1. 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

2. DISCLOSURES The presenter has no financial relationships to disclose.
This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS.
Neither PESG,AMSUS, nor any accrediting organization support or endorse any product or service mentioned in this activity.
PESG and AMSUS staff has no financial interest to disclose.
Commercial support was not received for this activity.

3. 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.

4. Learning Objectives
Principles of Force Health Protection (FHP) and JTTP
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

5. 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 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

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. So why count, why hear, why listen??

15. 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
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!!!

16. JTTP
JTTP 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

17. FHP Risk matrix Assessment of health risk to personnel

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

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

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

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

22. Health Risk Management Risk to the Operation

23. Health Risk Management Risk to Individuals

24. Health Risk Management Control Measures e.g. malaria

25. 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)

26. 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

27. 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)

28. 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
Audits carried out to date:
Afghanistan 2009
Afghanistan 2010
Afghanistan 2012
Sierra Leone 2015
South Sudan 2017
Lt Col Susanna Roughton RAMC - SHA(A)

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

30. 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)

31. 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)

32. 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)

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

34. Health Risk Management Force Health Protection audit – South Sudan

35. 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

36. South Sudan UK UNMISS DNBI

37. 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)

38. 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 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 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)

39. RECOMMENDATION FORMATP I D O L
TRAINING
EQUIPMENT
PERSONNEL
INFORMATION
(governance?)
DOCUMENTATION
or DOCTRINE
ORGANISATION
LOGISTICS

40. 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

41. 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

42. Continuing Professional Development
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