Stephen Derek Woolley

Introduction: Traveller's diarrhoea is a common complaint among deployed military personnel. Maintaining sample integrity prior to diagnostic testing is a key challenge in resource-limited environments. We report the comparison of three long-term ambient temperature stool sample stabilisation matrices for the detection of Cryptosporidium hominis from samples collected during an outbreak among British military personnel stationed in Kenya. Methods: A retrospective cohort of stool samples, each stabilised for more than 12 months at ambient temperatures using Flinders Technical Associate (FTA) cards, OMNIgene GUT tubes and DNA Shield faecal collection tubes, were analysed by Nanopore-based clinical metagenomic (CMgs) DNA sequencing and quantitative real-time PCR (qPCR) in the UK. The results were compared with BioFire FilmArray Gastrointestinal Panel testing carried out at the point of sampling in Kenya. Results: Cryptosporidium DNA was detected in 13/24 (54.2%) OMNIgene GUT samples by CMg following long-term storage, compared with 9/24 (37.5%) of DNA Shield samples. Samples stored on FTA cards did not identify Cryptosporidium DNA by CMg in any sample. OMNIgene GUT samples also had the highest rate of detection of C. hominis DNA by qPCR, with 23/24 samples testing positive, compared with 21/24 and 17/20 of DNA Shield and FTA samples, respectively. Conclusions: Samples stored in OMNIgene GUT tubes retained detectable levels of Cryptosporidium DNA in a higher proportion of samples following long-term storage. This study demonstrates the importance of selecting the optimal sample collection and stabilisation matrix for CMg and qPCR based diagnostic testing in austere environments.

Background: Up to 10% of patients report a penicillin allergy, yet >90% of these are inaccurate when assessed. Unnecessary second-line antibiotics contribute to poorer outcomes, increased antimicrobial resistance and higher costs. Accurate documentation supports stewardship and operational medical capability by improving clinical risk decisions, particularly in deployed or austere settings. We aimed to improve the proportion of adequately documented penicillin allergy records in a UK Defence primary care setting. Methods: In a baseline population (n=33/70 labelled patients), 21% (±10%, 95% CI) of records were adequately documented using national standards. A structured patient questionnaire, developed with NHS Lothian guidance, was piloted via email, refined and scaled across a broader primary care setting using SMS text messages plus follow-up email. Records were updated in the electronic health record. Using the Model for Improvement, three PDSA cycles tested usability, refined content and scaled implementation to the full cohort (n=504 coded penicillin allergy). Daily sampling (n=10/day) supported p-chart monitoring from a 21% baseline with a three-sigma upper control limit (UCL) of 60%. Results: 270/504 (54%) patients responded. Daily p-chart monitoring demonstrated sustained non-random improvement following intervention (day 8): median shifted from 20% (day 7) to 55% (day 12) and 65% (day 18), reaching the UCL by day 10. 38% of patients were unclear about their index allergic reaction. 33% reported a mild rash, 18% gastrointestinal upset and 18% angioedema. Symptoms associated with potential type 1 hypersensitivity or severe cutaneous reactions were infrequently reported. Using NHS protocols, an estimated 79% of documented penicillin-allergic service personnel would be suitable for drug provocation testing. Conclusion: A remote, patient-centred approach with standardised data entry improved documentation quality and is scalable across UK Defence Primary Healthcare. Next steps include embedding driver-diagram-informed actions (clinician awareness and digital templates), assessing prescribing outcomes and developing Defence standard operating procedures.

Background: We assessed the diagnostic agreement of BioFire FilmArray multiplex polymerase chain reaction (PCR) with Seegene Allplex PCR for testing fecal samples collected during a diarrhea outbreak in resource-limited settings. Methods: Fecal samples from consented British military personnel training in Kenya were collected without preservative and tested onsite with the FilmArray PCR platform. Anonymized corresponding samples frozen near the point of care were tested 16–18 months later in the United Kingdom using Seegene PCR (reference standard). We compared test sensitivity and specificity and assessed agreement using Cohen κ coefficients. Results: Samples were analyzed from 60 individuals (80% male; median age [interquartile range], 24 [22–28] years). The overall pathogen detection rates did not differ significantly between FilmArray and Seegene PCR (55 of 60 [91.7%] vs 53 of 59 [89.8%], respectively [P > .9]). Campylobacter spp detection was significantly higher with Seegene (17 of 59 [28.8%] vs 6 of 60 [10%] for FilmArray PCR P = .03). The sensitivity of FilmArray PCR was moderate for Cryptosporidium spp (65% [95% confidence interval, 45.37%–80.77%]), and low for Campylobacter spp (35.3% [14.21%–61.67%%) and norovirus (7.14% [.18%–33.87%]). Its specificity was good to excellent for detection of Campylobacter spp, Cryptosporidium spp, enteroaggregative Escherichia coli, and sapovirus. Conclusions: The study shows moderate concordance of FilmArray with Seegene PCR in the detection of 5 enteropathogens and poor to fair concordance for 7 others, but high-quality case-control studies are needed to assess agreement between these platforms. However, based on performance characteristics, including platform versatility and ease of use, and in the absence of a gold (reference) standard test, the FilmArray platform remains a suitable near-patient field-expedient platform for diarrhea diagnostics in resource-limited settings.

Human brucellosis is a zoonotic, bacterial infection caused by the intracellular, Gram-negative Brucella spp., which is common globally but rare in the United Kingdom, with approximately 20 imported cases per annum following travel to countries with high endemicity. Transmission typically occurs via the ingestion of infected animal products, including unpasteurised dairy products. Human-to-human transmission is rare, and routes include postpartum vertical transmission through breastfeeding. We report here on a familial cluster of three cases within a single UK-based Kurdish household of four, including a 11-month-old infant infected through the consumption of breast milk. Four months prior to presentation, the family had travelled together to northern Iraq for a 5-week holiday and all consumed local dairy products except for the children, including the 11-month-old, who was exclusively breastfed at the time. All three patients, including one adult male with complicated brucellosis, had a favourable outcome with medical therapy.: Brucellosis is an important differential diagnosis in returning travellers and specialist advice should be obtained early to prevent sequelae. It is also important for active case-finding, especially in family units with shared exposure. Paediatricians and adult physicians who may manage brucellosis should consider the possibility of vertical transmission in breastfeeding mothers.

Introduction Arboviruses are a diverse group of arthropod-borne pathogens and are emerging global public health threats with no approved therapeutics. Arboviruses are spreading rapidly, posing a health threat to UK Armed Forces (UKAF) service personnel (SP) through deployment to endemic regions. There are limited data on the burden of arboviral infections in UKAF SP. Methods A retrospective service evaluation of UKAF electronic healthcare records (eHRs) and statutory notifications to the Defence Public Health Unit was conducted. Cases with possible/confirmed dengue, chikungunya or Zika virus infections between 2005 and 2023 were included. eHRs were interrogated and trends analysed. Results Of 107 suspected infections between 2005 and 2023, 49 (45.8%) were laboratory-confirmed. Dengue fever was the most common (45/49) followed by chikungunya (3/49) and Zika (1/49) virus infections. The average yearly incidence of reported dengue infection increased from 0.51 cases per 100 000 UKAF SP per year in 2009–2011 to 3.85 cases per 100 000 SP per year in 2021–2023. 19/45 (42.2%) cases occurred during operational deployments and 24/45 (53.3%) during non-military activity. Dengue infection was most frequently acquired in Southeast Asia. Using WHO clinical severity criteria, 33/45 (73.3%) had dengue with warning signs and 5 (11.1%) had severe dengue. 23/45 (51.1%) dengue cases were hospitalised (median length of stay 5 days, IQR 3, range 1–9). No dengue fatalities or medical discharges occurred. Occupational impact was significant, with a median of 11 days stood down (IQR 10, range 0–45); 3/19 (15.8%) cases on operations required aeromedical evacuation (AEROMED). One deployed case of chikungunya required AEROMED and a 35-day downgrade. Conclusions Reports of arboviral infections, particularly dengue, are increasing in UKAF personnel, presenting an emerging health threat. This has implications for UKAF provision of deployed diagnostics and dengue vaccination policy. The rapid spread of arboviruses outside their traditional geographical areas, including into Europe, necessitates further surveillance and requires diagnostic and therapeutic research.

Introduction. Immediate identification of travellers’ diarrhoea-causing pathogens may not be possible in remote settings, but samples can be stored for epidemiological and related research. We collected pilot data to evaluate the utility of three different preservation media for testing stored faecal samples compared to immediate testing of fresh samples using the BioFire^® FilmArray^® multiplex PCR gastrointestinal panel (bioMérieux). Gap statement. No previous studies have demonstrated the utility of testing faecal samples directly by PCR BioFire^® FilmArray^® following prolonged storage and transportation in OMNIgene^®, DNA^™ shield and FTA^™ cards. Aims. To evaluate the reliability of OMNIgene^®, DNA shield^™ and FTA^™ card faecal storage and transport media in parallel, compared to initial testing of fresh faeces obtained from the same individuals at the time of presentation with diarrhoea in the field compare the results of faecal samples stored and transported at ambient temperature in OMNIgene^®, DNA shield^™ and FTA^™ cards then tested using PCR BioFire^® FilmArray^® 6–18 months later with those obtained from fresh faecal samples during a diarrhoea outbreak. Methodology. Fresh faecal samples were obtained from British military personnel who developed diarrhoea during deployment to Kenya between February-April 2022. Unpreserved fresh samples were tested onsite using PCR BioFire^® FilmArray^® and corresponding samples were stored at ambient temperature in OMNIgene^®200 (DNAgenotek^®), DNA/RNA shield DX^™ (Zymo Research) and Whatman FTA™ Elute cards (GE Healthcare) then repatriated to the UK for direct testing by PCR BioFire^® FilmArray^®, 6-18 months later. The most common enteropathogens evaluated were: Cryptosporidium spp., Enteroaggregative Escherichia coli (E. coli; EAEC), Enteropathogenic E. coli (EPEC), Shiga toxin-producing E. coli (STEC) and Campylobacter spp. Test results for the three storage modalities were compared to the fresh sample tests as a reference standard. Results. Samples from 60 individuals [80% male; median (interquartile range) age 24 (22–28) years] were analysed. Test sensitivity for Campylobacter spp. and EAEC was high across all three storage modalities (86.4–100%). OMNIgene^®200 and DNA/RNA shield^™ showed significant concordance with the reference standard test for other pathogens, but FTA^™ Elute card tests had low sensitivity for STEC and poor specificity for Campylobacter spp. Agreement between FTA^™ Elute cards and the reference standard test was low-moderate (kappa coefficient ≤0–0.49) for all enteropathogens. Conclusions. This study demonstrates successful PCR BioFire^® FilmArray^® utility in testing samples stored in different media and is the first to compare the use of OMNIgene^®200, DNA/RNA shield^™ and FTA^™ Elute cards simultaneously with the results of clinical samples. Stored samples were tested up to 18 months later with significant concordance observed in OMNIgene^®200 and DNA/RNA shield^™ compared to reference standard testing. The distorted performance of FTA^™ Elute card testing requires further optimisation. Testing of samples stored in these media is suitable for research studies, but their applicability with other molecular diagnostic platforms, or clinical diagnostics, requires confirmation.

Background Gastrointestinal illnesses are common during military training and operational deployments. We compared the incidence and burden of travellers’ diarrhoea (TD) reported by British service personnel (SP) during recent training exercises in Kenya and Oman. Methods SP completed a validated anonymous questionnaire regarding clinical features of any diarrhoeal illness, associated risk factors and impact on work capability after 6-week training exercises in 2018 in Kenya and 2018–2019 in Oman. Responses were tabulated for descriptive comparisons. Results Questionnaires were received from 388 (32%) SP in Kenya and 627 (52%) in Oman. The cumulative incidence of reported diarrhoea over 6-weeks was 14.2% (95% CI 8.02% to 22.61%) in Kenya compared with 3.9% (95% CI 1.10% to 9.91%) in Oman (OR 3.56, 95% CI 2.18 to 5.8; pConclusions The epidemiology, risk factors and burden of TD in Kenya were similar to previous descriptions, where overall incidence continues to decline. Incidence and burden were significantly lower in Oman, where both were much lower than historical descriptions. Peak timing of illness and associated risk factors differed between Kenya and Oman. Continued documentation and review of TD during training exercises at different geographical locations is essential to inform the chain of command about risks to operational effectiveness.