DoD Global, Laboratory-Based, Influenza Surveillance Program. USAF School of Aerospace Medicine & Defense Health Agency

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1 USAF School of Aerospace Medicine & Defense Health Agency DoD Global, Laboratory-Based, Influenza Surveillance Program Cumulative Results Locations 79 Collected 4,297 Tested 4,243 Influenza A 742 A(HN)pdm A(HN)pdm09 & B A(HN)pdm09 & Coronavirus A(HN)pdm09 & Parainfluenza A(H3N2) 03 A(H3N2) & B Influenza B* 368 B 367 B & Adenovirus Other Respiratory Pathogens,030 Adenovirus 6 Bordetella pertussis Chlamydophila pneumoniae 2 Coronavirus 85 Human Metapneumovirus 85 Mycoplasma pneumoniae 55 Parainfluenza 08 RSV 29 Rhinovirus/Enterovirus 27 Non-influenza Viral Coinfections 7 Non-influenza Bacterial Coinfections 6 -B. pertussis (3) -B. pertussis & M. pneumo () -C. pneumo (2) -C. pneumo & M. pneumo () -M. pneumo (9) Respiratory Highlights 5-28 May 206 (Surveillance Weeks 20 & 2) During 5-28 May 206, a total of 56 specimens were collected and received from 25 locations. Results were finalized for 52 specimens from 22 locations. During Week 20, three influenza A(HN)pdm09 and six influenza B viruses were identified. Four influenza B viruses were identified during Week 2. Approximately 22% of specimens tested positive for influenza during Week 20. The percent positive for Week 2 increased to approximately 28%, as fewer specimens were received. The influenza percent positive for the season is currently 26%. Flu activity continues to decrease in the United States. For this season, it has peaked nationally and is winding down. New York and Puerto Rico continue to report widespread flu activity. Influenza B viruses have been most common in recent weeks; however, A(HN)pdm09 has been predominant overall this season. Second waves of influenza B activity occur during many flu seasons. CDC continues to recommend influenza vaccination as long as influenza viruses are circulating. CDC also recommends that patients suspected of having influenza who are at high-risk of flu complications or who are very sick with flu-like symptoms should receive prompt treatment with influenza antiviral drugs without waiting for confirmatory testing (CDC Situation Update, Cited 2 June 206). This report contains the eighth molecular sequence analysis report and includes 93 specimens collected between 9 December 205 and 8 March 206. See page 8 for further details. This report will be last weekly report for this season. Subsequent reports for the remainder of this season will be distributed monthly. Table of Contents Respiratory Highlights Page Results by Region and Location for Specimens Collected during Weeks 20 & 2 Page 2 Laboratory Results - Cumulative for Season and Demographic Summary Page 3 Vaccination Status by Beneficiary Type Page 4 Geographic distribution of influenza subtype and activity level maps Pages 4 & 5 Cumulative Results by Region and Location Pages 6 & 7 Lab data are current as of 3 May 206. Results are preliminary and may change as more results are received. *Influenza B lineages will be reported in the periodic molecular sequencing reports. Molecular Sequence Analysis Report #8 Pages 8-3 DoD Global, Laboratory-Based, Influenza Surveillance Program Background Page 4 88ABW and PA guidance dated 0 November 205.

2 Table. Results by region and location for specimens collected during Weeks 20 & 2 A(HN)pdm09 B Adenovirus hmnv Parainfluenza Rhinovirus/Enterovirus No Pathogen Total Region* PACOM Kadena AB, Japan Region 2 JB McGuire-Dix-Lakehurst, NJ USMA - West Point, NY Region 3 NMC Portsmouth, VA Region 4 Eglin AFB, FL Ft Bragg, NC Maxwell AFB, AL Moody AFB, GA Robins AFB, GA Shaw AFB, SC Region 5 Wright-Patterson AFB, OH Region 6 Altus AFB, OK Laughlin AFB, TX Little Rock AFB, AR Sheppard AFB, TX Region 7 Offutt AFB, NE Region 8 Ellsworth AFB, SD Hill AFB, UT Region 9 Edwards AFB, CA Luke AFB, AZ Travis AFB, CA Region 0 NH Bremerton, WA Total *CONUS locations are based on Health & Human Services regions. Other locations are defined by COCOM. 88ABW and PA guidance dated 0 November

3 Laboratory Results - Cumulative for Season Graph. Percent influenza positive by week: surveillance year and through Week 2 of the surveillance year Note: Dual influenza coinfections are excluded from this graph. Specimens with pending results are used in the denominator to calculate percent positive, but are not displayed in the graph. Table 2. ILI by age group for the surveillance year through Week 2 Graph 2. ILI by beneficiary status for the surveillance year through Week 2 Age Group Frequency Percent Demographic Summary Of 4,243 ILI cases,,434 are service members (33.8%),,698 are children (40.0%), 708 are spouses (6.7%), and 403 (9.5%) are retirees and other beneficiaries. The median age of ILI cases with known age (n=4,243) is 23 (range 0, 95). 88ABW and PA guidance dated 0 November

4 Graph 3. Vaccination status by beneficiary type for the surveillance year through Week 2 Map. Influenza subtypes and activity level by region for the surveillance year through Week 2* Legend Influenza Activity - Past 2 eeks No activity (0% ) or no submissions Low ( 25% ) Moderate (25-49% ) High ( 50% ) Influenza Results - Cumulative Influenza A(H3N2) Influenza A(HN)pdm09 Influenza B Influenza A/not subtyped *Due to the receipt of a small number of specimens from Regions, 3, 5, 6, 7, 8, 9 and 0 activity level may be biased. 88ABW and PA guidance dated 0 November

5 Map 2. Influenza subtypes and activity level by country for the surveillance year through Week 2 (Pacific)* Map 3. Influenza subtypes and activity level for CENTCOM for the surveillance year through Week 2* Legend Influenza Activity - Past 2 eeks No activity (0% ) or no submissions Low ( 25% ) Moderate (25-49% ) High ( 50% ) Influenza Results - Cumulative Influenza A(H3N2) Influenza A(HN)pdm09 Influenza B Influenza A/not subtyped Note - Specimens for CENTCOM were tested at USAFSAM or Landstuhl Regional Medical Center (LRMC). *Due to the receipt of a small number of specimens from the region activity level may be biased. 88ABW and PA guidance dated 0 November

6 Laboratory Results Through Current Surveillance Week 2 Table 3. Cumulative results by region and location for specimens collected during the surveillance year Region* Deployed PACOM Region Region 2 Region 3 Region 4 A(HN)pdm09 A(H3N2) A(HN)pdm09 & B A(HN)pdm09 & Corona A(HN)pdm09 & Para A(H3N2) & B Country, Location B Country 2, Location A CFA Okinawa, Japan Eielson AFB, AK JB Elmendorf-Richardson, AK JR Marianas - Andersen AFB, Guam JR Marianas - NH Guam, Guam Kadena AB, Japan Kunsan AB, South Korea Misawa AB, Japan Osan AB, South Korea USCG Base Kodiak, AK Yokota AB, Japan Hanscom AFB, MA NHCNE Newport, RI USCG Academy, CT Ft Drum, NY JB McGuire-Dix-Lakehurst, NJ USMA - West Point, NY Dover AFB, DE JB Anacostia-Bolling, DC JB Andrews, MD JB Langley-Eustis, VA NCRM - Walter Reed NMMC, MD NMC Portsmouth, VA CGS Mobile, AL Columbus AFB, MS Eglin AFB, FL Ft Bragg, NC Ft Campbell, KY Hurlburt Field, FL JB Charleston (AF), SC Keesler AFB, MS MacDill AFB, FL Maxwell AFB, AL Moody AFB, GA NH Beaufort, SC NH Camp Lejeune, NC NH Jacksonville, FL Patrick AFB, FL Robins AFB, GA Seymour Johnson AFB, NC Shaw AFB, SC Tyndall AFB, FL B B & Adeno Adenovirus B. pertussis C. pneumoniae Coronavirus hmnv M. pneumoniae Parainfluenza RSV Rhinovirus/Enterovirus Non-Influenza Bacterial Coinfection Non-Influenza Viral Coinfection No Pathogen Total *CONUS locations are based on Health & Human Services regions. Other locations are defined by COCOM. (Cont d on page 7) 88ABW and PA guidance dated 0 November

7 Laboratory Results Through Current Surveillance Week 2 Table 3. Cumulative results by region and location for specimens collected during the surveillance year (Cont d from page 6) Region* Region 5 A(HN)pdm09 A(H3N2) A(HN)pdm09 & B A(HN)pdm09 & Corona A(HN)pdm09 & Para A(H3N2) & B B B & Adeno Adenovirus B. pertussis C. pneumoniae Coronavirus hmnv M. pneumoniae Parainfluenza RSV Rhinovirus/Enterovirus Non-Influenza Bacterial Coinfection Non-Influenza Viral Coinfection No Pathogen Total Scott AFB, IL Region 6 Wright-Patterson AFB, OH Altus AFB, OK Barksdale AFB, LA Cannon AFB, NM Laughlin AFB, TX Little Rock AFB, AR Sheppard AFB, TX Tinker AFB, OK USCG New Orleans, LA Region 7 Vance AFB, OK Ft Leavenworth, KS McConnell AFB, KS Region 8 Offutt AFB, NE Ellsworth AFB, SD FE Warren AFB, WY Hill AFB, UT Malmstrom AFB, MT Minot AFB, ND Peterson AFB, CO Region 9 USAF Academy, CO Beale AFB, CA CGS Humboldt Bay, CA Davis-Monthan AFB, AZ Edwards AFB, CA Luke AFB, AZ NH Twentynine Palms, CA Nellis AFB, NV Travis AFB, CA USCG Island Alameda, CA Region 0 Vandenberg AFB, CA Fairchild AFB, WA JB Lewis-McChord, WA Mt Home AFB, ID Total NH Bremerton, WA *CONUS locations are based on Health & Human Services regions. Other locations are defined by COCOM. 88ABW and PA guidance dated 0 November

8 Molecular Sequence Analysis Report USAFSAM Epidemiology Laboratory Service This is the eighth USAFSAM influenza sequence surveillance report for the influenza season and includes 93 specimens collected between 9 December 205 and 8 March 206. USAFSAM sentinel sites submitted specimens from which 87 of these sequences were determined, while the remaining six sequences were data obtained from the Armed Forces Research Institute of Medical Sciences (AFRIMS) in Thailand. Among the sequences analyzed for this report, 55 (59.%) were influenza A(HN)pdm09, 3 (4%) were influenza A(H3N2), eight (8.6%) were influenza B/Victoria, and 7(8.3%) were influenza B/Yamagata. The hemagglutinin (HA) gene from select influenza positives was sequenced using dye terminator, Sanger-based methods. Preliminary data are based on the sequence analysis of the hemagglutinin gene. Antigenic sites, receptor binding sites and glycosylation motifs are predicated upon correlations with previously published experimental evidence.,3,4 Sequence data was constructed and analyzed using multiple software programs. Genetic and predicted antigenic information that resulted from this analysis is shared with United States Centers for Disease Control and Prevention (CDC), World Health Organization (WHO) and potentially contribute to the seasonal Northern and Southern Hemisphere vaccine component selections. A(HN)pdm09 A(H3N2) B/Victoria B/Yamagata CONUS Alabama, Maxwell AFB 2 Arizona, Luke AFB 4 7 Delaware, Dover AFB Georgia, Moody AFB Illinois, Scott AFB 4 3 Kansas, McConnell AFB Kentucky, Ft Campbell 3 Maryland, JB Andrews 3 Maryland, NCRM Walter Reed NMMC Massachusetts, Hanscom AFB New Jersey, JB McGuire-Dix-Lakehurst 2 2 New Mexico, Cannon AFB New York, USMA West Point 9 North Carolina, Ft Bragg Ohio, Wright-Patterson AFB 4 Oklahoma, Altus AFB Oklahoma, Tinker AFB South Carolina, Shaw AFB 2 Texas, Laughlin AFB Utah, Hill AFB 4 7 Virginia, JB Langley-Eustis Virginia, NMC Portsmouth Washington, NH Bremerton 4 2 Wyoming, FE Warren AFB OCONUS Alaska, Eielson AFB Alaska, JB Elmendorf-Richardson Germany, Vilseck AHC Italy, USAG Vicenza Japan, Kadena AB Japan, Yokota AB Thailand, AFRIMS 2 4 TOTAL ABW and PA guidance dated 0 November

9 Influenza A(HN)pdm09 The influenza A(HN)pdm09 sequences are characterized in a neighbor-joining phylogenetic tree with reference strains rooted from the current vaccine strain, A/California/07/2009-like virus [Figure ]. The A(HN)pdm09 specimens characterized for this report exhibited an overall protein homology of % compared to the influenza vaccine component, A/California/07/2009-like virus. All of the A(HN)pdm09 viruses sequenced for this report contain mutations consistent with one of the circulating subgroups, referred as group 6B. This clade has recently been divided into two subclades, 6B. (distinguished by the mutations S62N and I26T) and 6B.2 (distinguished by the mutations V52T, V73I, E49G, and D50E). All of the influenza A(HN)pdm09 specimens sequenced for this report were in subgroup 6B.. Gain or loss of N-linked glycosylation sites has been shown to alter HA protein surface topology. A gain in glycosylation could be advantageous to the virus by virtue of a masking effect on important antibody recognition sites, thus potentially modulating viral antigenicity. 4 Observations are based solely on sequence motifs. For the influenza A(HN)pdm09 specimens characterized in this report, one mutation, S62N (serine to asparagine), was observed that could cause a gain of a glycosylation motif. Of the 37 mutations present in the A(HN)pdm09 specimens, 3 occurred at predicted antigenic sites and two at the receptor binding site. 2,5 88ABW and PA guidance dated 0 November

10 Influenza A(HN)pdm09 HA Phylogenetic Analysis Figure A(HN)pdm09 Vaccine strain: A/California/07/2009 Reference Strain February 206 March 206 ADD GLY Create Glycosylation Motif F CDC Reference Antigen # Egg Isolate P83S D97N K63Q S85T S203T A256T K283E I32V E374K S45N E499K S84N S62N ADD GLY I26T A/California/07/2009 # F A/Mississippi/0/203 F A/New Jersey/2679/206 A/New Jersey/2680/206 K40R A/Georgia/2662/206 A/Delaware/2529/206 A/Washington/2647/206 A/New York/2549/206 A/New York/2272/206 A/Maryland/2658/206 A/New York/2553/206 A/South Carolina/2558/206 A/Utah/2250/206 A/Utah/258/206 A/Delaware/2677/206 R205K A/New York/2744/206 A/Arizona/2535/206 A/Virginia/2687/206 A/Kentucky/2567/206 A/Delaware/2384/206 A/Maryland/2659/206 S7F A34V E235D A/Washington/2634/206 A/Alabama/2720/206 A/South Carolina/2767/206 A/Arizona/296/206 A/Oklahoma/2727/206 A/New York/2550/206 A/Arizona/254/206 A/Oklahoma/2782/206 V99A A/Illinois/2689/206 A/Utah/2583/206 A/New York/2673/206 A/Georgia/2663/206 A/Alabama/278/206 I267T A/Alaska/25/206 A/New York/2269/206 R205K A/Maryland/2683/206 A/Ohio/w390/206 D96E S83Y A/Delaware/2678/206 A/Massachusetts/2557/206 S57L V479I A/Kentucky/2275/206 A/Ohio/w355/206 K46E M257I A/Washington/2636/206 A/New York/2676/206 N3D T20A A/Georgia/2664/ A/HNpdm09 6B HA Consensus A/Virginia/2722/206 I96V A/Kentucky/2276/206 D269N K302E A/Ohio/2546/206 A/Ohio/w354/206 S7P R450K A/Germany/x65/206 K499E I500L A/Arizona/2426/206 A/New York/2675/206 A/Washington/2642/206 E66D A/Maryland/2572/206 A/Maryland/2682/206 I66V I79V N45T A/Wyoming/230/206 A/Michigan/45/205 F SAg I533V A/Utah/2249/206 6B. 206 A/HNpdm09 6B2 HA Consensus A/Minnesota/32/205 F 6B ABW and PA guidance dated 0 November

11 Influenza A(H3N2) The influenza A(H3N2) sequences are characterized in a neighbor-joining phylogenetic tree with reference strains rooted from a previous vaccine strain, A/Texas/50/202-like virus [Figure 2]. The A(H3N2) specimens characterized for this report exhibited an overall protein homology of % compared to the influenza vaccine component, A/Switzerland/975293/203-like virus. All of the influenza A(H3N2) specimens sequenced for this report were in clade 3C. Ten of the influenza A(H3N2) sequences classified as subclade 3C.2a and three classified as subclade 3C.3a. Among the influenza A(H3N2) specimens characterized in this report, five mutations: T0M (threonine to methionine), T28A (threonine to alanine), and N44S (asparagine to serine), and N58K (asparagine to lysine), and N246T (asparagine to threonine) were observed that could cause the loss of a glycosylation motif. Two other mutations, N28T (asparagine to threonine) and K60T (lysine to threonine), were observed that could cause the gain of a glycosylation motif. Of the 32 mutations present in the A(H3N2) specimens, occurred at predicted antigenic sites and three at the receptor binding site. 2, Influenza A(H3N2) HA Phylogenetic Analysis Figure A(H3N2) Vaccine strain: A/Switzerland/975293/203 Reference Strain December 205 February 206 March 206 ADD GLY Create Glycosylation Motif LOSS GLY Loss of Glycosylation Motif F CDC Reference Antigen # Egg Isolate LR Low Reactor to : A/Texas/50/202 ( 8 fold) N7K I406V G484E S32R A/Japan/2486/206 I55V A/Kentucky/2569/206 A/Alaska/232/205 N2K G479E A/Italy/x67/206 N28T ADD GLY N45S P98S N225D L3I N44S LOSS GLY F59Y Q3H D489N T28A LOSS GLY A38S R42G F59S K326R K60T ADD GLY R42K Q97R Q97K A/Wisconsin/20/205 F A/Thailand/KPPH00978/205 A/Thailand/KPPH00980/205 T0M LOSS GLY L243F N246T LOSS GLY A/Japan/2432/206 I40M R26Q V2I A/Arizona/274/206 A/Arizona/2425/206 A/Arizona/253/206 A/Arizona/2703/206 A/Hong Kong/480/204 # F A/South Australia/55/204 # LR F A/Switzerland/975293/203 # LR F Q97K S98P A/Arizona/2543/206 S32N A/Arizona/2699/206 N58K LOSS GLY V347M A372E Q50H 3C.3a 3C.2a A/Arizona/2709/206 F79L A/Texas/50/202 F ABW and PA guidance dated 0 November 205.

12 Influenza B The influenza B isolates are characterized in lineage specific; neighbor-joining phylogenetic trees with reference strains and are rooted from the reference strain B/Fujian Gulou/272/2008 for B/Victoria specimens [Figure 3] and from the previous reference strain B/Massachusetts/02/202-like virus for B/Yamagata specimens [Figure 4]. The distinguishing characteristic between the two influenza B lineages (Victoria & Yamagata) is defined by an amino acid deletion in viruses belonging to the Yamagata lineage. Eight (32%) of the 25 influenza B viruses characterized in this report fall into the Victoria lineage, while the other 7 (68%) fall into the Yamagata lineage. The influenza B/Victoria specimens characterized for this report exhibited a protein homology of % when compared to the B/Victoria vaccine component, B/Brisbane/60/2008-like virus, while the influenza B/Yamagata specimens exhibited a protein homology of % when compared to the B/Yamagata vaccine strain, B/Phuket/3073/203-like virus. All of the influenza B/Victoria specimens classify into clade VA, while all of the influenza B/Yamagata specimens classify into clade Y3. Two mutations, one in each lineage, were capable of creating a glycosylation motif. For the influenza B/Victoria specimens, this was K97N (lysine to asparagine) and for the influenza B/Yamagata specimens, it was I99T (isoleucine to threonine) Influenza B/Victoria HA Phylogenetic Analysis Figure 3 S82A B/Washington/2645/206 A54T C295S B/Thailand/PMKA4620/ B/Victoria Vaccine strain: B/Brisbane/60/2008 Reference Strain January 206 February 206 March 206 ADD GLY Create Glycosylation Motif F CDC Reference Antigen # Egg Isolate I7V I80V K284R R498K B/Kentucky/2299/206 B/North Carolina/254/206 V559I R279K B/Thailand/PMKD30/206 B/Brisbane/46/205 # F B/Thailand/PMKB0545/206 VA B/Indiana/25/205 # F N75K A2T V46I N65K S72P K97N ADD GLY N505D N29D G84E B/Thailand/PMKD8/206 R80G B/Maryland/2574/206 B/Brisbane/60/2008 # F B/Burkina Faso/078/203 B/Fujian Gulou/272/2008 # F ABW and PA guidance dated 0 November

13 Influenza B/Yamagata HA Phylogenetic Analysis Figure 4 B/Utah/2252/206 B/Utah/2254/206 B/Utah/225/ B/Yamagata Vaccine strain: B/Phuket/3073/203 Reference Strain February 206 March 206 ADD GLY Create Glycosylation Motif F CDC Reference Antigen # Egg Isolate K22R B/Ohio/w48/206 B/Alaska/258/206 B/Kansas/269/206 B/Washington/2637/206 Q22K B/Utah/2248/206 B/Virginia/272/206 B/Utah/2580/206 M252V L73Q V77I B/New York/2548/206 B/Washington/2639/206 B/New Mexico/2776/206 I290V V564I B/Texas/2282/206 K22R S286A B/Kentucky/2277/206 Y3 A2T I99T ADD GLY K48R A08P S50I N66Y G230D K299E E33K N6K A82T N203S B/Nevada/0/204 R467K I50V B/Utah/2295/206 B/Utah/276/206 R56K B/Brisbane/09/204 # F B/Phuket/3073/203 # F B/Bahrain/5/203 BYAM-3/BVIC- B/Arizona/08/203 F B/Massachusetts/02/202 F B/Brisbane/36/202 # F References:. Wright, P, Neumann, G, Kaqaoka, Y Orothomyxoviruses In: Knipe, D.M., Howley, P.M. (Eds.), Fields Virology. Wolters Kluwer, Lippincott Williams & Wilkins, Philadelphia, pp Kongchanagul A., Suptawiwat, O., Kanrai, P., Uiprasertkul, M., Puthavathana, P., and Auewarakul P. (2008) Positive selection at the receptor-binding site of haemagglutinin H5 in viral sequences derived from human tissues. Journal of Gen. Vir. 89, Cherry JL, Lipman DJ, Nikolskaya A, Wolf YI. Evolutionary Dynamics of N-Glycosylation Sites of Influenza Virus Hemagglutinin. PLoS Curr Influenza August 8: RRN Deem, M., and Pan, K. (2009). The epitope regions of H-subtype influenza A, with application to vaccine efficacy. Protein Engineering, Design and Selection. 22, no Wolf YI, Viboud C, Holmes EC, Koonin EV, Lipman DJ. Long intervals of stasis punctuated by bursts of positive selection in the seasonal evolution of influenza A virus. Biol Direct. 2006; : 34. Published online 2006 October 26. doi: 0.86/ USAFSAM POCs for sequence data and analysis are: 88ABW and PA guidance dated 0 November

14 USAF School of Aerospace Medicine & Defense Health Agency DoD Global, Laboratory-Based, Influenza Surveillance Program Background The DoD-wide program was established by the Global Emerging Infections Surveillance and Response System (GEIS) in 997. The surveillance network includes the U.S. Air Force School of Aerospace Medicine (USAFSAM) (sentinel site respiratory surveillance), the Naval Health Research Center (recruit and shipboard population-based respiratory surveillance), the Naval Medical Research Unit (NAMRU-3) in Cairo, Egypt, the Naval Medical Research Unit (NAMRU-2) in Phnom Penh, Cambodia, the Armed Forces Research Institute of Medical Sciences (AFRIMS) in Bangkok, Thailand, the Naval Medical Research Unit (NAMRU-6) in Lima, Peru, and the United States Army Medical Research Unit-Kenya (USAMRU-K) located in Nairobi, Kenya. This work is supported by the Air Force and GEIS Operations, a Division of the Armed Forces Health Surveillance Branch (AFHSB). Sentinel Site Surveillance at USAFSAM In 976, the U.S. Air Force Medical Service began conducting routine, global, laboratory-based influenza surveillance. Air Force efforts expanded to DoD-wide in 997. USAFSAM manages the surveillance program that includes global surveillance among DoD beneficiaries at over 95 sentinel sites (including deployed locations) and many non-sentinel sites (please see map below). Collaborating partner laboratories include five DoD overseas medical research laboratories (AFRIMS, NAMRU-2, NAMRU-3, NAMRU-6, USAMRU-K) who collect specimens from local residents in surrounding countries that may not otherwise be covered in existing surveillance efforts. Additionally, the Naval Health Research Center (NHRC) in San Diego, CA collects specimens from DoD recruit training centers and conducts surveillance along the Mexico border. Landstuhl Regional Medical Center (LRMC) and Tripler Army Medical Center (TAMC) assist USAFSAM by processing DoD specimens for the EUCOM region and the State of Hawaii, respectively. This process seeks to provide more timely results and efficient transport of specimens. Available on our website (listed below) is a list of previous weekly surveillance reports, program information (including an educational briefing and instruction pamphlets for clinic staff), and a dashboard containing respiratory data for our sentinel sites. Errata: For Public Health Services ; DSN For Laboratory Services ; DSN USAFSAM.PHRFlu@us.af.mil Collaborating Partners In addition to all participating DoD military sentinel sites, collaborating laboratories and medical centers (described above) may be further understood by reviewing the sites website. Click on the sites icon to be directed to their webpage. 88ABW and PA guidance dated 0 November 205.