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Introduction Symptomatic Coronavirus Disease 2019 (COVID-19) screening has been a cornerstone of case identification during the pandemic. Despite the myriad of COVID-19 symptoms, symptom screens have primarily focused on symptoms of influenza-like illnesses such as fever, cough, and dyspnea. It is unknown how well these symptoms identify cases in a young, healthy military population. This study aims to evaluate the utility of symptom-based screening in identifying COVID-19 through three different COVID-19 waves. Materials and Methods A convenience sample of 600 military trainees who arrived at Joint Base San Antonio-Lackland in 2021 and 2022 were included. Two hundred trainees with symptomatic COVID-19 before the emergence of the Delta variant (February-April 2021), when Delta variant was predominant (June-August 2021), and when Omicron was the predominant variant (January 2022) had their presenting symptoms compared. At each time point, the sensitivity of a screen for influenza-like illness symptoms was calculated. Results Of the 600 symptomatic active duty service members who tested positive for COVID-19, the most common symptoms were sore throat (n = 385, 64%), headache (n = 334, 56%), and cough (n = 314, 52%). Although sore throat was the most prominent symptom during Delta (n = 140, 70%) and Omicron (n = 153, 77%), headache was the most common before Delta (n = 93, 47%). There were significant differences in symptoms by vaccination status; for example, ageusia was more common in patients who were not completely vaccinated (3% vs. 0%, P = .01). Overall, screening for fever, cough, or dyspnea had a 65% sensitivity with its lowest sensitivity in the pre-Delta cases (54%) and highest sensitivity in Omicron cases (78%). Conclusions In this descriptive cross-sectional study evaluating symptomatic military members with COVID-19, symptom prevalence varied based on predominant circulating COVID-19 variant as well as patients’ vaccination status. As screening strategies evolve with the pandemic, changing symptom prevalence should be considered.

ObjectiveTo examine the association of leisure-time physical activity with mortality from influenza and pneumonia.MethodsA nationally representative sample of US adults (aged ≥18 years) who participated in the National Health Interview Survey from 1998 to 2018 were followed for mortality through 2019. Participants were classified as meeting both physical activity guidelines if they reported ≥150 min/week of moderate-intensity equivalent aerobic physical activity and ≥2 episodes/week of muscle-strengthening activity. Participants were also classified into five volume-based categories of self-reported aerobic and muscle-strengthening activity. Influenza and pneumonia mortality was defined as having an underlying cause of death with an International Classification of Diseases, 10th Revision code of J09–J18 recorded in the National Death Index. Mortality risk was assessed using Cox proportional hazards, adjusting for sociodemographic and lifestyle factors, health conditions and influenza and pneumococcal vaccination status. Data were analysed in 2022.ResultsAmong 577 909 participants followed for a median of 9.23 years, 1516 influenza and pneumonia deaths were recorded. Compared with participants meeting neither guideline, those meeting both guidelines had 48% lower adjusted risk of influenza and pneumonia mortality. Relative to no aerobic activity, 10–149, 150–300, 301–600 and >600 min/week were associated with lower risk (by 21%, 41%, 50% and 41%). Relative to ConclusionsAerobic physical activity, even at quantities below the recommended level, may be associated with lower influenza and pneumonia mortality while muscle-strengthening activity demonstrated a J-shaped relationship.

We describe the public health response to a military trainee who developed serogroup B meningococcal disease while sharing underwater breathing equipment. Despite high transmission risk, with rapid isolation and postexposure prophylaxis administration, there were no secondary cases. This case supports carefully weighing serogroup B meningococcal vaccination in high-risk settings.

International travelers are frequently at risk for travelers’ diarrhea (TD) and malaria. Doxycycline was one of the earliest antibiotics shown to have efficacy in TD prevention. With increasing resistance and recommendations against antibiotic chemoprophylaxis, doxycycline fell out of use. We evaluated TD incidence and risk factors in a prospective cohort of travelers, specifically in regard to malaria prophylaxis. Travelers’ diarrhea was defined as ≥ 3 loose stools in 24 hours or two loose stools in 24 hours associated with other gastrointestinal symptoms. The Poisson regression model with robust error variance was used to estimate the RR of TD. Three thousand two hundred twenty-seven trips were enrolled: 62.1% of participants were male, with a median age of 39 years (interquartile range [IQR] 27,59) and a median travel duration of 19 days (IQR 12,49); 17.4% developed TD; 32% traveled to Africa, 40% to Asia, and 27% to the Caribbean and Latin America; and 20% took doxycycline for malaria chemoprophylaxis, 50% took other antimalarials, and 30% took none. Decreased RR of TD was associated with doxycycline (RR 0.62 [0.47–0.82], P < 0.01) and military travel (RR 0.57 [0.47–0.70], P < 0.01). Increased risk of TD was associated with female gender (RR 1.28 [1.09–1.50], P < 0.01), hotel accommodations (RR 1.30 [1.10–1.53], P < 0.01), travel to tropical South America (RR 1.34 [1.09–1.64], P < 0.01), and duration of travel (RR 1.00 [1.00–1.01], P < 0.01). The use of doxycycline for malaria prophylaxis is associated with lower TD risk, suggesting increasing bacterial enteropathogen susceptibility similar to previous observations. Doxycycline selection for antimalarial chemoprophylaxis may provide additional traveler benefit in infection prevention.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in substantial morbidity and mortality since it was first described in December 2019 (1). Based on epidemiologic data showing spread in congregate settings (2-4), national, state, and local governments instituted significant restrictions on large gatherings to prevent transmission of disease in early March 2020. This and other nonpharmaceutical interventions (NPIs) have shown initial success in slowing the pandemic across the country (5). This report examines the first 7 weeks (March 1-April 18) of implementation of NPIs in Basic Military Training (BMT) at a U.S. Air Force base. In a population of 10,579 trainees, COVID-19 incidence was limited to five cases (47 per 100,000 persons), three of which were in persons who were contacts of the first patient. Transmission of symptomatic COVID-19 was successfully limited using strategies of quarantine, social distancing, early screening of trainees, rapid isolation of persons with suspected cases, and monitored reentry into training for trainees with positive test results after resolution of symptoms.

Travelers are often at risk for both influenza-like illness (ILI) and malaria. Doxycycline is active against pathogens causing ILI and is used for malaria prophylaxis. We evaluated the risk factors for ILI, and whether the choice of malaria prophylaxis was associated with ILI. TravMil is a prospective observational study enrolling subjects presenting to military travel clinics. Influenza-like illness was defined as subjective fever with either a sore throat or cough. Characteristics of trip and use of malaria prophylaxis were analyzed to determine association with development of ILI. Poisson regression models with robust error variance were used to estimate relative risk (RR) of ILI. A total of 3,227 trips were enrolled: 62.1% male, median age of 39 years (interquartile range [IQR] 27,59), median travel duration 19 days (IQR 12, 49); 32% traveled to Africa, 40% to Asia, and 27% to the Caribbean and Latin America. Military travel (46%) and vacation (40%) were most common reasons for travel. Among them, 20% took doxycycline, 50% other prophylaxis, and 30% took none; 8.7% developed ILI. Decreased RR of ILI was associated with doxycycline (RR 0.65 [0.43–0.99], P = 0.046) and military travel (RR 0.30 [0.21–0.43], P < 0.01). Increased risk of ILI was associated with female gender (RR 1.57 [1.24–1.98], P < 0.01), travel to Asia (RR 1.37 [1.08–1.75], P = 0.01), and cruises (RR 2.21 [1.73–2.83], P < 0.01). Use of doxycycline malaria prophylaxis is associated with a decreased risk of ILI. Possible reasons include anti-inflammatory or antimicrobial effects, or other unmeasured factors. With few strategies for decreasing ILI in travelers, these findings bear further investigation.

Background We assessed the compliance with self-collection of stool smears on Whatman® FTA® Elute Card (FTA Card) and detection of travellers’ diarrhoea (TD)-associated pathogens by using a quantitative Polymerase Chain Reaction (PCR) assay [customized TaqMan® array card (TAC)] in a prospective, observational cohort of travellers. Methods Enrolled travellers documented symptoms on a travel diary and collected an FTA Card during a diarrhoeal episode, or at the end of travel if they remained asymptomatic. TAC testing was performed on FTA Cards from TD cases and 1:1 matched asymptomatic controls and 1:1 matched loose stool cases that did not meet TD criteria. Odds ratios were used to determine the association between detected pathogens and TD. Results Of 2456 travellers, 484 (19.7%) completed an illness diary and met TD criteria, and 257 (53.1%) collected an FTA Card during the TD episode. FTA Cards were stored for a median of 2 years at room temperature (IQR: 1–4 years) before extraction and testing. The overall TAC detection rate in TD cases was 58.8% (95% CI: 52.5–64.8). Enterotoxigenic Escherichia coli was the most common pathogen in TD cases (26.8%), and 3.5% of samples were positive for norovirus. The odds of detecting TD-associated pathogens in 231 matched cases and asymptomatic controls were 5.4 (95% CI: 3.6–8.1) and 2.0 (95% CI: 1.1–3.7) in 121 matched TD and loose stool cases (P Conclusion FTA Cards are a useful adjunct to traditional stool collection methods for evaluating the pathogen-specific epidemiology of TD in austere environments. Qualitative detection of pathogens was associated with TD. Measures to improve compliance and quality of FTA Card collection with decreased storage duration may further optimize detection.

Mucormycosis is a fungal infection primarily afflicting immunocompromised or diabetic patients. Its presentation ranges from rhino-orbito-cerebral infections to disseminated mucormycosis with angioinvasion. We present a patient who developed a bowel obstruction one month after bone marrow transplant and was diagnosed with Rhizopus arrhizus diverticulitis despite antifungal therapy since transplantation. She underwent surgical removal with immediate fungal resurgence, declined further invasive intervention and was discharged on palliative isavuconazole. Seven months later she is alive with fungal containment. Keywords: Mucormycosis, Rhizopus arrhizus, Fungal diverticulitis, Salvage isavuconazole

We evaluated differences in pretravel care, exposures, and illnesses among pediatric and adult travelers, using a prospective, observational cohort. Eighty-one pediatric travelers were matched 1:1 with adult military dependents by travel region, destination’s malaria risk, and travel duration. Pediatric travelers were more likely to have coverage for hepatitis A and B (90% versus 67% of adults; 85% versus 44%), visit friends and relatives (36% versus 16%), report mosquito bites (69% versus 44%), and have close contact with wild or domesticated animals (40% versus 20%) than adults (P < 0.05). Subjects < 10 years of age were less likely to be prescribed antibiotics (28% versus 95%; RR = 0.63; 95% CI: 0.46–0.85) and antidiarrheals (9% versus 100%; RR = 0.10; 95% CI: 0.03–0.29) for travelers’ diarrhea (TD) self-treatment than adults. Travel medicine providers should emphasize strategies for vector avoidance, prevention of animal bites and scratches, and TD self-treatment in pediatric pretravel consultations.

Introduction There are many unique aspects to the practice of military Infectious Diseases (ID). San Antonio Uniformed Services Health Consortium Infectious Disease (ID) Fellowship is a combined Army and Air Force active duty program. Program leadership thought ID military unique curriculum (MUC) was well integrated into the program. We sought to verify this assumption to guide the decision to formalize the ID MUC. This study describes our strategy for the refinement and implementation of ID specific MUC, assesses the fellow and faculty response to these changes, and provides an example for other programs to follow. Methods We identified important ID areas through lessons learned from personal military experience, data from the ID Army Knowledge Online e-mail consult service, input from military ID physicians, and the Army and Air Force ID consultants to the Surgeons General. The consultants provided feedback on perceived gaps, appropriateness, and strategy. Due to restrictions in available curricular time, we devised a three-pronged strategy for revision: adapt current curricular practices to include MUC content, develop new learning activities targeted at the key content area, and sustain existing, effective MUC experiences. Learners were assessed by multiple choice question correct answer rate, performance during the simulation exercise, and burn rotation evaluation. Data on correct answer rate were analyzed according to level of training by using Mann–Whitney U test. Program assessment was conducted through anonymous feedback at midyear and end of year program evaluations. Results Twelve military unique ID content areas were identified. Diseases of pandemic potential and blood borne pathogen management were added after consultant input. Five experiences were adapted to include military content: core and noon conference series, simulation exercises, multiple choice quizzes, and infection control essay questions. A burn intensive care unit (ICU) rotation, Transport Isolation System exercise, and tour of trainee health facilities were the new learning activities introduced. The formal tropical medicine course, infection prevention in the deployed environment course, research opportunities and participation in trainee health outbreak investigations were sustained activities. Ten fellows participated in the military-unique spaced-education multiple-choice question series. Twenty-seven questions were attempted 814 times. 50.37% of questions were answered correctly the first time, increasing to 100% correct by the end of the activity. No difference was seen in the initial correct answer rate between the four senior fellows (median 55% [IQR 49.75, 63.25]) and the six first-year fellows (median 44% [IQR 39.25, 53]) (p = 0.114). Six fellows participated in the simulated deployment scenario. No failure of material synthesis was noted during the simulation exercise and all of the fellows satisfied the stated objectives. One fellow successfully completed the piloted burn ICU rotation. Fellows and faculty reported high satisfaction with the new curriculum. Conclusions Military GME programs are required by congress to address the unique aspects of military medicine. Senior fellow knowledge using the spaced interval multiple-choice quizzes did not differ from junior fellow rate, supporting our concern that the ID MUC needed to be enhanced. Enhancement of the MUC experience can be accomplished with minimal increases to curricular and faculty time.

Chemoprophylaxis with intramuscular benzathine penicillin G has been used widely by the U.S. military to prevent epidemics of group A streptococcus infections during basic training. The recent global shortage of benzathine penicillin prompted a detailed analysis of this issue in 2017 by military preventive medicine and infectious disease authorities in San Antonio, Texas, and San Diego, California, USA. This paper explores the history of group A streptococcus and chemoprophylaxis in the U.S. military training environment, current policy and practice, and challenges associated with widespread chemoprophylaxis. In light of the history presented, preventive medicine authorities at basic training centers should be extremely cautious about discontinuing benzathine penicillin chemoprophylaxis.

Background International travel is a risk factor for incident colonization with extended spectrum beta-lactamase (ESBL)-producing organisms. These and other multidrug-resistant (MDR) bacteria are major pathogens in combat casualties. We evaluated risk factors for colonization with MDR bacteria in US military personnel travelling internationally for official duty. Methods TravMil is a prospective observational study enrolling subjects presenting to military travel clinics. We analysed surveys, antimicrobial use data, and pre- and post-travel perirectal swabs in military travellers to regions outside the continental USA, Canada, Western or Northern Europe, or New Zealand, presenting to one clinic from 12/2015 to 12/2017. Recovered Gram-negative isolates underwent identification and susceptibility testing (BD Phoenix). Characteristics of trip and traveller were analysed to determine risk factors for MDR organism colonization. Results 110 trips were planned by 99 travellers (74% male, median age 38 years [IQR 31, 47.25]); 72 trips with returned pre- and post-travel swabs were completed by 64 travellers. Median duration was 21 days (IQR 12.75, 79.5). 17% travelled to Mexico/Caribbean/Central America, 15% to Asia, 57% to Africa and 10% to South America; 56% stayed in hotels and 50% in dormitories/barracks. Travellers used doxycycline (15%) for malaria prophylaxis, 11% took an antibiotic for travellers’ diarrhoea (TD) treatment (fluoroquinolone 7%, azithromycin 4%). Incident MDR organism colonization occurred in 8 travellers (incidence density 3.5/1000 travel days; cumulative incidence 11% of trips [95% CI: 4–19%]), all ESBL-producing Escherichia coli. A higher incidence of ESBL-producing E. coli acquisition was associated with travel to Asia (36% vs 7%, P = 0.02) but not with travel to other regions, TD or use of antimicrobials. No relationship was seen between fluoroquinolone or doxycycline exposure and resistance to those antimicrobials. Conclusions Incident colonization with MDR organisms occurs at a lower rate in this military population compared with civilian travellers, with no identified modifiable risk factors, with highest incidence of ESBL acquisition observed after South Asia travel.

Remediation of struggling learners is a challenge faced by all educators. In recognition of this reality, and in light of contemporary challenges facing infectious diseases (ID) fellowship program directors, the Infectious Diseases Society of America Training Program Directors’ Committee focused the 2018 National Fellowship Program Directors’ Meeting at IDWeek on “Remediation of the Struggling Fellow.” Small group discussions addressed 7 core topics, including feedback and evaluations, performance management and remediation, knowledge deficits, fellow well-being, efficiency and time management, teaching skills, and career development. This manuscript synthesizes those discussions around a competency-based framework to provide program directors and other educators with a roadmap for addressing common contemporary remediation challenges., Helping to remediate struggling learners is a common challenge for educators. Here ID fellowship training program directors provide tangible, actionable resources to assist with these efforts, which demand clear and objective data, thoughtful review and reflection, and collaboration among stakeholders.

Background Applications to infectious diseases fellowships have declined nationally; however, the military has not experienced this trend. In the past 6 years, 3 US military programs had 58 applicants for 52 positions. This study examines military resident perceptions to identify potential differences in factors influencing career choice, compared with published data from a nationwide cohort. Methods An existing survey tool was adapted to include questions unique to the training and practice of military medicine. Program directors from 11 military internal medicine residencies were asked to distribute survey links to their graduating residents from December 2016 to January 2017. Data were categorized by ID interest. Result The response rate was 51% (n = 68). Of respondents, 7% were ID applicants, 40% considered ID but reconsidered, and 53% were uninterested. Of those who considered ID, 73% changed their mind in their second and third postgraduate years and cited salary (22%), lack of procedures (18%), and training length (18%) as primary deterrents to choosing ID. Active learning styles were used more frequently by ID applicants to learn ID concepts than by those who considered or were uninterested in ID (P = .02). Conclusions Despite differences in the context of training and practice among military trainees compared with civilian colleagues, residents cited similar factors affecting career choice. Interest in global health was higher in this cohort. Salary continues to be identified as a deterrent to choosing ID. Differences between military and civilian residents' desire to pursue ID fellowship are likely explained by additional unmeasured factors deserving further study.

Recent conflicts have resulted in an unprecedented proportion of survivors of complex battlefield injuries. These patients are predisposed to infectious complications with multidrug-resistant organisms (MDROs). The epidemiology, prevention, and treatment of these infections are described, with emphasis on recent literature. Data from the Trauma Infectious Disease Outcomes Study (TIDOS) cohort have revealed a 27% rate of infectious complications in those evacuated after traumatic injury; this increases to 50% in the intensive care unit. Acinetobacter baumannii-calcoaceticus was common in casualties injured in Iraq, but was replaced by other extended-spectrum beta-lactamase-producing Enterobacteriaceae as well as fungi in casualties from Afghanistan. Prevention of infections includes short courses of narrow-spectrum prophylactic antimicrobials and infection control; the mainstay of wound infection prevention is debridement and irrigation. Treatment of many infections is primarily surgical and antimicrobial therapy directed against expected and recovered pathogens. Infections after combat trauma are common and complex, requiring a multidisciplinary approach to prevention and care.

Travelers are at risk for arbovirus infection. We prospectively enrolled 267 Department of Defense beneficiaries traveling to chikungunya-outbreak regions in the Americas between December 2013 and May 2015 and assessed travel characteristics and serologic exposure to chikungunya virus (CHIKV) and dengue virus (DENV). Ten ill-returning travelers were also assessed retrospectively. Self-reported mosquito exposure was common (64% of 198 evaluable travelers saw mosquitoes; 53% of 201 reported ≥ 1 bite). Increased exposure was associated with active-duty travelers (odds ratio [OR] = 2.6 [1.3-5.4] for seeing mosquitoes) or travelers visiting friends and relatives (VFR) (OR = 3.5 [1.0-10.0] for high-intensity bite exposure). Arbovirus infection was defined as seroconversion on plaque reduction neutralization testing (PRNT) of pre- and posttravel sera. For ill subjects enrolled posttravel, infection was defined by a positive convalescent PRNT and/or a positive reverse transcription polymerase chain reaction for CHIKV or DENV. We identified seven cases of arbovirus infection: four with CHIKV, five with DENV, and two with both. The composite attack rate for CHIKV and DENV infection was 3.7% of 108 evaluable, immunologically naïve, prospectively assessed travelers; there was serologic and/or polymerase chain reaction evidence of arbovirus infection in three of four evaluable (three of 10 total) ill-returning travelers. We identified both symptomatic and asymptomatic cases. Military purpose of travel and VFR travel accounted for five of seven cases. Pretravel counseling is important and should target higher risk groups. Given a shared vector between CHIKV, DENV, and Zika virus (ZIKV), this study can also help guide counseling for travelers to ZIKV-outbreak regions.

Erythrodermic psoriasis is a rare and potentially fatal skin condition. We present the case of a 68-year-old woman, with no prior dermatologic history, who was treated with steroid injection for an insect bite one month prior to presentation and subsequently developed a diffuse erythematous rash. She presented to a military medical center in shock, with weeping, coalesced plaques covering the majority of her skin. Skin biopsies revealed pustular psoriasis, and treatment with infliximab was initiated for erythrodermic psoriasis. After six weeks and three infliximab infusions, the cutaneous lesions had nearly completely resolved.

Infections complicating burns generally transition from Gram-positive to Gram-negatives over the first couple weeks, but this depends on multiple factors. The microbiology of infections complicating crude oil (CO) and hydraulic fracturing (FRAC) burns is unknown.We performed a retrospective study of patients with industrial thermal burns hospitalized2 days with ≥1 day in the ICU between 4/2011-11/2016. Burns were oil-related (ORB; CO or FRAC) or non-oil related (NORB). Epidemiology and microbiology during the first 15 hospital days was compared.149 patients were included, with 11 FRAC and 24 CO. CO burns were more severely burned than those with FRAC and NORB (p0.05). Mortality was 17% and 18% for CO and FRAC burns compared to 3% in NORB (p0.01). More cultures were obtained from ORB than NORB (p0.05). ORB were associated with Stenotrophomonas maltophilia and FRAC associated with Serratia marcescens and Candida glabrata. Patients with FRAC, CO and NORB had a median of 13, 3.5, and 4 days to first positive culture respectively (p=0.03).ORB were associated with more severe burns and unique microbiology. FRAC burns had longer to initial positive culture, potentially suggesting our current methodology is inadequate to diagnose infections associated with FRAC.

Key Points Question In congregant settings with the introduction of coronavirus disease 2019 (COVID-19), what clinical and laboratory findings are associated with an outbreak? Findings In this cohort study of 10 613 US Air Force basic trainees living congregantly in 263 cohorts, 3% were diagnosed with COVID-19 infection. Cohorts with trainees with more symptoms and lower cycle threshold values on reverse transcription–polymerase chain reaction assay were significantly associated with greater risk of transmission of COVID-19 within their cohorts. Meaning In this study, a higher number of symptoms and lower cycle threshold values were associated with subsequent clusters of outbreaks within cohorts and may be useful as risk factor measures if validated in future studies., Importance Owing to concerns of coronavirus disease 2019 (COVID-19) outbreaks, many congregant settings are forced to close when cases are detected because there are few data on the risk of different markers of transmission within groups. Objective To determine whether symptoms and laboratory results on the first day of COVID-19 diagnosis are associated with development of a case cluster in a congregant setting. Design, Setting, and Participants This cohort study of trainees with COVID-19 from May 11 through August 24, 2020, was conducted at Joint Base San Antonio–Lackland, the primary site of entry for enlistment in the US Air Force. Symptoms and duration, known contacts, and cycle threshold for trainees diagnosed by reverse transcription–polymerase chain reaction were collected. A cycle threshold value represents the number of nucleic acid amplification cycles that occur before a specimen containing the target material generates a signal greater than the predetermined threshold that defines positivity. Cohorts with 5 or more individuals with COVID-19 infection were defined as clusters. Participants included 10 613 trainees divided into 263 parallel cohorts of 30 to 50 people arriving weekly for 7 weeks of training. Exposures All trainees were quarantined for 14 days on arrival. Testing was performed on arrival, on day 14, and anytime during training when indicated. Protective measures included universal masking, physical distancing, and rapid isolation of trainees with COVID-19. Main Outcomes and Measures Association between days of symptoms, specific symptoms, number of symptoms, or cycle threshold values of individuals diagnosed with COVID-19 via reverse transcription–polymerase chain reaction and subsequent transmission within cohorts. Results In this cohort study of 10 613 US Air Force basic trainees in 263 cohorts, 403 trainees (3%) received a diagnosis of COVID-19 in 129 cohorts (49%). Among trainees with COVID-19 infection, 318 (79%) were men, and the median (interquartile range [IQR]) age was 20 (19-23) years; 204 (51%) were symptomatic, and 199 (49%) were asymptomatic. Median (IQR) cycle threshold values were lower in symptomatic trainees compared with asymptomatic trainees (21.2 [18.4-27.60] vs 34.8 [29.3-37.4]; P, This cohort study examines whether symptoms and laboratory results on the first day of COVID-19 diagnosis are associated with development of a case cluster in a congregant setting.

Background Travelers’ diarrhea (TD) is a leading threat to military readiness. Most trials of rifaximin chemoprophylaxis involve civilians or short-duration travel, whereas military travelers are exposed for longer periods at austere locations and are often physically taxed. We sought to assess efficacy of two regimens among military personnel deployed overseas. Methods This was a multi-site, double-blind, placebo-controlled trial of deployed military, randomized to placebo, rifaximin 550 mg daily, or rifaximin 550 mg twice-daily, for up to 42 days (1:1:1; 6 randomizations/block). Diaries were reviewed with subjects on return. Primary endpoint was time to first unformed stool (TFUS) in a TD episode. Other endpoints were assessed by intention to treat (ITT) and subgroups included incidence of any loose stool, meeting criteria for TD, safety, efficacy, adherence and impact to activity endpoints. Results 343 subjects were included in the ITT population. All UK travelers deployed to a single-site in Kenya; US travelers mostly deployed to various Asia-Pacific locations. Of 73 (21.2%) subjects reporting diarrhea, 42 (57.5%) met TD criteria. Among rifaximin-treated subjects, 15.9% (n=17) reported diarrhea in the twice-daily arm, 20.7% (n=25) in the daily arm, vs. 27.0% (n=31) of placebo recipients; p=.04 and 0.26 respectively. TD was reported by 10.3% (n=11) and 10.7% (n=13) in the daily and twice-daily arms, vs. 15.7% (n=18) among placebo recipients; p=0.24 vs. 0.26 respectively. Among UK personnel, a twice-daily regimen vs. placebo resulted in significantly fewer TD episodes (1.6% vs. 11.9%; p=0.03). Adverse events were similar between groups. Table 1: Demographics, endpoints, and adverse events (Comparisons are across placebo vs. each dosing regimen. Intent-to-treat [ITT] population defined as subjects enrolled into the study, randomized, travelled and had follow-up. p-values calculated from chi-square or Fisher’s exact test [categorical variables] and Wilcoxon-Mann-Whitney test [continuous variables]. Analyses performed on SAS v9.4. BID: twice-daily) Conclusion This is the first trial comparing two high-dose regimens of rifaximin prophylaxis in deployed personnel. Unlike prior reports, neither regimen was associated with an overall significant decrease in TD, potentially due to low overall TD incidence. However, the twice-daily regimen was associated with a numerically lower incidence of diarrheal stool, and in the UK subject group, there was a significant decrease of both TD and diarrheal stool. The impact of variability in regional TD risk, pathogen distribution and adherence in austere deployment environments on efficacy will be reviewed. Disclosures All Authors: No reported disclosures

Background The COVID-19 pandemic has been associated with significant spread in congregate settings and various forms of non-pharmaceutical interventions (NPI) have been implemented to prevent spread. Basic Military Training at Joint Base-San Antonio is the entrance to the US Air Force and has been associated with respiratory outbreaks in the past. A two-week arrival quarantine was implemented in March 2020. Effects on subsequent testing for COVID-19 after an arrival quarantine is unknown. Methods The first four weekly cohorts of trainees who underwent an arrival quarantine between March 16-April 13 were monitored during their 7 week training for COVID-19 symptoms. Symptoms, medical testing, and days removed from training were collected on every patient with possible COVID-19 symptoms including cough, shortness of breath, or fever. Testing during the two-week arrival quarantine were compared to the subsequent five weeks of training. Nominal variables were compared by chi squared or Fisher’s exact test as appropriate. Continuous variables were compared by Mann-Whitney U Test. Results A total of 2,573 started training during study period, 89 (3.4%) had symptoms concerning for COVID-19 and were tested. 5 (6%) patients tested positive, all of whom in the arrival quarantine. Compared to patients who completed quarantine (n=29), patients in the arrival quarantine who tested negative for COVID-19 (n=54) were tested more often (26 trainees a week vs. 5.8 later in training, p=< 0.0001), and received more rapid flu tests (74% vs. 38%, p=0.001) and multiplex respiratory PCR (15% vs. 0%, p=0.05). Trainees in quarantine were isolated longer for symptoms than patients who completed quarantine (median 3 vs. 2, p=0.01). There was no difference in presenting symptoms for trainees in quarantine or after quarantine. Conclusion Arrival quarantine appears to be an effective NPI, which in conjunction with other interventions prevented any COVID-19 transmission after quarantine completion. For those who went through arrival quarantine, there was more intense initial testing and initial longer symptomatic patient isolation, this was balanced by fewer symptomatic patients, less testing, and shorter isolations later in training. Disclosures All Authors: No reported disclosures

Background While fellows are expected to educate residents and students, they often receive limited formal instruction on how to teach. To address this, we developed a 2–4 week Clinical Educator Elective (CEE) for senior ID fellows. Goals were to increase fellow teaching engagement and promote excellence in medical education by improving understanding of adult learning theory and application to medical education. Methods Curriculum development: Methodology used Kern’s 6 step approach. A targeted needs assessment was obtained from CEE fellows at the start of the block. A reading list was created from key areas (table). Instructional methods included flipped classroom, learner-led discussions, and exercises in evaluation and feedback of peer and faculty teaching. Fellows completed a required capstone educational project. Learner Assessment: Standardized peer and faculty feedback surveys of fellow teaching were used. Program Assessment: CEE narrative assessments were evaluated. Anonymous pre- and post-CEE self-assessment fellow surveys rating their confidence in knowledge and skills in clinical education on a 1–10 scale (1 lowest, 10 highest) were compared. Post-CEE fellows’ medical student (MS3) teaching was compared to a 4-year pre-CEE historical cohort (PCHC). Results From 2017–9, 7 of 11 (64%) senior ID fellows completed the CEE. 5 (71%) were male, 3 started fellowship post-residency, 3 were chief residents, and 1 was an internist for 2 years. They had a median of 10 hours of prior faculty development (IQR 1–26). Career goals included GME in 6 of 7 pre-CEE. Narrative assessments revealed fellows highly valued the CEE. 6 available post-rotation surveys showed increased confidence in knowledge of adult learning theory, characteristics of effective educators, and fellows’ ability to teach across a range of settings (table). 5 of 7 CEE fellows precepted MS3s compared to 1 of 8 fellows in the PCHC (p=.04). CEE and PCHC fellows won 7 and 2 teaching awards, respectively. Fellows’ confidence in knowledge and skills of various aspects of medical education before and after the clinical educator elective Conclusion A CEE was highly valued and improved fellow self-assessed knowledge and skills in clinical teaching, even in those with prior teaching experience. It was also associated with more MS3 teaching. Future evaluations of long-term retention in academic medicine and teaching performance can further examine this approach. Disclosures All Authors: No reported disclosures

Trauma to the extremities is disproportionately represented in casualties of recent conflicts, accounting for >50% of injuries sustained during operations in Iraq and Afghanistan. Infectious complications have been reported in >25% of those evacuated for trauma, and 50% of such patients were treated in the intensive care unit (ICU). Osteomyelitis has been reported in 9% (14% of intensive care unit patients), and deep-wound infection in 27% of type III open-tibia fractures. Infections complicating extremity trauma are frequently caused by multidrug-resistant bacteria and have been demonstrated to lead to failure of limb salvage, unplanned operative take-backs, late amputations, and decreased likelihood of returning to duty. Invasive fungal infections of extremities have also presented a unique challenge in combat-injured patients, particularly in those with blast injuries with massive transfusion requirements and high injury severity scores. Infection prevention should begin at the time of injury and, although context-specific depending on the level of care, includes appropriate irrigation, surgical debridement, wound care and coverage, fracture fixation, and antibiotic prophylaxis, in addition to basic infection prevention measures. Clinical practice guidelines to address infection prevention after combat trauma (including extremity infection) were developed in 2007 and revised in 2011, with endorsement from the Surgical Infection Society and the Infectious Disease Society of America. Nevertheless, significant challenges remain, including austere environments of care, multiple transitions of care, and lack of coordinated efforts in prevention. Treatment of established infections is optimally multidisciplinary, particularly when deep wounds, bone, and joints are involved. Surgical debridement of overtly infected or necrotic tissue is necessary, with particularly aggressive margins if invasive fungal infection is suspected. Infected nonunion frequently requires the use of prosthetic materials for fixation, potentiating biofilm formation, and complicating medical therapy. Antibiotic therapy should be targeted at results of deep wound and bone cultures. However, this is complicated by frequent contamination of wounds, requiring differentiation between potential pathogens in terms of their virulence and decreased culture recovery in patient who have frequently received previous antibiotics. Lessons learned in infection prevention and treatment of orthopaedic trauma from combat can serve to inform the care of patients injured in natural disasters and noncombat trauma.

Travelers to developing regions are at risk for development of influenza-like illness (ILI). Little is known of traveler and trip characteristics associated with the development of ILI. TravMil is a prospective observational study, enrolling subjects presenting to six military travel clinics or predeployment-screening sites. We analyzed pre- and post-travel surveys from travelers visiting regions outside of the continental United States, Western or Northern Europe, Canada, Australia, or New Zealand between January 2010 and March 2016. Influenza-like illness was defined as a self-reported fever associated with either sore throat or cough. Trip and traveler characteristics were analyzed to determine risk factors for the development of ILI. Two thousand nine hundred and thirty-two trips were recorded (55% male, median age 45 years, 69% white, 51% on vacation, median travel duration 17 days). The 2,337 trips included the number of self-reported influenza vaccinations in the preceding 5 years (median 5). Eleven percent of the trips were complicated by an ILI lasting a median of 5 days; 70% and 17% of these reported upper and lower respiratory tract infection, respectively, and 12% reported both. On multivariate analysis, increased risk of ILI was associated with female gender (odds ratio [OR]: 1.60 [confidence interval (CI): 1.25-2.05], P < 0.01), age (years) (OR: 1.01 [CI: 1.01-1.02], P < 0.01); and duration of travel (days) (OR: 1.01 [CI: 1.00-1.01], P < 0.01). Influenza-like illness is common in travelers, regardless of traveler characteristics, purpose of travel, destination, or season of year. Female gender, older age, and longer duration of travel were associated with an increased risk of ILI. Additional tools and strategies are needed to prevent ILI in international travelers.

Mentor relationships are a key component of professional development within academic medicine. To date, there are no investigations into the prevalence and effects of mentor relationships within military academic medicine. This quality improvement initiative aimed to establish the prevalence and effects of mentorship, including whether sex differences exist among faculty at a military academic center, the San Antonio Uniformed Services Health Education Consortium, and identify opportunities to improve faculty development efforts for mentorship to benefit faculty at this institution.A 17-item survey was developed using an iterative process. Using the SurveyMonkey platform, the survey was distributed to each faculty member within the 33 Accreditation Council for Graduate Medical Education-accredited programs.A total of 104 responses (26%) were received from 393 total faculty members, including 48 Air Force, 45 Army, 3 Navy, and 8 Contractor/Government Service respondents. Thirty-four respondents were women (33%) and 70 were men (67%). Only 42% of faculty reported currently having a mentor. Thirty-nine respondents (38%; 44% men and 27% women) received formal mentorship at their first staff physician position after residency training. Mentorship helped respondents the most in the areas of clinical skills, understanding departmental/institutional culture, professionalism/officership, academic promotion/advancement, and clarification of priorities/goals. When asked whether more effective mentorship would affect their own decision to remain on active-duty military service, 14% responded "yes" and 28% responded "possibly."Increased mentorship has the potential to positively affect career development in military academic military medicine. Results from this study affirm previous reports that effective mentorship potentially represents a powerful tool for faculty retention. Future study should include other military medical academic centers to assess the generalizability of these results across US military medicine.

Introduction While several approaches have been described to teach antimicrobial stewardship (AS) practices, fewer have been aimed at infectious disease physicians. We developed a series of simulated AS meetings to train infectious disease fellows in the synthesis of AS interventions. Methods Three simulated AS committee scenarios were developed. Background lectures were given 1 week prior to the simulation during which multidisciplinary roles were assigned. Precourse work included review of primary literature pertinent to the scenario. Simulations were conducted over 1.5 hours. Individual and team performances were evaluated. Pre- and postsurveys were collected from fellows and faculty members to assess the format. Results Six infectious disease fellows participated in the series. Fellows demonstrated information synthesis and improvements in individual and team performance. Eighty-three percent of fellows before the simulation series and 100% postseries reported educating others on AS principles in the previous month. Fellows were satisfied with the series and requested more scenarios. Eight faculty members completed surveys. Thirty-eight percent of faculty before the series and 63% after completion reported that fellows viewed antimicrobial preauthorization as useful or necessary. Faculty supported the format, found it useful in evaluation of learners, and perceived that fellows benefited from the approach. Discussion Simulation is an effective and enjoyable way to train infectious disease fellows in AS and team utilization. Fellows demonstrated improvement in AS knowledge, skills, and attitudes and developed evidence-based interdisciplinary plans to solve AS challenges. Faculty also viewed this strategy as effective and sustainable.

During recent operations in Afghanistan, dismounted complex blast injuries (DCBI) have become increasingly common, and due to improvements in combat casualty care, these injuries are more survivable than they have been at any time in history. These patients are at high risk for infectious complications with infection rates as high as 50% in intensive care unit patients. The pathogens involved are often unique, including multidrug-resistant organisms and invasive fungi. This chapter summarizes the current literature on the epidemiology, microbiology, and outcomes of infectious complications in the predominantly DCBI combat casualty population and defines recommended measures for preventing these complications. These include wound management, use of antimicrobials, and both strategic and tactical infection prevention and control priorities. These recommendations are applicable throughout the continuum of casualty care with an emphasis on preventing infection beginning from the time of injury.

In over a decade of war, numerous advancements have been made to improve overall combat-related mortality, but infectious complications remain a leading cause of both morbidity and mortality in combat-related injured personnel. Here we will attempt to compare the challenges and lessons of combat-related injuries and infections from the Vietnam War with those of OIF/OEF. Throughout the Vietnam War and OIF/OEF, there have been similar infection-related challenges faced in caring for combat-related trauma patients. Both conflicts reinforced the importance of rapid medical evacuation and definitive surgical management of war wounds. They revealed the constant evolution of infecting organisms and the challenge of increasing antimicrobial resistance. We have also seen that with decreased mortality of severely injured personnel new morbidities must be addressed. Using the foundation of fragmented research from the Vietnam War, previously successful models were assembled into joint service research institutions which have allowed these questions to be addressed. However, many questions regarding measures to reduce infectious complications in our combat-injured personnel remain unanswered. Continued research building on established knowledge is critical for continued improvements in the care of combat-related trauma patients.

Although there is literature evaluating infectious complications associated with combat-related injuries from Iraq and Afghanistan, none have evaluated pneumonia specifically. Therefore, we assessed a series of pneumonia cases among wounded military personnel admitted to Landstuhl Regional Medical Center, and then evacuated further to participating U.S. military hospitals. Of the 423 casualties evacuated to the United States, 36 developed pneumonia (8.5%) and 30 of these (83.3%) were ventilator-associated. Restricting to 162 subjects admitted to intensive care, 30 patients had pneumonia (18.5%). The median Injury Severity Score was higher among subjects with pneumonia (23.0 vs. 6.0; p0.01). There were 61 first-isolate respiratory specimens recovered from 31 pneumonia subjects, of which 56.1% were gram-negative, 18.2% were gram-positive, and 18.2% were fungal. Staphylococcus aureus and Pseudomonas aeruginosa were most commonly recovered (10.6%, and 9.1%, respectively). Thirteen bacterial isolates (26.5%) were multidrug-resistant. Outcome data were available for 32 patients, of which 26 resolved their infection without progression, 5 resolved after initial progression, and 1 died. Overall, combat-injured casualties suffer a relatively high rate of pneumonia, particularly those requiring mechanical ventilation. Although gram-negative pathogens were common, S. aureus was most frequently isolated. Continued focus on pneumonia prevention strategies is necessary for improving combat care.

Between 1 January 2010 and 31 December 2016, a total of 14 U.S. and international military personnel in training at Joint Base San Antonio-Lackland, TX, were hospitalized due to suspected pulmonary tuberculosis (TB); of these, five personnel were diagnosed with active TB disease. Only one TB case had pulmonary symptoms, but these symptoms were not suggestive of TB. The incidence rate in the training population was 1.89 per 100,000 population (95% CI: 0.81, 4.42), with a higher rate when restricted to international military students attending the Defense Language Institute English Language Center. No instances of TB transmission were identified. The variety of atypical presentations and their resulting diagnostic and public health challenges prompted this retrospective review of all hospitalized cases. This case series highlights both the importance of a high index of clinical suspicion when TB is being considered in close congregate settings as well as the risk of overreliance on acid-fast bacilli staining and nucleic acid amplification testing for ruling out active pulmonary disease in young, otherwise healthy trainees. Practical solutions are suggested.

Introduction Nationally, the number of internal medicine physicians practicing in primary care has decreased amidst increasing interest in hospitalist medicine. Current priorities in the Military Health System include access to primary care and retention of trained personnel. Recently, we have conducted a study of military internal medicine residents' decision to enter infectious disease. As part of our larger effort, we saw an opportunity to characterize factors impacting decision making of internal medicine residents' desire to apply for subspecialty training and to extend active duty service obligations. Materials and Methods Questions were developed after discussion with various military graduate medical education and internal medicine leaders, underwent external review, and were added to a larger question set. The survey link was distributed electronically to all U.S. military affiliated residencies' graduating internal medicine residents in December 2016-January 2017. Data were analyzed by decision to apply to fellowship and decision to extend military obligation using Fisher's exact test or Pearon's chi-square test. Results Sixty-eight residents from 10 of 11 military residency programs responded, for a response rate of 51%. The majority (62%) applied to fellowship to start after residency completion. Reasons cited for applying to fellowship included wanting to become a specialist as soon as possible (74%), wishing to avoid being a general internist (57%), and because they are unable to practice as a hospitalist in the military (52%). Fellowship applicants were more likely to plan to extend their military obligation than non-applicants, as did those with longer duration of military commitments. No other factors, including Uniformed Services University attendance or participation in undergraduate military experiences, were found to impact plan to extend active duty service commitment. Conclusion The majority of graduating internal medicine residents apply for fellowship and report a desire to avoid being a general internist. Prospective fellows anticipate extending their active duty commitment, as do those with longer commitments.

Between 5 and 8 million people globally are infected with Trypanosoma cruzi, the causative parasitic agent of Chagas disease. The vast majority of incident infections originate in pockets of Latin America where domestic vector-borne transmission cycles are more common. Since 1955, when the first locally-acquired case was reported, fewer than 30 autochthonous cases have been documented in the United States. We describe the case of an 18-year-old US Air Force trainee, a native Texan with no travel history beyond the continental United States, who screened positive for T cruzi infection on blood donation and was subsequently found to have chronic Chagasic cardiomyopathy. This is the first documented case of Chagas disease in a US military trainee and one of the first known autochthonous cases of Chagasic cardiomyopathy in a Texas resident. Diagnostic, therapeutic, and military implications are discussed.

Background The San Antonio Uniformed Services Health Education Consortium Infectious Disease Fellowship program historically included a monthly short-answer and multiple-choice quiz. The intent was to ensure medical knowledge in relevant content areas that may not be addressed through clinical rotations, such as operationally relevant infectious disease. After completion, it was discussed in a small group with faculty. Over time, faculty noted increasing dissatisfaction with the activity. Spaced interval education is useful in retention of medical knowledge and skills by medical students and residents. Its use in infectious disease fellow education has not been described. To improve the quiz experience, we assessed the introduction of spaced education curriculum in our program. Materials and Methods A pre-intervention survey was distributed to assess the monthly quiz with Likert scale and open-ended questions. A multiple-choice question spaced education curriculum was created using the Qstream(R) platform in 2011. Faculty development on question writing was conducted. Two questions were delivered every 2 d. Incorrectly and correctly answered questions were repeated after 7 and 13 d, respectively. Questions needed to be answered correctly twice to be retired. Fellow satisfaction was assessed at semi-annual fellowship reviews over 5 yr and by a one-time repeat survey. Results Pre-intervention survey of six fellows indicated dissatisfaction with the time commitment of the monthly quiz (median Likert score of 2, mean 6.5 h to complete), neutral in perceived utility, but satisfaction with knowledge retention (Likert score 4). Eighteen fellows over 5 yr participated in the spaced education curriculum. Three quizzes with 20, 39, and 48 questions were designed. Seventeen percentage of questions addressed operationally relevant topics. Fifty-nine percentage of questions were answered correctly on first attempt, improving to 93% correct answer rate at the end of the analysis. Questions were attempted 2,999 times. Fellows consistently indicated that the platform was "highly enjoyed," "beneficial," a "fun format," and "completely satisfied." Fellows additionally commented that they desired more questions and considered the platform helpful in board preparation. Formal survey data post-intervention found that the fellows were satisfied with the new approach, found it to be useful in board preparation, overall educational value, and in-line with their personal learning style (median Likert score of 4 for all queries). Fellows were satisfied with time commitment, spending a mean of 47 min on the spaced education curriculum questions per month. Conclusions Introduction of a spaced education curriculum resulted in a sustained positive learner experience for >5 yr with demonstrated mastery of material. Spaced education learning is a viable addition to augment training experience, especially in areas of curricular gaps such as operational medicine. Correct answer data may also be useful to perform Accreditation Council for Graduate Medical Education-required objective assessment of knowledge.

Background International travelers are often at risk for travelers’ diarrhea (TD) and malaria. Doxycycline has activity against pathogens causing TD but hasn’t been used as TD prophylaxis since the 1980s when resistance emerged. We evaluated the incidence of and risk factors for TD, and whether the choice of malaria prophylaxis was associated with risk of TD. Methods TravMil is a prospective observational study enrolling subjects presenting to six military travel clinics. We analyzed pre- and post- travel surveys from travelers to regions outside of the continental United States, Western or Northern Europe, Canada or New Zealand between July 2010 and August 2018. TD was defined as ≥3 loose stools in a 24-hour period or two liquid or loose stools in a 24-hour period and ≥1 of the following: nausea, vomiting, abdominal pain, fever, or bloody stool. Characteristics of trip and traveler, and use of malaria prophylaxis (doxycycline, other, and none) were analyzed to determine risk factors for TD. A Poisson regression model with robust error variance was used to estimate relative risk of TD. Results A total of 3,227 travelers enrolled: 62.1% male, median age of 39 (IQR 27, 59), median travel duration 19 days (IQR 12, 49). 17.4% developed TD. 32% traveled to Africa, 40% to Asia, and 27% to the Caribbean, Mexico, Central, or South America. Military travel (46%) and vacation (40%) were most common reasons for travel. 20% took doxycycline for malaria prophylaxis, 50% other prophylaxis (89% atovaquone-proguanil), and 30% took none. Compared with those on no or other prophylaxis, doxycycline was associated with decreased risk for TD [RR 0.62 (0.47–0.82), P < 0.01], as was military travel [RR 0.57 (0.47–0.70), P < 0.01]. Increased risk of TD was associated with female gender [RR 1.28 (1.09–1.50), P < 0.01], staying in a hotel [RR 1.30 (1.10–1.53), P < 0.01], travel to tropical South America [RR 1.34 (1.09–1.64), P < 0.01], and duration of travel [RR 1.00 (1.00–1.01), P < 0.01]. Conclusion Compared with taking other or no prophylaxis, use of doxycycline for malaria prophylaxis is associated with lower TD risk, suggesting potential changes in resistance patterns, anti-inflammatory effects, or association with other unmeasured risk factors. Doxycycline may impact TD risk independently of other risk factors. Disclosures All authors: No reported disclosures.

Portable pulsed xenon ultraviolet disinfection (PPX-UVD) may reduce healthcare associated infections (HAI). There is limited data to inform use in burn intensive care units (BICU), where multidrug-resistant organisms (MDRO), especially gram negative rods (GNR), commonly cause disease. We evaluated PPX-UVD effects on environmental bioburden and rates of HAI and MDRO acquisition in a BICU. PPX-UVD was used for 3 months after standard cleaning of patient and operating rooms (ORs). Settle and touch plates in patient rooms and ORs were obtained after standard cleaning, pre-and post-PPX-UVD. HAI and MDRO acquisition were evaluated 1year prior to and for 3 month periods before, during, and after PPX-UVD. 110 touch and settle plates (33 pre- and 30 post-PPX-UVD) were obtained after standard cleaning, pre- and post-PPX-UVD. After PPX-UVD, environmental samples with any growth decreased (48% vs 31%, p=0.02), as did mean colony count/sample (2.8 pre- vs 1.6 post-, p=0.03). The 379 colonies largely represented skin commensals, without identified MDRO. Following PPX-UVD, no changes in device-associated infections, overall MDRO, or MDR GNR were seen, though a prolonged interval without healthcare-associated Clostridium difficile infection was observed. PPX-UVD in a BICU reduced overall environmental bioburden, without a statistically significant impact on HAI or MDRO.

On July 7, 2015, a man aged 22 years reported to sick call during basic military training at Lackland Air Force Base (AFB), Texas. He had erythematous, crusted papulovesicular lesions on the extensor surfaces of the upper and lower extremities. The patient was afebrile and otherwise well, and was evaluated later that day by the dermatology service. A viral infection was considered most likely because of the patient's age, absence of fever or constitutional symptoms, and the distribution and morphology of the lesions. The initial differential diagnosis included Henoch-Schonlein purpura, parvovirus B19, and Rocky Mountain spotted fever. However, the clinical signs, including the unique morphology and distribution of grouped vesicles and papules was suggestive of hand, foot, and mouth disease (HFMD), although the patient did not have oral lesions and reported no contact with another person with HFMD. A viral culture and punch biopsy of one of the lesions were obtained.

Up to 50% of combat injured patients from recent conflicts have suffered infectious complications, predominantly with multidrug-resistant (MDR) bacteria acquired nosocomially in the chain of tactical combat casualty care. These bacteria have ranged from MDR Acinetobacter baumannii-calcoaceticus associated with Operation Iraqi Freedom (OIF), to extended spectrum beta-lactamase producing Enterobacteriaceae from operations in Afghanistan. Experience from interventions at Level III facilities demonstrate that basic infection control (IC) procedures, such as improvements in hand hygiene, use of ventilator associated pneumonia bundles, and antimicrobial stewardship, can improve outcomes even in austere environments. While some systematic interventions have been implemented to mitigate this risk, including development of the Deployed Infection Control Course, the Multidrug-Resistance Surveillance Network, and the Trauma Infectious Disease Outcomes Study, ongoing vulnerabilities remain. Deployed microbiology capabilities should be strengthened, theater-level IC standard operating procedures should be implemented, and a joint, theater-level expert IC consultant should be appointed to be responsible for directing IC activities from Levels I to IV.

Background. There is limited information on compliance rates with anti-vectorial protective measures (AVPMs) during travel to countries with risk of dengue and chikungunya. We evaluated differences in mosquito exposures, and factors associated with AVPM compliance in travellers going to countries where the principal mosquito-borne infectious disease threat is falciparum malaria and those where risk of dengue or chikungunya predominates. Methods. Department of Defence beneficiaries with planned travel to regions where the predominant mosquito-borne infection is falciparum malaria, and those with predominantly dengue or chikungunya risk, were included. Regions were divided into three groups: ‘high-risk falciparum malaria’, ‘low-risk falciparum malaria’ and ‘chikungunya/dengue risk’. Demographics, trip characteristics, arthropod exposure and AVPM compliance were captured using pre- and post-travel surveys. Skin repellent compliance was defined as self-reported use, categorized as ‘often/every day’. A logistic regression model was used to estimate factors associated with AVPM compliance. Results. 183 (9%), 185 (9%) and 149 (7%) travelled to high and low falciparum malaria risk regions, and chikungunya/dengue risk regions, respectively. Overall, 53% (95% CI: 48–57%) and 16% (95% CI: 12–19%) were compliant with repellent use on skin and clothing, respectively. Daytime bites were reported more frequently in chikungunya/dengue risk regions than high malaria risk regions (37% vs. 10%), while night time bites were frequently in high malaria risk regions (53% vs 20%; P < 0.001). Compliance with skin repellents was associated with female gender [RR: 1.54 (95% CI: 1.05–2.28)], observing mosquitoes during travel [RR: 2.77 (95% CI: 1.76–4.36)] and travel during the rainy season [RR: 2.45 (95% CI: 1.66–3.71)]). Conclusions. Poor AVPM compliance was observed in the overall cohort. Compliance with skin repellent use was associated with female gender, observing mosquitoes and travelling during the rainy season, and was not associated with the risk of malaria or chikungunya/dengue at the travel destination.