[Management of the COVID-19 epidemic in the carrier battle group (January-April 2020) by the Armed Forces Epidemiology and Public Health Center]. / Gestion de l'épidémie de COVID-19 au sein du groupe aéronaval (janvier­avril 2020) par le Centre d'épidémiologie et de santé publique des armées.

Objectives: Faced with the COVID-19 epidemic that occurred within the naval air group and the nuclear aircraft carrier Charles de Gaulle, the French Armed Forces Epidemiology and Public Health Center (CESPA) carried out an investigation (January - April 2020) whose objectives were: to identify the possible routes of introduction of the virus ; to describe the characteristics of the epidemic and to describe and model the dynamics of the epidemic's spread. Methods: A telephone survey was conducted. The biological diagnoses were transmitted by the medical antennas. A time/place/population analysis was carried out, as well as the description of the clinical pictures with their exposure factors. The instantaneous reproduction rate Rt of the epidemic was modeled. A spatial analysis of the epidemic on board was carried out. Forty-three viral genomes were sequenced and compared to the reference bases. Results: 0f 1767 sailors, 1568 (89%) participated in the telephone survey and 1064 (67.9%) were confirmed cases. Four patient profiles have been described: asymptomatic (13.0%); non-specific symptomatic (8.1%); specific symptomatic (76.3%); severe cases (2.6%). In univariate and multivariate analysis, age, overweight and obesity were significantly associated with the risk of having a severe form. Smoking was a protective factor. The evolution kinetics of Rt was in favor of an introduction of the virus at the end of February with a reintroduction during the stopover in Brest. Analysis of viral genomes ruled out introduction and spread of a single strain. Conclusion: Despite the control measures taken, an epidemic occurred. The often pauci-symptomatic clinical pictures resulted in a delay in identification. CESPA was able to carry out this epidemiological investigation within a highly constrained timeframe, showing all the interest of its integrated public health model.

Leishmaniavirus genetic diversity is not related to leishmaniasis treatment failure.

OBJECTIVES: The outcome of American tegumentary leishmaniasis (ATL) may depend on the presence of the Leishmania RNA virus (LRV). This virus may be involved in treatment failure. We aimed to determine whether genetic clusters of LRV1 are involved in this therapeutic outcome. METHODS: The presence of LRV1 was assessed in 129 Leishmania guyanensis isolates from patients treated with pentamidine in French Guiana. Among the 115 (89%) isolates found to carry LRV1, 96 were successfully genotyped. Patient clinical data were linked to the LRV data. RESULTS: The rate of treatment failure for LRV1-positive isolates was 37% (15/41) versus 40% (2/5) among LRV1-negative isolates (p 0.88). Concerning LRV1 genotypes, two predominant LRV1 groups emerged, groups A (23% (22/96)) and B (70% (67/96)). The treatment failure rate was 37% (3/8) for group A and 45% (9/20) for group B (p 0.31). DISCUSSION: Neither the presence nor genotype of LRV1 in patients with L. guyanensis seemed to correlate with pentamidine treatment failure.

Incidence of acute respiratory tract infections (2006-2015) and influenza (2006-2013) among French armed forces.

OBJECTIVES: We aimed to assess the incidence of respiratory tract infections in military settings between 2006 and 2015. PATIENTS AND METHODS: We performed a retrospective epidemiological study of the entire military population from 2006 to 2015. Comprehensive data was collected from all medical centers, operational medical units, naval services, and army training hospitals and provided by the epidemiological surveillance of the armies. RESULTS: The annual average population of the study was 331,394 soldiers. For acute respiratory tract infections (2006-2015), 22,818 cases were reported in metropolitan France, 3,211 cases in French overseas territories, 1,595 cases in the French Navy, and 1,318 cases in external military operations for a total of 28,942 cases. For influenza (2006-2013), 934 cases were reported in metropolitan France, 101 cases in French overseas territories, and 23 cases in external operations, for a total of 1,058 cases. The mean incidence rate of acute respiratory tract infections expressed as case number per 1,000 person-years (PY) was 8.7 PY (95% CI [8.6-8.8]) with an exceptional increased incidence rate in 2009 (25.9 PY, 95% CI [25.4-26.4]). The mean incidence rate of influenza was 0.35 PY (95% CI [0.33-0.37]) with a peak incidence rate of 1.9 PY in 2009. CONCLUSION: Acute respiratory tract infections are at the forefront of infectious episodes in the French armies. Although not necessarily severe, current prevention measures are not enough to reduce the incidence threshold of these infections and need to be improved.

Medical evacuations of members of the French armed forces for infectious diseases in foreign operations.

OBJECTIVES: Medical evacuations from foreign settings are a major health and strategic problem for the armed forces. This work aimed to study the characteristics of French military evacuations due to infectious diseases. PATIENTS AND METHODS: We performed a retrospective study based on the registers of the French operational military staff for health to assess the characteristics of the strategic medical evacuation of French armed forces members on missions abroad between January 1, 2011 and December 31, 2016. RESULTS: Out of 4633 included cases, 301 medical evacuations (6.5%) were carried out due to infectious situations. More than half of patients were repatriated to surgical wards (162 patients, 54%), 108 patients (36%) to medical wards, 21 patients (7%) to intensive care units, six patients (2%) to an armed forces medical center, and four files (1%) were incomplete. Among infectious emergencies, malaria led to 30 evacuations (10%) including 11 to intensive care units and one death before evacuation. Infectious diseases requiring medical evacuation were most often mild and community-acquired. Most soldiers were evacuated without medical assistance. CONCLUSIONS: Infectious diseases during missions and medical repatriations carried out for infectious reasons are important epidemiological indicators to monitor. They make it possible to adapt preventive measures, training, and diagnostic and therapeutic tools which can be made available to front-line military physicians.

Epidemiology of respiratory pathogen carriage in the homeless population within two shelters in Marseille, France, 2015-2017: cross sectional 1-day surveys.

OBJECTIVES: To assess risk factors for respiratory tract infection symptoms and signs in sheltered homeless people in Marseille during the winter season, including pathogen carriage. METHODS: Data on 479 male participants within two shelters who completed questionnaires and a total of 950 nasal and pharyngeal samples were collected during the winters of 2015-2017. Respiratory pathogen carriage including seven viruses and four bacteria was assessed by quantitative PCR. RESULTS: The homeless population was characterized by a majority of individuals of North African origin (300/479, 62.6%) with a relatively high prevalence of chronic homelessness (175/465, 37.6%). We found a high prevalence of respiratory symptoms and signs (168/476, 35.3%), a very high prevalence of bacterial carriage (313/477, 65.6%), especially Haemophilus influenzae (280/477, 58.7%), and a lower prevalence of virus carriage (51/473, 10.8%) with human rhinovirus being the most frequent (25/473, 5.3%). Differences were observed between the microbial communities of the nose and throat. Duration of homelessness (odds ratio (OR) 1.77, p 0.017), chronic respiratory diseases (OR 5.27, p <0.0001) and visiting countries of origin for migrants (OR 1.68, p 0.035) were identified as independent risk factors for respiratory symptoms and signs. A strong association between virus (OR 2.40, p 0.012) or Streptococcus pneumoniae (OR 2.32, p 0.014) carriage and respiratory symptoms and signs was also found. CONCLUSIONS: These findings allowed identification of the individuals at higher risk for contracting respiratory tract infections to better target preventive measures aimed at limiting the transmission of these diseases in this setting.

Endocarditis in the Mediterranean Basin.

Infective endocarditis is a severe disease with high mortality. Despite a global trend towards an increase in staphylococcal aetiologies, in older patients and a decrease in viridans streptococci, we have observed in recent studies great epidemiologic disparities between countries. In order to evaluate these differences among Mediterranean countries, we performed a PubMed search of infective endocarditis case series for each country. Data were available for 13 of the 18 Mediterranean countries. Despite great differences in diagnostic strategies, we could classify countries into three groups. In northern countries, patients are older (>50 years old), have a high rate of prosthetic valves or cardiac electronic implantable devices and the main causative agent is Staphylococcus aureus. In southern countries, patients are younger (<40 years old), rheumatic heart disease remains a major risk factor (45-93%), viridans streptococci are the main pathogens, zoonotic and arthropod-borne agents are frequent and blood culture-negative endocarditis remains highly prevalent. Eastern Mediterranean countries exhibit an intermediate situation: patients are 45 to 60 years old, the incidence of rheumatic heart disease ranges from 8% to 66%, viridans streptococci play a predominant role and zoonotic and arthropod-borne diseases, in particular brucellosis, are identified in up to 12% of cases.

Asymptomatic Plasmodium falciparum and vivax infection in the neighborhood of Blondin, Saint-Georges-de-l'Oyapock District, French Guiana.

Optimized elimination strategies are needed to control transmission of malaria. As part of an elimination campaign, active detection of asymptomatic Plasmodium carriers by highly sensitive methods is deemed necessary. Asymptomatic carriage leads to complex scientific, ethical, and operational issues regarding individual or collective detection and treatment. To address this issue, a crosssectional study was carried out in French Guiana to determine the prevalence of asymptomatic Plasmodium carriage during an inter-epidemic season in the whole population of a neighborhood of Saint-Georges-de-l'Oyapock, along the Brazilian border. Fifty-eight participants out of 63 residents were screened. The median age was 23.3 years (range: 2 months-72 years), with a male/female sex-ratio of 0.56. The majority of the participants (74%, N = 43/58) reported a history of malaria, 12% (N = 7/58) during the past 12 months. All rapid diagnostic tests for malaria were negative. Among the 58 participants, malaria prevalence detected by nested-PCR (Polymerase Chain Reaction) was 3.6% (N = 2/56). Two asymptomatic carriers of Plasmodium were identified: one child with Plasmodium vivax and one adult with Plasmodium falciparum. These two carriers were treated and did not develop malaria within the eight months following the diagnosis. This study confirmed the presence of asymptomatic parasitaemias outside hyperendemic areas. However, the benefits of such an active detection and patient treatment to eliminate malaria in French Guiana need to be evaluated at a larger scale.

Challenging Investigation of a Norovirus Foodborne Disease Outbreak During a Military Deployment in Central African Republic.

In January 2016, a large-scale outbreak of acute gastroenteritis was reported among French armed forces deployed in the Central African Republic. Challenging investigations, conducted from France, made it possible to identify a norovirus genogroup II in both stool and food samples, confirming a norovirus foodborne disease outbreak. Infected food handler management is discussed.

Risk of daytime transmission of malaria in the French Guiana rain forest.

Between 2008 and 2014, there were 1070 malaria cases reported in French Guiana among members of the armed forces. Most of the malaria outbreaks investigated were multifactorial and followed missions conducted at illegal gold mining sites. For example, a malaria outbreak occurred in September 2013, three weeks after the deployment of 15 soldiers at Dagobert, which is such a site. The attack rate was 53%, with seven Plasmodium vivax infections and one coinfection with both Plasmodium vivax and Plasmodium falciparum. Two months later, an entomological investigation in the field caught 321 anopheles by the human landing catch method. Among them, 282 were Anopheles darlingi. One specimen was PCR-positive for P. vivax, for an infection rate of 0.4% (1/282). In 15.7% of these cases, the An. darlingi was caught during the day. The existence of daytime biting activity by An. darlingi in the Guianese forest might play a key role in malaria outbreaks among military personnel. This finding requires that the Army Health Service adapt its recommendations concerning malaria prevention in French Guiana.

Lung nodule in French Guiana in a immunocompetent patient.

We report the case of an immunocompetent French soldier stationed in French Guiana, who developed symptomatic pulmonary histoplasmosis.

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.

Interarch tooth size relationship of Indian population: does Bolton's analysis apply?

BACKGROUND: Orthodontists have several methods to detect inter arch-tooth size discrepancies in patients presenting for orthodontic treatment. Many methods such as Pont's analysis, Nance and Carey's analysis, Peck and Peck ratio, Bolton's analysis are commonly used methods. A thorough search of literature reveals a paucity of reliable data on the mesiodistal dimensions of the crowns of the permanent dentition of Indian population. Without information about the size of individual tooth and groups of teeth for Indian population, it is difficult for the clinician to make an adequate diagnosis and treatment plan and to carry out a plan of therapy. AIM: To determine the size of individual permanent tooth and the sex differences, with tooth size ratios according to Bolton's formula and to evaluate the reliability of Bolton's norms (Anterior/ Posterior) in Indian population. MATERIALS AND METHODS: One hundred and twenty cases in which an excellent occlusion was naturally existent with the mean age of 22 years (18-27 years) were selected in the study. The casts were prepared after taking alginate impression of maxillary and mandibular arches and pouring them immediately with dental stone. A sliding Digital Vernier calliper used to measure the teeth. The ratios of the mean of mesiodistal dimensions of types of teeth were computed. RESULTS: The mean overall ratio for the Indian population is found to be 92.11 with a standard deviation of 2.12. The values ranged from 86.50-97.13 and the median is 92.16. The mean anterior ratio for the Indian population is found to be 78.14 with a standard deviation of 2.59. CONCLUSION: Bolton's original data does not represent Indian population. In our study greater size variability was found in maxillary teeth as compared with mandibular teeth except mandibular first molar. Our study indicated that population-specific standards are necessary for clinical assessments. Significant differences were shown for the overall ratio and anterior ratio for both sexes as compared to Bolton's ratio.

[Delayed diagnosis of Plasmodium falciparum in a soldier in Uganda: false-positive rapid diagnostic test associated with reduced repeats in pfhrp2]. / Retard de diagnostic d'un accès palustre à Plasmodium falciparum chez un militaire en Ouganda : négativité des tests de diagnostic rapide associée à un polymorphisme de l'antigène HRP2.

Rapid diagnostic tests (RDTs) are the best alternative for malaria diagnosis where a microscopic examination cannot be performed. We report here the first case of P. falciparum (false-negative) misdiagnosis in a soldier stationed in Uganda, associated with a reduced number of repeats in the P. falciparum histidine-rich protein 2 gene (pfhrp2). This gene was subsequently sequenced to determine the reason for the discordance between the RDT results and the later microscopic examination. Ten repeats of the type 2 motif AHHAHHAAD and four repeats of the type 7 motif AHHAAD were found. This isolate belongs to the group of non-sensitive parasites (<43 repeats) that are not detected by HRP2 RDTs. This inappropriate case management could have been fatal for the patient. This case confirms the problem of negative RDT results in isolated situations and of basing a therapeutic strategy on these negative results. Investigations should be conducted in Uganda and other areas of Africa to determine the presence and the geographical spread of parasites with pfhrp2 gene deletion to ensure the best performance of RDTs.

Prevalence of word retrieval complaint and prediction of dementia in a population-based study of elderly subjects.

There is agreement that elderly people complain about word finding difficulties, particularly proper names. However, few studies have focused on the prevalence of this complaint in the general population, nor is it clearly known whether it is predictive of dementia. The aim of this study was to fill this gap using the PAQUID cohort. 1,838 people aged 65 or more completed questionnaires and neuropsychological evaluation regularly during 13 years. Results show that the complaint about proper name retrieval concerns 64% of people aged above 65 years, and the complaint about common names 30%. The complaint was not associated with enhanced risk of dementia, whereas short naming tests were. Only a marginal relation was found between these naming tests and word retrieval complaint. This study emphasizes the importance of proper name retrieval complaint in the general population and suggests that elderly subjects can be reassured in the absence of other symptoms.

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.

[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.