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      Enteric disease surveillance under the AFHSC-GEIS: Current efforts, landscape analysis and vision forward

      review-article
      1 , 2 , 3 , 4 , 5 , , the AFHSC-GEIS Enteric Surveillance Writing Group 6 , 7
      BMC Public Health
      BioMed Central

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          Abstract

          The mission of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) is to support global public health and to counter infectious disease threats to the United States Armed Forces, including newly identified agents or those increasing in incidence. Enteric diseases are a growing threat to U.S. forces, which must be ready to deploy to austere environments where the risk of exposure to enteropathogens may be significant and where routine prevention efforts may be impractical. In this report, the authors review the recent activities of AFHSC-GEIS partner laboratories in regards to enteric disease surveillance, prevention and response. Each partner identified recent accomplishments, including support for regional networks. AFHSC/GEIS partners also completed a Strengths, Weaknesses, Opportunities and Threats (SWOT) survey as part of a landscape analysis of global enteric surveillance efforts. The current strengths of this network include excellent laboratory infrastructure, equipment and personnel that provide the opportunity for high-quality epidemiological studies and test platforms for point-of-care diagnostics. Weaknesses include inconsistent guidance and a splintered reporting system that hampers the comparison of data across regions or longitudinally. The newly chartered Enterics Surveillance Steering Committee (ESSC) is intended to provide clear mission guidance, a structured project review process, and central data management and analysis in support of rationally directed enteric disease surveillance efforts.

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          Most cited references53

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          Acute gastroenteritis is followed by an increased risk of inflammatory bowel disease.

          Bacterial intestinal infections have been implicated as a possible cause of exacerbation of inflammatory bowel disease (IBD). We explored the relationship between infectious gastroenteritis and the occurrence of IBD using data from the General Practice Research Database. A cohort of patients aged 20-74 years with an episode of acute infectious gastroenteritis (n = 43,013) was identified. From the same source population, an age-, sex-, and calendar time-matched control group free of gastroenteritis was sampled (n = 50,000). Both cohorts were followed up for a mean duration of 3.5 years. The estimated incidence rate of IBD was 68.4 per 100,000 person-years after an episode of gastroenteritis and 29.7 per 100,000 person-years in the control cohort. The hazard ratio of IBD was 2.4 (95% confidence interval [CI], 1.7-3.3) in the gastroenteritis cohort compared with the control cohort, and the excess risk was greater during the first year after the infective episode (hazard ratio, 4.1; 95% CI, 2.2-7.4). The relative risk of developing Crohn's disease in the gastroenteritis cohort was greater than that of ulcerative colitis, especially during the first year after the infective episode (hazard ratio, 6.6; 95% CI, 1.9-22.4). Our results are compatible with the hypothesis that infectious agents causing an episode of infectious gastroenteritis could play a role in the initiation and/or exacerbation of IBD.
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            Postinfectious irritable bowel syndrome--a meta-analysis.

            Irritable bowel syndrome (IBS) is a heterogeneous disorder affecting 12% of the population worldwide. Several studies identify IBS as a sequela of infectious gastroenteritis (IGE) with reported prevalence ranging from 4% to 31% and relative risk from 2.5 to 11.9. This meta-analysis was conducted to explore the differences between reported rates and provide a pooled estimate of risk for postinfectious irritable bowel syndrome (PI-IBS). Electronic databases (MEDLINE, OLDMEDLINE, EMBASE, Cochrane database of clinical trials) and pertinent reference lists (including other review articles). Data were abstracted from included studies by two independent investigators; study quality, heterogeneity, and publication bias were assessed; sensitivity analysis was performed; and a summative effect estimate was calculated for risk of PI-IBS. Eight studies were included for analysis and all reported elevated risk of IBS following IGE. Median prevalence of IBS in the IGE groups was 9.8% (IQR 4.0-13.3) and 1.2% in control groups (IQR 0.4-1.8) (sign-rank test, p= 0.01). The pooled odds ratio was 7.3 (95% CI, 4.7-11.1) without significant heterogeneity (chi2 heterogeneity statistic, p= 0.41). Subgroup analysis revealed an association between PI-IBS risk and IGE definition used. This study provides supporting evidence for PI-IBS as a sequela of IGE and a pooled risk estimate revealing a sevenfold increase in the odds of developing IBS following IGE. The results suggest that the long-term benefit of reduced PI-IBS may be gained from primary prevention of IGE.
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              Incidence, etiology, and impact of diarrhea among long-term travelers (US military and similar populations): a systematic review.

              To determine regional estimates of pathogen-specific prevalence and incidence, as well as, describe morbidity associated with diarrhea among deployed US military and similar populations, a systematic review was conducted for publications between January 1990 to June 2005. Point estimates and confidence intervals of pathogen prevalence and travelers' diarrhea incidence were combined in a random effects model and assessed for heterogeneity. In total, 262 studies were identified for potential inclusion, of which 52 fulfilled inclusion criteria. Overall, 38% were from the Middle East, 29% from Southeast Asia, 27% from Latin America/Caribbean, and 6% from sub-Saharan Africa. Median duration of travel was 1.5 months (interquartile range, 1-3 months). Enterotoxigenic Escherichia coli (ETEC), Campylobacter, and Shigella were identified as causing 38-45% of diarrhea, with regional and population differences. Incidence based on self-report was higher than studies using passive surveillance or clinic-based methods (29 versus 7 versus 6 episodes per 100 person-months, respectively) without regional differences.
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                Author and article information

                Journal
                BMC Public Health
                BMC Public Health
                BioMed Central
                1471-2458
                2011
                4 March 2011
                : 11
                : Suppl 2
                : S7
                Affiliations
                [1 ]Armed Forces Health Surveillance Center, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA
                [2 ]Naval Medical Research Center Detachment, Centro Medico Naval “CMST,” Av. Venezuela CDRA 36, Callao 2, Lima, Peru
                [3 ]Naval Medical Research Unit No. 3, Extension of Ramses Street, Adjacent to Abbassia Fever Hospital, Postal Code 11517, Cairo, Egypt
                [4 ]Naval Medical Research Unit Number 2, Kompleks Pergudangan DEPKES R.I., JI. Percetakan Negara II No. 23, Jakarta 10560, Indonesia
                [5 ]Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA
                [6 ]US Army Medical Research Unit Kenya (USAMRU-K), U.S. Embassy, Attention: MRU, United Nations Avenue, Post Office Box 606, Village Market 00621 Nairobi, Kenya
                [7 ]U.S. Navy Environmental Preventive Medicine Unit No. 2, 1887 Powhatan Street, Norfolk, VA 23511, USA
                Article
                1471-2458-11-S2-S7
                10.1186/1471-2458-11-S2-S7
                3092417
                21388567
                806fbada-fa91-43bf-a78d-395dd3789e3f
                Copyright ©2011 Money et al; licensee BioMed Central Ltd.

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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