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File: 950825_0144pgv_00d.txt
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   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 
   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 
   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. 
   the immigration of nonindigenous persons into some regions may
   introduce nonendemic diseases and could change the baseline
   health status of the resident population.


   Diseases are prioritised in descending order of expected impact
   on military operations if no preventive measures are taken.


  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 
   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. 
   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 
   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 
   of clinical dysentery; carriers are common in apparently 
   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
   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.

   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 
   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 
  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 
  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 
  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 
   -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 
   and disruption of vector control programs could lead to
   indigenous transmission.

  INFLUENZA (1-10 days)
   Transmission: Direct or indirect contact with infectious
   Risk Period/Distribution: Year-round; risk elevated from 
December through February. Theater-wide.
   Remarks: Presumably highly endemic. Large outbreaks of 
   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 
  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 
  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 
  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 
   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.

   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) 
   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.


  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 
   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. 
   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 
   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 
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.

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.


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 
   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 
   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 
  focally endemic areas; the black fly, Simulium damnosum complex,
  is the primary vector).

  Sexually transmitted diseases: AIDS/HIV (through the end of 
  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

  Other infectious diseases: Trachoma (widespread, especially in
  rural areas and among nomadic tribesmen; control measures 
  incidence during the 198Os, but it is still the most common 
  of preventable blindness); intestinal helminthic infections
  (including hymenolepiasis, ascariasis, enterobiasis, 
  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 
   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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