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Medical Capabilities Study Kingdom of Saudi Arabia (U) Filename:01810543.592 Subject: Medical Capabilities Study Kingdom of Saudi Arabia (U) A Defense S&T Intelligence Study [ (b)(2) ] DIA TASK UNIT PT 1810-03-05L Date of Publication 15 May 1992 Information Cutoff Date 1 March 1992 Supersession Notice This document supersedes [ (b)(2) ], dated February 1983 [ (b)(2) ] POLLUTION PROBLEMS - Water pollution, the result of inadequate water and waste disposal systems and indiscriminate dumping of refuse, is a serious health problem in inhabited areas. Although modern sanitation systems are being installed in some of the larger cities, dumping of raw sewage into coastal waters, wadis (dried river beds), and vacant land areas is common. Wadis, polluted with waste materials, may flood with water during heavy downpours and contaminate local wells. Water supplied by municipal water systems, although chlorinated, may become contaminated due to faulty or improperly maintained distribution lines. Industrial pollution does not present a health hazard. This may change as technology and industry develop and as other priorities preclude the establishment of proper pollution controls. Currently, Saudi Arabia has no national regulation governing the disposal of hazardous and toxic wastes. The Saudi Arabian Meteorology and Environmental Protection Administration has issued draft national regulations for review and should have guidelines forthcoming. INVERTEBRATES, VERTEBRATES, AND PLANTS OF MEDICAL IMPORTANCE Poisonous centipedes, scorpions, and spiders common to Saudi Arabia are listed in Table III and poisonous snakes are listed in Table IV. Exposure to snakes should be avoided and precautions should be taken while in the field. All equipment and clothing should be carefully inspected, especially in the morning, prior to use. [ (b)(1) sec 1.3(a)(4) ] Dangerous marine life, while present in the waters off of the Arabian Peninsula, represents a minimal threat to military forces. Dangerous marine life includes sharks, venomous sea snakes (antivenin available from Commonwealth Serum Laboratories), sea wasps (jellyfish), Lionfish, and Stonefish. Two plants pose a slight operational problem for military personnel. Both plants, poppy anemone (Anemone coronaria) and sumac (Rhus coriaria), are found in northern Saudi Arabia, should not be consumed and are contact vesicants. TABLE III POISONOUS INVERTEBRATES COMMON NAME/ SCIENTIFIC NAME LOCATION/MEDICAL IMPORTANCE *Sources of Antivenin COMM: Commonwealth Serum Laboratories, 345 Poplar Road, Parkville, Victoria 3052, Australia. Telegram: "SERUMS," Melbourne; Telex AA 32789; Telephone 387-1066 IRAN: Institut d'Etat des Serums et Vaccins Razi, PO Box 656, Tehran, Iran LIPM: Lister Institute of Preventive Medicine, Elstree, Herts WD, England MERK: Merck, Sharpe, and Dohme, West Point, Pennsylvania 19486, USA SAIMR: South African Institute for Medical Research, P.O. Box 1038, Johannesburg 2000, Republic of South Africa, Telegraph: "BACTERIA"; Telephone: 724-1781 CENTIPEDES/(SCOLOPENTRA SPP.)(S. SUBSPINIPES)(S. MORSITANS)(S VALIDA) Found in Saudi Arabia. Hide in litter, under loose bark, stones, leaves, and debris in daytime. Nocturnal. Avoids very wet or extremely dry niches. S. morsitans color varies from yellow to reddish yellow and from olive to dark green. Head and last segment are brownish. S. subspinipes is all brown. Bites from Scolopendra species are painful.. Most are not dangerous, although S. morsitans has killed children. S. subspinipes suspected of killing children. Bites cause intense pain. May cause vomiting, headache, and swelling. Symptoms normally disappear in a few days with no aftereffects. * No antivenin available. SCORPION/(LEIURUS QUINQUESTRIATUS)(PANDINUS SPP)(ANDROCTONUS SPP) Found in dry areas. Hunt insects at night. Not aggressive. Sting only when molested or startled. Stings usually occur after dark. Most stings are not dangerous. Some fatal, especially in young children. Venom contains neurotoxins. Victim experiences intense pain at the site of sting, which may turn into a prickling or "goose flesh" sensation. Muscles contract, especially limbs and abdominal muscles. Reflex that forces eyes to close when threatened malfunctions. Victim's mind clouds, and victim often faints. Salivation and sweating increase. Eyes tear, pupils dilate, and vision becomes impaired. Often eyeball pulsates. Body temperature may fluctuate rapidly above and below "normal". Envenomation may increase or curtail the secretion of urine. Often blood appears in urine. Victim often vomits soon after being stung. Sometimes vomits blood. Death always results from respiratory paralysis. Some victims have fits of coughing. Symptoms often recede, then recur. Victim should be watched for at least 12 hours after the symptoms recede. *IRAN: "Polyvalent Scorpion Serum"; LIPM: "Scorpion" BLACK WIDOW/(LATRODECTUS MACTANS) Found in Saudi Arabia, in open fields, under stones, and near outhouses, houses, trash and dumps. Build irregularly-shaped webs near ground, in wheat, along trenches, below and beside large stones, in hollows of trees, and in bushes. Not aggressive. males do not bite; females bite if molested. Females stay in web. Most bites occur at harvest time. Black, with red or yellow-red spots on abdomen. One of the world's most poisonous spiders. Venom is neurotoxic. Bite may cause sharp pain at site of bite or may not be felt at all. Sever abdominal pain follows. Victim may experience redness at bite site, pain, and sweating. Pain can spread through body, accompanied by burning fever, shivering, nausea, restlessness, and weakness. Sever bites may cause cramps, paralysis, rigidity, weak pulse, labored breathing, stupor, and delirium. Victim may retain urine, go into shock, have bluish skin, nausea, vomiting, and die, although most victims recover after several days. *COMM: "Redback Spider" maybe effective; MERK: "Black Widow"; SAIMR: "Black Widow" TABLE IV POISONOUS VERTEBRATES COMMON NAME/SCIENTIFIC NAME LOCATION/MEDICAL IMPORTANCE CATEGORIES I: Major Risk: Frequency of bite/envenomation high; highly toxic II: Moderate Risk: Frequency of bite/envenomation moderate; venom may be highly toxic *SOURCES OF ANTIVENIN BEHR: Behring Institut, Behringwerke AG, D3550 Marburg (Lahn), Postfach 167, Germany. Telephone: (06421)39-0: Telefax: (06421)660064; Telex: 482320-02 bwd COMM: Commonwealth Serum Laboratories, 345 Poplar Road, Parkville, Victoria 3052, Australia. Telegram: "SERUMS," Melbourne; Telex AA 32789; Telephone 387-1066 FITZ: Fitzsimons Snake Park, Box 1, Snell Park, Durban, South Africa HAFF: Haffkine Bio-pharmaceutical Corporation Ltd., Parel, Bombay, India IRAN: Institut d'Etat des Serums et Vaccins Razi, PO Box 656, Tehran, Iran KASA: Central Research Institute Kasauli (Simla Hills), (H.P.) India PAST: Institut Pasteur Production, 3 Boulevard Raymond-Poincare, 92430-Marnes la Coquette, France. Telephone: (1)126.96.36.199; Telex: PASTVAC206464F SAIMR: South African Institute for Medical Research, P.O. Box 1038, Johannesburg 2000, Republic of South Africa, Telegraph: "BACTERIA"; Telephone: 724-1781 TASH: Research Institute of Vaccine and Serum, Ministry of Health, UI. Kafanova 93, Tashkent, Uzbekistan PUFF ADDER/(BITIS ARIETANS) Category I. Found in southwestern Saudi Arabia in savanna and grasslands from sea level to 2,800 meters elevation. Avoids unusually dry or wet areas. Often found near human habitation, agricultural areas. Large, bad tempered, slow moving, but can strike with amazing speed and force. Usually encountered along paths or around buildings. Its camouflage makes it difficult to see; this, coupled with snake's tendency to hold its ground, accounts for many snakebites. When excited, inflates body, hisses loudly, but may strike without warning. Very heavy-bodied; snake average length 0.9 meters (maximum recorded length 1.5 meters). Head is large, broad, triangular, distinct from neck, with blunt snout. Fangs may reach length of 12 to 18 millimeters depending of size of snake. Pupil of eye vertical. Tail short in males, very short in females. Snake's pattern and color quite definite, often blending with the environment. Dorsal coloration variable, ranging from yellow to yellow-brown, reddish-brown or gray, patterned with black of brown pale-edged chevrons running length of body towards tail, where pattern changes to dark and light crossbands. Ventral coloration yellow or white with black blotches. Largely nocturnal but may be encountered during day. Venom very toxic, demonstrating anticoagulant activity and procoagulant properties via platelet aggregation. Venom yield high, fangs exceptionally long. although not all bites result in envenomation, a bite by this species is serious, requiring immediate medial attention. Envenomation is characterized by enormous swelling. Onset of symptoms can be extremely raped. A bite on a toe or finger may cause gross swelling to the groin and/or armpit. Pain at bite site is extreme, there is massive shock (including pallor, faintness, sweating, nausea, vomiting, dilated pupils, weak pulse, cold clammy skin), and extensive tissue damage. Regional lymph nodes become enlarged, painful. Blood continues to ooze from punctures; after about 18 hours, blood may appear in saliva, urine, feces, vomitus, and small and large petechial hemorrhages may be seen beneath mucous membranes and under skin. Large blisters develop in region of bite. At about same time (or slightly earlier) true shock becomes apparent, with a drop in blood pressure, weakness, dizziness, nausea, vomiting, semiconsciousness or periods of unconsciousness. In untreated cases where shock does not intervene, hemorrhages extend to brain, resulting in convulsions and death. Hemorrhagic activity of venom especially high. Necrosis around bite site common, extensive. Damage may be extensive; may required amputation or result in permanent impairment of function. Massive amounts of antivenin may be required (up to 30 vials) to properly treat bite of this species Precautions must be taken to prevent serum sickness. *BEHR: "North Africa and West Africa," "Central Africa"; FITZ: "Polyvalent," unnamed cobra Bitis polyvalent; PAST: "Antirept Pasteur," "Bitis, Echis, Naja," "Pasteur Isper Afrique"; SAIMR: "Polyvalent" CARPET VIPER/SAW-SCALED VIPER/ARABIAN VIPER/(ECHIS COLORATUS)(E. COLORATUS) Category I. Found in Saudi Arabia in desert regions, yet is limited to rocky terrain and scrub brush. May be found at elevations up to 1,500 meters. Primarily nocturnal during dry, hot weather; sometimes active during day in cool weather. When hurried, resorts to sidewinding. During inactive periods, generally shelters in rodent burrows or under bushes or rocks. When disturbed, assumes figure-8 position and rubs the loops of the body together to produce a distinctive rasping sound. Strikes quickly and repeatedly with a considerable reach for a small snake. Topside: body is moderately stout to slender. Color is yellowish-gray, brownish-gray, or pale blue-gray. Back is darker than sides. Gray to tan blotches, or in some specimens, reddish or pinkish blotches run diagonally along the width. Underside: white, grayish-white, or yellowish-white, tippled with dark gray; chin and throat are white. Head: short and wide, distinct from neck. Blunt snout. Pale stripe from eye to angle of mouth. Tail: short; abruptly tapering from vent. length: 0.5 to 0.6 meters. Highly toxic venom and aggressiveness make E. coloratus a very dangerous snake. Fatalities reported. Venom is hemotoxic with hemorrhagic factors that contain both coagulant and anticcoagulant components. After bite, immediate local pain, swelling, and necrosis. Systemic symptoms include decreased blood pressure, fever, bleeding tendencies from gastrointestinal track, mucous membranes, venous punctures sites, muscles and subcutaneous tissues, and hematuria. *Antivenin apparently effective only if prepared from venoms of sam geographic taxonomic group. BEHR: "Near and Middle East," "North and West Africa"; HAFF: "Polyvalent"; IRAN: Poly-specific, "Echis" antivenin; KASA: "Polyvalent"; PAST: "Pasteur Ipser Afrique," "Antirept Pasteur"; TASH: "Monovalent (Echis carinatus)," "Polyvalent (Naja and Echis carinatus)"; SAIMR: "Echis"; ROGO: "Echis coloratus," "Arabian Echis" AFRICAN COBRA/(NAJA HAJE) Category II. Found in western Saudi Arabia in flat lands with scrubby bushes and grass clumps, irrigated fields, rocky hillsides, and old ruins. Often enters houses in search of prey. Probably not aggressive; often makes little effort at defense. Usually warns an intruder by rearing up with hood spread but may bite without spreading hood or may spread hood without raising upper body. Sometimes feigns death, even when handled. Responds quickly to movement and general shapes. Body shape is cobra-like, graceful, with even taper; males have longer tails, wider heads, and heavier hoods than females; smooth scales with dull sheen. Topside: brownish yellow, dark brown or almost black (young specimens are yellowish, head and neck black, body crossed by dark bands). Underside: yellowish, often mixed with brown; dark bars across neck. Head: short, wide, not distinct from neck; eye size moderate, pupils found. Tail: moderately long. Body moderately stout. Average length is 1.5 to 1.8 meters; maximum, 2.5 meters. Very dangerous because of large fangs and venom glands. Snake can inject large amounts in one envenomation; more toxic during summer than during winter; intravenous envenomation can kill in as few as 15 minutes. Venom is neurotoxic with proteolytic and anticoagulant components; also has a cardiotoxin that can stop the heart. Symptoms include euphoria or a "feeling of intoxication," followed by drowsiness; occasionally, dusk discoloration near bite site. followed by drooping eyelids (victims is conscious, but eyelid neuromuscular control is impaired), paralysis of eye muscles (may include impaired eye movement, blurred vision, double vision, dilated pupils); difficulty in speaking, opening mouth, moving lower jaw, sticking tongue out, swallowing; paralysis of palate (resulting in "nasal speech"); paralysis of face muscles (preventing smiling, puffing cheeks, moving lips, wrinkling forehead); weakness; "broken-neck syndrome); difficulty in swallowing (which may lead to aspiration of accumulated saliva, froth, viscid secretions, or vomit, and rapid death by suffocations; breathing difficulties - convulsions, shock, coma, cardiac arrest. Death may result from suffocation or respiratory difficulties. *BEHR: "Central Africa," "Near and Middle East," "North and West Africa"; PAST: "Antirept Pasteur, "Bitis-echis- Naja" (if available), "Near and Middle East" (if available), "Pasteur Ipser Afrique"; SAIMR: "Polyvalent" EYEHORNED VIPER/FALSE HORNED VIPER/FIELD'S HORNED VIPER/ (PSEUDOCERASTES PERSICUS FIELDI) Category II. Found in northern Saudi Arabia. Inhabits sandy and rock terrain to elevations of approximately 2,000 meters. Nocturnal. Sluggish during the day. Moves with a sidewinding motion. Placid during daylight. Becomes aggressive at night. When molested or disturbed, hisses loudly. Topside: wide relative to its length. colored pale gray or bluish-gray to khaki with gray or brownish-gray blotches or crossbands, which usually are much narrower than the space between them. Throat and sides of the body have alternating faint spots. Underside: White to cream. Head: short, wide, and distinct from the neck. Snout blunt, with small scale-covered horns just above the eyes. A dark brown band marks the side of the head just around the eye. Eyes are small to moderate with vertical elliptical pupils. Tail: black, narrow in relation to the body. Length: -.5 to 0.7 meters, maximum 0.9 meters. Highly toxic venom but moderate frequency of encounter and limited aggressiveness. Venom is neurotoxic. Few or no local symptoms of envenomation Usually local symptoms consist of minor pain, mild tingling of the extremity or local area, impaired digital dexterity, stiffness, and in more serious cases, weakness followed by ptosis. victim will be conscious but cannot respond. Death due to respiratory depression. *IRAN: "Persica Antivenin," Polyspecific. SECTION II DISEASES Food- and waterborne diseases are the major sources of morbidity for non-indigenous personnel in Saudi Arabia. Inadequate sanitation contributes to the incidence of acute diarrheal diseases, hepatitis A, enteric protozoal diseases, typhoid and paratyphoid fevers, and brucellosis. Sandfly fever, cutaneous leishmaniasis, and falciparum malaria are the primary vector-borne disease risks; other arboviral fevers are present. Acute respiratory infections (ARIs, including influenza) and dermatologic conditions occur worldwide and may become major sources of morbidity among non-indigenous personnel, particularly under stressful or poor hygienic conditions. In Saudi Arabia, risk for ARIs is elevated in the winter months; dusty environments can contribute to increased incidence. However, because of their ubiquity and the mission-dependent nature of their impact on operational readiness, ARIs and dermatologic conditions are not included in this study. The following diseases could adversely affect personnel during the initial 60 days of a military operation in Saudi Arabia. Normal incubation periods are shown in parentheses. Within each category, diseases are prioritized in descending order of expected impact on military operations if no preventive measures are taken. Extraordinary events, including epidemics of cyclic diseases, natural disasters, and national events leading to a compromise of established preventive medicine programs, may alter the prioritization. DISEASES WITH SHORT INCUBATION PERIODS (USUALLY LESS THAN 15 DAYS) ACURE DIARRHEAL DISEASES (6 hours to 10 days) TRANSMISSION: Ingestion of causative agents or their toxins in contaminated food or water. RISK PERIOD/DISTRIBUTION: Year-round; overall risk elevated from July through September; risk from bacterial etiologies is elevated from June through October; risk from viral etiologies is elevated from December through March. Countrywide; risk greater in rural village areas. REMARKS: Highly endemic. May be a major cause of morbidity among nonindigenous personnel. Frequently occurring pathogens include enterotoxigenic Escherichia coli (ETEC), Shigella spp. (primarily Sh. sonnei or Sh. flexneri, Salmonella spp., and Campylobacter spp. Salmonellosis increasingly is being reported. Multiple drug- resistant strains of Salmonella spp. and Shigella spp. are common. Rotavirus and enteropathogenic E. coli (EPEC) are common causes of diarrhea in children. ENTERIC PROTOZOAL DISEASES (1 week to seveal months) TRANSMISSION: Ingestion of causative agent(s) in fecally contaminated water or food. RISK PERIOD/DISTRIBUTION: Year-round; increased incidence in August and September. Countrywide. REMARKS: Moderately endemic. 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, is the most commonly detected intestinal parasite, and generally is associated with poor sanitary conditions. Amebiasis is the most common cause of clinical dysentery; carriers are common in apparently healthy adults. SANDFLY FEVER (3 to 4 days) TRANSMISSION/VECTOR ECOLOTY: Bite of an infective sand fly. Phlebotomus papatasi, the primary vector, is most active between dusk and dawn, has a limited flight range, is peridomestic in its breeding habits, and readily enters human habitations to feed. RISK PERIOD/DISTRIBUTION: Transmission occurs primarily from April through October, coinciding with vector activity, peaking in August and September. Foci may occur throughout the country, with elevated risk in village and periurban areas, paralleling the distribution of sand fly vectors. Risk may be lower along the western Saudi Arabia-Iraq border. REMARKS: Moderately endemic. Although local populations generally become immune during childhood, sandfly fever poses a significant risk to nonindigenous personnel. Sandfly fever caused significant morbidity among Allied forces in the Persian Gulf theater during World War II. Serological studies of the arbovirus indicate that the Sicilian and Naples viral serotypes are present. TYPHOID AND PARATYPHOID FEVERS (1 to 3 weeks) TRANSMISSION: Ingestion of causative agent(s) in food and water contaminated by feces or urine from infective humans. RISK PERIOD/DISTRIBUTION: Year-round, with increased incidence from June through August. Countrywide. REMARKS: Moderately endemic. Carriers, including expatriate workers, contribute to transmission. Multiple drug-resistance has been reported. May be a significant source of morbidity among nonindigenous personnel. MALARIA (12 to 14 days) TRANSMISSION/VECTOR ECOLOTY: Bite of an infective mosquito (Anopheles spp.). Primary vectors in endemic areas of Saudi Arabia are An. sergentii and An. arabiensis. Both will feed on humans indoors. RISK PERIOD/DISTRIBUTION: In endemic areas, 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 Medinah) 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. Malaria transmission has been interrupted in eastern, central, and northern Saudi Arabia. REMARKS: The most intense transmission occurs in the southwestern provinces. Plasmodium falciparum causes over 80 percent of the indigenous cases, with P. viviz causing nearly all other cases. A low level of chloroquine-resistant falciparum malaria is suspected in the southwest. (Resistance has been confirmed in adjacent areas in Yemen.) In nonendemic areas, imported cases generally are attributable to expatriate workers. Vector species are present in areas cleared of malaria. ARBOVIRAL FEVERS (Other than Sandfly Fever) (3 to 12 days) Lack of incidence data may reflect inadequacies in diagnostic capabilities. WEST NILE FEVER AND SINDBIS FEVER: Not officially documented, but are known to occur in neighboring countries; potential mosquito vectors (Culex spp.) are present. West Nile virus has 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): Enzootic in widely distributed discrete foci in agricultural areas, with a small number of clinical cases reported sporadically. The virus is transmined by infective Hyalomma spp. ticks or by exposure to infected animals (usually sheep, goats, and cattle) or humans. Transmission risk is greatest from May through September. An outbreak occurred in Saudi Arabia near Jiddah and Mecca in May 1990, and was associated with slaughtered sheep. Many infections apparently are asymptomatic, and serological evidence indicates exposure rates of up to 30 percent among persons associated with livestock. DENGUE FEVER: Historically reported in coastal areas, but current data are not available; the potential mosquito vectors, Aedes aegypti, is present. MENINGOCOCCAL MENINGITIS (2 to 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; peak incidence from November through February. Countrywide; increased risk under crowded living conditions and for personnel having close contact with local nationals. REMARKS: Endemic, usually occurring as sporadic cases; cyclic outbreaks occur. Group A usually predominates, but Group W-135 case reporting increased during the late 1980s. Group A outbreaks occurred following the 1987 Hajj. SEXUALLY TRANSMITTED DISEASES (2 days to 3 weeks) TRANSMISSION: Sexual contact. (STDS) RISK PERIOD/DISTRIBUTION: Year-round and countrywide. REMARKS: Endemic, but actual levels unclear. Gonorrhea predominates; penicillin-resistant strains of Neisseria gonorrhoeae and other acute STDs have not been officially reported, but presumably occur. CHOLERA (usually 2 to 3 days, range of 6 hours to 5 days) TRANSMISSION: Ingestion of causative agent, primarily in water contaminated with feces or vomitus from infective humans. RISK PERIOD/DISTRIBUTION: Undetermined. REMARKS: Endemic status unclear, but non-indigenous personnel on Western military rations are at low risk of.infection. Reported cases usually are imported, but limited outbreaks occur; outbreaks have occurred in neighboring countries as recently as 1991. DISEASES WITH LONG INCUBATION PERIODS (USUALLY MORE THAN 15 DAYS) ENTERICALLY TRANSMITTED ACUTE VIRAL HEPATITIS (A AND E) (15 to 65 days) TRANSMISSION: Person-to-person by the fecal-oral route. RISK PERIOD/DISTRIBUTION: Year-round and countrywide. REMARKS: Hepatitis A is highly endemic and may pose a major health risk to non-indigenous personnel; most Saudis contract hepatitis A virus infection during childhood. Hepatitis E has not been reported, but presumably occurs. LEISHMANIASIS (1 week to many months) TRANSMISSION/VECTOR ECOLOTY: 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 (Leishmania major) and P. sergenti (L tropica). The suspected vectors for visceral leishmaniasis (VL), caused by L donovani, are P. alexandri and P. papatasi. RISK PERIOD/DISTRIBUTION: Transmission occurs primarily from April through November, peaking July through September. Widespread, focally distributed. CL caused by L major occurs primarily in the eastern (an area of hyperendemicity may exist near the Al Hofuf oasis) and central provinces; by L tropica primarily in the mountains of the western provinces; and VL primarily in the southwestern Asir region. However, all forms may be present in leishmaniasis endemic areas. REMARKS: Most CL cases in rural and periurban areas are caused by L major; distribution is focal, based on the distribution of zoonotic reservoirs, primarily the fat-tailed sand rat (Psammomys obesus). CL cases caused by L tropica generally occur in village or urban areas; no animal reservoir has been identified. VL generally occurs in focal rural areas; peak incidence is from December to April; the reservoir is unknown, but jackals and dogs are suspected. SCHISTOSOMIASIS (2 to 6 weeks) TRANSMISSION/VECTOR ECOLOGY: Penetration of the skin by waterborne larval forms (cercariae) of the parasite that develop in snails in fresh water habitats. The primary intermediate host for Schistosoma mansoni (intestinal schistosomiasis) is Biomphalaria arabica and for S. haematobium (urinary schistosomiasis) is Bulinus spp. RISK PERIOD/DISTRIBUTION: Transmission occurs year-round; increased risk during the spring. Focally distributed in wadis, aqueducts, and cisterns in western regions, and oases in central regions. Intestinal schistosomiasis foci occur in the central (Hail, Riyadh), northern (Al Jawf), northwestern (Tabuk, Al Medinah), 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. REMARKS: Moderate infection rates in endemic areas; generally, S. mansoni infections predominate. An active control program reduced prevalence during the 1980s. Overall infection rate in 1988 was estimated at 1.8 percent, ranging from 0.6 to 26.1 percent in endemic foci. PARENTERALLY TRANSMITTED ACUTE VIRAL HEPATITIS (B, C, AND D) (15 to 180 days) TRANSMISSION: Contact With causative agent through blood transfusions, contaminated needles, sexual contact, and contaminated perineal wounds. RISK PERIOD/DISTRIBUTION: Year-round and countrywide. REMARKS: Hepatitis B virus (HBV) is moderately endemic; HBV antibodies are present in an estimated 20 to 40 percent of the population; the HBV carrier rate is estimated at 8 to 10 percent (hyperendemic foci exist). Hepatitis D has been found in approximately 10 to 20 percent of HBV carriers. Hepatitis C has not been reported, but presumably occurs. OTHER ENDEMIC DISEASES OF POTENTIAL MILITARY SIGNIFICANCE ZOONOTIC DISEASES: Brucellosis (enzootic, particularly in goats and camels; human cases, caused by Brucella melitensis, are common and usually are due to consumption of raw goat/camel milk or milk products; recent outbreaks reported); a 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 rural areas; jackals constitute the primary reservoir, with some spillover into stray dogs; few human cases reported annually). VECTOR-BORNE DISEASES Plague (flea-borne; no cases reported recently, but enzootic foci exist in the Asir region of the southwestern Arabian Peninsula and along the Tigris-Euphrates River extending to Kuwait, possibly including the northern border with Iraq); flea-borne typhus (enzootic areas in eastern Saudi Arabia and along the southwestern border with Yemen; sporadic cases occur); onchocerciasis (confined to the southwestern Arabian Peninsula in focally endemic areas; the black fly, Simulium damnosum complex, is the primary vector); tick-borne relapsing fever, louse-borne typhus, and louse-borne relapsing fever (cases have not been reported, but enzootic foci exist in Iraq). SEXUALLY TRANSMITTED DISEASES Syphilis (endemic, but prevalence unclear; probably the second most common STD); AIDS/HIV (through the end of 1990, only a few cases were reponed officially, additional cases are believed to have occurred; in-country HIV testing reportedly is performed, but limited data are available; no HIV infections were detected in a 1988 survey of blood donors in Mecca; considered a low risk). OTHER INFECTIOUS DISEASES Trachoma (widespread, especially in rural areas and among nomadic tribesmen; control measures reduced incidence during the 1980s, but trachoma remains the most common cause of preventable blindness); intestinal helminthic infections (hymenolepiasis, ascariasis, enterobiasis, and trichuriasis; common in rural areas and among lower socioeconomic groups); tuberculosis (endemic; annual incidence reportediy declined during the late 1980s, but prevalence remains moderate, especially among lower socioeconomic groups; initial multiple-drug resistance has been reported); acute hemorrhagic conjunctivitis (recent outbreaks have occurred in coastal areas of eastern and southwestern Saudi Arabia).
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