title: Surveillance of Food- and Smear-Transmitted Pathogens in European Soldiers with Diarrhea on Deployment in the Tropics: Experience from the European Union Training Mission (EUTM) Mali.
abstract: Introduction. Since 2013, European soldiers have been deployed on the European Union Training Mission (EUTM) in Mali. From the beginning, diarrhea has been among the most "urgent" concerns. Diarrhea surveillance based on deployable real-time PCR equipment was conducted between December 2013 and August 2014. Material and Methods. In total, 53 stool samples were obtained from 51 soldiers with acute diarrhea. Multiplex PCR panels comprised enteroinvasive bacteria, diarrhea-associated Escherichia coli (EPEC, ETEC, EAEC, and EIEC), enteropathogenic viruses, and protozoa. Noroviruses were characterized by sequencing. Cultural screening for Enterobacteriaceae with extended-spectrum beta-lactamases (ESBL) with subsequent repetitive sequence-based PCR (rep-PCR) typing was performed. Clinical information was assessed. Results. Positive PCR results for diarrhea-associated pathogens were detected in 43/53 samples, comprising EPEC (n = 21), ETEC (n = 19), EAEC (n = 15), Norovirus (n = 10), Shigella spp./EIEC (n = 6), Cryptosporidium parvum (n = 3), Giardia duodenalis (n = 2), Salmonella spp. (n = 1), Astrovirus (n = 1), Rotavirus (n = 1), and Sapovirus (n = 1). ESBL-positive Enterobacteriaceae were grown from 13 out of 48 samples. Simultaneous infections with several enteropathogenic agents were observed in 23 instances. Symptoms were mild to moderate. There were hints of autochthonous transmission. Conclusions. Multiplex real-time PCR proved to be suitable for diarrhea surveillance on deployment. Etiological attribution is challenging in cases of detection of multiple pathogens.
authors.affiliation: Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, 20359 Hamburg, Germany ; Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany.
authors.forename: Hagen
authors.initials: H
authors.lastname: Frickmann
authors.affiliation: Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany.
authors.forename: Philipp
authors.initials: P
authors.lastname: Warnke
authors.affiliation: Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, 20359 Hamburg, Germany.
authors.forename: Claudia
authors.initials: C
authors.lastname: Frey
authors.affiliation: Sub-Department VI.2, Department A, Military Medical Command, 56070 Koblenz, Germany.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Schmidt
authors.affiliation: Sub-Department VI.2, Department A, Military Medical Command, 56070 Koblenz, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Janke
authors.affiliation: Sub-Department VI.2, Department A, Military Medical Command, 56070 Koblenz, Germany.
authors.forename: Kay
authors.initials: K
authors.lastname: Erkens
authors.affiliation: Department II (Veterinary Medicine), Central Institute of the German Armed Forces Medical Service Kiel-Kronshagen, 24119 Kiel-Kronshagen, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Schotte
authors.affiliation: Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Köller
authors.affiliation: Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, 20359 Hamburg, Germany.
authors.forename: Winfried
authors.initials: W
authors.lastname: Maaßen
authors.affiliation: Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Podbielski
authors.affiliation: Department II (Veterinary Medicine), Central Institute of the German Armed Forces Medical Service Kiel-Kronshagen, 24119 Kiel-Kronshagen, Germany.
authors.forename: Alfred
authors.initials: A
authors.lastname: Binder
authors.affiliation: Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, 20359 Hamburg, Germany.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Hinz
authors.affiliation: Deployment Health Surveillance Capability/NATO MilMed COE, 80637 Munich, Germany.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Queyriaux
authors.affiliation: Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, 20359 Hamburg, Germany.
authors.forename: Dorothea
authors.initials: D
authors.lastname: Wiemer
authors.affiliation: Department of Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine Hamburg, 20359 Hamburg, Germany.
authors.forename: Norbert Georg
authors.initials: NG
authors.lastname: Schwarz
authors.affiliation: Department of Tropical Medicine at the Bernhard Nocht Institute, German Armed Forces Hospital of Hamburg, 20359 Hamburg, Germany.
authors.forename: Ralf Matthias
authors.initials: RM
authors.lastname: Hagen
mesh_terms: D000328:Adult; D000962:Antimalarials / Q000627:therapeutic use; D022121:Cholera Vaccines / Q000627:therapeutic use; D003967:Diarrhea / Q000175:diagnosis* / Q000517:prevention & control; D054307:Enterotoxigenic Escherichia coli / Q000302:isolation & purification; D004927:Escherichia coli Infections / Q000175:diagnosis / Q000517:prevention & control; D005062:European Union; D005243:Feces / Q000382:microbiology / Q000469:parasitology / Q000821:virology; D005260:Female; D005506:Food Contamination; D005838:Genotype; D006801:Humans; D008297:Male; D008302:Mali; D008875:Middle Aged; D008887:Military Medicine; D008889:Military Personnel; D060885:Multiplex Polymerase Chain Reaction; D060888:Real-Time Polymerase Chain Reaction; D014436:Typhoid-Paratyphoid Vaccines / Q000627:therapeutic use; D014780:Viruses / Q000302:isolation & purification; D001618:beta-Lactamases / Q000378:metabolism
chemical_list: D000962:Antimalarials; D022121:Cholera Vaccines; D014436:Typhoid-Paratyphoid Vaccines; D001618:beta-Lactamases