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Key Diagnostic Tests.

• Indirect hemagglutination;
• Complement fixation;
• Weil-Felix test (B. quintana is negative;)
• Culture of the organism on chocolate agar under 5% CO2 will produce colonies after 1-3 weeks;
• ELISA assay is commercially available and an immunofluorescence assay is available from the CDC.

Trench fever can be either slow or rapid in onset. In the rapid onset form, there is an incubation period of 8-30 days, after which there is a sudden development of symptoms, including severe headache, myalgia and pain in the lower body from the lumbar region to the shins. Shin pain is characteristic of the disease and splenomegaly is common.

Rigors were common in World War I. A short lived rash that may only last a few hours is often observed. The spleen is often enlarged.

The fever associated with the disease lasts a few days followed by remission and relapse after 5-6 days. There may be several rounds of remission and relapse. In some cases, the fever is typhoid-like

Depression and neurological sequelae are common and endocarditis may be found. The disease can recur for years, so patients may need to be monitored. As long as they are symptomatic, they can infect the louse and it will remain infective as long as it lives.

Medical and Physical Countermeasures.

Vaccination (Immunoprophylaxis)

A vaccine is not available.

Antibiotics

The disease responds well to antibiotics. Doxycycline (100 mg every 12 hours) for 5-7 days is the treatment of choice. Erythromycin (250 mg every six hours) is also effective.

Supportive care

Analgesics and antipyretics may be used to ease pain and inflammation. Depression was found in 80% of victims in World War I and psychological counseling may be necessary. Endocarditis has been seen in severe cases in the deprived (homeless alcoholics).

Decontamination

Bartonella can be killed by common disinfectants including ethanol, hypochlorite, and formaldehyde.

The agent is critically dependent upon its vector for transmission, so wide area decontamination with a pediculicide (a louse-killing agent such as lindane) is called for. Animal reservoirs (rats and mice) need to be monitored.

Agent Properties and Potential Uses

Trench fever is described as an agent of squalor. It is dependent upon poor personal hygiene and poor public health practices to thrive. It is most likely to be used against refugees or in Third World countries where it occassionally appears. It has been found in the homeless in the United States. This suggests that it may be used to eliminate resistance in areas already badly affected by conventional weapons or outbreaks may be may be an unplanned consequence of the destruction of the machinery of public health by conventional warfare.

Terrorist Acquisition and Attempted Use.

• None confirmed.

The History and Natural History of Trench Fever.

Trench fever takes its name from its first appearance in the trenches of the Western front of World War I. It was described in the medical literature for the first time in September 1915 as a "relapsing febrile illness of unknown origin" in an article by Major J. Graham in the Lancet in September 1915. It was dubbed trench fever in the Lancet less than two months later. In the course of the war it was to claim 800,000 victims. Neither side was prepared for the large scale trench warfare that the Western front devolved into and public health problems appeared almost immediately.

The problems were less severe for the Germans who largely controlled the better-drained high ground (and drained their latrines towards the Allies) and who built more permanent and better designed fortifications. For the Allies the trenches were seen as a temporary solution and although built to support a reasonable tactical doctrine they were public health disasters. They were often in the valleys below the German positions and any rain drained into them reducing the bottoms to mud. Duck boarding meant to keep the feet dry was often missing, damaged or lost in the mud. Sleeping was often in crowded unventilated pits dug into the sides of the trenches. Toilet and washing facilities were minimal or absent (under the best conditions, soldiers had a bath every 10 days). Latrines were built behind the trenches but were not used when the trenches were under fire (which was often). Corpses littering the no-man's land or incorporated into trench walls added to the problem. Even though men were rotated out of the trenches on fairly regular schedules, lice proliferated. They spread rapidly because men were not allowed to build fires for heat and in cold weather they crowded together for heat. Although men deloused themselves, the measures did not sterilize the excreta bearing the pathogen.

Lice had long been known to be a problem for soldiers in the field and for the poor. In fact, the presence of lice on children was seen as a sign of health amongst the poor of London in the 19th Century so effective measures against lice were up against social barriers. Medical officers did come up with a variety of more and less effective measures that did help control the louse problem.

As trench fever claimed 800,000 casualties, with few fatalities, in France and Belgium an outbreak of typhus on the Eastern front was claiming 6,000 victims a day and may have killed a quarter of the Serbian army. At the time and for some years afterward it was believed that there may have been some form of mutual exclusion of the two diseases.

Once the war was over and the trenches were evacuated, the disease dissappeared. It made a brief reappearance during the Second World War, but thanks to improvements in personal hygiene, better medical care, and less trench warfare, it was far less prevalent.

This appears to have been the last that was to be seen of the disease until the 1990's when cases began to be seen amongst the homeless in the United States and in AIDS victims. Where had it been all this time? How had it been surviving? As a relatively non-lethal agent that only occurs under unusual conditions the agent is not that well studied and it may have surprises for us yet.

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