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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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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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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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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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Global Influenza Summary: April 30, 2017

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Zika Virus Infections in Military Health System Beneficiaries

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4/17/2017
The introduction and rapid spread of the Zika virus (ZIKV), a Flavivrus of the Flaviviridae family, across the Western Hemisphere have posed a risk of infection to Military Health System (MHS) beneficiaries. This report documents: •	The impact of ZIKV transmission on MHS beneficiaries. •	ZIKV spread to nearly 50 countries and territories within a 17-month period. •	Among affected service members, the Army reported the most Zika cases. •	There have been 156 confirmed cases of Zika in MHS beneficiaries. •	A majority of cases reported exposure in Puerto Rico (n=91, 58.3%). Geographic regions of potential exposure to Zika cases in MHS beneficiaries between 01 Jan – 30 Nov 2016 included: •	Puerto Rico ( 91 cases) •	Caribbean ( 41 cases) •	Central America & Mexico (15 cases) •	South America (6 cases) •	Asia ( 3 cases) •	Unknown (3) •	U.S. Florida (1 case) Cases in Service Members Between 01 Jan – 30 Nov 2016 were: •	Army (48 cases) •	Coast Guard (29 cases) •	Air Force (16 cases) •	Navy (10 cases) •	Marine Corps (7 cases) Although most ZIKV infections are asymptomatic or have a relatively mild illness, the gravity of pregnancy and neurologic issues linked to infection remains a significant impetus for the continued surveillance of ZIKV in the MHS population. For more Zika surveillance and information on signs and symptoms, visit Health.mil/AFHSB

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

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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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Findings from The Department of Defense Global, Laboratory-Based Influenza Surveillance Program, 2015-2016 Influenza Season

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The Department of Defense (DoD) Global, Laboratory-Based, Influenza Surveillance Program monitors the circulation of influenza viruses throughout each influenza season. Each season runs from the beginning of October through end of the next September. During the 2015 – 2016 influenza season, a total of 4,591 specimens were tested from 80 locations. The predominant influenza strain was A (H1N1) pdm09. Additionally peak influenza activity occurred during weeks 7 – 13 (14 February – 2 April 2016). Of those submitted for routine surveillance, 1,182 (25.7%) tested positive for other respiratory pathogens, 377 (8.2%) tested positive for influenza B, 755 (16.5%) tested positive for influenza A, and 2,277 (49.6%) tested negative. For more information on the 2015-2016 influenza season and how to identify influenza-like illness (ILI), read the Medical Surveillance Monthly Report (MSMR) at Health.mil/AFHSB.

The Department of Defense (DoD) Global, Laboratory-Based, Influenza Surveillance Program monitors the circulation of influenza viruses throughout each influenza season. Each season runs from the beginning of October through end of the next September.

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Global Influenza Summary: April 16, 2017

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New and Improved Defense Medical Epidemiology Database

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The new and improved Defense Medical Epidemiology Database (DMED), known as DMED 5.0, is now only available online.  DMED provides timely and efficient access to data of active component personnel and medical event data.  It contains a subset of data from the Defense Medical Surveillance System (DMSS), offering remote access to tri-service epidemiologic data. Moreover, it protects privacy using only de-identified data and updates monthly.  The new DMED features an enhanced user interface, query data using ICD-9 and ICD-10 diagnostic codes granting authorized users to search multiple databases simultaneously. These users are U.S. military personnel (DoD-CaC users) or Federal partners and civilian collaborators in military medical research and operations. Authorized U.S. military personnel with access to DMED include medical providers, epidemiologists, medical researchers, safety officers, and medical operations and clinical support staff. Sign up for a new account at www.health.mil/dmed

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Minority Health Heat Illness Active Component U.S. Armed Forces, 2016

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Heat illness refers to a spectrum of disorders that occur when the body is unable to dissipate heat absorbed from the external environment and the heat generated by internal metabolic processes. As heat illness progresses, failure of one or more body systems can occur. This report summarizes reportable medical events of heat illnesses, heat-related hospitalizations and ambulatory visits among minority active component members (Black, non-Hispanic, Hispanic, and Asian/Pacific Islanders) during 2016. In 2016, incidence rates of heat stroke were highest among Asian/ Pacific Islanders than any other ethnicity. Crude incidence rate of “other heat illnesses” was higher among females than males.  Heat Incidence cases: •	Black, non-Hispanic heat illness incidence cases – 64 for heatstroke and 389 for other heat illnesses •	Hispanic heat illness incidence cases—  63 for heatstroke and 320 for other heat illnesses •	Asian/ Pacific Islander heat illness incidence cases – 32 for heatstroke and for  117 other heat illnesses Incidence rates: •	Black, non-Hispanic incidence rates – 0.30 for heatstroke and 1.84 for other heat illnesses •	Hispanic incidence rates – 0.33 for heatstroke and 1.67 for other heat illnesses •	Asian/Pacific Islander – 0.62 for heatstroke and 2.26 for other heat illnesses Of all military members, the youngest and most inexperienced marines and soldiers – particularly those training at installations in the south eastern U.S. – are at highest risk of heat illnesses including heat stroke, exertional hyponatremia, and exertional rhabdomyolysis. Learn more at www.Health.mil/MSMR

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Update: Exertional Hyponatremia U.S. Armed Forces, 2001-2016

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Exertional Hyponatremia occurs during or up to 24 hours after prolonged physical activity. It is defined by a serum, plasma or blood sodium concentration below 135 millequivalents per liter. This infographic provides an update on Exertional Hyponatremia among U.S. Armed Forces, information on service members at high risk. Exertional hyponatremia can result from loss of sodium and/or potassium as well as relative excess of body water. There were 1,519 incident diagnoses of exertional hyponatremia among active component service members from 2001 through 2016. 86.8 percent were diagnosed and treated without having to be hospitalized. 2016 represented a decrease of 23.3 percent from 2015. In 2016, there were 85 incident diagnoses of exertional hyponatremia among active component service members and 77.6 percent of exertional hyponatremia cases affected males.  The annual rate was higher among females. Service members age 40 and over were most affected by exertional hyponatremia. High risk service members of exertional hyponatremia were: •	Females •	Service members aged 19 years or younger •	White, non-Hispanic and Asian/ Pacific Islander service members •	Recruit Trainees •	Marine Corps members Learn more at www.Health.mil/MSMR

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Rhabdomyolysis by Location, Active Component, U.S. Armed Forces, 2012-2016 Fact Sheet

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This fact sheet provides details on Rhabdomyolysis by location for active component, U.S. Armed Forces during a five-year surveillance period from 2012 through 2016. The medical treatment facilities at nine installations diagnosed at least 50 cases each and, together approximately half (49.9%) of all diagnosed cases.

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Demographic and Military Traits of Service Members Diagnosed as Traumatic Brain Injury Cases

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3/30/2017

This fact sheet provides details on the demographic and military traits of service members diagnosed as traumatic brain injury (TBI) cases during a 16-year surveillance period from 2001 through 2016, a total of 276,858 active component service members received first-time diagnoses of TBI - a structural alteration of the brain or physiological disruption of brain function caused by an external force.

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