Novel influenza A(H1N1) outbreak among French armed forces in 2009: results of Military Influenza Surveillance System.

OBJECTIVES: An outbreak of novel A(H1N1) virus influenza, detected in Mexico in April 2009, spread worldwide in 9 weeks. The aim of this paper is to present the monitoring results of this influenza outbreak among French armed forces. STUDY DESIGN: The period of monitoring by the Military Influenza Surveillance System (MISS) was 9 months, from May 2009 to April 2010. METHODS: The main monitored events were acute respiratory infection (ARI), defined by oral temperature ≥38.5 °C and cough, and laboratory-confirmed influenza. Weekly incidence rates were calculated by relating cases to the number of servicepersons monitored. RESULTS: In continental France, the incidence of ARI increased from September 2009, with a weekly maxima of 401 cases per 100,000 in early December 2009 according to MISS. Estimations of the incidence of consultations which could be related to novel A(H1N1) influenza ranged from 48 to 57 cases per 100,000. CONCLUSIONS: The trends observed by MISS are compatible with French national estimations. The incidence of consultations which could be related to A(H1N1) influenza at the peak of the epidemic (194 cases per 100,000) was much lower than the national estimate (1321 cases per 100,000). This may be due to servicepersons who consulted in civilian facilities and were not monitored. Other explanations are the healthy worker effect and the younger age of the military population.

[Acute myelitis related to hepatitis A after travel to Senegal]. / Myélite aiguë transverse révélatrice d'une hépatite virale aiguë A au retour du Sénégal.

Neurological complications are rare following hepatitis A. Acute myelitis is even more uncommon. The purpose of this report is to describe a case of acute myelitis related to hepatitis A virus (HAV) in a 43-year-old-woman returning from Senegal. Diagnosis of myelitis was confirmed by spinal MRI and detection of anti-HAV Ig M antibodies in serum. The patient made a spontaneous clinical recovery in one month. Spinal MRI findings were normal at three months. Hepatitis A should be considered in the diagnostic approach to acute myelitis in returning travelers and patients living in highly endemic countries where prophylactic vaccination is unavailable.

[How to investigate and diagnose autochthonous hepatitis E?]. / Quand rechercher et comment diagnostiquer une hépatite E autochtone?

In developed countries, HEV infection was still recently considered as rare, and as an imported disease from endemic areas by travellers. Hepatitis E virus is now recognized mainly as an autochthonous disease in these countries. Although the source and the route of contamination remain uncertain, several cases of food-borne (zoonotic transmission) and blood-borne transmission have been recently reported. The mortality rates in industrialized countries seems to be higher than in endemic areas, since the infection occurs more frequently in elderly people with underlying chronic liver disease (mortality rate approaching 70% in this subgroup of patients). By contrast, whereas mortality rate rises by 20% during pregnancy in developing countries, no death in pregnant woman from developed countries secondary to an autochthonous case has been reported so far. Lastly, HEV infection may be a cause of chronic hepatitis in immunocompromised patients (mostly in solid organ-transplant recipients) which can evolve to cirrhosis.

Assessment of vaccination coverage of adolescents aged 16-18 years with an innovative electronic immunization record system.

OBJECTIVES: To measure vaccine coverage among adolescents aged 16-18 years who participated in the National Defense Preparation Day in the Aquitaine region using the free electronic immunization record. PATIENTS AND METHODS: We considered adolescents aged 16-18 years who participated in the National Defense Preparation Day in the Aquitaine region from April to October 2013. All participants received a letter explaining how to create an electronic immunization record. Those records were then validated by checking data against the copies of the vaccination cards brought by participants on the day they attended. Vaccination coverage was estimated for eight vaccinations according to the cumulative number of doses registered and vaccines recommended during childhood. RESULTS: Among the 18,714 participants, 9636 agreed to create an electronic immunization record of which 2781 were validated. Vaccination coverage was˃90% for tuberculosis, diphtheria-tetanus-poliomyelitis, measles-mumps-rubella, and Haemophilus influenzae type B, and˂90% for pertussis, hepatitis B, meningococcal C disease, and human papillomavirus. These coverage rates were close to those reported in other available sources. CONCLUSION: Our study calls attention to the insufficient vaccination of adolescents for pertussis, HBV, meningococcal C disease, and HPV. The absence of a system that routinely provides the vaccination status of this population is a major public health issue in France. The use of an electronic immunization record was innovative, but this tool is not extensively used in the general population and has been evaluated by Santé publique France (the French national public health agency).

[Effectiveness of triennial anti-influenza vaccination in French military during the 2003-2004 influenza season]. / Evaluation de l'efficacité clinique de la vaccination antigrippale triennale dans les armées (saison 2003-2004).

BACKGROUND: Influenza may rapidly disseminate within populations living in confined settings, causing considerable morbidity and disrupting daily activities. The French military health-care system set up since 1994 a prevention strategy based on triennial anti-influenza vaccination. The aim of this study was to evaluate the effectiveness of this strategy during the 2003-2004 influenza season. METHODS: We conducted a matched case-control study from 10/01/2003 through 3/31/2004. Cases were laboratory-confirmed influenza cases. The controls were not to have presented influenza during all the period of study. Controls were matched to cases by sex, army unit and age. Subgroups were categorized into four groups by vaccination regimen [0-1 year], [1-2 years], [2-3 years], [3 years and more or unvaccinated]. RESULTS: One hundred and eighteen cases and 435 controls were included. The proportion of correctly vaccinated subjects (

[Characterisation of viral agents with potential to cause diarrhea in Djibouti]. / Caractérisation des virus agents potentiels des diarrhées chez l'adulte à Djibouti.

Due to limited laboratory facilities in the tropics, the exact role of enteric viruses in causing diarrhea among adults in the tropics is unknown. The purpose of this report is to describe a multicenter study undertaken in Djibouti to determine the prevalence of a large panel of enteric viruses using immunochromatography; antigenic detection by ELISA, RT-PCR cellular inoculation, sequence analysis; and indirect serology. Study samples were collected from 108 patients presenting acute and sporadic diarrhea. Although they are well known causes of diarrhea in children, rotavirus and adenovirus were identified in only 2 and 5% of adults respectively. In contrast human caliciviruses (HuCVs) and enterovirus were identified in 25 and 42% of adult cases respectively. Uncommon genotypes of HuCVs and recombinant forms (junction pol/l cap) as well as a significant number of sapovirus (30%) were identified. Further study is needed to clarify the role of enterovirus (echovirus) in the etiology of acute diarrhea in adults. No polivirus was identified. These new data from the Horn of Africa increase our knowledge about the epidemiology of acute infectious diarrhea that is a major public health problem and potential danger for travelers.

[Impact and forecasting of hepatitis A immunization in French armed forces, 1990-2004]. / Impact et modélisation des effets attendus de la stratégie de vaccination contre les hépatites A chez les militaires français, 1990-2004.

BACKGROUND: Hepatitis A is a public health problem specially for migrants or travellers from industrialized countries with a low hepatitis A endemic level. French armed forces adopted an immunization strategy which first targeted overseas forces and subsequently was extended to all armed forces. In this work we studied the impact of this policy. METHODS: Epidemiological surveillance data from 1990 to 2004 was analyzed by Poisson regression and exponential models of decrease used to forecast future rates. RESULTS: From the 826 cases of hepatitis A reported during the study period, 266 (32.2%) occurred in overseas forces and 560 (67.8%) in forces stationed in France. Three periods could be identified in the decline of annual incidence: before 1994, with an average rate of 23.2 per 100,000; from 1994 to 1998: 10.2; and after 1998: 1.2 for all French armed forces. For overseas armed forces, the average rate was 117 per 100,000 before 1994 and 17.1 from 1994 to 1998 (p<0.001). For armed forces stationed in France, the average rate was 12.2 per 100,000 before 1998 and 0.9 after (p<0.001). For overseas armed forces, models clearly described the declining incidence subsequent to targeted immunization in 1995 and for armed forces stationed in France, the decline with generalized immunization starting in 1998. DISCUSSION: The impact of immunization against hepatitis A virus was significant both in an overseas population and in a population staying in France where the risk level can be considered low due to the low endemic rate in France. These results suggest that immunization should be proposed not only for travellers but also for the general population based on real knowledge of the situation and cost-effectiveness analyses.

[Waldenström's macroglobulinemia with an uncommon presentation]. / Macroglobulinémie de Waldenström: à propos d'une présentation clinicobiologique peu commune.

Waldenström's macroglobulinemia is a rare disease with an indolent clinical course. The median age of the affected patient is 65 years. Nevertheless, we report a case of Waldenström's macroglobulinemia revealed by a splenomegaly and severe pancytopenia, in a 51-year-old man without previous medical history. According to the recent consensus recommendations for the clinicopathological definition of Waldenström's macroglobulinemia, diagnosis was made through morphological and immunophenotypic data of medullary cells. The reduced survival of the patient is associated with the importance of the cytopenia.

[Contact tracing in a case of tuberculosis in a health care worker]. / Investigations autour d'un cas de tuberculose d'un soignant.

INTRODUCTION: Tuberculosis is a public health problem, of which the nosocomial transmission from a health care worker to patients has not been well documented. OBSERVATIONS: A Senegalese surgeon aged 32 was admitted to hospital on account of deterioration in his general health. He was found to have sputum positive tuberculosis and received standard treatment. We report the strategy employed for tracing the contacts of this health care worker. Of a total of 185 members of staff (permanent and temporary) and 91 patients who had been in contact with the index case, 180 (97.3%) and 71 (78%) respectively were screened. Of the 251 subjects screened, 5 staff (2.8%) and 11 patients (15.4%) showed evidence of latent tuberculous infection and 6 were treated. In total 97.3% of staff exposed were screened at the beginning of the study and 63% were reviewed at 3 months as opposed to 78% and 53% for the patients. CONCLUSION: This study shows poor compliance with the visit 3 months after exposure and the need to standardise the procedures in order to improve the screening and follow up of contacts.

[Fall in the seroprevalence of hepatitis A in French youth]. / Effondrement de la séroprévalence de l'hépatite virale A chez les jeunes français.

OBJECTIVE: An anti-hepatitis A virus seroprevalence survey was performed in 1997 in 1052 French army recruits (mean age: 21.2 years). To describe epidemiological trends, the current pattern was compared to previous results obtained by similar methods in 1985, 1990 and 1993. RESULTS: In 1997, overall anti-hepatitis A virus seroprevalence was 11.5%. The greatest risk factor of hepatitis A infection was related to travel in intermediate or highly endemic areas for hepatitis A virus: 46% of overseas residents (odds ratio = 10.3), 28% of recruits who had travelled in developing countries (odds ratio = 3.7) and 7.65% of French living in industrialised countries are anti-hepatitis A virus antibody positive. Moreover, seroprevalence was higher in subjects with a history of icteria (adjusted odds ratio = 3.5) and families with at least 3 children (adjusted odds ratio = 3). No association was found with drinking water, socioeconomic status such as baccalaureat degree, or parents profession. The seroepidemiological shift of hepatitis A, as assessed in three previous studies, shows a marked decrease of 20% in 12 years from 30.4% in 1985, to 21.3% in 1990, to 16.3% in 1993, and to 11.5% in 1997. The decrease in the prevalence of anti-hepatitis A virus was more marked in young adults who had never travelled in endemic countries (decrease of 20%) than those who had visited or lived in developing countries (decrease of 10%). CONCLUSION: Although France is not highly endemic for hepatitis A thanks to improved hygiene and housing conditions over the past 20 years, a pattern of intermediate endemicity was seen in French overseas areas in which the risk of outbreaks of hepatitis A was higher. The decrease in anti-hepatitis A virus seroprevalence in French youth can be used to draft a public health policy for hepatitis A control.

[Geographical distribution of hepatitis E virus genotypes]. / Répartition géographique des génotypes du virus de l'hépatite E.

Hepatitis E virus (HEV) is the major agent of acute hepatitis in developing countries where the infection occurs sporadically or in large waterborne epidemics. HEV, classified in the Caliciviridae, is not culturable. The detection of HEV RNA by RT-PCR in serum and stool samples is reliable during the 7 to 15 days following the onset of the disease. Restriction endonuclease analysis, cloning and sequencing of PCR products allow a phylogenetic analysis of HEV isolates. Although they belong to a single serotype, strains recovered from different geographical regions display a significant genetic heterogeneity. Sequencing data from ORF1 and ORF2 regions has led to the characterization of 3 distinct genotypes: genotype I gathering the Asian and African subgenotypes; genotype II gathering swine and human US strains; genotype III limited to the Mexico prototype. Novel variants are currently described from Africa (Nigeria), China and Europe (Greece and Italy). Each genotype appears to be related to a well defined geographical area. Nevertheless, a genetic variability is observed within endemic regions such as Asia or Africa. Nigerian endemic isolates especially could represent an intermediate stage in the evolutionary process towards genetic diversity. The animal reservoir, proved by the detection of HEV sequences by PCR among pigs in Nepal and in the USA, could help to resolve unanswered questions about the origin of HEV genotypes, their spread and evolution.

[Sero-epidemiological study of the hepatitis epidemic in Mitrovica in the aftermath of the war in Kosovo (1999)]. / Etude séro-épidémiologique des hépatites épidémiques à Mitrovica dans les suites de la guerre du Kosovo (1999).

In July 1999, after the return of the Kosovar refugees to their country, an outbreak of acute hepatitis A (HAV) and E (HEV) occurred. Epidemic hepatitis and diarrhoea are closely monitored communicable diseases which had been singled out as priorities by the health authorities of the former Republic of Yougoslavia. Several field surveys were undertaken: description of reported cases, serological study of clinical patients, study of anti-HAV seroprevalence in a school and a case control study to assess risk factors. The analysis of the reports indicates an epidemic peak at the end of September, 2 or 3 weeks after the start of the new school year, with an increase of cases relative to the age of the children in school. In a serologic study of 104 samples, we found an anti-HAV IgM positivity in 88% of the cases. Children were more likely to be positive when compared to teenagers and adults; likewise, consumers of well-water as versus those drinking network water (p = 0.03). The study of seroprevalence showed that transmission had taken place within the school. The case control study, in spite of its imperfections, indicated that consumption of water melon, the only fruit cultivated locally, is a factor which facilitates the HAV transmission. Circulation of the hepatitis E virus was confirmed for 4 sick persons (including 2 co-infected HAV-HEV) and in 4 persons without clinical symptoms. These results show the permanent risk of faeco-oral infections in this area and the need to develop a relevant prevention policy.

[Antiphospholipid syndrome and psychosis]. / Syndrome des antiphospholipides et psychose.

The authors studies literature on both psychiatrics manifestations in several auto-immune diseases like systemic lupus erythematosus and the antiphospholipid syndrome, and the impairment of immune functions in psychiatrics diseases. They try to expose the relevance of collaboration between Medical practitioners and psychiatrists to study the immunogenetic hypothesis of psychotic diseases.

[Non-vaccinal prophylaxis for orally transmitted diseases]. / La prophylaxie non vaccinale des maladies à transmission orale.

Many diseases are transmitted to man by consumption of contaminated food and drinking water. Orally transmitted diseases are among the main risks for travelers in developing and tropical countries. A variety of clinical manifestations can be observed but the diarrhea is the most common. In many cases bacterial gastroenteritis, typho-paratyphoidal fever, brucellosis, viral hepatitis, and various parasitic diseases can develop after various periods of incubation following consumption of contaminated food or drink with no initial reaction. Vaccination can afford protection against only few diseases. Prevention by applying good hygiene and common sense is the best method. By following the standard list of food precautions, travelers can minimize the main risks. Drug prophylaxis is recommended only under special circumstances. Travel medicine providers must have up-to-date information and possess the persuasive powers necessary to convince travelers to apply recommendations despite the major inconveniences.

[Outbreak of tropical phagedenic ulcers after the rainy season in Dijibouti]. / Recrudescence des ulcères phagédeniques a Djibouti pendant la saison des pluies.

The incidence of cutaneous ulcers was observed after the rainy season in Djibouti in 1997. Based on the study of epidemiologic, clinical, biological, and therapeutic features these lesion were classified as phagedenic ulcers. While direct examination showed numerous fusiform bacilli, cultures performed in one patient, led to isolation of numerous colonies of Prevotella loescheii. Though less common, two other anaerobic bacterial species were detected, i.e., Peptostreptococcus anaerobius and Peptostreptococcus sp.

[Status of resistance of HIV-1 strains in Africa: what is the role of viral surveillance networks?]. / Etat de la resistance des souches de VIH-1 en Afrique: quelle place pour les reseaux de surveillance virologique?

The human immunodeficiency virus (HIV-1) epidemic has spread dramatically in sub-Saharan African countries. Implementation of active antiretroviral (ARV) therapy programs is urgently needed. However this emergency situation must not extenuate the importance of preliminary studies on ARV resistance of African HIV-1 isolates. Findings show that genetic mutations underlying the resistance of African strains are generally identical to those observed in HIV-1 subtype B in industrialized countries. However the incidence of some mutations associated with mild resistance to protease inhibitors (PI) appears higher in African isolates. The potential impact of these mutations for development of frank resistance to PI is still unclear. The incidence of high-grade resistance markers in untreated subjects is low. While these results do not compromise use of ARV therapy in Africa, they underline the need to set up local networks for patient follow-up and to carry out epidemiological surveillance of HIV-1 resistance. Success of ARV therapies in Africa will also depend on economic and social programs.

[Hepatitis C in tropical areas]. / L'hépatite C sous les tropiques.

The tropical features of hepatitis C have not yet been fully elucidated due to the scarcity of data. However it has been estimated that two-thirds of the infected population lives in tropics. The most heavily affected regions are Africa, China, and southeast Asia with prevalence rates of 5.3, 3.0, and 2.4 p. 100 respectively. In several countries mostly in Africa, prevalence rates range from 5 to 10 p. 100 or higher. Age is a major risk factor for infection. The classic transmission modes, i.e., blood transfusion and intravenous drug use, do not account for these high prevalence rates. Another mechanism could be parenteral injection under unsafe conditions. The most widespread genotypes in tropical areas are genotypes 1, 2, and 3. Other genotypes can be encountered locally including genotype 4 in black Africa and Egypt, genotype 6 in southeast Asia, and genotypes 1 and 3 in India. The association of hepatitis C with chronic liver disease has been the focus of several studies, mainly in Africa. The seroprevalence of virus C ranges from 2 to 55 p. 100 in cases of chronic hepatitis or cirrhosis and from 0 to 47 p. 100 in cases of hepatocellular cancer. Hepatitis C could be the underlying cause of 33 to 50 p. 100 of chronic liver diseases not linked to virus B. It is observed more often in patients with chronic hepatitis or cirrhosis than cancer in which virus B is dominant. Infection by both virus is rare without liver disease but is more frequent in patients with cancer than chronic non-tumoral liver disease.