Skip to main content

Military Health System

Blood Lead Level Surveillance Among Pediatric Beneficiaries in the Military Health System, 2010–2017

Recommended Content:

Medical Surveillance Monthly Report

Abstract

The EpiData Center (EDC) has provided routine blood lead level (BLL) surveillance for Department of Defense (DOD) pediatric beneficiaries since 2011. Data for this study were collected and compiled from raw laboratory test records obtained from the Composite Health Care System Health Level 7 (HL7)-formatted chemistry data, allowing an overview of the number of tests performed and the number of elevated results. Between 2010 and 2017, there were 177,061 tests performed among 162,238 pediatric beneficiaries tested. Using only the highest test result per year for each individual, 169,917 tests were retained for analysis, of which 1,334 (0.79%) test results were considered elevated. The percentage of children with elevated BLLs generally decreased over the time period for children of every service affiliation. All tests throughout this time frame were evaluated using current standards and the protocol followed by the Centers for Disease Control and Prevention and the Department of the Navy (DON). The adoption of a standardized BLL surveillance methodology across the DOD supports a cohesive approach to an evolving public health surveillance topic.

What are the New Findings?

The EDC's BLL surveillance program established a methodology for lead exposure surveillance among DOD pediatric beneficiaries, providing critical data and valuable historical context for the interpretation of findings. Between 2010 and 2017, the percentage of children with elevated BLLs generally remained below 1.2%, and by 2017, the overall percentage was 0.5% for all children tested.

What is the Impact on Readiness and Force Health Protection?

Blood lead surveillance of DON pediatric beneficiaries is required under Bureau of Medicine and Surgery instruction 6200.14D. The EDC's methodology for BLL surveillance may be leveraged for consistent BLL surveillance across the DOD.

Background

Robust lead exposure surveillance is especially important in pediatric populations. There is no safe blood lead level (BLL) for children; even very low BLLs can increase the risk of harmful hematologic and neurologic effects.1 The U.S. Preventive Services Task Force concluded there is currently insufficient evidence to recommend BLL screening of asymptomatic children 5 years of age and younger.2 The Military Health System (MHS) does not require universal BLL screening for pediatric beneficiaries, but providers are directed to consider assessing the risk of lead exposure among children between 6 months and 6 years of age by parental questionnaire, in accordance with recommendations from the American Academy of Pediatrics.3 Children who screen positive on this questionnaire should have their BLLs tested. Additionally, clinical suspicion of lead exposure or poisoning should prompt a blood lead test. Providers should ensure the performance of follow-up care for any child with an elevated BLL, and retesting is recommended to confirm an initial elevated BLL and to monitor the decline in BLLs following treatment.4

Before 2012, a BLL of 10 µg/dL or greater was considered to be an elevated test result.In 2012, the Centers for Disease Control and Prevention (CDC) updated the guidelines for the blood lead reference value (BLRV) to 5 µg/dL or greater, based on National Health and Nutrition Examination Survey results showing declining BLLs in children.6 For an elevated BLL (5 µg/dL or greater) to be considered "confirmed," CDC requires 1 elevated result from a venous blood test or 2 elevated results from capillary blood tests within 12 weeks.7 Traditional blood lead laboratory test results are the preferred test for Department of the Navy (DON) BLL surveillance. Rapid testing results, like finger-stick tests obtained by MHS providers at the point of care, were used for BLL surveillance purposes until 30 August 2017 when the Bureau of Medicine and Surgery (BUMED) released an instruction stating point-of-care blood testing devices were no longer authorized for compliance with the childhood lead poisoning prevention program in the DON.8

Since 2011, the EpiData Center (EDC) at the Navy and Marine Corps Public Health Center (NMCPHC) has conducted routine BLL surveillance among Department of Defense (DOD) pediatric beneficiaries on a quarterly basis. An annual report based on data at the military treatment facility (MTF) level is also prepared on DON pediatric beneficiaries at the request of the Occupational and Environmental Medicine Department of NMCPHC. All surveillance reports are available to qualified DOD personnel upon request. The EDC's BLL surveillance program provides critical data and valuable historical context for evaluating lead exposure among DOD pediatric beneficiaries.

This article describes the EDC's methodology for BLL surveillance in DOD pediatric beneficiaries. This methodology represents a potential model for the development of a shared, standardized BLL surveillance method because it could be tailored to meet the unique needs of each DOD service while also maximizing the comparison, replication, and utility of findings. DON blood lead surveillance is modified from the CDC's standard blood lead surveillance definitions and classifications to best meet its needs using current capabilities. For every calendar year (CY), the EDC identifies elevated blood lead tests among DON pediatric beneficiaries and then verifies in the Armed Forces Health Longitudinal Technology Application (AHLTA) whether or not the provider followed up with the pediatric beneficiary. The EDC then provides a list of names of children that have not had follow-up testing to the Occupational and Environmental Medicine Department of NMCPHC.

Methods

Laboratory test records with a sample collection date in CYs 2010–2017 (01 January 2010 through 31 December 2017) were obtained from the Composite Health Care System (CHCS) Health Level 7 (HL7)-formatted chemistry laboratory data. The EDC receives a feed of CHCS HL7-formatted chemistry laboratory data and demographic information daily from the Defense Health Agency. These data include all records from MTFs using the CHCS across the DOD. Records were excluded if the sample was not blood, if the unit of measure or the test result could not be determined, or if the results indicated a test was not performed. For example, before CDC updated its BLRV, 122 test results were recorded as "<10." These results were removed from the final analysis, as it could not be determined if the results were less than the current BLRV of 5 µg/dL. Blood tests with the same sample collection date and date of certified results were excluded from the final sample, as these tests may have been unauthorized point of care tests8; moreover, it would have been highly unlikely for the laboratories to have been able to collect, analyze, and certify a sample on the same day. Zinc protoporphyrin (ZPP) tests, which measure the amount of ZPP in the blood (an indicator of chronic lead exposure) rather than BLL, were also excluded. If more than 1 BLL test result was identified for an individual in a single year, the highest BLL test result for that year was retained.

BLL tests administered to beneficiary children aged less than 18 years at the date and time of sample collection were included. Tests could either have been those completed within an MHS laboratory or those completed at an out-of-network laboratory, after which an MHS provider received and entered the results into AHLTA. Records were analyzed by sponsor service affiliation (Army, Air Force, Marine Corps, Navy, Other), age group (=6 years and 7–17 years), BLL value (<5 µg/dL, 5–9 µg/dL, 10–19 µg/dL, and =20 µg/dL), and geographic region (outside of the U.S., New England, Mid-Atlantic, Eastern North Central, Western North Central, South Atlantic, Eastern South Central, Western South Central, Mountain, Pacific). For sponsor service affiliation and geographic region, the percentage of elevated BLL tests per year was determined.

Results

From 01 January 2010 through 31 December 2017, 169,917 BLL records were retained for analysis (Table 1). The Army tested more pediatric beneficiaries than any other service affiliation during the reporting period. The majority of testing occurred among pediatric beneficiaries aged 6 years or younger across all branches of service.
Overall, the percentage of elevated BLLs among pediatric beneficiaries decreased from 2010 to 2017 (Figure). Less than 1% of pediatric BLL tests in any service were elevated in 2016 and 2017, and no children in the "other" category had an elevated BLL test since 2014.

For CYs 2010–2017, 96.2% of all BLL tests among pediatric beneficiaries were performed in the U.S. and 3.8% were performed elsewhere (Table 2). The percentages of elevated tests (0.8%) were equivalent for the 2 regions. Within the U.S., there were no tests performed in 9 states. Of all BLL tests in the U.S., 58.8% (n=96,089) were from the South Atlantic and Western South Central regions, which accounted for 54.8% (n=702) of all elevated BLLs. The New England region had the highest regional percentage of elevated BLLs (1.4%), but that percentage was based on just 22 elevated BLLs out of 1,561 tests, the lowest number of tests for any region. Among the states, Texas had the highest number of tests (n=29,340), followed by Virginia (n=25,852), but the percentages of tests with elevated BLLs were just 0.5% and 0.7%, respectively. The 5 states with the highest percentages of elevated BLLs (Connecticut, Rhode Island, Pennsylvania, New Hampshire, and Tennessee) accounted for just 22 elevated levels out of only 268 tests performed (Table 2). Among the remaining 37 states (including Washington, DC) that performed tests, the mean percentage positive was 0.9% and the values ranged from 0.3% (Arizona and Colorado) to 1.8% (Kansas and Mississippi).

Editorial Comment

Across the DOD, there were 177,061 tests performed between 2010 and 2017 among 162,238 pediatric beneficiaries. Some children may have had multiple tests occurring within the same year or during the totality of the reporting time frame because they had a positive lead questionnaire screen during a doctor's visit, exhibited clinical symptoms of lead poisoning per the provider's discretion, or had a prior elevated BLL test. For surveillance purposes, the highest BLL result per year per pediatric beneficiary was kept for analysis, leading to a final observation count of 169,917 BLL tests.

While the percentage of elevated BLL tests varied by sponsor service affiliation, the overall percentage of elevated BLL tests decreased from 2010 to 2017. The number of BLL tests among pediatric beneficiaries varied by state because of the location of fixed MTFs; however, in general, the percentage of elevated BLL tests did not differ between regions inside and outside of the U.S. The number of children tested within each branch of service likely varied because of the difference in the size of the service populations. Percentages of children with elevated BLLs could potentially be affected by the number of children tested within a branch of service or geographic region, whether the children tested were at a lower or higher risk of lead exposure, and the screening recommendations of the MHS.

To adequately identify and address lead exposure risks in their active duty and beneficiary populations, the DON and other DOD services might consider the adoption of a single, standardized method for BLL surveillance. A shared methodology would facilitate comparisons and reduce duplicative effort across the services. Ideally, a shared methodology would also be flexible and responsive to accommodate the challenges related to BLL surveillance in the DOD.

HL7-formatted data are routinely generated within the CHCS at fixed MTFs. HL7-formatted data do not include records from BLL tests without certified results. This may include specimens collected at an MTF that were sent to an out-of-network laboratory for testing. Data from Purchased CareThe TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.purchased care providers also were not included. Records from MHS GENESIS, a new electronic health record that launched in February 2017 at select MHS facilities, were unavailable. Therefore, records from the following MTFs throughout the Pacific Northwest region were not included in this analysis after the launch of MHS GENESIS at their facilities: Fairchild Air Force Base, Madigan Army Medical Center, Naval Health Clinic Oak Harbor, and Naval Hospital Bremerton. Changes in civilian and military testing policies, updates to exposure thresholds, population- or service-specific practices, and data limitations complicate comparisons over time and across services and limit the generalizability of findings.

The HL7-formatted chemistry database consists of nonculture laboratory test results (e.g., polymerase chain reaction and antigen testing). Providers may order a panel when patients present with nonspecific symptoms. If the test name or test results within a panel are not disease-specific, these results may not be captured in search terms used to query the chemistry data. Classifying chemistry tests involves extensive searching of free-text test result fields. It is possible that some test results were misclassified, though validation steps were included to reduce error. Venous and capillary BLL specimen samples are unable to be distinguished in the HL7-formatted chemistry data. Capillary specimen samples for lead testing are generally viewed as less reliable than venous samples because of the potential for lead contamination of specimens during collection that could result in false positives. For surveillance purposes, the EDC reports the highest BLL result per year per pediatric beneficiary and ensures that there is follow-up regarding that elevated test regardless of specimen sample type.

Universal BLL screening is not required in the MHS but is based on the discretion of healthcare practitioners. As a result, the proportion of pediatric beneficiaries with high BLLs may not be a true representation of the BLLs in the pediatric beneficiary population. However, the EDC's pediatric BLL surveillance methods may provide a starting point for discussions on the value of developing a standardized blood lead surveillance program across all DOD services.

Author affiliations: EpiData Center, Navy and Marine Corps Public Health Center, Portsmouth, VA (Ms. Kotas, Ms. Madden, Ms. Luse, and Ms. Carroll).

Acknowledgments: The authors thank Ashleigh McCabe and Angela Schlein for their support of this analysis and manuscript.

Disclaimers: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. The authors are employees of the U.S. Government. This work was prepared as part of their official duties. Title 17, U.S.C., §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C., §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person's official duties. This research was supported in part by an appointment to the Postgraduate Research Participation Program at the Navy and Marine Corps Public Health Center administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy and the Navy and Marine Corps Public Health Center.

References

1. Centers for Disease Control and Prevention. Health effects of lead exposure. https://www.cdc.gov/nceh/lead/prevention/health-effects.htm. Accessed 05 March 2020.

2. U.S. Preventive Services Task Force. Elevated blood lead levels in children and pregnant women: screening. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/elevated-blood-lead-levels-in-childhood-and-pregnancy-screening. Accessed 05 March 2020.

3. American Academy of Pediatrics. Detection of lead poisoning. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/lead-exposure/Pages/Detection-of-Lead-Poisoning.aspx. Accessed 05 March 2020.

4. Advisory Committee on Childhood Lead Poisoning Prevention, Centers for Disease Control and Prevention. Low level lead exposure harms children: a renewed call for primary prevention. https://www.cdc.gov/nceh/lead/ACCLPP/Final_Document_030712.pdf. Accessed 05 March 2020.

5. Centers for Disease Control and Prevention. Preventing lead poisoning in young children. https://wonder.cdc.gov/wonder/prevguid/p0000029/p0000029.asp. Accessed 05 March 2020.

6. Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey (NHANES). https://www.cdc.gov/nceh/lead/data/nhanes.htm. Accessed 05 March 2020.

7. Centers for Disease Control and Prevention. Standard surveillance definitions and classifications. https://www.cdc.gov/nceh/lead/data/case-definitions-classifications.htm. Accessed 05 March 2020.

8. Department of the Navy, Bureau of Medicine and Surgery. BUMED Instruction 6200.14D. Childhood Lead Poisoning Prevention. 30 August 2017.

Percentage of elevated (=5 µg/dL) pediatric BLL tests, by sponsor service affiliation, 2010–2017

Pediatric BLLs, by sponsor service affiliation and age group, 2010–2017

Number and percentage of elevated (=5 µg/dL) pediatric BLLs, by region and state, 2010–2017

You also may be interested in...

MSMR Vol. 29 No. 07 - July 2022

Report
7/1/2022

A monthly publication of the Armed Forces Health Surveillance Division. This issue of the peer-reviewed journal contains the following articles: Surveillance trends for SARS-CoV-2 and other respiratory pathogens among U.S. Military Health System Beneficiaries, Sept. 27, 2020 – Oct. 2,2021; Establishment of SARS-CoV-2 genomic surveillance within the MHS during March 1 – Dec. 31 2020; Suicide behavior among heterosexual, lesbian/gay, and bisexual active component service members in the U.S. Armed Forces; Brief report: Phase I results using the Virtual Pooled Registry Cancer Linkage system (VPR-CLS) for military cancer surveillance.

Recommended Content:

Health Readiness & Combat Support | Public Health | Medical Surveillance Monthly Report

Brief Report: Phase I Results Using the Virtual Pooled Registry Cancer Linkage System (VPR-CLS) for Military Cancer Surveillance

Article
7/1/2022
A patient at Naval Hospital Pensacola prepares to have a low-dose computed tomography test done to screen for lung cancer. Lung cancer is the leading cause of cancer-related deaths among men and women. Early detection can lower the risk of dying from this disease. (U.S. Navy photo by Jason Bortz)

The Armed Forces Health Surveillance Division, as part of its surveillance mission, periodically conducts studies of cancer incidence among U.S. military service members. However, service members are likely lost to follow-up from the Department of Defense cancer registry and Military Health System data sets after leaving service and during periods of time not on active duty.

Recommended Content:

Medical Surveillance Monthly Report

Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2021

Article
6/1/2022
Morbidity Burdens Attributable to Various Illnesses and Injuries, Deployed Active and Reserve Component Service Members, U.S. Armed Forces, 2021

As in previous years, among service members deployed during 2021, injury/poisoning, musculoskeletal diseases and signs/symptoms accounted for more than half of the total health care burden during deployment. Compared to garrison disease burden, deployed service members had relatively higher proportions of encounters for respiratory infections, skin diseases, and infectious and parasitic diseases. The recent marked increase in the percentage of total medical encounters attributable to the ICD diagnostic category "other" (23.0% in 2017 to 44.4% in 2021) is likely due to increases in diagnostic testing and immunization associated with the response to the COVID-19 pandemic.

Recommended Content:

Medical Surveillance Monthly Report

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Non-service Member Beneficiaries of the Military Health System, 2021

Article
6/1/2022
Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Non-service Member Beneficiaries of the Military Health System, 2021

In 2021, mental health disorders accounted for the largest proportions of the morbidity and health care burdens that affected the pediatric and younger adult beneficiary age groups. Among adults aged 45–64 and those aged 65 or older, musculoskeletal diseases accounted for the most morbidity and health care burdens. As in previous years, this report documents a substantial majority of non-service member beneficiaries received care for current illness and injury from the Military Health System as outsourced services at non-military medical facilities.

Recommended Content:

Medical Surveillance Monthly Report

Hospitalizations, Active Component, U.S. Armed Forces, 2021

Article
6/1/2022
Hospitalizations, Active Component, U.S. Armed Forces, 2021

The hospitalization rate in 2021 was 48.0 per 1,000 person-years (p-yrs), the second lowest rate of the most recent 10 years. For hospitalizations limited to military facilities, the rate in 2021 was the lowest for the entire period. As in prior years, the majority (71.2%) of hospitalizations were associated with diagnoses in the categories of mental health disorders, pregnancy-related conditions, injury/poisoning, and digestive system disorders.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance snapshot: Illness and injury burdens, reserve component, U.S. Armed Forces, 2021

Article
6/1/2022
Surveillance snapshot: Illness and injury burdens, reserve component, U.S. Armed Forces, 2021

Recommended Content:

Medical Surveillance Monthly Report

Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Active Component, U.S. Armed Forces, 2021

Article
6/1/2022
Absolute and Relative Morbidity Burdens Attributable to Various Illnesses and Injuries, Active Component, U.S. Armed Forces, 2021

In 2021, as in prior years, the medical conditions associated with the most medical encounters, the largest number of affected service members, and the greatest number of hospital days were in the major categories of injuries, musculoskeletal disorders, and mental health disorders. Despite the pandemic, COVID-19 accounted for less than 2% of total medical encounters and bed days in active component service members.

Recommended Content:

Medical Surveillance Monthly Report

Medical Evacuations out of the U.S. Central and U.S. Africa Commands, Active and Reserve Components, U.S. Armed Forces, 2021

Article
6/1/2022
Medical Evacuations out of the U.S. Central and U.S. Africa Commands, Active and Reserve Components, U.S. Armed Forces, 2021

The proportions of evacuations out of USCENTCOM that were due to battle injuries declined substantially in 2021. For USCENTCOM, evacuations for mental health disorders were the most common, followed by non-battle injury and poisoning, and signs, symptoms, and ill-defined conditions. For USAFRICOM, evacuations for non-battle injury and poisoning were most common, followed by disorders of the digestive system and mental health disorders.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance snapshot: Illness and injury burdens, recruit trainees, U.S. Armed Forces, 2021

Article
6/1/2022
Surveillance snapshot: Illness and injury burdens, recruit trainees, U.S. Armed Forces, 2021

Recommended Content:

Medical Surveillance Monthly Report

Ambulatory Visits, Active Component, U.S. Armed Forces, 2021

Article
6/1/2022
Ambulatory Visits, Active Component, U.S. Armed Forces, 2021

In 2021, the overall numbers and rates of active component service member ambulatory care visits were the highest of any of the last 10 years. Most categories of illness and injury showed modest increases in numbers and rates. The proportions of ambulatory care visits that were accomplished via telehealth encounters fell to under 15% in 2021, compared to 19% in 2020.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Snapshot: Tick-borne Encephalitis in Military Health System Beneficiaries, 2012–2021

Article
5/1/2022
iStock—The castor bean tick (Ixoedes ricinus). Credit: Erik Karits

Tick-borne Encephalitis in Military Health System Beneficiaries, 2012–2021. Tick-borne encephalitis (TBE) is a viral infection of the central nervous system that is transmitted by the bite of infected ticks, mostly found in wooded habitats in parts of Europe and Asia

Recommended Content:

Medical Surveillance Monthly Report

The Association Between Two Bogus Items, Demographics, and Military Characteristics in a 2019 Cross-sectional Survey of U.S. Army Soldiers

Article
5/1/2022
NIANTIC, CT, UNITED STATES 06.16.2022 U.S. Army Staff Sgt. John Young, an information technology specialist assigned to Joint Forces Headquarters, Connecticut Army National Guard, works on a computer at Camp Nett, Niantic, Connecticut, June 16, 2022. Young provided threat intelligence to cyber analysts that were part of his "Blue Team" during Cyber Yankee, a cyber training exercise meant to simulate a real world environment to train mission essential tasks for cyber professionals. (U.S. Army photo by Sgt. Matthew Lucibello)

Data from surveys may be used to make public health decisions at both the installation and the Department of the Army level. This study demonstrates that a vast majority of soldiers were likely sufficiently engaged and answered both bogus items correctly. Future surveys should continue to investigate careless responding to ensure data quality in military populations.

Recommended Content:

Medical Surveillance Monthly Report

Update: Sexually Transmitted Infections, Active Component, U.S. Armed Forces, 2013–2021

Article
5/1/2022
This illustration depicts a 3D computer-generated image of a number of drug-resistant Neisseria gonorrhoeae bacteria. CDC/James Archer

This report summarizes incidence rates of the 5 most common sexually transmitted infections (STIs) among active component service members of the U.S. Armed Forces during 2013–2021. In general, compared to their respective counterparts, younger service members, non-Hispanic Black service members, those who were single and other/unknown marital status, and enlisted service members had higher incidence rates of STIs.

Recommended Content:

Medical Surveillance Monthly Report

Evaluation of ICD-10-CM-based Case Definitions of Ambulatory Encounters for COVID-19 Among Department of Defense Health Care Beneficiaries

Article
5/1/2022
SEATTLE, WA, UNITED STATES 04.05.2020 U.S. Army Maj. Neil Alcaria is screened at the Seattle Event Center in Wash., April 5. Soldiers from Fort Carson, Colo., and Joint Base Lewis-McChord, Wash. have established an Army field hospital center at the center in support of the Department of Defense COVID-19 response. U.S. Northern Command, through U.S. Army North, is providing military support to the Federal Emergency Management Agency to help communities in need. (U.S. Army photo by Cpl. Rachel Thicklin)

This is the first evaluation of ICD-10-CM-based cased definitions for COVID-19 surveillance among DOD health care beneficiaries. The 3 case definitions ranged from highly specific to a lower specificity, but improved balance between sensitivity and specificity.

Recommended Content:

Medical Surveillance Monthly Report

Exertional Hyponatremia, Active Component, U.S. Armed Forces, 2006–2021

Article
4/1/2022
Marine Corps Cpl. Luis Alicea drinks water after a combat conditioning exercise at Naval Air Station Joint Reserve Base New Orleans, May 20, 2019. Photo By: Marine Corps Lance Cpl. Jose Gonzalez.

Exertional (or exercise-associated) hyponatremia refers to a low serum, plasma, or blood sodium concentration (below 135 mEq/L) that develops during or up to 24 hours following prolonged physical activity. Acute hyponatremia creates an osmotic imbalance between fluids outside and inside of cells.

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 12
Refine your search
Last Updated: February 02, 2022
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery