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Jeffery Paulson, CAPT, MC USNFleet Forces Command

Norfolk, VA, USA

L06 Understand DNBI in the Maritime Environment

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Implement FHP

FHP

Elements of DNBI

Challenges of a Ship Environment

Management of Outbreaks

Sources of Information

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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

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Implement FHP

Goals of FHP{Environment, Occupation, Disease}

Maximize Health of the Forces

Protect the Health of the Forces

Minimize threats

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Implement FHP

Measures of FHP

Disease Rates

Injury Rates

Baseline Measures

Metrics of Changes

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FHP Process

Hazard Identification

Health Risk Assessment

Health Risk Management

Health Risk Control

Health Risk Communication

Evaluation

AJMedP-4

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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

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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

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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

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DNBI categories -US

Fever, unexplained

Influenza –like illness

Lower respiratory illness

Rash

Localized cutaneous lesion

GI – infectious

Botulism-like

Neurological

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DNBI categories -US

Psychiatric, Mental Disorders

Heat/Cold Injuries

Injury, Recreational/Sport

Injury, Motor Vehicle Accident

Injury, Work/Training

Injury, Other

All other

Totals

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.

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.

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Ship Challenges

Isolated

Austere

Close Quarters

Little Recreational Time

And….a target during hostile action

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SUMMARY

Force Health ProtectionDefinitions, Issues and Considerations

Disease, Non-Battle InjuryDefinitions, Example

Ship Considerations and Outbreaks

Future CourseEffective DNBI data and analysis is key

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Jeffery Paulson, CAPT MC USNDirector, Surface Medicine Navy Bureau of Medicine and Surgery

Fleet Forces Command, Norfolk, VA USA

757-836-0106 Email: jeffery.paulson@navy.mil

Questions…

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.