A B S T R A C T S

Plenary 1(Monday, May 18, 2015)

Plenary 2 (Tuesday, May 19, 2015)

Plenary 3 (Thursday, May 21, 2015)

Plenary 4 (Friday, May 22, 2015)

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How Medical Military Service Might or Should be Involved in Ebola Outbreak Relief

Eric Bertherat, Mikiko SengaWorld Health Organization

Aside from pandemics, the 2014Ebola outbreak is the largest everrecorded in the past century, affecting six African countries (Mali, Nigeria, Guinea, Sierra Leone, Liberia, Senegal,). With over 24,350 cases and 10,000 deaths reported by mid-March 2015, the outbreak has disrupted the economy, strained international relations, and impairedalready fragile healthcare systems. To significantly ramp up Ebola response efforts in west Africa, the World Health Organization (WHO) has welcomed the contribution from various governments, including military assistance. International military support to the heavily affected countries (Guinea, Liberia and Sierra Leone)has been provided either through WHO mechanisms or bilaterally, and has been in the areas of, but not limited to, logistics, healthcare, and training of health workers.In collaboration with the Ministries of Defence and Health, international militarieshave helped establish regional command and control, andtheir staging bases have facilitated the coordination of response and expedited the transportation of equipment, supplies and personnel, as well as construction of Ebola Treatment Units. These efforts have strengthened national capacities in the threemost affected countries to intensify response activities. In non-affected countries, military hospitals have been usually referenced in the countries’ preparedness plan on handling of an imported case.In the affected countries, the missions of the national armies can be impacted as militaries are potential victims as any citizens and the military hospitals are susceptible to receive Ebola cases. The national forces also participate in the control operations through logistical assistance, control at the borders and eventually security assistance to the control operation teams. As demonstrated in the current outbreak,the strong ability to respond to an outbreak is critical for immediate containment of disease, and military support is inevitable in complex emergencies.

A System of Epidemiological Real Time Surveillance Useful for Outbreaks Relief

COL Jean-Baptiste Meynard, MD, PhDProfessor of Epidemiology and Public Health

CESPA DeputyDirectorNATO/COMEDS/Force Health Protection Working Group Chairman

During the NATO Prague Summit (2002), five initiatives were decided to enhance the preparedness and the response against the weapons of mass destruction. One of them concerned a “real time surveillance system interoperable between allied Nations”. In 2015, there is only one existing real time surveillance system interoperable between NATO Nations: the French “alerteet surveillance en temps réel” ASTER system, driven by the “centre d’épidémiologie et de santé publique des armées” (CESPA) in Marseilles, France. This system is currently functioning among the French Forces deployed in French Guiana, in Djibouti, and in Mali. It is also used for the surveillance of the European Union Training Mission in Mali in collaboration with the Military Medical Center of Excellence(MILMED CoE) / Deployment Health Surveillance Capability (DHSC) based in Munich. ASTER makes it possible for the NATO medical community to modify the process of surveillance, taking into account syndromic surveillance connected with the mandatory EPINATO-2 system, while waiting for the development by ACT of the future MEDICS system. It is a part of the Deployment Health Surveillance Courses that have been organized by the MILMED CoE and the CESPA in Marseilles since 2013. ASTER will also be deployed during the Vigorous Warrior Exercise in June 2015 in Czech Republic.Real time surveillance is an important capacity for the Force Health Protection, providing an early warning capacity to improve the response to a CBRN attack or a natural disease.

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Chinese PLA Medical Response to the Ebola Outbreak in West Africa

Yinying Lu, Xuezhang Duan, Zhiqiang Sun, Yingjie Zhuang, Hui Xia, Ningbo Zhan, Huijuan Duan* The 302 Hospital of Chinese PLA, Chinese Military Medical Team in Sierra Leone

Author for correspondence and oral speaker: Dr. Huijuan DUAN

The epidemic of Ebola virus disease (EVD) in West Africa has been the largest ever recorded in history. The three most-affected countries— Guinea, Liberia, and Sierra Leone faced enormous challenges in implementing control measures to stop transmission and providing clinical care for patients with EVD. At the call of the WHO and the affected countries, within the national civil-military coordination mechanism, the People’s Liberation Army of China (Chinese PLA) has responded rapidly to the deadliest epidemic outbreak by deploying medical teams and aid medical equipment and materials to the affected countries. Totally 6 batches of military medical teams with over 500 professionals were deployed successively by the PLA to Sierra Leon and Liberia providing clinical treatment and care, infection prevention and control, and health promotion and training. The PLA medical team in Sierra Leone spent about a week converting a general hospital into a specialized Ebola observation and treatment centre in Freetown, Sierra Leon, which came into function soon for patients screening, care and treatment. In Monrovia, Liberia, it took only one month for the PLA to build up a high-quality Ebola Treatment Unit (ETU) with 100 beds capacity, which was run and operated by experienced PLA medical professionals. Taking advantage of the rich experiences in fighting against SARS in 2003 and emergency response capabilities in various domestic and international disaster relief operations, the PLA medical teams, together with all the international partners on the ground, have played significant roles in containing the spreading of the epidemic. Totally 940 suspected patients and 295 confirmed EVD cases have been consulted and treated in the Chinese ETUs, while at the same time the PLA has achieved the miracle of zero infection among its medical professionals. The paper is providing an overview on the PLA emergency response to the Ebola outbreak, summarizing best practices on pre-deployment preparedness, EVD case management, infection prevention and control, multi-lateral coordination and communication, logistic support, etc.., and also sharing valuable lessons learned, all of which will be very enlightening for severe epidemic outbreak responses in the future. Key words: Ebola outbreak, Chinese PLA medical teams, infection prevention and control, patients care and management, multi-lateral coordination and communication.

The UK Military Contribution to the International Response to the Ebola Outbreak in Sierra Leone

Sonia Phythian UK

As at 30 Mar 15 there have been 25,030 probable, confirmed and suspected cases of Ebola Virus Disease (EVD) in Guinea, Liberia and Sierra Leone, with 10,398 deaths. In August 2014 the World Health Organisation officially declared the EVD outbreak an international public health emergency and published a roadmap to guide and coordinate the international response; aiming to curb the continuing EVD transmission worldwide within 6-9 months. The UK, owing to its strong bilateral links, has been the framework nation for international efforts in Sierra Leone. Defence has supported the Government of Sierra Leone’s efforts to contain the outbreak of EVD by providing appropriate military capacity for the Department for International Development-led UK contribution until responsibility can be transferred to Other Government Departments, Non-Government Organisations and Internal Agencies. At the peak of military activity, in Nov 14, 833 personnel deployed split evenly across two key areas: healthcare workers in both EVD and non-EVD roles; and support co-ordination of the Sierra Leonean response. UK military contribution has included: provision of a Combined Joint Inter-Agency Task Force HQ; the design and construction of six UK-funded Ebola Treatment Centres; establishment of an Ebola Training Academy which trained 4,019 healthcare workers, logisticians and hygienists; operation of the Kerrytown 12-bed (decreasing to 8-bed) EVD Treatment Unit; support to National and District Ebola Response Centres; and deployment of RFA ARGUS providing Rotary Wing, non-EVD medical care and riverine shuttle service. The UK remains committed to the long term plan for Sierra Leone in ‘getting to zero.’

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Military Medicine Perspective on Emerging and Re-emerging Infectious Diseases in Southeast Asia

Ram Rangsin, MD MPH DrPHDepartment of Military and Community Medicine

Phramongkutklao College of Medicine, the Royal Thai Army, Bangkok, Thailand

Southeast Asia is among the world fastest growing economic regions.Crowded population, increasing in travel, changes in ecological system lead SEA into the higher risks for Emerging and Re-emerging infectious diseases (EID).The region have faced tremendous challenges on several EID including dengue hemorrhagic fever, HIV-1, nipah virus, SARS, chikungunya virus, avian influenza, pandemic influenza, leishmaniasis andartemisinin-resistant Plasmodium falciparum. Interactions between wildlife, domestic animals and human populations play an important role for EID. The known wildlife animals includes birds, civets, and bats. Many domestic animalswere found to be related to the EID in human included paltry chickens and pigs. One health conceptto ensure the multidisciplinary integration for detection and disease control became an important approach.Especially, in the situation of unknown pathogen. Surveillance focusing on a cluster of patients or unexplained deaths with history of high fever and hemorrhage / pneumonia / encephalitis should be expanded.Military personnel is at high risk for contacting the emerging and re-emerging diseases. Military personnel may contacted the diseases during deployments inside or outside the region. On the other hand, in some situation medical units may be deployed to the affected area of an uncontrolled outbreak. The strong network for diseases surveillance and rapid outbreak responses among military medicine community is required for the more sustainablesystem.EID are inevitable in this region. EID issue is considered as one of the major regional threats in Southeast Asia and has been included for ASEAN Defence Ministers Meeting (ADMM), under the ASEAN Political - Security Community.

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Growing Humanitarian Needs in Contemporary Armed ConflictHumanitarian Response and Operations from the International Committee of the Red

Cross

Pascal HundtICRC

Armed conflict today is evolving rapidly, shows no signs of abating. The way armed conflicts are evolving – more in number, longer in duration and broader in regional impact – is generating more suffering, and increasing vulnerabilities. Men, women and children face enormous suffering, including injury and death whilst hundreds of thousands have been forced to flee their homes, losing their homes and livelihoods. Fragmentation of power and of armed groups operating with unclear command structures are increasing the asymmetrical nature of conflicts. Battlefields continue to expand into cities, taking a heavy toll on all segments of the population. The aim of the ICRC’s work and activities is to provide, without any form of discrimination, essential and immediate assistance and protection to people affected by armed conflict. The ICRC is convinced that to be able to accomplish this the organization must adhere strictly to the fundamental principles of humanity, impartiality, neutrality and independence. In light of the UN peacekeeping operations, the ICRC has developed a privileged bilateral dialogue with UN peacekeeping missions in areas of armed conflict. The interaction regularly addresses the application of International Humanitarian Law (IHL), the conduct of hostilities, Protection of non-combatants as well as IHL sensitization for troops being deployed into peacekeeping missions.

Jordan : a Refugee HavenA Spirit of Solidarity and Shared Responsibility

The Syrian Crises Case

Maj. General Dr. Khalaf M. Al Jader Al-SarhanSenior Consultant Urologist

Director GeneralJordanian Royal Medical Services

The Chairman of Pan Arab Regional working Group For Military Medicine

Background :The Jordanian Royal Medical Services (RMS) , Jordan’s Proud and enduring legacy was first established in the year 1941 with one doctor while acknowledging that big results require big dreams with the ultimate goal of providing quality health care and supporting the wellbeing of the men and women of the Jordanian Armed forces and the people of the Hashemite kingdom of Jordan.A spirit Of Solidarity and Shared ResponsibilityThe devastating increased frequency and scary scale of natural and man-made disasters, as well as the changing nature and severity of conflict, call upon us all for a united increased planning and attention to humanitarian action and its impact on people’s lives around the Globe.For Decades, RMS has lending a healing and a help hand across the Globe in a spirit of Solidarity and shared responsibilities . Caring for patients and alleviation of their suffering is our highest priority. We are there when disaster strikes, providing immediate assistance, accompanied by the rapid deployment of our unsung heroes, made up of personnel and urgently needed resources and supplies. We are there when civilian lives are devastated by conflict,The Jordanian Royal Medical Services is there to provide protection and life-saving assistance.Jordan ...A Refugee HavenJordan is a reflection of the and openhearted compassion ,we Jordanians have always throughout history have opened our hearts and focused our energy to help one another, love our neighbors as we love ourselves , and make good happen . Jordan hosts the third largest number of refugees in the world, and the largest refugee community and number of Refugees nationalities globally when compared with the population.We believe in protecting life, health and ensuring respect for the human being. The sum of which helps us promote mutual understanding, friendship, cooperation and a long lasting peace amongst all people.

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The Role of Indonesian Defence Force’ Medical Unit in Peacekeeping Operations

MG (Ret) Heridadi, MD, MSc Indonesia

Indonesia peacekeeping contributions started in 1956 when Garuda Contingent was first deployed to Middle East as part of the United Nations Emergency Force. Since then Indonesia has actively participated in numerous peacekeeping missions ranging from small groups of military observer/staff officer to full-fledged participation in Cambodia, Bosnia Herzegovina, Democratic Republic of the Congo, Lebanon, Haiti and Darfur. A team of medical unit plays an important role in every peacekeeping operation deployment to ensure the health and well being of members by providing excellent medical care in the field. Not only were members of Indonesian contingent assisted in medical care, humanitarian assistance was also provided to mitigate the plight of local people, refugees or internal displace people (IDPs) who were sick or injured and in desperate need of medical care. A team of medical unit was also involved with ICRC to assist and bring relief to civilians affected by armed conflict. The role of IndonesianContingent in humanitarian assistance was, among other things, in United Nations Protection Force (UNPROFOR) mission in Bosnia (1994-1998) where 1 Medical Battalion was deployed. Humanitarian assistance is often regarded as key to success in UN Peacekeeping operation in mission area.

Mobile Technologies to Support Humanitarian Missions

Col USAF (Ret) MC Jim Fike, MDUSA

The protection of both military forceand civilian health is vital to maintaining readiness and conducting humanitarian assistance and disaster responsemilitary medical missions worldwide. Most military medical training and downrange performance support involves a combination of classroom and distance-learning education and training, exercises, real world experience and reachback capabilities that are dependent on the communication capacity of the deployed forces (which is often limited in austere conditions). A relatively new field, mobile Learning (m-Learning), is the instantaneous delivery of relevant content, uniquely designed to render on mobile devices--in a way that quickly satisfies an individual’s need for targeted, interactive information to gather knowledge, learn a skill, solve a problem or seek help, from a remote location. A study published by the US Department of Defense Counter-Terrorism Technical Support Working Group found that mobile learning techniques work best when used to enhance on-the-job learning and productivity. As a result, the first formal DoD mobile learning technology infrastructure development project, called the Mobile Learning Environment (MoLE) project, was initiated. The MoLE project succeeded in developing a prototype, cross-platform mobile App technical infrastructure (open source) that enables mobile learning content to be shared between several different smartphone platforms, optimizing the content design for effective mobile engagement. Based on feedback from many subject matter experts, the content for this and subsequent research initiatives focused on pre-deployment training, access to medical resources while performing a mission, machine foreign language translation, and electronic data collection/patient documentation. The results of those research projects and potential for their adoption and use within the international military medical community (focusing on humanitarian assistance, but with application to military force health protection missions) will be discussed.

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The United States Global Health Security Agenda and the Department of Defense

David Smith, MDDeputy Assistant Secretary of Defense for Force Health Protection and Readiness

By now, much of the world has heard about the United States Global Health Security Agenda. But, what is this Agenda? The vision of the Global Health Security Agenda is a world safe and secure from global health threats posed by infectious diseases—where we can prevent or mitigate the impact of naturally occurring outbreaks and intentional or accidental releases of dangerous pathogens, rapidly detect and transparently report outbreaks when they occur, and employ an interconnected global network that can respond effectively to limit the spread of infectious disease outbreaks in humans and animals, mitigate human suffering and the loss of human life, and reduce economic impact. There are measured objectives the United States has adopted and has encouraged other countries to adopt similar metrics.The United States Department of Defense plays an important role in the Global Health Security Agenda or GHSA. The most basic intersection of health and security for the US Department of Defense is the health protection and readiness of our Armed Forces who are responsible for safeguarding the security of the United States. The outbreak of Ebola in West Africa has highlighted the need for strategic partnershipswith Military, Federal, State, Local, International, and NGO relationships. This talk will present the GHSA, the intersection of Global Health and Security, andthe United States Department of Defense’s role in the GHSA.

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Modern Chemical, Biologic, Radiologic and Nuclear Hazards and Health Protection Strategy

Colonel (Ret) Prof. Alexander Grebenyuk, MD, PhDThe Nikiforov Russian Center of Emergency and Radiation Medicine, EMERCOM of Russia

Military doctors of all countries are carrying out a very important mission: provision of medical care to wounded, sick and injured regardless of ethnic, political or religious affiliation of the affected people. This is especially important for chemical, biologic, radiologic and nuclear (CBRN) hazards, in which medical care will require a very large number of people both military and civilian. During wartime CBRN hazards are nuclear, biologic and chemical weapons (NBC); impact of the destroyed chemical, biologic and radiologic hazardous facilities; battle smokes, masking curtains and aerosols; defoliants and riot-control agents; diversionary poisons. During peacetime CBRN hazards are formed by the extreme factors of chemical, biologic, radiologic and nuclear accidents; military occupational poisons; drugs, insecticides; poisonous animals and plants; terrorist acts. Danger of any of these CBRN factors demands carrying out measures of health protection. Change of shape of modern armies and the big number of tasks for medical service has changed also health protection strategy. In XX century the primary goal of health protection was to save the life of soldiers at NBC action in war. Now it is required not only to rescue life, but also to keep health and professional serviceability of military staff and civil personnel in numerous factors of CBRN nature in various conditions.Keywords: CBRN factors, health protection, military medicine.

Medical Management of CBRN Casualties from Role 1 to Role 2: the French Perspective

Frederic Dorandeu1, COL, Prof., PharmD., PhD, Benoit Quentin2 COL, MD1Advisor to the French Surgeon General for Medical Defence against Chemical Risks. IRBA, Toxicology and

Chemical Risks Department (head), BP 73, 91 223 Brétigny-sur-Orge Cedex, France2French Armed Forces Medical Directorate (Direction centrale du Service de santé des armées), Fort Neuf de

Vincennes, Cours des Maréchaux, 75 614 Paris Cedex 12

As recently clearly shown, the threat from chemical agents has not diminished although its nature has evolved. The threat from CBRN agents remains thus clearly identified by NATO, especially if acquired and used by terrorists, and needs to be properly addressed. Despite more than 10 years of operations in Afghanistan where CBRN was not considered important, the French Military Health Service kept a close attention to these scenarios and developed new doctrines, equipment and training. The management of CBRN casualties requires a standardized framework to optimize medical response, especially in a multinational setting. The NATO-agreed principles of CBRN casualty management are recognition (detect & diagnose), safety, first-aid, casualty assessment and triage, life-saving interventions, and casualty hazard management (contain, decontaminate & isolate); then will come the supportive and definitive treatment before rehabilitation. In order to provide emergency medical care, some decontamination should be performed. To help the medical teams at the role 1 level, we designed a kit that gives them the necessary equipment to quickly assess the casualty and, after a localized and limited decontamination (individual protective equipment, and skin), give the necessary medical attention. New medical decontamination chains have also entered service. Deployed between a role 1 and a role 2 medical facility, they are tasked to receive all medical casualties, assess and treat them before thorough disrobing and decontamination, and further treatment. In this talk, we will present the main characteristics of the current doctrine, equipment, technics and procedures, and training. Keywords: CBRN environment, casualty management, decontamination

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Are Military Hospitals Prepared to Deal with CBRN Casualties in Urban Environment?

BG (ret’d) Ioannis Galatas, MDGreece

After a disaster (natural or man-made) all casualties end up at hospitals both public and military. Same is expected after a CBRN terrorist attack in urban environment with the addition of worried well that might compromise the health system and even collapse it. The biggest lesson learned from the Tokyo subway sarin incident is that ALL hospitals and clinics in the affected city would be involved in casualties’ management. Therefore it is impermanent all medical facilities to be prepared for such a remote potential. There are three major pillars in hospitals’ CBRN preparedness: (1) Infrastructure; (2) personnel; and (3) specialized equipment. Without hardening our hospitals and without investing on people working there no emergency CBRN response plan is applicable. And if cost is supposed to be the biggest obstacle worldwide, first responders must improvise and apply simple solutions that will not cost much while they will do the job. Finally training is the cornerstone in preparedness schedules and plans. By conducting a prescheduled drill once a year experience gained will disappear shortly. All misfortunes happen during off working hours, during vacation time and at night – so be prepared via realistic, down-to-earth drills that will not end at the hospital’s main gate assuming that doctors and nurses at the ED know what to do. And if you want to set the base for a very effective hospital’s defense, introduce “CBRN Medicine” at the curricula of universities’ medical and nursing schools thus providing future front-line health professional the necessary assets that will enhance their differential diagnosis capabilities and prepare them to look the enemy in the eyes! On the other hand the nicest thing about not planning is that failure comes as a complete surprise, rather than being preceded by a period of worry and depression!

The use of Anthrax and Orthopox Therapeutic Antibodies from Human Origin in Biodefense

Cdr Dr Stef StienstraNetherlands

IntroductionIt is impossible to protect whole nations from the effects of bioterrorism by preventive vaccination. There are too many possible agents, the costs would be exorbitantly high, and the health risks associated with complex mass vaccination programs would be unacceptable for the public health authorities. Adequate protection, however, could be provided via a combination of rapid detection and diagnosis with proper treatment for those exposed to biological weapon agents. Preferably this should be done with therapeutics, which would be beneficial in all stages of infection to disease. Monoclonal antibodies, preferably from human origin, can be used to prevent severe complications by neutralizing or blocking the pathological elements of biological agents and these are the optimal candidates to be deployed in case of biological warfare or a bioterrorist event. Recent research in aerosol challenged rabbits has shown that the application of a combination of a human monoclonal antibody against the protective antigen (PA) and one against the lethal factor (LF) of the anthrax toxin is highly efficacious even when given 48 hours after the exposure. In this models, all animals are symptomatic around 30 hrs after exposure and all exposed but untreated rabbits have died around 90 hrs after exposure. This new development offers a safe and effective therapy, which could save lives even days after the bioterror victims have been infected with anthrax spores. Study Design & Production Process The human body is one of the better, and most suitably equipped places for the generation of monoclonal antibodies, intended for effective treatment of humans. Such antibodies will be optimal in specificity, affinity, in functional and pharmacological properties. In addition, the chances on adverse effects and cross-reactivity with human tissues will be minimal. For these reasons, the human immune response is used as a basis for the selection and generation of antibodies by the Dutch company IQ Therapeutics in Groningen, in close cooperation with the US Naval Medical Research Center and financially supported by the Dutch Armed Forces and the US Defense Threat Reduction Agency,. Persons, immunised against or infected with an agent of interest, donate blood cells in this research program voluntarily. This blood is used to select the white blood cells producing the antibodies of interest. Those cells are the basis of the fully human monoclonal antibodies generated with IQ’s Cloning the Human Response™ technology. The antibody-producing B lymphocytes are preserved by processing them according a novel human adaptation of Köhler and Millstein’s mouse hybridoma technology. After having identified and studied the antibodies in question, the genes encoding the antibody are transferred to the human PER.C6 production platform (Crucell BV), which can typically produce around 3-10 g/l therapeutic antibody, but the culture of this human cell line can also be done in an XD™

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(eXtreme Density) process to obtain higher yields (>20 g/l). In this way, effective therapeutic fully human IgG1 (K-light chain) antibodies, with an affinity of around 10-10 M against the protective antigen (PA) and 10-9 M against the lethal factor (LF) toxin components of Bacillus anthracis have been generated and are currently under development. Currently antibodies against orthopox viruses are generated as well from donors, which have been immunized with vaccinia. Other projects are the development of therapeutic antibodies for MRSA (methicillin resistant Staphylococcus aureus) and Enterococcus spp. RESULTS, clinical studies in the coming yearBoth human antibodies against the anthrax toxin components are efficacious in vitro (Toxin Neutralization Assay EC50 of 0.3nM and 0.1nM respectively for anti-PA and anti-LF) and in vivo in pre- and post-exposure settings, mice and rabbits (inhalation). The anti-LF antibody (IQNLF) will be tested in a phase I clinical trial in Q3 of 2010. GMP material is already available for testing in humans. The anti-PA antibody is in a pre-clinical stage, as are the other antibodies mentioned. A remarkable result is that we have seen a strong additive effect in the treatment of anthrax infections when both anti-LF and anti-PA are used simultaneously. Studies have shown that a so chosen sub-optimal dose of anti-PA affording 50% protection can be supplemented with a small dosage of anti-LF to obtain 100% survival of the rabbits infected with 100 lethal dosages of anthrax by inhalation.The rabbit inhalation studies indicated that with the use of the dual antibody approach (anti-LF and Anti-PA), the window of treatment after inhalation of anthrax spores can be extended as well. Whilst the onset of disease in the rabbit anthrax inhalation studies is in 25-29 hours, the lifesaving treatment of the animals with a normal dose has proven to still be effective when the treatment is given 48 hours after the lethal dose in a model where the mean time to death of untreated animals is around 90 hrs after exposure. This is important for the real life setting as not everybody will immediately be aware of the infection with anthrax spores, or will have access to immediate treatment. The ability of the dual antibody approach, enabling successful treatment even when victims are clearly symptomatic, will have a significant impact on managing the anthrax threat. CONCLUSION, Instant Immunity™ in biodefenseIQ Therapeutics has successfully generated and developed fully human monoclonal antibodies against the lethal factor and protective antigen of Bacillus anthracis. The same technology can be used to generate antibodies for passive immunisation after (suspected) exposure to other biological threat agents. As such antibodies are effective immediately after application, the antibodies have been termed Instant Immunity™ antibodies.There is a strong added effect when human antibodies directed against LF and PA are administered together. This leads to higher survival rates, possible dose sparing and an extended window of treatment, even after the victim has become symptomatic. KEY WORDSBioterrorism threat, anthrax, toxin, smallpox, monkey pox, orthopox, MRSA. .

Approaches towards Countermeasures for CBRN issues in Japan

COL Tom Kodera and CAPT GentaroTsumatoriNational Defense Medical College, Ministry of Defense, JAPAN

Chemical, Biological, Radiological, and Nuclear (CBRN) attacks are nowreal threatswe are facing todayin our modern world, it is crucial to understand how to protect, care and manage the CBRNcasualties inmilitary medicine. In this session, I would like to present the Japanese Ministry of Defense efforts and approaches in dealing with this. In 1995, Tokyo experienced the firstsarinterrorism attackin the world. Other chemical and biological agentswere used in Japan. After anthrax terrorism in the United States in 2001, we realised that we might have possible CBRN attacks.For these reasons, theJapanese Ministry of Defense has developed policies for counter CBRN measures along with other agencies within the Japanesegovernment. Firstly, I would like to outlinesome important points of these policies andcapabilities.Next, I will describe the activities of the Japan Self-Defense Forces (JSDF) in the Great Eastern Japan Earthquake. Japan conducted the largest disaster relief operation in 2011, anddispatchedJSDF units to Fukushima for dealing with the nuclear power plant accident.Some challenges will be discussed.Finally, I will introduce current topics regarding countermeasures against CBRN such as recent outcomes of our basic researchand efforts towards our medical education. Through this discussion,I will emphasize the need for continued systematic and progressive efforts to build international collaboration for our future.

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Turning Data into Decisions: Lessons of War

Eric UlsterUSA

The Surgical Critical Care Initiative (SC2i) is a collaborative effort established by the Military Health System to develop decision-making tools in the management of complex critically injured patients, to dramatically improve outcomes and contain costs. The SC2I developed its research agenda in response to clear clinical and economic needs to improve and individualize surgical critical care. By integrating groundbreaking advances in biomarker characterization, biorepository infrastructure, and advanced informatics, the SC2i is supporting the rapid discovery, development, and validation of clinical decision-support (CDS) tools for use in the management critically injured patients. The SC2i has developed CDS tools by combining clinical and biomarker data using best of kind machine learning algorithms as well as advanced statistical analysis. One such tool, the WounDX, combines serum and effluent inflammatory biomarkers with clinical data to accurately predict the timing of surgical wound closure This model has been validated using internal cross validation and produced a mean AUC of .74. The SC2i’s models such as the WounDX are being rapidly integrated into clinical practice within both military and civilian healthcare systems, maximizing outcomes and containing costs.

Transforming UK Military Medical Doctrine from Lessons on Operations – The Operational Patient Care Pathway

Sonia PhythianUK

Clinical care for combat trauma patients has transformed over the decade that has seen highly challenging operations in Iraq and Afghanistan. Incremental improvements in the system of care have led to a significant number of unexpected survivors compared to the performance of civilian trauma systems. The speed and quality of medical care can reduce the mortality and morbidity of operational patients. The Operational Patient Care Pathway (OPCP) provides a series of unifying concepts that articulate the clinical requirements for the UK military health services support (HSS) system on operations. This includes the system of clinical care for the ‘medical’ or ‘non-trauma patient’ as well as trauma care, and with regard to specific challenges of the Chemical Biological Radiological and Nuclear threat.

Application of the OPCP is informed by the 10-1-2+2 Medical Planning Guideline. This is the guideline for the location of clinical capabilities (Enhanced First Aid Care, Enhanced Field Care, Damage Control Surgery and Acute Medicine, In-Theatre Surgery) by time in the OPCP. The key to successful delivery of the OPCP is the continuous and incremental provision of clinical care to meet the needs of the operational patient, independent of organisational boundaries. The 10 Instruments of Military Health Care is a unified description of the medical capabilities to be considered to generate and deliver effective HSS on operations. The OPCP provides a single framework for these medical capabilities and clinical activities within the Deployed Medical Operational Capability to provide a seamless, escalatory increase in clinical care for the operational patient.

Microsurgery in the War Wounds Treatment

BG Prof. Marijan Novakovic, MD, PhDMilitary Medical Academy

Medical Faculty of the University of DefenseBelgrade - Serbia

During september 1991. – august 1995. period and may 1999. – june 1999. period, we treated 1679 patients, wounded in the war, with tissue defects.Free flaps were applied in 138 patients.In regard to the age, the youngest was 11 years old, and the oldest was 59 years old patient. The most common

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localization of the war wounds was head and neck (in 43 patients). We were applied: scapular free flap in 27 patients, scapular osteocutaneous in 9 patients, latissimus dorsi muscle in 4 patients, latissimus dorsi miocutaneous in 41 patients, radial forearm osteocutanous in 8 patients, fibular osteocutaneous in 22 patients and fibular vascularized bone graft in 27 patients. Early complications were noted in 27 patients, and the most common complication was venous thrombosis (in 16 patients). After unsuccessful revision, we have had to do secondary reconstruction in 11 cases.Using free flaps, we had primary success in 115 patients, and total success in 136 patients. According to our experience we can conclude that the advantages of using free flaps are: single act surgical procedure, achieve adequate soft-tissue coverage, enhance blood supply in recepient region, earlier beginning of physical therapy and reduction rate of amputation.Key Words: war wounds, tissue defects, microsurgery

Nepal, Nijmegen and North Pole…High Level Activities in Rehabilitating Canadian Armed Forces veterans…An Expedition Doctor’s Perspective.

Markus BesemannCanada

Rehabilitating injured service personnel have high expectations for re-integration of intrepid activities that formed part of their training and lifestyle before they were injured or became ill. The integration of sport in the rehabilitation process is well documented and has proven immensely beneficial as we have known since WWI. More recently many organizations have offered the opportunity for injured and ill veterans to participate in expeditions to remote regions in order to rebuild confidence, esprit de corps and assist in the rehabilitation process. This session outlines the perspective of an expedition doctor and rehabilitation specialist following three such events and allows the audience to draw their own conclusions as to the utility and effectiveness of such interventions.