[Epidemiological aspects of Ebola virus disease in Guinea (december 2013-april 2016)]. / Aspects épidémiologiques de la maladie à virus Ebola en Guinée (décembre 2013­avril 2016).

Ebola Zaire species variant Makona between its emergence in December 2013 and April 2016, resulted in an epidemic of Guinea importance and unprecedented gravity with 3814 reported cases of which 3358 were confirmed (88.0%) and 2544 were died (66.7%). The epidemic has evolved in phases: a silent phase without identification of all fatal cases until February 2014; a first outbreak from March 2014, when the alarm is raised and the virus detected, which lasted until July 2014; a second increase, which was the most intense, from August 2014 to January 2015 focused primarily on the forest Guinea; and a final increase from February 2015 centered on lower Guinea and the capital Conakry. Adapting strategies in 2015 (initiative "Zero Ebola in 60 days" active case search and suspicious deaths and awareness of active prefectures, microbanding the last affected communities and raking around these localities) and ring vaccination of contacts around confirmed cases has allowed to gradually control the main outbreak in October 2015. But a survivor was originally resurgence in forest areas between March and April 2016 with 10 cases including 8 deaths. The epidemic has particularly affected the forest Guinea region (44% and 48% of Guinean cases and deaths), elderly women (≥ 50 years), and health professionals (211 cases including 115 deaths); however, almost one-third of the patients (32.6%) was not provided supportive care in the Ebola centers. The epidemic is currently marked by the resurgence of small foci, from excreting subjects cured of the virus who have been controlled so far successfully. The survivors are the subject of special attention. It is necessary to learn lessons from the response to better prepare for the future, to improve knowledge about the natural history of the Ebola virus disease, and to rethink communication in this regard with the public and its leaders.

Antibiotic therapy and staphylococcal skin infections in a tropical malarial zone (Guyana). Practices in conventional and exceptional situations.

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.

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.

Prevention of infectious diseases during military deployments: a review of the French armed forces strategy.

Military personnel in operations have always paid a high toll to infections. In the 21st century some of these diseases still cause outbreaks with significant morbidity and impact on deployments. The new configuration of the French Armed Forces requires the permanent preparedness of deployable units. During deployments, soldiers are at least exposed to the infectious diseases that are observed in travellers, but with a potentially severe impact for the combatting strengths and a risk for cancelation or failure of the operational durability. The most common disabling infections during military deployments are faeco-oral transmitted diseases including diarrhoea. Preventing infectious diseases during deployments is of great concern and the French medical service has established a strategy based on different components; risk assessment and preparation, immunizations, protective measures and chemoprophylaxis, health education, health surveillance, outbreak investigations and medical tracking. In this review, the authors present the context of deployment of the French Armed Forces, the main health risks they are exposed to and develop the key points of the force health protection strategy, focused on infections related to military deployments.

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.

Feedback on the management of the 2011 measles outbreak by French military general practitioners: an evaluation study.

OBJECTIVE: Preventive measures were implemented in the French armed forces to limit the measles outbreak that occurred in 2010 and 2011. This study aimed to obtain feedback concerning the management of this outbreak by the French military general practitioners. METHOD: A cross-sectional study was conducted among the general practitioners (GPs) in military units located in metropolitan France. The 60 military units that reported at least one measles case in 2011 were included. Data were collected using self-administered questionnaires. RESULTS: The acceptance of preventive measures against measles was good (measures "totally justified" for 77.8%) and most of the military GPs considered that the outbreak had no significant impact on their activities. The management of measles cases was perceived as not very problematic but difficulties were encountered in the identification of contacts around cases (48.1% of respondents) and in the identification of vaccine recipients among these contacts (more than 80% of respondents reporting difficulties in the collection of measles and vaccination histories). The organization of vaccination around cases was also perceived as difficult. CONCLUSIONS: Preventive measures around measles cases were well accepted by the military GPs, which could reflect their preparedness in the face of the outbreak. However, vaccination did not seem to be well understood or accepted by military patients, underlining the essential role of military GPs in patient information. Difficulties in the collection of vaccination and measles histories among contacts could be overcome by an early transcription of individual medical records in the military medical files of newly enlisted personnel. A more generalized use of oral fluid testing devices, which can be shipped at ambient temperature, would simplify diagnosis in the armed forces.

Emergence of Plasmodium ovale malaria among the French Armed Forces in the Republic of Ivory Coast: 20 years of clinical and biological experience.

BACKGROUND: French military surveillance identified an increase in Plasmodium ovale attacks among soldiers in Ivory Coast. This emergence and the low sensitivity of biological tests raise the question of a possible role of P. ovale variant species. METHODS: Epidemiological data about P. ovale attacks from 1993 to 2012 were studied; the species diagnosis was based on a thin blood smear and/or a quick diagnostic test. Clinical and biological features in soldiers hospitalized in 2 French military hospitals were also reviewed. Malaria polymerase chain reaction followed by genotyping was performed when available. RESULTS: French military physicians declared 328 P. ovale attacks over the 20-year study. A peak of incidence occurred in 2005. Among patients with positive blood smears, the quick diagnostic test was positive in 33 of 101 tests performed. The hospital study showed that symptoms and biological changes were not specific, which made diagnosis challenging: fever, anemia, and thrombocytopenia were not present in 20%, 71%, and 23% of the 45 confirmed cases, respectively. It was possible to perform molecular investigations on 19 clinical isolates: 18 were classic haplotypes with additional polymorphism and 1 was variant. CONCLUSIONS: This emergence of P. ovale malaria enabled a good description to be made in nonimmune patients. The lack of sensitivity of both clinical features and quick diagnostic tests suggests an underestimation. Reasons for this outbreak are especially intense exposure to the vectors and the insufficient efficacy of doxycycline against P. ovale. The polymorphism of classic haplotypes of P. ovale rather than variant forms could be involved.

[History of malaria control in the French armed forces: from Algeria to the Macedonian front during the first World War]. / Histoire de la lutte contre le paludisme dans l'armée française : de l'Algérie à l'Armée d'Orient pendant la Première Guerre mondiale.

The French joint military health corps has long experience in malaria control. Many military physicians played an essential role in the 19th century: Maillot revolutionized malaria treatment by using quinine during the conquest of Algeria, and Laveran discovered the causal parasite (the genus Plasmodium) there. This experience continued under the direction of Laveran and the Sergent brothers on the eastern front in Greek Macedonia during World War I. The vast coordinated control plan established on this front from 1917 delivered the French infantrymen from malaria and led to victory over the Bulgarian forces, which capitulated in September 1918.

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.

Adverse events following vaccination in the French armed forces: An overview of surveillance conducted from 2002 to 2010.

French military personnel are subject to a compulsory vaccination schedule. The aim of this study was to describe vaccine adverse events (VAE) reported from 2002 to 2010 in armed forces. VAE are routinely surveyed by the military Centre for epidemiology and public health. For each case, military practitioners fill a notification form, providing patient characteristics, clinical information and vaccines administered. For this study, VAE following influenza A(H1N1)pdm09 vaccination were excluded. Among the 473 cases retained, 442 (93%) corresponded to non-severe VAE,including local, regional and systemic events, while 31 corresponded to severe VAE, with two leading to significant disability. The global VAE reporting rate (RR) was 14.0 per 100,000 injections. While stationary from 2002 to 2008, the RR increased from 2009. The most important observations were a marked increase of VAE attributed to Bacillus Calmette-Guérin (BCG) vaccine from 2005 to 2008, a high RR observed with the inactivated diphtheria-tetanus (toxoids)-poliovirus vaccine combined with acellular pertussis vaccine (dTap-IPV) from 2008 and an increase in RR for seasonal influenza vaccine VAE in 2009. Our RR for severe VAE (1.1 VAEper 100,000) appears comparable with rates observed among United States civilians and military personnel. The increase observed from 2009 could be partly explained by the influenza A(H1N1)pdm09 pandemic which increased practitioner awareness towards VAE. In conclusion, the tolerance of the vaccines used in French armed forces appears acceptable.

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.

Blood and body fluid exposures in the French military.

BACKGROUND: Occupational exposure to blood and body fluids (BBFs) is a hazard of many occupations, particularly hospital-based health care providers. However, non-hospital-based health care workers (HCWs) and other personnel not providing health care are also at risk. AIMS: To present the results of surveillance of accidental exposure to BBFs among non-hospital-based French military personnel between 2007 and 2009, comparing different occupational categories. METHODS: The study population included all French military personnel subjected to occupational BBF exposure in a non-hospital setting. BBF exposure was defined as any percutaneous (needlestick injury, scalpel cut, etc.) or mucocutaneous (splash to mucosa, eyes or non-intact skin) exposure to blood, a biological fluid contaminated with blood or a fluid known to transmit blood-borne pathogens. RESULTS: Between 1 January 2007 and 31 December 2009, 704 occupational BBF exposures were reported in non-hospital-based French military personnel. Annualized BBF exposure incidence rates were statistically different among health care workers in non-hospital settings, firefighters, 'gendarmes' and other military personnel, with respectively 38.7, 5.4, 0.8 and 0.1 exposures per 1000 persons per year. Among the 97 cases of HIV post-exposure prophylaxis (PEP) initiated, the source patient's HIV status was unknown in 78 cases (84%). CONCLUSIONS: These results suggest that the appropriateness of HIV PEP initiation in the French military should be reviewed. Adapting French guidelines for managing BBF exposure, for non-hospital-based environments should be considered.

Food-borne outbreak of norovirus infection in a French military parachuting unit, April 2011.

On 13 April 2011 the medical service of a French military parachuting unit reported an outbreak of acute gastroenteritis involving 147 persons among the military personnel. Meals suspected to have caused the outbreak (pasta and some raw vegetables) were tested for norovirus by PCR. The same norovirus (genogroup I) was found in some of the food items consumed by the cases and in a cook who prepared the meals.

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.

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.

Resurgence of measles in the French military forces in 2010.

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 and to describe the increase in incidence. Measles was surveyed from 1992 to 2010. Criteria for report were those used for French national compulsory notification. The data, concerning active military personnel, were provided by the physicians in the armed forces using anonymous data collection forms. Between 1992 and July 2010, 689 cases of measles were notified. Since 2002, the mean incidence rate was 1 case per 100,000. A significant increase has been observed for 2010 (13.9 cases per 100,000 in 2010 versus 1.8 in 2009). The 28 cases reported in 2010 involved five clusters and three isolated cases. The mean age of affected subjects was 27 years. Only 30% of cases had been vaccinated. The epidemic resurgence of measles observed in 2010 in the French armed forces follows the same pattern as that observed nationally and at European level, and can be seen as the likely consequence of inadequate vaccination cover.

[A(H1N1) influenza surveillance in the French armed forces: adapting the surveillance systems to the pandemic setting]. / Surveillance épidémiologique de la grippe A(H1N1) 2009 dans les armées françaises: adaptation des systèmes de surveillance au contexte pandémique.

OBJECTIVES: An outbreak of A(H1N1) virus influenza, detected in Mexico during April 2009, spread around the world in nine weeks. French armed forces had to adapt their epidemiological surveillance systems to this pandemic. Our aim was to present surveillance results. DESIGN: There are two influenza surveillance systems in French armed forces: one permanent throughout the year and one seasonal, the Military influenza surveillance system (SMOG). The pandemic threat led to an early reactivation of SMOG, before the initiation of a daily surveillance system specifically dedicated to A(H1N1) influenza. RESULTS: In metropolitan France, the increase of respiratory infections was observed as of September 2009, with a maximum of 401 cases for 100,000 at the beginning of December according to SMOG. The estimated rate of consultations related to A(H1N1) influenza ranged between 46 and 65 cases for 100,000. For military units operating outside of metropolitan France, a peak of incidence was observed in August (400 cases for 100,000). CONCLUSION: The trends observed by influenza military surveillance networks were compatible with French ones. Concerning French forces in operations, the increase of incidence observed in August was the consequence of the influenza outbreak in the Southern hemisphere. Estimations of consultations rate related to A(H1N1) influenza, ranged between 127 and 194 cases for 100,000 at the beginning of December, lower than the national rate (1321 cases for 100,000), a consequence of the age pyramid in the military population.

[Pertussis surveillance in French military forces in 2007]. / Surveillance épidémiologique de la coqueluche dans les armées françaises en 2007.

OBJECTIVES: Pertussis surveillance in the French general population was stopped in 1986. Pertussis was added to the list of illnesses surveyed by the military epidemiological surveillance network because of outbreaks having occurred among French servicepersons and in military high schools. This study had for aim to report the results of the first year of surveillance. DESIGN: Pertussis declaration criteria were those recommended in 2006 by the French council for public hygiene. The data concerning active military servicepersons was collected by physicians of all military medical units. An anonymous declaration form was used for data collection. RESULTS: In 2007, 66 cases of pertussis were reported in the military forces, 10 of which were excluded after a negative biological test. The classification of the 56 included cases was: 46% biologically confirmed cases, 20% clinically confirmed cases, 14% suspected cases, and 6% epidemiologically confirmed cases. The incidence density rate was 16.3 cases for 100,000 servicepersons-years. Age under 20 was associated with a 4.6 fold higher risk to develop pertussis. CONCLUSIONS: The high incidence rate observed in individuals under 20 years of age could reflect a shift of pertussis reservoir to young adults, as observed in industrialized countries after generalization of vaccination programs. However, several years of surveillance will be needed to confirm this hypothesis. Meanwhile, the military epidemiological network could constitute an important surveillance marker of pertussis among adults in France.