The military as a neglected pathogen transmitter, from the 19th century to COVID-19: A systematic review

Abstract

Background: The risk of outbreaks escalating into pandemics has soared with globalization. Therefore, understanding transmission mechanisms of infectious diseases has become critical to formulating global public health policy. This systematic review assessed the evidence for the military as a disease vector, an historically relevant one, yet overlooked in times of COVID-19. Methods: We searched 3 electronic databases without temporal restrictions. We identified 2010 of 6477 studies spanning over two centuries (1810 – 2020) that met our inclusion criteria and provided evidence for the military as a pathogen transmitter, within itself or between it and civilians. Two researchers independently extracted study data using a standardized form. Through team discussions, studies were grouped according to their type of transmission mechanism and direct quotes were extracted to generate themes and sub–themes. A content analysis was later performed and frequency distributions for each theme were generated. Results: Biological mechanisms driving transmission included person–to–person transmission, contaminated food and water, vector–borne, and airborne routes. Social mechanisms facilitating transmission included crowded living spaces, unhygienic conditions, strenuous working, training conditions, absent or inadequate vaccination programs, pressure from military leadership, poor compliance with public health advice, contractor mismanagement, high–risk behaviours, and occupation–specific freedom of movement. Contaminated food and/or water was the most common biological transmission route. Living conditions were the most common social transmission mechanism, with young, low ranking military personnel repeatedly reported as the most affected group. Certain social mechanisms, such as employment–related freedom of movement, were unique to the military as a social institution. While few studies explicitly studied civilian populations, considerably more contained information that implied that civilians were likely impacted by outbreaks described in the military. Conclusions: Features of the military identified in this study pose a significant public health threat, especially to countries with substantial military presence or underdeveloped health systems. Many social transmission mechanisms, unlike biological ones, were unique to the military, facilitating large–spreader events and affecting civilian health. As an increasingly interconnected world faces the challenges of COVID–19 and future infectious diseases, the identified features of the military may exacerbate current and similar challenges and impair attempts to implement successful and equitable pandemic policies.