A cross-sectional analysis of clinical presentations of and risk factors for enteric protozoan Infections in an Active Duty Population during Operation Iraqi Freedom

BACKGROUND Infectious travelers' diarrhea (TD) is a well-appreciated problem among service members serving abroad, particularly where infrastructure is limited due to ongoing combat operations, and efforts at sanitation and hygiene may not be considered an immediate priority. Bacterial and viral causes of travelers' diarrhea are well-described among deployed service members, however, gastrointestinal protozoan infections among deployed service members are less well documented. This study's purpose was to identify potential risk factors for, and clinical presentations of, enteric protozoan infections in an active duty military population deployed to combat operations in the Southwest Asia. METHODS A cross-sectional study of enteric protozoan infections among US service members deployed in Al-Asad Air Base, Iraq in support of Operation Iraqi Freedom (OIF) was conducted in summer 2004. Subjects were obtained through a randomized sector sampling scheme, and through presentations for care at the air base medical facilities. All study participants provided a stool sample, either diarrhea or solid, upon study entry and completed a questionnaire documenting demographic information, clinical symptoms of any prior diarrheal episodes, and health risk behaviors. Basic diagnostic microscopy for protozoa was conducted to include acid-fast and modified trichrome staining. RESULTS Four hundred thirty-seven subjects were included in the analysis, and 75 (17.1 %) subjects were found to have enteric protozoan infections as identified by diagnostic stool microscopy. Blastocystis hominis (n = 36), Entamoeba coli (n = 25), Endolimax nana (n = 20), and Entamoeba histolytica (n = 5) were the predominant organisms isolated. Crude incidence of prior episodes of diarrhea was greater among subjects from whom enteric protozoa were isolated compared to those without (IRR 1.66, 95 % CI 1.47-1.87). Bivariate analysis of health risk and hygiene behaviors found increased odds for presence of Blastocystis hominis among those service members who reported off base ice (OR 3.61, 95 % CI 1.40-9.28) and raw vegetable consumption (OR 8.18, 95 % CI 1.40-47.5). CONCLUSIONS This study suggests that US service members deployed to the early stages of OIF were at greater risk of acquiring enteric protozoa than previously understood. The noted prevalence of enteric protozoa among US service members in this study is higher than in prior reports, approaching prevalence expected in the general host nation population, suggesting that US service members operating at Al-Asad Air Base in early OIF were exposed to greater degrees of fecally contaminated food and water, and poor hygienic and sanitation practices. Consumption of food and water prepared by host nation parties in Southwest Asia may place US service members at risk for acquiring intestinal protozoa.