The military as a neglected pathogen transmitter, from the 19th century to COVID-19: A systematic review
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Abstract
Background
The risk of outbreaks escalating into pandemics has soared with globalization. Therefore, understanding transmission mechanisms of infectious diseases has become critical to formulating global public health policy. This systematic review assessed evidence in the medical and public health literature for the military as a disease vector.
Methods
We searched 3 electronic databases without temporal restrictions. Two researchers independently extracted study data using a standardized form. Through team discussions, studies were grouped according to their type of transmission mechanism and direct quotes were extracted to generate themes and sub-themes. A content analysis was later performed and frequency distributions for each theme were generated.
Results
Of 6477 studies, 210 met our inclusion criteria and provided evidence, spanning over two centuries (1810 – 2020), for the military as a pathogen transmitter, within itself or between it and civilians. Biological mechanisms driving transmission included person-to-person transmission, contaminated food and water, vector-borne, and airborne routes. Contaminated food and/or water were the most common biological transmission route. Social mechanisms facilitating transmission included crowded living spaces, unhygienic conditions, strenuous working, training conditions, absent or inadequate vaccination programs, pressure from military leadership, poor compliance with public health advice, contractor mismanagement, high-risk behaviours, and occupation-specific freedom of movement. Living conditions were the most common social transmission mechanism, with young, low ranking military personnel repeatedly reported as the most affected group. Selected social mechanisms, such as employment-related freedom of movement, were unique to the military as a social institution. While few studies explicitly studied civilian populations, considerably more contained information that implied that civilians were likely impacted by outbreaks described in the military.
Conclusions
This study identified features of the military that pose a significant threat to global health, especially to civilian health in countries with substantial military presence or underdeveloped health systems. While biological transmission mechanisms are shared by other social groups, selected social transmission mechanisms are unique to the military. As an increasingly interconnected world faces the challenges of COVID-19 and future infectious diseases, the identified features of the military may exacerbate current and similar challenges and impair attempts to implement successful and equitable global public health policies.
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SciScore for 10.1101/2021.10.09.21264758: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
Software and Algorithms Sentences Resources , Ovid EMBASE, and Web of Science) using combinations of Medical Subject Headings (MeSH) and keyword search terms with no temporal restrictions. EMBASEsuggested: (EMBASE, RRID:SCR_001650)MeSHsuggested: (MeSH, RRID:SCR_004750)(Google Scholar) to identify COVID-19 studies in military populations that addressed our research question. Google Scholarsuggested: (Google Scholar, RRID:SCR_008878)Results from OddPub: Thank you for sharing your data.
Results from LimitationRecognizer: We detected the following …SciScore for 10.1101/2021.10.09.21264758: (What is this?)
Please note, not all rigor criteria are appropriate for all manuscripts.
Table 1: Rigor
Ethics not detected. Sex as a biological variable not detected. Randomization not detected. Blinding not detected. Power Analysis not detected. Table 2: Resources
Software and Algorithms Sentences Resources , Ovid EMBASE, and Web of Science) using combinations of Medical Subject Headings (MeSH) and keyword search terms with no temporal restrictions. EMBASEsuggested: (EMBASE, RRID:SCR_001650)MeSHsuggested: (MeSH, RRID:SCR_004750)(Google Scholar) to identify COVID-19 studies in military populations that addressed our research question. Google Scholarsuggested: (Google Scholar, RRID:SCR_008878)Results from OddPub: Thank you for sharing your data.
Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:Limitations: Our review has limitations: we could not calculate disease incidences among study populations because military personnel participants were often transferred, granted leave, or completed training prior to study completion, so participants were lost to follow-up. Therefore, even for studies reporting incidence rates (Table S1), these were likely underreported. Additionally, incidence rates may also be skewed because authors only obtained samples for laboratory testing from very small subsets of populations in a military base or restricted participation to symptomatic subjects. Therefore, the sample size from which incidence was determined was frequently not representative of the actual phenomenon of interest, i.e., disease incidence.
Results from TrialIdentifier: No clinical trial numbers were referenced.
Results from Barzooka: We did not find any issues relating to the usage of bar graphs.
Results from JetFighter: We did not find any issues relating to colormaps.
Results from rtransparent:- Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
- Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
- No protocol registration statement was detected.
Results from scite Reference Check: We found no unreliable references.
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