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Game Overview
Con Man Games, SmashGames
SmashGames
15 Jun, 2017
Adventure, Puzzle, Strategy, Horror
Kindergarten is an abstract puzzle adventure game. You play as a student in a school that’s a bit…off. The teacher is trying to get rid of her kids. the janitor is frequently seen cleaning up blood. The cafeteria is serving the same slop over and over again. Kids are walking around with strange devices planted on them after visiting the principal, and one of your fellow classmates has gone missing. It’s up to you to figure out what’s going on, because your life might depend on it.
Classic Kindergarten fun!
You know…all the things you did while you were in Kindergarten.
Key Fetures:
Take part in show and tell!
Play house with Cindy!
Get beat up by the school bully!
Talk to the weird kid!
Destroy school property!
Get poisoned!
Solve a missing person’s case!
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4INFECTIOUS DISEASES DIAGNOSED IN US TROOPS WHO SERVED IN THE PERSIAN GULF WAR, OPERATION ENDURING FREEDOM, OR OPERATION IRAQI FREEDOMInfectious diseases have accompanied war throughout recorded history; the clinical aspects of Operation Desert Shield (ODSh), Operation Desert Storm (ODSt), Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) have been no different. Although medical and epidemiologic personnel in the US military can anticipate troops’ exposure to many pathogens and mitigate their effects, naturally-occurring pathogens infected some troops during these operations. This chapter summarizes information about the infectious diseases and pathogens identified in US troops who served or are serving in ODSh, ODSt, OIF, or OEF.
That information comes from several sources, including published scientific literature, medical surveillance monthly reports published by the Army Medical Surveillance Activity, the Centers for Disease Control and Prevention (CDC), and infectious disease experts at the Department of Defense (DOD) and the Department of Veterans Affairs. In, the committee evaluates the published scientific literature about the possible long-term adverse health outcomes of nine of the diseases discussed in this chapter.Thriving on the troops’ crowded and sometimes unsanitary living conditions, microbial pathogens have caused primarily diarrheal illnesses and acute upper respiratory infections during ODSt, ODSh, OEF, and OIF (Hyams et al. 2001a; Paparello et al. 1993; Richards et al.
1993a; Thornton et al. 2005; Wasserman et al. Smaller numbers of military personnel have had various insect-borne diseases, nosocomial infections, brucellosis, chickenpox, meningococcal disease, and Q fever.Even this chapter’s comprehensive review of public documents may not capture the full burden of infectious disease on US troops who have served in southwest and south-central Asia. Military medical investigators’ primary mission is to apply their findings to maintain troops’ health and they might not always publish summary reports in medical journals. In addition, field commanders may be reluctant to report illnesses perceived as trivial (such as vomiting and diarrhea) even when an outbreak of disease interferes with military operations (Matson 2005).
Finally, a new policy purveyed by the DOD restricts the publication of some kinds of medical information that enemy combatants could use to gain an advantage over US troops (Department of the Army 2005b). Enteric Infections in the Gulf WarThe leading cause of morbidity among American forces deployed to the Persian Gulf region was diarrheal disease (Hyams et al.
From August 1990 to May 1991, about 50% of surveyed ground troops and personnel onboard the USNS Mercy experienced at least one episode of acute diarrhea (Haberberger et al. 1994; Hyams et al. Large outbreaks of watery diarrhea began in August 1990; outbreaks of more severe, bloody diarrhea began in the following month. In addition, gastroenteritis with vomiting as a primary symptom occurred both sporadically and epidemically throughout the war. Laboratory AnalysisHyams and colleagues collected clinical and epidemiologic data from male US troops stationed in northeastern Saudi Arabia to determine the causes and prevalence of diarrheal disease among the troops, risk factors for diarrheal disease in the field, and the effectiveness of pharmacologic treatments (Hyams et al. From 432 soldiers who sought medical care and presented with gastroenteritis, stool samples were collected and examined for numerous enteropathogens, as described below and summarized in. The soldiers collectively represented all branches of the military, several regions of northeastern Saudi Arabia, and a variety of living conditions.
Gastroenteritis was defined as diarrhea (three or more loose or watery stools within 24 hours), abdominal cramps, vomiting, or bloody stools.The stool specimens were cultured for various pathogens: E. Coli, Salmonella, Shigella, Aeromonas, Plesiomonas, Yersinia, Vibrio spp., and Campylobacter. Bacterial enteropathogens were identified with the methods described in Manual of Clinical Biology, 4th edition (Kelly et al. The specimens were also examined for parasites with direct microscopy and for group A rotavirus with a commercial monoclonal-antibody-based immunoassay. Stool specimens and serum from subsets of patients underwent other tests for adenovirus, astrovirus, calicivirus, coronavirus-like agents, group A rotavirus, and norovirus (also known as Norwalk virus). One or more bacterial enteropathogens were identified in 49.5% of the stool cultures, representing 214 patients.
Enterotoxigenic E. Coli (ETEC), Shigella sonnei, or both were found in cultures from 205 of those patients.
The scientists also found nontyphoid Salmonella spp., enteroinvasive E. Coli, and Campylobacter.
Tests for viruses yielded positive results for norovirus and rotavirus. There was no evidence of parasitic infection. IdentifiedEnteropathogen or EnterotoxinYes (No. Patients)No (No. Patients)Salmonella spp. TABLE 4.2 Summary of Test Results for Viral Enteropathogens and Enterotoxins in Stool or Serum from Subsets of US Military Personnel with Gastroenteritis During Operation Desert ShieldIdentifiedEnteropathogenYes (No. Patients)No (No.
Patients)In stool samples from 19 patients with vomiting as a primary symptom, November-December 1990Enzyme immunoassay results:Adenovirus-xNorovirusx (3)x (16)Rotavirus (group A)-xImmune electron microscopy results (in 13 of 19 specimens):Adenovirus-xAstrovirus-xCalicivirus-xCoronavirus-like agents-x. IdentifiedEnteropathogen or EnterotoxinYes (No. Patients)No (No.
(%) of PatientsSalmonella (not S. Typhi)7 (1.6)Campylobacter2 (0.5)a Bacterial enteropathogens were identified in 214 (49.5%) of the 432 stool samples collected.b The total percentage of isolates is higher than the percentage of patients with an identified enteropathogen because 36 patients had mixed infections.c Two patients had mixed heat-labile and heat-stabile enterotoxigenic E. Coli infections, with individual colonies producing either heat-labile or heat-stable toxin alone.SOURCE: Reprinted with permission from Hyams et al. 1991.Hyams and colleagues tested E. Coli-like organisms for heat-labile and heat-stabile toxin by using alkaline phosphate-conjugated oligonucleotide DNA probes and Y-1 adrenal cell and suckling-mouse assays (Hyams et al. Later, Wolf and colleagues further analyzed the Hyams et al. ETEC isolates for their toxin distribution, and other factors (Wolf et al.
A given strain of ETEC may produce heat-labile enterotoxin (LT), heat-stabile enterotoxin (ST), or both. LT is nearly identical with the toxin that causes cholera. Some 85% of 132 ETEC isolates from 124 symptomatic Gulf War troops produced LT.
TABLE 4.4 Toxin distribution Among 132 ETEC Isolates from 124 US Troops with Gastroenteritis during Operation Desert StormToxinNo. (percentage) of isolatesLT and ST59 (45)LT53 (40)ST20 (15)SOURCE: Adapted with permission from Wolf et al.
1993.Antimicrobial susceptibility. Using the disk-diffusion method, Hyams and colleagues determined which of five antibiotics would most effectively treat the strains of ETEC and Shigella identified in the stool cultures. Up to 63% of the ETEC and up to 85% of the Shigella specimens were resistant to several of the antibiotics most accessible to clinicians in the field , including trimethoprim-sulfamethoxazole, the antibiotic most frequently used to treat diarrhea during the early stages of ODSh deployment. In contrast, the scientists found, ETEC and Shigella were 100% susceptible to ciprofloxacin and norfloxacin. Hyams and colleagues reported that empiric results of antibiotic treatment for diarrheal disease in the field led military clinicians to gravitate toward ciprofloxacin and norfloxacin over time. Clinicians also reportedly administered quinolone drugs to affected critical combat troops to shorten the duration of gastroenteric symptoms. Epidemiologic AnalysisTo learn the prevalence of and risk factors for diarrheal disease among US troops stationed in northeastern Saudi Arabia during ODSh, Hyams and colleagues administered an epidemiologic survey to 2,022 personnel from all branches of the military in October-December 1990 (Hyams et al.
After an average of 2 months in Saudi Arabia, 57% of those surveyed had suffered at least one episode of diarrhea. The symptoms of diarrheal disease had led 22% of all respondents to seek medical care, and had prevented 20% of all respondents from performing their duties. Thirty-two percent of those surveyed had experienced two or more separate episodes of diarrhea. In some units, the attack rate was 5-10% per week.A univariate analysis of potential risk factors for the transmission of diarrheal disease during ODSh suggested an association between an episode of diarrhea and eating salad, dining in a mess hall, and drinking from a canteen.
(A laboratory study of 12 heads of lettuce obtained from food-distribution facilities in September 1990 found coliform bacteria in all 12; ETEC was identified in two (Hyams et al. 1991).) No association was found between an episode of diarrhea and obtaining food from local vendors, eating in a local restaurant, or drinking bottled water. A multivariate analysis of these risk factors and an evaluation of published research on the transmission of Shigella indicated that flies and relatively poor personal hygiene probably accounted for the spread of ETEC and Shigella.The disabling effect of repeated outbreaks of diarrheal disease in US forces during ODSh despite the best available preventive measures led Hyams and colleagues to call for the development of a vaccine to protect troops (Hyams et al. DOD is supporting development of such vaccines (Stephens and Nataro 2004). ShigellaThe presence of immunoglobulin A (IgA) and immunoglobulin G (IgG) anti- Shigella lipopolysaccharide (LPS) in predeployment serum did not offer protective immunity to infection by Shigella spp. Among US ground troops who participated in the Persian Gulf War, Hyams and colleagues reported (Hyams et al. The investigators reached that conclusion by studying a cohort of 883 combat troops and support personnel in three Marine Corps units who were flown directly to Saudi Arabia in late December 1990 and directly back to the United States in May 1991.
Initially stationed in Saudi Arabia, and then relocated to Kuwait, the subjects lived in remote, rugged, desert camps. US military personnel prepared most of their food, which came from the United States except for local fresh produce. The subjects drank both locally produced bottled water and water purified by reverse-osmosis (Hyams et al.
1993).The investigators obtained serum samples from all members of the three units who were accessible during the week before their deployment and the 2 two days after their return (827 subjects). Paired serum samples were tested for antibodies to both S. Sonnei and S. Epidemiologic questionnaires were also administered to this cohort before and after deployment.Among the 827 subjects, 18% seroconverted during ODSh and ODSt; that underscored earlier findings that troops deployed to ODSh and ODSt faced a considerable risk of Shigella infection.
The study revealed the absence of an association between seroconversion and the occurrence of diarrheal symptoms. Overall, 60% of the cohort reported one or more episodes of diarrhea, and 18% reported diarrhea with fever. In contrast, many troops who seroconverted were asymptomatic.Because S. Sonnei LPS cross-reacts with the LPS of Plesiomonas shigelloides, some of the high concentrations of serum antibodies observed in samples from the 827 marines might not have been the result of exposure to Shigella spp. To determine whether exposure to Shigella led. To persistently high antibody concentrations in some subjects and seroconversions in others, Mikhail and colleagues examined how a subset of the paired serum samples reacted to four Shigella invasion plasmids, which cross-react with just one enteroinvasive strain of E. Coli (Mikhail et al.
They also used ELISA to detect antibodies to S. In their report, the authors noted that antibodies to LPS and invasion plasmid antigens in serum increase and decrease within 4 months during naturally acquired Shigella infections.Only 12 sets of serum samples were large enough to use for this experiment (six from seroconverters and six with persistently high concentrations of antibodies to S.
By using Western blot, the investigators observed antibody reactions to numerous invasion plasmid antigens both before and after deployment in serum from troops with persistently high concentrations of antibodies to S. Sonnei LPS, which suggest that they had been exposed to S. Sonnei before deployment and were repeatedly exposed to it during deployment. In the postdeployment serum from troops who seroconverted, the scientists observed IgA and IgG recognition of additional invasion plasmid antigens and increased concentrations of antibodies to S. Sonnei LPS—even in two soldiers who were asymptomatic for diarrheal illness throughout the war. The authors interpreted those results as an indication that troops who seroconverted had been exposed repeatedly to S. Sonnei in the field.
NorovirusNorovirus (NV) and Norwalk-like viruses caused both sporadic cases and outbreaks of acute gastroenteritis among ground troops and shipboard personnel throughout the Gulf War. Brief and debilitating, NV gastroenteritis usually causes acute vomiting, diarrhea, nausea, and abdominal cramps that last 1-2 days. Some people never develop symptoms even after direct challenge, but others are repeatedly susceptible to symptomatic infection. All infected people shed highly contagious NV in stools from as early as 15 hours after exposure to as late as 14 days after. Studies of NV infections among military personnel indicate that crowding is the most important risk factor for transmission (McCarthy et al. 2000).After the Gulf War, Hyams and colleagues demonstrated the incidence of NV infection among troops deployed to Saudi Arabia and Kuwait from late December 1990 through May 1991 (Hyams et al.
Using the paired serum samples from the 883-troop cohort described above, the investigators used ELISA to measure antibody activity to recombinant NV particles. The investigators defined evidence of infection as a 4-fold or greater increase in titer of anti-NV antibodies from predeployment serum to postdeployment serum.Matching the ELISA results with the subjects’ clinical symptoms, as reported in the aforementioned postdeployment epidemiologic questionnaire, the investigators obtained the results displayed in. After adjusting for oversampling of subjects with vomiting, the investigators estimated that NV infected 6% of the study population. TABLE 4.6 Number of Subjects with Various Clinical Manifestations of Enteric Disease and Serologic Evidence of Norovirus InfectionNo. (%) with ComplaintNo. (%) with ≥ 4-fold Increase in Norovirus Antibody (n = 32)Clinical ManifestationEntire Cohort (n = 883)Subjects Tested for Norovirus Infection (n = 404)Vomiting alone17(1.9)17(4.2)4 (23.5)Vomiting and diarrhea117(13.3)117(29.0)14 (12.0)Diarrhea alone406(46.0)170(42.1)11 (6.5)No vomiting or diarrhea343(38.8)100(24.8)3 (3.0)SOURCE: Reprinted with Permission from Hyams et al. Enteric Parasitic InfectionsEnteric parasites may have infected a small percentage of troops deployed to the Persian Gulf region in 1990 and 1991 (Malone et al.
Malone and colleagues studied the risk of enteric parasitic disease in a cohort of 422 marines returning from Saudi Arabia and Kuwait after 5 months of service on the front lines of ODSt. Like the marines described above, this cohort had little contact with local populations. The investigators collected stool samples from the troops within 2 days of their arrival in the United States. The specimens were analyzed for evidence of helminthic and protozoan infections according to the thimerisol (Merthiolate)-iodine-formalin concentration technique.The only evidence of enteric parasitic infection found in the cohort was Giardia lamblia cysts in specimens from nine marines, or 2% of the subjects.
Four of the nine troops had experienced an episode of diarrhea while deployed to the Middle East, and seven of the nine had previously been deployed aboard a ship that made port calls in the Mediterranean. None of the nine marines had diarrhea when their stool samples were obtained.Oster and Sanford make passing reference to “a few” cases of amebiasis among troops deployed to the Persian Gulf War (Oster and Sanford 1992); however, the report lacks supporting epidemiologic, clinical, and microbiologic data. The committee is unaware of other reports of amebiasis among Gulf War troops. Shipboard Military PersonnelAbout 46% of the 870 military personnel deployed to the Persian Gulf aboard the hospital ship USNS Mercy T-AH 19 had at least one episode of diarrhea in the period August 1990-January 1991 (Paparello et al. That finding is derived from the results of an epidemiologic survey designed to assess the prevalence and effects of diarrheal illness among shipboard personnel deployed to the Middle East during ODSh.The USNS Mercy was a referral hospital for patients from other ships in the Persian Gulf and ground-based medical facilities during ODSh. From December 13, 1990, to January 7, 1991, investigators distributed a voluntary questionnaire to all Navy personnel aboard the ship; about 83% (N = 722) completed it.
The questions covered demographics; history of eating off the ship; job description; location of spaces where subjects worked, ate, and slept; and gastrointestinal symptoms. In contrast with the populations of most other studies described in this chapter, 32% of the subjects were female.In addition to the results listed in, the investigators found that officers were more likely to report an episode of diarrhea and more often unable to perform routine duties due to diarrhea than enlisted personnel. One explanation, the authors speculated, is that officers tended to eat in a wide variety of local restaurants during visits to foreign ports, whereas enlisted. Personnel did not. The investigators also found independent associations between lower age (range, 17 to 31 years) and an episode of diarrhea with vomiting and between female sex and an episode of diarrhea with vomiting. The authors speculated about many explanations for the latter finding: that women were more likely to report symptoms to sick call, that a greater percentage of women than men were officers, and that women worked more closely with patients and thus were more often exposed to diarrheal pathogens.
TABLE 4.7 Morbidity Due to Diarrheal Disease Among 722 US Navy Shipboard Personnel Deployed to the Persian Gulf During ODShSymptoms and OutcomesFraction of Troops(N = 722),%Diarrhea46.3Diarrhea and fever11.6Diarrhea and vomiting6.2Sick-call visit7.6Inability to work6.0SOURCE: Adapted with permission from Paparello et al. 1993.Most of the 8.3% of subjects who received medication responded to treatment with norfloxacin or ciprofloxacin. The investigators suspected but could not confirm an infectious etiology for most cases of diarrheal disease among the USNS Mercy’s crew on the basis of the acute onset and short duration of most cases and a frequent association with eating in foreign ports. The relatively small space for living, eating, and attending to patients aboard the USNS Mercy promoted close contact that may have facilitated the transmission and spread of enteric pathogens among the crew and between patients and crew.
Epidemiologic Investigations of GastroenteritisAn epidemiologic survey of 15,459 deployed troops conducted in January-March 2004 revealed that 74.5% of military personnel had experienced at least one episode of diarrhea while serving in OEF, OIF, or both (Sanders et al. Sanders and colleagues of the Navy’s Enteric Disease Research Program reached that finding and others through a survey designed to assess the incidence and effect of the most common illnesses and noncombat injuries among deployed US troops participating in OEF and OIF. The investigators’ findings related to diarrheal disease are discussed here, and findings pertinent to respiratory disease and leishmaniasis are presented later.The survey posed 199 questions that covered demographics, clinical information, general health, and health-risk behaviors and attitudes. The questions were dispersed among 20 unique single-page forms, each containing 19-21 questions (some questions appeared on multiple forms).
That enabled the researchers to obtain a representative distribution of responses. The investigators verified the accuracy, integrity, and internal validity of the data obtained from each form.The troops who completed the questionnaire represented about 11% of the US military force in OEF and OIF during the study period. The study subjects either were participating in the military’s rest and recuperation (R&R) program in Doha, Qatar, or had stopped at an American.
Air base en route to the United States for a 2-week break after an initial tour of duty in Afghanistan or Iraq.Analysis of the survey data revealed that self-reported symptoms of diarrheal disease were moderately severe and multiple episodes common. Gastroenteritis occurred more frequently among troops deployed to Iraq (76.8%) than to Afghanistan (54.4%). The duration and severity of symptoms were greater for troops in Iraq than in Afghanistan. Contains additional salient data obtained through the survey about the occurrence of diarrheal illness among US forces during OEF and OIF. TABLE 4.8 Impact of Diarrhea Among US Military Personnel Deployed to Iraq and Afghanistan, 2003-2004Characteristics of illnessNo. Cases in Iraq(N,% or range )No.
Cases in Afghanistan(N,% or range )pExperienced diarrhea7,553(76.8)543(54.4)14 days)9.87.5-12.1Chronic diarrhea (30 days)3.31.9-4.7DispositionConfined to quarters (bedrest)14.211.5-16.9Days in quarters2.01-2Hospitalized1.80.7-2.8NOTE: CI = confidence interval.a Ranges are from the 25th percentile to the 75th percentile (the interquartile range).b No statistical differences in these characteristics were observed between sites.c Values are median and interquartile range.SOURCE: Adapted with permission from Sanders et al. 2005a.Sanders and colleagues note that recall and selection bias may have influenced their results. They assert that the point estimates derived probably can be generalized to the entire population of US troops deployed to Iraq and Afghanistan for OEF and OIF.The results presented above validate the findings of an earlier, smaller study in which Sanders and colleagues found that diarrheal illness among troops deployed to OEF and OIF occurred at a high rate and frequently manifested with severe symptoms (Sanders et al. 2005b; Sanders et al. They also found that diarrheal illness appeared to interfere with military operations more during OEF and OIF than during ODSh. They reached those conclusions by analyzing data collected from an anonymous questionnaire administered to 4,348 volunteers in the period October 27, 2003-January 27, 2004.
The epidemiologic questionnaire was designed to assess the incidence of diarrheal illness and its associated symptoms, treatment, and impact on military missions. Diarrhea was defined as three or more loose or liquid stools in 24 hours or two or more loose or liquid stools associated with other gastrointestinal symptoms or fever.The respondents, who participated voluntarily, had been deployed for a median of 8 months to Iraq and 6.7 months to Afghanistan. Most were on R&R in Doha, Qatar; others were traveling through Incirlik Air Base, Turkey, after their deployment to Iraq had ended. Although Sanders and colleagues noted several sampling biases in their study, they concluded that it was unlikely that their results overestimated rates of diarrheal illness in the overall population of troops in Iraq and Afghanistan.Sixty-four percent of respondents stationed in Afghanistan and 77% stationed in Iraq reported one or more episodes of diarrhea during their deployment. More than half the subjects reported multiple episodes. The amount of time spent off a military compound was associated with an increased risk of developing diarrhea.
The investigators concluded that time spent off a base probably represented a surrogate measure of exposure to local food and drink.The investigators found that diarrheal illness affected military operations in OEF and OIF more than it had during ODSh. Of the survey participants, 45% experienced an episode of diarrhea severe enough to decrease job performance for a median of 3 days; 62% of subjects sought medical care for diarrheal illness at least once, and 17% were consequently confined to bed rest for a median of 2 days. For nearly one-third of troops with diarrhea, treatment included intravenous rehydration.
Personnel deployed to Iraq were more likely to experience diarrheal illness, to have multiple episodes, and to have severe diarrhea (more than 10 stools per day).Sanders and colleagues did not attempt to identify the etiologic agents of diarrheal illness in their study population. Nevertheless, they speculated that ETEC and other enteropathogenic forms of E.
Coli probably caused most episodes of diarrhea that respondents described as watery. They also speculated that norovirus caused many cases of diarrheal disease in troops who experienced vomiting as a primary symptom. TABLE 4.9 Demographics and Diarrheal Illness Characteristics of US Military Personnel Deployed to Iraq and AfghanistanCharacterization of DiarrheaOccurrence Among Troops Stationed in Iraq (N = 3915) N (%)Occurrence Among Troops Stationed in Afghanistan (N = 255) N (%)Watery2815 (72)149 (58)Vomiting (mainly)317 (8)6 (2)Blood in diarrhea128 (3)5 (2)Diarrhea with fever471 (12)23 (9)a These characterizations reflect absolute responses that are not mutually exclusive and may include symptoms across multiple episodes.SOURCE: Adapted with permission from Sanders et al.
And diagnostic support (Thornton et al. Located in a city about 175 km south of Baghdad, the laboratory collected and analyzed stool samples and other clinical specimens from 30 First Marine Expeditionary Force battalion aid stations and several other medical stations in the area. Thornton and colleagues published the results of their analysis of 129 stool specimens collected from April 24 to June 1, 2003, from 33 medical stations scattered across south-central Iraq.The authors reported that large outbreaks of nausea, vomiting, and diarrhea lasting 24-48 hours occurred in the First Marine Expeditionary Force from early April though the middle of May, suggesting a viral etiology for most cases of gastroenteritis during that period.
Febrile dysentery predominated in that population beginning in the middle of May.Numerous factors placed the troops of the First Marine Expeditionary Force at risk for gastroenteritis, the authors wrote. The primitive nature of the camps, overcrowding, and filth flies in latrines and dining facilities characterized the troops’ unsanitary living environment.
Local ambient temperatures climbed to 40°C during the period of study. Some troops broke military rules to eat locally prepared food, particularly grilled chicken.
Finally, a relatively small number of microorganisms are capable of causing shigellosis and norovirus gastroenteritis in humans. In an editorial commentary on Thornton’s report, Matson postulates that robustly healthy people who become dehydrated during daily activity may face a greater risk of severe outcome when infected with norovirus (Matson 2005).The investigators used plating, biochemical identification, antigen serologic testing, fluorescent antibody antigen detection, and enzyme immunoassay to evaluate stool specimens diagnostically for enteropathogens. Specifically, they tested specimens for pathogenic E. Coli, Campylobacter spp., Salmonella spp., Shigella spp., Giardia spp., and Cryptosporidium. Coli was tested for heat-labile and heat-stabile enterotoxins; additionally, investigators plated stool with gross blood or fecal leukocytes on sorbitol-MacConkey agar to detect enterohemorrhagic E.
The antimicrobial susceptibility of detected bacteria was evaluated with the disk-diffusion method.Reverse-transcriptase polymerase chain reaction (PCR) was used to detect norovirus. In addition, the authors sequenced the RNA polymerase genes of detected norovirus to distinguish strains, compare the strains with each other and with known strains, and analyze the occurrence of norovirus strains by military unit and timing.illustrates the results of the laboratory-based diagnostic evaluation. One or more enteropathogens were detected in 57 of the 129 stool samples (44%). Norovirus was detected in 23% of the specimens; the investigators found 21 norovirus strains among 30 agent-positive patients. The most frequently detected bacterial enteropathogens were Shigella sonnei and Shigella flexneri; they were isolated from a total of 20% of the specimens.
The presence of fecal leukocytes in 43 of 109 stool samples (39%) indicated inflammatory diarrhea, the investigators concluded.Most of the bacterial isolates tested by Thornton and colleagues were doxycycline-resistant , and several bacterial enteropathogens identified in prior studies of military populations were observed less frequently in this study population. For those reasons, both the authors and Matson (the editorial commentator) postulated that the mandatory dose of doxycycline (100 mg/day) taken by personnel in the First Marine Expeditionary Force for antimalarial prophylaxis may also have reduced the potential impact of bacterial enteric pathogens.Extrapolating their results to the entire First Marine Expeditionary Force, Thornton and colleagues conservatively estimated that several thousand cases of norovirus illness occurred in.