Infectious Diseases of War

Infectious Diseases of War: Overview

• Wound Infections
• Sexually Transmitted Diseases
• Foodborne Diseases
• Vectorborne Diseases
• Biological Warfare

Wound Infections

• Treat as with similar casualties in peacetime.
• Assess Tetanus immunity status- Toxoid should be given if 1. Initial series not completed or... 2. If more than 10 years has elapsed singe last booster- Tetanus Immune Globulin should be given 1. If wound is over six hours old ... or ... 2. Stellate ... 3. Missle injury ... 4. Frostbite ... 5. Burn 6. Crush injury- Observe for Clostridial Myositis
• Surgical debridement
• Antibiotic therapy

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Sexually Transmitted Diseases

• Gonorrhea
• Syphillis
• Chlamydia
• Sexually Acquired Viral Diseases

  Hepatitis B

  AIDS

  Chancroid

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Foodborne Diseases

• Salmonella
• Staph. Aureus
• Cholera
• Shigella

Salmonella:

Most common cause of food outbreaks in the US
Present within 24 hours of ingestion
Diarrhea
Prolonged Fever
Abdominal Pain
Hepatosplenomegaly
Most clear spontaneously
Antibiotics may promote carrier state
When blood cultures are positive, oral chloramphenicol

Staph. Aureus

Sudden Onset
Usually presents within two hours of ingestion

Prevention of Foodborne Illnesses

Cook Food over 140 degrees F.Over 160 for poultry
Store food under 45 degrees F.
Lyster bags - chlorination of water
Washing of vegetables/fruits
Monitor carefully - communicatesuspect when two or more patientshave similar GI symptoms

Cholera

Acute, profuse, watery diarrhea
Hypotension
Possible exposure to contaminated water
Stool smears and cultures - Vibrio Cholera
Treat with Glucose/Electrolyte SolutionIV or Oral (with chlorinated water)
Cholera Vaccineside effects common<50% effectiveMultiple doses necessary
Tetracycline

Shigella

Bloody and/or mucousy diarrhea
Fecal leukocytes on smear - suspicious
Colitis on sigmoidoscopy - suspicious
Confirmed by culture
TreatmentAmpicillin or TMP/SMX

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Vectorborne Diseases

• Malaria
• Dengue
• Rabies

Review by systems affected:

Malaria

Mosquito-borne protozoanPlasmodium species
Prevent by mosquito protection at duskVietnam experience - most affected were involved in night patrol.
Prevented by chloroquine
Some chloroquine resistance developing
World-wide drug-resistant malaria registry @ Fort Detrick, MD

Dengue

Also known as "break-bone" fever
Transmitted by mosquitoes
Becomming common in Texas, Northern Mexico, Cuba
Fever
Intense headache=Retro-orbital pain
Arthralgias/myalgias
Mortality low
Debilitating for several weeks

Rabies

Has occurred from military troop"adoption" of local animalsor pets.

Exotic Disease-Listed by presenting symptoms

• General
• Chest
• Gut
• Liver
• Skin
• Central Nervous System

General Symptoms-Fever

General-Anemia

Leishmoniasis, Visceral
Malaria
Hookworm
Diphyllobothriasis

General- Lymphadenopathy

Plague
Toxoplasmosis
TrypoanosomiasisAfrican and American
Filariasis

General- Eosinophilia

Toxocariasis
Filariasis
Fascioliasis
Schistosomiasis
Stronglyoidiasis
Trichinosis

Chest- Cough

Lassa Fever
Plague
Tuberculosis
Paragonimiasis

Gut- Abdominal Pain

Shigellosis
Typhoid
Fascioliasis
Strongyloidiasis

Gut- Diarrhea

Cholera
Shigellosis
Amebiasis
Giardiasis
Strongyloidiasis
Trichinosis

Gut- Dysentery

Amebiasis
Shigellosis

Liver- Jaundice

Hepatitis
Yellow Fever

Liver- Hepatomegaly

Typhoid
Leishmoniasis, visceral
Toxocariasis
Echinococcosis
Fascioliasis
Schistosomiasis

Liver- Splenomegaly

Typhoid
Leishmoniasis, Visceral
Malaria
Schistosomiasis

Skin Lesions

Smallpox
Leprosy
Leishmoniasis, Cutaneous and Mucocutaneous
Enterobiasis
Onchocerciasis

Central Nervous System

Malaria
Toxoplasmosis
Trypanosomiasis, African
Schistosomiasis
Taeniasis Solium

Biological Warfare

• Anthrax
• Botulinum Toxin
• Smallpox
• Exotic viral illnesses

  Lassa fever

  Rift Valley Fever

  Biological Warfare--Detection and Protection

No Detection Capability- Sick Soldier the index case- monitor unusual events closely
Protection- Protective mask- Pre-exposure vaccination

Anthrax

High Interest in Persian Gulf Conflict
Outbreak in Sverdiosk
Clinical Presentations- Cutaneous- Gastrointestinal- Inhalation
Spore-forming bacterium- Global distribution- Extremely stable
Technology allows growth of enormous quantities easily
Several grams contain tens of thousands of human lethal doses

Anthrax Dissemination

Readily dispersed by aerosol over hundreds of square miles
No means of detection available
Target will not recognize attack untildisease occurs (days later)

Inhalation Anthrax

Incubation period - 1 to 8 days
Rare in natural state
95% lethal to non-immune persons
Initial symptoms - malaise, cough, fever
Short period of improvement
Terminal symptoms- Abrupt onset of dyspnea, stridor, cyanosis- Tachycardia- Rapid Progression to shock & death
Chest X-ray - widened mediastinum
No effective treatment after onset of symptoms

Inhalation Anthrax: Treatment

No cases of pulmonary anthrax in vaccinated pts.
16/18 cases fatal with antibiotics alone
Ciproflaxin 1000 mg initially followedby 750 mg po (500mg?) BID
Alternate - Doxycycline 100mg BID IV/PO
Once confirmed continue antibiotics for at leastfour weeks and complete vaccination series
Antibiotics alone not protective in monkeys
Partial vaccination with Antibiotics protective

Anthrax- Gastrointestinal

Caused by eating foods contaminated with spores
Abdominal Pain
Bloody Diarrhea
Fever
Body Aches
Fatigue

Anthrax- Cutaneous

Caused by contamination of wounds by bacteria or spores
Most Common Form
Least Harmful Form
Painless, ulcerated sore taking months to heal,even when treated.

Anthrax Vaccine-Immunogenicity

Over 85% with some antibiody after 1 dose
Over 90% seropositive after 3 doses
Rhesus monkeys with two vaccine doses survive large aerosol challenge

Anthrax Vaccine- Dosage and Administration

Two doses two weeks apart
Third dose at least two weeks after second dose
Must be kept refrigerated, not frozen
Anthrax VaccineSide Effects
6 % mild local discomfort
<1% more severe local reactionresulting in limited use of armfor 24-48 hours
Mild systemic reactions uncommon- muscle aches, fatigue, low grade temp
Severe systemic reactions rare
Small, firm, painless nodules at injection site- may persist for several weeks

Butulism Toxin

Delivery by Artillery, Missles,Aircraft, Terrorists
Product of a bacteria (toxin) in nature
Purified, weaponized, inhaled or ingested
Small amounts can cause (within 36 hours)-

weakness- dizziness- dry mouth- constipation- blurred vision- photosensitivity

Muscle weakness progressing to respiratory paralysis
Anti-toxin is available in limited quantities
Toxin can be washed off surfaces

Smallpox

Fever, chills, myalgias
Non-specific rash

Third day - small pink maculae
Spreads from Face to Extremities
Become umbilicated and vesicular
Three more days - pustular with return of symptoms
Resolution the following week

Death only in children and the elderly
Infectious throughout the course of the illness- including crusting periods