Nine Service Connected Infectious Diseases from OEF/OIF

1. Nine Service Connected Infectious Diseases from OEF/OIF Terry Walters MD MPH Office of Public Health

2. Case • A 30 year old Veteran seeks care from his primary care provider for headache, chills, myalgias, fevers, and a non-productive cough. The Veteran is concerned about burn pits. • What are critical questions you should ask? • Have you been deployed? • Yes I was in Iraq • What was your job in the military? • I was a 68T • Don’t stop there! Ask if you don’t know what a 68T does. (It is an Army Veterinarian Technician)

3. Relevancy High index of suspicion of uncommon infectious diseases in new Veterans • Health care providers caring for Veterans need to ask a travel & job history and be aware that OIF/OEF Veterans have been exposed to a variety of infectious diseases with long term adverse health effects. • This lecture will cover 9 infectious diseases that have been found to be presumptively associated with service in OIF/OEF. These Veterans may be eligible for service connection.

4. SWA Infectious Diseases • Malaria • Brucellosis • Campylobacter Jejuni • Coxiella Burnetii (Q fever) • Mycobacterium Tuberculosis • Nontyphoid Salmonella • Shigella • Visceral Leishmaniasis • West Nile Fever

5. VA Compensation Claims Process The VA determines existence of chronic disabilities incurred or aggravated by military service. VA compensates the veteran for the residuals of such disabilities. • Three requirements for a grant of service connection • An in-service event (incurred or aggravated) • A current condition, and • A medical nexus establishing a link

6. What is a presumption? • Generally, there must be evidence showing a disability resulted from injury or disease in service • Presumptions of service connection relieve Veterans of burden of providing evidence relating to either the existence of an event in service or the nexus between an event in service and the current disability • “It must be at least 10% disabling within 1 year from date of military separation.” • Malaria, Brucellosis, Campylobacter Jejuni, Q fever, Nontyphoid Salmonella, Shigella • No time constraint – Tuberculosis, Visceral Leishmaniasis

7. Southwest Asis ID Presumptions Institute of Medicine (IOM) considered diseases with the following characteristics • Are prevalent in Southwest Asia (SWA) • Have been diagnosed among U.S. troops serving in SWA • Are known to cause long-term adverse health effects

8. Malaria • Classic symptoms of malaria: cyclical occurrence of sudden coldness followed by rigor and then fever and sweating lasting four to six hours, occurring every two days in P. vivax and P. ovale infections, while every three days for P. malariae. • Other sx: shivering, arthralgia (joint pain), vomiting, anemia (caused by hemolysis), hemoglobinuria, retinal damage, and convulsions • Diagnosis: Blood film (preferred), Antigen tests, PMR • Treatment: WHO guidelines 2010, artemisinin-based combination therapies (ACTs) recommended for uncomplicated P. Falciparum malaria. P. vivax requires clearance of liver forms with primaquine • Issues: neuropsychiatric side effects can occur with Mefloquine (Larium) more information available at http://www.warrelatedillness.va.gov/education/exposures/lariam.asp

9. Brucellosis • Highly contagious zoonosis caused by ingestion of unsterilized milk or meat from infected animals or close contact with their secretions. • Ask about consumption of local food (unpasteurized dairy products) or handling of animals in SWA • Sx. include undulant fever, sweats, headaches, back pains, and physical weakness. Severe infections of the central nervous systems or lining of the heart may occur. • Can also cause long-lasting or chronic symptoms that include recurrent fevers, joint pain, and fatigue • Diagnosis: agent in blood or bone marrow (very slow growing) also antibodies • Treatment: difficult – combination of doxycycline (45 days) and streptomycin (14 days)

10. Camphylobacter Jejuni'twisted bacteria' • curved, helical shaped, non-spore forming, Gram-negative, bacteria commonly found in animal feces • Most common causes of human gastroenteritis in the world • linked with subsequent development of Guillain-Barré syndrome (GBS) • Infection with C. jejuni usually results in enteritis, which is characterized by abdominal pain, diarrhea, fever, and malaise. • The use of antibiotics, on the other hand, is controversial except in severe cases • Severe (accompanying fevers, blood in stools) or prolonged cases may require ciprofloxacin, erythromycin, azithromycin or norfloxacin

11. Coxiella Burnetii (Q fever) • Small obligate intracellular bacterial Gram-negative bacteria that are highly resistant to environmental stresses • Inhalation of one organism will yield disease in 50% of the population making C. burnetii the one of the most infectious organism known to man. • Infection results from inhalation of endospores, and from contact with the milk, urine, feces, vaginal mucus, or semen of infected animals. Rarely, the disease is tick borne. The incubation period is 9–40 days. • Disease occurs in two stages: an acute stage that presents with headaches, chills, and respiratory symptoms, and an insidious chronic stage. • Diagnosis is usually based on serology • While most infections clear up spontaneously, treatment with tetracycline or doxycycline appears to reduce the symptomatic duration and reduce the likelihood of chronic infection. (which can take up to 4 years of antibiotics)

12. Mycobacterium Tuberculosis • Low infectivity ~10% of people infected with M. tuberculosis ever develop the disease • Bacillus may lie dormant in the body for decades until reactivation • Non-specific initial symptoms, loss of appetite, fever, productive cough, loss of energy, weight loss, and night sweats • Diagnosis: The presence of acid-fast-bacilli (AFB) on a sputum smear, Interferon-Gamma Release Assays (IGRAs) • Treatment complex due to multi drug resistance

13. Nontyphoid Salmonella • Endotoxin from Salmonella cause most sx. • Incorrectly prepared meats, infected eggs, egg products, and milk when not prepared, handled, or refrigerated properly. Handling reptiles or rodents, tainted fruits or vegetables. • Sx: Fever, Chills, Headache (with a sudden onset), Stomach cramps, Diarrhea, Nausea, Vomiting • Sx can last up to 8 weeks usually 4-7 days • Complications: Abscesses, Reiter’s Syndrome leading to reactive arthritis, colitis • Treatment: prevention of dehydration, surveillance for complications

14. Shigella • Shigellosis is an food-borne infectious disease caused by a group of bacteria called Shigella. • Most who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria. The diarrhea is often bloody. • Shigellosis usually resolves in 5 to 7 days. • Usual treatment is supportive with fluid replacement • Reiter's disease and hemolytic uremic syndrome are possible sequelae that have been reported in the aftermath of shigellosis.

15. Visceral Leishmanasis (VL) • Parasitic disease spread through the bite of a sand fly • Second-largest parasitic killer in the world (after malaria), responsible for an estimated 500,000 cases each year worldwide • Sx: include fever, weight loss, mucosal ulcers, fatigue, anemia and substantial swelling of the liver and spleen. • without proper treatment the mortality rate for VL is close to 100% • Diagnosis: diagnosis is visualization of the parasites in splenic or bone marrow aspirates. Serologic testing also available • Treatment: Paromomycin IM Injection, Amphotericin B, oral Miltefosine

16. West Nile Fever • Mosquito borne viral (flavivirus) disease • Infection can follow three paths, asymptomatic (78%), mild febrile illness (21%), encephalitis (1%) • Diagnosis: Serology of blood or CSF • Risk factors for developing a more severe form of West Nile virus include: • Conditions that weaken the immune system, such as HIV, organ transplants, and recent chemotherapy • Older or very young age • Pregnancy • Treatment: some HIV antiretroviral drug have shown some promise • Complications from severe West Nile virus infection include: • Brain damage (10% of those with encephalitis) • Permanent muscle weak

17. Summary • Our Veteran recently returned from Iraq with non-specific symptoms could who a variety of significant infectious diseases associated with his service. • Many of these infectious diseases are uncommon in the US and have significant sequelae if untreated. • Questions?