for countermeasures or an investigation  Potential Adverse Impact on Readiness!  Designed for Higher Authority  Less useful at the deckplate level

10. NATO UNCLASSIFIED Releasable to the INTERNET DNBI categories -US  Fever, unexplained  Influenza –like illness  Lower respiratory illness  Rash  Localized cutaneous lesion  GI – infectious  Botulism-like  Neurological

11. NATO UNCLASSIFIED Releasable to the INTERNET DNBI categories -US  Psychiatric, Mental Disorders  Heat/Cold Injuries  Injury, Recreational/Sport  Injury, Motor Vehicle Accident  Injury, Work/Training  Injury, Other  All other  Totals

12. Outbreak: Acute Respiratory Illness USS Mystery from 01 Feb to 22 May 2xxx. Epidemiological data and the subsequent investigation and report by Navy PH officials indicated: –DNBI reports indicated to Navy PH officials that lower respiratory illness rates were excessive, so the PMU contacted the Surgeons to offer assistance. –The problem lingered on and eventually PH investigators were flown to the ship to determine the nature of the problem and hopefully get it under control before the ship’s Tiger cruise passengers joined the crew in HI –Outbreak involved 162 episodes of illness and 67 admissions to the medical ward. 50 were admitted with x-ray-confirmed pneumonia. –The event originated in a small cluster of cases in early February following a port visit to Jebel Ali, Dubai. It was concentrated in a particular berthing area. –Epidemiologic study indicated that the clinical presentation was consistent with an etiology of Mycoplasma pneumonia. Lab data later confirmed this diagnosis. –The epidemic lasted several weeks –The PMU investigator reported that DNBI surveillance might have provided an opportunity for an earlier interdiction of the disease.

13. Pandemic Influenza 2009 Fleet DNBI process was updated to capture influenza like illnesses. Fleet ILI information from DNBi surveillance was reported by the SG’s staff to the CNO in weekly Pandemic SITREPS. Affected and non-affected ships were known precisely. The extent to which different ships were affected was known. Health surveillance information was shared liberally between the Navy and Marine Corps Public Health Center and the Naval Health Research Center (NHRC), since NHRC was providing lab support to ships experiencing outbreaks. Calculated expected ILI rates were used to develop a OPNAV Pandemic Influenza response matrix based on varying levels of ill in fleet units.

14. NATO UNCLASSIFIED Releasable to the INTERNET Ship Challenges  Isolated  Austere  Close Quarters  Little Recreational Time  And….a target during hostile action

15. NATO UNCLASSIFIED Releasable to the INTERNET SUMMARY  Force Health Protection  Definitions, Issues and Considerations  Disease, Non-Battle Injury  Definitions, Example  Ship Considerations and Outbreaks  Future Course  Effective DNBI data and analysis is key

16. NATO UNCLASSIFIED Releasable to the INTERNET Jeffery Paulson, CAPT MC USN Director, Surface Medicine Navy Bureau of Medicine and Surgery Fleet Forces Command, Norfolk, VA USA 757-836-0106 Email: jeffery.paulson@navy.mil Questions …

17. Norovirus: Outbreak Prevention and Control DNBI data was used to estimate the burden of GI and norovirus illnesses and outbreaks occurring aboard fleet units. –During the 24 month period from 01 Jan 2009 to 31 Dec 2010 we estimated: –there were 21,840 unique health care (HC) visits for complaints of GI illness from all etiologies in the U.S. Fleet. –158 outbreaks of GI illnesses may have occurred causing about 12,000 of the unique HC visits for GI illnesses of which roughly 80 (causing 6000 unique HC visits) might be attributed to NoV infections. DNBI data: –Can be used as an outcome measure for prevention efforts detailed in a new NMCPHC prevention and control guide –Illustrates that norovirus illnesses are an important source of morbidity in fleet units. –Can provide information about the fleets performance of Medical Event Reporting. For example, 65 GI outbreaks were reported/identified via DNBI surveillance. Six of those affected units completed MERs to detail the event and their responses to it.