Volume 93, Issue 5
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Infectious diarrhea has been among the most common maladies of military deployments throughout time. The U.S. military experienced a significant burden from this disease in the middle eastern and north African campaigns of World War II (WWII). This article compares patterns of disease experienced in WWII with the recent military deployments to the same region for Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). Remarkable similarities in the prevalence and risk factors were noted, which belie the assumed improvements in prevention against these infections. In both campaigns, peaks of diarrhea occurred shortly after arrival of new personnel, which were seasonally associated and were linked to initial lapses in field sanitation and hygiene. It is important to reassess current strategies, especially, in light of emerging evidence of the chronic sequelae of these common infections to include a reemphasis on or reexamination of vaccine development, rapid field diagnostics, treatment algorithms, and antimicrobial prophylaxis.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Cook GC, , 2001. Influence of diarrhoeal disease on military and naval campaigns. J R Soc Med 94: 9597. [Google Scholar]
  2. Connor P, Farthing MJ, , 1999. Travellers' diarrhoea: a military problem? J R Army Med Corps 145: 95101.[Crossref] [Google Scholar]
  3. Cirillo VJ, , 2008. Two faces of death: fatalities from disease and combat in America's principal wars, 1775 to present. Perspect Biol Med 51: 121133.[Crossref] [Google Scholar]
  4. Cirillo VJ, , 2000. Fever and reform: the typhoid epidemic in the Spanish-American War. J Hist Med Allied Sci 55: 363397.[Crossref] [Google Scholar]
  5. U.S. Army Medical Service, 1955. Preventive Medicine in World War II. Vol. IV: Communicable Diseases Transmitted Chiefly Through Respiratory and Alimentary Tracts. Washington, DC: Department of the Army, Office of the Surgeon General. [Google Scholar]
  6. U.S. Army Medical Service, 1976. Chapter VII: The Middle East Countries. Preventive Medicine in World War II. Part III: The Mediterranean. Washington, DC: Department of the Army, Office of the Surgeon General. [Google Scholar]
  7. Wiltse CM, , 1965. The Medical Department: Medical Service in the Mediterranean and Minor Theaters. Washington, DC: Department of the Army, Office of the Chief of Military History. [Google Scholar]
  8. Connor P, Porter CK, Swierczewski B, Riddle MS, , 2012. Diarrhoea during military deployment: current concepts and future directions. Curr Opin Infect Dis 25: 546554.[Crossref] [Google Scholar]
  9. Matson DO, , 2005. Norovirus gastroenteritis in US Marines in Iraq. Clin Infect Dis 40: 526527.[Crossref] [Google Scholar]
  10. Riddle MS, Tribble DR, Putnam SD, Mostafa M, Brown TR, Letizia A, Armstrong AW, Sanders JW, , 2008. Past trends and current status of self-reported incidence and impact of disease and nonbattle injury in military operations in southwest Asia and the Middle East. Am J Public Health 98: 21992206.[Crossref] [Google Scholar]
  11. Preventive Medicine, Southwest Pacific Area, 1945. Diarrheal Diseases of the Southwest Pacific Area. Memorandum for Deputy Chief Surgeon, February 25, 1945. [Google Scholar]
  12. 1946. Survey of intestinal parasites in soldiers being separated from service. Bull US Army Med Dep 6: 259262. [Google Scholar]
  13. Hyams KC, Bourgeois AL, Merrell BR, Rozmajzl P, Escamilla J, Thornton SA, Wasserman GM, Burke A, Echeverria P, Green KY, , 1991. Diarrheal disease during Operation Desert Shield. N Engl J Med 325: 14231428.[Crossref] [Google Scholar]
  14. Cox K, , 2006. In-theater health surveillance: what's hot, what's not. 9th Annual Force Health Protection Conference, August 6–11, 2006. Albuquerque Convention Center, Albuquerque, NM. [Google Scholar]
  15. Murray CK, Reynolds JC, Schroeder JM, Harrison MB, Evans OM, Hospenthal DR, , 2005. Spectrum of care provided at an echelon II Medical Unit during Operation Iraqi Freedom. Mil Med 170: 516520.[Crossref] [Google Scholar]
  16. Grainge C, Heber M, , 2005. The role of the physician in modern military operations: 12 months experience in southern Iraq. J R Army Med Corps 151: 101104.[Crossref] [Google Scholar]
  17. Monteville MR, Riddle MS, Baht U, Putnam SD, Frenck RW, Brooks K, Moustafa M, Bland J, Sanders JW, , 2006. Incidence, etiology, and impact of diarrhea among deployed U.S. military personnel in support of Operation Iraqi Freedom and Operation Enduring Freedom. Am J Trop Med Hyg 75: 762767. [Google Scholar]
  18. Sanders JW, Putnam SD, Frankart C, Frenck RW, Monteville MR, Riddle MS, Rockabrand DM, Sharp TW, Tribble DR, , 2005. Impact of illness and non-combat injury during Operations Iraqi Freedom and Enduring Freedom (Afghanistan). Am J Trop Med Hyg 73: 713719. [Google Scholar]
  19. 2004. Chapter 4: Combat Service Support, Topic F: Health Service Support, Subtopic 4: Field Sanitation Teams. Operation Iraqi Freedom Combined Arms Assessment Team II Initial Impressions Report. Fort Leavenworth, KS: Center for Army Lessons Learned. [Google Scholar]
  20. Harris MD, Johnson CR, , 2006. Preventive medicine in Task Force 1st Armored Division during Operation Iraqi Freedom. Mil Med 171: 807812.[Crossref] [Google Scholar]
  21. Putnam SD, Sanders JW, Frenck RW, Monteville M, Riddle MS, Rockabrand DM, Sharp TW, Frankart C, Tribble DR, , 2006. Self-reported description of diarrhea among military populations in operations Iraqi freedom and enduring freedom. J Travel Med 13: 9299.[Crossref] [Google Scholar]
  22. Hyllner S, Heinlaid H, , 1964. Diarrhea in tourists and hygiene—observations during a field study of diarrheal symptoms in Scandinavian tourists in the Canary Islands during the years 1960–63. Nord Hyg Tidskr 45: 113. [Google Scholar]
  23. Kean BH, , 1959. The diarrhea of American travelers abroad. Minn Med 42: 17491751. [Google Scholar]
  24. Thornton SA, Sherman SS, Farkas T, Zhong W, Torres P, Jiang X, , 2005. Gastroenteritis in US Marines during Operation Iraqi Freedom. Clin Infect Dis 40: 519525.[Crossref] [Google Scholar]
  25. Sanders JW, Putnam SD, Antosek LE, Rockabrand DM, Herbst J, Tribble DR, Riddle MS, Sharp TW, Monteville MR, , 2005. A cross-sectional, case finding study of traveler's diarrhea among US military personnel deployed to Iraq [Abstract 697]. Annual Meeting of the American Society of Tropical Medicine and Hygiene. Washington, DC: American Society of Tropical Medicine and Hygiene. [Google Scholar]
  26. Cronquist AB, Mody RK, Atkinson R, Besser J, Tobin D'Angelo M, Hurd S, Robinson T, Nicholson C, Mahon BE, , 2012. Impacts of culture-independent diagnostic practices on public health surveillance for bacterial enteric pathogens. Clin Infect Dis 54 (Suppl 5): S432S439.[Crossref] [Google Scholar]
  27. Buss SN, Leber A, Chapin K, Fey PD, Bankowski MJ, Jones MK, Rogatcheva M, Kanack KJ, Bourzac KM, , 2015. Multicenter evaluation of the BioFire FilmArray gastrointestinal panel for the etiologic diagnosis of infectious gastroenteritis. J Clin Microbiol 53: 915925.[Crossref] [Google Scholar]
  28. Khare R, Espy MJ, Cebelinski E, Boxrud D, Sloan LM, Cunningham SA, Pritt BS, Patel R, Binnicker MJ, , 2014. Comparative evaluation of two commercial multiplex panels for detection of gastrointestinal pathogens by use of clinical stool specimens. J Clin Microbiol 52: 36673673.[Crossref] [Google Scholar]
  29. DeBruyn GHS, Borwick A, , 2000. Antibiotic treatment for travelers' diarrhea. Cochrane Database Syst Rev 3: 121. [Google Scholar]
  30. Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, DuPont HL, Bia FJ, Fischer PR, Ryan ET, , 2006. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis 43: 14991539.[Crossref] [Google Scholar]
  31. Wingate D, Phillips SF, Lewis SJ, Malagelada JR, Speelman P, Steffen R, Tytgat GN, , 2001. Guidelines for adults on self-medication for the treatment of acute diarrhoea. Aliment Pharmacol Ther 15: 773782.[Crossref] [Google Scholar]
  32. Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, Hennessy T, Griffin PM, DuPont H, Sack RB, Tarr P, Neill M, Nachamkin I, Reller LB, Osterholm MT, Bennish ML, Pickering LK, , 2001. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis 32: 331351.[Crossref] [Google Scholar]
  33. 1985. Travelers' diarrhea. National Institutes of Health Consensus Development Conference Statement. Natl Inst Health Consens Dev Conf Consens Statement 5: 17. [Google Scholar]
  34. Riddle MS, Tribble DR, Jobanputra NK, Jones JJ, Putnam SD, Frenck RW, Sanders JW, , 2005. Knowledge, attitudes, and practices regarding epidemiology and management of travelers' diarrhea: a survey of front-line providers in Iraq and Afghanistan. Mil Med 170: 492495.[Crossref] [Google Scholar]
  35. Hayat AM, Tribble DR, Sanders JW, Faix DJ, Shiau D, Armstrong AW, Riddle MS, , 2011. Knowledge, attitudes, and practice of travelers' diarrhea management among frontline providers. J Travel Med 18: 310317.[Crossref] [Google Scholar]
  36. Institute of Medicine (US) Committee on Military Nutrition Research, 1993. Nutritional Needs in Hot Environments: Applications for Military Personnel in Field Operations. Washington, DC: The National Academies Press. [Google Scholar]
  37. Gear HS, , 1944. Hygiene aspects of the El Alamein victory, 1942. BMJ 1: 383387.[Crossref] [Google Scholar]
  38. Riddle MS, Tribble DR, Cachafiero SP, Putnam SD, Hooper TI, , 2008. Development of a travelers' diarrhea vaccine for the military: how much is an ounce of prevention really worth? Vaccine 26: 24902502.[Crossref] [Google Scholar]
  39. Riddle MS, Sanders JW, Putnam SD, Tribble DR, , 2006. Incidence, etiology, and impact of diarrhea among long-term travelers (US military and similar populations): a systematic review. Am J Trop Med Hyg 74: 891900. [Google Scholar]
  40. Riddle MS, Halvorson HA, Shiau D, Althoff J, Monteville MR, Shaheen H, Horvath EP, Armstrong AW, , 2007. Acute gastrointestinal infection, respiratory illness, and noncombat injury among US military personnel during Operation Bright Star 2005, in northern Egypt. J Travel Med 14: 392401.[Crossref] [Google Scholar]
  41. Hurst AF, , 1918. Medical Diseases of the War, 2nd edition. London, United Kingdom: Edward Arnold and Co. [Google Scholar]
  42. Chaudhary NA, Truelove SC, , 1962. The irritable colon syndrome. A study of the clinical features, predisposing causes, and prognosis in 130 cases. Q J Med 31: 307322. [Google Scholar]
  43. Stewart GT, , 1950. Post-dysenteric colitis. BMJ 1: 405409.[Crossref] [Google Scholar]
  44. Pike BL, Porter CK, Sorrell TJ, Riddle MS, , 2013. Acute gastroenteritis and the risk of functional dyspepsia: a systematic review and meta-analysis. Am J Gastroenterol 108: 15581563, quiz 1564.[Crossref] [Google Scholar]
  45. Thabane M, Kottachchi DT, Marshall JK, , 2007. Systematic review and meta-analysis: the incidence and prognosis of post-infectious irritable bowel syndrome. Aliment Pharmacol Ther 26: 535544.[Crossref] [Google Scholar]
  46. Halvorson HA, Schlett CD, Riddle MS, , 2006. Postinfectious irritable bowel syndrome—a meta-analysis. Am J Gastroenterol 101: 18941899, quiz 1942.[Crossref] [Google Scholar]
  47. Connor BA, Riddle MS, , 2013. Post-infectious sequelae of travelers' diarrhea. J Travel Med 20: 303312.[Crossref] [Google Scholar]
  48. Strober W, Fuss I, Mannon P, , 2007. The fundamental basis of inflammatory bowel disease. J Clin Invest 117: 514521.[Crossref] [Google Scholar]
  49. Eckburg PB, Relman DA, , 2007. The role of microbes in Crohn's disease. Clin Infect Dis 44: 256262.[Crossref] [Google Scholar]
  50. Danese S, Fiocchi C, , 2006. Etiopathogenesis of inflammatory bowel diseases. World J Gastroenterol 12: 48074812. [Google Scholar]
  51. Baumgart DC, Carding SR, , 2007. Inflammatory bowel disease: cause and immunobiology. Lancet 369: 16271640.[Crossref] [Google Scholar]
  52. Lee BJ, Bak YT, , 2011. Irritable bowel syndrome, gut microbiota and probiotics. J Neurogastroenterol Motil 17: 252266.[Crossref] [Google Scholar]
  53. Wolvers D, Antoine JM, Myllyluoma E, Schrezenmeir J, Szajewska H, Rijkers GT, , 2010. Guidance for substantiating the evidence for beneficial effects of probiotics: prevention and management of infections by probiotics. J Nutr 140: 698S712S.[Crossref] [Google Scholar]
  54. Bollet AJ, , 2002. Civil War Medicine: Challenges and Triumphs. Tucson, AZ: Galen Press. [Google Scholar]
  55. Porter CK, Thura N, Riddle MS, , 2013. Quantifying the incidence and burden of postinfectious enteric sequelae. Mil Med 178: 452469.[Crossref] [Google Scholar]

Data & Media loading...

  • Received : 14 Mar 2015
  • Accepted : 13 May 2015
  • Published online : 04 Nov 2015

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error