Epidemiologic investigation of an outbreak of cutaneous leishmaniasis in a defined geographic focus of transmission.

An outbreak of cutaneous leishmaniasis occurred in a unit of 608 Puerto Rican national guardsmen conducting jungle warfare training in the Panama Canal Area in July 1984. An epidemiologic investigation of reported nonhealing, ulcerating skin lesions was conducted among 540 (89%) unit members in November and December 1984. Fifteen (88%) of 17 individuals with chronic, ulcerating skin lesions were confirmed as cases of cutaneous leishmaniasis by culture or histopathology. Twelve cases yielded positive Leishmania cultures, identified as L. braziliensis panamensis by cellulose acetate electrophoresis. Evaluation of different diagnostic techniques revealed that direct examination of tissues by Giemsa-stained histological examination was the most sensitive test (87% sensitivity), with an indirect immunofluorescent antibody test being rather insensitive (67%). All but one of the confirmed cases operated in small units that trained and slept overnight at a mortar firing site for a period of three days, yielding a site-specific attack rate of 22% (14 of 64). This contrasted with a much lower attack rate of 0.2% (1 of 476), experienced by unit members who trained at other locations during the same time frame (P less than 0.001). The median incubation period calculated from day of arrival at the mortar firing site was 17 days (range 2-78) for the 15 confirmed cases. Available personal protection methods, such as the use of insect repellents, were not appropriately implemented by unit personnel and thus, were not found to effectively protect against Leishmania infection. This is the largest reported outbreak of cutaneous leishmaniasis in military personnel associated with a single geographic focus of infection and contrasts with the usual sporadic disease experience in Panama.

Immunogenicity achieved by the intradermal hepatitis B vaccination programme for US Army soldiers in Korea.

Hepatitis B virus (HBV) infections are a significant threat to the 30,000 US Army soldiers stationed in South Korea. Hepatitis B surface antigen carrier rates in some Korean populations may run as high as 15%, and HBV incidence estimates for US soldiers in Korea have ranged from 0.6 to 6% per year. In response to this threat, on 1 October 1986 the US Army instituted a mandatory three-dose (0, 30-60, and 60+ days), 0.1 ml per dose, intradermal (i.d.) immunization regimen for all soldiers bound for permanent assignments in Korea. Although shown to be immunogenic in experimental studies, the i.d. route had never been attempted on as large a scale as in this operational setting. During September 1987, an evaluation of programme compliance and immune response was conducted. For those who received three doses according to schedule, antibody response was similar to that reported by previous controlled trials that used the i.d. approach. The three-dose i.d. series appeared to provide protective antibody levels in at least 67% of soldiers, but, consistent with previous trials, antibody levels were approximately one-half those obtained following intramuscular vaccination. We conclude that, as a cost-reduction strategy, wide-scale use of intradermal hepatitis B vaccine may be useful in situations characterized by short-term increased HBV infection risk.

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.

Outbreak of hemorrhagic fever with renal syndrome among U.S. Marines in Korea.

Fourteen of 3,754 U.S. Marines who participated in a joint United States-Republic of Korea training exercise during the autumn of 1986 developed hemorrhagic fever with renal syndrome (HFRS). Clinical and laboratory findings among cases included fever, headache, fatigue, gastrointestinal dysfunction, thrombocytopenia, and proteinuria. Ten individuals were hospitalized; 2 died. No subclinical infections were identified through a post-deployment screen of sera obtained from 2,053 exercise participants. Analysis of questionnaires identified no environmental, occupational, or temporal factors as risks for developing disease. However, 13 of the 14 cases occurred among individuals housed at 1 of the 2 base camps used during the exercise. This outbreak represents the largest cluster of HFRS cases among U.S. personnel in the Republic of Korea since the Korean conflict.

Effect of spectinomycin use on the prevalence of spectinomycin-resistant and of penicillinase-producing Neisseria gonorrhoeae.

Because of the high prevalence of penicillinase-producing Neisseria gonorrhoeae in the Republic of Korea, spectinomycin has been used there in the primary treatment of gonococcal infections in U.S. military personnel since 1981, but there have been increasingly frequent reports of treatment failures with spectinomycin. We conducted a clinical study to determine the efficacy of spectinomycin treatment in 124 U.S. servicemen in the Republic of Korea who had urethral gonococcal infections. Ninety-seven patients were treated with spectinomycin alone and evaluated in a follow-up visit. In eight patients (8.2 percent), this treatment was unsuccessful. Antibiotic-sensitivity testing on isolates from seven of the patients with treatment failure demonstrated that six isolates were highly resistant to spectinomycin (minimal inhibitory concentration, greater than or equal to 100 micrograms per milliliter). None of the spectinomycin-resistant strains had become resistant to penicillin, either through the production of penicillinase or through a chromosomal mutation. Although the mechanism of spectinomycin resistance appears to be a chromosomal mutation, these isolates were generally sensitive to other antibiotics. The prevalence of resistance to spectinomycin resulted in the substitution of ceftriaxone for the primary treatment of gonorrhea acquired by U.S. military personnel in the Republic of Korea. We believe that the rapid emergence of spectinomycin resistance in this population mandates a cautious approach to widescale use of the drug and indicates a need to broaden current surveillance programs.