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File: 950901_0143pgv_00d.txt
AFMIC Weekly Wire
Filename:0143pgv.00d
Subject: AFMIC Weekly Wire
INTRODUCTION -
This special weekly wire discusses diseases endemic in the local
population that will be important to medical forces in the Middle
East because of the likelihood of humanitarian medical assistance
for refugees or displaced persons. Diseases are prioritized in
descending order of expected impact on humanitarian medical
missions. Additionally, because of the length of time in the
Area of Operation (AO), these diseases will be increasingly
important to operational units. Common or local names for the
diseases are in parenthesis. The available statistics on the
prevalence and incidence of many of these diseases are incomplete,
making reported rates and numbers of cases generally,unreliable
indicators of true prevalence or endemicity. Transmission factors
that are unique or important in this region are discussed.
Complete
discussions on incubation periods, routes of transmission, and
clinical signs and symptoms are available in standard texts and
are
beyond the purpose of this wire.
Military conflict will weaken 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 will change
the baseline health status of the resident population.
TABLE OF CONTENTS
A. ACUTE CHILDHOOD DIARRTffA (Eshal)
B. INTESTINAL PAITES
C. TRACHOMA (Ramad)
D. CHILDHOOD DISEASES (Diphtheria, Measles, Pertussis,
Poliomyelitis, Tetanus)
E. BRUCELLOSIS (Al-Brosliyat)
F. TUBERCULOSIS (Al-Sol)
G. ECHINOCOCCOSIS (Hydatid Disease)
H. RABIES (Al-Kalab)
I. Q FEVER
J. PLAGE (Taa'on)
K. ANiIAX (Al-Jamra)
L. TYPHUS, LOUSE-BOENE (Epidemic Typhus)
M. TYPHUS, MURINE (Endemic Typhus)
N. NO ENDEMIC SYPHILIS (Bejel)
O. LEPROSY (Al-Jotham)
P. ONCHOCERCIASIS (Sowda)
Q. TOXOPLASMOSIS
R. LEPTOSPIROSIS
ACUTE CHILDHOOD DIARRTff'.A (Eshal)
Disease Agents: In children younger than 5 years suffering from
acute diarrhea, the most common enteropathogens isolated, in
descending frequency, generally are rotavirus (37-44 percent),
Salmonella, enteropathogenic Escherich,a coli, Shigella, and
Campylobacter jejuni. The most common parasite isolated is Giardia
lamblia (4-7 percent of the cases). Multiple infections are seen
in
about 1 percent of the children. Cholera is not endemic in the
region; imported cases (and outbreaks) occur, but cholera should
not be a significant cause of childhood diarrhea in refugee
populations.
Distribution/Risk Period: widespread. Year-round. Seaon~ increases
in rotaviral diarrheas primarily in cold months (December-March),
but also in the hot dry season (July-September). Seasonal
increases
in bacterial etiologies occur from June to October; protozoal
cases
peak in August and September.
Remarks: Rotavirus is a leading `cause of gastroenteritis in young
children (aged less than 5 years) in Kuwait and Saudi Arabia; ihe
incidence is lower in breast-fed than in bottle-fed× infants.
Rotavirus diarrhea is a major pediatric health problem, with up to
30 percent of the children havind concurrent upper respiratory
infection. Among the bacterial etiologies, multiple drug
resistance
is common among Salmonella and Shigella isolates.
INTESTINAL PARASITES
Intestinal parasitic infections (IPI) are not notifiable diseases;
the true prevalence and incidence of these diseases are unknown.
Agents: Most common IPI are amebiasis, giardiasis, ascariasis,
trichuriasis, enterobiasis, and hymenolepiasis. Human
dicrocoeliasis (Dicrocoelium dendriticum) has been reported from
Saudi Arabia and is commonly associated with drinking raw milk or
eating raw liver (camel, cattle, goat, or sheep). Taeniasis
(Taenia
saginata) and fascioliasis are reported from discrete foci. Low
levels of Trichostrongylus columbriformis and Strongyloides
stercoralis have been detected in northern Iraq.
Distribution/Risk Period: widely distributed; but vary
geographically and depend on many socioeconomic factors; more-
common among lower socioeconomic levels than middle and upper
levels. In developed regions, roundworms and whipworms are present
at low levels. Hookworm Ancylostoma duodenale) infections
generally occur in primitive rural communities where promiscuous
defecation exists. Enteric protozoal agents (Giardia lamblia and
Entamoeba histolytica) are commonly isolated from all regions.
Transmission of most agents occurs year-round, with seasonal
increases in the dry season. Human cases of dicrocoeliasis peak in
October and November.
Remarks: Highest IPI rates can be anticipated in expatriate
workers from less-developed countries and from indigenous people
from rural areas. A high rate (63 percent) of intestinal parasite
infection was found in a hospital-based study in Kuwait. A similar
study in Riyadh revealed that 323 of 3800 patients examined were
infected with potential pathogens - Giardia, Hymenolepsis nana, E.
histolytica, and Ascaris being the most frequent (in descending
order). Similar levels were detected in community-based studies in
northern Iraq, where IPI rates reached 18.3 percent; prevalence
for
roundworms (Ascaris lumbricoides) in rural areas near Bagdad and
Babylon is estimated to be slightly more than 5 percent. In Saudi
Arabia, IPI rates may be highest in rural communities in the Asir
province; IPI in children from urban areas are most commonly due
to
G. lamblia (13.5%), followed by Enterobius vermicularis (4.2%) and
H. nana; the general incidence of other helminthic parasites is
low. In a two year study from Abu Dhabi, United Arab Emirates,
stool samples of 42,022 food handlers, hookworms were found in
13.8% of the samples, whipworm 6.9%, and roundworms 2.6%.
Interruption of potable water supplies and sewage disposal and
deteriorated sanitary conditions in developed regions wttl
increase
the incidence of most of these parasites.
TRACHOMA (Ramad)
Transmission: Primarily transmitted by direct contact with ocular
and nasopharyngeal discharges on fingers and contaminated
materials
(face cloths and cosmetic khol sticks used to darken ,eyelids).
Filth flies (primarily Musca sorbens, the market or bazaar fly,
but
also M. domestica) contribute to the spread of the disease.
DistrIbution/Risk Period: widely distributed and highly endemic,
particularly in rural areas with poor hygiene. Year-round.
Remarks: In endemic areas, the highest infection rates are in
children. Prevalence of active cases in Oman is an estimated 5-15
percent and is 10 percent in Yemen. Approximately 22 percent of
the
Saudi population suffer from trachoma and about 6.2% have active
trachoma; the disease is hyperendemic in the Eastern Province of
Saudi Arabia. Control measures reduced incidence in the 1980s, but
trachoma is still the most widespread eye disease in this region
and the leading cause of preventable blindness.
CHILDHOOD DISEASES (Diphtheria, Measles, Pertussis, Poliomyelitis,
and Tetanus)
Distribution: Endemic, but marked regional variations in reported
incidence exist. Based on the number of reported cases (data
available through 1988-89), more developed countries (Saudi
Arabia,
Kuwait, Bahrain, Oman, and UAE) have a lower incidence. Generally,
- Yemen and Iraq have the highest rates.
Vaccination Programs: Expanded programs of immunization (EPI) have
improved vaccination coverage and reduced the incidence of
targeted
diseases in the region since the early-1980s. In 1988-89, Saudi
Arabia, Kuwait, Oman, UAE, and Bahrain reported that approximately
85-90 percent (weighted `average) of infants had received a
complete vaccination series (OPV, DPT, measles, and BCG). Percent
coverage was lower in Iraq and Qatar. Yemen had the poorest
coverage, 35-45 percent. Remarks: Refugee populations that have
relied on EPI to control childhood diseases will be at increased
risk for outbreaks or epidemics when vaccination programs are
interrupted.
BRUCELLOSIS (Al-Brosliyat)
Transmission/Reservoir: Over 80% of reported human cases are due
to
consumption of raw dairy products (goat and camel milk and
cheeses). Contact with infected material plays a minor role. In
human cases not associated with direct animal or product exposure,
most appear to have contracted the disease while travelling
through
areas contaminated with animal fetal tissues. The disease is
endemic in natural reservoirs (goats, sheep, camels, and cattle)
which principally are infected with Brucella melitensis. The
prevalence of infection of sheep and goats commonly exceeds 10
percent. B. abortus has been isolated from camels, but the
clinical
significance is unclear.
Distribution/Risk Period: Widespread, but regional variations
exist. Human cases caused by B. melitensis are widely distributed,
in both rural and urban areas. seasonally distributed, with most
cases occurring March to July, peaking in April and May. Peak
incidence of cases associated with environmental exposu~ coincides
with the lambing and kidding seasons.
Remarks: One of the commonest human infectious diseases in the
region; many areas have experienced true increases in incidence,
`with some outbreaks reaching epidemic proportions. Particularly
common among farmers, shepherds, nomadic tribesmen, and their
families (10-25 percent sero-prevalence has been detected- in
agricultural workers). Annual incidence increased greatly-in
Kuwait
in the early 1980s, with the incidence reported in 1985 thirty
times higher than in 1976. Other neighboring countries have
experienced similar increases. In Oman, about 300 human cases are
reported annually, with the majority in the Dhofar region, where
it
occurs in epidemic proportions among the Jebali people. The rise
may be partially due to increased clinical awareness aand improved
diagnostic capabilities, but highly mobile animal herds and
uncontrolled importation of live animals have interfered with
control efforts. For each case reported an estimated 25 cases are
unrecognized or unreported.
TUBERCULOSIS (Al-Sol)
Transmission/Reservoir: Most tuberculosis (TB) is caused by human-
to-human transmission of Mycobacterium tuberculosis. zoonotic
tuberculosis is of lesser significance.
Distribution/Risk Period: TB is widely distributed throughout the
region, however, countries have varying levels of prevalence.
Remarks: TB is an important disease in the indigenous
population. Most of the reported human cases are pulmonary
rather than disseminated or extrapulmonary. Tuberculous cervical
lymphadenitis represents a significant portion of the
extrapulmonary TB in Saudi Arabia (biopsied neck masses are
frequently diagnosed as tuberculosis). Based on the estimated
level of risk of infection (the proportion of the population which
has been infected or reinfected in the course of one year),
countries in the region can be grouped into three categories of
prevalence. Countries with low- prevalence (risk of infection
0.1-0.2 percent) are Bahrain and Kuwait. In Bahrain, infection
rates in expatriate workers from less-developed countries were
found to be 7 times higher than in Bahrainis. High-prevalence
(2.0-3.0 percent) is reported from Yemen. All other countries in
the region have intermediate level prevalence (0.5-1.5 percent).
All countries in the region, except Iraq, are known to have
incorporated childhood BCG vaccination of children into their
Expanded Program of Immunization (EPI). A 21.3 percent prevalence
of resistance to primary antituberculous drugs was reported from
Riyadh, Saudi Arabia. Primary resistance to INH was 19.4 percent;
primary and secondary resistance to rifampicin was 3 percent and
33.7 percent, respectively. Most isolates from patients with
acquired resistance to rifampicin also were resistant to INH.
ECHINPCPCCPSOS (Hydatid Disease)
Transmission/Reservoir: Carnivores harboring the adult
tapeworms (Echinococcus granulosus) become infected by eating
viscera of intermediate hosts containing hydatid cysts; the
dog-sheep cycle (particularly associated with dogs used for
sheep Herding) is important in this region. Cattle, goats, and
camels are lesser important intermediate hosts. Infection rates
in dogs vary by region and locality, with highest rates (67 to
100 percent) reported in Irbil province of northern Iraq.
In 1976, the prevalence in dogs in Kuwait was-found to be 23
percent, but levels may have declined. Stray dogs in urban areas
commonly are infected by feeding on uncooked offal discarded
from slaughter houses; up to 15 percent of stray dogs near
Al-Hassa, Saudi Arabia reportedly were infected.
Distribution/Risk Period: Endemic and enzootic, especially in
rural agricultural areas where dogs are used to herd grazing
animals, particularly sheep. However, human cases also occur in
larger urban areas. widely distributed and highly
endemic/enzootic in Iraq. Reportedly, the highest prevalence in
Saudi Arabia exists in the southern and western regions followed
by the central region.
Moderately endemic in Kuwait. Year-round.
Remarks: Important parasitic infection in this region,
particularly among groups having intimate contact with dogs (and
objects soiled with feces). Islamic teachings stress avoidance of
dogs; however, this does not provide complete protection. The
highest incidence of human disease generally is in the 31 to 40
year old age group.
Human infection rates in Iraq are estimated to be slightly less
than 1 percent, accounting for 1 percent of all
surgical
procedures; in highly endemic areas of Saudi Arabia, it has
accounted for 5 percent of all major surgical operations. In
Kuwait, the majority of recently reported cases were in non-
- Kuwaitis.
RABIES (Al-Kalab)
Transmission/Reservoir: Sylvatic and urban rabies are
important. Urban rabies, with stray dogs (cats and other animals
to a lower extent) serving as the reservoir and main source of
human exposure, is reported from cities and villages of most
countries. The principal enzootic reservoir for sylvatic rabies
is the desert fox, and spill over into stray dog and cat
populations frequently occurs. Sheep rabies is reported with low
sporadic Occurrence.
Distribution/Risk Period: In Saudi Arabia, human cases are very
sporadic, usually in the northern or eastern rural areas.
Although Oman had been considered to be provisionally free of
rabies, the disease is endemic in this region, with
recently reported laboratory-confirmed cases in foxes and sheep
and a human case.
Rabies is present but of low incidence in Qatar and the UAE.
Kuwait and Bahrain are considered rabies-free; the last case ×of
animal rabies in Kuwait was reported in October 1987.
Year-round transmission occurs, but an increased risk in the
spring and summer can be expected due to elevated animal
populations and increases in animal bites in warmer seasons.
Remarks: Dog and cat bites/scratches will probably be the
primary sources of human exposure and reasons for
past-exposure prophylaxis. Animal cases are likely to be
unrecognized and underreported by the indigenous population.
Additionally, the disruption following the Iraqi invasion and
possible military conflict, may allow reintroduction into
previously free areas.
Q FEVER
Transmission/Reservoir: commonly transmitted by airborne
dissemination of rickettsia (Coxiella burnetii) and secondarily
by direct contact with infected animals and from consumption of
raw milk. Domestic animals, rodents, and ticks (primarily
Hyalomma
dromedarii) serve as natural reservoirs.
Distribution/Risk Period: Widely distributed throughout the
region; serolog×ical studies suggest that it is highly endemic in
eastern Saudi Arabia, and it may be endemic in other areas at
similar levels.' Enzootic in livestock. Year-round.
Remarks: Sporadic cases have been reported areawide, but
incidence is suspected to be greater that reported due to limited
dagnostic capabilities. Serology from indigenous personnel in
rural areas indicates that subclinical infection develops in
childhood and virtually all young adults have had sensitizing
contact (inducing acquired immunity).
PLAGUE (Taa'on)
Transmission/Reservoir: Primarily transmitted by the bite of an
infective flea (primarily Xenopsylla cheopis, the oriental rat
flea, but also Pulex irritans, the human flea). Reservoirs for
sylvatic plague in the region include gerbils (Meriones spp and
Gerbillus gerbillus) and desert voles. Rattus rattus may serve
as
a reservoir around dwellings in endemic areas.
Distribution/Risk Period: Occurs areawide. Natural
occurring
enzootic foci of plague historically have existed between the
- Tigris and Euphrates rivers and adjacent territories extending
from Syria to the Persian Gulf, possibly including Kuwait. In
Iraq, the highlands near the border with Syria historically have
been an enzootic focus. Although plague is considered eradicated
in Saudi Arabia (last reported outbreak occurred in 1969 along
the Yemen border in the Khawlan district), sylvatic (wild rodent)
plague should be considered focally enzootic in the Asir upland
plains in the southwestern portion of the Arabian peninsula.
Year-round, but especially during hot, dry months.
Remarks: Underreported.
ANTHRAX (Al-Jamra)
Transmission/Reservoir: Enzootic, primarily in sheep and goats.
Infections in these animals serve as the primary method of
environmental and product contamination with spores. Many of the
reported human cases are unable to identify the true source of
their infection.
Distribution/Risk Period: Widely distributed, but focally endemic.
Occurs sporadically in rural areas during summer months.
Remarks: Cutaneous cases predominate, followed by gastrointestinal
and pulmonary forms. Cases and outbreaks are most likely in
nomadic
populations, farmers, and shepherds and in people handling
infected
animal products (wool, hides, meats, etc). In Iraq, 200 to 269
human cases were officially reported annually from 1976 to 1980.
TYPHOS, LOOSE-BORNE (Epidemic Typhus)
Transmission/Reservoir: By rubbing crushed body lice (Pediculus
humanus) or their feces into the bite site or abrartons; lice
defecate rickettsiae (Rickettsia prowazeki) while feeding. Man is
the -reservoir and maintains the infection during inter-epidemic
periods.
`Distribution/Risk Period: Thought to be present, but prevalence
is
unknown. Endemic foci are preseht in Iraq. Northern Saudi Arabia
and Kuwait are at the southern limits of the distribution belt in
the Middle East. The disease may be present in the Southwest
regions×of the Arabian Peninsula (Asir Province of Saudi Arabia
and
Yemen). `Seasonal, usually more prevalent in colder months.
Remarks: Louse-borne typhus is commonly associated with over-
crowding, transient populations, impovershed people, and poor
sanitary conditions; refugee populations would be at increased
risk. In 1977, 19 cases were reported from Iraq, with most cases
from July to September. An outbreak was reported among nomadic
tribes in northern Saudi Arabia in 1961 resulting in 49 cases and
2 deaths.
TYPHUS, MURINE (Endemic Typhus)
Transmission/Reservoir: Primary vectors are infective fleas,
usually Xenopsylla cheopis (oriental rat flea) and potentially
Ctenocephalides felis (cat flea). The disease is maintained in
nature by a rat-flea-rat cycle; large rodent populations
contribute
to the spread of murine typhus.
Distribution/Risk Period: Thought to be present areawide, but
prevalence is unknown. In Saudi Arabia, human cases occur along
the
Red Sea coast, the northern province, and along the Persian Gulf
`coast. Year-round, but peaks during the summer months.
Remarks: Sporadic cases are reported. An outbreak occurred in
Kuwait in 1978 with 254 clinical cases detected; the highest
attack rates were among people in lower socioeconomic levels.
Deteriorated sanitary conditions in Kuwait will elevate rodent
populations which will contribute to increased incidence of murine
typhus.
NONVENEREAL ENDEMIC SYPHILIS (Bejel)
Distribution/Risk Period: Moderately endemic. Widely distributed,
particularly in remote rural areas where the standard of hygiene
is
low and access to health services is limited. Year-round.
Remarks: Primarily confined to nomadic and semi-nomadic
tribesmen
(Bedouins), where the prevalence may reach 20 percent; the
majority
of clinical cases are between 15 and 35 years old. The majority of
cases aquire the infection in childhood. The seropositivity rate
is
higher among females. The social consequences of mistaking bejel
for venereal syphylis in a conservative Islamic culture must be
recognized.
LEPROSY (Al-Jotham)
Distribution/Risk Period: Indigenous transmission occurs at low
levels. Distributed throughout the region, with regional
variations
expected. Generally associated with areas of crowding, poverty,
poor sanitation, and substandard living conditions. Year-round.
Remarks: Prevalence remains low. Increased incidence was reported
in Kuwait prior to 1985, attributed to the increased immigration
of
expatriate workers from endemic areas; from 1983 to 1988, over 95
percent of the patients were immigrants. In 1979, cases were
reported from throughout Saudi Arabia, but a foci existed in the
southwest region. In 1986, the prevalence in Saudis was 4.1 per
100,000, and in non-Saudis was 126.5 (most non-Saudis were from
`endemic areas). Tuberculoid leprosy was significantly more common
in Saudi than non-Saudi patients;' the prevalence of the other
types of leprosy was the same for both groups.
ONCHOCERCIASIS (Sowda)
Transmis'sion/Reservoir: The black fly (Simulium damnosum complex)
is the primary vector species in the region.
Distribution/Risk Period: Confined to the southwest
Arabian peninsula (Saudi Arabia and Yemen) in focally endemic
areas. Cases have been reported in the Asir region of southwest
Saudi Arabia (in villages around Khamis Mushayt). In Yemen, it
is endemic in all westward flowing permanent streams (wadis)
between the northern Wadi Surdud and the southern Wadi Ghayl at
elevations of 300 to 1,200 meters; cases have been reported from
Hodeida to Taiz (most occurred in Al Barh between Mokha and
Taiz). Although not reported, the disease probably occurs
throughout the length of Yemen, in wadis flowing into the Gulf of
Aden and the Red Sea. Seasonal, when blackflies are present.
Remarks: Reporting has been limited, making prevalence and
incidence estimates unreliable. An estimated 60,000 people are at
risk in endemic areas in southwest Yemen. Dermatologic
manifestations of onchocerciasis (sowda) predominate in Yemen;
-ocular manifestations (river blindness) were common in the cases
reported from Saudi Arabia.
TOXOPLASMOSIS
Transmission/Reservoir: Human infection is primarily
aquired through contact with cat feces or food contaminated with
oocysts or through consumption of raw meat containing
bradyzoites, principally from sheep and goats. Raw goat and
sheep milk containing tachyzoites possibly may be a source of
infection. Domestic and wild felines are the only definitive
hosts; cat feces is the source of environmental contamination
with oocysts. Numerous mammalian intermediate hosts exist;
rodents are important sources of infection for felines. The
prevalence of infection in sheep and goats is related to the
abundance of felines in pasture lands.
Distribution/Risk Period: Widely distributed. - Year-round.
Remarks: Seroprevalence is high. Human prevalence in Saudi Arabia
is an estimated 33 percent; 58 to 95 percent prevalence was found
in Kuwait. Serosurveys indicate that infection may be more
prevalent in nomads (Bedouins).
LEPTOSPIROSIS
Transmission/Reservoir: All domestic animals as well as many wild
animals, especially rodents, may serve as reservoirs of-infection.
Many serotypes have been reported from the region, but the
predominant" `Serotype(s) in an area is dependant on specific
ecologic conditions.
Distribution/Risk Period: Leptospires require a slightly alkaline
and strictly fresh water environment, which may restrict their
presence in eastern Saudi Arabia or in the salt marshes of
southern
Iraq (`south of Basrah). Conditions in oases are favorable for
leptospire survival. The disease can be expected to be focally
`distributed. Primarily a risk during warm months of the year
(June
to September).
Remarks: Limited reports suggest a very low endemicity. Cases are
sporadically reported from the region; the risk of aquiring the
disease ,and the number of expected cases in indigenous people are
low. Leptospirosis generally is occupationally related. Elevated
rodent populations may contribute to increased transmission.
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