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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)47.41.79.22; 
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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