The military and hepatitis B.

Hepatitis B virus (HBV) is an important cause of morbidity in military forces. HBV threatens a safe blood supply for mass casualties, contributes to rising health care costs and presents an occupational risk to health care workers. The susceptibility of soldiers reflects that of other residents of their country of origin. In intermediate and high-prevalence regions, infections usually occur in young adults and follow exposure to an HBV carrier through blood or sexual contact. Control of HBV infections must rely on education regarding risk factors, screening of blood donors and immunization. Military populations provide unique opportunities for studying the epidemiology of hepatitis B and carrying out mass vaccination programmes.

Military immunizations. Past, present, and future prospects.

The United States military immunizes its forces against a variety of infectious diseases of military importance. Military vaccines can be divided into several categories: (1) routinely administered vaccines for recruits and the total force; (2) deployment-specific vaccines, (3) occupational vaccines based on specific job-associated risks, and (4) experimental limited use vaccines for special contingency situations. New vaccines based on new technological advances are being developed to meet the continuous requirements of the military.

An outbreak of hookworm infection associated with military operations in Grenada.

During 1983, a multinational military intervention took place on Grenada. After deployment, troops from several U.S. Army units noted signs and symptoms consistent with soil-transmitted helminthic infection. Of 684 soldiers screened five to seven weeks post-deployment, over 20% reported abdominal pain and/or diarrhea during or after the action. Eosinophilia of at least 10% was observed in 119 (22.5%) of 529 soldiers evaluated further; eosinophilia of 5-9% was documented in another 126 (23.8%) of the 529 soldiers. Stool examinations confirmed hookworm infection in 35 soldiers. One case of strongyloidiasis was also documented. Infection was attributed to ground exposure near homes with compromised sanitation. Units that joined the operation after the initial assault phase were at low risk of hookworm infection.

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.

Circumcision as a risk factor for urethritis in racial groups.

A retrospective population-based case-control study of sexually transmitted urethritis was conducted at a large military base over a 21-month period. During the study, 9,514 patients were seen for sexually transmitted disease. The analysis was restricted to active duty males and showed that Blacks had 14.8 times the incidence rate of gonococcal urethritis (GCU) and 4.7 times the rate of nongonococcal urethritis (NGU) compared to Whites. There were slightly fewer cases of NGU than GCU. A case-control study of active duty soldiers showed that both Black and White circumcised subjects were 1.65 times as likely to have NGU as uncircumcised subjects (95% CI: 1.37-2.00). However, circumcision was not associated with an increased incidence of GCU.

An oocyst-transmitted outbreak of toxoplasmosis: patterns of immunoglobulin G and M over one year.

Sera from 32 patients who became ill after jungle combat training were tested for antibodies to Toxoplasma gondii using the indirect immunofluorescence test. Swift rises of both IgG and IgM antibodies occurred within 2 weeks of infection. Reduction in IgM titers, due to competitive suppression by IgG antibody, occurred in most but not all cases. Suppression of IgM reaction by IgG antibody could be prevented by adsorption of serum with Staphylococcus aureus containing protein A. Antibody of the IgM class could be detected at greater than or equal 1:256 level in many sera at 6-month and 1-year intervals after exposure. In groups with exposures such as were experienced in this study, the presence of IgM antibody titers in single serum specimens cannot be used to indicate recent exposure. Both IgG and IgM antibody may rise together to high levels very rapidly after infection; IgM did not precede IgG antibody in our 32 subjects.

American cutaneous leishmaniasis: a comparison of three sodium stibogluconate treatment schedules.

Thirty-six patients with American cutaneous leishmaniasis were randomized to receive intravenous sodium stibogluconate for 10 days at a dose of 600 mg antimony (Sb) per day by one of three schedules: once daily by rapid infusion (A), by continuous 24 hr infusion (B), or in divided doses every eight hours by rapid infusion (C). Patients not cured after initial treatment were rerandomized to one of the other treatment schedules. An additional 19 patients who were not part of the randomized study received standard (STD) sodium stibogluconate treatment (600 mg Sb once daily by rapid infusion for 10 days, identical with schedule A). In the randomized study, the overall cure rate after the first course of treatment was 64%, but was higher for schedule A (100%) than for B (50%) or C (42%) (P less than 0.01). Considering all courses of treatment, schedule A was more effective (94%) than B (53%) or C (43%) (P less than 0.01). Paradoxically, patients in group A had a higher cure rate than patients in group STD (42% after the first course of treatment and 51% when all courses of treatment were considered). Side effects were mild and well tolerated. Total side effects were more frequent in groups B + C (52%) than A + STD (23%) due to an increased incidence of subjective complaints (26% vs. 10%, P less than 0.05) in patients receiving other than once daily rapid infusion. We conclude that giving the same total amount of sodium stibogluconate in three divided doses or by continuous infusion offers no advantage over standard, once daily treatment of American cutaneous leishmaniasis.

Rapid serodiagnosis of leptospirosis using the IgM-specific Dot-ELISA: comparison with the microscopic agglutination test.

The dot enzyme-linked immunosorbent assay (Dot-ELISA) was compared to the microscopic agglutination test (MA test) for the diagnosis of human leptospirosis. Of 177 sera from 68 soldiers who trained in the Republic of Panama, 102 sera were positive in the MA test and 93 of these sera were positive in the IgM-specific Dot-ELISA. Incidence of infection was 50 of 68 patients with the MA test and 48 of 68 in the IgM Dot-ELISA. Five MA test-positive sera were reactive only in the IgG-specific Dot-ELISA, suggesting previous exposure. All 21 infecting serovars of Leptospira interrogans, as determined by positive reactions in the MA test or culture of blood and urine specimens, were reactive in the Dot-ELISA. Of 75 sera negative in the MA test, 61 were nonreactive in the Dot-ELISA. However, 9 of these 14 Dot-ELISA-positive/MA test-negative sera were acute samples from patients whose later sera were MA test-positive. Positive reactions in the IgM Dot-ELISA occurred in 2 of 30 control, 4 of 10 Lyme disease, 1 of 11 relapsing fever, and 1 of 8 yaws sera; 10 syphilis patient sera were nonreactive. The IgM-specific Dot-ELISA appears to be sensitive and specific for the serodiagnosis of acute leptospirosis. In addition, this rapid test is inexpensive, simple to perform, utilizes minute volumes of killed leptospiral antigen and is easily adaptable to field use.

An efficacy trial of doxycycline chemoprophylaxis against leptospirosis.

Because leptospirosis has been an important cause of morbidity in U.S. soldiers training in the Republic of Panama, we conducted a randomized, double-blind, placebo-controlled field trial during the fall of 1982 to determine whether doxycycline was an effective chemoprophylactic agent against this infection. Doxycycline (200 mg) or placebo was administered orally on a weekly basis and at the completion of training to 940 volunteers from two U.S. Army units deployed in Panama for approximately three weeks of jungle training. Twenty cases of leptospirosis occurred in the placebo group (an attack rate of 4.2 per cent), as compared with only one case in the doxycycline group (attack rate, 0.2 per cent, P less than 0.001), yielding an efficacy of 95.0 per cent. This study demonstrated the value of doxycycline as a prophylactic drug against leptospirosis.

Resistance trends of Neisseria gonorrhoeae in the Republic of Korea.

Penicillinase-producing Neisseria gonorrhoeae has increased in the Far East to the point that penicillin can no longer be recommended as the drug of choice, mandating a change to spectinomycin. As part of an ongoing surveillance of antibiotic susceptibilities, minimal inhibitory concentrations of penicillin, tetracycline, spectinomycin, trimethoprim-sulfamethoxazole, cefoxitin, ceftriaxone, cefotaxime, and moxalactam were determined. A disturbing, steady increase in resistance to spectinomycin was documented.

Gonococcal pilus vaccine. Studies of antigenicity and inhibition of attachment.

A gonococcal pilus vaccine or placebo was injected subcutaneously or intramuscularly into 71 human volunteers. The vaccine was found to be safe. The principal adverse reaction was a complaint of a sore arm, which was caused, at least in part, to the volume of material injected. 6 of 64 (9%) volunteers receiving the larger doses also complained of malaise. The vaccine was found to be antigenic. All of the volunteers developed an immunoglobulin class-specific antibody response as measured by a solid phase radioimmunoassay. The antibody was capable of blocking the attachment of gonococci to epithelial cells. A slight antibody response was also demonstrated to gonococcal lipopolysaccharide but the antibody responsible for blocking attachment of gonococci was directed entirely at the pilus protein. The stimulated antibodies were shown to crossreact with isolated pili of heterologous gonococcal strains and to block the attachment of heterologous gonococci. Absorption of immune sera by a heterologous pilus reduced the inhibition of attachment antibodies to pre-immune level, suggesting that the immune response was directed at a common pilus determinant.

A military community outbreak of hepatitis type A related to transmission in a child care facility.

An outbreak of hepatitis type A occurred among military personnel and dependents on a military post in Anchorage, Alaska, August 1976-April 1977. One hundred sixteen clinical cases of hepatitis were identified over a nine-month-period. Ninety-six per cent of those cases that were tested demonstrated IgM antibody to hepatitis A virus. A large child care facility was implicated as a major focus of hepatitis virus transmission. Sixty-four (55%) of the cases were directly or indirectly linked to the child care facility. The length of time that a child spent at the facility appeared to increase the child's risk of developing hepatitis and the risk of his transmitting the hepatitis A virus to other members of the immediate household.

Cutaneous leishmaniasis associated with jungle training.

In November 1977, 627 soldiers belonging primarily to the First Battalion, 82nd Airborne Division, stationed at Fort Bragg, were sent to the Canal Zone, Panama, for jungle warfare training. A medical surveillance program incorporating pre- and post-evaluations over a 6-month period with dermatologic examinations, questionnaires, and serologic tests was established. Ten cases of cutaneous leishmaniasis (1.6/100 men) were diagnosed by positive Leishmania culture. The demonstrated lack of sensitivity and specificity of the indirect fluorescent antibody test and the direct agglutination test render these serological methods useless as diagnostic screening methods in the early stages of this disease.