Prospective screening for sexually transmitted infections among US service members with Chlamydia trachomatis or Neisseria gonorrhoeae infection.

BACKGROUND: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are the most common bacterial causes of sexually transmitted infection (STI) in the United States (US). The purpose of this study was to determine the frequency of reinfection during a six-month study period and to evaluate the retesting interval for those infected with CT or NG. METHODS: We conducted a prospective, six-month follow-up study among US military personnel with new onset, laboratory-confirmed CT or NG, recruited from an STI clinic at a large military base from January 2018 to January 2020. Each participant was randomly assigned to one of four groups, which differed only by the timing of the first study-associated follow-up visit after CT or NG diagnosis. RESULTS: Of the 347 initially recruited into the study, 267 participants completed a follow-up visit prior to their scheduled, final visit 6 months after initial infection. The median age at enrollment was 22 years and 41.0% were female. There were 32 (12.0%) reinfections (30 CT and 2 NG) after treatment of an index diagnosis of CT or NG within the six-month study period. Six of the CT reinfections were only detected at the final visit. A review of medical records revealed additional CT and NG reinfections. The probability of detecting a reinfection did not vary significantly by timing of follow-up. CONCLUSIONS: The likelihood of detecting CT or NG reinfection did not differ according to time of follow up visit among study participants, thus supporting CDC guidance to retest three months post treatment. Efforts should continue to focus on STI prevention and risk reduction.

Human T-lymphotropic virus infections in active component service members, U.S. Armed Forces, 2000-2008.

Emergency whole blood transfusions may increase the risk of transmitting bloodborne pathogens, including human T-lymphotropic viruses (HTLVs). U.S. military personnel with any medical encounter for HTLV infection during 2000-2013;2008 were identified from surveillance data. Using both inclusive and restrictive case definitions, the incidence of diagnoses of HTLV infection was analyzed in relation to demographic factors and prior deployment. There were 247 "possible" cases of HTLV infection identified, or 1.88 cases per 100,000 person-years (p-yrs) (95% CI 1.66, 2.13). Seventy of these met the restrictive definition, translating to a rate of 0.53 per 100,000 p-yrs (95% CI 0.42, 0.67). Under the restrictive definition, a higher rate was noted among females versus males (RR 2.37; 95% CI 1.41, 3.98), service members with a healthcare occupation versus those who are primarily trained to engage in combat (RR 2.54; 95% CI 1.06, 6.10), and service members with any deployment experience (RR 8.98; 95% CI 5.61, 14.37). These findings, and a prior military case report of transfusion-transmitted HTLV-I, suggest a need to better define the epidemiology of HTLV in U.S. military personnel to further ensure emergency transfusion safety.

Chlamydia trachomatis infection rates among a cohort of mobile soldiers stationed at Fort Bragg, North Carolina, 2005-2010.

BACKGROUND: Fort Bragg, a large Army installation with reported high Chlamydia trachomatis (Ct) infection rates, is characterized by a highly mobile population and a surrounding Ct-endemic community. We assessed the rates of Ct incidence and recurrence among the installation's active component Army personnel and determined the association of soldier transience, sociodemographic factors, and history of sexually transmitted infection (STI) with these rates. METHODS: A cohort of soldiers stationed at Fort Bragg during 2005 to mid-2010 was followed for incident and recurrent Ct infection using laboratory-confirmed reportable disease data. Linkage to demographic and administrative data permitted multivariate analysis to determine association of covariates with initial or recurrent infection. RESULTS: Among 67,425 soldiers, 2,198 (3.3%) contracted an incident Ct infection (crude incidence, 21.7 per 1,000 person-years). Among soldiers followed for incident infection, 223 (10.6%, crude incidence 110.8 per 1,000 person-years) contracted a recurrent Ct infection. Being female, of lower rank, under 26 years of age, of non-white race, single, or with a high school diploma or less was significantly associated with incident Ct infection. Having breaks in duty or having deployments during follow-up was associated with a lower infection rate. Among women, having prior deployments was associated with a lower rate of both incident and recurrent infection. Specifically associated with recurrent infection in women was age under 21 years or no education beyond high school. CONCLUSIONS: This analysis reaffirms risk factors for Ct infection determined in other studies. In addition, infection risk was lower for more mobile soldiers and tied to the specific location of their regular duty assignment. The findings support the STI prevention efforts at Fort Bragg and the surrounding community, regardless of how often or for how long soldiers have deployed for military operations.

Respiratory health status of US Army personnel potentially exposed to smoke from 2003 Al-Mishraq Sulfur Plant fire.

OBJECTIVE: To assess the impact of exposure to a 2003 sulfur plant fire on the health of deployed US Army personnel. METHODS: The authors identified a small firefighter group known to be at the fire source and a larger, more dispersed population. Self-reported health status and respiratory health outcomes for these two groups were reviewed compared with two unexposed groups. RESULTS: Self-reported health concerns, difficulty breathing, and shortness of breath were common in the exposed. Rates for chronic respiratory conditions increased in all groups from before to after deployment. Postdeployment medical encounters for chronic respiratory conditions among the exposed did not differ significantly from the unexposed comparison groups. CONCLUSION: Potential exposure to the sulfur fire was positively associated with self-reported health concerns and symptoms but not with clinical encounters for chronic respiratory health conditions.

Short communication: Investigation of incident HIV infections among U.S. army soldiers deployed to Afghanistan and Iraq, 2001-2007.

The U.S. Army initiated an investigation in response to observations of a possible increase in HIV incidence among soldiers deployed to combat. Human immunodeficiency virus (HIV)-infected U.S. Army soldiers are not eligible to deploy. Combat presents a health hazard to HIV-infected soldiers and they pose a threat to the safety of the battlefield blood supply and their contacts. All soldiers are routinely screened for HIV every 2 years and those who deploy are also screened both prior to and after deployment. Seroconversion rates were estimated for all soldiers who deployed to Afghanistan or Iraq in the period 2001-2007 and all active duty soldiers who did not. Seroconverters with an estimated date of infection, based on calculation of the midpoint between the last seronegative and first seropositive test date, that was either before or during deployment were eligible for inclusion. Confidential interviews and medical record reviews were conducted to determine the most likely time, geographic location, and mode of infection. Reposed predeployment samples were tested for HIV ribonucleic acid. The HIV seroconversion rate among all soldiers who deployed was less than the rate among those who did not deploy: 1.04 and 1.42 per 10,000 person-years, respectively. Among 48 cases, most were determined to have been infected in the United States or Germany and prior to deployment (n=20, 42%) or during rest and relaxation leave (n=13, 27%). Seven seronegative acute infections were identified in the predeployment period. Subtype was determined for 40 individuals; all were subtype B infections. All were acquired through sexual contact. These findings can inform development of preventive interventions and refinement of existing screening policy to further reduce HIV-infected deployed soldier person time.

Hospitalized patients with 2009 pandemic influenza A (H1N1) virus infection in the United States--September-October 2009.

Given the potential worsening clinical severity of 2009 pandemic influenza A (H1N1) virus (pH1N1) infection from spring to fall 2009, we conducted a clinical case series among patients hospitalized with pH1N1 infection from September through October 2009. A case patient was defined as a hospitalized person who had test results positive for pH1N1 virus by real-time reverse-transcription polymerase chain reaction. Among 255 hospitalized patients, 34% were admitted to an intensive care unit and 8% died. Thirty-four percent of patients were children <18 years of age, 8% were adults ≥ 65 years of age, and 67% had an underlying medical condition. Chest radiographs obtained at hospital admission that had findings that were consistent with pneumonia were noted in 103 (46%) of 255 patients. Among 255 hospitalized patients, 208 (82%) received neuraminidase inhibitors, but only 47% had treatment started ≤ 2 days after illness onset. Overall, characteristics of hospitalized patients with pH1N1 infection in fall 2009 were similar to characteristics of patients hospitalized with pH1N1 infection in spring 2009, which suggests that clinical severity did not change substantially over this period.

Transfusion-transmissible viral infections among US military recipients of whole blood and platelets during Operation Enduring Freedom and Operation Iraqi Freedom.

BACKGROUND: Current US military clinical practice guidelines permit emergency transfusions of non-Food and Drug Administration (FDA)-compliant freshly collected blood products in theaters of war. This investigation aimed to characterize the risks of transfusion-transmitted infections (TTIs) associated with battlefield transfusions of non-FDA-compliant blood products. STUDY DESIGN AND METHODS: US Service members who received emergency transfusion products in Iraq and Afghanistan (March 1, 2002-September 30, 2007) were tested for hepatitis C virus (HCV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV) infections using reposed pre- and posttransfusion sera. Selected regions of viral genomes from epidemiologically linked infected recipients and their donors were sequenced and compared. RESULTS: Of 761 US Service members who received emergency transfusion products, 475 were tested for HCV, 472 for HIV, and 469 for HBV. One transfusion-transmitted HCV infection (incidence rate of 2.1/1000 persons) was identified. The pretransfusion numbers (prevalence per 1000 persons) were HCV-four (8/1000), HIV-zero (0/1000), chronic HBV-two (4 /1000), and naturally immune (antibody to HBV core antigen)-nine (19/1000). CONCLUSION: One HCV TTI was determined to be associated with emergency blood product use. The pretransfusion HCV and HBV prevalence in transfusion recipients, themselves members of the potential donor population, indicates better characterization of the deployed force's actual donor population, and further investigations of the TTI prevalence in these donors are needed. These data will inform countermeasure development and clinical decision making.

An outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus complex infection in the US military health care system associated with military operations in Iraq.

BACKGROUND: We investigated an outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus complex infection among US service members injured in Iraq. METHODS: The investigation was conducted in Iraq and Kuwait, in the 2 military hospitals where the majority of injured service members were initially treated. After initially characterizing the outbreak, we evaluated 3 potential sources of infection for the period March 2003 to December 2004. The evaluation included screening samples that were obtained from the skin of patients for the presence of colonization and assessing the soil and health care environments for the presence of A. baumanii-calcoaceticus complex organisms. Isolates obtained from samples from patients in US Military treatment facilities, as well as environmental isolates, were genotypically characterized and compared using pulsed-field gel electrophoresis. RESULTS: A. baumanii-calcoaceticus complex organisms were present on the skin in only 1 (0.6%) of 160 patients who were screened and in 1 (2%) of 49 soil samples. A. baumanii-calcoaceticus complex isolates were recovered from treatment areas in 7 of the 7 field hospitals sampled. Using pulsed-field gel electrophoresis, we identified 5 cluster groups in which isolates from patients were related to environmental isolates. One cluster included hospitalized patients who had not been deployed to Iraq. Among the clinical isolates, only imipenem, polymyxin B, and colistin demonstrated reliable in vitro antimicrobial activity. Generally, the environmental isolates were more drug susceptible than were the clinical isolates. CONCLUSIONS: Our findings suggest that environmental contamination of field hospitals and infection transmission within health care facilities played a major role in this outbreak. On the basis of these findings, maintaining infection control throughout the military health care system is essential. Novel strategies may be required to prevent the transmission of pathogens in combat field hospitals.

Identification of Acinetobacter species and genotyping of Acinetobacter baumannii by multilocus PCR and mass spectrometry.

Members of the genus Acinetobacter are ubiquitous in soil and water and are an important cause of nosocomial infections. A rapid method is needed to genotype Acinetobacter isolates to determine epidemiology and clonality during infectious outbreaks. Multilocus PCR followed by electrospray ionization mass spectrometry (PCR/ESI-MS) is a method that uses the amplicon base compositions to genotype bacterial species. In order to identify regions of the Acinetobacter genome useful for this method, we sequenced regions of six housekeeping genes (trpE, adk, efp, mutY, fumC, and ppa) from 267 isolates of Acinetobacter. Isolates were collected from infected and colonized soldiers and civilians involved in an outbreak in the military health care system associated with the conflict in Iraq, from previously characterized outbreaks in European hospitals, and from culture collections. Most of the isolates from the Iraqi conflict were Acinetobacter baumannii (189 of 216 isolates). Among these, 111 isolates had genotypes identical or very similar to those associated with well-characterized A. baumannii isolates from European hospitals. Twenty-seven isolates from the conflict were found to have genotypes representing different Acinetobacter species, including 8 representatives of Acinetobacter genomospecies 13TU and 13 representatives of Acinetobacter genomospecies 3. Analysis by the PCR/ESI-MS method using nine primer pairs targeting the most information-rich regions of the trpE, adk, mutY, fumC, and ppa genes distinguished 47 of the 48 A. baumannii genotypes identified by sequencing and identified at the species level at least 18 Acinetobacter species. Results obtained with our genotyping method were essentially in agreement with those obtained by pulse-field gel electrophoresis analysis. The PCR/ESI-MS genotyping method required 4 h of analysis time to first answer with additional samples subsequently analyzed every 10 min. This rapid analysis allows tracking of transmission for the implementation of appropriate infection control measures on a time scale previously not achievable.

An outbreak of malaria in US Army Rangers returning from Afghanistan.

CONTEXT: With numerous US military personnel currently deployed throughout the world, military and civilian health care professionals may encounter imported malaria from this population. OBJECTIVE: To identify malaria in US Army personnel deployed to a combat zone. DESIGN, SETTING, AND PATIENTS: Case series in the US Army health care system. A total of 38 cases of malaria were identified in a 725-man Ranger Task Force that deployed to eastern Afghanistan between June and September 2002. MAIN OUTCOME MEASURES: Identification of malaria cases and soldiers' self-report of compliance with antimalarial measures. RESULTS: A total of 38 patients were infected with Plasmodium vivax, yielding an attack rate of 52.4 cases per 1000 soldiers. Diagnosis was confirmed a median of 233 days (range, 1-339 days) after return from the malaria endemic region, with additional laboratory findings noting anemia and thrombocytopenia. One case was complicated with acute respiratory distress syndrome during the patient's primary attack and a spontaneous pneumothorax during relapse. This case accounted for 1 of 2 relapse cases in the study population. From an anonymous postdeployment survey of 72% (521/725) of the task force, the self-reported compliance rate was 52% for weekly chemoprophylaxis, 41% for terminal (postdeployment) chemoprophylaxis, 31% for both weekly and terminal chemoprophylaxis, 82% for treating uniforms with permethrin, and 29% for application of insect repellent. CONCLUSIONS: Delayed clinical presentation can occur with P vivax. Symptoms are often vague, but malaria should be included in the differential diagnosis for soldiers returning from an endemic region. Suboptimal compliance with preventive measures can result in a malaria outbreak.

Acute eosinophilic pneumonia among US Military personnel deployed in or near Iraq.

CONTEXT: Acute eosinophilic pneumonia (AEP) is a rare disease of unknown etiology characterized by respiratory failure, radiographic infiltrates, and eosinophilic infiltration of the lung. OBJECTIVES: To describe a case series of AEP, illustrate the clinical features of this syndrome, and report the results of an epidemiologic investigation. DESIGN, SETTING, AND PARTICIPANTS: Epidemiologic investigation of cases of AEP identified both retrospectively and prospectively from March 2003 through March 2004 among US military personnel deployed in or near Iraq. Survivors were offered a follow-up evaluation. MAIN OUTCOME MEASURE: Morbidity and mortality related to AEP. RESULTS: There were 18 cases of AEP identified among 183,000 military personnel deployed in or near Iraq during the study period, yielding an AEP incidence of 9.1 per 100,000 person-years (95% confidence interval, 4.3-13.3). The majority of patients (89%) were men and the median age was 22 (range, 19-47) years. All patients used tobacco, with 78% recently beginning to smoke. All but 1 reported significant exposure to fine airborne sand or dust. Known causes of pulmonary eosinophilia (eg, drug exposures or parasitic disease) were not identified. Epidemiologic investigation revealed no evidence of a common source exposure, temporal or geographic clustering, person-to-person transmission, or an association with recent vaccination. Six patients underwent bronchoalveolar lavage (median eosinophilia of 40.5%). All patients developed peripheral eosinophilia (range, 8%-42%). Mechanical ventilation was required in 67% for a median of 7 (range, 2-16) days. Two soldiers died; the remainder responded to corticosteroids and/or supportive care. Twelve individuals were reevaluated a median of 3 months after diagnosis. At that point, 3 patients reported mild dyspnea and 1 reported wheezing. All patients had finished treatment and had either normal or nearly normal spirometry results. None had recurrent eosinophilia. CONCLUSIONS: AEP occurred at an increased rate among this deployed military population and resulted in 2 deaths. Failure to consider AEP in the differential diagnosis of respiratory failure in military personnel can result in missing this syndrome and possibly death. The etiology of AEP remains unclear, but the association with new-onset smoking suggests a possible link.