SARS-CoV-2 Epidemic in the Israeli Defense Force-Lessons Learned From Our rt-PCR Screening Policy.

BACKGROUND: During the SARS-CoV-2 pandemic, multiple preventative measures were used to prevent the virus from spreading in the population. The Israeli defense force deployed further means to contain the disease, including putting units in quarantine, physical distancing and using masks, gowns and disinfectants when in contact with suspected patients. METHODS: We used reverse transcriptase-polymerase chain reaction (rt-PCR) tests to screen for patients among asymptomatic soldiers within units participating in civilian aid or in close contact with known patients, using personal protective equipment. Positive results were repeated and followed with serological testing to verify the nature of results. RESULTS: Between April and May 2020, we screened a total of 1,453 soldiers in 13 different units. We found 11 false positive results, leading to unnecessary measures until resolution, and three true positive results (0.2%). All true positive results had unreported symptoms concomitant with SARS-CoV-2 disease. These results led to the resolution of this screening policy. CONCLUSION: Screening asymptomatic army personnel in this setting with rt-PCR test for SARS-CoV-2 is not warranted and leads to unnecessary false positive results. Efforts should be directed at identifying symptomatic patients.

Lessons from outbreaks of COVID-19 at Israeli military bases.

BACKGROUND: To mitigate the spread of coronavirus disease 2019 (COVID-19), national guidelines, in accordance with international health authorities, mandated 14 days of quarantine for every close contact of a confirmed COVID-19 patient. Although health benefits are obvious, consequences are profound, especially for organizations required to maintain operational preparedness. OBJECTIVES: To present the Israel Defense Force (IDF) experience with outbreaks regarding quarantined individuals. To weigh the consequences of quarantined individuals needed for workforce and operation. METHODS: All positive COVID-19 cases in the IDF, as measured by a positive rRT-PCR test result, between 29 February and 18 May 2020 were evaluated. Numbers of positive individuals, quarantined individuals, and confirmatory exams conducted were collected. We compared the events in four units with the largest outbreaks and assessed the impact of confirmed cases, tests conducted, and workforce loss due to quarantine. RESULTS: Of the 187 soldiers who tested positive for COVID-19, source of infection was traced to 140 soldiers (75%). Almost no medical treatment was delivered, and hospitalization was rare. We found a median of 15.2% (interquartile range 5.3-34) for decline in unit workforce due to quarantine measures. Maximum reduction reached 47% of the workforce in one unit. CONCLUSIONS: Despite a relatively small number of confirmed cases, units underwent a substantial change in mode of operation due to the toll of quarantined individuals. In certain populations and organizations, perhaps a more liberal application of isolation and contact tracing is suitable due to the heavy economic burden and consequences in term of operational readiness.

Military medical research in the IDF: an array of fields and interests.

BACKGROUND: War is as old as history. Some may say it is older. The first Biblical war, dated 1880-1875 BCE, is depicted in the book of Genesis between nine kings in the vicinity of the Jordan river near Jericho. By the end of the war, Abraham (Abram) gets involved in saving his nephew Lot. In addition to war, military medicine also has its roots in historical times. Hippocrates (460-377 BCE), the father of medicine, derived his medical knowledge from the battlefield, and Sushruta [1], the father of plastic surgery, mentioned the physician's preventive role in noting environmental hazards: "A common practice of the enemy is to poison the wells on the roadside, the articles of food, the shades of trees, and the fuel and forage for cattle; hence, it is incumbent on a physician marching with the troops to inspect, examine, and purify these before using any of them, in case they are poisoned." The Greeks stated new ideas of military health, pointing to fitness promotion, gymnastics, and healthy diets to prevent illness. Over the centuries, from Alexander the Great to Napoleon's army and wars in the 20th century, military conflicts have led to the death of hundreds of millions of people from trauma and war-related disease. Amazingly analyses of the 18th and 19th centuries have shown that 80% of the soldiers died from disease, and historians and military personnel agree that during armed conflicts in known history, only a minority of soldiers perished by the sword. In Israel, the Israel Defense Forces-Medical Corps (IDF-MC) holds a unique position embedded in military and civilian national medicine. All medical personnel (e.g., physicians, nurses, technicians, veterinarians) who work in the IDF-MC receive their diplomas from civilian universities, train in civilian hospitals, and continue to practice in the national health system. The majority of these professionals continue to work in different civilian medical platforms in Israel after finishing their mandatory service. The IDF-MC's primary mission is to provide optimal medical care to IDF soldiers at all times (including wartime), to prevent disease and promote health, advance military medicine, and aid the civilian sector as ordered by the Government of Israel. In this special issue of Israel Medical Association Journal (IMAJ) is to expose readers to the continuous efforts of the IDF-MC to fulfill its mission by promoting research in multiple medical fields, including trauma, ambulatory care, health administration. In addition, in this issue of IMAJ, authors discuss the unique collaboration with the civilian system during the coronavirus disease 2019 (COVID-19) pandemic. Trauma and trauma-related injuries are the main focus of military medical research. Ben-Avi and colleagues [2] described outcomes of emergent exploratory thoracotomies on military casualties and addresses parameters that may impact the survival of these casualties. Minervini [3] further discussed the issue. Bez et al. [4] researched the impact of isolated versus non-isolated traumatic brain injuries on injury identification and decision-making by care providers in austere scenarios. Tsur and co-authors [5] described the characteristics of a unique type of terror attack: vehicle ramming. Additional examples of treatments provided in the military prehospital arena were analyzed by Nakar and colleagues [6] who discussed how to assess pain medications administered to trauma casualties in the past two decades by IDF-MC care providers. Rittblat et al. [7] further described the use of freeze-dried plasma, a blood component used in the prehospital arena and administered via intraosseous vascular access. The IDF-MC is a continuously changing organization emphasizing the adoption of advanced technologies and devices. Chen et al. [8] presented a blinded study on the use of point-of-care ultrasound and remote telementored ultrasound by inexperienced operators, and Sorkin et al. [9] described the BladeShield 101: a novel device for the battlefield designed to continuously measure vital signs and medical treatment provided and to transfer data through roles of care. In this special issue of IMAJ, authors also discusse gender-related aspects at the core of medical treatment. Segal et al. [10] examined whether missed injuries were related to the medical provider's gender, while Gelikas et al. [11] assessed whether treatment with analgesia was associated with casualty gender in the military prehospital trauma setting Over the past two and a half years, the COVID-19 pandemic has been a significant part of our lives. During these years, medical systems and teams throughout Israel and around the world struggled to adapt to this new disease and save lives fighting the pandemic. Geva et al. [12] and Shental et al. [13] discussed the impact of COVID-19 on the IDF medical system, lessons learned during the outbreak, and effects of different diseases during these times on medical treatment provided by the IDF to soldiers.

Humanitarian Medical Aid Mission in the Middle of a Pandemic - Israeli Experience in Equatorial Guinea.

INTRODUCTION: In March 2021, a series of explosions shook a military base in Bata, Equatorial Guinea. As a response to government officials' request, the Israel Defense Forces Medical Corps (IDF-MC) deployed an emergency aid team that faced two major challenges: (1) understanding the scenario, the injury patterns, and the needs of the local medical system; and (2) minimizing the coronavirus disease 2019 (COVID-19) outbreak threats. This report describes the team design, the activities performed before and during the deployment, analyzes the pathology encountered, and shares lessons learned from the mission. SOURCES: Data were collected from the delegation protocols and IDF medical records. All activities of the Israeli delegation were coordinated with the local government. OBSERVATIONS: The local authorities reported that a total of 107 people were killed and more than 700 people were wounded. The team was the first international team to arrive at the scene and assisted the local medical teams to treat 231 patients in the three local hospitals and 213 patients in field clinics in the villages surrounding Bata. The COVID-19 pandemic influenced the operation of this mission, and caution measures were activated. ANALYSIS: Unplanned explosions at munitions sites (UEMS) are a growing problem causing the medical teams to face unique challenges. By understanding the expected challenges, the team was reinforced with a plastic surgeon, portable ultrasound devices, a large amount and a variety of antibiotics, whole blood units, and freeze-dried plasma. Rehabilitation experts were needed in some cases in the week following the injury. An important key for the success of this kind of medical aid delegation is the collaboration with the local medical teams, which enhances patient care.

Myocarditis following COVID-19 vaccination - A case series.

There have been reports of myocarditis following COVID-19 vaccination. We surveyed all hospitalized military personnel in the Isareli Defense Forces during the period of the COVID-19 vaccination operation (12/28/2021-3/7/2021) for diagnosed myocarditis. We identified 7 cases of myocarditis with symptoms starting in the first week after the second dose of COVID-19 Pfizer-BioNTech vaccine. One case of myocarditis diagnosed 10 days after the second dose of the vaccine was not included. These 8 cases comprise of all events of myocarditis diagnosed in military personnel during this time period. All patients were young and generally healthy. All had mild disease with no sequalae. The incidence of myocarditis in the week following a second dose of the vaccine was 5.07/100,000 people vaccinated. Due to the nature of this report no causality could be established. Clinicians should be aware of the possibility of myocarditis following Pfizer-BioNTech vaccination. True incidence rates should be further investigated.

Sub-cutaneous Pfizer/BioNTech COVID-19 vaccine administration results in seroconversion among young adults.

Route of vaccine administration plays a role in extent and quality of immunogenicity. 790 military personnel accidentally received the first of two doses of Pfizer/BioNTech mRNA anti Covid-19 vaccine using a needle intended for subcutaneous administration. A serological blood test (on day 21, prior to the second intramuscular dose) was performed, analyzing whether immunological response was elicited. 98.2% demonstrated seroconversion. IgG titers were negatively correlated with age and did not correlate with BMI. Our results could help reassure providers confronted with a similar mistake and may even imply a possibly new and effective administration route.

Data Empowerment of Decision-Makers in an Era of a Pandemic: Intersection of "Classic" and Artificial Intelligence in the Service of Medicine.

BACKGROUND: The COVID-19 outbreak required prompt action by health authorities around the world in response to a novel threat. With enormous amounts of information originating in sources with uncertain degree of validation and accuracy, it is essential to provide executive-level decision-makers with the most actionable, pertinent, and updated data analysis to enable them to adapt their strategy swiftly and competently. OBJECTIVE: We report here the origination of a COVID-19 dedicated response in the Israel Defense Forces with the assembly of an operational Data Center for the Campaign against Coronavirus. METHODS: Spearheaded by directors with clinical, operational, and data analytics orientation, a multidisciplinary team utilized existing and newly developed platforms to collect and analyze large amounts of information on an individual level in the context of SARS-CoV-2 contraction and infection. RESULTS: Nearly 300,000 responses to daily questionnaires were recorded and were merged with other data sets to form a unified data lake. By using basic as well as advanced analytic tools ranging from simple aggregation and display of trends to data science application, we provided commanders and clinicians with access to trusted, accurate, and personalized information and tools that were designed to foster operational changes and mitigate the propagation of the pandemic. The developed tools aided in the in the identification of high-risk individuals for severe disease and resulted in a 30% decline in their attendance to their units. Moreover, the queue for laboratory examination for COVID-19 was optimized using a predictive model and resulted in a high true-positive rate of 20%, which is more than twice as high as the baseline rate (2.28%, 95% CI 1.63%-3.19%). CONCLUSIONS: In times of ambiguity and uncertainty, along with an unprecedented flux of information, health organizations may find multidisciplinary teams working to provide intelligence from diverse and rich data a key factor in providing executives relevant and actionable support for decision-making.

Promoting Compliance to COVID-19 Vaccination in Military Units.

BACKGROUND: On December 27th, 2020, the Israeli Defense Forces initiated a mass COVID-19 vaccination campaign aiming to vaccinate its personnel. This population upheld specific characteristics in terms of age and sex, lack of significant comorbidities, and a general scarcity of risk factors for sustaining a severe COVID-19 illness. We present the measures taken to increase vaccination compliance, and the vaccination rate that followed these actions. Our secondary goal was to compare between vaccination rates in frontline battalions and highly essential military units (group A) and rear administration and support military units (group B). METHODS: This was a retrospective review that included 70 military units that were composed of 18,719 individuals of both sexes, mostly free of significant comorbidities. We divided the challenges of maximizing vaccination rates into two main categories: vaccine compliance (including communication and information) and logistical challenges. We compared the vaccination rates in groups A and B using a multivariable linear regression model. A P-value of .05 was considered significant. RESULTS: The mean age in 70 military units was 22.77 ± 1.35 (range 18-50) years, 71.13% males. A total of 726 (3.88%) individuals have been found positive for SARS-CoV-2 between March 1st, 2020 and February 18th, 2021. On February 18th, 2021, 54 days after the vaccination campaign was launched, 15,871 (84.79%) of the study population have been vaccinated by the first dose of Pfizer COVID-19 vaccine, expressing an 88.21% compliance rate (excluding recovered COVID-19 cases who were not prioritized to be vaccinated at this stage). Vaccination compliance in military units from group A was found to be higher when compared to group B (P < .001), leading to a 90.02% of group A population being either previously SARS-CoV-2 positive or COVID-19 vaccinated. CONCLUSIONS: A designated army campaign led by a multidisciplinary team could rapidly achieve a high COVID-19 vaccination rate. The information presented can serve organizations worldwide with similar characteristics that plan a mass COVID-19 vaccination campaign.

Short Communication: Combining Ethics With Efficiency-Israel Defense Forces' Experience in Clinical Trials During the Coronavirus Disease 2019 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic, first reported in China, soon spread worldwide, has evolved into one of the most complex global public health crises the world has encountered in the last several decades. Conducting military medical research is vital to study the unique influences of military service conditions on soldiers' health and to improve the medical response in various emergency periods. The Israel Defense Forces (IDF) Medical Corps maintains an Institutional Review Board (IRB) which reviews clinical studies conducted within the IDF. During the COVID-19 pandemic, the IRB of the IDF had to rapidly implement procedural modifications in order to comply with expanding urgent demands for research without compromising ethical standards. The ethical dilemmas and the IDF policy and perspective are outlined in this article.

Self-reported symptoms in healthy young adults to predict potential coronavirus disease 2019.

OBJECTIVE: To assess the utility of self-reported symptoms in identifying positive coronavirus disease 2019 (COVID-19) cases among predominantly healthy young adults in a military setting. METHODS: A questionnaire regarding COVID-19 symptoms and exposure history was administered to all individuals contacting the Israeli Defence Forces Corona call-centre, before PCR testing. Surveyed symptoms included cough, fever, sore throat, rhinorrhoea, loss of taste or smell, chest pain and gastrointestinal symptoms. Factors were compared between positive and negative cases based on confirmatory test results, and positive likelihood ratios (LR) were calculated. Results were stratified by sex, body mass index, previous medical history and dates of questioning, and a multivariable analysis for association with positive test was conducted. RESULTS: Of 24 362 respondents, 59.1% were men with a median age of 20.5 years (interquartile range 19.6-22.4 years). Significant positive LRs were associated with loss of taste or smell (LR 3.38, 95% CI 3.01-3.79), suspected exposure (LR 1.33, 95% CI 1.28-1.39) and fever (LR 1.26, 95% CI 1.17-1.36). Those factors were also associated with positive PCR result in a multivariable analysis (OR 3.51, 95% CI 3.04-4.06; OR 1.86, 95% CI 1.65-2.09; and OR 1.34, 95% CI 1.19-1.51, respectively). Reports of loss of taste or smell increased gradually over time and were significantly more frequent during the late period of the study (63/5231, 1.21%; 156/7941, 1.96%; and 1505/11 190, 13.45%: p < 0.001). CONCLUSION: Loss of taste or smell, report of a suspicious exposure and fever (>37.5°C) were consistently associated with positive LRs for a positive SARS-CoV-2 PCR test result, in a population of predominantly young and healthy adults.

Clinical Course and Outcomes of Severe Covid-19: A National Scale Study

Knowledge of the outcomes of critically ill patients is crucial for health and government officials who are planning how to address local outbreaks. The factors associated with outcomes of critically ill patients with coronavirus disease 2019 (Covid-19) who required treatment in an intensive care unit (ICU) are yet to be determined. Methods: This was a retrospective registry-based case series of patients with laboratory-confirmed SARS-CoV-2 who were referred for ICU admission and treated in the ICUs of the 13 participating centers in Israel between 5 March and 27 April 2020. Demographic and clinical data including clinical management were collected and subjected to a multivariable analysis;primary outcome was mortality. Results: This study included 156 patients (median age = 72 years (range = 22-97 years));69% (108 of 156) were male. Eighty-nine percent (139 of 156) of patients had at least one comorbidity. One hundred three patients (66%) required invasive mechanical ventilation. As of 8 May 2020, the median length of stay in the ICU was 10 days (range = 0-37 days). The overall mortality rate was 56%;a multivariable regression model revealed that increasing age (OR = 1.08 for each year of age, 95%CI = 1.03-1.13), the presence of sepsis (OR = 1.08 for each year of age, 95%CI = 1.03-1.13), and a shorter ICU stay(OR = 0.90 for each day, 95% CI = 0.84-0.96) were independent prognostic factors. Conclusions: In our case series, we found lower mortality rates than those in exhausted health systems. The results of our multivariable model suggest that further evaluation is needed of antiviral and antibacterial agents in the treatment of sepsis and secondary infection.

Measures to Limit COVID-19 Outbreak Effects Among Military Personnel: Preliminary Data.

INTRODUCTION: The COVID-19 outbreak posed a threat to the readiness of military forces as well as their ability to fulfill missions. Seeing that military forces have been encountering similar challenges, we found it eminent to share the Israeli Defense Force (IDF) Northern Command's (NC) preliminary experience. MATERIALS AND METHODS: We retrospectively summarized the actions that were taken by our team, focusing on 18 battalions at the Israeli NC. These actions included promoting a series of organizational changes in terms of social distancing and medical regulations as well as working to strengthen medical leadership through designated video meetings with medical commanders across our organization. Meetings included relevant clinical education, updates, and leadership building. These actions and others were aimed to increase our influence on the decision-making processes. While we conducted real-time reverse transcriptase polymerase chain reaction SARS-CoV-2 laboratory tests for soldiers who were suspected to have COVID-19 (those presenting with compatible signs and symptoms after having been exposed to a confirmed COVID-19 patient), we were not able to screen healthy populations, nor did we have serum antibody serologic tests available during the study period. We reviewed the COVID-19 outbreak national data, obtained from Ministry of Health publishings and the IDF databases. Data were included from February 26th, 2020 (day 0, first COVID-19 patient in Israel) to April 19th, 2020 (day 53, about 1 month after most of the COVID-19 regulation were issued in the NC). RESULTS: The mean age of the battalion soldiers was 21.29 ± 4.06 (range 18-50), 81.34% male. Most restrictions were issued on day 18. On day 53, 98.85% of the personnel in the battalions were kept active and asymptomatic in their units. CONCLUSIONS: Despite the limited availability of laboratory testing for COVID-19 our actions enabled us to lead a strict risk-management policy while maintaining most of the available workforce.