[Social representations of public health among healthcare workers within the French Armed Forces]. / Les représentations sociales de la santé publique chez les professionnels de santé dans les armées françaises.

BACKGROUND: Public health is a multidisciplinary activity whose fields of action are acquiring an increasingly broad. The Service de santé des armées (SSA) has always had a culture of public health problems thanks to doctors specialized in the treatment of major diseases. Often involved in public health activities, health professionals nevertheless have a fragmented vision. The objective was to describe the social representations of public health of military healthcare workers. METHOD: The responders were doctors, nurses, veterinarians and pharmacists practicing in different areas of SSA (caregivers, administrators, policy makers) and were interviewed by telephone. A question of spontaneous evocation on the representations of public health in the army was asked. The overall lexical analysis was performed according to the method of rank-frequency. Categorical analysis was conducted to better understand the whole lexical field use. RESULTS: There were 90 responders. The most salient terms were "prevention, epidemiological surveillance and vaccination". The categorical analysis showed that doctors used a lexical field primarily focused on diseases and risk behaviors, nurses on the specifics of military surveillance and policy makers about the cross-discipline. CONCLUSION: Public health in the army is mainly represented by epidemiological surveillance and prevention. Given the non-mentioned fields, a strengthening of communication on the current challenges of public health would probably improve adherence of healthcare professionals since public health takes on more and more importance in the development of the national health policy and management of health crises.

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.

Chikungunya infection: self-reported rheumatic morbidity and impaired quality of life persist 6 years later.

This study presents the 6-year follow-up of French gendarmes exposed to the chikungunya (CHIK) infection in 2006 on Reunion Island. The aim was to see to what extent the subjective health differences observed in 2008 (30 months after infection) between CHIK infected (CHIK+) and noninfected (CHIK-) gendarmes still persisted in 2012, and to investigate a possible return to a pre-CHIK health status for CHIK+ subjects. Gendarmes were contacted by mail in 2012 and asked to complete a self-questionnaire asking for morbidity, health care and medicines consumption since the last follow-up in 2008. Quality of life (QoL) after 6 years was evaluated using the SF-36 scale. In comparison with CHIK- subjects (n = 171), CHIK+ (n = 81) presented with higher rheumatic but also nonspecific morbidity such as headaches and fatigue associated with a large psychological impact, frequent depressive moods and social disabilities, leading to a significant impairment of the QoL and higher health care consumption. When restricted to CHIK+ subjects, comparing the data with that of 2008 showed persistent but decreasing self-reported rheumatic morbidity, and an increase over time of chronic discomfort (headache, fatigue) and depressive moods, resulting in no overall improvement in QoL. Despite possible cohort attrition bias, the comparability of CHIK+/CHIK- subjects allows the assumption of a long-term impact of CHIK infection with less chance of returning to a previous health status. Although these results may be specific to the 2006 virus strain, we recommend that public health strategies in the epidemic-prone countries include a response to the consequences of chronic post-CHIK disorders.

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.

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.

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.

[Sexual exposure to HIV in the French armed forces between 2005 and 2007]. / Expositions sexuelles au VIH dans les armées françaises de 2005 a 2007.

BACKGROUND: Non-occupational HIV exposure in the French forces has been placed under epidemiological surveillance since 2000. This surveillance programme provides an indirect indicator of risky sexual behaviour among military personnel. PATIENTS AND METHODS: All cases of non-occupational exposures in French military personnel that meet the notification criteria, wherever they occur, are reported by a military physician, with data being collected from 2005 to 2007. RESULTS: Between January 2005 and December 2007, 2241 cases of sexual exposure within the French forces were filed. The annual incidence was 214.3 per 100,000 with an average patient age of 26 years. Sexual exposures concerned men in 99.2% of cases and occurred overseas in 92.9% of cases. Partners were sex-workers in 66.7% of cases. Failure to use condoms adequately during sexual intercourse was reported in 15.5% of cases. In cases where condoms were used, exposure to HIV resulted either from condom rupture or slippage. Postexposure HIV prophylaxis was prescribed in 70.5% of cases. DISCUSSION: The majority of cases of sexual exposure reported in the French armed forces involved high risk of HIV transmission. However, since the beginning of surveillance in 2000, no cases of HIV seroconversion have been reported following postexposure antiretroviral prophylaxis. The non-occupational postexposure prophylaxis strategy is not in question.

[Dengue virus infection in neotropical forest mammals: incidental hosts or potential reservoirs?]. / Infection par le virus de la dengue de mammifères sauvages en région néotropicale: hôtes accidentels ou réservoirs potentiels?

The arboviral disease with the highest human incidence in South America is dengue fever. In French Guiana, where all four dengue serotypes, i.e., DENV-1, DENV-2, DENV-3 and DENV-4, are present, the disease is endemic with epidemic outbreaks. Though previous serological studies have suggested a sylvatic cycle, involvement of wild mammals in the dengue cycle in the neotropics has never been confirmed. The purpose of this study was to search for the presence of DENV in wild animals captured at two different sites between 2001 and 2007. About 10,000 trap/nights were performed leading to the capture of 464 non-flying mammals (rodents and marsupials). In addition, mistnests placed in the same zone yielded 152 bats. Reverse transcription-polymerase chain reaction amplification to detect infection by any of the four dengue serotypes demonstrated viral RNA in the livers and/or sera of 92 captured animals. Sequence analysis of amplification products revealed that the DENV-1, DENV-3 and DENV-4 serotypes were distinct from those circulating in humans at the same periods. Analysis for DENV-2 showed that some strains were divergent from concurrent human strains but that others were identical. The latter finding suggests that wild neotropical mammals living in periurban area can be infected by dengue virus strains circulating in humans. However, further investigation will be needed to determine if neotropical mammals are incidental hosts or potential reservoirs of dengue virus.

[Pathophysiological mechanisms of dengue fever: critical review of current concepts]. / Mécanismes physiopathologiques de la dengue: revue critique des hypothèses.

In the 20th century dengue fever became one of the leading causes of morbidity and mortality throughout the tropics. The dengue virus is an arbovirus transmitted by Aedes mosquitoes. There are four distinct serotypes of dengue arbovirus (DENV-1, 2, 3, 4). According to the World Health Organization, a person infected by one of the dengue viruses can develop symptoms ranging from the classical self-limiting form characterized by high temperature, headache, myalgia, and arthralgia to the severe, potentially fatal, form known as dengue shock syndrome. For over 40 years the main explanation for the pathogenesis of dengue has been based on the "antibody-dependent enhancement" (ADE) concept stating that enhancing antibodies acquired during a primary infection increase the number of infected cells, and thus the level of viremia, during secondary infection. However the severity of dengue is not limited to dengue shock syndrome and there are many cases that do not conform to the ADE concept. A meta-analysis could provide crucial information for resolving this controversy and open the way for development of a monovalent vaccine against the dengue virus as for the closely related yellow fever virus.

[Real time epidemiological surveillance within the armed forces: concepts, realities and prospects in France]. / Surveillance épidémiologique en temps réel dans les armées; concepts, réalités et perspectives en France.

BACKGROUND: In 2002, the North Atlantic Treaty Organization took five initiatives in order to enhance the defence capacities against the massive destruction weapons, one of them concerned the development of an interoperable surveillance system, giving in real time some informations permitting early warning to the commanders. Thoughts in France to improve the military surveillance system, methodological constraints and first results are shown. METHODS: Medical, technological, human and organisational aspects had to be taken into account to develop real time surveillance within the armed forces, and also specific military constraints. In order to evaluate the validity of its methodology, the "Institut de médecine tropicale du service de santé des armées" developed a prototype, set up in French Guyana and which took part in a second time at a multinational exercise. RESULTS: The "surveillance spatiale des épidémies au sein des forces armées de Guyane" has been set up in 2004, formed by both a recording and an analysis networks. This system permits to provide in real time some dashboards directly operational for the commanders. The exhaustiveness rate has been evaluated at 104%, compared to the traditional surveillance. It permitted three times to detect outbreaks several weeks before the other systems. Some limits have been identified, as the use of personal digitalized assistants. The involvement in a multinational exercise showed the system's efficacy, by detecting two simulated outbreaks, but also its interoperability. In 2006, it has been decided to extend the concept by deploying its second generation within the French armed forces in Djibouti. The "alerte et surveillance en temps réel" disposal permitted to take into account multiple geographical localizations. CONCLUSION: A real time surveillance system is an essential alarm disposal, however it is only an information tool within the complex activity of piloting the sanitary situation. It must be integrated within the whole situation expertise supports, represented also by medical intelligence, epidemiological investigations and prediction of the epidemiological phenomenon evolution.