The pragmatic management of rabies risk in Operation DAMAN 50 (Lebanon, October 2024-February 2025): A case study for evidence-based military medicine in the field

The French Armed Forces are regularly deployed in areas of endemic rabies, a virus responsible for 59,000 deaths worldwide every year. During Operation DAMAN 50 at the end of year 2024, a rapid conflict intensification in southern Lebanon significantly increased rabies exposure of French servicemen and decreased access to laboratory analyses. Exposures of military personnel to scratches from cats of unknown rabies status multiplied, putting extreme strain on post-exposure prophylaxis (PEP) stocks. To minimize the risk of a PEP shortage and its consequences, medical personnel deployed in Operation DAMAN 50 adopted a pragmatic strategy that adapted existing recommendations to the situation. At the individual level, the watch-and-see PEP occurred only if veterinarian cat observation was possible. It relied on pathophysiological, epidemiological, environmental and operational data and despite the lack of reliable laboratory at that time. On the wider scale, the strategy involved controlling the feline population. Based on clinical field skills and global appreciation of original situations of military practitioners, it maintained operational capacity while reserving limited vaccine supplies to patients with greatest need.