Sandrine Duron

The measles outbreak in the French military forces – 2010–2011: Results of epidemiological surveillance

OBJECTIVE Since the start of 2010 there has been a flare-up of measles in France, following on the resurgence observed in 2008. The aim of this study was to present results of the epidemiological surveillance of measles in the French armed forces in metropolitan France and to describe the outbreak that occurred in 2010 and 2011. METHODS Criteria for report were those used for French national compulsory notification. The data, concerning active military personnel, were derived from epidemiological surveillance from 1992 to 2011 for the incidence rates and from notification forms completed in 2010 and 2011 by the military practitioners for the description of characteristics of cases. RESULTS Between January 1992 and July 2010, 833 cases of measles were reported. Since 2002, the mean incidence rate had been 1 case p.100,000. A significant increase in incidence was observed in 2010 (10.1 p.100,000) and in 2011 (41.4 p.100,000). Clusters of cases accounted for 72.3% of cases. Rates were much higher among subjects under 30. Only 68.6% of cases had been previously vaccinated with at least one dose of MMR vaccine. The mean vaccine coverage among contacts of cases was approximated to 54.3%. CONCLUSIONS The outbreak of measles observed in 2010 and 2011 in the French armed forces followed the same pattern as that observed nationally and at European level, and can be seen as the likely consequence of inadequate vaccination coverage.

Ebola Virus–Related Encephalitis

Ebola patients frequently exhibit behavioral modifications with ideation slowing and aggressiveness, sometimes contrasting with mild severity of Ebola disease. We performed lumbar punctures in 3 patients with this presentation and found Ebola virus in all cerebrospinal fluid samples. This discovery helps to discuss the concept of a specific Ebola virus encephalitis.

Organ failures on admission in patients with Ebola virus disease

Dear Editor, The actual outbreak of Ebola virus disease (EVD) started in December 2013 in West Africa, and spread from Guinea to Sierra Leone and Liberia. Organ dysfunctions during EVD have only been described through case reports managed in high income countries, and data are still lacking [1]. The Sepsis-related Organ Failure Assessment (SOFA) score has been developed to quantitatively describe the degree of organ dysfunction in intensive care unit septic patients [2]. We aimed to characterize the severity of Ebola patients admitted to our center by calculating the SOFA score on admission. After approval by the local ethics committee, SOFA score was calculated in Ebola-infected patients using the most abnormal values from the first 24 h after admission. Data were collected between January and April 2015. A total of 38 patients were admitted, of whom 22 were infected with Ebola. Results are expressed as mean ± standard deviation. The mean age of confirmed cases was 33 years (±9). Mean viral load expressed as cycle threshold (CT) at admission was 21.6 (±3.9). On the 22 patients, six died (mortality rate of 27.3 %). Mean SOFA score at admission was 2.6 (±1.7). SOFA score at admission was significantly higher in non-survivors than in survivors (4.8 ± 1.7 versus 1.7 ± 1, P = 0.001). Mean viral load was also higher in non-survivors (CT at 17.7 ± 3.8 versus 23 ± 3.1, P = 0.006). Renal dysfunction was the most frequent dysfunction on admission in non-survivors (Fig. 1). Relationships between admission patients’ conditions and outcome have never been explored during EVD, except for age and viral load [3]. A study analyzing the WHO case investigation form data of 3343 infected patients reported a high mortality rate above 70 %, but patients’ organ dysfunctions could not have been scored [4]. In this study, hemorrhage, coma, and ‘‘difficulty breathing’’ were not commonly reported in patients who died, suggesting that massive fluid loss due to gastrointestinal disorders may be the main factor of worse outcome. Another study reported a lower mortality rate of 43 % [3]. Risk of death was associated with an older age, but this study failed in identifying other factors, mainly because biological data on admission were also limited as no routine clinical laboratory testing was available. Presented data showed that patients were hemodynamically stable on admission and had no respiratory dysfunction (3 % of patients with oxygen therapy). Our results highlighted two main points. The first is that cardiovascular, respiratory, and neurological dysfunctions were not common on admission in Ebola patients, even in non-survivors. The second is the frequency of renal dysfunction. Acute kidney injury during EVD may be promoted by several factors: hypovolemia due to gastrointestinal fluid loss, inflammatory response, viral injury as suggested by histopathological examination of tissues from infected animals showing indications of interstitial nephritis [5]. Larger studies are needed to describe objectively organ dysfunction in Ebola patients and evolution during stay. It may also help to optimize the preparation of treatment facilities according to local available resources for the next outbreaks.

Mortality among active-duty male French Armed Forces, 2006-10.

BACKGROUND In the Armed Forces, knowledge about the causes of deaths is required in order to develop prevention strategies. This study presents the main characteristics of causes of deaths among male active-duty personnel in the French Armed Forces during the 2006-10 period and compares them with the general French male population. METHODS The data are provided by military public health surveillance. Comparisons of the specific mortality rates (MR) were performed using a Poisson regression. Standardized mortality ratios (SMRs) were calculated to compare mortality with the general French male population. RESULTS There were 1455 deaths among male active-duty personnel during the study period [MR: 100.9 per 100,000 person-years (PY); 95% confidence interval 95.7-106.1]. The 17-24 age group was characterized by violent deaths: transport accident (MR: 45.9 per 100,000 PY) and suicide (18.8 per 100 000 PY). Overall SMRs show significantly lower MR compared with the French national MR with the exception of SMR for transport accident and suicide in the 17-24 age group. CONCLUSIONS There is a significantly lower deficit of mortality compared with the French male general population, reflecting a strong healthy worker effect. However, health promotion programmes should continue to put emphasis on transport accident especially among the 17-24 age group.

Factor associated with risky sexual behaviors among the French general population

Background Despite prevention programs, a rising incidence of sexually transmitted infections is currently reported in France. Aims Research factors associated with risky sexual behaviors (RSBs) among the French population. Methods Subjects aged 15‐54 years from the French national survey ‘Baromètre santé 2010’ were included (n = 16 598). RSB was defined as having multiple partners or failure to use condom at first intercourse with a new partner over past 12 months. Factors associated were identified using one logistic regression by gender. Results The overall RSB prevalence was 9.5%, being higher among men (P < 0.001). Factors associated with RSB for both genders were young age (OR = 1.5), single status (men: OR = 7.1; women: OR = 6.4), homosexual relations (men: OR = 2.0; women: OR = 3.2), low incomes (men: OR = 1.5; women: OR = 1.4), use of cannabis (men: OR = 1.4; women: OR = 3.0). Men‐specific factors were history of STI (OR = 2.5) and alcohol drunkenness (OR = 2.2), and women‐specific factors history of suicide attempt (OR = 1.6) and history of sexual assault (OR = 1.6). Conclusions Confirming most of known determinants of RSB, this study also identified some specific risky patterns for whom preventive actions can be developed: multiusers of psychoactive substances, people living with low incomes, women having sex with women or presenting history of psychological vulnerability (suicide attempts, sexually harassed).

The 2009 A(H1N1) influenza pandemic in the French Armed Forces: epidemiological surveillance and operational management.

OBJECTIVE The main objective of this study was to evaluate the contribution of a newly implemented daily surveillance system to the management of the 2009 A(H1N1) influenza pandemic by the military decision-makers at different levels in the French Department of Defence. METHODS The study sample included all medical advisors in the Ministry of Defence and the French Armed Forces Staff and also the members of the specific committee dedicated to flu pandemic control. The variables studied were mental representation of epidemiology, relevance, usefulness, and real-time use of surveillance data using quantitative questionnaires and qualitative face-to-face semistructured interviews. RESULTS Among the risk managers of the flu pandemic in the Armed Forces, 84% responded. The data generated by epidemiological surveillance were considered relevant and useful, and were reported as effectively used. On the basis of the information produced, concrete actions were planned and implemented in the French Armed Forces. CONCLUSION In a pandemic situation involving low mortality, the daily monitoring of the disease did not target public health issues, but it was mainly used to assess the availability of the Armed Forces in real time. For the military staff, epidemiological surveillance represents an essential information tool for the conduct of operations.

Monitoring of returnees from Ebola-affected areas: lessons learned based on the experience of French armed forces deployed in Guinea, 2015

Introduction During the 2014-15 Ebola virus disease (EVD) outbreak in West Africa, French armed forces were involved in the treatment and management of Ebola patients in Guinea. The constant flow of military personnel returning from their deployment posed a risk of secondary dissemination of the Ebola virus. Our objective was to describe the follow-up of returning service members that was implemented to prevent this risk of dissemination in France. Method For the French military, a specific complementary follow-up was added to the national monitoring to take into account the need for a detailed record for follow-up of returning military personnel and to keep the military chain of command informed. Results All the 410 service members deployed in Guinea underwent monitoring among whom 22 were suspected of EVD. Three of them were considered as possible EVD cases but none of them was tested positive for EVD. Conclusion The monitoring organized for French service members deployed in Guinea made it possible to follow all exposed military personnel after their return, know their health status on a near real-time basis and be aware of all alerts. To reach this goal the collaboration with French national health agencies was necessary and should be improved in the future.

Prevalence and risk factors of sexually transmitted infections among French service members

Introduction Sexually Transmitted Infections (STIs) have always represented a public health concern in the military, yet most studies rely on self-reports among non-random samples of military populations. In addition, most of the studies exploring STI rates among the military focus on US service members. This paper assesses the prevalence and correlates of STIs in the French military using biomarkers and compares self-reported versus diagnosed STIs. Methods Data are drawn from the COSEMIL study, a national sexual health survey conducted in the French military in 2014 and 2015. A random sample of 784 men and 141 women aged 18–57 years completed a self-administered questionnaire and provided biological samples for STI testing. We used logistic regression modeling to identify the correlates of STI diagnosis and self-reports. Results The prevalence of diagnosed STIs was 4.7% [3.8–5.9], mostly due to Chlamydia trachomatis. This rate was four times higher than the 12 months self-reported rate of 1.1% [0.6–2.3]. Reported STI rates were similar among men and women (1.1% versus 1.8%), but diagnosed STI rates were twice as high among females versus males (10.4% versus 4.1%, p = 0.007). There were significant differences in the determinants of reported versus diagnosed STIs. In particular, age and sexual orientation were associated with reported STIs, but not with diagnosed STIs. Conversely, STI counseling and depression were associated with STI diagnosis but not with STI reports. Conclusion This study underlines the need to use biomarkers in population-based surveys, given the differential and substantial underreporting of STIs. Results also highlight the need for programmatic adaptation to address gender inequalities in STI rates, by developing women’s health services in the French military. Addressing such needs not only benefits women but could also serve as a strategy to reduce overall STI rates as most military women have military partners, increasing the risk of internal transmission.

Sexual health in the French military: A multidimensional and gendered perspective

BackgroundSexual health in the military comprises a range of concerns including sexually transmitted infections (STI), unintended pregnancy, sexual violence and sexual dysfunction. This study aims to estimate the prevalence of sexual health concerns by gender in the French military and compare these prevalences to estimates in the general population.MethodsCOSEMIL, the first sexual health survey in the French military comprises a probability sample of 1500 military personnel. Chi-square tests were used to compare lifetime abortion, STIs and sexual assault, and recent sexual dysfunction and sexual satisfaction by gender and explore the association between these indicators and current sexual risk (condom use at last intercourse).ResultsWomen were more likely than men to declare negative sexual health outcomes, with the greatest difference related to sexual assault (24.3% versus 5.1% of males, p < 0.001) and sexual dysfunction hindering sexuality (15.2% of females versus 5.3% of males, p < 0.001). Women were also twice as likely to report ever having an STI (6.7% versus 3.4%, p = 0.03). Comparison with the French general population indicates lower percentages of STIs among military men (2.9% versus 4.9%) and higher percentages of abortion (17.6% versus 14.3%) forced sex (10.6% versus 7.4%) and sexual dysfunction (14.2% versus 9.3%) among military women.ConclusionThese results highlight gendered pattern of sexual health in the French military with women suffering greater sexual risks than men. Military health services should include women’s health services to address the sexual and reproductive health gender gap.

Force health protection during the Ebola crisis: French experience in Guinea

Dear Sir We have read with interest the article by Bricknell et al [1][1] previously published in this journal and we would like to continue this debate by reporting the French Defense Medical Service (DMS) experience in a similar position in Guinea and the role of Force Health Protection (FHP).