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A 12-Year Analysis of Nonbattle Injury Among US Service Members Deployed to Iraq and Afghanistan

Educational Objective To identify the nonbattle injuries (NBIs) seen in US service members in Iraq and Afghanistan.
1 Credit CME
Key Points

Question  What are the causes and trend of nonbattle injury among US service members deployed to Iraq and Afghanistan?

Findings  In a cohort study of US military casualties among service members evacuated from Iraq and Afghanistan, nonbattle injury accounted for approximately one-third of total casualties and 11.5% of all deaths. The proportion of nonbattle injury was consistent and predictable.

Meaning  These findings document the significance and magnitude of nonbattle injury in the deployed environment; prevention of nonbattle injury could reduce a portion of the injury burden sustained during war.


Importance  Nonbattle injury (NBI) among deployed US service members increases the burden on medical systems and results in high rates of attrition, affecting the available force. The possible causes and trends of NBI in the Iraq and Afghanistan wars have, to date, not been comprehensively described.

Objectives  To describe NBI among service members deployed to Iraq and Afghanistan, quantify absolute numbers of NBIs and proportion of NBIs within the Department of Defense Trauma Registry, and document the characteristics of this injury category.

Design, Setting, and Participants  In this retrospective cohort study, data from the Department of Defense Trauma Registry on 29 958 service members injured in Iraq and Afghanistan from January 1, 2003, through December 31, 2014, were obtained. Injury incidence, patterns, and severity were characterized by battle injury and NBI. Trends in NBI were modeled using time series analysis with autoregressive integrated moving average and the weighted moving average method. Statistical analysis was performed from January 1, 2003, to December 31, 2014.

Main Outcomes and Measures  Primary outcomes were proportion of NBIs and the changes in NBI over time.

Results  Among 29 958 casualties (battle injury and NBI) analyzed, 29 003 were in men and 955 were in women; the median age at injury was 24 years (interquartile range, 21-29 years). Nonbattle injury caused 34.1% of total casualties (n = 10 203) and 11.5% of all deaths (206 of 1788). Rates of NBI were higher among women than among men (63.2% [604 of 955] vs 33.1% [9599 of 29 003]; P < .001) and in Operation New Dawn (71.0% [298 of 420]) and Operation Iraqi Freedom (36.3% [6655 of 18 334]) compared with Operation Enduring Freedom (29.0% [3250 of 11 204]) (P < .001). A higher proportion of NBIs occurred in members of the Air Force (66.3% [539 of 810]) and Navy (48.3% [394 of 815]) than in members of the Army (34.7% [7680 of 22 154]) and Marine Corps (25.7% [1584 of 6169]) (P < .001). Leading mechanisms of NBI included falls (2178 [21.3%]), motor vehicle crashes (1921 [18.8%]), machinery or equipment accidents (1283 [12.6%]), blunt objects (1107 [10.8%]), gunshot wounds (728 [7.1%]), and sports (697 [6.8%]), causing predominantly blunt trauma (7080 [69.4%]). The trend in proportion of NBIs did not decrease over time, remaining at approximately 35% (by weighted moving average) after 2006 and approximately 39% by autoregressive integrated moving average. Assuming stable battlefield conditions, the autoregressive integrated moving average model estimated that the proportion of NBIs from 2015 to 2022 would be approximately 41.0% (95% CI, 37.8%-44.3%).

Conclusions and Relevance  In this study, approximately one-third of injuries during the Iraq and Afghanistan wars resulted from NBI, and the proportion of NBIs was steady for 12 years. Understanding the possible causes of NBI during military operations may be useful to target protective measures and safety interventions, thereby conserving fighting strength on the battlefield.

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Article Information

Accepted for Publication: March 4, 2018.

Corresponding Author: Tuan D. Le, MD, DrPH, US Army Institute of Surgical Research, 3698 Chambers Pass, Ste B, Bldg 3611, Joint Base San Antonio, Fort Sam Houston, TX 78234 (tuan.d.le5.civ@mail.mil).

Published Online: May 30, 2018. doi:10.1001/jamasurg.2018.1166

Author Contributions: Dr Le had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Le, Gurney, Gross, Chung, Stockinger, Nessen, Pusateri, Akers.

Acquisition, analysis, or interpretation of data: Le, Gurney, Nnamani, Stockinger, Nessen, Pusateri, Akers.

Drafting of the manuscript: Le, Gurney, Nessen, Akers.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Le, Nessen.

Administrative, technical, or material support: Le, Chung, Stockinger, Nessen, Pusateri, Akers.

Study supervision: Gurney, Gross, Chung, Stockinger, Nessen, Pusateri, Akers.

Conflict of Interest Disclosures: None reported.

Funding/Support: The work was supported by the US Army Institute of Surgical Research and in part by an appointment to the Internship/Research Participation Program at the US Army Institute of Surgical Research, administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the US Department of Energy and the Environmental Protection Agency.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content of this publication is the sole responsibility of the authors and does not necessary reflect the views or policies of the Department of the Army, Department of the Navy, US Army Institute of Surgical Research, Brooke Army Medical Center, Army Trauma Training Center, US Army Medical Research and Materiel Command, Uniformed Services University of the Health Sciences, or the Department of Defense.

Additional Contributions: Taylor Schlotman, PhD, and Subrata Haldar, PhD, US Army Institute of Surgical Research, provided critical review and editing of the manuscript. They were not compensated for their contribution. We also thank the study participants, the staff of the Joint Trauma System, and US Army Institute of Surgical Research that made this work possible.

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