Evaluation of arthropod-borne viruses and other infectious disease pathogens as the causes of febrile illnesses in the Khartoum Province of Sudan.

The relative importance of arthropod-borne and other disease pathogens as the cause of an outbreak of febrile illnesses was assessed during August 1988, following severe flooding in Khartoum, Sudan. A total of 200 patients with acute febrile illness and 100 afebrile controls were enrolled in the study during October and November 1988; at the Omdurman Military Hospital, Khartoum, Sudan. Sera were tested for IgM and IgG antibodies to six arthropod-borne viruses by an enzyme-linked immunoabsorbent assay, and for similar antibodies to Lassa fever, Crimean-Congo hemorrhagic fever, and Ebola and Marburg viruses by an indirect fluorescence assay. Thick and thin blood smears were examined microscopically for malaria parasites, and fecal and blood specimens were tested for bacteria by standard culture methods. Among the acute and convalescent sera collected from 67 febrile patients, five cases were caused by sandfly fever Sicilian (SFS), six by sandfly fever Naples (SFN), and 12 by unidentified phleboviruses. Of 233 remaining unpaired, acute-phase sera collected from cases and controls, 49 (21%) had IgM antibodies to SFS or SFN, RVF, West Nile (WN), and Chikungunya (CHIK) viruses. Forty-three (22%) of 192 febrile cases and two of the 100 afebrile controls were positive for Plasmodium falciparum, and bacterial enteropathogens were associated with 25 (13%) cases and four controls. These data indicated that phleboviruses and to a lesser extent, WN, P. falciparum, and enterobacterial pathogens were causes of acute febrile illnesses following the 1988 flood in Khartoum, Sudan.

Safety and immunogenicity of a prototype oral whole-cell killed Campylobacter vaccine administered with a mucosal adjuvant in non-human primates.

The safety and immunogenicity of two prototype oral Campylobacter killed whole-cell (CWC) vaccines were tested in rhesus monkeys. Animals were immunized with a primary two-dose series (days 0 and 14) of vaccine consisting of CWC (10(10) particles/dose) given alone or in combination with 0.5-1000 micrograms of the heat-labile enterotoxin of Escherichia coli as an oral adjuvant (OA). A booster vaccination, 4 weeks after primary immunization, was given to animals receiving CWC alone or supplemented with 0.5, 5 or 50 micrograms of OA. Both CWC and CWC-OA were well tolerated, with no adverse side-effects noted. Campylobacter-specific as well as adjuvant-specific antibody-secreting cells (ASCs) were determined in peripheral blood collected 7 days after each vaccine dose. Campylobacter-specific IgA ASC responses were enhanced by OA in a dose-dependent manner (p = 0.025), while IgG ASC responses were not. Seroconversions (both IgA and IgG) to Campylobacter antigens were also enhanced in monkeys receiving adjuvanted vaccine. No significant booster vaccination effect was observed in circulating ASCs in any of the immunization groups. In vitro T-cell proliferative responses to Campylobacter jejuni antigens were somewhat enhanced in both the CWC and CWC-OA immunization groups. These results demonstrate that CWC-OA is safe and superior to CWC alone in its ability to stimulate both local and systemic Campylobacter-specific IgA and IgG responses in primates and they support its further evaluation in human clinical studies.

Etiology of acute diarrhea among United States Embassy personnel and dependents in Cairo, Egypt.

The purpose of this study was to identify the enteropathogens causing acute diarrheal disease in Americans living in the North Africa/Middle East region during a 34-month period from February 12, 1985 to December 30, 1987 to guide preventive and therapeutic measures. Stool specimens were examined and an epidemiologic questionnaire was administered to patients with acute diarrhea at the Outpatient Health Unit of the United States Embassy in Cairo, Egypt. The subjects consisted of 126 American employees and dependents of the U. S. Embassy in Cairo, Egypt with diarrhea of less than two-weeks duration. Subjects received routine medical care administered by the U.S. Embassy Medical staff. A possible etiologic agent was detected in 41% of the subjects. Enteroadherent Escherichia coli was the most commonly isolated enteropathogen. A high degree of antimicrobial resistance was noted among the bacterial isolates, but all were susceptible to the quinolone antibiotics. Episodes of acute diarrhea occurring among American expatriates in Cairo, Egypt were primarily of bacterial etiology, but only a small portion were caused by the bacterial pathogens routinely identified in a standard clinical bacteriology laboratory. Most of the diarrheal episodes were due to noninvasive enteroadherent E. coli that may cause prolonged disease requiring antimicrobial therapy.

Diarrheal disease aboard a U.S. Navy ship after a brief port visit to a high risk area.

In August 1988, a study was conducted to determine the etiology and risk factors associated with travelers' diarrhea among U.S. military personnel after a 5-day port visit to Alexandria, Egypt. Twenty-one percent of the 2,747 evaluated crew members of the USS John F. Kennedy reported an episode of acute diarrhea, which led to 155 sick-call visits and at least 110 lost man-days. The most common pathogen identified was enterotoxigenic Escherichia coli, and all isolated bacterial enteropathogens were sensitive to quinolone drugs. Independent risk factors for the development of diarrhea included: (1) consuming any meal ashore and specifically eating meats, desserts, or a buffet meal; and (2) a recent history of travelers' diarrhea. These data indicate that even brief port visits to developing countries pose a major threat to the health of U.S. shipboard personnel.

Chlamydia trachomatis associated with chronic dysuria among patients with Schistosoma haematobium.

Eighty-seven Egyptians with Schistosoma haematobium infection (current or past) and chronic dysuria seen at the Theodor Bilharz Research Institute outpatient urology clinic in Imbaba, Cairo, Egypt were investigated for Chlamydia trachomatis infection. Direct fluorescent antibody tests (DFAT) showed 30 urethral swabs (35%) and 40 urine sediments (46%) were positive for Chlamydia. Indirect fluorescent antibody testing showed 29 (34%) serum samples and 25 (29%) urethral smears were positive for Chlamydia. There was a highly significant association between patients with active Schistosoma infection and those with urine and urethral specimens positive for Chlamydia by DFAT (P < 0.01).

Detection of immunoglobulin A in urine specimens from children with Campylobacter-associated diarrhea by a chemiluminescent indicator-based western immunoblot assay.

A Western blot (immunoblot) assay was used to detect Campylobacter-specific immunoglobulin A in urine. Acute-phase urine samples from six children with Campylobacter diarrhea had titers ranging from 2 to 8. The highest titer was detected 4 days postonset. Campylobacter-specific immunoglobulin A was undetectable in the paired convalescent-phase specimens and urine samples from three control children.

Treatment of traveler's diarrhea with ciprofloxacin and loperamide.

To determine the efficacy of loperamide given with long- and short-course quinolone therapy for treating traveler's diarrhea, 142 US military personnel were randomized to receive a single 750-mg dose of ciprofloxacin with placebo, 750 mg of ciprofloxacin with loperamide, or a 3-day course of 500 mg of ciprofloxacin twice daily with loperamide. Culture of pretreatment stool specimens revealed campylobacters (41%), salmonellae (18%), enterotoxigenic Escherichia coli (ETEC, 6%), and shigellae (4%). Of the participants, 87% completely recovered within 72 h of entry. Total duration of illness did not differ significantly among the three treatment groups, but patients in the 3-day ciprofloxacin plus loperamide group reported a lower cumulative number of liquid bowel movements at 48 and 72 h after enrollment compared with patients in the single-dose ciprofloxacin plus placebo group (1.8 vs. 3.6, P = .01; 2.0 vs. 3.9, P = .01). While not delivering a remarkable therapeutic advantage, loperamide appears to be safe for treatment of non-ETEC causes of traveler's diarrhea. Two of 54 patients with Campylobacter enteritis had a clinical relapse after treatment that was associated with development of ciprofloxacin resistance.

Significance of flagella in colonization resistance of rabbits immunized with Campylobacter spp.

Cross-protection among different Lior and Penner serogroups of Campylobacter spp. was studied. Rabbits were orally immunized by gastric feeding with Campylobacter spp., and 27 to 30 days later, they were challenged with matched or unmatched serogroups by the removable intestinal tie adult rabbit diarrhea (RITARD) procedure. When immunized animals were challenged with different Lior serotypes, no protection against colonization was seen; however, when challenged with homologous Lior serogroups, protection was demonstrated. Immune animals were colonized for an average of 1 day or less versus at least 6 days for nonimmune animals. Rabbits challenged with matched Penner-unmatched Lior strains showed only marginal protection. Our study also demonstrated that flagella are important in initiating colonization and eliciting protective immunity. Campylobacter coli VC167B3, an isogenic, nonflagellated mutant, did not colonize rabbits regardless of the route of administration. Single feeding of the mutant strain did not protect the host, whereas three feedings, 48 h apart, resulted in complete protection against the flagellated parent strain. When mutant strain immunized rabbits were challenged with other strains of the same Lior serotype, marginal protection was obtained. Immunogold labeling indicated that there is one or more antigens on the cell surface of the nonflagellated mutant which reacts with a polyclonal antiserum from organisms of the same Lior serogroup. These data implicated the flagellum as the cross-strain protective component of the Lior antigen complex.

Re-examination of Rattus norvegicus as an animal model for Aeromonas-associated enteritis in man.

We have developed an oral feeding model for Aeromonas hydrophila enteritis using Rattus norvegicus with clindamycin pretreatment. All animals in the clindamycin group developed a self-limited, loose stool by day four of feeding. Intestinal examination revealed evidence of enteritis. Moreover, antibiotic usage may be a predisposing risk factor to infection.

Travelers' diarrhea among United States military personnel during joint American-Egyptian armed forces exercises in Cairo, Egypt.

A study was conducted of travelers' diarrhea in a United States military population on deployment in Cairo, Egypt, during July and August 1987. Acute diarrhea requiring medical attention developed in 183 (4%) of 4,500 troops. A possible etiologic agent was identified in 49% of all diarrhea cases. Enteric pathogens associated with cases of diarrhea included: Enterotoxigenic Escherichia coli (17% ST-producers, 13% LT-producers, and 3% LT/ST-producers); Shigella (9%); Campylobacter spp. (2%); Salmonella (2%); and Vibrio cholerae non-01 serogroup (2%). Other enteric pathogens isolated from one episode each of diarrhea included Aeromonas hydrophila group, Plesiomonas shigelloides, and Bacillus cereus. Yersinia enterocolitica, enteroinvasive E. coli, intoxications by Clostridium perfringens and Clostridium difficile, and pathogenic enteric parasites were not found in any of the 183 patients with diarrhea. A survey of military personnel not requesting medical care indicated that up to 40% of troops may have had diarrhea during this deployment. Acute gastroenteritis is a potential cause of substantial morbidity in U.S. military personnel deployed to Egypt.

Epidemiology of bacterial pathogens associated with infectious diarrhea in Djibouti.

During a survey examining the causes of diarrhea in the East African country of Djibouti, 140 bacterial pathogens were recovered from 209 diarrheal and 100 control stools. The following pathogens were isolated at comparable frequencies from both diarrheal and control stools: enteroadherent Escherichia coli (EAEC) (10.6 versus 13%), enterotoxigenic E. coli (ETEC) (11 versus 10%), enteropathogenic E. coli (EPEC) (7.7 versus 12%), Salmonella spp. (2.9 versus 3%), and Campylobacter jejuni-C. coli (3.3 versus 5%). Surprisingly, the EAEC strains isolated did not correspond to well-recognized EPEC serogroups. No Yersinia spp., enteroinvasive E. coli, or enterohemorrhagic E. coli were isolated during the course of this study. Only the following two genera were recovered from diarrheal stools exclusively: Shigella spp. (7.7%) and Aeromonas hydrophila group organisms (3.3%). Shigella flexneri was the most common Shigella species isolated. Patients with Shigella species were of a higher average age than were controls (27 versus 13 years), while subjects with Campylobacter or Salmonella species belonged to younger age groups (2.6 and 1.6 years, respectively). Salmonella cases were more often in females. Shigella diarrhea was associated with fecal blood or mucus and leukocytes. ETEC was not associated with nausea or vomiting. Anorexia, weight loss, and fever were associated with the isolation of Salmonella and Aeromonas species. EAEC, ETEC, EPEC, and Shigella species were resistant to most drugs used for treating diarrhea in Africa, while the antibiotic most active against all bacteria tested was norfloxacin. We conclude that in Djibouti in 1989, Shigella and Aeromonas species must be considered as potential pathogens whenever they are isolated from diarrheal stools and that norfloxacin should be considered the drug of choice in adults for treating severe shigellosis and for diarrhea prophylaxis in travelers.

Rapid diagnosis of tuberculous meningitis by frequency-pulsed electron-capture gas-liquid chromatography detection of carboxylic acids in cerebrospinal fluid.

The frequency-pulsed electron-capture gas-liquid chromatography technique described previously by Brooks et al. was modified and applied to the studies of coded and routine clinical specimens. Uncentrifuged cerebrospinal fluid (2 ml) was extracted under acidic conditions, derivatized, and analyzed by frequency-pulsed electron-capture gas-liquid chromatography on large-bore fused silica polar and nonpolar capillary columns. The frequency-pulsed electron-capture gas-liquid chromatography profile of carboxylic acids (C2 through C22) along with identification of tuberculostearic acid, established by retention time comparison of derivatized tuberculostearic acid and derivatized sample extract, strongly suggests the presence of Mycobacterium tuberculosis in patients with lymphocytic meningitis. Results from 41 coded cases and 75 clinical cases showed that the frequency-pulsed electron-capture gas-liquid chromatography test had a specificity of 91% and a sensitivity of 95%.

[Aeromonas hydrophila in the drinking water in Djibouti: commensal germ or diarrhea-causing agent?]. / Aeromonas hydrophila dans les eaux de boisson a Djibouti: germe commensal ou agent de diarrhée?

To investigate the bacteriological quality of drinking water used by inhabitants of the Republic of Djibouti who were not supplied with piped running water, we analysed 16 fresh-water samples from various sources. Only 3 samples were sterile; they were taken from village pumps and from a water-truck. Eleven samples yielded colonies of Aeromonas hydrophila too numerous to be counted; they were taken from water tanks, metal barrels, or wells dug in either dry river beds or along the seashore. We speculate that this high isolation frequency of Aeromonas hydrophila in fresh water samples may be related to conditions that are exceptionally favourable for the growth of the bacterium (e.g. high temperature and elevated concentrations of certain salts and minerals in the fresh water of Djibouti). We wonder nevertheless whether the infected water supplies were a source of diarrhoea for humans. Indeed, antibiotic resistance patterns were dissimilar when the 11 environmental strains were compared to 7 strains of Aeromonas hydrophila isolated from diarrhoeal patients in Djibouti during the same period. More studies are needed to determine if Aeromonas hydrophila is always a commensal inhabitant of fresh water in Djibouti, or if it can be a cause of infectious diarrhoea. Accordingly, Public Health authorities in Djibouti will be able to decide if water from wells and tanks is safe for drinking, or if it needs disinfection before consumption.

Norfloxacin for the prophylaxis of travelers' diarrhea in U.S. military personnel.

Norfloxacin, an oral fluoroquinolone (dose 400 mg daily), was compared to a placebo in a double blinded randomized trial for the prophylaxis of travelers' diarrhea. The study was of U.S. Navy and Marine Corps personnel on shore leave in Alexandria, Egypt. A total of 222 subjects were available (105 norfloxacin, 117 placebo). In the placebo group, 26% (30/117) developed acute diarrhea vs. 2% (2/105) in the norfloxacin group. There were no significant side effects in either group.