X. Deparis

Value of syndromic surveillance within the Armed Forces for early warning during a dengue fever outbreak in French Guiana in 2006.

BackgroundA dengue fever outbreak occured in French Guiana in 2006. The objectives were to study the value of a syndromic surveillance system set up within the armed forces, compared to the traditional clinical surveillance system during this outbreak, to highlight issues involved in comparing military and civilian surveillance systems and to discuss the interest of syndromic surveillance for public health response.MethodsMilitary syndromic surveillance allows the surveillance of suspected dengue fever cases among the 3,000 armed forces personnel. Within the same population, clinical surveillance uses several definition criteria for dengue fever cases, depending on the epidemiological situation. Civilian laboratory surveillance allows the surveillance of biologically confirmed cases, within the 200,000 inhabitants.ResultsIt was shown that syndromic surveillance detected the dengue fever outbreak several weeks before clinical surveillance, allowing quick and effective enhancement of vector control within the armed forces. Syndromic surveillance was also found to have detected the outbreak before civilian laboratory surveillance.ConclusionMilitary syndromic surveillance allowed an early warning for this outbreak to be issued, enabling a quicker public health response by the armed forces. Civilian surveillance system has since introduced syndromic surveillance as part of its surveillance strategy. This should enable quicker public health responses in the future.

Survey of Alcohol, Tobacco, and Cannabis Use in the French Army

ABSTRACT The aim of the current study is to describe the consumption rate of alcohol, tobacco, and cannabis in the French Army. A cross-sectional two strata randomized survey was performed between October 2006 and March 2007 using self-report questionnaires (n = 990) to collect individual characteristics, consumption, and addictive behaviors with urinal tests for cannabis (n = 985). The surveyed sample comprised 59% privates, 26% non-commissioned officers, and 6% officers, was predominantly male (89%) and young (median age: 29 years), and had a low level of education (60% attended secondary school). The consumption rate was high: 54.1% were active tobacco smokers, 56.0% were heavy drinkers, 20.5% declared drunkenness more than once per month, 52.6% at least experienced cannabis while 12.3% were occasional users, 8.2% were regular users, and 15.0% displayed multi-risk behaviors. Consumption was higher in the younger age (18 to 25 years) and lower educational group, leading to a high prevalence among privates and suggesting an “army effect.” However, large scale behavioral social studies may help distinguish between personal and peer effect among the targeted population.

Malaria control strategies in French armed forces.

Each year, 40,000 French soldiers deploy or travel through malaria-endemic areas. Despite the effective control measures that were successively implemented, malaria remains a public health concern in French armed forces with several important outbreaks and one lethal case every two years. This article describes the malaria control strategy in French armed forces which is based on three combined strategies: i) Anopheles vector control to prevent infection with the implementation of personal protection against vectors (PPAV) adapted to the field living conditions of the troops. ii) Chemoprophylaxis (CP) to prevent the disease based on prescription of effective and well tolerated doxycycline. iii) Management of cases through early diagnosis and appropriate treatment to prevent death. In isolated conditions in endemic areas, rapid diagnosis tests (RDT) are used as first-line tests by military doctors. Treatment of uncomplicated Plasmodium falciparum (P. falciparum) malaria is based either on the piperaquine tetraphosphate-dihydroartemisinin association since 2013, or on the atovaquone-proguanil association. First-line treatment of severe P. falciparum malaria is based on IV artesunate. These measures are associated with constant education of the military, epidemiological surveillance of malaria cases and monitoring of parasite chemosensitivity.

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.

Epidemiology of food-borne disease outbreaks in the French armed forces: A review of investigations conducted from 1999 to 2009

OBJECTIVE Aim of this study was to describe the main characteristics of food-borne disease outbreaks (FBDOs) in the French armed forces from 1999 to 2009. METHODS FBDOs are reported to the military epidemiological surveillance system, which concerns all active military personnel. Investigation reports published from 1999 to 2009 were reviewed. RESULTS Among the 180 FBDOs reported, 48.3% occurred overseas. The mean reporting rate was 2.4 outbreaks p.100,000 in France and 26.7 p.100,000 overseas, reaching to 39.3 p.100,000 in Africa. Digestive symptoms were predominant among cases. Laboratory analyses on cases were positive in 29.4% of FBDOs. The most frequently isolated agents were shigella (15.4%). Laboratory analyses on food samples were positive in 18.9% of outbreaks, the most frequently isolated agent being Clostridium perfringens (15.7%). Only 7 FBDOs were documented by concordant analyses in both patients and food samples. CONCLUSIONS The reporting rate was much higher among military deployed overseas, which can be the consequence of a lack of hygiene due to operational imperatives and the consumption of local food which does not meet safety standards. In operational settings, laboratory evidence may be difficult to obtain and a timely epidemiological investigation in some cases proves valuable to identify the likely vehicle of infection and to guide targeted intervention measures.

Surveillance of adverse events following vaccination in the French armed forces, 2011–2012

OBJECTIVES French military personnel are subject to a compulsory vaccination schedule. The aim of this study was to present the results of surveillance of vaccine adverse events (VAEs) reported from 2011 to 2012 in the French armed forces. STUDY DESIGN VAEs were surveyed among all French armed forces from 2011 to 2012 by the epidemiological departments of the military health service. For each case, a notification form providing patient and clinical information was provided. METHODS Case definitions were derived from the French drug safety guidelines. Three types of VAE were considered: non-serious, serious and unexpected. Incidence rates were calculated by relating VAEs to the number of vaccine doses delivered. RESULTS In total, 161 VAE cases were reported. The overall VAE reporting rate was 24.6 VAEs per 100,000 doses, and the serious VAE rate was 1.3 per 100,000 doses (nine cases). The serious VAEs included two cases of Guillain-Barré syndrome, one case of optic neuritis, one case of a meningeal-like syndrome, one case of rheumatoid purpura, one case of acute asthma and three cases of fainting. The highest rates of VAE were observed with the Bacille Calmette-Guérin vaccine (BCG) (482.3 per 100,000 doses), inactivated diphtheria-tetanus-poliovirus with acellular pertussis vaccine (dTap-IPV) (106.1 per 100,000 doses) and meningococcal quadrivalent glycoconjugate vaccine (MenACWY-CRM) (39.3 per 100,000 doses). CONCLUSIONS The global rates of VAE observed in 2011 and 2012 confirm the increase that has been observed since 2009 in the French armed forces, which could reflect improved practitioner awareness about VAEs and the use of certain vaccines added to the vaccination schedule recently (dTap-IPV in 2008 and MenACWY-CRM in 2010). VAEs appear to be relatively rare, particularly serious VAEs, which indicates acceptable tolerance of vaccines.

Increase in reported adverse events following seasonal influenza vaccination among the French armed forces, 2008–2009: Possible role of stimulated reporting and background cases of influenza-like infection

OBJECTIVES In September 2009, an increase in seasonal influenza vaccine adverse events (VAE), compared with reports for previous years, was detected among the French armed forces in the setting of an extended immunization campaign. This work presents the results of this investigation. STUDY DESIGN VAE were surveyed among all French military personnel from 2008 to 2009 by Epidemiological Departments of the French Military Health Service. For each case, a notification form was completed, providing patient and clinical information. METHODS Case definitions were derived from the French drug vigilance guidelines. Three types of VAE were considered: non-serious, serious and unexpected. Incidence rates were calculated by relating VAE to the number of vaccine doses injected. RESULTS Forty-seven seasonal influenza VAE were reported in continental France: 18 in 2008 and 29 in 2009. The annual reporting rate was higher in 2009 (31.6 vs 16.6 VAE per 100,000 injections, respectively). The highest monthly incidence was observed in September 2009 (60.8 events per 100,000 injections). Two other peaks were observed in February 2008 and March 2009. The incidence in September 2009 was not significantly different from the incidences in February 2008 and March 2009. It was observed that incidence peaks occurred during influenza epidemic periods. One serious neurological VAE was observed. CONCLUSIONS The increase in seasonal influenza VAE in late 2009 mainly involved non-serious events, and could reflect stimulated reporting in the context of the A(H1N1)pdm09 pandemic. VAE reporting rates were highest during influenza epidemic periods, which could be explained by VAE being wrongly attributed to the vaccine when symptoms could reflect coincident background cases of viral infection.

Is serving in the armed forces associated with tobacco or cannabis initiation? A study of onset sequences before and after joining the French armed forces.

The aim of this study was to evaluate whether joining the military could constitute a predictor of subsequent tobacco or cannabis use. Data from four cross-sectional surveys conducted between 2005 and 2009 in the French armed forces were used to constitute a retrospective cohort (n=4208). A Markov multi-state model was fitted, estimating the probabilities at 1year for all possible pathways between entry into the military profession, tobacco initiation and cannabis initiation. The model was adjusted for current substance use status. Substance initiation appeared to mainly occur before entering the services than during the service period (3.0 times greater likelihood for tobacco and 2.5 times greater likelihood for cannabis). Probabilities of primo-initiation (i.e. starting with that substance) before joining the services were similar for tobacco (3.6% at one year) and cannabis (3.5%). When the study was restrained to current users, although differences were not statistically significant, probabilities of substance primo-initiation during the service period seemed to be greater than before. While the substance use itinerary in the French general population most often begins by tobacco, military seem to have a higher propensity to cannabis primo-initiation, which could traduce more sensation-seeking behaviors. If certain results in our study could also evoke a propensity to substance initiation during the service period, we did not find evidence to verify the hypothesis of a military social inducing effect. Further research is needed to identify behavioral characteristics which could explain increased use during the service period.

Acute acoustic trauma in the French armed forces during 2007–2014

Context: Despite existing preventive measures, the number of acute acoustic trauma (AAT) cases reported to the French Military Epidemiological Surveillance System (MESS) remains high. Aims: The objective of this study was to describe AAT and the preventive measures already implemented. Subjects and Methods: We conducted a descriptive cross-sectional analysis of AAT using data from the MESS for the period 2007–2014. In addition, we reviewed the current prevention measures that exist in the French armed forces. Statistical Analysis Used: Comparisons between different incidence rates were made by Poisson and quasi-Poisson regression. Results: Between 2007 and 2014, 10,487 AAT cases were reported to the MESS, with a significant decrease in 2013 (P < 0.001). AAT incidence rates were the highest among those aged <25 years − 14.3 per 1000 person-years (PYs) (P < 0.001), and those in the army; with 8.1 per 1000 PYs (P < 0.001), and men had almost twice the risk of women (P < 0.001). AAT mainly occurred in training schools or at camps during exercises. The main prevention actions identified were the following: official regulations, education, making hearing protection devices (HPDs) available for all service members, and regular hearing monitoring. A working group has been set up and has proposed an informative chapter in the weapon handling instruction book, an AAT simulator, and a new HPD, the 3M® earplug, with an information brochure. Conclusions: AAT rates decreased from 2007 to 2014 in the French armed forces. Further analysis is needed to identify the underlying factors involved to improve the prevention actions proposed. The MESS and targeted surveys will assess the impact of the different prevention measures implemented.

Antibiothérapie et infections cutanées staphylococciques en zone impaludée équatoriale (Guyane). Pratiques en situations conventionnelle et d’exception

A problem of community-acquired Staphylococcus aureus skin infections emerged in the French armed forces in 2004, in a malaria-endemic areas. The high incidence rate led us to evaluate military staff practices. This was a cross-sectional survey of doctors and nurses deployed as officers in French Guyana since 2006. The definition of skin and soft-tissue infection came from the criteria for epidemiological surveillance of the armed forces. We studied the management of antibiotic therapy and its related difficulties. In all, 47 officers responded. At the Military Medical Center (MMC), 23.4% of respondents routinely prescribed antibiotics, compared with 36.2% when stationed in the jungle (p<0.05%). Complication led 68.1 of staff to prescribe antibiotic prescriptions at the MMC, compared with 46.8% in the jungle (p<0.05%). Finally, 22.5% of those at MMC prescribed antibiotic coverage of surgical drainage, compared with 14.8% in the jungle (p<0.05%). Pristinamycin and fusidic acid were the preferred antibiotics. Two-thirds of the staff reported difficulties in jungle management. This first study indicates the need for an update of military medical recommendations. Personnel training must continue to enable them to provide appropriate aggressive management in the current endemic context.