Clinical activity at the UK military level 2 hospital in Bentiu, South Sudan during Op TRENTON from June to September 2017

Infectious diseases in German military personnel after predominantly tropical deployments: a retrospective assessment over 13 years

OBJECTIVES

Military deployments to the tropics are associated with specific infection risks. To add to the available epidemiological information, infectious disease risks in German military personnel returning from predominantly tropical deployments were assessed.

METHODS

Since 2006, German soldiers returning from predominantly tropical deployments have been offered the opportunity of returnee screenings at the Department of Tropical Medicine and Infectious Diseases of the Bundeswehr Hospital Hamburg. Case files and diagnostic results recorded between 2006 and 2018 were retrospectively assessed to identify deployment-associated infectious disease risks.

RESULTS

Along with high enteric colonisation rates with apathogenic protozoa and resistant Enterobacteriaceae, direct or indirect proof of infections among the 764 assessed cases comprised Plasmodium spp (n=37), Giardia duodenalis (n=21), Schistosoma spp (n=14), Yersinia enterocolitica (n=5), Strongyloides stercoralis (n=3), Campylobacter jejuni (n=1), Leishmania spp (n=1) and Salmonella enterica (n=1), as well as latent infections with Mycobacterium tuberculosis complex (n=8). The infections were mainly imported from the African region and Eastern Mediterranean region and high proportions of cases lacked typical symptoms. Reported side effect rates of antimalarial chemoprophylaxis for mefloquine (n=121), atovaquone/proguanil (n=49) and doxycycline (n=6) were 36.3%, 19.3% and 11.8%, respectively, while non-compliance rates were 12.9%, 13.0% and 5.9%, respectively.

CONCLUSIONS

Considerable rates of infections with sometimes atypical or absent symptoms confirm a need for returnee screenings after tropical deployments. High reported side effect rates for mefloquine support its replacement by atovaquone/proguanil or doxycycline for antimalarial chemoprophylaxis.

Musculoskeletal Injuries at the Chinese Peacekeeping Level II Hospital in Wau, South Sudan, 2018-2022

INTRODUCTION

Musculoskeletal injuries (MSIs) are common among U.N. military personnel and cause a substantial toll, but little is known about the actual risks and changes of MSIs. The Chinese level II hospital (CHN L2H) was the highest-level hospital in the Western Sector of the U.N. Mission in South Sudan (UNMISS). This study reviewed and analyzed the MSIs managed by the CHN L2H in UNMISS.

METHODS

Medical records of MSIs in CHN L2H from September 2018 to July 2022 were identified. We analyzed all the MSIs and treatment procedures.

RESULTS

A total of 857 patients from more than 40 countries were included (86.8% men, average age of 37.83 years), consisting of 457 troop-contributing country, 231 U.N. local, and 169 U.N. international personnel. The most common injury was lumbar muscle strain (14.2%). Sports-related mechanism (29.2%) was the most frequent cause of MSIs. The most significant proportions of anatomical regions were the lumbar spine (22.52%), hand (13.77%), and foot (10.97%). No-steroid anti-inflammatory drugs (43.99%), physical therapy (20.54%), and immobilization (11.32%) were the most used treatments.

CONCLUSIONS

MSIs are common diseases in the CHN L2H in the Western Sector of UNMISS. The universality and complexity of MSIs demonstrate the urgent need to improve prevention, treatment, and rehabilitation.

Communicable diseases in humanitarian operations and disasters

Military organisations have battled communicable disease for millennia. They have pioneered disease prevention from the Crusades to the World Wars and continue to do so today. Predeployment vaccinations and chemoprophylaxis are effective in preventing communicable disease, as is reliable vector destruction and bite prevention, especially in the era of multidrug resistant organisms. These measures are unlikely to be fully possible in disasters, but reactive vaccination and efforts to reduce exposure to communicable disease should be a priority. Communicable diseases can be challenging to diagnose-the UK Defence Medical Services have become familiar with tools such as multiplex PCR and mass spectrometry. These have the potential to accurately identify organisms and sensitivity patterns in austere environments. Management of communicable diseases depends on accurate diagnosis and has a largely well-established evidence base but can be limited by a lack of resources and skills in an austere setting, therefore telemedicine can assist diagnosis and treatment of infections by projecting specialist skill. Systems such as EpiNATO2 are useful in monitoring diseases and identifying trends in order to establish control measures. Many of these tools and techniques are effective in austere environments and offer learning opportunities for those providing care in similar settings. Further research is ongoing into diagnostic tools as well as remote management.

Infection Prevention and Control Lead Link Practitioner: a new deployed role piloted on Exercise SAIF SAREEA 3

Disease non-battle injury has plagued British expeditionary forces through the ages. While in recent years significant mortality has reduced, it has had a large impact on operational effectiveness, at times leading to closure of major medical treatment facilities (MTFs).Infection Prevention and Control (IPC) benefits from a subject matter expert and champion to ensure it remains at the front of people's minds and to be on hand to manage acute and dynamic situations. To mitigate the lack of an IPC Nursing Officer, we piloted a deployed military IPC Lead Link Practitioner (IPC-LL) for the first time on a large-scale overseas exercise (SAIF SAREEA 3). An experienced generalist nurse deploying as the IPC-LL (after specific training) provided pre-deployment IPC education and preparation, deployed IPC advice, undertook mandatory audits and monitored IPC compliance throughout the MTFs on the exercise. Data from 22 IPC audits conducted on the exercise showed that the presence of the IPC-LL improved IPC compliance and standards overall in the MTF where based, compared with others. In addition, a gastroenteritis outbreak occurred and was successfully managed with significant input from the IPC-LL. The IPC-LL was also able to add value by pre-empting potential IPC problems from occurring.There is a small pool of deployable Infection Prevention and Control Nursing Officers, so this new IPC-LL role could help to fill the capability gap. The IPC-LL could be the dedicated person focusing on IPC elements, reducing the IPC risk within the deployed field hospital setting where deployed experts are not available.

Aeromedical evacuation: experiences from the UK military level 2 hospital in Bentiu, South Sudan, during Op TRENTON

INTRODUCTION

Aeromedical Evacuation (AE) is a vital role of the Defence Medical Services (DMS). With a far-reaching defence global footprint, an AE capability is crucial to enable movement of patients in the fastest, safest and least stressful way that meets or exceeds the level of care an injured or ill person may expect to receive in the UK. Operation (Op) TRENTON is a UK military humanitarian operation in support of the United Nations (UN) Mission in South Sudan.

METHODS

A retrospective analysis was carried out of all patients who underwent AE from the UK level 2 hospital at Bentiu during Op TRENTON over a 17-month period from June 2017 to October 2018.

RESULTS

14 patients underwent AE. The median age was 36 (22-64) years and all patients were male. 21% of AEs were for UK personnel and 79% were for UN personnel. 29% of AEs were due to non-battle injury with the remainder due to disease. Musculoskeletal was the largest diagnostic group (n=4) followed by respiratory (n=3), cardiovascular (n=2), undifferentiated febrile illness (n=2), neurology (n=1), renal medicine (n=1) and psychiatry (n=1).

CONCLUSIONS

Patients requiring AE from the level 2 hospital at Bentiu mostly had musculoskeletal and medical pathology, a stark contrast to the trauma patient cohort from operations in the past. The majority of patients had definitive care under the medical team highlighting the requirement for DMS physicians and the AE team, to be trained in acute, general and aviation medicine. The majority of AE moves were for UN personnel and on UN airframes, highlighting the importance of a sound understanding of the nations we are working with.

Undifferentiated febrile illnesses in South Sudan: a case series from Operation TRENTON from June to August 2017

Undifferentiated febrile illnesses present diagnostic and treatment challenges in the Firm Base, let alone in the deployed austere environment. We report a series of 14 cases from Operation TRENTON in South Sudan in 2017 that coincided with the rainy season, increased insect numbers and a Relief in Place. The majority of patients had headaches, myalgia, arthralgia and back pain, as well as leucopenia and thrombocytopenia. No diagnoses could be made in theatre, despite a sophisticated deployed laboratory being available, and further testing in the UK, including next-generation sequencing, was unable to establish an aetiology. Such illnesses are very likely to present in tropical environments, where increasing numbers of military personnel are being deployed, and clinicians must be aware of the non-specific presentation and treatment, as well as the availability of Military Infection Reachback services to assist in the management of these cases.

Heat Adaptation in Military Personnel: Mitigating Risk, Maximizing Performance

The study of heat adaptation in military personnel offers generalizable insights into a variety of sporting, recreational and occupational populations. Conversely, certain characteristics of military employment have few parallels in civilian life, such as the imperative to achieve mission objectives during deployed operations, the opportunity to undergo training and selection for elite units or the requirement to fulfill essential duties under prolonged thermal stress. In such settings, achieving peak individual performance can be critical to organizational success. Short-notice deployment to a hot operational or training environment, exposure to high intensity exercise and undertaking ceremonial duties during extreme weather may challenge the ability to protect personnel from excessive thermal strain, especially where heat adaptation is incomplete. Graded and progressive acclimatization can reduce morbidity substantially and impact on mortality rates, yet individual variation in adaptation has the potential to undermine empirical approaches. Incapacity under heat stress can present the military with medical, occupational and logistic challenges requiring dynamic risk stratification during initial and subsequent heat stress. Using data from large studies of military personnel observing traditional and more contemporary acclimatization practices, this review article (1) characterizes the physical challenges that military training and deployed operations present (2) considers how heat adaptation has been used to augment military performance under thermal stress and (3) identifies potential solutions to optimize the risk-performance paradigm, including those with broader relevance to other populations exposed to heat stress.

OP TRENTON 3: An analysis of primary care presentations to a deployed role 1 in support of a United Nation peacekeeping operation

OBJECTIVES

Health data of operational relevance from South Sudan are lacking, outdated and non-representative. This study sets out to record and analyse primary healthcare (PHC) presentations to a deployed UK Level 1 Primary Healthcare Centre (L1 PHC) facility in Bentiu, South Sudan, to inform on disease prevalence for UK Military Personnel in a sub-Saharan Operational environment.

METHODS

A prospective single-centre cohort study was completed for all PHC presentations to a UK L1 PHC facility while deployed on the United Nations Mission to South Sudan from June 2017 to November 2017.

RESULTS

861 episodes of clinical care were recorded at Bentiu Camp during the 6-month period. 82% were from disease; 18% non-battle injuries and no battle injuries were seen. As per EPINATO2 categorisation, the top three presentations were acute gastrointestinal disease, dermatological disease and routine clinical care. Differences were noted for June-August and September-November, as a proportion of total cases seen. It was noted that gastrointestinal illnesses were three times more likely in the first half of the operation and bites and sting almost twice as likely.

CONCLUSIONS

Gastrointestinal disease results in a significant burden on humanitarian operations where an extended Relief-in-Place is a key area of risk. The EPINATO2 reporting tool provides insufficient detail for planning purposes and an improved method of data collection is required. Targeting the diagnosis and management of infectious diseases during predeployment training should prepare L1 PHC for the most common cases encountered. Delivery of targeted Force Health Protection training for all personnel with early deployment of L1 PHC forward could improve support to commanders during the highest risk periods.