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Table 2 Frequencies of Social Mechanisms of Transmission among included articles

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

Category Theme Description No. (%)
Policies Occupation-specific freedom of movement Ability to leave base premises and/or country of military training despite outbreak or symptoms of disease
Bypassing host country laws (e.g., criminal/civil charge immunity, lack of airport screenings) due to a Status of Forces Agreement (SOFA), i.e., agreement between host nation and foreign nation outlining rights and privileges of foreign military personnel stationed in host nation
26 (14)
Vaccination programs Exclusion of specific ranks from obtaining vaccinations
Limited supply of pharmaceuticals or vaccines
Discontinuation of vaccines
Lack of vaccination program
Substandard expectations of immunization for incoming recruits
18 (10)
Institutional Living conditions High population density within military bases, crowded barracks, crowded shared living spaces (e.g., dining halls, lavatories)
Rats, bats, or other vector carriers sharing living quarters
Poor hygiene/sanitation conditions
Semi-open living environments allowing greater than usual freedom of movement
Living conditions that promote presence of microorganisms
76 (42)
Training conditions1 High-intensity military exercise contributing to increased mental and physical stress
Military exercise increasing exposure to contaminated areas
Training schedules (e.g., long hours, nocturnal activities)
Environmental conditions limiting access to resources (e.g., clean water, healthcare) or which adversely impact health (e.g., low air quality)
43 (24)
Working conditions2 Serving in endemic, rural, remote, or unmaintained areas
Serving in environmental conditions which limit access to resources (e.g., clean water, healthcare) or which adversely impact health (e.g., low air quality)
Combat duty exposing personnel to greater risk (e.g., terrain, contact with combatants)
Requirement of frequent movement
42 (23)
Poor public health management and services Lack of regular testing for HIV/STIs
Lack of implementation of sufficient preventative measures in at-risk environments
Lack of implementation of sufficient post-outbreak measures (i.e., isolation of personnel with symptoms)
Insufficient or lack of health education
Insufficient or lack of communication of risk by military officers to subordinates
Absence of protective equipment or resources
Medical resources which are not adequate for fulfilling the needs of personnel
Lack of monitoring of compliance status with public health advice
36 (20)
Poor infrastructure Structural building problems, mould within living space(s), inadequate ventilation system(s) in buildings, poor facilities (e.g., lack of sufficient lavatories for the number of personnel in building, lack or insufficient access to clean drinking water) 28 (16)
Food contamination3 Inadequate or irresponsible hygiene practices leading to food/water contamination
Inadequate medical attention for ill staff
Infrastructure issues which lead to food contamination
Delivery of contaminated food
19 (11)
Contractor mismanagement3 Action(s) by outsourced company/individual that may adversely impact military personnel’s health 7 (4)
Pressure from military leadership Fear of disciplinary action for missing training or work to seek medical care
Implicit expectation to continue duties despite feeling ill
Explicit intimidation from superiors
4 (2)
Individual Ignoring public health advice Non-compliance or poor adherence with protective health measures
Delay or failure to seek medical care out of negligence or unspecified reasons
42 (23)
High risk behaviour Substance abuse
Unprotected sexual relations, sexual relations with commercial sex workers, visits to brothels or bawdy houses
21 (12)
  1. Articles with quotes corresponding to more than one mechanism were counted for multiple mechanisms
  2. 1Training conditions only applies to military personnel who were participating in military training or exercises at time of outbreak
  3. 2Working conditions only applies to military personnel who were not participating in military training or exercises at time of outbreak
  4. 3If an article described the occurrence of food contamination resulting from outsourced food services, the article will be listed under both “Food contamination” and “Contractor mismanagement