The epidemiology of self-reported diarrhea in operations Iraqi Freedom and Enduring Freedom John W. Sanders a, *, Shannon D. Putnam b , Mark S. Riddle c , David R. Tribble c , Nishith K. Jobanputra d , James J. Jones d , Daniel A. Scott c , Robert W. Frenck a a Naval Medical Research Unit #3, Cairo, Egypt b Naval Medical Research Unit #2, Jakarta, Indonesia c Navy Medical Research Center, Silver Spring, MD, USA d Uniformed Services University of the Health Sciences, Bethesda, MD, USA Received 23 April 2004; accepted 17 June 2004 Abstract Diarrhea remains a potential cause of compromised military effectiveness. To assess diarrhea rates and mission impact in operations in Iraq and Afghanistan, a survey was administered to soldiers participating in the “Rest and Recuperation” program in Doha, Qatar. Between October and December 2003, 2,389 volunteers completed a questionnaire designed to assess the occurrence and impact of diarrhea. The median length of deployment was 7.2 months, 70% reported at least one episode, and 56% had multiple episodes of diarrhea. Overall, 43% reported decreased job performance for a median of 2 days, and 17% reported being on bed rest for a median of 2 days. While this survey showed high rates of diarrhea associated with decreased operational effectiveness, the results are consistent with prior military operations in this region. Further research is needed to develop better methods for illness prevention and its minimization on operational impact. © 2004 Elsevier Inc. All rights reserved. 1. Introduction Historically, diarrhea is one of the most common medical conditions afflicting deployed military personnel (Cook, 2001) with an average incidence of 29% per month (Sanchez et al., 1998). While diarrhea is generally a self- limited illness, the associated morbidity taxes operational health care resources, causes alterations in mission planning and may reduce mission effectiveness through temporary manpower losses. During the Korean War, 78,970 days from duty were lost due to diarrhea and dysentery. In Viet- nam, admission rates to hospitals or quarters was higher than malaria by a 4:1 ratio, making it the largest single disease of the war (Connor and Farthing, 1999). During the first Gulf War, up to 57% of deployed military personnel reported diarrhea, with 20% temporarily unable to perform their duties (Hyams et al., 1991). Currently, there are approximately 130,000 U.S. military personnel deployed to Operation Iraqi Freedom (OIF) and an additional 10,000 deployed to Operation Enduring Free- dom (OEF) in Afghanistan. Considering the history of di- arrhea among deployed military forces, it is likely having a significant influence on daily operations despite modern preventive medicine measures. To assess the impact of diarrhea on operational effectiveness, a system was estab- lished to survey soldiers while on a “Rest and Recupera- tion” (R&R) program at Camp As Sayliyah in Doha, Qatar. 2. Materials and methods The U.S. Army systematically selected units from Iraq and Afghanistan to participate in the R&R program. Troops from these units were sent to Camp As Sayliyah in Doha, Qatar, the principal R&R location. Upon arrival, volunteers completed a questionnaire adapted from previous studies designed to assess diarrhea incidence, associated symptoms, treatment; and mission impact (Sanders et al., 2002). Diar- rhea 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 (nausea, vomiting, or ab- dominal cramps) or fever (Sanchez et al., 1998; Sanders et * Corresponding author. NAMRU3 PSC 452 Box 117 FPO AE 09835. Tel: 011-202-342-1375; fax: 011-202-342-9625. E-mail address: sandersj@namru3.org (J.W. Sanders). Diagnostic Microbiology and Infectious Disease www.elsevier.com/locate/diagmicrobio 50 (2004) 89 –93 0732-8893/04/$ – see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.diagmicrobio.2004.06.008