Risk assessment and prevention of malaria among Italian troops in Afghanistan, 2002 to 2011.

BACKGROUND: Malaria prevention policy is different among coalition troops in Afghanistan, ranging from the combined use of suppressive and terminal chemoprophylaxis to the absence of any prophylactic regimen. The objective of this study was to assess the compliance with malaria prevention measures and the risk of malaria among Italian troops in Afghanistan. METHODS: Target population was the cohort of 32,500 army soldiers deployed in Afghanistan, 2002 to 2011; eligible subjects were the 21,900 soldiers stationed in endemic areas, who were prescribed mefloquine chemoprophylaxis. Adherence to chemoprophylaxis was assessed by a cross-sectional study in a volunteer sample of 5,773 (26.4%) of eligible subjects. The risk of malaria was assessed by detecting malaria cases in the target population. RESULTS: Mefloquine chemoprophylaxis was administered to 4,123 (71.4%) of the 5,773 enrolled soldiers and 3,575 (86.7%) of these took it regularly; however, compliance dropped from 80.9% (2,592/3,202) in 2002 to 2006 to 59.5% (1,531/2,571) in 2007 to 2011 (p < 0.01). Adverse events were reported by 875 (21.2%) of the 4,123 soldiers taking mefloquine, but caused irregularity or interruption of chemoprophylaxis only in 48 (1.2%) and 113 (2.7%) subjects, respectively. No serious adverse events were reported. No malaria cases occurred in Afghanistan, and one Plasmodium vivax case was reported in Italy, yielding an incidence rate of 3.24 cases per 10,000 person-months of exposure (1/3,091) during the transmission season of 2003. CONCLUSIONS: In spite of the decreasing compliance with chemoprophylaxis, suggesting a low perception of the risk of malaria, this study confirmed the good tolerability of mefloquine in the military. The risk of malaria for Italian troops in Afghanistan was very low, and chemoprophylaxis was suspended in 2012. A similar policy may be adopted by the generality of International Security Assistance Force troops, and any chemoprophylaxis may be restricted to soldiers stationing in areas where the risk of malaria is substantial.

[Cancer incidence in the military: an update]. / Condizione militare e morbosità per cancro: il punto della situazione.

An abnormally elevated rate of Hodgkin's lymphoma was reported in 2001 among Italian soldiers in Bosnia and Kosovo since 1995: a surveillance system was therefore set up for the military community. Preliminary results for a longer period (1996-2007) have shown incidence rates lower than expected for all malignancies. No significant difference was registered between observed and expected cases of Hodkin's lymphoma: the excess of reported cases for this malignancy in 2001-2002 was probably due to a peak occurred in 2000 among the whole military; it is therefore unrelated to deployment in the Balkans, and probably represents a chance event. Moreover, a significant excess of thyroid cancer was reported among the whole military.The estimated number of incident cases, including those missed by the surveillance system, was not significantly higher than expected for all cancers; conversely, the estimated incidence rate of thyroid cancer was significantly increased; this excess, however, is probably due to a selection bias.These data concerning cancer surveillance in the Italian military are consistent with lacking evidence of an increased cancer incidence among troops of other countries deployed in the areas of Iraq, Bosnia, and Kosovo, where armour penetrating depleted uranium shells have been used. However, a comprehensive assessment of cancer morbidity in the military requires a revision of the privacy regulations, in order to link individual records of military personnel and data bases of the National Health Service.

Evaluation of cancer surveillance completeness among the Italian army personnel, by capture-recapture methodology.

OBJECTIVE: This study provides an assessment of completeness of cancer surveillance and incidence estimates for all malignancies, Hodgkin's lymphoma and thyroid cancer in the Italian army, for the years 2001-2007. METHODS: The two-source capture-recapture method was employed, using both Chapman's and Chao's formulae, on the basis of cancer notifications from military hospitals and unit infirmaries. The estimated incident cases were then confronted with the corresponding expected cases; the standardized incidence ratios and 95% confidence intervals (SIR [95% CI]) were then calculated. RESULTS: A total of 442 cancer notifications, concerning 371 cases, were reported (311 from army hospitals and 131 from unit infirmaries; of these, 71 were overlapping). The estimated total number of cases, by Chapman's and Chao's formulae, was 571 and 688, respectively. Overall, sensitivity of the surveillance system was 65% by Chapman's and 54% by Chao's estimators. Completeness of notification was significantly higher in younger patients, in those previously deployed in Bosnia or Kosovo, and for cases of Hodgkin's lymphoma. Estimated SIRs, using both formulae, were not significant for all malignancies and Hodgkin's lymphoma, but significant for thyroid cancer (SIR: 2.25 [1.61-2.89] by Chapman's formula, and 3.12 [1.81-4.43] by Chao's estimator). CONCLUSION: Completeness of cancer registry of the Italian military is low, and methods to improve its sensitivity are discussed. Overall, the estimated number of incident cancer cases, including Hodgkin's lymphoma, is not significantly higher than expected, except thyroid cancer. The increased incidence of this malignancy requires further investigation; however, in the military, as well as in the general population, this may be partly due to the growing availability of diagnostic opportunities in the last decades. Moreover, detection of thyroid cancer may be further facilitated by a selection bias generated by the annual and pre-/post-deployment medical examinations and blood tests routinely performed on all military personnel.

Cancer surveillance in Italian army peacekeeping troops deployed in Bosnia and Kosovo, 1996-2007: preliminary results.

OBJECTIVE: An excess of cancer cases was reported in 2000 among Italian troops involved in peacekeeping operations in Bosnia and Kosovo. A preliminary assessment of cancer risk in this cohort was done for the period 1996-2007, based on cancer surveillance activity, which was started in 2001. METHODS: A retrospective cohort study was done among 27361 Italian Army soldiers deployed in Bosnia, 31052 deployed in Kosovo, and a control group of non-deployed soldiers, whose number varies from 130275 in 1996 to 40967 in 2007. Standardized incidence ratio and 95% confidence intervals (SIR [95% CI]) of the main types of tumours were computed as the ratio of the observed and expected cases. RESULTS: 98 incident cancers were reported among soldiers deployed in Bosnia, 66 in those stationed in Kosovo and 388 in non-deployed personnel. Overall, cancer incidence was lower than expected in all groups. Annual SIR was significantly higher than expected in 2000 for Hodgkin's lymphoma only among troops deployed in Bosnia (4.34 [1.18-11.12]) and non-deployed personnel (3.48 [1.67-6.39]); and in 2001 for thyroid cancer only among troops deployed in Bosnia (5.28 [1.44-13.51]). CONCLUSION: Although further investigation is needed, these preliminary results give no indication of an increased risk of cancer for Italian soldiers who were stationed in Bosnia and Kosovo. The cluster of Hodgkin's lymphoma in 2000 and of thyroid cancer in 2001 were sporadic events, they did not specifically affect deployed personnel and are unlikely to be related to environmental exposures in the Balkans.