The epidemiology of self-reported diarrhea in operations Iraqi freedom and enduring freedom

doi:10.1016/j.diagmicrobio.2004.06.008

Diagnostic Microbiology and Infectious Disease

Volume 50, Issue 2, October 2004, Pages 89-93

https://doi.org/10.1016/j.diagmicrobio.2004.06.008 Get rights and content

Abstract

Diarrhea remains a potential cause of compromised military effectiveness. To assess diarrhea rates and mission impact in operations in Iraq and Afghanistan, a survey was administered to soldiers participating in the “Rest and Recuperation” program in Doha, Qatar. Between October and December 2003, 2,389 volunteers completed a questionnaire designed to assess the occurrence and impact of diarrhea. The median length of deployment was 7.2 months, 70% reported at least one episode, and 56% had multiple episodes of diarrhea. Overall, 43% reported decreased job performance for a median of 2 days, and 17% reported being on bed rest for a median of 2 days. While this survey showed high rates of diarrhea associated with decreased operational effectiveness, the results are consistent with prior military operations in this region. Further research is needed to develop better methods for illness prevention and its minimization on operational impact.

Introduction

Historically, diarrhea is one of the most common medical conditions afflicting deployed military personnel (Cook, 2001) with an average incidence of 29% per month (Sanchez et al., 1998). While diarrhea is generally a self-limited illness, the associated morbidity taxes operational health care resources, causes alterations in mission planning and may reduce mission effectiveness through temporary manpower losses. During the Korean War, 78,970 days from duty were lost due to diarrhea and dysentery. In Vietnam, admission rates to hospitals or quarters was higher than malaria by a 4:1 ratio, making it the largest single disease of the war (Connor and Farthing, 1999). During the first Gulf War, up to 57% of deployed military personnel reported diarrhea, with 20% temporarily unable to perform their duties (Hyams et al., 1991).

Currently, there are approximately 130,000 U.S. military personnel deployed to Operation Iraqi Freedom (OIF) and an additional 10,000 deployed to Operation Enduring Freedom (OEF) in Afghanistan. Considering the history of diarrhea among deployed military forces, it is likely having a significant influence on daily operations despite modern preventive medicine measures. To assess the impact of diarrhea on operational effectiveness, a system was established to survey soldiers while on a “Rest and Recuperation” (R&R) program at Camp As Sayliyah in Doha, Qatar.

Section snippets

Materials and methods

The U.S. Army systematically selected units from Iraq and Afghanistan to participate in the R&R program. Troops from these units were sent to Camp As Sayliyah in Doha, Qatar, the principal R&R location. Upon arrival, volunteers completed a questionnaire adapted from previous studies designed to assess diarrhea incidence, associated symptoms, treatment; and mission impact (Sanders et al., 2002). Diarrhea was defined as three or more loose or liquid stools in 24 hours, or two or more loose or

Results

The study was conducted from October 27 to December 4, 2003. Of the 5,309 U.S. military personnel participating in R&R during that period, 2,389 (45%) individuals completed the questionnaire, representing approximately 2% of the personnel deployed to Iraq and Afghanistan (Iraq = 2,130, Afghanistan = 181, missing = 78). The distribution of military rank among all personnel participating in R&R and those completing the questionnaire were similar. Troops were deployed a median of 7.2 months [IQR

Discussion

The R&R program offered a unique opportunity to estimate diarrhea incidence and its impact on troops deployed to Iraq and Afghanistan. Given the broad sampling of the deployed population and the number of respondents, our results should represent the collective experience of U.S. military personnel deployed to these areas. Demographics of the surveyed individuals closely reflect the demographics of combat-ready troops in the U.S. Army (‘Army Demographics FY03’, Office of the Deputy Chief of

Author's contributions

Study Concept/Design: Sanders, Putnam, Riddle, Tribble, Jobanputra; Acquisition of Data: Sanders, Jones, Jobanputra; Analysis: Putnam, Riddle; Interpretation: Sanders, Putnam, Riddle, Tribble; Drafting manuscript: Sanders, Putnam, Riddle, Jobanputra; Critical revision of the manuscript for important intellectual content: Sanders, Putnam, Riddle, Scott, Tribble, Frenck; Statistical expertise: Putnam, Riddle; Obtained funding: Sanders, Frenck, Scott; Administrative/technical/material support:

Acknowledgements

NAMRU3: Manal Mustafa, Yasmine Farid, Mohammed Assem, and Amani Badawi; NAMRU2: Andrew Whitehurst; Camp As Sayliyah (Doha, Qatar): SSGT Christopher Parks, Jaime Bland, CPT Kenneth Brooks.

References (11)

J.A. Adachi et al.
Empirical antimicrobial therapy for traveler's diarrhea
Clin Infect Dis
(2000)
J.D. Arthur et al.
A comparative study of gastrointestinal infections in United States soldiers receiving doxycycline or mefloquine for malaria prophylaxis
Am J Trop Med Hyg
(1990)
P. Connor et al.
Travellers' diarrhoeaa military problem?
J R Army Med Corps
(1999)
G.C. Cook
Influence of diarrhoeal disease on military and naval campaigns
J R Soc Med
(2001)
K.C. Hyams et al.
Diarrheal disease during Operation Desert Shield
N Engl J Med
(1991)

There are more references available in the full text version of this article.

Cited by (49)

A single dose of ciprofloxacin reduces the duration of diarrhea among service members deployed in Africa
2023, Infectious Diseases Now
To assess the effectiveness of the adjunction of a one-gram single dose of ciprofloxacin to a symptomatic treatment for the early treatment of uncomplicated diarrhea during military operations of the French service members in Africa.
This phase IV, multicentric, randomized, open-label, controlled trial was conducted in Chad, Mali, and in Central African Republic. A total of 267 French service members having at least one loose stool in the previous 24 hours were enrolled from May 2015 to June 2016. Participants were randomized to receive ciprofloxacin 1 g and a symptomatic treatment (racecadotril 100 mg three times a day and ad libidum oral rehydration solution) or a symptomatic treatment alone. The primary outcome was the duration of the diarrhea. Secondary outcomes were evaluated at the 72-hour endpoint and included recovery status, number of loose stools, frequency and duration of associated symptoms and safety of treatments.
Among 267 participants, 242 completed the trial. Participants receiving ciprofloxacin and a symptomatic treatment (n = 124) were significantly more likely to be cured at the endpoint than those who only received a symptomatic treatment (118): 94.4 % versus 74.6 % (OR = 5.7; 95 %CI: [2.4–13.6]; p < 10^-3). The antibiotic therapy reduced the average diarrhea duration by 30 % (p = 10^-4). Fever at inclusion was associated with a longer episode (HR = 0.61; 95 %CI: [0.41–0.89]; p = 0.012). No adverse event of medications was reported.
A single dose of ciprofloxacin was effective and safe in treating uncomplicated diarrhea among service members in Africa.
Epidemiology of travelers’ diarrhea
2018, Travel Medicine
Acute diarrhea is the most common medical complaint of international travelers to high-risk tropical and semitropical regions of the world. Enterotoxigenic Escherichia coli (ETEC) is the most common cause with strains of Campylobacter jejuni and other invasive bacterial enteropathogens also important causes especially in South Asia. Treatment can shorten the disease. Loperamide and other drugs acting symptomatically can decrease the number of watery stools passed and antimicrobial agents can shorten the overall illness. Because of the significance of acquiring fecal carriage of multidrug-resistant Enterobacteriaceae with antibiotics, most travel authorities only recommend treatment with these drugs when illness is moderate to severe. Mild illness, which allows people to function relatively normally, is best left untreated or treated symptomatically. A major health consequence of travelers' diarrhea (TD) is development of postinfectious functional bowel disease, which may occur in as many as 5% of those reporting TD.
Military Perspectives on Brain Injuries: Implications on Clinical Trials
2018, Handbook of Neuroemergency Clinical Trials: Second Edition
Military medical providers rely on civilian medical research to advanced care. The clinical practice guidelines developed for civilian practice is used by the military. Similarly, the same journals, expert panel reviews, and so on are all used by military medicine. However, due largely to limited civilian interest, there are specific medical conditions for which the Department of Defense (DoD) must itself conduct or sponsor. Examples of these conditions are hemorrhagic shock, explosive blast traumatic brain, malaria, and others. For many military patients, the highest level of care will be a medic, who may be required to render care for prolonged periods when evacuation is not possible. For these, the DoD will develop research programs that are conducted either by funding civilian medical scientists or engaging intramural DoD scientists. Importantly, the ethics and other rules of conduct regulating civilian medical research apply equally to the military scientists. These include all the typical human subject informed consent, animal use protocols, and review board approvals. For any human subject work done on behalf of the DoD, a second level of Human Use approval is required. DoD supported medical research, whether conducted on behalf of military or civilian patients, is meant to benefit everyone.
Military Perspectives on Brain Injuries: Implications on Clinical Trials
2017, Handbook of Neuroemergency Clinical Trials
Military medical providers rely on civilian medical research to advanced care. The clinical practice guidelines developed for civilian practice is used by the military. Similarly, the same journals, expert panel reviews, and so on are all used by military medicine. However, due largely to limited civilian interest, there are specific medical conditions for which the Department of Defense (DoD) must itself conduct or sponsor. Examples of these conditions are hemorrhagic shock, explosive blast traumatic brain, malaria, and others. For many military patients, the highest level of care will be a medic, who may be required to render care for prolonged periods when evacuation is not possible. For these, the DoD will develop research programs that are conducted either by funding civilian medical scientists or engaging intramural DoD scientists. Importantly, the ethics and other rules of conduct regulating civilian medical research apply equally to the military scientists. These include all the typical human subject informed consent, animal use protocols, and review board approvals. For any human subject work done on behalf of the DoD, a second level of Human Use approval is required. DoD supported medical research, whether conducted on behalf of military or civilian patients, is meant to benefit everyone.
Do alcohol-based hand rubs reduce the incidence of acute diarrhea during military deployments? A prospective randomized trial
2017, Travel Medicine and Infectious Disease
Citation Excerpt :
In fact, diarrhea among military travelers deployed globally in conflict and peacekeeping activities remains one of the most important health threats [4], with an overall incidence ranging from 5 to 30 episodes p.100 person-months [5]. Although most often benign, diarrhea is a potential cause of compromised military effectiveness during operational deployments [6]. In tropical countries, large outbreaks can occur [7] like the one affecting the French armed forces in April 2013 in Mali: over 5 weeks, 270 cases were reported, accounting to a 16% attack rate [8].
Acute diarrhea remains a public health concern in armed forces deployed in tropical areas where access to water and soap is limited. This study aims to assess the effectiveness of alcohol-based hand rubs (ABHR) on incidence of diarrhea in poor hygiene conditions.
A prospective randomized trial was conducted between November 2014 and January 2015 among French military troops deployed in Africa to compare a group of soldiers receiving usual hand hygiene recommendations (control group), to a group of soldiers who received ABHR in addition to usual hand hygiene recommendations (intervention group). Data on diarrhea and hygiene behaviors were collected using self-questionnaires. The incidence rate of diarrhea episodes in groups was compared.
Participation rate was 59% (236/400). The proportion of individuals who used ABHR was 97% in the intervention group and 62% in the control group. The overall incidence rate of diarrheal episodes was observed to be in the region of 60 per 100 persons-month without any significant difference between groups after adjustment on confounding factors (p = 0.93). Handwashing with soap was used on average 4 times a day in the control group and twice a day in the intervention group (p = 0.93). It was the only significant protective factor for diarrhea (p < 10⁻³).
Our results support that supplying soap and good quality water should be a priority on the field.
Epidemiology of Travelers' Diarrhea
2013, Travel Medicine: Third Edition

View all citing articles on Scopus

View full text

BacteriologyThe epidemiology of self-reported diarrhea in operations Iraqi freedom and enduring freedom

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Author's contributions

Acknowledgements

Empirical antimicrobial therapy for traveler's diarrhea

Clin Infect Dis

A comparative study of gastrointestinal infections in United States soldiers receiving doxycycline or mefloquine for malaria prophylaxis

Am J Trop Med Hyg

Travellers' diarrhoeaa military problem?

J R Army Med Corps

Influence of diarrhoeal disease on military and naval campaigns

J R Soc Med

Diarrheal disease during Operation Desert Shield

N Engl J Med

Bacteriology
The epidemiology of self-reported diarrhea in operations Iraqi freedom and enduring freedom