SARS-CoV-2 population dynamics in immunocompetent individuals in a closed transmission chain shows genomic diversity over the course of infection.

Background: SARS-CoV-2 remains rapidly evolving, and many biologically important genomic substitutions/indels have characterised novel SARS-CoV-2 lineages, which have emerged during successive global waves of the pandemic. Worldwide genomic sequencing has been able to monitor these waves, track transmission clusters, and examine viral evolution in real time to help inform healthcare policy. One school of thought is that an apparent greater than average divergence in an emerging lineage from contemporary variants may require persistent infection, for example in an immunocompromised host.

The contribution of human conflict to the development of antimicrobial resistance.

Human conflict, such as the ongoing conflict in Ukraine, is an important driver of antimicrobial resistance. Here, we describe the challenges when addressing this problem during an ongoing conflict and the opportunities available to reduce the spread of antimicrobial resistance.

The 2022 monkeypox outbreak: A UK military perspective.

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.

Development and operation of the defence COVID-19 lab as a SARS-CoV-2 diagnostic screening capability for UK military personnel.

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.

Management of a large outbreak of COVID-19 at a British Army training centre: lessons for the future.

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.

Novel equipment used in the UK Role 2 medical treatment facility as part of Operation TRENTON in South Sudan.

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.

Diarrhea and associated illness characteristics and risk factors among British active duty service members at Askari Storm training exercise, Nanyuki, Kenya, January-June 2014.

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.

Undifferentiated febrile illnesses in South Sudan: a case series from Operation TRENTON from June to August 2017.

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.

An outbreak of Shigella boydii serotype 20 in January 2015 amongst United Kingdom healthcare workers involved in the Ebola response in Sierra Leone.

In January 2015, Public Health England and the United Kingdom (UK) Ministry of Defence investigated cases of diarrhoea and fever in military personnel recently returned to the UK after supporting the response to the Ebola epidemic in Sierra Leone. Tests for Ebola virus infection were negative. PCR tests detected the ipaH gene in 10/12 faecal specimens, and Shigella boydii serotype 20 was isolated from 7 patients.

Comparison of stool collection and storage on Whatman FTA Elute cards versus frozen stool for enteropathogen detection using the TaqMan Array Card PCR assay.

The use of Polymerase Chain Reaction (PCR) assays for pathogen detection in travelers' diarrhea (TD) field studies is limited by the on-site processing and storage requirements for fecal specimens. The objectives of this investigation were to i) characterize the pathogen distribution in deployed military personnel with TD using the TaqMan® Array Card PCR (TAC) on frozen stool and diarrheal smears on Whatman FTA Elute cards (FTA cards), and to ii) compare TAC detection of enteropathogen targets using smeared FTA cards and frozen stool, using TAC on frozen stool as the 'reference standard'. Stool samples, obtained from active duty personnel with acute TD enrolled in a field trial, were smeared onto FTA cards and stored at room temperature.

Deployed military general internal physician's toolkit: the recent past and near future.

Introduction: The 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.

Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone.

Background: Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting.

Methods: Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015.

Trial Evaluating Ambulatory Therapy of Travelers' Diarrhea (TrEAT TD) Study: A Randomized Controlled Trial Comparing 3 Single-Dose Antibiotic Regimens With Loperamide.

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.

Use of multiplex PCR to rapidly diagnose febrile patients during a gastroenteritis outbreak among Ebola virus treatment unit workers.

Multiplex PCR can provide rapid diagnosis for patients presenting with an acute undifferentiated febrile illness. Such technology is useful in deployed settings, where access to conventional microbiological diagnosis is limited. It was used in Sierra Leone to guide management of febrile healthcare workers, in whom Ebola virus disease was a possible cause.

What are the critical steps in processing blood cultures? A prospective audit evaluating current practice of reporting blood cultures in a centralised laboratory serving secondary care hospitals.

Aims: To assess current procedures of processing positive blood cultures against national standards with an aim to evaluate its clinical impact and to determine the utility of currently available rapid identification and susceptibility tests in processing of blood cultures.

Methods: Blood cultures from three secondary care hospitals, processed at a centralised laboratory, were prospectively audited. Data regarding processing times, communication with prescribers, changes to patient management and mortality within 30 days of a significant blood culture were collected in a preplanned pro forma for a 4-week period.

Real-time, portable genome sequencing for Ebola surveillance.

The Ebola virus disease epidemic in West Africa is the largest on record, responsible for over 28,599 cases and more than 11,299 deaths. Genome sequencing in viral outbreaks is desirable to characterize the infectious agent and determine its evolutionary rate. Genome sequencing also allows the identification of signatures of host adaptation, identification and monitoring of diagnostic targets, and characterization of responses to vaccines and treatments.

Diagnosis of Febrile Illnesses Other Than Ebola Virus Disease at an Ebola Treatment Unit in Sierra Leone.

Patients with febrile illnesses presenting to an Ebola treatment unit in Sierra Leone had a wide range of diagnoses other than Ebola virus disease. Rapid diagnostic tests were useful in confirming these diagnoses, reducing the length of patient stay with valuable consequences. These alternative diagnoses should assist in future planning.

Deployed antimicrobial stewardship: an audit of antimicrobial use at Role 3.

Introduction: Infections due to multidrug-resistant organisms are increasingly prevalent, and antimicrobial stewardship has become a priority for many healthcare organisations, including the Defence Medical Services. In military environments, infectious diseases remain a significant burden, and infections complicating the care of modern complex combat injuries are well recognised. A focus on infection prevention and control in the deployed environment is essential, and an important element of this is an antimicrobial formulary and stewardship programme.

Enteric disease on Operation HERRICK.

Background: It is increasingly recognised that diarrhoeal disease is an important contributor to disease non-battle injury (DNBI) rates on operations. Current data collection methods (J97/EPINATO) rely on self-presentation of patients to medical care, which is likely to under-record the true incidence of diarrhoea in theatre. Along with this, the data recording itself is less than adequate, with acknowledged issues in classification of diarrhoeal disease within J97/EPINATO categories.

Contact lens-related microbial keratitis in deployed British military personnel.

Aims: To quantify the effect of contact lens-related microbial keratitis (CLMK) in the British Defence personnel particularly those in active service in the Arabian Gulf and Afghanistan between June 2001 and January 2007.

Methods: A retrospective review of all British military personnel who developed contact lens-related keratitis during deployment.

Results: A total of 27 cases (27, eyes, 23, male; median age 26 (range 19-41) years) were identified, of whom 19 cases were evacuated from Iraq alone.