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.
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
. Applicable publications also were found by a comprehensive
examination of the reference section of articles dealing with this topic.
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
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 .
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 . 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 .
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 .
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.
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 . Although acute diarrhea was a frequent
complaint, the majority of troops experienced mild, traveler's-type diarrhea
which resolved spontaneously after a few days .
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)
. 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 .
As expected from recent U.S. military deployments in this
between 20% and 80% of bacterial enteropathogens were resistant to antibiotics
commonly used to treat acute diarrhea, including trimethoprim-sulfamethoxazole,
tetracycline, and ampicillin . However,
all isolated bacterial pathogens were found to be sensitive to quinolone
drugs which became standard therapy for severe cases of acute diarrhea
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
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 
(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 . 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 .
Viral gastroenteritis also was a cause of morbidity among
U.S. troops during both Operation Desert Shield and Operation Desert Storm
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 .
Affected troops generally had acute self-limited symptoms which lasted
for 24-48 hours.
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 
and an outbreak of chicken pox in a military field hospital .
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 .
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
Because cutaneous leishmaniasis had been a problem for foreign
troops stationed in Iran and Iraq during World War II ,
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" ,
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 .
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 .
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 .
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 .
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 . 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 . 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 .
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 
and in a serosurvey of 865 ground troops who were evaluated predeployment
and postdeployment .
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 .
No evidence of typhus or spotted fever-group rickettsia
infection was found in the serologic evaluation of 37 febrile troops 
and deployment serosurvey of 865 ground troops .
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 .
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 , local dairy production
facilities were regularly inspected by U.S. military veterinary personnel
, 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 .
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 , 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
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 .
Biologic warfare agents also have been suggested as a possible
etiology of unexplained illnesses .
Iraq is suspected of having a program that produced Bacillus anthracis,
Clostridium perfringens, and Clostridium botulinum ,
but there was no report during the war of casualties consistent with exposure
to biological warfare agents . 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
An unknown or emerging infectious disease has been hypothesized
as a possible cause of unexplained illnesses ,
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" .
Some of the veterans with unexplained illnesses have presented
with symptoms and signs consistent with a diagnosis of chronic fatigue
syndrome . 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) , 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
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 , 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].
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
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 .
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 . 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 .
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
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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, ).
Number (%) of stool samples*
|Enterotoxigenic E. coli
|Heat labile toxin
|Heat stable toxin
|Heat labile toxin/heat stale toxin
|Heat labile toxin and heat stable toxin+
|Enteroinvasive E. coli
* 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
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.