Skip to main content

Military Health System

Brief Report: The Challenge of Interpreting Repeated Positive Tests for SARS-CoV-2 Among Military Service Members, Fort Jackson, SC, 2020–2021

Image of Gloved hand holding an example of a negative rapid test for the SARS-CoV-2 virus (COVID-19). An example of a negative rapid test for the SARS-CoV-2 virus (COVID-19). The Texas Military Department has begun distributing rapid COVID-19 tests to its service members across the state as a force health protection measure. This will ensure that the Soldiers and Airmen serving their communities during the COVID-19 pandemic remain healthy and safe. (Photo by ENS Charles E. Spirtos)

Recommended Content:

Medical Surveillance Monthly Report

Background

Reinfection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is believed to be uncommon. However, suspected cases of reinfection have been reported from multiple countries, and many of these cases have been associated with SARS-CoV-2 variants.1-3 As the spread of the variants increases, so may the risk of reinfection. Reinfection is defined here as persons who were infected once, recovered, and then later became infected again. Unfortunately, it is difficult to differentiate reinfection from 1) reactivation of the virus which persisted after the original infection (despite apparent clinical recovery), 2) persistence of non-viable viral debris, or 3) laboratory error or variation. In one large contact tracing study in Korea, for example, 285 patients were found to have persistent positive results for up to 12 weeks after initial infection, but the Korea Centers for Disease and Prevention (KCDC) found no evidence of transmissibility or ability to isolate replication-competent virus.4

It is important to know if a person is re-infected in order to understand the true burden of disease. In addition, public health interventions, including isolation, investigating unvaccinated contacts, and vaccination are required for each case. Although a history of prior infection has been associated with an 84% lower risk of infection,5 subsequent reinfections have been increasing.6,7 Letizia et al. reported the rate of new infections among those with positive antibodies, even in a rigidly controlled basic training environment, to be 1.1 cases per person-year.7 Furthermore, belief that previous infection with SARS-CoV-2 leads to immunity from reinfection may result in behaviors which increase the likelihood of transmission and infection, including hesitancy and delays in vaccination.8 For these reasons, it is important to understand the scope and impact of recurrent SARS-CoV-2 positive tests in military and civilian populations.

This report details a case series of service members with repeated positive tests for SARS-CoV-2 in a U.S. Army Training and Doctrine Command installation. The current findings underscore the need for a standardized approach to identify and respond to suspected cases of SARS-CoV-2 reinfection, and highlight the challenges of using this information to guide effective Force Health Protection (FHP) and communication strategies among Department of Defense (DOD) personnel.

Clinical Presentations

SARS-CoV-2 positive cases were identified through public health surveillance activities within the Moncrief Army Community Hospital's Department of Preventive Medicine at Fort Jackson, SC. Suspected cases were tested using the Cepheid Xpert® Xpress SARS-CoV-2 test on the GeneXpert® System (Cepheid Inc., Lawrence Livermore National Labs, CA) and the BinaxNOW™ (Abbott Diagnostics Scarborough, Inc., Scarborough, ME) antigen card. Both are authorized for use under a Food and Drug Administration Emergency Use Authorization. The Xpert Xpress SARS-CoV-2 utilizes real-time reverse-transcription polymerase chain reaction (qRT-PCR) testing for qualitative and quantitative detection of viral nucleic acid from patients suspected of infection with the SARS-CoV-2 virus. Approved for use as a qualitative diagnostic, this assay (run on the GeneXpert system) generates a report that includes result interpretation and the cycle threshold (Ct) value, (i.e., the number of cycles required in order for the signal to cross and exceed the background threshold). The Ct value is inversely proportional to the number of copies of the target nucleic acid (i.e., copy number) and the number of whole viral genomes in the actual sample. Earlier or lower Ct values suggest a higher viral load, while later or higher values suggest a lower viral load. The BinaxNOW™ antigen card is a lateral flow immunoassay, point-of-care test (POCT) used strictly for the qualitative detection of SARS-CoV-2 nucleocapsid protein antigen.

Eight service members with recurrent positive SARS-CoV-2 tests were identified at Fort Jackson, SC between July 2020 and March 2021 (Table). All were enlisted service members ranging in age from 18 to 31 years of age (mean=23.6 years) (data not shown). None of the 8 service members were identified as close contacts of one another. Six were male; 5 were originally identified as Army basic trainees; 6 had initially reported no symptoms, although 2 of the 6 later displayed symptoms upon reinfection; one had recently returned from an overseas location (data not shown). None had any SARS-CoV-2 tests performed (qRT-PCR or POCT) other than those listed (Table). The average number of days between 2 positive tests was 174 (range: 117–243 days). None had received any doses of COVID-19 vaccine by the time of the potential second infection. None of the patients were hospitalized at any time, and all recovered without any complications. Only one was employed in health care. Of note, all service members were isolated and had their contacts quarantined during both episodes.

All 8 of the service members met the Centers for Disease Control and Prevention (CDC) case definition for confirmed or probable infection with both the first and the second positive test; 9 and, therefore all were reported as COVID-19 cases both times as per DOD reporting requirements.10 The confirmed cases all had a positive qRT-PCR, while the probable cases had symptoms, which met the clinical criteria, and a positive rapid test. The criteria for investigation of suspected reinfection from the CDC were used to assess the likelihood of COVID-19 reinfection.11 The factors which make reinfection more likely included: presence of symptoms, interval ≥ 90 days between positive tests, lower or earlier Ct values (i.e., less than 33), and presence of at least 1 negative test between occurrences. The CDC also requires that a respiratory sample from each infection episode be available for further investigation using genomic sequencing, but no such specimens were available for any of these service members. Many of the Ct values seen in these service members were high or late (i.e., weakly positive), suggesting that they are more likely to be false positives or persistent low-level positives from an earlier infection. Based on these criteria, 2 were considered to be possible reinfections, 3 were unlikely, and 3 had insufficient information to assess.

Editorial Comment

The risk of having a positive test for SARS-CoV-2 after prior infection has been estimated at 14.8%, but this includes both viral persistence as well as reinfections.12 Younger patients, such as the service members seen in this report, have been shown to be more likely to have recurrent positives, and they are the predominant group with delayed (>90 days) recurrent positives.13 However, in the absence of genome sequence data, it is difficult to determine if the cases are truly reinfections. In this study, 3 of the 8 patients identified were assessed as unlikely to have had a reinfection and 3 had insufficient information to assess reinfection. Complicating this assessment is the fact that there is no standardized or accepted definition of a SARS-CoV-2 reinfection, although several have been proposed.14,15 Another limitation of this study that should be taken into consideration when interpreting the results was the use of quantitative data from the GeneXpert, which was approved as a qualitative but not a quantitative test. Finally, rapid POCTs can vary in sensitivity and specificity based on viral load and patient presentation.

For these reasons, a more thorough investigation is recommended for future suspected cases of reinfection using the CDC investigation protocol.11 Specifically, viral culture and genomic sequencing of paired specimens (one from each episode) should be undertaken to confirm the presence of transmissible virus and to identify unique variants or infections.11,16 The CDC protocol states that investigations of reinfection should prioritize persons in whom SARS-CoV-2 RNA has been detected ≥ 90 days since first SARS-CoV-2 infection whether or not symptoms were present.11 Persons with COVID-19-like symptoms and detection of SARS-CoV-2 RNA 45–89 days since first SARS-CoV-2 infection may also be investigated if they had a symptomatic second episode and no obvious alternate etiology for COVID-19-like symptoms or close contact with a person known to have laboratory-confirmed COVID-19.11 The investigation of both groups requires paired specimens and is only recommended for those with a cycle threshold (Ct) value <33 or if the Ct value is unavailable. Genomic testing can then provide evidence of whether the second positive test represents a true reinfection. Serial collection of respiratory specimens and serologic testing may also help to assess reinfection status.

The uncertainty in the reinfection status also has implications for surveillance data and public health response. If these are true cases of reinfection, then they should be counted as new incident cases. However, if they are false positives or persistent positives from the original infection, counting them will result in overestimates of the true disease burden. The reinfection status of most of these service members is doubtful or uncertain based on the criteria listed above, suggesting that service members should be counted only once as incident cases until more compelling evidence of true reinfection is presented. Additionally, the isolation of most of the service members in this study (and quarantine of their close contacts) was probably unnecessary given the low likelihood of transmissibility suggested by the Ct values. Nevertheless, due to the uncertainty around these cases, it was reasonable to take a conservative approach in the context of an ongoing pandemic. The uncertainty about such cases underscores the need for further investigation of patients with recurrent positive tests so that they may have their disease status correctly classified, which would enable more effective counseling regarding individual behaviors and a more targeted public health response.

Finally, these results suggest the need for clear public health risk communication to previously infected individuals, particularly regarding the risk of reinfection and the potential mitigating effects of vaccination. Previously infected individuals who believe that they are immune may be less likely to use masks, to adhere to social distancing requirements, or to receive the vaccine. Recent data has shown that service members who were previously infected with COVID-19 were less likely to receive vaccination, even after adjusting for demographics, comorbidities, and other factors.8 Previously infected individuals who remain unvaccinated have been shown to have a 2.3 times higher likelihood of reinfection compared to those who were previously infected and then vaccinated,6 and these individuals may then transmit the infection to others. Public health and medical personnel should consider specifically targeting previously infected individuals for vaccination campaigns.

Author affiliations: USAMEDDAC, Fort Jackson, SC (COL Kwon, 1LT Shadwick, and COL Hall); GEIS, AFSHD, Silver Spring, MD (Dr. Bazaco, Dr. Morton, and Ms. Hartman); Department of Preventive Medicine & Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD (COL Mancuso).

Disclaimer: The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Ser­vices University, the U.S. Army, or the Department of Defense.

References

  1. Nonaka CKV, Franco MM, Graf T, et al. Genomic Evidence of SARS-CoV-2 Reinfection Involving E484K Spike Mutation, Brazil. Emerg Infect Dis. 2021;27(5):1522–1524.
  2. Zucman N, Uhel F, Descamps D, Roux D, Ricard JD. Severe reinfection with South African SARS-CoV-2 variant 501Y.V2: A case report. Clin Infect Dis. 2021;ciab129.
  3. Harrington D, Kele B, Pereira S, et al. Confirmed reinfection with SARS-CoV-2 variant VOC-202012/01. Clin Infect Dis. 2021;ciab104.
  4. Korea Centers for Disease Control & Prevention. Findings from Investigation and Analysis of re-positive cases. 18 May 2020. Korea Central Disaster Control and Prevention (KCDC): Seoul, Korea.
  5. Hall VJ, Foulkes S, Charlett A, et al. SARS-CoV-2 infection rates of antibody-positive compared with antibody-negative health-care workers in England: a large, multicentre, prospective cohort study (SIREN). Lancet. 2021;397(10283):1459–1469. 
  6. Cavanaugh AM, Spicer KB, Thoroughman D, Glick C, Winter K. Reduced risk of reinfection with SARS-CoV-2 after COVID-19 vaccination-Kentucky, May-June 2021. MMWR Morb Mortal Wkly Rep. 2021;70(32):1081–1083. 
  7. Letizia AG, Ge Y, Vangeti S, et al. SARS-CoV-2 seropositivity and subsequent infection risk in healthy young adults: a prospective cohort study. Lancet Respir Med. 2021;9(7):712–720.
  8. Lang MA, Stahlman S, Wells NY, et al. Disparities in COVID-19 vaccine initiation and completion among active component service members and health care personnel, 11 December 2020-12 March 2021. MSMR. 2021;28(4):2–9. 
  9. Centers for Disease Control and Prevention (CDC). Coronavirus Disease 2019 (COVID-19) 2020 Interim Case Definition, Approved April 5, 2020. Updated 5 Aug 2020. Accessed 20 April 2021. https://wwwn.cdc.gov/nndss/conditions/coronavirus-disease-2019-covid-19/case-definition/2020/
  10. US Army Public Health Center. SURVEILLANCE OF COVID-19 IN THE DEPARTMENT OF DEFENSE. Technical Information Paper No. 98-122-0720. Accessed 20 April 2021. https://phc.amedd.army.mil/PHC%20Resource%20Library/cv19-surveillance_in_the_DOD.pdf
  11. Centers for Disease Control and Prevention (CDC). Investigative criteria for suspected cases of SARS-CoV-2 reinfection (ICR). Updated 27 Oct 2020. Accessed 20 April 2021. https://www.cdc.gov/coronavirus/2019-ncov/php/invest-criteria.html
  12. Azam M, Sulistiana R, Ratnawati M, et al. Recurrent SARS-CoV-2 RNA positivity after COVID-19: a systematic review and meta-analysis. Sci Rep. 2020;10(1):20692. 
  13. Vancsa S, Dembrovszky F, Farkas N, et al. Repeated SARS-CoV-2 positivity: analysis of 123 cases. Viruses. 2021;13(3):512.
  14. Gousseff M, Penot P, Gallay L, et al. Clinical recurrences of COVID-19 symptoms after recovery: Viral relapse, reinfection or inflammatory rebound? J Infect. 2020;81(5):816–846.
  15. Tomassini S, Kotecha D, Bird PW, Folwell A, Biju S, Tang JW. Setting the criteria for SARS-CoV-2 reinfection - six possible cases. J Infect. 2021;82(2):282–327. 
  16. Rhoads D, Peaper DR, She RC, et al. College of American Pathologists (CAP) Microbiology Committee Perspective: Caution must be used in interpreting the Cycle Threshold (Ct) value. Clin Infect Dis. 2021;72(10):e685–e686.

TABLE. Characteristics of patients with recurrent positive tests for SARS-CoV-2

You also may be interested in...

Musculoskeletal Injuries During U.S. Air Force Special Warfare Training Assessment and Selection, Fiscal Years 2019–2021.

Article
8/1/2022
U.S. Air Force Capt. Hopkins, 351st Special Warfare Training Squadron, Instructor Flight commander and Chief Combat Rescue Officer (CRO) instructor, conducts a military free fall equipment jump from a DHC-4 Caribou aircraft in Coolidge, Arizona, July 17, 2021. Hopkins is recognized as the 2020 USAF Special Warfare Instructor Company Grade Officer of the Year for his outstanding achievement from January 1 to December 31, 2020.

Musculoskeletal (MSK) injuries are costly and the leading cause of medical visits and disability in the U.S. military.1,2 Within training envi­ronments, MSK injuries may lead to a loss of training, deferment to a future class, or voluntary disenrollment from a training pipeline, all of which are impediments to maintaining full levels of manpower and resources for the Department of Defense.

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Pain and Post-Traumatic Stress Disorder Screening Outcomes Among Military Personnel Injured During Combat Deployment.

Article
8/1/2022
U.S. Air Force Airman 1st Class Miranda Lugo, right, 18th Operational Medical Readiness Squadron mental health technician and Guardian Wingman trainer, and Maj. Joanna Ho, left, 18th OMRS director of psychological health, discuss the suicide prevention training program, Guardian Wingman, at Kadena Air Base, Japan, Aug. 20, 2021. Guardian Wingman aims to promote wingman culture and early help-seeking behavior. (U.S. Air Force photo by Airman 1st Class Anna Nolte)

The post-9/11 U.S. military conflicts in Iraq and Afghanistan lasted over a decade and yielded the most combat casualties since the Vietnam War. While patient survivability increased to the high­est level in history, a changing epidemiology of combat injuries emerged whereby focus shifted to addressing an array of long-term sequelae, including physical, psychologi­cal, and neurological issues.

Recommended Content:

Medical Surveillance Monthly Report

Prevalence and Distribution of Refractive Errors Among Members of the U.S. Armed Forces and the U.S. Coast Guard, 2019.

Article
8/1/2022
Ophthamologist Air Force Maj. Thuy Tran evaluates a patient during an eye exam. (U.S. Air Force photo by Tech. Sgt. John Hughel)

During calendar year 2019, the estimated prevalence of myopia, hyperopia, and astigmatism were 17.5%, 2.1%, and 11.2% in the active component of the U.S. Armed Forces and 10.1%, 1.2%, and 6.1% of the U.S. Coast Guard, respectively.

Recommended Content:

Medical Surveillance Monthly Report

Establishment of SARS-CoV-2 Genomic Surveillance Within the Military Health System During 1 March–31 December 2020.

Article
7/1/2022
Dr. Peter Larson loads an Oxford Nanopore MinION sequencer in support of COVID-19 sequencing assay development at the U.S. Army Medical Research Institute of Infectious Diseases, Fort Detrick, Maryland. (Photo by John Braun Jr., USAMRIID.)

This report describes SARS-CoV-2 genomic surveillance conducted by the Department of Defense (DOD) Global Emerging Infections Surveillance Branch and the Next-Generation Sequencing and Bioinformatics Consortium (NGSBC) in response to the COVID-19 pandemic. Samples and sequence data were from SARS-CoV-2 infections occurring among Military Health System (MHS) beneficiaries from 1 March to 31 December 2020.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Trends for SARS-CoV-2 and Other Respiratory Pathogens Among U.S. Military Health System Beneficiaries, 27 September 2020–2 October 2021.

Article
7/1/2022
Staff Sgt. Misty Poitra and Senior Airman Chris Cornette, 119th Medical Group, collect throat swabs during voluntary COVID-19 rapid drive-thru testing for members of the community while North Dakota Army National Guard Soldiers gather test-subject data in the parking lot of the FargoDome in Fargo, N.D., May 3, 2020. The guardsmen partnered with the N.D. Department of Health and other civilian agencies in the mass-testing efforts of community volunteers. (U.S. Air National Guard photo by Chief Master Sgt. David H. Lipp)

Respiratory pathogens, such as influenza and adenovirus, have been the main focus of the Department of Defense Global Respiratory Pathogen Surveillance Program (DoDGRPSP) since 1976.1. However, DoDGRPSP also began focusing on SARS-CoV-2 when COVID-19 was declared a pandemic illness in early March 2020.2. Following this declaration, the DOD quickly adapted and organized its respiratory surveillance program, housed at the U.S. Air Force School of Aerospace Medicine (USAFSAM), in response to this emergent virus.

Recommended Content:

Medical Surveillance Monthly Report

Suicide Behavior Among Heterosexual, Lesbian/Gay, and Bisexual Active Component Service Members in the U.S. Armed Forces.

Article
7/1/2022
  The DOD’s theme for National Suicide Prevention Month is “Connect to Protect: Support is Within Reach.” Deployments, COVID-19 restrictions, and the upcoming winter season are all stressors and potential causes for depression that could lead to suicidal ideations. Options are available to individuals who are having thoughts of suicide and those around them (Photo by Kirk Frady, Regional Health Command Europe).

Lesbian, gay, and bisexual (LGB) individuals are at a particularly high risk for suicidal behavior in the general population of the United States. This study aims to determine if there are differences in the frequency of lifetime suicide ideation and suicide attempts between heterosexual, lesbian/gay, and bisexual service members in the active component of the U.S. Armed Forces. Self-reported data from the 2015 Department of Defense Health-Related Behaviors Survey were used in the analysis.

Recommended Content:

Medical Surveillance Monthly Report

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

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

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

Recommended Content:

Medical Surveillance Monthly Report

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

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

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

Recommended Content:

Medical Surveillance Monthly Report

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

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

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

Recommended Content:

Medical Surveillance Monthly Report

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

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

Recommended Content:

Medical Surveillance Monthly Report

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

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

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

Recommended Content:

Medical Surveillance Monthly Report

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

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

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

Recommended Content:

Medical Surveillance Monthly Report

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

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

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

Recommended Content:

Medical Surveillance Monthly Report

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

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

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

Recommended Content:

Medical Surveillance Monthly Report

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

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

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 13
Refine your search
Last Updated: October 18, 2022
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery