The Defence General Practitioner: an Updated Definition and Model

The geopolitical setting has changed significantly since the definition of UK Armed Forces General Practice was published in 2012. New operating models require medical services to provide smaller teams operating at greater reach from secondary care and logistical support. The Defence Medical Services have reorganised to meet these changing needs. Defence general practices (DGPs) are key enablers of the Defence strategic effort, both integral to deployed units, in preparing forces for deployment and managing their rehabilitation back to fitness. A formal role performance statement (RPS) has been created to guide the training and development of DGPs to meet these changing requirements. The RPS details the additional scope of practice, beyond the national GP licensing standard, in which DGPs work. In this article, we compare and contrast the RPS with the previous definition of a DGP. The resultant updated model recharacterises the extended roles into five themes of DGP built on the foundation of the Royal College of General Practitioners curriculum. This new model provides the platform on which to develop the clinical specialty over the next decade and highlights avenues for educational interventions to develop future generations of DGPs.

Burden of drug-resistant tuberculosis among contacts of index cases: a protocol for a systematic review

INTRODUCTION

People having close contact with drug-resistant tuberculosis (DR-TB) patients are at increased risk of contracting and developing the disease. However, no comprehensive review has been undertaken to estimate the burden of DR-TB among contacts of DR-TB patients. Therefore, the current systematic review will quantify the prevalence and incidence of DR-TB among contacts of DR-TB patients.

METHOD AND ANALYSIS

Systematic searches will be conducted in Medline, Embase, Web of Science, Scopus, Cochrane Central Register of Controlled trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINHAL) databases. The search will be conducted without restrictions on time, language and geography. A random-effects meta-analysis will be conducted for effect estimates. The pooled prevalence and incidence of DR-TB will be compared between people with and without contact with DR-TB patients. The presence of heterogeneity between studies will be assessed by Higgins I2 statistics. Subgroup analysis will be conducted to determine the source of heterogeneity. The risk of bias will be assessed using a visual inspection of the funnel plot and Egger's regression test statistics. Trim and fill analysis will be done in the presence of publication bias. A sensitivity analysis will be conducted by trimming low-quality studies. The systematic review will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines.

ETHICS AND DISSEMINATION

Ethical approval will not be required for this study as it will be a systematic review and meta-analysis based on previously published evidence. The findings of the systematic review will be presented at scientific conferences and published in scientific journals.

PROTOCOL REGISTRATION

The protocol is published in PROSPERO with registration number CRD42023390339.

Australian Defence Force Global Health Engagement through malaria and other vectorborne disease programmes in the Pacific and Southeast Asia

Global Health Engagement is one method employed by the Australian Defence Force (ADF) in pursuit of its objectives to shape Australia's strategic environment and to deter actions against Australia's interests. Two recent examples of such engagements are malaria mitigation programmes led by the ADF Malaria and Infectious Disease Institute in partnership with the Vietnam People's Army and the Papua New Guinea Defence Force. Both programmes were designed with extensive collaboration with host nation stakeholders, empowered local institutions and governance systems, built the capacity of the host nation with the aim of achieving independence from Australian support and met the strategic policy requirements of all nations involved. Process and outcome measures were built into both programmes, providing partner nations with the necessary assurance that funding was being used effectively. The long-term nature of each programme engendered personal trust between individuals and cultural understanding between military units. Recognising the value of formal education in the design and conduct of such programmes, ADF officers participate as students and instructors in the US Uniformed University of the Health Sciences course in Global Health and Global Health Engagement. Critically, this educational opportunity is afforded to future leaders in all professions related to health, including clinicians, military health planners and commanders. While an essential prerequisite to Global Health Engagement Programmes is their technical viability and validity, the most important key to success in the military context is a widespread understanding of how they achieve desired strategic effects for all involved.

International modified Delphi study on malaria preventive behaviour: new themes, contexts and framework for future research on Plasmodium knowlesi malaria

INTRODUCTION

Plasmodium knowlesi malaria is a non-human simian malaria that threatens Southeast Asian rural communities. Studies indicate that non-compliant bednet usage, travelling into the forest and working as farmers and rubber tappers put communities at risk for infection. Despite guidelines, malaria incidence increases yearly and has become a public health concern. In addition to research gaps addressing factors that influence malaria prevention behaviour in these communities, there are no specific guidelines to facilitate strategies against the threat of P. knowlesi malaria.

METHOD

To examine potential factors that influence malaria-prevention behaviour in communities exposed to P. knowlesi malaria, 12 malaria experts participated in a modified Delphi study; every participant maintained their anonymity throughout the study. Three Delphi rounds were conducted via different online platforms between 15 November 2021 and 26 February 2022, and consensus was achieved when 70% of the participants agreed on a particular point with a 4-5 median. The results from the open-ended questions were then subjected to thematic analysis, and the dataset generated by this study was analysed using a deductive and inductive approach.

RESULTS

After a systematic, iterative process, knowledge and belief, social support, cognitive and environmental factors, past experience as a malaria patient, and the affordability and feasibility of a given intervention were critical contributors to malaria-prevention behaviour.

CONCLUSION

Future research on P. knowlesi malaria could adapt this study's findings for a more nuanced understanding of factors that influence malaria-prevention behaviour and improve P. knowlesi malaria programmes based on the expert consensus.

Forecasting models for leprosy cases: a scoping review protocol

INTRODUCTION

Leprosy is a neglected tropical disease caused by Mycobacterium leprae that mainly affects the skin, the peripheral nerves, the mucosa of the upper respiratory tract and the eyes. Mathematical models and statistical methodologies could play an important role in decision-making and help maintain the gains in elimination programmes. Various models for predicting leprosy cases have been reported in the literature, but they have different settings and distinct approaches to predicting the cases. This study describes the protocol for a scoping review to identify and synthesise information from studies using models to forecast leprosy cases.

METHODS AND ANALYSIS

A scoping review methodology will be applied following the Joanna Briggs Institute methodology for scoping reviews and will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews. We will perform a systematic search from when each database started until April 2022 and we will include the following electronic databases: MEDLINE via PubMed, Embase, Cochrane Library and Latin American and Caribbean Health Science Literature Database. Data will be extracted and recorded on a calibrated predefined data form and will be presented in a tabular form accompanied by a descriptive summary. The Prediction Model Study Risk of Bias Assessment Tool (PROBAST) will be used.

ETHICS AND DISSEMINATION

No ethical approval is required for this study. This scoping review will identify and map the methodological and other characteristics of modelling studies predicting leprosy cases. We hope that the review will contribute to scientific knowledge in this area and act as a basis for researchers designing and conducting leprosy models. This information can also be used to enhance national surveillance systems and to target specific policies. The protocol and consequent publications of this scoping review will be disseminated through peer-reviewed publications and policy briefs.

SYSTEMATIC REVIEW REGISTRATION

This scoping review was registered in the Open Science Framework (https://doi.org/10.17605/OSF.IO/W9375).

Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence

OBJECTIVES

The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts.

DESIGN

A comparative case study approach, analysing variation in outcomes across different settings.

SETTING

Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case.

PARTICIPANTS

28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria.

INTERVENTIONS

The interventions included different mRDT training packages, supervision, supplies and community sensitisation.

OUTCOME MEASURES

Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider adherence to positive mRDTs (% Plasmodium falciparum positive prescribed/given Artemisinin Combination Treatment); (3) provider adherence to negative mRDTs (% P. falciparum negative not prescribed/given antimalarial).

RESULTS

Outcomes varied widely across cases: 12-100% mRDT uptake; 44-98% adherence to positive mRDTs; 27-100% adherence to negative mRDTs. Providers appeared more motivated to perform well when mRDTs and intervention characteristics fitted with their own priorities. Goodness of fit of mRDTs with existing consultation and diagnostic practices appeared crucial to maximising the impact of mRDTs on care, as did prior familiarity with malaria testing; adequate human resources and supplies; possible alternative treatments for mRDT-negative patients; a more directive intervention approach and local preferences for ACTs.

CONCLUSIONS

Basic training and resources are essential but insufficient to maximise the potential of mRDTs in many contexts. Programme design should respond to assessments of provider priorities, expectations and capacities. As mRDTs become established, the intensity of supporting interventions required seems likely to reduce.

What drives inappropriate antibiotic dispensing? A mixed-methods study of pharmacy employee perspectives in Haryana, India

OBJECTIVES

There are only 0.70 licensed physicians per 1000 people in India. Thus, pharmacies are a primary source of healthcare and patients often seek their services directly, especially in village settings. However, there is wide variability in a pharmacy employee's training, which contributes to inappropriate antibiotic dispensing and misuse. These practices increase the risk of antibiotic resistance and poor patient outcomes. This study seeks to better understand the factors that drive inappropriate antibiotic dispensing among pharmacy employees in India's village communities.

DESIGN

We conducted a mixed-methods study of the antibiotic dispensing practices, including semistructured interviews and a pilot cross-sectional Knowledge, Attitudes and Practice survey. All data were transcribed, translated from Hindi into English, and coded for themes.

SETTING

Community pharmacies in villages in Haryana, India.

PARTICIPANTS

We recruited 24 community pharmacy employees (all male) by convenience sampling. Participants have a range of characteristics regarding village location, monthly income, baseline antibiotic knowledge, formal education and licensure.

RESULTS

75% of pharmacy employees in our study were unlicensed practitioners, and the majority had very limited understanding of antibiotic resistance. Furthermore, only half could correctly define the term antibiotics. All reported that at times they dispensed antibiotics without a prescription. This practice was more common when treating patients who had limited access to a licensed physician because of economic or logistic reasons. Many pharmacy workers also felt pressure to provide shortened medication courses to poorer clientele, and often dispensed only 1 or 2 days' worth of antibiotics. Such patients rarely returned to the pharmacy for the complete course.

CONCLUSIONS

This study highlights the need for short-term, intensive training programmes on antibiotic prescribing and resistance that can be disseminated to village pharmacies. Programme development should take into account the realities of working with poor clientele, especially in areas of limited healthcare access.

Health research capacity development in low and middle income countries: reality or rhetoric? A systematic meta-narrative review of the qualitative literature

OBJECTIVES

Locally led health research in low and middle income countries (LMICs) is critical for overcoming global health challenges. Yet, despite over 25 years of international efforts, health research capacity in LMICs remains insufficient and development attempts continue to be fragmented. The aim of this systematic review is to identify and critically examine the main approaches and trends in health research capacity development and consolidate key thinking to identify a more coherent approach.

METHODS

This review includes academic and grey literature published between January 2000 and July 2013. Using a predetermined search strategy, we systematically searched PubMed, hand-searched Google Scholar and checked reference lists. This process yielded 1668 papers. 240 papers were selected based on a priori criteria. A modified version of meta-narrative synthesis was used to analyse the papers.

RESULTS

3 key narratives were identified: the effect of power relations on capacity development; demand for stronger links between research, policy and practice and the importance of a systems approach. Capacity development was delivered through 4 main modalities: vertical research projects, centres of excellence, North-South partnerships and networks; all were controversial, and each had their strengths and weaknesses. A plurality of development strategies was employed to address specific barriers to health research. However, lack of empirical research and monitoring and evaluation meant that their effectiveness was unclear and learning was weak.

CONCLUSIONS

There has been steady progress in LMIC health research capacity, but major barriers to research persist and more empirical evidence on development strategies is required. Despite an evolution in development thinking, international actors continue to use outdated development models that are recognised as ineffective. To realise newer development thinking, research capacity outcomes need to be equally valued as research outputs. While some development actors are now adopting this dedicated capacity development approach, they are in the minority.

Leptospirosis in a British soldier after travel to Borneo

Undifferentiated febrile illness in a returning soldier is a common problem encountered by serving medical officers. A 32-year-old soldier presented to Birmingham Heartlands Hospital with fever and acute kidney injury after return from Borneo. Leptospirosis was suspected and empirical antibiotics were started before subsequent confirmation by serology and PCR. Leptospirosis is common in South-East Asia, and troops exercising in jungle areas, and in the UK, are at risk. Advice, including inpatient management when appropriate, is available from the UK Role 4 Military Infectious Diseases and Tropical Medicine Service.

Evaluation of a programme for 'Rapid Assessment of Febrile Travelers' (RAFT): a clinic-based quality improvement initiative

BACKGROUND

Fever in the returned traveller is a potential medical emergency warranting prompt attention to exclude life-threatening illnesses. However, prolonged evaluation in the emergency department (ED) may not be required for all patients. As a quality improvement initiative, we implemented an algorithm for rapid assessment of febrile travelers (RAFT) in an ambulatory setting.

METHODS

Criteria for RAFT referral include: presentation to the ED, reported fever and travel to the tropics or subtropics within the past year. Exclusion criteria include Plasmodium falciparum malaria, and fulfilment of admission criteria such as unstable vital signs or significant laboratory derangements. We performed a time series analysis preimplementation and postimplementation, with primary outcome of wait time to tropical medicine consultation. Secondary outcomes included number of ED visits averted for repeat malaria testing, and algorithm adherence.

RESULTS

From February 2014 to December 2015, 154 patients were seen in the RAFT clinic: 68 men and 86 women. Median age was 36 years (range 16-78 years). Mean time to RAFT clinic assessment was 1.2±0.07 days (range 0-4 days) postimplementation, compared to 5.4±1.8 days (range 0-26 days) prior to implementation (p<0.0001). The RAFT clinic averted 132 repeat malaria screens in the ED over the study period (average 6 per month). Common diagnoses were: traveller's diarrhoea (n=27, 17.5%), dengue (n=12, 8%), viral upper respiratory tract infection (n=11, 7%), chikungunya (n=10, 6.5%), laboratory-confirmed influenza (n=8, 5%) and lobar pneumonia (n=8, 5%).

CONCLUSIONS

In addition to provision of more timely care to ambulatory febrile returned travellers, we reduced ED bed-usage by providing an alternate setting for follow-up malaria screening, and treatment of infectious diseases manageable in an outpatient setting, but requiring specific therapy.

Coordination and relationships between organisations during the civil-military international response against Ebola in Sierra Leone: an observational discussion

The Ebola virus disease (EVD) crisis in West Africa began in March 2014. At the beginning of the outbreak, no one could have predicted just how far-reaching its effects would be. The EVD epidemic proved to be a unique and unusual humanitarian and public health crisis. It caused worldwide fear that impeded the rapid response required to contain it early. The situation in Sierra Leone (SL) forced the formation of a unique series of civil-military interagency relationships to be formed in order to halt the epidemic. Civil-military cooperation in humanitarian situations is not unique to this crisis; however, the slow response, the unusual nature of the battle itself and the uncertainty of the framework required to fight this deadly virus created a situation that forced civilian and military organisations to form distinct, cooperative relationships. The unique nature of the Ebola virus necessitated a steering away from normal civil-military relationships and standard pillar responses. National and international non-governmental organisations (NGOs), Department for International Development (DFID) and the SL and UK militaries were required to disable this deadly virus (as of 7 November 2015, SL was declared EVD free). This paper draws on personal experiences and preliminary distillation of information gathered in formal interviews. It discusses some of the interesting features of the interagency relationships, particularly between the military, the UK's DFID, international organisations, NGOs and departments of the SL government. The focus is on how these relationships were key to achieving a coordinated solution to EVD in SL both on the ground and within the larger organisational structure. It also discusses how these relationships needed to rapidly evolve and change along with the epidemiological curve.

'The worm that got away': parainfectious atypical optic neuritis associated with schistosomiasis infection

Although optic neuritis is commonly associated with multiple sclerosis, patients with atypical optic neuritis require further investigations to exclude other associated conditions. We report a woman presenting with cough, fatigue, atypical optic neuritis with chiasmitis. She responded partially to corticosteroids and we subsequently found she had a ground-glass lung nodule. Follow-up CT scan of thorax at 12 months showed new parenchymal lung lesions that suggested schistosomiasis. Further questioning by a respiratory physician identified, in retrospect, a previous exposure history; serological testing confirmed schistosoma infection. She was treated with praziquantel and slowly improved clinically, with radiological improvement in the optic chiasm, regression of the parenchymal lung lesions but with the ground glass nodule unchanged. We diagnosed parainfectious optic neuritis associated with schistosomiasis, based upon exposure history, serological confirmation and radiological features, together with the response to treatment, and having excluded other causes of an atypical optic neuritis.

Health protection during the Ebola crisis: the Defence Medical Services approach

This paper is a narrative of the policies, procedures, mitigations and observations of the application of Force Health Protection measures applied by the Ministry of Defence (MOD) for the deployment of military personnel to West Africa as part of the UK contribution to the international response to the Ebola crisis from July 2014 to July 2015. The MOD divided the threat into three risk categories: risk from disease and non-battle injury, Ebola risk for non-clinical duties and Ebola risk for healthcare workers. Overall risk management was directed and monitored by the OP GRITROCK Force Health Protection Board. There were six cases of malaria, four outbreaks of gastrointestinal disease, two needlestick injuries in Ebola-facing healthcare workers, one MOD Ebola case and five non-needlestick, high-risk exposures. This experience reinforces the requirement for the Defence Medical Services to have a high level of organisational competence to advise on Force Health Protection for the MOD.

Two cases of cutaneous leishmaniasis in Dutch military personnel treated with oral miltefosine

INTRODUCTION

In the Netherlands, cutaneous leishmaniasis is most commonly seen in military personnel deployed on a mission or training abroad. The treatment of two Dutch soldiers who acquired cutaneous leishmaniasis with oral miltefosine was evaluated. Adverse effects were monitored and the improvement of skin lesions was assessed.

CASE REPORTS

A military nurse with a painless Chiclero's ulcer due to Leishmania (Viannia) braziliensis acquired in Belize and a military physical training instructor with itchy swelling and small ulcer of the back of his left elbow due to L. donovani/infantum complex acquired in Ibiza were treated with oral miltefosine 50 mg three times a day for 28 days.

DISCUSSION

Both patients responded well to oral miltefosine. Adverse effects were mild. Increase of creatinine levels was seen while liver transaminase levels were unremarkable.

CONCLUSIONS

Miltefosine proved to be a convenient, effective and well-tolerated treatment option in the treatment of cutaneous leishmaniasis in Dutch military personnel.

A case of a chlorine inhalation injury in an Ebola treatment unit

We present a 26-year-old male British military nurse, deployed to Sierra Leone to treat patients with Ebola virus disease at the military-run Kerry Town Ebola Treatment Unit. Following exposure to chlorine gas during routine maintenance procedures, the patient had an episode of respiratory distress and briefly lost consciousness after exiting the facility. Diagnoses of reactive airways disease, secondary to the chlorine exposure and a hypocapnic syncopal episode were made. The patient was resuscitated with minimal intervention and complete recovery occurred in less than 1 week. This case highlights the issues of using high-strength chlorine solution to disinfect the red zone. Although this patient had a good outcome, this was fortunate. Ensuring Ebola treatment centres are optimally designed and that appropriate management systems are formulated with extraction scenarios rehearsed are important to mitigate the chlorine-associated risk.

Understanding the investigators: a qualitative study investigating the barriers and enablers to the implementation of local investigator-initiated clinical trials in Ethiopia

OBJECTIVES

Clinical trials provide 'gold standard' evidence for policy, but insufficient locally relevant trials are conducted in low-income and middle-income countries. Local investigator-initiated trials could generate highly relevant data for national governments, but information is lacking on how to facilitate them. We aimed to identify barriers and enablers to investigator-initiated trials in Ethiopia to inform and direct capacity strengthening initiatives.

DESIGN

Exploratory, qualitative study comprising of in-depth interviews (n=7) and focus group discussions (n=3).

SETTING

Fieldwork took place in Ethiopia during March 2011.

PARTICIPANTS

Local health researchers with previous experiences of clinical trials or stakeholders with an interest in trials were recruited through snowball sampling (n=20).

OUTCOME MEASURES

Detailed discussion notes were analysed using thematic coding analysis and key themes were identified.

RESULTS

All participants perceived investigator-initiated trials as important for generating local evidence. System and organisational barriers included: limited funding allocation, weak regulatory and administrative systems, few learning opportunities, limited human and material capacity and poor incentives for conducting research. Operational hurdles were symptomatic of these barriers. Lack of awareness, confidence and motivation to undertake trials were important individual barriers. Training, knowledge sharing and experience exchange were key enablers to trial conduct and collaboration was unanimously regarded as important for improving capacity.

CONCLUSIONS

Barriers to trial conduct were found at individual, operational, organisational and system levels. These findings indicate that to increase locally led trial conduct in Ethiopia, system wide changes are needed to create a more receptive and enabling research environment. Crucially, the creation of research networks between potential trial groups could provide much needed practical collaborative support through sharing of financial and project management burdens, knowledge and resources. These findings could have important implications for capacity-strengthening initiatives but further research is needed before the results can be generalised more widely.

Randomised controlled trial of weekly chloroquine to re-establish normal erythron iron flux and haemoglobin recovery in postmalarial anaemia

OBJECTIVE

To determine if low-dose weekly chloroquine (CQ) therapy improves recovery from malaria-associated anaemia.

DESIGN

Proof of concept randomised clinical trial.

SETTING

West Kiang District, Lower River Region, The Gambia.

PARTICIPANTS

Children resident in participating communities, aged 12-72 months, with uncomplicated malaria identified using active case detection over two consecutive malaria transmission seasons.

INTERVENTIONS

In 2007, eligible children were randomised to chloroquine-sulfadoxine/pyrimethamine (CQ-SP) or co-artemether (ACT) antimalarial therapy, and after parasite clearance on day 3 were subsequently re-randomised (double-blind) to weekly low-dose CQ (5 mg/kg) or placebo. In 2008, all eligible children were treated with ACT and subsequently randomised to CQ or placebo.

OUTCOME MEASURES

The primary outcome was a change in haemoglobin from baseline (day 3 of antimalarial treatment) to day 90 in the CQ and placebo treatment arms. Secondary outcomes were changes in urinary neopterin as a marker of macrophage activation, markers of erythropoietic response and prevalence of submicroscopic parasitaemia. Change in haemoglobin in the placebo arm by initial antimalarial treatment was also assessed.

RESULTS

In 2007, 101 children with uncomplicated malaria were randomised to antimalarial treatment with CQ-SP or ACT and 65 were subsequently randomised to weekly CQ or placebo. In 2008, all children received ACT antimalarial treatment and 31 were subsequently randomised to receive weekly CQ or placebo. Follow-up to day 90 was 96%. There was no effect of weekly CQ vs placebo on change in haemoglobin at day 90 (CQ+10.04 g/L (95% CI 6.66 to 13.42) vs placebo +7.61 g/L (95% CI 2.88 to 12.35)). There was no effect on the secondary outcomes assessed, or effect of initial antimalarial therapy on haemoglobin recovery. Higher day 90 haemoglobin correlated independently with older age, not being stunted, higher haemoglobin at day 0 and adequate iron status at day 3.

CONCLUSIONS

Weekly low-dose CQ after effective antimalarial treatment is not effective in improving recovery from postmalarial anaemia.

TRIAL REGISTRATION

The clinical trial registration number is NCT00473837 (ClinicalTrials.gov).