DIARRHEAL DISEASE

Enteric Infections in the Gulf War

The leading cause of morbidity among American forces deployed to the Persian Gulf region was diarrheal disease (Hyams et al. 1995a). From August 1990 to May 1991, about 50% of surveyed ground troops and personnel onboard the USNS Mercy experienced at least one episode of acute diarrhea (Haberberger et al. 1994; Hyams et al. 1991). Large outbreaks of watery diarrhea began in August 1990; outbreaks of more severe, bloody diarrhea began in the following month. In addition, gastroenteritis with vomiting as a primary symptom occurred both sporadically and epidemically throughout the war.

Ground Troops
Laboratory Analysis

Hyams and colleagues collected clinical and epidemiologic data from male US troops stationed in northeastern Saudi Arabia to determine the causes and prevalence of diarrheal disease among the troops, risk factors for diarrheal disease in the field, and the effectiveness of pharmacologic treatments (Hyams et al. 1991). From 432 soldiers who sought medical care and presented with gastroenteritis, stool samples were collected and examined for numerous enteropathogens, as described below and summarized in Table 4.1. The soldiers collectively represented all branches of the military, several regions of northeastern Saudi Arabia, and a variety of living conditions. Gastroenteritis was defined as diarrhea (three or more loose or watery stools within 24 hours), abdominal cramps, vomiting, or bloody stools.

The stool specimens were cultured for various pathogens: E. coli, Salmonella, Shigella, Aeromonas, Plesiomonas, Yersinia, Vibrio spp., and Campylobacter. Bacterial enteropathogens were identified with the methods described in Manual of Clinical Biology, 4th edition (Kelly et al. 1985). The specimens were also examined for parasites with direct microscopy and for group A rotavirus with a commercial monoclonal-antibody-based immunoassay. Stool specimens and serum from subsets of patients underwent other tests for adenovirus, astrovirus, calicivirus, coronavirus-like agents, group A rotavirus, and norovirus (also known as Norwalk virus). One or more bacterial enteropathogens were identified in 49.5% of the stool cultures, representing 214 patients. Enterotoxigenic E. coli (ETEC), Shigella sonnei, or both were found in cultures from 205 of those patients. The scientists also found nontyphoid Salmonella spp., enteroinvasive E. coli, and Campylobacter. Tests for viruses yielded positive results for norovirus and rotavirus. There was no evidence of parasitic infection.

TABLE 4.1 Summary of Test Results for Enteropathogens in Stool or Serum from 432 US Military Personnel with Gastroenteritis During Operation Desert Shield

 

Identified

Enteropathogen or Enterotoxin

Yes (No. patients)

No (No. patients)

Bacteria

 

 

Aeromonas

--

x

Campylobacter spp.

x (2)

x (430)

Enteroinvasive E. coli

x (3)

x (429)

Enterotoxigenic E. coli

x (128)

x (304)

Plesiomonas

--

x



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