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AFMIC Weekly Wire

Subject: AFMIC Weekly Wire

This special weekly wire discusses diseases endemic in the local
population that will be important to medical forces in the Middle
East because of the likelihood of humanitarian medical assistance
for refugees or displaced persons. Diseases are prioritized in
descending  order  of expected  impact  on humanitarian medical
missions.  Additionally, because of the length of time in the
Area of Operation  (AO),  these diseases will be  increasingly
important to operational units. Common or local names for the
diseases are in parenthesis.  The available statistics on the
prevalence and incidence of many of these diseases are incomplete,
making reported rates and numbers of cases generally,unreliable
indicators of true prevalence or endemicity. Transmission factors
that are unique or important in this region are discussed. 
discussions on incubation periods, routes of transmission, and
clinical signs and symptoms are available in standard texts and 
beyond the purpose of this wire.
        Military conflict will weaken existing medical 
infrastructure, reduce preventive medicine programs, interfere 
with waste-disposal, and compromise personal hygiene;  these  
factors will lead to increased  incidence  of  endemic  diseases. 
 Additionally, the immigration  of  nonindigenous  persons  into  
some  regions  may introduce nonendemic diseases and will change 
the baseline health status of the resident population.

  C. TRACHOMA (Ramad)
  D. CHILDHOOD DISEASES   (Diphtheria,   Measles,   Pertussis,
Poliomyelitis, Tetanus)
  E. BRUCELLOSIS (Al-Brosliyat)
  G. ECHINOCOCCOSIS (Hydatid Disease)
  H. RABIES (Al-Kalab)
  J. PLAGE (Taa'on)
  K. ANiIAX (Al-Jamra)
  L. TYPHUS, LOUSE-BOENE (Epidemic Typhus)
  M. TYPHUS, MURINE (Endemic Typhus)
  O. LEPROSY (Al-Jotham)

Disease Agents: In children younger than 5 years suffering from
acute diarrhea,  the most common enteropathogens  isolated,  in
descending frequency, generally are rotavirus  (37-44 percent),
Salmonella,  enteropathogenic  Escherich,a  coli,  Shigella,  and
Campylobacter jejuni. The most common parasite isolated is Giardia
lamblia (4-7 percent of the cases). Multiple infections are seen 
about 1 percent of the children. Cholera is not endemic in the
region; imported cases (and outbreaks) occur, but cholera should
not be a significant cause of childhood diarrhea in refugee
Distribution/Risk Period: widespread. Year-round. Seaon~ increases
in rotaviral diarrheas primarily in cold months (December-March),
but also in the hot dry season (July-September). Seasonal 
in bacterial etiologies occur from June to October; protozoal 
peak in August and September.
Remarks: Rotavirus is a leading `cause of gastroenteritis in young
children (aged less than 5 years) in Kuwait and Saudi Arabia; ihe
incidence is lower in breast-fed than in bottle-fed� infants.
Rotavirus diarrhea is a major pediatric health problem, with up to
30 percent of the children havind concurrent upper respiratory
infection. Among the bacterial etiologies, multiple drug 
is common among Salmonella and Shigella isolates.

Intestinal parasitic infections (IPI) are not notifiable diseases;
the true prevalence and incidence of these diseases are unknown.
Agents: Most common IPI are amebiasis, giardiasis, ascariasis,
trichuriasis,    enterobiasis,    and    hymenolepiasis.    Human
dicrocoeliasis (Dicrocoelium dendriticum) has been reported from
Saudi Arabia and is commonly associated with drinking raw milk or
eating raw liver (camel, cattle, goat, or sheep). Taeniasis 
saginata) and fascioliasis are reported from discrete foci. Low
levels  of  Trichostrongylus  columbriformis  and  Strongyloides
stercoralis have been detected in northern Iraq.
  Distribution/Risk Period:     widely     distributed; but vary 
geographically and depend on many socioeconomic factors; more- 
common among lower socioeconomic levels than middle and upper 
levels. In developed regions, roundworms and whipworms are present 
at low levels. Hookworm Ancylostoma duodenale) infections 
generally occur in primitive rural communities where promiscuous 
defecation exists. Enteric protozoal agents (Giardia lamblia and 
Entamoeba histolytica) are commonly isolated from all regions. 
Transmission  of most agents occurs year-round, with seasonal 
increases in the dry season. Human cases of dicrocoeliasis peak in 
October and November.
Remarks:   Highest IPI rates can be anticipated in expatriate
workers from less-developed countries and from indigenous people
from rural areas. A high rate (63 percent) of intestinal parasite
infection was found in a hospital-based study in Kuwait. A similar
study in Riyadh revealed that 323 of 3800 patients examined were
infected with potential pathogens - Giardia, Hymenolepsis nana, E.
histolytica, and Ascaris being the most frequent (in descending
order). Similar levels were detected in community-based studies in
northern Iraq, where IPI rates reached 18.3 percent; prevalence 
roundworms (Ascaris lumbricoides) in rural areas near Bagdad and
Babylon is estimated to be slightly more than 5 percent. In Saudi
Arabia, IPI rates may be highest in rural communities in the Asir
province; IPI in children from urban areas are most commonly due 
G. lamblia (13.5%), followed by Enterobius vermicularis (4.2%) and
H. nana; the general incidence of other helminthic parasites is
low. In a two year study from Abu Dhabi, United Arab Emirates,
stool samples of 42,022 food handlers, hookworms were found in
13.8%  of  the  samples,  whipworm  6.9%,  and  roundworms  2.6%.
Interruption of potable water supplies and sewage disposal and
deteriorated sanitary conditions in developed regions wttl 
the incidence of most of these parasites.

Transmission: Primarily transmitted by direct contact with ocular
and nasopharyngeal discharges on fingers and contaminated 
(face cloths and cosmetic khol sticks used to darken ,eyelids).
Filth flies (primarily Musca sorbens, the market or bazaar fly, 
also M. domestica) contribute to the spread of the disease.
DistrIbution/Risk Period: widely distributed and highly endemic,
particularly in rural areas with poor hygiene. Year-round.
Remarks: In endemic areas, the highest infection rates are in
children. Prevalence of active cases in Oman is an estimated 5-15
percent and is 10 percent in Yemen. Approximately 22 percent of 
Saudi population suffer from trachoma and about 6.2% have active
trachoma; the disease is hyperendemic in the Eastern Province of
Saudi Arabia. Control measures reduced incidence in the 1980s, but
trachoma is still the most widespread eye disease in this region
and the leading cause of preventable blindness.

CHILDHOOD DISEASES (Diphtheria, Measles, Pertussis, Poliomyelitis,
and Tetanus)
Distribution: Endemic, but marked regional variations in reported
incidence exist.  Based on the number of reported cases  (data
available through 1988-89), more developed countries (Saudi 
Kuwait, Bahrain, Oman, and UAE) have a lower incidence. Generally,
- Yemen and Iraq have the highest rates.
Vaccination Programs: Expanded programs of immunization (EPI) have
improved vaccination coverage and reduced the incidence of 
diseases in the region since the early-1980s. In 1988-89, Saudi
Arabia, Kuwait, Oman, UAE, and Bahrain reported that approximately
85-90 percent (weighted `average) of infants had received a 
complete vaccination series (OPV, DPT, measles, and BCG). Percent 
coverage was lower in Iraq and Qatar. Yemen had the poorest 
coverage, 35-45 percent. Remarks: Refugee populations that have 
relied on EPI to control childhood diseases will be at increased 
risk for outbreaks or epidemics when vaccination programs are 

   BRUCELLOSIS (Al-Brosliyat)
Transmission/Reservoir: Over 80% of reported human cases are due 
consumption  of  raw dairy  products  (goat and  camel milk  and
cheeses). Contact with infected material plays a minor role. In
human cases not associated with direct animal or product exposure,
most appear to have contracted the disease while travelling 
areas contaminated with animal fetal tissues.  The disease is
endemic in natural reservoirs (goats, sheep, camels, and cattle)
which principally are infected with Brucella melitensis.  The
prevalence of infection of sheep and goats commonly exceeds 10
percent. B. abortus has been isolated from camels, but the 
significance is unclear.
Distribution/Risk Period:  Widespread,  but  regional variations
exist. Human cases caused by B. melitensis are widely distributed,
in both rural and urban areas. seasonally distributed, with most
cases occurring March to July, peaking in April and May. Peak
incidence of cases associated with environmental exposu~ coincides
with the lambing and kidding seasons.
Remarks:    One of the commonest human infectious diseases in the
region; many areas have experienced true increases in incidence,
`with some outbreaks reaching epidemic proportions. Particularly
common among farmers,  shepherds, nomadic tribesmen, and their
families  (10-25  percent sero-prevalence has  been detected- in
agricultural workers). Annual incidence increased greatly-in 
in the early 1980s, with the incidence reported in 1985 thirty
times higher than in  1976.  Other neighboring countries have
experienced similar increases. In Oman, about 300 human cases are
reported annually, with the majority in the Dhofar region, where 
occurs in epidemic proportions among the Jebali people. The rise
may be partially due to increased clinical awareness aand improved
diagnostic  capabilities,  but  highly mobile  animal herds  and
uncontrolled importation of live animals have interfered with
control efforts. For each case reported an estimated 25 cases are
unrecognized or unreported.

Transmission/Reservoir: Most tuberculosis (TB) is caused by human-
to-human transmission of Mycobacterium tuberculosis.  zoonotic
tuberculosis is of lesser significance.
Distribution/Risk Period: TB is widely distributed throughout the
region, however, countries have varying levels of prevalence.
Remarks:    TB is an important disease in the indigenous 
population.  Most of the reported human cases  are pulmonary  
rather than disseminated or extrapulmonary. Tuberculous cervical 
lymphadenitis represents a significant portion of the 
extrapulmonary TB in Saudi Arabia  (biopsied  neck  masses  are  
frequently  diagnosed  as tuberculosis). Based on the estimated 
level of risk of infection (the proportion of the population which 
has been infected or reinfected in the course of one year), 
countries in the region can be grouped into three categories of 
prevalence. Countries with low- prevalence (risk of infection 
0.1-0.2 percent) are Bahrain and Kuwait. In Bahrain, infection 
rates in expatriate workers from less-developed countries were 
found to be 7 times higher than in Bahrainis.  High-prevalence  
(2.0-3.0 percent)  is  reported from Yemen. All other countries in 
the region have intermediate level prevalence (0.5-1.5 percent). 
All countries in the region, except Iraq, are known to have 
incorporated childhood BCG vaccination of children into their 
Expanded Program of Immunization (EPI). A 21.3 percent prevalence 
of resistance to primary antituberculous drugs was reported from 
Riyadh, Saudi Arabia. Primary resistance to INH was 19.4 percent; 
primary and secondary resistance to rifampicin was 3 percent and 
33.7 percent, respectively. Most isolates from patients with 
acquired resistance to rifampicin also were resistant to INH.

ECHINPCPCCPSOS     (Hydatid Disease)
  Transmission/Reservoir:      Carnivores harboring the adult 
tapeworms   (Echinococcus granulosus) become infected by eating 
viscera of  intermediate hosts containing hydatid cysts; the 
dog-sheep cycle   (particularly associated with dogs used for 
sheep Herding)  is   important in this region. Cattle, goats, and 
camels are lesser  important intermediate hosts.  Infection rates 
in dogs vary by  region and locality,  with highest rates  (67  to 
 100 percent)   reported  in  Irbil  province  of  northern  Iraq. 
 In  1976,  the   prevalence in dogs in Kuwait was-found to be 23 
percent, but levels  may have declined. Stray dogs in urban areas 
commonly are infected   by feeding on uncooked offal discarded 
from slaughter houses; up to  15 percent of stray dogs near 
Al-Hassa, Saudi Arabia reportedly  were infected.
  Distribution/Risk Period: Endemic and enzootic, especially in 
rural   agricultural areas where dogs are used to herd grazing 
animals,   particularly sheep. However, human cases also occur in 
larger urban   areas. widely distributed and highly 
endemic/enzootic in Iraq.   Reportedly, the highest prevalence in 
Saudi Arabia exists in the southern and western regions  followed 
by the central region. 
  Moderately endemic in Kuwait. Year-round.
  Remarks: Important parasitic infection in this region, 
particularly  among groups having intimate contact with dogs (and 
objects soiled  with feces). Islamic teachings stress avoidance of 
dogs; however, this does not provide complete protection. The 
highest incidence of  human disease generally is in the 31 to 40 
year old age group.
  Human infection rates in Iraq are estimated to be slightly less
  than  1  percent,  accounting  for  1  percent  of  all  
  procedures;  in highly endemic areas of Saudi Arabia,  it has
  accounted for 5 percent of all major surgical operations.  In
  Kuwait,  the majority of recently reported cases were in non-
- Kuwaitis.

  RABIES (Al-Kalab)
Transmission/Reservoir:        Sylvatic and urban rabies are 
important.  Urban rabies, with stray dogs (cats and other animals 
to a lower  extent) serving as the reservoir and main source of 
human exposure,  is  reported  from cities  and villages of most 
countries.  The  principal enzootic reservoir for sylvatic rabies 
is the desert fox,  and spill over into stray dog and cat 
populations frequently   occurs. Sheep rabies is reported with low 
sporadic Occurrence.  
  Distribution/Risk Period: In Saudi Arabia, human cases are very
  sporadic, usually in the northern or eastern rural areas. 
Although  Oman had been considered to be provisionally free of 
rabies, the  disease  is  endemic  in  this  region,  with  
recently  reported laboratory-confirmed cases in foxes and sheep 
and a human case.
  Rabies is present but of low incidence in Qatar and the UAE. 
Kuwait and Bahrain are considered rabies-free; the last case �of 
animal  rabies  in  Kuwait  was  reported  in  October  1987.  
Year-round   transmission occurs, but an increased risk in the 
spring and summer  can be expected due to elevated animal 
populations and increases in  animal bites in warmer seasons.
  Remarks:  Dog and cat bites/scratches will probably be the 
primary  sources  of  human  exposure  and  reasons  for  
past-exposure  prophylaxis.  Animal cases  are likely to be 
unrecognized and underreported by the indigenous population.  
Additionally,  the   disruption following the Iraqi invasion and 
possible military   conflict, may allow reintroduction into 
previously free areas.
  Transmission/Reservoir:  commonly transmitted     by    airborne
  dissemination of rickettsia (Coxiella burnetii) and secondarily 
by  direct contact with infected animals and from consumption of 
raw  milk. Domestic animals, rodents, and ticks (primarily 
  dromedarii) serve as natural reservoirs.
  Distribution/Risk Period: Widely distributed throughout the 
region;  serolog�ical studies suggest that it is highly endemic in 
eastern  Saudi Arabia, and it may be endemic in other areas at 
similar   levels.' Enzootic in livestock. Year-round.
  Remarks: Sporadic cases have been reported areawide, but 
incidence  is suspected to be greater that reported due to limited 
dagnostic  capabilities. Serology from indigenous personnel in 
rural areas   indicates that subclinical infection develops in 
childhood and   virtually all young adults have had sensitizing 
contact (inducing  acquired immunity).

  PLAGUE (Taa'on)
  Transmission/Reservoir: Primarily transmitted by the bite of an
  infective flea (primarily Xenopsylla cheopis, the oriental rat
  flea, but also Pulex irritans, the human flea). Reservoirs for
  sylvatic plague in the region include gerbils (Meriones spp and
  Gerbillus gerbillus) and desert voles. Rattus rattus may serve 
  a reservoir around dwellings in endemic areas.
  Distribution/Risk  Period:  Occurs  areawide.  Natural  
  enzootic foci of plague historically have existed between the
- Tigris and Euphrates rivers and adjacent territories extending 
from  Syria to the Persian Gulf, possibly including Kuwait. In 
Iraq, the highlands near the border with Syria historically have 
been an  enzootic focus. Although plague is considered eradicated 
in Saudi   Arabia (last reported outbreak occurred in 1969 along 
the Yemen  border in the Khawlan district), sylvatic (wild rodent) 
plague  should be considered focally enzootic in the Asir upland 
plains in  the southwestern portion of the Arabian peninsula. 
Year-round, but especially during hot, dry months.
  Remarks: Underreported.

   ANTHRAX (Al-Jamra)
  Transmission/Reservoir: Enzootic, primarily in sheep and goats.
  Infections  in these animals  serve as  the  primary method  of
  environmental and product contamination with spores. Many of the
  reported human cases are unable to identify the true source of
  their infection.
Distribution/Risk Period: Widely distributed, but focally endemic.
Occurs sporadically in rural areas during summer months.
Remarks: Cutaneous cases predominate, followed by gastrointestinal
and pulmonary forms. Cases and outbreaks are most likely in 
populations, farmers, and shepherds and in people handling 
animal products (wool, hides, meats, etc). In Iraq, 200 to 269
human cases were officially reported annually from 1976 to 1980.

TYPHOS, LOOSE-BORNE (Epidemic Typhus)
Transmission/Reservoir: By rubbing crushed body lice (Pediculus
humanus) or their feces into the bite site or abrartons; lice
defecate rickettsiae (Rickettsia prowazeki) while feeding. Man is
the -reservoir and maintains the infection during inter-epidemic
`Distribution/Risk Period: Thought to be present, but prevalence 
unknown. Endemic foci are preseht in Iraq. Northern Saudi Arabia
and Kuwait are at the southern limits of the distribution belt in
the Middle East. The disease may be present in the Southwest
regions�of the Arabian Peninsula (Asir Province of Saudi Arabia 
Yemen). `Seasonal, usually more prevalent in colder months.
Remarks:  Louse-borne typhus is commonly associated with over-
crowding,  transient populations,  impovershed people,  and poor
sanitary conditions; refugee populations would be at increased
risk. In 1977, 19 cases were reported from Iraq, with most cases
from July to September. An outbreak was reported among nomadic
tribes in northern Saudi Arabia in 1961 resulting in 49 cases and
2 deaths.

TYPHUS, MURINE (Endemic Typhus)
Transmission/Reservoir:  Primary  vectors  are  infective  fleas,
usually Xenopsylla cheopis (oriental rat flea) and potentially
Ctenocephalides felis (cat flea). The disease is maintained in
nature by a rat-flea-rat cycle; large rodent populations 
to the spread of murine typhus.
Distribution/Risk Period: Thought to be present areawide,  but
prevalence is unknown. In Saudi Arabia, human cases occur along 
Red Sea coast, the northern province, and along the Persian Gulf
`coast. Year-round, but peaks during the summer months.
Remarks:   Sporadic cases are reported. An outbreak occurred in
Kuwait in 1978 with 254 clinical cases detected; the highest 
attack rates were among people in lower socioeconomic levels. 
Deteriorated   sanitary conditions in Kuwait will elevate rodent 
populations which will contribute to increased incidence of murine 

Distribution/Risk Period: Moderately endemic. Widely distributed,
particularly in remote rural areas where the standard of hygiene 
low and access to health services is limited. Year-round.
Remarks:   Primarily confined to nomadic and semi-nomadic 
(Bedouins), where the prevalence may reach 20 percent; the 
of clinical cases are between 15 and 35 years old. The majority of
cases aquire the infection in childhood. The seropositivity rate 
higher among females. The social consequences of mistaking bejel
for venereal syphylis in a conservative Islamic culture must be

LEPROSY (Al-Jotham)
Distribution/Risk Period: Indigenous transmission occurs at low
levels. Distributed throughout the region, with regional 
expected. Generally associated with areas of crowding, poverty,
poor sanitation, and substandard living conditions. Year-round.
Remarks: Prevalence remains low. Increased incidence was reported
in Kuwait prior to 1985, attributed to the increased immigration 
expatriate workers from endemic areas; from 1983 to 1988, over 95
percent of the patients were immigrants.  In 1979, cases were
reported from throughout Saudi Arabia, but a foci existed in the
southwest region. In 1986, the prevalence in Saudis was 4.1 per
100,000, and in non-Saudis was 126.5 (most non-Saudis were from
`endemic areas). Tuberculoid leprosy was significantly more common
in Saudi than non-Saudi patients;' the prevalence of the other 
types of leprosy was the same for both groups.

Transmis'sion/Reservoir: The black fly (Simulium damnosum complex)
is the primary vector species in the region.
  Distribution/Risk  Period:       Confined  to  the  southwest  
Arabian peninsula (Saudi Arabia and Yemen) in focally endemic 
areas. Cases  have been reported in the Asir region of southwest 
Saudi Arabia (in   villages around Khamis Mushayt). In Yemen, it 
is endemic in all  westward flowing permanent streams (wadis) 
between the northern  Wadi Surdud and the southern Wadi Ghayl at 
elevations of 300 to  1,200 meters; cases have been reported from 
Hodeida to Taiz (most  occurred in Al Barh between Mokha and 
Taiz). Although not reported, the disease probably occurs 
throughout the length of Yemen, in wadis flowing into the Gulf of 
Aden and the Red Sea. Seasonal, when blackflies are present.
Remarks:  Reporting  has  been  limited,  making  prevalence  and
incidence estimates unreliable. An estimated 60,000 people are at
risk  in  endemic  areas  in  southwest  Yemen.   Dermatologic
manifestations of onchocerciasis  (sowda)  predominate in Yemen;
-ocular manifestations (river blindness) were common in the cases
reported from Saudi Arabia.

  Transmission/Reservoir:     Human  infection  is  primarily  
aquired  through contact with cat feces or food contaminated with 
oocysts or   through consumption of raw meat containing 
bradyzoites, principally  from  sheep  and  goats.  Raw  goat  and 
 sheep  milk  containing  tachyzoites possibly may be a source of 
infection. Domestic and  wild felines are the only definitive 
hosts; cat feces is the source  of environmental contamination 
with oocysts. Numerous mammalian intermediate  hosts  exist;  
rodents  are  important  sources  of infection for felines. The 
prevalence of infection in sheep and  goats is related to the 
abundance of felines in pasture lands.
Distribution/Risk Period: Widely distributed. - Year-round.
Remarks: Seroprevalence is high. Human prevalence in Saudi Arabia
is an estimated 33 percent; 58 to 95 percent prevalence was found
in  Kuwait.  Serosurveys  indicate  that  infection may  be more
prevalent in nomads (Bedouins).

Transmission/Reservoir: All domestic animals as well as many wild
animals, especially rodents, may serve as reservoirs of-infection.
Many  serotypes have been  reported  from  the  region,  but the
predominant" `Serotype(s)  in an  area  is  dependant  on specific
ecologic conditions.
Distribution/Risk Period: Leptospires require a slightly alkaline
and strictly fresh water environment, which may restrict their
presence in eastern Saudi Arabia or in the salt marshes of 
Iraq (`south of Basrah). Conditions in oases are favorable for
leptospire survival. The disease can be expected to be focally
`distributed. Primarily a risk during warm months of the year 
to September).
Remarks:  Limited reports suggest a very low endemicity. Cases are
sporadically reported from the region; the risk of aquiring the
disease ,and the number of expected cases in indigenous people are
low. Leptospirosis generally is occupationally related. Elevated
rodent populations may contribute to increased transmission.



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