- Email: [email protected]
Diarrhoeal disease—a military perspective
TRANSACTIONSOF
THE ROYAL SOCETYOFTROPICAL
Diarrhoeal Diarrhoeal M. E. Kilpatrick*
disease: disease-a
MEDICINEAND
current military
HYGIENE
(1993)
concepts
s3147
87, SUPPLEMENT 3,47-48
and future
challenges
perspective
United States Naval Medical Research Unit No. 3, Cairo, Egypt
Abstract Diarrhoeal disease has always been a major medical problem during military operations. Lost personnel time has been significant, with over 50% of deployed forces being affected and unable to do their jobs for several days. During ‘Operation Desert Shield’ in Saudi Arabia in 1990, the US military took extensive precautions to prevent diarrhoeal disease. Surveys from 1% of the 200 000 US military personnel in Saudi Arabia indicated that 97% experienced diarrhoea, 22% sought medical care, and 19% were not able to perform their duties while affected. Medical evaluation of 452 individuals with diarrhoea determined a bacterial aetiology in 50% and a clear relationship with consumption of local fruits and raw vegetables. Prophylactic antibiotic administration was not a reasonable proposal and treatment was effective only when susceptibility patterns of local enteric agents were considered. Research efforts must continue for diagnostic tests to indicate which individuals with diarrhoeal disease would benefit from early antibiotic therapy and for development of vaccines effective against the common agents of diarrhoeal disease. Napoleon recognized that a military force travels on its stomach because of dependence on its supply line for food as well as material. Whenever a military force moves, there is a requirement for execution of detailed plans which provide flexibility for the various scenarios which could be expected to be encountered. The medical planning aspects for military operational activity must primarily focus on the expected military battle casualties in order to provide facilities for evacuation from the battle area to optimal early surgical support. The helicopter allows rapid movement of wounded or injured personnel to comprehensive medical facilities; civilian application of this capability is now standard for trauma centres. The other focus of military medical planning is on non-battle casualties. While less glamorous, this provides benefit for many more military personnel. Infectious diseases have accounted for the largest category of hospital admissions of US military personnel in World War II and the Korean and the Viet Nam conflicts (COATES et aZ., 1958; OGNIBENE & BARRETT, 1982). They are certainly the primary cause of military personnel reporting sick during any operational activity. Diarrhoeal disease has consistently been the most common medical problem, affecting up to 90% of military personnel during an operational deployment and making it the major medical threat. While death or medical evacuation are no longer expected results of diarrhoeal disease, the morbidity it produces can be significant, as shown by an attack rate of 55% in the US Army in Korea (OGNIBENE & BARRETT, 1982), the loss to active service of 50% of US Marines for 3 d in Lebanon (DANIELL et al., 1985), and the incapacitation of 20% of an aircraft carrier crew for 3 d after a port visit in the Mediterranean (BOURGEOIS et al., 1990). The US military’s experience during ‘Operation Desert Shield’ in Saudi Arabia during 1990 demonstrates the military perspective of diarrhoeal disease. There was no lack of knowledge or medical information on diarrhoeal disease for that area of the world. The attack rate among US military personnel during previous exercises in the Arabian Gulf area and in adjoining regions ranged from 20% to 60% (HUREWITZ, 1960; ROWE et al:, 1970; TAYLOR et al., 1991). Armed with this information, the US military developed an operational medicine-infectious disease contingency team which provided preventive medicine support, research and development expertise and medical intelligence capabilities to the usual medical planning and patient care provision components. A task force ‘chain of command’ was established to assure medical co-ordination with the operational activities The preventive medicine component established a safe water supply system with reverse osmosis water purifica‘Present address: Naval Hospital, Orlando, USA.
tion units capable of producing 1.4~ 106L [300 000 gallons] of potable water a day and certification of local distributors of bottled water or chlorinated municipal water systems (HYAMS et al., 1991). Latrines were erected or slit trenches were provided and Lister bags were used for drinking water and hand washing. However, the living conditions in field camps and barracks provided many opportunities for the lowering of personal and environmental hygiene standards. The Navy research and development component established a forward laboratory in the abandoned Al Huwaylat hospital in Jubai!, Saudi Arabia, and provided capabilities for bacteriological culturing, antibiotic susceptibility testing, enzyme immunoassays, fluorescent microscopy, deoxyribonucleic acid probe and polymerase chain reaction diagnostics. Emphasis was focused on diarrhoeal disease, hepatitis, febrile and upper respiratory diseases, and detection and identification of biological warfare agents. The staff of the Navy forward laboratory were frequently reminded that this was the ‘real thing’ by the recurring gas mask drills. ‘Desert Shield’, by definition, did not have battle casualties but it was not free of disease and non-battle injuries (DNBI). The DNBI rates per 100 US Navy and Marine Corps personnel in the Jubail area during 3 early weeks of deployment are shown in the Table (USNAVTable. Illness among US Naval and Marine Corps early weeks of ‘Operation Desert Shield’ in Saudi l-8 Diagnosis Heat injury Diarrhoea Dermatological Respiratory IlljUly Ophthalmological Unexplained Psychiatric Y’ercentages illness.
fever of deployed
units during the Arabia, 1990”
Weekly morbidity reports September 9-15 September 23-29 September (n=2787) (n=5500) (n=3000) 0.2 5.9 2.7 4.4 I.0 0.3 -co. 1 0.1
0.2 0.8 1.8 0.9 1.3 0.1
from
reporting
0.0 9.1 1.3 0.6 1.0 0.2 0.1
experiencing
CENTCOM SURGEON, 1991). Diarrhoeal disease was consistently at or near the top of the list. The Navy forward laboratory played a critical role in determining the aetiologic agents of diarrhoea in 50% of 432 affected personnel (HYAMS et al., 1991), even though 20% had received antibiotic therapy (generally trimethoprim-sulfamethoxazole) before having faecal cultures made. The antibiotic resistance patterns of the enteric agents were similar to those previously reported in the region (BOURGEOIS et al., 1990; TAYLOR et al., 1991). In order to assess the impact of diarrhoeal disease on more than 200 000 US mili-
S3148 tary personnel deployed during the early stages of ‘Desert Shield’, a questionnaire was used to evaluate 2022 individuals (HYAMS et al., 1991). About 57% reported having diarrhoea during amean’deployment of 55 d (range &120 dl. Twentv-six nercent had had one enisode of diarrhoea, 15% 2 episodes, 7% 3 episodes and l-O% had 4 or more episodes. Medical care was sought by 22%, and 19% reported that they were not able to perform their military task while affected. Intravenous fluid replacement was required for some severe cases. It was recognized that the local fruits and raw vegetables were sources of enteric agents; enterotoxigenic Escherichia coli was isolated from lettuce. Appropriate washing or disinfecting would have required swimming pools filled with chlorinated water, not an option in that environment. When these items were eliminated from the diet, there was a dramatic drop in diarrhoea rates but flies and poor hygiene conditions were believed to contribute to sporadic episodes of shigellosis. Two lessons previously learned by military medical planners were obviously not heeded by operational planners and were relearned. When the food sunnlv line included local fruits and vegetables to boost morale, there was not the capability to clean them adequately and they became vectors of diarrhoeal disease. The second lesson was that the selection of antibiotics for use in the area was not based on available medical information concerning diarrhoeal disease agents and appropriate medications had then to be obtained. Diarrhoeal disease from the military perspective is essentially travellers’ diarrhea. While the usual preventive measures such as washing hands before eating, consuming hot foods only, avoiding ice, and eating only fruits which can be peeled, are effective for civilian travellers, deployed military personnel cannot always exercise those ontions. Enterotoxigenic E. coli is the most common bacterial agent causing travellers’ diarrhoea and 80% of travellers’ diarrhoea is believed to be of bacterial aetiology (DUPONT et al., 1986). The general lack of fever and the mild symptomatology in military personnel with diarrhoeal disease during ‘Desert Shield’ reinforce enterotoxigenic E. coli as the predominant organism. Treatment of diarrhoeal disease or consideration of antimicrobial chemoprophylaxis assume added degrees of difficultv for medical nlanners. Education of nersonnel to assure adequate hydiation is always imporiant, even when water is in short supply. Including antibiotics with a spectrum adequate for the usual enteric agents in a geographical location is important for the medical pharmacies-sources from which to obtain appropriate agents are not always immediately available. Understanding that at least 80% of cases are self-limiting is important for the deployed individual as well as for the medical care provider. Bronhvlaxis would have nosed major logistical nightmare;. It would have been impossible to deliver a prophylactic agent for daily consumption to the deployed military personnel and assume that it would be taken. While short-term prophylaxis has been shown to be protective (BOURGEOIS et al., 1990), the cost of protecting 200 000 people made it prohibitive. Uncertainty about the duration of ‘Operation Desert Shield’ obviated shortterm prophylaxis and there were no data on long-term
prophylaxis. The theoretical concerns were side effects of the drug on individuals in a military deployed situation and the risk of super-infection with agents resistant to the prophylactic antibiotic and subsequent clinical illness. Current US military research and development efforts are directed toward develonina ranid, field-annlicable diagnostic tests which would mdicate which individuals with diarrhoeal disease would benefit from early antibiotic therapy. The current indications for immediate treatment are fever, bloody diarrhoea, or severe dehydration. Other research efforts are directed towards development of vaccines which will provide significant protection against the common agents of travellers’ diarrhoea. The military requirements for such vaccines would ideally be oral administration with ability to enhance immunological protection with a booster dose while the personnel are being rapidly deployed to an operational theatre. In the final analysis, diarrhoeal disease does not produce a different disease complex in military personnel compared to civilians. The manner in which the military must manage its large contingent of healthy travellers, who do not always have adequate hygienic conditions, creates a unique perspective in dealing with prevention, management and treatment of diarrhoeal disease. References
Bourgeois, A. L., Scott, D. A., Haberberger, R. L., Thornton, S. A. & Hyams, K. C. (1990). Norfloxacin for the prophylaxis of travelers’ diarrhea in U.S. military personnel. American Journal of Tropical Medicine and Hygiene, 42, 160164. Coates,, J. B., Hoff, E. & Hoff, I’. M., editors (1958). Preventive Medicine in World War II. Vol. IV, Diarrhea and Dysentey. Washington, DC: Office of the Surgeon General and Center for Military History, pp. 319-413. Daniell, F. D., Walz, S. E., Crafton, L. D. & Bolton, H. J. (1985). Field preventive medicine and epidemiological surveillance: the Beirut, Lebanon experience, 1982. Militay Medicine, 150, 1756. DuPont, H. L., Ericsson, C. D., Johnson, I’. C. & Cabada, F. J. (1986). Antimicrobial agents in the prevention of travelers’ diarrhea. Review of Infectious Diseases, 8, supplement, S167s171. Hurewitz, S. (1960). Military medical problems for the Lebanon crisis. Military Medicine, 125, 26-35. Hyams, K. C., Bourgeois, A. L., Merrell, B. R., Rozmajzl, I’., Escamilla, J., Thornton, S. A., Wasserman, G. M., Burke, A., Echeverria, P., Green, K. Y., Kapikian, A. Z. &Woody, J. N. (1991). Diarrhea1 disease during Operation Desert Shield. New EnglandJournal ofMedicine, 325,1423-1425. Ognibene, A. J. & Barrett, O., editors (1982). InternalMedicine in Vietnam. Vol. 2, General Medicine and Infectious Diseases. Washington, DC: Office of the Surgeon General and Center for Military History, pp. 345-354. Rowe, B., Taylor, J. & Bettelheim, K. (1970). An investigation of travellers’ diarrhoea. Lancet, i, l-5. Taylor, D. N., Sanchez, J. L., Candler, W., Thornton, S., McQueen, C. & Echeverria, I’. (1991). Treatment of travelers’ diarrhea: ciprofloxacin plus loperamide compared with ciprofloxacin alone: a placebo-controlled, randomized trial. Annals oflnternal Medicine, 114,731-734. USNAVCENTCOM Surgeon 11991). Weeklv Command Health Reports, August 199cMay‘ 1991. Norfolk, Virginia, USA: Navy Environmental Health Command, mimeographed report.
THE ROYAL SOCETYOFTROPICAL
Diarrhoeal Diarrhoeal M. E. Kilpatrick*
disease: disease-a
MEDICINEAND
current military
HYGIENE
(1993)
concepts
s3147
87, SUPPLEMENT 3,47-48
and future
challenges
perspective
United States Naval Medical Research Unit No. 3, Cairo, Egypt
Abstract Diarrhoeal disease has always been a major medical problem during military operations. Lost personnel time has been significant, with over 50% of deployed forces being affected and unable to do their jobs for several days. During ‘Operation Desert Shield’ in Saudi Arabia in 1990, the US military took extensive precautions to prevent diarrhoeal disease. Surveys from 1% of the 200 000 US military personnel in Saudi Arabia indicated that 97% experienced diarrhoea, 22% sought medical care, and 19% were not able to perform their duties while affected. Medical evaluation of 452 individuals with diarrhoea determined a bacterial aetiology in 50% and a clear relationship with consumption of local fruits and raw vegetables. Prophylactic antibiotic administration was not a reasonable proposal and treatment was effective only when susceptibility patterns of local enteric agents were considered. Research efforts must continue for diagnostic tests to indicate which individuals with diarrhoeal disease would benefit from early antibiotic therapy and for development of vaccines effective against the common agents of diarrhoeal disease. Napoleon recognized that a military force travels on its stomach because of dependence on its supply line for food as well as material. Whenever a military force moves, there is a requirement for execution of detailed plans which provide flexibility for the various scenarios which could be expected to be encountered. The medical planning aspects for military operational activity must primarily focus on the expected military battle casualties in order to provide facilities for evacuation from the battle area to optimal early surgical support. The helicopter allows rapid movement of wounded or injured personnel to comprehensive medical facilities; civilian application of this capability is now standard for trauma centres. The other focus of military medical planning is on non-battle casualties. While less glamorous, this provides benefit for many more military personnel. Infectious diseases have accounted for the largest category of hospital admissions of US military personnel in World War II and the Korean and the Viet Nam conflicts (COATES et aZ., 1958; OGNIBENE & BARRETT, 1982). They are certainly the primary cause of military personnel reporting sick during any operational activity. Diarrhoeal disease has consistently been the most common medical problem, affecting up to 90% of military personnel during an operational deployment and making it the major medical threat. While death or medical evacuation are no longer expected results of diarrhoeal disease, the morbidity it produces can be significant, as shown by an attack rate of 55% in the US Army in Korea (OGNIBENE & BARRETT, 1982), the loss to active service of 50% of US Marines for 3 d in Lebanon (DANIELL et al., 1985), and the incapacitation of 20% of an aircraft carrier crew for 3 d after a port visit in the Mediterranean (BOURGEOIS et al., 1990). The US military’s experience during ‘Operation Desert Shield’ in Saudi Arabia during 1990 demonstrates the military perspective of diarrhoeal disease. There was no lack of knowledge or medical information on diarrhoeal disease for that area of the world. The attack rate among US military personnel during previous exercises in the Arabian Gulf area and in adjoining regions ranged from 20% to 60% (HUREWITZ, 1960; ROWE et al:, 1970; TAYLOR et al., 1991). Armed with this information, the US military developed an operational medicine-infectious disease contingency team which provided preventive medicine support, research and development expertise and medical intelligence capabilities to the usual medical planning and patient care provision components. A task force ‘chain of command’ was established to assure medical co-ordination with the operational activities The preventive medicine component established a safe water supply system with reverse osmosis water purifica‘Present address: Naval Hospital, Orlando, USA.
tion units capable of producing 1.4~ 106L [300 000 gallons] of potable water a day and certification of local distributors of bottled water or chlorinated municipal water systems (HYAMS et al., 1991). Latrines were erected or slit trenches were provided and Lister bags were used for drinking water and hand washing. However, the living conditions in field camps and barracks provided many opportunities for the lowering of personal and environmental hygiene standards. The Navy research and development component established a forward laboratory in the abandoned Al Huwaylat hospital in Jubai!, Saudi Arabia, and provided capabilities for bacteriological culturing, antibiotic susceptibility testing, enzyme immunoassays, fluorescent microscopy, deoxyribonucleic acid probe and polymerase chain reaction diagnostics. Emphasis was focused on diarrhoeal disease, hepatitis, febrile and upper respiratory diseases, and detection and identification of biological warfare agents. The staff of the Navy forward laboratory were frequently reminded that this was the ‘real thing’ by the recurring gas mask drills. ‘Desert Shield’, by definition, did not have battle casualties but it was not free of disease and non-battle injuries (DNBI). The DNBI rates per 100 US Navy and Marine Corps personnel in the Jubail area during 3 early weeks of deployment are shown in the Table (USNAVTable. Illness among US Naval and Marine Corps early weeks of ‘Operation Desert Shield’ in Saudi l-8 Diagnosis Heat injury Diarrhoea Dermatological Respiratory IlljUly Ophthalmological Unexplained Psychiatric Y’ercentages illness.
fever of deployed
units during the Arabia, 1990”
Weekly morbidity reports September 9-15 September 23-29 September (n=2787) (n=5500) (n=3000) 0.2 5.9 2.7 4.4 I.0 0.3 -co. 1 0.1
0.2 0.8 1.8 0.9 1.3 0.1
from
reporting
0.0 9.1 1.3 0.6 1.0 0.2 0.1
experiencing
CENTCOM SURGEON, 1991). Diarrhoeal disease was consistently at or near the top of the list. The Navy forward laboratory played a critical role in determining the aetiologic agents of diarrhoea in 50% of 432 affected personnel (HYAMS et al., 1991), even though 20% had received antibiotic therapy (generally trimethoprim-sulfamethoxazole) before having faecal cultures made. The antibiotic resistance patterns of the enteric agents were similar to those previously reported in the region (BOURGEOIS et al., 1990; TAYLOR et al., 1991). In order to assess the impact of diarrhoeal disease on more than 200 000 US mili-
S3148 tary personnel deployed during the early stages of ‘Desert Shield’, a questionnaire was used to evaluate 2022 individuals (HYAMS et al., 1991). About 57% reported having diarrhoea during amean’deployment of 55 d (range &120 dl. Twentv-six nercent had had one enisode of diarrhoea, 15% 2 episodes, 7% 3 episodes and l-O% had 4 or more episodes. Medical care was sought by 22%, and 19% reported that they were not able to perform their military task while affected. Intravenous fluid replacement was required for some severe cases. It was recognized that the local fruits and raw vegetables were sources of enteric agents; enterotoxigenic Escherichia coli was isolated from lettuce. Appropriate washing or disinfecting would have required swimming pools filled with chlorinated water, not an option in that environment. When these items were eliminated from the diet, there was a dramatic drop in diarrhoea rates but flies and poor hygiene conditions were believed to contribute to sporadic episodes of shigellosis. Two lessons previously learned by military medical planners were obviously not heeded by operational planners and were relearned. When the food sunnlv line included local fruits and vegetables to boost morale, there was not the capability to clean them adequately and they became vectors of diarrhoeal disease. The second lesson was that the selection of antibiotics for use in the area was not based on available medical information concerning diarrhoeal disease agents and appropriate medications had then to be obtained. Diarrhoeal disease from the military perspective is essentially travellers’ diarrhea. While the usual preventive measures such as washing hands before eating, consuming hot foods only, avoiding ice, and eating only fruits which can be peeled, are effective for civilian travellers, deployed military personnel cannot always exercise those ontions. Enterotoxigenic E. coli is the most common bacterial agent causing travellers’ diarrhoea and 80% of travellers’ diarrhoea is believed to be of bacterial aetiology (DUPONT et al., 1986). The general lack of fever and the mild symptomatology in military personnel with diarrhoeal disease during ‘Desert Shield’ reinforce enterotoxigenic E. coli as the predominant organism. Treatment of diarrhoeal disease or consideration of antimicrobial chemoprophylaxis assume added degrees of difficultv for medical nlanners. Education of nersonnel to assure adequate hydiation is always imporiant, even when water is in short supply. Including antibiotics with a spectrum adequate for the usual enteric agents in a geographical location is important for the medical pharmacies-sources from which to obtain appropriate agents are not always immediately available. Understanding that at least 80% of cases are self-limiting is important for the deployed individual as well as for the medical care provider. Bronhvlaxis would have nosed major logistical nightmare;. It would have been impossible to deliver a prophylactic agent for daily consumption to the deployed military personnel and assume that it would be taken. While short-term prophylaxis has been shown to be protective (BOURGEOIS et al., 1990), the cost of protecting 200 000 people made it prohibitive. Uncertainty about the duration of ‘Operation Desert Shield’ obviated shortterm prophylaxis and there were no data on long-term
prophylaxis. The theoretical concerns were side effects of the drug on individuals in a military deployed situation and the risk of super-infection with agents resistant to the prophylactic antibiotic and subsequent clinical illness. Current US military research and development efforts are directed toward develonina ranid, field-annlicable diagnostic tests which would mdicate which individuals with diarrhoeal disease would benefit from early antibiotic therapy. The current indications for immediate treatment are fever, bloody diarrhoea, or severe dehydration. Other research efforts are directed towards development of vaccines which will provide significant protection against the common agents of travellers’ diarrhoea. The military requirements for such vaccines would ideally be oral administration with ability to enhance immunological protection with a booster dose while the personnel are being rapidly deployed to an operational theatre. In the final analysis, diarrhoeal disease does not produce a different disease complex in military personnel compared to civilians. The manner in which the military must manage its large contingent of healthy travellers, who do not always have adequate hygienic conditions, creates a unique perspective in dealing with prevention, management and treatment of diarrhoeal disease. References
Bourgeois, A. L., Scott, D. A., Haberberger, R. L., Thornton, S. A. & Hyams, K. C. (1990). Norfloxacin for the prophylaxis of travelers’ diarrhea in U.S. military personnel. American Journal of Tropical Medicine and Hygiene, 42, 160164. Coates,, J. B., Hoff, E. & Hoff, I’. M., editors (1958). Preventive Medicine in World War II. Vol. IV, Diarrhea and Dysentey. Washington, DC: Office of the Surgeon General and Center for Military History, pp. 319-413. Daniell, F. D., Walz, S. E., Crafton, L. D. & Bolton, H. J. (1985). Field preventive medicine and epidemiological surveillance: the Beirut, Lebanon experience, 1982. Militay Medicine, 150, 1756. DuPont, H. L., Ericsson, C. D., Johnson, I’. C. & Cabada, F. J. (1986). Antimicrobial agents in the prevention of travelers’ diarrhea. Review of Infectious Diseases, 8, supplement, S167s171. Hurewitz, S. (1960). Military medical problems for the Lebanon crisis. Military Medicine, 125, 26-35. Hyams, K. C., Bourgeois, A. L., Merrell, B. R., Rozmajzl, I’., Escamilla, J., Thornton, S. A., Wasserman, G. M., Burke, A., Echeverria, P., Green, K. Y., Kapikian, A. Z. &Woody, J. N. (1991). Diarrhea1 disease during Operation Desert Shield. New EnglandJournal ofMedicine, 325,1423-1425. Ognibene, A. J. & Barrett, O., editors (1982). InternalMedicine in Vietnam. Vol. 2, General Medicine and Infectious Diseases. Washington, DC: Office of the Surgeon General and Center for Military History, pp. 345-354. Rowe, B., Taylor, J. & Bettelheim, K. (1970). An investigation of travellers’ diarrhoea. Lancet, i, l-5. Taylor, D. N., Sanchez, J. L., Candler, W., Thornton, S., McQueen, C. & Echeverria, I’. (1991). Treatment of travelers’ diarrhea: ciprofloxacin plus loperamide compared with ciprofloxacin alone: a placebo-controlled, randomized trial. Annals oflnternal Medicine, 114,731-734. USNAVCENTCOM Surgeon 11991). Weeklv Command Health Reports, August 199cMay‘ 1991. Norfolk, Virginia, USA: Navy Environmental Health Command, mimeographed report.