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Medical evacuations of members of the French armed forces for infectious diseases in foreign operations
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Original article
Medical evacuations of members of the French armed forces for infectious diseases in foreign operations Évacuations médicales de militaires franc¸ais pour des pathologies infectieuses en opérations extérieures K. Simon a,∗ , P.-Y. Cordier a , V. Pommier de Santi b,c , A. Luft d , C. Brossier b , E. Peytel a , F. Simon e a Pôle bloc-anesthésie-réanimation-urgences, service d’accueil des urgences, hôpital d’instruction des armées LAVERAN, BP 60149, 13384 Marseille cedex 13, France b Centre d’épidémiologie et de santé publique des armées, GSBdD Marseille Aubagne – CESPA, BP 40029, 13568 Marseille cedex 02, France c SSA, VITROME, IHU-Méditerranée infection, Aix Marseille université, IRD, AP–HM, Marseille, France d Pôle OBS 2B/123, État-major opérationnel santé M7, 60, boulevard du Général Martial-Valin, CS 21623, 75509 Paris cedex 15, France e Pôle formation enseignement recherche, hôpital d’instruction des armées LAVERAN, BP 60149, 13384 Marseille cedex 13, France
a r t i c l e
i n f o
Article history: Received 18 March 2018 Received in revised form 15 November 2018 Accepted 13 September 2019 Available online xxx Keywords: Fever French armed forces Infectious diseases Malaria Medical evacuations
a b s t r a c t 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. © 2019 Elsevier Masson SAS. All rights reserved.
r é s u m é Mots clés : Évacuations médicales Fièvre Forces armées franc¸aises Maladies infectieuses Paludisme
Objectifs. – Les évacuations médicales en contexte de projection sont un problème sanitaire et stratégique majeur pour nos armées. Ce travail a pour but d’étudier les caractéristiques des évacuations de militaires franc¸ais pour des pathologies infectieuses. Patients et méthodes. – Étude rétrospective sur registre de l’État-Major Opérationnel Santé ayant étudié les caractéristiques des évacuations médicales stratégiques des militaires franc¸ais en mission à l’étranger entre le 1er janvier 2011 et le 31 décembre 2016. Résultats. – Sur 4633 dossiers inclus, 301 évacuations médicales (6,5 %) ont été réalisées pour des situations infectieuses. Plus de la moitié des patients ont été rapatriés vers des services de chirurgie (162 patients
∗ Corresponding author. E-mail address: [email protected] (K. Simon). https://doi.org/10.1016/j.medmal.2019.09.011 0399-077X/© 2019 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Simon K, et al. Medical evacuations of members of the French armed forces for infectious diseases in foreign operations. Med Mal Infect (2019), https://doi.org/10.1016/j.medmal.2019.09.011
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soit 54 %), 108 patients (36 %) vers des services de médecine, 21 patients (7 %) en réanimation, six patients (2 %) dans un centre médical des armées et quatre dossiers (1 %) étaient incomplets. Parmi les urgences infectieuses, le paludisme était à l’origine de 30 évacuations (10 %) dont 11 cas de paludisme grave à P. falciparum évacués vers des services de réanimation, et un décès avant évacuation. Les pathologies infectieuses motivant une évacuation médicale étaient le plus souvent bénignes et cosmopolites. La majorité des militaires ont été évacués sans accompagnant médical. Conclusions. – Les pathologies infectieuses en mission et les rapatriements sanitaires effectués pour des motifs infectieux sont des indicateurs épidémiologiques importants à surveiller. Ils permettent d’adapter les mesures de prévention, la formation, et les outils diagnostiques et thérapeutiques à mettre à disposition des médecins militaires de l’avant. ´ ´ es. © 2019 Elsevier Masson SAS. Tous droits reserv
1. Introduction Infectious diseases have always been part of the life of military personnel, and have influenced the history of countries. Infectious diseases contracted during foreign operations remain a major health and strategic issue for the armed forces [1]. Infectious diseases are associated with major risks because of their high incidence, potential severity, and significant impact on operational capacity [2–4]. The operation zones of the French armed forces are often endemic for infectious diseases because of multiple factors: low socio-economic status of countries, tropical countries, lack of health facilities. Some of these infections are particularly frequent because of poor hygiene due to community living conditions, operational situation, and fecal pollution. Other infections are favored by the tropical climate such as malaria, schistosomiasis, or leishmaniasis. Some infectious risks are specific to the armed forces because of war wound infections and exposure to biological weapons. Besides their frequency, these infectious diseases may be severe and potentially fatal. French armed forces have increasingly been sent to tropical countries over the past 10 years, and severe P. falciparum malaria accounts for one death every two years on average among armed forces personnel [5,6]. Medical evacuation of armed forces personnel infected during an operation may be justified in various situations: inability to conduct the mission, need of additional diagnostic examinations, initiation of a specific treatment, or monitoring of a specific treatment. The French army health service makes a distinction between “tactical medical evacuations” and “strategic medical evacuations”. Tactical medical evacuations consist in transferring the soldier to the nearest adequate health facility in the theater of operations, while strategic medical evacuations consist in repatriating the soldier to a health facility in metropolitan France [7]. A total of 718 strategic medical evacuations were carried out in 2015 [8]. Medical evacuation from a foreign theater of operations is complex. It is associated with high cost and strong operational impact. Such evacuations require human resources and means, and may disrupt the military mission. Specific measures may also need to be implemented as such infections are potentially contagious, and patients may require to be isolated for instance [9–11]. We aimed to evaluate the characteristics of strategic medical evacuations of French armed forces personnel between 2011 and 2016 for infectious diseases. We aimed to identify “critical” situations requiring repatriation to metropolitan France. 2. Material and methods 2.1. Type of study We performed a register-based retrospective study of French armed forces personnel serving overseas who benefited from a
strategic medical evacuation to metropolitan France between January 1, 2011 and December 31, 2016.
2.2. Data sources Epidemiological data of French armed forces personnel serving overseas between January 1, 2011 and December 31, 2016, with the location of the missions, were collected from the registers of the French operational military staff for health (French acronym EMO-S). All requests for strategic medical evacuations of French armed forces personnel are centralized at the M3/MEDEVAC unit of the EMO-S. A regulating physician is in charge of organizing the evacuation. Data of the medical evacuation is documented in a specific database. The present study is based on the analysis of this database. Collected data included the patient, the theater of operations, the infectious disease requiring evacuation, the transportation characteristics, and the destination. Within the French center for epidemiology and public health of the armed forces (French acronym CESPA), the functional unit known as “Epidemiological surveillance and intervention” monitors the health of armed forces personnel. The surveillance is based on monitoring approximately 60 disorders or diseases declared through weekly epidemiological messages by the unit’s physicians. We assessed the data from this epidemiological surveillance and compared it with strategic medical evacuations of French armed forces personnel for infectious diseases over the same period of time. Diseases included in the epidemiological surveillance are detailed in Table 1.
2.3. Inclusion criteria and analyzed data All French armed forces personnel repatriated from a geographical area outside of metropolitan France via strategic medical evacuation organized by the EMO-S between January 1, 2011 and December 31, 2016 were included in the analysis. Files with missing data such as the date of birth, nationality, diagnosis, and country of origin were excluded from the analysis. Patients who died before being evacuated were also excluded. Assessed criteria were: • characteristics of patients (age, rank, environmental affiliation in the army); • chronology of evacuation; • leaving country for evacuation; • reasons for evacuation; • initial classification of patients by the requesting physician; • effective conditions of evacuation; • destination hospital and department.
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Table 1 List of the 60 diseases subject to epidemiological surveillance by CESPA. Liste des 60 affections soumises à la surveillance épidémiologique du CESPA. Diseases under surveillance Fecal pollution and foodborne diseases Amebiasis Botulism Brucellosis Cholera Diarrhea contracted during external and overseas operations Typhoid and paratyphoid fever Q fever Hepatitis A and E Listeriosis Poliomyelitis Shigellosis Collective foodborne diseases (cluster and case) Bloodborne diseases and sexually-transmitted diseases or sexual and/or blood exposure Hepatitis B HIV infection Acquired immune deficiency syndrome (AIDS) Sexually-transmitted infections Accidental exposure to blood Risky sexual behavior Vector-borne diseases Yellow fever Cutaneous leishmaniasis Malaria Plague Typhus fever Viral hemorrhagic fever Dengue-like syndromes Scabies Airborne diseases Diphtheria Febrile acute respiratory tract infections Legionellosis Invasive meningococcal infections Mumps Measles Rubella Chickenpox Tuberculosis Drug-induced tuberculosis Pertussis Other communicable diseases Anthrax Exposure to rabies Fever of unknown origin during external and overseas operations Leptospirosis Suspicion of Creutzfeldt–Jakob disease and related diseases Tetanus Tularemia Monkeypox including smallpox Rabies Staphylococcal-like infections Confirmed S. aureus infections with presence of the gene encoding for Panton-Valentine leukocidin (PVL) or resistant to an antibiotic Urinary or digestive schistosomiasis Non-communicable diseases Heatstroke related to physical exercise Mental disorders related to trauma Self-destructive behavior Mesothelioma Accidental diseases contracted during operations Weapon or explosive device injuries Acute acoustic trauma Physical injury during external operation Other disorders under surveillance Adverse events of vaccines Adverse events of chemoprophylaxis Syndrome or disease contracted during a specific environmental risk context Death All-cause death
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2.4. Classification of reasons for evacuation We performed a retrospective classification of medical evacuations into three categories based on the reasons for evacuation mentioned in the EMO-S register: • medical evacuations for infectious situations: reasons clearly indicating an infectious disease (malaria, acute febrile diarrhea, pneumonia, peritonitis, etc.). These medical evacuations were further assessed as part of the present study; • medical evacuations for potential infectious situations: reasons potentially related to an infectious disease (chronic diarrhea, pain, wounds, burns, etc.) but for which available data was not sufficient to classify them in the “Medical evacuation for infectious situations” category. These medical evacuations were not further assessed in the present study because of lack of sufficient data; • medical evacuations for non-infectious situations: medical evacuations for reasons unrelated to infectious diseases (pregnancy, closed fracture, psychiatric disorders, etc.). Reasons for medical evacuations for infectious diseases were retrospectively transcribed into medical diagnoses using the 2017 French ICD-10 currently used for classification of diseases in hospital settings [12]. 2.5. Diagnosis of severity The infection severity was assessed based on the initial classification made by the requesting physician and on the means allocated to the evacuation. We used the classification system defined in the STANAG 3204 standardization agreement of the North Atlantic Treaty Organization (NATO) to define the urgency of the mission − hereafter referred to as “priority” − (from P1 to P3), and the level of care required − referred to as “dependency” − (from D1 to D4) [13]. The patient’s profile can thus be easily assessed, without having to use detailed medical information, and one can easily decide on the type of medical assistance required (ICU specialist, physician, paramedics, or no medical assistance), the type of aircraft required, the patient’s position during transfer and transfer conditions between the airport and the destination ward (ambulance, with or without medical assistance, light vehicle). Particular attention was paid to evacuations to intensive care units. 2.6. Statistical analysis We performed a descriptive data analysis using XLSTAT® . 3. Results 3.1. Study population Between January 1, 2011 and December 31, 2016, the French armed forces sent 187,337 soldiers to foreign operation zones, including 75% of prepositioned forces and 25% of external operations. The geographical distribution of French units in operation zones is presented in Fig. 1. Over the study period a total of 4718 requests for strategic medical evacuations were filed. We excluded 85 files for the following reasons:
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Fig. 1. French armed forces members sent abroad between 2011 and 2016. Militaires franc¸ais en projection à l’étranger entre 2011 et 2016.
Fig. 2. Flowchart of patients in the study. Schéma des flux de patients dans l’étude.
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K. Simon et al. / Médecine et maladies infectieuses xxx (2019) xxx–xxx Table 2 Demographic characteristics of French armed forces members benefiting from strategic evacuation for infectious situations between 2011 and 2016. Caractéristiques démographiques des militaires franc¸ais évacués par MEDEVAC stratégiques pour situation infectieuse entre 2011 et 2016.
Age (years) 18–24 25–35 35–49 50 or above Environmental affiliation in the army Ground forces Navy Air Force French Foreign Legion National police force French Defense Health Service Fuel Service of the Armies Military rank Enlisted rank Non-commissioned officer Subaltern officer First officer Chief chaplain
Numbers
Frequency
103 117 79 2
34.2 38.9 26.2 0.7
189 57 29 13 7 5 1
62.8 19.0 9.6 4.3 2.3 1.7 0.3
194 80 16 10 1
64.5 26.6 5.3 3.3 0.3
5
3.5. Destination Patients were mainly repatriated to surgical wards (162 patients, 54%), medical wards (108 patients, 36%), and intensive care units (21 patients, 7%). Fifty-seven patients of those repatriated to medical wards were admitted to infectious and tropical disease departments. Four files (1%) were incomplete and six patients (2%) were evacuated to a military hospital. Most patients were repatriated to military hospitals in Paris (94.3%): Bégin Hospital received 182 patients, Percy Hospital 67 patients, and Val de Grâce Hospital 35 patients. Military hospitals located in the south of France received eight patients: five in Sainte Anne and three in Laveran. Three evacuation destinations were not documented in the files. 3.6. Reasons for evacuation A total of 163 patients were evacuated for surgical infectious diseases and 138 for medical conditions. Reasons for evacuation are detailed in Table 3. 3.7. Urgency of evacuation and diagnosis of severity
• 52 incomplete files; • 14 civil personnel evacuations; • 10 evacuations canceled including three patients who died on the theater of operations; • 6 members of foreign armies; • evacuations departing from metropolitan France (Corsica). Of the 4633 files included, 301 were related to medical evacuations for infectious situations and 628 to medical evacuations for potentially infectious situations. Fig. 2 details the distribution of patients.
3.2. Demographic characteristics The mean age of the 301 patients presenting with an infectious disease was 30 years (median: 28 years). The youngest patient was 18 years old and the oldest was 55 years old. Most evacuated patients were members of the army ground forces of enlisted ranks. Distribution by age, environmental affiliation, and rank is detailed in Table 2.
3.7.1. Evaluation by the requesting physician Priority of evacuation and patient’s dependency initially assessed by the requesting physician are presented in Table 4. 3.7.2. Means allocated to the medical evacuation A total of 229 evacuations (76%) were carried out via military aircraft, including 46 (15%) individual medical evacuations using governmental planes. Similarly, 69 evacuations (23%) were carried out via civil airplanes and three (1%) by other means (two by boats from the French Navy and one by land transportation). The transportation team was made of only a nurse for 123 evacuations (41%), a non-resuscitating physician for 29 evacuations (10%), and a resuscitation specialist for 32 evacuations (11%). A total of 115 patients (38%) were repatriated without any medical assistance and two files were incomplete. During transportation, 235 patients (78%) were sited, 64 (21%) were lying down, and data was missing in two files. Secondary transportation from the airport to the hospital was carried out by light vehicle for 236 patients (78%) and by ambulance for 61 patients (20%). Data related to secondary transportation was missing for four patients. Mean time between the evacuation request and arrival in France was 107 hours, with a median of 89 hours. Distribution of time to evacuation to metropolitan France according to priority as initially assessed by the requesting physician is presented in Fig. 5.
3.3. Geographical origin of strategic medical evacuations Ten countries accounted for 77.1% of evacuations during the study period: Mali (n = 55), Central African Republic (n = 33), Djibouti (n = 31), Chad (n = 25), Afghanistan (n = 24), French Guyana (n = 20), Ivory Coast (n = 12), United Arab Emirates (n = 12), Gabon (n = 11), and Niger (n = 9). French overseas territories accounted for 10.6% of evacuations: French Guyana (n = 20), Martinique (n = 6), New Caledonia (n = 4), Reunion (n = 1), Mayotte (n = 1). Fig. 3 details the geographical origins of medical evacuations for infectious situations.
3.4. Chronological distribution Fig. 4 details the chronological distribution of evacuations by trimesters between 2011 and 2016, confronted with the starting dates of the major theaters of operations during the study period.
3.7.3. Evacuations to intensive care units Medical conditions were predominant among the 21 patients repatriated to intensive care units, with 11 patients presenting with severe malaria, three patients with sepsis of unknown origin, and two with bacterial pneumonia. Severe infectious surgical conditions accounted for five cases, including two tonsillar abscesses requiring tracheotomy before evacuation and three peritonitis cases. 3.8. Conditions declared during the military mission over the same period Over the study period 23,390 cases of diarrhea, 1261 cases of fever of unknown origin, and 1106 cases of malaria were declared to the CESPA among French armed forces members in missions outside of metropolitan France. One malaria-related death was declared before evacuation in a weekly epidemiological message
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Fig. 3. Geographic origin of strategic medical evacuations for infectious situations of armed forces members between 2011 and 2016. Origine géographique des MEDEVAC stratégiques pour situation infectieuse des militaires franc¸ais entre 2011 et 2016.
Fig. 4. Quarterly distribution of strategic medical evacuations of French armed forces members for infectious situations between 2011 and 2016. Distribution par trimestre des MEDEVAC stratégiques de militaires franc¸ais pour situation infectieuse entre 2011 et 2016.
during the study period. Table 5 details the infectious diseases declared between 2011 and 2016 as part of the epidemiological surveillance of French armed forces members in missions. 4. Discussion Infectious diseases were significant causes of strategic medical evacuations in the present study. Surveillance of such medical evacuations should contribute to assessing the effectiveness of
infectious risk prevention strategies during military missions, as well as treatment effectiveness within the healthcare chain on the field. Over the study period 6.5% of strategic medical evacuations were decided because of infectious situations. One should add the 13.6% of medical evacuations for potentially infectious situations that have not been assessed for lack of data. Such results are similar to those published in other studies reporting that infectious diseases were responsible for 10% to 20% of medical evacuations
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Table 3 Causes of strategic evacuations for infectious situations between 2011 and 2016. Motifs des MEDEVAC stratégiques pour situation infectieuse entre 2011 et 2016.
Distribution of infectious situations Surgical infectious diseases Skin and soft tissue infections Pilonidal cyst infection Skin abscess, furuncle, and anthrax Intraabdominal and digestive infection Appendicitis Cholecystitis Peritonitis Dental and ENT infections Dental and periodontal infection Abscesses Medical infectious diseases Infections related to specific risks incurred during external operations Vector-borne diseases Malaria Dengue Airborne diseases Respiratory tract tuberculosis Viral pneumonia Meningitis Fecal pollution-related diseases Diarrhea and gastro-enteritis of suspected infectious origin Viral hepatitis Water-related diseases Schistosomiasis Animal-related diseases Animal bite Conflict-related diseases Infected open wound on various body parts Accidental exposure to blood Fever of unknown origin Fever of unknown origin Cosmopolitan diseases Skin infections Localized skin and soft tissue infection Infectious mononucleosis Chickenpox Mycosis Respiratory tract infections Bacterial pneumonia Superinfected chronic bronchitis Renal and urological infections Acute pyelonephritis Acute prostatitis Superinfected nephritic colic Orchitis and epididymitis ENT and eye infections Cornea infection Herpes zoster infection Toxoplasmosis Conjunctivitis Suppurative otitis media Mastoiditis and related infections Mumps Rheumatic infections Infectious arthritis Reactive arthritis Osteopathy Digestive infections Superinfected diverticulosis of the intestines Superinfected ulcerative colitis Other infectious diseases of the intestines
Total
%
301 163 78 47 31 66 48 11 7 19 10 9 138 52
100.0 54.2 25.9 15.6 10.3 21.9 15.9 3.7 2.3 6.3 3.3 3.0 45.8 17.3
32 30 2 6 4 1 1 4 3
10.6 10.0 0.7 2.0 1.3 0.3 0.3 1.3 1.0
1 1 1 6 6 3 2 1 14 14 72 22 18 2 1 1 11 10 1 12 6 3 2 1 14 3 3 2 2 2 1 1 8 4 3 1 5 3 1 1
0.3 0.3 0.3 2.0 2.0 1.0 0.7 0.3 4.7 4.7 23.9 7.3 6.0 0.7 0.3 0.3 3.7 3.3 0.3 4.0 2.0 1.0 0.7 0.3 4.7 1.0 1.0 0.7 0.7 0.7 0.3 0.3 2.7 1.3 1.0 0.3 1.7 1.0 0.3 0.3
of French armed forces members in missions abroad [14,15]. This data confirms that infections are a major risk for members of the armed forces sent abroad. Infections are associated with high morbidity in theaters of operations, and may compromise the military mission [2,3]. Infectious diseases contracted by members of the armed forces depend on the operational context, and our study
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Table 4 Initial assessment of patients by the requesting physician. Évaluation initiale du patient par le médecin demandeur.
Priority P1 urgent P2 priority P3 routine Dependency D1 high D2 moderate
D3 low D4 minimum
Unknown
Evacuation in less than 12 hours Evacuation in less than 24 hours No specific deadline for evacuation Patient requiring intensive care (intubation-ventilation) Patient requiring continuous surveillance (surveillance, perfusion, oxygen) and whose state is likely to deteriorate during the flight Stable patient without any risk of deterioration (nursing care) Patient without need for assistance during the flight, but requiring mobility aid Missing data
Numbers
Frequency (%)
22
7.3
22
7.3
257
85.4
15
5.0
23
7.6
44
14.6
210
69.8
9
3.0
results seem to confirm the increased risk of infectious diseases in theaters with high operational involvement, especially at the start of a new mission. This may be explained by living conditions and precarious hygiene at the start of a new mission, which are later improved once infrastructures and living areas have been set up [16]. Changes in operational missions as well as their variety may also have decreased the armed forces’ experience related to countryside living in tropical areas. Surgical diseases accounted for more than half of medical evacuations for infectious situations. Surgical assistance to armed forces personnel should remain a key concern in the organization of the medical assistance chain, irrespective of the operational context [17–19]. Infections requiring medical evacuations reported in the present study were mainly cosmopolitan infections. A high number of soft tissue infections and mainly pilonidal cyst infections (47 cases) was reported in the present cohort. Pilonidal cysts present as a cavity under the skin, following accumulation of hairs penetrating within the dermis at the intergluteal cleft level. Hairs act as foreign bodies and trigger an inflammatory reaction. An inflammatory granuloma develops as a subcutaneous pseudocyst that may remain mildly inflammatory or get infected. Infection of the pseudocyst may lead to acute abscess or to the formation of a skin fistula. This infection is mostly observed in young adults, with a higher number of cases reported in men (75%). The global incidence among the general population is estimated at 26 cases per 100,000 individuals. Common contributing factors are marked hairiness, oily skin, overweight (BMI >25), deep intergluteal cleft, poor hygiene, being seated several hours a day and repeated frictions, and family history of pilonidal cyst. This disease − called the “jeep disease” during World War II − is frequently observed among armed forces personnel and is favored by the warm and humid climatic conditions of the missions [20,21]. Acute episodes are treated by urgent drainage of pus to ease the patient’s pain and to stop the infection from spreading. Despite initially adequate surgical management, patients usually need to be evacuated as they require long-term healing care and are associated with prolonged operational incapacity. Such results should lead to better diagnosing skin lesions at risk of complications on the field and to strengthening effort on health education and hygiene measures in missions (absence of shaving of these body parts, daily washing with neutral soap and water, and meticulous drying of the intergluteal cleft).
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Fig. 5. Distribution of times to evacuation between the medical evacuation request and arrival in France by initial priority. Répartition des délais d’évacuation entre la demande de MEDEVAC et l’arrivée en France classés selon la priorité initiale.
Table 5 Disorders reported to the CESPA on mission outside of mainland France between 2011 and 2016. Affections déclarées au CESPA en mission hors France métropolitaine entre 2011 et 2016. Disorders declared to the CESPA by weekly epidemiological messages among French armed forces members in missions outside of metropolitan France between 2011 and 2016 Fecal pollution diseases Diarrhea Shigellosis Cluster of collective foodborne diseases Amebiasis Schistosomiasis Typhoid and paratyphoid fever Sexually-transmitted or bloodborne diseases or sexual or blood exposure Risky sexual behavior Accidental exposure to blood Sexually-transmitted infection besides HIV Hepatitis B HIV infection Vector-borne diseases Dengue-like syndrome Malaria Cutaneous leishmaniasis Scabies Airborne diseases Febrile acute respiratory tract infection Q fever Chickenpox Influenza Tuberculosis Pertussis Measles Other communicable diseases Fever of unknown origin Staphylococcal infection Exposure to rabies Leptospirosis Other diseases under surveillance Adverse event of chemoprophylaxis Adverse event of vaccines
23,390 67 52 36 20 5
1455 255 228 19 2 1819 1106 115 11 1412 40 32 28 7 6 5 1261 1018 239 34 85 34
The epidemiological profile of infections reported in our cohort contrasts with those reported in other studies. Rapp et al. performed a study of French armed forces personnel repatriated to a Paris military hospital between 2004 and 2013, and reported a higher proportion of tropical diseases: malaria, arboviroses, bilharziasis, viral hepatitis A and E [22]. Rapp et al.’s study was performed in an infectious disease hospital ward, while we
performed our study from a different standpoint and thus evidenced problematic diseases on the field. Our study findings reveal that among urgent infectious diseases contracted on the field, severe P. falciparum is still problematic with 11 patients evacuated to intensive care units. One malariarelated death occurring before evacuation during the study period should be added to that figure. Severe P. falciparum malaria was a worrying cause of severe infections among members of the armed forces in our study. However, with 30 evacuations for 1106 cases of malaria declared to the CESPA, most cases of malaria are successfully taken care of on the field by military physicians using rapid diagnostic tests and curative treatment available at the military health facility on the field [5]. Health education and prevention of vector-borne diseases during military missions require regular information of exposed armed forces members and their hierarchy, as well as constant surveillance of compliance with chemoprophylaxis [23]. Albeit rare, specific situations may be associated with evacuation difficulties. Two patients were thus repatriated because of obstructive tonsillar abscesses that required tracheostomy before evacuation [24,25]. However, infectious diseases requiring medical evacuations mainly concerned mild diseases and most patients were evacuated without medical assistance. By comparing medical evacuations for confirmed infections with epidemiological surveillance data, we can assess the effectiveness of prevention strategies against infectious risks. Among diseases related to fecal pollution, infectious diarrhea accounted for 15% of consultations with the military physician (at the medical station) in Mali during the Barkhane operation, but only accounted for three evacuations in our cohort study [26]. A French study performed in 2017 demonstrated the benefit of a single-dose antibiotic therapy for diarrhea in members of the armed forces sent to external operations to reduce operational incapacity [27]. Such management strategy of diarrhea cases on the field by military physicians seems to be adequate and effective in treating patients and in avoiding medical evacuations [28,29]. Conversely, some medical evacuations could be avoided with better management of specific risks. This is the case for dental infections for which regular dental check-up and clinical and panoramic dental examination should be performed before departing. Implementing additional dental clinics on the field, for instance in partnership with local dentists, and training military physicians to dental care and first-line treatment could decrease the number of evacuations for tooth infections [30].
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Although providing new data, our study has several limitations related to data sources. We did not take into account intra-theater medical evacuations that may sometimes be required for managing some diseases without systematic repatriation to metropolitan France [14]. We also noticed suboptimal notification of some infections. For instance Rapp et al. reported a significant number of HIV primary infections or risky sexual behaviors, that we did not observe in our cohort [22]. “Risky sexual behavior” kits have been implemented on the field, and this may explain the reduced number of patients evacuated for such reasons. Finally, the database that we used for the present study is a medical and aviation tool with nonstandardized and imprecise data entry by people who may not be medical personnel. Substantial data is lacking such as the patients’ sex, and retrospective diagnostic classification may represent a substantial methodological bias. Data entry in the database has been standardized in January 2018 and extensive work is underway to update items collected in the medical evacuation register to optimize the use of medical data and to use such data for designing logistic, treatment, and preventive measures. 5. Conclusion Infectious diseases contracted in missions by French armed forces members and medical evacuations decided for such reasons are major epidemiological indicators that should be monitored. Such indicators help adapt prevention measures, training, and therapeutic and diagnostic tools used by front-line military physicians. Prevention and management of infectious diseases in military missions are still challenging. The Ebola outbreak recently reminded the scientific community that repatriation of highly contagious patients is still problematic [31]. The emergence and presence of multidrug-resistant bacteria in countries where French armed forces are being sent, and the high prevalence of carriage of multidrug-resistant bacteria among members of the armed forces also raise issues of evacuation conditions, isolation measures, and choice of antibiotic therapy [32–35]. Contribution of authors K.S. (primary author) and P.Y.C. designed the study protocol, contributed to data collection and analysis, and wrote the article. V.P.d.S., A.L., and E.P. contributed to reviewing the article. C.B. contributed to data collection. F.S. designed the study protocol and contributed to reviewing the article. Disclosure of interest The authors declare that they have no competing interest. Acknowledgment The authors would like to thank all people involved in the management of patients included in the study, as well as the EMO Health for supporting the French armed forces abroad. References [1] Haus-Cheymol R, Kraemer P, Simon F. Les risques infectieux en opérations extérieures. Med Armees 2009;37:435–52. [2] Burns DS, Riley MR, Mason A, Bailey MS. UK Role 4 military infectious diseases and tropical medicine cases in 2005–2013. J R Army Med Corps 2018;164(2):77–82. [3] Sanders JW, Putnam SD, Frankart C, et al. Impact of illness an non-combat injury during Opérations Iraqi Freedom and Enduring Freedom (Afghanistan). Am J Trop Med Hyg 2005;73(4):713–9.
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Original article
Medical evacuations of members of the French armed forces for infectious diseases in foreign operations Évacuations médicales de militaires franc¸ais pour des pathologies infectieuses en opérations extérieures K. Simon a,∗ , P.-Y. Cordier a , V. Pommier de Santi b,c , A. Luft d , C. Brossier b , E. Peytel a , F. Simon e a Pôle bloc-anesthésie-réanimation-urgences, service d’accueil des urgences, hôpital d’instruction des armées LAVERAN, BP 60149, 13384 Marseille cedex 13, France b Centre d’épidémiologie et de santé publique des armées, GSBdD Marseille Aubagne – CESPA, BP 40029, 13568 Marseille cedex 02, France c SSA, VITROME, IHU-Méditerranée infection, Aix Marseille université, IRD, AP–HM, Marseille, France d Pôle OBS 2B/123, État-major opérationnel santé M7, 60, boulevard du Général Martial-Valin, CS 21623, 75509 Paris cedex 15, France e Pôle formation enseignement recherche, hôpital d’instruction des armées LAVERAN, BP 60149, 13384 Marseille cedex 13, France
a r t i c l e
i n f o
Article history: Received 18 March 2018 Received in revised form 15 November 2018 Accepted 13 September 2019 Available online xxx Keywords: Fever French armed forces Infectious diseases Malaria Medical evacuations
a b s t r a c t 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. © 2019 Elsevier Masson SAS. All rights reserved.
r é s u m é Mots clés : Évacuations médicales Fièvre Forces armées franc¸aises Maladies infectieuses Paludisme
Objectifs. – Les évacuations médicales en contexte de projection sont un problème sanitaire et stratégique majeur pour nos armées. Ce travail a pour but d’étudier les caractéristiques des évacuations de militaires franc¸ais pour des pathologies infectieuses. Patients et méthodes. – Étude rétrospective sur registre de l’État-Major Opérationnel Santé ayant étudié les caractéristiques des évacuations médicales stratégiques des militaires franc¸ais en mission à l’étranger entre le 1er janvier 2011 et le 31 décembre 2016. Résultats. – Sur 4633 dossiers inclus, 301 évacuations médicales (6,5 %) ont été réalisées pour des situations infectieuses. Plus de la moitié des patients ont été rapatriés vers des services de chirurgie (162 patients
∗ Corresponding author. E-mail address: [email protected] (K. Simon). https://doi.org/10.1016/j.medmal.2019.09.011 0399-077X/© 2019 Elsevier Masson SAS. All rights reserved.
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soit 54 %), 108 patients (36 %) vers des services de médecine, 21 patients (7 %) en réanimation, six patients (2 %) dans un centre médical des armées et quatre dossiers (1 %) étaient incomplets. Parmi les urgences infectieuses, le paludisme était à l’origine de 30 évacuations (10 %) dont 11 cas de paludisme grave à P. falciparum évacués vers des services de réanimation, et un décès avant évacuation. Les pathologies infectieuses motivant une évacuation médicale étaient le plus souvent bénignes et cosmopolites. La majorité des militaires ont été évacués sans accompagnant médical. Conclusions. – Les pathologies infectieuses en mission et les rapatriements sanitaires effectués pour des motifs infectieux sont des indicateurs épidémiologiques importants à surveiller. Ils permettent d’adapter les mesures de prévention, la formation, et les outils diagnostiques et thérapeutiques à mettre à disposition des médecins militaires de l’avant. ´ ´ es. © 2019 Elsevier Masson SAS. Tous droits reserv
1. Introduction Infectious diseases have always been part of the life of military personnel, and have influenced the history of countries. Infectious diseases contracted during foreign operations remain a major health and strategic issue for the armed forces [1]. Infectious diseases are associated with major risks because of their high incidence, potential severity, and significant impact on operational capacity [2–4]. The operation zones of the French armed forces are often endemic for infectious diseases because of multiple factors: low socio-economic status of countries, tropical countries, lack of health facilities. Some of these infections are particularly frequent because of poor hygiene due to community living conditions, operational situation, and fecal pollution. Other infections are favored by the tropical climate such as malaria, schistosomiasis, or leishmaniasis. Some infectious risks are specific to the armed forces because of war wound infections and exposure to biological weapons. Besides their frequency, these infectious diseases may be severe and potentially fatal. French armed forces have increasingly been sent to tropical countries over the past 10 years, and severe P. falciparum malaria accounts for one death every two years on average among armed forces personnel [5,6]. Medical evacuation of armed forces personnel infected during an operation may be justified in various situations: inability to conduct the mission, need of additional diagnostic examinations, initiation of a specific treatment, or monitoring of a specific treatment. The French army health service makes a distinction between “tactical medical evacuations” and “strategic medical evacuations”. Tactical medical evacuations consist in transferring the soldier to the nearest adequate health facility in the theater of operations, while strategic medical evacuations consist in repatriating the soldier to a health facility in metropolitan France [7]. A total of 718 strategic medical evacuations were carried out in 2015 [8]. Medical evacuation from a foreign theater of operations is complex. It is associated with high cost and strong operational impact. Such evacuations require human resources and means, and may disrupt the military mission. Specific measures may also need to be implemented as such infections are potentially contagious, and patients may require to be isolated for instance [9–11]. We aimed to evaluate the characteristics of strategic medical evacuations of French armed forces personnel between 2011 and 2016 for infectious diseases. We aimed to identify “critical” situations requiring repatriation to metropolitan France. 2. Material and methods 2.1. Type of study We performed a register-based retrospective study of French armed forces personnel serving overseas who benefited from a
strategic medical evacuation to metropolitan France between January 1, 2011 and December 31, 2016.
2.2. Data sources Epidemiological data of French armed forces personnel serving overseas between January 1, 2011 and December 31, 2016, with the location of the missions, were collected from the registers of the French operational military staff for health (French acronym EMO-S). All requests for strategic medical evacuations of French armed forces personnel are centralized at the M3/MEDEVAC unit of the EMO-S. A regulating physician is in charge of organizing the evacuation. Data of the medical evacuation is documented in a specific database. The present study is based on the analysis of this database. Collected data included the patient, the theater of operations, the infectious disease requiring evacuation, the transportation characteristics, and the destination. Within the French center for epidemiology and public health of the armed forces (French acronym CESPA), the functional unit known as “Epidemiological surveillance and intervention” monitors the health of armed forces personnel. The surveillance is based on monitoring approximately 60 disorders or diseases declared through weekly epidemiological messages by the unit’s physicians. We assessed the data from this epidemiological surveillance and compared it with strategic medical evacuations of French armed forces personnel for infectious diseases over the same period of time. Diseases included in the epidemiological surveillance are detailed in Table 1.
2.3. Inclusion criteria and analyzed data All French armed forces personnel repatriated from a geographical area outside of metropolitan France via strategic medical evacuation organized by the EMO-S between January 1, 2011 and December 31, 2016 were included in the analysis. Files with missing data such as the date of birth, nationality, diagnosis, and country of origin were excluded from the analysis. Patients who died before being evacuated were also excluded. Assessed criteria were: • characteristics of patients (age, rank, environmental affiliation in the army); • chronology of evacuation; • leaving country for evacuation; • reasons for evacuation; • initial classification of patients by the requesting physician; • effective conditions of evacuation; • destination hospital and department.
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Table 1 List of the 60 diseases subject to epidemiological surveillance by CESPA. Liste des 60 affections soumises à la surveillance épidémiologique du CESPA. Diseases under surveillance Fecal pollution and foodborne diseases Amebiasis Botulism Brucellosis Cholera Diarrhea contracted during external and overseas operations Typhoid and paratyphoid fever Q fever Hepatitis A and E Listeriosis Poliomyelitis Shigellosis Collective foodborne diseases (cluster and case) Bloodborne diseases and sexually-transmitted diseases or sexual and/or blood exposure Hepatitis B HIV infection Acquired immune deficiency syndrome (AIDS) Sexually-transmitted infections Accidental exposure to blood Risky sexual behavior Vector-borne diseases Yellow fever Cutaneous leishmaniasis Malaria Plague Typhus fever Viral hemorrhagic fever Dengue-like syndromes Scabies Airborne diseases Diphtheria Febrile acute respiratory tract infections Legionellosis Invasive meningococcal infections Mumps Measles Rubella Chickenpox Tuberculosis Drug-induced tuberculosis Pertussis Other communicable diseases Anthrax Exposure to rabies Fever of unknown origin during external and overseas operations Leptospirosis Suspicion of Creutzfeldt–Jakob disease and related diseases Tetanus Tularemia Monkeypox including smallpox Rabies Staphylococcal-like infections Confirmed S. aureus infections with presence of the gene encoding for Panton-Valentine leukocidin (PVL) or resistant to an antibiotic Urinary or digestive schistosomiasis Non-communicable diseases Heatstroke related to physical exercise Mental disorders related to trauma Self-destructive behavior Mesothelioma Accidental diseases contracted during operations Weapon or explosive device injuries Acute acoustic trauma Physical injury during external operation Other disorders under surveillance Adverse events of vaccines Adverse events of chemoprophylaxis Syndrome or disease contracted during a specific environmental risk context Death All-cause death
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2.4. Classification of reasons for evacuation We performed a retrospective classification of medical evacuations into three categories based on the reasons for evacuation mentioned in the EMO-S register: • medical evacuations for infectious situations: reasons clearly indicating an infectious disease (malaria, acute febrile diarrhea, pneumonia, peritonitis, etc.). These medical evacuations were further assessed as part of the present study; • medical evacuations for potential infectious situations: reasons potentially related to an infectious disease (chronic diarrhea, pain, wounds, burns, etc.) but for which available data was not sufficient to classify them in the “Medical evacuation for infectious situations” category. These medical evacuations were not further assessed in the present study because of lack of sufficient data; • medical evacuations for non-infectious situations: medical evacuations for reasons unrelated to infectious diseases (pregnancy, closed fracture, psychiatric disorders, etc.). Reasons for medical evacuations for infectious diseases were retrospectively transcribed into medical diagnoses using the 2017 French ICD-10 currently used for classification of diseases in hospital settings [12]. 2.5. Diagnosis of severity The infection severity was assessed based on the initial classification made by the requesting physician and on the means allocated to the evacuation. We used the classification system defined in the STANAG 3204 standardization agreement of the North Atlantic Treaty Organization (NATO) to define the urgency of the mission − hereafter referred to as “priority” − (from P1 to P3), and the level of care required − referred to as “dependency” − (from D1 to D4) [13]. The patient’s profile can thus be easily assessed, without having to use detailed medical information, and one can easily decide on the type of medical assistance required (ICU specialist, physician, paramedics, or no medical assistance), the type of aircraft required, the patient’s position during transfer and transfer conditions between the airport and the destination ward (ambulance, with or without medical assistance, light vehicle). Particular attention was paid to evacuations to intensive care units. 2.6. Statistical analysis We performed a descriptive data analysis using XLSTAT® . 3. Results 3.1. Study population Between January 1, 2011 and December 31, 2016, the French armed forces sent 187,337 soldiers to foreign operation zones, including 75% of prepositioned forces and 25% of external operations. The geographical distribution of French units in operation zones is presented in Fig. 1. Over the study period a total of 4718 requests for strategic medical evacuations were filed. We excluded 85 files for the following reasons:
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Fig. 1. French armed forces members sent abroad between 2011 and 2016. Militaires franc¸ais en projection à l’étranger entre 2011 et 2016.
Fig. 2. Flowchart of patients in the study. Schéma des flux de patients dans l’étude.
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K. Simon et al. / Médecine et maladies infectieuses xxx (2019) xxx–xxx Table 2 Demographic characteristics of French armed forces members benefiting from strategic evacuation for infectious situations between 2011 and 2016. Caractéristiques démographiques des militaires franc¸ais évacués par MEDEVAC stratégiques pour situation infectieuse entre 2011 et 2016.
Age (years) 18–24 25–35 35–49 50 or above Environmental affiliation in the army Ground forces Navy Air Force French Foreign Legion National police force French Defense Health Service Fuel Service of the Armies Military rank Enlisted rank Non-commissioned officer Subaltern officer First officer Chief chaplain
Numbers
Frequency
103 117 79 2
34.2 38.9 26.2 0.7
189 57 29 13 7 5 1
62.8 19.0 9.6 4.3 2.3 1.7 0.3
194 80 16 10 1
64.5 26.6 5.3 3.3 0.3
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3.5. Destination Patients were mainly repatriated to surgical wards (162 patients, 54%), medical wards (108 patients, 36%), and intensive care units (21 patients, 7%). Fifty-seven patients of those repatriated to medical wards were admitted to infectious and tropical disease departments. Four files (1%) were incomplete and six patients (2%) were evacuated to a military hospital. Most patients were repatriated to military hospitals in Paris (94.3%): Bégin Hospital received 182 patients, Percy Hospital 67 patients, and Val de Grâce Hospital 35 patients. Military hospitals located in the south of France received eight patients: five in Sainte Anne and three in Laveran. Three evacuation destinations were not documented in the files. 3.6. Reasons for evacuation A total of 163 patients were evacuated for surgical infectious diseases and 138 for medical conditions. Reasons for evacuation are detailed in Table 3. 3.7. Urgency of evacuation and diagnosis of severity
• 52 incomplete files; • 14 civil personnel evacuations; • 10 evacuations canceled including three patients who died on the theater of operations; • 6 members of foreign armies; • evacuations departing from metropolitan France (Corsica). Of the 4633 files included, 301 were related to medical evacuations for infectious situations and 628 to medical evacuations for potentially infectious situations. Fig. 2 details the distribution of patients.
3.2. Demographic characteristics The mean age of the 301 patients presenting with an infectious disease was 30 years (median: 28 years). The youngest patient was 18 years old and the oldest was 55 years old. Most evacuated patients were members of the army ground forces of enlisted ranks. Distribution by age, environmental affiliation, and rank is detailed in Table 2.
3.7.1. Evaluation by the requesting physician Priority of evacuation and patient’s dependency initially assessed by the requesting physician are presented in Table 4. 3.7.2. Means allocated to the medical evacuation A total of 229 evacuations (76%) were carried out via military aircraft, including 46 (15%) individual medical evacuations using governmental planes. Similarly, 69 evacuations (23%) were carried out via civil airplanes and three (1%) by other means (two by boats from the French Navy and one by land transportation). The transportation team was made of only a nurse for 123 evacuations (41%), a non-resuscitating physician for 29 evacuations (10%), and a resuscitation specialist for 32 evacuations (11%). A total of 115 patients (38%) were repatriated without any medical assistance and two files were incomplete. During transportation, 235 patients (78%) were sited, 64 (21%) were lying down, and data was missing in two files. Secondary transportation from the airport to the hospital was carried out by light vehicle for 236 patients (78%) and by ambulance for 61 patients (20%). Data related to secondary transportation was missing for four patients. Mean time between the evacuation request and arrival in France was 107 hours, with a median of 89 hours. Distribution of time to evacuation to metropolitan France according to priority as initially assessed by the requesting physician is presented in Fig. 5.
3.3. Geographical origin of strategic medical evacuations Ten countries accounted for 77.1% of evacuations during the study period: Mali (n = 55), Central African Republic (n = 33), Djibouti (n = 31), Chad (n = 25), Afghanistan (n = 24), French Guyana (n = 20), Ivory Coast (n = 12), United Arab Emirates (n = 12), Gabon (n = 11), and Niger (n = 9). French overseas territories accounted for 10.6% of evacuations: French Guyana (n = 20), Martinique (n = 6), New Caledonia (n = 4), Reunion (n = 1), Mayotte (n = 1). Fig. 3 details the geographical origins of medical evacuations for infectious situations.
3.4. Chronological distribution Fig. 4 details the chronological distribution of evacuations by trimesters between 2011 and 2016, confronted with the starting dates of the major theaters of operations during the study period.
3.7.3. Evacuations to intensive care units Medical conditions were predominant among the 21 patients repatriated to intensive care units, with 11 patients presenting with severe malaria, three patients with sepsis of unknown origin, and two with bacterial pneumonia. Severe infectious surgical conditions accounted for five cases, including two tonsillar abscesses requiring tracheotomy before evacuation and three peritonitis cases. 3.8. Conditions declared during the military mission over the same period Over the study period 23,390 cases of diarrhea, 1261 cases of fever of unknown origin, and 1106 cases of malaria were declared to the CESPA among French armed forces members in missions outside of metropolitan France. One malaria-related death was declared before evacuation in a weekly epidemiological message
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Fig. 3. Geographic origin of strategic medical evacuations for infectious situations of armed forces members between 2011 and 2016. Origine géographique des MEDEVAC stratégiques pour situation infectieuse des militaires franc¸ais entre 2011 et 2016.
Fig. 4. Quarterly distribution of strategic medical evacuations of French armed forces members for infectious situations between 2011 and 2016. Distribution par trimestre des MEDEVAC stratégiques de militaires franc¸ais pour situation infectieuse entre 2011 et 2016.
during the study period. Table 5 details the infectious diseases declared between 2011 and 2016 as part of the epidemiological surveillance of French armed forces members in missions. 4. Discussion Infectious diseases were significant causes of strategic medical evacuations in the present study. Surveillance of such medical evacuations should contribute to assessing the effectiveness of
infectious risk prevention strategies during military missions, as well as treatment effectiveness within the healthcare chain on the field. Over the study period 6.5% of strategic medical evacuations were decided because of infectious situations. One should add the 13.6% of medical evacuations for potentially infectious situations that have not been assessed for lack of data. Such results are similar to those published in other studies reporting that infectious diseases were responsible for 10% to 20% of medical evacuations
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Table 3 Causes of strategic evacuations for infectious situations between 2011 and 2016. Motifs des MEDEVAC stratégiques pour situation infectieuse entre 2011 et 2016.
Distribution of infectious situations Surgical infectious diseases Skin and soft tissue infections Pilonidal cyst infection Skin abscess, furuncle, and anthrax Intraabdominal and digestive infection Appendicitis Cholecystitis Peritonitis Dental and ENT infections Dental and periodontal infection Abscesses Medical infectious diseases Infections related to specific risks incurred during external operations Vector-borne diseases Malaria Dengue Airborne diseases Respiratory tract tuberculosis Viral pneumonia Meningitis Fecal pollution-related diseases Diarrhea and gastro-enteritis of suspected infectious origin Viral hepatitis Water-related diseases Schistosomiasis Animal-related diseases Animal bite Conflict-related diseases Infected open wound on various body parts Accidental exposure to blood Fever of unknown origin Fever of unknown origin Cosmopolitan diseases Skin infections Localized skin and soft tissue infection Infectious mononucleosis Chickenpox Mycosis Respiratory tract infections Bacterial pneumonia Superinfected chronic bronchitis Renal and urological infections Acute pyelonephritis Acute prostatitis Superinfected nephritic colic Orchitis and epididymitis ENT and eye infections Cornea infection Herpes zoster infection Toxoplasmosis Conjunctivitis Suppurative otitis media Mastoiditis and related infections Mumps Rheumatic infections Infectious arthritis Reactive arthritis Osteopathy Digestive infections Superinfected diverticulosis of the intestines Superinfected ulcerative colitis Other infectious diseases of the intestines
Total
%
301 163 78 47 31 66 48 11 7 19 10 9 138 52
100.0 54.2 25.9 15.6 10.3 21.9 15.9 3.7 2.3 6.3 3.3 3.0 45.8 17.3
32 30 2 6 4 1 1 4 3
10.6 10.0 0.7 2.0 1.3 0.3 0.3 1.3 1.0
1 1 1 6 6 3 2 1 14 14 72 22 18 2 1 1 11 10 1 12 6 3 2 1 14 3 3 2 2 2 1 1 8 4 3 1 5 3 1 1
0.3 0.3 0.3 2.0 2.0 1.0 0.7 0.3 4.7 4.7 23.9 7.3 6.0 0.7 0.3 0.3 3.7 3.3 0.3 4.0 2.0 1.0 0.7 0.3 4.7 1.0 1.0 0.7 0.7 0.7 0.3 0.3 2.7 1.3 1.0 0.3 1.7 1.0 0.3 0.3
of French armed forces members in missions abroad [14,15]. This data confirms that infections are a major risk for members of the armed forces sent abroad. Infections are associated with high morbidity in theaters of operations, and may compromise the military mission [2,3]. Infectious diseases contracted by members of the armed forces depend on the operational context, and our study
7
Table 4 Initial assessment of patients by the requesting physician. Évaluation initiale du patient par le médecin demandeur.
Priority P1 urgent P2 priority P3 routine Dependency D1 high D2 moderate
D3 low D4 minimum
Unknown
Evacuation in less than 12 hours Evacuation in less than 24 hours No specific deadline for evacuation Patient requiring intensive care (intubation-ventilation) Patient requiring continuous surveillance (surveillance, perfusion, oxygen) and whose state is likely to deteriorate during the flight Stable patient without any risk of deterioration (nursing care) Patient without need for assistance during the flight, but requiring mobility aid Missing data
Numbers
Frequency (%)
22
7.3
22
7.3
257
85.4
15
5.0
23
7.6
44
14.6
210
69.8
9
3.0
results seem to confirm the increased risk of infectious diseases in theaters with high operational involvement, especially at the start of a new mission. This may be explained by living conditions and precarious hygiene at the start of a new mission, which are later improved once infrastructures and living areas have been set up [16]. Changes in operational missions as well as their variety may also have decreased the armed forces’ experience related to countryside living in tropical areas. Surgical diseases accounted for more than half of medical evacuations for infectious situations. Surgical assistance to armed forces personnel should remain a key concern in the organization of the medical assistance chain, irrespective of the operational context [17–19]. Infections requiring medical evacuations reported in the present study were mainly cosmopolitan infections. A high number of soft tissue infections and mainly pilonidal cyst infections (47 cases) was reported in the present cohort. Pilonidal cysts present as a cavity under the skin, following accumulation of hairs penetrating within the dermis at the intergluteal cleft level. Hairs act as foreign bodies and trigger an inflammatory reaction. An inflammatory granuloma develops as a subcutaneous pseudocyst that may remain mildly inflammatory or get infected. Infection of the pseudocyst may lead to acute abscess or to the formation of a skin fistula. This infection is mostly observed in young adults, with a higher number of cases reported in men (75%). The global incidence among the general population is estimated at 26 cases per 100,000 individuals. Common contributing factors are marked hairiness, oily skin, overweight (BMI >25), deep intergluteal cleft, poor hygiene, being seated several hours a day and repeated frictions, and family history of pilonidal cyst. This disease − called the “jeep disease” during World War II − is frequently observed among armed forces personnel and is favored by the warm and humid climatic conditions of the missions [20,21]. Acute episodes are treated by urgent drainage of pus to ease the patient’s pain and to stop the infection from spreading. Despite initially adequate surgical management, patients usually need to be evacuated as they require long-term healing care and are associated with prolonged operational incapacity. Such results should lead to better diagnosing skin lesions at risk of complications on the field and to strengthening effort on health education and hygiene measures in missions (absence of shaving of these body parts, daily washing with neutral soap and water, and meticulous drying of the intergluteal cleft).
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Fig. 5. Distribution of times to evacuation between the medical evacuation request and arrival in France by initial priority. Répartition des délais d’évacuation entre la demande de MEDEVAC et l’arrivée en France classés selon la priorité initiale.
Table 5 Disorders reported to the CESPA on mission outside of mainland France between 2011 and 2016. Affections déclarées au CESPA en mission hors France métropolitaine entre 2011 et 2016. Disorders declared to the CESPA by weekly epidemiological messages among French armed forces members in missions outside of metropolitan France between 2011 and 2016 Fecal pollution diseases Diarrhea Shigellosis Cluster of collective foodborne diseases Amebiasis Schistosomiasis Typhoid and paratyphoid fever Sexually-transmitted or bloodborne diseases or sexual or blood exposure Risky sexual behavior Accidental exposure to blood Sexually-transmitted infection besides HIV Hepatitis B HIV infection Vector-borne diseases Dengue-like syndrome Malaria Cutaneous leishmaniasis Scabies Airborne diseases Febrile acute respiratory tract infection Q fever Chickenpox Influenza Tuberculosis Pertussis Measles Other communicable diseases Fever of unknown origin Staphylococcal infection Exposure to rabies Leptospirosis Other diseases under surveillance Adverse event of chemoprophylaxis Adverse event of vaccines
23,390 67 52 36 20 5
1455 255 228 19 2 1819 1106 115 11 1412 40 32 28 7 6 5 1261 1018 239 34 85 34
The epidemiological profile of infections reported in our cohort contrasts with those reported in other studies. Rapp et al. performed a study of French armed forces personnel repatriated to a Paris military hospital between 2004 and 2013, and reported a higher proportion of tropical diseases: malaria, arboviroses, bilharziasis, viral hepatitis A and E [22]. Rapp et al.’s study was performed in an infectious disease hospital ward, while we
performed our study from a different standpoint and thus evidenced problematic diseases on the field. Our study findings reveal that among urgent infectious diseases contracted on the field, severe P. falciparum is still problematic with 11 patients evacuated to intensive care units. One malariarelated death occurring before evacuation during the study period should be added to that figure. Severe P. falciparum malaria was a worrying cause of severe infections among members of the armed forces in our study. However, with 30 evacuations for 1106 cases of malaria declared to the CESPA, most cases of malaria are successfully taken care of on the field by military physicians using rapid diagnostic tests and curative treatment available at the military health facility on the field [5]. Health education and prevention of vector-borne diseases during military missions require regular information of exposed armed forces members and their hierarchy, as well as constant surveillance of compliance with chemoprophylaxis [23]. Albeit rare, specific situations may be associated with evacuation difficulties. Two patients were thus repatriated because of obstructive tonsillar abscesses that required tracheostomy before evacuation [24,25]. However, infectious diseases requiring medical evacuations mainly concerned mild diseases and most patients were evacuated without medical assistance. By comparing medical evacuations for confirmed infections with epidemiological surveillance data, we can assess the effectiveness of prevention strategies against infectious risks. Among diseases related to fecal pollution, infectious diarrhea accounted for 15% of consultations with the military physician (at the medical station) in Mali during the Barkhane operation, but only accounted for three evacuations in our cohort study [26]. A French study performed in 2017 demonstrated the benefit of a single-dose antibiotic therapy for diarrhea in members of the armed forces sent to external operations to reduce operational incapacity [27]. Such management strategy of diarrhea cases on the field by military physicians seems to be adequate and effective in treating patients and in avoiding medical evacuations [28,29]. Conversely, some medical evacuations could be avoided with better management of specific risks. This is the case for dental infections for which regular dental check-up and clinical and panoramic dental examination should be performed before departing. Implementing additional dental clinics on the field, for instance in partnership with local dentists, and training military physicians to dental care and first-line treatment could decrease the number of evacuations for tooth infections [30].
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Although providing new data, our study has several limitations related to data sources. We did not take into account intra-theater medical evacuations that may sometimes be required for managing some diseases without systematic repatriation to metropolitan France [14]. We also noticed suboptimal notification of some infections. For instance Rapp et al. reported a significant number of HIV primary infections or risky sexual behaviors, that we did not observe in our cohort [22]. “Risky sexual behavior” kits have been implemented on the field, and this may explain the reduced number of patients evacuated for such reasons. Finally, the database that we used for the present study is a medical and aviation tool with nonstandardized and imprecise data entry by people who may not be medical personnel. Substantial data is lacking such as the patients’ sex, and retrospective diagnostic classification may represent a substantial methodological bias. Data entry in the database has been standardized in January 2018 and extensive work is underway to update items collected in the medical evacuation register to optimize the use of medical data and to use such data for designing logistic, treatment, and preventive measures. 5. Conclusion Infectious diseases contracted in missions by French armed forces members and medical evacuations decided for such reasons are major epidemiological indicators that should be monitored. Such indicators help adapt prevention measures, training, and therapeutic and diagnostic tools used by front-line military physicians. Prevention and management of infectious diseases in military missions are still challenging. The Ebola outbreak recently reminded the scientific community that repatriation of highly contagious patients is still problematic [31]. The emergence and presence of multidrug-resistant bacteria in countries where French armed forces are being sent, and the high prevalence of carriage of multidrug-resistant bacteria among members of the armed forces also raise issues of evacuation conditions, isolation measures, and choice of antibiotic therapy [32–35]. Contribution of authors K.S. (primary author) and P.Y.C. designed the study protocol, contributed to data collection and analysis, and wrote the article. V.P.d.S., A.L., and E.P. contributed to reviewing the article. C.B. contributed to data collection. F.S. designed the study protocol and contributed to reviewing the article. Disclosure of interest The authors declare that they have no competing interest. Acknowledgment The authors would like to thank all people involved in the management of patients included in the study, as well as the EMO Health for supporting the French armed forces abroad. References [1] Haus-Cheymol R, Kraemer P, Simon F. Les risques infectieux en opérations extérieures. Med Armees 2009;37:435–52. [2] Burns DS, Riley MR, Mason A, Bailey MS. UK Role 4 military infectious diseases and tropical medicine cases in 2005–2013. J R Army Med Corps 2018;164(2):77–82. [3] Sanders JW, Putnam SD, Frankart C, et al. Impact of illness an non-combat injury during Opérations Iraqi Freedom and Enduring Freedom (Afghanistan). Am J Trop Med Hyg 2005;73(4):713–9.
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