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AFHSB's health surveillance program supports Defense Department global health engagement efforts

U.S. Air Force Senior Airman Joshua Douglass, left, an aerospace medical technician, watches as Liberian health care workers properly put on their personal protective equipment as part response by the Defense Department operation to provide logistics, training and engineering support during the Ebola virus outbreak. (U.S. Army photo by Staff Sgt. Terrance D. Rhodes) U.S. Air Force Senior Airman Joshua Douglass, left, an aerospace medical technician, watches as Liberian health care workers properly put on their personal protective equipment as part response by the Defense Department operation to provide logistics, training and engineering support during the Ebola virus outbreak. (U.S. Army photo by Staff Sgt. Terrance D. Rhodes)

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Armed Forces Health Surveillance Division | Global Emerging Infections Surveillance | Antimicrobial Resistance (AMR) Surveillance | Febrile and Vector-Borne Infections (FVBI) Surveillance | Enteric Infections (EI) Surveillance | GEIS Partners | Global Health Engagement

Both the U.S. Armed Forces’ operational posture and the emergence and spread of infectious diseases relevant to military operations have evolved in recent decades. Worldwide, people are more mobile and interconnected than ever before. At the same time, land use in the developing world is changing in such a way that long-dormant pathogens have the opportunity to re-emerge and become health problems for a significant proportion of the population again. These conditions threaten not only the health of populations, but also the security and stability of nations around the world.

The Defense Department has long recognized the link between global health and security, and its global health engagement efforts address the intersection of these concerns. Defense Department health agencies are primarily focused on protecting the health of the force and medical readiness, but their global health engagement efforts also address other security priorities for the U.S. government such as helping partner nations build health capacity, combatting global health threats (e.g., emerging infectious diseases and antibiotic-resistant bacteria), and supporting U.S. government humanitarian assistance and disaster relief initiatives.

The Global Emerging Infections Surveillance (GEIS) section of the Armed Forces Health Surveillance Branch (AFHSB) supports global health engagement by leveraging a network of Defense Department laboratory partners that are positioned in critical locations globally and work with partner nations to combat infectious disease threats. Defense Department laboratories around the world execute coordinated, integrated surveillance efforts to detect and respond to febrile and vector-borne infections, respiratory infections, antimicrobial-resistant and sexually transmitted infections, and enteric infections regardless of the source. These efforts are conducted in more than 70 countries and serve to protect the health of a highly mobile force by informing risk assessments and countermeasure development, providing support to outbreak response efforts when they arise, and supporting operational access and freedom of movement in high-threat areas.

In support of the Defense Health Agency’s combat support efforts, the GEIS network’s ultimate goal is early, accurate detection of emerging infectious disease and rapid communication regarding those that potentially threaten the health of U.S. forces so that preventive measures can be taken to enable operational readiness and mitigate the risk of mission failure. Surveillance efforts are conducted in partnership with partner nation ministries of health and defense, thereby improving their health capacity by enabling rapid identification and response to infectious disease threats to their population and strengthening relationships with key U.S. partners. In this way, the GEIS program supports the U.S. geographic combatant commands (GCCs) in their areas of responsibility, advancing their campaign plans, lines of efforts, and end states. Additionally, by providing direct technical support to GCC-led international scientific coalitions and strategic engagement efforts, GEIS enhances Defense Department global health engagements and advances information sharing with partner nations. These activities ultimately better inform force health protection decision making at the GCCs and enable global health security for partner nations and U.S. government assets abroad.

Throughout December, in celebration of the Global Health Engagement Month, AFHSB will showcase some of the surveillance efforts conducted by GEIS’s laboratory partners around the world. These stories are available on DHA’s Global Health Engagement Spotlight page.

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Surveillance Snapshot: Influenza Immunization among U.S. Armed Forces Healthcare Workers, August 2012 – April 2017

Infographic
10/31/2017
Did you know …?  During the 2016 – 2017 influenza season, each of the three services attained greater than 94% compliance among healthcare personnel. The U.S. Advisory Committee on Immunization Practices recommends that all healthcare personnel be vaccinated against influenza to protect themselves and their patients. The Joint Commission requires that healthcare organizations have influenza vaccination programs for practitioners and staff, and that they work toward the goal of 90 percent receipt of influenza vaccine. This snapshot of a five-year surveillance period (August 2012 – April 2017) shows  that the active component healthcare personnel of the Army, Navy, and Air Force has exceeded the percentage compliance with influenza immunization requirement in each year. •	Line graph showing the percentage of healthcare specialists and officers with records of influenza vacation by influenza year (1 August through 30 April) and service, active, U.S. Armed Forces, August 2012 – April 2017 displays. Access the full snapshot in MSMR Vol. 24 No. 10 October 2017 at Health.mil/MSMR There are two photos featured on the infographic: 1.	A service member being vaccinated with the flu vaccine displays  2.	A photo of vaccine administrators shows.

This snapshot of a five-year surveillance period (August 2012 – April 2017) details influenza immunization compliance among the active component healthcare personnel of the Army, Navy, and Air Force.

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Armed Forces Health Surveillance Division

Challenges with diagnosing and investigating suspected active Tuberculosis disease in military trainees

Infographic
9/14/2017
The incidence rates of active tuberculosis (TB) disease in the general U.S. population and the U.S. military have declined over the past two decades, with foreign birth remaining one of the strongest correlates of risk. Recently, there have been several atypical and asymptomatic presentations of active and suspected TB cases among the population of trainees at Joint base San Antonio – Lackland, TX. Between 1 January 2010 and 31 December 2016, a total of 14 U.S. and international military personnel in training at JBSA – Lackland were hospitalized for suspected pulmonary TB. The variety of atypical presentations and their resulting diagnostic and public health challenges promoted this retrospective review of all hospitalized cases. This case series raises concerns about the increasing reliance on molecular tests for rapid diagnosis of active TB, especially in patients with minimal to no pulmonary symptoms. Findings •	The incidence rate in the training population was 1.89 per 100,000 population •	5 of 14 U.S. and international military personnel were diagnosed with active TB disease •	All were male, aged 19 – 29 years •	Only one TB case had pulmonary symptoms, but these were not suggestive of TB •	8 of 14 trainees were asymptomatic at the time of hospital admission, and tuberculin skin test and interferon gamma release assay results were highly variable Chart displays with descriptions and diagnoses of trainees hospitalized for suspected active tuberculosis, Joint Base San Antonio  – Lackland, TX, 2010 – 2016 (N=14). Access the report in MSMR Vol. 24 No. 8 August 2017 at Health.mil/MSMR  Images featured on infographic: •	Human lungs •	Image of TB

The incidence rates of active tuberculosis (TB) disease in the general U.S. population and the U.S. military have declined over the past two decades, with foreign birth remaining one of the strongest correlates of risk. This infographic documents findings from several atypical and asymptomatic presentations of active and suspected TB cases among the population of trainees at Joint Base San Antonio – Lackland, TX between 1 January 2010 and 31 December 2016.

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Armed Forces Health Surveillance Division

Multiple Sclerosis among service members of the active and reserve components of the U.S. Armed Forces and among other beneficiaries of the Military Health System, 2007 – 2016

Infographic
9/14/2017
Multiple sclerosis (MS) is an immune-mediated inflammatory demyelinating disease of the central nervous system, affecting approximately 400,000 people in the U.S. and more than two million people worldwide. The inflammatory demyelination and axonal injury that characterize MS result in significant clinical disability and economic burden. This study makes a useful contribution to the literature on temporal changes in the incidence of MS by sex and race/ ethnicity. A map of the U.S. displays to show a visual about the 400,000 people affected by MS in the country. An image of Earth displays to show a visual about the more than 2 million people worldwide affected by MS. FINDINGS •	Between 2007 and 2016, a total of 2,031 active component service members received incident diagnoses of MS •	The overall unadjusted incidence rate was 14.9 cases per 100,000 p-yrs •	During the surveillance period, unadjusted annual incidence rates of MS decreased by 25.4% •	The highest overall incidence rates were observed among service members diagnosed after age 30 with rates peaking among those aged 40 years or older. First line graph shows:  annual incidence rates of MS were higher among female service members than male service members and decreased by 42.2% during the 10-year period.  Second line graph shows:  The higher overall incidence of MS among non-Hispanic blacks was found among females, and to a lesser degree among males. Median age at MS case-defining diagnosis •	Age 32 years among active component members •	Age 37 years among reserve / guard members •	Age 48 years among non-service member beneficiaries  Common MS Symptoms •	Numbness •	Tingling in limbs •	Visual Loss •	Double Vision •	Mother Weakness •	Gait Disturbance Images showings these symptoms display. Access the full report in MSMR Vol. 24 No. 3 August 2017 at Health.mil/MSMR

Multiple sclerosis (MS) is an immune-mediated inflammatory demyelinating disease of the central nervous system, affecting approximately 400,000 people in the U.S. and more than two million people worldwide. This infographic documents data on the temporal changes in the incidence of MS by sex and race/ ethnicity.

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Armed Forces Health Surveillance Division

Mid-season influenza vaccine effectiveness estimates for the 2016 – 2017 influenza season

Infographic
8/28/2017
The Department of Defense (DoD) conducts year-round influenza surveillance for military healthcare beneficiaries and select civilian populations. Data from routine respiratory surveillance are used to estimate mid-season influenza vaccine effectiveness (VE) and these findings are shared at the Food and Drug Administration’s advisory committee meeting on U.S. influenza vaccine strain selection. DoD VE estimates from the Defense Health Agency’s Armed Forces Health Surveillance Branch (AFHSB) and Naval Health Research Center (NHRC) are presented in this report. Findings •	For all influenza types: VE was 42% as found by AFHSB-Air Force Satellite Cell, similar to NHRC’s overall VE of 45% •	Influenza A (H3N2) VE was 42% by AFHSB-AF estimation and VE was 46% as estimated by NHRC •	VE for Influenza B was slightly higher at 53% as estimated by AFHSB-AF •	AFHSB analysis found that VE against influenza A was 3% and VE against influenza A (H3N2) was 33% Table showing the mid-season influenza effectiveness estimates, 2016 –2017 displays. The mid-season influenza VE estimates indicated that vaccination reduced the odds of medically attended influenza infection by approximately 45% among DoD dependents and civilians. Access the full report in MSMR Vol. 24 No. 8 August 2017 at Health.mil/MSMR  Three photos display on this infographic: 1.	An elderly woman receiving a flu show from a female service member 2.	Female service member receives a flu shot 3.	Male physician hold a flu shot

This infographic documents Department of Defense mid-season influenza vaccine effectiveness estimates from the Defense Health Agency’s Armed Forces Health Surveillance Branch and Naval Health Research Center for the 2016 – 2017 influenza season.

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Armed Forces Health Surveillance Division | Influenza Summary and Reports

Tdap vaccination coverage during pregnancy, active component service women, 2006 – 2014

Infographic
8/14/2017
Pertussis, commonly known as “whooping cough,” is a vaccine-preventable illness more common and more severe in children than in adults. Infections during the first few months of life can be particularly severe, with almost all deaths from pertussis occurring in infants less than 6 months of age. A vaccinated mother’s antibodies against pertussis protect the baby during pregnancy until it can receive the vaccine at two months of age. Approximately 400 probable and 50 confirmed cases occur annually among service members and other adult beneficiaries of the Military Health System. In 2012, the Advisory Committee on Immunization Practices recommended Tdap for every pregnancy to reduce the burden of pertussis in infants. This surveillance study assessed Tdap vaccination coverage among pregnant service women during 2006 through 2014. FINDINGS: •	There were records of a total of 137,133 live birth deliveries to service women •	Only 1%  – 3% of service women received a Tdap vaccine during pregnancy from 2006  – 2011 •	Tdap vaccination coverage increased substantially  – 8% in 2012 to 54% in 2014 •	Navy women had the highest  annual proportion of vaccine coverage at 65% in 2014 •	First deliveries had the highest vaccination coverage at 57% in 2014 •	Fourth or subsequent deliveries had the lowest coverage at 41% in 2014 More education and attention by military physicians and pregnant service women about the benefits of Tdap vaccination are needed to bring coverage closer to 100%. Learn more in MSMR Vol. 22 No. 5 May 2015 at Health.mil/MSMR  Images on graphic: •	Baby icon to depict live birth deliveries •	Pie charts showing the findings in visual form •	Line graph showing the percent vaccinated among Navy, Marine Corps, Army, Air Force and Coast Guard The line graph shows the annual percentages of active component service women with a live birth delivery who received a Tdap vaccine during pregnancy, by year of delivery and service, 2011– 2014.

This infographic documents findings from a surveillance study that assessed Tdap vaccination coverage among pregnant service women during 2006 through 2014.

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Armed Forces Health Surveillance Division | Tetanus-Diphtheria-Pertussis | Women's Health

Surveillance Snapshot Norovirus Outbreaks among Military Forces, 2008 – 2016

Infographic
8/8/2017
Norovirus (NoV) is a highly contagious virus and a leading cause of gastroenteritis among military populations. There are many different strains of norovirus and immunity to one strain does not protect against another. Why Norovirus Strains Are Leading Causes of Acute Gastrointestinal Illness Outbreaks •	Multiple transmission routes include person-to-person direct contact, contaminated food and water, clothes or utensils that carry infection  •	Resistant to extreme temperatures and standard cleaning solutions •	No lasting immunity This report summarizes the NoV outbreaks in military forces in both garrison and deployed settings during 2008 – 2016. Table from this MSMR article displays and includes month/year of outbreak onset, setting, estimated attack rate (EAR)/ no. of NoV cases, and description. Access the report in MSMR Vol. 24 No.7 July 2017 at Health.mil/MSMR

Norovirus (NoV) is a highly contagious virus and a leading cause of gastroenteritis among military populations. There are many different strains of norovirus and immunity to one strain does not protect against another. This report summarizes the NoV outbreaks in military forces in both garrison and deployed settings during 2008 – 2016.

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Armed Forces Health Surveillance Division

Skin and Soft Tissue Infections Active Component, U.S. Armed Forces, 2013 – 2016

Infographic
7/24/2017
Skin and soft tissue infections (SSTIs) are common in both military and non-military populations. Due to the nature of the military training environment, risk factors associated with SSTIs such as crowding, infrequent hand washing/ bathing, skin abrasions and trauma, and environmental contamination favor the acquisition and transmission of Staphylococcus spp. and Streptococcus spp. These pathogens are the major causative agents of SSTIs and lead to outbreaks of disease.

This report documents the incident cases of skin and soft tissue infections among active component U.S. military member during a 4-year surveillance period.

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Armed Forces Health Surveillance Division

Age-Period-Cohort Analysis of Colorectal Cancer Service Members Aged 20-59 Years Active Component U.S. Armed Forces, 1997 – 2016

Infographic
7/24/2017
Among cancers affecting both men and women, colorectal cancer is the third most common cancer and the second leading cause of death from cancer in the U.S. This report documents the time-varying elements of age, period, and birth cohort effects in the epidemiology of colorectal cancer among members of the active component.

This report documents the time-varying elements of age, period, and birth cohort effects in the epidemiology of colorectal cancer among members of the active component.

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Armed Forces Health Surveillance Division

Heat Illness Prevention: Use the Buddy System to Stay Cool and Safe

Infographic
7/20/2017
Did you know that exposure to heat and heat-related illnesses can cause a spectrum of disorders that includes minor conditions such as heat cramps to the more severe condition known as heat stroke? To protect U.S. service members, it is important for commanders, small unit leaders, training cadre, and supporting medical personnel to encourage the use of the buddy system to prevent these conditions – especially during training at recruit centers and installations. The buddy system pairs service members to stay motivated and hold each other accountable of their physical limits during training exercises. Protecting Service Members from Heat Illness •	Do not exercise when sick. Intense workouts can increase susceptibility to illness, including infection and diarrhea. •	Dump heat by taking a cold shower or ice slush immersion before a workout. •	Wear a cooling vest to keep skin cool and dry in the heat. Learn more about heat illness prevention at Health.mil/AFHSB Stay cool. Stay hydrated. Stay informed. #BeatTheHeat Source: Dr. Francis G. O’Connor, a professor and chair of Military and Emergency Medicine and associate director for the Consortium on Health and Military Performance at the Uniformed Services University of the Health Sciences.

This infographic documents the use of the buddy system to prevent heat-related illnesses.

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Armed Forces Health Surveillance Division | Summer Safety

Preventable and Treatable: Know the Signs of Heat Exhaustion

Infographic
7/20/2017
Warmer temperatures and strenuous physical activity put service members at higher risk of heat illnesses. It is important for commanders, small unit leaders, training cadre, and supporting medical personnel – particularly at recruit training centers and installations with large combat troop populations – to educate service members about the risks early signs and symptoms, and preventive treatment measures related to heat illnesses. Signs of Dehydration •	Light-headed/ Dizzy/ Headache •	Fever •	Lack of sweat •	Dark yellow urine •	Thirst Under the signs of dehydration section an image of a man experiencing these early signs and symptoms of heat illnesses. Staying Hydrated •	Hydrate with water and eat rich foods with water before, during, and after exercise. •	Decrease the intensity of the physical activity. Under the staying hydrated section graphics of a water bottle, glass of water, runner and cyclist appear. Signs of Heat Stroke •	Fatigue •	Combative •	Confused •	Muscle cramps Under the signs of heat stroke section, a man experiencing these symptoms of heat stroke displays. Effective Ways to Cool Off a Heat Stroke Victim •	Make an “ice burrito” by wrapping the victim in cold sheets, ice packs, and wet towels •	Immerse victim in cold water Images of ice and a man under a shower appear.  Ways to Treat Heat Exhaustion •	Use a rectal thermostat to read core body temperatures to diagnose and treat heat stroke •	Provide IV fluid replacement •	Spray with cool mist Image of rectal thermostat, man in a hospital bed with an IV and a man being sprayed with cool mist appear. Learn more about heat illness by reading MSMR Vol. 24 No. 3 – March 2017 at Health.mil/MSMR Source: Dr. Francis FG. O’Connor, a professor and chair of Military and Emergency Medicine and associate director for the Consortium on Health and Military Performance at the Uniformed Services University of the Health Sciences.

This infographic documents the risks, early signs and symptoms, and preventive treatment measures related to heat illnesses.

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Armed Forces Health Surveillance Division | Summer Safety

Incidence of Escherichia Coli Intestinal Infections Active Component, U.S. Armed Forces, 2007 – 2016

Infographic
7/11/2017
Escherichia coli bacteria normally live in the lower intestines of healthy people and animals. Most varieties of E. coli are harmless, but certain types of E. coli are among the most frequent bacterial causes of diarrhea. This report summarizes the counts, rates, and trends of E. coli gastrointestinal infections in active component service members over the past 10 years. Findings: •	During 2007 – 2016, there were 290 incident cases of E. coli infection among active duty service members •	The overall incidence rate was 2.3 cases per 100,000 person-years (p-yrs) •	Annual incidence rates peaked at 4.7 cases per 100,000 p-yrs. in 2016 •	Cases were shown to peak during warmer months Overall rates were higher for: •	Persons aged 50 years or older •	Persons aged 25-29 years •	Females at twice the rate of males •	Non-Hispanic white service members •	Air Force members •	Service members in healthcare occupations Two graphs appear on infographic: One graph shows the annual numbers of incident cases and incidence rates of E. coli infection, active component, U.S. Armed Forces, 2007 – 2016. The second graph shows the cumulative number of incident cases of E. coli infection by calendar month, active component, U.S. Armed Forces, 2007 – 2016. Access the report in MSMR Vol. 24 No. 6 – June 2017 at Health.mil/MSMR

This report summarizes the counts, rates, and trends of Escherichia coli gastrointestinal infections in active component service members over the past 10 years.

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Armed Forces Health Surveillance Division

Incidence of Nontyphoidal Salmonella Intestinal Infections Active Component, U.S. Armed Forces, 2007 – 2016

Infographic
7/11/2017
The term nontyphoidal salmonellae (NTS) refers to gram-negative bacteria of the genus Salmonella except for the specific strains S. typhi and S. paratyphi. NTS are a leading cause of foodborne illness in the U.S. and of acute gastrointestinal illness among members of the active component of the U.S. Armed Forces. This report summarizes the counts, rates, and trends of nontyphoidal Salmonella infections in active component service members during a 10-year surveillance period. Findings  •	During 2007 – 2016, there were 1,536 incident cases of nontyphoidal Salmonella infection among active duty service members •	The overall incidence rate was 12.4 cases per 100,000 person-years (p-yrs) •	In 2016, the annual incidence rates peaked at 15.9 cases p-yrs •	Cases were shown to peak during the summer months Graph displays highlighting findings above for annual numbers of incident cases and incidence rates of nontyphoidal salmonellosis, active, component, U.S. Armed Forces, 2007 – 2016.  Overall rates were higher in: •	 Females •	Persons Aged 25-29 years •	Aged 50 years or older Access the report in the MSMR Vol. 24 No. 6 – June 2017 at Health.mil/MSMR

This report summarizes the counts, rates, and trends of nontyphoidal Salmonella infections in active component service members during a 10-year surveillance period.

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Armed Forces Health Surveillance Division

Estimate of the Incidence of Norovirus Infections Active Component, U.S. Armed Forces, 2007 - 2016

Infographic
7/11/2017
The norovirus (NoV) is a highly infective and easily transmitted pathogen that imposes a significant public health burden across geographic regions as the causative pathogen for approximately 18% of all diarrhea cases worldwide. This report estimates the incidence of NoV diagnoses among active component service members during a 10-year surveillance period using medical record documentation of diagnoses of NoV infection and of positive laboratory tests for the virus. Findings During the 10-year surveillance period, there were 709 incident cases of NoV infection among active duty service members. •	The overall incidence rate was 5.7 cases per 100,000 person-years (p-yrs) •	Annual incidence rates ranged from a low of 2.5 cases per 100,000 p-yrs in 2008 to a high 11.2 cases per 100,000 p-yrs in 2010 •	Higher numbers of diagnosed cases were reported during November-March Graph depicting the above information displays. Overall rates were highest in: •	Female service members •	Persons Aged 24 years or younger •	Army members •	Junior enlisted •	Recruits Comparing the results of this analysis to modeled estimates of the underreported incidence of the NoV infections demonstrated the limited utility of using only medical encounter diagnoses, reportable events, and laboratory data to report on NoV incidence. Access the report in MSMR Vol. 24 No. 6 June 2017 at Health.mil/MSMR

This report estimates the incidence of norovirus diagnoses among active component service members during a 10-year surveillance period.

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Armed Forces Health Surveillance Division

Viral Hepatitis A, Active Component, U.S. Armed Forces, 2007 - 2016

Infographic
6/19/2017
Hepatitis A is a liver infection caused by the hepatitis A virus (HAV). An estimated 1.4 million cases are reported worldwide each year. HAV is highly contagious and is a concern of the U.S. military as widespread outbreaks can occur due to contaminated food or water and spread by unsanitary food and water handling practices. This report estimates the frequencies, incidence rates, trends, and correlates of risk of hepatitis A among active component service members of the U.S. military during 2007 – 2016. Findings: During the 10-year surveillance period, there were 237 incident diagnoses of acute hepatitis A. The overall incidence rate was 1.88 cases per 100,000 person-years (p-yrs.). In 2012, rates peaked at 2.94 per 100,000 p-yrs. Rates dipped to 1.41 per 100,000 p-yrs. in 2015 and increased to 2.22 per 100,000 p-yrs in 2016. The graph shows the incident cases and incidence rates of acute Hepatitis A, by gender, active component, U.S. Armed Forces, 2007 – 2016. The bars on the graph show the number of individuals diagnosed and the lines show incidence rates per 100,000 p-yrs. See on page 3 FIGURE 1. Incident cases and incidence rates of acute hepatitis A, by gender, active component, U.S. Armed Forces, 2007–2016 of the  May 2017 MSMR Vol. 24 No. 5. Key chart includes: pink bar for number of female service members, blue bar for number of male service members, solid yellow line for incidence rate, and dash line for U.S. population rate. Source: www.cdc.gov/hepatitis/statistics/2014surveillance/index.htm#tabs-1170596-1  High Risks of Hepatitis A •	Youngest age group of service members •	Service members who work in healthcare occupations •	Air Force and Navy members •	Unknown race/ethnicity and non-Hispanic black service members HAV vaccines in current use are highly effective. Learn more at Health.mil/MSMRArchives  Small figure of male is seen on graphic with a circle highlighting his liver.

This infographic documents the frequencies, incidence rates, trends, and correlates of risk of hepatitis A among active component service members of the U.S. military during 2007-2016.

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Armed Forces Health Surveillance Division

Surveillance Snapshot: Respiratory Infections Resulting in Hospitalizations, U.S. Air Force Recruits, October 2010 – February 2017

Infographic
6/19/2017
A number of vaccine and non-vaccine interventions have been used to reduce the historically high burden of respiratory infections during military training. This snapshot displays the trend in hospitalizations for respiratory infections, stratified by major pathogens, and associated hospital days for all recruits in U.S. Air Force Basic Military Training at Joint Base San Antonio Lackland, TX. Preventive measures: •	Hand Hygiene •	“Head-to-toe” sleeping arrangements •	Liberal use of respiratory face masks •	Isolation of febrile trainees •	Stringent gas mask cleaning protocol •	Universal provision of seasonal influenza vaccine during non-summer months Interventions: •	Year-round adenovirus vaccine (Ad4 and Ad7) was reintroduced November 2011 •	Group A streptococcus chemoprophylaxis transitioned from oral penicillin to intramuscular benzathine penicillin January 2012 Surveillance Findings: •	No recruits have been hospitalized due to adenovirus or group A streptococcus since the respective interventions were implemented. •	The adenovirus vaccine and benzathine penicillin chemoprophylaxis decrease the likelihood of severe respiratory disease outbreaks •	Downward trend in respiratory infection hospitalizations Bar graph shows the number of hospitalized for respiratory infection  per 1 million training days as well as lost training days per 1 million training days (line graph) from October 2010 to February 2017. Color coding on chart: •	Orange for Adenovirus •	Gray is for Group A streptococcus •	Yellow is for Influenza •	Blue is for Other/ Unknown •	Red is for Lost Training Days Learn more at Health.mil/MSMR where you can find the surveillance snap shot from MSMR Vol. 24 No. 4 – May 2017. In background of infographic can see human body highlight the respiratory system.

This infographic displays the trend in hospitalizations for respiratory infections, stratified by major pathogens, and associated hospital days for all recruits in U.S. Air Force Basic Military Training at Joint Base San Antonio Lackland, TX.

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Armed Forces Health Surveillance Division
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