Reprinted with permission of Clinical Infectious Diseases.
Copyright by the University of Chicago Press, 1995. Reference:
Clin Infect Dis 1995;20:1497-1504.
The Impact of Infectious Diseases on the Health of U.S. Troops Deployed to the Persian Gulf During Operations Desert Shield/Desert Storm
Kenneth C. Hyams1
Kevin Hanson2
F. Stephen Wignall3
Joel Escamilla4
Edward C. Oldfield III5
1. Epidemiology Division, Naval Medical Research Institute, Bethesda, Maryland
2. Office of the I Marine Expeditionary Force (MEF) Surgeon, I MEF, Camp Pendleton, California
3. U.S. Naval Medical Research Unit No. 2, Jakarta, Indonesia
4. Navy Environmental and Preventive Medicine Unit No. 6, Pearl Harbor, Hawaii
5. Division of Infectious Diseases, Eastern Virginia Medical School, Norfolk, Virginia
The opinions and assertions contained herein are the private ones
of the authors and are not to be construed as official or
reflecting the views of the U.S. Department of Defense or the
U.S. Department of the Navy.
Abstract
An assessment was conducted of the impact of infectious diseases
on the 697,000 U.S. troops deployed to the Persian Gulf during
1990-1991 in Operations Desert Shield and Desert Storm. The
incidence of nonbattle injuries, including infectious diseases,
during this conflict was lower than during previous wars
involving U.S. military personnel. The major reported causes of
morbidity were generally mild cases of acute diarrheal and upper
respiratory disease. The most unexpected outcome was the lack of
arboviral infections, particularly sandfly fever, and the
occurrence among U.S. troops of 12 cases of visceral
leishmaniasis due to Leishmania tropica. The fact that
infectious diseases were not a major cause of lost manpower, in
sharp contrast to the experience among military personnel in
World War II, can be attributed to a combination of factors: the
presence of a comprehensive infrastructure of medical care,
extensive preventive medicine efforts, and several fortuitous
circumstances. Beneficial conditions that may not be present in
future conflicts in this region include isolation of most combat
troops to barren desert locations during the cooler, winter
months, which provided the least favorable conditions for
transmission of arthropod-borne diseases.
Introduction
Between August 1990 and March 1991, the United States deployed a
total of 697,000 troops to the Persian Gulf during Operations
Desert Shield (the buildup period) and Desert Storm (the 6-week
war with Iraq). In contrast to previous wars, a higher percentage
of deployed troops were reservists/National Guard personnel (17%)
and women (7%).
Throughout this massive deployment, there was substantial concern
that infectious diseases that are endemic in this area of the
world could threaten the health of coalition troops [1,2]. On the
basis of experience with infectious diseases among military
personnel during World War II, foreign troops stationed in the
Persian Gulf were expected to be at especially high risk of
shigellosis, malaria, sandfly fever, and cutaneous leishmaniasis
[3,4]. Epidemiologic surveillance of deployed troops and studies
conducted during the 4 years since the war with Iraq have
provided a better understanding of the threat of infectious
diseases in the Persian Gulf and also help provide a guide for
the diagnosis and treatment of ill Gulf war veterans.
An assessment was conducted of the impact of infectious diseases
on U.S. troops by use of published reports and data derived from
the U.S. Navy's weekly surveillance system of outpatient visits
among approximately 40,000 Marine Corps ground troops deployed to
northeastern Saudi Arabia. A MEDLINE search for relevant articles
in any language was conducted with the following MESH headings:
Operation Desert Shield, Operation Desert Storm, Gulf war,
Persian Gulf, Middle East, Iraq, Kuwait, and Saudi Arabia. In
addition, 594 citations were examined in a "Current
Bibliographies in Medicine" prepared in March 1994 by the
National Library of Medicine [5]. Applicable publications also
were found by a comprehensive examination of the reference
section of articles dealing with this topic.
Background
After Iraq invaded Kuwait on August 2, 1990, U.S. troops were
rapidly transported to the theater of operations mostly by
aircraft. On arrival, combat troops were crowded together in
warehouses and tents at initial staging areas and then moved to
isolated desert locations in northeastern Saudi Arabia (figure
1). Although most ground troops lived in tents, it was necessary
to use a wide variety of buildings in military and guest worker
camps to accommodate U.S. military personnel.
Food supplies had to be procured from numerous sources to meet
the immediate needs of such a large force, and most troops ate
prepackaged meals supplemented by fresh food obtained from nearby
countries [6]. In contrast to the food supplies, potable water
was obtained from only a few closely monitored sources,
predominantly commercial bottled water and military
reverse-osmosis units.
Military personnel were extremely busy and at high risk of injury
and disease during Operations Desert Shield and Desert Storm;
more than 500,000 troops were rushed into an inhospitable desert
environment, readied equipment, conducted training exercises, and
eventually fought a war [7]. The first 2 months of the deployment
were particularly hazardous because the weather was extremely hot
(mean high temperature of 107�F), and heat stress was a major
health threat. However, by December and January when the majority
of troops were deployed, the weather had become much cooler (mean
high temperature, 72�F).
A comprehensive health care system was established by the U.S.
military to provide for the medical demands expected in a
prolonged war with massive casualties [8-10]. In addition, an
extensive preventive medicine effort was initiated that included
strict monitoring of the purity of potable water, inspection of
food sources and supplies, maintenance of field camp sanitation,
institution of an arthropod vector control program, and
administration of booster doses of routine vaccinations
(principally typhoid and tetanus), influenza vaccine during the
fall, and immune serum globulin [10].
Besides these standard preventive medicine procedures, a
continuous program of disease surveillance and a sophisticated
laboratory for the diagnosis of infectious diseases were
established in Saudi Arabia by the U.S. Navy at the beginning of
Operation Desert Shield [11]. Because of these innovations, it
was possible to monitor U.S. troops more closely than had been
feasible previously. Outpatient morbidity data were collected
from a population of approximately 40,000 U.S. Marine Corps
combat troops in a weekly surveillance program, which provided
risk assessment information that was most specific for U.S.
ground troops deployed in northeastern Saudi Arabia.
Medical surveillance among the 40,000 U.S. Marines and
hospitalization statistics indicated that the "disease
nonbattle injury" rate, which includes infectious diseases,
was lower during this military campaign than in any major war
involving U.S. military personnel [3,12,13]. Furthermore, the
incidence of nonbattle injuries steadily decreased during the
deployment as weather conditions improved, troops adapted to the
demands of the deployment, and disease surveillance efforts
quickly identified major health hazards (figure 2). In addition
to low morbidity rates, fewer deaths occurred among U.S. military
personnel deployed in Operations Desert Shield and Desert Storm
than initially anticipated: 148 killed in action and 226
noncombat deaths resulting primarily from accidental injuries
[14,15]. No deaths due to infectious diseases were reported.
Although a high level of health and combat readiness was
maintained among deployed troops, nondisabling acute enteric and
respiratory infections were a frequent occurrence in the Persian
Gulf.
Gastroenteritis
Diarrheal disease was the leading cause of infectious disease
morbidity among U.S. troops [2,16]. At the beginning of the rapid
buildup of troops in August-September 1990, when the weather was
very hot, outbreaks of acute diarrhea were common. More than 50%
of the troops in some initially deployed units reported an
episode of acute diarrhea, as defined by three or more loose or
watery stools in a 24-hour period [16]. Although acute diarrhea
was a frequent complaint, the majority of troops experienced
mild, traveler's-type diarrhea which resolved spontaneously after
a few days [16].
The primary enteropathogens identified in cases of acute diarrhea
from all branches of the military were enterotoxigenic Escherichia
coli (ETEC) and Shigella sonnei (table 1) [16]. Other
species of Shigella, non-typhi Salmonella,
enteroinvasive E. coli, and Campylobacter were
found much less often. No confirmed, acute case of cholera,
typhoid fever, amoebic dysentery, or giardiasis was reported
among U.S. troops. Also, examination of stool samples from 422
combat troops after the war did not find an increased risk of
enteric protozoan or helminthic infections [17].
As expected from recent U.S. military deployments in this region
[18,19], between 20% and 80% of bacterial enteropathogens were
resistant to antibiotics commonly used to treat acute diarrhea,
including trimethoprim-sulfamethoxazole, tetracycline, and
ampicillin [16]. However, all isolated bacterial pathogens were
found to be sensitive to quinolone drugs which became standard
therapy for severe cases of acute diarrhea [20].
The wide diversity of colonization factor antigens, serotypes,
plasmid profiles, and antibiograms among isolated strains of ETEC
and Shigella species indicated that there were numerous
sources of enteric pathogens [16,21]. Fresh, locally grown
produce was the primary suspected source during early outbreaks
[6,16], but the possibility that enteric pathogens were carried
from the United States by a few, minimally symptomatic troops
could not be ruled out.
The major risk factor for diarrheal disease among initially
deployed ground troops was consumption of fresh fruits and
vegetables obtained from neighboring countries, as demonstrated
by the precipitous decrease in rates of diarrheal disease when
these food items were identified as a risk factor and removed
from the diet of the ground troops [16] (figure 3). After the
initial outbreaks, diarrheal disease continued to occur at a
lower and declining rate among ground troops; the major risk
factor for transmission became deployment to field locations
[16]. Once enteropathogens were introduced into populations of
crowded ground troops who were living in tents without modern
indoor plumbing, endemic transmission appeared to continue by
close personal contact, contamination of communal latrines and
washing facilities by troops with acute diarrhea, and possibly
desert filth flies, which were a ubiquitous nuisance [22,23].
Other distinctive risk factors for transmission of diarrheal
disease were identified in isolated outbreaks and cases of acute
gastroenteritis and involved preparation of meals by foreign food
handlers and use of locally catered meals [20,24]. For shipboard
personnel, a major risk factor for diarrheal disease was eating
in local restaurants while they were on shore leave [25].
Viral gastroenteritis also was a cause of morbidity among U.S.
troops during both Operation Desert Shield and Operation Desert
Storm [16,26]. Beginning in the cooler months of November and
December 1990, outbreaks of Norwalk virus infection,
characterized predominantly by vomiting, occurred in widely
scattered ground units [16,27]. A serologic study of 404 Desert
Storm troops indicated that up to 6% of some combat units may
have been infected with Norwalk virus [26]. Affected troops
generally had acute self-limited symptoms which lasted for 24-48
hours.
Respiratory Disease
Acute, common cold-type respiratory complaints were a widespread
cause of minor morbidity during both Operation Desert Shield and
Operation Desert Storm, especially during periods of initial
deployment and crowding (figure 4) [25,28,29]. The British also
reported an increase in community-acquired pneumonia during
deployment among their 42,000 Desert Shield/Storm troops [30] and
an outbreak of chicken pox in a military field hospital [31].
There was the additional concern that respiratory disease would
result from exposure to the sand in this region which can be
extremely fine and powdery [28,32]. Although ground troops were
constantly exposed to blowing sand and sand suspended at ground
level by the movement of troops and equipment, a survey of 2,598
U.S. troops indicated that upper respiratory symptoms, other than
chronic rhinorrhea, were most common among the minority of troops
who resided in air-conditioned buildings [28]. This finding
suggests that troops living and working in tightly constructed
buildings were more likely to transmit respiratory pathogens
among themselves than troops living in the field in tents.
Similar findings have been observed in U.S. military recruit
camps where troops living in modern, energy-efficient barracks
with closed ventilation systems are at higher risk of
respiratory-transmitted infections [33].
Leishmaniasis
Because cutaneous leishmaniasis had been a problem for foreign
troops stationed in Iran and Iraq during World War II [34], it
was anticipated that U.S. ground troops would also be at risk.
However, it was not anticipated that U.S. troops would be at risk
of visceral leishmaniasis, which is not endemic to this area. Nor
was it expected that Persian Gulf veterans infected with Leishmania
tropica, which causes cutaneous disease, would present with
visceral infection without the classic severe symptoms and signs
of kala-azar [35-39]. Mildly symptomatic visceral L. tropica
infection, named "viscerotropic leishmaniasis" [35],
previously had not been described among Western guest workers or
the local populations of Saudi Arabia, although there have been
isolated reports of L. tropica causing visceral disease in
Africa and Southwest Asia [40,41].
To date, 12 cases of visceral and 19 cases of cutaneous
leishmania infection have been reported among U.S. Gulf war
veterans who were deployed to Saudi Arabia, Kuwait, and southern
Iraq [42]. L. tropica was found in cases of visceral
disease and Leishmania major in cutaneous cases in which
parasites could be cultured and evaluated by isoenzyme analysis
[39].
Among the 12 U.S. veterans with visceral L. tropica
infection, one was asymptomatic and the rest presented with
various systemic signs of disease, predominantly fever,
hepatosplenomegaly, and lymphadenopathy, but they did not have
cutaneous manifestations [36]. Laboratory studies revealed very
mild anemia and modest aminotransferase evaluations, but unlike
patients with kala-azar, these patients usually have not had
leukopenia, thrombocytopenia, or hypergammaglobulinemia [36].
Three of the veterans with visceral leishmaniasis also had other
systemic diseases: HIV type 1 infection, renal cell carcinoma,
and acute infection due to Epstein-Barr virus [36,38].
Evaluating Desert Storm veterans for visceral L. tropica
infection has been difficult because there is no sensitive and
specific serologic or skin screening test. All infections have
had to be diagnosed by the identification of parasites in bone
marrow or lymph node biopsy specimens by means of either culture
or an indirect immunofluorescence assay, which are demanding
procedures because this disease is characterized by a low
parasite burden.
Although it has been difficult to diagnosis visceral L.
tropica infection, no indication has been found of widespread
leishmania transmission among the more than 40,000 U.S. troops
who have been evaluated clinically in the Department of Veterans
Affairs and Department of Defense Persian Gulf health registries
[42]. In addition, all patients who had visceral leishmania
infection except one have had objective signs of disease, which
should be apparent if large numbers of troops were infected. The
small number of cases of cutaneous leishmaniasis, which is more
common in Saudi Arabia and easier to diagnose than visceral
leishmaniasis, further suggests that leishmania infection was not
widespread.
There are several possible reasons for a low number of cases of
cutaneous and visceral leishmaniasis among U.S. troops. For one,
insecticides and repellents were used against arthropod vectors
in areas where ground troops were camped. Also, most combat
troops were stationed in the open desert rather than in oases or
urban areas where the sandfly vector and primary leishmania host,
desert rodents, thrive [43-45]. Lastly, the time of the year when
U.S. troops were deployed may have been critical [46]. In this
region, sandflies are most active during the hot summer months
[43,45]. Although the first U.S. troops were sent to Saudi Arabia
on August 8, 1990, the peak of the buildup did not occur until
the cooler winter season between December and February, and the
majority of troops had returned to the U.S. by May 1991.
Consequently, most troops were deployed during the lowest period
of sandfly activity.
Other Arthropod-Borne Infections
At the beginning of Operation Desert Shield, sandfly fever was
considered one of the most serious infectious disease threats to
the combat readiness of U.S. troops because this viral infection
had been a cause of widespread morbidity in Iran and Iraq during
World War II [43]. Although not a cause of mortality, the high
fever and intense debility caused by sandfly fever nevertheless
can incapacitate large numbers of nonimmune troops for brief
periods of time.
During Operations Desert Shield and Desert Storm, no outbreak of
febrile disease consistent with sandfly fever or other
arthropod-borne diseases was reported or observed in the U.S.
Navy disease surveillance system of 40,000 Marine Corps
personnel. Also, no evidence of this arboviral infection was
found in serologic studies of 37 cases of acute fever
unaccompanied by diarrhea among troops from widely varying units
[47] and in a serosurvey of 865 ground troops who were evaluated
predeployment and postdeployment [48].
The reasons why U.S. troops were at low risk of sandfly fever may
be related to the low number of cases of leishmaniasis because
these two diseases are transmitted by the same sandfly vector.
Use of insecticides and limited sandfly activity during the cold
winter months when most troops were deployed would have lessened
the risk of transmission of both diseases [45,46]. Furthermore,
because of differences in geographic location, the risk of
sandfly fever may not have been as great for Desert Storm troops
who were deployed in the open deserts of Saudi Arabia as for
World War II soldiers who were stationed further north in the
urban centers and river valleys of Iraq and Iran (figure 1)
[43,45].
In addition to sandfly fever, Desert Shield/Storm troops were
evaluated for other acute arthropod-borne viral diseases,
including dengue, Sindbis, West Nile fever, Rift Valley fever,
and Crimean-Congo hemorrhagic fever [47,48]. Only one patient
with West Nile fever, who presented with a 4-day self-limited
course of high fever and arthralgias was identified [47].
No evidence of typhus or spotted fever-group rickettsia infection
was found in the serologic evaluation of 37 febrile troops [47]
and deployment serosurvey of 865 ground troops [48]. These data,
plus the low occurrence of arboviral infections and
leishmaniasis, indicate a very low risk overall of
arthropod-borne diseases among U.S. troops during Operations
Desert Shield and Desert Storm.
Other Infectious Diseases
Infectious diseases that historically have plagued military
populations--malaria, sexually transmitted diseases (STDs), and
viral hepatitis--were not a problem during this deployment of
U.S. troops. Malaria has been eradicated in northeastern Saudi
Arabia and Kuwait where most U.S. troops were stationed but still
occurs in Iraq where coalition forces operated for only a brief
period of time. Consequently, just seven cases of malaria due to Plasmodium
vivax were reported among U.S. troops who had crossed into
southern Iraq [12,38]. STDs also were an infrequent finding
because of very limited contact between U.S. troops and other
populations. As for acute hepatitis, only a few cases of
hepatitis A and B were observed among U.S. troops because of
prophylaxis with immune serum globulin, extensive prior screening
of U.S. troops for the use of illicit drugs, and strict
monitoring of the chlorination and purity of the potable water
supply [49].
Brucellosis and Q fever are endemic in the Middle East and were a
potential threat to the health of U.S. troops. To date, there has
been no reported diagnosis of brucellosis among Desert Storm
troops and only three cases of Coxiella burnetii infection
[47,50]. The low risk of these two infectious diseases probably
was due to the fact that only commercial, pasteurized cow milk
products were provided to U.S. troops [51], local dairy
production facilities were regularly inspected by U.S. military
veterinary personnel [6], and most troops had very limited or no
contact with herds of animals.
Other infectious diseases found in the Middle East were not a
problem for Persian Gulf troops. There has been no reported case
of schistosomiasis, echinococcosis, or active tuberculosis, but
there were two cases of meningococcal disease [38].
Unexplained Illnesses
Since the end of the Gulf war, several thousand veterans from
widely diverse military units have complained of chronic
non-specific symptoms which have not been readily explained
[5,42]. In the Department of Veterans Affairs and Department of
Defense self-referred health registries of ill or concerned
Persian Gulf veterans, the most common complaints have been
chronic fatigue, headache, muscle and joint pain, shortness of
breath, intermittent diarrhea, cough, and neuropsychological
complaints, including sleep disturbance, difficulty
concentrating, forgetfulness, irritability, and depression
[42,52]. No documented fever, characteristic skin rash, or
consistent abnormality in results of laboratory tests currently
has been identified. There has been no published report of
similar unexplained illnesses among >100,000 non-U.S.
coalition troops [42], except that in June 1994 Great Britain's
Ministry of Defense reported diverse, non-specific symptomatology
in 33 veterans, which was consistent at that time with the normal
incidence of these symptoms in that country's military population
[53].
Various infectious diseases have been considered as possible
causes of unexplained illnesses, including visceral
leishmaniasis, brucellosis, Q fever, Lyme disease, tuberculosis,
and retroviral infections [5,54]. However, these infectious
diseases have not been found to be the cause of unexplained
illnesses among 150 ill Gulf war veterans who were intensively
evaluated at three Veterans Affairs referral centers [12,42]. In
addition, evaluation of 27 symptomatic veterans found no increase
in titers of serum antibody to two recently recognized infectious
agents, Mycoplasma fermentans and M. penetrans
(personal communication, Dr. Shyh-Ching Lo, Armed Forces
Institute of Pathology, Washington, DC). Of note, arthropod-borne
viral diseases endemic in the Persian Gulf, such as sandfly
fever, are not known to cause chronic infection and disease [55].
Biologic warfare agents also have been suggested as a possible
etiology of unexplained illnesses [56]. Iraq is suspected of
having a program that produced Bacillus anthracis, Clostridium
perfringens, and Clostridium botulinum [57], but
there was no report during the war of casualties consistent with
exposure to biological warfare agents [12]. In addition, these
specific agents and their toxins are highly lethal in minute
quantities and would not be expected to produce chronic,
nonspecific symptoms years after exposure.
An unknown or emerging infectious disease has been hypothesized
as a possible cause of unexplained illnesses [58], but evaluated
veterans have had no unusual or characteristic symptoms or signs
that would indicate a unique infectious process. Moreover, a
National Institutes of Health Technology Workshop on the
"Persian Gulf Experience and Health" held in April 1994
concluded that "no single or multiple etiology or biological
explanation for the reported [unexplained] symptoms was
identified from the data available to the panel," and that
"no single disease or syndrome is apparent, but rather
multiple illnesses with overlapping symptoms and causes"
[5].
Some of the veterans with unexplained illnesses have presented
with symptoms and signs consistent with a diagnosis of chronic
fatigue syndrome [12]. On the basis of general population surveys
that indicate that the crude prevalence of chronic fatigue
syndrome may be >100 cases per 100,000 (personal
communication, Dr. William C. Reeves, Viral Exanthems and
Herpesvirus Branch, Centers for Disease Control and Prevention)
[59], several hundred Desert Shield/Storm veterans could present
with this medical condition. Preliminary evaluations of two
groups of 85 and 37 symptomatic Gulf war veterans found a
possible increase in titers of serum antibody to Epstein-Barr
virus antigens [60,61], but these veterans have not been
evaluated in controlled, blinded studies [62,63].
Because most veterans became ill several weeks to more than a
year after returning to the United States, rather than after an
illness while in the Persian Gulf [64], epidemic neuromyasthenia
is an unlikely explanation for chronic fatigue and other
generalized symptoms. In suspected outbreaks of epidemic
neuromyasthenia, the incubation period appeared to be short and
the onset of fatigue often coincided with an initial, flu-like,
acute illness [65-67].
Conclusion
The incidence of nonbattle injuries, including infectious disease
morbidity, was lower during Operations Desert Shield and Desert
Storm than during any previous war involving U.S. military
personnel [12,13]. The fact that infectious diseases were not a
major cause of lost manpower, unlike the experience of Western
troops in the Persian Gulf during World War II, can be attributed
to a combination of factors. One important factor was the
presence of a comprehensive infrastructure of medical care, which
was capable of controlling any highly infectious disease like
shigellosis [9,20]. Another major factor was the extensive
preventive medicine effort by the U.S. military, which included
continuous disease surveillance and rapid diagnostic support to
quickly identify and correct health hazards [16]. In addition to
these clinical and preventive medicine efforts, several
fortuitous factors unique to this deployment contributed to a
very low rate of infectious disease morbidity, principally
isolation of troops in barren desert locations and cooler winter
conditions during the height of the troop buildup.
Whether changes since World War II in the environment or the
animal and human reservoir of infection in the Persian Gulf
contributed to a low risk of infectious disease morbidity among
U.S. troops also has to be considered. In Saudi Arabia and
Kuwait, a modern health and sanitation system has been built and
many previously endemic infectious diseases have been nearly
eliminated in recent years, including schistosomiasis and malaria
[68,69]. The decreased endemicity of infectious diseases in this
region would have reduced the threat for coalition troops.
The primary cause of infectious disease morbidity among Desert
Shield/Storm troops was generally mild acute diarrheal and
respiratory disease, which was expected from prior experiences of
deployed U.S. troops [18,19]. Because of the unavoidable crowding
during a rapid mobilization for war and inevitable exposure to
infectious disease pathogens, especially in tropical and
developing countries, diarrheal and respiratory diseases will
remain a problem for U.S. troops until effective vaccines are
developed.
The most unexpected medical outcome of this deployment to the
Persian Gulf was the very low risk of arthropod-borne infections,
particularly sandfly fever. In World War II, the highest attack
rate for sandfly fever occurred among troops stationed in the
Persian Gulf, with a peak rate of 235 cases/1,000 personnel in
August 1943 [43]. The reason why Desert Storm troops were not at
a similarly high risk may have been due to the deployment of most
ground troops to the open desert during the cooler winter months,
which provided the least favorable conditions for
arthropod-transmitted diseases like sandfly fever and
leishmaniasis [46].
Although U.S. troops were at low risk of incapacitation from
infectious diseases during the Persian Gulf war, other military
campaigns may not be so fortunate. Chance events, like the time
of year and geographic location of deployment, can have a major
impact on the risk of transmission of infectious diseases and
result in higher morbidity among deployed troops. History teaches
that the outcome of future battles could be swayed by infectious
diseases. Therefore, the U.S. military must continue to support
an aggressive program of preventive medicine, which is guided
during deployments by continuous disease surveillance and on-site
laboratory analyses. In addition, it is critical for the military
to maintain an infectious diseases research program to develop
new vaccines, improved medical treatments, and more accurate and
rapid diagnostic tests.
This work was supported by the U.S. Naval Medical Research and
Development Command, NMC, NCR, Bethesda, Maryland.
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Table 1. Bacterial enteropathogens identified in stool samples
from 432 U.S. military personnel with acute gastroenteritis
during Operation Desert Shield (reprinted by permission of The
New England Journal of Medicine, [16]).
| Enteropathogen | Number (%) of stool samples* |
| Enterotoxigenic E. coli | |
| Heat labile toxin | 15 (3.5) |
| Heat stable toxin | 44 (10.2) |
| Heat labile toxin/heat stale toxin | 64 (14.8) |
| Heat labile toxin and heat stable toxin+ | 2 (0.5) |
| Enteroinvasive E. coli | 3 (0.7) |
| Shigella species | |
| S. dysenteriae | 4 (0.9) |
| S. flexneri | 12 (2.8) |
| S. boydii | 8 (1.9) |
| S. sonnei | 89 (20.6) |
| Salmonella (non-typhi) | 7 (1.6) |
| Campylobacter | 2 (0.5 |
* Thirty-six patients had mixed bacterial infections.
+ Two patients had individual colonies producing either heat
labile toxin or heat stable toxin only.
For the following figures please click on the
accompanying document:
Military Medicine in Operations Desert Shield and Desert
Storm: The Navy Forward Laboratory, Biological Warfare Detection,
and Preventive Medicine
Figure 1. Not included; please refer to Clin Infect Dis
1995;20:1497-1504, for map.
Figure 2. Weekly rates for total outpatient (sick call) visits
among approximately 40,000 Marine Corps ground troops stationed
in Northeaster Saudi Arabia who participated in the U.S. Navy
disease surveillance system.
Figure 3. Weekly gastroenteritis outpatient rates among
approximately 40,000 Marine Corps ground troops stationed in
northeastern Saudi Arabia. The arrow indicates when fresh produce
was removed from the diet following identification of enteric
disease pathogens by preventive medicine personnel and the
subsequent sharp decrease in the incidence of diarrheal disease.
Figure 4. Weekly respiratory disease outpatient rates among
approximately 40,000 Marine Corps ground troops stationed in
northeastern Saudi Arabia. The arrows indicate the two primary
periods of time when U.S. Marine Expeditionary Force (MEF)
personnel were being transported to the theater of operations,
which also coincided with increased rates of respiratory disease.
-end-