Defense Health Care
Force Health Protection and Surveillance Policy Compliance Was Mixed, but Appears Better for Recent Deployments Gao ID: GAO-05-120 November 12, 2004A lack of servicemember health and deployment data hampered investigations into the nature and causes of illnesses reported by many servicemembers following the 1990-91 Persian Gulf War. Public Law 105-85, enacted in November 1997, required the Department of Defense (DOD) to establish a system to assess the medical condition of servicemembers before and after deployments. Following its September 2003 report examining Army and Air Force compliance with DOD's force health protection and surveillance policies for Operation Enduring Freedom (OEF) and Operation Joint Guardian (OJG), GAO was asked in November 2003 to also determine (1) the extent to which the services met DOD's policies for Operation Iraqi Freedom (OIF) and, where applicable, compare results with OEF/OJG; and (2) what steps DOD has taken to establish a quality assurance program to ensure that the military services comply with force health protection and surveillance policies.
Overall compliance with DOD's force health protection and surveillance policies for servicemembers that deployed in support of OIF varied by service, installation, and policy requirement. Such policies require that servicemembers be assessed before and after deploying overseas and receive certain immunizations, and that health-related documentation be maintained in a centralized location. GAO reviewed 1,862 active duty and selected reserve component servicemembers' medical records from a universe of 4,316 at selected military service installations participating in OIF. Overall, Army and Air Force compliance for sampled servicemembers for OIF appears much better compared to OEF and OJG. For example, (1) lower percentages of Army and Air Force servicemembers were missing pre- and post-deployment health assessments for OIF; (2) higher percentages of Army and Air Force servicemembers received required pre-deployment immunizations for OIF; and (3) lower percentages of deployment health-related documentation were missing in servicemembers' permanent medical records and at DOD's centralized database for OIF. The Marine Corps installations examined generally had lower levels of compliance than the other services; however, GAO did not review medical records from the Marines or Navy for OEF and OJG. Noncompliance with the requirements for health assessments may result in deployment of servicemembers with existing health problems or concerns that are unaddressed. It may also delay appropriate medical follow-up for a health problem or concern that may have arisen during or after deployment. In January 2004, DOD established an overall deployment quality assurance program for ensuring that the services comply with force health protection and surveillance policies, and implementation of the program is ongoing. DOD's quality assurance program requires (1) reporting from DOD's centralized database on each service's submission of required pre-deployment and post-deployment health assessments for deployed servicemembers, (2) reporting from each service regarding the results of the individual service's deployment quality assurance program, and (3) joint DOD and service representative reviews at selected military installations to validate the service's deployment health quality assurance reporting. DOD officials believe that their quality assurance program has improved the services' compliance with requirements. However, the services are at different stages of implementing their own quality assurance programs as mandated by DOD. At the installations visited, GAO analysts observed that the Army and Air Force had centralized quality assurance processes in place that extensively involved medical personnel examining whether DOD's force health protection and surveillance requirements were met for deploying/re-deploying servicemembers. In contrast, GAO analysts observed that the Marine Corps installations did not have well-defined quality assurance processes for ensuring that requirements were met for servicemembers.
GAO-05-120, Defense Health Care: Force Health Protection and Surveillance Policy Compliance Was Mixed, but Appears Better for Recent Deployments
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
November 2004:
Defense Health Care:
Force Health Protection and Surveillance Policy Compliance Was Mixed,
but Appears Better for Recent Deployments:
GAO-05-120:
GAO Highlights:
Highlights of GAO-05-120, a report to Congressional Requesters:
Why GAO Did This Study:
A lack of servicemember health and deployment data hampered
investigations into the nature and causes of illnesses reported by many
servicemembers following the 1990-91 Persian Gulf War. Public Law 105-
85, enacted in November 1997, required the Department of Defense (DOD)
to establish a system to assess the medical condition of service-
members before and after deployments. Following its September 2003
report examining Army and Air Force compliance with DOD‘s force health
protection and surveillance policies for Operation Enduring Freedom
(OEF) and Operation Joint Guardian (OJG), GAO was asked in November
2003 to also determine (1) the extent to which the services met DOD‘s
policies for Operation Iraqi Freedom (OIF) and, where applicable,
compare results with OEF/OJG; and (2) what steps DOD has taken to
establish a quality assurance program to ensure that the military
services comply with force health protection and surveillance policies.
What GAO Found:
Overall compliance with DOD‘s force health protection and surveillance
policies for servicemembers that deployed in support of OIF varied by
service, installation, and policy requirement. Such policies require
that servicemembers be assessed before and after deploying overseas and
receive certain immunizations, and that health-related documentation be
maintained in a centralized location. GAO reviewed 1,862 active duty
and selected reserve component servicemembers‘ medical records from a
universe of 4,316 at selected military service installations
participating in OIF. Overall, Army and Air Force compliance for
sampled servicemembers for OIF appears much better compared to OEF and
OJG. For example:
* Lower percentages of Army and Air Force servicemembers were missing
pre- and post-deployment health assessments for OIF.
* Higher percentages of Army and Air Force servicemembers received
required pre-deployment immunizations for OIF.
* Lower percentages of deployment health-related documentation were
missing in servicemembers‘ permanent medical records and at DOD‘s
centralized database for OIF.
The Marine Corps installations examined generally had lower levels of
compliance than the other services; however, GAO did not review medical
records from the Marines or Navy for OEF and OJG. Noncompliance with
the requirements for health assessments may result in deployment of
servicemembers with existing health problems or concerns that are
unaddressed. It may also delay appropriate medical follow-up for a
health problem or concern that may have arisen during or after
deployment.
In January 2004, DOD established an overall deployment quality
assurance program for ensuring that the services comply with force
health protection and surveillance policies, and implementation of the
program is ongoing. DOD‘s quality assurance program requires (1)
reporting from DOD‘s centralized database on each service‘s submission
of required pre-deployment and post-deployment health assessments for
deployed servicemembers, (2) reporting from each service regarding the
results of the individual service‘s deployment quality assurance
program, and (3) joint DOD and service representative reviews at
selected military installations to validate the service‘s deployment
health quality assurance reporting. DOD officials believe that their
quality assurance program has improved the services‘ compliance with
requirements. However, the services are at different stages of
implementing their own quality assurance programs as mandated by DOD.
At the installations visited, GAO analysts observed that the Army and
Air Force had centralized quality assurance processes in place that
extensively involved medical personnel examining whether DOD‘s force
health protection and surveillance requirements were met for
deploying/re-deploying servicemembers. In contrast, GAO analysts
observed that the Marine Corps installations did not have well-defined
quality assurance processes for ensuring that requirements were met for
servicemembers.
What GAO Recommends:
Because GAO has already made recommendations aimed to improve force
health protection and surveillance and because of the recent
implementation of DOD‘s quality assurance program, GAO is not making
any additional recommendations regarding the program at this time. DOD
reviewed a draft of this report and concurred with its findings.
www.gao.gov/cgi-bin/getrpt?GAO-05-120.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Clifton Spruill at (202)
512-4531 or spruillc@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Services' Compliance with Force Health Protection and Surveillance
Requirements for OIF Was Mixed, but Appears Better Than for OEF/OJG:
Implementation of DOD's Deployment Health Quality Assurance Program
Is Ongoing:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Percent of Servicemember Pre-deployment Blood Samples Held in
Repository:
Table 2: Blood Samples Drawn for Re-deploying Servicemembers Only:
Table 3: Documentation of In-theater Visits in Permanent
Medical Records:
Table 4: Percent Distribution of Servicemembers by Number of Missing
Required Immunizations Prior to Deployment:
Table 5: Percent of Servicemember Health Assessments and Immunizations
Found in Centralized Database That Were Not Found in Servicemembers'
Medical Records:
Table 6: Percent of Health Assessments and Immunizations Found in
Servicemembers' Medical Records That Were Not Found in Centralized
Database:
Table 7: Servicemember Sample Sizes at Each Visited Installation:
Figures:
Figure 1: Percent of Servicemembers Missing Pre-deployment Health
Assessments:
Figure 2: Percent of Servicemembers Missing Post-deployment Health
Assessments:
Figure 3: Percent of Servicemembers Missing Required Pre-deployment
Immunizations:
Figure 4: Percent of Servicemembers That Did Not Have Current
Tuberculosis Screening:
Figure 5: Percent of Health Assessments Found in Centralized Database
That Were Not Found in the Servicemember's Medical Records:
Figure 6: Percent of Health Assessments and Immunizations Found in
Servicemembers' Medical Records That Were Not Found in the Centralized
Database:
Abbreviations:
AMSA: Army Medical Surveillance Activity:
CITA: Comprehensive Immunization Tracking Application:
DOD: Department of Defense:
GEMS: Global Expeditionary Medical Support:
MEDPROS: Medical Protection System:
OEF: Operation Enduring Freedom:
OIF: Operation Iraqi Freedom:
OJG: Operation Joint Guardian:
SAMS: Shipboard Non-tactical Automated Data Processing Automated
Medical System:
TMIP: Theater Medical Information Program:
United States Government Accountability Office:
Washington, DC 20548:
November 12, 2004:
The Honorable Duncan L. Hunter:
Chairman:
Committee on Armed Services:
House of Representatives:
The Honorable Christopher H. Smith:
Chairman:
Committee on Veterans' Affairs:
House of Representatives:
Following the 1990-91 Persian Gulf War, many servicemembers experienced
health problems that they attributed to their military service in the
Persian Gulf. However, subsequent investigations into the nature and
causes of these illnesses were hampered by a lack of servicemember
health and deployment data.
In response, the Congress enacted legislation in November 1997
requiring the Department of Defense (DOD) to establish a system for
assessing the medical condition of servicemembers before and after
their deployment to locations outside the United States and requiring
the centralized retention of certain health-related data associated
with the servicemember's deployment.[Footnote 1] The system is to
include the use of pre-deployment medical examinations and
post-deployment medical examinations, including an assessment of mental
health and the drawing of blood samples. DOD was also required to
establish a quality assurance program to ensure compliance. DOD has
implemented specific force health protection and surveillance policies.
These policies include pre-and post-deployment health assessments
designed to identify health issues or concerns that may affect the
deployability of servicemembers or that may require medical attention;
pre-deployment immunizations to address possible health threats in
deployment locations; pre-deployment screening for tuberculosis; and
the retention of blood samples on file prior to deployment and the
collection of a post-deployment blood sample.
In September 2003, we reported that the Army and Air Force, for
servicemembers deployed in support of Operation Enduring Freedom (OEF)
and Operation Joint Guardian (OJG), did not comply with DOD's force
health protection and surveillance policies for many active duty
servicemembers, including the policies that the servicemembers be
assessed before and after deploying overseas, that the services
document receipt of certain immunizations, and that health-related
documentation be maintained in a centralized location.[Footnote 2] We
had previously reported in May 1997 on several similar problems
associated with the implementation of DOD's deployment health
surveillance policies for servicemembers deployed to Bosnia in support
of a peacekeeping operation.[Footnote 3]
Concerned about the repercussions of the military services' failure to
comply with DOD's force health protection and surveillance policies and
the need to better understand the adverse health effects of war, you
asked us, in November 2003, to examine the military services'
implementation of DOD's force health protection and surveillance
policies for servicemembers' deployments to Iraq in support of
Operation Iraqi Freedom (OIF).[Footnote 4] More specifically, we
focused our work on the military services' deployments to Southwest
Asia for OIF to address the following two questions:
1. To what extent did the military services meet DOD's force health
protection and surveillance system requirements for servicemembers
deployed to Southwest Asia in support of OIF and, where applicable, did
compliance improve compared to OEF/OJG?
2. What steps has DOD taken to establish a quality assurance program to
ensure that the military services comply with force health protection
and surveillance policies?
To accomplish these objectives, we obtained the force health protection
and surveillance policies applicable to the OIF deployment from the
U.S. Central Command, the Office of the Assistant Secretary of Defense
for Health Affairs, and the services' Surgeons General. For each
service, we identified those installations that had amongst the largest
deployments or redeployments of servicemembers during specified time
frames. Because of concerns about the reliability of overall personnel
deployment data, we obtained data from the selected installations on
the universe of those servicemembers who deployed or redeployed from
the selected installations. To test the implementation of these
policies, we reviewed samples or, in some instances, the entire
universe of medical records for servicemembers at seven military
installations.[Footnote 5] In total, we reviewed medical records of
1,328 active duty servicemembers--including 750 Army servicemembers,
270 Marine Corps servicemembers, 146 Air Force servicemembers, and 162
Navy servicemembers. In addition, we reviewed medical records for 409
Army reserve servicemembers and 125 Army National Guard servicemembers.
To provide assurances that the data were reliable and that our review
of the selected medical records was accurate, we requested the
installations' medical personnel to reexamine those medical records
that were missing required health assessments or immunizations and
adjusted our results where documentation was subsequently identified.
We also requested installation medical personnel to check all possible
sources for missing pre-and post-deployment health assessments and
missing immunizations. We also examined, for all medical records within
our review, the completeness of the centralized records at the Army
Medical Surveillance Activity (AMSA),[Footnote 6] which is tasked with
centrally collecting deployment health-related information for all of
the military services. Further, we interviewed officials with the
Office of the Deployment Health Support Directorate within the Office
of Assistant Secretary of Defense for Health Affairs, the offices of
the services' Surgeons General, and the military installations that we
visited for medical records review regarding the quality assurance
processes established to ensure compliance with DOD force health
protection and surveillance policies. For more detailed information of
our scope and methodology, see appendix I. We performed our work from
November 2003 through August 2004 in accordance with generally accepted
government auditing standards.
Results in Brief:
Overall compliance with DOD's force health protection and surveillance
policies for servicemembers who deployed in support of OIF varied by
service, by installation, and by policy requirement. Army and Air Force
compliance during OIF for the installations in our review appears much
better compared to the installations included in our previous
review[Footnote 7] of OEF and OJG. Installations we examined from the
Marine Corps, on the other hand, generally had lower levels of
compliance across the policy requirements we examined when compared to
other services; however, we did not review medical records from the
Marines or Navy in our previous review. Our review disclosed that the
extent of policy compliance varied in the following areas:
* Deployment health assessments. The Army and the Air Force
installations were generally missing small percentages (less than
10 percent) of pre-deployment health assessments. In contrast,
pre-deployment health assessments were missing for an estimated
63 percent[Footnote 8] of the servicemembers at one Marine Corps
installation and for about 27 percent at the other Marine Corps
installation reviewed. The Navy installation in our review was missing
pre-deployment health assessments for 24 percent of the servicemembers.
Post-deployment health assessments were completed for most
servicemembers (95 percent or more) in our samples, except at one of
the Marine Corps installations we visited. While almost all
post-deployment health assessments for the services were completed
within DOD required time frames except for one Army installation, many
of the pre-deployment health assessments in our samples were not.
Except for servicemembers at one of the two Marine Corps installations
visited, a health care provider reviewed all but small percentages of
the completed health assessments as required by DOD policy.
* Immunizations and other health requirements. Servicemembers receiving
all of the pre-deployment immunizations required for OIF, based on the
documentation we reviewed, ranged from 52 percent to 98 percent at the
installations visited. The percentage of servicemembers missing two or
more of the required immunizations, based on the documentation
reviewed, ranged from 0 to about 11 percent at the installations
visited. Servicemembers missing current tuberculosis screening at the
time of their deployment ranged from 3 percent to 64 percent at the
installations visited. Between less than 1 and 14 percent of the
servicemembers at the installations had blood samples in the repository
that were older than the required limit of 1 year at the time of
deployment. Many servicemembers in our review at the two Marine Corps
installations visited were missing their required post-deployment blood
draw--19 percent at one installation and 13 percent at the other.
* Completeness of medical records and centralized data collection.
Generally, servicemembers' permanent medical records at the
installations we visited were missing small percentages (less than
11 percent) of pre-and post-deployment health assessments and
immunizations we found at AMSA, with the exception of one Army and one
Marine Corps installation in our review. We also checked whether
servicemember in-theater health care visits were documented in the
servicemember's medical record at two Army and two Marine Corps
installations that used manual patient sign-in logs, and found varying
levels of missing documentation of the visits we reviewed. The Air
Force and Navy installations used automated systems for recording
in-theater health care visits, but we found that 20 of 40 visits
reviewed at one location were not also documented in servicemembers'
medical records. Moreover, the AMSA database--designed to function as
the centralized collection location for deployment health-related
information for all military services--was lacking documentation of
many health assessments and immunizations that we found in
servicemembers' medical records at the installations we visited. For
example, for one of the Marine Corps installations in our review, AMSA
was missing all of the pre-deployment health assessments, 26 percent of
the post-deployment health assessments, and 44 percent of the
immunizations that we found in the servicemembers' medical records.
Although the number of installations we visited was limited and
different than those in our previous review with the exception of Fort
Campbell, the Army and Air Force's compliance with the requirements for
OIF appears much better compared to the services' compliance for the
installations we reviewed for OEF and OJG. Because our previous report
on compliance with requirements for OEF and OJG focused only on the
Army and Air Force, we were unable to provide comparable data for the
Navy and Marine Corps. To compare overall data from Army and Air Force
active duty servicemembers reviewed for OEF/OJG with OIF, we aggregated
data from all records examined in these two reviews to provide some
perspective and determined that:
* Lower percentages of Army and Air Force servicemembers were missing
pre-and post-deployment health assessments in OIF compared to OEF/OJF
and, in some cases, the services were in full compliance. For example,
Army servicemembers at the Army installation reviewed who were missing
post-deployment health assessments upon return from OIF was 0 percent
compared to an average of 29 for the installations we reviewed in OEF/
OJG.
* Higher percentages of Army and Air Force servicemembers received all
of the required pre-deployment immunizations based on the documentation
reviewed for OIF compared to OEF/OJG. In one notable example,
98 percent of the Air Force active duty servicemembers received all of
the required immunizations before deploying for OIF, compared with an
average of 71 percent for OEF/OJG.
* Lower overall percentages of deployment health-related documentation
were missing in the servicemembers' permanent medical records and at
DOD's centralized database for OIF compared to OEF/OJG, for both the
Army and the Air Force. Also, immunizations for Army servicemembers
found in the medical record but missing from the centralized database
was an average of 9 percent in OIF compared to an average of 62 percent
in OEF/OJG.
In January 2004, DOD established an overall deployment quality
assurance program for ensuring that the services comply with force
health protection and surveillance policies, and implementation of the
program is ongoing. DOD's quality assurance program requires
(1) reporting from DOD's centralized database on each service's
submission of required pre-deployment and post-deployment health
assessments for deployed servicemembers, (2) reporting from each
service regarding the results of the individual service's deployment
health quality assurance program, and (3) joint DOD and service
representative reviews at selected military installations to validate
the service's deployment health quality assurance reporting. DOD
officials believe that their quality assurance program has improved the
services' compliance with requirements. However, the services are at
different stages of implementing their own quality assurance programs
as mandated by DOD. For example, as of September 2004, the Army had
conducted quality assurance reviews to assess compliance with force
health protection and surveillance requirements at 10 Army
installations. However, according to an official in the office of the
Surgeon General of the Navy, no decisions have been reached regarding
whether periodic audits of Navy servicemembers' medical records will be
conducted to assess compliance with DOD requirements. At the
installations we visited, we observed that the Army and Air Force had
centralized quality assurance processes in place that extensively
involved medical personnel examining whether DOD's force health
protection and surveillance requirements were met for deploying/re-
deploying servicemembers. In contrast, we observed that the Marine
Corps installations we reviewed did not have well-defined quality
assurance processes for ensuring that the requirements were met for
servicemembers. We did not evaluate the effectiveness of DOD's
deployment quality assurance program because of the relatively short
time of its implementation.
In a September 2004 report, we made recommendations to improve the
submission and timeliness of pre-and post-deployment health assessments
to AMSA.[Footnote 9] Specifically, we recommended that the Secretary of
Defense direct the Commandant of the Marine Corps to establish a
mechanism to oversee the submission of pre-and post-deployment
assessments to AMSA, and to direct the Under Secretary of Defense for
Personnel and Readiness, in concert with the service secretaries, to
take steps to improve the electronic submission of pre-and
post-deployment health assessments. In a September 2003 report, we also
recommended that DOD establish an effective quality assurance program
and we continue to believe that implementation of such a program could
help the Marine Corps improve its compliance with force health
protection and surveillance requirements. Because of these prior
recommendations and the recency of DOD's implementation of its quality
assurance program, we are not making any additional recommendations
regarding the program at this time.
DOD reviewed a draft of this report and concurred with its findings.
Background:
In September 2003, we reported that the Army and Air Force did not
comply with DOD's force health protection and surveillance requirements
for many servicemembers deploying in support of OEF in Central Asia and
OJG in Kosovo at the installations we visited.[Footnote 10]
Specifically, our review disclosed problems with the Army and Air
Force's implementation of DOD's force health protection and
surveillance requirements in the following areas:
* Deployment health assessments. Significant percentages of Army and
Air Force servicemembers were missing one or both of their pre-and
post-deployment health assessments and, when health assessments were
conducted, as many as 45 percent of them were not done within the
required time frames.
* Immunizations and other pre-deployment requirements. Based on the
documentation we reviewed, as many as 46 percent of servicemembers in
our samples were missing one of the pre-deployment immunizations
required, and as many as 40 percent were missing a current tuberculosis
screening at the time of their deployment. Up to 29 percent of the
servicemembers in our samples had blood samples in the repository older
than the required limit of 1 year at the time of deployment.
* Completeness of medical records and centralized data collection.
Servicemembers' permanent medical records at the Army and Air Force
installations we visited did not always include documentation of the
completed health assessments that we found at AMSA and at the
U.S. Special Operations Command. In one sample, 100 percent of the
pre-deployment health assessments were not documented in the
servicemember medical records that we reviewed. Furthermore, our review
disclosed that the AMSA database was lacking documentation of many
health assessments and immunizations that we found in the
servicemembers' medical records at the installations visited.
We also wrote in our 2003 report that DOD did not have oversight of
departmentwide efforts to comply with health surveillance requirements.
There was no effective quality assurance program at the Office of the
Assistant Secretary of Defense for Health Affairs or at the Offices of
the Surgeons' General of the Army or Air Force that helped ensure
compliance with force health protection and surveillance policies. We
believed that the lack of such a system was a major cause of the high
rate of noncompliance we found at the installations we visited, and
thus recommended that the department establish an effective quality
assurance program to ensure that the military services comply with the
force health protection and surveillance requirements for all
servicemembers. The department concurred with our recommendation.
The problems that we identified in our 2003 report were similar to
those we had reported in May 1997 for Army servicemembers deployed to
Bosnia in support of a peacekeeping operation.[Footnote 11] Following
the publication of our May 1997 report, the Congress, in November 1997,
included a provision in the National Defense Authorization Act for
Fiscal Year 1998 requiring the Secretary of Defense to establish a
medical tracking system for servicemembers deployed overseas as
follows:
"(a) SYSTEM REQUIRED--The Secretary of Defense shall establish a system
to assess the medical condition of members of the armed forces
(including members of the reserve components) who are deployed outside
the United States or its territories or possessions as part of a
contingency operation (including a humanitarian operation,
peacekeeping operation, or similar operation) or combat operation.
"(b) ELEMENTS OF SYSTEM--The system described in subsection (a) shall
include the use of predeployment medical examinations and
postdeployment medical examinations (including an assessment of mental
health and the drawing of blood samples) to accurately record the
medical condition of members before their deployment and any changes in
their medical condition during the course of their deployment. The
postdeployment examination shall be conducted when the member is
redeployed or otherwise leaves an area in which the system is in
operation (or as soon as possible thereafter).
"(c) RECORDKEEPING--The results of all medical examinations conducted
under the system, records of all health care services (including
immunizations) received by members described in subsection (a) in
anticipation of their deployment or during the course of their
deployment, and records of events occurring in the deployment area that
may affect the health of such members shall be retained and maintained
in a centralized location to improve future access to the records.
"(d) QUALITY ASSURANCE--The Secretary of Defense shall establish a
quality assurance program to evaluate the success of the system in
ensuring that members described in subsection (a) receive predeployment
medical examinations and postdeployment medical examinations and that
the recordkeeping requirements with respect to the system
are met."[Footnote 12]
As set forth above, these provisions require the use of pre-deployment
and post-deployment medical examinations to accurately record the
medical condition of servicemembers before deployment and any changes
during their deployment. In a June 30, 2003, correspondence with GAO,
the Assistant Secretary of Defense for Health Affairs stated that "it
would be logistically impossible to conduct a complete physical
examination on all personnel immediately prior to deployment and still
deploy them in a timely manner." Therefore, DOD required both pre-and
post-deployment health assessments for servicemembers who deploy for 30
or more continuous days to a land-based location outside the United
States without a permanent U.S. military treatment facility. Both
assessments use a questionnaire designed to help military healthcare
providers in identifying health problems and providing needed medical
care. The pre-deployment health assessment is generally administered at
the home station before deployment, and the post-deployment health
assessment is completed either in theater before redeployment to the
servicemember's home unit or shortly upon redeployment.
As a component of medical examinations, the statute quoted above also
requires that blood samples be drawn before and after a servicemember's
deployment. DOD Instruction 6490.3, August 7, 1997, requires that a
pre-deployment blood sample be obtained within 12 months of the
servicemember's deployment.[Footnote 13] However, it requires the blood
samples be drawn upon return from deployment only when directed by the
Assistant Secretary of Defense for Health Affairs. According to DOD,
the implementation of this requirement was based on its judgment that
the Human Immunodeficiency Virus serum sampling taken independent of
deployment actions is sufficient to meet both pre-and post-deployment
health needs, except that more timely post-deployment sampling may be
directed when based on a recognized health threat or exposure. Prior to
April 2003, DOD did not require a post-deployment blood sample for
servicemembers supporting the OEF and OJG deployments.
In April 2003, DOD revised its health surveillance policy for blood
samples and post-deployment health assessments. Effective May 22, 2003,
the services were required to draw a blood sample from each redeploying
servicemember no later than 30 days after arrival at a demobilization
site or home station.[Footnote 14] According to DOD, this requirement
for post-deployment blood samples was established in response to an
assessment of health threats and national interests associated with
current deployments. The department also revised its policy guidance
for enhanced post-deployment health assessments to gather more
information from deployed servicemembers about events that occurred
during a deployment. More specifically, the revised policy requires
that a trained health care provider conduct a face-to-face health
assessment with each returning servicemember to ascertain (1) the
individual's responses to the health assessment questions on the
post-deployment health assessment form; (2) the presence of any mental
health or psychosocial issues commonly associated with deployments;
(3) any special medications taken during the deployment; and
(4) concerns about possible environmental or occupational exposures.
Services' Compliance with Force Health Protection and Surveillance
Requirements for OIF Was Mixed, but Appears Better Than for OEF/OJG:
The overall record of the military services in meeting force health
protection and surveillance system requirements for OIF was mixed and
varied by service, by installation visited, and by specific policy
requirement; however, our data shows much better compliance with these
requirements in the Army and Air Force installations we reviewed
compared to the installations in our earlier review of OEF/OJG. Of the
installations reviewed for this report, the Marine Corps generally had
lower levels of compliance than the other services.
Services' Compliance on All Requirements Uneven, but Marine Corps
Lags Behind:
None of the services fully complied with all of the force health
protection and surveillance system requirements, which include
completing pre-and post-deployment health assessments, receipt of
immunizations, and meeting pre-deployment requirements related to
tuberculosis screening and pre and post-deployment blood samples. Also,
the services did not fully comply with requirements that
servicemembers' permanent medical records include required
health-related information, and that DOD's centralized database
includes documentation of servicemember health-related information.
Health Assessments:
Servicemembers in our review at the Army and Air Force installations
were generally missing small percentages of pre-deployment health
assessments, as shown in figure 1. In contrast, pre-deployment health
assessments were missing for an estimated 63 percent of the
servicemembers at one Marine Corps installation and for 27 percent at
the other Marine Corps installation visited. Similarly, the Navy
installation we visited was missing pre-deployment health assessments
for about 24 percent of the servicemembers; however, we note that the
pre-deployment health assessments reviewed for Navy servicemembers were
completed prior to June 1, 2003, and may not reflect improvements
arising from increased emphasis following our prior review of the Army
and Air Force's compliance for OEF/OJG.[Footnote 15]
Figure 1: Percent of Servicemembers Missing Pre-deployment Health
Assessments:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate. Representations of data without confidence intervals
indicate that the sample represents 100 percent of the eligible
population.
These percentages reflect assessments from all sources and without
regard to timeliness.
[End of figure]
At three Army installations we visited, we also analyzed the extent to
which pre-deployment health assessments were completed for those
servicemembers who re-deployed back to their home unit after
June 1, 2003. Servicemembers associated with these re-deployment
samples deployed in support of OIF prior to June 1, 2003. For two of
these Army installations--Fort Eustis and Fort Campbell--we estimate
that less than 1 percent of the servicemembers were missing
pre-deployment health assessments. However, approximately 39 percent
of the servicemembers that redeployed back to Fort Lewis on or after
June 1, 2003, were missing their pre-deployment health assessments.
Post-deployment health assessments were missing for small percentages
of servicemembers, except at one of the Marine Corps installations we
visited, as shown in figure 2.
Figure 2: Percent of Servicemembers Missing Post-deployment Health
Assessments:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate. Representations of data without confidence intervals
indicate that the sample represents 100 percent of the eligible
population.
These percentages reflect assessments from all sources and without
regard to timeliness.
[End of figure]
Although the Army provides for waivers for longer time frames, DOD
policy requires that servicemembers complete a pre-deployment health
assessment form within 30 days of their deployment and a
post-deployment health assessment form within 5 days upon redeployment
back to their home station.[Footnote 16] For consistency and
comparability between services, our analysis uses the DOD policy for
reporting results. These time frames were established to allow time to
identify and resolve any health concerns or problems that may affect
the ability of the servicemember to deploy, and to promptly identify
and address any health concerns or problems that may have arisen during
the servicemember's deployment. For servicemembers that had completed
pre-deployment health assessments, we found that many assessments were
not completed on time in accordance with requirements. More
specifically, we estimate that pre-deployment health assessments were
not completed on time for:
* 47 percent of the pre-deployment health assessments for the active
duty servicemembers at Fort Lewis;
* 41 percent of the pre-deployment health assessments for the active
duty servicemembers and for 96 percent of the Army National Guard unit
at Fort Campbell; and:
* 43 percent of the pre-deployment health assessments at Camp Lejeune
and 29 percent at Camp Pendleton.
For the most part, small percentages--ranging from 0 to 5 percent--of
the post-deployment health assessments were not completed on time at
the installations visited. The exception was at Fort Lewis, where we
found that about 21 percent of post-deployment health assessments for
servicemembers were not completed on time.
DOD policy also requires that pre-deployment and post-deployment health
assessments are to be reviewed immediately by a health care provider to
identify any medical care needed by the servicemember.[Footnote 17]
Except for servicemembers at one of the two Marine Corps installations
visited, only small percentages of the pre-and post-deployment health
assessments, ranging from 0 to 6 percent, were not reviewed by a health
care provider. At Camp Pendleton, we found that a health care provider
did not review 33 percent of the pre-deployment health assessments and
21 percent of the post-deployment health assessments for its
servicemembers .
Noncompliance with the requirements for pre-deployment health
assessments may result in servicemembers with existing health problems
or concerns being deployed with unaddressed health problems. Also,
failure to complete post-deployment health assessments may risk a delay
in obtaining appropriate medical follow-up attention for a health
problem or concern that may have arisen during or following the
deployment.
Immunizations and Other Health Requirements:
Based on our samples, the services did not fully meet immunization and
other health requirements for OIF deployments, although all
servicemembers in our sample had received at least one anthrax
immunization before they returned from the deployment as required.
Almost all of the servicemembers in our samples had a pre-deployment
blood sample in the DOD Serum Repository but frequently the blood
sample was older than the one-year requirement. The services' record in
regard to post-deployment blood sample draws was mixed.
The U.S. Central Command required the following pre-deployment
immunizations for all servicemembers who deployed to Southwest Asia in
support of OIF: hepatitis A (two-shot series); measles, mumps, and
rubella; polio; tetanus/diphtheria within the last 10 years; typhoid
within the last 5 years; and influenza within the last
12 months.[Footnote 18] Based on the documentation we reviewed, the
estimated percent of servicemembers receiving all of the required
pre-deployment immunizations ranged from 52 percent to 98 percent at
the installations we visited (see fig. 3). The percent of
servicemembers missing only one of the pre-deployment immunizations
required for the OIF deployment ranged from 2 percent to 43 percent at
the installations we visited. Furthermore, the percent of
servicemembers missing 2 or more of the required immunizations ranged
from 0 percent to 11 percent.
Figure 3: Percent of Servicemembers Missing Required Pre-deployment
Immunizations:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate. Representations of data without confidence intervals
indicate that the sample represents 100 percent of the eligible
population.
[End of figure]
Figure 4 indicates that 3 to about 64 percent of the servicemembers at
the installations visited were missing a current tuberculosis screening
at the time of their deployment. A tuberculosis screening is deemed
"current" if it occurred within 1 year prior to deployment.
Specifically, the Army, Navy, and Marine Corps required servicemembers
deploying to Southwest Asia in support of OIF to be screened for
tuberculosis within 12 months of deployment. The Air Force requirement
for tuberculosis screening depends on the servicemember's occupational
specialty; therefore we did not examine tuberculosis screening for
servicemembers in our sample at Moody Air Force Base due to the
difficulty of determining occupational specialty for each
servicemember.
Figure 4: Percent of Servicemembers That Did Not Have Current
Tuberculosis Screening:
[See PDF for image]
Notes: = 95 percent confidence interval, upper and lower bounds for
each estimate. Representations of data without confidence intervals
indicate that the sample represents 100 percent of the eligible
population.
[End of figure]
Although not required as pre-deployment immunizations, U.S. Central
Command policies require that servicemembers deployed to Southwest Asia
in support of OIF receive a smallpox immunization and at least one
anthrax immunization either before deployment or while in theater. For
the servicemembers in our samples at the installations visited, we
found that all of the servicemembers received at least one anthrax
immunization in accordance with the requirement. Only small percentages
of servicemembers at two of the three Army installations, the Air Force
installation, and the Navy installation visited did not receive the
required smallpox immunization. However, an estimated 18 percent of the
servicemembers at Fort Lewis, 8 percent at Camp Lejeune, and 27 percent
at Camp Pendleton did not receive the required smallpox immunization.
U.S. Central Command policies also require that deploying
servicemembers have a blood sample in the DOD Serum Repository not
older than 12 months prior to deployment.[Footnote 19] Almost all of
the servicemembers in our review had a pre-deployment blood sample in
the DOD Serum Repository, but frequently the blood samples were older
than the 1-year requirement. As shown in table 1 below, 14 percent of
servicemembers at Camp Pendleton had blood samples in the repository
older than 1 year.
Table 1: Percent of Servicemember Pre-deployment Blood Samples Held in
Repository:
Army: Installation/type of sample: Ft. Campbell;
Army: Installation/type of sample: Ft. Campbell: Active (Deploying
sample);
Had blood sample in repository: Percent: 100%;
Had blood sample in repository: Confidence interval[A]: 99.01-100;
Had blood sample in repository: N: 300;
Blood sample older than 1 year: Percent: 4%;
Blood sample older than 1 year: Confidence interval[A]: 2.08-6.88;
Blood sample older than 1 year: N: 300.
Army: Installation/type of sample: Ft. Campbell: Reserve (Re-deploying
sample);
Had blood sample in repository: Percent: 100%;
Had blood sample in repository: Confidence interval[A]: 98.21-100;
Had blood sample in repository: N: 166;
Blood sample older than 1 year: Percent: 8%;
Blood sample older than 1 year: Confidence interval[A]: 4.69-13.75;
Blood sample older than 1 year: N: 166.
Army: Installation/type of sample: Ft. Campbell: Guard (Deploying
sample);
Had blood sample in repository: Percent: 100%;
Had blood sample in repository: Confidence interval[A]: [B];
Had blood sample in repository: N: 125;
Blood sample older than 1 year: Percent:
