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.

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.

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.

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.

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.

[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 (

Maternal mortality in West Africa. Rates, causes and substandard care from a prospective survey.

BACKGROUND: According to estimates of maternal mortality rates from WHO/UNICEF, the West African rates appear to be among the world's highest. The precision of these estimates from general mortality models is far from ideal and no information on the distribution of causes of death is provided. The principal objective of our study is to describe the maternal mortality, estimation of the rates and distribution of obstetric causes, from a population based survey of pregnant women carried out in West Africa. We also present the main characteristics of the deaths that occurred, including avoidable aspects. METHODS: The survey included all the pregnant women living in seven defined areas, from December 1994 through June 1996, depending on the area. Twenty thousand three hundred and twenty-six pregnant women (94.3% of all those identified) agreed to participate and 19,545 were followed throughout the second trimester of pregnancy, delivery and the puerperium. Physicians from the survey team made special enquiries about all maternal deaths. But the deaths occurring during the first months of pregnancy could not be estimated. A subcommittee analyzed all the deaths, assigned the underlying cause and discussed the avoidable aspects of the death. RESULTS: Sixty-six deaths were reported. Fifty-five (three late) were deaths due to obstetric causes; six were fortuitous deaths, and no cause could be defined for five. As a mean and for pregnancy after week 25, the maternal mortality rate was estimated at 311 (95% CI 234-404) per 100,000 live births and 852 (95% CI 456-1457) in rural areas. Hemorrhages accounted for 29% of obstetric deaths, uterine rupture 13%, eclampsia and infectious diseases 11% each. Seventy-four percent of the direct obstetric causes were considered avoidable. CONCLUSION: Confidential enquiries into maternal deaths in West Africa are not just a concern of the others. They are urgently requested to promote the improvement of health services.

Cellular immune responses of a Senegalese community recently exposed to Schistosoma mansoni: correlations of infection level with age and inflammatory cytokine production by soluble egg antigen-specific cells.

A recently reported epidemic of Schistosoma mansoni infection in Senegal provided an opportunity to study the dynamics of the development of immunity to human schistosomiasis. We report here on the cell-mediated immune response in a population of 99 females and 95 males, with particular emphasis on the relationship between intensity of infection and age. We found that the intensity of infection correlated negatively with age in females but not in males. In men and women, both Th1- and Th2-type cytokines were detected upon in vitro stimulation of PBMCs with soluble egg antigen (SEA) or soluble adult worm antigens (SWAP). In the female group, SEA-induced PBMC proliferation was associated with the production of IFN-gamma, IL-2 and IL-5, all of which correlated negatively with intensity of infection. Most cytokine production correlated positively with age. Spontaneous production of TNF-alpha, IL-6 and IL-10 was higher in the infected population than in an uninfected control group. Our results suggest that immunity to infection could be more pronounced in the female population and associated with a Th0/1 + 2 pattern of cytokine secretion mediated by soluble egg antigen (SEA).

Specificity of the solid phase alkaline phosphatase immunocapture assay for the diagnosis of human Schistosoma mansoni infection.

The species specificity of the solid phase alkaline phosphatase immunocapture assay (APIA) for the immunological detection of human immunoglobulin G antibodies to the alkaline phosphatase of adult Schistosoma mansoni was evaluated. Sera from schistosomiasis patients from South America, West Africa, south-east Asia and uninfected control subjects were compared. Only the sera of patients infected with S. mansoni gave positive results. There was no apparent difference between 2 populations infected with S. mansoni, one from South America and the other from West Africa. The results with sera from various regions of West Africa were also indistinguishable. Although the APIA was not able to discriminate the geographical origin of the S. mansoni-infected subjects, the method appeared to be specific for S. mansoni and suitable for use in the immunodiagnosis of schistosomiasis mansoni, particularly in endemic areas where mixed infections of Schistosoma spp. occur.

Organometric investigations of the spleen and liver by ultrasound in Schistosoma mansoni endemic and nonendemic villages in Senegal.

With the intention of ultrasonographically assessing hepatosplenic morbidity in Schistosoma mansoni infection and of validating the grading system applied (Cairo classification), 191 subjects in a schistosomiasis endemic village and 247 controls from a nonendemic village in northern Senegal underwent sonographic examination of the liver and spleen. Measurements of the diameters of the peripheral periportal vein branches, the main portal vein stem, liver size (left lobe and right lobe), and spleen length in the endemic village were compared with those in the nonendemic village to evaluate the much discussed influence of S. mansoni infection on those variables. To subtract this presumed influence from reference values for the named variables, they are given as measured in the nonendemic village, stratified by body weight, enabling future investigators on schistosomiasis-induced morbidity to refer to these reference values. The 95th percentile regarding peripheral periportal vein branch diameter in the control groups was exceeded in 24% of the subjects in the endemic group. It was exceeded by 6% for the main portal vein stem diameter, 13% for the left liver lobe, 12% for the right liver lobe, and 14% for the spleen length. According to the Cairo classification, 97% of the endemic population and 81% of the controls had periportal thickening of the liver, mostly grade I. We conclude that 1) hepatic morbidity in the S. mansoni endemic area was low, despite strikingly high intensities of infection; 2) the Cairo classification in its present form overestimates periportal thickening, especially in the case of mild morbidity; and 3) body height-dependent reference values, obtained from endemic controls, must be applied for organometric parameters.

Indicateurs de coagulation intravasculaire disseminee (CIVD) dans les hematomes retroplacentaires

Dans cette etude portant sur 100 cas pris en charge a la maternite de St-Louis (Senegal); les auteurs attirent l'attention sur la frequence importante des troubles de l'hemostase (CIVD) source de morbidite et de mortalite maternelle. Les caracteristiques cliniques; biologiques et echographiques de chaque patiente sont etudiees afin de determiner des indicateurs de survenue de CIVD en cas d'hematome retroplacentaire. A partir de ces indicateurs; sont proposes un score de risque et un arbre decisionnel. Les auteurs font part de leur experience de l'operation cesarienne vaginale dont l'interet et les indications dans la prise en charge des HRP sont discutes

Immuno-epidemiology of Schistosoma mansoni infections in a recently exposed community in Senegal.

Schistosoma mansoni was introduced in the Senegal basin around 1988, due to man-made ecological changes. Since 1991, we investigate a recent but very intense focus, Ndombo, a village near the city of Richard Toll where the outbreak was first described. Four cohorts, each a random sample (+/- 400 subjects each) from this community, were examined and followed up after treatment, starting at 8 month intervals over a 2-year period. Each cohort is examined parasitologically (Kato-Katz), clinically, serologically (circulating antigen and antibody profiles); treated with praziquantel 40 mg/kg; followed up 6-10 weeks, one and two years after treatment; and monitored for water contact patterns and local snail densities. In the first cohort, the prevalence was 91%, with a mean egg count of 663 epg. Prevalences are near 100% in all age groups, but egg counts decline strongly in adults. Antigen detection in serum and urine confirmed that the egg counts genuinely reflect variations of worm burdens, not e.g. of worm fecundity. This is surprising, as in this focus acquired immunity in adults should not have yet developed according to current hypothesis. The antigen detection assays (CAA/CCA) showed high sensitivity and quantitative power, and promising perspectives as a research tool and possibly as a method for non-invasive diagnosis and screening in urine. Epidemiological in subsequent cohorts were highly similar, although seasonal variations were observed possibly due to transmission fluctuations. Anti-AWA and anti-SEA IgE levels increased with age, while IgG4 peaked in the age-group 10 years and correlated well with egg counts.(ABSTRACT TRUNCATED AT 250 WORDS)

PIP: A cohort analysis was performed in Ndombo, Senegal, a community of about 4000, in the epicenter of the schistosomiasis outbreak. Four randomly selected cohorts of +or- 400 subjects were surveyed. Each cohort was examined parasitologically, clinically, and serologically (circulating antigen and antibody profiles); treated with praziquantel 40 mg/kg; and followed up at 6-12 weeks and at 1 and 2 years after treatment. The first cohort numbered 422 individuals, of which 91% had positive egg counts, with a mean egg count of 663 eggs per gram feces (epg). Quantitative egg counts in those aged 10-14 were 1409 epg and then declined to 632 epg in the age group 20-29 and to 266 epg in the age group over 40. In cohorts 2 and 3, examined in the spring and autumn, egg counts were substantially lower, particularly in adults, as compared with cohorts 1 and 4, which were both examined in the summer season. 94% of the subjects were positive in the serum circulating anodic antigen (CAA) ELISA, 83% in the serum CAA ELISA, and 95% in the urine circulating cathodic antigen (CCA) ELISA; CAA in urine was less sensitive, and was negative in half of the urine samples. Positivity rates for all assays increased with rising egg counts, and circulating antigen concentrations in both serum and urine correlated well with egg counts. IgE showed a significant increase with age, while IgG4 peaked in the age groups 10-15 and/or 15-19 years. A strong correlation between IgG, IgGl, and IgG4 against both crude antigens with pretreatment egg load was observed. Of the subjects in the first cohort, 61% reported abdominal pain, 33% diarrhea; only 16% showed mild hepatomegaly and only a few children had mild splenomegaly. In the first cohort, 82% of 298 reexamined subjects were still positive for S. mansoni 12 weeks after treatment with praziquantel 40 mg/kg. One year after treatment, cohort 1 showed mean egg counts in children (5-19 years) at 358 epg as compared with 1188 epg pretreatment.

[Effect of 2 vaccination strategies on developments during the epidemic of meningococcal A meningitis in N'Djamena (Chad) in 1988]. / Effet de deux stratégies de vaccination sur l'évolution de l'épidémie de ménigite à méningocoque A survenue à N'Djamena (Tchad) en 1988.

From February till May 1988, during an epidemic of group-A meningococcal disease, 4542 cases of meningitis were reported in N'Djamena, the capital of Chad (550,000 inhabitants). A first selective vaccination campaign was carried out between 5 and 14 March; 156,500 vaccine doses (polyvalent: group A and C: Institut Mérieux) were given using jet injectors. The target population for this first campaign consisted of groups such as school-children and the armed forces. As the epidemic continued, a mass vaccination campaign was implemented one month later between 8 and 14 April 1988; this was targeted at the whole population above 1 year of age, not previously immunized, and 266,738 doses of vaccine were injected. One week after the start of the second campaign, the number of reported cases fell sharply and, within four weeks, the epidemic was halted. The vaccination coverage rate, evaluated by a WHO cluster survey method in people above one year of age, was 95.5%. These results show (i) the failure of selective vaccination, restricted to only at-risk groups, to halt the epidemic; (ii) the efficacy of the mass vaccination campaign aimed at the whole population; and (iii) the feasibility in tropical Africa of such a mass campaign which must be carried out in a few days.