UK Troops in Afghanistan Contract Mystery Illness

[Reasonable Rascal]

From the Harvard ProMed List

Date: Wed 15 May 2002
Source: BBC News Online, Wed 15 May 2002 [edited]
<http://news.bbc.co.uk/hi/english/uk/newsid_1989000/1989777.stm>


UK Troops in Afghanistan Contract Mystery Illness
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Eighteen British soldiers serving in Afghanistan have been struck down with a mystery fever. The Ministry of Defence (MoD) has confirmed that two are "seriously ill". One of them has been flown back to Britain and another to Germany. All the sick are military medical personnel working at 34 Field Hospital in Bagram which has now been closed -- except to treat cases of the unidentified fever. All the 350 troops who staff the hospital have been confined to either their quarters or the hospital. A German field hospital is now providing back-up for other medical treatment for the marines taking part in the ongoing Operation Snipe.

It was initially thought the disease was meningitis but tests have ruled that "unlikely". Paul Adams, the BBC's defence correspondent in Bagram says some theories have suggested it could be enteric fever - which is related to typhoid. The MoD has "categorically" confirmed the illness was not the result of a bio-terrorist attack.

A spokesman said: "The exact nature of the illness is not yet known and medical tests continue to [establish] the cause. "However the illness appears to be contagious and as a precaution 34 Field Hospital has been closed to all but similar cases. "It will be reopened for normal medical cover as soon as possible."

Brigadier Roger Lane, commander of the troops, said soldiers first started reporting symptoms 3 days ago, including fever, diarrhoea and vomiting. He said the area around 34 Field Hospital had been isolated and military police were deployed to prevent trespassers. Lieutenant Colonel Ben Curry, with the troops in Bagram, told the BBC: "Clearly, this is a serious situation and we are taking steps to prevent any further spread."

Shadow Defence Secretary Bernard Jenkin is calling on the government to hold an inquiry into the outbreak. Mr Jenkin is also urging the government to look into allegations British troops are ill-equipped to work in Afghanistan. He said he had seen UK soldiers in Kabul using trench-based latrines and showering "under plastic bags in tents" while those of other nationalities had permanent toilets in prefab buildings.

About 1700 troops are currently deployed at Bagram. British marines have been involved in two military operations in eastern Afghanistan since arriving in the country last month.

--
ProMED-mail
<promed@promedmail.org>

[An apparently severe febrile illness striking over 5% of medical personnel at a single field hospital in Afghanistan is indeed alarming. There is little in this report to suggest the etiology of the illness. The symptoms of fever, diarrhea, and vomiting are not specific nor is it clear what initially prompted consideration of meningitis. Failure to isolate a causative agent after 3 days makes a typical bacterial pathogen less likely. Possibilities include rickettsial or viral pathogens or a toxin exposure among many others. Enteric fever, mentioned as a possibility in the news story, does not typically present with prominent GI manifestations. ProMED-mail will post further developments in this story as they become available. We would especially welcome any information from those with first hand knowledge of the situation. - Mod.LM]
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Reproduced under Fair Use for Education doctrine

[Reasonable Rascal]

Date: Fri 17 May 2002
Source: BBC News Online, Fri 17 May 2002 [edited]
<http://news.bbc.co.uk/hi/english/world/south_asia/newsid_1992000/1992451.stm>

More British Troops Struck By Illness
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Twenty more British troops have contracted a mystery illness in Afghanistan, bringing the total number struck down to 38. One of the new sufferers is believed to be a Royal Marine of 45 Commando, the first case of the unidentified fever in the fighting force. He is seriously ill and was being flown back to the UK on Fri 17 May 2002. The marines are currently taking part in their first combat of the war in Afghanistan,
joining US and Australian troops battling al-Qaeda fighters in the eastern mountains.

Two of the other new cases, all medical personnel, were said to have stabilized after responding to treatment for the stomach illness at their base. The remainder have shown symptoms of vomiting and diarrhoea but were said to be less seriously ill. The marine is thought to be the first case from outside the 34 Field Hospital at Bagram Airbase, where the outbreak started. That has raised concerns that the disease could spread through the rest of the camp.

Tests are under way to try to discover the nature of the illness affecting the troops. It was first reported on Mon 13 May 2002, and 18 medical personnel at the hospital had been stuck drown by Wed 15 May 2002. Eight were so ill they were evacuated to Europe and the UK. The remainder were treated at the hospital, which was closed as a precautionary measure except to further suspected cases of the illness. The 60 or so staff based there were quarantined, while almost 300 other troops were confined to their quarters for fear of spreading the fever. The Ministry of Defence (MoD) was on Thu 16 May 2002 working on the theory that contaminated food was to blame for the outbreak. All troops have been put on sterilised food rations and bottled water.

Defence minister Dr Lewis Moonie said that it was "most unlikely" that the illness was the result of a biological attack. Microbiologist Dr Mahmoud Halablab, of King's College, London, said gastroenteritis seemed the most likely cause.

[Reasonable Rascal]

Source: The Herald
http://www.theherald.co.uk/news/archive/17-5-19102-0-16-25.html


Local may have been carrier at Bagram
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AN act of military charity two weeks ago may have triggered the outbreak of suspected enteric fever which has struck down 18 medical personnel and closed the UK's only field hospital in Afghanistan. Medics at the quarantined 34 Field Hospital at Bagram airbase were concentrating on the possibility that an Afghan civilian male admitted briefly for treatment may have been the carrier.

Enteric fever is a form of paratyphoid rife in the region. Caused by poor hygiene, it is spread by droplet infection from coughing, sneezing or spitting, or by contamination from faeces [Paratyphoid fever is primarily transmitted by the fecal-oral route most commonly in contaminated food or water. Transmission by droplet infection is not the usual route. Mod.MPP] Incubation time is between 10 and 14 days and matches the gap between the admission of the civilian and the outbreak.

Eight of the soldiers have been flown out of the country, seven back to the UK and one to a US army hospital in Germany for emergency treatment. Two were described yesterday as "serious but stable".

The victims reported symptoms including vomiting, diarrhoea, and fever four days ago in what was feared to be meningitis. The hospital was immediately placed under armed guard and the 333 staff, patients, and support units on site isolated. The remaining victims at the base are receiving nursing from staff wearing masks, gloves and disposable gowns.

Colonel Ben Curry, Royal Marine spokesman at the base, said "the symptoms are congruent with enteric febrile illness".
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[Reasonable Rascal]

Date: Sat 18 May 2002 13:41
Source: Ananova
http://www.ananova.com/news/story/sm_590639.html?menu=news.latestheadlines.worldnews

Troops taken ill with 'winter vomiting bug'
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The mystery illness that has struck British troops serving in Afghanistan is believed to be the so-called winter vomiting bug.

Several positive diagnoses of the disease, also known as Norwalk-like virus, have been made, and although tests are not complete on all those affected it is "highly likely" it is to blame.

The strain is "virtually identical" to the bug which swept Britain earlier this year, a source says.

The harsh conditions faced by troops in Afghanistan, particularly dehydration caused by the heat, produced more extreme symptoms than the disease has in the UK, confusing experts, the source adds.

However there is "no suggestion" the British forces had taken the disease with them to the Royal Marines' Bagram airbase.

The disease is thought to have hit 25 UK troops, with others presenting milder symptoms, who are thought to be suffering from more common diarrhea bugs.

The disease had been confirmed in two cases by the Public Health Laboratory and it was "highly likely" that it had affected the other 23 with serious symptoms, the source said.

The virus is extremely similar to that which caused major problems in British hospitals earlier this year, according to a Ministry of Defence medical expert.

"If not identical is it virtually identical," he said.

Fresh food, brought in by civilian contracts through Pakistan, is a possible cause. This will be examined in an investigation into the outbreak, a defence source said.
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Reproduced under Fair Use for Education doctrine.

[Reasonable Rascal]

Date: 18 May 2002 13:24 - (SA)
Source: News24.com / AFP
http://www.news24.com/News24/World/Asia/0,1113,2-10-20_1186804,00.html


Soldiers hit by 'stomach bug'
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Prague - The mystery illness which has struck British soldiers serving in Afghanistan was identified by Czech military doctors on Saturday as dysentery caused by shigella bacteria.

"It is a dysentery caused by shigella bacteria. There is no mystery," said Colonel Jindrich Sitta, the commander of the Czech military hospital in Afghanistan, who was quoted in Dnes newspaper.

Shigella infects the mucous lining of the colon, causing inflammation.

Epidemics occur regularly in parts of the world with poor hygiene standards, with the disease being spread by diarrhea, contaminating water, unwashed hands, as well as by flies.

Illness caused by shigella bacteria normally last at least a week, but can last longer.

Sitta said that the Czech hospital will take over some of the functions of the British military hospital on Monday.

The hospital and over 300 British troops, have been placed under quarantine since the contagious illness struck.

On Saturday a British military spokesperson, Lieutenant-Colonel Ben Curry said that 39 personnel had been affected although only 15 were in need of treatment.

Symptoms of the disease include diarrhea and vomiting.

A total of nine servicemen have been flown out of Bagram since the outbreak of the disease. One was flown to Germany while the rest were sent to Britain.

"Those medivacked back to the UK are still listed as very seriously ill but we have been encouraged by reports that they have stabilized," Curry said.

The spokesperson told reporters that two doctors, both experts in communicable diseases, were due to arrive at this coalition air base over the weekend.

He said it was still too early to classify the disease but an initial theory that it might be a type of meningitis had now been ruled out.

"The doctors believe, given the symptoms of diarrhea and vomiting, that we are dealing with... a form of stomach bug. Unfortunately that's an occupational hazard in this part of the world.

"The strange thing seems to be that some people are affected more than others. At the moment we cannot determine why that is."

Date: 18 May 2002 13:24 - (SA)
From: ProMED-mail <promed@promedmail.org>

[As shigellosis is a bacterial etiology and Norwalk-like virus (NLV) is a viral etiology we have 2 very different etiologies hypothesized here. Readers are reminded that this has been an exceptional year for NLV in the UK, with widespread outbreaks resulting in many school and hospital closures, the latter due to outbreaks with transmission within the hospitals (see ProMED-mail postings referenced below).

While it is possible to have 2 concurrent gastrointestinal outbreaks ongoing in the same population, one does wonder why the identification of _shigella sp_ bacteria took several days, if it was the predominant organism responsible for this outbreak.]

[Reasonable Rascal]

"The epidemiological and viral results confirm NLV as the major cause..."
***********************

Date: Sat, 18 May 2002 20:16:53 +0100 (BST)
From: Dr Angus Nicoll mbrahamuk@yahoo.co.uk


Illness in Military Personnel in Afghanistan - the UK situation as of at 3 pm Saturday 18 May 2002
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It has been reported by the UK Ministry of Defence that there has been an outbreak of diarrhoeal, vomiting and febrile illness in a military field hospital in a war zone in Afghanistan see
<http://www.phls.co.uk/publications/CDR%20Weekly/pages/news.html#afghan>

Some of the cases have been transferred to Europe [& caused secondary infections there -- see below. - Mod.JW]

Patients infected in Afghanistan
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The first patient arrived in a UK hospital on Tue 14 May [2002]. He had been moderately unwell and had had diarrhoea and vomiting, and reportedly also meningism. On 17 May, 6 more patients transferred having had symptoms of vomiting and diarrhoea. All were relatively well on arrival and have remained so. Another moderately to very unwell patient was transferred to Germany. No information is available on that case except that his condition is improving. Another 3 patients are awaiting repatriation to the UK, one of these is reportedly moderately to severely unwell. Patients have not gone to other countries.

Infected contacts
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Two or 3 adults who had direct contact with the cases outside Afghanistan have developed the same symptoms of diarrhoea and vomiting: 2 men in the airvac crew and one female contact in the UK.

Cause
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Faeces of 4 patients and one of the contacts have tested positive for Norwalk like virus (NLV) at the Public Health Laboratory Service Central Public Health Laboratory (by RT-PCR and/or electron microscopy), [said] Dr David Brown. Further investigations are being undertaken. So far, bacteriological investigations have all been negative but are difficult to interpret in patients who have received antibiotics. However, despite reasonable speculation in ProMED no shigella was detected.

Control measures
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Normal infection control measures for a viral gastrointestinal outbreak are being applied for those potentially and actually exposed in the UK staff. Contacts have been followed up and many are now outside the expected incubation period for NLV. Surveillance will continue.

Conclusion
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The epidemiological and viral results confirm NLV as the major cause of the gastrointestinal outbreak in UK military personnel in Afghanistan, with some transfer to the UK.

--
Drs Angus Nicoll (Director), Dilys Morgan & Olof Horstick
Communicable Disease Surveillance Centre, UK

Drs David Brown & Rob George Central Public Health Laboratory
Public Health Laboratory Service, UK
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[Reasonable Rascal]

Date: Sun 19 May 2002

[The following comment from Dr Ronald Warner is a response to the ProMED-mail report "Unidentified fever, British troops - Afghanistan (03)", posted on 18 May 2002, and archived as 20020518.4256. - Mod.CP]


An earlier outbreak of Norwalk-like virus gastroenteritis in a military setting
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We investigated a large mid-summer outbreak of Norwalk [-like virus] gastroenteritis at the United States Air Force Academy (Warner RD, Carr RW, McClesky FK, et al. A large nontypical outbreak of Norwalk virus gastroenteritis ... Arch Intern Med 1991; 151: 2419-24). We described the
outbreak as "nontypical" because frequencies of signs and symptoms were not what we would have expected, based on published [until then] Norwalk-like virus outbreaks; over 100 (17 per cent) of the ill cadets required hospital
admission for intravenous rehydration.

That outbreak seems to resemble the situation in Afghanistan among the British troops: military, a more homogeneous [age and sex] population than
that of the general population, high levels of physical activity and stress, and dehydration in a high altitude environment. In addition, at the
time of the on-site investigation, we did not find cases that could be attributed to person to person transmission; however, some months later when speaking with a physician who worked in the academy hospital's emergency department [during the outbreak] I learned that there had indeed
been several cases of a clinically indistinguishable malady among his medics, about 36 to 40 hours after they attended the cadets with the most profuse vomiting and diarrhea.

Unfortunately, no clinical specimens were submitted from those cases! It would appear that patients suffering from Norwalk-like viral
gastroenteritis pose a significant risk for transmitting the agent to care-givers who do not practise universal precautions re: exposure to
vomitus and feces.

--
Ronald D Warner DVM, PhD
Associate Professor, Clinical Preventive Medicine
Dept of Family and Community Medicine
School of Medicine, Texas Tech University Health Sciences Center - Lubbock
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Regarding this outbreak or any other it goes to show that strict compliance with universal precautions is key to healthcare cowrker safety and limiting the spread of the illness.

RR