The epidemiological and clinical characteristics of diarrhea associated with enteropathogenic, enteroaggregative and diffuse-adherent Escherichia coli in Egyptian children.

A total of 220 enteroadherent Escherichia coli were identified from 729 Egyptian children with diarrhea using the HEp-2 adherence assay. Enteropathogenic E.coli (EPEC = 38) was common among children <6 months old and provoked vomiting, while diffuse-adhering E.coli (DAEC = 109) induced diarrheal episodes of short duration, and enteroaggregative E.coli (EAEC = 73) induced mild non-persistent diarrhea. These results suggest that EPEC is associated with infantile diarrhea in Egyptian children.

Evidence for subclinical avian influenza virus infections among rural Thai villagers.

BACKGROUND: Regions of Thailand reported sporadic outbreaks of A/H5N1 highly pathogenic avian influenza (HPAI) among poultry between 2004 and 2008. Kamphaeng Phet Province, in north-central Thailand had over 50 HPAI poultry outbreaks in 2004 alone, and 1 confirmed and 2 likely other human HPAI infections between 2004 and 2006. METHODS: In 2008, we enrolled a cohort of 800 rural Thai adults living in 8 sites within Kamphaeng Phet Province in a prospective study of zoonotic influenza transmission. We studied participants' sera with serologic assays against 16 avian, 2 swine, and 8 human influenza viruses. RESULTS: Among participants (mean age 49.6 years and 58% female) 65% reported lifetime poultry exposure of at least 30 consecutive minutes. Enrollees had elevated antibodies by microneutralization assay against 3 avian viruses: A/Hong Kong/1073/1999(H9N2), A/Thailand/676/2005(H5N1), and A/Thailand/384/2006(H5N1). Bivariate risk factor modeling demonstrated that male gender, lack of an indoor water source, and tobacco use were associated with elevated titers against avian H9N2 virus. Multivariate modeling suggested that increasing age, lack of an indoor water source, and chronic breathing problems were associated with infection with 1 or both HPAI H5N1 strains. Poultry exposure was not associated with positive serologic findings. CONCLUSIONS: These data suggest that people in rural central Thailand may have experienced subclinical avian influenza infections as a result of yet unidentified environmental exposures. Lack of an indoor water source may play a role in transmission.

In vitro activity and single-step mutational analysis of rifamycin SV tested against enteropathogens associated with traveler's diarrhea and Clostridium difficile.

Rifamycin SV is a broad-spectrum, poorly absorbed antimicrobial agent that, when coupled with MMX technology, is being targeted for the oral treatment of traveler's diarrhea (TD) and Clostridium difficile-associated disease (CDAD). Rifamycin SV was tested for activity against 911 TD-associated enteropathogens and 30 C. difficile isolates collected from several global surveillance studies. Rifamycin SV demonstrated similar antimicrobial activity levels against the Enterobacteriaceae, with MIC50 values ranging from 32 to 128 µg/ml for all but one strain (an enterotoxigenic Escherichia coli at >512 µg/ml). For non-Enterobacteriaceae strains, MIC50 values ranged from 2 to 8 µg/ml, with the exception of Campylobacter spp., for which all strains had MIC values of >512 µg/ml. Rifamycin SV also demonstrated excellent activity (MIC50 of ≤ 0.03 µg/ml) against most C. difficile strains (including one hypervirulent NAP1 strain), and this activity was even superior to the potency observed for vancomycin, metronidazole, and rifaximin. In mutational passaging studies, rifamycin SV induced stable resistance and showed a mutation frequency in E. coli similar to that of rifampin. This study presents the potency of rifamycin SV for enteropathogens commonly recovered from patients with TD and CDAD. Additional in vitro and in vivo studies appear necessary to determine the utility of rifamycin SV as an oral agent for the prevention and treatment of TD and CDAD.

Enteric disease surveillance under the AFHSC-GEIS: current efforts, landscape analysis and vision forward.

The mission of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) is to support global public health and to counter infectious disease threats to the United States Armed Forces, including newly identified agents or those increasing in incidence. Enteric diseases are a growing threat to U.S. forces, which must be ready to deploy to austere environments where the risk of exposure to enteropathogens may be significant and where routine prevention efforts may be impractical. In this report, the authors review the recent activities of AFHSC-GEIS partner laboratories in regards to enteric disease surveillance, prevention and response. Each partner identified recent accomplishments, including support for regional networks. AFHSC/GEIS partners also completed a Strengths, Weaknesses, Opportunities and Threats (SWOT) survey as part of a landscape analysis of global enteric surveillance efforts. The current strengths of this network include excellent laboratory infrastructure, equipment and personnel that provide the opportunity for high-quality epidemiological studies and test platforms for point-of-care diagnostics. Weaknesses include inconsistent guidance and a splintered reporting system that hampers the comparison of data across regions or longitudinally. The newly chartered Enterics Surveillance Steering Committee (ESSC) is intended to provide clear mission guidance, a structured project review process, and central data management and analysis in support of rationally directed enteric disease surveillance efforts.

Evaluation of an influenza-like illness case definition in the diagnosis of influenza among patients with acute febrile illness in Cambodia.

BACKGROUND: Influenza-like illness (ILI) is often defined as fever (>38.0°C) with cough or sore throat. In this study, we tested the sensitivity, specificity, and positive and negative predictive values of this case definition in a Cambodia patient population. METHODS: Passive clinic-based surveillance was established at nine healthcare centers to identify the causes of acute undifferentiated fever in patients aged two years and older seeking treatment. Fever was defined as tympanic membrane temperature >38°C lasting more than 24 hours and less than 10 days. Influenza virus infections were identified by polymerase chain reaction. RESULTS: From July 2008 to December 2008, 2,639 patients were enrolled. From 884 (33%) patients positive for influenza, 652 presented with ILI and 232 acute fever patients presented without ILI. Analysis by age group identified no significant differences between influenza positive patients from the two groups. Positive predictive values (PPVs) varied during the course of the influenza season and among age groups. CONCLUSION: The ILI case definition can be used to identify a significant percentage of patients with influenza infection during the influenza season in Cambodia, assisting healthcare providers in its diagnosis and treatment. However, testing samples based on the criteria of fever alone increased our case detection by 34%.

Influenza virus infection among pediatric patients reporting diarrhea and influenza-like illness.

BACKGROUND: Influenza is a major cause of morbidity and hospitalization among children. While less often reported in adults, gastrointestinal symptoms have been associated with influenza in children, including abdominal pain, nausea, vomiting, and diarrhea. METHODS: From September 2005 and April 2008, pediatric patients in Indonesia presenting with concurrent diarrhea and influenza-like illness were enrolled in a study to determine the frequency of influenza virus infection in young patients presenting with symptoms less commonly associated with an upper respiratory tract infection (URTI). Stool specimens and upper respiratory swabs were assayed for the presence of influenza virus. RESULTS: Seasonal influenza A or influenza B viral RNA was detected in 85 (11.6%) upper respiratory specimens and 21 (2.9%) of stool specimens. Viable influenza B virus was isolated from the stool specimen of one case. During the time of this study, human infections with highly pathogenic avian influenza A (H5N1) virus were common in the survey area. However, among 733 enrolled subjects, none had evidence of H5N1 virus infection. CONCLUSIONS: The detection of influenza viral RNA and viable influenza virus from stool suggests that influenza virus may be localized in the gastrointestinal tract of children, may be associated with pediatric diarrhea and may serve as a potential mode of transmission during seasonal and epidemic influenza outbreaks.

Three Indonesian clusters of H5N1 virus infection in 2005.

BACKGROUND: Since 2003, the widespread ongoing epizootic of avian influenza A (H5N1) among poultry and birds has resulted in human H5N1 cases in 10 countries. The first case of H5N1 virus infection in Indonesia was identified in July 2005. METHODS: We investigated three clusters of Indonesian cases with at least two ill persons hospitalized with laboratory evidence of H5N1 virus infection from June through October 2005. Epidemiologic, clinical, and virologic data on these patients were collected and analyzed. RESULTS: Severe disease occurred among all three clusters, including deaths in two clusters. Mild illness in children was documented in two clusters. The median age of the eight patients was 8.5 years (range, 1 to 38). Four patients required mechanical ventilation, and four of the eight patients (50%) died. In each cluster, patients with H5N1 virus infection were members of the same family, and most lived in the same home. In two clusters, the source of H5N1 virus infection in the index patient was not determined. Virus isolates were available for one patient in each of two clusters, and molecular sequence analyses determined that the isolates were clade 2 H5N1 viruses of avian origin. CONCLUSIONS: In 2005 in Indonesia, clusters of human infection with clade 2 H5N1 viruses included mild, severe, and fatal cases among family members.

Cross-sectional survey of anthrax vaccine coverage and KAP among deployed US military.

The recently refocused effort on anthrax (AVA) vaccination has been the source of much ethical and legal deliberation. However, the factors affecting one's decision to receive any or all of the vaccine doses are poorly understood. Using a self-administered questionnaire, we sought to evaluate AVA coverage among a cross-section of deployed active duty US military personnel and identify factors associated with receipt of the vaccine. A questionnaire was distributed to U.S. military personnel deployed to Iraq, Afghanistan and surrounding areas. Questions solicited demographic information, AVA vaccination status, and agreement to several questions attempting to assess the respondent's knowledge and attitudes regarding anthrax and the AVA vaccine. Of the 1,743 participants, 40.6% reported receiving all AVA vaccine doses. Older age and service in the Army were associated with an increased likelihood of AVA vaccination. Additionally, those who neither agreed nor disagreed with specific questions commonly rejected the AVA vaccine compared to those who agreed or disagreed to the same question. The only factor clearly associated with receipt or rejection of the AVA vaccine was whether the respondent thought that the anthrax vaccine is as safe as other vaccines. The individual decision to receive the AVA vaccine is most likely a multifactorial decision process even in a military population. Targeted educational interventions should be developed to increase AVA coverage and further understand drivers of vaccine receipt.

Nonbattle injury among deployed troops: an epidemiologic study.

(n = 150) Nonbattle injury (NBI) continues to be a leading cause of morbidity among troops currently deployed to Iraq and Afghanistan. To assess NBI incidence, impact, and risk factors, a survey was given to soldiers during mid- or postdeployment from Iraq, Afghanistan, and surrounding region, from January 2005 through May 2006. Among 3,367 troops completing a survey, 19.5% reported at least one NBI, and 85% sought care at least once for their symptoms. Service component, rank, and unit type were among factors associated with differential NBI risk. Twenty percent stated that NBI resulted in back-up personnel being called or shift change to cover impacted duties, and among those reported having been grounded from flight status, a third were the result of NBI. NBI continues to be a problem in recent deployments, and given the findings on individual and potential operational impact indicators, NBI should be viewed as a primary force health protection problem.

Past trends and current status of self-reported incidence and impact of disease and nonbattle injury in military operations in Southwest Asia and the Middle East.

OBJECTIVES: To evaluate the evolutional changes in disease and nonbattle injury in a long-term deployment setting, we investigated trends of selected disease and nonbattle injury (NBI) incidence among US military personnel deployed in ongoing military operations in Southwest Asia and the Middle East. METHODS: Participants completed an anonymous questionnaire concerning diarrhea, acute respiratory illness (ARI), and NBIs. We compared incidence, morbidity, and risk associations of disease and NBI incidence with historical data. We analyzed a clinic screening form to describe trends in diarrhea incidence over a 3-year period. RESULTS: Between April 2006 and March 2007, 3374 troops completed deployment questionnaires. Incidence of diarrhea was higher than that of ARI and NBI (12.1, 7.1, and 2.5 episodes per 100 person-months, respectively), but ARI and NBI resulted in more-frequent health system utilization (both P < .001) and decreased work performance (P < .001 and P = .05, respectively) than did diarrhea. Compared with historical disease and NBI incidence rates, diarrhea and NBI incidence declined over a 4-year period, whereas ARI remained relatively constant. CONCLUSIONS: Diarrhea, ARI, and NBI are important health concerns among deployed military personnel. Public health and preventive measures are needed to mitigate this burden.

Factors associated with the use of protective measures against vector-borne diseases among troops deployed to Iraq and Afghanistan.

BACKGROUND AND METHODS: Vector-borne diseases are known threats to deployed troops. We performed a cross-sectional study of troops deployed to Southwest Asia between January 2005 and February 2007 to evaluate practices of personal protective measures and their relationship to self-report of Old World cutaneous leishmaniasis (CL), a marker of vector-borne disease threat. RESULTS: Regular or always N, N-diethyl-m-toluamide (DEET) use was low (2-5%). Associations for DEET use were command emphasis, branch of service, uniform treatment with permethrin, and duty station. Uniform treatment with permethrin was associated with branch of service, command emphasis, and use of DEET. We identified 22 cases of CL (incidence density of 1.8-3.7 per 100 person-years) with increased risk among Reserve/National Guard components, Air Force and Marine personnel. CONCLUSIONS: Commanders can influence the use of the military insect repellent system. Unit-based treatment of uniforms improves prevalence. CL incidence may be higher than previously reported.

Azithromycin and loperamide are comparable to levofloxacin and loperamide for the treatment of traveler's diarrhea in United States military personnel in Turkey.

BACKGROUND: The recommended treatment for traveler's diarrhea is the combination of an appropriate antibiotic (usually a fluoroquinolone) and loperamide. Azithromycin compared favorably with fluoroquinolones in trials that did not include the use of loperamide, but combination therapy has not, to our knowledge, been studied to date. METHODS: A randomized, double-blind trial was conducted at Incirlik Air Base, Turkey, fromJ une 2003 through August 2004. Adults from the United States with noninflammatory diarrhea were randomized to receive a single dose of azithromycin (1000 mg; 106 persons) or levofloxacin (500 mg; 101 persons) plus loperamide (4 mg initially and as needed thereafter). Volunteers maintained a symptom diary and were evaluated on days 1, 3, and 7 after treatment. RESULTS: No differences were noted with respect to pretreatment symptoms or pathogen distribution. Enterotoxigenic Escherichia coli was the most common pathogen isolated (from 45% of patients in the azithromycin group and 42% of patients in the levofloxacin group), and Campylobacter species was the second most common pathogen isolated (from 6% of patients in the azithromycin group and 9% of patients in the levofloxacin group). Median time to last diarrheal stool (azithromycin group, 13 h; levofloxacin group, 3 h), median time to resolution of associated symptoms (2 days), and additional loperamide usage (azithromycin group, 39% of patients; levofloxacin group, 34% of patients) were similar between groups. Azithromycin use was associated with more nausea in the 30 min after dosing (azithromycin group, 8% of patients; levofloxacin group, 1% of patients; Pp.004), but no vomiting or other adverse events were noted in either group. CONCLUSIONS: Single-dose treatment with azithromycin (1000 mg) and loperamide is as effective as single-dose treatment with levofloxacin (500 mg) and loperamide for noninflammatory diarrhea. Although nausea after dosing is uncommon, it is more frequently associated with azithromycin than with levofloxacin. Future studies should focus on determining whether lower doses of azithromycin would decrease the frequency of nausea and decrease treatment costs without affecting efficacy.

Group A rotavirus-associated diarrhea in children seeking treatment in Indonesia.

BACKGROUND: Globally, group A rotavirus causes significant morbidity and mortality among children. Limited data exist on the epidemiology of rotavirus disease among Indonesian children. OBJECTIVES: We describe the epidemiology of rotavirus-associated diarrhea among Indonesian children <6 years of age, including clinical symptoms and genotypes. STUDY DESIGN: We conducted a hospital-based, case series study at four referral hospitals between February 2004 and February 2005 among children with diarrhea. Rotavirus positivity was defined by a positive result from either EIA or RT-PCR. A semi-nested RT-PCR was used to determine specific rotavirus genotypes. RESULTS: 1660 stools were tested for pathogens. The overall rotavirus prevalence was 45.5%. Children with rotavirus-associated diarrhea were significantly younger (p<0.0001) and more likely to be hospitalized (81.3% versus 72.2%; p<0.0001). Symptoms associated with rotavirus included, vomiting, fever, nausea, fatigue and dehydration, while bloody stool was significantly less common with rotavirus-associated diarrhea. CONCLUSION: Rotavirus was an important contributor of morbidity to our study sample. Rotavirus genotyping demonstrated a temporal shift from G1-G4 to G9, but this was highly associated with the P[8] gene, suggesting that a multivalent rotavirus vaccine, incorporating G9 P[8] antigen, may reduce the burden of diarrheal illnesses among Indonesian children.

Self-reported incidence of snake, spider, and scorpion encounters among deployed U.S. military in Iraq and Afghanistan.

Much has been written about injury, diarrhea, and respiratory cases but less is known about other threats, specifically snake, scorpion, and spider encounters. To examine the risk from local fauna, a cross-sectional study using an anonymous survey was conducted among U.S. troops in Southwest Asia between January 2005 and May 2006. Among 3,265 troops, 9 cases (0.3%) of snakebites and 85 cases (2.6%) of spider stings and scorpion bites were reported, equating to an incidence of 46.1 per 10,000 person-months for scorpion/spider encounters and 4.9 per 10,000 person-months for snakebites. There was a significant association with service branch and toileting facilities for snakebites. Season, deployment location, rank, and toileting facilities were associated with differential risk of scorpion/spider encounters. Troops are at risk for local fauna encounters while deployed in the current operational environment. The potential morbidity, mortality, and operational impact of these health hazards need to be considered.

Incidence, etiology, and impact of diarrhea among long-term travelers (US military and similar populations): a systematic review.

To determine regional estimates of pathogen-specific prevalence and incidence, as well as, describe morbidity associated with diarrhea among deployed US military and similar populations, a systematic review was conducted for publications between January 1990 to June 2005. Point estimates and confidence intervals of pathogen prevalence and travelers' diarrhea incidence were combined in a random effects model and assessed for heterogeneity. In total, 262 studies were identified for potential inclusion, of which 52 fulfilled inclusion criteria. Overall, 38% were from the Middle East, 29% from Southeast Asia, 27% from Latin America/Caribbean, and 6% from sub-Saharan Africa. Median duration of travel was 1.5 months (interquartile range, 1-3 months). Enterotoxigenic Escherichia coli (ETEC), Campylobacter, and Shigella were identified as causing 38-45% of diarrhea, with regional and population differences. Incidence based on self-report was higher than studies using passive surveillance or clinic-based methods (29 versus 7 versus 6 episodes per 100 person-months, respectively) without regional differences.

Incidence, etiology, and impact of diarrhea among deployed US military personnel in support of Operation Iraqi Freedom and Operation Enduring Freedom.

A health assessment survey was collected from US military personnel deployed to the Middle East taking part in the "Rest and Recuperation" program or on temporary assignment to Camp As Sayliyah Doha, Qatar, from January to December 2004. In addition, a concurrent clinic-based observational study was conducted to determine pathogen etiology and potential risk factors. From 28,322 health assessment surveys, overall self-reported incidence of diarrhea was 4.9 cases per 100 person-months. Disease incidence increased with rank and was higher in Iraq compared with Afghanistan. During this period, 109 US military personnel with acute diarrhea and 85 asymptomatic personnel were enrolled in the observational study. Enterotoxigenic E. coli (ETEC) was the predominant pathogen (32%), followed by enteroaggregative E. coli (12%) and Salmonella spp. (6%). These data are consistent with previous reports implicating ETEC as the primary cause of acute diarrhea for military personnel deployed to this region.

Clinic-based surveillance for bacterial- and rotavirus-associated diarrhea in Egyptian children.

To identify enteropathogens for vaccine development, we implemented clinic-based surveillance for severe pediatric diarrhea in Egypt's Nile River Delta. Over 2 years, a physician clinically evaluated and obtained stool samples for microbiology from patients with diarrhea and less than 6 years of age. In the first (N = 714) and second clinic (N = 561), respectively, 36% (N = 254) and 46% (N = 260) of children were infected with rotavirus, enterotoxigenic Escherichia coli (ETEC), Campylobacter, or Shigella. When excluding mixed rotavirus-bacterial infections, for the first and second clinic, 23% and 10% had rotavirus-associated diarrhea, and 14% and 17% had ETEC-associated diarrhea, respectively. Campylobacter-associated diarrhea was 1% and 3%, and Shigella-associated diarrhea was 2% and 1%, respectively, for the two clinics. Rotavirus-associated diarrhea peaked in late summer to early winter, while bacterial agents were prevalent during summer. Rotavirus-associated cases presented with dehydration, vomiting, and were often hospitalized. Children with Shigella- or Campylobacter-associated diarrhea reported as watery diarrhea and rarely dysentery. ETEC did not have any clinically distinct characteristics. For vaccine development and/or deployment, our study suggests that rotavirus is of principle concern, followed by ETEC, Shigella, and Campylobacter.

Enterotoxigenic Escherichia coli colonization factor types collected from 1997 to 2001 in US military personnel during operation Bright Star in northern Egypt.

Operation Bright Star (OBS) is a biennial, multinational exercise in Egypt involving 15000 US troops. Consistent with past observations in deployed troops, diarrhea is the most significant cause of morbidity. Focused efforts are ongoing to develop vaccines against the most common pathogens affecting our troops. As part of these efforts, diarrhea surveillance was conducted during OBS to monitor pathogens associated with illness and to identify new vaccine targets. A retrospective review was conducted of prior studies with similar methods. Soldiers with diarrhea presenting to the OBS clinic provided a stool sample that was inoculated into Carey-Blair transport media. Within 3 days, the Cary-Blair tubes were transported to the Naval Medical Research Unit no. 3 in Cairo where bacterial culture was performed. As part of the evaluation, 5 Escherichia coli-like colonies were collected and tested for toxin production using the GM1-ELISA. Toxin-positive isolates were further tested for colonization factors (CF) by a dot-blot assay using a standardized panel of monoclonal antibodies against CFA/I, CS1-CS7, CS17, CS8 (CFA/III), CS12 (PCFO159), and CS14 (PCFO166). Enterotoxigenic E. coli (ETEC) was the most frequently isolated pathogen during each OBS from which data were collected. The rate of ETEC-associated diarrhea ranged from 22% to 58%. Over time, there were dramatic shifts in the frequency and distribution of CFs. Over the 5 years of study, an increasing number of ETEC isolates had no known CF identified, and in 2001, only 40% of ETEC was associated with known CFs. The most commonly identified CF was CS6. Diarrheal disease, particularly ETEC, continues to be a common malady among US military personnel deployed to Egypt. We have identified ETEC CF types, especially CS6, which should be considered potential vaccine candidates. However, despite intensive testing, CFs could not be identified in most of the ETEC isolated, highlighting the need for further studies to identify novel CFs and alternative vaccine targets.

Epidemic infectious gastrointestinal illness aboard U.S. Navy ships deployed to the Middle East during peacetime operations--2000-2001.

BACKGROUND: Infectious gastrointestinal illness (IGI) outbreaks have been reported in U.S. Navy ships and could potentially have an adverse mission impact. Studies to date have been anecdotal. METHODS: We conducted a retrospective analysis of weekly reported disease and non-battle injury health data collected in 2000-2001 from 44 U.S. Navy ships while sailing in the 5th Fleet (Persian Gulf and nearby seas). RESULTS: During this period, 11 possible IGI outbreaks were identified. Overall, we found 3.3 outbreaks per 100 ship-weeks, a mean outbreak duration of 4.4 weeks, and a mean cumulative ship population attack rate of 3.6%. Morbidity, represented by days lost due to personnel being placed on sick-in-quarters status, was higher during outbreak weeks compared to non-outbreak weeks (p = 0.002). No clear seasonal distribution was identified. CONCLUSION: Explosive outbreaks due to viruses and bacteria with the potential of incapacitating large proportions of the crew raise serious concerns of mission impact and military readiness.

Self-reported description of diarrhea among military populations in operations Iraqi Freedom and Enduring Freedom.

BACKGROUND: Infectious diarrhea is among the most common medical problems associated with military deployments and has been reported as a frequent problem for troops currently deployed to Iraq and Afghanistan. Lacking is information describing clinical presentation, risk behaviors, and treatment of travelers' diarrhea in this population. METHODS: An anonymous cross-sectional survey was conducted among 15,459 US military personnel deployed to Southwest Asia during 2003 to 2004. RESULTS: Overall, diarrhea was commonly reported (76.8% in Iraq and 54.4% in Afghanistan) and was frequently severe (more than six stools/d) (20.8% in Iraq and 14.0% in Afghanistan) or associated with fever (25.8%), vomiting (18% with diarrhea and 16.5% without), persistent symptoms (>14 d, 9.8%), or chronic symptoms (>30 d, 3.3%). Diarrhea was associated with time spent off military compounds and eating local food. Over 80% of respondents sought care for their symptoms, usually at the lowest echelon of care (field medic), and were most often treated with either loperamide or an antibiotic. Self-treatment with loperamide or Pepto-Bismol was also common and successful with only 9% of self-treated individuals reporting seeking further medical care. CONCLUSIONS: Infectious diarrhea is a common problem for US military personnel, and associated fevers and vomiting are more common than in past conflicts in the region. As with past studies, time spent off base and local food consumption, both more common in Iraq than Afghanistan, continue to be the most important risk factors for acquiring diarrhea. The majority of soldiers reported seeking care for diarrhea, but appropriate treatment, including self-treatment with over-the-counter medicines, was generally successful. Further studies should be conducted to evaluate appropriate treatment algorithms, including the use of self-treatment, for deployed military personnel.