Military Medicine in Operations Desert Shield and Desert Storm:

The Navy Forward Laboratory, Biological Warfare Detection, and Preventive Medicine

Background

When U.S. troops were deployed to Saudi Arabia in August 1990, military medicine was prepared for the unique health risks our troops faced in the Persian Gulf. The U.S. military operates a network of six overseas infectious disease research laboratories, which serve as training sites for military medical personnel and scientists (1). These laboratories are regional centers of excellence for basic and applied research that benefit both the U.S. military and host nations by identifying infectious disease risks and developing improved prevention, control, and treatment measures.
 
One of the oldest overseas laboratories is located in Cairo, Egypt: the U.S. Naval Medical Research Unit No. 3 (NAMRU-3). NAMRU-3 has operated continuously since 1946, including the 7-year period (1967 to 1973) when there was a break in diplomatic relations between the USA and Egypt (2). NAMRU-3 has a long and distinguished record training U.S. and foreign medical personnel, assisting local health ministries and the WHO, and representing the United States abroad.
 
The research efforts at NAMRU-3 are extensive and include vaccine and drug development and disease surveillance. Research investigations frequently involve field studies in various countries in the Middle East, where numerous temporary laboratories have been established over the last 40 years (2). Consequently, when Operation Desert Shield began, the Navy had a sophisticated diagnostic laboratory and an active research and surveillance program in the Middle East, plus medical personnel with extensive experience in this region. U.S. Navy doctors and scientists knew what infectious diseases threatened our troops; understood what diagnostic tests were needed in Saudi Arabia; and, most critically, knew how to effectively operate in this region.
 
Navy Forward Laboratory
 
Beginning in August 1990, U.S. Navy preventive medicine personnel and scientists began evaluating infectious disease risks among deployed troops. In September 1990, the Navy Forward Laboratory (NFL) was established at the "Marine Corps Hospital" in El-Jubail, Saudi Arabia (3). The "Marine Corps Hospital" was an unoccupied civilian hospital that had all the requirements to accommodate a modern diagnostic laboratory: an unused clinical facility, running water, and climate control. Laboratory equipment and supplies were quickly flown into the theater by commercial airlines from Cairo, Egypt, the U.S. Navy Environmental and Preventive Medicine Unit No. 7 (NEPMU-7) in Naples, Italy, and various medical facilities in the USA.
 
The Navy Forward Laboratory in El-Jubail, Saudi Arabia; satellite laboratories established by the NFL in El Mishab, El Khanjar, and Kuwait City; and out of theater support for the NFL during the Persian Gulf war.
 

 
The NFL eventually had a staff of eight personnel: four Medical Service Corps officers (microbiologists), two Medical Corps officers (infectious diseases specialists), and two Hospital Corpsmen (advanced laboratory technicians). The NFL was attached to the Naval Logistics Support Command and reported directly to the NAVCENT Surgeon, whose leadership was critical in establishing and maintaining the laboratory. The NFL developed into a state-of-the-art infectious disease diagnostic laboratory that had the capabilities of a well-equipped laboratory in the USA, including DNA probes and polymerase chain reaction (PCR) analysis (3). When fully operational, the NFL served as the theater-wide, infectious diseases reference laboratory for coalition forces.
 

Naturally Occurring Infections
 
During Operation Desert Shield, the main focus of the NFL was to analyze blood and stool samples from patients and to assist preventive medicine personnel. In order to carry out these duties, the staff of the laboratory maintained two rental cars, which were used extensively to travel throughout Northeastern Saudi Arabia, evaluating patients and assessing health risks.
During these travels, one of the first questions that arose pertained to the numerous piles of dead animals that were scattered across the desert. Beginning in August 1990, these collections of dead animals were evaluated by U.S. veterinary personnel, who determined that their deaths were due to natural causes among the large herds of sheep, goats, and camels kept by the Bedouin in this region (4). The local residents left the dead animals in specific locations for counting and compensation from the government (5). In the desert, these dead animals tended to dry out rather than rot quickly.
 
The piles of dead animals naturally were of concern to U.S. troops who camped near these locations (4). Although the animals themselves were not thought to pose a direct health risk, they were considered to be a potential breeding ground for insect-transmitted diseases. As a result, military entomologists thoroughly sprayed the piles of dead animals with insecticides. This spraying may explain some subsequent reports of dead animals and insects, particularly among troops who arrived in Saudi Arabia in January and February 1991 at the start of the war. These newly arrived troops would not have known that dead animals had been in the desert for at least five months before hostilities began.
 
Acute diarrheal disease and common-colds were the main infectious disease problems during the early stages of the deployment. Epidemiological surveys indicated that approximately two-thirds of ground troops had acute diarrhea during both Operation Desert Shield and Desert Storm (6). Nearly all cases of diarrhea were due to the infectious agents NFL personnel had identified during prior deployments of U.S. troops to the Middle East, mainly traveler's type diarrhea ("tourista" or the "trots") and Shigella. No case of typhoid fever, cholera, or amoebic dysentery was identified by laboratory analysis (6).
 
U.S. troops also frequently had acute upper respiratory infections and complaints (cough, sore throat, sneezing, runny nose), which occurs any time troops are crowded together and rapidly deployed overseas. There also was concern that the fine blowing sand in Saudi Arabia was causing respiratory problems. However, epidemiological surveys determined that respiratory symptoms were more common among the minority of troops who worked and slept in air-conditioned buildings than among personnel living in tents or open warehouses (7). Troops living in tightly constructed buildings had more symptoms because in closed and crowded spaces they were more likely to pass respiratory infections among each other. These respiratory infections were found on analysis in the NFL to be caused by common viral and bacterial agents, like influenza (6).
 
A major concern for medical personnel was the threat of two infectious diseases (sand fly fever and leishmaniasis) that are transmitted by sand flies, because they had caused problems for U.S. and British troops during World War II. Extensive surveillance and testing of U.S. troops, however, did not identify a single case of sand fly fever, and only 12 cases of visceral and 20 cases of cutaneous leishmaniasis were diagnosed after the war among over 750,000 U.S., British, and Canadian Gulf war veterans (8). In addition, the sand fly vectors could not be found during and after the war in most locations where our troops were deployed (6, 9). The very low number of illnesses caused by sand flies and other insects may have been due to:

1) the deployment of most troops to barren desert locations where sand flies and their animal hosts do not live;
2) the deployment of most U.S. troops during the cooler winter months of December to February when insects are least active; and,
3) the use of insecticides and repellents.

There were only seven cases of malaria, three cases of Q-fever, one case of West Nile fever, and no case of brucellosis identified among U.S. troops (6). The infectious diseases diagnosed during this wartime deployment were the same ones found in peacetime when U.S. troops are sent to the Middle East. Although preventive measures can reduce the risk of diarrheal and respiratory infections, these common infections cannot be totally avoided during crowded deployments to tropical and developing countries. The only possibility for complete prevention is from research and development of effective vaccines and preventive measures.
 

Biological Warfare Detection Capabilities
 
During Operation Desert Storm, the emphasis of the NFL shifted from routine infectious disease problems to the threat of biological warfare (BW) (3). From the beginning of the deployment, it was clear that to protect U.S. and coalition troops against the potential use of biological warfare, an in-theater laboratory capable of detecting BW agents was essential. Therefore, the NFL diagnostic capabilities and staff were augmented during Operation Desert Shield to deal with the threat of biological warfare. At the start of Operation Desert Storm, the NFL was prepared to detect potential BW agents.
 
The techniques used for the identification of potential BW agents were developed by worldwide experts and represented existing state-of-the-art test methods. The NFL used technologies that encompassed a full range of laboratory techniques, including:
 
1) bacteriological identification and microscopy;
2) immunologic-based assays for detecting bacterial and viral antigens and antibodies; and,
3) molecular techniques, like PCR.
 
Various types of samples could be analyzed in the NFL, both biological samples (like blood) and environmental samples from soil, water, and air collectors.
 
The most likely BW threat from Iraq, based on the best intelligence at the time, was from the use of weapons loaded either with the bacterium, Bacillus anthracis, or with the botulinum toxin -- a toxin produced by the bacterium, Clostridium botulinum. The bacteria that cause anthrax and botulism both occur naturally in the environment. Anthrax affects livestock and causes disease among humans working closely with infected animals or their hides. Anthrax is a good BW agent because when inhaled, it causes rapid death from massive bleeding in the lungs. Botulinum toxin is a highly lethal substance, which causes disease in the United States when contaminated food is improperly canned or stored. Because this toxin causes very rapid paralysis and death in minute amounts, it is ideal for biological weapons production.
 
The extensive number of assays maintained in the NFL were capable of detecting not only the most likely BW agents (anthrax and botulinum toxin) but also additional, potential bacterial, viral, and toxic agents. Samples received and analyzed at the laboratory also were sent to laboratories in the United States (U.S. Army Medical Research Institute of Infectious Diseases, Ft Detrick, MD) and the United Kingdom (Chemical Biologic Defense Establishment, Porton Down) for further confirmatory analysis.
 
As previously noted, a common observation in the theater of operation was the piles of dead animals. During the course of the war, samples from seven dead goats were analyzed by the Navy Forward Laboratory BW team. Using the array of laboratory techniques available in the NFL, no BW agent was detected in these samples. Also, 33 samples from air collectors stationed around the theater of operation did not contain evidence of BW contamination. Other samples analyzed by the NFL and found negative for BW agents included water samples obtained after the war from the Royal Palace in Kuwait City.
 
Because of the inherent limitations of any laboratory test, especially newly developed assays, all samples analyzed for BW agents were subjected to repeated testing with dissimilar assay methods to confirm results. Multiple tests are required when the results involve an important question, such as potential exposure to BW or CW agents, because no test for biological or chemical agents is foolproof. Even in the routine hospital and outpatient clinic setting, multiple tests are often required to diagnose a patient's condition because of the limitations of any test method.
 
Although requiring additional time and labor, this concept of overlapping and different assay methods had the benefit of significantly enhancing the range and accuracy of the BW detection capability in the NFL during the Persian Gulf war. For example, infectious or chemical agents contained in a sample may be in such a form or amount that it cannot be detected by one method alone. In addition, there is the problem of false negative and false positive test results, which are unavoidable problems with all assays. By using different tests to analyze samples, questionable test results could be identified and corrected.
 
Despite a search for BW agents from clinical, environmental, and veterinary samples, no evidence of a BW agent was detected during Operation Desert Shield or Desert Storm. Nevertheless, one of the lessons learned during the Gulf war was the necessity to have an in-theater biological laboratory, like the NFL, when large numbers of troops are deployed. Identification of biological agents in-theater provides an early warning capability of hostile BW usage, allowing for timely implementation of effective prophylactic and therapeutic measures.
 
Another lesson learned was that more rapid BW assay methods are needed, which has been the focus of the military's biological defense research program since the Persian Gulf war. The present number of BW agents that can be detected is now much expanded. New methods also have been designed to detect BW agents in a broad range of substances other than clinical samples, including soil and sand samples, water samples, and even samples obtained from hard surfaces by swabbing. A greatly improved version of a rapid assay for BW agents has been developed at the U.S. Navy Medical Research Institute (NMRI), Bethesda, MD. Assays similar to standard pregnancy tests are capable of detecting a growing list of BW agents in about 15 minutes.
 

Summary
 
The NFL provided a critical diagnostic capability during Operations Desert Shield and Desert Storm that added to DoD's effective patient care and preventive medicine efforts. Just as importantly, the NFL provided commanders with accurate information about the nature of the biological threat during this wartime deployment.
 
There were two principal reasons for the success of the NFL. For one, the military's network of overseas infectious diseases research laboratories was essential. These laboratories offer specialized training for DoD personnel in foreign environments and provide support during deployments. The other reason for the success of the NFL was the early recognition and acceptance of the laboratory by all echelons of command, particularly the support provided by BUMED 02 and the NAVCENT Surgeon.
 
Since the end of the Gulf War, the forward laboratory concept has been institutionalized into the Forward Deployed Laboratory (FDL), under the coordination of the Navy Environmental Health Center (NEHC), Norfolk, Virginia. When deployed, this laboratory is composed of a "core" infectious disease diagnostic capability. Layered on top of this "core" are specialized capabilities (modules), such as BW detection. Presently, the BW detection module is provided by the Biological Defense Research Program (BDRP) at the Naval Medical Research Institute (NMRI), where a mobile laboratory for BW detection has been developed.
 
The NMRI mobile BW laboratory additionally has critical national security uses outside of military deployments. NMRI laboratory personnel and the mobile laboratory have been utilized to actively support U.S. and international agencies in countering BW threats, including the United Nations controlled sanctions of Iraq and the recent question of a biological threat in a package left at B'nai B'rith in Washington, DC.
 
 
Preventive Medicine and Surveillance
 
During Operations Desert Shield and Storm, the U.S. military initiated extensive disease prevention, control, and surveillance efforts (6,10). The Preventive Medicine (PM) activities among U.S. Marine Corps troops provided one example of this comprehensive effort. When U.S. Marines deployed to the Persian Gulf in August 1990, PM personnel were among the first to arrive. Because of the medical threats that Marine Corps units face during deployments, highly trained PM specialists are "built into" the Marine Table of Organization at multiple levels. Preventive medicine experts are assigned to front line units of the Division and Wing, to the combat medical support elements of the Force Service Support Group, and to the highest headquarters levels. These specialists know what illnesses might affect Marines and sailors in a particular area, like the Persian Gulf, and how to prevent health problems in field settings.
 
 
Within the First Marine Division, an Environmental Health Officer (EHO) is assigned to the Division Surgeon's staff to advise on key PM issues, such as field sanitation, protection of food and water, proper immunizations, and the prevention of insect-borne diseases. At the unit level, a PM Technician (PMT) works within the battalion medical department to carry out basic PM measures. The PMT's and the EHO's worked together during the Persian Gulf deployment to insure that:

1) food and water were safe to consume;
2) field sanitation measures were in place to prevent the
spread of disease;
3) flies and other insects were controlled; and,
4) proper immunizations were received.

Preventive Medicine personnel also advised unit leaders on the prevention of heat casualties and on the appropriate countermeasures for biting insects. The Marine Aircraft Wing has its own EHO assigned to the Wing Surgeon's staff, and PMT's at each Marine Aircraft Group perform similar functions. Naval Mobile Construction Battalions (SeaBee's) assigned to Marine forces also had a similar PM capability built into their structure. From the beginning of Operation Desert Shield, PM personnel were serving at the front lines, using their knowledge and experience to identify and prevent potential health problems before they affected the Marines' vital mission.
 
At the Medical Battalion of the First Force Service Support Group (FSSG), a large PM section was deployed, which consisted of EHO's, entomologists (experts in insect and pest control) and a team of PMT's, augmented with additional personnel from a Navy Disease Vector Ecology and Control Center, Jacksonville, Florida. This section brought extensive PM equipment and supplies, including insect and rodent control products, water testing gear, and chlorine to purify water. Their mission was to provide higher level back-up for the first line PM personnel at Division and Wing. This enhanced capability was positioned with Combat Service Support Detachments in support of forward Wing and Division units. In addition, the Medical battalion PM section provided direct support to battalions in the FSSG. Together, the Marine Corps PM teams ensured the very best in field preventive measures, where and when they were needed most.
 

Surveillance
 
One of the most important priorities in any PM effort is to recognize disease and non-battle injury (DNBI) problems early, while they can be more readily controlled. For the first time in U.S. Marine Corps history, a system of DNBI surveillance was established at the beginning of the Gulf deployment to track key illness and injury rates at virtually every Marine and SeaBee Medical Aid Station. A Navy Preventive Medicine physician was augmented to the MARCENT Surgeon's staff at the beginning of the operation to continuously analyze DNBI rates and identify any unusual patterns. In addition, all admissions to medical battalion facilities or Navy Fleet Hospitals were continuously monitored throughout the Gulf deployment to detect unusual or unanticipated diseases.
 
By tracking actual DNBI rates and trends in nearly all units, PM personnel were in position to respond immediately to problems and apply appropriate countermeasures. Based on the expected medical threats in the Persian Gulf, special attention was focused on the following DNBI categories, which were devised specifically to identify health problems that could degrade combat effectiveness:
 
 
Heat injury -- one of the most significant health threats early in the deployment;
 
Diarrhea -- a potentially epidemic problem in field conditions;
 
Skin conditions -- a significant cause of lost man-days in many previous conflicts;
 
Respiratory conditions -- colds, pneumonia and other respiratory problems are common and can be widespread during any deployment;
 
Injury/musculoskeletal conditions -- a major cause of lost man-days from training and
deployment activities;
 
Eye problems -- eye infections, such as "pink eye," can be epidemic in field conditions,
and corneal abrasions from blowing sand was also a risk in the desert;
 
Unexplained fevers -- an unexplained fever may be the first sign of diseases, such as sand fly fever, malaria, and other serious infections;
 
Psychiatric conditions -- the stresses of deployment and combat often manifest in psychiatric symptoms;
 
Other conditions -- other problems seen at sick call not fitting into the above categories.
 
 
Each week, unit aid stations reviewed their sick call logbooks and determined how many Marines or sailors were treated for the above categories of health problems. A unit-specific DNBI rate was then calculated for each category, based on how many Marines or sailors were assigned to the unit. These simple calculations allowed PM personnel to determine what percentage of the unit was treated during the prior week for these key problems. If the percentage was higher than expected, the cause was investigated.
 
The DNBI surveillance system demonstrated that PM efforts were very successful in keeping Marines and sailors healthy during Operations Desert Shield and Desert Storm. On average, approximately six percent of ground troops were treated per week for some type of illness or injury. This compares favorably to the DNBI rates in garrison troops at Camp Pendleton, California, where approximately four percent of personnel per week are treated. Furthermore, DNBI rates decreased during the deployment as troops adapted to field conditions and PM efforts identified and controlled health threats.
 
 
Total weekly rates of outpatient visits among approximately 40,000 Marine Corps ground troops stationed in northeastern Saudi Arabia.
 

 
DNBI surveillance proved its worth early in the deployment, when elevated diarrhea rates were detected simultaneously in numerous U.S. Marine units located throughout Saudi Arabia. The force-wide average diarrhea rate rose to approximately four percent per week, with some units experiencing significantly higher rates. Recognizing these elevated diarrheal rates early enabled PM personnel to rapidly identify specific problems with the contract food sources that had to be used in the initial stages of a rapid wartime deployment. Fresh produce initially procured outside of the normal supply system was shown by the Navy Forward Laboratory to contain local, diarrhea causing bacteria (6). This problem was rapidly corrected, and diarrhea rates quickly dropped below one percent per week for the remainder of the deployment. This rate of illness is only slightly higher than the normal diarrhea rate seen in garrison at Camp Pendleton.
 
Weekly rates of gastroenteritis among outpatients in approximately 40,000 Marine Corps ground troops stationed northeastern Saudi Arabia.
 

Respiratory disease rates remained generally low during Operations Desert Shield and Storm, with few cases requiring hospitalization. Rates of outpatient treatment were slightly higher early in the deployment when troops tended to be crowded together during air travel and in staging areas. Respiratory disease rates rapidly declined as troops spread out, but rose again when the weather turned cold. These acute respiratory illness patterns are similar to what is typically seen in the U.S. and were not a significant problem for U.S. Marines. The British also experienced increased rates of respiratory disease during periods of deployment and crowding (6). It is noteworthy that treatment for respiratory complaints did not increase from exposure to smoke after the Iraqi army ignited over 600 oil well fires in Kuwait a the end of the war.
Weekly rates of respiratory disease among outpatients in 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 deployed.
 

In all other DNBI categories, illness rates were remarkably low. In spite of extremely hot and humid conditions at the beginning of the deployment, less than 0.3% of the force per week (3 cases per 1000 per week) required treatment at an aid station for heat injury. Strong Command emphasis on providing abundant water and acclimatizing troops scored a major victory against this major health threat. In addition to these low rates, only about one percent of the force was treated per week for skin problems, mainly fungal infections and heat rash. This rate is comparable to that seen in garrison setting during hot and humid conditions.
 
Importantly, the surveillance system did not detect either sand fly fever or cutaneous leishmaniasis (which causes skin sores) among U.S. Marines. These infectious diseases are transmitted by sand flies and were expected to be major problems in the Persian Gulf. Entomologist, PMT's and EHO's were on constant lookout for sand fly vectors, but very few were identified.
 
All other DNBI rates, including injuries, eye problems, psychiatric conditions, and unexplained fevers were remarkably low throughout the deployment, and well within the expected norms. It is noteworthy that the rate of unexplained fevers remained essentially zero throughout the deployment. This DNBI category was designed as an early warning indicator to detect unusual insect-borne infections, such as sand fly fever, malaria, and dengue. Most of these infections take time to diagnose, but they typically begin with an acute febrile illness. The absence of unexplained fevers was reassuring to medical and PM personnel, indicating that Marines and sailors were not experiencing serious infections. This finding was corroborated by the near absence of disease carrying sand flies and mosquitoes during the deployment. Furthermore, no individual was hospitalized for these illnesses during the deployment, except for one case of West Nile fever -- an acute flu-like viral infection (6).
 
 
Weekly rates of outpatient visits for injuries, eye problems, psychiatric evaluation, and febrile illness among approximately 40,000 Marine Corps ground troops stationed in northeastern Saudi Arabia.
 

 
Although this pioneering system of DNBI surveillance was not perfect, it was a critical tool in immediately defining the major patterns of illness and injury in each Marine unit for most of the deployment. Combined with hospital surveillance, it clearly demonstrated that U.S. Marine Corps and Navy ground personnel remained very healthy during Operations Desert Shield and Storm. Also, when a problem arose, it was quickly identified and overcome.
 
This DNBI surveillance system proved so successful that it was adopted as the standard approach for all subsequent joint deployments involving U.S. military personnel. It has been modified and successfully used during Operation Restore Hope in Somalia, during the Haiti intervention, and during the current operation in Bosnia.
 
 
Conclusion
 
The U.S. military was ready for the health threats our troops encountered in the Persian Gulf war. As a result, the disease non-battle injury (DNBI) rate during this war was lower than in previous major conflicts involving U.S. military personnel (11,12). The good health of U.S. troops was due in part to comprehensive preventive medicine efforts, accurate and rapid laboratory diagnosis, and the extensive health care system that was established in Saudi Arabia during Operation Desert Shield (13).
 
Besides these medical measures, several fortunate circumstances aided U.S. troops, including:

1) deployment to barren desert locations during cooler
winter months when insect activity is lowest;
2) limited contact with non-military populations;
3) very limited access to alcohol; and,
4) the great strides made in Saudi Arabia and Kuwait during
the last several decades in public health and the elimination of
local diseases.

Although wars cannot be conducted as large epidemiological studies, greater infectious disease diagnostic and surveillance information was collected on U.S. troops during the Persian Gulf deployment than in prior wars. Since the end of the Persian Gulf war, these data have aided investigators in the search for the causes of veterans' health problems. To date, the primary chronic infectious disease problem identified among veterans has been 12 cases of visceral leishmania infection. Nevertheless, investigations are continuing for other possible chronic infectious disease problems.
 
The principal unanswered health question following the war with Iraq has been the unknown nature and causes of the unexplained symptoms experienced by some Gulf war veterans. Because similar physical symptoms have been reported by war veterans since the U.S. Civil War (14), hard to answer questions about veterans' health could arise after future wars. The improved surveillance and diagnostic methods pioneered during the Persian Gulf war and more recent improvements in medical record keeping will help the DoD and VA provide the best health care possible for both current and future veterans.
 
Bibliography
 

1. Gambel JM, Hibbs RG. U.S. Military overseas research laboratories. Mil Med 1996;161:638- 645.

2. Hibbs RG. NAMRU-3: forty-six years of infectious disease research. Mil Med 1993;158:484-488.

3. Hyams KC, Bourgeois AL, Escamilla J, Burans J, Woody JN. The Navy Forward Laboratory during Operations Desert Shield/Desert Storm. Mil Med 1993;158:729-732.

4. Spencer L. Colonel Alm recounts vital role of veterinarians in Persian Gulf conflict. J Am Vet Med Assoc 1991;199:305-309.

5. Persian Gulf Veterans Coordinating Board. Unexplained iillnesses among Desert Storm veterans: a search for causes, treatment, and cooperation. Arch Intern Med. 1995;155:262-268.

6. Hyams KC, Hanson K, Wignall FS, Escamilla J, Oldfield EC. The impact of infectious diseases on the health of U.S. troops deployed to the Persian Gulf during Operations Desert Shield and Desert Storm. Clin Infect Dis 1995;20:1497-1504.

7. Richards AL, Hyams KC, Watts DM, Rozmajzl PJ, Woody JN, Merrell BR. Respiratory disease among military personnel in Saudi Arabia during Operation Desert Shield. Am J Public Health 1993;83:1326-1329.

8. Magill AJ, Grogl M, Gasser RA, Sun W, Oster CN. Visceral infection caused by Leishmania tropica in veterans of Operation Desert Storm. N Engl J Med 1993;328:1383-1387.

9. Cope SE, Schultz GW, Richards AL, et al. Assessment of arthropod vectors of infectious diseases in areas of U.S. troop deployment in the Persian Gulf. Am J Trop Med Hyg 1996;54:49-53.

10. Wasserman GM, Martin BL, Hyams KC, Merrill BR, Oaks HG, McAdoo HA. A survey of outpatient visits in a United States Army Forward Unit during Operation Desert Shield. Mil Med 1997;162:374-379.

11. Lindsay GC, Dasey C. Operations Desert Shield/Storm infectious disease rates: A fortuitous anomaly. United States Army Medical Research and Development Command News 1992;February:5-6.

12. Defense Science Board. Report of the Defense Science Board Task Force on Persian Gulf War Health Effects. Washington, DC: Office of the Under Secretary of Defense for Acquisition and Technology; June 1994.

13. Blanck RR, Bell WH. Special reports: Medical aspects of the Persian Gulf war. Medical support for American troops in the Persian Gulf. N Engl J Med 1991;324:857-859.

14. Hyams KC, Wignall FS, Roswell R. War syndromes and their evaluation: From the U.S. Civil War to the Persian Gulf War. Ann Intern Med 1996;125:398-405.
 
For additional technical information please click on the following articles:
 

The Navy Forward Laboratory during Operations Desert Shield/Desert Storm. Mil Med 1993;158:729-732.
 

The impact of infectious diseases on the health of U.S. troops deployed to the Persian Gulf during Operations Desert Shield and Desert Storm. Clin Infect Dis 1995;20:1497-1504.
 

War syndromes and their evaluation: From the U.S. Civil War to the Persian Gulf War. Ann Intern Med 1996;125:398-405.

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