Nine Service Connected Infectious Diseases from OEF/OIF

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Nine Service Connected Infectious Diseases from
OEF/OIF

• Terry Walters MD MPH
• Office of Public Health

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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
• Dont stop there! Ask if you dont know what a
  68T does. (It is an Army Veterinarian Technician)

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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.

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SWA Infectious Diseases

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

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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

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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

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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

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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/e
  ducation/exposures/lariam.asp

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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)

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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

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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 940 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)

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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

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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, Reiters Syndrome
  leading to reactive arthritis, colitis
• Treatment prevention of dehydration,
  surveillance for complications

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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.

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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

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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

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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?