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Lt Col Bruce Copley, MPH, PhD Chief Epidemiologist

18 Feb 03. Overview. HistoryOrganization and functionsData and surveillance issuesResearch: recent research/investigations. Epidemiologists at the AF Safety Center. ?A Brief History"?A History of Its Brief Existence". 18 Feb 03. AFEB Recommendation. ?The AFEB concludes that Military Medical Dep

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Lt Col Bruce Copley, MPH, PhD Chief Epidemiologist

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    2. 18 Feb 03 Overview History Organization and functions Data and surveillance issues Research: recent research/investigations

    3. Epidemiologists at the AF Safety Center “A Brief History” “A History of Its Brief Existence”

    4. 18 Feb 03 AFEB Recommendation “The AFEB concludes that Military Medical Departments can make significant contributions to the future success of injury prevention programs. That success depends on . . . strengthening partnerships with the Service Safety Centers and line commanders who have the primary responsibility for preventing injuries” Hansen B & Jones B. Injuries in the Military: A Hidden Epidemic (report to the Armed Forces Epidemiological Board, 1996)

    5. 18 Feb 03 AFEB-sponsored team visit to Safety Ctr 1997: AF/MIQ tasks OPHSA to provide epidemiological assistance to Center OPHSA contracts with AFEB members and advisors 2 team visits in 1997; members: Col (Dr) Bruce Jones, USACHPPM Col Vicky Fogelman, Exec Secy AFEB Prof Susan Baker, Johns Hopkins Ctr for Injury Prev Research Maj (Dr) Paul Amoroso, USA Research Institute for Env Med Maj Bruce Copley, AF OPHSA (coordinator)

    6. 18 Feb 03 Major recommendations Continue to focus on acquiring Class C (generally high freq, lower severity) mishaps in addition to the sentinel events (Classes A & B) Modernize the existing electronic reporting system Provide analytical feedback to the field Partner with OPHSA for specific analytical work Consider changing manpower structure to accommodate an AFMS epidemiologist

    7. 18 Feb 03 SEPR: SE-SG Partnership The Air Force response to the recommendation 1997 – 1st epidemiologist position authorized and filled (Lt Col) * 1999 – 2nd epidemiologist position authorized and filled (Maj – Lt Col) 2001 – 3rd epidemiologist position authorized and filled (Capt) * Doctorate requirement established in FY2000

    8. 18 Feb 03

    9. Epidemiology & Research Role

    10. 18 Feb 03 Public Health Model of Injury Prevention & Control Identify and prioritize problems (injury surveillance) Quantify and prioritize risk factors (analytic injury research) Identify existing or develop new strategies to prevent occupational injuries (countermeasures) Implement the most effective injury control measures (program/policy implementation) Monitor the results of intervention efforts (evaluation) This is the PH model adapted for injuries which doesn’t differ (except for references to injuries) from the model used to address any PH problemThis is the PH model adapted for injuries which doesn’t differ (except for references to injuries) from the model used to address any PH problem

    11. 18 Feb 03 Incomplete PH model in DoD Injury control/prev programs aren’t Medical Identify and prioritize problems Quantify and prioritize risk factors Identify existing or develop new strategies to prevent occupational injuries Implement the most effective injury control measures Monitor the results of intervention efforts In DoD, injury prev/control programs are a Line/safety program. #3: Medical personnel are generally weak in this area except for a few officers (mostly PMOs) who have training and experience on what interventions would work. Even doctoral trained injury epidemiologists (like me) may easily find risk/causal factors, but we can’t always know how to build a fix #4: Medical has historically been completely out of the loop here, as this step generally means “taking the intervention/program to the streets” which also includes policy implementation if the intervention is across-the-board. Safety programs aren’t Medical obviously.In DoD, injury prev/control programs are a Line/safety program. #3: Medical personnel are generally weak in this area except for a few officers (mostly PMOs) who have training and experience on what interventions would work. Even doctoral trained injury epidemiologists (like me) may easily find risk/causal factors, but we can’t always know how to build a fix #4: Medical has historically been completely out of the loop here, as this step generally means “taking the intervention/program to the streets” which also includes policy implementation if the intervention is across-the-board. Safety programs aren’t Medical obviously.

    12. Data and Surveillance Issues

    13. 18 Feb 03 Ground Rules: DoD Instruction 6055.7 Accident Investigation, Reporting, and Record Keeping Scope: Accidental death, injury, occupational illness, and property damage Injury defined: Traumatic wound or other condition caused by external force or deprivation (drowning, suffocation, exposure, cold injury, dehydration) Exclusions: Suicide, homicide, workplace violence, legal intervention Also, combat-related injuries and deaths not included—Casualty Reporting System accounts for these Non-AF units (e.g., joint commands)

    14. 18 Feb 03 Mishap categories (severity levels) DoDI 6055.7 & AFI 91-204 Class A Class B Class C Cost = $1M+ Fatal or totally disabling (perm) Lost aircraft Cost: $200K - <$1M Partially disabling (perm) 3+ people hospitalized Cost: $20K - <$200K LWI 8+hrs beyond current; occ illness (any lost time)

    15. Safety vs Medical Injury Case Definitions and Levels of Severity

    16. 18 Feb 03 USAF Injury Pyramid—Medical Definition* In reality, we spend most of our time (naturally) where the demand is highest Internal and external customers’ demands are very similar Very little activity at Levels 4-5 (gray area at top) Time spent at each level proportional to the strata of the pyramid But, this only includes analytical time, not time spent doing non-analytical things (next slide covers that)In reality, we spend most of our time (naturally) where the demand is highest Internal and external customers’ demands are very similar Very little activity at Levels 4-5 (gray area at top) Time spent at each level proportional to the strata of the pyramid But, this only includes analytical time, not time spent doing non-analytical things (next slide covers that)

    17. 18 Feb 03

    18. 18 Feb 03 Surveillance operations Reporting via web-based AF Safety Automated System (AFSAS) World-wide reporting locations at base safety offices Aviation, ground, weapons, and occ illness modules Occupational illness module—a prototype Being appended to USAF’s Command Core System for comprehensive occupational health management All occupational (injury and illness) data will then be maintained at Safety Ctr (proposed transfer of occ illness from AFIERA) IERA will have open access

    19. 18 Feb 03 Real-time occ injury & illness info Rates/100 servicemembers, available on “desktop icon”

    20. 18 Feb 03 Linkage to DMSS data Objective: enhance surveillance completeness 2 levels of injury/mishap surveillance Passive: Rely exclusively on supervisors’ reports Active: Access MTF medical logs to find unreported cases Problem: About 50% of injuries initially treated outside MTFs (contract care, MTF closures, ED closures); biggest impact on USAF Solution: electronically alert Safety of injury-related hospitalization (? lost workday) using DMSS data Base-specific notifications posted to secure web site MOA signed; first download on 13 Feb

    21. 18 Feb 03 Research activity Multi-disciplinary operational epidemiological behavioral/human factors Covers all functional areas (flight, ground, weapons)

    22. Motor vehicle crashes, Class A FY88-FY02: Initiators and contributing factors Lt Col Bruce Copley Lt Col Julie Robinson Lt Col Maggie Meigs Capt Matt Shim

    23. 18 Feb 03 Driving behaviors: mishap initiators Automobiles vs Motorcycles, Class A FY88-FY02

    24. 18 Feb 03 Top 5 contributing factors: Autos vs motorcycles Percent of Class A mishaps in which each factor was noted

    25. Relation between mishap rates & occupational stresses due to manpower demand and operational tempo Lt Col Bruce Copley Capt Matt Shim

    26. 18 Feb 03 Stressed vs non-stressed career fields Dominant AFSCs by number in enlisted career fields Official designation by AF/XPM Manpower-stressed Security forces (21,960)* Crypto linguist (2,904) Comm network/switch/ crypto systems (2,575) Intel application (2,229) Comm cable & antenna & telephone sys (1,920) Non-stressed fields A/C Propulsion/AGE/ Egress/Fuel Sys (19,455) Fighter/tactical AC maintenance (13,307) Aerospace/Helo Maint (12,975) Info Management (10,766)

    27. 18 Feb 03 Manpower-stressed career fields Comparison of mishap rates

    28. 18 Feb 03 Manpower-stressed career fields Comparison of period mishap rates by cohort

    29. 18 Feb 03 Manpower-stressed career fields Comparison of cohort mishap rates by period

    30. 18 Feb 03 Conclusion Period effects > cohort (exposure) effects Cohort effect: Mild–not statistically significant in either pd, but post-9/11 rate increase higher in stressed group Rates in stressed group higher even before 9/11 Period effect: Moderate—statistically significant in both pds; post-9/11 stressed rate increase ?2x non-stressed Both stressed and non-stressed are affected by the post-9/11 demands

    31. 18 Feb 03 Operational tempo (OPSTEMPO) stresses Dominant AFSCs by number in enlisted career fields OPSTEMPO-stressed Security forces (21,960) All medical (21,666) All communication (13,176) All intelligence (10,202) All transportation (10,128) All air crew (7,358) Non-stressed fields A/C Propulsion/AGE/ Egress/Fuel Sys (19,455) Fighter/tactical AC maintenance (13,307) Aerospace/Helo Maint (12,975) Info Management (10,766)

    32. Are injury incidence rates higher in recently re-deployed airmen?: A nested case-control study Lt Col Bruce Copley Supplemental DMSS medical and personnel data, database linkage, and linked data set construction provided by Army Medical Surveillance Activity (USACHPPM)

    33. 18 Feb 03 Study parameters Outcome—Safety: Injuries reported via USAF mishap reporting system; date range: 9 Jun 00 – 30 Sep 02 Outcome—Medical: 1st injury-related medical visits, same date range; AMSA/DMSS case definition; in- and out-patient medical data systems, both MTF and outsourced Exposure (both series): Redeployed within past 30 days (from date of injury as determined by cases); rtn from deployment date range: 13 Jan 00 – 11 Sep 02; deployment duration at least 30 days Controls selected from DMSS at random from USAF active duty population on date of injury

    34. 18 Feb 03 Injury incidence rate ratios 30- & 60-day return from “30+ day deployment” vs otherwise* USAF Oct 99-Aug 02

    35. Acute non-battle injuries in USAF personnel deployed to Southwest Asia (pre-9/11) Lt Col Bruce Copley Lt Col Kevin Grayson (AFIERA)

    36. 18 Feb 03 Methods Data Source: Global Expeditionary Medical System (GEMS) Records all in- and out-patient visits in deployed locations Wider array of injury severity than in Safety database Considerable work needed to restrict data to newly-occurring injuries (eliminating repeat visits, etc) = “incidence” All but USAF records removed Repeat visits removed Assumes stable denominator through 180 days (everyone had Day 1, . . . , Day 180) Study period: 12 months before 9/11

    37. 18 Feb 03 Overall USAF perspective Rates/1,000 airmen

    38. 18 Feb 03 USAF Injury Incidence Rates by elapsed day in SWA

    39. 18 Feb 03 Predicted rates for operational planning

    40. 18 Feb 03 Injury incidence by external cause

    41. 18 Feb 03 External cause of injury & disposition

    42. Occupational injury surveillance & research Lt Col Bruce Copley Lt Col Bruce Burnham

    43. 18 Feb 03 2 Case definitions Broad Includes injuries sustained in the USAF-owned environment Includes military PT Specific = “industrial” Includes only injuries sustained while within premises of an actual worksite or performing job-specific task Excludes military PT Exclusions in both definitions: “Horseplay” as categorized in the mishap reports Sports and recreation injuries (e.g., lunchtime pick-up game)

    44. 18 Feb 03 Occupational injury surveillance “Industrial” case definition, FY92-FY02

    45. 18 Feb 03 USAF Occupational Injury Rate Trends Civilian vs Military

    46. 18 Feb 03 Number of civilian occupational injuries mil vs civ, by major command, FY92-FY02

    47. 18 Feb 03 Occupational (industrial) injuries Avg age by anatomical region, mil and civ

    48. 18 Feb 03 Occupational injuries, FY95-FY02 Enlisted occupational categories*, drill-down

    49. 18 Feb 03 Occupational injury surveillance External causes of 321 occ injuries in security forces

    50. 18 Feb 03 Workplace injury rates General Schedule employees, FY92-FY02

    51. 18 Feb 03 Occupational injury surveillance External causes of 237 occ injuries in civilian firefighters

    52. 18 Feb 03 Future research & surveillance agenda Research Occupation-specific external cause analyses Continuing to monitor effects of deployments, OPSTEMPO, and manpower shortages Human factor research on flight-related mishaps Surveillance Set alert and action thresholds for “outbreaks” of specific aviation failures or sentinel injuries via time-series analysis Participation in DoD efforts to further qualify, quantify, and understand lost workday injuries

    53. Points of contact: Lt Col Bruce Copley (505) 846-0792 Lt Col Bruce Burnham (505) 846-2663 DSN prefix: 246 Organizational (branch) email: afsc.sepr@kirtland.af.mil

    54. 18 Feb 03

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