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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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