The 2009 A(H1N1) influenza pandemic in the French Armed Forces: evaluation of three surveillance systems.

BACKGROUND: The French military forces had to modify their epidemiological surveillance systems at the time of the 2009 A(H1N1) influenza pandemic. The aim of this article was to present an evaluation of the different systems used. METHODS: Two influenza surveillance systems are usually used in the French forces: one permanent (Surveillance épidémiologique des armées or SEA) and one seasonal (Système militaire d'observation de la grippe or SMOG). The pandemic required the implementation of a daily surveillance system (Surveillance quotidienne--SQ), which aimed to monitor disrupted activity owing to 2009 A(H1N1) influenza. The qualitative evaluation of these three systems during the period from September 2009 to February 2010 was performed using 11 criteria based on the list defined by Centers for Disease Control and Prevention of Atlanta. RESULTS: Although it included only 30 sentinel units vs. 320 for the other systems, the SMOG system was the best-performing system in terms of relevance, feasibility, efficacy, quality of data, usefulness, acceptability, efficiency and cost/benefits/costs ratio. The SQ proved very expensive in terms of logistics. CONCLUSION: The SQ did not bring any significant advantage compared with the weekly surveillance schemes. In the eventuality of another similar episode, influenza surveillance could be significantly improved by using the SMOG system extended to more units for better geographical coverage.

Plasmodium vivax Malaria among military personnel, French Guiana, 1998-2008.

We obtained health surveillance epidemiologic data on malaria among French military personnel deployed to French Guiana during 1998-2008. Incidence of Plasmodium vivax malaria increased and that of P. falciparum remained stable. This new epidemiologic situation has led to modification of malaria treatment for deployed military personnel.

Pig liver sausage as a source of hepatitis E virus transmission to humans.

BACKGROUND: The source and route of autochthonous hepatitis E virus (HEV) infections are not clearly established in industrialized countries despite evidence that it is a zoonosis in pigs. We investigated the role of figatellu, a traditional pig liver sausage widely eaten in France and commonly consumed raw, as a source of HEV infection. METHODS: A case-control study was conducted of 3 patients who presented autochthonous hepatitis E and 15 members of their 3 different families. Anti-HEV immunoglobulin G and immunoglobulin M antibody testing was performed with commercial assays. HEV RNA was detected in serum samples of patients and in pig liver sausages by means of real-time polymerase chain reaction and sequenced by means of in-house sequencing assays. Genetic links between HEV sequences were analyzed. RESULTS: Acute or recent HEV infection, defined by detection of anti-HEV immunoglobulin M antibodies and/or HEV RNA, was observed in 7 of 13 individuals who ate raw figatellu and 0 of 5 individuals who did not eat raw figatellu (P=.041). Moreover, HEV RNA of genotype 3 was recovered from 7 of 12 figatelli purchased in supermarkets, and statistically significant genetic links were found between these sequences and those recovered from patients who ate raw figatellu. CONCLUSION: Our findings strongly support the hypothesis of HEV infection through ingestion of raw figatellu.

Advantages and limits of real-time epidemiological surveillance during military deployments: the experience of the French Armed Forces.

To perform epidemiological surveillance during deployments, the French military health service has developed a real-time surveillance approach. The objective was to identify the benefits and problems of this approach. A prototype of real-time surveillance has been set up in French Guiana since 2004. Its permanent evaluation has allowed identifying strengths and weaknesses. The experience has permitted expansion of the concept to French forces in Djibouti and also development of a global approach for the whole French armed forces. Real-time surveillance has shown its usefulness for early warning during different real and simulated situations. Functional and architectural choices have permitted interoperability with allied nations. However, the information produced was only the first step of the diagnostic epidemiological situation followed by other investigations. This first step of development has highlighted the required complementarity with traditional epidemiological surveillance.

[Marseilles, the Indian Ocean and Chikungunya virus]. / Marseille, l'Océan indien et le virus Chikungunya.

In recent decades Marseilles, through immigration, has become the largest Comorian city outside the archipelago. It is also home to a faculty of medicine that has made infectious diseases one of its fields of excellence. During the last two years, Marseilles has spearheaded the metropolitan French response to the Chikungunya crisis in the Indian Ocean region, and especially in the Reunion Island and Mayotte. Laveran military teaching hospital (Hôpital d'instruction des armées, HIA) has managed one of the largest metropolitan cohorts. Its teams have also reported the broad clinical spectrum of the disease in its later stages, and especially the high incidence of incapacitating tenosynovitis and distal arthritis, as well as the occurrence of a transient acrosyndrome during the second and third months in nearly one-quarter of patients. Importantly, they have also identified a mixed cryoglobulin in more than 90% of patients, the level of which matches clinical symptoms and is sensitive to systemic steroid therapy. This discovery opens the way to a better understanding of the pathophysiology of this viral disease. The Tropical Virology laboratory of the Tropical Medicine Institute of the Army health service (IMTSSA), which has close links with the national references center (CNRS) arbovirus laboratory, has developed new diagnostic tools, notably based on RT-PCR. Together with national reference center (CNRS), the laboratory produces and supplies antigens for Chikungunya serological tests in metropolitan France and overseas. It has taken into account the presence of cryoglobulins, which can lead to false-negative results in infected patients, and has considerably increased the diagnostic yield of serological techniques. The laboratory's fundamental research focuses on genomic characterization of viral variants isolated from humans and from the vector, and also on viral protease expression, for functional studies and antiviral candidate drug selection. The laboratory also collaborates with clinical teams in Reunion and metropolitan France working on humoral and cellular immune responses and on the different clinical forms of the disease. The Epidemiology and Public Health Department of IMTSSA conducted an epidemiological study of all gendarmes working in Reunion at the end of the epidemic (June 2006). This study, done in partnership with the tropical virology laboratory and CNRS, is helping to complete the clinical description of the epidemic, in an unbiased population. In 2007, it will form the basis for a prospective cohort study in which these patients will be monitored for several years to better document the chronic phase of the disease in a population with excellent healthcare access. Finally, the department has provided the civil authorities with advice and support in disease-control operations in Reunion. Communication played an important role in the management of this crisis, showing how crucial it now is for healthcare professionals to develop relevant skills. The Army Health Service in Maarseilles was never isolated from its university partners, as witnessed by clinical collaboration between Laveran HIA and CHU Nord (a Marseilles teaching hospital) and by virological cooperation between the IMTSSA and Etablissement français du sang (EFS) laboratories. This experience is highly encouraging with respect to the creation in Marseilles of a healthcare research network (RTRS) devoted to tropical and emerging infectious diseases.

Web services based syndromic surveillance for early warning within French Forces.

OBJECTIVES: Syndromic surveillance for early warning in military context needs a robust, scalable, flexible, ubiquitous, and interoperable surveillance system. METHODS: We have designed our surveillance system as a collaborative network of web services on the basis of a skill oriented decomposition of the overall task and a formal model of epidemiological events. RESULTS: The services (integration devices, epidemiologic receivers, information processing devices, GUI clients) are distributed in several locations in France and French Guiana using a secured network. CONCLUSIONS: This system is in operation since several months. It has already early detected two outbreaks before conventional surveillance systems.

Surveillance of Food- and Smear-Transmitted Pathogens in European Soldiers with Diarrhea on Deployment in the Tropics: Experience from the European Union Training Mission (EUTM) Mali.

Introduction. Since 2013, European soldiers have been deployed on the European Union Training Mission (EUTM) in Mali. From the beginning, diarrhea has been among the most "urgent" concerns. Diarrhea surveillance based on deployable real-time PCR equipment was conducted between December 2013 and August 2014. Material and Methods. In total, 53 stool samples were obtained from 51 soldiers with acute diarrhea. Multiplex PCR panels comprised enteroinvasive bacteria, diarrhea-associated Escherichia coli (EPEC, ETEC, EAEC, and EIEC), enteropathogenic viruses, and protozoa. Noroviruses were characterized by sequencing. Cultural screening for Enterobacteriaceae with extended-spectrum beta-lactamases (ESBL) with subsequent repetitive sequence-based PCR (rep-PCR) typing was performed. Clinical information was assessed. Results. Positive PCR results for diarrhea-associated pathogens were detected in 43/53 samples, comprising EPEC (n = 21), ETEC (n = 19), EAEC (n = 15), Norovirus (n = 10), Shigella spp./EIEC (n = 6), Cryptosporidium parvum (n = 3), Giardia duodenalis (n = 2), Salmonella spp. (n = 1), Astrovirus (n = 1), Rotavirus (n = 1), and Sapovirus (n = 1). ESBL-positive Enterobacteriaceae were grown from 13 out of 48 samples. Simultaneous infections with several enteropathogenic agents were observed in 23 instances. Symptoms were mild to moderate. There were hints of autochthonous transmission. Conclusions. Multiplex real-time PCR proved to be suitable for diarrhea surveillance on deployment. Etiological attribution is challenging in cases of detection of multiple pathogens.

Doxycycline-chloroquine vs. doxycycline-placebo for malaria prophylaxis in nonimmune soldiers: a double-blind randomized field trial in sub-Saharan Africa.

Failures of malaria chemoprophylaxis have been related to a lack of compliance with doxycycline due to its short elimination half-life. Adding a molecule with a long half-life to doxycycline could be useful to take over from this drug in case of occasional missed doses. A double-blind, placebo-controlled randomized field trial was designed to compare the tolerability of a doxycycline-chloroquine combination vs. doxycycline as malaria prophylaxis among French soldiers deployed in Africa. Data from 936 volunteers were analyzed. In both groups, the proportion of volunteers who reported at least one adverse effect was about 57%. Tolerability was similar in the groups except for a higher proportion of nausea or vomiting in the doxycycline-chloroquine group. The reported compliance rate was 86.6% and was similar in the two groups. Eight Plasmodium falciparum malaria cases were diagnosed in the doxycycline group and seven in the doxycycline-chloroquine group. The efficacy of the two chemoprophylaxis regimens was similar. Our study was the first randomized field trial to assess a doxycycline-chloroquine combination as malaria prophylaxis and showed no significant decrease of overall tolerability of the combination compared with doxycycline alone. Our results showed that a doxycycline-chloroquine combination could be a safe combination for malaria chemoprophylaxis.

Survey of alcohol, tobacco, and cannabis use in the French army.

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.

[Airport malaria]. / Paludisme d'aéroport.

Airport malaria is a particular form of autochthonous malaria: it happens when the Plasmodium infected Anopheles genus mosquito travels from an endemic area to a malaria free airport. Since 1969, 30 cases of airport malaria have been reported in France, 2 during summer 2008. The severity of airport malaria is explained by the frequency of Plasmodium falciparum infecting non immune individuals and an often important diagnosis delay. It is a compulsory notification disease in France. The International Health Regulations (IHR) require states to check that airplanes coming from malaria or arboviral endemic area are systematically disinsected. Vector control measures have to be implemented within a distance of at least 400 meters around the perimeter of airports in malaria or arboviral endemic areas. In France, this measure applies to all airports of French overseas territories, except for the island of Saint-Pierre and Miquelon.

Distributed and Mobile Collaboration for Real Time Epidemiological Surveillance during Forces Deployments.

This paper presents a pilot project of a real time syndromic surveillance system in French armed forces for early warning of biological attack by mass destruction weapons. For simulating the situation of a theatre of operations and its organisation, an electronic syndromic surveillance system covering all branches of service in French Guiana (about 3,000 persons) has been deployed and connected to a surveillance centre in France. This system has been design taking in account a collaborative view of epidemiological surveillance and the mobility of forces in extreme conditions. Several kinds of hardware, from rugged personal digital assistant to desktop computer, and several telecommunication links, from PSTN to satellite data links, are used. This system allows a quick report of cases, which are georeferenced. In the first results, some problems associated with the human and the technical aspects have been reported, in association with some immediate advantages.