Gastroenteritis in US Marines during Operation Iraqi Freedom

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
Clinical Infectious Diseases (Impact Factor: 8.89). 03/2005; 40(4):519-25. DOI: 10.1086/427501
Source: PubMed


Approximately 83,000 US Marines participated in the opening phase of Operation Iraqi Freedom in Spring 2003. A Navy Preventive Medicine laboratory was set up in Ad Diwaniyah, Iraq, to provide clinical diagnostic support for Marine medical units during a period of repositioning in south-central Iraq.
Specimen collection boxes were sent to >30 primary care medical stations handling 500-900 personnel each. The laboratory had capability to detect many different disease agents, especially those causing febrile illness. Diarrheal stool diagnostic evaluation included plating and biochemical identification, antigen serologic testing, fluorescent antibody antigen detection, disk diffusion antimicrobial susceptibility testing, enzyme immunoassay, and reverse-transcriptase polymerase chain reaction for norovirus (NV). Confirmation and sequencing work for NV was done at Cincinnati Children's Hospital Medical Center (Ohio).
By far the most common reason for infectious disease sick call visits was gastrointestinal illness; no other symptoms had equivalent impact. An enteropathogen was detected in 57 (44%) of 129 stool samples, with NV detected in 30 stool samples (23%) obtained from 14 different battalion or similar-sized units; next in frequency were Shigella flexneri and Shigella sonnei, which were isolated from 26 stool samples (20%) obtained from 15 units. Sequencing the NV RNA polymerase gene demonstrated that NV strains represented 7 genetic clusters, including 2 strains from genogroup I and 5 from genogroup II. Ciprofloxacin was effective in vitro against most bacterial agents, but neither doxycyline (which was taken daily as the antimalarial prophylaxis dose) nor trimethoprim-sulfamethoxazole were effective.
Multiple strains of Shigella species and NV predominated, probably because they do not require a large inoculum to cause infection. Otherwise, personnel remained free of infectious illness during this phase of the conflict, because other infectious agents were rare or absent.

6 Reads
  • Source
    • "Although generally considered mild and of short duration in healthy young adults (e.g. soldiers), A. Lopes-João et al. / Journal of Clinical Virology 68 (2015) 73–75 Norovirus gastroenteritis can diminish operational effectiveness and impede force readiness, as demonstrated by an array of military units in Iraq [8] [10] [11]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Gastroenteritis is one of the most common infectious diseases in the military populations and can diminish operational effectiveness and impede force readiness. The present study investigates the cause and the source of an acute gastroenteritis outbreak that occurred during a military exercise of the Portuguese Army, in February 2013. A retrospective investigation was performed and stool samples, food items and water were screened for common foodborne bacteria and viruses, namely Norovirus GI, Norovirus GII, Astrovirus, Rotavirus, Adenovirus and Sapovirus. From the total of 160 soldiers that participated in the military exercise 20 developed gastroenteritis (attack rate of 12.5%). Symptoms were predominantly vomiting (n=17, 85%) and diarrhoea (n=9, 45%). The first cases occurred 24-48h after drinking water from the creek, the plausible origin of the outbreak. The epidemic peak was registered 2 days after and the last cases 6 days after, upon returning to base. No pathogenic bacteria were found in stools however virological analysis revealed the presence of multiple enteropathogenic viruses, namely Norovirus GI (GI.3), Norovirus GII (GII.4 New Orleans 2009), Astrovirus and Sapovirus, as single or co-infections. Food and water samples were not tested for the presence of viruses due to exhaustion of samples on bacteriological analysis. To the best of our knowledge this is the first report of a viral gastroenteritis outbreak among military personnel in the Portuguese Army. Copyright © 2015 Elsevier B.V. All rights reserved.
    Journal of Clinical Virology 05/2015; 68. DOI:10.1016/j.jcv.2015.05.008 · 3.02 Impact Factor
  • Source
    • "In fact, NoV strains have been a major cause of sporadic cases and outbreaks of gastroenteritis among ground troops in the 1991 Gulf War, as well as recent and ongoing operations in Iraq, Afghanistan and the Horn of Africa [4]. For example, NoV was found in the greatest number of stool samples (23%) collected in a study on gastroenteritis in US Marine Corps units during Operation Iraqi Freedom [5]. In addition to these combat operation settings, NoV outbreaks have been found to frequently occur during shipboard deployments. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Norovirus (NoV) has been identified as a significant cause of acute gastrointestinal illness among deployed military troops. We conducted a cost-effectiveness analysis for the use of a NoV vaccine in the military using a previously developed model that evaluated vaccines for ETEC, Campylobacter, and Shigella for prevention of non-outbreak associated travelers' diarrhea. Under conservative assumptions, acquisition of a NoV vaccine by the Department of Defense is estimated to result in a cost-effectiveness ratio per duty day lost to illness (CERDDL) of $1344 compared to a CERDDL of $776, $800, and $1275 for ETEC, Campylobacter sp., and Shigella sp., respectively compared to current management strategies. The absolute value of avoiding a duty day lost is likely to vary under different scenarios, and further study is needed to evaluate how improved diagnostics and prevention of outbreaks may impact the relative value of this vaccine. Overall, this study demonstrates the utility of a previously established evidence-based decision tool for prioritization of vaccine acquisition in an important target population.
    Vaccine 07/2014; 32(40). DOI:10.1016/j.vaccine.2014.07.070 · 3.62 Impact Factor
  • Source
    • "Norovirus is recognized as a major cause of gastroenteritis outbreaks in military populations [6], and other semi-closed or closed institutions such as hospitals, elder care homes, cruise ships, and nurseries [7]. Norovirus strains were a major cause of outbreaks and sporadic cases of gastroenteritis among US ground troops during the Persian Gulf War in 1991, where NoV infection was in one report the most common cause of disability [6] as well as coalition forces in Gulf War II and the Afghanistan campaign beginning in 2002 [8], [9], [10], [11]. As many as 73% of enteric viral gastroenteritis cases among British troops deployed from 2002–2007 were associated with NoV [9]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The present study demonstrates that multiple NoV genotypes belonging to genogroup II contributed to an acute gastroenteritis outbreak at a US military facility in Turkey that was associated with significant negative operational impact. Norovirus (NoV) is an important pathogen associated with acute gastroenteritis among military populations. We describe the genotypes of NoV outbreak occurred at a United States military facility in Turkey. Stool samples were collected from 37 out of 97 patients presenting to the clinic on base with acute gastroenteritis and evaluated for bacterial and viral pathogens. NoV genogroup II (GII) was identified by RT-PCR in 43% (16/37) stool samples. Phylogenetic analysis of a 260 base pair fragment of the NoV capsid gene from ten stool samples indicated the circulation of multiple and rare genotypes of GII NoV during the outbreak. We detected four GII.8 isolates, three GII.15, two GII.9 and a sole GII.10 NoV. Viral sequences could be grouped into four clusters, three of which have not been previously reported in Turkey. The fact that current NoV outbreak was caused by rare genotypes highlights the importance of norovirus strain typing. While NoV genogroup II is recognized as causative agent of outbreak, circulation of current genotypes has been rarely observed in large number of outbreaks.
    PLoS ONE 05/2012; 7(5):e35791. DOI:10.1371/journal.pone.0035791 · 3.23 Impact Factor
Show more