Update: Cold Weather Injuries, Active and Reserve Components, U.S.

Armed Forces,
July 2011June 2016
Francis L. ODonnell, MD, MPH (COL, USA, Ret.); Stephen B. Taubman, PhD

From July 2015 through June 2016, a total of 447 members of the active
(n=383) and reserve (n=64) components had at least one medical encounter
with a primary diagnosis of cold injury. The numbers of affected individuals
in both components were the lowest since the 20112012 cold season, when
the total was 394. In the active component, the service-specific incidence rates
for each of the four services were lower than the respective rates for the previous (20142015) cold season. Frostbite was the most common type of cold
injury. During the five cold seasons in the surveillance period (20112016),
rates tended to be higher among service members who were in the youngest age groups; female; black, non-Hispanic; or in the Army. The numbers of
cold injuries associated with service in Iraq and Afghanistan have fallen precipitously in the past four cold seasons and included just 11 cases in the most
recent year.

.S. military members are often

assigned to, and perform duties
in, cold weather climates where
they may be exposed to cold and wet environments. Such conditions pose the threat
of hypothermia, frostbite, and non-freezing cold injury such as immersion foot. The
human physiologic responses to cold exposure preserve core body temperature, but
those responses may not be sufficient to prevent hypothermia if heat loss is prolonged.
Moreover, those responses include constriction of the peripheral (superficial) vascular
system, which may result in non-freezing
injuries or hasten the onset of actual freezing
of tissues (frostbite). Traditional measures
to counter the dangers associated with cold
environments include minimizing loss of
body heat and protecting superficial tissues
through such means as protective clothing,
shelter, physical activity, and nutrition.
Military training or mission requirements in cold and wet weather may place
service members in situations where they
may be unable to be physically active, find
warm shelter, or change wet or damp clothing.1,2 Military history has well documented
Page

12

the toll of cold weather injuries, and for

many years the U.S. Armed Forces have
developed and improved robust training,
doctrine, procedures, and protective equipment and clothing to counter the threat
from cold environments.1,3,4 Although these
measures are highly effective, cold injuries
continue to affect hundreds of service members each year.5 Continuous surveillance of
these injuries is essential to inform additional steps needed to reduce the impact of
cold weather on service members health
and their mission accomplishment.
This update summarizes frequencies,
rates, and correlates of risk of cold injuries
among members of active and reserve components of the U.S. Armed Forces during the
past 5 years.

METHODS

The surveillance period was 1 July 2011

through 30 June 2016. The surveillance population included all individuals who served
in an active or reserve component of the
U.S. Armed Forces at any time during the

surveillance period. For analysis purposes,

cold years or cold seasons were defined
by 1 July through 30 June intervals so that
complete cold weather seasons could be
represented in year-to-year summaries and
comparisons.
For this analysis, the Defense Medical
Surveillance System (DMSS) and the Theater Medical Data Store (which maintains
records of medical encounters of service
members deployed to Southwest Asia and
the Middle East) were searched for records
of inpatient and outpatient care for the
diagnoses of interest (frostbite, immersion
injury, hypothermia, and other specified/
unspecified effects of reduced temperature). A case was defined by the presence of
an ICD-9 or ICD-10 code for one of the
cold injuries in the first diagnostic position of a record of health care (Table 1). The
Military Health System (MHS) converted
to the ICD-10 coding system on 1 October 2015. Because the ICD-10 system provides many more specific diagnostic codes
for the cold injuries of interest than did
ICD-9 (249 codes vs. 8 codes), the cases in
this analysis were defined by consolidating
the different coding systems in the manner
shown in Table 1. It should be noted that the
former category of immersion foot now
encompasses immersion foot and hand
because the ICD-10 coding system provides
a specific code for such injuries of the hand.
Cases of cold injuries were also sought in the
DMSS records of cases identified via electronic notifications of so-called reportable
medical events (RMEs). The DoD guidelines
for RMEs require the reporting of cases of
frostbite, hypothermia, and immersion foot,
but not other specified/unspecified effects
of reduced temperature.6 Cases of chilblains
are not included in this report because the
condition is common, infrequently diagnosed, usually mild in severity, and thought
to have minimal medical, public health, or
military impacts.
MSMR Vol. 23 No. 10 October 2016

TA B L E 1 . ICD-9/ICD-10 diagnostic codes

for cold weather injuries

ICD-9 codes ICD-10 codes

991.0, 991.1,
991.2, 991.3

T33.***A,
T34.***A

Immersion
foot and hand

991.4

T69.0**A

Hypothermia

991.6

T68.XXXA

991.8, 991.9

T69.8XXA,
T69.9XXA

Frostbite

Other and
unspecified

*Wild card; codes with any characters in those positions should be included.

To estimate the number of unique individuals who suffered a cold injury each
cold season and to avoid counting followup healthcare encounters after single episodes of cold injury, only one cold injury per
individual per cold season was included. In
summaries of the incidence of the different
types of cold injury diagnoses, one of each
type of cold injury per individual per cold
season was included. For example, if an individual was diagnosed with more than one
type of cold injury in a single cold season,
each of those different types of injury would
be counted in the tally of injuries. If a service
member had multiple medical encounters
for cold injuries on the same day, only one
encounter was used for analysis (hospitalizations were prioritized over reportable events
which were prioritized over ambulatory visits). Annual incidence rates of cold injuries
(per 100,000 person-years [p-yrs] of service)
were estimated only for the active component because the start and end dates of all
active duty service periods of reserve component members were not available. The
number of cold injuries was summarized by
the location at which the service member
was treated for the cold injury as identified
by the Defense Medical Information System
Identifier (DMISID) recorded in the medical
record of the cold injury. This differs from
the method used to aggregate cold injuries
by location in last years summary in which
the location of injury was determined by the
unit zip code of the service member at the
time of the cold injury. Because cold injuries may be sustained during field training
October 2016 Vol. 23 No. 10 MSMR

exercises, temporary duty, or other instances

where a service member may not be located
at his/her usual duty station, it was felt that
DMISID was a better proxy for the location
of the cold injury. Parent DMISID was used
to roll up cold injuries by location for the
purposes of this summary.
R E SULT S

20152016 cold season

From July 2015 through June 2016, a
total of 447 members of the active (n=383)
and reserve (n=64) components had at least
one medical encounter with a primary diagnosis of cold injury. The numbers of affected
individuals in both the active and reserve
components were the lowest since the 2011
2012 cold season, when the total was 394.
By using only one cold injury diagnosis per
individual during the cold season, the overall incidence rate for all active component
service members in 20152016 (29.5 per
100,000 p-yrs) was 23% lower than the rate
(38.2 per 100,000 p-yrs) for the 20142015
cold season but slightly higher than the rates
for the first two seasons of the surveillance
period. In 20152016, the service-specific
incidence rates for each of the four services
(Army, Navy, Air Force, and Marine Corps)
were lower than the respective rates during
the previous (20142015) cold season (Table
2, Figure 1).
The 255 active component Army service members who received at least one
diagnosis of a cold injury (rate: 53.1 per
100,000 p-yrs) during the 20152016 cold
season accounted for 66.6% of active component members affected among all services. The 74 members of the Marine Corps
diagnosed with a cold injury represented
19.3% of all affected service members. Navy
service members (n=19) had the lowest service-specific rate of cold injuries during the
20152016 cold season (rate: 5.8 per 100,000
p-yrs) (Table 2, Figure 1).
When all injuries were considerednot
just the numbers of individuals affected
frostbite was the most common type of cold
injury (n=146 or 36.8% of all cold injuries)
among active component service members
in 20152016. In the Air Force, 45.9% of

all cold injuries were frostbite, whereas in

the other services, the proportions of cases
of frostbite ranged from 38.7% (Army) to
26.7% (Marine Corps) (Tables 3a3d). For the
Navy and Air Force, the 20152016 numbers
and rates of frostbite injuries in active component service members were the lowest of
the past 5 years. For immersion injuries, the
Army number of cases and the incidence
rate for 20152016 were higher than any of
the prior 4 years. Although the number of
immersion injury cases in the Marine Corps
decreased by 78% from the anomalously
high count during the 20142015 cold season, cases and rates of hypothermia among
Marines increased in 20152016 and were
the highest of the 5-year surveillance period
(Table 3d).

Five cold seasons: July 2011June 2016

During the 5-year surveillance period,
overall rates of cold injuries in the active
component were higher in females than in
males mainly because of the striking difference between the rates for female (rate:
75.4 per 100,000 p-yrs) and male (rate: 50.3
per 100,000 p-yrs) service members in the
Army. In the other three services, the rates
in females were less than 10% higher than
the male rates. In all the services, females
had higher rates of frostbite and lower rates
of immersion injury than did males (Tables
3a3d).
In all of the services, overall rates of
cold injuries were higher among black, nonHispanic service members than among
those of other race/ethnicity groups. In particular, within the Army and Marine Corps,
rates of cold injuries were approximately
twice as high in black, non-Hispanic service members as in white, non-Hispanic or
other race/ethnicity groups (Tables 3a3d).
Additionally, black, non-Hispanic service
members had incidence rates of cold injuries
greater than the rates of other race/ethnicity
groups in nearly every military occupational
category during 20112016 (data not shown).
Rates of cold injuries were higher among
the youngest service members (less than 20
years old) and generally declined with each
succeeding older age group. Enlisted members of the Army, Navy, and Air Force had
higher rates than officers, but the opposite
was true in the Marine Corps (Tables 3a3d).
Page 13

TA B L E 2 . Any cold injury (one per person per year), by service and component, U.S. Armed Forces, July 2011June 2016
Army
Active component

Navy

Air Force

Marine Corps

All services

No.

Ratea

No.

Ratea

No.

Ratea

No.

Ratea

No.

Ratea

1,336

51.5

152

9.5

293

18.3

447

46.6

2,228

33.0

Jul 2011Jun 2012

187

33.5

23

7.2

70

21.3

57

28.5

337

24.0

Jul 2012Jun 2013

246

45.7

21

6.7

57

17.3

67

34.3

391

28.4

Jul 2013Jun 2014

377

72.4

48

15.0

78

23.9

112

57.9

615

45.2

Jul 2014Jun 2015

271

54.6

41

12.8

53

17.0

137

73.7

502

38.2

Jul 2015Jun 2016

255

53.1

19

5.8

35

11.3

74

40.1

383

29.5

All years (2011-2016)

Reserve component
All years (20112016)

285

13

42

61

401

Jul 2011Jun 2012

39

57

Jul 2012Jun 2013

46

11

15

72

Jul 2013Jun 2014

92

14

117

Jul 2014Jun 2015

61

12

15

91

Jul 2015Jun 2016

47

64

Overall, active and reserve

All years (20112016)

1,621

165

335

508

2,629

Jul 2011Jun 2012

226

27

76

65

394

Jul 2012Jun 2013

292

21

68

82

463

Jul 2013Jun 2014

469

52

85

126

732

Jul 2014Jun 2015

332

44

65

152

593

Jul 2015Jun 2016

302

21

41

83

447

Rate per 100,000 p-yrs

F I G U R E 1 . Annual incidence rates of cold injuries, by service, active component, U.S. Armed
Forces, July 2011June 2016
80.0

60.0

Marine Corps

800

Air Force
Navy

700

50.0

600

40.0

Marine Corps
Air Force
Navy
Army

30.0

No. of cold injuries

Cases per 100,000 p-yrs

70.0

Army

F I G U R E 2. Annual numbers of cold injuries,

by service and cold season, active and
reserve components, U.S. Armed Forces,
July 2011June 2016

20.0
10.0
0.0

500
400
300
200

Page

14

Jul 2015Jun 2016

Jul 2014Jun 2015

Jul 2013Jun 2014

from the active component and 401 from the

reserve component. Of all affected reserve
component members, 71.1% (n=285) were
members of the Army (Table 2). Overall, soldiers accounted for the majority (61.7%) of
all cold injuries affecting active and reserve
component service members (Figure 2).

Jul 2012Jun 2013

In the Army, Air Force, and Marine Corps,

rates were highest among service members
in infantry/artillery/combat engineering
related occupations (Tables 3a, 3c, 3d).
During the 5-year surveillance period,
the 2,629 service members who were
affected by any cold injury included 2,228

Jul 2011Jun 2012

100

MSMR Vol. 23 No. 10 October 2016

TA B L E 3a. Diagnoses of cold injuries, one per type per person per year, active component, U.S. Army, July 2011June 2016
Frostbite

Immersion injury

Hypothermia

Unspecified

All cold injuries

No.

Ratea

No.

Ratea

No.

Ratea

No.

Ratea

No.

Ratea

679

26.2

188

7.2

199

7.7

330

12.7

1,396

53.8

Male

541

24.2

172

7.7

177

7.9

236

10.6

1,126

50.3

Female

138

38.6

16

4.5

22

6.1

94

26.3

270

75.4

White, non-Hispanic

285

18.4

98

6.3

117

7.6

146

9.4

646

41.8

Black, non-Hispanic

287

53.6

52

9.7

39

7.3

129

24.1

507

94.6

Other

107

20.9

38

7.4

43

8.4

55

10.7

243

47.4

Total
Sex

Race/ethnicity

Age
<20

62

43.4

24

16.8

19

13.3

56

39.2

161

112.6

2024

295

39.2

89

11.8

92

12.2

142

18.9

618

82.1

2529

145

23.3

46

7.4

53

8.5

61

9.8

305

49.1

3034

87

19.9

21

4.8

21

4.8

35

8.0

164

37.5

3539

50

16.2

1.6

2.9

16

5.2

80

25.9

4044

23

11.1

1.0

1.4

15

7.2

43

20.7

45+

17

13.7

0.8

1.6

4.0

25

20.2

615

29.2

147

7.0

165

7.8

294

13.9

1,221

57.9

64

13.2

41

8.4

34

7.0

36

7.4

175

36.0

234

35.4

99

15.0

95

14.4

90

13.6

518

78.3

33

40.3

2.4

8.6

9.8

50

61.1

Repair/engineering

126

23.7

20

3.8

31

5.8

60

11.3

237

44.6

Comm/intel

157

24.7

38

6.0

37

5.8

88

13.8

320

50.3

Health care

39

14.9

2.7

3.0

29

11.1

83

31.6

Other

90

21.4

22

5.2

21

5.0

55

13.1

188

44.6

20112012

99

17.7

14

2.5

27

4.8

55

9.8

195

34.9

20122013

138

25.7

42

7.8

25

4.6

53

9.9

258

48.0

20132014

204

39.2

46

8.8

55

10.6

89

17.1

394

75.6

20142015

135

27.2

18

3.6

55

11.1

75

15.1

283

57.0

20152016

103

21.4

68

14.2

37

7.7

58

12.1

266

55.4

Rank
Enlisted
Officer
Occupation
Infantry/artillery/combat eng.
Armor/motor transport

Cold year (JulJun)

*Rate per 100,000 person-years

Of all active component service members who were diagnosed with a cold
injury (n=2,200), 166 (7.5% of the total)
were affected during basic training. The
Army (n=67) and Marine Corps (n=91)
accounted for 95.2% of all basic trainees
who suffered a cold injury (data not shown).
Additionally, during the surveillance
period, 62 service members affected with
cold injuries (2.8% of the total) were hospitalized, and most of the hospitalized cases
were members of either the Army (n=38)
or Marine Corps (n=23) (data not shown).
October 2016 Vol. 23 No. 10 MSMR

Cold injuries in Iraq and Afghanistan

During the 5-year surveillance period,
238 cold injuries were diagnosed and
treated in Iraq and Afghanistan. Of these,
half (n=118) were frostbite; 57 (24%) were
immersion injuries; 22 (9%) were hypothermia; and 41 (17%) were unspecified cold
injuries. Cold injuries most often occurred
in deployed service members who were male
(n=198; 83%); white, non-Hispanic (n=124;
52%); aged 2024 years (n=114; 48%); in the
Army (n=165; 69%); enlisted grade (n=217;

91%); and in infantry/artillery/combat engineeringrelated occupations (n=74; 31%).

Of all 238 cold injuries during the surveillance period, 89% occurred in the first 3
years. There were 38 cold injuries during July
2013 through June 2014, only 14 during July
2014 through June 2015, and 11 during July
2015 through June 2016 (data not shown).

Cold injuries by location

Twenty-two military locations were
associated with at least 30 incident cold
Page 15

TA B L E 3b. Diagnoses of cold injuries, one per type per person per year, active component, U.S. Navy, July 2011June 2016
Frostbite

Immersion injury

Hypothermia

Unspecified

All cold injuries

No.

Ratea

No.

Ratea

No.

Ratea

No.

Ratea

No.

Ratea

69

4.3

25

1.6

31

1.9

31

1.9

156

9.8

Male

48

3.6

21

1.6

31

2.3

27

2.0

127

9.6

Female

21

7.5

1.4

0.0

1.4

29

10.4

White, non-Hispanic

31

3.8

10

1.2

14

1.7

14

1.7

69

8.4

Black, non-Hispanic

18

7.4

1.2

2.9

2.9

35

14.4

Other

20

3.7

12

2.2

10

1.9

10

1.9

52

9.7

<20

20

23.2

4.6

2.3

4.6

30

34.8

2024

14

2.8

12

2.4

1.8

12

2.4

47

9.4

2529

18

4.5

1.2

14

3.5

1.5

43

10.7

3034

3.5

0.8

0.8

0.8

15

5.8

3539

2.2

0.5

1.6

2.2

12

6.5

4044

2.9

1.0

0.0

2.9

6.7

45+

1.6

0.0

1.6

0.0

3.2

63

4.7

24

1.8

27

2.0

28

2.1

142

10.7

2.2

0.4

1.5

1.1

14

5.2

Infantry/artillery/combat eng.

3.8

0.9

1.9

1.9

8.5

Armor/motor transport

6.5

6.5

6.5

3.2

14

22.7
6.3

Total
Sex

Race/ethnicity

Age

Rank
Enlisted
Officer
Occupation

Repair/engineering

21

3.1

0.7

1.2

1.3

43

Comm/intel

3.4

0.8

1.1

1.1

17

6.5

Health care

4.4

1.6

2.7

3.3

22

12.0

23

7.5

10

3.2

2.9

2.9

51

16.6

10

3.1

1.3

1.6

1.3

23

7.2

Other
Cold year (JulJun)
20112012
20122013

2.2

1.6

1.9

1.3

22

7.0

20132014

33

10.3

0.0

12

3.8

1.9

51

16.0

20142015

13

4.0

10

3.1

1.6

13

4.0

41

12.8

20152016

1.8

1.8

0.9

1.2

19

5.8

*Rate per 100,000 person-years

injuries (one per person) among active

and reserve component service members
during the 5-year surveillance period. The
locations with the highest 5-year counts of
incident injuries were Fort Wainwright, AK
(n=138); Parris Island/Beaufort, SC (103);
Fort Carson, CO (94); Fort Benning, GA
(94); Bavaria (Vilseck/Grafenwoehr), Germany (86); MCB Quantico, VA (86); and
Fort Bragg, NC (81). During the 2015
2016 cold season, the numbers of incident
Page

16

cases of cold injuries were higher at just six

of the 22 locations, compared to the previous 20142015 cold season. The most noteworthy increase was found at the Armys
bases at Vilseck and Grafenwoehr, Germany (whose health care comes from the
Armys Bavaria Medical Department Activity) where there were 48 total cases treated.
Of that total, 28 cases (24 immersion injuries and four cases of superficial frostbite)
had their encounters during February 911,

2016. Figure 3 shows the numbers of cold

injuries during 20152016 and the median
numbers of cases for the previous 4 years
for those locations that had at least 30 cases
during the past 5 years. For 16 of the 22
installations, the numbers of cases in 2015
2016 were at or below the median counts
for the previous 4 years. The large increase
in cases at Vilseck/Grafenwoehr represents
the only instance of a location where the
years case count was much greater than the
MSMR Vol. 23 No. 10 October 2016

TA B L E 3c . Diagnoses of cold injuries, one per type per person per year, active component, U.S. Air Force, July 2011June 2016
Frostbite

Immersion injury

Hypothermia

Unspecified

All cold injuries

No.

Ratea

No.

Ratea

No.

Ratea

No.

Ratea

No.

Ratea

183

11.4

31

1.9

42

2.6

47

2.9

303

18.9

148

11.4

30

2.3

34

2.6

29

2.2

241

18.5

35

11.5

0.3

2.6

18

5.9

62

20.4

White, non-Hispanic

109

10.3

24

2.3

30

2.8

33

3.1

196

18.5

Black, non-Hispanic

33

15.3

1.4

3.3

4.2

52

24.2

Other

41

12.5

1.2

1.5

1.5

55

16.7

<20

12

18.3

13.7

4.6

4.6

27

41.2

2024

87

19.6

1.8

14

3.1

19

4.3

128

28.8

2529

47

11.1

1.9

15

3.5

13

3.1

83

19.6

3034

14

4.8

0.7

2.0

2.0

28

9.5

3539

15

7.2

1.4

1.0

1.4

23

11.1

4044

6.0

0.9

0.0

0.9

7.7

45+

1.9

0.0

3.7

3.7

9.3

157

12.2

29

2.3

36

2.8

37

2.9

259

20.1

26

8.2

0.6

1.9

10

3.2

44

13.9

Infantry/artillery/combat

75.3

0.0

0.0

0.0

75.3

Armor/motor transport

17.3

0.0

8.7

0.0

26.0

Repair/engineering

62

11.9

1.5

10

1.9

13

2.5

93

17.9

Comm/intel

35

9.4

1.1

1.9

1.9

53

14.2

Health care

5.8

0.0

1.9

2.6

16

10.3

67

12.5

19

3.6

21

3.9

23

4.3

130

24.3

20112012

40

12.1

2.4

13

3.9

2.7

70

21.3

20122013

33

10.0

2.4

2.7

10

3.0

60

18.2

20132014

52

15.9

2.5

2.5

12

3.7

80

24.5

20142015

41

13.2

1.0

1.3

2.6

56

18.0

20152016

17

5.5

1.3

2.6

2.6

37

12.0

Total
Sex
Male
Female
Race/ethnicity

Age

Rank
Enlisted
Officer
Occupation

Other
Cold year (JulJun)

*Rate per 100,000 person-years

median of recent years. Figure 4 displays the

geographical distribution of the locales that
have had the most cases in the last 5 years
and depicts the numbers of cases for each.
EDITORIAL COMMENT

Overall incidence rates of cold injuries

in U.S. service members declined during
the most recent two winters after having
October 2016 Vol. 23 No. 10 MSMR

peaked in winter 20132014 when much of

the eastern U.S. experienced much colderthan-average weather attributed to a weakening of the polar vortex.5 For the Navy
and Air Force, the rates of all cold injuries
in 20152016 were the lowest of any year
of the surveillance period. The 20152016
rates for the Army and Marine Corps were
lower than the rates for the previous 2 years
but still higher than the rates for the first 2
years of the surveillance period.

Frostbite was the most common type

of cold injury for service members in all
the services except for the Marine Corps,
in which hypothermia was the most common in 20152016. Factors associated
with increased risk of cold injury in previous years were again noted during the
most recent cold season. Rates of cold
injuries were higher among service members who were the youngest (less than 20
years old), female, enlisted, and of black,
Page 17

TA B L E 3d. Diagnoses of cold injuries, one per type per person per year, active component, U.S. Marine Corps, July 2011June 2016
Frostbite

Total

Immersion injury

No.

Ratea

114

11.9

No.

Hypothermia

Unspecified

All cold injuries

Ratea

No.

Ratea

No.

Ratea

No.

Ratea

150

15.6

110

11.5

86

9.0

460

48.0

Sex
Male

98

11.0

148

16.7

100

11.3

78

8.8

424

47.7

Female

16

22.7

2.8

10

14.2

11.4

36

51.1

Race/ethnicity
White, non-Hispanic

54

8.7

109

17.6

60

9.7

52

8.4

275

44.4

Black, non-Hispanic

41

43.2

10

10.5

23

24.2

18

19.0

92

96.9

Other

19

7.8

31

12.7

27

11.1

16

6.6

93

38.2

<20

20

16.3

66

53.8

31

25.3

15

12.2

132

107.7

2024

54

12.4

73

16.8

49

11.3

43

9.9

219

50.4

2529

23

12.0

4.2

24

12.5

15

7.8

70

36.5

3034

14

14.3

1.0

4.1

11

11.2

30

30.7

3539

3.1

3.1

1.6

1.6

9.4

4044

3.0

0.0

3.0

0.0

5.9

45+

0.0

0.0

0.0

7.2

7.2

Age

Rank
Enlisted

83

9.7

138

16.2

104

12.2

65

7.6

390

45.8

Officer

31

28.9

12

11.2

5.6

21

19.6

70

65.3

37

17.4

14

6.6

16

7.5

16

7.5

83

39.0

5.0

5.0

5.0

10.0

10

25.1
15.5

Occupation
Infantry/artillery/combat eng.
Armor/motor transport
Repair/engineering

3.3

3.8

12

5.0

3.3

37

Comm/intel

22

10.4

0.9

3.8

16

7.6

48

22.7

Health care

45

17.6

123

48.2

72

28.2

42

16.5

282

110.5

20112012

4.0

18

9.0

22

11.0

4.5

57

28.5

20122013

17

8.7

19

9.7

15

7.7

20

10.2

71

36.3

20132014

52

26.9

20

10.3

20

10.3

24

12.4

116

60.0

20142015

17

9.2

76

40.9

23

12.4

25

13.5

141

75.9

20152016

20

10.8

17

9.2

30

16.3

4.3

75

40.7

Other
Cold year (JulJun)

*Rate per 100,000 person-years

non-Hispanic race/ethnicity. Increased

rates of cold injuries affected all enlisted
and most officer occupations among black,
non-Hispanic service members. In particular, rates of frostbite were appreciably
higher in black, non-Hispanics. The MSMR
has previously noted that this latter pattern
suggests that other factors such as physiologic differences or previous cold weather
experience are possible explanations for
increased susceptibility.5
Page

18

The numbers of cold injuries associated with service in Iraq and Afghanistan
have fallen precipitously in the past four
cold seasons and the 11 cases in the most
recent year are the fewest in the surveillance period. This reduction in the number of cases is almost certainly a byproduct
of the dramatic decline in the numbers
of service members in that region and
changes in the nature of military operations there.

The 1 October 2015 MHS adoption

of the ICD-10 coding system greatly
increased the number of possible diagnostic codes for cold injuries. This increase
was especially true for frostbite. Under the
now-superseded ICD-9 system, the four
possible frostbite codes covered injuries of
the face, hand, foot, and other and unspecified sites. The new ICD-10 codes distinguish superficial frostbite injuries from
those with tissue necrosis. Within each of
MSMR Vol. 23 No. 10 October 2016

Figure 3 locations

60
Red bars: incident cases in 20152016 exceed the median of previous four seasons
Green bars: incident cases in 20152016 are less than or equal to the median of previous four seasons
Horizontal lines: median number of incident cases in the previous four seasons (20112015)

50

50

Great Lakes, IL

Portsmouth/Norfolk, VA

Ft. Jackson, SC

Ft. Riley, KS

Ft. Hood, TX

JB Elmendorf-Richardson, AK

Camp Lejeune, NC

Ft. Leonard Wood, MO

Ft. Sill, OK

Ft. Drum, NY

San Diego, CA

Camp Pendleton, CA

South Korea

Parris Island / Beaufort, SC

10

JB Lewis-McChord, WA

10

Ft. Carson, CO

20

MCB Quantico, VA

20

Ft. Campbell, KY

30

Ft. Bragg, NC

30

Ft. Benning, GA

40

Ft. Wainwright, AK

40

Bavaria (Vilseck), GY

Cold injury cases, 20152016

60

Median no. of cold injury cases per year, 20112015

3. Annual number of cold injuries, cold year 20152016, and median number of cold injuries, cold years 20112015, at locations with at least 30
F I G U R E 3 . Figure
Annual
number of cold injuries, cold year 20152016, and median number of cold injuries, cold years 20112015, at locations with at least 30
cold injuries during the surveillance period, active component members, U.S. Armed Forces, July 2011June 2016
cold injuries during the surveillance period, active component members, U.S. Armed Forces, July 2011June 2016

F I G U R E 4 . Total numbers of cold injuries at locations with at least 30 cold injuries during the surveillance period, active component members, U.S. Armed
Forces, July 2011June 2016

Page 1

October 2016 Vol. 23 No. 10 MSMR

Page 19

those two categories, it is possible to specify injuries to ear, nose, other part of the
head, neck, thorax, abdominal wall, lower
back and pelvis, arm, wrist, hand, fingers,
hip and thigh, knee and lower leg, ankle,
foot, toes, and other and unspecified sites.
For certain of these body parts, there are
codes that indicate whether the frostbite
injury was on the right, left, or unspecified
side of the body. Lastly, the final characters of ICD-10 codes permit distinguishing
initial health encounters from subsequent
ones and from encounters for sequelae. The
total of 222 ICD-10 codes for frostbite has
the potential for enabling more anatomically specific analyses in the future that
may point the way to priorities in preventive strategies. Because the ICD-10 data in
this report reflected only 9 months of cold
weather injuries, the many diverse ICD-10
codes were aggregated to permit comparison with the ICD-9 codes that were in use
for most of the surveillance period.
Policies and procedures are in place
to protect service members against cold
weather injuries. Modern cold weather
uniforms and equipment provide excellent protection against the cold when
used correctly. However, in spite of these

safeguards, a significant number of individuals within all military services continue to

be affected by cold weather injuries each
year. It is important that awareness, policies, and procedures continue to be emphasized to reduce the toll of such injuries. In
addition, enhancements in protective technologies deserve continued research. It
should be noted that this analysis of cold
injuries was unable to distinguish between
injuries sustained during official military
duties (training or operations) and injuries associated with personal activities not
related to official duties. To provide for all
circumstances that pose the threat of cold
weather injury, service members should
know well the signs of cold injury and how
to protect themselves against such injuries
whether they are training, operating, fighting, or recreating under wet and freezing
conditions.
The most current cold injury prevention materials are available at http://
phc.amedd.army.mil/topics/discond/
cip/Pages/default.aspx.
Author affiliation: Armed Forces Health Surveillance Branch, Silver Spring, MD.

REFERENCES
1. Pozos RS (ed.) Section II. Cold environments.
in Medical Aspects of Harsh Environments, Vol. 1.
DE Lounsbury and RF Bellamy, eds. Washington,
DC: Office of the Surgeon General, Department of
the Army, United States of America, 2001:311609.
2. Castellani JW, OBrien C, Baker-Fulco C,
Sawka MN, Young AJ. Sustaining health and
performance in cold weather operations. Technical
Note No. TN/02-2. U.S. Army Research Institute of
Environmental Medicine, Natick, MA. October 2001.
3. DeGroot DW, Castellani JW, Williams JO,
Amoroso PJ. Epidemiology of U.S. Army cold
weather injuries, 19801999. Aviat Space Environ
Med. 2003;74(5):564570.
4. Candler WH, Ivey H. Cold weather injuries
among U.S. soldiers in Alaska: a five-year review.
Mil Med. 1997;162(12):788791.
5. Armed Forces Health Surveillance Center.
Update:Cold weather injuries, active and reserve
component, U.S. Armed Forces, July 2010June
2015. MSMR. 2015;22(10):712.
6. Armed Forces Health Surveillance Center.
Armed Forces Reportable Events Guidelines and
Case Definitions, March 2012. http://www.health.
mil/Military-Health-Topics/Health-Readiness/
Armed-Forces-Health-Surveillance-Branch/
Reports-and-Publications. Accessed on 29
September 2016.

MSMRs Invitation to Readers

Medical Surveillance Monthly Report (MSMR) invites readers to submit topics for consideration as the basis for future MSMR reports. The
MSMR editorial staff will review suggested topics for feasibility and compatibility with the journals health surveillance goals. As is the case with
most of the analyses and reports produced by Armed Forces Health Surveillance Branch staff, studies that would take advantage of the healthcare
and personnel data contained in the Defense Medical Surveillance System (DMSS) would be the most plausible types. For each promising topic,
Armed Forces Health Surveillance Branch staff members will design and carry out the data analysis, interpret the results, and write a manuscript
to report on the study. This invitation represents a willingness to consider good ideas from anyone who shares the MSMRs objective to publish
evidence-based reports on subjects relevant to the health, safety, and well-being of military service members and other beneficiaries of the Military
Health System (MHS).
In addition, MSMR encourages the submission for publication of reports on evidence-based estimates of the incidence, distribution,
impact, or trends of illness and injuries among members of the U.S. Armed Forces and other beneficiaries of the MHS. Information about
manuscript submissions is available at www.health.mil/Military-Health-Topics/Health-Readiness/Armed-Forces-Health-Surveillance-Branch/
Reports-and-Publications/Medical-Surveillance-Monthly-Report/Instructions-for-Authors.
Please email your article ideas and suggestions to the MSMR editorial staff at: dha.ncr.health-surv.mbx.afhs-msmr@mail.mil.

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MSMR Vol. 23 No. 10 October 2016