Understanding the Strengths and Limitations of Current Methods for Surveying Partner Nation Medical Facilities.

INTRODUCTION: During exercises or operations, there may be times when U.S. medical capabilities are not available and the next best or only option may be to use partner nation (PN) or host nation capabilities. Joint Publication 4-02 Joint Health Services states that "medical planners should always consider the quality, suitability, and availability of multinational and host-nation support." It is normal practice for medical planners to survey PN medical capabilities as part of the pre-deployment planning process. Currently, medical capability surveys are not conducted in a consistent and systematic manner across the DoD global health engagement enterprise. The lack of a systematic approach undermines medical operations planners' ability to conduct efficient and adequate pre-deployment surveys. MATERIALS AND METHODS: The article presents the results of a descriptive analysis of 62 unclassified medical capability surveys of PN or host nation facilities from the U.S. Africa Command (USAFRICOM) area of responsibility that were conducted by U.S. DoD personnel. The team characterized the content and formats of surveys with respect to what medical capabilities were described, how the capabilities were described, and how the information was presented. These analyses focused on determining if a surveyor obtained information about a capability, not whether or not the facility had a capability. RESULTS: Approximately 75-80% of surveys included information describing the presence or absence of five key capabilities: Emergency department/trauma care, surgical services, intensive care unit, laboratory, and imaging. Conversely, 30-50% of surveys did not include any information describing the presence or absence of five other key capabilities: Pharmacy, blood bank, mass casualty plans, land evacuation, or air evacuation. Information on key capabilities and administrative information was not consistently reported across the sample of surveys. There was substantial variation in how capabilities were characterized, including number of staff, staff training, and available equipment. Additionally, the order in which information was presented in surveys varied within and across components. CONCLUSIONS: There are significant inconsistencies in the types of capabilities and services documented and how the quality of the capabilities and services is characterized. These inconsistencies can be attributed, in part, to the absence of information that explicitly confirmed whether or not the facility had a capability. Such variation results in obscured or incomplete depictions of facility capabilities, thereby undermining the ability of medical planners to coordinate effective medical readiness for engagements, exercises, or real-life operations. Guidance and survey templates could support better-informed decision-making by including information about survey methods and documenting the lack of confirmatory information. The DoD enterprise should consider how guidance and a standard survey template could improve the relevance, accuracy, and efficiency of data collection and reporting.

Evaluation of a Multisectoral Health Security Alliance Program Through Perceptions of Member States: African Partnership Outbreak Response Alliance (APORA).

INTRODUCTION: U.S. DoD global health engagements offer opportunities for strategic engagement and building capability in collaboration with foreign military and civilian counterparts. Global health engagement activities can take the form of health security alliances and allow the USA and its allies and partners to prepare for, mitigate, and respond to emerging biothreats and other harmful health events that may negatively impact national security. One such example is the African Partnership Outbreak Response Alliance (APORA), which was designed to expand African Partner Nation militaries' infectious disease outbreak response capabilities. This publication evaluates the development, implementation, and outcomes of APORA to better understand the program's effectiveness in developing Partner Nation medical capabilities and the efficacy of health security alliances more broadly. MATERIALS AND METHODS: Key informant interviews, focus groups, and questionnaires were used to collect responses from a sample of participants who attended an in-person APORA event in May 2022. The research team conducted thematic analysis of all responses to identify common themes and sub-themes in participants' perspectives and to elucidate findings and recommendations for future endeavors. RESULTS: The analysis determined that participants attended the APORA event primarily to disseminate and apply knowledge, skills, and abilities gained at the event to their own health system structures. Overall, participants indicated that APORA contributed to their countries' military medical and civilian cooperation, as well as their countries' military medical capabilities. Longer-term partners (i.e., 4+ years of APORA membership) agreed more strongly with these sentiments; newer partners (i.e., 1-3 years of APORA membership) were more likely to be neutral or agree to some extent. Participants also valued the opportunity to solidify global, regional, local, and peer partnerships and considered the ability to create partnerships of great importance to their countries' national health security. Language barriers were often listed as a hindrance to event participation and the overall integration of a regional health system response. Participants also cited resource scarcity, network erosion (particularly because of the coronavirus disease 2019 pandemic), and a lack of disseminating and communicating value-add in how APORA could/is providing to their member countries' health systems as key barriers. CONCLUSIONS: As a whole, these findings support APORA's objectives to develop and leverage partnerships to support medical capacity building, promote collaboration between military and civilian sectors, and increase access to opportunities and financial resources. Further evaluation is required to capture additional civilian perspectives while continuing to expand upon military perspectives in order to produce more generalizable findings. That said, this study enables key stakeholders to understand how to strengthen and expand future alliances to improve both health and security outcomes.

Postinfectious gastrointestinal disorders following norovirus outbreaks.

BACKGROUND: The US Centers for Disease Control and Prevention estimates 20.9 million norovirus infections annually in the United States. Although the acute disease burden is sizeable, emerging data suggest norovirus may be associated with chronic gastrointestinal problems. We identified known outbreaks in US military recruits and used the Defense Medical Encounter Database (DMED) to identify the risk of new onset functional gastrointestinal disorders (FGD) and gastroesophageal reflux disease (GERD). METHODS: Subjects reporting for care of acute gastroenteritis (AGE) at a military treatment clinic during 3 known norovirus outbreaks were identified. Each AGE subject was matched with up to 4 subjects with unrelated medical encounters. Medical encounter data were analyzed for the duration of military service time (or a minimum of 1 year) to assess for incident FGD or GERD. Relative risks were calculated using regression models. RESULTS: We identified 1718 subjects from 3 outbreaks. After controlling for important demographic covariates, the incidence of constipation, dyspepsia, and GERD was approximately 1.5-old higher (P < .01) in AGE-exposed subjects than matched subjects. We also noted variability in outcome incidence across outbreaks. CONCLUSIONS: It appears that the risk of dyspepsia, constipation, and GERD are higher among those who have AGE during a confirmed norovirus outbreak. Although these findings need confirmation, they suggest that dysmotility may result subsequent to these infections. If confirmed, the costs and morbidity associated with the chronic consequences of norovirus should be considered.

Acute gastrointestinal infection, respiratory illness, and noncombat injury among US military personnel during Operation Bright Star 2005, in Northern Egypt.

BACKGROUND: In the fall 2005, approximately 7,500 US military personnel participated in an exercise in the Egyptian desert. The epidemiology of disease and noncombat injury among deployed troops is important in the context of assessing current mitigation strategies and the development of future ones. METHODS: To assess the prevalence and impact of diarrhea and enteropathogen distribution, we conducted a case series study. To assess the relative impact of diarrhea compared to respiratory infection and injury, we conducted a post-deployment survey and compared these data to clinic-based syndromic surveillance data. RESULTS: We enrolled 43 patients with acute diarrhea, 21 (49%) having one or more pathogens isolated. Enterotoxigenic Escherichia coli (n= 16), enteroaggregative E coli (n= 3), and Shigella spp. (n= 3) were the most common pathogens identified. Respiratory illness had the highest incidence (73 episodes/100 person-months) compared to diarrhea (35 episodes/100 person-months) and noncombat injury (17 episodes/100 person-months), though noncombat injury more frequently resulted in lost duty days and health-care utilization. CONCLUSIONS: Noncombat injuries and illnesses have had a significant impact on military missions and continue to result in force health protection challenges today. Future studies are needed to test and evaluate countermeasures to mitigate these illnesses and injuries to increase the health of the individuals and optimize mission readiness.

Self-reported incidence of snake, spider, and scorpion encounters among deployed U.S. military in Iraq and Afghanistan.

Much has been written about injury, diarrhea, and respiratory cases but less is known about other threats, specifically snake, scorpion, and spider encounters. To examine the risk from local fauna, a cross-sectional study using an anonymous survey was conducted among U.S. troops in Southwest Asia between January 2005 and May 2006. Among 3,265 troops, 9 cases (0.3%) of snakebites and 85 cases (2.6%) of spider stings and scorpion bites were reported, equating to an incidence of 46.1 per 10,000 person-months for scorpion/spider encounters and 4.9 per 10,000 person-months for snakebites. There was a significant association with service branch and toileting facilities for snakebites. Season, deployment location, rank, and toileting facilities were associated with differential risk of scorpion/spider encounters. Troops are at risk for local fauna encounters while deployed in the current operational environment. The potential morbidity, mortality, and operational impact of these health hazards need to be considered.

Knowledge, attitudes, and practice of travelers' diarrhea management among frontline providers.

BACKGROUND: Many studies have found acute gastrointestinal infections to be among the most likely reason for clinic visits among forward deployed soldiers and are considered a significant contributor to morbidity in this population. This occurs despite the controlled food and water distribution systems under which military populations operate. Furthermore, recent studies have indicated that providers often fail to appropriately identify and treat the typical causes of these infections. To adequately address this issue, an assessment of gaps in knowledge, practice, and management of acute diarrhea in deployed troops was conducted. METHODS: A multiple-choice survey was developed by clinical researchers with expertise in travelers' diarrhea (TD) and provided to a convenience sample of clinical providers with a broad range of training and operational experience. The survey evaluated provider's knowledge of TD along with their ability to identify etiologies of various syndromic categories of acute gastrointestinal infections. Providers were also queried on selection of treatment approaches to a variety of clinical-based scenarios. RESULTS: A total of 117 respondents completed the survey. Most were aware of the standard definition of TD (77%); however, their knowledge about the epidemiology was lower, with less than 24% correctly answering questions on etiology of diarrhea, and 31% believing that a viral pathogen was the primary cause of watery diarrhea during deployment. Evaluation of scenario-based responses showed that 64% of providers chose not to use antibiotics to treat moderate TD. Furthermore, 19% of providers felt that severe inflammatory diarrhea was best treated with hydration only while 25% felt hydration was the therapy of choice for dysentery. Across all provider types, three practitioner characteristics appeared to be related to better scores on responses to the nine management scenarios: having a Doctor of Medicine or Doctor of Osteopathy degree, greater knowledge of TD epidemiology, and favorable attitudes toward antimotility or antibiotic therapy. CONCLUSION: Results from this survey support the need for improving knowledge and management of TD among deploying providers. The information from this study should be considered to support the establishment and dissemination of military diarrhea-management guidelines to assist in improving the health of military personnel.