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File: 950825_0144pgv_00d.txt
OPERATIONS (KTO)
Filename:0144pgv.00d
DISEASES OF OPERATIONAL IMPORTANCE - KUWAIT THEATER OF-
OPERATIONS (KTO)
KEY JUDGMENTS:
1. Food- and waterborne diseases pose the most significant
disease threat to military personnel in the KTO. Diarrheal
diseases, principally of bacterial etiology, are the greatest
threat, followed by other enteric infections and hepatitis A.
2. Acute respiratory infections (ARIs) and dermatologic
conditions occur worldwide and may become a major source of
morbidity among nonindigenous personnel, particularly under
stressful or poor hygienic conditions. However, due to their
- ubiquity and the mission dependent nature of their impact on
operational readiness, ARIs and dermatologic conditions are not
included in this product. ARIs can significantly impact the -
operational readiness of air crews; crowded living conditions,
poor personal hygiene, and dusty environments will contribute
to
increased incidence.
3. Sandfly fever is the most widespread vector-borne disease in
the Middle East. Sandfly fever caused significant morbidity
among Allied forces in the Persian Gulf theater during World
War II and poses a significant risk to nonindigenous
personnel. Other important vector-borne diseases include
malaria, leishmaniasis, other arboviral fevers.
4. Other diseases endemic in the local population will be
important due to the likelihood of humanitarian medical
assistance for refugees, displaced persons, or prisoners of
war.
Additionally, these diseases will become increasingly important
to operational units as the duration of deployment increases in
she KTO.
5. Military conflict will stress existing medical
infrastructure, reduce preventive medicine programs, interfere
with waste -disposal, and compromise personal hygiene. These
factors will lead to increased incidence of endemic diseases.
Additionally,
the immigration of nonindigenous persons into some regions may
introduce nonendemic diseases and could change the baseline
health status of the resident population.
DISEASES OF OPERATIONAL IMPORTANCE
Diseases are prioritised in descending order of expected impact
on military operations if no preventive measures are taken.
DISEASES WITH SHORT INCUBATION PERIODS (USUALLY LESS THAN 15
DAYS)
AGUTE DIARRHEAL. DISEASES (6 hours to 1O days)
Transmission: Ingestion Of causative agents or their toxins
in contaminated food or water.
Risk Period/Distribution: Year-round, with overall risk
elevated
from July through September; risk from bacterial etlo1ogies is
elevated from June through October, and risk from viral
etiologies is elevated from December through March.
Theater-wide.
Risk greater in rural village areas.
Remarks: Moderately endemic; may be a major cause of morbidity
among nonindigenous personnel. Frequently occurring pathogens
include enterotoxigenic Escherichia coli (ETEC), Shigella spp.
(primarily S. sonnei or S. flexneri), Salmonella spp., and
Campylobacter spp. Salmonellosis increasingly is being
reported.
Multiple drug-resistance strains of Salmonella and Shigella are
present. Rotavirus and enteropathogenic E× coli (EPEC) are
common causes of diarrhea in children.
ENTERIC PROTOZOAL DISEASES (1 week to several months)
Transmission: Ingestion of causative agents in fecally
contaminated water or food.
Risk Period/Distribution: Year-round, with increased incidence
in August to September. Theater-wide.
Remarks: Frequently associated with more chronic infections,
protozoans such as Entamoeba histolytica, Giardia lamblia, and
Cryptosporidium spp. can cause acute diarrhea. Moderately
endemic; clinical cases of giardiasis and amebiasis are common.
Giardiasis usually is seen in children and is the most commonly
detected intestinal parasite. Amebiasis is the most common
cause
of clinical dysentery; carriers are common in apparently
healthy
adults, including higher socioeconomic groups in urban areas.
- SANDFLY FEVER (3-4 days)
Transmission/Vector Ecology: Bite of an infective sand fly.
Phlebotomus papatasi, the primary vector, is most active between
dusk and dawn, has a limited flight range, is peri-domestic in
its breeding habits, and readily enters human habitations to
feed.
Risk Period/Distribution: Transmission occurs primarily from
April to October, coinciding with vector activity, which peaks
in August and September. Foci may occur throughout the region,
paralleling the distribution of sand fly vectors. Sandfly
distribution occurs in a broad belt across central and eastern
Saudi Arabia extending into Iraq. Risk may be lower in Bahrain
and along the western Saudi Arabia-Iraq border.
Remarks: Local populations generally become immune during
childhood. The Sicilian and Naples viruses are present.
TYPHOID AND PARATYPHOID FEVERS (1-3 weeks)
Transmission: Ingestion of causative agent in food and water
contaminated by feces or urine of infective humans.
Risk Period/Distribution: Year-round, with increased incidence
from June to August. Theater-wide.
Remarks: Moderately endemic, with the majority of reported
cases
due to Salmonella typhi. The carrier rate likely is high, but
data are not available. Multiple drug resistance has been
reported. May be a significant source of morbidity among
nonindigenous personnel.
MAlARIA (12-14 days)
Transmission/Vector Ecology: Bite of an infective mosquito
(Anopheles spp.). Primary vectors in endemic areas of Saudi
- Arabia are An. sergentii and An. arabiensis. The primary
mosquito vectors in Iraq are An. sacharovi and An. superpictus
countrywide, and An. stephensi (associated with urban malaria)
in the south; larva of An. sacharovi breed in brackish as-well as
fresh water. All willfeed on humans indoors.
Risk Period/Distribution: Prior to the Iraqi invasion, malaria
was not endemic in Kuwait. Malaria transmission has been
interrupted in eastern, central, and northern Saudi Arabia,
Bahrain, and central and southern Iraq. In Saudi Arabia,
transmission occurs year-round, with a seasonal peak from
October
through April. Risk exists up to 2,000 meters elevation in rural
and urban areas of the Tihama coastal region and the Asir
highlands in the southwest (Jizan, Asir, and Al Bahah
provinces).
Risk in the western provinces (Makkah and Al Madinah) is limited
to rural valley foci in the Hijaz mountains. Urban areas in the
western provinces are risk free, although vector species may be
present. In Iraq, transmission occurs from May through November,
with a seasonal peak in July and August. Risk areas include
rural
and urban areas in the northern provinces of Dahuk, Ninawa,
Irbil, As Sulaymaniyah, and Tamin at elevations below 1,500
meters. (Baghdad is risk free.)
Remarks: In Saudi Arabia, the most intense transmission occurs
in the southwestern provinces. Plasmodium falciparum causes over
80
-percent of the indigenous cases, with P. vivax causing nearly
all the remainder. A low level of chloroqulne-resistant
falciparum malaria is suspected in the southwest. (Resistance has
been confirmed in adjacent areas in Yemen.) A persistent low
level of endemicity exists in northern Iraq; nearly all indigenous
cases are attributed to P. vivax, and drug-resistant falciparum
malaria is not considered a risk. In the KTO, most cases reported
from non-endemic areas are imported, attributable to expatriate
workers. Competent malaria vectors are present in areas cleared
of malaria, and the influx of large numbers of possible
carriers
and disruption of vector control programs could lead to
indigenous transmission.
INFLUENZA (1-10 days)
Transmission: Direct or indirect contact with infectious
droplets.
Risk Period/Distribution: Year-round; risk elevated from
December through February. Theater-wide.
Remarks: Presumably highly endemic. Large outbreaks of
influenza
have occurred. During the late 19805, isolates of influenza
A(H3N2) predominated over A(KINI) and B.
ARBOVIRAL EFVERS (Other than Sandfly fever) (3-12 days)
Lack of incidence data may reflect inadequacies in diagnostic
capabilities. West Nile fever and Sindbis fever have not been
documented, but are known to occur in neighboring countries;
potential mosquito vectors (Culex spp.) are present. West Nile
virus been serologically detected in Kuwait; Sindbis virus has
been isolated from mosquitoes in eastern Saudi Arabia. Risk would
be greatest in' spring and summer months.
- Crimean-Congo hemorrhagic fever (CCHF) is enzootic, especially
in
northern Iraq, and is widely distributed in discrete foci, with
a small number of clinical cases reported sporadically. The virus
is transmitted by infective Hyalomma spp. ticks or by exposure
to
infected animals (usually sheep, goats, or cattle) or humans.
Transmission risk is greatest from May through September. In
Iraq, CCHF first was reported in 1979 from Baghdad, Dyala, and
Karbala; an unconfirmed source reported over 300 fatalities
among
Egyptian agricultural workers in 1980. An outbreak occurred in
Saudi Arabia near Jeddah and Mecca in May 1990, and was
associated with slaughtered sheep. The virus circulates in rural
agricultural areas. Many infections are apparently asymptomatic,
and serological evidence indicates exposure rates of up to 30
percent among persons associated with livestock.
Dengue fever has historically been reported in southern Iraq
and
eastern coastal areas, but current data is not available; the
potential mosquito vector, Aedes aegypti, is present.
MENINGCCOCCAL MENINGITIS (2-10 days, usually 3 to 4 days)
Transmission: Direct contact, including droplets and discharges
from noses and throats of infected persons.
Risk Period/Distribution: Year-round, with peak incidence from
November through February. Theater-wide, with increased risk
under crowded living conditions and for personnel having close
contact with local nationals.
Remarks: Endemic but cyclic. Usually occurs as sporadic cases,
but with epidemics every 8 to 12 years. Most cases occur in
children and young adults. Group A usually predominates, but an
unconfirmed outbreak attributed to Group WI 35 occurred in
Basrah in 1989; additionally, Group W-135 case reporting
increased in Kuwait and Saudi Arabia during the `late 1980s.
SEXUALLY TRANSMITTED DISEASES (STDs) (2 days to 3 weeks)
Transmission: Sexual contact.
Risk Period/Distribution: Year-round; countrywide.
Remarks: Endemic but levels are unclear. Recent unconfirmed
reports indicate that gonorrhea is a severe problem in Iraq.
Penicillin-resistant strains of Neisseria gonorrhoeae (PPNG)
and
other acute STDs have not been officially reported, but
presumably occur.
CHOLERA (usually 2-3 days, range of 6 hours to 5 days)
Transmission: Ingestion of causative agent, primarily in water
contaminated with feces or vomitus of infective humans.
Risk Period/Distribution: Undetermined.
Remarks: Endemic status unclear, but nonindigenous personnel on
western military rations are at low risk of infection. Cases in
Kuwait and Saudi Arabia usually are imported, but limited
outbreaks occur. Although cases were not reported officially
from Iraq in the 1980s (the most recent reported outbreak
occurred in 1978), outbreaks have occurred in neighboring
countries as
recently as 1990.
DISEASES WITH LONG INCUBATION PERIODS (USUALLY MORE THAN II
DAYS)
ENTERICALLY TRANSMITTED ACUTE yIRAL HEPATITIS (A AND E) (15-65
days) Transmission: Person to person by the fecal-oral route.×
Risk Period/Distribution: Year-round, countrywide.
Remarks: Hepatitis A is highly endemic and may pose a major
health threat to nonindigenous personnel; most indigenous
personnel contract hepatitis A virus infection during
childhood.
Hepatitis E has not been reported, but presumably occurs.
LEISHAANIASIS (l week to many months)
Transmission/Vector Ecology: Bite of an infective sand fly
(Phlebotomus spp.). Most sand flies are active between dusk and
dawn, and have a very limited flight range. The primary vectors
for cutaneous leishmaniasis (CL) include P. papatasi for
Leishmania major and P. sergenti for L. tropica. The suspected
vectors for visceral leishmaniasis (VL), caused by i. donovani
infantum, are P. alexandri and P. papatasi.
Risk Period/Distribution: Transmission primarily occurs from
April through November, peaking July to September. In the
Arabian peninsula, L. major occurs primarily in the eastern and
central provinces of Saudi Arabia, Kuwait, and Bahrain; L. tropica
occurs primarily in the mountains of the western provinces; and VL
- occurs primarily in the southwestern Arabian peninsula.
However,
all forms may be present in leishmaniasis endemic areas. In
Iraq, both forms of CL and VL occur countrywide, but cases are
more commonly reported from foci in the central regions.
Remarks: CL caused by L. predominates in the KTO, and
usually occurs in rural and peri-urban areas; the principal
zoonotic reservoirs are rodents, particularly gerbils
(Psammomys
obesus and Meriones spp. ), which establish their burrows in
foci where halophilic plants are available as a food source. In
Iraq, most CL cases, especially in urban areas (such as Baghdad
and Mosul), are caused by L. tropica, with peak incidence from
October through February. No animal reservoir has been
identified, and the disease likely circulates only between
humans and sand flies. In the KTO, VL is more common in focal
rural areas having alluvial soil and peak incidence is from
December to April. The reservoir for VL is unknown, but ;ackals
and dogs are suspected.
SCHISTOSOMIASIS (2 to 6 weeks)
Transmission/Vector Ecology: Penetration of the skin by
waterborne larval forms (cercariae) that develop in snails in
fresh water impoundments. In Saudi Arabia, the primary
intermediate host for Schistosoma mansoni (intestinal) is
Biomphalaria arabica and for S. haematobium (urinary,) is Bulinus
spp. In Iraq, the primary intermediate host for S. haematobium is
Bulinus truncatus.
Risk Period/Distribution: Transmission occurs year-round, with
increased risk in Saudi Arabia during the spring (March through
May) and in Iraq from June through September. In Sarn#i Arabia,
distribution is focal in wadis, aqueducts, and cisterns in
western regions and in oasis in central regions: intestinal
schistosomiasis foci occur in the central (Hail, Riyadh),
northern (Al Jawf), northwestern (Tabuk, Medina), midwestern
(Makkah, Al Bahah), and southwestern (Asir and Najran highlands)
provinces; urinary schistosomiasis foci occur in the lowlands of
the southwestern (Jizan) and midwestern (Makkah) provinces. In
Iraq,.,'foci are distributed in areas near the Tigris and
Euphrates
Rivers, especially in the central regions; no transmission occurs
south of Basrah because the delta waters are too saline for the
snail intermediate hosts.
Remarks: S. mansoni predominates in Saudi Arabia. only.
haematobium is present in Iraq, which has low level prevalence in
endemic foci. Reported annual case totals in most areas decreased
in the 1980s as a result of control programs.
PARENTERllLLY TRANSMITTED ACUTE VIRAL HEPATITIS (B, C, AND D) (15-
180 days)
Transmission: Contact with causative agent through blood
transfusions, contaminated needles, sexual contact, and
contaminated perineal wounds.
Risk Period/Distribution: Year-round, theater-wide.
Remarks: Hepatitis B virus (HBV) is prevalent in the general
population (an estimated 20 to 40 percent of the population have
antibodies), and the HBV carrier rate is estimated at 2 to 4
percent. Hepatitis D has been found in approximately 5 to 40
-percent of HBV carriers. Hepatitis C has not been reported, but
presumably occurs.
OTHER DISEASES ENDEMIC IN THE INDIGENOUS POPULATION
Zoonotic diseases: Brucellosis (enzootic, particularly in goats
and camels; human cases, usually due to consumption of raw goat
or camel milk, caused by B melitensis are common, with recent
outbreaks); Q fever (enzootic; rarely reported in humans, but
human serology in rural areas indicates exposure); anthrax
(enzootic, with outbreaks in livestock reported; occupational
exposure usually involves sheep); echinococcosis (enzootic, with
stray dogs in rural agricultural and urban areas commonly
infected; hydatid disease in humans accounts for 1 percent of all
surgical procedures); rabies (enzootic, particularly in the
northern rural areas of Iraq; jackals constitute the primary
reservoir, with some spillover into stray dogs; few human cases
reported annually).
Vectorborne diseases: Plague (flea-borne; cases have not been
reported, but enzootic foci historically have existed in the
highlands near the Iraq-Syria border, along the
Tigris-Euphrates
river extending to Kuwait, and in the Asir region of the
southwestern Arabian peninsula); flea-borne typhus (enzootic
areas in eastern Saudi Arabia, Kuwait, and southern Iraq;
sporadic cases occur); tick-borne relapsing fever (cases have
not been reported, but restricted enzootic foci exist in a belt
through central Iraq, extending from Syria to
Iran),'louse-borne
typhus (last reported in 1978 from endemic foci in central
Iraq); louse-borne relapsing fever (endemic in northern Iraq);
- onchocerciasis (confined to the southwestern Arabian peninsula
in
focally endemic areas; the black fly, Simulium damnosum complex,
is the primary vector).
Sexually transmitted diseases: AIDS/HIV (through the end of
1990,
few cases of have been officially reported; additional cases are
believed to have occurred; in-country HIV testing reportedly is
performed, but no data are available); syphilis (present at low
levels).
Other infectious diseases: Trachoma (widespread, especially in
rural areas and among nomadic tribesmen; control measures
reduced
incidence during the 198Os, but it is still the most common
cause
of preventable blindness); intestinal helminthic infections
(including hymenolepiasis, ascariasis, enterobiasis,
trichuriasis
common in rural areas and among lower socioeconomic groups);
tuberculosis (endemic, annual incidence reportedly declined
during the late 1980s, but prevalence remains moderate,
especially in rural areas); acute hemorrhagic conjunctivitis
(recent outbreaks have occurred in coastal areas of eastern and
southwestern Saudi Arabia).
CONCLUSION: The overall threat of indigenous infectious
diseases
in Iraq, Kuwait, Saudi Arabia, and Bahrain is moderate and can
be further reduced through preventive measures. Good preventive
medicine, troop discipline, disease surveillance, and command
emphasis at all levels will be important for limiting the
infectious disease threat to operational units.
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