Reprinted with permission of Military Medicine: The Official Journal of AMSUS. Copyright by the Association of Military Surgeons of the United States, 1993. Reference: Mil Med 1993;158(11):729-732.
 

The Navy Forward Laboratory During Operations Desert Shield/Desert Storm
 
CDR Kenneth C. Hyams,1 MC USN
CAPT August L. Bourgeois,2 MSC USN
CAPT Joel Escamilla,3 MSC USN
LCDR James Burans,1 MSC USN
CAPT James N. Woody,4 MC USN (Ret)

1. U.S. Naval Medical Research Institute, Bethesda, MD
2. U.S. Naval Medical Research Unit No. 3, Cairo, Egypt. Present address: U.S. Naval Medical Research Institute, Bethesda, MD
3. U.S. Naval Medical Research Institute Detachment, Lima, Peru. Present address: Navy Environmental and Preventive Medicine
Unit No. 6, Pearl Harbor, HI
4. U.S. Naval Medical Research and Development Command, Bethesda, MD
 
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 the Navy or the Department of Defense.
 
Abstract
 
The Navy Forward Laboratory (NFL) was an advanced infectious disease laboratory which provided a theater-wide reference diagnostic capability during Operations Desert Shield/Storm. During Operation Desert Shield, when massive numbers of troops were being deployed, the NFL primarily supported medical personnel in the diagnosis and treatment of infectious diseases. During the war, the laboratory provided rapid biologic warfare diagnostic support. The NFL demonstrated the benefits of a comprehensive, on-site diagnostic laboratory when large numbers of troops are deployed to high risk areas and demonstrated the importance of military medical research laboratories for training of scientists and physicians, threat assessment, and product development.
 
Introduction
 
The Navy Forward Laboratory (NFL) was an advanced infectious disease diagnostic laboratory which served as a theater-wide reference laboratory during Operations Desert Shield/Desert Storm. The primary responsibilities of the NFL were to: (1) provide laboratory diagnosis of clinical cases of infectious diseases, (2) assist in threat assessment of infectious diseases of military importance, (3) detect potential biologic warfare (BW) agents, and (4) render public health assistance. The establishment, organization, and functions of the NFL provide valuable lessons which demonstrate the need for state-of-the-art diagnostic support in regions with a high infectious disease threat and demonstrate the important role of Navy medical research in the support of operational forces.
 
Establishment of the Laboratory
 
The deployment of American troops to the Persian Gulf in August 1990 set into motion Naval Medical Research and Development Command (NMRDC) contingency plans to support operational forces. Strategies to combat infectious disease threats in the Middle East had been developed during decades of support of American troops operating in this region by the Naval Medical Research Unit No. 3 (NAMRU-3), located in Cairo, Egypt.1-4 Investigations conducted by Navy research personnel in local populations and aboard U.S. ships and surveillance directed by the Navy Environmental and Preventive Medicine Unit No. 7 (NEPMU-7), Naples, Italy, had demonstrated that infectious diseases, particularly multi-drug resistant bacterial diarrhea, would be a major problem.4-8 Also, sandfly fever, dengue, West Nile fever, Crimean-Congo hemorrhagic fever, rickettsial diseases, acute viral hepatitis, and leishmaniasis were known infectious disease hazards in this region.9-11
 
With the initiation of massive troop deployments, NMRDC identified personnel to staff a forwardly deployed laboratory, prepared mobile laboratory equipment and supplies for shipment, and procured quinolone drugs for the treatment of drug-resistant diarrhea. Initial members of the NFL were deployed to the Persian Gulf in August 1990 to provide a preliminary evaluation of infectious disease problems and to determine the usefulness of a comprehensive diagnostic laboratory. The need for additional laboratory support was immediately apparent because of high rates of diarrheal disease among the first groups of deployed ground troops and concerns about a BW attack.12,13
 
With the approval and critical support of the NAVCENT Surgeon and his staff, the NFL was established in September 1990. The rapid deployment of full diagnostic capabilities was aided by the availability of an abandoned hospital on the northeastern coast of the Arabian peninsula. With the assistance of the MARCENT Surgeon and the U.S. 1st Medical Battalion, 1st FSSG, 1st Marine Expeditionary Force, laboratory equipment and supplies were installed in the former clinical laboratory of this hospital. In mid-September 1990, the NFL began accepting clinical samples for analysis.
 
Existing hospital facilities provided a number of advantages for the deployment of a sophisticated diagnostic capability using advanced technology, including a clean, temperature controlled environment, 110-V electrical power, running water, and a functioning autoclave and water distiller. Although the NFL's capabilities had been field-tested aboard the cramped quarters of Navy ships and in remote Third-World locations and was designed to function in a variety of structures, including tents, the dedicated work space of the abandoned hospital provided an ideal working environment.
 
The NFL was administratively attached to the Naval Logistics Support Command (Medical, N-9), Naval Forces Central Command, and reported directly to the NAVCENT Surgeon. The laboratory was authorized eight personnel: four Medical Service Corps microbiologists, two Medical Corps infectious disease sub-specialists, and two laboratory technicians. The NFL received direct technical support from several Navy facilities: (1)NAMRU-3 in Cairo, Egypt; (2) the Naval Medical Research Institute in Bethesda, Maryland; NEPMU-7 in Naples, Italy; and the Naval Medical Research Institute Detachment in Lima, Peru. Critical support was also provided by the Armed Forces Research Institute of Medical Sciences in Bangkok, Thailand; U.S. Army Medical Research Institute of Infectious Diseases and Walter Reed Army Institute of Research in Washington; the National Institutes of Health in Bethesda, Maryland; and the Chemical Biologic Defense Establishment in Porton Down, United Kingdom.
 
Laboratory Capabilities
 
The diagnostic capabilities of the NFL were extensive, ranging from classic bacteriological culture methods to antibiotic susceptibility testing, enzyme-immunoassay, fluorescent microscopy, diagnostic DNA probes, and polymerase chain reaction (Table I). Although standard microbiologic laboratory tests were routinely used, numerous specialized, research-level, diagnostic procedures had to be employed in the NFL to provide health care providers with the clinical information needed to effectively treat combat troops in this environment. Examples of specialized techniques which U.S. military research had helped develop included DNA probes and rapid diagnostic assays for identification of potential BW agents from clinical and environmental samples.14
 
Although there were several well-equipped and well-staffed clinical laboratories attached to American military medical facilities in-theater, none had been designed to diagnose common diarrheal and respiratory disease pathogens or potential BW agents. As fitted their mission, these laboratories had been intended to support the care of acutely injured troops. Consequently, the NFL provided invaluable support as the only comprehensive reference laboratory for the diagnosis of infectious diseases, especially in the period before hostilities began. Over time, it was possible to transfer some of the NFL's materials and expertise to other laboratories to increase theater diagnostic capabilities. However, some tests, like those used to diagnose travelers' diarrhea and some BW agents, were by necessity research-level endeavors because no standardized, commercial assays were available and experienced research personnel and a highly specialized laboratory were required to obtain accurate and rapid results.
 
Functions during Operation Desert Shield
 
During Operation Desert Shield when massive numbers of troops were being deployed to the Middle East, the NFL primarily supported clinical personnel in the diagnosis and treatment of common infectious disease problems (Tables II and III). Clinical specimens were submitted to the NFL from health care providers from all branches of the military, and NFL personnel routinely visited military medical facilities to collect samples and provide diagnostic support. In addition, NFL personnel aided in the surveillance of infectious disease transmission among deployed troops.15,16
 
Diarrheal disease was the major infectious disease problem for our troops. Epidemiologic surveys indicated that approximately 60% of ground troops experienced at least one episode of acute diarrhea and that 20% of troops sought medical care for diarrheal disease.16,17 As anticipated from prior research, a major finding of the laboratory was that the most important causes of acute diarrhea, enterotoxigenic Escherichia coli and Shigella, were resistant to the drugs commonly recommended for the treatment of acute diarrhea.16 The patterns of antibiotic resistance correlated with clinical observations which indicated that patients with acute diarrhea were not consistently responding to trimethoprim-sulfamethoxazole, tetracycline, or ampicillin. The NFL's determination that diarrheal disease was being caused by drug-resistant bacterial enteropathogens resulted in changes in therapy, with greater and more effective use of quinolone drugs, which helped preserve combat readiness.
 
Acute respiratory disease was another common, although usually not severe, infectious disease problem for our troops.18 The high prevalence of respiratory complaints probably resulted from crowding in buildings tightly constructed to withstand the climate of the Arabian desert and from blowing sand and sand suspended at ground level by the movement of personnel and troops.18 The NFL evaluated clinical samples from patients with respiratory complaints for a wide range of both bacterial and viral pathogens (Table III).
 
It was anticipated that acute febrile disease caused by arboviral infections, particularly sandfly fever, would be a major problem based on the experience of military personnel operating in this region during World War II.10 However, arboviral infections, except for a few cases of West Nile fever, were not identified in our personnel.19 Also, two infectious disease problems, malaria and sexually transmitted diseases, which had caused significant morbidity in past wars were very uncommon.
 
In addition to direct diagnostic support of physicians and corpsman caring for patients with infectious diseases, the NFL assisted preventive medicine personnel in the control of infectious disease transmission. Microbiologic studies conducted by the NFL, which indicated that uncooked, regionally acquired, vegetables were common sources of enteric pathogens, helped institute additional preventive measures to eliminate potentially contaminated food items and to ensure effective disinfection measures.16
 
Functions during Operation Desert Storm
 
During the war with Iraq, the major focus of the laboratory shifted to providing rapid BW diagnostic support. There was less need for diarrheal disease assessment because large outbreaks had ended due to preventive medicine measures; however, sporadic cases of diarrheal disease continued to occur with other enteropathogens, like Norwalk virus, becoming more common causes of illness during the cooler winter period of Operation Desert Storm.17
 
Although no BW attack was ever documented, the NFL provided continuous, active BW surveillance during the war as the principal on-site BW diagnostic laboratory. These laboratory activities served a very important function by reassuring medical and line personnel about the nature of the threat they were confronting. Fielding of several newly developed BW test systems during the course of the war also permitted extensive evaluation and optimization of these systems.
 
At the end of the war, the NFL temporarily established a satellite laboratory in Kuwait City to provide infectious disease diagnostic support for the troops who had relocated to Kuwait and Iraq. This laboratory also provided humanitarian assistance to the people of Kuwait by aiding in the assessment of infectious disease outbreaks which resulted from the breakdown of water and sanitation facilities during the war. NFL personnel also assisted Kuwaiti laboratory staff obtain critically needed laboratory supplies.
 
Keys to Success of the NFL
 
There were two principal keys to the early mobilization and deployment of the NFL and the subsequent accomplishments of the laboratory. For one, the prior overseas experience, particularly in the Middle East, by Navy medical research personnel was crucial to the success of the NFL. Most of the personnel assigned to the laboratory had conducted infectious disease research outside of the U.S. and at NAMRU-3 in Cairo, Egypt. Therefore, when Operation Desert Shield began, U.S. Navy research personnel knew the major infectious disease threats in this region and what was needed to provide diagnostic support to clinical personnel. In addition, the staff of the NFL was able to quickly and effectively operate in this region because of their understanding of the people and culture of the Middle East.
 
The other major key to success was the early recognition and acceptance of the NFL by all echelons of command. In particular, the support of BUMED 02 and the NAVCENT Surgeon and his staff was critical in establishing the laboratory and providing administrative assistance. Other keys to success included extensive personnel and technical resources on-station in the Middle East at the Navy research unit in Cairo, Egypt, and NEPMU-7; assistance from U.S. Army and civilian research facilities; mobility in theater; and flexibility in staffing to respond to changing disease threats.
 
Conclusion
 
The Navy Forward Laboratory demonstrated the benefits of a state-of-the-art, comprehensive, on-site, diagnostic laboratory capability when large numbers of troops are deployed to regions with a high risk of infectious disease transmission. In future mass deployments of troops to tropical and developing countries, a laboratory like the NFL should be considered a necessity for the optimal care of patients with infectious diseases. The success of the NFL also validated the importance of U.S. military research laboratories for disease threat assessment, product development, and training of uniformed medical scientists who can be deployed to areas of conflict.
 
 
The authors wish to thank all the individuals who served in the Navy Forward Laboratory and who supported its work; they did an outstanding job. This work was supported by the Naval Medical Research and Development Command, Naval Medical Command, National Capitol Region, Bethesda, MD.
 
References
1. Kilpatrick ME, Sheffield JE: Illness in American military men in Egypt. Milit Med 1986;151:548-9.

2. Scott DA, Haberberger RL, Thornton SA, et al: Norfloxacin for the prophylaxis of travelers' diarrhea in U.S. military personnel. Am J Trop Med Hyg 1990;42:160-4.

3. Oldfield EC, Bourgeois AL, Omar AM, et al: Empirical treatment of Shigella dysentery with trimethoprim: five-day course vs. single dose. Am J Trop Med Hyg 1987;37:616-23.

4. Haberberger RL, Mikhail IA, Burans JP, et al: Travelers' diarrhea among United States military personnel during joint American-Egyptian armed forces exercises in Cairo, Egypt. Milit Med 1991;156:27-30.

5. Daniell FD, Crafton LD, Walz SE, et al: Field preventive medicine and epidemiologic surveillance: the Beirut, Lebanon experience, 1982. Milit Med 1985:150:171-6.

6. Bourgeois AL, Gardiner CH, Thornton SA, et al: Etiology of acute diarrhea among U.S. military personnel deployed to South America and West Africa. Am J Trop Med Hyg 1993;48:243-8.

7. Mikhail IA, Fox E, Haberberger RL, et al: Epidemiology of bacterial pathogens associated with infectious diarrhea in Djibouti. J Clin Microbiol 1990;28:956-61.

8. Taylor DN, Sanchez JL, Candler W, et al: Treatment of travelers' diarrhea: ciprofloxacin plus loperamide compared with ciprofloxacin alone. A placebo-controlled, randomized trial. Ann Intern Med 1991;114:731-4.

9. Hyams KC, Oldfield EC, Scott RN, et al: Evaluation of febrile patients in Port Sudan, Sudan: isolation of dengue virus. Am J Trop Med Hyg 1986;35:1040-4.

10. Quin NE: The impact of diseases on military operations in the Persian Gulf. Milit Med 1982;147:728-34.

11. Mansour NS, Fryauff DJ, Modi GB, et al: Isolation and characterization of Leishmania major from Phlebotomus papatasi and military personnel in North Sinai, Egypt. Trans R Soc Trop Med Hyg 1991;85:590-1.

12. Gasser RA, Magill AJ, Tramont EC: The threat of infectious disease in Americans returning from Operation Desert Storm. N Engl J Med 1991;324:859-64.

13. Oldfield EC, Wallace MR, Hyams KC, et al: Endemic infectious diseases of the Middle East. Rev Infect Dis 1991;13:S197-217.

14. Oprandy JJ, Thornton SA, Gardiner CH, et al: Alkaline phosphatase-conjugated oligonucleotide probes for enterotoxigenic Escherichia coli in travelers to South America and West Africa. J Clin Microbiol 1988;26:92-5.

15. Paperillo S, Garst P, Bourgeois L, et al: Diarrheal and respiratory disease aboard the hospital ship, USNS Mercy, during Operation Desert Shield. Milit Med 1993;158:392-5.

16. Hyams KC, Bourgeois AL, Merrell BR, et al: Diarrheal disease during Operation Desert Shield. N Engl J Med 1991;325:1423-8.

17. Hyams KC, Malone JD, Kapikian AZ, et al: Norwalk virus infection among Desert Storm troops. J Infect Dis 1993;167:986-7.

18. Richards AL, Hyams KC, Watts DM, et al: Respiratory disease in military personnel deployed to Saudi Arabia during Operation Desert Shield. Am J Pub Health (in press).

19. Richards AL, Hyams KC, Merrell BR, et al: Medical aspects of Operation Desert Storm. N Engl J Med 1991;325:970.

TABLE I
 
NFL LABORATORY TECHNOLOGIES

Classic bacteriological culture methods

Antibiotic susceptibility testing

Enzyme immunoassays

Fluorescent microscopy

Diagnostic DNA probes Polymerase chain reaction
 

TABLE II
 

INFECTIOUS DISEASE AREAS OF SPECIAL INTEREST

 
 
Diarrheal disease
Febrile illness
Acute hepatitis
Acute upper respiratory illness
Detection and identification of BW agents
 

TABLE III
 

DIAGNOSTIC CAPABILITIES OF NFL

 
 
Diarrheal disease agents
Enterotoxigenic E. coli (ETEC)
 
Shigella sp.
 
Salmonella sp.
Vibrio sp.
 
Cryptosporidium
 
Rotavirus
 
Intestinal Ova and Parasites
 
Viral disease
 
Sand fly fever (Naples and Sicilian)
 
West Nile fever
 
Rift Valley fever
 
Crimean-Congo hemorrhagic fever
 
Sindbis
 
Dengue
 
Haatan
Hepatitis A and B
 
Rickettsial fevers
 
Q fever
 
Murine typhus
 
Mediterranean spotted fever
 
Respiratory diseases
 
Legionella pneumophila
 
Mycoplasma pneumoniae
 
Influenza virus A and B/Parainfluenza 1,2,3
 
Respiratory syncytial virus
 
Adenovirus
 
Streptococcus sp. and Neisseria sp.
Miscellaneous agents
 
Malaria
 
Yersinia pestis
 
Francisella tularensis
 

 
 
 

 

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