The importance of militaries from developing countries in global infectious disease surveillance

Dental service for United Nations peacekeepers coping with COVID-19 in Bukavu: preparation, implementation and recommendation

Background

The Chinese level 2 hospital (CHH L2) deployed in Bukavu provides medical supports to peacekeepers in MONUSCO. This study aimed to statistically analyze the types of oral and maxillofacial problems and corresponding treatments provided from October 2018 to September 2022, and to describe the trends of dental service pre and post COVID-19 outbreak.

Methods

The medical records of all patients visited to the CHN L2 during the 48 months were collected and were accessed for the research purposes between October 2018 and September 2022. Dental visitors were counted and identified with nationality and occupations. Dental service was categorized as emergency, routine and evacuation. Diagnosis and treatments provided were statistically analyzed.

Results

952/3,913 (24.33%) of the visitors to CHN L2 during this period were referred to dentistry, including 50 females (5.25%) and 902 males (94.75%). The proportion of UN military personnel is 91.39% (870/952). A total of 1,116 teeth and mucosa problems were treated. Dental emergencies represented 13.98% percent (156/1, 116). 2,180 dental treatments (2.29 procedures per patient) were provided: dental radiographs taken (618, 28.30%), local anesthesia (448, 20.55%), RCT (373, 15.14%), resin composite filling (330, 15.14%), extraction (248, 11.38%) and other treatments (164, 7.52%). The number of monthly visitors was significantly affected by the COVID-19 epidemic (p < 0.05), pre-COVID-19 (total 151 ± 51, dental 33 ± 13) and post-COVID-19 (total 51 ± 21, dental 13 ± 8), the lowest number was in July 2020, 6 months after the COVID-19 outbreak (total 16 and dental 3).

Conclusions

Dentistry is the most frequently visited department in the CHH L2 in Bukavu, and the number of visitors were affected by the COVID-19 epidemic. Treatments related to dental caries, pulpitis, apical periodontitis, and wisdom teeth problems account for the majority of dental service. The variety and severity of dental problems demonstrate the urgent need for training in multiple specialized skills for deployed military dental personnel.

The Rise of the Militarized State? African Developmental Militarism, Public Works Projects, and Praetorian Politics in Kenya

This article analyses the civil–military relations in Kenya in the context of civilian-activated politicization that is taking place the same way it happens in Latin America and the United States under the former Trump administration. In Kenya, this involves the use of the military in noncombat internal missions such as infrastructure development and management of public institutions especially where such institutions are perceived to be inefficient due to corruption both in public and private sectors. Judging from the outcomes of public works undertaken by the military, corruption and inefficiencies cannot be ruled out. This is demonstrated by the Kenya–Somalia Border Securitization Project where 34 million dollars was used to erect a 10-km fence in the war against terrorism. The outcomes of this study negate the logic of the proponents of developmental militarism in Africa who have been vocal in advocating the deployment of the soldiers to solve noncombat social challenges in the continent. Based on three case studies examined, deploying the military to engage in public works projects brings the military into a political minefield, is not productive, and proves to be an unreliable way to combat internal political corruption.

A Scoping Review of Non-Communicable Diseases among the Workforce as a Threat to Global Peace and Security in Low-Middle Income Countries

Non-communicable diseases (NCDs) continue to pose a threat to public health. Although their impact on the workforce is widely recognized, there needs to be more understanding of how NCDs affect peace and security, particularly in low-middle-income countries. To address this, we conducted a scoping review and presented a narrative to explore how NCDs in the workforce threaten peace and security. Out of 570 papers screened, 34 articles, comprising 26 peer review and 8 grey literature, met the study criteria. Our findings reveal that while no study has drawn a direct relationship between NCDs in the workforce in LMICs and peace and security, several studies have demonstrated a relationship between NCDs and economic growth on one hand and economic growth and peace and security on the other. Therefore, using economic growth as a proximal factor, our findings show three pathways that link NCDs in the workforce to peace and security: (i) NCDs lead to low productivity and poor economic growth, which can threaten public peace and security; (ii) NCDs in the workforce can result in long-term care needs, which then puts pressure on public resources and have implications for public expenditure on peace and security; and (iii) household expenditures on caring for a family member with an NCD can destabilize families and create an unfavourable condition that threatens peace and security. This research highlights the dual threat of NCDs to health and security, as they impact human resources and community structures crucial for peace and security. The results underscore the importance of considering the workplace as a strategic setting for NCD prevention, which will have long-term implications for economic growth and peace and security.

A Historical Review of Military Medical Strategies for Fighting Infectious Diseases: From Battlefields to Global Health

The environmental conditions generated by war and characterized by poverty, undernutrition, stress, difficult access to safe water and food as well as lack of environmental and personal hygiene favor the spread of many infectious diseases. Epidemic typhus, plague, malaria, cholera, typhoid fever, hepatitis, tetanus, and smallpox have nearly constantly accompanied wars, frequently deeply conditioning the outcome of battles/wars more than weapons and military strategy. At the end of the nineteenth century, with the birth of bacteriology, military medical researchers in Germany, the United Kingdom, and France were active in discovering the etiological agents of some diseases and in developing preventive vaccines. Emil von Behring, Ronald Ross and Charles Laveran, who were or served as military physicians, won the first, the second, and the seventh Nobel Prize for Physiology or Medicine for discovering passive anti-diphtheria/tetanus immunotherapy and for identifying mosquito Anopheline as a malaria vector and plasmodium as its etiological agent, respectively. Meanwhile, Major Walter Reed in the United States of America discovered the mosquito vector of yellow fever, thus paving the way for its prevention by vector control. In this work, the military relevance of some vaccine-preventable and non-vaccine-preventable infectious diseases, as well as of biological weapons, and the military contributions to their control will be described. Currently, the civil-military medical collaboration is getting closer and becoming interdependent, from research and development for the prevention of infectious diseases to disasters and emergencies management, as recently demonstrated in Ebola and Zika outbreaks and the COVID-19 pandemic, even with the high biocontainment aeromedical evacuation, in a sort of global health diplomacy.

Civil-military cooperation in the management of infectious disease outbreaks: a scoping review

INTRODUCTION

Civil-military cooperation (CMC) in infectious disease outbreak responses has become more common, and has its own cooperation dynamics. These collaborations fit WHO's call for multisectoral cooperation in managing health emergencies according to the emergency management cycle (EMC). However, the literature on CMC on this topic is fragmented. The core aim of this review is to understand the breadth and dynamics of this cooperation by using the EMC as a framework and by identifying challenges and opportunities in the management of outbreaks.

METHODS

A scoping review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guideline was conducted. A systematic search for peer-reviewed journals was performed in PubMed, Embase, Web of Science and Scopus. Eligible papers addressed substantive contributions to the understanding of CMC. Papers were categorised by EMC phase and relevant information on study characteristics and areas of cooperation were extracted from the data. Recurring themes on challenges and opportunities in cooperation were identified by means of qualitative interpretation analysis.

RESULTS

The search resulted in 8360 papers; 54 were included for analysis. Most papers provided a review of activities or expert opinions. CMC was described in all EMC phases, with the fewest references in the recovery phase (n=1). In total, eight areas of CMC were explored. Regarding the better understanding of cooperative dynamics, the qualitative analysis of the papers yielded five recurring themes covering challenges and opportunities in CMC: managing relations, framework conditions, integrating collective activities, governance and civil-military differences.

CONCLUSION

Guided by these five themes, successful CMC requires sustainable relations, binding agreements, transparency, a clear operational perspective and acknowledgement of organisational cultural differences. Early and continuous engagement proves crucial to avoid distrust and tension among stakeholders, frequently caused by differences in strategical goals. Original research on this topic is limited.

The Nigerian Military Public Health Response to COVID-19: A 14-Month Appraisal

The COVID-19 pandemic has caused significant morbidity and mortality since its emergence in December 2019. In Nigeria, the government inaugurated the Presidential Task Force on COVID-19 to coordinate resources while the Nigeria Centre for Disease Control led the public health response. The Nigeria Ministry of Defence Health Implementation Programme (MODHIP), in partnership with the US Army Medical Research Directorate - Africa/Nigeria, responded immediately to the pandemic by establishing a public health emergency operations center to coordinate the military response in support of national efforts. MODHIP has 5 functional units and 6 pillars that coordinate testing, surveillance, case management, risk communication, logistics, research, and infection prevention and control. It developed an incident action plan and each pillar had its own terms of reference to guide specific response activities while preventing duplication of efforts within the military and the Nigeria Centre for Disease Control. In addition, awareness and sensitization sessions were conducted on preventive practices for COVID-19 and infrastructure was provided for hand hygiene and screening at all military facilities. Military laboratories were configured for SARS-CoV-2 testing while selected military health facilities were equipped and designated as COVID-19 treatment centers. Research proposals aimed at better understanding the disease and controlling it were also developed. The traditional combat role of the military was redirected to complement this public health emergency response. In this article, we highlight gaps, opportunities, and lessons to improve military participation in public health emergency response in the future. More funding and multisectoral collaboration with civilian institutions are key to strengthening military public health emergency preparedness and response capabilities.

Publication Trends in Neglected Tropical Diseases of Latin America and the Caribbean: A Bibliometric Analysis

(1) Background: Neglected tropical diseases (NTDs) have been overlooked on the global health agenda and in the priorities of national systems in low- and middle-income countries (LMICs). In 2012, the Sustainable Development Goals (SDGs) were created to ensure healthy lives and promoting well-being for all. This roadmap set out to accelerate work to overcome the global impact of NTDs. Almost a decade has passed since NTDs were re-launched as a global priority. Investment in research and development, as well as the production of scientific literature on NTDs, is expected to have increased significantly. (2) Methods: A bibliometric analysis of the scientific production of Latin America and the Caribbean (LAC) was carried out in relation to 19 endemic NTDs. These data were compared with the scientific production in malaria, tuberculosis, and HIV/AIDS. The database available from Thomson Reuters Web of Science (WoS) was used. In addition, the average annual growth percentage was calculated for each disease. (3) Results: In the last decade, the NTDs with the highest number of publications in the world were dengue and leishmaniasis. The United States was the most prolific country in the world in 15 out of 19 NTDs analyzed. In the LAC region, Brazil was the largest contributor for 16 of the 19 NTDs analyzed. Arboviral diseases showed the highest average annual growth. The number of publications for malaria, tuberculosis and HIV/AIDS was considerably higher than for NTDs. The contribution of most LAC countries, especially those considered to be LMICs, is inadequate and does not reflect the relevance of NTDs for the public health of the population. (4) Conclusions: This is the first bibliometric analysis to assess the trend of scientific documents on endemic NTDs in LAC. Our results could be used by decision makers both to strengthen investment policies in research and development in NTDs.

Military Participation in Health Security: Analysis of Joint External Evaluation Reports and National Action Plans for Health Security

Militaries around the world play an important but at times poorly defined and underappreciated role in global health security. They are often called upon to support civilian authorities in humanitarian crises and to provide routine healthcare for civilians. Military personnel are a unique population in a health security context, as they are highly mobile and often deploy to austere settings domestically and internationally, which may increase exposure to endemic and emerging infectious diseases. Despite the role of militaries, few studies have systematically evaluated their involvement in global health security activities including the Global Health Security Agenda. We analyzed Joint External Evaluation (JEE) mission reports (n = 94) and National Action Plan for Health Security plans (n = 12), published as of July 2020, to determine the extent to which military organizations were involved in the evaluation process, military involvement in health security activities were described, and specific recommendations were provided for the country's military. For JEE reports, descriptions of military involvement were highest in 3 of the 4 core areas: Respond (76%), Prevent (39%), and Detect (32%). Similarly, National Action Plan for Health Security plans mentioned military involvement in the same 3 core areas: Respond (58%), Prevent (33%), and Detect (33%). Only 28% of JEE reports provided recommendations for the military in any of the core areas. Our results indicate that military roles and contributions are incorporated into some aspects of country-level health security activities, but that more extensive involvement may be warranted to improve national capabilities to prevent, detect, and respond to infectious disease threats.

Malaria prevalence, knowledge, perception, preventive and treatment behavior among military in Champasak and Attapeu provinces, Lao PDR: a mixed methods study

Background

Malaria is a major health problem in Lao People's Democratic Republic (Lao PDR) with high transmission in remote and forest areas, particularly in the South. The military is at risk of malaria infection especially those deployed in forest areas. This study determined the prevalence of malaria infection and assessed knowledge, perception, and preventive and treatment behavior regarding malaria among military personnel in two southern provinces in Lao PDR.

Methods

Quantitative and qualitative approaches were undertaken in Champasak and Attapeu provinces in 2017. From 313 military personnel, quantitative data were collected through questionnaire-based interviews and blood samples used for parasite detection by polymerase chain reaction (PCR). Qualitative data were collected through 7 focus group discussions and 17 in-depth interviews among 49 military personnel. Fisher's exact test and Mann-Whitney U test were used to assess the association between malaria infection and participant characteristics. Content analysis for qualitative data was performed to explore perception and treatment behaviors regarding malaria.

Results

The prevalence of malaria infection was 11.2% (Plasmodium falciparum: 1.3%, Plasmodium vivax: 9.3% and mixed infections: 0.6%). Many participants understood that malaria is transmitted through mosquito bites, although they did not necessarily know the name of vector mosquitoes (Anopheles). Surprisingly, more than a half also believed that malaria is transmitted through drinking stream water. One-third of the participants used long-lasting insecticidal nets. Due to limited supply, participants were often unable to use mosquito repellent and coils when necessary. Because participants were unable to receive timely diagnosis and appropriate treatment for malaria in their camps, they commonly practiced self-treatment using antibiotics, painkillers, and/or traditional medicines. They only go to a healthcare facility through their supervisor if their conditions worsen.

Conclusions

The prevalence of symptomatic and asymptomatic malaria was conspicuous among military in forest areas. Many participants believed that malaria is transmitted not only by mosquito bites but also from drinking stream water. Preventive equipment was often insufficient. Self-treatment was practiced before referring to healthcare facility. To further prevent military from contracting malaria, the National Malaria Control Program and military body should provide adequate and suitable health education, protective equipment, and on-site malaria case management.

Lessons learned from twelve years of HIV Seroprevalence and Behavioral Epidemiology Risk Survey (SABERS) development and implementation among foreign militaries

Circumstances within the military environment may place military personnel at increased risk of contracting sexually transmitted infections including HIV. Since 2005, RTI International has provided technical assistance to the Seroprevalence and Behavioral Epidemiology Risk Surveys (SABERS) program and supported the development and implementation of SABERS survey instruments in 18 countries. RTI staff collaborated with the Department of Defense HIV/AIDS Prevention Program and host country military and health care leadership to develop a fully tested, culturally appropriate survey and data collection instrument and build local capacity by identifying and training local interviewers. We summarize the critical steps, challenges faced, and lessons learned from 12 years' experience developing, testing, and implementing SABERS instruments among military populations in Africa, Asia, and the Caribbean.

Strategies to Prevent Cholera Introduction during International Personnel Deployments: A Computational Modeling Analysis Based on the 2010 Haiti Outbreak

BACKGROUND

Introduction of Vibrio cholerae to Haiti during the deployment of United Nations (UN) peacekeepers in 2010 resulted in one of the largest cholera epidemics of the modern era. Following the outbreak, a UN-commissioned independent panel recommended three pre-deployment intervention strategies to minimize the risk of cholera introduction in future peacekeeping operations: screening for V. cholerae carriage, administering prophylactic antimicrobial chemotherapies, or immunizing with oral cholera vaccines. However, uncertainty regarding the effectiveness of these approaches has forestalled their implementation by the UN. We assessed how the interventions would have impacted the likelihood of the Haiti cholera epidemic.

METHODS AND FINDINGS

We developed a stochastic model for cholera importation and transmission, fitted to reported cases during the first weeks of the 2010 outbreak in Haiti. Using this model, we estimated that diagnostic screening reduces the probability of cases occurring by 82% (95% credible interval: 75%, 85%); however, false-positive test outcomes may hamper this approach. Antimicrobial chemoprophylaxis at time of departure and oral cholera vaccination reduce the probability of cases by 50% (41%, 57%) and by up to 61% (58%, 63%), respectively. Chemoprophylaxis beginning 1 wk before departure confers a 91% (78%, 96%) reduction independently, and up to a 98% reduction (94%, 99%) if coupled with vaccination. These results are not sensitive to assumptions about the background cholera incidence rate in the endemic troop-sending country. Further research is needed to (1) validate the sensitivity and specificity of rapid test approaches for detecting asymptomatic carriage, (2) compare prophylactic efficacy across antimicrobial regimens, and (3) quantify the impact of oral cholera vaccine on transmission from asymptomatic carriers.

CONCLUSIONS

Screening, chemoprophylaxis, and vaccination are all effective strategies to prevent cholera introduction during large-scale personnel deployments such as that precipitating the 2010 Haiti outbreak. Antimicrobial chemoprophylaxis was estimated to provide the greatest protection at the lowest cost among the approaches recently evaluated by the UN.

The effectiveness of the department of defense's field manual 3-11 in detecting, deterring and degrading the breach of a combat base by a human-borne with bioagent (HBBA): perceptions of security personnel

BACKGROUND

The department of defense's FM 3-11 is among the military's field manuals for preparing for, reacting to and recovering from chemical, biological, radiological and nuclear attacks. Since post 9-11, U.S. military service members have been deployed in the global war on terrorism. This study attempted to determine the effectiveness of the FM 3-11 in detecting, deterring or preventing a human-borne with bioagent (HBBA) terrorist breach at an entry control point (ECP).

METHOD

This time-specific, cross-sectional study disseminated a validated survey tool with Cronbach's α > 0.82 to respondents who have had antiterrorism training and combat ECP experience. The return rate was greater than 75.0 %; however, many of the respondents failed to meet the inclusion criteria. Consequently, only 26 questionnaires were included in the sample.

RESULTS

The results revealed that while over 60.0 % of the respondents either strongly agreed or agreed that biointelligence, the deployment of biodetectors and the use of biowarning systems could be effective in preventing an ECP breach by a terrorist with a bioagent, the use of protective equipment and immunization to decontaminate service members or other TTPs would never prevent a breach. A large percentage of respondents claimed that soldiers at the ECP lacked the devices or the knowledge to detect an HBBA at an ECP, and 72.0 % suggested modifying current ECP TTPs to include education, training and equipment for security personnel at military base ECPs.

CONCLUSION

If obtained from appropriate sources and communicated to the personnel at the ECP in an effective or timely manner, the possible effectiveness of certain TTPs in the FM 3-11, specifically FM 3-11.86 (intelligence), might increase.

The possibility of a human-borne with bioagent (HBBA) terrorist at foreign FOB ECPs: the perceptions of U.S. military or security personnel, a preliminary report

BACKGROUND

The global war on terrorism has prompted an increase in the deployment of security personnel from multi-national forces on foreign lands, especially in places where known terrorist groups are based. The aim of this study was to obtain U.S. military and security personnel's perceptions of the possibility of encountering a human-borne with bioagent (HBBA) terrorist at an entry control point (ECP).

METHODS

This study was a mixed-method, cross-sectional, survey-based, time-limited study. A validated, five-option Likert scale questionnaire with Cronbach's alphas of 0.82 and 0.894 for Constructs 1 and 2 was distributed to over 113 respondents with combat experience.

RESULTS

The results indicated that 92.3 % of the respondents thought it was possible for a terrorist to employ a biological agent to cause terror; 61.5 % claimed it was either possible or very possible, and 26.9 % claimed it was somewhat possible for a terrorist carrying a biological agent to successfully breach a combat Forward Operating Bases (FOB) ECP undetected. 26.9 % of the respondents agreed that "ECP soldiers are knowledgeable about bioagents (BA)", only 15.4 % responded that ECP soldiers have effective devices for detecting a BA on a terrorist at an ECP.

CONCLUSION

Despite some limitations, this pre-study tends to indicate that while many U.S. military or security personnel acknowledge the possibility of an HBBA terrorist breach and the vulnerability of U.S. combat post ECPs to a BA breach, the soldiers at the ECPs lack adequate knowledge or devices to effectively detect a BA on a terrorist at an ECP.

Emerging and re-emerging infectious diseases: challenges and opportunities for militaries

The communal nature of living and training environments, alongside suboptimal hygiene and stressors in the field, place military personnel at higher risk of contracting emerging infectious diseases. Some of these diseases spread quickly within ranks resulting in large outbreaks, and personnel deployed are also often immunologically naïve to otherwise uncommonly-encountered pathogens. Furthermore, the chance of weaponised biological agents being used in conventional warfare or otherwise remains a very real, albeit often veiled, threat. However, such challenges also provide opportunities for the advancement of preventive and therapeutic military medicine, some of which have been later adopted in civilian settings. Some of these include improved surveillance, new vaccines and drugs, better public health interventions and inter-agency co-operations. The legacy of successes in dealing with infectious diseases is a reminder of the importance in sustaining efforts aimed at ensuring a safer environment for both military and the community at large.

The Great East Japan Earthquake: a need to plan for post-disaster surveillance in developed countries

After a devastating earthquake and tsunami struck north-eastern Japan in March 2011, the public health system, including the infectious disease surveillance system, was severely compromised. While models for post-disaster surveillance exist, they focus predominantly on developing countries during the early recovery phase. Such models do not necessarily apply to developed countries, which differ considerably in their baseline surveillance systems. Furthermore, there is a need to consider the process by which a surveillance system recovers post-disaster. The event in Japan has highlighted a need to address these concerns surrounding post-disaster surveillance in developed countries. In May 2011, the World Health Organization convened a meeting where post-disaster surveillance was discussed by experts and public health practitioners. In this paper, we describe a post-disaster surveillance approach that was discussed at the meeting, based on what had actually occurred and what may have been, or would be, ideal. Briefly, we describe the evolution of a surveillance system as it returns to the pre-existing system, starting from an event-based approach during the emergency relief phase, a syndromic approach during the early recovery phase, an enhanced sentinel approach during the late recovery phase and a return to baseline during the development phase. Our aim is not to recommend a specific model but to encourage other developed countries to initiate their own discussions on post-disaster surveillance and develop plans according to their needs and capacities. As natural disasters will continue to occur, we hope that developing such plans during the "inter-disaster" period will help mitigate the surveillance challenges that will arise post-disaster.

A growing global network's role in outbreak response: AFHSC-GEIS 2008-2009

A cornerstone of effective disease surveillance programs comprises the early identification of infectious threats and the subsequent rapid response to prevent further spread. Effectively identifying, tracking and responding to these threats is often difficult and requires international cooperation due to the rapidity with which diseases cross national borders and spread throughout the global community as a result of travel and migration by humans and animals. From Oct.1, 2008 to Sept. 30, 2009, the United States Department of Defense's (DoD) Armed Forces Health Surveillance Center Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) identified 76 outbreaks in 53 countries. Emerging infectious disease outbreaks were identified by the global network and included a wide spectrum of support activities in collaboration with host country partners, several of which were in direct support of the World Health Organization's (WHO) International Health Regulations (IHR) (2005). The network also supported military forces around the world affected by the novel influenza A/H1N1 pandemic of 2009. With IHR (2005) as the guiding framework for action, the AFHSC-GEIS network of international partners and overseas research laboratories continues to develop into a far-reaching system for identifying, analyzing and responding to emerging disease threats.

Beyond traditional surveillance: applying syndromic surveillance to developing settings--opportunities and challenges

BACKGROUND

All countries need effective disease surveillance systems for early detection of outbreaks. The revised International Health Regulations [IHR], which entered into force for all 194 World Health Organization member states in 2007, have expanded traditional infectious disease notification to include surveillance for public health events of potential international importance, even if the causative agent is not yet known. However, there are no clearly established guidelines for how countries should conduct this surveillance, which types of emerging disease syndromes should be reported, nor any means for enforcement.

DISCUSSION

The commonly established concept of syndromic surveillance in developed regions encompasses the use of pre-diagnostic information in a near real time fashion for further investigation for public health action. Syndromic surveillance is widely used in North America and Europe, and is typically thought of as a highly complex, technology driven automated tool for early detection of outbreaks. Nonetheless, low technology applications of syndromic surveillance are being used worldwide to augment traditional surveillance.

SUMMARY

In this paper, we review examples of these novel applications in the detection of vector-borne diseases, foodborne illness, and sexually transmitted infections. We hope to demonstrate that syndromic surveillance in its basic version is a feasible and effective tool for surveillance in developing countries and may facilitate compliance with the new IHR guidelines.