Assessing the Acceptability and Feasibility of a Web-Based Screening for Psychoactive Substance Users Among a French Sample of University Students and Workers: Mixed Methods Prospective Study

Background

Early detection in the prevention of addictive behaviors remains a complex question in practice for most first-line health care workers (HCWs). Several prevention measures have successfully included a screening stage followed by a brief intervention in case of risk-related use or referral to an addiction center for problematic use. Whereas early detection is highly recommended by the World Health Organization, it is not usually performed in practice.

Objective

The aim of this study was to assess the acceptability and feasibility of a web-based app, called Pulsio Santé, for health service users and first-line prevention HCW and to carry out an exhaustive process of early detection of psychoactive substance use behaviors.

Methods

A mixed methods prospective study was conducted in 2 departments: HCWs from the regional occupational health department and from the university department of preventive medicine dedicated to students were invited to participate. Participants 18 years or older who had been seen in 2017 by a HCW from one of the departments were eligible. The study procedure comprised 5 phases: (1) inclusion of the participants after a face-to-face consultation with an HCW; (2) reception of a text message by participants on their smartphone or by email; (3) self-assessment by participants regarding their substance use with the Pulsio Santé app; (4) if participants agreed, transfer of the results to the HCW; and (5) if participants declined, a message to invite them to get in touch with their general practitioner should the assessment detect a risk. Several feasibility and acceptability criteria were assessed by an analysis of a focus group with the HCW that explored 4 themes (usefulness and advantages, problems and limitations, possible improvements, and finally, integration into routine practice).

Results

A total of 1474 people were asked to participate, with 42 HCWs being involved. The percentage of people who agreed to receive a text message or an email, which was considered as the first level of acceptability, was 79.17% (1167/1474). The percentage of participants who clicked on the self-assessment link, considered as the second level of acceptability, was 60.24% (703/1167). The percentage of participants who completed their self-evaluation entirely, which was considered as the first level of feasibility, was 76.24% (536/703). The percentage of participants who shared the results of their evaluation with the HCWs, considered as the second level of feasibility, was 79.48% (426/536). The qualitative study showed that there were obstacles on the side of HCWs in carrying out the recommended interventions for people at risk based on their online screening, such as previous training or adaptations in accordance with specific populations.

Conclusions

Quantitative results showed good acceptability and feasibility of the Pulsio Santé app by users and HCWs. There is a need for further studies more directly focused on the limitations highlighted by the qualitative results.

Impact at two years of an intervention on empowerment among medical care teams: study protocol of a randomised controlled trial in a large French university hospital

BACKGROUND

Empowerment of hospital workers is known as a key factor of organizational performance and occupational health. Nevertheless, empowering workers remains a real challenge. As in many traditional organizations, hospitals follow a bureaucratic model defined by a managerial culture of control and a stratified organization, which at once weaken professionals' mastery of their work and hinder their commitment and performance. Based on the existing literature this protocol describes a new managerial and organizational transformation program as well as the study design of its effect on worker empowerment in a large French public hospital. The project is funded by the French Ministry of Health for a total of 498,180 €.

METHODS

This study is a randomized controlled trial conducted in a French university hospital complex (CHU). The CHU comprises 12 sub-centers (SC) with about 20 care units and 1000 employees each. Randomization is performed at SC level. The intervention lasts 12 months and combines accompaniment of healthcare teams, frontline managers and SC directors to empower first-line professionals in the experimental SC. Quantitative outcome measurements are collected over 2 years during mandatory check-ups in the occupational medicine department. The primary outcomes are structural and psychological empowerment, motivational processes, managerial practices, working conditions, health and performance. Mixed linear modeling is the primary data analysis strategy.

DISCUSSION

The protocol was approved by the CHU health ethics committee. The results of the analysis of the intervention effects will be reported in a series of scientific articles. The results will contribute to reflection on prevention and management policies, and to the development of Workplace Quality-of-Life. If the intervention is a success, the system will warrant replication in other SCs and in other health facilities.

TRIAL REGISTRATION

The study was retrospectively registered at ClinicalTrials.gov on July 4, 2019 (NCT04010773).

Syndromic surveillance of potentially epidemic infectious diseases: Detection of a measles epidemic in two health centers in Gabon, Central Africa

Measles is a respiratory disease caused by the measles virus (MV) belonging to the Paramyxovirus family and the Morbillivirus genus. Due to a failure in maintaining immunization coverage in some countries, measles is a re-emerging disease in the human population, especially in Africa. The aim of this study was to describe a measles epidemic in Gabon. At first, a syndromic surveillance was set up. Blood samples from febrile patients with maculopapular rash were taken and sent to the measles reference center in Cameroon for laboratory confirmation. Between March and May 2016, 79 clinically suspected cases were reported including 82.3% (n=65) and 17.7% (n=14) in Oyem and Libreville, respectively. In total, 39.2% (n=31) of children were 11 months-old, 34.2% (n=27) were children aged 1 to 4 years, 11.4% (n=9) were older children from 5 to 9 years, 6.3% (n=5) of children were aged 10 to 15 years and 8.9% (n=7) were 15 years and older. 53.3% (16/30) were laboratory confirmed. This measles outbreak reiterates the importance of maintaining a high level of vaccine coverage in Gabon for vaccine-preventable diseases, as well as the usefulness of a near-real-time surveillance system for the detection of infectious diseases.

Ross River Virus Seroprevalence, French Polynesia, 2014-2015

Ross River virus (RRV), spread by Aedes and Culex mosquitoes, is the most commonly transmitted arbovirus in Australia. A serosurvey of blood donors in French Polynesia during 2011–2013 suggested that RRV circulated without being detected. We report RRV circulation in French Polynesia based on further screening of blood samples collected during 2014–2015.

Seroprevalence of Dengue and Chikungunya Virus Antibodies, French Polynesia, 2014-2015

We investigated dengue and chikungunya virus antibody seroprevalence in French Polynesia during 2014-2015. Dengue virus seroprevalence was ≈60% among schoolchildren and >83% among the general population; chikungunya virus seroprevalence was <3% before and 76% after Zika virus emergence (2013). Dengue virus herd immunity may affect Zika virus infection and pathogenesis.

Implementation and Initial Analysis of a Laboratory-Based Weekly Biosurveillance System, Provence-Alpes-Côte d'Azur, France

We describe the implementation of an automated infectious disease surveillance system that uses data collected from 210 microbiologic laboratories throughout the Provence-Alpes-Côte d’Azur region in France. Each week, these facilities report bacterial species that have been isolated from patients in their area. An alarm is triggered whenever the case count for a bacterial species infection exceeds 2 SDs of the historical mean for that species at the participating laboratory. At its inception in July 2013, the system monitored 611 bacterial species. During July 1, 2013–March 20, 2016, weekly analyses of incoming surveillance data generated 34 alarms signaling possible infectious disease outbreaks; after investigation, 14 (41%) of these alarms resulted in health alerts declared by the regional health authority. We are currently improving the system by developing an Internet-based surveillance platform and extending our surveillance to include more laboratories in the region.

Factor associated with risky sexual behaviors among the French general population

Background

Despite prevention programs, a rising incidence of sexually transmitted infections is currently reported in France.

Aims

Research factors associated with risky sexual behaviors (RSBs) among the French population.

Methods

Subjects aged 15-54 years from the French national survey 'Baromètre santé 2010' were included (n = 16 598). RSB was defined as having multiple partners or failure to use condom at first intercourse with a new partner over past 12 months. Factors associated were identified using one logistic regression by gender.

Results

The overall RSB prevalence was 9.5%, being higher among men (P < 0.001). Factors associated with RSB for both genders were young age (OR = 1.5), single status (men: OR = 7.1; women: OR = 6.4), homosexual relations (men: OR = 2.0; women: OR = 3.2), low incomes (men: OR = 1.5; women: OR = 1.4), use of cannabis (men: OR = 1.4; women: OR = 3.0). Men-specific factors were history of STI (OR = 2.5) and alcohol drunkenness (OR = 2.2), and women-specific factors history of suicide attempt (OR = 1.6) and history of sexual assault (OR = 1.6).

Conclusions

Confirming most of known determinants of RSB, this study also identified some specific risky patterns for whom preventive actions can be developed: multiusers of psychoactive substances, people living with low incomes, women having sex with women or presenting history of psychological vulnerability (suicide attempts, sexually harassed).

Building test data from real outbreaks for evaluating detection algorithms

Benchmarking surveillance systems requires realistic simulations of disease outbreaks. However, obtaining these data in sufficient quantity, with a realistic shape and covering a sufficient range of agents, size and duration, is known to be very difficult. The dataset of outbreak signals generated should reflect the likely distribution of authentic situations faced by the surveillance system, including very unlikely outbreak signals. We propose and evaluate a new approach based on the use of historical outbreak data to simulate tailored outbreak signals. The method relies on a homothetic transformation of the historical distribution followed by resampling processes (Binomial, Inverse Transform Sampling Method-ITSM, Metropolis-Hasting Random Walk, Metropolis-Hasting Independent, Gibbs Sampler, Hybrid Gibbs Sampler). We carried out an analysis to identify the most important input parameters for simulation quality and to evaluate performance for each of the resampling algorithms. Our analysis confirms the influence of the type of algorithm used and simulation parameters (i.e. days, number of cases, outbreak shape, overall scale factor) on the results. We show that, regardless of the outbreaks, algorithms and metrics chosen for the evaluation, simulation quality decreased with the increase in the number of days simulated and increased with the number of cases simulated. Simulating outbreaks with fewer cases than days of duration (i.e. overall scale factor less than 1) resulted in an important loss of information during the simulation. We found that Gibbs sampling with a shrinkage procedure provides a good balance between accuracy and data dependency. If dependency is of little importance, binomial and ITSM methods are accurate. Given the constraint of keeping the simulation within a range of plausible epidemiological curves faced by the surveillance system, our study confirms that our approach can be used to generate a large spectrum of outbreak signals.

Acute acoustic trauma in the French armed forces during 2007-2014

CONTEXT

Despite existing preventive measures, the number of acute acoustic trauma (AAT) cases reported to the French Military Epidemiological Surveillance System (MESS) remains high.

AIMS

The objective of this study was to describe AAT and the preventive measures already implemented.

SUBJECTS AND METHODS

We conducted a descriptive cross-sectional analysis of AAT using data from the MESS for the period 2007-2014. In addition, we reviewed the current prevention measures that exist in the French armed forces.

STATISTICAL ANALYSIS USED

Comparisons between different incidence rates were made by Poisson and quasi-Poisson regression.

RESULTS

Between 2007 and 2014, 10,487 AAT cases were reported to the MESS, with a significant decrease in 2013 (P < 0.001). AAT incidence rates were the highest among those aged <25 years - 14.3 per 1000 person-years (PYs) (P < 0.001), and those in the army; with 8.1 per 1000 PYs (P < 0.001), and men had almost twice the risk of women (P < 0.001). AAT mainly occurred in training schools or at camps during exercises. The main prevention actions identified were the following: official regulations, education, making hearing protection devices (HPDs) available for all service members, and regular hearing monitoring. A working group has been set up and has proposed an informative chapter in the weapon handling instruction book, an AAT simulator, and a new HPD, the 3M® earplug, with an information brochure.

CONCLUSIONS

AAT rates decreased from 2007 to 2014 in the French armed forces. Further analysis is needed to identify the underlying factors involved to improve the prevention actions proposed. The MESS and targeted surveys will assess the impact of the different prevention measures implemented.

Zika Virus Seroprevalence, French Polynesia, 2014-2015

During 2013-2014, French Polynesia experienced an outbreak of Zika virus infection. Serosurveys conducted at the end of the outbreak and 18 months later showed lower than expected disease prevalence rates (49%) and asymptomatic:symptomatic case ratios (1:1) in the general population but significantly different prevalence rates (66%) and asymptomatic:symptomatic ratios (1:2) in schoolchildren.

Herbal Medicine Practices of Patients With Liver Cancer in Peru: A Comprehensive Study Toward Integrative Cancer Management

Rationale: The highest burden of liver cancer occurs in developing countries, where the use of herbal medicine (HM) is still widespread. Despite this trend, few studies have been conducted to report HM practices of patients with a hepatic tumor in the developing world. Hence, this study aimed to document the use of HM among patients with liver cancer in Peru. Study Design and Methods: A comparative behavioral epidemiological survey was conducted among liver cancer patients attending the National Cancer Institute of Peru. Information was obtained by direct interviews based on a semistructured questionnaire. The use of HM in Peruvian liver cancer patients was reported, first, regarding general consumption prior to the onset of disease, and second, after the appearance of symptoms that patients would relate to their tumor. In parallel, general consumption of HM in noncancerous people was assessed as a comparative figure. A correspondence analysis was performed to reveal potential associations between the symptoms of cancer and the specific use of HM. Results: Eighty-eight patients and 117 noncancerous individuals participated in the survey. Overall, 68.3% of the people interviewed claimed to use HM on a regular basis for general health preservation. Furthermore, 56.8% of the patients turned to plants first to treat the disorders for which they later came to the cancer care center. When compared with the number of plant species used routinely (n = 78), a selection of plants was made by patients in response to the symptoms of cancer (n = 46). At least 2 plant species, Aloe vera and Morinda citrifolia, were significantly associated with the treatment of liver cancer–related symptoms in the patient group. Conclusions: The present study is the first survey on the HM practices of patients with liver cancer in Latin America and, more broadly, in the developing world. Our findings confirm that HM remains one of the principal primary health care resources in Peru, even for a severe disease like liver cancer. These traditional, complementary and alternative medicine practices should be taken into consideration in Peruvian health programs aiming to educate the population in cancer prevention and treatment, as well as integrative cancer management.

[Students assessment of teaching method used in the module "Help thesis writing": intended for interns at the Armed Forces Hospitals and held at the Army Center for Epidemiology and Public Health, Marseilles]

INTRODUCTION

Educational assessment focuses on training institutions, programs, teachers or students. It may be predictive, summative or formative. Assessment of teaching by students (ATS) is one of the assessment tools included in the last category.

OBJECTIVE

Assessing teaching of the first part of the "Help thesis writing" training course.

MATERIAL AND METHODS

This is a cross-sectional study classified under the "ATS" agreement and focused on the "Help thesis writing" module provided to 27 participants preparing their end-of-study at CESPA.

RESULTS

Participant representativeness was 100%. F/M sex ratio was 2, the average age was 25.5 years +/- 2.7 years, the respondents were mainly students serving as interns in general medicine. Over 85% of students said he had received no prior training in the treated areas. The participants had expectations that roughly met the objectives of the training. Apart from teaching rhythm which was deemed unsuitable by more than half of participants, 80% of participants were satisfied with the other aspects evaluated and 95.8% of them were planning to attend the second part of training. All the participants judged the training as helpful to significantly improve their knowledge and were certain it might have a positive impact on their research projects.

CONCLUSION

Our study aimed to develop teacher-student complicity in order to achieve a common goal: "IMPROVING THE FORMATION".

Antibiotic therapy and staphylococcal skin infections in a tropical malarial zone (Guyana). Practices in conventional and exceptional situations

A problem of community-acquired Staphylococcus aureus skin infections emerged in the French armed forces in 2004, in a malaria-endemic areas. The high incidence rate led us to evaluate military staff practices. This was a cross-sectional survey of doctors and nurses deployed as officers in French Guyana since 2006. The definition of skin and soft-tissue infection came from the criteria for epidemiological surveillance of the armed forces. We studied the management of antibiotic therapy and its related difficulties. In all, 47 officers responded. At the Military Medical Center (MMC), 23.4% of respondents routinely prescribed antibiotics, compared with 36.2% when stationed in the jungle (p<0.05%). Complication led 68.1 of staff to prescribe antibiotic prescriptions at the MMC, compared with 46.8% in the jungle (p<0.05%). Finally, 22.5% of those at MMC prescribed antibiotic coverage of surgical drainage, compared with 14.8% in the jungle (p<0.05%). Pristinamycin and fusidic acid were the preferred antibiotics. Two-thirds of the staff reported difficulties in jungle management. This first study indicates the need for an update of military medical recommendations. Personnel training must continue to enable them to provide appropriate aggressive management in the current endemic context.

Factors associated with malaria chemoprophylaxis compliance among French service members deployed in Central African Republic

BACKGROUND

Malaria is a public health concern in the French armed forces, with 400-800 cases reported every year and three deaths in the past 2 years. However, lack of chemoprophylaxis (CP) compliance is often reported among service members. The aim of this study was to explore factors associated with CP compliance.

METHODS

A retrospective study (1296 service members) was carried out among troops deployed in Central African Republic. Determinants of CP were collected by self-questionnaire. Socio-demographic variables, behavioural characteristics, belief variables, operational determinants such as troops in contact (TIC) and number of nights worked per week and peer-to-peer reinforcement were studied. Relationships between covariates and compliance were explored using logistic regressions (outcome: compliance as a dummy variable).

RESULTS

Chemoprophylaxis compliance was associated with other individual preventive measures against mosquito bites (bed net use, OR (odds ratio) = 1.41 (95% CI [1.08-1.84]), and insecticide on clothing, OR = 1.90 ([1.43-2.51]) and malaria-related behaviours (taking chemoprophylaxis at the same time every day, OR = 2.37 ([1.17-4.78]) and taking chemoprophylaxis with food, OR = 1.45 ([1.11-1.89])). High perceived risk of contracting malaria, OR = 1.59 ([1.02-2.50]), positive perception of CP effectiveness, OR = 1.62 ([1.09-2.40]) and the practice of peer-to-peer reinforcement, OR = 1.38 ([1.05-1.82]) were also associated with better compliance. No association was found with TIC and number of nights worked.

CONCLUSIONS

This study, which shows a positive relationship between peer-to-peer reinforcement and CP compliance, also suggests the existence of two main personality profiles among service members: those who seek risks and those who are health-conscious. Health education should be expanded beyond knowledge, know-how and motivational factors by using a comprehensive approach based on identification of health determinants, development of psychosocial skills and peer-to-peer reinforcement.

Outbreak definition by change point analysis: a tool for public health decision?

Background

Most studies of epidemic detection focus on their start and rarely on the whole signal or the end of the epidemic. In some cases, it may be necessary to retrospectively identify outbreak signals from surveillance data. Our study aims at evaluating the ability of change point analysis (CPA) methods to locate the whole disease outbreak signal. We will compare our approach with the results coming from experts’ signal inspections, considered as the gold standard method.

Methods

We simulated 840 time series, each of which includes an epidemic-free baseline (7 options) and a type of epidemic (4 options). We tested the ability of 4 CPA methods (Max-likelihood, Kruskall-Wallis, Kernel, Bayesian) methods and expert inspection to identify the simulated outbreaks. We evaluated the performances using metrics including delay, accuracy, bias, sensitivity, specificity and Bayesian probability of correct classification (PCC).

Results

A minimum of 15 h was required for experts for analyzing the 840 curves and a maximum of 25 min for a CPA algorithm. The Kernel algorithm was the most effective overall in terms of accuracy, bias and global decision (PCC = 0.904), compared to PCC of 0.848 for human expert review.

Conclusions

For the aim of retrospectively identifying the start and end of a disease outbreak, in the absence of human resources available to do this work, we recommend using the Kernel change point model. And in case of experts’ availability, we also suggest to supplement the Human expertise with a CPA, especially when the signal noise difference is below 0.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0271-x) contains supplementary material, which is available to authorized users.

Epidemiological and entomological studies of a malaria outbreak among French armed forces deployed at illegal gold mining sites reveal new aspects of the disease's transmission in French Guiana

BACKGROUND

In December 2010, a Plasmodium vivax malaria outbreak occurred among French forces involved in a mission to control illegal gold mining in French Guiana. The findings of epidemiological and entomological investigations conducted after this outbreak are presented here.

METHODS

Data related to malaria cases reported to the French armed forces epidemiological surveillance system were collected during the epidemic period from December 2010 to April 2011. A retrospective cohort study was conducted to identify presumed contamination sites. Anopheles mosquitoes were sampled at the identified sites using Mosquito Magnet and CDC light traps. Specimens were identified morphologically and confirmed using molecular methods (sequencing of ITS2 gene and/or barcoding). Anopheles infections with Plasmodium falciparum and P. vivax were tested by both enzyme-linked immunosorbent assay and real-time PCR.

RESULTS

Seventy-two P. vivax malaria cases were reported (three were mixed P. falciparum/P. vivax infections), leading to a global attack rate of 26.5% (72/272). Lack of compliance with vector control measures and doxycycline chemoprophylaxis was reported by patients. Two illegal gold mining sites located in remote areas in the primary forest were identified as places of contamination. In all, 595 Anopheles females were caught and 528 specimens were formally identified: 305 Anopheles darlingi, 145 Anopheles nuneztovari s.l., 63 Anopheles marajoara and 15 Anopheles triannulatus s.l. Three An. darlingi were infected by P. falciparum (infection rate: 1.1%) and four An. marajoara by P. vivax (infection rate: 6.4%).

DISCUSSION

The main drivers of the outbreak were the lack of adherence by military personnel to malaria prevention measures and the high level of malaria transmission at illegal gold mining sites. Anopheles marajoara was clearly implicated in malaria transmission for the first time in French Guiana. The high infection rates observed confirm that illegal gold mining sites must be considered as high level malaria transmission areas in the territory.

CONCLUSIONS

Illegal gold mining activities are challenging the control of malaria in French Guiana. Collaboration with neighbouring countries is necessary to take into account mobile populations such as gold miners. Malaria control strategies in the French armed forces must be adapted to P. vivax malaria and sylvatic Anopheles species.

Surveillance of adverse events following vaccination in the French armed forces, 2011-2012

OBJECTIVES

French military personnel are subject to a compulsory vaccination schedule. The aim of this study was to present the results of surveillance of vaccine adverse events (VAEs) reported from 2011 to 2012 in the French armed forces.

STUDY DESIGN

VAEs were surveyed among all French armed forces from 2011 to 2012 by the epidemiological departments of the military health service. For each case, a notification form providing patient and clinical information was provided.

METHODS

Case definitions were derived from the French drug safety guidelines. Three types of VAE were considered: non-serious, serious and unexpected. Incidence rates were calculated by relating VAEs to the number of vaccine doses delivered.

RESULTS

In total, 161 VAE cases were reported. The overall VAE reporting rate was 24.6 VAEs per 100,000 doses, and the serious VAE rate was 1.3 per 100,000 doses (nine cases). The serious VAEs included two cases of Guillain-Barré syndrome, one case of optic neuritis, one case of a meningeal-like syndrome, one case of rheumatoid purpura, one case of acute asthma and three cases of fainting. The highest rates of VAE were observed with the Bacille Calmette-Guérin vaccine (BCG) (482.3 per 100,000 doses), inactivated diphtheria-tetanus-poliovirus with acellular pertussis vaccine (dTap-IPV) (106.1 per 100,000 doses) and meningococcal quadrivalent glycoconjugate vaccine (MenACWY-CRM) (39.3 per 100,000 doses).

CONCLUSIONS

The global rates of VAE observed in 2011 and 2012 confirm the increase that has been observed since 2009 in the French armed forces, which could reflect improved practitioner awareness about VAEs and the use of certain vaccines added to the vaccination schedule recently (dTap-IPV in 2008 and MenACWY-CRM in 2010). VAEs appear to be relatively rare, particularly serious VAEs, which indicates acceptable tolerance of vaccines.

Chikungunya infection: self-reported rheumatic morbidity and impaired quality of life persist 6 years later

This study presents the 6-year follow-up of French gendarmes exposed to the chikungunya (CHIK) infection in 2006 on Reunion Island. The aim was to see to what extent the subjective health differences observed in 2008 (30 months after infection) between CHIK infected (CHIK+) and noninfected (CHIK-) gendarmes still persisted in 2012, and to investigate a possible return to a pre-CHIK health status for CHIK+ subjects. Gendarmes were contacted by mail in 2012 and asked to complete a self-questionnaire asking for morbidity, health care and medicines consumption since the last follow-up in 2008. Quality of life (QoL) after 6 years was evaluated using the SF-36 scale. In comparison with CHIK- subjects (n = 171), CHIK+ (n = 81) presented with higher rheumatic but also nonspecific morbidity such as headaches and fatigue associated with a large psychological impact, frequent depressive moods and social disabilities, leading to a significant impairment of the QoL and higher health care consumption. When restricted to CHIK+ subjects, comparing the data with that of 2008 showed persistent but decreasing self-reported rheumatic morbidity, and an increase over time of chronic discomfort (headache, fatigue) and depressive moods, resulting in no overall improvement in QoL. Despite possible cohort attrition bias, the comparability of CHIK+/CHIK- subjects allows the assumption of a long-term impact of CHIK infection with less chance of returning to a previous health status. Although these results may be specific to the 2006 virus strain, we recommend that public health strategies in the epidemic-prone countries include a response to the consequences of chronic post-CHIK disorders.

Identification of initial severity determinants to predict arthritis after chikungunya infection in a cohort of French gendarmes

Background

The objective was to identify severity characteristics of initial chikungunya infection (CHIKV) stages associated with post-CHIKV arthritis and arthralgia.

Methods

French gendarmes exposed to the 2005–2006 CHIKV epidemic in Reunion Island who completed the 2006 (self-reporting acute and early chronic [median: 6 months] symptoms) and 2008 (Endpoint [median: 30 months]: self-perceived recovery and rheumatic disorders (RDs)) surveys were included. Multinomial logistic regression and multiple correspondence analysis (MCA) were used. Arthralgia was defined by joint pain and/or stiffness and arthritis by joint swelling in addition to pain and/or stiffness.

Results

In 2008, 124 (31.3%)/403 participants (101 CHIKV+/302 CHIKV-) reported arthralgia and 57 (14.1%) arthritis. The multivariate model kept CHIKV infection, comorbidity and acute stage depressed mood as independent prognostic factors for both arthralgia and arthritis, but found early chronic stage RD as the main determinant of the same RD two years later.

The MCA performed with the 85 CHIKV + patients who answered the question on self-perceived recovery enabled the calculation of severity scores based on initial symptoms that were strongly associated with persistent arthritis and, to a lesser extent, to arthralgia in bivariate analyses. The MCA graph clearly distinguished arthritis as the only RD associated with early severity indicators represented by sick leave, joint swelling and depressed mood during the acute stage, and early chronification of arthritis and depressed mood.

Conclusion

Initial CHIKV severity predicted recovery, with higher severity associated with arthritis and lower severity with arthralgia. More interestingly, specific markers of post-CHIKV arthritis, which can easily be used by clinicians for case management, were identified.

Malaria control strategies in French armed forces

Each year, 40,000 French soldiers deploy or travel through malaria-endemic areas. Despite the effective control measures that were successively implemented, malaria remains a public health concern in French armed forces with several important outbreaks and one lethal case every two years. This article describes the malaria control strategy in French armed forces which is based on three combined strategies: i) Anopheles vector control to prevent infection with the implementation of personal protection against vectors (PPAV) adapted to the field living conditions of the troops. ii) Chemoprophylaxis (CP) to prevent the disease based on prescription of effective and well tolerated doxycycline. iii) Management of cases through early diagnosis and appropriate treatment to prevent death. In isolated conditions in endemic areas, rapid diagnosis tests (RDT) are used as first-line tests by military doctors. Treatment of uncomplicated Plasmodium falciparum (P. falciparum) malaria is based either on the piperaquine tetraphosphate-dihydroartemisinin association since 2013, or on the atovaquone-proguanil association. First-line treatment of severe P. falciparum malaria is based on IV artesunate. These measures are associated with constant education of the military, epidemiological surveillance of malaria cases and monitoring of parasite chemosensitivity.

Kinetics of dengue non-structural protein 1 antigen and IgM and IgA antibodies in capillary blood samples from confirmed dengue patients

Large-scale epidemiological surveillance of dengue in the field and dengue patient management require simple methods for sample collection, storage, and transportation as well as effective diagnostic tools. We evaluated the kinetics of three biological markers of dengue infection-non-structural protein 1 (NS1) antigen, immunoglobulin M (IgM), and IgA-in sequential capillary blood samples collected from fingertips of confirmed dengue patients. The overall sensitivities and specificities of the tests were 96% and 100%, respectively, for NS1, 58.1% and 100%, respectively, for IgM, and 33% and 100%, respectively, for IgA. During the acute phase of the disease, NS1 was the best marker of dengue infection, with a sensitivity of 98.7%, whereas from day 5, all three markers exhibited relevant levels of sensitivity. This first descriptive study of the kinetics of biological markers of dengue in capillary blood samples confirms the usefulness of this biological compartment for dengue diagnosis and argues for its exploitation in community-level and remote settings.

The French Military influenza surveillance system (MISS): overview of epidemiological and virological results during four influenza seasons--2008-2012

QUESTION UNDER STUDY

Influenza is a viral infection caused by a pathogen with considerable ability for genetic mutation, which is responsible for seasonal outbreaks as well as pandemics. This article presents the results of epidemiological and virological monitoring of four successive influenza outbreaks in the French armed forces, for the period 2008 to 2012.

METHODS

The main events monitored were acute respiratory infection (ARI). Weekly incidence rates were calculated by relating cases to the number of servicepersons monitored.

RESULTS

In continental France, the incidence rates for ARI and for medical consultation attributable to influenza were highest during the pandemic and decreased to reach their lowest values in 2010–2011 and 2011–2012. In terms of virological results, the 2008–2009 outbreak was mainly due to the A(H3N2) virus, while the 2009–2010 pandemic and the following season saw the emergence of the A(H1N1) pdm09 strain. The last season 2011–2012 was characterised by a predominant circulation of A(H3N2) viruses.

CONCLUSIONS

Despite some limitations, the MISS represents a good source of information about influenza in young people. Virological results are compatible with those reported by most other influenza surveillance networks, but could be improved by a better knowledge of the other respiratory viruses in circulation in the military community.

Dengue surveillance in the French armed forces: a dengue sentinel surveillance system in countries without efficient local epidemiological surveillance

Surveillance of travel-acquired dengue could improve dengue risk estimation in countries without ability. Surveillance in the French army in 2010 to 2011 highlighted 330 dengue cases, mainly in French West Indies and Guiana: DENV-1 circulated in Guadeloupe, Martinique, French Guiana, New Caledonia, Djibouti; DENV-3 in Mayotte and Djibouti; and DENV-4 in French Guiana.

The accuracy of self-reported data concerning recent cannabis use in the French armed forces

BACKGROUND

The aims were to evaluate the accuracy of self-report of past-month cannabis use in a representative sample of French military staff members and to evaluate the scale of the prevarication bias.

METHOD

Data from three cross-sectional surveys conducted between 2005 and 2008 (n = 3493) were used. The characteristics of self-report (sensitivity, specificity, positive predictive value and negative predictive value) were computed using tetrahydrocannabinol detection in urine as the reference.

RESULTS

The prevalence for past-month cannabis use was 16.1% and for positive testing was 13.4%. The discriminant power of self-report was good, with an area under the receiver operating characteristics curve 0.90. Specificity (94.5%) and negative predictive values (97.8%) were good, but sensitivity (85.7%) and positive predictive values (70.4%) were lower. The lowest sensitivity values were observed in the higher categories of personnel and in the Navy, which could reflect some prevarication in these sub-populations who might believe they were more exposed to sanctions if detected.

CONCLUSIONS

Despite certain limitations of urine analysis as a reference, because of its poor detection of occasional users, our study is in favour of good accuracy of self-reported data on cannabis use, even among the military. However, our results, derived from a population study, do not enable any assumptions on the validity of self-reported data collected during individual testing procedures for the purpose of improving occupational safety.

Adverse events following vaccination in the French armed forces: An overview of surveillance conducted from 2002 to 2010

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Adverse events following vaccination in the French armed forces: An overview of surveillance conducted from 2002 to 2010

French military personnel are subject to a compulsory vaccination schedule. The aim of this study was to describe vaccine adverse events (VAE) reported from 2002 to 2010 in armed forces. VAE are routinely surveyed by the military Centre for epidemiology and public health. For each case, military practitioners fill a notification form, providing patient characteristics, clinical information and vaccines administered. For this study, VAE following influenza A(H1N1)pdm09 vaccination were excluded. Among the 473 cases retained, 442 (93%) corresponded to non-severe VAE,including local, regional and systemic events, while 31 corresponded to severe VAE, with two leading to significant disability. The global VAE reporting rate (RR) was 14.0 per 100,000 injections. While stationary from 2002 to 2008, the RR increased from 2009. The most important observations were a marked increase of VAE attributed to Bacillus Calmette-Guérin (BCG) vaccine from 2005 to 2008, a high RR observed with the inactivated diphtheria-tetanus (toxoids)-poliovirus vaccine combined with acellular pertussis vaccine (dTap-IPV) from 2008 and an increase in RR for seasonal influenza vaccine VAE in 2009. Our RR for severe VAE (1.1 VAEper 100,000) appears comparable with rates observed among United States civilians and military personnel. The increase observed from 2009 could be partly explained by the influenza A(H1N1)pdm09 pandemic which increased practitioner awareness towards VAE. In conclusion, the tolerance of the vaccines used in French armed forces appears acceptable.

Mortality among active-duty male French Armed Forces, 2006-10

BACKGROUND

In the Armed Forces, knowledge about the causes of deaths is required in order to develop prevention strategies. This study presents the main characteristics of causes of deaths among male active-duty personnel in the French Armed Forces during the 2006-10 period and compares them with the general French male population.

METHODS

The data are provided by military public health surveillance. Comparisons of the specific mortality rates (MR) were performed using a Poisson regression. Standardized mortality ratios (SMRs) were calculated to compare mortality with the general French male population.

RESULTS

There were 1455 deaths among male active-duty personnel during the study period [MR: 100.9 per 100,000 person-years (PY); 95% confidence interval 95.7-106.1]. The 17-24 age group was characterized by violent deaths: transport accident (MR: 45.9 per 100,000 PY) and suicide (18.8 per 100 000 PY). Overall SMRs show significantly lower MR compared with the French national MR with the exception of SMR for transport accident and suicide in the 17-24 age group.

CONCLUSIONS

There is a significantly lower deficit of mortality compared with the French male general population, reflecting a strong healthy worker effect. However, health promotion programmes should continue to put emphasis on transport accident especially among the 17-24 age group.

Plasmodium vivax Malaria among military personnel, French Guiana, 1998-2008

We obtained health surveillance epidemiologic data on malaria among French military personnel deployed to French Guiana during 1998–2008. Incidence of Plasmodium vivax malaria increased and that of P. falciparum remained stable. This new epidemiologic situation has led to modification of malaria treatment for deployed military personnel.

Increase in reported adverse events following seasonal influenza vaccination among the French armed forces, 2008-2009: possible role of stimulated reporting and background cases of influenza-like infection

OBJECTIVES

In September 2009, an increase in seasonal influenza vaccine adverse events (VAE), compared with reports for previous years, was detected among the French armed forces in the setting of an extended immunization campaign. This work presents the results of this investigation.

STUDY DESIGN

VAE were surveyed among all French military personnel from 2008 to 2009 by Epidemiological Departments of the French Military Health Service. For each case, a notification form was completed, providing patient and clinical information.

METHODS

Case definitions were derived from the French drug vigilance guidelines. Three types of VAE were considered: non-serious, serious and unexpected. Incidence rates were calculated by relating VAE to the number of vaccine doses injected.

RESULTS

Forty-seven seasonal influenza VAE were reported in continental France: 18 in 2008 and 29 in 2009. The annual reporting rate was higher in 2009 (31.6 vs 16.6 VAE per 100,000 injections, respectively). The highest monthly incidence was observed in September 2009 (60.8 events per 100,000 injections). Two other peaks were observed in February 2008 and March 2009. The incidence in September 2009 was not significantly different from the incidences in February 2008 and March 2009. It was observed that incidence peaks occurred during influenza epidemic periods. One serious neurological VAE was observed.

CONCLUSIONS

The increase in seasonal influenza VAE in late 2009 mainly involved non-serious events, and could reflect stimulated reporting in the context of the A(H1N1)pdm09 pandemic. VAE reporting rates were highest during influenza epidemic periods, which could be explained by VAE being wrongly attributed to the vaccine when symptoms could reflect coincident background cases of viral infection.

Novel influenza A(H1N1) outbreak among French armed forces in 2009: results of Military Influenza Surveillance System

OBJECTIVES

An outbreak of novel A(H1N1) virus influenza, detected in Mexico in April 2009, spread worldwide in 9 weeks. The aim of this paper is to present the monitoring results of this influenza outbreak among French armed forces.

STUDY DESIGN

The period of monitoring by the Military Influenza Surveillance System (MISS) was 9 months, from May 2009 to April 2010.

METHODS

The main monitored events were acute respiratory infection (ARI), defined by oral temperature ≥38.5 °C and cough, and laboratory-confirmed influenza. Weekly incidence rates were calculated by relating cases to the number of servicepersons monitored.

RESULTS

In continental France, the incidence of ARI increased from September 2009, with a weekly maxima of 401 cases per 100,000 in early December 2009 according to MISS. Estimations of the incidence of consultations which could be related to novel A(H1N1) influenza ranged from 48 to 57 cases per 100,000.

CONCLUSIONS

The trends observed by MISS are compatible with French national estimations. The incidence of consultations which could be related to A(H1N1) influenza at the peak of the epidemic (194 cases per 100,000) was much lower than the national estimate (1321 cases per 100,000). This may be due to servicepersons who consulted in civilian facilities and were not monitored. Other explanations are the healthy worker effect and the younger age of the military population.

Adverse events following pandemic influenza vaccine Pandemrix® reported in the French military forces--2009-2010

BACKGROUND

In the face of the A(H1N1) 2009 influenza pandemic, in October 2009 the French military health service (SSA) initiated a large vaccination campaign with Pandemrix(®) vaccine in the military forces. The aim of this study was to describe vaccine adverse events (VAE) reported during this campaign.

METHODS

VAE and the number of people vaccinated were surveyed by the SSA Epidemiological network across all military forces during the campaign, from October 2009 to April 2010. For each case, a notification form was completed, providing patient and clinical information. Three types of VAE were considered: non-serious, serious and unexpected.

RESULTS

There were 315.4 reported VAE per 100,000 vaccinations. Vaccination and VAE incidence rate peaks coincided with influenza epidemic peak in early December. The number of injected doses was 49,138, corresponding to a 14.5% vaccination coverage among military personnel, and 155 VAE were reported, including 5 serious VAE (1 Guillain-Barre syndrome, 2 malaises and 1 convulsive episode). Most VAE were non-serious (97.1%). Among these, 6 cases of local, rapidly regressive paresthesia were observed.

DISCUSSION

The military VAE surveillance system constitutes the only observatory on benign VAE in France. The reporting rate was much higher after the pandemic vaccine than after the seasonal vaccine, which may be a reflection of stimulated reporting. This report provides a useful description of VAE among military personnel during a mass emergency vaccination program, showing that the tolerance of the pandemic vaccine appeared acceptable.

The challenge of diagnosing Plasmodium ovale malaria in travellers: report of six clustered cases in French soldiers returning from West Africa

Background

Plasmodium ovale is responsible for 5% of imported malaria in French travellers. The clinical and biological features of six clustered cases of P. ovale malaria in an army unit of 62 French soldiers returning from the Ivory Coast are reported.

Case report

All patients were symptomatic and developed symptoms on average 50 days after their return and 20 days after the end of chemoprophylaxis (doxycycline). Clinical features included fever (6/6), mostly tertian (4/6), aches (6/6), nausea (3/6), abdominal pain (2/6), diarrhoea (2/6), or cough (2/6). Thrombocytopaenia was lower than 100,000/mm³ in half the cases only, and the haemoglobin count was normal for all patients. The diagnosis was made after at least three thick and thin blood smear searches. Parasitaemia was always lower than 0.5%. All rapid diagnostic tests were negative for HRP2 and pLDH antigens.

Discussion

Plasmodium ovale malaria is currently a problem to diagnose in travellers, notably in French soldiers returning from the Ivory Coast. Early attempts at diagnosis are difficult due to the lack of specific clinical features, the rarity of biological changes and the poor sensitivity of diagnostic tools to detect low parasitaemia. Thus, the diagnosis is commonly delayed or missed. Physicians should be aware of this diagnostic challenge to avoid relapses and provide prompt and adequate treatment with chloroquine and radical cure with primaquine.

Gastrointestinal illnesses among French forces deployed to Djibouti: French military health surveillance, 2005-2009

Despite an increase in foreign tourism and in the numbers of foreign military personnel deployed to Djibouti, little is known about the risk of gastrointestinal illness in this country in eastern Africa. To assess risk and to describe common features of gastrointestinal illnesses, reports of illness derived from military health surveillance data collected during 2005-2009 among French service members deployed to Djibouti were reviewed. Diarrhea was the most common problem; it had an annual incidence ranging from 260 to 349 cases per 1,000 person-years. The risk was higher among soldiers deployed short-term (four months) than among soldiers deployed long-term (two years). This five-year review of French health surveillance data documents a significant burden of diarrhea among French soldiers in Djibouti. The identification of factors associated with risk may permit efficient targeting of interventions to reduce morbidity from gastrointestinal illness.

Survey of alcohol, tobacco, and cannabis use in the French army

The aim of the current study is to describe the consumption rate of alcohol, tobacco, and cannabis in the French Army. A cross-sectional two strata randomized survey was performed between October 2006 and March 2007 using self-report questionnaires (n = 990) to collect individual characteristics, consumption, and addictive behaviors with urinal tests for cannabis (n = 985). The surveyed sample comprised 59% privates, 26% non-commissioned officers, and 6% officers, was predominantly male (89%) and young (median age: 29 years), and had a low level of education (60% attended secondary school). The consumption rate was high: 54.1% were active tobacco smokers, 56.0% were heavy drinkers, 20.5% declared drunkenness more than once per month, 52.6% at least experienced cannabis while 12.3% were occasional users, 8.2% were regular users, and 15.0% displayed multi-risk behaviors. Consumption was higher in the younger age (18 to 25 years) and lower educational group, leading to a high prevalence among privates and suggesting an "army effect." However, large scale behavioral social studies may help distinguish between personal and peer effect among the targeted population.