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Mid-season flu activity increase: How to keep healthy

Navy Hospital Corpsman Kenny Liu, from San Jose, assigned to USS Gerald R. Ford's medical department, prepares a needle with a flu vaccination in the ship's hangar bay. (U.S. Navy photo by Mass Communication Specialist Seaman Apprentice Angel Thuy Jaskuloski) Navy Hospital Corpsman Kenny Liu, from San Jose, assigned to USS Gerald R. Ford's medical department, prepares a needle with a flu vaccination in the ship's hangar bay. (U.S. Navy photo by Mass Communication Specialist Seaman Apprentice Angel Thuy Jaskuloski)

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Influenza can affect anyone, from the everyday civilian to the active-duty service member. Current trends show an increase in flu activity at the halfway point of the season. While it’s too early in the season to determine the overall severity of the flu, the Military Health System maintains readiness and resourcefulness to protect the armed forces and their loved ones from effects of the flu.

The U.S. Centers for Disease Control and Prevention (CDC) has found an elevated level of influenza activity earlier in the season than is typically observed around this time. As of Jan. 16, the CDC estimates that there have been approximately 4,800 flu-related deaths and 87,000 hospitalizations nationwide this season. Active surveillance by the Defense Health Agency’s Armed Forces Health Surveillance Division (AFHSD) has also found high levels of influenza activity among military personnel.

Despite the increase in activity, MHS is prepared to sustain the health of service members and their families. All military personnel are required to be immunized against the flu annually to decrease susceptibility to infection.

“Immunization is important given that military personnel live and work in close proximity with other members of the community,” said Navy Cmdr. Shawn Clausen of AFHSD’s Epidemiology and Analysis section.

While involvement in patient-care activities and participation in large gatherings increases the risk of infection, early data and discussions with the CDC show that the risk among military members and the general population appears to be similar. To get ahead of this risk, the Department of Defense has already distributed more than 3.3 million doses of influenza vaccine throughout the military. As of Jan. 16, approximately 90 percent of all service members have been vaccinated.

Vaccination is recommended not just for military members, but also their loved ones, according to Janet Brunader, a research nurse in the Vaccine Safety & Evaluation section of the Defense Health Agency’s Immunization Healthcare Division.

“The good news is that although seasonal influenza vaccine is not always a perfect match, it is still the best way to provide protection against influenza disease,” she said. Brunader suggests that everyone 6 months or older get a flu shot each year in the fall. Children over 6 months of age but under age 8 years who have never had a flu shot should get two shots – one shot followed by another at least four weeks later. Children who have had at least one flu shot in the past only need to get one flu shot each year.

There are numerous ways in addition to vaccination to keep safe against the flu.

“One helpful suggestion, in addition to washing your hands before eating or handling food, is to avoid touching your eyes, nose, or face with your unwashed hands,” Brunader said. “This will help prevent spreading germs from surfaces to your eyes, nose, or mouth.”

Since flu viruses can also spread through the air, Brunader suggests staying at least six feet away from people who are coughing, sneezing, or blowing their nose. If you already have the flu, coughing into a tissue or the bend of the elbow will reduce the spread of viruses. Those suspecting they have the flu should contact a health care provider within two days of the symptoms. Early treatment with anti-influenza drugs can shorten the duration of illness.

Beneficiaries can receive flu vaccines through their closest military hospital and retail networks. TRICARE representatives can help determine how to get the vaccine if a person is unable to visit a military hospital. MHS also has an archive of influenza resources for beneficiaries to learn more about the flu and what they need to do to keep safe during the season.

Among the four types of flu, influenza A and B are the main two strains that cause “flu season.” AFHSD has paid close attention to both of these strains this year.

“As reflected in the U.S. among civilian populations [this season], the majority of laboratory-confirmed influenza-positive specimens continued to be influenza subtype B [Victoria lineage],” said Navy Cmdr. Mark Scheckelhoff from AFHSD’s Global Emerging Infections Surveillance section. "In recent weeks, the incidence of influenza A, specifically A(H1N1)pdm09, has increased steadily and appears that it will soon become the most predominant strain.”

According to early data from AFHSD, most of the U.S. is experiencing at least “moderate” levels of flu and flu-like activity, with the exception of a few states. Globally, temperate areas of Europe are also observing increased incidences of the flu, with areas of Central and Western Africa continuing to have elevated activity as well. Most of South and Central America and most areas of South and Southeast Asia are reporting “low” levels of activity, but the World Health Organization characterizes other areas of Asia as either “elevated” or “increasing.”

To monitor progression of the flu through the season, AFHSD produces a tri-service consolidated influenza report weekly to reflect data from military hospitals. The CDC also produces a more holistic view on how influenza is affecting the rest of the country.

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

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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.

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Seizures among Active Component service members, U.S. Armed Forces, 2007 – 2016

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This retrospective study estimated the rates of seizures diagnosed among deployed and non-deployed service members to identify factors associated with seizures and determine if seizure rates differed in deployment settings. It also attempted to evaluate the associations between seizures, traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD) by assessing correlations between the incidence rates of seizures and prior diagnoses of TBI and PTSD. Seizures have been defined as paroxysmal neurologic episodes caused by abnormal neuronal activity in the brain. Approximately one in 10 individuals will experience a seizure in their lifetime. Line graph 1: Annual crude incidence rates of seizures among non-deployed service members, active component, U.S. Armed Forces data •	A total of 16,257 seizure events of all types were identified among non-deployed service members during the 10-year surveillance period. •	The overall incidence rate was 12.9 seizures per 10,000 person-years (p-yrs.) •	There was a decrease in the rate of seizures diagnosed in the active component of the military during the 10-year period. Rates reached their lowest point in 2015 – 9.0 seizures per 10,000 p-yrs. •	Annual rates were markedly higher among service members with recent PTSD and TBI diagnoses, and among those with prior seizure diagnoses. Line graph 2: Annual crude incidence rates of seizures by traumatic brain injury (TBI) and recent post-traumatic stress disorder (PTSD) diagnosis among non-deployed active component service members, U.S. Armed Forces •	For service members who had received both TBI and PTSD diagnoses, seizure rates among the deployed and the non-deployed were two and three times the rates among those with only one of those diagnoses, respectively. •	Rates of seizures tended to be higher among service members who were: in the Army or Marine Corps, Female, African American, Younger than age 30, Veterans of no more than one previous deployment, and in the occupations of combat arms, armor, or healthcare Line graph 3: Annual crude incidence rates of seizures diagnosed among service members deployed to Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn, U.S. Armed Forces, 2008 – 2016  •	A total of 814 cases of seizures were identified during deployment to operations in Iraq and Afghanistan during the 9-year surveillance period (2008 – 2016). •	For deployed service members, the overall incidence rate was 9.1 seizures per 10,000 p-yrs. •	Having either a TBI or recent PTSD diagnosis alone was associated with a 3-to 4-fold increase in the rate of seizures. •	Only 19 cases of seizures were diagnosed among deployed individuals with a recent PTSD diagnosis during the 9-year surveillance period. •	Overall incidence rates among deployed service members were highest for those in the Army, females, those younger than age 25, junior enlisted, and in healthcare occupations. Access the full report in the December 2017 MSMR (Vol. 24, No. 12). Go to www.Health.mil/MSMR

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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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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.

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Cold weather injuries by military location, U.S. Armed Forces, July 2012 – June 2017

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1/18/2018
From July 2016 through June 2017, a total of 24 military locations had at least 30 incident cold weather injuries (one per person, per year) among active and reserve component service members.  The locations with the highest 5-year counts of incident injuries were: •	Fort Wainwright, AK (175) •	Bavaria (Grafenwoehr/Vilseck), Germany (110) •	Marine Corps Recruit Depot Parris Island/ Beaufort, SC (102) •	Fort Benning, GA (99) •	Fort Carson, CO (88) •	Marine Corps Base Quantico, VA (86) •	Fort Bragg, NC (78) Map displays the information above. 2016 – 2017 cold season During the 2016 – 2017 cold season, the numbers of incident cases of cold weather injuries were higher than the counts for the previous 2015-2016 cold season at seven of the 24 locations. The most noteworthy increase was found at the Army’s Fort Wainwright, where there were 48 total cases diagnosed in 2016 – 2017 , compared to just 16 during the 2015 – 2016 cold season. Bar chart shows annual number of cold weather injuries (cold season 2016 – 2017) and median number of cold weather injuries (cold seasons 2012 – 2016) at military locations with at least 30 cold weather injuries during the surveillance period, active component, 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 Image in background includes  service members out in the snow.

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Incidence rates of cold weather injuries: Non-Hispanic black service members, five cold weather seasons, July 2012 – June 2017

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Did you know for all of the services, overall rates of cold weather injuries were higher among non-Hispanic black service members than among those of other race/ethnicity groups? •	Rates of cold weather injuries among non-Hispanic black service members were two-times as high as those among non-Hispanic white or other race/ethnicity groups.  •	The rates of frostbite among non-Hispanic black service members were three-times those of the other race/ethnicity groups. Access the full report in the October 2017 MSMR (Vol. 24, No. 10). Go to www.Health.mil/MSMR  #ColdReadiness Image of non-Hispanic black service member in the snow displays.

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2016 – 2017 Cold Season, Cold Weather Injuries, Active and Reserve Components, U.S. Armed Forces

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or the 2016 – 2017 cold season, the number of active component service members with cold weather injuries was the lowest of the last 18 cold seasons since the Medical Surveillance Monthly Report (MSMR) began reporting such data in the 1999-2000 cold season. Findings •	The overall incidence rate for cold weather injuries for all active component service members in 2016 – 2017 was 15% lower than the rate for the 2015 – 2016 cold season. •	The 2016 – 2017 rate was the lowest of the entire five year surveillance period. •	In the 2016 – 2017 cold season, the Army’s incidence rate of 41.0 per 100,000 person-years for active component soldiers was 18% lower than the Army’s lowest previous rate in 2012 – 2013. •	In the Navy, Air Force, and Marine Corps, the active component rate for 2016 – 2017 was only slightly higher than their lowest rates during the 2012—2017 surveillance period. Pie chart 1 (left side of infographic): Cold Weather Injuries, By Service, Active Component, 2016 – 2017 data •	Army 57.6% (n=189) •	Marine Corps 21.0% (n=69) •	Air Force - 13.1% (n=43) •	Navy – 8.2% (n=27) •	The sharp decline in the Army rate during the 2016 – 2017 cold season drove the overall decline for all services combined. Pie chart 2 (right side of infographic): Percentage distribution by service of cold weather injuries among reserve component service members during cold season 2016 – 2017  •	Army 72.9% (n=43) •	Marine Corps 13.5% (n=8) •	Air Force 13.5% (n=8) •	Navy (n= 0) •	For the 2016 – 2017 cold season, the overall rate of cold weather injuries for the reserve component and the rates for each of the services except the Air Force were lower than in any of the previous four seasons. Access the full report in the October 2017 MSMR (Vol. 24, No. 10). Go to: www.Health.mil/MSMR

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Cold weather injuries during deployments, July 2012 – June 2017

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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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Percentages of each Service’s cold weather injuries, 2016 – 2017 cold season

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Did you know when all cold weather injuries were considered, not just the numbers of individuals affected, frostbite was the most common type of cold weather injury, comprising 53% (n=177) of all cold weather injuries among active component service members in 2016 – 2017? •	In the Air Force and Army respectively, 60.9% and 58.9% of all cold weather injuries were frostbite, whereas the proportions in the Marine Corps (42.9%) and Navy (25.0%) were much lower. •	For the Navy, the 2016-2017 number and rate of frostbite injuries in active component service members were the lowest of the past 5 years. •	The number of immersion injury cases in 2016 – 2017 in the Marine Corps was the lowest of the 5-year surveillance period. Bar graph: Percentages of each Service’s cold weather injuries that were frostbite, 2016 – 2017 cold season •	Air Force (60.9%) •	Army (58.9%) •	Marine Corps (42.9%) •	Navy (25.0%) For all active component service members during the 2016 – 2017, the proportions of non-frostbite cold weather injuries were as follows: •	19.5% hypothermia •	17.7% immersion injuries •	9.9% Other & unspecified 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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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.

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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

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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.

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

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

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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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