Medical surveillance of multinational peacekeepers deployed in support of the United Nations Mission in Haiti, June-October 1995.

BACKGROUND: Multinational peacekeepers, both military and civilian, often deploy to areas of the world where significant health threats are endemic and host country public health systems are inadequate. Medical surveillance of deployed personnel enables leaders to better direct health care resources to prevent and treat casualties. Over a 5-month period, June to October 1995, a medical surveillance system (MSS) was implemented in support of the United Nations Mission in Haiti (UNMIH). Information obtained from this system as well as lessons learned from its implementation and management may help decrease casualty rates during future multinational missions. METHODS: Over 90% of UNMIH personnel (80% military from over 11 countries and 20% civilian from over 70 countries) stationed throughout Haiti participated in the MSS. A weekly standardized reporting form included the number of new outpatient visits by disease and non-battle injury (DNBI) category and number of personnel supported by each participating UN medical treatment facility (MTF). Previously, medical reporting consisted of simple counts of patient visits without distinguishing between new and follow-up visits. Weekly incidence rates were determined and trends compared within and among reporting sites. The diagnoses and numbers of inpatient cases per week were only monitored at the 86th Combat Support Hospital, the facility with the most sophisticated level of health care available to UN personnel. RESULTS: The overall outpatient DNBI incidence rate ranged from 9.2% to 13% of supported UN personnel/week. Of the 14 outpatient diagnostic categories, the three categories consistently with the highest rates included orthopaedic/injury (1.6-2.5%), dermatology (1.3-2.2%), and respiratory (0.9-2.2%) of supported UN personnel/week. The most common inpatient discharge diagnoses included suspected dengue fever (22.3%), gastro-enteritis (15%), and other febrile illness (13.5%). Of the 249 patients who presented with a febrile illness, 79 (32%) had serological evidence of recent dengue infection. Surveillance results helped lead to interventions that addressed issues related to field sanitation, potable water, food preparation and vector control. CONCLUSIONS: Despite hurdles associated with distance, language, and communications, the MSS was a practical and effective tool for UNMIH force protection. UN requirements for standardized medical surveillance during deployments should be developed and implemented. Furthermore, planners should recognize that if ongoing medical surveillance and related responses are to be effective, personnel should be trained prior to deployment and resources dedicated to a sustained effort in theatre.

Seroprevalence of hepatitis E virus among United Nations Mission in Haiti (UNMIH) peacekeepers, 1995.

Information about the prevalence of hepatitis E virus (HEV) infection is sparse in many countries. Following the identification of four cases of acute HEV infection among Bangladeshi soldiers, a serologic survey was conducted to determine the prevalence of HEV infection among other peacekeepers from the United Nations Mission in Haiti (UNMIH) and Haitian civilians. Of the 981 participants in the survey, 876 were soldiers from eight UNMIH-participating countries representing Asia, Africa, and the Americas, and 105 were Haitian civilians. The prevalence of HEV infection by country (from highest to lowest) included Pakistan (62%), India (37%), Nepal (37%), Bangladesh (27%), Djibouti (13%), Honduras (6%), Guatemala (5%), Haiti (3%), and the United States (2%). More than 90% of those surveyed from Guatemala, Haiti, and Honduras, where prevalence data has been scarce, appeared susceptible to HEV infection. Future multinational missions like the UNMIH might also present unique opportunities to study health threats of widespread interest.

Gender-related efficacy difference to an extended duration formulation of topical N,N-diethyl-m-toluamide (DEET).

A clinical trial (n = 120, 60 males and 60 females) was conducted to assess the efficacy of an extended duration tropical insect/arthropod repellent (EDTIAR) topical formulation of N,N-diethyl-m-toluamide (DEET). The amount of EDTIAR (mean +/- confidence interval), applied by participants in accordance with label directions, was not significantly different between females (3.66 +/- 0.32 mg/cm2) and males (3.45 +/- 0.33 mg/cm2). There also was no significant difference in the number of Anopheles stephensi mosquitoes biting the control arm of females or males at 0, 3, 6, 9, and 12 hr. While gender had no effect on feeding, the time of day did effect mosquito feeding with fewer mosquitoes feeding in the afternoon than in the morning or evening. The percent protective efficacy at 0, 3, 6, 9, and 12 hr was 100.0, 99.3, 92.8, 79.7 and 66.3 for females, and 100.0, 100.0, 97.6, 91.9, and 77.5 for males. These data are inconsistent with the EDTIAR label claim that the repellent provides 95% or greater protection against mosquitoes for 12 hr or more under normal use conditions. The results of a multivariate regression analysis indicated that 1) protection decreased linearly as time after application of repellent increased (P < 0.001), 2) individuals who applied higher doses of repellent were better protected against mosquito bites (P < 0.001), 3) females experienced significantly less protection over time than did males (P = 0.005), and 4) the estradiol concentration in the blood had no effect on efficacy of the repellent (P = 0.110).

A cluster of acute hepatitis E infection in United Nations Bangladeshi peacekeepers in Haiti.

In the fall of 1995, within a month of deployment to Haiti for peacekeeping duty, four Bangladeshi soldiers developed acute icteric hepatitis in rapid succession. Hepatitis E virus (HEV) was found to be the etiology by demonstrating HEV genomic sequences in serum samples by the polymerase chain reaction (PCR) and serologically by the detection of elevated IgM titers to HEV. No case had serologic evidence of acute hepatitis A or C infection. The soldiers had probably acquired their infection while living in a cantonment area outside Dhaka, Bangladesh for one month prior to deployment. Cloning and sequencing of amplified PCR products demonstrated a single strain suggestive of a common source of infection. Furthermore, high genomic identity with Asian strains of HEV and dissimilarity with the Mexican strain was demonstrated, verifying that the strain had indeed been imported. Human waste management from the Bangladesh camp in Haiti was strictly controlled and no secondary cases were observed. A convenience sample of 105 (12%) soldiers from the Bangladesh battalion (850 men) revealed anicteric or asymptomatic HEV infection in seven (7%) of 105. This report contains the first demonstration of acute hepatitis E in natives of Bangladesh and demonstrates the power of the PCR in the rapid diagnosis and epidemiologic analysis of HEV infection. More importantly, this cluster demonstrates the importation of an important infectious disease by multinational peacekeepers to a potentially susceptible host country.

Laboratory diagnosis of acute dengue fever during the United Nations Mission in Haiti, 1995-1996.

We evaluated laboratory methods to confirm a clinical diagnosis of dengue. Acute sera were collected from personnel (n = 414) supporting the United Nations Mission in Haiti and presenting with febrile illness consistent with dengue fever or no apparent underlying cause. Dengue virus was recovered from 161 of 379 acute sera by inoculation into C6/36 cell culture. While 93 of 414 acute sera had detectable IgM antibodies, the IgM capture ELISA (MAC ELISA) had a sensitivity of only 13% compared with the virus isolation gold standard. If presumptive dengue fever cases were identified by both virus isolation and the presence of IgM, virus isolation and the MAC ELISA had clinical sensitivities of 69% and 40%, respectively. This study suggests that a combination of laboratory methods that target virus or subviral components as well as anti-viral IgM antibodies may be necessary for sensitive laboratory diagnosis with acute sera.

Japanese encephalitis vaccine (inactivated, BIKEN) in U.S. soldiers: immunogenicity and safety of vaccine administered in two dosing regimens.

The safety and immunogenicity of Japanese encephalitis (JE) vaccine (Nakayama strain, monovalent / BIKEN) was studied in 538 U.S. soldiers in 1990. Three doses of vaccine from three consecutively manufactured lots were given on days 0, 7, and either 14 or 30. Serum for antibody determination was drawn at months 0, 2, and 6. Japanese encephalitis plaque reduction neutralization tests were performed by three laboratories on each specimen. Five hundred twenty-eight (98%) participants completed the immunization series. All recipients without antibody before immunization developed neutralizing antibody against JE virus. There were no differences in geometric mean titer among the three test lots at months 2 and 6. Soldiers who received the third dose on day 30 had higher titers at both time points. Antibody to yellow fever had no significant effect on immune response to vaccine. Conclusions drawn from analysis of serologic data from the three labs were nearly identical. Symptoms were generally limited to mild local effects and were reduced in frequency with each subsequent does in the series (21% to 11%; P < 0.0001). Generalized symptoms were rare (e.g., fever = 5%) with no reported cases of anaphylaxis.

Deployed US Army soldiers' knowledge and use of personal protection measures to prevent arthropod-related casualties.

The recommendation to use personal protection measures (PPMs) to prevent arthropod-related diseases and nuisance bites is a common element of travel medicine consultation.1-3 Prevention of arthropod-related casualties is especially important to the military, given the often intense exposure of service members to biting arthropods and the threat of personnel losses to mission success. In the 1980s, 75% deet (N,N-diethyl-m-toluamide) was the US military-issue insect repellent for use on skin and clothing. Collaboration between military and civilian researchers led to the implementation in 1991 of the current US military system of PPMs which has three components: topical application of 33% extended-duration deet, treatment of field uniforms with permethrin, and proper wearing of field uniforms.4-6 Compared to military-issue 75% topical deet, 33% extended-duration deet prevents bites up to three times longer (as long as 12 hours), is less greasy, and has lower plasticizing properties. Field uniforms treated with the contact toxicant, permethrin, are also necessary to minimize bites from crawling arthropods such as ticks and chiggers. Implementation of all three components of this system is a safe and effective means of reducing the threat posed by biting arthropods.7 We conducted a questionnaire survey to assess the degree of deployed soldiers' knowledge of the US military's system of PPMs and use of PPMs in general. Survey results may promote the development of better ways to advise and teach military and civilian travelers about the proper use of PPMs given the multitude of available products and practices.

U.S. military overseas medical research laboratories.

Many infectious disease threats to U.S. military operations are uncommon in the United States. The advanced development and testing of countermeasures, such as vaccines, drugs, or insect repellents, requires the capability to study militarily important infectious diseases where they occur. With formal agreements between the U.S. and each host country, the U.S. military operates seven overseas medical research laboratories (labs). Six labs conduct infectious disease research and are distributed over three continents: Africa (labs in Egypt and Kenya), Asia (labs in Indonesia and Thailand), and South America (labs in Brazil and Peru). One other lab is located in Germany and conducts psychosocial research related to military personnel and their families. In addition to product development, these labs play vital roles supporting overseas deployments, providing technical training, and promoting international relations. Also, these labs are well positioned to become part of a developing global surveillance and response system to help address the threat posed by emerging infectious diseases. This article will present an overview of this unique medical research capability, describe the history and some of the activities of each lab, and discuss the importance of maintaining these labs in the 21st century.

Prostatodynia in United Nations peacekeeping forces in Haiti.

Prostatodynia is a clinical entity associated with voiding symptoms and pelvic pain suggestive of prostatitis but with a normal prostate examination and without evidence of inflammation or infection in expressed prostatic secretions. The problem tends to be chronic and is vexing in its management. Although thought to be a common condition, prevalence data are generally lacking. From June to October 1995, the U.S. Army's 86th Combat Support Hospital provided medical support to a multinational United Nations peacekeeping force in Haiti. Patients diagnosed with prostatodynia were more common (13 cases) than men with other urologic problems (urolithiasis, 6 cases; urinary tract infection, 6 cases; scrotal abscess/mass, 2 cases; epididymitis, 1 case). Patients tended to be young (mean age 29.8), had multiple visits, failed to respond to multiple courses of antibiotics for presumed "prostatitis," and denied recent sexual relations. Some patients reported having had similar symptoms on prolonged separation from their spouses in the past that resolved with resumption of normal intercourse. Masturbation, however, had no impact on symptoms and was painful in some individuals. Terazosin, an alpha-antagonist, and stress-reduction therapy led to improvement in some patients' symptoms. A discussion of these retrospective findings in light of what is known about the possible etiologies and treatment of prostatodynia is presented. Prostatodynia appears to be a common problem in deployed troops and can lead to frequent use of medical services. Physicians supporting long deployments need to be aware of this entity.

Lessons learned from producing health information booklets for deploying U.S. military personnel.

Health information booklets deliver information to large groups quickly and economically. Rapidly deploying soldiers are a group that needs such information. Military personnel responsible for the health of troops should know of the materials produced to meet this need so that they can facilitate booklet distribution. The Walter Reed Army Institute of Research within the U.S. Army Medical Research and Material Command has produced health information booklets in support of deployments to Southwest Asia, Somalia, Rwanda, Haiti, and the former Republics of Yugoslavia. This article describes these booklets' content, use during military operations, distribution, costs, and benefits. A discussion of lessons learned includes steps to develop and evaluate health information and is followed by an explanation of the current situation. We offer suggestions to improve the booklet development process; our experience may be helpful to others developing health information materials for military personnel or civilians.

Children of human immunodeficiency virus-infected members of the Army Reserve components.

OBJECTIVES: Little is known about the numbers of children who will be left without one or both parents because of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome. This report evaluates childbearing patterns among U.S. Army reserve component members, a group largely made up of men with limited contact with the military. METHODS: HIV status was determined from routinely collected data, with demographic information obtained from personnel records. Number of children was estimated from number of dependents reported. No information was available on the infection status of children or spouses of members. RESULTS: There were 1,884 HIV-positive members, with an estimated total of 843 children. Childbearing patterns varied across several demographic characteristics. Among 14 metropolitan statistical areas, the proportion reporting any children and the number of children of infected members per 100,000 varied substantially. CONCLUSIONS: This report documents the numbers of children of HIV-positive adults in this population and provides evidence that certain metropolitan areas will be disproportionately affected.

Survey of U.S. Army soldiers' knowledge, attitudes, and practices regarding personal protection measures to prevent arthropod-related diseases and nuisance bites.

This study examined U.S. Army soldiers' knowledge, attitudes, and practices regarding personal protection measures (PPMs) to prevent arthropod-related diseases and nuisance bites. Soldiers attending 1 of 13 U.S. Army training courses either completed a written questionnaire (N = 1,007) or participated in a group interview (N = 65). Respondents primarily used repellents to prevent nuisance insect bites (55%) rather than to prevent disease (38.7%). Less than one-third correctly identified the military-issue repellents to be used on skin (31.7%) or clothing (26.1%). More than half (57.6%) thought that commercial products were better than military-issue repellents, but most (74.2%) reported that they did not have enough or any information about the U.S. military's system of PPMs. Soldiers have poor knowledge of U.S. military doctrine regarding PPMs and still prefer to use commercial products. A focused strategy to ensure the appropriate use of PPMs by service members should be developed, implemented, and evaluated.

Dengue among United Nations mission in Haiti personnel, 1995: implications for preventive medicine.

The incidence of dengue infections has been increasing in the Caribbean, and cases have been identified among successive deployments of multinational peacekeepers to Haiti (1994-1997). In the absence of an effective vaccine or chemoprophylaxis to prevent dengue fever, vector-control operations and use of personal protection measures to prevent arthropod bites are the most effective means of limiting disease transmission. During our 5-month deployment as part of the United Nations Mission in Haiti, 79 cases of recent dengue fever were identified among 249 patients (32%) presenting with febrile illness to the 86th Combat Support Hospital. Further investigation revealed low unit readiness to perform standard vector-control activities and poor individual adherence to measures to prevent arthropod bites. Command enforcement of existing field preventive medicine doctrine is essential to prevent casualties caused by dengue, other arthropod-borne infections, and nuisance arthropod bites during military deployments.

Microbiological laboratory results from Haiti: June-October 1995.

From June to October 1995, the U.S. Army's 86th Combat Support Hospital was deployed in Haiti in support of the United Nations peacekeeping mission. The hospital's mission was to provide comprehensive health care to United Nations military and civilian personnel in Haiti. The hospital's laboratory, with microbiological and parasitological capability, was a critical asset in light of the infectious disease threats in Haiti. A total of 356 microbiological (5.4%) and 887 parasitological (13.4%) tests were performed, out of a total of 6628 laboratory tests. One finding was the discovery of antibiotic-resistant urinary isolates of Escherichia coli. These were from community-acquired infections and included strains resistant to ampicillin (6/15), trimethoprim+sulfamethoxazole (6/15), and ciprofloxacin (2/15). Ampicillin (8/15) and trimethoprim+sulfamethoxazole (3/15) resistance was also noted in Shigella spp. However, no chloroquine-resistant strains of malaria were encountered. Dengue virus, also mosquito borne, was a major pathogen. Antimicrobial-resistant nosocomial pathogens were also encountered. Deployed laboratories should be able to determine antimicrobial susceptibility and perform microbial identification to guide clinical management, conduct medical surveillance, and detect emerging resistance.

Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years.

Antibiotic resistance trends were examined for Shigella species, nontyphoidal Salmonella species, enterotoxigenic Escherichia coli (ETEC), and Campylobacter species isolates from indigenous persons and travelers in Thailand for up to 15 years. Resistance to trimethoprim-sulfamethoxazole was found in >90% of Shigella and 40% of ETEC and nontyphoidal Salmonella isolates. Resistance to nalidixic acid was found in 97%-100% of Shigella dysenteriae 1 strains isolated between 1992 and 1995. Ciprofloxacin resistance was detected in 1% of ETEC isolates in 1994 and 1995 and in one of 349 nontyphoidal Salmonella isolates in 1995. Ciprofloxacin resistance among Campylobacter species increased from zero before 1991 to 84% in 1995 (P < .0001). Azithromycin resistance was found in 7%-15% of Campylobacter isolates in 1994 and 1995, as well as 15% of ETEC and 3% of Salmonella isolates in 1995. Enteric pathogens in Thailand have developed resistance to virtually all antibiotics routinely used in the treatment of diarrhea, as well as the newer fluoroquinolone and macrolide classes of drugs.

Safety and efficacy of intravenous sodium stibogluconate in the treatment of leishmaniasis: recent U.S. military experience.

The efficacy and toxicity of sodium stibogluconate (SSG) at a dosage of 20 mg/(kg.d) for either 20 days (for cutaneous disease) or 28 days (for visceral, mucosal, or viscerotropic disease) in the treatment of leishmaniasis is reported. Ninety-six U.S. Department of Defense health care beneficiaries with parasitologically confirmed leishmaniasis were prospectively followed for 1 year. One patient was infected with human immunodeficiency virus; otherwise, comorbidity was absent. Clinical cure occurred in 91% of 83 cases of cutaneous disease and 93% of 13 cases of visceral/viscerotropic disease. Adverse effects were common and necessitated interruption of treatment in 28% of cases, but they were generally reversible. These included arthralgias and myalgias (58%), pancreatitis (97%), transaminitis (67%), headache (22%), hematologic suppression (44%), and rash (9%). No subsequent mucosal leishmaniasis was identified, and there were no deaths attributable to SSG or leishmaniasis.