Natalie Wells - Academia.edu (original) (raw)

Papers by Natalie Wells

Research paper thumbnail of Effectiveness of Smallpox Vaccination to Prevent Mpox in Military Personnel

New England Journal of Medicine

Research paper thumbnail of Brief report: Phase I results using the virtual pooled registry cancer linkage system (VPR-CLS) for military cancer surveillance

Research paper thumbnail of Post –acute sequalae of COVID-19 and cardiac outcomes in U. S. military members

International Journal of Cardiology Cardiovascular Risk and Prevention

Research paper thumbnail of Obesity prevalence among active component service members prior to and during the COVID-19 pandemic, January 2018-July 2021

Research paper thumbnail of COVID-19 Booster Vaccination in the U.S. Military, August 2021–January 2022

American Journal of Preventive Medicine

Research paper thumbnail of Abstract C055: Human papillomavirus vaccination among US military service women

Cancer Epidemiology, Biomarkers & Prevention

Human papillomavirus (HPV) is the second most commonly diagnosed sexually transmitted infection i... more Human papillomavirus (HPV) is the second most commonly diagnosed sexually transmitted infection in US service women, though the incidence has declined over the last decade, from 364.4 per 10,000 woman-years in 2007 to 90.0 per 10,000 woman-years in 2016. Despite the Department of Defense (DoD) routine vaccination recommendation for eligible service members age 17-26 years and provision of the vaccine free of charge, coverage remains low. During the years 2006-2011, only 22.5% of eligible women initiated the 3-dose series of the quadrivalent HPV vaccine, and it is not known whether receipt of the vaccine varies by demographic, military-specific, or other. We evaluated receipt of the HPV vaccine in a large cohort of active duty service women over the period 2001-2015. The women are part of the Millennium Cohort Study, which comprises over 200,000 current and past service members and is the largest longitudinal cohort of service members in military history. Briefly, participants were f...

Research paper thumbnail of COVID-19 and depressive symptoms among active component U.S. service members, January 2019-July 2021

Research paper thumbnail of Effectiveness of mRNA-1273, BNT162b2, and JNJ-78436735 COVID-19 Vaccines Among US Military Personnel Before and During the Predominance of the Delta Variant

JAMA Network Open

IMPORTANCE No studies to date have evaluated the effectiveness of 3 COVID-19 vaccines in the US m... more IMPORTANCE No studies to date have evaluated the effectiveness of 3 COVID-19 vaccines in the US military population, especially during the circulation of the SARS-CoV-2 Delta (B.1.617.2) variant. OBJECTIVE To estimate the effectiveness of the mRNA-1273, BNT162b2, and JNJ-78436735 vaccines among US military personnel before and during the predominance of the Delta variant in the US. DESIGN, SETTING, AND PARTICIPANTS This case-control study was conducted among all unvaccinated and fully vaccinated US military personnel who had a documented SARS-CoV-2 test performed in the US between January 1 and September 24, 2021. Individuals were identified using Department of Defense (DOD) electronic medical, laboratory, and surveillance databases. The pre-Delta period was defined as January 1 to May 31, 2021, and the Delta period as June 19 to September 24, 2021. Case individuals were defined by a positive polymerase chain reaction SARS-CoV-2 test result or a positive antigen test result with symptoms. Control individuals had at least 1 negative SARS-CoV-2 test result. EXPOSURES COVID-19 vaccination with the mRNA-1273, BNT162b2, or JNJ-78436735 vaccine, assessed from DOD electronic vaccination records. MAIN OUTCOMES AND MEASURES COVID-19 vaccine effectiveness overall, by vaccine type, and by outcome stratified by the pre-Delta and Delta periods in the US. Vaccine effectiveness was estimated as 100 × (1 − odds ratio) in a logistic regression model with adjustment for potential confounders. RESULTS The cohort included 441 379 individuals, with 290 256 in the pre-Delta period (236 555 [81%] male; median age, 25 years [range, 17-68 years]) and 151 123 in the Delta period (120 536 [80%] male; median age, 26 years [range, 17-70 years]). Adjusted vaccine effectiveness of all vaccines was significantly higher during the pre-Delta period (89.2%; 95% CI, 88.1%-90.1%) compared with the Delta period (70.2%; 95% CI, 69.3%-71.1%) for all outcomes, an overall decrease of 19%. mRNA-1273 vaccine effectiveness was highest in the pre-Delta (93.5%; 95% CI, 91.9%-94.7%) and Delta (79.4%; 95% CI, 78.3%-80.4%) periods for all outcomes, whereas the JNJ-78436735 vaccine had the lowest effectiveness during the pre-Delta (81.8%; 95% CI, 74.2%-87.1%) and Delta (38.3%; 95% CI, 34.5%-41.9%) periods. Effectiveness for all vaccines during both periods was higher for symptomatic infection and hospitalization among individuals with SARS-CoV-2 infection. (continued) Key Points Question Did the effectiveness of the mRNA-1273, BNT162b2, and JNJ-78436735 COVID-19 vaccines change among US-based military personnel before and during the predominance of the SARS-CoV-2 Delta (B.1.617.2) variant? Findings In this case-control study of 441 379 active US military personnel, overall COVID-19 vaccine effectiveness decreased by 19% from the pre-Delta to the Delta period. JNJ-78436735 had the lowest overall vaccine effectiveness in the pre-Delta (81.8%) and Delta (38.3%) periods. Meaning In this study, COVID-19 vaccine effectiveness decreased among US-based military personnel during the time of SARS-CoV-2 Delta variant predominance, especially for recipients of the JNJ-78436735 vaccine; this finding supports the use of booster doses to increase effectiveness.

Research paper thumbnail of Sepsis Hospitalizations Among Active Component Service Members Us Armed Forces 20112020

MSMR, Nov 1, 2021

The objective of this study was to assess the incidence and trends of sepsis hospitalizations in ... more The objective of this study was to assess the incidence and trends of sepsis hospitalizations in the active component U.S. military over the past decade. Between 1 January 2011 and 31 December 2020, there were 5,278 sepsis hospitalizations of any severity recorded among the active component. The overall incidence was 39.8 hospitalizations per 100,000 person-years (p-yrs). Annual incidence increased 64% from 2011 through 2019, then dropped considerably in 2020. Compared to their respective counterparts, rates were highest among female service members, the oldest and youngest age groups, and recruits. The gap in sepsis hospitalization rates between female and male service members increased over the surveillance period. Pneumonia was the most commonly co-occurring infection, followed by genitourinary infections. Among female service members, genitourinary infections were more commonly diagnosed compared to pneumonia. The most common non-infection co-occurring diagnoses were acute kidney failure and acute respiratory failure. This study demonstrates an apparent sex disparity in sepsis rates and further study is recommended to understand its cause.

Research paper thumbnail of Cervical cancer screening compliance among active duty service members in the US military

Preventive Medicine Reports, 2022

Research paper thumbnail of Surveillance snapshot: Cervical cancer screening among U.S. military service women in the Millennium Cohort Study, 2003-2015

Research paper thumbnail of Long-acting reversible contraceptive use, active component service women, U.S. Armed Forces, 2016-2020

MSMR, 2021

Long-acting reversible contraceptives (LARCs) are highly effective means of birth control that ca... more Long-acting reversible contraceptives (LARCs) are highly effective means of birth control that can improve service women's overall health and readiness. This report expands upon prior data and summarizes the annual prevalence (overall and by demographics) of LARC use from 2016 through 2020 among active component U.S. service women, compares LARC prevalence to the prevalence of short-acting reversible contraceptives (SARCs), and evaluates the probability of continued use of LARCs by type. LARC use increased from 21.9% to 23.9% from 2016 through 2019 while SARC use decreased from 28.3% to 24.9%. Both SARC and LARC use decreased in 2020 which may have been related to the coronavirus disease 2019 (COVID-19) pandemic. The prevalence of intrauterine devices (IUDs) was greater than implants, and IUDs also had a higher probability of continuation than implants. At 12 months, the continuation for IUDs was 81% compared to 73% for implants. At 24 months, the probabilities of continuation w...

Research paper thumbnail of Air Evacuation of Service Members for COVID-19 in U.S. Central Command and U.S. European Command From 11 March 2020 Through 30 September 2020

MSMR, 2020

This report documents the numbers of air evacuations for diagnoses of coronavirus disease 2019 (C... more This report documents the numbers of air evacuations for diagnoses of coronavirus disease 2019 (COVID-19) among U.S. active duty service members (ADSMs) from locations in U.S. Central Command (CENTCOM) and U.S. European Command (EUCOM) areas of responsibility. Counted were COVID-19 evacuations both within and out of each of the theaters from 11 March through 30 September 2020. Of the 186 evacuations originating in CENTCOM, 185 resulted in the patients arriving at Landstuhl in EUCOM and 1 was within theater. A total of 169 of the CENTCOM evacuations took place in June through August 2020 and only 1 occurred in September. Of the 39 air evacuations originating in EUCOM, 38 were intra-theater transfers and 1 was to a CONUS facility. Most (n=32) of the EUCOM evacuations occurred in September. Evacuees were most often members of the Army (71%), enlisted personnel (63%), males (91%), and aged 30 years or older (58%). Among a random sample of 56 evacuees, 20% were asymptomatic. Among those ...

Research paper thumbnail of Disparities in COVID-19 Vaccine Initiation and Completion Among Active Component Service Members and Health Care Personnel, 11 December 2020-12 March 2021

MSMR, 2021

The objective of this study was to assess overall vaccine initiation and completion in the active... more The objective of this study was to assess overall vaccine initiation and completion in the active component U.S. military, with a focus on racial/ethnic disparities. From 11 December 2020 through 12 March 2021, a total of 361,538 service members (27.2%) initiated a COVID-19 mRNA vaccine. Non-Hispanic Blacks were 28% less likely to initiate vaccination (95% confidence interval: 25%-29%) in comparison to non-Hispanic Whites, after adjusting for potential confounders. Increasing age, higher education levels, higher rank, and Asian/Pacific Islander race/ethnicity were also associated with increasing incidence of initiation after adjustment. When the analysis was restricted to active component health care personnel, similar patterns were seen. Overall, 93.8% of those who initiated the vaccine series completed it during the study period, and only minor differences in completion rates were noted among the demographic subgroups. This study suggests additional factors, such as vaccine hesita...

Research paper thumbnail of HPV-Related Cancers: A Growing Threat to U.S. Military Health and Readiness

Military Medicine, 2021

The incidence of human papillomavirus (HPV) related cancers is growing in the United States. Acti... more The incidence of human papillomavirus (HPV) related cancers is growing in the United States. Active duty service members (ADSM) have higher rates of HPV infection than civilians and are therefore at greater risk of developing HPV-related cancers. The purpose of this commentary is to examine the burden of HPV-related cancers in ADSM. The current HPV vaccination and cervical cancer screening uptake rates of U.S. ADSM are presented, including a literature review of military-focused studies on HPV vaccination and cervical cancer screenings. We provide directions for future research, interventions, and policy recommendations to improve HPV-related cancer prevention among ADSM.

Research paper thumbnail of Racial Disparities in Prenatal Care Utilization and Infant Small for Gestational Age Among Active Duty US Military Women

Maternal and Child Health Journal, 2020

Objectives To examine racial disparities in prenatal care (PNC) utilization and infant small for ... more Objectives To examine racial disparities in prenatal care (PNC) utilization and infant small for gestational age (SGA) among active duty US military women, a population with equal access to health care and known socioeconomic status. Methods Department of Defense Birth and Infant Health Research program data identified active duty women with singleton live births from January 2003 through August 2015. Administrative claims data were used to define PNC utilization and infant SGA, and log-binomial regression models estimated associations with race/ethnicity. To examine whether associations between maternal race/ethnicity and infant SGA were subject to effect measure modification, respective analyses were stratified by demographic and health characteristics. Results Overall, 12.2% of non-Hispanic White women initiated PNC after the first trimester, compared with 14.8% of American Indian/Alaska Native, 15.1% of Asian/Pacific Islander, 14.2% of non-Hispanic Black, and 13.0% of Hispanic women. Infant SGA prevalence was 2.4% and 1.6% among non-Hispanic Black and White women, respectively (aRR 1.52, 95% CI 1.40-1.64). This disparity persisted across stratified analyses, particularly among non-Hispanic Black versus White women with a preeclampsia or hypertension diagnosis in pregnancy (RR 1.96, 95% CI 1.67-2.29) and those aged 35 + years at infant birth (RR 2.04, 95% CI 1.56-2.67). Conclusions for Practice In multiple assessments of PNC utilization and infant SGA, non-Hispanic Black military women had consistently worse outcomes than their non-Hispanic White counterparts. This suggests that equal access to health care does not eliminate racial disparities in outcomes or utilization; additional research is needed to elucidate the underlying etiology of these disparities.

Research paper thumbnail of Safety of tetanus, diphtheria, and acellular pertussis vaccination among pregnant active duty U.S. military women

Vaccine, 2020

Background: The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine was approved for U.S.... more Background: The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine was approved for U.S. adults in 2005 and recommended for administration in every pregnancy in 2012, with optimal timing between 27 and 36 weeks' gestation. In the military, however, a current Tdap vaccination status is compulsory for service, and active duty women may be inadvertently exposed in early pregnancy. Safety data in this population are limited. Objectives: To assess safety of inadvertent (0-13 weeks' gestation) and recommended (27-36 weeks' gestation) exposure to the Tdap vaccine in pregnancy. Methods: Pregnancies and live births from Department of Defense Birth and Infant Health Research program data were linked with military personnel immunization records to determine pregnancy Tdap vaccine exposure among active duty women, 2006-2014. Multivariable Cox and generalized linear regression models estimated associations between Tdap vaccine exposure and adverse pregnancy or infant outcomes. Results: Of 145,883 pregnancies, 1272 were exposed to the Tdap vaccine in the first trimester and 9438 between 27 and 36 weeks' gestation. Neither inadvertent nor recommended vaccine exposure were associated with spontaneous abortion, preeclampsia, or preterm labor. Among 117,724 live born infants, 984 were exposed to the Tdap vaccine in the first trimester and 9352 between 27 and 36 weeks' gestation. First trimester exposure was not associated with birth defects, growth problems in utero, growth problems in infancy, preterm birth, or low birth weight. Tdap vaccine exposure between 27 and 36 weeks' gestation was not associated with any adverse infant outcome. Conclusions: Among a population of active duty women in the U.S. military who received the Tdap vaccine during pregnancy, we detected no increased risks for adverse maternal, fetal, or infant outcomes. Our findings corroborate existing literature on the safety of exposure to the Tdap vaccine in pregnancy.

Research paper thumbnail of Atovaquone-proguanil exposure in pregnancy and risk for adverse fetal and infant outcomes: A retrospective analysis

Travel Medicine and Infectious Disease, 2019

Background: Malaria in pregnancy can cause severe maternal and fetal complications. Chloroquine (... more Background: Malaria in pregnancy can cause severe maternal and fetal complications. Chloroquine (CQ) and mefloquine (MQ) are recommended for chemoprophylaxis in pregnancy, but are not always suitable. Atovaquone-proguanil (AP) might be a viable option for malaria prevention in pregnancy, but more safety data are needed. Methods: Data for pregnancies and live births among active duty military women, 2003-2014, from the Department of Defense Birth and Infant Health Research program were linked with pharmacy data to determine antimalarial exposure. Multivariable Cox and logistic regression models were used to assess the relationship of antimalarial exposure with fetal and infant outcomes, respectively. Results: Among 198,164 pregnancies, 50 were exposed to AP, 156 to MQ, and 131 to CQ. Overall, 17.6% of unexposed pregnancies and 28.0%, 16.0%, and 6.1% of pregnancies exposed to AP, MQ, and CQ, respectively, ended in fetal loss (spontaneous abortion or stillbirth) (adjusted hazard ratios [aHR] = 1.46, 95% confidence interval [CI] 0.87-2.46; aHR = 1.06, 95% CI 0.72-1.57; and aHR = 0.47, 95% CI 0.24-0.94, respectively). Conclusions: The small number of AP exposed pregnancies highlights the difficulty in assessing safety. While definitive conclusions are not possible, these data suggest further research of AP exposure in pregnancy and fetal loss is warranted. Twitter line: More research on fetal loss following atovaquone-proguanil exposure in pregnancy is warranted.

Research paper thumbnail of The Department of Defense Birth and Infant Health Research Program: Assessing the Reproductive Health of U.S. Active-Duty Women

Seminars in Reproductive Medicine, 2018

As the percentage of women serving in the active-duty military continues to grow, and as their ro... more As the percentage of women serving in the active-duty military continues to grow, and as their roles continue to expand, the importance of monitoring reproductive health in the military community increases. The Department of Defense Birth and Infant Health Research (BIHR) program conducts ongoing epidemiologic studies to assess potential increased risks for adverse reproductive and infant health outcomes in the military population. Military personnel endure unique physical and mental demands as a part of their occupational duties (e.g., extensive preventive care, numerous trainings, and deployments), which require special consideration as parental exposures in reproductive health research that cannot be well assessed in the general population. From 2003 to 2014, the BIHR program captured 250,604 pregnancies among approximately 2.4 million active-duty women of reproductive age when limited to non-cadet Army, Air Force, Navy, and Marine Corps personnel. Approximately 15,000 live birth...

Research paper thumbnail of The Impact of Nurse Case Management Home Visitation on Birth Outcomes in African-American Women

Journal of the National Medical Association, 2008

The views expressed in this article are those of the authors and do not necessarily reflect the o... more The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, Department of the Navy, Department of Defense or the U. S. government. Dr. Wells is a military service member (employee of the U.S. government). This work was prepared as a part of her official duties. Title 17, USC §101 defines a U.S. government work as a work prepared by a military service member or employee of the U.S. government as part of the person's official duties. Despite substantial reductions in U.S. infant mortality rates, racial disparities persist, with black Americans experiencing 2.4 times the rate of their white counterparts. Low birthweight and preterm delivery contribute to this disparity. Methods-To examine the association between antepartum nurse case management home visitation and the occurrence of low birthweight and preterm deliveries in African-American women in Montgomery County, MD, a retrospective cohort study was conducted using existing data from 109 mothers who were enrolled in the Black Babies Start More Infants Living Equally Healthy (SMILE) program. Logistic regression analysis was used. Results-Women who received antepartum home visits were 0.37 (CI 0.15-0.94) times less likely to experience preterm delivery than women who did not receive antepartum home visits. The effect of antepartum home visits on preterm delivery was independent of level of prenatal care, negative life events and number of prior live births. There was no significant association between antepartum home visits and low birthweight. Conclusion-Antepartum home visits appeared to be protective against preterm delivery and could contribute to reducing racial disparities in infant mortality. Further study is needed to understand and replicate specific program components that may contribute to improved birth outcomes in African-American women.

Research paper thumbnail of Effectiveness of Smallpox Vaccination to Prevent Mpox in Military Personnel

New England Journal of Medicine

Research paper thumbnail of Brief report: Phase I results using the virtual pooled registry cancer linkage system (VPR-CLS) for military cancer surveillance

Research paper thumbnail of Post –acute sequalae of COVID-19 and cardiac outcomes in U. S. military members

International Journal of Cardiology Cardiovascular Risk and Prevention

Research paper thumbnail of Obesity prevalence among active component service members prior to and during the COVID-19 pandemic, January 2018-July 2021

Research paper thumbnail of COVID-19 Booster Vaccination in the U.S. Military, August 2021–January 2022

American Journal of Preventive Medicine

Research paper thumbnail of Abstract C055: Human papillomavirus vaccination among US military service women

Cancer Epidemiology, Biomarkers & Prevention

Human papillomavirus (HPV) is the second most commonly diagnosed sexually transmitted infection i... more Human papillomavirus (HPV) is the second most commonly diagnosed sexually transmitted infection in US service women, though the incidence has declined over the last decade, from 364.4 per 10,000 woman-years in 2007 to 90.0 per 10,000 woman-years in 2016. Despite the Department of Defense (DoD) routine vaccination recommendation for eligible service members age 17-26 years and provision of the vaccine free of charge, coverage remains low. During the years 2006-2011, only 22.5% of eligible women initiated the 3-dose series of the quadrivalent HPV vaccine, and it is not known whether receipt of the vaccine varies by demographic, military-specific, or other. We evaluated receipt of the HPV vaccine in a large cohort of active duty service women over the period 2001-2015. The women are part of the Millennium Cohort Study, which comprises over 200,000 current and past service members and is the largest longitudinal cohort of service members in military history. Briefly, participants were f...

Research paper thumbnail of COVID-19 and depressive symptoms among active component U.S. service members, January 2019-July 2021

Research paper thumbnail of Effectiveness of mRNA-1273, BNT162b2, and JNJ-78436735 COVID-19 Vaccines Among US Military Personnel Before and During the Predominance of the Delta Variant

JAMA Network Open

IMPORTANCE No studies to date have evaluated the effectiveness of 3 COVID-19 vaccines in the US m... more IMPORTANCE No studies to date have evaluated the effectiveness of 3 COVID-19 vaccines in the US military population, especially during the circulation of the SARS-CoV-2 Delta (B.1.617.2) variant. OBJECTIVE To estimate the effectiveness of the mRNA-1273, BNT162b2, and JNJ-78436735 vaccines among US military personnel before and during the predominance of the Delta variant in the US. DESIGN, SETTING, AND PARTICIPANTS This case-control study was conducted among all unvaccinated and fully vaccinated US military personnel who had a documented SARS-CoV-2 test performed in the US between January 1 and September 24, 2021. Individuals were identified using Department of Defense (DOD) electronic medical, laboratory, and surveillance databases. The pre-Delta period was defined as January 1 to May 31, 2021, and the Delta period as June 19 to September 24, 2021. Case individuals were defined by a positive polymerase chain reaction SARS-CoV-2 test result or a positive antigen test result with symptoms. Control individuals had at least 1 negative SARS-CoV-2 test result. EXPOSURES COVID-19 vaccination with the mRNA-1273, BNT162b2, or JNJ-78436735 vaccine, assessed from DOD electronic vaccination records. MAIN OUTCOMES AND MEASURES COVID-19 vaccine effectiveness overall, by vaccine type, and by outcome stratified by the pre-Delta and Delta periods in the US. Vaccine effectiveness was estimated as 100 × (1 − odds ratio) in a logistic regression model with adjustment for potential confounders. RESULTS The cohort included 441 379 individuals, with 290 256 in the pre-Delta period (236 555 [81%] male; median age, 25 years [range, 17-68 years]) and 151 123 in the Delta period (120 536 [80%] male; median age, 26 years [range, 17-70 years]). Adjusted vaccine effectiveness of all vaccines was significantly higher during the pre-Delta period (89.2%; 95% CI, 88.1%-90.1%) compared with the Delta period (70.2%; 95% CI, 69.3%-71.1%) for all outcomes, an overall decrease of 19%. mRNA-1273 vaccine effectiveness was highest in the pre-Delta (93.5%; 95% CI, 91.9%-94.7%) and Delta (79.4%; 95% CI, 78.3%-80.4%) periods for all outcomes, whereas the JNJ-78436735 vaccine had the lowest effectiveness during the pre-Delta (81.8%; 95% CI, 74.2%-87.1%) and Delta (38.3%; 95% CI, 34.5%-41.9%) periods. Effectiveness for all vaccines during both periods was higher for symptomatic infection and hospitalization among individuals with SARS-CoV-2 infection. (continued) Key Points Question Did the effectiveness of the mRNA-1273, BNT162b2, and JNJ-78436735 COVID-19 vaccines change among US-based military personnel before and during the predominance of the SARS-CoV-2 Delta (B.1.617.2) variant? Findings In this case-control study of 441 379 active US military personnel, overall COVID-19 vaccine effectiveness decreased by 19% from the pre-Delta to the Delta period. JNJ-78436735 had the lowest overall vaccine effectiveness in the pre-Delta (81.8%) and Delta (38.3%) periods. Meaning In this study, COVID-19 vaccine effectiveness decreased among US-based military personnel during the time of SARS-CoV-2 Delta variant predominance, especially for recipients of the JNJ-78436735 vaccine; this finding supports the use of booster doses to increase effectiveness.

Research paper thumbnail of Sepsis Hospitalizations Among Active Component Service Members Us Armed Forces 20112020

MSMR, Nov 1, 2021

The objective of this study was to assess the incidence and trends of sepsis hospitalizations in ... more The objective of this study was to assess the incidence and trends of sepsis hospitalizations in the active component U.S. military over the past decade. Between 1 January 2011 and 31 December 2020, there were 5,278 sepsis hospitalizations of any severity recorded among the active component. The overall incidence was 39.8 hospitalizations per 100,000 person-years (p-yrs). Annual incidence increased 64% from 2011 through 2019, then dropped considerably in 2020. Compared to their respective counterparts, rates were highest among female service members, the oldest and youngest age groups, and recruits. The gap in sepsis hospitalization rates between female and male service members increased over the surveillance period. Pneumonia was the most commonly co-occurring infection, followed by genitourinary infections. Among female service members, genitourinary infections were more commonly diagnosed compared to pneumonia. The most common non-infection co-occurring diagnoses were acute kidney failure and acute respiratory failure. This study demonstrates an apparent sex disparity in sepsis rates and further study is recommended to understand its cause.

Research paper thumbnail of Cervical cancer screening compliance among active duty service members in the US military

Preventive Medicine Reports, 2022

Research paper thumbnail of Surveillance snapshot: Cervical cancer screening among U.S. military service women in the Millennium Cohort Study, 2003-2015

Research paper thumbnail of Long-acting reversible contraceptive use, active component service women, U.S. Armed Forces, 2016-2020

MSMR, 2021

Long-acting reversible contraceptives (LARCs) are highly effective means of birth control that ca... more Long-acting reversible contraceptives (LARCs) are highly effective means of birth control that can improve service women's overall health and readiness. This report expands upon prior data and summarizes the annual prevalence (overall and by demographics) of LARC use from 2016 through 2020 among active component U.S. service women, compares LARC prevalence to the prevalence of short-acting reversible contraceptives (SARCs), and evaluates the probability of continued use of LARCs by type. LARC use increased from 21.9% to 23.9% from 2016 through 2019 while SARC use decreased from 28.3% to 24.9%. Both SARC and LARC use decreased in 2020 which may have been related to the coronavirus disease 2019 (COVID-19) pandemic. The prevalence of intrauterine devices (IUDs) was greater than implants, and IUDs also had a higher probability of continuation than implants. At 12 months, the continuation for IUDs was 81% compared to 73% for implants. At 24 months, the probabilities of continuation w...

Research paper thumbnail of Air Evacuation of Service Members for COVID-19 in U.S. Central Command and U.S. European Command From 11 March 2020 Through 30 September 2020

MSMR, 2020

This report documents the numbers of air evacuations for diagnoses of coronavirus disease 2019 (C... more This report documents the numbers of air evacuations for diagnoses of coronavirus disease 2019 (COVID-19) among U.S. active duty service members (ADSMs) from locations in U.S. Central Command (CENTCOM) and U.S. European Command (EUCOM) areas of responsibility. Counted were COVID-19 evacuations both within and out of each of the theaters from 11 March through 30 September 2020. Of the 186 evacuations originating in CENTCOM, 185 resulted in the patients arriving at Landstuhl in EUCOM and 1 was within theater. A total of 169 of the CENTCOM evacuations took place in June through August 2020 and only 1 occurred in September. Of the 39 air evacuations originating in EUCOM, 38 were intra-theater transfers and 1 was to a CONUS facility. Most (n=32) of the EUCOM evacuations occurred in September. Evacuees were most often members of the Army (71%), enlisted personnel (63%), males (91%), and aged 30 years or older (58%). Among a random sample of 56 evacuees, 20% were asymptomatic. Among those ...

Research paper thumbnail of Disparities in COVID-19 Vaccine Initiation and Completion Among Active Component Service Members and Health Care Personnel, 11 December 2020-12 March 2021

MSMR, 2021

The objective of this study was to assess overall vaccine initiation and completion in the active... more The objective of this study was to assess overall vaccine initiation and completion in the active component U.S. military, with a focus on racial/ethnic disparities. From 11 December 2020 through 12 March 2021, a total of 361,538 service members (27.2%) initiated a COVID-19 mRNA vaccine. Non-Hispanic Blacks were 28% less likely to initiate vaccination (95% confidence interval: 25%-29%) in comparison to non-Hispanic Whites, after adjusting for potential confounders. Increasing age, higher education levels, higher rank, and Asian/Pacific Islander race/ethnicity were also associated with increasing incidence of initiation after adjustment. When the analysis was restricted to active component health care personnel, similar patterns were seen. Overall, 93.8% of those who initiated the vaccine series completed it during the study period, and only minor differences in completion rates were noted among the demographic subgroups. This study suggests additional factors, such as vaccine hesita...

Research paper thumbnail of HPV-Related Cancers: A Growing Threat to U.S. Military Health and Readiness

Military Medicine, 2021

The incidence of human papillomavirus (HPV) related cancers is growing in the United States. Acti... more The incidence of human papillomavirus (HPV) related cancers is growing in the United States. Active duty service members (ADSM) have higher rates of HPV infection than civilians and are therefore at greater risk of developing HPV-related cancers. The purpose of this commentary is to examine the burden of HPV-related cancers in ADSM. The current HPV vaccination and cervical cancer screening uptake rates of U.S. ADSM are presented, including a literature review of military-focused studies on HPV vaccination and cervical cancer screenings. We provide directions for future research, interventions, and policy recommendations to improve HPV-related cancer prevention among ADSM.

Research paper thumbnail of Racial Disparities in Prenatal Care Utilization and Infant Small for Gestational Age Among Active Duty US Military Women

Maternal and Child Health Journal, 2020

Objectives To examine racial disparities in prenatal care (PNC) utilization and infant small for ... more Objectives To examine racial disparities in prenatal care (PNC) utilization and infant small for gestational age (SGA) among active duty US military women, a population with equal access to health care and known socioeconomic status. Methods Department of Defense Birth and Infant Health Research program data identified active duty women with singleton live births from January 2003 through August 2015. Administrative claims data were used to define PNC utilization and infant SGA, and log-binomial regression models estimated associations with race/ethnicity. To examine whether associations between maternal race/ethnicity and infant SGA were subject to effect measure modification, respective analyses were stratified by demographic and health characteristics. Results Overall, 12.2% of non-Hispanic White women initiated PNC after the first trimester, compared with 14.8% of American Indian/Alaska Native, 15.1% of Asian/Pacific Islander, 14.2% of non-Hispanic Black, and 13.0% of Hispanic women. Infant SGA prevalence was 2.4% and 1.6% among non-Hispanic Black and White women, respectively (aRR 1.52, 95% CI 1.40-1.64). This disparity persisted across stratified analyses, particularly among non-Hispanic Black versus White women with a preeclampsia or hypertension diagnosis in pregnancy (RR 1.96, 95% CI 1.67-2.29) and those aged 35 + years at infant birth (RR 2.04, 95% CI 1.56-2.67). Conclusions for Practice In multiple assessments of PNC utilization and infant SGA, non-Hispanic Black military women had consistently worse outcomes than their non-Hispanic White counterparts. This suggests that equal access to health care does not eliminate racial disparities in outcomes or utilization; additional research is needed to elucidate the underlying etiology of these disparities.

Research paper thumbnail of Safety of tetanus, diphtheria, and acellular pertussis vaccination among pregnant active duty U.S. military women

Vaccine, 2020

Background: The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine was approved for U.S.... more Background: The tetanus, diphtheria, and acellular pertussis (Tdap) vaccine was approved for U.S. adults in 2005 and recommended for administration in every pregnancy in 2012, with optimal timing between 27 and 36 weeks' gestation. In the military, however, a current Tdap vaccination status is compulsory for service, and active duty women may be inadvertently exposed in early pregnancy. Safety data in this population are limited. Objectives: To assess safety of inadvertent (0-13 weeks' gestation) and recommended (27-36 weeks' gestation) exposure to the Tdap vaccine in pregnancy. Methods: Pregnancies and live births from Department of Defense Birth and Infant Health Research program data were linked with military personnel immunization records to determine pregnancy Tdap vaccine exposure among active duty women, 2006-2014. Multivariable Cox and generalized linear regression models estimated associations between Tdap vaccine exposure and adverse pregnancy or infant outcomes. Results: Of 145,883 pregnancies, 1272 were exposed to the Tdap vaccine in the first trimester and 9438 between 27 and 36 weeks' gestation. Neither inadvertent nor recommended vaccine exposure were associated with spontaneous abortion, preeclampsia, or preterm labor. Among 117,724 live born infants, 984 were exposed to the Tdap vaccine in the first trimester and 9352 between 27 and 36 weeks' gestation. First trimester exposure was not associated with birth defects, growth problems in utero, growth problems in infancy, preterm birth, or low birth weight. Tdap vaccine exposure between 27 and 36 weeks' gestation was not associated with any adverse infant outcome. Conclusions: Among a population of active duty women in the U.S. military who received the Tdap vaccine during pregnancy, we detected no increased risks for adverse maternal, fetal, or infant outcomes. Our findings corroborate existing literature on the safety of exposure to the Tdap vaccine in pregnancy.

Research paper thumbnail of Atovaquone-proguanil exposure in pregnancy and risk for adverse fetal and infant outcomes: A retrospective analysis

Travel Medicine and Infectious Disease, 2019

Background: Malaria in pregnancy can cause severe maternal and fetal complications. Chloroquine (... more Background: Malaria in pregnancy can cause severe maternal and fetal complications. Chloroquine (CQ) and mefloquine (MQ) are recommended for chemoprophylaxis in pregnancy, but are not always suitable. Atovaquone-proguanil (AP) might be a viable option for malaria prevention in pregnancy, but more safety data are needed. Methods: Data for pregnancies and live births among active duty military women, 2003-2014, from the Department of Defense Birth and Infant Health Research program were linked with pharmacy data to determine antimalarial exposure. Multivariable Cox and logistic regression models were used to assess the relationship of antimalarial exposure with fetal and infant outcomes, respectively. Results: Among 198,164 pregnancies, 50 were exposed to AP, 156 to MQ, and 131 to CQ. Overall, 17.6% of unexposed pregnancies and 28.0%, 16.0%, and 6.1% of pregnancies exposed to AP, MQ, and CQ, respectively, ended in fetal loss (spontaneous abortion or stillbirth) (adjusted hazard ratios [aHR] = 1.46, 95% confidence interval [CI] 0.87-2.46; aHR = 1.06, 95% CI 0.72-1.57; and aHR = 0.47, 95% CI 0.24-0.94, respectively). Conclusions: The small number of AP exposed pregnancies highlights the difficulty in assessing safety. While definitive conclusions are not possible, these data suggest further research of AP exposure in pregnancy and fetal loss is warranted. Twitter line: More research on fetal loss following atovaquone-proguanil exposure in pregnancy is warranted.

Research paper thumbnail of The Department of Defense Birth and Infant Health Research Program: Assessing the Reproductive Health of U.S. Active-Duty Women

Seminars in Reproductive Medicine, 2018

As the percentage of women serving in the active-duty military continues to grow, and as their ro... more As the percentage of women serving in the active-duty military continues to grow, and as their roles continue to expand, the importance of monitoring reproductive health in the military community increases. The Department of Defense Birth and Infant Health Research (BIHR) program conducts ongoing epidemiologic studies to assess potential increased risks for adverse reproductive and infant health outcomes in the military population. Military personnel endure unique physical and mental demands as a part of their occupational duties (e.g., extensive preventive care, numerous trainings, and deployments), which require special consideration as parental exposures in reproductive health research that cannot be well assessed in the general population. From 2003 to 2014, the BIHR program captured 250,604 pregnancies among approximately 2.4 million active-duty women of reproductive age when limited to non-cadet Army, Air Force, Navy, and Marine Corps personnel. Approximately 15,000 live birth...

Research paper thumbnail of The Impact of Nurse Case Management Home Visitation on Birth Outcomes in African-American Women

Journal of the National Medical Association, 2008

The views expressed in this article are those of the authors and do not necessarily reflect the o... more The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, Department of the Navy, Department of Defense or the U. S. government. Dr. Wells is a military service member (employee of the U.S. government). This work was prepared as a part of her official duties. Title 17, USC §101 defines a U.S. government work as a work prepared by a military service member or employee of the U.S. government as part of the person's official duties. Despite substantial reductions in U.S. infant mortality rates, racial disparities persist, with black Americans experiencing 2.4 times the rate of their white counterparts. Low birthweight and preterm delivery contribute to this disparity. Methods-To examine the association between antepartum nurse case management home visitation and the occurrence of low birthweight and preterm deliveries in African-American women in Montgomery County, MD, a retrospective cohort study was conducted using existing data from 109 mothers who were enrolled in the Black Babies Start More Infants Living Equally Healthy (SMILE) program. Logistic regression analysis was used. Results-Women who received antepartum home visits were 0.37 (CI 0.15-0.94) times less likely to experience preterm delivery than women who did not receive antepartum home visits. The effect of antepartum home visits on preterm delivery was independent of level of prenatal care, negative life events and number of prior live births. There was no significant association between antepartum home visits and low birthweight. Conclusion-Antepartum home visits appeared to be protective against preterm delivery and could contribute to reducing racial disparities in infant mortality. Further study is needed to understand and replicate specific program components that may contribute to improved birth outcomes in African-American women.