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DHA recognizes 25 years of AFHSB's health surveillance journal

Medical technicians wearing masks and entering information on a computer Georgia Army National Guardsman Pfc. Loran Jones, a combat medic with the Marietta-based 248th Medical Company, 265th Chemical Battalion, updates patient medical records at Wellstar Atlanta Medical Center in Atlanta, Ga. In May, the Georgia National Guard strategically deployed medical support teams to hospitals to augment medical staff. (Photo by Spc. Isaiah Matthews.)

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Armed Forces Health Surveillance Division | Medical Surveillance Monthly Report

This year, the Armed Forces Health Surveillance Branch (AFHSB) celebrated the 25th anniversary of its peer-reviewed journal, the Medical Surveillance Monthly Report (MSMR). The MSMR offers readers evidence-based estimates of the health-related conditions and trends prevalent among U.S. military members and their associated populations.

“MSMR surveillance information and the published explanations of such information facilitate military leaders’ understanding of the public health measures that help to preserve the health and readiness of our armed forces,” said Dr. Francis O’Donnell, MSMR editor. Established in 1995, the MSMR was created as a flagship publication and public health authority within the Army Medical Surveillance Activity (AMSA), the forerunner of the AFHSB, a part of the Public Health Directorate at the Defense Health Agency.

“The 25 years of reports in the MSMR have dealt with a myriad of illnesses, injuries, and health threats that have challenged our military members. The rich historical record preserved in MSMR archives helps in assessments of the military importance of current health threats and in the development of policies to prevent or mitigate their medical and military operational impacts,” said Dr. John Brundage former editor and co-founder of the report.

Many studies in the MSMR are based on summaries of medical administrative data that are routinely provided to AFHSB and integrated into the Defense Medical Surveillance System (DMSS) for health surveillance purposes. The DMSS is an active database of health-related information on service members who have served in the military since 1990. It contains billions of records including medical encounters such as hospitalizations, outpatient visits, immunizations, reportable medical events, health risk appraisals, and deployment health assessments; demographic characteristics; and military experiences like deployments, assignments, and casualty information.

According to Brundage, Dr. Mark Rubertone, chief of AFHSB’s Data Management & Technical Support section, played an essential role in the production of the MSMR from its inception. Rubertone led the collection and assembly of military health surveillance-related data (initially, in the AMSA and then the Defense Medical Surveillance System) in the 1990s that allowed for a new method of statistical and epidemiologic analyses by military health surveillance professionals. “There would not have been a MSMR without the vision, dedication, and relentless efforts of Doctor Mark Rubertone,” credits Brundage.

“It has been a real pleasure witnessing the MSMR’s evolution to a peer-reviewed journal.  My association with the MSMR remains one of the efforts I am most proud of during my service in the DoD," stated Rubertone, as he expressed congratulations to the current and past MSMR staff on 25 years of tireless, comprehensive health surveillance reporting. This point-of-view was strongly supported by Dr. Jose “Toti” Sanchez, deputy chief, AFHSB, who since his early days at the Walter Reed Army Institute of Research in the early 1990’s saw the potential and relevance of this publication in providing a unique military-relevant perspective to the major public health problems faced by the U.S. military.

The MSMR is published on a monthly basis and is available online only in a downloadable PDF format. To subscribe to the MSMR, visit https://health.mil/msmr.

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Insomnia and motor vehicle accident-related injuries, Active Component, U.S. Armed Forces, 2007 – 2016

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1/25/2018
Insomnia is the most common sleep disorder in adults and its incidence in the U.S. Armed Forces is increasing. A potential consequence of inadequate sleep is increased risk of motor vehicle accidents (MVAs). MVAs are the leading cause of peacetime deaths and a major cause of non-fatal injuries in the U.S. military members. To examine the relationship between insomnia and motor vehicle accident-related injuries (MVAs) in the U.S. military, this retrospective cohort study compared 2007 – 2016 incidence rates of MVA-related injuries between service members with diagnosed insomnia and service members without a diagnosis of insomnia. After adjustment for multiple covariates, during 2007 – 2016, active component service members with insomnia had more than double the rate of MVA-related injuries, compared to service members without insomnia. Findings:  •	Line graph shows the annual rates of motor vehicle accident-related injuries, active component service members with and without diagnoses of insomnia, U.S. Armed Forces, 2007 – 2016  •	Annual rates of MVA-related injuries were highest in the insomnia cohort in 2007 and 2008, and lowest in 2016 •	There were 5,587 cases of MVA-related injuries in the two cohorts during the surveillance period. •	Pie chart displays the following data: 1,738 (31.1%) in the unexposed cohort and 3,849 (68.9%) in the insomnia cohort The highest overall crude rates of MVA-related injuries were seen in service members who were: •	Less than 25 years old •	Junior enlisted rank/grade •	Armor/transport occupation •	 •	With a history of mental health diagnosis •	With a history of alcohol-related disorders Access the full report in the December 2017 (Vol. 24, No. 12). Go to www.Health.mil/MSMR Image displays a motor vehicle accident.

To examine the relationship between insomnia and motor vehicle accident-related injuries (MVAs) in the U.S. military, this retrospective cohort study compared 2007 – 2016 incidence rates of MVA-related injuries between service members with diagnosed insomnia and service members without a diagnosis of insomnia.

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Five cold seasons: July 2012-June 2017, Active reserve component service members who were diagnosed with a cold weather injury

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1/18/2018
Did you know during the 5-year surveillance period, the 2,717 service members who were affected by any cold weather injury included 2,307 from the active component and 410 from the reserve component. Overall, Army members comprised the majority (61.6%) of all cold injuries affecting active and reserve component service members. Of all affected reserve component members, 71.7% (n=294) were members of the Army. Cold weather injuries During Basic Training Of all active component service members who were diagnosed with a cold weather injury (n= 2,307), 230 (10.0% of the total) were affected during basic training. Additionally, during the surveillance period, 60 service members who were diagnosed with cold weather injuries during basic training (2.6% of the total) were hospitalized, and most (93.3%) of the hospitalized cases were members of either the Army (n=32) or Marine Corps (n=24). Cold weather injuries during basic training pie chart: The Army (n=122) and Marine Corps (n=99) comprised 96.1% of all basic trainees who were diagnosed with a cold weather injury. Access the full report in the October 2017 MSMR (Vol. 24, No. 10). Go to: www.Health.mil/MSMR  #ColdReadiness Image of service member tracking in the snow is the infographic background graphic.

This infographic provides information on active and reserve component service members who were affected by any cold weather injury during the July 2012 – June 2017 cold seasons.

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Update: Cold Weather Injuries, Active and reserve components, U.S. Armed Forces, July 2012 – June 2017

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1/18/2018
The total number of cold weather injuries among active component service members in 2016 – 2017 cold season was the lowest since 1999. 2016 – 2017 versus the previous four cold seasons  •	A total of 387 members of the active (n=328) and reserve (n=59) components had at least one medical encounter with a primary diagnosis of cold weather injury. •	Rates tended to be higher among service members who were in the youngest age groups, female, non-Hispanic black, or in the Army. •	Cold weather injuries associated with overseas deployments have fallen precipitously in the past three cold seasons due to changes in military operations in Iraq and Afghanistan. There were just 10 cases in the 2016 – 2017 season.  •	Frostbite was the most common type of cold weather injury. Bar chart displays numbers of service members who had a cold injury (one per person per year), by service and cold season, active and reserve components, U.S. Armed Forces, July 2012 – June 2017. Access the full report in the October 2017 MSMR (Vol. 24, No. 10). Go to: www.Health.mil/MSMR  #ColdReadiness

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Cold weather injuries during deployments, July 2012 – June 2017

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1/18/2018
During the 5-year surveillance period, 105 cold weather injuries were diagnosed and treated in service members deployed outside the U.S. of these, 39 (37%) were immersion injuries; 33 (31%) were frostbite; 16 (15%) were hypothermia; and 17 (16%) were “unspecified” cold weather injuries. Pie chart for cold weather injuries during deployments displays depicting the information above. Number of cold weather injuries bar chart: Of all 105 cold weather injuries during the surveillance period, 68% occurred during the first two cold seasons. Bar chart shows the number of cold weather injuries by year: •	2012-2013 cold season had 35 cold weather injuries •	2013-2014 cold season had 100 cold weather injuries •	2014 -2015 cold season had 13 cold weather injuries •	2015-2016 cold season had 11 cold weather injuries •	2016 – 2017 had 10 cold weather injuries Access the full report in the October 2017 MSMR (Vol. 24, No. 10). Go to: www.Health.mil/MSMR  #ColdReadiness

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Complications and Care Related to Pregnancy, Labor and Delivery among Active Component Service Women U.S. Armed Forces, 2012 – 2016

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1/5/2018
Maternal complications and delivery outcomes are important components of the overall health and well-being of reproductive-age service women. This analysis provides an update on pregnancy complications and characterizes the counts, rates, and trends of several specific pregnancy complications. FINDINGS •	55,601 U.S. service women whose pregnancies resulted in 63,879 live births had 657,060 medical encounters •	For all age groups, percentages of live births affected by preterm labor decreased, but during 2012 – 2016, the percentages of pregnant service members diagnosed with obesity increased. •	The percentage of pregnant service members affected by gestational diabetes was more than twice as high for obese women, compared with non-obese women (12.4% vs. 5.5%). Bar graph shows the number of medical encounters with a primary (first-listed) diagnosis of any pregnancy-related complication or indication for care decreased each year between 2012 and 2016. Access the full report in the November 2017 MSMR (Vol. 24, No. 11). Go to: www.Health.mil/MSMR  Background image: New born being provided medical attention by nurse. Secondary image: babies of diverse background on a blanket.

This analysis provides an update on pregnancy complications and characterizes the counts, rates, and trends of several specific pregnancy complications.

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Contraception among active component service women, U.S. Armed Forces, 2012 – 2016

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1/5/2018
Because the majority of women serving in the Armed Forces are of childbearing age, and women’s military career opportunities have expanded into combat roles, contraceptive health care is an increasingly important public health issue. The lack of available, population-based descriptive information on contraceptive use among U.S. service women has generated questions and concerns about ready access to these medical products. This infographic summarizes the annual prevalence of permanent sterilization, as well as use of long – and short-acting reversible contraceptives (LARCs and SARCs, respectively), contraceptive counseling services, and use of emergency contraception from 2012 through 2016, among active component service women. FINDINGS •	2012 through 2016, Sterilization decreased from 4.2% to 3.6% LARC use increased from 17.2% to 21.7%; SARC use decreased from 38.5% to 30.4%. •	Emergency contraception use increased from 0.4% to 1.9%. •	Among deployed women, the average annual prevalence of permanent sterilization was 4.2%. •	For deployed women, LARC use was 17.9% SARC use was 28.0%. •	Emergency contraception use among deployed women was 0.4%. •	262,907 (76.2%) women of childbearing potential (WOCBP) used either a LARC or a SARC at some time during the surveillance period. •	The vast majority of service women have utilized at least one form of contraception, and women are selecting LARCs in greater numbers with each passing year. The bar graph displays information on the annual prevalence of contraceptive utilization, by type, service women of child-bearing potential, active component, U.S. Armed Forces, 2012– 2016. Graphic displayed: contraception option. Access the full report in the November 2017 MSMR (Vol. 24, No. 11). Go to: www.Health.mil/MSMR

This infographic summarizes the annual prevalence of permanent sterilization, as well as use of long – and short-acting reversible contraceptives (LARCs and SARCs, respectively), contraceptive counseling services, and use of emergency contraception from 2012 through 2016, among active component service women.

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Five cold seasons: July 2012 – June 2017, Cold injuries during deployments

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11/3/2017
During the 5-year surveillance period, 105 cold injuries were diagnosed and treated in service members deployed outside of the U.S. Of these 105 cold injuries, 68% occurred in the first two cold seasons. Total no. of cold injuries, by season: •	35 cold injuries during cold season 2012 – 2013 •	36 during 2013 – 2014 •	13 during 2014 – 2015 •	11 during 2015 – 2016 •	10 during 2016 – 2017 The decrease in the number of cases is most likely a byproduct of: •	The dramatic decline in the number of service members deployed to Iraq and Afghanistan •	Changes in the nature of military operations there Access the full report in MSMR Vol. 24 No. 10 October 2017 at Health.mil/MSMR Pie Chart showing cold injuries during deployments: •	39 Immersion •	33 Frostbite •	17 unspecified  •	16 Hypothermia Background image shows service member walking in the snow.

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Measles, Mumps, Rubella, and Varicella: Among service members and other beneficiaries of the Military Health System, 2010 – 2016

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11/3/2017
Measles, mumps, rubella, and varicella (MMR/V) are highly communicable infectious diseases whose causative agents are spread through contact with contaminated surfaces or airborne droplets. MMR/V were common in the U.S. before the introduction of licensed vaccines: measles (1963), mumps (1967), rubella (1969), and varicella (1995). Since then, these vaccines have been important components of routine pediatric preventive care. This report highlights the recent trends in MMR/V in both military and civilian populations as well as the importance of primary and booster vaccinations.  During 2010 – 2016, there were: •	11 confirmed measles cases – one was in a service member. •	76 confirmed mumps cases – 28 were in service members. •	7 confirmed rubella cases – two were in service members. •	62 confirmed varicella cases among service members. The reporting of cases of varicella in non-military personnel was not mandated until 2017. Individuals at highest risk for MMR/V •	Infants •	Unvaccinated persons •	Inadequately vaccinated persons •	Individuals living in communities with low vaccination rates •	Persons living in crowded and unsanitary conditions •	Those with compromised immune systems Access the full report in MSMR Vol. 24 No. 10 October 2017 for more information at Health.mil/MSMR A picture of service members in communal area displays as well as an image of team work activities.

This infographic highlights the recent trends in Measles, Mumps, Rubella, and Varicella (MMR/V) in both military and civilian populations as well as the importance of primary and booster vaccinations.

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

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

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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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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

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

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

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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.

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Surveillance Snapshot Norovirus Outbreaks among Military Forces, 2008 – 2016

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

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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
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