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Throughout the long history of armed conflict, disease and non-battle injury (DNBI) have always caused much greater morbidity and mortality than battle injury—a situation that has endured throughout recent operations in Iraq and Afghanistan where DNBI has continued to be responsible for the bulk of presentations to supporting medical services, both at Role 1 and to UK Role 3 medical treatment facilities. Infection, in its many and varied guises, is responsible for many of these cases and can present a significant challenge both to the capability of the Defence Medical Services and to the operational effectiveness of combat units. There is no reason to believe that this pattern will change in the time that remains before current operations draw to a close.
As UK Armed Forces return to contingency operations it is increasingly likely that small force elements will be deployed to diverse geographical locations where the challenges posed by infection will be different, requiring their medical support to use knowledge and skills that may be outside their previous experience.
This edition of the journal draws on the expertise and experience of the department of military medicine and others to focus attention on those infections that are most likely to be relevant to uniformed medical staff during future operations. Some of these are highlighted because they are common, such as respiratory and skin and soft tissue infection, while others such as malaria and hepatitis are likely to acquire greater importance as service personnel deploy to countries carrying greater risk of these infections.
Military infection and microbiology services are working ever more closely together and the establishment of a centre, linked to the Royal Centre for Defence Medicine and based at Birmingham Heartlands Hospital, where consultants in Infectious Diseases and Sexual Health are based, uniformed specialty registrars are trained and military patients are treated is an important development that is also highlighted.
A detailed précis on tropical infection is outside the scope of this edition and those wishing to extend their knowledge and skills in this area are directed to the Military Infection and Tropical Medicine course which is to be re-established in 2013 and held bi-annually. Details regarding the course and application procedures can be found on the Joint Medical Command schedule of courses.
Infectious disease and other related areas rightly remain high on the research priority list of the Surgeon General and, as such, form one of the four main pillars of research effort within military medicine. Infection will not go away and we must be proactive and diligent in developing strategies for the prevention, identification and optimal management of infection within the future operational environment. Many of the authors who have contributed to this edition of the journal are playing important roles in realising this goal.
Connor showcases the work of the Military Enteric Disease Group who are investigating the burden, aetiology and optimal management of diarrhoeal disease in the operational environment. Their paper reporting the extent of diarrhoea on Operation HERRICK reveals how widespread this problem is and the impact it has on working days that are lost from frontline activity. These data are put into context by the editorial which highlights the progress made so far, in close collaboration with partners in the United States Navy, and the challenges that are still to be faced in this area.
Easby et al take the reader methodically through the recognition and management of sepsis—the syndrome that marks the final common pathway of a variety of severe infections. Their article places this life-threatening condition in a clear military context and provides practical guidance for the early recognition and intervention that is the key to maximising survival.
Undifferentiated febrile illness
The patient with fever and no clear focus of infection presents a diagnostic and management challenge in any healthcare setting. This is compounded in an austere environment with limited laboratory facilities. The systematic evaluation of ‘Helmand Fever’ reported previously by Bailey in this journal brought attention to this problem and the same author, with Burns, now presents a comprehensive review of the subject which will be a valuable aide memoire to the clinician faced with a similar clinical dilemma.
Malaria has been a threat to many military operations over the years and remains an enormous global health issue with approximately 250 million cases and 1 million deaths annually. Over 90% of these cases present in Africa and Kenya, where UK forces exercise regularly, are among the countries carrying the highest incidence. Fletcher et al provide a timely reminder of the recognition, management and all important prevention strategies for this most important of infectious diseases.
The relationship between serving personnel and sexually transmitted infection is not new and remains an unfortunate reality. With the arrival of HIV infection and the relative decline of syphilis the scope of the problem has changed and the review by Dufty gives an overview of the nature, impact and management of sexually transmitted infections in the 21st century with an appropriate emphasis again on prevention and education as well as recognition and management.
As the body's largest organ, it is surprisingly easy to overlook the contribution of what we would consider ‘minor’ skin diseases to the morbidity of soldiers on operations. The articles by Bailey focusing on tropical skin diseases and that of Lamb and Morgan which covers the whole spectrum, both tropical and domestic, remind us of the significant potential for morbidity and even mortality from dermatological infections.
The Footnote and Endpiece is an intriguing historical article from Greece which reminds us of the long association between the military and infectious diseases and highlights how difficult it was to control these diseases when the aetiology was still being ascribed to miasmas. The fascinating origin of the term quarantine and early descriptions of malarial fevers among others provides a fitting end to this edition which showcases the modern approach to infectious disease in the military.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.