3rd Force Health Protection NATO Congress 2016

3rd Force Health Protection NATO Congress 2016

S1

3rd Force Health Protection NATO Congress 2016 Hamburg, 19th to 21st September 2016 Helmut-Schmidt-University Generals, admirals, officers, colleagues, ladies and gentlemen, we have the great pleasure to introduce the program of the 3rd Force Health Protection Congress 2016 of the NATO which is held from 19th to 21st September 2016 at the Helmut Schmidt University of Hamburg, Germany (www.hsu-hh.de). The timely topic is “Tropical Medicine and Infectious Diseases in an International Military Context”. The scientific program has been jointly organized by the NATO Centre of Excellence for Military Medicine Deployment Health Surveillance Capability (NATO MILMED COE DHSC) as the international partner and the Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, as the national partner. The German Society for Military Medicine and Pharmacy (GSMMP/DGWMP) will stage an accompanying industrial exhibition from 19th to 21st September 2016. The concept has proved to be very successful during the two previous Force Health Protection Congresses of the NATO. The presence of world-leading scientists strongly contributes to the excellent reputation of the conference. The Force Health Protection Congresses of the NATO are well established as important international scientific platforms with a clear emphasis on military and preventive medicine. The focus on tropical and infectious disease medicine in 2016 reflects the increasing numbers of military operations in tropical settings with increased infection risks. The reasonable attendance fee with further partial waver for presenting authors makes this conference very attractive also for participants from abroad. There will be ample opportunity for establishing contacts with civilian and military researchers from all over the world. It is a venue for experts that are highly interested also in the latest concepts and products in the areas of diagnostics, therapy and prevention of frequent and dangerous infectious diseases. Besides infection-related sessions, the scientific program of the 3rd Force Health Protection Congress 2016 of the NATO will also feature topics of particular interest such as “Prevention (programs, prophylaxis, vaccines)“, “Diagnostics (modern technologies, rapid tests)“, “Therapy (novel approaches)“, “Outbreak investigation and management (latest experience, Ebola)“, “Health surveillance and screening“, „Imported pathogens“, and “Medical management in austere environments“. Internationally renowned experts will attend the conference to give insight into their latest research findings, and high-profile exhibitors will be present to complement the prestigious event. The presentation of industrial research and development data in chosen scientific sessions provides added value to the program. We thank you very much for your interest in the highly relevant topics with a strong focus on military and deployment medicine and your participation in the 3rd Force Health Protection Congress 2016 of the NATO! Sincerely,

Colonel (MD) Dr. László FAZEKAS Director of NATO Centre of Excellence for Military Medicine, Budapest

Brigadier General (MD) Dr. Joachim HOITZ Head of the German Armed Forces Hospital of Hamburg

Wehrmedizinische Monatsschrift 60 (2016), 8/2016

S2

3rd Force Health Protection NATO Congress 2016 – Abstracts –

Opening lectures Force Health Protection (FHP) in NATO deployments

consequences after deployment. All these examples underline the efforts still needed in identification, treatment and prevention domains.

Hans-Ulrich Holtherm

Neglected Tropical Diseases: Challenges in Diagnostics and Control

Bundeswehr Medical Academy, Munich, Germany

Bernhard Fleischer

The perception of medical support during current NATO deployments often focuses on trauma and emergency medicine, especially the rescue chain and immediate life saving and surgical interventions. Nevertheless the reality of these deployments shows, that diseases and non battle related injuries (DNBI) cause a lot more of soldiers work days lost than battle related trauma or injuries, and therefore significantly influence readiness and operability of the deployed forces.

Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany

FHP is a key factor improving forces’ readiness and health. Every nation has implemented policies and practices in order to protect and maintain healthy forces. NATO ‘s role in this is to communicate and coordinate the different policies and practices, enhance compatibility and increase interoperability in preparation of- and during NATO deployments. The NATO COMEDS Force Health Protection Working Group (FHP WG) is a subject matter expert forum and responsible for the production and concurrent actualization of FHP related doctrinal documents and STANAGs. The work of the FHP WG therefore directly supports mission oriented improvement of interoperability and standardization in the broad field of FHP among the NATO Allies and partner nations. The presentation provides an overview of the different aspects and medical specializations of mission oriented FHP. The important role of interdisciplinary collaboration in the fields of control of infectious diseases, environmental medicine, occupational medicine, veterinary medicine including food and water hygiene and entomology is described. Additionally a short description of the FHP contributing capabilities “Medical Intelligence” and “Deployment Health Surveillance” is provided, in order to enhance the understanding of a comprehensive and successful FHP system for the deployed military forces of NATO. Infectious diseases on deployment - past and present Marc Morillon International committee of military medicine

Even living at the time of antibiotics and vaccines, infectious diseases remain still a threat for soldiers and for military forces deployed in operations. Looking at military history, one can easily find a lot of examples of sanitary disasters or operations failures due to infectious diseases. Some infectious agents such as plague bacillus, smallpox and yellow fever viruses appear to be no more of concern (if we exclude the eventuality of an intentional military use for some of them). Some others such as enteropathogen bacteria (French revolutionary wars, Crimea expedition, World War One) have been and remain old companions for the armies. Among vectors transmitted diseases, malaria (Walcheren expedition, Madagascar, Korea, Vietnam) is still the most famous and remains a very serious threat in endemic countries. In some other cases, fighting forces may play the role of dispersing agents (typhus outbreak in Europe following Napoleon’s campaign against Russia). The more recent example of cholera outbreak in Haïti following the deployment of a United Nations contingent remind us that this risk still exists. Today, diarrheal diseases remain the most frequent infectious event. In most of the cases, etiologic agents are unknown and there is still a need of researches concerning detection and treatment. Malaria and a lot of arthropod transmitted diseases (leishmaniasis, arboviruses, rickettsosis) are frequent and often underestimated. Forces from different countries deployed in Africa have experimented schistosomiasis and we suspect that leptospirosis are much more frequent that it is believed. Besides immediate consequences on individuals and sometimes on the mission, one should consider also long term


Neglected Tropical Diseases (NTDs) are a heterogenous group of mostly infectious diseases, that have in common that they affect nearly exclusively people in poor and remote areas of the tropics. The 17 diseases that form the priority list of WHO leave over one billion infected and up to two billion at risk. NTDs are markers and drivers of poverty and NTD control or elimination can make a proportionately greater contribution to development than many other investments. The road map of WHO for the years 2012 to 2017 had set five interventions for the 17 NTDs: innovative and intensified disease management; preventive chemotherapy; vector ecology and management; veterinary public-health services; and the provision of safe water, sanitation and hygiene. Much progress has been made as current programmes have reached in 2012 800 million annual treatments in 70 countries. A major part of this success is due to donated quality assured essential medicines valued at 2-3 US$ billion annually by pharmaceutical companies. For several diseases early case finding and reliable diagnostics are the critical bottle neck for control. Especially for NTDs the development of field-friendly diagnostic assays is of utmost importantance. Here the need for on site tests is the same as for health protection of Armed Forces in the field. For a final elimination of NTDs more tools are required and research will be an essential component to reach this goal.

Tropical dermatology Management of cutaneous leishmaniasis in military missions Marcellus Fischer Bundeswehr Hospital Hamburg, Department of Dermatology, Hamburg, Germany

Cutaneous leishmaniasisis a prevailing problem for any military deployment especially in semi-arid areas in the Near and Middle east. A short summary of the present epidemiologic situation is given as well as clinical manifestations of cutaneous leishmaniasis and common diagnostic measures are pointed out. The response to treatment varies according to the species. Therefore, a species-specific approach is proposed. An overview of published treatment options and treatment recommendations are given for each of the most important Leishmania species. Drugs for systemic and topical treatment are presented and discussed with regard to their application, use and adverse effects. Indications for local or systemic treatment are proposed. From trenches in Flandern to long-term patrols in Afghanistan: prevention and treatment of foot diseases Philipp Schachtschneider, Marcellus Fischer Bundeswehr Hospital Hamburg, Department of Dermatology, Hamburg, Germany

First reported during the Napoleonic wars, immersion feet became a challenging problem in trenches in WWI. More than a hundred thousand soldiers were suffering from trench feet because of bad hygienic conditions and fights in muddy, flooded battlefields on the western front on each side. As long as regular change of a soldier’s footwear wasn’t possible in the beginning, many combatants lost their feet due


to threatening infections. Only after introducing preventive strategies, the situation could have been improved. Although many lessons were learned from this period of time, military medical services of all participating nations in ISAF mission were dealing with foot diseases. Those were leading to increasing lost man-days after introducing long-term patrols. Foot fungus and plantar pitting were the new “trench foot” of the military mission in Afghanistan. Although a high standard of therapeutically options were present in field hospitals, prevention was once again in the focus of military leaders and medical services. To face the special climate conditions in Afghanistan, foot wear had to be breathable but at the same time water-resistant. Steady change of socks and combat boots are as necessary as keeping the soldier’s feet dry and well groomed. After implementing the required supply lines as well as stocks of clothing and instructing soldiers on their mission, lost man-days due to foot diseases were reduced. Rickettsioses in military medicine Andrea Vanegas Bundeeswehr Hospital, Department of Dermatology, Hamburg, Germany

Rickettsioses are emerging zoonotic infections around the world and are an important topic in the field of military infectious diseases. Exposer of military personnel in endemic regions is common not only in humanity or during military deployments but also in non-deployments settings. In the last 25 years, the knowledge of Rickettsioses has increased, however, the diagnose of rickettsial disease continues to be a challenge in many settings due to its symptoms being shared with many other febrile and exanthematic diseases. Determining the presence of rickettsial disease in the military is relevant to developing strategies for its prevention and diagnosis for prompt treatment. My overview will consist of a short review of the clinical features of rickettsial disease, its relevant epidemiological, and risk factors both around the world and within the military community.

S3

Worldwide, nearly 400 million people are infected with Chlamydia trachomatis (146 million.), Neisseria gonorrhea (51 million), Syphilis (5 million) and Trichomonas vaginalis (239 million.). Since Europe is consolidating more and more, the infection numbers of STD`s are expected to grow further in the upcoming years. At the moment, there is a significantly higher incidence of STD`s in Eastern Europe. From 2000 - 2006, the Robert-Koch-Institute detected a threefold ascent in cases of syphilis in Germany. Three in 100.000 inhabitants are infected with syphilis in Germany, whereas the numbers in Eastern Europe a five to ten times higher. Europe and Germany have experienced a further increase in Sexual Transmitted Diseases cases since 2013. According to the Robert Koch Institute, men are affected by those diseases much more then woman. The incidence in Gonorrhea is three times higher in man then in woman, whilst Syphilis appears five times more often in men then in woman. Gonorrhea is particularly problematic since Neisseria gonorrhea has developed a resistance to all antibiotics currently available. When it comes to syphilis, penicillin is the common treatment of choice although it can not be used when allergies occur. On top of that, alternative medication against syphilis such as azithromycin have lost their effectiveness. In conclusion, education and an appeal for safer sex are the most important and currently the only effective approach to prevent of a global epidemic At the moment, the German army has dispatched 6320 soldiers to 3 continents working on 7 operations. Sexuality in deployment abroad is still a taboo topic, that is marginally addressed but provides a high potential for conflicts. Knowledge, attitudes and practices on Sexually Transmitted Infections among the French armed forces Sandrine Duron1, Pauline Brouillet2, Magali Billhot3 French armed forces center for epidemiology and public health, Marseille, France 2 Val de Grâce Military medical academy, Paris, France 3 Val de Grâce Military hospital, Paris, France 1

Condylomata acuminata- how can a patient complete his mission Sabrina Fehrmann Bundeswehr Hospital Hamburg, Department of Dermatology, Hamburg, Germany

Anogenital warts are the most common clinical manifestation of human papillomavirus ( HPV) infections. The lecture gives an overview about the characteristics of condylomata acuminata, diagnostics, clinical manifestations and treatment. Especially possible treatment strategies for military missons abroad will be pointed out. Finally some clinical cases will be presented and the audience will be invited to decide about the treatment on the background of a millitary deployment.

Sexually diseases

transmitted

and

gynecological

The impact of sexual transmitted diseases in military missions with special regard to syphilis and gonorrhea Carola Edler, Marcellus Fischer Bundeswehr Hospital Hamburg, Department of Dermatology, Hamburg, Germany

In the last 10 years there has been a massive increase in incidence of sexually transmitted diseases.

Introduction: Sexually Transmitted Infections (STIs) remain a major public health issue. Soldiers are a vulnerable population for STIs because of the missions and community life. This study was meant to establish a report of knowledge, attitudes and practices concerning STIs in a French military men sample. Methods: This study was a cross-sectional, multicentric survey with an anonymous standardized questionnaire. Data were collected from February to April 2015 interrogating serving soldiers from 3 French armed forces medical centers. 340 questionnaires were dispatched; all of them were recorded and analyzed. Results: Knowledge about STIs was insufficient, overall average was 13/20. In their entire life, 43 % have declared at least one sexual exposure (SE). 82 % of the respondents declared that their last SE took place in France, while 15 % when deployed overseas. Concerning medical history of STIs, 8,2 % have declared contracting at least one STI in their life with no case of HIV or viral hepatitis. Having multiple sexual partners was the only risk factor identified in the study. Discussion: Knowledge of French soldiers concerning STIs is insufficient and they have poorer results than the general French population. SE is common with a half of the respondents declaring having at least one. Intensifying reflection and prevention concerning STIs seems to


S4


be essential in order to encourage protective health behavior among French soldiers. Brucellosis in aborted women admitted to hospitals in Lahore, Pakistan Hosny El-Adawy1, Saba Yasmin2, Iahtasham Khan3, Falk Melzer1, Heinrich Neubauer1 Friedrich-Loeffler-Institut, Institute for Bacterial Infections and Zoonoses, Jena, Germany 2 Department of Microbiology, University of veterinary and animal sciences Lahore, Pakistan 3 Section of Epidemiology and Public Health, College of Veterinary and Animal Sciences, Jhang, Pakistan 1

Introduction: Brucellosis is a zoonotic disease caused by obligate intracellular Gram-negative bacteria of genus Brucella (B.). According to OIE (Office International des Epizooties) it is the second most important zoonotic disease in the world after rabies. Humans mostly get infected by B. abortusand B. melitensiswhich cause high morbidity and socioeconomic losses. The present study was designed to reveal the impact of brucellosis with a focus on abortion in Pakistani women. Material and Methods: In this study blood samples (n=200) were collected from aborted women from different hospitals of Lahore, Pakistan. Sera samples were initially tested with Rose Bengal Plate Test (RBPT). For molecular confirmation and species identification, all samples were subjected to real-time PCR using Brucella genus-specific and later on species-specific primers and probes. Results: A seroprevalence of 7 % was found and from 39 samples (19.5 %) B. abortus DNA was amplified. Out of 200 patients 31(79 %) were admitted to hospital presenting with fever and joint pain, 23 (58.9 %) reported abortion at the end of 2nd trimester, 19 (48.7 %) consumed raw milk, 8 (20.5 %) had a history of joint pain and fever and only 5 (12.8 %) reported previous exposure to animals. No sample tested positive for B. melitensis DNA. Conclusion: Brucellosis seems to be a major cause for abortion in women in Pakistan. The outcome of this study should alert health officials to design and implement control strategies for brucellosis in Pakistan including educational work for adolescents and an awareness campaign for women early in pregnancy. Evaluation of HIV cases in the Tertiary Military Hospital Gurkan Mert1, Gonca Fidan2 Gulhane MilitaryMedical Academy, Dept. Of Infectious Diseases and Clinical Microbiology, Ankara, Turkey 2 Agrı Military Hospital, Dept. Of Infectious Diseases and Clinical Microbiology, Agri, Turkey 1

Objective: Turkey is among the countries with low incidence rates of HIV infection. But it is observed in recent years contrarily to other regions of the world, HIV infection incidence in our regionis in an upward trend. Among the soldier on military duty or the people applying for military to be soldier, problematic HIV cases seen more often than before. In this study, things to evaluate these patients isanalysed. Method: Records of HIV positive soldier on military duty or people applying for military to be soldierwas examined between 2011 and 2015. Results: 52 male patient with mean age 23±4 were evaluated (table). Results of this patients were presented in a table. Principally medical treatment surely started to patients with CD4 cell count < 500 cells/ mm³ according to guidelines. Control examination after 6 months or 1 year is recommended to patients whose CD4 cell count is unable meet criteria for starting antiretroviral therapy. Antiretroviral therapy of patients started treatment before was revised and drug resistance tests


repeated. Patients with comorbidities consultated with other clinics. Side effects of drugs researched. Conclusion: Problems of this young age patient group gradually increasing. During military duty it is thought to give medical therapy to HIV positive patients independent from HIV RNA and CD4 cell count. Because possibility of not applying hospital or any doctor due to some reasons is high after completing military duty. This group is sexually active and taking no treatment, also having a social impact on them. So evaluation of HIV infection in this group should be performed more attentive.

Surveillance I Fever among the Turkish Military Personnel Returned from Overseas Mission Bilal Bakir1, Gurkan Mert2 Gulhane Military Medical Academy, Dept. of Public Health, Ankara, TURKEY

1

Gulhane Military Medical Academy, Dept. of Infectious Disease and Clinical Microbiology, Ankara, TURKEY.

2

Introduction: Military personnel returned back to home from active deployment might have fever among other health problems. Evidence so far indicates that 30 % of personnel seeking medical care after a deployment have fever of different reasons. In this study, we examined the military personnel who referred to our hospital to determine the distribution of fever with the exception of respiratory problems. Method: All the records from 2013 through 2015 were screened retrospectively for the Turkish military Personnel who were routinely examined after returning back from the duty in different countries. Location of travel, exposure history and vaccination record were obtained from the records that were reported by personnel at the time of examination. Results: Every year 2,500 Turkish military personnel deployed for overseas mission. Among Patients admitted to the hospital after mission, the leading causes of fever were Plasmodium spp. in the 11 patients (include one patient Plasmodium falciparum, mostly plasmodium vivax), then diarrhea/dysentery nontyphoidal Salmonella spp., in five patients, and urinary tract infection /pyelonephritis in three patients. The plasmodium diagnosis was made by using thick and thin smear including all returned from malarious areas. We have found one P.falciparum chloroquine sensitive case confirmed with PCR, he came from Gambia. Others plasmodium cases returned from Middle East (5), West Africa (2), Somalia (2) and Afghanistan (1). Conclusions: Fever have occurred in limited number among the personnel returned from the duty, but some of them like P. falciparum can be fatal and chemoprophylaxis is not 100 % protective. Arab Spring in Tunisia: Confronting the challenge of infectious disease Maher Beji1,2, R. Allani1,2 1. General Directory of Military Health, Tunisia 2. Faculty of Medicine of Tunis – University of Tunis El Manar, Tunisia

Arab spring is a combination of popular protests with various coverage extent and intensities and occurred in some Arab countries. Tunisia was the first country that hosted the beginning of these waves since the end of 2010 and then followed by other countries. It involved numerous challenges, among them, those faced by the national health system. In fact, Health facilities had to deal with immediate problems related to the management of traumatic patients and displaced populations from a neighbour country. Both military and public health institutions had seen their activities increased.


In February 2011, Tunisia had provided assistance and medical support to thousands of migrants and refugees of various nationalities fleeing the ongoing fighting in Libya. With the support of United Nations’ agencies and many national and international NGOs, camps have been installed on the border in a Saharan environment. More than 18,000 medical consultations were provided. More than 235 wounded in action during civilian war have been treated in military field hospital. Jointly, other activities were performed in coordination with the various stakeholders covering the camp hygiene, promotion of mental health, epidemiological survey of communicable diseases and maternal and child health support. Tunisia observed in recent years an increase of communicable diseases’ incidence. Tuberculosis incidence raised from 20.6 to 22.4 per 100,000 inhabitants between 2009 and 2012. Two to 3 cases of human rabies were declared yearly. The increase of this incidence could be related to the limitation of rabies vaccination and dogs’ shooting. The re-emergence of infectious diseases was also observed. H1N1 flu was responsible for six deaths in March 2016. West Nile virus was isolated in 2012 in 66 subjects from 653 screened. It was the origin of 28 cases of meningoencephalitis with favourable evolution under treatment. In 2013, four cases of malaria identified and qualified of airport malaria were the first cases registered in the country since 1979. Imported Malaria and the persistence of local anophelisme may facilitate the relocation of the malaria-endemic.

S5

while81.9 % of brucellosis cases were not considered for Brucella infection. Contact with cattle and goats, slaughtering animals, and consumption of raw cattle milk were significantly associated with brucellosis and Q-fever. Discussion: Our results suggest that bacterial zoonoses are common but underappreciated as a cause of fever in febrile patients. Increased awareness of clinicians, access to reliable diagnostic assays and preventive interventions targeting significant risk factors are recommended. Measles seroprevalence, outbreaks and vaccine coverage in Rwanda Eric Seruyange1,2,6, Jean-Bosco Gahutu2, Claude Mambo Muvunyi2, Zena Uwimana3, Maurice Gatera4, Theogene Twagirumugabe2,6, Swaibu Katare5, Ben Karenzi1, Tomas Bergström6 Rwanda Military Hospital, Kigali, Rwanda College of Medicine and Health Sciences, University of Rwanda, Rwanda 3 National Reference Laboratory, Rwanda Biomedical Centre, Kigali, Rwanda 4 Expanded Program on Immunization, Rwanda Biomedical Centre, Kigali, Rwanda 5 National Centre for Blood Transfusion, Rwanda Biomedical Centre, Kigali, Rwanda 6 Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Sweden 1 2

The impact of the Arab spring had no negative impact on Tunisian health system, since the support of health is still developing in all areas and in all regions despite the increased demand particularly linked to the massive presence of Libyan nationals.

Introduction: Measles outbreaks are reported after insufficient vaccine coverage, especially in countries recovering from natural disaster or conflict. We compared seroprevalence to measles in blood donors in Rwanda and Sweden, and explored distribution of active cases of measles and vaccine coverage in Rwanda.

Etiology of Non-malaria febrile illness in rural Northeastern Kenya: A cross-sectional Hospital based study John Njeru1,2,3, Klaus Henning1, Mathias Pletz2, Regine Heller4, Sam Kariuki3, Eric Fèvre5,6, Heinrich Neubauer1

Materials and Methods: 516 Rwandan and 215 Swedish blood donors were assayed for measles-specific IgG by ELISA. Data on vaccine coverage and acute cases in Rwanda from 1980 to 2014 were collected, and IgM on serum samples and PCR on nasopharyngeal (NPH) swabs from suspected measles cases during 2010-2011 were analyzed.

Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler- Institute, Jena, Germany 2 Center for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany 3 Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya 4 Institute for Molecular Cell Biology, Center for Molecular Biomedicine, Friedrich Schiller University of Jena, Jena, Germany 5 Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom 6 International Livestock Research Institute(ILRI), Nairobi, Kenya

Results: Seroprevalence of measles was significantly higher in Swedish blood donors (92.6 %; 95 % C: 89.1 - 96.1 %) compared to Rwandan subjects (71.5 %; 95 % CI: 67.6 - 75.4 %) and more pronounced Africa (5 - 6 %). Differences were also obvious for ribotype distribution and toxin repertoires. Predominant ribotypes were RT 001/072 and zoonotic RT 078 in Germany, SLO160 and RT 017 in Indonesia, and RT 084 in Africa. A high percentage of a toxigenic strains was found in Africa. Antibiotic resistance pattern showed significant differences: In comparison to the other countries more isolates from German patients were resistant against moxifloxacin. Conclusion: CDI is present not only in Germany, but also in African and Asian countries indicating that Clostridium difficile should also be considered as a pathogen in patients suffering from diarrhoea in Asian and African countries.

Ebola – lessons identified, lessons learned, an what remains Medical evacuation of critically ill patients with highly contagious diseases Christian Herzog Robert Koch Institute, Federal Information Centre for Biological Threats and Special Pathogens, Berlin, Germany

Medical evacuation (MedEvac) of critically ill patients with highly contagious diseases over long distances is very challenging. During the recent outbreak of Ebola virus disease (EVD) in West Africa, most MedEvac providers were not able to transport critically ill EVD patients and to treat them on board. Most EVD patients remained untreated during evacuation. Deterioration of the patient’s general condition during the flight was feared in most cases. Under the responsibility of the German Federal Foreign Office, a MedEvac Airbus A340 with an isolation unit on board was brought into service during the EVD outbreak. To our knowledge, it was the


only MedEvac solution at that time, which allowed direct access to and intensive care of critically ill EVD patients. All necessary standard operating procedures were in place to assure adequate containment, patient transfer on a stretcher, intensive care treatment, decontamination etc. Emergency protocols have been developed in case of sudden loss of cabin pressure or personal injuries in the containment zone. The German MedEvac airplane was designed as a short-term emergency solution. It has been taken out of service at the end of the humanitarian crisis in West Africa. It is just a matter of time that the next Public Health emergency will require engagement of international health care workers. Proper MedEvac solutions are crucial for their engagement and to assure their safety in an outbreak response. However, a MedEvac solution to transport and treat critically ill patients with highly contagious and aerosol transmissible infectious diseases will not be readily available. Germany is willing to cooperate and share concepts and protocols with interested partners to implement a longterm MedEvac capacity. Emergency vaccines - Challenges and lessons learned from Ebola Marylyn Addo University Medical Center Hamburg-Eppendorf, Section Infectious Diseases and Tropical Medicine, Hamburg, Germany

The recent large emerging diseases outbreaks including the two public health emergencies of international concern (PHEIC), the Ebola Virus outbreak in Westafrica and the more recent ongoing ZIKA-Virus outbreak, have illustrated that critical gaps in preparedness, prevention and management capabilities remain. For these two diseases and for the majority of emerging viruses, there are no licensed vaccines or therapeutic modalities. We will here report challenges and unpublished results from a Phase 1 Ebola Vaccine trial during the peak of the EVD epidemic in 2014/2015 conducted in Hamburg as part of an international consortium (VEBCON). We demonstrated that the live-attenuated vaccine rVSV-EBOV-GP was safe and immunogenic with seroconversion in all vaccine recipients and durable neutralizing antibody responses . However, T cell responses to the vaccine were of low magnitude, while early innate signatures were strong and predicted the antibody response on day 28. Based on these results dose finding was established for ongoing phase 2 and 3 clinical trials, where the vaccine subsequently was shown to confer 100 % efficacy to prevent Ebola virus infection in early analyses. The vaccine is currently being prepared for licensing anticipated in 2017. Based on the experiences from these rapid vaccine development efforts the presentation will also place these results in the context of ongoing international efforts to improve preparedness and research and development of emerging diseases. The isolation hospital - a new asset within the network of Red Cross emergency response units Jörg Haas German Red Cross

The Ebola Outbreak 2014/15 in West Africa made the worldwide lack of assets and coordination for outbreak preparedness, early warning and (a deployable) response clearly visible for both decision-makers and professionals. Considering the joint mission of the German Red Cross with the German Armed Forces 2014/15 in Monrovia and the profound experiences of German Red Cross Emergency Response Units with worldwide disaster response missions, the German Red Cross was chosen to build up optimized outbreak response assets as a German pool resource of the European Emergency Response Capacity (EERC). This initiative including contributions from different European countries, formerly known as White Helmets, is now referred to as European Medical Corps.


In this context, the German Red Cross level of ambition goes in at least four significant aspects - consistent integration in the regional health care architecture, individual isolation of suspect cases, classification of assets as WHO Emergency Medical Teams and stepwise escalation with three different epidemic response units - beyond the need for merely meeting the established standards. Each aspect contains a structural and/or processs-related answer to one or more of the problems identified during a profound lessons learned process. Consequently, the German Red Cross mind-set for its epidemic response assets is shaped by the need for interoperability, flexibility, timeliness, effectiveness, ethical awareness and a high standard of medical and nursing care as well as infection protection for staff and patients alike. However, no organisation or institution alone is able to cope with the challenges of worldwide outbreak response. Therefore, this presentation should be considered as an invitation to those who are dedicated to outbreak preparedness, early warning, or emergency response, in one or another way, in order to contribute to the ambitious European Medical Corps project and make it a truly humanitarian success story. Outbreak response in the aftermath of West Africa´s Ebola Crisis – VISIT: a civil-military interface pilot Katalyn Rossmann Bundeswehr Medical Service Headquarters, Munich, Germany

Background: The Ebola Outbreak in West Africa has catapulted Health as a topic on the Global Agenda of Politics at the G7-Summit as well as on the Security Agenda at the Munich Security Conference. Health Advocacy Champions as Bill Gates expect the international military to provide solutions for future humanitarian health challenges. Due to the analysis of many international organizations and think tanks surveillance and medical intelligence are seen as technical gaps in the outbreak response especially in resource poor settings. Objectives: Provision of a comprehensive analysis of necessary infectious diseases outbreak management capabilities for future scenarios of humanitarian relevance. Therefore, we developed as an example for civil-military interface capabilities an operational research project: to test a “Disease Outbreak Early Warning and Response tool for and with refugees in Germany” called “VISIT”. Purpose: Epidemiological health protection of refugee and host nation population as well as the provision of evidence-based & rational risk communication of refugee´s burden on the national society. Design, setting, participants: VISIT project cooperation partners launch a syndromic and specific surveillance protocol. Application of the protocol to a selected refugee setting in Lower Saxony. Data entry via medical personnel/assistant staff trained by Bundeswehr and Refugee/Community Health Worker with training standardized by Ethnomedical Centre Hanover. Hard- & Software: Application for Community Health Worker developed by University of the Bundeswehr, Munich for Smartphone/Pad and Digi-Pen for medical personnel/assistant staff. The DigiPen technology combines medical reporting, reporting of notifiable diseases and syndromic surveillance aspects in order to reduce & optimize medical staff´s reporting effort as well as maximizing their compliance to syndromic surveillance. Data transfer via Bundeswehr University Munich into NATO MilMedCOE DHSC/Analysis Center of the Bundeswehr Munich, Analysis of the syndrome based data, development of feedback (pdf-file). Provision feedback to data enterers and responsible authorities as well as on-site provision of rapidly deployable outbreak investigation teams (RDOIT) resp. syndrome based laboratory surveillance of the Bundeswehr in case of severe warnings in order to provide early response to

S9

a possible outbreak and to scientifically evaluate Early Warning Analysis Tool´s specificity. First results: pilot study is intended to start in March 2016. First results of the project´s operational level “syndromic surveillance” will be provided at the conference. The strategic evaluation of the project regarding the success of the implementation of a complex Public Health intervention is expected to be started after the pilot study phase. Furthermore qualitative research projects are planned to be conducted by Master students in order to test the mechanisms of impact and maintenance on the data enterer level. Conclusions: to be discussed

Teaching and training Fighting the Ebola epidemic in West Africa - A story of success of joint military and interministerial training Tobias Limmer Federal Ministry of Defence, Bonn, Germany

By order of the day of the Federal Minister of Defence dated 22 September 2014 members of the Bundeswehr were called up to volunteer for participation in a humanitarian relief operation to fight the Ebola epidemic in Liberia by assisting the DEU Red Cross (DRK) in setting up and operating an Ebola Treatment Unit (ETU). In accordance with this, the personnel to be deployed were to undergo, among other things, intensive preparations for dealing with the Ebola disease and the persons infected with Ebola. Deploying Bundeswehr personnel in support of the fight against Ebola in West Africa generated special training requirements. The contents of training included on the one hand elements independent of operational posts.The focus of the training was on handling personal protective equipment (PPE) which, at the same time, was considered a “non-compensatory subject”. The training organization of the Bundeswehr has succeeded at very short notice in ensuring a goal-oriented qualification of Bundeswehr personnel to support the fight against Ebola. Within the framework of joint military and interministerial training, a total of 181 members of the Bundeswehr were qualified. 89 % of all the persons interviewed upon return from deployment felt that they had received adequate training for their humanitarian relief operation. Due to the fact that, with a view to the conduct of training, responsibilities have been clearly specified and agencies have been tasked with providing training and support services, associated with continuous coordination of training issues, especially with the DEU Red Cross, it has been possible to gather valuable training experience for similar future operations. Force Health Protection lectures for Staff Officers and General / Admiral Staff Officers Thomas Benner Bundeswehr Command and Staff College - Medical Service and Health Sciences Department, Hamburg, Germany

Force Health Protection as a subset of Force Protection has to be incorporated in the commander’s decision making. That requires an iterative process among specialized medical staffs and operational planners. To properly incorporate health related aspects into the planning process and harmonize with other staff functions all staff officers should have knowledge of the medical contribution to the planning and decision making process at all levels (tactical, operational, strategic). The Bundeswehr Command and Staff College provides the Basic Staff Officers Course as well as the General and Admiral Staff Officers Course and a variety of seminars and workshops. The Medical Service and Health Sciences Department as part of the Command and Staff College provides all health related topics to the lectures and trainings.


S 10


Force Health Protection issues are mandatory in lectures and exercises for land, sea and air operations. The students get trained in the aspects of medical contribution to the operational planning process. Furthermore topics on Global Health Security as well as the “Military Medical Support in the Humanitarian Arena” are parts of the portfolio at the Command and Staff College.

NATO Deployment Health Surveillance training

This lecture will show how Force Health Protection is integrated in the training of all Bundeswehr staff officers.

Specific NATO Deployment Health Surveillance training is essential to ensure effective data collection and analysis. For this purpose NATO MILMED COE (Training and DHSC branches) organizes an annually training course together with the French Forces Epidemiology and Public Health Centre (CESPA) in Marseille. It makes students from NATO and non-NATO partner nations familiar with principles and tools for deployment health surveillance (i.e. ASTER, EpiNATO-2) and outbreak investigation. Furthermore, DHSC provides a power-point based learning tool for in-theatre training of health care providers.

The prevention programs for Dengue fever / Dengue hemorrhagic fever for air force helicopter pilots while deployed as combat search and rescue team in the air force base Mukti Arja Berlian Atang Sanjaya AFB Hospital, Bogor, Indonesia

Dengue is a disease caused by Dengue virus and spread by Aides aegypti mosquito, which can cause pain and even death. Dengue fever is an acute benign syndrome that occurs in the tropics. Dengue viruses are classified into Group B arthropod borne viruses (Arbovirus) and is now known as the genus flavivirus, family Flaviviridae, which has 4 types namely serotypes DEN-1, DEN-2, DEN-3 and DEN-4. Fourth serotypes of this virus, closely related antigenically. Infection with one serotype will cause lifelong antibodies against serotype is concerned but there is no protection against other serotypes. Someone living in endemic areas can become infected in three even four serotypes during his lifetime. In Indonesia serotype DEN-3 is the predominant serotype and is associated with severe cases. In Indonesia, the mosquito Aedes aegypti is found widespread throughout the country, both urban and rural areas, except in areas that the altitude is more than 1000 meters above sea level. The development of mosquito life it takes about 10-12 days from egg to adult. Only female mosquitoes bite and suck human blood to ripen their eggs. The age of female mosquitoes ranged between 2 weeks to 3 months, or an average of 1.5 months, depending on the temperature of the surrounding air humidity. Symptoms of dengue disease is often not visible. Classical Dengue Fever emerged in non immune, non indigenous adults and children. Symptoms begin on day 5 to day 10 of incubation. DHF / DSS usually appear from individuals infected with dengue fever, his blood sucked by Aides aegypti mosquito, then some time after that suck bite the healthy people. Healthy people are becoming infected and falling ill. Sudden high fever on the day I - II then down and up again on the V - VI (Saddle Back Appearance). Because of Indonesia is a tropical region and is an endemic area, Where the person living in endemic areas can become infected in three even four serotypes during his lifetime. Thus there must be a programs efforts to prevent the infection among the helicopter pilot who was performing its duties in the stand-by SAR Combat in RI Territory. Prevention steps are: 1. Before departing to and after returning from the place of assignment, doing routine blood tests, Anti Body Immunoglobulin and inspection of non-structural proteins (NS 1-7) 2. Keeping the body in shape (fit/healthy) by way of routine/regular sport and consuming sufficient foods, and if necessary the consumption of vitamins 3. Maintain the cleanliness of the environment, because mosquitoes love with the place that there are many objects that hung in the house, like a curtain, mosquito nets and clothing in the dark room is dark and damp 4. Use mosquito nets when sleeping and if necessary, use mosquito repellent.


Ralf M. Hagen, Nagpal Hoysal, Michael McCown, Benjamin Queyriaux. Deployment Health Surveillance Capability NATO MilMed COE, Munich , Germany

Outbreak detection and prevention Early detection of unusual outbreaks of disease – are we prepared? Ernst-Jürgen Finke1, Dieter Oberndörfer2, Martin Weber1, René Gottschalk3 Academy for Crisis Management, Emergency Planning and Civil Protection of the Federal Office of Civil Protection and Disaster Assistance 2 Frankfurter Institut für Rettungsmedizin & Notfallversorgung, Feuerwehrund Rettungsdienstakademie, Branddirektion, Frankfurt/Main, Germany 3 Gesundheitsamt Frankfurt/Germany 1

Introduction: European community is facing serious challenges by a difficult international security and humanitarian situation. Thereby, biological risks e.g. import of dangerous diseases or accidental and deliberate release of pathogens cannot be excluded. First signals of biological dangerous situations may be unusual outbreaks of diseases. Early detection of such events will safe lifes and prevent further spread of communicable diseases. Problems of early detection of unusual outbreaks and possible solutions will be discussed. Literature review: Based on a selected literature recherche we have identified and assessed some unusual outbreaks of infectious diseases occurring in Germany. We focused on air and food borne diseases like legionnaire`s disease and haemorrhagic enteritis, because they could be mimicked in case of biocriminal or bioterrorist attacks. Despite existing reporting system and surveillance networks detection, diagnostics and reporting of unusual outbreaks of these diseases were delayed, significantly. As result epidemiological investigations and antiepidemic measures could start first shortly before or after the peak of an epidemic. Conclusions: The early detection and management of unusual outbreaks could be improved by increasing the vigilance and awareness of rescue services, practitioners and clinicians in case of sudden occurence of patients with similar clinical pictures and history of disease, interdisciplinary communication and immediate information of public health officials, early initiation of microbiological investigations, using valid rapid diagnostic assays and laboratory procedures, improvement of infectiological and epidemiological training of physicians. Presentation of the structure of the response of the Free and Hanseatic city of Hamburg concerning Ebola Martin Dirksen-Fischer Hamburg Port Health Center, Free and Hanseatic City of Hamburg, Hamburg, Germany Introduction: The ever evolving dangers of Ebola and other emerging diseases ask for a combined and timely reaction from the state of Hamburg and its val-


ued partners, be they clinicians, Police, Fire brigade or the Port and Airport authorities.

Methods: In this presentation we will introduce the main activities of the Public Health system in our city of Hamburg while responding to the Ebola threat.. When the call from the WHO was received , asking for the treatment of an Ebola patient in Hamburg, decisions had to be made. The structure of the so called “Fachstab Seuchenschutz”, a working group of the city and its partners in the case of such situations is introduced. Results: The threat of outbreaks like Ebola in West Africa in 2014 will remain. A city like Hamburg, connected directly via maritime traffic and via airlines as well needs the capacities to respond . The main structure of our response is presented. Brazil’s scientific and technological production in response to the Zika epidemia Jochen Junker1, Marcia Lenzi1; Jonice Oliveira2 1

Centro de Desenvolvimento Tecnológico em Saúde, Fiocruz, Brazil Federal University of Rio de Janeiro – Department of Computer Sciences, Rio de Janeiro, Brazil

2

Zika virus is an arbovirus of the Flaviviridae family. Its identification occurred in 1947 in Uganda; occurrences of human infection were reported in an isolated and sporadic form with a large part of asymptomatic individuals. In Brazil, since November 2014 and mainly in the beginning of 2015, the Northeast states reported a great outbreak of a new exanthematic disease. The clinical condition led some researchers to consider the hypothesis of Zika virus. This was confirmed in April 2015 through PCR (1). Brazil was faced with the co-circulation of three arboviruses: DENV, ZIKV and CHIKV (Dengue virus, Zika virus and Chikungunya virus). Because the severe symptoms linked to ZIKV and or the co-occurrence of ZIKV and dengue or chicungunya infections, Brazil has an important play in the research and development scenario. This work aims to analyze publications on this disease by Brazilian researchers retrieved from national and international databases, analyzed and processed with text-mining tools in order to standardize author- and institution’s names and addresses. Co-authorship networks based on these publications will be assembled, visualized and analyzed with social network analysis software packages. Network visualization and analysis will enable us to characterize network components by area of work, identify institutions as well as authors playing major roles as central hubs or located at critical network cut-points and readily detect authors or institutions participating in large international scientific collaborating networks.

S 11

received 61 confirmed and suspected cases of EVD. Between December 2014 and August 2015, French servicemen rotated on a 2-month schedule, leading to a constant flux of soldiers returning to France with a risk of secondary dissemination of Ebola virus. Our objective is to describe the follow-up implemented for the returning servicemen to prevent this risk of dissemination in F rance. Method: Follow-up consisted in a body temperature self-monitoring twice a day during the 21st days after return. Servicemen had to report the temperatures measured on specific forms collected and analyzed at the end of the follow-up. Tracking was passive or active depending on their level of exposure in Guinea. In case of fever (≥ 38°C) or compatible symptoms onset, servicemen were considered as suspected case and had to call emergency coordination center. Results: In all, 410 military staffs were deployed in Guinea. During the follow-up period after return, 22 suspected cases occurred among whom 3 were considered as possible EVD cases and transferred to referent infectious disease treatment facility. None of them was confirmed for EVD. Conclusion: The specific monitoring organized for French soldiers deployed in Guinea allowed to follow during the 21st days after their return all the military personnel exposed, to know their health status on a near-real time basis and to be aware of all the alerts. No confirmed EVD case occurred.

Expert Talk “Management of highly contagious diseases on military missions options for a multinational approach” Military Health and the International Health Regulations(2005) considerations for outbreak response and management Dennis Faix Military Population Health, Naval Health Research Center, San Diego, CA, USA

A brief review of the International Health Regulations (IHR(2005)) and the timeline for implementation will be presented. Implications for military health systems in the detection, verification, reporting and response to public health events will be covered, with a special emphasis on international operations. A consensus statement on military medical understanding of the impact of the IHR(2005) in deployed environments will be reviewed.

Medication side effects, pathophysiology, and immunology

How to monitor returnees from Ebola stroked areas? Experience of French armed forces deployed in Guinea, 2015

Malaria Chemoprophylaxis and Self-Reported Impact on Ability to Work: Mefloquine vs Doxycycline

Gabriel Bédubourg2,3,4, Ghislain Manet1,2, Guillaume Velut2, Franck de Laval5, Aurélie Mayet2,3,4, Franck Berger2, Aïssata Dia2, Jean-Baptiste Meynard2,3,4,6, Rémy Michel2,3,4,6, Sandrine Duron2,3,4

David Ross, Andrew Terrell; Richard Firth, Mike Forde

Technical unit for animal epidemiology, Regional Armed forces health service office, Toulon, France 2 French armed forces center for epidemiology and public health, Marseille, France 3 ”Sciences Economiques & Sociales de la Santé et traitement de l’Information Médicale”, Marseille, France. 4 Aix Marseille Université, Marseille, Marseille, France. 5 French Guiana Armed forces health service Office, Cayenne, French Guiana 6 Val-de-Grâce Military Medical Academy, Paris, France 1

Introduction: During the Ebola virus disease outbreak (EVD) in West Africa in 2013-2015, French armed forces health service set up in Conakry a dedicated treatment center for healthcare workers, which

Royal Army Academy Sandhurst, Army Health Unit, Camberley, United Kingdom

Background: It is well known that, when taken for malaria chemoprophylaxis, both mefloquine and doxycycline are commonly associated with adverse effects. However, the relative impact of these on travellers’ ability to work is not so well understood. The aim of this study was to identify which drug has the lesser impact on ability to work as measured by self-reported severity of adverse effects via a questionnaire. Methods: Questionnaire based two-arm cohort study. Participants were soldiers selected from 10 consecutive units training in Kenya during 2012 and 2013. The exposure was either doxycycline or mefloquine and the main outcome measure was impact upon ability to work. Each


S 12


cohort was advised to take doxycycline or mefloquine with exceptions at the individual level where medically or occupationally advised.

Dengue and theDevelopment of a vaccine suitable for travelers

Results: Significantly more (p