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DIARRHEAL DISORDERS IN THEATERS OF OPERATIONS AND OTHER OVERSEAS AREAS
Approximately 75 percent of reported cases of diarrhea and dysentery were among the troops located overseas (which comprised 40 percent of the average strength of the United States Army). The crude rate for overseas troops was 40 cases per 1,000 troops per annum (table 54). Table 62 lists the rates in the respective theaters and areas.
All overseas theaters exceeded the rate of 9 for diarrheas and dysenteries, achieved by troops in the continental United States, except the colder Alaskan and North American areas and the tropical but well-sanitated Panama Canal Zone, a subdivision of the Latin American area.
European Theater of Operations, 1942-45 13
During the war years, the European theater contained 16.4 percent of the average strength of the total United States Army, and it provided 10.4 percent of the reported cases of diarrhea and dysentery-considerably less than its expected share.The average annual rate for the United States Army in Europe was 14 per annum per 1,000 strength, with 54,196 cases reported (table 54). The rate was lower than for any other overseas theater except Alaska and the North American areas.It exceeded by about one-half the rate for troops in the continental United States, 9 per 1,000 per annum.
TABLE 62.-Incidence rate of diarrhea and dysentery in the several theaters and areas, 1942-45
Rates for these diseases in the European theater for the successive war years beginning with 1942 were 17, 12, 13, and 14, respectively, per 1,000 average strength.The rate of 17, the highest for the theater, is related to outbreaks in transports bringing troops to the United Kingdom and to the unsettled conditions attendant on the development of sanitary facilities at new bases in
13 All material in this section, except when otherwise noted, is taken from Gordon, J. E.: A History of Preventive Medicine in the European Theater of Operations, U. S. Army, 1941-45. [Official record.]
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England. The rates for the 2 subsequent years were not far different from those of troops in the continental United States; in fact, the rates for 1943 were the same. The increase which occurred following the invasion of the Continent was not nearly as great as might have been anticipated for troops in combat and engaged in an active war of movement.The rate of 13.6 per annum per 1,000 average strength for American troops in Europe during the interval from February 1942 to December 1945 compares favorably with the rate of 28.9 for these diseases in the American Expeditionary Forces in World War I. The wide difference in the two rates becomes even more significant in the light of the fact that data for World War II include all cases excused from duty (thus excluding outpatients but including quarters as well as hospital cases), whereas the World War I data include only the more seriously ill actually sent to hospital.
Mortality.-The theater had one death ascribed to bacillary dysentery and a second to unclassified dysentery. Amebic dysentery caused two deaths (table 63). All four were in 1945. Two deaths were recorded among cases of diarrhea. These six deaths give a mortality rate per 1,000 for all diarrheal
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diseases of about 0.002; this rate is amazingly low as compared with experience of former wars and is equally surprising when contrasted with the experience of German prisoners of war (table 64). Modern sanitary practice has its reward, not only in man-hours but in fewer deaths.
Monthly and seasonal incidence.-Examination of the successive monthly rates for the European theater (chart 30) reveals no excess rates regularly associated with any particular season. Peaks of incidence seem to be associated more with other factors than with those strictly related to climate and season; such factors as movement of troops and interruption of sanitation discipline by field and combat conditions seemed to be the main influence.
As in other theaters, sporadic cases occurring more or less continuously comprise a considerable proportion of the diarrhea and dysentery cases. Peaks in curves of incidence were usually related to groupings of cases to give epidemics of varying size.The frequency and size of the latter are important in determining whether the total experience of a theater is good or bad. The European theater was particularly fortunate with relation to both frequency and size of such occurrences in that, during the 4 years, there was only a total of 5 months in which the rates slightly exceeded 20 per 1,000 per annum (chart 30).
Intestinal infections during operations in the United Kingdom.-In Great Britain, the sporadic occurrence of diarrheas and dysenteries was related largely to eating and drinking in civilian establishments, whereas actual outbreaks or small epidemics of diarrhea were most frequently related to faulty sanitation or careless messing practice within the affected unit. Most of the unit outbreaks were foodborne.
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The three major forces of the United States Army present in the United Kingdom experienced somewhat different frequencies of diarrheal disease. The Services of Supply experienced rates consistently higher than those of Ground Forces, and the Air Forces had the best record (chart 31). The Services of Supply conducted an intensive food-conservation program which resulted in foodborne outbreaks through use of leftover foods; this, coupled with other factors such as lack of refrigeration and somewhat lower standards of mess sanitation, accounted for their higher rates.
In chart 31, which shows the incidence of diarrheal disease, the graph pertaining to the Air Forces contains the fewest sharp peaks of weekly or monthly incidence. The mess sanitation and personnel of the Air Forces were more adequate in general, and there was less inclination on the part of Air Force personnel to conserve food. There was also less sporadic diarrheal disease among this personnel, which is accounted for by the fact that their stations were relatively isolated, and there was less opportunity to patronize civilian eating establishments.
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The Ground Forces during 1943 experienced a number of foodborne outbreaks, some large, especially in August, September, and October. Early 1944 saw an improvement; concentration of troops in mobilization areas took place, and special emphasis was laid upon sanitary mess management. The result was virtual elimination of major foodborne epidemics, and the incidence rapidly declined to a level even lower than that for the Air Forces.
Within the Services of Supply, the Central Base Section experienced consistently higher rates than other sections, presumably because of greater numbers of sporadic cases which were attributed to the opportunity for personnel to patronize eating and drinking establishments in the London area.
Intestinal infections during continental operations.-After the invasion of Europe, theater rates for diarrhea and dysentery rose to a peak of over 20 by December 1944, the increase being largely related to troops in combat under field conditions. Nevertheless, the rates were exceptionally low for troops in active combat. The peak monthly rate (following the artificially high rate of 70 in July 1944) for troops on the Continent (chart 30) was in December 1944, only 25 per 1,000 strength. Troops remaining in the United Kingdom continued to maintain low rates comparable with those of the previous year.
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The Ninth Air Force, which was engaged in tactical missions and operated under field conditions, was the principal unit of the Army Air Forces on the Continent. The rates for this organization compare favorably with those of the Eighth Air Force which remained in England on fixed bases and under relatively static living conditions. Ninth Air Force personnel experienced three fair-sized epidemics of diarrheal disease, the sharpest of which occurred in the first week of December 1944. This naturally influenced over-all Air Force rates on the Continent. Notwithstanding, Army Air Force personnel had less diarrhea and dysentery than did personnel of the Ground Forces or Communications Zone (chart 32).
"Ground Forces went through some of the most difficult days of the European campaign with rates for the, diarrheas and dysenteries that were almost unbelievably good. The diarrheal disorders were certainly not frequent; in fact, their general absence was a matter of comment." Gordon attributed this good record early in the campaign to the troops' being on C and K field rations which he considers were a first-class preventive against foodborne disease. As diets became more complicated and A and B field rations were used, the rates increased.
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Communications Zone personnel maintained a good record, but monthly rates for diarrheas and dysenteries were most irregular, with frequent small outbreaks (chart 32). This is considerably different from the experience of the Ground Forces whose rates increased during the hard fighting in the last quarter of 1944 and the early part of 1945 and then decreased. The increase in rates for the Ground Forces, which started in September and attained its high point of 38 cases per 1,000 strength in the week ending 15 December 1944, reflects the general epidemic wave which involved all the field armies in an extensive and progressive manner. The second peak of about 25 per 1,000 which occurred late in February 1945 reflects heavy fighting in a war of movement in that and preceding months.
Epidemiologic case report 1. -During the history of the European theater, there was only one widespread outbreak of diarrheal disease. It involved large numbers of troops and persisted for several weeks. During the first week of October 1944, the epidemic began among troops of the XIX Corps then located near Maastrieth, Holland. At this same time and place, there existed an epidemic of a similar diarrheal disease among the civilian population. The disease spread southward and was reported from several units of the XIII Corps in the middle of October. It passed to the First U. S. Army during November and later in that month invaded the Third LT. S. Army (chart 33).During December, it became widespread in the Seventh U. S. Army. The Seventh U. S. Army already
CHART 33. -Intestinal infections, including common diarrhea, in First, Third, Seventh, and Ninth U. S. Armies in the European Theater of1Operations, by weeks, from approximate date units entered combat to date of redeployment
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had experienced the highest rates for diarrheal disease of any of the armies in the theater, but a marked decrease in rates had occurred during successive weeks in November. The disease causing the December epidemic in the Seventh U. S. Army was recognized to be different in clinical character from diarrheal diseases which hitherto had affected this army.
The epidemiologic observation was made that officers and men were involved alike and that when a unit became involved the peak of incidence built up rapidly within 4 to 8 days and then gradually tapered off during the next 3 or 4 weeks.This was not suggestive of foodborne or waterborne diarrheas. Spread seemed to occur by steady progression or extension. In each affected unit, the incidence was not extremely high at any one time, although before the epidemic had run its course the majority of members were afflicted. As an example, at the general dispensary in Luxembourg there were 187 patients treated during November and the first 2 weeks of December. Yet 30 was the greatest number treated on any 1 day. It was known that prevalence was much greater than reported figures indicate, since many did not report to sick call and only a few of these were admitted to hospital.
The clinical observation was made that the typical case was definitely mild. There was sudden onset with abdominal cramps and from 4 to 8 watery stools within 24 hours. Symptoms persisted for 1 or 2 days, rarely longer. Nausea and vomiting were not typical, but anorexia was, and it persisted for a few days. Blood, pus, and mucus were not present in the stools. Fever was seldom a symptom and rarely exceeded 100o F. There was noleukocytosis. In all units except those of the Third U. S. Army, coryza typically preceded the diarrhea by about 2 days, occurred concomitantly, or developed shortly after the diarrhea.
Laboratory observations were made during the October outbreak in the XIX Corps and later at Luxembourg. No enteric pathogens were recovered. However, laboratory studies on the more seriously ill patients of at least one unit of the Third U. S. Army revealed many positive cultures for Flexner bacilli. This particular outbreak was definitely shigellosis. In other units of this army, Shigella were recovered with increasing frequency as the epidemic progressed, and were considered to be responsible for many of the mild cases during this widespread episode. In the Seventh U. S. Army, Shigella were recovered from about 15 percent of stools examined by a laboratory which had had much experience with dysentery in North Africa. The serologic type distribution was as follows:
Shigella paradysenteriae | Number |
| Flexner I | 1 |
| Flexner II | 4 |
| Flexner III | 2 |
| Flexner V | 9 |
| Flexner VI | 1 |
| Boyd IV (P 274) | 1 |
Shigella ambigua | 4 |
Shigella sonnei | 2 |
In none of the laboratories was Salmonella recovery significant.
That epidemiologic history repeats itself is suggested by the resemblance of this epidemic to the World War I epidemic of diarrhea and mild dysenteries among combat troops during the period from 1 July through 30 September 1918.The two were similar clinically and in apparent mode of spread. Both occurred during a peak of military endeavor under conditions requiring marked emphasis on field sanitary discipline.
This epidemic, although traceable from one unit or army to another in a contiguous manner, probably represented a collection of epidemics of diarrheas and mild dysenteries rather than a single entity as usually thought of in terms of a single etiologic agent. Causes of the southward spread of this epidemic were inherent in the numerous opportunities for breaks in field sanitation discipline in armies under combat conditions.
Outbreaks on troop transports.-Within a period of a few weeks, during August and September 1943, several sharp outbreaks of diarrheal disease
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occurred on transports carrying troops to Europe. At the time, crowding of troops on transports was extreme because of the rapid buildup in strength necessary for the coming operations in France. During one crossing, the transport Argentina had approximately 3,000 cases. Other transports on which excess diarrheal disease occurred were the Shawnee, the Cristobal, and the Capetown Castle.
Troops had not been specifically trained for the shipboard conditions they encountered and had difficulty accommodating themselves to this new restricted environment. Medical and line officers were frequently inexperienced, as were some of the transport commanders. Messing and toilet facilities were inadequate for the numbers of troops carried. Opportunities for contact infection and messhall spread of diarrheal disease were obvious.
Laboratory facilities aboard these vessels were so inadequate that the specific etiologic agents responsible for these outbreaks were not determined in any instance. However, at least one was suggestive of bacillary dysentery because laboratory studies in England after troops disembarked resulted in recovery of Sh. sonnei from a few residual cases of diarrhea.
Most of the diagnoses were within the common diarrhea category, and only one death occurred among the thousands of cases recorded.
Control of this epidemic situation depended upon alleviating the overcrowded conditions of troop transports. The measures to be applied had to originate in the Zone of Interior, at ports of embarkation, and at staging areas. Special reports from the European theater supplemented the routine reports of transport medical officers. Appropriate measures were instituted at ports of embarkation; furthermore, the military situation no longer required overcrowding. The result was that only eight instances of excessive rates for diarrhea occurred in 378 troop movements overseas to the European theater during the first 5? months of 1944. None were serious.
In June 1944, the Nieuw Amsterdam experienced a severe outbreak. Because of the high attack rate on this vessel and of the fact that the summer season was at hand with the possibility of a seasonal upswing in incidence, and because the military situation required increasing numbers of troops, the aid of authorities in the Zone of Interior was again sought. Control measures instituted gave definite results because only one other epidemic of serious proportions occurred thereafter, in August 1944 on board the Mariposa which was seriously overcrowded with 9,326 troops among whom over 2,000 were reported to have had a diarrheal disorder.
Epidemiologic case report 2.-The largest single outbreak of diarrheal disease during the war years in the European theater occurred aboard the Argentina during the crossing which ended at Glasgow, Scotland, on 4 September 1943, after sailing from New York about the middle of August. Approximately 3,000 patients reported to sick call, among the 6,153 Negro troops, ship's company, and naval gun crew. Many other milder cases occurred. One soldier died of acute diarrheal disease. The microbiologic agent involved was never determined. Some of the more acutely ill who were taken ashore at Glasgow were examined, and stool cultures were made. Cultures were reported negative for common enteric pathogens.
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The ship was grossly overcrowded, soldiers were required to sleep in shifts, and the messes were constantly serving meals from galleys which at the outset had been reported by the transport surgeon to have numerous sanitary deficiencies. Facilities for washing and sterilizing messgear were inadequate. Furthermore, toilet and bathing facilities were inadequate for such a large number of passengers.
The description by the port physician at Glasgow is quoted as follows: 14
The first impression was of gross overcrowding; the second, of filth and dirt everywhere. A long queue of soldiers waited outside the door of the dispensary, some so weak they had to sit or lie on the deck. The epidemic of dysentery had begun 4 days out of New York.All galleys, including that of the Navy gun crew and the civilian crew, were in a deplorable state of sanitation. The main troop galley was the worst of the lot. The supposedly clean kitchen utensils had dirt, grease, and decaying food stuck to them. The stoves and tables were very dirty with old burnt grease and decayed food particles. The garbage disposal was extremely unsanitary. Garbage cans were coated with decaying organic matter and had not been washed for a long time. They were piled helter-skelter in a corner of the kitchen, and their contents were spilled all over the deck. The troops were messing in the main messhall. Half-eaten food was thrown over the tables and floor. In fact, the floor was so covered with waste food that one had to be careful not to slip and fall. The garbage cans just outside the main messhall were the most nauseating scene I have seen on board a ship. Half a dozen soldiers were standing in garbage 2 to 3 inches deep around 5 or 6 garbage cans filled to overflowing with uneaten food. Sterilization and washing of trays was unsatisfactory. There was not enough soap in the water and the water was not hot enough to really clean the trays in the very brief period that they were immersed. Inspection of the rest of the ship-troop quarters, decks, and latrines revealed conditions just as unsanitary as in the kitchens. The troop quarters reek with vomitus and diarrheal fecal matter from those who were ill and could not find a place in the latrines to relieve themselves. The latrines themselves were beyond description. I can truly say that I have never seen a United States Transport in such deplorable sanitary condition.
Epidemiologic case report 3.-An epidemic occurred on the transport Shawnee on 10 September 1943 that lasted for 2 days and subsided by the time the ship docked at Bristol, England, on 15 September. Of the 1,843 military personnel aboard, 362 cases of diarrhea were reported. The transport surgeon observed that foodhandlers of the ship's permanent personnel were unaffected and that they ate their food in the galley. Although inspection revealed no obvious contamination of food, he believed that it had become contaminated somewhere between the galley and the messhall. He further observed that kitchen police of the 2190-S Task Force had been relieved by men of the 2190-K Task Force on 9 September, the day before the epidemic started. He believed that carriers existed in the 2190-K Task Force kitchen police and returned the other group to duty. Whether or not his hypothesis was correct, the fact remains that no additional cases occurred after the change in foodhandlers.
Epidemiologic case report 4.-An outbreak of diarrheal disease on the transport Cristobal occurred in association with the reported fact that there were only 200 compartment steel trays available to serve 3,000 troops at the rate of from 700 to 900 servings per hour. Facilities for washing and sterilizing even this small number of trays at such a rate of speed were unsatisfactory. 15
Epidemiologic case report 5.-An epidemic of 170 cases of diarrheal disease occurred among troops on the transport Capetown Castle on the third day of a transatlantic crossing, and 20 additional cases occurred on the fourth day. The ship's surgeon believe the out-
14 Letter, Port Medical Inspector, to the Port Surgeon, 5 Sept. 1943, subject: Sanitary Report of USAT Argentina.
15 Letter, Deputy Base Surgeon, Eastern Base Section, to Chief Surgeon, European Theater of Operations, U. S. Army, 13 Sept. 1943, subject: Outbreak of Diarrhea Aboard the U. S. Army Transport "Cristobal."
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break was related to inadequacies in the methods of washing messgear. Accordingly, chlorine was added to the final rinse water.No further difficulty occurred during the voyage.
Diarrheal disease by racial groups.-Negro troops in World War I had less reported diarrheal disease than did white. In World War II, in the European theater, the rates (chart 34) among Negro troops were generally lower than those for white troops. This was true both in the United Kingdom and on the Continent. The rates were lower too among Negro troops in the continental United States and in at least one other theater of operations where separate data are available.
Diarrheal diseases among enemy prisoners of war.-In the European theater, the most serious problem with the diarrheas and dysenteries occurred not among American troops but among enemy prisoners of war.
Rates for diarrheas and dysenteries for prisoners during the last quarter
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of 1944 and the first few months of 1945 were roughly 10 times as great as those for United States troops. Extensive crowding into cages under the emergency conditions associated with the often sudden reception of a large number of prisoners favored spread of the infectious agents of intestinal disease. Deficiencies of sanitation and inadequacies of messing facilities, which seem inevitably to occur during such operations, provided additional impetus to the diarrheas and dysenteries. That the rates were not higher is due largely to the policy of not retaining prisoners on the Continent any longer than necessary. They were removed to Great Britain or to the Americas, where diarrheal disease did not constitute a major problem among them.
The main problem existed among the prisoners in the enclosures on the continent of Europe. When the number of prisoners taken was great, overcrowding was increased, and sanitation breakdowns were frequent. Under these conditions the rates went up. The high rate for December 1944, 185.4 per 1,000 prisoners per annum (table 64), was associated with the reception of large numbers taken at the Battle of the Bulge.
Improvement in rates occurred thereafter until April 1945 when the rate was 74.6. Then came the end of the war in the first week of May. Tremendous numbers of prisoners had to be accommodated in hastily prepared facilities because those already provided were hopelessly insufficient. Men were crowded into enclosures which at first were little more than cages. Water supplies were safe but were not sufficient at many enclosures; messing and kitchen equipment was inadequate as were methods for sterilizing messgear. In some enclosures, men slept in pup tents, foxholes, improvised shelters, or in the open. Flies were prevalent, although DDT, when available, was used to suppress them.
Unprecedented rains fell in several of the enclosures, which led to much mud and thoroughly chilled and soaked the prisoners. In this setting, an epidemic of dysentery broke out but was confined to the prisoners. In some of the larger camps, two or three thousand persons were sick at the same time.
In May 1945, 80,952 cases of diarrhea and dysentery occurred, and rates soared to 734.6 per 1,000; the majority of cases were in the first 2 weeks of that month. In June, 60,978 cases occurred, and the rate dropped to 326.9 per 1,000.
Hospitals had been established to take care of seriously ill patients. As rapidly as possible, water supplies were increased, and messing and sanitary facilities were improved. Before the end of May, remarkable accomplishments in prison-enclosure sanitation had been made. But dysentery had taken over with a speed greater than that necessary for the institution of proper preventive measures.
The clinical severity of the disease in this epidemic is illustrated by the 833 deaths among that particular group of 403,142 prisoners who were under the jurisdiction of the Advance Section, Communications Zone, during the 6-week period from 1 May to 15 June 1945.
Clinical, epidemiologic, and laboratory evidence suggest that a great
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proportion of these cases were bacillary dysentery. Several strains of the Flexner type of dysentery bacilli were isolated.
Common diarrheas.-Over 90 percent of intestinal infections in the European theater were reported under one or another of the diagnostic titles included in the group of common diarrheas. During the 4 war years, there were approximately 50,000 cases, or 12 cases per 1,000 men per annum. The higher rates (over 20 per 1,000 per annum) in the last quarter of 1942 were related to Operation TORCH, and the increase in the spring of 1944 was related to the concentration of troops in southern England in preparation for the Normandy invasion. Contrary to expectation, the Normandy invasion itself did not result in a reported increase, but the Battle of the Bulge and operations thereafter in the winter of 1944-45 did result in some of the highest rates of the theater experience.
Analysis of sources of infections in 154 outbreaks of common diarrhea, occurring in the theater during the war years and recorded in sanitary reports or through special epidemiologic studies, revealed that 67 outbreaks had been ascribed to contaminated foods, 13 to impure water supplies, and 28 to unsanitary conditions in messes. For 46 of these reported outbreaks, the causative factor was undetermined. Thus, in the European theater, the causes of outbreaks were most frequently related to food, and only 12 percent of the outbreaks of determined cause were related to water.
As mentioned elsewhere, food poisoning became separately reportable in the United States Army in 1944. The distinction between foodborne common diarrhea and food poisoning is more or less artificial, and there is little doubt that many foodborne outbreaks continued to be reported as common diarrhea. The terminology perhaps implied to the reporting medical officers a more careful consideration of cause. If laboratory studies revealed either an actual pathogen or a suspected pathogen, the outbreak was more likely to be reported as food poisoning. If no laboratory studies were made or if studies made were negative, the outbreak often was reported as common diarrhea. Nevertheless, epidemiologic considerations are the same in both instances. Transmission of infection by food was the most common mechanism in the common diarrheas.
Another chapter of this history is devoted to food poisoning, so that attention is now directed to waterborne common diarrhea. True waterborne outbreaks of common diarrhea typically involved a large proportion of the exposed military population. The onsets were sudden, and the outbreaks terminated promptly. They usually involved engineer construction units, combat troops in the field, or other units using temporary or untested emergency water supplies.
Three epidemiologic case reports illustrate this relatively rare type of outbreak:
Epidemiologic case report 6.- On 27 September 1943, the 2d Battalion, 347th Engineer General Service Regiment, with a strength of approximately 900 men, experienced the beginning of an epidemic when 31 men were seized with nausea or vomiting, malaise, intestinal cramps, or diarrhea. All were afebrile. On 28 September, 102 others reported at
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sick call, and on the following day 29 new cases occurred. More than half of the men of the battalion were mildly ill, and only the more severely ill reported to sick call. Most of the patients recovered within 24 to 36 hours.
At that time, the battalion was constructing a large camp in Great Britain, and the permanent water supply was to be drawn from a river. A chlorination and filtration plant lead just been completed but was not yet working properly. As a result of a misunderstanding, the water from this new source was turned on at a time when raw water actually passed into the distribution system for only a few hours in the morning of 26 September. Lemonade made from this water was served in the messhalls.
Samples of water from the distribution system taken on 27 September were subsequently shown to be heavily contaminated with colon bacilli. The use of the water was permitted but only after collection in Lyster bags and chlorination; otherwise the outbreak might have been more extensive.
Epidemiologic case report 7.-In September 1943, troops of Site B of the 127th Army Air Force Station experienced a small outbreak entirely limited to troops at that site and not extending to other parts of the station. The site became contaminated by the overflow of sewage which was caused by the failure of a sewage pump. Drinking water was subsequently found to be nonpotable, whereas the supply to other sites on the station was safe. Epidemiologic investigation eliminated food as a likely cause of the diarrhea. Emergency measures were taken with reference to the water, and the outbreak subsided promptly.16
Epidemiologic case report 8.-The 2d Chemical Mortar Battalion in France moved to a new location and utilized a French water point as their source of supply. The water used was found to be nonpotable and nonchlorinated. Chlorination was instituted and the outbreak, which already had involved more than one-fourth of the battalion, ceased. 17
The dysenteries.-Of the 54,196 cases of diarrheas and dysenteries (table 54) which were reported during the war years, approximately 8 percent were reported as dysentery of one form or another. Army regulations required that a specific infectious agent be recovered before a case received either a diagnosis of bacillary dysentery or amebic dysentery. The diagnosis of dysentery, unclassified, was used if clinical criteria alone were used. Examination of morbidity report data revealed that this category comprised the greater proportion of cases. Bacillary dysentery was next most frequent, and amebic dysentery was of lowest reported incidence. The rate in this theater for dysenteries, all forms, was slightly over 1 per 1,000 strength per year. For unclassified dysentery, the rate was 0.5; for bacillary dysentery, 0.4; and amebic dysentery, 0.3.
When incidence figures (tables 59, 60, and 61) based upon sample tabulations of individual medical records for both primary and secondary diagnoses among excused-from-duty patients are used, the order is changed. Bacillary dysentery takes the lead with 1,948 cases tabulated, representing a rate of 0.44 per 1,000 strength per annum. Amebic dysentery was next most frequent among these more severely ill patients with 1,622 tabulated cases, or 0.37 case per 1,000 per annum. Unclassified dysentery was least frequent with 1,007 tabulated cases, or 0.23 case per 1,000 per annum.
Thus, it is apparent that diagnoses were changed with considerable
16 Epidemiological Report, Army Air Force Station 127, 18 Sept. 1943, subject: Epidemic of Gastrointestinal Disease.
17 Letter, Office of the Surgeon, 2d Chemical Battalion, to Commanding General, European Theater of Operations, U. S. Army, 1 Dec. 1944, subject: Monthly Sanitary Report.
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frequency after admission and laboratory study and that in this process cases were added to the bacillary dysentery and amebic dysentery categories and were subtracted from the unclassified dysentery category.
Since amebic dysentery is discussed elsewhere in this volume, it is sufficient to state here that a large proportion of the cases diagnosed as amebic dysentery were in patients who previously had been stationed in the Mediterranean theater and that this portion of the cases represented relapses of previous infections. It was believed that relatively little endemic infection existed in the civilian populations of Great Britain and France and that primary infection in this theater was not frequent.
Bacillary dysentery tended to occur under combat conditions. This tend ency is typical of experience in many wars. Under such conditions, laboratory diagnosis becomes difficult, and the result is that many cases fall into the unclassified group or are diagnosed with the common diarrheas, the latter diagnosis being used especially for the milder cases.
During the period from January 1944 to June 1945, 1,054 cases of bacillary dysentery were reported. This represented approximately 30 percent of all forms of dysentery reported on morbidity reports during that period. It is almost certain that a large proportion of unclassified dysentery was of bacillary etiology. Together these forms represent about 75 percent of the dysenteries. Incidence data (table 59) based on sample tabulations of individual medical records reveal that there, were 1,948 cases of bacillary during the 1942-45 period, representing an incidence rate of 0.44. The highest annual incidence rates occurred during the last year in association with continental operations.
There was little clear-cut evidence of a typical seasonal distribution. The monthly rates were higher in association with troop movements or combat interruptions in sanitary disciplines.
No extensive outbreak is included in the list of confirmed epidemics of bacillary dysentery which came to the attention of the theater epidemiologic service. The largest epidemic involved 183 patients at Camp Northway in the Ash Church garrison area in England and was caused by a Flexner dysentery bacillus.
Among the outbreaks of diarrheal disease which occurred on troop transports, several of which were suggestive of bacillary dysentery outbreaks, there is some evidence to confirm the suggestion and also to confirm the belief that transport outbreaks resulted in epidemic spread which continued to affect the incidence in the European theater.
Epidemiologic case report 9. -On 24 January 1943, at a staging area in England, a suspected case of bacillary dysentery was confirmed by the finding of Sh. sonnei in the feces. During the next 3 weeks, 54 similar cases occurred of which 19 were confirmed as Sonne dysentery by microbiologic methods. These cases occurred among a shipment of 1,000 men who arrived at the staging area directly from a troop transport which had brought them to England. Dysentery had not been previously recognized at this area nor had any outbreaks of diarrheal disease occurred. Furthermore, the men had been restricted to the camp area since their arrival on 12 January. Questioning revealed that one man, at least, had had acute diarrhea and was mildly ill for 3 days aboard the transport but had not
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reported his illness. Thirty-six foodhandlers among the group were examined soon after the outbreak began. One was found to be a carrier of the Sonne dysentery bacillus.
The outbreak did not spread at this time to other units in the staging area. It was considered to have started on the troop transport, and the foodhandler carrier was considered to be the immediate source of the infection at the staging area.
Most of the recorded outbreaks of confirmed bacillary dysentery involved small numbers of cases, usually fewer than 50. Many confirmed cases seemed to occur in small groupings of three or four at a time.
The following is illustrative of a foodborne outbreak of this disease:
Epidemiologic case report 10.-The headquarters mess of Services of Supply at Cheltenham, England, housed about 40 senior officers of the theater. The attendants were mainly British civilians. An outbreak of diarrheal disease among the domestic staff began about 1 February 1943 and ultimately involved 15 persons, 3 of whom were resident officers. Bacteriologic examination of the stools of 11 foodhandlers revealed 2 carriers of Sh. sonnei. Removal of the carriers served to terminate the outbreak.
Another example of a clear-cut foodborne outbreak is that of 23 cases among officers and nurses of the First Medical General Laboratory, caused by contaminated tomato juice served at breakfast on 10 March 1945. Sh. paradysenteriae of the Boyd 103 type were recovered.
In one instance in this theater, an outbreak was clearly attributed to water. The same Shigella organism was reported to have been recovered from patients and from the water itself.
Sh. sonnei was most frequently encountered in this theater, and Sh. paradysenteriae (Boyd 103) and Sh. ambigua were also frequently identified. Most laboratories limited their examination to species differentiation.
Mediterranean Theater of Operations
The "filth diseases of man" have been prevalent for generations in most of the area which came to be known during World War II as the Mediterranean Theater of Operations.The destruction of war added to sanitary problems in those parts of the theater which had been better sanitated. The absence of sanitary facilities among civilian populations, especially in North Africa, was general. The habit among natives of North Africa of promiscuously depositing feces upon the ground, coupled with swarms of flies present during the summer, provided ideal conditions for the dysenteries. A little less than 6 percent of the total average strength of the Army was concentrated in this hyperendemic environment, and this theater contributed almost 20 percent of the total cases of diarrhea and dysentery during the war years. One-fourth of the cases in overseas troops were in this theater. Among the overseas theaters of operations, the Mediterranean ranked third in the reported incidence of these diseases, China-Burma-India and Africa-Middle East theaters ranking first and second (table 62). The average strength during 1942-45 was 360,891, and the total number of reported cases was 100,649, a rate of 70 cases per 1,000 strength per annum (table 54).
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The preventive medicine officer of the Mediterranean theater observed that the troops landing in North Africa at the opening of the theater in late 1942 and early 1943 were not adequately trained in details of housekeeping and sanitation which must extend down to the lowest echelons to be effective.He stated that "once the forces saw the results of neglect in the diarrhea outbreak which was almost universal in 1943 * * * it was no longer necessary to convince anyone of the importance of sanitation." 18During June 1943, the rate attained the epidemic high of 445 cases per 1,000 per annum (chart 35), and the outbreak stretched across all of North Africa, from Tunis to Casablanca.This early experience focused attention upon sanitation and preventive measures which resulted in the lowering of rates in subsequent years.
Annual rates.-The rate for 1943 was 132 cases per 1,000 strength and for the subsequent 2 years 54 and 22 cases, respectively (table 54). The downward trend was attributed to many factors, including seasoning of troops and frequent sanitary inspections to ensure food and water sanitation, proper disposal of waste, fly control, and examination of foodhandlers. The shift of large numbers of troops from North Africa to Italy was also a contributing factor. The downward trend also emphasizes the value of preventive medicine.From the opening of the theater to the wave of the 1943 epidemic in September, more than 500,000 men were exposed to the hyperendemic environment for the first time and during the dysentery season; whereas something like half that number of new men had entered the theater during the interval from the end of the
18 See footnote 5, p. 327.
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1943 epidemic to the end of the 1944 dysentery season (to increase the average strength to about 700,000 in August 1944). A reduction in the incidence of diarrhea and dysentery was to some extent related to the proportion of unseasoned troops. The rate was exceedingly high when all troops were newcomers to the theater, and as the proportion of unseasoned troops declined the rate declined. The decline in 1945 may also be explained similarly. However, it is difficult in retrospect to determine the actual percentage of cases in 1944 contributed by new men entering the theater. Although not too well substantiatedepidemiologically, there exists the documented general opinion that during 1944 and 1945 new troops entering the theater were badly affected, whereas diarrheal diseases did not tend to recur in severe form among troops who had been in the theater for several months.In the annual report for 1943 19 the, statement is made that, "* * * outbreaks were particularly prevalent in newly arrived organizations and in replacement depots * * *. Those outbreaks which occurred late in the summer were largely confined to units new in the theater or to those involved in operations that made it difficult to control the sanitation of their environments." Hurevitz states: 20 "Another factor may have been the large number of new arrivals * * *.Troops who have been in North Africa may have developed a partial immunity to some of the more common varieties of Shigella, but definite proof of this is lacking."
Seasonal occurrence and monthly rates.-Chart 35 shows monthly rates for diarrhea and dysentery. The seasonal fluctuation is marked by increased incidence about May, reaching a peak in June or July, and tapering off in September or October. The peak rates were 445 in June during the epidemic of 1943 and 114 in July 1944.
The 1943 epidemic.-The 1943 epidemic in North Africa coincided with the movement of prisoners of war (among whom bacillary dysentery was common) from the Tunisian battlefields back to Casablanca, with the beginning of warm weather, and with an abundant fly population. Poor sanitary conditions in prisoner-of-war trains gave ample opportunity for the disease to spread to military personnel establishments along the rail routes. These circumstances, coupled with the fact that there was an early shortage of medical supplies, helped to set the stage. Few messes had screens, and a shortage of insect-control sprays and sprayers was particularly evident in the Eastern Base Section. Furthermore, troops recently arrived from the United States were accustomed to high levels of sanitation and did not appreciate the details entailed in maintaining high levels of field sanitation or the personal hygiene necessary during warm months in this new environment.
Dysentery became epidemic in the Eastern Base Section and in the 34th Infantry Division about 17 May 1943, in the Atlantic Base Section about 19 May 1943, and in the Mediterranean Base Section by 24 May 1943. Flies became abundant in all areas about this time, and the epidemic was soon present across the entire North African occupied area. Units of the 34th Infantry Di-
19 Annual Report, Medical Section, Mediterranean Theater of Operations, United States Army, 1943.
20 Hurevitz, H. M.: Dysentery and Common Diarrheas in MTOUSA.[Official record.]
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vision with a rating of "good sanitation" had low dysentery rates, while units with a rating of "fair sanitation" had high rates.21 Directives which stressed the unit command responsibility for sanitation resulted in improved sanitation and fly control, and the rates for the theater dropped from 445 cases per 1,000 troops in June to slightly over 200 in July despite the invasion of Sicily, which was under way during the last 3 weeks of July.
The 1943 epidemic was one of the most extreme outbreaks of diarrhea and dysentery experienced by the United States Army over a large area. During June 1943, when the rate was 445, illnesses from diarrheal disease accounted for 36 percent of all admissions and for 14 percent of all noneffectiveneSS.22 The noneffective rate rose to 5.5 (chart 36). During the year of 1943, diarrheal conditions caused 14 percent of all admissions for disease and 6 percent of noneffectiveness charged to disease (table 67).
Laboratory facilities sufficient to make stool cultures on any appreciable part of cases were clearly not at hand. However, more cases of bacillary dysentery were identified in this theater during this epidemic year than in any other theater during any war year, although three other theaters during this same year had higher rates. Whenever diarrheal infections were studied bacteriologically, one or another type of Shigella was usually recovered; one laboratory in the theater was able to confirm the presence of Shigella organisms in over 50 percent of stool specimens. The theater wide epidemic of recognized
21 Long, P. H: A Historical Survey of the Activities of the Section of Preventive Medicine, Office of the Surgeon, Mediterranean Theater of Operations, U. S. Army, 3 Jan. 1943 to 15 Aug. 1943. [Official record.]
22 See footnote 20, p. 364.
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bacillary dysentery occurred simultaneously with an epidemic of diarrheas and dysenteries, and a large proportion of the latter doubtless was unrecognized bacillary dysentery.
The German Army both in North Africa and later in Italy suffered diarrheal disease presumably with higher rates and with more severe illness. It is amazing that the Germans, who went to such detail in training for the North African environment woefully neglected training in the rudiments of field sanitation. Promiscuous deposition of feces in areas previously held by the Nazis was noted repeatedly by Allied troops. Dudley claims that Rommel blamed dysentery as one of the chief reasons for his North African defeat (p. 319).
Intestinal infections under combat conditions.-Actual combat conditions do not lessen the need for good field sanitation, but application is often difficult and sometimes impossible. Foodhandling for combat troops is always a problem, but foodborne disease can be prevented in considerable measure. The observation was made in this theater (as in the European theater) that certain units had a most favorable experience with dysentery while in combat and existing on C and K field rations; other units not using these individual packaged rations were hard hit.
The Italian campaign and the landings at Salerno came during the wane of the dysentery season. Combat troops continued to experience a high incidence of dysentery throughout October and November 1943. Combat conditions created by the assault of the Gothic Line 1 year later, in 1944, again contributed to prolongation of the dysentery season into November. The experience of the Fifth U. S. Army in Italy provides an interesting epidemiologic case history:
Epidemiologic case report 11.-The Fifth U. S. Army, after landing in Salerno, during the latter part of 1943 experienced a jump in the rate for diarrheas and dysenteries to 72 cases per 1,000 troops in October. As the military situation became somewhat more stabilized and as cold weather set in, the monthly rate declined to 36 in January and 37 in May, 1944. The expected seasonal rise in incidence occurred thereafter; rates of 103 and 135 were reached during June and July, respectively. This rise coincided with the onset of warm weather, the fly season, the fresh-fruit season, and sustained combat activity.During August and September, the rates fell to 83 and 76, respectively (chart 37).This drop was ascribed to changes in the weather and stabilization of the front.Unit messes were utilized, and sanitary provisions were enforced among combat troops. On 12 September, an offensive was launched against the Gothic Line.Thereafter, an unexpected nonseasonal rise in rates occurred which was in contrast to the Fifth U. S. Army experience of the previous year.The monthly rate rose to 160 in October, during the height of the epidemic.
Thereafter, the monthly rate declined and was 83 in November and 41 cases in December. The rates during the October epidemic reflect only the hospital and quarters cases, and it is known that many cases of diarrhea were treated on a duty status under circumstances which did not enable good reporting. This epidemic occurred primarily among combat troops and not in service troops. Occurrence was associated with combat conditions. The fall rains and cold weather caused troops to seek shelter in areas where sanitary conditions were poor and where flies were often numerous.Water discipline was lax, and typhoid fever in civilians of the area indicated contamination of wells.Much of this contamination was probably related to the heavy rainfall and to backwater of sewage systems which had been broken by enemy demolitions. Facilities for washing messgear at the front were scant. Latrines became waterlogged, and feces sometimes floated over unit areas. As soon as the
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CHART 37.-Diarrhea and dysentery in the Fifth U. S. Army in Italy, 1944
offensive stopped and positions were stabilized, the level of field sanitation was raised, and the diarrhea rate began to decline from its unseasonable October peak.
This epidemic further illustrates the strong association of diarrheal disease with combat conditions, and emphasizes that preventive measures must be focused upon frontline troops and their environment.
Racial differences.-The interesting epidemiologic observation was made in this theater that Negro troops experienced consistently lower rates for intestinal disease than did white troops. No explanation was offered, but two possibilities were suggested: (1) That a much higher percentage of Negro than of white troops are engaged in service activities where their living establishments are reasonably stable and therefore better sanitated; and (2) that, because of greater previous exposure to enteric infection, there is greater immunity among Negroes.
Common diarrheas.-Common diarrhea represented approximately 85 percent of the intestinal disease noted on morbidity reports (Form 86ab) for this theater of operations. Some 85,000 cases of common diarrhea were reported (table 65).The diarrheas are described as often severe, with blood and pus in many cases, and as having been commonly identified, when examined bacteriologically, with Flexner dysentery bacilli.
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In the Office of the Surgeon, the opinion was expressed, though it was not supported by reported data, that the great majority of common diarrheas were actually bacillary dysentery. Gilmore 23 stated: "When it has been possible to do careful bacteriology most of these outbreaks have been found to be due to bacillary dysentery infections, so that to the relatively small number of bacillary dysenteries reported as such should be added a large percentage of the common diarrheas." For example, Gowen reported 24 that 55 percent of 250 consecutive specimens from cases of acute enteritis in North Africa were positive for Shigella.
Protozoal dysentery.-Gilmore stated further: "It is believed that many of the so-called protozoal dysenteries are actually bacillary cases in which protozoa were also found. It is felt that the increased number of cases of protozoal dysentery reported in 1944 and 1945 as compared with 1943 cases is largely a reflection of the greater interest in the problem of etiology of [this class of the] intestinal diseases."
The hospitals receiving about 40 percent of the cases in 1944 were staffed by physicians and others especially interested in protozoologic methods. The same medical facilities were not staffed with individuals of equal training and interest in bacteriologic techniques. In contrast to most other theaters, peak rates for protozoal dysentery for this theater were in 1944 rather than in 1945, although the rates were high in 1945 (table 60). In 1945, amebic dysentery represented 4 percent of all intestinal infections, and in the previous year, 2.3 percent (table 65). It is reasonable that prolonged exposure in the theater accounts for some of the increase. By contrast, bacillary dysentery,
23 See footnote 5, p. 327.
24 Gowen, G. H.: Acute Enteritis in North Africa.Bull. U. S. Army M. Dept. No. 71: 55-58, December 1943.
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unclassified dysentery, and the common diarrheas affect troops soon after entry, and rates tend to decrease with time. In all, only about 1.3 percent of dysenteries and diarrheas (plus bacterial food poisoning, paratyphoid, and typhoid) in this theater were reported as amebic dysentery. Amebiasis therefore was not a major problem, although two deaths, both in 1943, were attributed to this disease (table 63).
Unclassified dysentery.-Approximately 9 percent of diarrheas and dysenteries were unclassified dysentery. Almost 9,000 cases were reported by the preventive medicine officer of the theater (table 65), but data in table 61 reflect only 5,364. The incidence rate for the war years was 3.62 cases per 1,000 per annum, and in the epidemic year of 1943 it was 8.13 cases per 1,000 per annum, approximately two-thirds of the cases having occurred in this year. The majority were believed to be actually bacillary dysentery in which rectal swabs or stool specimens were not examined for lack of laboratory facilities. However, that the diagnosis was not frequently changed to bacillary dysentery after admission is evidenced by the fact that reported cases for bacillary dysentery (table 65) approximate incidence figures based on tabulations of individual medical records. Either the number of cases of unclassified dysentery reported on WD MD Form 86ab included about 3,000 cases that were not admitted to hospital or the diagnosis for these 3,000 cases was changed to something other than dysentery.
One death in 1944 was ascribed to this cause (table 63).
Bacillary dysentery.-Over 4,000 cases of bacillary dysentery (tables 59 and 65) were recognized in the Mediterranean theater and represented about 4 percent of the total number of diarrheas and dysenteries reported in the theater; the incidence rate was 2.81 cases per annum per 1,000 average strength. During the epidemic year of 1943, almost 5 percent of all cases were reported as bacillary dysentery, and the incidence rate was over 6 cases per 1,000 per annum. Although bacillary dysentery caused severe illness in many patients and, together with unclassified dysentery, contributed to considerable noneffectiveness, it is remarkable that no deaths were reported from bacillary dysentery (table 63).
Of 778 cultures submitted by outlying laboratories to the 15th Medical General Laboratory for confirmation, 539 were Shigellae and 239 coliform and paracolon bacilli. The indication is that the smaller laboratories in the theater were doing good determinative enteric bacteriologic examinations.
Hurevitz stated that during the epidemic year of 1943, between 50 and 60 percent of stool specimens from patients with diarrheal disease submitted to laboratories of the theater yielded Shigella. The proportion in Italy during 1944 was smaller (10 to 15 percent), but during the fall outbreak in the Fifth U. S. Army about 30 percent of the specimens were positive.
A previously unidentified strain of Shigella, responsible for an outbreak in the 2d Replacement Depot, was isolated by the 2d Medical Laboratory at Casablanca, North Africa; 209 (53 percent) of 392 cultures gave this organism. Maj. Aaron H. Stock of the 2d Medical Laboratory designated
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the organism Sh. paradysenteriae, type T. During the outbreak, this strain was recovered from a healthy Italian prisoner of war serving as foodhandler for the 2d Replacement Depot. Much significance was placed upon identifying the carrier because the strain was not among common strains in the theater. The carrier had a history of dysentery while with the Italian Army in Ethiopia during 1939.The strain was isolated again in 1945 by the 15th Medical General Laboratory.
Most recognized members of the Shigella group were isolated by one or another of the laboratories in this theater. Sh. dysenteriae (Shiga) was relatively uncommon, being reported from various laboratories with a frequency up to 8 percent. Sh. sonnei had about the same frequency, except that the 15th Medical General Laboratory in Naples during 1944 encountered it in 118 (20 percent) of 588 positive cultures (table 66). Some laboratories found Sh. ambigua in from 5 to 20 percent of cultures; other laboratories did not find it at all.
TABLE 66.-Dysentery organisms isolated at the 15th Medical General Laboratoryduring 1944
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Africa-Middle East Theater
The Africa-Middle East theater had an average strength of 36,838 during the interval between June 1942 and December 1945 (0.6 percent of the total average strength of the Army) but experienced, during the 3%-year period, no less than 18,830 reported cases of dysentery and diarrhea. This small population contributed 3.6 percent of total Army cases for a rate during the combined war years of 128. This theater ranks a close second to the Asiatic (China-Burma-India) theater which had the top rate of 131 (table 54). High carrier rates for dysentery bacilli were encountered regularly in native populations of these two areas whenever laboratory examinations were made, with rates varying from 6 to 10 percent; there was also a high incidence of both amebiasis and helminth carriers.
Environmental circumstances associated with a subtropical climate, poor facilities for feces disposal and promiscuous deposition of feces by natives, polluted-water supplies, abundance of flies, and a military situation which favored contact with natives and contamination of soldiers' food, all contributed to the high rates in this theater.
As in several other theaters and areas (notable exceptions are the ChinaBurma-India and Southwest Pacific), the annual rates declined each successive year; thus, the rates for the years 1942 to 1945, inclusive, were 196, 170, 115, and 79, respectively. The rare occurrence of acute diarrhea for troops in the second summer was a subject of comment, as was the fact that new troops in the area were badly affected. Bulmer, 25 describing the situation which the British Army encountered in the Middle East theater at this same time, says "Probably every soldier in the M. E. F. had at least one attack of acute diarrhoea, usually soon after arrival * * *. Not all cases of diarrhoea were admitted to hospital * * * only about 6 percent of those reporting sick were sent to hospital." This could well have been said of United States troops. There is little doubt that the many mild unreported cases contributed to lowered military efficiency, especially among new troops entering the theater.
German troops in various portions of this theater had excessively high rates of intestinal diseases, and their field sanitary discipline was lax. That the otherwise exceptionally well-disciplined Afrika Korps neglected basic preventive procedures is illustrated in the following report of Col. H. S. Gear, British Assistant Director of Hygiene in the Middle East: 26
Enemy defensive localities are obvious from the amount of feces lying on the surface of the ground * * *. This contempt for hygiene became such a menace to the enemy as to affect from 40 to 50 % of his front-line troops, as interrogation of captured medical officers revealed * * *. The enemy appears to have no conception of the most elementary sanitary measures, and has a dysentery rate so very much higher than ours that it is believed that the poor physical condition of his troops played a great part in the recent victory at El Alamein.
25 Bulmer, E.: A Survey of Tropical Diseases as Seen in the Middle East. Tr. Roy. Soc. Trop. Mod. & 11yg. 37: 225-242, February 1944.
26 Gear, H. S.: Hygiene Aspects of the El Alamein victory, 1942. Brit. M. J. l: 383-387, March 1944.
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Deaths and noneffectiveness resulting from diarrheal disorders.-Chart 38 shows incidence rates and noneffective rates from diarrheas and dysenteries as a class, from the inception of activities in the theater to the middle of 1944. One writer of a history of the Middle East component of the theater compares noneffectiveness due to these causes with that due to malaria. He states:27 "A few months of the year, malaria would cause more man-days lost, but on the calendar-year average, gastro-intestinal infections were well ahead."
In the Persian Gulf Command (Iran) during 1942, 1 of every 7 patients admitted had an intestinal infection .28 In the Africa-Middle East theater during the war years, diarrheas and dysenteries accounted for 14.3 percent of all admissions for disease. During 1943 (a year for which this type of data is at hand), over 15 percent of admissions and 7 percent of all noneffectiveness from disease was of this origin (table 67).Of the 22 deaths ascribed to diarrhea (including gastroenteritis, ileitis, and ulcerative colitis) among overseas admissions in 1942-45 (table 56), 1 was reported among admissions in the Middle East; only 1 death was due to dysentery, a case of bacillary dysentery in 1942 (table 63).
Seasonal and monthly incidence.-Chart 39 reveals that the lowest rates for the theater were in February and March 1943, January and February 1944, and February and December 1945.In 1943, 1944, and 1945, peak rates developed in May and incidence continued high through October and November, except in 1945. This seasonal pattern was punctuated with numerous epidemics in summer months consistent with the occurrence of a considerable amount of
27 Ward, Thomas G.: History of Preventive Medicine, U. S. Army Forces in the Middle East, 19 Oct. 1941 to 23 June 1944, Vol. 111. [Official record.]
28 McNaughton, L. M.: History of Preventive Medicine, Persian Gulf Command. [Official record.]
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bacillary dysentery. In fact, the Africa-Middle East theater had higher incidence rates for bacillary dysentery than any other, and the incidence rates for unclassified dysentery were the second highest. Although the dysentery season was ushered in by appearance of flies, the disease did not always decline with the end of the fly season. In November 1944, the case rate. was 129 per 1,000 per annum despite the reduction in flies prior to that time.
Comparable seasonal fluctuations occurred in the several component subdivisions of the theater: Central Africa, Persian Gulf Command, and the Middle East.
Somewhat less dysentery and diarrhea was reported during 1942 and 1943 among troops in Central Africa than in the Middle East component, although peak case rates of 180 per 1,000 in November 1942 and 126 in May 1943 were anything but low; these peak case rates are to be compared with the rates of 243 cases per 1,000 in November 1942 and 343 cases per 1,000 in May of 1943 in that portion of the theater designated as the Middle East. During 1944, the Persian Gulf Command and Middle East experienced strikingly similar rates, but during 1945 the Persian Gulf Command showed slightly more improvement than in the latter component. The average strength of the Persian Gulf Command steadily decreased during the period of improvement, whereas the average strength of the Middle East continued to build up through July 1945.This suggests that new unseasoned troops entering the theater may have contributed to the excess incidence of the Middle East or that the Persian Gulf Command maintained a relatively higher proportion of seasoned troops during 1945. The high incidence of intestinal diseases in the Middle East Service Command, particularly those troops stationed in camps near Cairo (transients passing through those stations), was due in part to the fact that these
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soldiers frequently were able to go to the nearby city for food and recreation, and often were careless in their choice. "Military personnel had not been adequately informed of the dangers of consuming raw and uncooked fruits and vegetables from native sources, and almost invariably over 70 percent of personnel among newly arriving units suffered a gastro-intestinal upset within a few weeks of arrival." 29
Epidemiologic case report 12.-United States Army personnel in the Belgian Congo slept in tents and used food prepared in poorly screened kitchens.30 Pit latrines were screened at the outset. Flies were numerous. A native village and a Congoese military camp were within flyrange of Army kitchens and barracks. Native huts were scattered in the brush near the camp. Bacillary and endamebic dysentery were prevalent among natives. The nearby city had restaurants which were patronized by the troops. Kitchens of some of these restaurants were unclean by Army standards. The Army nurses were billeted in a hotel for 2 1/2
29 See footnote 27, p. 372.
30 Dunham, C. D., and Gillespie, W. II.: Diarrheal Diseases in U. S. Troops in Belgian Congo. Bull. U. S. Army M. Dept. No. 78: 76-80, July 1944.
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months, and many contracted febrile diarrhea. Four nurses were admitted to the hospital with bacillarv dysentery, and one died of a fulminating infection. After 3 months, barracks and messhalls were ready for the nurses, and, except for one case of gastroenteritis, no more diarrheal disease occurred among them. That bacillary dysentery constituted a significant portion of the diarrheal disease problem at this location in the Belgian Congo is evidenced by the following 1943 bacteriologic findings:
Cases | |
Sh. paradysenteriae (Flexner) | 8 |
Sh. paradysenteriae ( Sonne) | 2 |
Sh. dysenteriae ( Shiga) | 1 |
Sh. dysenteriae ( Schmitz) | 5 |
Shigella species ( Flexner and Sonne) | 1 |
Shigella species ( Flexner and Schmitz) | 1 |
The common diarrheas.-Numerous investigators were of the opinion that the major portion of "gyppy tummy," "basra-belly," and common diarrhea in this area were due to dysentery bacilli. Others were not able to show, with any consistency, any microbial agent. In most units, the entire biologic gradient of mild diarrhea, severe diarrhea, and clinically typical dysentery with blood, pus, and mucus in the stools appeared simultaneously. Bulmer, in a British general hospital in the Middle East asked: "* * * why ascribe the mild `gyppy tummy' to the ingestion of sand, or a draught on the abdomen at night., or some other curious theory, and incriminate the dysentery bacillus for the severer forms? The selective media now available should establish the clinically irresistible conclusion that they are the same disease * * *." The causes of common diarrhea remain unknown, but many mild infections by Shigella bacilli probably were reported as one or another of the common diarrheas.
Epidemiologic case report 13.- During the militarily critical month of August 1942, a case rate of 335 per 1,000 was attained for diarrhea and dysentery in the Africa-Middle East theater. The case rate for the Middle East component of the theater for that month was 497 per 1,000 which is one of the highest monthly rates experienced during World War 11 (chart 39). The average strength of Middle East troops was only a little over 3,000 during this month, and only 123 cases contributed to produce this rate. However, it is of more than passing interest that similar high rates were observed in British troops in this theater during this same month.31 Our allies fared as badly in this environmental situation. Powerful reinforcements of fit, tough, and `yell-disciplined British troops arrived in the theater during August. Although these troops subsequently proved themselves to be extremely tough, they were attacked promptly by diarrheal disease to such extent that a military campaign could not have been successfully conducted during the first few weeks after their arrival. One of the hospitals providing medical care for these British reinforcements admitted as many as 90 new cases of acute diarrhea in 1 day, and 450 beds were occupied at one time by clinical dysentery cases. Of one battalion, 350 men were in hospital for weeks, and 180 were admitted on a single day with diarrhea. Concurrently, other British troops who had been in the theater for a few months were relatively free from dysentery. Although there was some contact, it is believed that the high incidence of diarrhea and dysentery among United States troops was related more to the general environmental situation and contact with native populations than to a spread from British to United States troops. The military lesson to be learned from this epidemiologic case report is that unseasoned troops from Europe or the United States entering the Middle East for the first time, especially during the summer months, may be expected promptly to become
31 See footnote 25, p. 371.
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militarily noneffective because of diarrheal disease. Either seasoned troops must be used for military operations or a period of time must be allowed for diarrheal disease to run its course.
The dysenteries. Incidence rates for dysentery, all forms, ranged as high as 162 cases per 1,000 troops in the Middle East Service Command, whereas the highest rate for the other forces was 40.32
During the period 1942-45, the incidence rate for bacillary dysentery in the entire theater was 14.52 cases per 1,000 average strength per annum. The annual rates for the 4 successive years were, respectively, 20.51, 17.46, 15.97, and 8.19 cases per 1,000 average strength. The rates are almost double those of the nearest comparable theater, China-Burma-India, which had a rate of 8.91 cases per 1,000 average strength per annum, during the same interval (table 59).Of 18,830 cases of dysentery and diarrhea reported in the Africa-Middle East theater (table 54), 212 were diagnosed as bacillary dysentery. One death in 1942 gives an annual rate of 0.68 death per 100,000 average strength during the history of the theater (table 63). In the China-Burma India theater, less than 1.5 percent of the cases of diarrheal disease were recorded as bacillary dysentery. More protozoal dysentery was identified among common diarrheas in the China-Burma-India theater than in the Africa-Middle East theater. The reverse is true of bacillary dysentery. In the China-Burma-India theater, special directives, an amebiasis register, and other measures directed attention to amebic dysentery, whereas in the Middle East theater, the emphasis was on Shigella or other bacterial pathogens. The following statement was included in a report entitled "Dysenteries in Iran" which was distributed in 1943 by Headquarters, Persian Gulf Command: 33 Any medical officer not submitting stools of a dysentery patient for laboratory examination, where facilities exist, is guilty of criminal negligence * * *.In the Middle East the bacillary type of dysentery appears to be the more common." Since both amebic and bacillary dysentery in United States Army practice requires identification of the infectious agent, such incentives probably account for much of the difference noted, and the rates tend to reflect the amount and kind of laboratory work. Among the several theaters, the Africa-Middle East had the highest rates for bacillary dysentery and the second highest rates for unclassified and amebic dysentery (table 62).
Most outbreaks of dysentery in the Middle East that were adequately investigated epidemiologically and bacteriologically were caused by a Flexner type of dysentery bacillus.
China-Burma-India Theater
This theater had an average strength of 108,362, or about 1.8 percent of the total Army, during the war years. This small population suffered 10.9 percent of all reported dysentery and diarrhea in the United States Army,
32 Essential Technical Medical Data, Headquarters, U. S. Army Forces in the Middle East, for October 1944.
33 Report, Maj. A. A. Carabelli, MC, 10 May 1943, subject: Dysenteries in Iran.
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with 56,951 reported cases and a rate of 131 cases per 1,000 strength, the highest rate of any of the theaters of operations (table 54).
China, Burma, and India are all hyperendemic areas in respect to diarrheal disease. Many sanitary practices of these overcrowded populations, both personal and communal, are tied to habits and customs of generations past. The saving and collection of night soil for agricultural purposes and the promiscuous deposition of filth including feces and garbage favored survival and spread of the infectious agents of intestinal diseases. Food is commonly unprotected from dust, rodents, and flies. Refrigeration is almost universally lacking. Flies are generally abundant. Diarrhea and dysentery, bacillary and protozoal, are constantly present.
These diseases were quickly established among United States troops entering this environment, where standards of sanitation were so different from those at home. Close contact with the native population was often demanded by the military situation. Native help was almost universally employed in foodhandling throughout the theater.
In the China sector, arrangements existed whereby the Chinese Government provided food and lodging for United States Army personnel. A Chinese Government agency, the War Area Service Command, organized and staffed messes and living accommodations at stations and airfields. Air shipments over "the Hump" were limited to essential military materials, and personnel and sanitation materials had low priority. The United States Army in China, in certain respects, was a nonpaying guest, and severe criticism of sanitation was not considered diplomatic. However, inspections were made by medical officers, and mess sergeants were assigned to supervise. Ultimately, new equipment and sanitation supplies were provided, and a gradual improvement in sanitation was achieved. Separate data for the sectors of the theater are available for the period from November 1944 through December 1945.The China rate for diarrheas and dysenteries was 122 cases per 1,000 troops per annum, contrasted with a rate of 86 for the India-Burma sector. The latter sector had the benefit of a belatedly organized preventive medicine program and the opening of area and research laboratories.
Annual rates.-The annual incidence rate for reported dysenteries and diarrheas for 1942 was 123 cases per 1,000 troops and for the successive 3 years was 146, 181, and 93, respectively, per 1,000 (table 54).During 1943, approximately 15 percent of all admissions for disease were for diarrhea or dysentery, accounting for some 9 percent of noneffectiveness (table 67).
The average strength of the theater constantly increased until March 1945, which marked the peak monthly average strength of over 250,000 men. Unseasoned troops were sent regularly to this theater. The greatest increase was in 1944, which also was the year with the highest incidence rate for diarrheas and dysenteries. Expansion in strength often exceeded available facilities; consequently, overcrowding existed, and sanitary facilities were insufficient. The lowest yearly incidence rate was in 1945 when the fewest new
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men entered the theater and when demobilization led to rapidly decreasing strength. General sanitation also improved.
Control.-According to Van Auke,34 "there was no organized control program for the enteric infections until 1944." In 1942, a letter was sent to troop units describing sanitary procedures applicable to fresh fruits and vegetables prior to consumption, and another letter was sent describing treatment and prevention of selected tropical diseases. The latter letter included two lines pertaining to enteric diseases, a summary statement that prevention is dependent upon good sanitation. In December 1943, another letter having theaterwide distribution prescribed methods for preparing fruits and vegetables and precautions in the use of native foodhandlers. Other than these letters, no recommendations were made, and organization commanders were left to shift for themselves in spite of a diarrhea and dysentery rate which had reached 256 per 1,000 per annum in July 1943 and 326 per 1,000 per annum in July 1944 (chart 40).
34 Van Auken, H. S.: A History of Preventive Medicine in the United States Army Forces of the India-Burma Theater, 1942 to 1945. [Official record.]
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The situation received attention in June 1944 when a Sub-Commission on Dysentery of the Army Epidemiological Board, Office of the Surgeon General, United States Army, arrived to investigate diarrheal disease. Surveys were made by this Sub-Commission of troops in the Calcutta and Ledo areas. Many defects in environmental sanitation practices were noted, and the diagnosis and prevention of diarrheal disease were considered to be unsatisfactory generally. The Sub-Commission believed that widespread use of native Indians as cooks and foodhandlers was important as a factor in the spread of these diseases among United States Army troops. "Of great importance is the experience of a number of organizations that as soon as they removed Indians from the kitchens the diarrheal rates dropped." 35
The Sub-Commission 36 recognized the inadequacy of the training of laboratory personnel for work with enteric pathogens and of laboratory supplies and equipment. Identification of protozoa was frequently inaccurate, and few laboratories were able to do good bacteriologic work. Time was devoted by this group to improving laboratory services, with emphasis on amebic dysentery, a disease judged of much importance in this theater. As a further result, the theater surgeon and the theater commander instituted a campaign to bring diarrheal disease under control. Appropriate directives were sent to Subordinate commands, and special attention was given to improving mess sanitation. Attention was also paid to improving restaurant sanitation in certain eating establishments in large cities, especially Calcutta, at which United States Army personnel were permitted to dine. A special sanitary inspector was assigned to the Services of Supply surgeon who was charged with checking and improving mess and restaurant sanitation throughout the theater. A theater preventive medicine section was formed for the first time, late in 1944. Arrangements were made for better distribution of sanitation supplies, especially compound germicidal rinse; for sanitary messgear and utensils; for insecticidal spray; and for an all-purpose soap. A pamphlet on water sanitation was distributed. Furthermore, commanding officers were held strictly accountable for sanitation in their commands and were advised to reduce native labor in Army messes to a minimum and to place such labor under strict supervision. Contact, at least by letter, was made thereafter with commands reporting high incidence of diarrheal disease.
In October 1944, another observer group, referred to as the Kelser Mission, arrived in the theater. Inadequate water-heating facilities and refrigeration were recognized as additional defects to be remedied, along with the need for better laboratory facilities in clinical diagnosis and bacteriologic control of water supplies.
The 29th Medical Laboratory arrived in the theater in May 1945 with the specific assignment to investigate diarrheas. This group worked primarily on the etiology of diarrhea in the Calcutta and New Delhi areas. This laboratory
35 See footnote 34, p. 378.
36 (1) Report, Sub-Commission on Dysentery, Army Epidemiological Board, 15 Dec. 1944. (2) See footnote 7, p. 328.
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supplemented the 9th Medical Laboratory which had been functioning as an area laboratory for the past several months.
The general reduction in diarrheal disease during 1945 was largely influenced by preventive methods instituted as a result of the missions to the theater and by the control which resulted from administrative achievement of a preventive medicine organization giving emphasis to control of intestinal diseases. The decrease in rates was more notable in the India than in the China sector; the greatest preventive effort was expended in the India sector. Furthermore, the Ledo Road building activity was nearly completed in the first quarter of 1945, and regular motor convoy service to China was inaugurated. Reasonably sanitary camps were established for stops along the road. Extensive troop movements through unsanitated areas were no longer necessary except for small numbers traveling by rail, homeward bound, from Assam to Karachi. Enforcement of sanitary regulations, more sanitation supplies, and a change in operational status of the theater thus had effect in reducing the rates for diarrheal disease.
Improvements in sanitation related to threat of cholera epidemic.-No discussion of diarrheal disease in the China-Burma-India theater would be complete without mention of the fact that there were no reported cases of cholera among United States Army troops in the Calcutta area during the 1945 cholera epidemic. Cholera assumed epidemic proportions in the native population of Calcutta in February 1945, and a high incidence continued into June. More than 3,500 cases and 1,200 deaths were reported in the Calcutta area. Fourteen cases were reported among approximately 700 British military personnel billeted at the Grand Hotel in Calcutta; 135 United States Army officers, also billeted at this hotel, were moved out on the day cholera was reported. A medical survey revealed 21 mild cases of cholera among the 1,700 hotel employees. Periodic immunization against cholera, as required for United States Army troops, was not required for British troops. Including cases at the Grand Hotel, the British Army had 27 cases with 2 deaths.
The Medical Department of the United States Army took special action to protect the 24,500 troops in the Calcutta area. The epidemic served effectively in bringing about improvements in mess sanitation, foodhandling and water purification, fly control, and supervision of native foodhandlers in Army messes. The Allied Hygiene Committee increased its activities and required that restaurants in bounds to United States military personnel should have their employees immunized against cholera. More important, emphasis was placed upon the serving and eating of hot cooked foods only, the sterilization of drinking water, and the necessity for drinking only water known to be safe. It is impossible to determine how much these measures contributed to the over-all prevention of diarrheal disease, but doubtless some portion of the improved incidence rates in the Calcutta area, at least for the year 1945, may be attributed to this situation.
By contrast, the China sector of the theater, which did not receive as much benefit from the increased impetus given to preventive medicine in the theater
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late in the war, experienced two outbreaks of cholera among United States Army troops, with 13 cases and 2 deaths, comprising the sole experience of the United States Army with cholera in World War II (p. 459).
Reliability of laboratory diagnosis.-Bacteriologic diagnosis of diarrheas and dysenteries was often inaccurate or not attempted. Reliable work simply was not done during the first 2 years of the theater and thereafter was accomplished at only a few laboratories. In many laboratories, technicians examined stools for E. histolytica, but some diagnosed "anything that moved under the, microscope" as that organism. Van Auken noted that "the faults lay in inexperienced, untrained personnel in the laboratories and lack of equipment and supplies authorized for the smaller hospitals which served much of the Theater.' There is little wonder that during the peak month of July 1944 three cases of amebic dysentery were found for each case of bacillary dysentery found and almost half of the recognized dysenteries (bacillary, amebic, and unclassified) were amebic. Amebic dysentery was undoubtedly a frequent disease in this theater, more so than in most others, but the true incidence of shigellosis is certainly not reflected in recorded data.
The training of laboratory technicians was begun at the 9th Medical Laboratory in December 1944. The laboratory arrived in the theater early in 1944, was opened in August as a separate organization providing theaterwide service, and became belatedly the first true public health or area laboratory in the theater. No attempt was made to train new technicians but to improve the standards of performance of technicians already working in the theater. Deficiencies were corrected, and special emphasis was placed on parasitology and recognition of E. histolytica. Although some attention was given to determinative bacteriology of enteric pathogens, few laboratories had much capability in enteric bacteriology upon which to build. The commanding officer of the 9th Medical Laboratory was appointed theater laboratory consultant in February 1945. He inspected numerous hospital laboratories to improve the quality of work and the liaison with his own central laboratory. Improvement in some laboratories was definite, but demobilization came before full results were manifest.
Of all cases of diarrhea and dysentery reported in June 1945, 26 percent were recorded as amebic dysentery, whereas in June 1944 only 15 percent had been so diagnosed and in June 1943 only 5 percent. The emphasis given laboratory diagnosis of amebic dysentery is illustrated by the 1,067 cases of dysentery and diarrhea reported for the India-Burma sector in January 1945; some 43 percent (454) were called amebic dysentery, an extraordinary frequency for a winter month. The Sub-Commission on Dysentery of the Army Epidemiological Board expressed the belief that amebic dysentery was a greater problem in the theater than bacillary, because of higher reported incidence and because of its chronic nature. Bacillary dysentery was stressed as being a mild illness of short duration, in contrast to the more severe and chronic course of amebic dysentery as seen in the theater.
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Monthly rates and seasonal incidence.-Except for an occasional winter month, monthly rates for diarrheas and dysenteries were never under 100 cases per 1,000 strength until the fall of 1945 (chart 40). The months with the lower rates were November through April, and the peak rates occurred in late summer, July having the highest rate. Noneffectiveness per 1,000 strength was 6 or more during July and September 1943 and during July 1944 (chart 41). The frequency coincides with that of flies which are prevalent in parts of the theater (Calcutta) throughout the year, November or December being the better months and July the worst. The sharp epidemic peaks in summer are more suggestive of bacillary dysentery than of amebic dysentery. Indeed, the actual bacillary dysentery incidence of 8.91 cases per 1,000 strength per annum for the period 1942-45 is the second highest rate reported for bacillary dysentery for any theater during the war (table 59). The rate for amebic dysentery was 23.61 cases per 1,000 per year, almost three times as high (table 60).
Rail travel and troop transport in relation to diarrheal disorders.-During the war, troops and supplies were landed at Karachi and Bombay on the west coast of India, the sea route to Calcutta having been rejected as too dangerous because of Japanese submarines. Not until late 1944 were any significant numbers of troops debarked at Calcutta. The port was, however, an extremely important terminus for operations incident to the construction of the Ledo Road. Troops were therefore shipped by rail across about 2,000 miles of the width of India, to Calcutta and thence to upper Assam, the orbit of troop concentration. Troop units crossing India had much intestinal illness, seldom failing to have many members hospitalized at the end of the journey near
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Ledo, at Calcutta, or elsewhere en route. Troops held over in the Bombay area awaiting transportation were assigned to several camps. An inspection of Camp Deolali in June 1943 revealed large numbers of flies in kitchens having numerous other sanitary defects. Food was inadequately refrigerated and exposed to flies; messhalls were not screened; and latrines were of the bucket type, unprotected from flies. Many troops embarked upon the long rail journey already suffering from diarrhea.
Poor sanitation along the railroads, especially at stopping places, was general, sanitary control over the train-side vendors and station restaurants being nonexistent. The men often ate at these unauthorized places. Water carried to the coaches was potentially contaminated, for it came from unauthorized sources. During the first few months after the theater was established, sanitation supplies were short. In the beginning, troops were not adequately briefed regarding these conditions and the procedure for keeping healthy. Not until 10 August 1945 did the first theaterwide directive appear, providing for sanitary control of troops in transit. The directive, entitled "Transportation Procedures," was issued in time to be of value for homeward-bound personnel at the end of the war.
Many troops traveled from Assam to Karachi, the major port of debarkation, by airlift instead of by rail. However, more than 20,000 troops were sent by train on a 2,470-mile trip over a route not previously used by United States troops. Special preparations were made for this rail movement in the light of past experience and in compliance with special directives. During October 1945, some 7;986 troops arrived in Karachi, and only 18 men were hospitalized because of diarrheal disease. In November, 4,632 men arrived, and 12 were hospitalized. This experience compares favorably with that of earlier years of rail travel in the theater.
The common diarrheas.-For all war years, the India-Burma sector of the theater had more than 29,000 admissions for the common diarrheas representing 58 percent of the admissions for all diarrheal diseases. With each successive year of operation, the percentage of diarrheal disease diagnosed as common diarrhea decreased because of increasing separation of definite entities, mainly amebic dysentery. In late months of 1942, 77 percent of diarrheal disease was called common diarrhea; in the 3 subsequent years, the proportions for common diarrhea declined to 65, 61, and 49 percent, respectively.
Several studies of microbial agents of the common diarrheas were made late in the war by various laboratory teams. The Sub-Commission on Dysentery of the Army Epidemiological Board studied 369 hospitalized patients and 175 with diarrhea treated in two dispensaries. Dysentery bacilli were recovered from 24 percent of the hospitalized cases and 16 percent of the dispensary cases. This study and other studies of the common diarrheas undertaken late in 1944 and in 1945 led to the estimate that at least one-fifth of the common diarrheas in the theater were shigellosis.
Another laboratory team of the 29th Medical Laboratory investigated the etiology of nonspecific diarrhea in the theater during 1945. One group
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worked with troops in the Calcutta area and a second at Delhi. Studying consecutive cases of diarrhea and utilizing good parasitologic and bacteriologic techniques, they obtained the following results: 37
Calcutta group (100 cases) | Delhi group (164 cases) | |
Bacteriologically positive instances | 49 | 95 |
| Shigella | (11) | (35) |
| Salmonella | (3) | (6) |
| Paracolon | (35) | (54) |
Parasitologically positive instances | 36 | 42 |
| Endamoeba histolytica | (17) | (6) |
| Endamoeba coli | (8) | (10) |
| Endolimax nana | (1) | (7) |
| Chilomastix mesnili | (1) | (4) |
| Iodamoeba b?tschlii | (1) | (2) |
| Trichomonas homilis | (3) | (4) |
| Isospora homilis | (1) | (0) |
| Giardia lamblia | (2) | (7) |
| Dientamoeba fragilis | (0) | (1) |
| Hookworm ova | (2) | (1) |
Negative instances | 34 | 69 |
Only one stool and rectal-swab examination was made in each case. As many investigators have demonstrated, the percentage of enteric pathogens recovered would have mounted if repeated specimens had been examined. The findings are not at all inconsistent with those of the Sub-Commission on Dysentery of the Army Epidemiological Board and lend further support to the belief that at least one-fifth of common diarrhea in this theater was shigellosis. That the intermediate paracolon group are potential etiologic agents of common diarrhea was suggested by findings of the 29th Medical Laboratory. The diarrhea known as Delhi belly was thought to be the clinical type from which these organisms were recovered.
The following epidemiologic case reports demonstrate some of the problems in determining etiology of the common diarrheas where the usual enteric pathogens are not found : 38
Epidemiologic case report 14. -Numerous cases of common diarrhea characterized by mild watery stools were prevalent in Base Section II and were less frequent at the 20th General Hospital and at Base Section III during October 1944.Laboratory studies by the enteric commission led it to believe that this condition was not a mild bacillary dysentery. Stools from three typical cases were used for inoculation of monkeys. One cubic centimeter of each specimen was introduced through a nasal catheter into the stomach of each of two monkeys. The animals were kept under observation for at least 1 week. All six monkeys had normal stools and showed no signs of illness. The etiology remains unknown.
37 Essential Technical Medical Data, Headquarters, U. S. Forces, India-Burma Theater, for October 1945.
38 See footnote 7, p. 328.
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Epidemiologic case report 15.-An organization of about 100 men, over a period of 3 days, had 18 cases clinically resembling bacillary dysentery requiring hospitalization. There was fever and frequent bowel movements containing blood, mucus, and pus. Vomiting was present in a few cases. Two cultures were made from each of fifteen cases; in no instance were dysentery bacilli found. Blood agar and other media inoculated with the stools of two typical cases showed no recognizable pathogens. A carrier survey was made on the organization, and not a single carrier was found. Stools from 2 typical cases were used for monkey inoculations, 2 monkeys for each specimen, and each animal was given 1 cc. of stool through a tube into the stomach. The monkeys remained well. Questioning failed to show that any new or replated dishes had been used in the mess, and no acid drinks had been served before the outbreak. Urine from five typical cases was examined by the 9th Medical Laboratory. None contained appreciable amounts of heavy metal. All cases recovered promptly, and no more appeared in the organization. The cause of the outbreak is not explained.
Despite concerted effort in the theater in search of agents of the dysenteries, especially amebas, a large number of cases severe enough to be diagnosed as clinical dysentery remained undetermined. Not all such cases were diagnosed as dysentery, unclassified; many were called common diarrhea.
Should United States troops ever again be deployed in this theater, advance planning and provision of well-trained laboratory and epidemiologic teams would be a necessity.
The dysenteries.-According to data submitted by Van Auken, unclassified dysentery accounted for about 13 percent of all diarrheal disease, the proportion each year being essentially constant except for 1942 when it was 6.5 percent. No deaths were ascribed to this cause. The bulk of unclassified dysenteries were probably bacterial, because, in view of the effort directed toward protozoal forms, especially during the last months of the war, had they been protozoal they would have been classified. Bacillary dysentery and unclassified dysentery together accounted for about 21 percent of diarrheal disease, essentially equaling amebic dysentery. Incidence of unclassified dysentery was lowest in the colder months of January and February and highest in June, July, and August. The incidence rate for the war years as judged by sample tabulations of individual medical records, including secondary diagnoses, was 12.3 cases per annum per 1,000 average strength, almost twice as high as in any other theater.
Amebic dysentery, on the other hand, was the diagnosis for more than 20 percent of all diarrheal disease during the 1942-45 interval. During 1942 and 1943, approximately 10 percent of all diarrheal disease was determined to be amebic; this figure increased in 1944 to about 20 percent and in 1945 to 30 percent.
Much of the relative increase in amebic dysentery may be attributed to an increase in the prevalence of the disease as the period of exposure in the theater lengthened. Other and equally probable factors are the interest in amebic dysentery manifested by the Sub-Commission on Dysentery of the Army Epidemiological Board, the emphasis on parasitologic laboratory examination of feces, the meager facilities for bacteriologic diagnosis, the development of a theaterwide amebic dysentery register with special health record
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forms, and various special and specific directives. Furthermore, laboratory diagnosis of E. histolytica was generally unreliable until late 1945, except at a few laboratories. Some medical officers also believed that the diagnosis of amebic dysentery often was used when amebic dysentery carrier or amebiasis would have been more proper; because of the existing "amebaphobia" many of the latter were treated as cases of amebic dysentery. These are factors to be considered in a retrospective appraisal of the situation as it existed in the theater. The following epidemiologic case report is illustrative: 39
Epidemiologic case report 16.-This report is based on observations made on 748 cases of amebiasis. Of these, 218 were admitted to the United States Army Hospital in Calcutta during the period May 1943 through June 1944.The remaining 530 were admitted to the United States Army Hospital at Panagarh from July 1944 to February 1945.
On the whole, sanitary control was far superior in the Panagarh area, yet the hospital admission rate for amebiasis was seven times as high there as it was in Calcutta. There were 530 cases of amebiasis in the 3,727 admissions to the Panagarh hospital and only 218 in the 10,961 admissions to the Calcutta hospital.
In striking contrast were the admission rates for bacillary dysentery and acute enteritis, presumably of infectious origin. In Calcutta, the ratio of nonamebic to amebic diarrhea was approximately 3 to 1, while in Panagarh this ratio was reversed. The greater prevalence of nonamebic diarrhea in Calcutta was to be expected in view of the poorer sanitary conditions prevailing there, but the lower incidence of amebiasis was difficult to explain.
It was believed that this paradox could be explained by several factors. The first of these was the length of service in India. At the time of this study, the majority of troops in the Calcutta area had been in India between 6 months and a year, and there were many recent arrivals, while in the Panagarh area the vast majority had been there between 18 months and 2 years. Obviously, the longer exposure to infection played a role in the higher incidence of amebiasis in Panagarh, but it was not the only factor, since the admission rate in Calcutta never approached that in Panagarh during the following year.
Another factor which was considered of great importance was the diligence with which amebiasis was hunted. Before coming to Panagarh, the medical officers on duty at the hospital there had had considerable experience with the disease in the Middle East; they soon had all medical officers in the area ameba conscious. Most of the installations had dispensaries equipped with microscopes, and all cases of diarrhea and other gastrointestinal disturbances were investigated. In addition, a number of enthusiastic flight surgeons, in an effort to control the disease, undertook to do stool examinations on all their personnel. Except in the presence of active diarrhea, the routine stool examinations at both the hospital and the dispensaries were done after the administration of a strong purge. Purgation was rarely used in Calcutta, and as a consequence many cases were probably missed.
Food and water contaminated with E. histolytica cysts, either directly or through the agency of carriers and flies, are generally considered responsible for the transmission of amebiasis. If food and water were the only factors involved, it is difficult to explain the high incidence of the disease in the Panagarh area, where sanitary control was excellent. That the protection of food and water was actually effective is indicated by the low incidence of nonamebic diarrheas. It seems reasonable, then, to assume that some other mode of transmission was in operation in this area.
There is good reason to believe that the environment in the Panagarh area was heavily contaminated with E. histolytica cysts. Most installations were in the midst of an agricultural area where human feces were used as fertilizer. Numerous natives were employed in construction work and as guards, personal bearers, laundrymen, and clerks. They
39 Klatskin, G.: Observations on Amebiasis in American Troops Stationed in India.[Official record.]
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rarely used the special latrines that were provided for them. The cysts of E. histolytica soon lose their viability when subjected to drying, but the warm, humid climate afforded them ample protection especially during the long monsoon. There is every reason to believe that the environment was heavily contaminated with viable cysts and that this was one of the most important factors in the spread of the disease in the Panagarh area.
The incidence of amebiasis and amebic dysentery doubtless was relatively high compared with their incidence in most other theaters, and much of the actual amebic dysentery was correctly diagnosed. However, some diarrheal disease of other nature was incorrectly diagnosed as amebic dysentery.
Despite the excessive frequency of amebic dysentery in this theater, only 2 deaths occurred, 1 in 1943 and 1 in 1945, a record which compares favorably with the experience in the Southwest Pacific where the death rate was higher and incidence lower (tables 60 and 63).
Bacillary dysentery.-Approximately 8 percent of dysenteries and diarrheas were diagnosed as bacillary dysentery. Sampling tests suggest 20 percent as a more likely figure. Less than 4,000 cases in the India-Burma sector were reported during the war years. 40 Laboratory facilities and trained microbiologists were very few. Diagnosis was frequently made on the basis of pus and mucus in the stools, without the benefit of laboratory confirmation. The rates for bacillary dysentery were highest during the period from June through September.
The incidence rate of 8.9 cases per annum per 1,000 average strength during the war years is the second highest for bacillary dysentery among the several theaters, exceeded only by the incidence rate in the Africa-Middle East theater (table 62).The rates by years were 4.00, 15.45, 11.35, and 6.07, respectively (table 59). Two deaths from bacillary dysentery occurred in 1943, again representing the second highest mortality rate among theaters (table 63).
The Sub-Commission on Dysentery observed that the convalescent carrier rate, was low in a series of 47 patients adequately treated with sulfadiazine; 4 carriers (less than 10 percent) were observed on the basis of 2 or 3 successive cultures started 4 days after treatment was stopped. There were no untreated controls. The following tabulation illustrates the results and the prevalent Shigella types found in followup cultures on cases of bacillary dysentery treated with sulfadiazine at the 20th General Hospital:
Type found | Number treated | Number showing positive cultures |
Flexner V | 11 | 2 |
Flexner W | 9 | 1 |
Flexner Z | 1 | 0 |
Boyd 88 | 2 | 0 |
Boyd 103 | 5 | 0 |
Shiga | 5 | 0 |
Sh. ambiguya | 14 | 1 |
40
See footnote 34, p. 378
.
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Although no controls were used, Hardy had elsewhere shown that 75 percent of untreated patients are carriers when ordinarily discharged from the hospital and 13 percent are carriers 10 weeks later. The three patients with Flexner infection who were carriers did not respond to additional sulfadiazine.
The Sub-Commission spent much time in India making carrier surveys. From 1 August to 5 November 1944, inclusive, 103 (5.3 percent) of 1,936 presumably healthy persons were found to be carriers of dysentery bacilli. Military units with the highest carrier rates were also the units with the poorest level of general sanitation; in one instance, 13 percent of personnel were carriers of dysentery bacilli. The percentage of carriers was 5 percent or more in three companies. Mass treatment was instituted to determine the value of sulfadiazine in remedying the carrier state. A 2-gm. initial dose of sulfadiazine followed by 1 gm. each morning and night thereafter to a total of 10 gm. was given to each man. By this means, the carrier rate for 726 men was reduced from 9 percent to 0.4 percent. No patients with diarrhea reported to sick call from these units for "a considerable period of time following the mass treatment." Table 68 illustrates the results.
The Sub-Commission believed one outbreak to be caused by Shiga's bacillus. The outbreak is here described because of the relative infrequency of this infection.
Epidemiologic case report 17.-Early in September, a quartermaster unit of 95 men sent 4 cases of Shiga dysentery to the 20th General Hospital. This unit had arrived in India on 8 August and entrained immediately. Severe diarrhea occurred en route, and, on arrival in Assam on 17 August, four men were admitted to a medical facility as having clinical bacillary dysentery. The unit reached Burma on 21 August 1944.The number of cases of diarrhea reached a peak on 1 September. The unit was visited on 6 September. Forty-two men gave
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a history of diarrhea, twelve attended sick call, and a total of ten required hospitalization. Four of the twelve men at sick call were reported positive for E. histolytica. Many of the patients had blood, pus, and mucus in the stool, the exudate resembling that of bacillary dysentery. Cultures were made by the rectal-swab method from all men at the unit. Since it had not been believed practical to take plated media to the unit, the swabs were placed in tubes containing saline. Plates streaked on return to the laboratory were found heavily overgrown, and Shiga's bacillus was isolated from one individual only. This method was unquestionably unsatisfactory, since one would have predicted that, in view of the large number of cases of clinical dysentery, at least 20 percent of the unit would have had cultures positive for Shiga. The entire unit was given sulfadiazine in the dosage used for carrier studies. Three days after sulfadiazine was administered, the diarrheas stopped. Cultures were made again from all men at the unit on 20 September, in this instance the rectal swab material being plated directly on "S.-S." agar. No positive cultures were found. Though laboratory evidence is lacking, it is reasonable to assume that the outbreak was one of Shiga dysentery and that sulfadiazine contributed to its control.
The distribution of serologic types of Shigella organisms encountered by the Army Epidemiological Board Sub-Commission in India, as compared with Boyd's isolation, is presented in table 69.
Pacific Area
This area had an average strength corresponding to approximately 4.8 percent of the total Army. It contributed 34,697 cases of diarrhea and dysentery (table 54), equivalent to about 6.6 percent of all reported cases. The
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incidence rate for the area was 29.9 cases per annum per 1,000 average strength and ranked fifth among the incidence rates for overseas theaters (table 62).
Hawaiian Department, 1940-41.-The Hawaiian Department of the United States Army in the 2 years before the attack on Pearl Harbor experienced no more than occasional outbreaks of diarrhea] disease.41Annual incidence rates were low; in 1940 the rate was 1.4.The small population was well housed, and sanitation was excellent. The annual rate for 1941 increased to 18, chiefly as the result of three outbreaks. Two resulted in rates of 39 for March and 32 for June of that year. The third outbreak was prolonged through August, September, and October, with a peak rate of 87.5 in September (chart 42).The first two epidemics were caused by bacterial food poisoning; the third included some bacillary dysentery, which is endemic in the Islands.
41 History of Preventive medicine, U. S. Army Forces, Middle Pacific, 7 Dec. 1941 to 2 September 1945. [Official record.]
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Incidence.-For the Pacific Ocean Area as a whole, exclusive of the Southwest Pacific area which was a separate theater, the yearly incidence rates for diarrheas and dysenteries for the 4 war years were 34, 43, 28, and 19 (table 54). Separate rates are presented for the Central Pacific and the South Pacific divisions of the Pacific Ocean Area for the years 1942 and 1943 and for the first half of 1944. Although the South Pacific had the smaller average strength, rates for diarrheas and dysenteries were much higher than for the Central Pacific, a difference largely related to the fact that a significant proportion of the strength of the Central Pacific was concentrated in the Hawaiian Islands where sanitation was at a relatively high level. The occurrence of 172 cases of dysentery and diarrhea during March, 4 months after the attack on Pearl Harbor, resulted in a sharp increase in the rate for that particular month to 32, but this was no higher than the rates for any of the 3 peak months of the previous year (chart 42). The Central Pacific rates remained fairly low except for a peak of 37 in November 1942. This rise may be chiefly accounted for by the epidemic of bacillary dysentery on Canton Island, during thedevelopment of that base, to be later described. Central Pacific rates again fell fairly low, but fluctuated slightly, until December 1943. Thereafter, total area rates exceeded 10 until November 1945. This last and more persistent rise was associated with combat activity on islands and atolls such as Tarawa, Kwajalein, Eniwetok, Saipan, and Guam. The following epidemiologic case report is illustrative. 42
Epidemiologic case report 18.-During the last week of November 1943, bacillary dysentery occurred in epidemic form in several regiments of an infantry division engaged in field exercises on coral wastelands on Oahu, T. H. The epidemic was brought promptly under control by emphasis on proper sanitation, especially sanitation related to improved methods of feces disposal and by isolation and treatment of cases and carriers. This outbreak served as an important training lesson in sanitation for this division which subsequently assaulted and captured the southern islands of Kwajalein atoll with a minimum of diarrhea, the first Pacific island occupation in which dysentery was not a major problem.
Logistic problems associated with the distant transport of supplies doubtless contributed to the excessive rates in the South Pacific of more than 100 in March, September, and December 1942, and January and February 1943.
Incidence declined from 171 in December 1942 to 27 in July 1944 in the South Pacific. Monthly rates for the total Pacific Ocean Area parallel those of the South Pacific, but are lower.T he theater peak of 83 was in December 1942, following which the trend was a decline to 7 in November 1945. This declining trend was intermittently interrupted by sharp increases related to outbreaks during or shortly after the capture of Tarawa, Saipan, Guam, Iwo Jima, and Okinawa.
Seasonal occurrence of diarrheas and dysenteries is less clearly defined in this area than in most others. The area included vast expanses of ocean from New Zealand South of the Equator to Hawaii in the north. Outbreaks in New Zealand and other southern areas tended to occur in December, January,
42 See footnote 41, p 390.
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and February. Peak monthly rate for noneffectiveness in the South Pacific area approached 3 per 1,000 strength and occurred in February 1943 (chart 43). The relatively stable physical environments of the islands and atolls near the Equator resulted in intermittent diarrheal disease with no regular or clear-cut seasonal variation sufficient to be reflected in the gross rates.
In these locations, occurrence was more related to other factors such as combat or specific lack of sanitary facilities before fixed and sanitated bases were established, than to seasonal changes. For example, initial rates were especially high for troops on Espiritu Santo and the Russell Islands and quite high for the Fiji Islands and New Caledonia (chart 44). The following epidemiologic case reports illustrate diarrheal disease on certain Pacific islands: 43
Epidemiologic case report 19.-Approximately 1 month before Pearl Harbor day, an expedition of civilian construction workers departed with supporting troops from Oahu to set up bases on Canton and Christmas Islands. This project was designed for training and testing in problems of field sanitation in subtropical and tropical coral atolls. Beginning in September 1942 and extending through the spring of 1943, an outbreak of bacillary dysentery occurred on Canton Island. Bacilli of the Flexner group were recovered from over 400 patients and more than 225 others had diarrhea or dysentery, but positive stool cultures were not obtained. This outbreak was considered serious because of the large proportion of the command affected and because of "the strategical importance of the island as an airbase on the route to Australia, and the close proximity of strong Japanese bases in the Gilbert Islands." Before adequate control measures could be taken, a large number of carriers had been built up, as was discovered by a laboratory team that took rectal-swab cultures on all personnel. Carriers were treated with sulfaguanidine "with satisfactory results."Following this outbreak and until September 1943, all personnel arriving at and departing from the Canton Island garrison were checked by rectal-swab or stool culture for bacillary dysentery infection. Weiss and Finerman have reported the results of their studies of this outbreak.
43 (1) See footnote 41, p. 390. (2) Finerman, W. B., and Weiss, J. E.: Control of Bacillary Dysentery in a Tropical Outpost. Report of 1,000 Cases. Bull. U. S. Army M. Dept. No. 81: 71-82, October 1944.
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During the course of the continuing investigation, more than 17,000 stool or rectalswab cultures were done, and over 1,000 individuals were found infected with Shigella bacilli. Later study of a sample of 100 strains from this outbreak revealed that 97 percent were Shigella W and 3 percent were Shigella Flexner Z.
The reported cases from this one outbreak and study account for approximately half of the cases of bacillary dysentery reported for the entire
Pacific Ocean Area during the period from 1942 through 1943.
During the outbreak, or shortly thereafter, organizations surveyed showed about 11 percent of the population
at risk to be carriers. Units which had greater admission rates
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for clinical disease also had the higher carrier rates. The number of carriers found in some units exceeded the number of clinical cases in those units.
Toward the end of the study, after treatment of known carriers with sulfonamide drugs
,
only 0.3 percent of troops leaving the island showed positive stool or rectal-swab cultures.
One death occurred among the 818 admissions during the first wave (there were two peaks of incidence) in a 24-year-old white male who was only moderately ill on admission. Symptoms did not seem sufficiently severe to be compatible with death, which occurred on the second day without obvious cause. Shigella were recovered at post mortem examination from the lower one-third of the ileum and from the cecum.
The procedure adopted for immediate control of this epidemic which was given greatest
emphasis was the search for carriers and their
elimination by treatment.
In
accomplishing
this, over 17,000 stool or rectal-swab cultures were taken at this one small island outpost, an almost impossible or impractical method for a larger military population.
The cause of the epidemic was attributed to the difficulty which had been encountered in construction of safe pit latrines in coral sand. Ground water used for bathing was found heavily polluted. Flies were prevalent also, and latrines and messhalls had not been properly protected. The situation was remedied by construction of fly-proofed latrines with impervious concrete pits which were emptied by means of portable cesspool pumps into a truck-mounted cesspool tank, and the pit contents were then dumped into the sea in areas where there was an offshore current.
Epidemiologic case report 20.-Troops and construction personnel were sent to Baker Island in September 1943 for the purpose of building an airbase in preparation for the campaign in the Gilbert Islands. The surf made landings difficult, and the construction of sanitary facilities was delayed. Although no enemy opposition was encountered, there was a high noneffective rate because bacillary dysentery spread rapidly through the entire island garrison during October. A laboratory team was sent to Baker Island to make stool cultures and discover carriers for treatment, as had been done on Canton Island. As sanitation was improved and control of flies instituted, patients and carriers were treated with sulfaguanidine in doses of 10 gm. daily, and the epidemic was brought under control. The number of drug reactions was reported to have been high.
Perhaps the most important lesson which was learned from these two outbreaks was that diarrheal disease, especially bacillary dysentery, may be expected to occur whenever a coral island or atoll is occupied by military forces. This will be true unless adequate, safe means can be rapidly provided for sewage disposal without contamination of the usually limited water supply and unless fly breeding can be rigidly controlled.
Southwest Pacific Area
During the war years, approximately 7 percent of the average strength of the total Army was in the Southwest Pacific area. Summary of statistical health report data reveals that 22 percent of all reported cases of dysenteries and diarrheas of the entire United States Army during this interval occurred in this area. The monthly average strength attained a high of 1,160,212 men and the average mean strength for the war years was 428,223.In terms of military population, this area was second only to the European Theater of Operations. Among the several theaters and areas, it produced the greatest actual number of cases of diarrhea and dysentery with 114,909 reported cases.
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The incidence rate for this interval was 67 per 1,000 (table 54), fourth highest rate (table 62) for a theater or area and a rate exceeded only by the China Burma-India (131), the Africa-Middle East (128), and the Mediterranean theaters (70).
The annual rates of incidence of diarrheas and dysenteries for this area fluctuated considerably because the dynamic character of operations introduced great numbers of men in successive years into a variety of new environments. The progressive buildup of strength is shown by a mean strength of 3,641 in January 1942 and 1,160,212 in October 1945. During 1942 and 1943, troops were introduced into constantly expanding campsites in Australia where need for increased sanitation facilities occasionally exceeded the existing installations. The northward movement with the progress of the war caused troops to enter new environments, from Australia to New Guinea and to the Philippines. The annual rates ranged from 55 in 1944 to 74 in 1945, with 59 and 70 in 1942 and 1943, respectively (table 54).In the latter year, approximately 7 percent of admissions for disease and 3 percent of noneffectiveness were due to diarrhea and dysentery (table 67).The highest annual rate, that of 1945, marked the return to the Philippines, where a large Army was involved in combat operations under conditions which favored intermingling with a friendly native population in which diarrheal disease had been notoriously hyperendemic for many years.
During 1945, rates for diarrheas and dysenteries in Army troops in areas other than the Philippines continued a downward trend which started in 1944. Thus, for troops on the Australian mainland the 1944 rate was 23 and dropped to an estimated 5 in 1945.In areas other than Australian mainland and the Philippines, the 1944 rate was 54 and in 1945 an estimated 28 (first 8 months only).The Army returned to the Philippines in October 1944 and for 1945 had the high rate of 104 (table 54).Again the rates of diarrhea and dysentery demonstrated that when large numbers of troops enter a hyperendemic area for the first time and under combat conditions high rates may be expected; while troops of the same theater, consisting chiefly of seasoned personnel living under more or less stabilized conditions, experience declining rates.
Seasonal occurrence.-Monthly distributions of diarrheal diseases varied, as might be expected, with the northward march. In Australia, peak rates were in October and December 1942 and February 1943, remaining high through March. Rates were, lowest in the colder months of May, June, July, and August. For areas other than Australian mainland and the Philippines, January was the month of highest rates in 1944 and 1945 (years for which separate data for subdivisions of the theater are available). By contrast, in the more northerly Philippines seasonal peaks were in June, July, and August, a complete reversal, according to months, within a single theater of operations (chart 45).
Seasonal occurrence among troops in the Philippines before World War II, during 1940 and 1941, resulted in rates under 30 except for the peak months of May, June, July, and August. Sharp seasonal peaks occurred during these
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years, reaching over 90 in 1940 and over 70 in 1941.Following the return to the Philippine sunder combat conditions, peak monthly rates for diarrheas and dysenteries were in March and June, 171 and 165, respectively. With demobilization and cessation of hostilities, the rates for diarrheal disease rapidly declined in succeeding months to become more nearly comparable to those of the prewar Army.
Diarrhea and dysentery deaths.-In the Southwest Pacific and Pacific Ocean Areas, deaths due to conditions included as common diarrheas in this chapter totaled 8 (p. 303). For bacillary dysentery 10 deaths occurred, another 12 were from unclassified dysentery, and 16 resulted from amebic dysentery, a total of 38 (table 63).
The entire United States Army had only 64 deaths due to dysentery (tables 56 and 63) of which 38 (59 percent) were among admissions in the
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Pacific areas. Within the 12 percent of mean strength located in these areas, 24 of these 38 deaths occurred in 1945, and all but 1 occurred among admissions in the Southwest Pacific.
Australian mainland.-Troops arriving in Australia in March 1942 had an incidence rate of 70 cases per annum per 1,000 strength which dropped to 20 cases during April but increased to 43 cases in May. The rate of 29 cases in June was followed in successive months by a continuing rise to a peak of over 100 in December 1942 and February 1943 (chart 45).
This increased frequency was anticipated. In an endorsement to a letter 44 from a subordinate command, the Chief Surgeon of the United States Army Services of Supply for the area expressed the opinion that an outbreak of diarrhea or enteritis in the winter months of June and July in the Motor Transport Command was strongly suggestive, clinically and epidemiologically, of bacillary dysentery. He issued the warning that "unless every known method of prevention is instituted, the dysentery rate and non-effective rate will greatly increase * * *. It is strongly recommended that the Surgeon of your Command seriously consider the possibility of endemic dysentery and make recommendations to you for the necessary action to control * * * this disease." The warning unfortunately was not given theaterwide emphasis.
A medical officer at the 2/7th Australian General Hospital at Port Moresby recorded 45 that the majority of patients hospitalized with diarrhea or dysentery came from camps in isolated areas in small villages, often along rivers in which all drinking water was chlorinated and which utilized deep trench latrines. Flies were plentiful in these locations during the hot months. From September 1942 to February 1944, 12.4 percent of all admissions to this hospital were for diarrhea or dysentery, and 2,849 cases were observed. The experience of this hospital accounts for a major part of the bacillary and unclassified dysentery reported for the area during these 18 months as follows:
Cases | Percent | |
Bacteriologically proved dysentery | 1,026 | 36.0 |
Bacteriologically not proved dysentery | 1,784 | 62.0 |
Amebic dysentery and amebiasis | 39 | 1.4 |
| Total | 2,849 | 100.0 |
The strains of dysentery bacilli recovered in the 1,026 bacteriologically proved cases were:
Percent | |
Sh. dysenteriae | 13.4 |
Sh. paradysenteriae, Flexner types | 76.0 |
Sh. ambigua (Schmitz) | 8.0 |
Sh. paradysenteriae, Boyd IV, P 274 | 2.4 |
Sh. sonnei | .2 |
44 Letter, Headquarters, Motor Transport Command, No. 1, U. S. Army Forces in Australia, to Chief Quartermaster. U. S. Army Forces in Australia, 8 July 1942, subject: Report Regarding Outbreak of Enteritis in Recent Convoy, with 1st endorsement thereto, dated 23 July 1942.
45 Report, Major Fortune, 2/7th Australian General Hospital, 1944, subject: Dysentery at Port Moresby.
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The majority of the bacteriologically not proved diarrheas seen at this hospital were believed to be bacillary dysentery in which the organism was not recovered, because the majority showed typical sigmoidoscopic findings and followed the same course.
No deaths occurred in 2/7th Australian General Hospital experience, although two ascribed to bacillary dysentery were included in 1943 records of the area (table 63). Table 70 shows the experience at this hospital in terms of severity of infection, based upon symptoms, fever, number of stools, and sigmoidoscopic findings of 474 patients with bacillary dysentery according to type of bacillus. Dysentery as seen at this hospital was considered mild.
A seasonal area rate exceeding 100 was seen again in October 1943 (chart 45). The sort of occurrence contributing to this high rate is illustrated by the following epidemiologic case report: 46
Epidemiologic case report 21.-Seven explosive outbreaks of diarrhea occurred among troops of the 24th Infantry Division while being transported by railroad between Camp Caves and Toorbul Point, Queensland, Australia, during September and October 1943. Division combat teams were undergoing amphibious training at Toorbul Point. Each outbreak of diarrhea had the characteristics of a point epidemic, with explosive onset and short duration. Cultures never proved the stools to contain dysentery bacilli.
The outbreaks of 29 October are typical. Train 808 was returning troops from Toorbul Point when 89 cases of diarrhea with nausea and vomiting occurred among 339 United States Army personnel. All had eaten a meal at the railway station cafe at Gympie, and many had also eaten pies or cakes at stands adjacent to the railway stations. A subsequent inspection of the eating establishment at Gympie and Bundaberg revealed many deficiencies such as exposed food, many flies in the station and kitchen, lack of screening, inadequate refrigeration, and inadequate dishwashing facilities.
On train 812, examination of box lunches purchased by troops at Caboolture, Queensland, revealed that some meat pies in the lunches were maggot infested and others were sour.
Type "C" or other suitable rations were recommended for personnel on troop trains and eating at stations prohibited until such time as restaurants were under United States Army inspection and supervision, or improved to meet Army standards.
46 Letter, Division Surgeon, 24th Infantry Division, to Commanding General, Sixth U. S. Army, 4 Nov. 1943, subject: Special Sanitary Report.
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The conclusion to be drawn is that if diarrheal disease is to be prevented, adequate advance arrangements are necessary for feeding of troops during movements of units by train.
Figures are available after January 1944 from periodic summary reports to permit separation of experiences of troops on the Australian mainland from others in the area. Late in 1944, data became available for separate evaluation of disease in troops which had returned to the Philippines. Chart 45 shows a sharp rise in incidence of diarrheas and dysenteries for troops on the Australian mainland from 25 in February 1944 to over 65 in April, with subsequent sharp decline,. An explanation of the March and April excess was sought by the surgeon of Base Section 1. The following epidemiologic case report summarizes the findings: 47
Epidemiologic case report 22.-A survey of the several United States Army units stationed in Base Section 1, Darwin, Australia, was made late in April 1944 to determine conditions which might be responsible for the recent unusual rate of gastrointestinal diseases, principally diarrhea.
The 340th Engineer General Service Regiment (less Company A) had averaged 16 outpatients with diarrhea daily for the past 2 weeks, and 4 cases had been hospitalized.
The 49th Air Depot Group had averaged 12 outpatients with diarrhea daily at camp dispensary during 2 weeks, and 2 cases had been hospitalized.
The detachment of 119th Ordnance Company consisting of 38 men had 6 cases of diarrhea of which 4 were hospitalized.
Chinese Labor Camp detachment reported only one case with symptoms of clinical dysentery but stool cultures were not made.
Company A, 340th Engineer General Service Regiment reported one case of diarrhea.
Typical symptoms of the more than 300 cases were headache, malaise, abdominal pains, frequent watery stools, moderate tenesmus, and mild dehydration. The 12 hospitalized cases evidenced hyperpyrexia of 100?̊ to 104̊? F. and generally severe symptoms. Only one case showed blood and pus in stools, diagnosed as clinical dysentery.
The majority of nonhospitalized patients returned to duty after 24 hours. Sulfaguanidine therapy was used.
Water supplies were potable at all camps.
No camp of the surveyed units had any fly proofing of kitchens and messhalls.Flies were prevalent especially in kitchens and messhalls of the 340th Engineer General Service Regiment main camp. Two camps had latrines less than 100 yards from messhalls.Flies were not numerous at the Company A camp.
Although other modes of transmission were not excluded, the outbreak was attributed to food contaminated by flies.
New Guinea sector (areas of Southwest Pacific other than Australian mainland and Philippines).-United States Army troops in New Guinea experienced a rate of 54 per 1,000 per annum for diarrheas and dysenteries in 1944 with 24,235 cases or 14 percent of all reported communicable disease in this sector (table 54).
Although the area is a hyperendemic area, rates did not attain the high levels of the Philippines, China-Burma-India, or the Middle East. Troops in New Guinea were stationed in most instances beyond the range and influence of native villages.
47 Report, Medical Inspector, Headquarters, Base Section 1, U. S. Army Services of Supply, 28 Apr. 1944, Subject: Investigation of Gastro-intestinal Diseases in Base Section l.
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During the early weeks of 1945, when rates for diarrheal disease were soaring for the area, the rate in New Guinea was 39, one-fourth of that in the Philippines.
After January 1944 until the end of the war, the rate in this sector declined steadily from 82 to 15 except for a brief seasonal rise in January 1945.
The Japanese enemy in New Guinea experienced high rates for diarrheas and dysenteries. Dudley 48 makes the claim that sulfaguanidine, which the Japanese did not have, saved Port Moresby and that dysentery and malnutrition were in large measure responsible for the Japanese defeat in this location.
The Philippines.-When the Philippines were invaded in October 1944, Southwest Pacific area rates for these diseases were at the relatively low level of 37 (chart 45). Monthly rates for the area then soared constantly to 119 in March 1945 and to 138 in June. Rates for the area other than the Philippines were rapidly declining during this interval.
By February 1945, practically all of the Sixth U. S. Army was on Luzon. The rate for diarrhea and dysentery was 186.For Services of Supply troops in the Philippines the rate was 119.49 Diarrheal disease with the exception of infectious hepatitis was the most important communicable disease from the standpoint of noneffectiveness.
In contrast to the situation in New Guinea, United States Army troops in the Philippines came into close contact with the native population. 50 No restrictions were placed upon fraternization with the civilian population. Troops ate large quantities of food and delicacies prepared by the friendly Filipinos under uncertain sanitary conditions, which goes far to explain the high incidence of diarrhea and dysentery. Sanitary facilities and habits of the civilian population had deteriorated during Japanese occupation and by destructive effects of war. Satisfactory sanitation was difficult to achieve, because troops were stationed frequently in or near barrios and towns. Many areas had high water tables giving a hazard heightened by the torrential rains that occurred shortly after the troops arrived. Amebic dysentery, seldom recognized in New Guinea, was encountered frequently on Leyte. Rates for diarrheal disease increased during the active phase of the Leyte campaign, but the invasion of Luzon brought real trouble. A widespread sanitation and public health program was initiated in cooperation with civilian authorities. Emphasis was placed on the building and use of latrines by civilians, and upon the collection of refuse and construction of drainage ditches. Posters and various educational signs were used. Troops were instructed in the disease problems of local areas and in measures to prevent infection. Particular emphasis was placed on avoiding native foods, drinking only from authorized water points, avoiding bathing in creeks or streams, and observing fly control.
Fighting within Manila had destroyed or damaged public utilities. The
48 Dudley, Sir Sheldon F.: Our National Ill Health Service; An Essay on the Preservation of Health. London: Watts & Co., 1953.
49 See footnote 11, p. 345.
50 Annual Report, Chief Surgeon, U. S. Army Forces, Western Pacific, 1945.
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city water system was out of operation, and it was necessary for engineer water-supply companies to serve both civilian and military needs. Water sources were heavily contaminated, but potable water was obtained by heavy chlorination. Other sanitary facilities had also been destroyed. Dangers rested in the vast amounts of uncollected garbage and waste, a huge fly population, and numerous unburied dead in streets and buildings. Dwelling areas were congested, and unsanitary conditions characterized markets and foodpeddlers. Damaged water and sewage systems were rehabilitated, the dead were buried, and garbage and waste disposal and fly control were begun.The rate for reported diarrheal disease in the Philippines rose steadily during early 1945, to attain 171 per 1,000 per annum for the month of March. Thereafter with improvements in general sanitation and in the military situation, rates declined except for 165 in the month of June 1945 (chart 45).
A preventive medicine officer writing to the Deputy Chief Surgeon of the Southwest Pacific Area decried the situation and felt that diarrheal disease should have more attention. He stated: 51
At present, much more time is being spent on venereal disease control, which is only one-eighth as important. At present, a lot of time is being spent making surveys of [helminth] parasites that are not, collectively speaking, of great importance to the Army from the standpoint of producing non-effectiveness. They are of scientific interest and important to civilians who expect to spend their lives in the locality or to individual soldiers. But, it is extremely improbable that the intestinal parasitic diseases would ever immobilize an Army or result in a non-effective rate comparable to bacillary dysentery, the paratyphoid infections or infectious hepatitis. Explosive outbreaks of intestinal parasitic diseases are uncommon and the immediate effects not nearly so disabling as in the case of intestinal diseases of bacterial origin * * *. Experience since the beginning of the invasion of the Philippines has shown that the control of gastro-intestinal infections will be one of the most important public health problems from now until the end of the war.
This preventive medicine officer requested additional personnel and facilities. He was emphasizing a cardinal principle of epidemiologic practice: to evaluate the disease situation and stress the need for attention to the more important causes of noneffectiveness and death. Laboratory effort was seemingly on helminths and ameba, for the reported rate for bacillary dysentery was only 2.71 (table 59). Nevertheless, 6 of the 16 deaths from bacillary dysentery in World War II and for the entire Army were in this area and in the last months of 1944 and early 1945. Furthermore, 11 of 16 deaths from unclassified dysentery occurred in this area and within the same time limits (table 63).
Medical care in the Philippines operation was comparable to that in other theaters. A reasonable conclusion is that case fatality was artificially high because of failure to recognize and report bacillary dysentery, and recognition and reporting is dependent on laboratory diagnosis. Of each 750 cases of bacillary dysentery reported in this area during 1942-45, 1 patient died, whereas 1 death for each 2,000 reported cases occurred in the China-Burma-India and the Africa-Middle East theaters-the other 2 theaters reporting high incidence of bacillary dysentery. There is little evidence of dysentery in a more virulent
51 See footnote 11, p. 345.
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form, although about 8 percent of strains from the 19th Medical Service Detachment (General Laboratory) in the Leyte campaign were Shiga type; more frequently encountered Shigella were ambigua, V, W, Boyd 88, and Z. Boyd 103, Sh. sonnei, and Sh. alkalescens were also encountered.
Despite the large amount and excellent quality of determinative enteric bacteriology performed by this laboratory and several others, the conclusion seems logical that many cases of bacillary dysentery infections in this area were not reported as such, but remained especially in the common diarrhea or unclassified dysentery categories.
Incomplete data from summary reports.-During the first 5 months of 1945, when rates for diarrhea( disease were at their highest point, the rates for amebic dysentery rose steadily. In contrast, rates for bacillary and unclassified dysentery and common diarrhea reached a peak in March and thereafter declined.52 Distributions by clinical form during these months were 72 percent for common diarrhea and 12 percent each for amebic and unclassified dysentery. Bacillary dysentery accounted for only 4 percent.
The area rate for bacillary dysentery was 3.30 per annum per 1,000 average strength for the years 1942-45 (table 59). The Southwest Pacific ranks third among theaters and areas in bacillary dysentery, exceeded only by the Africa-Middle East and China-Burma-India theaters (table 62).
The rates by year, 1942 to 1945, were 2.44, 7.20, 3.18, and 2.71.The high rate of 7.20 is largely related to the extensive bacteriologic work on diarrheas and dysentery by the hospital laboratory at Port Moresby. The 2.71 cases of bacillary dysentery per annum per 1,000 average strength during 1945 is low considering that the rate for all diarrheal diseases in the Philippines in the same period was over 100 cases per annum per 1,000 average strength.
Latin American Area
This area included the Panama Canal Department, the Antilles Department, and the South Atlantic Division, and 1.6 percent of the average strength of the Army during the war years. The share of reported diarrheas and dysenteries, 1.4 percent of the Army's total, was in proportion to strength.
The rate of 19 per 1,000 per annum was sixth highest rate among the overseas theaters (table 62). The average strength of 95,613 during the 4 war years contributed some 7,320 reported cases of diarrhea and dysentery (table 54), the South Atlantic Division having the highest rate among divisions of the area and the Panama Canal Department the lowest, a tribute to the existing high standards of sanitation. The Panama rate of 5 for the war years compared with the rate of 9 for troops in the continental United States, with 25 for the Antilles Department, and 75 for the South Atlantic Division. No deaths in the Latin American area either from bacillary or unclassified dysentery occurred. Amebic dysentery caused one death in 1942 (table 63).
52 Memorandum for file, Maj. P. E. Sartwell, MC, 1 Sept. 1945, subject: Cases and Rates of Diarrheal Diseases in Pbilippines and Southwest Pacific Area (,Including Philippines), January-May 1945.
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The rate of 75 for the South Atlantic Division was exceeded by ChinaBurma-India 131), Africa-Middle East (128), and was close to the rate of 70 for troops in the Mediterranean theater.
Seasonal incidence. United States Army troops in the Latin American area were concentrated close to the Equator. The monthly rates (chart 46) for diarrheas and dysenteries reflect no definite seasonally recurring peaks of incidence in any subdivision of the area.
Panama Canal Department.-The annual rate for diarrheas and dy senteries was 3 in 1940 and 1941 (table 54).Rates in the war years were slightly higher, 5 for the entire period. In only 2 months did monthly rates exceed 8 per 1,000 per annum, in April 1942 and March 1945 with 76 and 78 actual reported cases of dysentery and diarrhea.In this sanitation-conscious department,53 there were more months with little or no diarrhea' disease than months with rates over 8 (chart 46).The epidemiologic relationship between common diarrhea
53 Cox, W. C.: The Prevention of Disease in the U. S. Army During World War II, the Panama Canal Department, 1 Jan. 1940 to Oct. 1945, vol. 1.General Health Measures.[Official record.]
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and the dysenteries is emphasized by experiences such as this. The common diarrheas are preventable as well as bacillary dysentery.
South Atlantic Division.-The annual rates for diarrheas and dysenteries during the 4 war years were 112, 114, 65, and 40, respectively (table 54). Initial rates were excessively high, but with seasoning of troops and general improvement in local sanitation of military establishments the situation improved.
The trend in monthly rates started with over 200 early in 1942 and ended with less than 30 in 1945, although interrupted by repeated sharp peaks, the highest being 384 in January 1943. That these were outbreaks of bacillary dysentery is suggestive, but data are not at hand to substantiate this possibility.
The Antilles Department.-The frequency of diarrheas and dysenteries for troops stationed in these semitropical islands was fairly uniform throughout the war years. Monthly fluctuations in rates were not great and averaged 25 per 1,000 per annum. Brief epidemiologic case reports illustrate the nature of diarrheas and dysenteries in widely scattered island outposts of the department.54
Epidemiologic case report 23.-A brief epidemic of bacillary dysentery occurred at Fort Brooke, Puerto Rico, in May 1942.Five patients with diarrhea were admitted to hospital, and two cases were due to Newcastle-type dysentery bacillus. Cultures were made from the 300 men of the detachment, and 38 were found to be carriers of the same strain. The Puerto Rican Department laboratory believed this represented person-to-person spread after infection from an outside source. Patients and carriers were treated with suflaguanidine, and all became free of the bacillus.
At Camp Tortuguero, Puerto Rico, during the war years, 502 patients with enteric disease were treated at this station, varying from mild diarrhea to severe bacillary infections. There were no deaths. A few instances of amebiasis were without serious complication.
At Borinquen Field, Puerto Rico, numbers of cases and rates for enteritis were:
Year | Cases | Rate |
1942 | 34 | 7.4 |
1943 | 72 | 12.6 |
1944 | 50 | 18.3 |
1945 (through September) | 54 | 17.5 |
Only severe cases were represented, admissions to hospital at this field being so limited.
During Christmas week of 1944, epidemic diarrhea involved approximately 2,000 persons, the difficulty due to a break in technique in reconstituting milk.Cans in which the milk was stored had not been properly cleaned and sterilized. High-pressure steam sterilization was instituted thereafter, and further trouble was avoided. No infectious agent was recovered during the outbreak.
Scattered cases of diarrhea occurred on the base seemingly related to eating in the surrounding towns. Small group outbreaks from time to time were attributed to Puerto Rican foodhandlers employed in base commissary and messes. They required constant supervision and instruction in sanitary foodhandling and personal hygiene.
About 100 persons eating at the officer's mess had diarrhea in January 1945. The origin was presumably in crushed ice. Sixteen cases of amebic dysentery were recognized from March to August 1942 with no demonstrable source of infection.
Seven cases of bacillary dysentery were seen from August to November 1942 and one other in July 1944.Sources of infection were undetermined.
54History of Medical Department Activities, Antilles Department, Preventive Medicine. [Official record.]
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At Fort Bundy, Puerto Rico, the few cases of diarrhea were mild and of short duration and included no dysentery.
In Jamaica, British West Indies, only 49 patients with enteric infection were sufficiently ill to be admitted to hospital; 10 bacillary dysentery, 1 amebic dysentery, and the remainder common diarrhea. No outbreaks of food poisoning were recognized.
In Curacao, Netherlands West Indies, the rainy season and the fly season occur in late fall and early winter. About 50 percent of patients admitted with enteric disease had bacillary dysentery of the Flexner or Schmitz types.
The 359th Station Hospital, Trinidad, British West Indies, admitted 243 cases of common diarrhea during the war years; 39 enterocolitis, 95 gastroenteritis, 39 colitis, 15 diarrhea, and 55 enteritis.
One epidemic of food poisoning led to hospitalization of 50 patients on 3 October 1943. The outbreak was related to chicken pie, meat for which had been cooked 16 hours previously and thereafter held at room temperature before the pies were made. Hemolytic Staphylococcus albus was recovered from the meat, but no pathogens from stools of patients.
Several cases of dysentery were due to Shigella of undetermined types. Of 8 cases of amebic dysentery, 5 were among officers and men attending the School of Jungle Warfare during late 1943 and early 1944.They were believed due to a cook harboring the organism.
In British Guiana, South America, excluding outpatients, admissions for diarrheas and dysenteries were as follows:
Year | Number per 1,000 per annum |
1942 | 1.3 |
1943 | 18.0 |
1944 | 14.0 |
1945 ( first 8 months only) | 3.0 |
This base had no serious outbreaks nor was there a death from intestinal infection. Sanitary conditions were excellent.
Bacillary dysentery.-For the area as a whole and for all war years, slightly more than 300 cases of bacillary dysentery were identified (table 59), with no deaths.
The laboratory of the 161st General Hospital was especially active in enteric bacteriology.55 The hospital cared for 64 cases of Flexner-type dysentery, 2 Sonne and 2 Newcastle, with 9 others unclassified. The 43 cases of bacillary dysentery at this one hospital in 1943 were more than half of all those which occurred in the Latin American area that year. The Antilles Department had far less diarrhea and dysentery than the South Atlantic Division, yet one-fifth of the area total was from this single hospital. The amount of laboratory work often determines the amount of bacillary dysentery.
North American Area and Alaskan Department
The best rates for diarrheas and dysenteries during the war years, lower even than for troops in the continental United States, were attained by troops stationed in the North American area and in Alaska. The exact rates were 4 for the North American area and 5 for troops in the Alaskan Department, comparable alone with the Panama Canal Department rate of 5 (table 54), a subdivision of the Latin American area.
55 Professional History of Internal medicine in world War II, The Antilles Department.[Official record.]
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The North American area had an average strength of 44,253, but troops were located in such widely separated places as Newfoundland, Greenland, Iceland, and Bermuda. Reported cases of dysentery and diarrhea numbered 732. Thus, 0.7 percent of the average strength of the Army contributed approximately 0.1 percent of the total intestinal infection.
The Alaskan Department with an average strength of 72,345 had 1,427 cases of dysentery and diarrhea, so that 1.2 percent of average Army strength had only 0.3 percent of the total cases.
No deaths occurred in either area.
Monthly and seasonal incidence.--Monthly rates in the Alaskan Department reflect no clear-cut seasonal incidence. Rates rose from 2 cases per annum per 1,000 average strength in April 1942 to 15 in May 1943.Thereafter, and with a declining average monthly strength in the area, rates fell to 1 in August 1945 (chart 47). Dysentery rates remained low although bacillary dysentery was considered endemic in civilian and native settlements.The rate for bacillary dysentery was 0.6, with only 30 reported cases.The relatively high incidence of diarrheal disease in 1943 is partially explained by a concomitant frequency of gastrointestinal diseases ranging from gastric hyperacidity and gastric neurosis to peptic ulcer.56 The new units coming to the command had a high proportion of older and limited service men, many reclassified by their draft, boards and having an EPTI (existing prior to induction) status.Many minor gastric disturbances classed as common diarrhea were believed related to the existing monotony of the diet.The professional opinion was that low morale was also reflected in such disorders.
56Manning, F. G.: History of Preventive Meicine in World War II, Northwest Service Command. (Official record.]
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Occasional small outbreaks of food poisoning occurred. Recognized bacillary dysentery and even unclassified dysentery were rare. Amebic dysentery was almost nonexistent.
The North American area gives suggestion of some seasonal occurrence of diarrheas and dysenteries since rates are highest in midsummer. Cases were so few that rates of over 6 per 1,000 per annum were attained in only 12 months of the 4 war years, 10 of those being summer months.
Factors contributing to low incidence.-Reasons for the low incidence of diarrheas and dysenteries in these two areas as contrasted to all others are not easily determined from the available data but may possibly include the following:
1. The type of climate and the cold environment found especially in Alaska, Iceland, and Greenland. (However, the tropical but well-sanitated Panama Canal Department had as good a record.)
2. The exercise of good control over water supplies for all bases in Alaska and most bases in other portions of these areas.
3. Low endemicity diarrheal disease in native population. Diarrhea] disease, however, was prevalent and occasionally epidemic. In Newfoundland; for instance, 10,000 to 12,000 cases of diarrhea occurred in Saint John's during the summer of 1942.57
4. Adequate screening and protection of foodstuffs from flies; also relatively low prevalence of the common Musca domestica in many military units.
5. Rapid installation of water carriage sewage disposal units until, by the end of 1943 in Alaska especially, practically every unit was so provided regardless of how remote the location.
6. Decrease in average strength after summer of 1943. <>
7. Use of military foodhandlers.
8. Routine and frequent sanitation inspections with emphasis on mess sanitation.
9. Rigid emphasis in Alaska on mess sanitation.(This was more forcefully brought home to those with command functions whenever and wherever the diarrhea] rate showed tendency to increase and also resulted, doubtless, in failure to report some few sporadic and mild outbreaks for fear of reprimand.)
10. Isolation and lack of contact with native population in many of these locations.
11. Practical public health educational programs regarding sanitation. In the history of preventive medicine in the Northwest Service Command, Manning states
It is surprising that the diarrheal disease rate was not appreciably higher in the early days of this Command. There were rapid changes in mess personnel in contractor camps. Education of camp managers and mess stewards * * * was a slow and difficult problem * * *. By 1945 screening of buildings, where required, had become universal; the flush toilet had replaced the pit latrine even in the most isolated camps; dishwashing procedures had become more standardized; mess personnel had become conscious of the need
57 History of Preventive Medicine in World War II, Eastern Defense Command.[Official record.]
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for mess sanitation and how to accomplish it; * * * and camp foremen, along with company commanders, were contacting medical facilities to assure that monthly examinations were conducted on schedule; our people had been educated.
Iceland Base Command. In this command, according to the history of preventive medicine for the Eastern Defense Command, "intestinal infections have been practically nonexistent * * *. In fact, such long periods of time elapsed between the isolated cases that no special records of these diseases were kept. No epidemics of this type of disease ever occurred. Even in the early days of the command and during the period of maximum troop strength many weeks elapsed between cases and those were isolated individual cases, never groups."
Greenland Base Command.-For this command, the history just cited states: "'There is no record of any serious outbreak of intestinal infections. We have never had any cases of amebic or bacillary dysentery, cholera, or protozoan infections. There have been a few isolated instances of common diarrhea resulting from spoiled or improperly prepared food but never to any serious extent."
Newfoundland Base Command.-Apparently this base command contributed a large proportion of the total diarrheal disease for the area. Diarrhea was particularly prevalent at this command throughout the war. In 1942, the incidence rates for diarrhea at Fort Pepperell and Fort McAndrew, two of the larger units in Newfoundland, were 20.27 and 25.11 cases, respectively, per 1,000 average strength; in 1943, 35.87 and 28.28, respectively; in 1944, 19.36 and 13.24; and in 1945, 18.26 and 18.10. Unclassified dysentery occurred in 1942 only at Fort Pepperell, at a rate of 2.53 cases per 1,000 average strength; bacillary dysentery occurred at this fort in only one of the war years-1944 at a rate of 0.40 case per 1,000 average strength. Although there was no dysentery at Fort McAndrew during the war, an isolated case of typhoid fever occurred there in 1944.
An epidemic estimated at 10 to 12 thousand cases of diarrhea occurred in Saint John's, Newfoundland, during August and September 1942. During this interval, soldiers were ordered not to eat or drink in any establishment in that city. This shows that diarrheal disease was prevalent in Newfoundland and might account for the relatively high incidence in contrast to other base commands of the area.
Bermuda Base Command.-Outbreaks of diarrheal disease were small, and only two occurred, with 28 cases in one instance and 33 in the other; both were considered the result of food infections and occurred in June 1944 and in April 1945.A few reported sporadic cases of diarrhea and of mild dysentery occurred.58
Bacillary dysentery.-Only 39 cases of bacillary dysentery were reported in these areas during 1942-45 (table 59). Over-all incidence was 0.08, and rates for individual years were 0.10, 0.07, 0.05 and 0.15, respectively, the lowest rates reported in any theater or major command area. There were no deaths,
58 See footnote 57, p. 407.
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and noneffective rates were extremely low. Unclassified dysentery was similarly infrequent. Some few were cases reported from Alaska in 1943; none in 1945. Worthy of note is that in this area with so little recognized dysentery, the incidence of common diarrhea was also extremely low.
