MILITARY MEDICINE, 179, 2:183, 2014
The 2009 A(H1 N1) Influenza Pandemic in the French Armed Forces: Epidemiological Surveillance and Operational Management MAJ Jean-Baptiste Pohl, Frenoh Military Medical Service*; LTC Au relie Mayet, French Military Medical Servicef; MAJ Gabriel Be'dubourg, French Military Medical Servicef; MAJ Sandrine Duron, French Military Medical Servicef; COL Re'my Michel, French Military Medical Servicef; COL Xavier Deparis, French Military Medical Servicef; COL Christophe Rapp, French Military Medical Servicef; General Patrick Godart, French Military Medical Service§; General Rene Migliani, French Military Medical Servicef; COL Jean-Baptiste Meynard, French Military Medical Servicef
ABSTRACT Objective: Tbe main objective of tbis study was to evaluate tbe contribution of a newly implemented daily surveillance system to the management of the 2009 A(HINI) influenza pandemic by the military decision-makers at different levels in tbe French Department of Defence. Methods: The study sample included all medical advisors in tbe Ministry of Defence and tbe French Armed Forces Staff and also the members of tbe specific committee dedicated to flu pandemic control. Tbe variables studied were mental representation of epidemiology, relevance, usefulness, and realtime use of surveillance data using quantitative questionnaires and qualitative face-to-face semistructured interviews. Results: Among tbe risk managers of tbe flu pandemic in tbe Armed Forces, 84% responded. Tbe data generated by epidemiological surveillance were considered relevant and useful, and were reported as effectively used. On tbe basis of tbe information produced, concrete actions were planned and implemented in the Frencb Armed Forces. Conclusion: In a pandemic situation involving low mortality, tbe daily monitoring of tbe disease did not target public bealtb issues, but it was mainly used to assess tbe availability of the Armed Forces in real time. For tbe military staff, epidemiological surveillance represents an essential information tool for the conduct of operations.
INTRODUCTION Influenza is a viral infection with a seasonal increase in winter. Influenza viruses have great genetic plasticity. Antigenic drift causes epidemics and antigenic shift causes pandemics. In April 2009, a new variant influenza virus was identified.''^ It produced clustered cases in Mexico and in the United States. Biological analyses showed that the virulence and infectivity of the virus were similar to those of seasonal influenza viruses.^'"* Only few people had immune predispositions toward this new type of influenza. Because of its epidemic or even pandemic potential, influenza is a public health issue. The associated mortality is not negligible, and from an economic point of view, this disease constitutes a financial burden. For the community, influenza outbreaks cause absence at work and can have an impact on a country's economic vitality.'^"^ The missions of the Armed Forces require continuous availability at all times, patiicularly in outbreak setting. In view of this major health threat, the French Department of Defense (DoD) needed to be *National Office of the French Military Medical Department, Fort Neuf de Vincennes, Cours des Maréchaux, Paris Cedex 12 75614, France. tMilitary Centre for Epidemiology and Public Health (CESPA), GSBdD Marseille Aubagne, 111 Avenue de la Corse, BP40026. Marseille 13568, France. tBegin Military Teaching Hospital, 69 Avenue de Paris. Saint-Mandé 94163, France. §DoD, French Military Command, 14 Rue Saint-Dominique, Paris SP 07 75700, France. doi: 10.7205/MILMED-D-13-00261
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able to assess the medical status of its forces in real time so as to institute appropriate medical countermeasures. In the French Armed Forces, two systems usually monitor influenza: Surveillance Epidemiologique dans les Armées (SEA), general epidemiological surveillance in the Armed Forces, and the Système Militaire d'Observation de la Grippe (SMOG), a military surveillance system monitoring only influenza. The Military Department of Epidemiology, which in 2010 became the Centre d'Epidemiologie et de Santé Publique des Arme'es, coordinated these two systetns. During the pandemic, the epidemiological surveillance systems were adapted to the pandemic context. The clusters of influenza cases were investigated as specified in the French national recommendations.^ The SEA was upgraded (awareness raising among physicians concerning the importance of epidemiological monitoring and reporting) and the SMOG was reactivated in May.**'' On request from the Joint Chief of Staff, a daily influenza surveillance system (syndromic surveillance)'"•" was set up in the French Armed Forces (Surveillance quotidienne [SQ]) (Table I). The aim of the SQ system was to monitor the impairment of the activities of the military units due to influenza. An evaluation study conducted after the pandemic showed that the SQ, despite being exhaustive and reactive during this pandemic episode, involved unacceptable logistic costs from an epidemiological point of view, and did not significantly improve influenza surveillance compared to the usual weekly surveillance schemes." However, after considering the cotistant urging from the Joint Staff to obtain daily data during
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Management of 2009 A(H1N¡) Influenza Pandemic in the French Armed Forces TABLE L
Characteristics of the Different Systems of Epidemiological Surveillance Used in the French Armed Forces Military System for Monitoring Flu (SMOG)
Daily Monitoring (SQ)
All Active Military Units All Year Round Weekly
30 Military Sentinel Units Seasonal (From October to April) Weekly
All Active Military Units Pandemic Daily
64 Health Events Including Nfb of Confirmed Influenza Cases and Nb of ILI Cases
Nb of Influenza Cases Nb of ILI Cases Nb of Samples Performed Nb of Sick Leaves Nb of Days of Consultation
Nb of Influenza Cases Nb of ILI Cases Nb of Sick Leaves
Epidemiological Surveillance System in the Armed Forces (SEA)
System Monitored Units Monitoring Period Frequency of Collection and Analysis Events Monitored
ILI, influenza-like infection (not laboratory confirmed); Nb. number.
this episode, we hypothesized that decision-makers could view the SQ not only as a useful surveillance tool but also as a necessity. The objective of this study was thus to evaluate the contribution of epidemiological surveillance to the management of the infiuenza A(H INI) 2009 pandetnic at different levels of the DoD, and to understand how the daily data collected, although considered as not essential for the epidemiologists, provided assistance in decision-making for the pandemic risk managers in the French Armed Forces. METHODS
Participants The population surveyed was composed of the tnedical practitioners responsible for decision-making during the pandetnic
episode at two levels of authority (Fig. 1); loint Military Command (strategic level of command and senior forces commanders) and French Military Medical Department (national office and regional offices). At the top level of the ministry, the Defense Minister is normally responsible for the prevention and control of a pandemic in the Armed Forces. The actual responsibility is delegated to lower levels of command-in-charge of operational maintenance. Medical practitioners from different levels in the DoD (strategic level, composed of senior forces commanders from each branch of the Armed Forces) are naturally the contacts for health information on these levels and are the link between the expertise provided by the French Military Medical Department and loint Military Command. These medical advisors are in charge of developing and managing plans for action. Because of their medical training, they were
Strategic level of command
^MINISTEROF DEFENSq Crisis
CHIEF OF DEFENSE
Military Medical Department National Office
MEDICAL SERVICE Medical crisis cell
Seniorforces commanders Military Medical Department regional offices
I Presence of medical advisors
FIGURE 1. Organizational diagram of decision-making concerning the control of A(H I N I ) pdmO9 influenza pandemic in the French Anned Forces. CFA. CSFA, FAN, FSM, AVIA, and CFT are sublevéis of the different branches of Armed Forces.
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part of the survey population. During the pandemic, a specific pandemic operational center was created in the DoD, In the National Office of the French Military Medical Department, another specific structure was created: the influenza pandemic crisis committees {cellules de crise) that worked in collaboration with the DoD pandemic operational center. The members of these committees, specifically dedicated to the management of the influenza pandemic, were also included in the survey population. At local levels, regional directorates are in charge of the medical departments. From each of these directorates, a physician was designated as the "referent" for the influenza pandemic. These physicians were also included in the survey population.
TABLE II.
Variables Studied Different variables were chosen to assess the real contribution of surveillance data. These criteria were selected among those commonly used for evaluating surveillance systems. The choice then focused on those that best fitted the military setting and the management of a health risk in real —perceptions of decision-making processes related to the management of the pandemic; —perceptions of epidemiological surveillance (relevance, usefulness, and use); and —areas of decisional back up for which concrete action was taken after analysis of surveillance data.
Sarnple of the Questionnaire Used for the Study
Which was your representation of the influenza A (HlNl) 2009 pandemic? 1918-1919 influenza pandemic (Spanish flu)—very high mortality rate 1968-1969 A influenza outbreak (Hong Kong flu)—high mortality rate 1976 American swine flu—reduced mortality rate but overestimated by public health managers As part of your business, how do you consider epidemiological data provided by the military systems, compared with those published by tbe civilian public bealth instances? Pioxy Complementary Useless Don't know How do you consider exhaustive daily epidemiological data? Very useful Somewhat useful Not very useful Useless Don't know Daily surveillance data completed those from tbe usual weekly military surveillance system, Wbicb is, according to you, the main reason to justify this periodicity of monitoring? Reactivity of the Armed forces Early study of epidemic trends Early estimation of disruption of activities Don't know As part of your business, bow often did you use data produced by the daily surveillance system? Daily Fvery two days Once a week Less than once a week How often did the command ask you for epidemiological data concerning the pandemic in tbe Armed forces? Daily Fvery two days Once a week Less tban once a week During command meetings, how often epidemiological data were presented? Often Sometimes Rarely Never As part of your activity of counseling, bow often did you use epidemiological data to support your proposals to decision-makers? Often Sometimes Rarely Never If you used epidemiological data produced, have some of your proposals not been implemented despite the support of these data? Yes No Don't know Which data wbere expected by tbe command (several responses possible)? Sick leave rate and Impact of the Trends for the pandemic Don't know operational downtime pandemic in the armed forces Have decisions of any kind been taken following the presentation of military epidemiological data to decision-makers (several responses possible)? Modification in the Adjustment of the Modification in Anticipation or additiotial Strengthening of Alerting or planning of national permanent the planning preparation for military preventive measures designation of international operations security system of national logistics and supply and hygiene suppletnentary or international personnel on guard maneuvers In case of a new influenza pandemic, wbich system would be the most appropriate? Usual weekly epidemiological Military surveillance system Influenza daily surveillance system surveillance in the armed forces monitoring only influenza (syndromic surveillance) In case of a new influenza pandemic, wbicb system would be tbe least appropriate? Usual weekly epidetniological Military surveillance system Influenza daily surveillance surveillance in the aimed forces monitoring only influenza system (syndromic surveillance) In case of a new influenza pandemic, the contribution of daily and exbaustive data would be? Veiy helpful Somewhat useful Not very useful Useless Some questions aiming to verify the participant's knowledge about existing surveillance systems are not presented here.
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Data Coilection Data were collected using two complementary tools. A 24-item self-administered questionnaire was sent to all subjects (Table II). The small size of the population studied enabled this part of the study to be exhaustive. The study was completed with a semi structured interview of 20 to 30 minutes administered to a subsample of five respondents from the initial responders. The selection criteria were related to the study objectives: five physicians were identified for their hierarchical position at the highest levels of authority, or because they had occupied a key position in coordinating the response to the pandemic in the DoD. These interviews, using open-ended questions, focused on the main topics included in the questionnaire and the feedback of medical advisors concerning their relations with the decisionmakers at the highest level of DoD (quality of relations, usefulness of data collected for decision-making, decisions taken in response to information transmitted, etc.).
Statisticai Analysis Statistical analyses were performed using the Epi Info software, version 3.5.3 (Centers for Disease Control and Prevention, Atlanta, Georgia, 2001). Fisher's exact test was used to compare proportions. These analyses were completed by a qualitative analysis of interviews using lexical analysis. RESULTS In all, 25 subjects were included in the survey. The response rate was 84% for the questionnaire-based survey (5 respondents in the regional Military Medical Departments, 6 in the National Office of the French Military Medical Department, 4 in the strategic level of command, and 6 among senior
forces commanders). Four of the five physicians (80%) selected for an interview were interviewed. One respondent was unavailable for an interview due to professional reasons. Most of the subjects included (80%) determined that the data provided by the epidemiological surveillance systems were adequate and of military interest. The results revealed that clinical irnplications (number of cases of influenza, acute respiratory infections with fever, and confirmed or possible cases) were the most important outcomes for the responders. Administrative data (short-term sick leave, indicators of medical activity) were reported to be the focus for only 50% of respondents. However, for highest-level decision-makers in the DoD, the data that were considered best suited for military settings were administrative information. In case of a new pandemic, the SQ system was considered as the best-suited system by the highest-level decisionmakers in the DoD, whereas the SEA system was considered the most relevant by Military Medical Department staff {p = 0.025). The SQ was considered as the least suitable system by the Military Medical Department staff {p = 0.05). The SMOG was considered as the least suitable .system for monitoring the pandemic (Fig. 2). The establishment of SQ in case of a new pandemic episode was considered useful by high-level decision-makers in the Ministry and it was deemed unnecessary by the staff from Military Medical Department (Fig. 3). This difference in approach to the problem was significant across decision-making levels (p = 0.004). As shown in Figure 4, the priority fields of decisions identified by the respondents were hygiene, alert capacity, logistics, and military operations. In the pandemic setting, decisions were rnade in the areas of logistics (especially, early in the pandemic period) and general health safety: storage and delivery of respiratory masks, oseltamivir tabs.
Q Military medical service - regional office (n=5j B Military medical service - national office (n=6) D Strategic level of command in=4) • Senior forces commanders (n=6)
I
SEA
M o s t a d a p t e d system
FIGURE 2.
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SMOG
SQ
SEA
SMOG
Less suitable system
Perceived usefulness of the three military epidemiological systems according to the different levels of decision-making.
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Management of 2009 A(H1N1) Influenza Pandemic in the Erench Armed Eorces 16
OMilitarymedica! service - regional office n=5
14-
d Military medicaf service - national office n=6 nstrategic level of command (n=:4i
12
• Senior forces commanders ¡0=6)
10 (U S c
8
F ^^^^m
6
4
0 Useful
Uitlüíb
FIGURE 3. Perceived usefulness of daily surveillance (SQ) in case of a I uture new pandemic, according to the different levels of decision-making.
and hydroalcoholic gel. Certain activities were adapted to the progression of the pandemic: postponement of military exercises in nonessential training camps (to reduce crowding), postponement of travel by military authorities, one military school closure, and cancellation of scheduled maneuvers. The analysis of the qualitative interviews revealed that according to the feedback of medical advisors, the decisionmakers prefen-ed the SQ system for three main reasons: daily periodicity that allowed short response time, monitoring of administrative data, and monitoring of the Armed Forces as a whole. Thus, epidemiological data were not considered here as public health information. The decision-makers were expecting an operational assessment of the pandemic rather than a medical view. Decision-makers considered managerial concerns (absenteeism and unavailability) as poignant and relevant to operational information as opposed to medical concerns (morbidity and mortality).
Some reasons were cited to justify these preferences. Eirst, the investigation of clusters in the prepandemic phase raised awareness among authorities in the DoD regarding the usefulness of specific structures dedicated to pandemic control. At a very early stage, they therefore approved the establishment of an operational center for the pandemic and a crisis committee to coordinate the different actors. Second, the Armed Forces needed to possess specific data so as to put media discourse into perspective, and also to analyze the epidemiological data from a military viewpoint. Einally, from a qualitative point of view, the logistics of the Armed Forces, including those of the Military Medical Department, was considered important by the subjects interviewed. They reported that logistics were planned on a daily basis, depending on units that were available and free from influenza. The ability of the Armed Forces to contribute to the resilience of the nation was analyzed each day and enabled the anticipation of possible requests from other ministries. In case of a serious health crisis, respondents considered that the surveillance data would have ensured the reactivity of military units by identifying those available. DISCUSSION
Usefulness of a Daily Surveillance System at the Decision-Making Level The main result of this study, among military medical decisionmakers, was a perceived usefulness of daily monitoting (SQ) greater than that reported for other systems (SEA and SMQG). This perceived usefulness increased at higher decisional levels where respondents mentioned that daily monitoring would also be useful in the event of another pandemic. This result is not in accordance with that of a previous evaluation study conducted on the same military surveillance systems, where the participants were military epidemiologists and Q Military medical service - regional office (n=5) i3 Miiitary medicai service - national office (n=6) • Strategic level of command (n-4) • Senior forces commanders (n=6)
I FIGURE 4.
Main priority fields of decisions identified by the respondents according to different levels of decision-making.
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general practitioners." According to this study, the SQ did not provide any significant advantage compared to the weekly surveillance schemes usually used. In the event of a future similar episode, respondents rejected the possibility of the reimplementation of a daily surveillance system, considering that influenza surveillance could be significantly improved by using the SMOG system extended to more units for better geographical coverage.' ' This discordance shows the gap that can exist between public health actors (clinicians and epidemiologists) and military decision-makers. Public health agents consider that the objective of a surveillance system is to detect outbreaks and to monitor trends in an outbreak so as to implement preventive measures and evaluate the effectiveness of these measures.'° Weekly surveillance schemes, used by health authorities in several countries, are well-suited to these objectives. In the French Armed Forces, epidemiological surveillance goes far beyond the immediate field of public health. It is indeed a decisional back up for military action.''* This approach to disease surveillance, including that involving daily monitoring, is not well accepted by the French military medical staff. In contrast, it is well accepted by the military decision-makers. Thus, considering the high human and financial cost of daily monitoring," we can wonder if the part played in this case by epidemiologists, medical doctors, and public health professionals was the most appropriate for the production and analysis of data to be used for military decision-making. For decision-makers, particularly in the Armed Forces, surveillance systems aim to assist in the conduct of operations. Decision can thus be considered as a multifactor social construction. Authorities from outside of the DoD, including the Ministry of Health, participated in the decision-making process and also in the analysis of surveillance data. The data produced were intended for real action. Major areas of decision (logistics, hygiene) as well as specific problems that needed an immediate response were identified. The data described as useful and relevant from an operational point of view were the data such as availability or absenteeistn and not the data, such as morbidity or mortality, usually provided by tnedical epidemiologists, which are indicators for public health. Decision-makers also need exhaustive data to visualize a given situation as a whole. For this reason, the SMOG, even if monitoring absenteeism, was not considered as suitable by decision-makers because it included only 30 sentinel units. The systematic integration of personnel administration data in usual health surveillance systems could be proposed but may imply too much logistical constraints and could not respond to the real-time imperative. Hence, military epidemiology can be considered here as an operational parameter. We need to define the conceptual and strategic relevance of daily surveillance. We must now integrate different systems, including real-time systems'^'"' such as eai^ly-warning systems and real-time monitoring,'^''^ which are cuiTently in the design phase and enable the pace of data
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collection and analysis to be matched to the needs of decisionmaking. To improve acceptability by the tnedical staff and to reduce the workload of health professionals, we need to automate the collection of epidemiological data from the shared military medical files.'^ Finally, the detection and real-time monitoring of disease by traditional epidemiological systems need to integrate and combine the new communication technologies and new modes of information exchange.^"'^' The scope for generalization of this study is limited because of the context of a pandemic with low mortality. Thus, the use of its epidemiological data had a lesser impact in terms of public health as the aim was to assess the availability of forces on a daily basis. What would have happened during a pandemic with high mortality? What would have been the impact of the different indicators? Their relevance and usefulness would probably have been unchanged, but the use made of the data would have been different, with a greater focus on public health.
Study Limitations The high response rate, over 80%, and the good involvemetit of medical advisors for this study contribute to the validity of our investigation and the scope of the results. The tnain results were significant and consistent in many respects. The 25 physicians included were representative of the medical advisors present during the pandemic influenza because our survey exhaustively included all physicians working at advisory or decision-making levels during the A(HINI) 2009 influenza pandemic. Among staff both on the strategic level and in the Military Medical Department, there were some nonresponders. No category of staff was particularly impacted by this lack of data. This enabled us to compare results for different levels of decision-making. Nevertheless, this study cannot be seen as completely unbiased. We initially wanted to interview the personnel in charge of decision-making during the pandemic. However, because of constraints weighing on senior military and political actors, the population surveyed was exclusively composed of medical advisors, who cannot be considered as strictly representatives of decision-makers. This choice provided some stability in responses, as there is a high turnover in the Joint Cotnmand, but it was also a source of selection bias despite the relative proximity of advisors with their superiors. This use of proxy opinion entails shifts in viewpoint (medical advisor instead of military authority) and can induce some response bias. However, in the area of public health, it could be expected that medical advisors and decisionmakers have similar viewpoints and shared objectives."" Thus, it is likely that the medical advisors provided a relatively representative feedback concerning the points of view of decision-makers. Finally, this study was initiated almost 2 years after the emergence of the pandemic influenza virus and the itnplementation of the first medical countermeasures. Although this
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temporality is acceptable in terms of scientific and epidemiological investigation, it involves a risk of memory bias. There could also be a prevarication bias; in the DoD, despite the assurances that we could guarantee privacy, it was possible that some responses were directed, CONCLUSION Although the gain was considered small for the medical community, daily monitoring for epidemiological surveillance in the French Armed Forces appears relevant and useful for the tnilitary decision-makers. The epidemiological data were used in this instance for action. We must now anticipate the next pandemic and define the place and periodicity of epidemiological surveillance suited to the needs of medical physicians and public health professionals, but also to the needs of military decision-makers. Epidemiology contributes to the planning and conduct of military operations. ACKNOWLEDGMENTS We thank the Centre d'e'pideijiiolo^ie el de saute' publique des arme'es (France), the medical advisors of the French DoD, and Prof Joel Ankri, in charge of methodological teaching for public health interventions in the University of Versailles (France). We have no funding source to declare. This work was flnanced by French public funds from the DoD.
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The 2009 A(H1 N1) Influenza Pandemic in the French Armed Forces: Epidemiological Surveillance and Operational Management MAJ Jean-Baptiste Pohl, Frenoh Military Medical Service*; LTC Au relie Mayet, French Military Medical Servicef; MAJ Gabriel Be'dubourg, French Military Medical Servicef; MAJ Sandrine Duron, French Military Medical Servicef; COL Re'my Michel, French Military Medical Servicef; COL Xavier Deparis, French Military Medical Servicef; COL Christophe Rapp, French Military Medical Servicef; General Patrick Godart, French Military Medical Service§; General Rene Migliani, French Military Medical Servicef; COL Jean-Baptiste Meynard, French Military Medical Servicef
ABSTRACT Objective: Tbe main objective of tbis study was to evaluate tbe contribution of a newly implemented daily surveillance system to the management of the 2009 A(HINI) influenza pandemic by the military decision-makers at different levels in tbe French Department of Defence. Methods: The study sample included all medical advisors in tbe Ministry of Defence and tbe French Armed Forces Staff and also the members of tbe specific committee dedicated to flu pandemic control. Tbe variables studied were mental representation of epidemiology, relevance, usefulness, and realtime use of surveillance data using quantitative questionnaires and qualitative face-to-face semistructured interviews. Results: Among tbe risk managers of tbe flu pandemic in tbe Armed Forces, 84% responded. Tbe data generated by epidemiological surveillance were considered relevant and useful, and were reported as effectively used. On tbe basis of tbe information produced, concrete actions were planned and implemented in the Frencb Armed Forces. Conclusion: In a pandemic situation involving low mortality, tbe daily monitoring of tbe disease did not target public bealtb issues, but it was mainly used to assess tbe availability of the Armed Forces in real time. For tbe military staff, epidemiological surveillance represents an essential information tool for the conduct of operations.
INTRODUCTION Influenza is a viral infection with a seasonal increase in winter. Influenza viruses have great genetic plasticity. Antigenic drift causes epidemics and antigenic shift causes pandemics. In April 2009, a new variant influenza virus was identified.''^ It produced clustered cases in Mexico and in the United States. Biological analyses showed that the virulence and infectivity of the virus were similar to those of seasonal influenza viruses.^'"* Only few people had immune predispositions toward this new type of influenza. Because of its epidemic or even pandemic potential, influenza is a public health issue. The associated mortality is not negligible, and from an economic point of view, this disease constitutes a financial burden. For the community, influenza outbreaks cause absence at work and can have an impact on a country's economic vitality.'^"^ The missions of the Armed Forces require continuous availability at all times, patiicularly in outbreak setting. In view of this major health threat, the French Department of Defense (DoD) needed to be *National Office of the French Military Medical Department, Fort Neuf de Vincennes, Cours des Maréchaux, Paris Cedex 12 75614, France. tMilitary Centre for Epidemiology and Public Health (CESPA), GSBdD Marseille Aubagne, 111 Avenue de la Corse, BP40026. Marseille 13568, France. tBegin Military Teaching Hospital, 69 Avenue de Paris. Saint-Mandé 94163, France. §DoD, French Military Command, 14 Rue Saint-Dominique, Paris SP 07 75700, France. doi: 10.7205/MILMED-D-13-00261
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able to assess the medical status of its forces in real time so as to institute appropriate medical countermeasures. In the French Armed Forces, two systems usually monitor influenza: Surveillance Epidemiologique dans les Armées (SEA), general epidemiological surveillance in the Armed Forces, and the Système Militaire d'Observation de la Grippe (SMOG), a military surveillance system monitoring only influenza. The Military Department of Epidemiology, which in 2010 became the Centre d'Epidemiologie et de Santé Publique des Arme'es, coordinated these two systetns. During the pandemic, the epidemiological surveillance systems were adapted to the pandemic context. The clusters of influenza cases were investigated as specified in the French national recommendations.^ The SEA was upgraded (awareness raising among physicians concerning the importance of epidemiological monitoring and reporting) and the SMOG was reactivated in May.**'' On request from the Joint Chief of Staff, a daily influenza surveillance system (syndromic surveillance)'"•" was set up in the French Armed Forces (Surveillance quotidienne [SQ]) (Table I). The aim of the SQ system was to monitor the impairment of the activities of the military units due to influenza. An evaluation study conducted after the pandemic showed that the SQ, despite being exhaustive and reactive during this pandemic episode, involved unacceptable logistic costs from an epidemiological point of view, and did not significantly improve influenza surveillance compared to the usual weekly surveillance schemes." However, after considering the cotistant urging from the Joint Staff to obtain daily data during
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Management of 2009 A(H1N¡) Influenza Pandemic in the French Armed Forces TABLE L
Characteristics of the Different Systems of Epidemiological Surveillance Used in the French Armed Forces Military System for Monitoring Flu (SMOG)
Daily Monitoring (SQ)
All Active Military Units All Year Round Weekly
30 Military Sentinel Units Seasonal (From October to April) Weekly
All Active Military Units Pandemic Daily
64 Health Events Including Nfb of Confirmed Influenza Cases and Nb of ILI Cases
Nb of Influenza Cases Nb of ILI Cases Nb of Samples Performed Nb of Sick Leaves Nb of Days of Consultation
Nb of Influenza Cases Nb of ILI Cases Nb of Sick Leaves
Epidemiological Surveillance System in the Armed Forces (SEA)
System Monitored Units Monitoring Period Frequency of Collection and Analysis Events Monitored
ILI, influenza-like infection (not laboratory confirmed); Nb. number.
this episode, we hypothesized that decision-makers could view the SQ not only as a useful surveillance tool but also as a necessity. The objective of this study was thus to evaluate the contribution of epidemiological surveillance to the management of the infiuenza A(H INI) 2009 pandetnic at different levels of the DoD, and to understand how the daily data collected, although considered as not essential for the epidemiologists, provided assistance in decision-making for the pandemic risk managers in the French Armed Forces. METHODS
Participants The population surveyed was composed of the tnedical practitioners responsible for decision-making during the pandetnic
episode at two levels of authority (Fig. 1); loint Military Command (strategic level of command and senior forces commanders) and French Military Medical Department (national office and regional offices). At the top level of the ministry, the Defense Minister is normally responsible for the prevention and control of a pandemic in the Armed Forces. The actual responsibility is delegated to lower levels of command-in-charge of operational maintenance. Medical practitioners from different levels in the DoD (strategic level, composed of senior forces commanders from each branch of the Armed Forces) are naturally the contacts for health information on these levels and are the link between the expertise provided by the French Military Medical Department and loint Military Command. These medical advisors are in charge of developing and managing plans for action. Because of their medical training, they were
Strategic level of command
^MINISTEROF DEFENSq Crisis
CHIEF OF DEFENSE
Military Medical Department National Office
MEDICAL SERVICE Medical crisis cell
Seniorforces commanders Military Medical Department regional offices
I Presence of medical advisors
FIGURE 1. Organizational diagram of decision-making concerning the control of A(H I N I ) pdmO9 influenza pandemic in the French Anned Forces. CFA. CSFA, FAN, FSM, AVIA, and CFT are sublevéis of the different branches of Armed Forces.
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part of the survey population. During the pandemic, a specific pandemic operational center was created in the DoD, In the National Office of the French Military Medical Department, another specific structure was created: the influenza pandemic crisis committees {cellules de crise) that worked in collaboration with the DoD pandemic operational center. The members of these committees, specifically dedicated to the management of the influenza pandemic, were also included in the survey population. At local levels, regional directorates are in charge of the medical departments. From each of these directorates, a physician was designated as the "referent" for the influenza pandemic. These physicians were also included in the survey population.
TABLE II.
Variables Studied Different variables were chosen to assess the real contribution of surveillance data. These criteria were selected among those commonly used for evaluating surveillance systems. The choice then focused on those that best fitted the military setting and the management of a health risk in real —perceptions of decision-making processes related to the management of the pandemic; —perceptions of epidemiological surveillance (relevance, usefulness, and use); and —areas of decisional back up for which concrete action was taken after analysis of surveillance data.
Sarnple of the Questionnaire Used for the Study
Which was your representation of the influenza A (HlNl) 2009 pandemic? 1918-1919 influenza pandemic (Spanish flu)—very high mortality rate 1968-1969 A influenza outbreak (Hong Kong flu)—high mortality rate 1976 American swine flu—reduced mortality rate but overestimated by public health managers As part of your business, how do you consider epidemiological data provided by the military systems, compared with those published by tbe civilian public bealth instances? Pioxy Complementary Useless Don't know How do you consider exhaustive daily epidemiological data? Very useful Somewhat useful Not very useful Useless Don't know Daily surveillance data completed those from tbe usual weekly military surveillance system, Wbicb is, according to you, the main reason to justify this periodicity of monitoring? Reactivity of the Armed forces Early study of epidemic trends Early estimation of disruption of activities Don't know As part of your business, bow often did you use data produced by the daily surveillance system? Daily Fvery two days Once a week Less than once a week How often did the command ask you for epidemiological data concerning the pandemic in tbe Armed forces? Daily Fvery two days Once a week Less tban once a week During command meetings, how often epidemiological data were presented? Often Sometimes Rarely Never As part of your activity of counseling, bow often did you use epidemiological data to support your proposals to decision-makers? Often Sometimes Rarely Never If you used epidemiological data produced, have some of your proposals not been implemented despite the support of these data? Yes No Don't know Which data wbere expected by tbe command (several responses possible)? Sick leave rate and Impact of the Trends for the pandemic Don't know operational downtime pandemic in the armed forces Have decisions of any kind been taken following the presentation of military epidemiological data to decision-makers (several responses possible)? Modification in the Adjustment of the Modification in Anticipation or additiotial Strengthening of Alerting or planning of national permanent the planning preparation for military preventive measures designation of international operations security system of national logistics and supply and hygiene suppletnentary or international personnel on guard maneuvers In case of a new influenza pandemic, wbich system would be the most appropriate? Usual weekly epidemiological Military surveillance system Influenza daily surveillance system surveillance in the armed forces monitoring only influenza (syndromic surveillance) In case of a new influenza pandemic, wbicb system would be tbe least appropriate? Usual weekly epidetniological Military surveillance system Influenza daily surveillance surveillance in the aimed forces monitoring only influenza system (syndromic surveillance) In case of a new influenza pandemic, the contribution of daily and exbaustive data would be? Veiy helpful Somewhat useful Not very useful Useless Some questions aiming to verify the participant's knowledge about existing surveillance systems are not presented here.
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Data Coilection Data were collected using two complementary tools. A 24-item self-administered questionnaire was sent to all subjects (Table II). The small size of the population studied enabled this part of the study to be exhaustive. The study was completed with a semi structured interview of 20 to 30 minutes administered to a subsample of five respondents from the initial responders. The selection criteria were related to the study objectives: five physicians were identified for their hierarchical position at the highest levels of authority, or because they had occupied a key position in coordinating the response to the pandemic in the DoD. These interviews, using open-ended questions, focused on the main topics included in the questionnaire and the feedback of medical advisors concerning their relations with the decisionmakers at the highest level of DoD (quality of relations, usefulness of data collected for decision-making, decisions taken in response to information transmitted, etc.).
Statisticai Analysis Statistical analyses were performed using the Epi Info software, version 3.5.3 (Centers for Disease Control and Prevention, Atlanta, Georgia, 2001). Fisher's exact test was used to compare proportions. These analyses were completed by a qualitative analysis of interviews using lexical analysis. RESULTS In all, 25 subjects were included in the survey. The response rate was 84% for the questionnaire-based survey (5 respondents in the regional Military Medical Departments, 6 in the National Office of the French Military Medical Department, 4 in the strategic level of command, and 6 among senior
forces commanders). Four of the five physicians (80%) selected for an interview were interviewed. One respondent was unavailable for an interview due to professional reasons. Most of the subjects included (80%) determined that the data provided by the epidemiological surveillance systems were adequate and of military interest. The results revealed that clinical irnplications (number of cases of influenza, acute respiratory infections with fever, and confirmed or possible cases) were the most important outcomes for the responders. Administrative data (short-term sick leave, indicators of medical activity) were reported to be the focus for only 50% of respondents. However, for highest-level decision-makers in the DoD, the data that were considered best suited for military settings were administrative information. In case of a new pandemic, the SQ system was considered as the best-suited system by the highest-level decisionmakers in the DoD, whereas the SEA system was considered the most relevant by Military Medical Department staff {p = 0.025). The SQ was considered as the least suitable system by the Military Medical Department staff {p = 0.05). The SMOG was considered as the least suitable .system for monitoring the pandemic (Fig. 2). The establishment of SQ in case of a new pandemic episode was considered useful by high-level decision-makers in the Ministry and it was deemed unnecessary by the staff from Military Medical Department (Fig. 3). This difference in approach to the problem was significant across decision-making levels (p = 0.004). As shown in Figure 4, the priority fields of decisions identified by the respondents were hygiene, alert capacity, logistics, and military operations. In the pandemic setting, decisions were rnade in the areas of logistics (especially, early in the pandemic period) and general health safety: storage and delivery of respiratory masks, oseltamivir tabs.
Q Military medical service - regional office (n=5j B Military medical service - national office (n=6) D Strategic level of command in=4) • Senior forces commanders (n=6)
I
SEA
M o s t a d a p t e d system
FIGURE 2.
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SMOG
SQ
SEA
SMOG
Less suitable system
Perceived usefulness of the three military epidemiological systems according to the different levels of decision-making.
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OMilitarymedica! service - regional office n=5
14-
d Military medicaf service - national office n=6 nstrategic level of command (n=:4i
12
• Senior forces commanders ¡0=6)
10 (U S c
8
F ^^^^m
6
4
0 Useful
Uitlüíb
FIGURE 3. Perceived usefulness of daily surveillance (SQ) in case of a I uture new pandemic, according to the different levels of decision-making.
and hydroalcoholic gel. Certain activities were adapted to the progression of the pandemic: postponement of military exercises in nonessential training camps (to reduce crowding), postponement of travel by military authorities, one military school closure, and cancellation of scheduled maneuvers. The analysis of the qualitative interviews revealed that according to the feedback of medical advisors, the decisionmakers prefen-ed the SQ system for three main reasons: daily periodicity that allowed short response time, monitoring of administrative data, and monitoring of the Armed Forces as a whole. Thus, epidemiological data were not considered here as public health information. The decision-makers were expecting an operational assessment of the pandemic rather than a medical view. Decision-makers considered managerial concerns (absenteeism and unavailability) as poignant and relevant to operational information as opposed to medical concerns (morbidity and mortality).
Some reasons were cited to justify these preferences. Eirst, the investigation of clusters in the prepandemic phase raised awareness among authorities in the DoD regarding the usefulness of specific structures dedicated to pandemic control. At a very early stage, they therefore approved the establishment of an operational center for the pandemic and a crisis committee to coordinate the different actors. Second, the Armed Forces needed to possess specific data so as to put media discourse into perspective, and also to analyze the epidemiological data from a military viewpoint. Einally, from a qualitative point of view, the logistics of the Armed Forces, including those of the Military Medical Department, was considered important by the subjects interviewed. They reported that logistics were planned on a daily basis, depending on units that were available and free from influenza. The ability of the Armed Forces to contribute to the resilience of the nation was analyzed each day and enabled the anticipation of possible requests from other ministries. In case of a serious health crisis, respondents considered that the surveillance data would have ensured the reactivity of military units by identifying those available. DISCUSSION
Usefulness of a Daily Surveillance System at the Decision-Making Level The main result of this study, among military medical decisionmakers, was a perceived usefulness of daily monitoting (SQ) greater than that reported for other systems (SEA and SMQG). This perceived usefulness increased at higher decisional levels where respondents mentioned that daily monitoring would also be useful in the event of another pandemic. This result is not in accordance with that of a previous evaluation study conducted on the same military surveillance systems, where the participants were military epidemiologists and Q Military medical service - regional office (n=5) i3 Miiitary medicai service - national office (n=6) • Strategic level of command (n-4) • Senior forces commanders (n=6)
I FIGURE 4.
Main priority fields of decisions identified by the respondents according to different levels of decision-making.
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general practitioners." According to this study, the SQ did not provide any significant advantage compared to the weekly surveillance schemes usually used. In the event of a future similar episode, respondents rejected the possibility of the reimplementation of a daily surveillance system, considering that influenza surveillance could be significantly improved by using the SMOG system extended to more units for better geographical coverage.' ' This discordance shows the gap that can exist between public health actors (clinicians and epidemiologists) and military decision-makers. Public health agents consider that the objective of a surveillance system is to detect outbreaks and to monitor trends in an outbreak so as to implement preventive measures and evaluate the effectiveness of these measures.'° Weekly surveillance schemes, used by health authorities in several countries, are well-suited to these objectives. In the French Armed Forces, epidemiological surveillance goes far beyond the immediate field of public health. It is indeed a decisional back up for military action.''* This approach to disease surveillance, including that involving daily monitoring, is not well accepted by the French military medical staff. In contrast, it is well accepted by the military decision-makers. Thus, considering the high human and financial cost of daily monitoring," we can wonder if the part played in this case by epidemiologists, medical doctors, and public health professionals was the most appropriate for the production and analysis of data to be used for military decision-making. For decision-makers, particularly in the Armed Forces, surveillance systems aim to assist in the conduct of operations. Decision can thus be considered as a multifactor social construction. Authorities from outside of the DoD, including the Ministry of Health, participated in the decision-making process and also in the analysis of surveillance data. The data produced were intended for real action. Major areas of decision (logistics, hygiene) as well as specific problems that needed an immediate response were identified. The data described as useful and relevant from an operational point of view were the data such as availability or absenteeistn and not the data, such as morbidity or mortality, usually provided by tnedical epidemiologists, which are indicators for public health. Decision-makers also need exhaustive data to visualize a given situation as a whole. For this reason, the SMOG, even if monitoring absenteeism, was not considered as suitable by decision-makers because it included only 30 sentinel units. The systematic integration of personnel administration data in usual health surveillance systems could be proposed but may imply too much logistical constraints and could not respond to the real-time imperative. Hence, military epidemiology can be considered here as an operational parameter. We need to define the conceptual and strategic relevance of daily surveillance. We must now integrate different systems, including real-time systems'^'"' such as eai^ly-warning systems and real-time monitoring,'^''^ which are cuiTently in the design phase and enable the pace of data
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collection and analysis to be matched to the needs of decisionmaking. To improve acceptability by the tnedical staff and to reduce the workload of health professionals, we need to automate the collection of epidemiological data from the shared military medical files.'^ Finally, the detection and real-time monitoring of disease by traditional epidemiological systems need to integrate and combine the new communication technologies and new modes of information exchange.^"'^' The scope for generalization of this study is limited because of the context of a pandemic with low mortality. Thus, the use of its epidemiological data had a lesser impact in terms of public health as the aim was to assess the availability of forces on a daily basis. What would have happened during a pandemic with high mortality? What would have been the impact of the different indicators? Their relevance and usefulness would probably have been unchanged, but the use made of the data would have been different, with a greater focus on public health.
Study Limitations The high response rate, over 80%, and the good involvemetit of medical advisors for this study contribute to the validity of our investigation and the scope of the results. The tnain results were significant and consistent in many respects. The 25 physicians included were representative of the medical advisors present during the pandemic influenza because our survey exhaustively included all physicians working at advisory or decision-making levels during the A(HINI) 2009 influenza pandemic. Among staff both on the strategic level and in the Military Medical Department, there were some nonresponders. No category of staff was particularly impacted by this lack of data. This enabled us to compare results for different levels of decision-making. Nevertheless, this study cannot be seen as completely unbiased. We initially wanted to interview the personnel in charge of decision-making during the pandemic. However, because of constraints weighing on senior military and political actors, the population surveyed was exclusively composed of medical advisors, who cannot be considered as strictly representatives of decision-makers. This choice provided some stability in responses, as there is a high turnover in the Joint Cotnmand, but it was also a source of selection bias despite the relative proximity of advisors with their superiors. This use of proxy opinion entails shifts in viewpoint (medical advisor instead of military authority) and can induce some response bias. However, in the area of public health, it could be expected that medical advisors and decisionmakers have similar viewpoints and shared objectives."" Thus, it is likely that the medical advisors provided a relatively representative feedback concerning the points of view of decision-makers. Finally, this study was initiated almost 2 years after the emergence of the pandemic influenza virus and the itnplementation of the first medical countermeasures. Although this
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temporality is acceptable in terms of scientific and epidemiological investigation, it involves a risk of memory bias. There could also be a prevarication bias; in the DoD, despite the assurances that we could guarantee privacy, it was possible that some responses were directed, CONCLUSION Although the gain was considered small for the medical community, daily monitoring for epidemiological surveillance in the French Armed Forces appears relevant and useful for the tnilitary decision-makers. The epidemiological data were used in this instance for action. We must now anticipate the next pandemic and define the place and periodicity of epidemiological surveillance suited to the needs of medical physicians and public health professionals, but also to the needs of military decision-makers. Epidemiology contributes to the planning and conduct of military operations. ACKNOWLEDGMENTS We thank the Centre d'e'pideijiiolo^ie el de saute' publique des arme'es (France), the medical advisors of the French DoD, and Prof Joel Ankri, in charge of methodological teaching for public health interventions in the University of Versailles (France). We have no funding source to declare. This work was flnanced by French public funds from the DoD.
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