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How the military stays ready during disease outbreaks

Headshot of Dr. Sanchez Dr. Toti Sanchez is a senior scientist and deputy chief at Armed Forces Health Surveillance Branch

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Armed Forces Health Surveillance Branch | Coronavirus

A Q & A with Dr. Jose L. (Toti) Sanchez, Senior Scientist & Deputy Chief, AFHSB


What is your focus area?

A major component of my work is to ensure that major health surveillance program plans and initiatives are current and reflect alignment with the Defense Health Agency’s Strategic Plan. Under the guidance of AFHSB’s Chief, I also help to build strong scientific and collaborative relationships within the Public Health Directorate.

How do you monitor disease outbreaks?

I spend a significant amount of time monitoring the many peer-reviewed, governmental and international association reports. I also analyze the disease outbreak reports and coordinate data gathering and report generation from AFHSB’s Global Emerging Infections Surveillance, Epidemiology and Analysis), and Integrated Biosurveillance  sections.

In my role as Senior Scientist at AFHSB, I serve on the Infectious Disease Clinical Research Program Operational Steering Committee, a “think-tank” committee of experts who provide guidance on military-relevant research efforts in support of the U.S. military’s force health protection needs. I also work as an instructor at the Uniformed Services University of the Health Sciences. I ensure students and residents in public health learn the basic skills of outbreak investigation, associated surveillance, and research initiatives.

How do you support AFHSB's response to COVID-19?

The COVID-19 pandemic has placed an immense workload on our AFHSB staff to produce analyses and reports for DHA leadership, senior DoD officials, the Secretary of Defense, and respond to questions from Congressional officials. In my role as Deputy Chief, AFHSB, I ensure that reports, documents and COVID-19 related policy reviews are accurate and produced in a timely fashion from AFHSB’s three sections. Since February 2020, I’ve reviewed and provided input to nearly 70 executive summaries , several information and position papers, and at least 20 weekly surveillance summaries addressing COVID-19 issues.

Where have you traveled in this role?

My travel is mainly limited to the National Capital Region. I’ve participated in tabletop drills such as an interagency simulation for Crimson Contagion, a response to a severe influenza pandemic. I’ve also served as a representative to the Defense Health Board to evaluate health surveillance matters such as COVID-19 and respiratory infections in support of DHA’s Combat Support Agency mission.

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

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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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Risk Factors for Tinea Pedis Infections (Athlete’s Foot) among U.S. Armed Forces

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6/19/2017
Athlete’s foot is a chronic fungal infection of the feet and toes that is common among military service members. Risk factors for infection include: •	High-intensity training •	Heavy sweating •	Protracted shoe/boot wearing •	Less frequent sock changes During field training exercises or deployment, service members may be exposed to additional risk factors for athlete’s foot including hot and humid ambient weather, poor skin hygiene, and close-quarter living. The condition’s most common clinical presentation is infection in the space between the toes. If left untreated this pattern of infection may cause… •	Softening and breaking down of skin resulting from prolonged exposure to moisture (maceration) •	Reddening of skin caused by congestion of the capillaries in the lower layers of the skin (erythema) •	Fissures of the skin These changes in the skin increase the risk of cellulitis, a serious bacterial infection of the skin capable of spreading to other parts of the body. Read this brief report “Tinea Pedis, Active Component, U.S. Armed Forces, 2000 – 2016,” which summarizes the impact of the condition among U.S. active component service members. Access the report in MSMR Vol. 24 No. 5 – May 2017 at Health.mil/MSMR.  Background graphic of the infographic is a pair of feet diagnosed with athlete’s foot but instead of showing breakage of skin we see the leg and foot of a military service member walking through water.

This infographic documents the risk factors for tinea pedis infections (athlete’s foot).

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Tinea Pedis (Athlete’s Foot) U.S. Armed Forces, 2000-2016

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6/19/2017
Athlete’s foot is a common problem among military service members. Known by the medical term, Tinea Pedis, the condition causes a chronic fungal infection of the feet and toes. It is the most common dermatophyte infection among adults. Up to 25% of the global population is affected by tinea pedis at any given time. Findings: During the 17-year surveillance period there were a total of 193,432 medical encounters for tinea pedis. Of these total encounters, 91% were ambulatory visits. Of 459 hospitalization records that contained diagnoses of athlete’s foot during the surveillance period, a total of 275 (59.9%) had a primary diagnosis of cellulitis or abscess of the foot or leg during the incident tinea pedis hospitalization. Where this information displays two feet are seen. The pie chart shows in an orange pie slice the 59.9% or 275 military service members that had a primary diagnosis of cellulitis or abscess of the foot or leg during the incident tinea pedis hospitalization. The rest of the pie chart shows in purple the 184 other hospitalization records. Background of the pie chart shows a foot.  High Risks for tinea pedis infections: •	Males – overall incident rate 17.4% higher than females •	Service members younger than 20 years of age •	Black, non-Hispanic and Hispanic service members •	Junior enlisted service members Given these costs, prevention efforts such as training and education about foot and skin health warrant continual emphasis, especially during initial entry training and in preparation for field exercises and deployments to warm locations. Learn more at Health.mil/MSMR Top of image shows foot with tinea pedis (athlete’s foot).

This infographic summarizes the counts, rates, trends and demographic characteristics of diagnoses of tinea pedis among U.S. active component service members during 2000 -2016.

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Healthcare Burdens Attributable to Various Mental Disorders, U.S. Armed Forces 2016

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5/25/2017
Did you know…? In 2016, mood disorders and substance abuse accounted for 25.9% of all hospital days. Together, four mental disorders – mood, substance abuse disorders, adjustment, and anxiety – and two maternal conditions – pregnancy complications and delivery – accounted for 53.6% of all hospital bed days. And 12.4% of all hospital bed days were attributable to injuries and poisonings. Here are the mental disorders that affected U.S. Armed Forces in 2016: Pie Chart titled Bed days for mental disorders in 2016: •	Mood Disorder (46,920 bed days) – the orange pie slice. •	Substance Abuse Disorders (44,746 bed days) – the blue pie slice. •	Adjustment Disorder (30,017 bed days) – the purple pie slice. •	Anxiety Disorder (20,458 bed days) – the gray pie slice. •	Psychotic Disorder (6,532 bed days) – the light blue pie slice. •	All other mental disorders (3,233 bed days) – the violet pie slice. •	Personality disorder (2,393 bed days) – the forest green pie slice. •	Somatoform (552 bed days) – the lime green pie slice. •	Tobacco dependence (2 bed days) – the white pie slice. Bar graph shows percentage and cumulative percentage distribution, burden “conditions” that accounted for the most hospital bed days, active component, U.S. Armed Forces 2016.  % of total bed days (bars) for mood disorder, substance abuse disorders, adjustment disorder, pregnancy complications; delivery; anxiety disorder; head/neck injuries, all other digestive diseases, other complications NOS; other back problems, all other signs and symptoms; leg injuries, all other maternal conditions; all other neurologic conditions; all other musculoskeletal diseases; all other skin diseases;  back and abdomen; appendicitis; all other infectious and parasitic diseases; all other cardiovascular diseases; all other mental disorders; all other respiratory diseases; arm/shoulder injuries; poisoning, drugs; foot/ankle injuries; other gastroenteritis and colitis; personality disorder; lower respiratory infections; all other genitourinary diseases; all other malignant neoplasms; cerebrovascular disease.  See more details on this bar graph in the Medical Surveillance Monthly Report (MSMR) April 2017 Vol. 24 No. 4 report, page 4. This annual summary for 2016 was based on the use of ICD-10 codes exclusively. Read more on this analysis at Health.mil/MSMR. #LetsTalkAboutIt Background of graphic is a soldier sitting on the floor in a dark room.

This infographic documents the mental disorders that affected U.S. Armed Forces in 2016.

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Erectile Dysfunction among Male Active Component Service members

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5/25/2017
Erectile dysfunction (ED) is defined as the persistent inability to achieve and sustain an erection that is adequate for sexual intercourse. ED can result from a problem with any of the above: •	Hormones •	Emotions •	Nerves •	Muscles •	Blood vessels These factors are required for an erection include. Picture is a brain (left) and a male figure (right) showing the heart and main arteries of the body. The top three most common ED diagnoses are: 1.	Psychosexual dysfunction 2.	Hypoactive sexual desire disorder 3.	Male orgasmic disorder Image shows a couple outside together during sunset. House displays in background. Causes of ED (Shows cut out of male body highlighting areas of the body where causes happen) •	Unrealistic sexual expectations •	Depression/ Anxiety/ Stress or other mental health issues •	High blood pressure •	Diabetes •	Obesity •	Injuries that affect the pelvic area or spinal cord •	Low testosterone •	Aging, Substance Abuse Demographics: •	Incidence rate of erectile dysfunction are higher among black, non-Hispanic servicemen when compared to other race/ethnicity groups. •	Black non-Hispanic service members have higher incidence rates of several conditions known to be risk factors for erectile dysfunction, including hypertension, obesity and diabetes. •	Separated, divorced and widowed servicemen had a higher incidence rate of ED than servicemen never married. •	Servicemen never deployed had the highest crude incidence rate of erectile dysfunction. Get the facts •	Erectile dysfunction is the most common sexual complaint reported by men to healthcare providers •	Among male service members nearly half of erectile dysfunction cases related predominantly or exclusively to psychological factors. •	Incidence rates of psychogenic erectile dysfunction are greater than organic erectile dysfunction for service members. •	Organic erectile dysfunction can result from physical factors such as obesity, smoking, diabetes, cardiovascular disease or medication use. •	Highest incidence rates were observed in those aged 60 years or older. •	Those 40 years or older are most commonly diagnosed with erectile dysfunction. Effective against erectile dysfunction •	Regular exercise  ( Shows soldier running) •	Psychological counseling (Shows two soldiers engaging in mental health counseling. They are seating on a couch).  •	Quit smoking ( shows lit cigarette)  •	Stop substance abuse ( Shows to shot glasses filled with alcohol) •	Nutritional supplements ( Shows open pill bottle of supplements) •	Surgical treatment ( Shows surgical instruments) Talk to your partner Although Erectile Dysfunction (ED) is a difficult issue for sex partners to discuss, talking openly can often be the best way to resolve stress and discover underlying causes. If you are experiencing erectile dysfunction, explore treatment options with your doctor. Learn more about ED by reading ‘Erectile Dysfunction Among Male Active Component Service Members, U.S. Armed Forces, 2004 – 2013.’ Medical Surveillance Monthly Report (MSMR) Vol. 21 No. 9 – September 2014 at www.Health.mil/MSMRArchives. Follow us on Twitter at AFHSBPAGE. #MensHealth

Erectile dysfunction (ED) is defined as the persistent inability to achieve and sustain an erection that is adequate for sexual intercourse. This infographic provides details on the ways ED impacts male active component services members of the U.S. Armed Forces.

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Medical encounters, by condition, U.S. Armed Forces 2016

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5/25/2017
This infographic documents the three burden of disease related conditions that accounted for the most medical encounters among the active component of the U.S. Armed Forces in 2016. LONG FORM: In 2016, the three burden of disease related conditions accounted for the most medical encounters were: •	Other back problems •	All other musculoskeletal diseases •	Knee injuries Altogether they accounted for 25.1% of all illness-and injury-related medical encounters overall. More Findings The top nine conditions that accounted for the most medical encounters accounted for 53.1% of all illness-and-injury –related medical encounters overall. In general, the conditions that accounted for the most medical encounters were predominantly musculoskeletal disorders such as the back) injuries to the knee, arm, shoulder, foot or ankle, and mental disorders like anxiety and adjustment conditions. View more findings at www.Health.mil/MSMR    Graphic details This graphic displays the musculoskeletal of a male service member’s body to show the bones of the back and knees.

This infographic documents the three burden of disease related conditions that accounted for the most medical encounters among the active component of the U.S. Armed Forces in 2016.

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Accidental Drownings Among U.S. Service Members

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5/25/2017
Military members are at risk for unintentional drownings during training, occupational activities and off-duty recreation. Increase your awareness today to lower your risks: Drowning prevention: Water-related recreational activities in or near water can be potentially dangerous – particularly for non-swimmers and weak swimmers – in hazardous conditions and settings (e.g., storms, currents, riptides), and when safety measures are not observed. Military members are at risk for unintentional drownings during training, occupational activities and off-duty recreation. Here are four ways you can prevent unintentional drowning: •	Wear life jackets. •	Take swim lessons to become a stronger swimmer. •	Swim with a buddy; never swim alone. •	Be knowledgeable of water environments you are in. Increase your awareness and lower your risks by reading the Medical Surveillance Monthly Report (MSMR) Vol. 22 No. 6 – June 2015 report “Update: Accidental drownings, active component, U.S. Armed Forces, 2005 – 2014 at www.Health.mil/MSMR  #SwimSafe Follow us on Twitter for more information at AFHSBPAGE. Also check out hashtag #SwimSafe. Source: Defense Health Agency, Armed Forces Health Surveillance Branch. Graphic shows: •	Man swimming in pool •	Mom with three children swimming in pool. •	Woman swimming in pool

Military members are at risk for unintentional drownings during training, occupational activities and off-duty recreation. This infographic provides swim safety information to help increase awareness and lower the risks of accidental drownings among service members.

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Absolute and Relative Morbidity Burdens Attributable to various illnesses and injuries: Non-service member beneficiaries of the Military Health System, 2016

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5/18/2017
Individuals who are eligible for care through the Military Health System (MHS) are known as beneficiaries. MHS beneficiaries include family members of active component service members, the National Guard and Reserve service members, retirees and eligible family members of retirees. In 2016, there were approximately 9.4 million beneficiaries eligible for health care in the MHS. Findings: •	In 2016, a total of 6,589,843 non-service member beneficiaries of the MHS had 86,486,080 medical encounters. •	On average, each individual who accessed care from the MHS had 13.1 medical encounters over the course of the year. •	The top three morbidity-related categories accounted for 34.5% of all medical encounters. Top Three Morbidity-Related Categories Pie Chart •	Injuries and poisonings (10.5%) – pie slice shown in the color of lavender.  •	Signs, symptoms, and ill-defined conditions (11.9%) – pie slice shown in green. •	Musculoskeletal diseases (12.2%) - pie slice shown in dark blue. •	Orange of pie chart indicates the other morbidity related categories (make up approximately 65.4% of the pie chart). Signs, symptoms, and ill-defined conditions, injuries and poisonings, and disorders of the sense organs were the illness/injury categories that affected the most individuals (44.9%, 34.7%, and 30.3% of all beneficiaries who received any care, respectively). Learn more at Health.mil/MSMR Other images seen on graphic:  Father and baby daughter at medical appointment with a family doctor from the MHS.

Individuals who are eligible for care through the Military Health System (MHS) are known as MHS beneficiaries. This graphic provides information on the absolute and relative morbidity burdens attributable to various illnesses and injuries among non-service member beneficiaries of the MHS in 2016.

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Absolute and Relative Morbidity Burdens Attributable to Various illnesses and Injuries, Active Component, U.S. Armed Forces, 2016

Infographic
5/18/2017
everal classification systems and morbidity measures have been developed to quantify absolute and relative morbidity burdens attributable to various illnesses and injuries among the active component of the U.S. Armed Forces in 2016. They determine to a large extent the conclusions that may be drawn regarding the relative “importance” of various conditions – and, in turn, the resources that may be indicated to prevent or minimize their impacts. This annual summary provides: •	142 categories based on a modified version of the classification system developed for the Global Burden of Disease (GBD) study. •	25 burden of disease-related conditions for all illness-and injury-specific diagnoses (as defined by the ICD-10). Findings: •	In 2016, 550,213 service members received medical care for injury/poisoning, more than any other morbidity related category. •	Injury/poisoning accounted for more medical encounters (n= 2,755,387) than any other morbidity category – that is 24.8% of all medical encounters overall. •	Together, injury/poisoning and mental disorders accounted for 56.2% of all hospital bed days and 41.8% of all medical encounters. Medical Encounters Pie Chart Display: •	There were a total of 11,113,506 medical encounters overall (whole pie chart or 100%) •	A total of 2,755,387 for the injury/poisoning category or 24.793% for injury/poisoning ( purple slice of pie chart that is labeled Injury/poisoning) •	A total of 1,895,156 categorized as mental disorders or 17.053% for mental disorders ( lime green slice of pie chart that is labeled mental disorders) •	Together, injury/poisoning and mental disorders accounted  for 41.8 of all medical encounters •	All other medical encounters is approximately 58.2% (dark green slice of the pie chart that is labeled all other medical encounters). For more findings, view the full MSMR report at Health.mil/AFHSB Images included on graphic: DHA logo, Military vehicle and helicopter propellers.

Several classification systems and morbidity measures have been developed to quantify absolute and relative morbidity burdens attributable to various illnesses and injuries among the active component of the U.S. Armed Forces. This graphic highlights findings about the active component of the U.S. Armed Forces in 2016.

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Ambulatory visits, Active Component, U.S. Armed Forces, 2016

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5/18/2017
This infographic documents the frequencies, rates, trends and characteristics of ambulatory healthcare visits of active component members of the U.S. Army, Navy, Air Force, and Marine Corps during 2016. Findings •	During 2016, there were 19,158,557 reported ambulatory visits of active component service members. •	On average each service member had approximately 15 ambulatory encounters during the year. •	In 2016, four major diagnostic categories accounted for 72.6% of all illness-and injury-related ambulatory visits among active component service members. Pie Chart •	Signs, Symptoms, and ill-defined conditions (8.8%) – pie slice is blue;  military woman with illness seen. •	Disorders of the nervous system and sense organs (10.8%) – pie slice shows many getting his eye examined by a doctor. •	Mental Disorders (16.8%) –  pie slice is green; shows man sitting on the floor who is seeking mental health treatment. •	Musculoskeletal system/connective tissue disorders (36.3%) – pie slice is red; physician is treating patient for musculoskeletal system/ connective tissue disorders. The 2016 number of visits for musculoskeletal disorders (n= 4,198,896) is the highest annual count in the past 13 years. Learn about the largest percentage increases and decreases in ambulatory visits during 2012-2016 at www.Health.mil/MSMR.  Other images seen on graphic: transparent background shows entrance to an Emergency Center.

This infographic documents the frequencies, rates, trends and characteristics of ambulatory healthcare visits of active component members of the U.S. Army, Navy, Air Force, and Marine Corps during 2016.

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The Defense Medical Epidemiology Database System Overview Fact Sheet

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5/12/2017

This fact sheet provides a system overview of the Defense Medical Epidemiology Database (DMED). DMED is a web-based tool to remotely query de-identified active component personnel and medical event data contained within the Defense Medical Surveillance System (DMSS). Learn about the newly released version of DMED and its key features in this document.

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Global Influenza Summary: May 7, 2017

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5/7/2017

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Global Influenza Summary: April 30, 2017

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4/30/2017

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DoD Global, Laboratory-Based Influenza Surveillance Program, 2014- 2015 Season

Infographic
4/17/2017
The DoD Global, Laboratory-Based, Influenza Surveillance Program is a DoD-wide, year-round program that tests respiratory specimens from DoD beneficiaries presenting to military treatment facilities with influenza-like illness (ILI). ILI is defined as an illness characterized by a fever 100.5 degrees F or greater and cough or sore throat within 72 hours of seeking treatment. Sentinel sites submit 6-10 specimens per week from beneficiaries presenting with ILI. Each specimen is tested via reverse transcription-polymerase chain reaction (RT-PCR) and viral culture. The 2014-2015 influenza season was dominated by influenza A (H3N2) at the beginning; however by Week 10, identifications of influenza B viruses were more numerous than for influenza A. Out of a total of 6,432 specimens, 32.7% were positive for influenza. Additionally 19.6% of specimens were positive for other respiratory pathogens while 47.7% specimens were negative. The molecular characterization of specimens showed that the majority of influenza A (H3N2) viruses circulating had drifted from the vaccine strain by December 2014. This finding was in agreement with the Centers for Disease Control and Prevention and World Health Organization observations during the 2014-2015 influenza season. For more information visit Health.mil/AFHSB

The DoD Global, Laboratory-Based, Influenza Surveillance Program is a DoD-wide, year-round program that tests respiratory specimens from DoD beneficiaries presenting to military treatment facilities with influenza-like illness (ILI).

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