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Routledge M, Lyon J, Vincent C, Gordon Clarke A, Shawcross K, Turpin C, Cormack H, Robson SC, Beckett A, Glaysher S, Cook K, Fearn C, Goudarzi S, Hutley EJ, Ross D. Management of a large outbreak of COVID-19 at a British Army training centre: lessons for the future. BMJ Mil Health 2023; 169:488-492. [PMID: 34772689 PMCID: PMC8594976 DOI: 10.1136/bmjmilitary-2021-001976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/07/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The COVID-19 pandemic has posed major challenges for infection control within training centres, both civilian and military. Here we present a narrative review of an outbreak that occurred at the Royal Military Academy Sandhurst (RMAS) in January-March 2021, in the context of the circulating, highly transmissible SARS-CoV-2 variant B.1.1.7. METHODS Testing for SARS-CoV-2 was performed using a combination of reverse transcriptase PCR and Lateral Flow Devices (LFDs). Testing and isolation procedures were conducted in line with a pre-established symptom stratification system. Genomic sequencing was performed on 10 sample isolates. RESULTS By the end of the outbreak, 185 cases (153 Officer Cadets, 32 permanent staff) had contracted confirmed COVID-19. This represented 15% of the total RMAS population. This resulted in 0 deaths and 0 hospitalisations, but due to necessary isolation procedures did represent an estimated 12 959 person-days of lost training. 9 of 10 (90%) of sequenced isolates had a reportable lineage. All of those reported were found to be the Alpha lineage B.1.1.7. CONCLUSIONS We discuss the key lessons learnt from the after-action review by the Incident Management Team. These include the importance of multidisciplinary working, the utility of sync matrices to monitor outbreaks in real time, issues around Officer Cadets reporting symptoms, timing of high-risk training activities, infrastructure and use of LFDs. COVID-19 represents a vital learning opportunity to minimise the impact of potential future pandemics, which may produce considerably higher morbidity and mortality in military populations.
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Affiliation(s)
- Matthew Routledge
- Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
- Medical Officer, 254 Medical Regiment, Cambridge, UK
| | - J Lyon
- Senior Medical Officer, Royal Military Academy Sandhurst, Camberley, UK
| | - C Vincent
- Medical Planner, HQ Army Recruiting and Initial Training Command, Pewsey, UK
| | - A Gordon Clarke
- XO, HQ Army Recruiting and Initial Training Command, Pewsey, UK
| | - K Shawcross
- Environmental Health, Medical Branch, Head Quarters Regional Command, Aldershot, UK
| | - C Turpin
- ACOS, Royal Military Academy Sandhurst, Camberley, UK
| | - H Cormack
- Chief of Staff, HQ Army Recruiting and Initial Training Command, Pewsey, UK
| | - S C Robson
- School of Pharmacy & Biomedical Science, University of Portsmouth, Portsmouth, UK
- Centre for Enzyme Innovation, University of Portsmouth, Portsmouth, UK
- School of Biological Sciences, University of Portsmouth, Portsmouth, UK
| | - A Beckett
- Centre for Enzyme Innovation, University of Portsmouth, Portsmouth, UK
| | - S Glaysher
- Research & Innovation, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - K Cook
- School of Pharmacy & Biomedical Science, University of Portsmouth, Portsmouth, UK
| | - C Fearn
- School of Pharmacy & Biomedical Science, University of Portsmouth, Portsmouth, UK
| | - S Goudarzi
- School of Pharmacy & Biomedical Science, University of Portsmouth, Portsmouth, UK
| | - E J Hutley
- Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - D Ross
- Parkes Professor, Army Medical Services, Camberley, UK
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Pallett SJC, Boyd SE, O'Shea MK, Martin J, Jenkins DR, Hutley EJ. The contribution of human conflict to the development of antimicrobial resistance. Commun Med (Lond) 2023; 3:153. [PMID: 37880348 PMCID: PMC10600243 DOI: 10.1038/s43856-023-00386-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/13/2023] [Indexed: 10/27/2023] Open
Abstract
Pallet et al. discuss the impact of human conflict on development of antimicrobial resistance. They overview approaches to limit the spread of antimicrobial resistance, using the ongoing conflict in Ukraine as an example of the challenges and opportunities.
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Affiliation(s)
- Scott J C Pallett
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK.
| | - Sara E Boyd
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, L69 3GE, UK
| | - Matthew K O'Shea
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Jessica Martin
- Department of Clinical Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - David R Jenkins
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, LE1 5WW, UK
| | - Emma J Hutley
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
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Woolley SD, Dermont M, Adam M, Pallet SJC, Reece N, Hoysal N, Holden G, Attridge KK, Fletcher TE, O'Shea MK, Hutley EJ, Nicol ED, Lamb LE. The 2022 monkeypox outbreak: A UK military perspective. Travel Med Infect Dis 2022; 52:102540. [PMID: 36587754 PMCID: PMC9800014 DOI: 10.1016/j.tmaid.2022.102540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/13/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022]
Abstract
With the emergence of SARS-CoV-2 and now monkeypox, the UK Defence Medical Services have been required to provide rapid advice in the management of patients with airborne high consequence infectious diseases (A-HCID). The Defence Public Health Network (DPHN) cadre, consisting of closely aligned uniformed and civilian public health specialists have worked at pace to provide evidence-based recommendations on the clinical management, public health response and policy for monkeypox, with military medicine and pathology clinicians (primarily infectious disease physicians and medical microbiologists). Military environments can be complicated and nuanced requiring specialist input and advice to non-specialists as well as unit commanders both in the UK and overseas. DPHN and military infection clinicians have close links with the UK National Health Service (NHS) and the UK Health Security Agency (UKHSA), allowing for a dynamic two-way relationship that encompasses patient management, public health response, research and development of both UK military and national guidelines. This is further demonstrated with the Royal Air Force (RAF) Air Transport Isolator (ATI) capability, provided by Defence to support the UK Government and UKHSA. Military infectious disease clinicians are also embedded within NHS A-HCID units. In this manuscript we provide examples of the close interdisciplinary working of the DPHN and Defence clinicians in managing military monkeypox patients, co-ordinating the public health response, advising the Command and developing monkeypox policy for Defence through cross-government partnership. We also highlight the co-operation between civilian and military medical authorities in managing the current outbreak.
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Affiliation(s)
- S D Woolley
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Tropical and Infectious Disease Unit, Royal Liverpool Hospital, Liverpool, UK.
| | - M Dermont
- Defence Public Health Unit, DMS Whittington, Lichfield, UK
| | - M Adam
- Regional Infectious Diseases Unit, Western General Hospital, NHS Lothian, Edinburgh, UK; Tactical Medical Wing, RAF Brize Norton, Carterton, UK
| | - S J C Pallet
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK; Infection and Immunity Clinical Academic Group, St George's Hospital, London, UK
| | - N Reece
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK; Department of Microbiology, Queen Alexandra Hospital, Portsmouth, UK
| | - N Hoysal
- Defence Public Health Unit, DMS Whittington, Lichfield, UK
| | - G Holden
- Defence Public Health Unit, DMS Whittington, Lichfield, UK
| | - K K Attridge
- RAF Health Directorate, RAF High Wycombe, Buckinghamshire, UK
| | - T E Fletcher
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Tropical and Infectious Disease Unit, Royal Liverpool Hospital, Liverpool, UK; Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - M K O'Shea
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK; Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK; Department of Infectious Diseases and Tropical Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - E J Hutley
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK; Department of Microbiology, Frimley Park Hospital, Camberley, UK
| | - E D Nicol
- RAF Health Directorate, RAF High Wycombe, Buckinghamshire, UK; Department of Cardiology, Royal Brompton Hospital, London, UK
| | - L E Lamb
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK; Department of Infectious Diseases, Royal Free Hospital, London, UK
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Weller SA, Armstrong SR, Bailey S, Burnell HT, Burt EL, Cant NE, Cawthorne KR, Chester M, Choules JE, Coe NA, Coward L, Cox VL, Emery ER, Evans CP, Finn A, Halford CM, Hamblin KA, Harrison GV, Hartley MG, Hudson C, James B, Jones HE, Keyser E, Lonsdale CL, Marshall LE, Maule CE, Miles JA, Newstead SL, Nicholls M, Osborne C, Pearcy AS, Penny LD, Perrot R, Rachwal P, Robinson V, Rushton D, Stahl FM, Staplehurst SV, Stapleton HL, Steeds K, Stephenson K, Thompson IJ, Thwaite JE, Ulaeto DO, Waters N, Wills DJ, Wills ZS, Rees C, Hutley EJ. Development and operation of the defence COVID-19 lab as a SARS-CoV-2 diagnostic screening capability for UK military personnel. BMJ Mil Health 2022; 170:e002134. [PMID: 35878971 PMCID: PMC10958320 DOI: 10.1136/military-2022-002134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/03/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND In the face of the COVID-19 pandemic, the Defence Science and Technology Laboratory (Dstl) and Defence Pathology combined to form the Defence Clinical Lab (DCL), an accredited (ISO/IEC 17025:2017) high-throughput SARS-CoV-2 PCR screening capability for military personnel. LABORATORY STRUCTURE AND RESOURCE The DCL was modular in organisation, with laboratory modules and supporting functions combining to provide the accredited SARS-CoV-2 (envelope (E)-gene) PCR assay. The DCL was resourced by Dstl scientists and military clinicians and biomedical scientists. LABORATORY RESULTS Over 12 months of operation, the DCL was open on 289 days and tested over 72 000 samples. Six hundred military SARS-CoV-2-positive results were reported with a median E-gene quantitation cycle (Cq) value of 30.44. The lowest Cq value for a positive result observed was 11.20. Only 64 samples (0.09%) were voided due to assay inhibition after processing started. CONCLUSIONS Through a sustained effort and despite various operational issues, the collaboration between Dstl scientific expertise and Defence Pathology clinical expertise provided the UK military with an accredited high-throughput SARS-CoV-2 PCR test capability at the height of the COVID-19 pandemic. The DCL helped facilitate military training and operational deployments contributing to the maintenance of UK military capability. In offering a bespoke capability, including features such as testing samples in unit batches and oversight by military consultant microbiologists, the DCL provided additional benefits to the UK Ministry of Defence that were potentially not available from other SARS-CoV-2 PCR laboratories. The links between Dstl and Defence Pathology have also been strengthened, benefitting future research activities and operational responses.
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Affiliation(s)
- Simon A Weller
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - S R Armstrong
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - S Bailey
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - H T Burnell
- Operations Division, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - E L Burt
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - N E Cant
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - K R Cawthorne
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - M Chester
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - J E Choules
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - N A Coe
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - L Coward
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - V L Cox
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - E R Emery
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C P Evans
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - A Finn
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C M Halford
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - K A Hamblin
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - G V Harrison
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - M G Hartley
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C Hudson
- Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - B James
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - H E Jones
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - E Keyser
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C L Lonsdale
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - L E Marshall
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C E Maule
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - J A Miles
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - S L Newstead
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - M Nicholls
- Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - C Osborne
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - A S Pearcy
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - L D Penny
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - R Perrot
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - P Rachwal
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - V Robinson
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - D Rushton
- Platform Systems Division, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - F M Stahl
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - S V Staplehurst
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - H L Stapleton
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - K Steeds
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - K Stephenson
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - I J Thompson
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - J E Thwaite
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - D O Ulaeto
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - N Waters
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - D J Wills
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - Z S Wills
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - C Rees
- CBR Division, Defence Science and Technology Laboratory Porton Down, Salisbury, UK
| | - E J Hutley
- Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
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Ralph J, Hutley EJ, Nordmann G. Novel equipment used in the UK Role 2 medical treatment facility as part of Operation TRENTON in South Sudan. BMJ Mil Health 2021; 167:350-352. [PMID: 34083372 DOI: 10.1136/bmjmilitary-2020-001693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/21/2020] [Accepted: 12/26/2020] [Indexed: 11/04/2022]
Abstract
The deployment of a UK military Role 2 Medical Treatment Facility (MTF) to South Sudan during Operation TRENTON into an isolated location and austere environment with a prolonged hold produced potential medical planning challenges. The MTF was augmented with both specific personnel and equipment in order to meet these challenges. This paper discusses equipment available in this facility not previously used at Role 2 before and how it could be used to supplement medical operational deployments in future.
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Affiliation(s)
- James Ralph
- Royal Centre for Defence Medicine Clinical Unit, Queen Elizabeth Hospital, Birmingham, West Midlands, UK
| | - E J Hutley
- Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - G Nordmann
- Academic Department of Anaesthesia, Royal Centre for Defence Medicine, Birmingham, UK.,Head of Capability Combat Service Support (Medical), Capability Directorate, UK Army Headquarters, Andover, UK
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6
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Mackenzie H, Opoku F, Hutley EJ, Biswas JS. The enhanced deployed laboratory on Operation TRENTON: enabling advanced clinical care and research in the austere environment. BMJ Mil Health 2021; 167:367-368. [PMID: 34035156 DOI: 10.1136/bmjmilitary-2021-001879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Hector Mackenzie
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - F Opoku
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - E J Hutley
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - J S Biswas
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK .,Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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Burns DS, Porter CK, Gutierrez RL, McDavid NC, Hutley EJ, Riddle MS, Connor P. Diarrhea and associated illness characteristics and risk factors among British active duty service members at Askari Storm training exercise, Nanyuki, Kenya, January-June 2014. MSMR 2020; 27:4-7. [PMID: 32876465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Travelers' diarrhea (TD) has historically been common among deployed military personnel and remains a leading infectious disease threat to this population. The risk factors, work performance, and illness associated with TD among British active duty service members exercising at British Army Training Unit Kenya (BATUK) were assessed. Members of the British Army who were finishing a 6-week combined arms training exercise in Nanyuki, Kenya, completed routine public health surveillance questionnaires. Survey data included information on demographics, rank, risk factors, illness characteristics, and impact on work performance. Among 1,227 survey respondents, 21.9% (n=269) reported having diarrhea, with an estimated 824 days of total missed work and 1,215 days of work underperformance. The majority of cases (54.6%) had multiple diarrheal episodes. One quarter (24.9%) of the respondents with TD sought medical care and 19.7% were bedded down because of their illness. There were no statistically significant differences between the TD and no TD groups on the demographic characteristics examined. The strongest risk factor for diarrhea was having a colleague with diarrhea (adjusted odds ratio=51.78; 95% confidence interval: 29.44-91.06). TD had a notable impact on duty status and operational capability. Efforts are needed to improve BATUK's participant education on the importance of diarrheal disease prevention and management.
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Biswas JS, Lentaigne J, Burns DS, Osborne JC, Simpson AJ, Hutley EJ, Hill NE, Bailey MS. Undifferentiated febrile illnesses in South Sudan: a case series from Operation TRENTON from June to August 2017. BMJ Mil Health 2020; 167:358-361. [PMID: 32094218 DOI: 10.1136/jramc-2019-001238] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/17/2019] [Accepted: 07/19/2019] [Indexed: 11/03/2022]
Abstract
Undifferentiated febrile illnesses present diagnostic and treatment challenges in the Firm Base, let alone in the deployed austere environment. We report a series of 14 cases from Operation TRENTON in South Sudan in 2017 that coincided with the rainy season, increased insect numbers and a Relief in Place. The majority of patients had headaches, myalgia, arthralgia and back pain, as well as leucopenia and thrombocytopenia. No diagnoses could be made in theatre, despite a sophisticated deployed laboratory being available, and further testing in the UK, including next-generation sequencing, was unable to establish an aetiology. Such illnesses are very likely to present in tropical environments, where increasing numbers of military personnel are being deployed, and clinicians must be aware of the non-specific presentation and treatment, as well as the availability of Military Infection Reachback services to assist in the management of these cases.
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Affiliation(s)
- Jason S Biswas
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK .,Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - J Lentaigne
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - D S Burns
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - J C Osborne
- Rare and Imported Pathogens Laboratory, Public Health England Porton, Salisbury, UK
| | - A J Simpson
- Rare and Imported Pathogens Laboratory, Public Health England Porton, Salisbury, UK
| | - E J Hutley
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
| | - N E Hill
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - M S Bailey
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
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Riddle MS, Connor P, Fraser J, Porter CK, Swierczewski B, Hutley EJ, Danboise B, Simons MP, Hulseberg C, Lalani T, Gutierrez RL, Tribble DR. Trial Evaluating Ambulatory Therapy of Travelers' Diarrhea (TrEAT TD) Study: A Randomized Controlled Trial Comparing 3 Single-Dose Antibiotic Regimens With Loperamide. Clin Infect Dis 2018; 65:2008-2017. [PMID: 29029033 DOI: 10.1093/cid/cix693] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/07/2017] [Indexed: 02/07/2023] Open
Abstract
Background Recommended treatment for travelers' diarrhea includes the combination of an antibiotic, usually a fluoroquinolone or azithromycin, and loperamide for rapid resolution of symptoms. However, adverse events, postdose nausea with high-dose azithromycin, effectiveness of single-dose rifaximin, and emerging resistance to front-line agents are evidence gaps underlying current recommendations. Methods A randomized, double-blind trial was conducted in 4 countries (Afghanistan, Djibouti, Kenya, and Honduras) between September 2012 and July 2015. US and UK service members with acute watery diarrhea were randomized and received single-dose azithromycin (500 mg; 106 persons), levofloxacin (500 mg; 111 persons), or rifaximin (1650 mg; 107 persons), in combination with loperamide (labeled dosing). The efficacy outcomes included clinical cure at 24 hours and time to last unformed stool. Results Clinical cure at 24 hours occurred in 81.4%, 78.3%, and 74.8% of the levofloxacin, azithromycin, and rifaximin arms, respectively. Compared with levofloxacin, azithromycin was not inferior (P = .01). Noninferiority could not be shown with rifaximin (P = .07). At 48 and 72 hours, efficacy among regimens was equivalent (approximately 91% at 48 and 96% at 72 hours). The median time to last unformed stool did not differ between treatment arms (azithromycin, 3.8 hours; levofloxacin, 6.4 hours; rifaximin, 5.6 hours). Treatment failures were uncommon (3.8%, 4.4%, and 1.9% in azithromycin, levofloxacin, and rifaximin arms, respectively) (P = .55). There were no differences between treatment arms with postdose nausea, vomiting, or other adverse events. Conclusions Single-dose azithromycin, levofloxacin, and rifaximin with loperamide were comparable for treatment of acute watery diarrhea. Clinical Trial Registration NCT01618591.
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Affiliation(s)
- Mark S Riddle
- Naval Medical Research Center, Silver Spring, Maryland
| | - Patrick Connor
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Jamie Fraser
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Chad K Porter
- Naval Medical Research Center, Silver Spring, Maryland
| | - Brett Swierczewski
- Armed Forces Research Institute for the Medical Sciences, Bangkok, Thailand
| | - Emma J Hutley
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | | | | | | | - Tahaniyat Lalani
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland.,Naval Medical Center, Portsmouth, Virginia
| | | | - David R Tribble
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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10
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Parsons I, Hutley EJ, Gibb I, Lentaigne J, Wilson D, Cox AT. Deployed military general internal physician’s toolkit: the recent past and near future. J ROY ARMY MED CORPS 2018; 164:230-234. [DOI: 10.1136/jramc-2017-000846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/29/2017] [Accepted: 12/01/2017] [Indexed: 11/04/2022]
Abstract
IntroductionThe role of the military physician in Deployed Hospital Care involves the diagnosis and management of a wide variety of disease states. Broad clinical skills need to be complemented by judicious use of a limited array of investigations. No study has specifically quantified what investigations physicians use on operations.MethodsA retrospective cross-sectional study was performed to ascertain what investigations were undertaken on all patients managed by the General Internal Medicine teams over a 14 month period during a recent enduring operation in Afghanistan. A record was also made of investigations that were unavailable but considered desirable by the treating physician in order to inform clinical or occupational decisions.Results676 patients were admitted during the study period. Blood tests were performed in 96% of patients, plain radiographs in 50%, CT in 12% and ultrasound in 12%. An ECG was performed in over half (57%) and a peak flow in 11%. The most desirable, but unavailable, investigations were cardiac monitoring and echocardiography (24% and 12% of patients, respectively).DiscussionThe data produced by this study both identified and quantified the investigations used by physicians during a mature operational deployment. This can be used in addition to accurate medical intelligence to inform and rationalise the diagnostic requirements for future operations as well as the provision of training. Technological advancements, particularly in weight and portability, are likely to enable more complex investigational modalities to be performed further forward on military deployments.
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Evans TO, Fominyam T, Matthews SW, Bailey MS, Hutley EJ. Use of multiplex PCR to rapidly diagnose febrile patients during a gastroenteritis outbreak among Ebola virus treatment unit workers. J ROY ARMY MED CORPS 2016; 163:73-75. [DOI: 10.1136/jramc-2016-000662] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/25/2016] [Accepted: 06/27/2016] [Indexed: 11/04/2022]
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Hutley EJ, Matheson ASM, Biswas J, Green AD. Rapid intelligence and failing weapons: meeting the challenges of 21st century infections in the deployed clinical environment. J ROY ARMY MED CORPS 2013; 159:144-9. [PMID: 24109134 DOI: 10.1136/jramc-2013-000122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
MESH Headings
- Anti-Bacterial Agents/therapeutic use
- Cellulitis/diagnosis
- Cellulitis/drug therapy
- Cellulitis/microbiology
- Cholera/diagnosis
- Cholera/microbiology
- Diagnosis, Differential
- Drug Resistance, Multiple, Bacterial
- Dysentery, Bacillary/diagnosis
- Dysentery, Bacillary/microbiology
- Escherichia coli
- Escherichia coli Infections/diagnosis
- Escherichia coli Infections/drug therapy
- Humans
- Male
- Microbial Sensitivity Tests
- Military Personnel
- Pneumonia, Ventilator-Associated/diagnosis
- Pneumonia, Ventilator-Associated/drug therapy
- Pneumonia, Ventilator-Associated/microbiology
- Polymerase Chain Reaction
- Spectrometry, Mass, Matrix-Assisted Laser Desorption-Ionization
- Staphylococcal Skin Infections/diagnosis
- Staphylococcal Skin Infections/drug therapy
- Staphylococcus aureus
- United Kingdom
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Affiliation(s)
- Emma J Hutley
- Royal Centre for Defence Medicine, ICT Centre, Birmingham, West Midlands, UK
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Hutley EJ, Chand MA, Hounsome G, Kelsey MC. Fosfomycin: an oral agent for urinary infection caused by extended spectrum beta-lactamase producing organisms. J Infect 2010; 60:308-9. [PMID: 20114062 DOI: 10.1016/j.jinf.2010.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 01/21/2010] [Indexed: 10/19/2022]
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