Force Health Protection Fighting Health Protection threats on the front line Lt Col Susanna Roughton MB BS MRCGP MFPH AMFTM MSc RAMC Consultant in Public Health Medicine

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DISCLAIMER The views presented here reflect those of the presenter and do not necessarily represent the opinions of the UK Ministry of Defence or the British Army.

Learning Objectives Principles of Force Health Protection (FHP) and JTTP 4.10.1 Force Health Protection Audits Analysis of recommendations Contribution of Occupational Health to FHP Contribution of Health Promotion to FHP Contribution of Environmental Health to FHP The clinician’s contribution to FHP

References AJP-01(D) Allied Joint Doctrine AJP-3.14(A) Allied Joint Doctrine for Force Protection AJP-4.10 (B) Allied Joint Doctrine for Medical Support AJP-3.8(A) Chemical, Biological, Radiological and Nuclear (CBRN) Defence JDP 3-61 Joint Doctrine Publication Counter CBRN – The Military Contribution JSP 950 Lflt 1-4-1 The Operational Patient Care Pathway JSP 950 Lflts 7-1-1, 7-2-2, 3-3-1 AJP: Allied Joint Publication – NATO publications with some UK elements in 3.8 and 4.10 JDP: Joint Doctrine Publication – UK National JSP: Joint Service Publication – UK military

What is Force Protection (FP)? “Measures and means to minimise vulnerability”. FP directly employs capabilities to reduce the likelihood of adversarial effects in order to preserve freedom of action and operational effectiveness of the force” Threat = deliberate enemy action Hazard = natural or man made dangers Source: JDP 3-64: Joint Force Protection.

What is Force Health Protection? Force Health Protection (FHP) is a subset of FP Sum of all efforts to reduce or eliminate the incidence of Disease and Non-Battle Injury (DNBI) – thereby enhancing operational health readiness and combat effectiveness FHP activity should enable the Joint Force’s freedom to operate in spite of the presence of hazards or threats in the area of operations Source: AJP-4.10: Allied Joint Medical Support Doctrine

What is Force Health Protection? It consists of actions taken to counter the debilitating effects of environment, disease and selected special weapon systems through preventative measures for personnel, systems and operational formations. Source: AJP-4.10: Allied Joint Medical Support Doctrine

Force Health Protection - Tasks Promote behaviour that encourages health and minimises risk. Identify risks and threats to the health of the Population at Risk (PAR). Advise commanders on health risks and threats and the limitations they may impose on the force. Advise commanders on necessary preventative and control measures. Advise on the quality of the living and working environment. Gather epidemiological and other technical information. Audit implementation of FHP measures. Source: DN12/08: Force Health Protection and Health Risk Management

Force Health Protection – Public Health Tasks Promote behaviour that encourages health and minimises risk. Identify risks and threats to the health of the Population at Risk (PAR). Advise commanders on health risks and threats and the limitations they may impose on the force. Advise commanders on necessary preventative and control measures. Advise on the quality of the living and working environment. Gather epidemiological and other technical information. Audit implementation of FHP measures. Source: DN12/08: Force Health Protection and Health Risk Management

Force Generation Pathway Force Health Protection Medical Intelligence Health Protection Morbidity Surveillance Medical Planning Recording Environmental Exposure CBW Monitoring Employability Deployability Mitigation of health hazards of the workplace Med FP audits Operational Deployments Recruit Collect health data: PUD Smoking - Fitness - Obesity - Alcohol - Sexual Health - Suicide rate - Dental health - Immunisation schedules - Post-code - Employability Train Health Promotion Quality Health Services Epidemiology Health Information Post-deployment Health Surveillance Health Research Identifying cohorts Discharge Analysis of Medical Discharges Force Generation Pathway Force Health Protection Pre-deployment Medical Preparation of the Force Med FP Audits Pre deployment briefings Pre-Recruitment Understand health of population: - Smoking Post-Discharge Health surveillance of veterans Post discharge health surveillance NHS Care & Health Protection NHS Care & Health Protection Discharge Pathway Health Information

What is audit LATIN Audire: To hear LATIN LATE MIDDLE ENGLISH auditus hearing MEDIEVAL LATIN The word audit stems fro the Latin “to hear”. Historically, accounts were submitted verbally so financial auditors literally “heard” a summary of accounts from a business. But note: the word listen also stems fro the latin word “audite” LATIN Auditus compoti: Audit (of an account) Audite: To listen

What is audit LATIN Audire: To HEAR LATIN LATE MIDDLE ENGLISH auditus hearing MEDIEVAL LATIN I labour this point because all too often in healthcare audit, it seems that the counting element has taken over. Counting bed days, counting swabs used or crutches not returned. But without hearing, listening and understanding as to why a system of work is the way it is, counting alone will not bring about CHANGE…… which is ultimately what we want to achieve most of all from audit. If it was just about counting then we can do that from the comfort of our own computers….. And certainly that forms an element of the Force health Protection audit….. But as a start point more then the final product LATIN Auditus compoti: Audit (of an account) Audite: To LISTEN

So why count, why hear, why listen??

Infectious Disease - Historical Florence Nightingale – statistician primarily, and nurse as a secondary duty (in my view) did a lot of counting….…. but importantly she took those counts and made them accessible to others to understand and act upon – as illustrated by these impeccable polar area diagrams depicting death rates during the Crimean Campaign of 1854-55. The data shows the blue wedge which signifies preventable or mitigatable deaths , red is death from wounds and black – all other causes The data was irrefutable but she still had an uphill battle on her hands to bring about the much needed changes…… and things are not so different today. Fortunately, our death stats don’t look like that any more!!!

JTTP 4.10.1 JTTP 4.10.1 dated 30 Mar 17 All hazards approach as per JSP 950 Lflt 1-4-1 Health Risk Management (HRM) Use of the FHP audit tool

FHP Risk matrix Assessment of health risk to personnel

Health Risk Management Process FHP audit Tolerate Treat the Transfer risk Terminate

FHP contributors Public Health Occupational health Environmental health General Practice Oral Health Veterinary support Mental health IPC Laboratory capabilities Medical intelligence

Vaccinations Joint Service Policy Lflt 7-1-1 Core “routine” vaccinations at entry Core “travel” vaccines Consent Administrative arrangements Responsibilities Vaccine Read codes

Malaria Chemoprophylaxis Joint Service Policy – Preventing malaria in military personnel Routinely reviewed Responsibilities Anti-malarial choices ABCD of malaria Special considerations

Health Risk Management Risk to the Operation

Health Risk Management Risk to Individuals

Health Risk Management Control Measures e.g. malaria

Force Health Protection Instruction Op TRENTON – Force Health Protection Audit Force Health Protection Instruction Enshrined in the Force Health Protection Instruction Lt Col Susanna Roughton RAMC - SHA(A)

FHPB Force Health Protection Board 4 monthly “Owned” by Surgeon General Review and assure the FHP control measures put in place by Permanent Joint headquarters and Front Line Commands for current operations and major exercises Endorsement of Force Health Protection Instruction

Op TRENTON – Force Health Protection Audit FHP audits Purpose of FHP audit is to assess level of adherence to the FHP instruction Main questions: To what extent have the FHP instructions been followed? Were you adequately prepared? Was the kit and equipment issued adequate for role? What are the barriers and enablers to compliance with the FHPI? Are FHP Standard Operating Procedures and local policies adequate? Lt Col Susanna Roughton RAMC - SHA(A)

Force Health Protection Audit Op TRENTON – Force Health Protection Audit Force Health Protection Audit Med FP audit process initiated on Op HERRICK (Afghanistan) in 2009 Formalised in JTTP 4.10.1 Audits carried out to date: Afghanistan 2009 Afghanistan 2010 Afghanistan 2012 Sierra Leone 2015 South Sudan 2017 Lt Col Susanna Roughton RAMC - SHA(A)

FHP AUDIT TEAM COMPOSITION OH EH PH Other Afghanistan  Afghanistan 2011 Sierra Leone 2015   South Sudan 2017 MH Poland/Estonia 2017 Nigeria 2018

South Sudan FHP audit 11,000 miles Date Location/travel Sat 17 Jun Op TRENTON – Force Health Protection Audit South Sudan FHP audit Date Location/travel Sat 17 Jun UK - Nairobi Sun 18 Jun Nairobi - Juba Mon 19 Jun Juba - Malakal Tues 20 Jun Malakal - Bentiu Wed 21 Jun Bentiu Thurs 22 Jun Bentiu - Juba Fri 23 Jun Juba - Nairobi Sat 24 Jun Nairobi - UK 11,000 miles Lt Col Susanna Roughton RAMC - SHA(A)

FHP audit team Lt Col Susanna Roughton – SO1 Public Health (Army) Op TRENTON – Force Health Protection Audit FHP audit team Lt Col Susanna Roughton – SO1 Public Health (Army) Major Gerwyn Michael – MH nurse DCMH Donnington SSgt Kevin Shawcross – 2IC JSHU BFC Lt Col Susanna Roughton RAMC - SHA(A)

FHP audit process FHP audit tools: Focus groups Direct observation Op TRENTON – Force Health Protection Audit FHP audit process FHP audit tools: Focus groups Direct observation Review of SOPs and policies in place Interviews with key personnel Audit of EpiNATO data Anonymised questionnaire survey Specific to South Sudan: OMHNE questionnaire Malaria side effects survey Health brief survey > 15kg paper Lt Col Susanna Roughton RAMC - SHA(A)

FHP Audit South Sudan Questionnaire Focus groups COGNOS searches EpiNATO (2) data Interviews OMHE questionnaire A general nosey around

Health Risk Management Force Health Protection audit – South Sudan

South Sudan FHP audit - findings 99.4% had had their vaccines checked 100% cholera, 95.1% seasonal flu 95.1% pre-deployment medical assessment 98.8% had had a pre-deployment briefing 92.8% Medically fully fit 100% MLD had an MRA No inappropriate deployments Morale good on the whole

South Sudan UK UNMISS DNBI

Key recommendations Future surveys should include questions about: Op TRENTON – Force Health Protection Audit Key recommendations Future surveys should include questions about: how bite avoidance measures and anti-malarials were obtained Smoking habits Insect bite avoidance measures need to be enforced more robustly Light cotton long sleeved shirts should be issued There are several recommendations relating to FHP relevant SOPs that were reviewed Briefs need to emphasis the importance of other insect disease vectors and their different biting habits There must be a clear staffing process for writing, reviewing, endorsing and publishing SOPs The processes laid down in JSP 539 must be adhered to Additional assurance of the water supply needs to be investigated The composition of the EHT team should reflect the isolated nature of the operation Lt Col Susanna Roughton RAMC - SHA(A)

VECTOR BOURNE DISEASES Op TRENTON – Force Health Protection Audit VECTOR BOURNE DISEASES Prevailing attitude: “mozzies at dawn and dusk” Lack of awareness of other vectors or diseases such as Chikungunya, Dengue, Sleeping sickness, Yellow Fever etc Lack of awareness of other vector biting habits Operational seroconversion research One of the issues that has arisen as a result of carrying out these audits is a certain “complacency” about vector borne diseases. People know about malaria and to avoid mosquitos at dawn and dusk but they seem to be unaware of other insects and other vector borne diseases. Seroconversion for Infectious pathogens in UK military personnel deployed to Afghanistan between 2008-11 showed that military personnel were exposed to Rickettsia, Coxiella burnetti, Hantavirus and Sandfly fever. Half of the (albeit modest number of) seroconversions were vector borne diseases. There was evidence of seroconversion during the op tour in up to 3% of personnel. We continue to carry out seroconversion research on troops deploying to other parts of the world. Data on troops deployed on exercise to Kenya between 2009-2014 showed a similar preponderance of vector borne disease in the 0.48% of soldiers who showed evidence of seroconversion – most of whom were asymptomatic Lt Col Susanna Roughton RAMC - SHA(A)

RECOMMENDATION FORMAT P I D O L TRAINING EQUIPMENT PERSONNEL INFORMATION (governance?) DOCUMENTATION or DOCTRINE ORGANISATION LOGISTICS

COMMON THEMES Recommendations reflect the team’s specialty interests (OH/MH etc) Recommendations reflect the operational context however…… Common themes: Long sleeved shirts for malarial areas EH/combat hygiene duties Training Utilisation Locations and posts Vector control

RECOMMENDATIONS FOR THE FUTURE Standardised approach Standardised Terms of Reference Standardised reporting of recommendations Clarify processes and responsibilities for staffing and monitoring of actions on recommendations “Pre-audit” audit Experience and corporate memory

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