Gastroenteritis in US Marines during Operation Iraqi Freedom

Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
Clinical Infectious Diseases (Impact Factor: 9.42). 03/2005; 40(4):519-25. DOI: 10.1086/427501
Source: PubMed

ABSTRACT 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.

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    • "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]. "
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    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 · 3.47 Impact Factor
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    • "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. "
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    Vaccine 07/2014; 32(40). DOI:10.1016/j.vaccine.2014.07.070 · 3.49 Impact Factor
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    • "In the United States alone, the CDC estimates 23 million annual NV infections causing 50,000 hospitalizations and 300 deaths (Mead et al. 1999), and considers NVs to be the most common cause of foodborne disease outbreaks (MMWR 2009). Norovirus outbreaks commonly occur in semi-closed communities such as hospitals, schools, nursing homes, disaster relief situations, cruise ships and military settings (MMWR 2008; MMWR 2005b; MMWR 2005a; MMWR 2002b; MMWR 2002a; Fankhauser et al. 1998; McCarthy, Estes, and Hyams 2000; Thornton et al. 2005). The virus family Caliciviridae, of which NVs constitute a genus, are classified as Category B biodefense agents because they cause incapacitating acute disease, are easily spread through multiple routes of transmission, are highly infectious, and are extremely environmentally stable. "
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    Virology 12/2011; 421(2):202-10. DOI:10.1016/j.virol.2011.09.030 · 3.28 Impact Factor
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