**4. Conclusions**

geographic distribution of this resistant strain of *Campylobacter* from regional to global. Other bacteria responsible for diarrhea have also shown resistance in deployed military personnel. During Operation Desert Storm, US military forces suffered from high rates of gastrointestinal infections. Of 432 US military personnel reporting with gastroenteritis, 17% were found to be infected with antibiotic resistant *E. coli*, 54% of *Shigella sonnei* infections were resistant as

Other diseases, while not specifically resistant, have shown a propensity for expansion of its geographic distribution through military operations. Cholera was historically contained to the Indian subcontinent but was brought to other areas of the globe through shipping and trade, including the slave trade. However, the first cholera pandemic occurred from 1817 to 1823, caused by the movement of British troops and camp followers in the Indian subcontinent and abroad. A similar pattern occurred during the Crimean War [51]. Asiatic cholera was first introduced to the US by immigrants arriving at seaports. While rare up until the mid-1800s, cholera rapidly expanded in the US, partially by the movement of troops westward. This westward expansion of military forces, and subsequent expansion of cholera, resulted in outbreaks among civilian populations who would not otherwise have been exposed [52]. More recently, humanitarian military operations resulted in the introduction of cholera to an area where it had not been endemic. In 2010, a catastrophic earthquake struck Haiti, effectively destroying its infrastructure. In response, the United Nations mobilized peace keeping forces to aid in security and recovery. By October 2010, Haiti began to see cholera cases appear in the local populace. As of July 2015, almost 750,000 cases of cholera had occurred on Haiti, resulting in almost 9000 deaths [53]. Genotyping of the cholera strain indicate the source was from South Asia, particularly the Bangladesh and Indian subcontinent. During the peacekeeping operations, the United Nations sent military personnel from Nepal to support the operation. Based on the genotyping, and the peacekeepers present, it was concluded that the source of the outbreak was the Nepalese military personnel who had set their camp up along a river bank that served as a source of domestic water for the Haitians [54]. The resulting outbreak was the largest cholera outbreak to ever occur. It was not until December of 2016 that the UN Secretary-General, Ban Ki-Moon, acknowledged the UN's role in the disaster. This episode drastically illustrates the potential for military forces to import diseases to areas where they

are deployed and the scope of the potential outcome when this occurs.

One final note involves organisms that are normally not pathogenic, but have the potential to become so, especially when individuals are exposed to a novel strain. *Acinetobacter baumannii* are common bacteria found in the soil, on skin and other surfaces, particularly artificial surfaces. Recently, *Acinetobacter baumannii* has emerged as an important pathogen in hospital settings, resulting in nosocomial infections in patients with an associated increase in morbidity, morality and health care costs. Since operations began in Iraq, the incidence of infection by *Acinetobacter baumannii* in US military personnel has increased [55]. While *Acinetobacter baumannii* is not unique to Iraq or Afghanistan, multi-drug resistant forms, until recently, were relatively rare in the US [56]. Molecular genotyping of the multidrug resistant forms found on US personnel, indicate a subtype found in the Middle East as the primary infectious agent

were many other causative agents [50].

94 Current Issues in Global Health

**3.8. Other bacterial infections**

The introduction of novel diseases is a hot topic not only in the United States, but also in Europe, South America and globally [61]. This has become more important as these diseases have re-emerged and spread. Within the last 20 years alone, the increased number of military operations has resulted in a marked increase in the movement of personnel and equipment. As military forces are increasingly mobilized globally in combat and peace keeping roles, the risks of increasing the distribution of emerging infectious diseases will also increase. Detection and control of these emerging diseases will be a major challenge, not only for those countries where military operations are occurring, but also in the countries providing personnel and equipment for these operations [38]. As the disruption of impacted societies increases due to military operations, it is reasonable to expect the emergence or re-emergence of diseases will increase. While increasing military deployments and operations may increase the risk and rate of the spread of infections and emerging diseases, these same militaries can improve surveillance by partnering with local governments and officials to improve their capacity and capabilities. These mutual engagements could potentially reduce the time for detection of an epidemic of global significance. While detection and control of emerging disease is the major challenge facing humans today, partnered engagements may serve to reduce the risk. Going forward, militaries may need to expand their role in post-disaster assistance, surveillance and other activities that could possibly expand the public health capacity of the civilian populations.
